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ILLUSTRATED BIT
INTERESTING AND INSTRUCTIVE CASES,
PRACTICAL, PATHOLOGICAL, AND PHYSIOLOGICAL
              OBSERVATIONS J


  By JAMES BEDINGFIELD, Surgeon ;
        Late Apothecary to the Bristol Infirmary.
 " By a union of experience and reasoning, are the great and valuable objects
of Medical Science to be attained."—London Medical Repository, JVo. 19,-' P. 2.
                    ____      .^    *%

              WITH  NOTESJ^^^^J^;;*.^

       By STEPHEN W. WILLIAMS, M. D.
First American from the last London Edition.
       GREENFIELD, Mass.
PRINTED AND PUBLISHED BY ANSEL PHELPS,
          Nov. 1823. 
         District of Massachusetts, to wit *.

                                            District Clerk's Office.
  Be it remembered, that on the twenty-fifth day of September, A. D. 1823,
in the forty-eighth year of the Independence of the United States of America,
Ansel Phelps,  of the said  district, has deposited in this  Office the title of a
Book, the right whereof he claims as Proprietor, in the words following, to wit :
  " A Compendium of Medical Practice, illustrated by  interesting and instruc-
tive  cases, and by Practical, Pathological, and Physiological Observations ;  by
James Bedingfield, Surgeon ;  late apothecary to the Bristol Infirmary.  ^By
a union of experience and reasoning, are the great and valuable objects of Medi-
cal Science to be attained."—London Medical Repository, JVo. 19, P. 2.  With
Notes, by Stephen W. Williams, M. D.  First American, from the last Lon-
don edition."
  In conformity to the Act of the Congress of the United States intitled, " An
act for the encouragement of learning, by securing the copies of maps, charts
and books, to the Authors and Proprietors of such copies during the times there-
in mentioned ;" and also to An act intitled, » An act supplementary to An act
intitled, " An act for the encouragement of learning, by securing the copies of
maps, charts and books, to the Authors and Proprietors of such copies during the
times therein mentioned ; and extending the benefits thereof to the arts of de-
signing, engraving and etching historical and other prints."
                                              JNO.  W. DAVIS,
                                    Clerk of the District of Massachusetts. 
oomnnnnse
SECTION  I.
On Diseases of the Brain, Sfc.
         Page.\
Painful Affections of the Scalp       5
Tinea Capitis                     6
Hydrocephalus Externus            8
Hydrocephalus Internus            9
    Case  1                      9
          2                     12
          3                     13
          4                     14
          5                     15
Apoplexia                       21
Hemiplegia                     22
    Case  6                     24
Phrenitis                       26
Inflammation of the Pia Mater     27
    Case 7                    27
Cerebri Abscessus               29
    Case 8                    29
Epilepsia                       32
Chorea Sancti Viti               34
Tetanus                       35
    Case 9                    36
Tic Douloureux                 37
   Case 10                    38
The Functions of the Brain        39
SECTION  II.
On Diseases of the Fauces, Trachea, Sfc.
Ophthalmia                     46
Dentitio                       47
Odontalgia                     48
Cynanche                      50
Pharyngis Ulceratio              51
   Case 11                    51
Laryngis Ulceratio               54
   Case 12                    54
Laryngis et Tracheae Ulceratio     55
   Case 13                    55
Bronchitis                      58
   Case 14
Hasmoptysis
   Case 15
        16
Phthisis Pulmonalis
Pneumonia
Pleuritis
Empyema
   Case 17
Hydrothorax
58
61
61
62
65
67
68
69
69
75
Carditis                         79
   Case  18                     79
Hydrops Pericardii               82
   Case  19                     83
Ventriculorum Cordis Inflammatio   86
   Case  20                     86
On the Velocity and Inequality of
  the Action of the Heart          89
       SECTION III.

On Diseases of the Heart, Sfc.
                   Case 21
Polypi of the Heart
Aneurism of the Aorta
    Case 22
The Functions of the  Pulmonary
  Artery
 89
 92
 94
 94

100 
rv
CONTENTS.
SECTION  IV.
Dyspepsia
    Case 23
Pyrosis
Haematemesis
Ulceration of the Stomach
    Case 24
Gastritis
    Case 25
On the Effects of Ardent Spirits up-
  on the Stomach
On the Effects of Arsenic on the
  Stomach
    Case 26
On the Structure of the Pylorus
Splenitis
Induration of the Pancreas
Biliary Calculi
Icterus
Hepatitis
    Case 27
Chronic Hepatitis
On the Diseases of the Stomach, Sfc.
             Pa*e.\
               104 On the Function of the Liver
               104 Peritonitis
               106     Case  28
               107           29
               108           30
               108 Peritonitis Chronica
               110 Enteritis
               110 Ascites
                       Case  31
               112 Tabes Mesenterica
                   Diarrhoea
               114 Tympanites
               115 On Worms
               116 Taenia
               117 Lumbrici
               118 \ortae Descendentis Ulceratio
               119 Nephritis
               120 Diabetes
               121     Case 32
               121 On the Function of the Kidneys
               123
Page.
  123
  124
  125
  125
  126
  128
  129
  129
  132
  133
  134
  134
  135
  135
  136
  136
  140
  140
   141
  142
SECTION  V.
On Diseases of the Pelvic Viscera.
Affections of the Bladder
Affections of the Rectum
Affections of the Uterus
Hysteria
144
146
148
148
Emansio Mensium
Amenorrhoea
Leucorrhoea
Menorrhagia
150
150
150
151
Diseased Spine
Psoas Abscess
        SECTION  VI.
On Affections of the Spine, Sfc.
            I52|Fracture of the Spine
            153     Case 33
153
153
Theory of Fever
Typhus
Febres Intermittentes
Scarlatina
    Case 34
Rubeola
SECTION  VII.

     l56IPertussis
     157 Variola
     I61|Variola Vaccina
     I62iSyphilis
     163 Erysipelas
     165
166
167
168
168
170
Diseases of the Skin
Anasarca
Sphacelus
 SECTION VIII.

General Affections.
      173 Scrophula
      173 Rheumatismus Acutus
      174 Rheumatismus Chronicus
175
176
177 
VWMOlg
  This volume forms an epitome of the medical prac-
tice of the Bristol Infirmary during the last five years.
The object  which  its  author has  had  principally in
view, is the  recommendation of that practice in the  dif-
ferent diseases treated of, which he has  seen, upon the
whole, to be the most successful.   He trusts that to the
junior members  of the medical profession, and to those
whose conversation has been rather with books than ac-
tual disease, his endeavours to promote a knowledge of
the most efficient remedies will not prove unacceptable.
  In the schools of physic, and in books, such a multi-
plicity of remedies for diseases is sometimes enumeratedj
that the inexperienced practitioner is bewildered  in his
choice of them.  In this volume he will find that an al-
lusion to medicines of doubtful or of but little efficacy, is
very rarely  made.
  The  authenticity of the cases related may  be  relied
upon.   Well aware of the difficulty of engaging the at-
tention to the perusal of long cases, the author has com-
pressed his, as much as possible.   It is to be regretted
that this indifference to cases prevails, for they form a
species of reading more beneficial than any other : noth-
ing can exceed its utility but actual attendance upon the
diseased.
  So numerous a selection of unsuccessful cases  as the
author has made for the illustration of disease, seldom
appears in one volume.   This selection will, he  trusts. 
IV                   PREFACE.
be attended with its advantages.  It will tend to prove
that the grand object to be kept in view in the practice
of medicine, is the prevention of a derangement of struc-
ture ; and that no means  will be found  so effectual for
that purpose as  copious venesection, and a strictly anti-
phlogistic regimen.
  The observations which  the author has occasionally
introduced, were made by the bedside of the patient.
  The practical and the speculative parts of the work
are carefully separated from each other.   One  advan-
tage which the author hopes that his physiological con-
jectures will be  found  to possess, over  many daily ob-
truded upon the Public, is, that however  defectively
supported by argument and experiment they may be,
they will lead to a successful practice.
  The author is aware that in some parts of his volume
he has been  betrayed into the adoption of an egotistic,
in other parts of a dictatorial style.   For this he craves
the indulgence of the reader.  Almost every thing here
recorded has passed under his immediate observation.
Ardently and deeply  interested in  all  that he has de-
scribed,  he so completely identified self  with  subject,
that he found it  impossible to separate them.
   Where he assumes a dictatorial language, it must  be
remembered that he is not insisting upon the efficacy of
his individual practice, but upon that of Physicians who
have long distinguished themselves  by  an eminent dis-
play of talent, and who now most deservedly enjoy the
public confidence. 
A
COMPENDIUM

        OF
      SECTION I.

ON DISEASES OF THE BRAIN, &c.
                    CHAPTER I.

           Painful Affections of the Scalp.

  THE  scalp is liable to painful affections, the causes
of which it is frequently very difficult, and even impos-
sible, to ascertain.   Sometimes, they may be traced to
an injury inflicted upon the part at a distant period ; at
others, they appear to arise spontaneously.  Derange-
ment in the functions of the digestive organs often pre-
cedes the local  affection, and they are uniformly aggra-
vated by it.  It not uncommonly happens that a partial
or universal puffiness may be discovered upon examina-
tion ; the scalp however is sometimes excessively tender
to the  touch  without exhibiting any visible marks of
disease.
  Mr. Abernethy has descsibed these cases with great
minuteness, perspicuity and elegance ; to his  works*
I must therefore refer all those who are desirous of ob-
taining full information relative to them.   Some com-
  * See Abernethy on the Constitutional Oriain and Treatment of Local Injuries. 
6
Tinea Capitis
plicated and violent affections of this kind have fallen
under my observation. Although, from their commence-
ment to their termination they were highly interesting;
they were of such long duration that I  fear I could not
describe them in detail without appearing tedious.
  For their relief I have seen extensive incisions of the
scalp resorted to, but without any durable advantage.
In one case the trephine was applied upon the left parie-
tal bone;  but little good resulted from the operation.
                     Treatment.
  A judicious regulation of the digestive organs will be
found more beneficial than any local application or sur-
gical aid.   The blue pill unquestionably will, if proper-
ly administered, establish a more healthy action in the
liver and alimentary canal than any other remedy.   In
these affections it will be found peculiarly serviceable.
Fowler's solution of arsenic ought to accompany its ex-
hibition.   In what manner  this  medicine  affords relief
in these and  other diseases it is  impossible to explain.
Five grains of the mercurial mass taken once, twice, or
thrice a week, as circumstances may indicate, and  eight
drops of the solution  three times a day,  will, in  these
complaints, afford more speedy aud permanent  benefit
than any other means that I have been able to observe.
                    CHAPTER II.

                   Tinea Capitis.

In cute capillata ad radices capillorum, ulcuscula humorem in crustam albam
    friabilem abeuntem fundentia.—CI. iv. O. vii. G. cxxx. Cdlleni.

  Tinea Capitis is a  very prevalent disease amongst
the lower classes of society in this  city;  it appears to
have its origin in a want  of cleanliness; it is however 
Tinea Capitis.                  7
                     Treatment.
extremely probable that animalcule have a considerable
share in its  production.   The same remedies  which
prove so efficacious  for the cure of psora, are equally so
in this malady.
  Sulphur in combination  with tar seldom  fails to re-
move it; when however it has been allowed to acquire
a considerable degree of malignity,  it will be necessary
to vary the applications as well as the mode of applying
them.   If the head be very scaly, or covered with thick
and indurated crusts, the practice pursued at this hospi-
tal, is to invest the whole scalp with a poultice of linseed
meal.   Some tar ointment with sulphur may be  advan-
tageously combined with the poultice.   After  this plan
has been put in force, the hair is to be completely re-
moved  with  a razor and  the parts  anointed with the
ointment night and morning.  Previously to rubbing on
the ointment  it will be extremely  proper to wash the
head with soft  soap and water.
  There is  a species of Tinea or Porrigo much  more
difficult of removal, although less disgusting to the eye.
It is in the highest degree contagious, and whenever it
gets  admission into a seminary of education, or other
large establishment,  it is  not easily eradicated.  The
hair  falls  from the head  either partially or entirely,
The denuded places  look as if they had been stripped
of their covering by a razor or a pair of scissors. Whit-
ish furfuraceous scales, which sometimes  adhere with
great pertinacity, form upon the bared parts.

                     Treatment.
   With this species of tlie complaint mercurial prepa-
 rations succeed more speedily than sulphurous.
   If the scalp be not entirely free  from hair, what  re-
 mains should be removed with a razor.  A blister should 
8              Hydrocephalus Extenius
then be applied, and  dressed with mercurial  ointment.
Should a morbid skin be reproduced, anoint the scalp
with an  ointment composed of equal  parts  of tar and
mercurial ointment.   For this preparation  diluted ni-
trated ointment of quicksilver may sometimes be advan-
tageously substituted.  Frequent washing is in this spc
cies of the disease highly desirable.
                     CHAPTER III.

               Hydrocephalus Externus.

     Capitis intumescentia mollis, inelastica, Hiantibus cranii suturis.—
                 CI. iii. O. ii. G. lxxii. Culleni.

   This disease uniformly and inevitably proves sooner
or later fatal.  Its appearances are so universally known,
that it would be  superfluous  in me to dwell upon them.
It probably is the  consequence of original defective or-
ganization in the brain.*   Before it  manifests itself by
any enlargement or  other  symptom,  its existence may
be sometimes  recognized by the veins of the scalp be-
coming varicose.  The most beautiful appearance I ever
saw those vessels  assume was upon the integuments in-
vesting the head  of a hydrocephalic patient.f   The
cranium was large, but had not acquired an immoderate
size.   In the cases I have witnessed there has been but
a scanty growth of hair.

  * Dr. Spurzheim has, I think, very satisfactorily shewn, that the deposition of
fluid takes place within the ventricles, and not between the membranes of the
brain as generally supposed.  If it be so, the disease must no longer be designat-
ed—external.
  t The superficial veins upon the abdomen often present the same appearance
before any great accumulation of water has taken place within its cavity. 
               Hydrocephalus Internus             9

                    CHAPTER IV.

              Hydrocephalus* Internus.

  It is perhaps to be lamented, that professional men
sacrifice so much of their time in searching after specif-
ics for diseases which  have been proved by the experi-
ence of ages, utterly incurable.  Would they  but em-
ploy it in devising measures for their prevention ; and
zealously insist upon the necessity of their being rigor-
ously adopted; from what a series of sufferings and
miseries would they deliver mankind !
  When once Hydrocephalus Internus is fully deve-
loped, medicine can achieve but  little.  I will  relate
several cases of this  lormidable  disease; detail the ap-
pearances which presented themselves upon dissection;
investigate its nature; point out that which I conceive
to be the most judicious mode of treating it; and finally
give such directions  as will, I hope, if steadily pursued,
preserve many from  becoming its victims.

                      CASE I.

  On the 21st of January.  1811, a Boy, aged 15, by the
name of Jesse Clissold, applied for relief as an out-pa-
tient to the Bristol Infirmary.
  His mother stated, " that he had been in an  indiffer-
ent state  of  health  for a  considerable length of time;
that three  or four days previous to his application he
had been unmercifully beaten by some boys, and that
he had scarcely held his head up since."
  His appearance was by no means unhealthy.  His
countenance was florid, his complexion clear.   He com-
plained of slight headach and a sore throat.   His pulse
was full and  rather frequent, the tongue white,  the ton-
sils slightly  inflamed,  the parotid  glands were  very
  * More properly, Hydrencephalus.
              2 
10            Hydrocephalus Internus.

much enlarged, the bowels were confined, and there was
a little oppression about the chest.   The enlargement
of the  glands principally attracted  attention, and the
disease was considered to be Cynanche Parotidcea,  at-
tended with a more than usual degree of inflammatory
diathesis.   An emetic was  ordered to be taken in the
evening, a purgative on the following morning, and  af-
terwards four grains of the antimonial powder every  six
hours.   On the 24th, he appeared to be nearly in  the
same state.  A blister was  ordered  to  the chest, and a
saline mixture to  be taken in lieu of the powders.
  On the 31st, he was admitted into the Infirmary.
  Ten ounces of  blood was drawn from the arm and
fifteen  grains of the cathartic powder of the House,*
were taken on the following morning.
  February 1st.  Pulse soft and rather frequent, throat
sore, tongue white, parotids  not much enlarged, skin
rather dry.
  2nd. Delirium with laud and frequent  moaning came
on during the night, pulse strong and frequent, bowels
costive.  Ordered a stimulating enema.   Eight ounces
of blood were abstracted from the external jugular vein.
A blister  was  applied between the shoulders.   Three-
grains  of calomel were taken at ten o'clock at night,  and
repeated on the following morning at four o'clock.
   3rd. Has some lucid intervals.   Pulse  full, tongue
moist.   The bleeding was ordered to be repeated,  and
three grains  of calomel to be administered every three
hours till copious evacuations should be procured. The
blood exhibited no inflammatory appearance.
   4th. Bowels open, pulse 100 in the minute and soft^
tongue clean and moist.   Passed a more comfortable
night,  delirium continues, stools fetid  and black, picks
his nose and lips.  Ordered three  grains of calomel to
be taken every six hours.
     * This powder is formed of five grains of calomel, and fifteen of jalap. 
              Hydrocephalus Internus.            11

  5th. Delirium unabated, picking of the bed clothes,
involuntary discharge of faeces, pupils dilated ; Strabis-
mus.
  6th. Continued  in the  same  state till seven o'clock
this morning, at which hour he expired.
                    Examination.
  The  vessels of the pia mater were very much dis-
tended with blood, and a large  quantity of the same
fluid escaped from the lateral sinuses through an acci-
dental opening made into it, while sawing the occipital
bone.  The texture of the hemispheres appeared to  be
natural.
  Upon making an incision by the side of the raphe into
the lateral ventricle, a large quantity of water was dis-
charged ; the right lateral Ventricle was very much dis-
tended and appeared to have contained  more than two
ounces  of the fluid,  the  left ventricle was filled with
about an ounce and a half; the choroid  plexuses were
remarkably pale. They in all probability were rendered
so by the water in which they floated, having after death
deprived them of the red particles of the blood; in other
words, they had a sodden  appearance.  The foramen
of Monro was remarkably distinct, a small  quantity of
water was situated between the folds of the septum luci-
dum, the third ventricle contained nearly half an ounce
of the serous  fluid,  the pineal gland was   destitute of
gritty particles, the fourth ventricle was in a healthy
state, the prominences of the basis of the brain were re-
markably distinct.
           Appearances in the thoracic cavity.
   The surfaces of the lungs had a tuberculated appear-
ance, but no tubercles existed within the substance of
those organs ;  there were  slight adhesions between the
pleura and its reflected portion; a  mass of coagulable
lymph was found  in the right, ventricle of the heart. 
12            Hydrocephalus Internus.

        Appearances in the abdominal cavity.
  All the abdominal viscera were perfectly healthy, but
the stomach was very much contracted, and its internal
siurface beautifully corrugated.
  I have seen a similar appearance in the stomachs of
two executed patients.
  These stomachs are preserved in the Museum at St.
Thomas's hospital.
  There were slight marks  of external violence  on the
sides and back.

                     CASE II.

  A boy 17 years of age, was admitted into the infirma-
ry on April the 4th, 1811.   Some  months previous to
his admission he received a blow upon his knee ; inflam-
mation and suppuration were the consequence ; the lig-
aments covering the joint became very much thickened ;
pus was continually  passing out of the joint; there was
great constitutional irritation, and as there was but  lit-
tle chance of saving  the limb, it  was deemed advisable
to remove it.   It was considered a favorable case to op-
erate  upon.  About four  days after the  operation the
boy began to  complain of headach, and the  stump as-
sumed an unfavorable aspect.  The former symptom
was  unregarded, and stimulants were freely  exhibited,
with a view of bettering the condition of  the stump.—
The affection of the head  daily increased in violence.
The patient screamed with  vehemence in  the day time,
and disturbed the whole ward by his moanings at night.
He at length became  delirious ; his eyes looked glassy,
but the pupils were but slightly dilated.
  On the  following  day the patient became comatose.
The stimulating plan was laid aside,  and the antiphlo-
gistic regimen adopted.  Blood was  twice taken from
the temporal artery ; once  from the jugular  vein ; and
once from the arm ;  in all about  forty ounces.  A blis- 
              Hydrocephalus Internus.            13

ter was applied to the scalp, and three grains of calo-
mel were given every six hours.   This practice was
however  adopted too late,  to afford  any reasonable
ground to hope that it would be attended with success.
The patient died on the 6th of May.   The brain ex-
hibited the same appearances as those related in the for-
mer case, except that there was a larger quantity of wa-
ter  contained  in the lateral ventricles.   There  was
throughout the whole of this case but a very slight dila-
tation of the pupil.   I do not recollect that its  diameter
ever measured more than one line.   The application of
the strongest light would not however stimulate the iris
to a further contraction.  In Jesse Clissold's case the di-
latation was considerably greater, but there was through-
out its whole progress a tendency to  contract,  whenev-
er a strong light was suffered to fall upon the eye.
  The lad whose case is above narrated was of a scro-
phulous habit  of body.

                     CASE III.

  Mary Ann Nelson, aged three years, a sickly child,
and of a very diminutive  size, was admitted into the In-
firmary on May the 1st,  1815, in order to be  operated
on for a hare lip.
  The head was large, the skin delicate, and there were
other marks of a scrophulous disposition about the pa-
tient.   The  operation was performed, and the lip  at the
end of three or four days began to unite.  At  this time
she was attacked with severe pain in the head, scream-
ed violently, and refused all nutriment.   A  cathartic
powder was administered, and  afterwards a  grain  of
calomel  every six  hours.  On the following  day the
child became comatose; and there was considerable di-
latation of the pupils.   A blister was  applied  to the
head.  The calomel was persisted in,  and a scruple  of
mercurial ointment was rubbed upon the abdomen every
night,  This practice was unattended with the slightest 
14           Hydrocephalus  Interims.
diminution in the violence of the symptoms ; and on the
4th of June, the patient died.   No opportunity occurred
of ascertaining the state of the brain, but little doubt can
exist of there having been considerable effusion into the
ventricles.
  I should have observed that the mouth was affected
by the mercury.

                    CASE IV.

  A sickly child, 4 years of age,  with deformed rickety
limbs, was placed under the care of the Surgeon of the
week.  A few days after her admission she was attack-
ed with all the symptoms commonly attendant upon hy-
drocephalus internus.  There was also great accelera-
tion of the pulse and  a  hot skin.   She screamed at in-
tervals and refused all kinds of  food.  Two grains  of
calomel combined with eight of jalap were given to her,
and afterwards a grain of calomel every six hours.
  On the following morning  she appeared  somewhat
better; her pulse was slower and her skin  more cool.
The body was directed to be sponged and the cathartic
and calomel to be repeated.   The next day she appear-
ed much better; she had voided with her  faeces two
lumbrici, about four inches  in length each ;  she took a
little nutriment and did  not complain of her head ; the
pupils  were less  dilated; the powder and calomel were
repeated.
   She passed on the  following day another worm, and
from this time gradually recovered.  One grain of calo-
mel combined with ten grains of tin filings were admin-
istered every morning for about  a week, and the child
left the house free from  any hydrocephalic symptoms.
   That this was a genuine case of hydrocephalus Inter-
nus may be disputed.   I can only say, that I never saw
a case  in which the symptoms of  the disease were more
decidedly marked. 
              Hydrocephalus  Internus.            15

                     CASE V.

  A boy, sixteen years  of age, was admitted into the
Infirmary for a tumor in the thigh.   This tumor,  upon
more minute investigation,  was ascertained to form the
most dependent part of a psoas abscess.   The lad com-
plained of universal indisposition, and there was a slight
acceleration of his pulse.
  On the  23d  of July he became feverish ; skin hot,
tongue dry, great pain in the head.  A purgative was
prescribed, and he was desired to be kept cool.
  On the 25th, his pulse was hard and rapid, his face
flushed, his skin hot; there was but a slight  dilatation
of the pupils, but he complained of excessive pain in
the head.  It was  evident  that the disease  had  made
very considerable progress, and that no time was  to be
lost.
  Ten ounces of blood were directed to be taken front
the temporal artery, and the following medicines were
prescribed.
  It. Calom. ppt. gr. iij. 6ta. quaq. hor.
  Mist.  Salin. unc. viii. Inf. Digit, dr.  vi. M.  Capt.
cochl. iij. 6ta. quaq. hor.
  His body was likewise sponged with vinegar an<fl
water.
  26th.  Pulse rather slower,  skin cooler, pupils more
dilated, delirium during the night, cannot be made to
answer questions, bowels open.
   The temporal artery was again opened, and twelve
ounces of blood drawn from it; a large blister was ap-
plied to the head; the calomel and mixture were contin-
ued with an addition of two  drachms of the  infusion of
the latter;  a drachm and a half of strong mercurial
ointment was rubbed upon each thigh at bed time.
   27th.  Pulse 130, but softer, pupil very much dilated,
but contracts upon being exposed to a strong light,  his
stools pass involuntarily.  Friction with the mercurial 
16            Hydrocephalus  Internus.

ointment was directed  night and morning ;  the calomel
pill was omitted at bedtime, and a grain of opium with
three grains of antimonial powder substituted,
  28th. Salivary glands slightly affected ; the patient
could be roused, and replied readily to questions pro-
posed.  He swallowed a little food,  tongue foul, pulse
very frequent, pupils less dilated, fseces discharged in-
voluntarily.  In the afternoon he began to pick the bed-
clothes, became insensible to all external objects, and
died on the following morning.
                   Examination.
  The brain exhibited evident marks of active vascular
action having existed. Upon cutting off the hemispheres
numerous minute spots  of blood exuded from the divid-
ed vessels.   The texture of the brain  itself was firm,
and  rather  more glutinous  than is  usually met with.
The ventricles  did not contain  so large a  quantity  of
water as was expected to be found within  them;  only
two ounces were collected, and about half an ounce es-
caped.  I am inclined to believe, that a partial absorp-
tion had taken  place  previous  to the death of the pa-
tient.   The abdominal  viscera were all  in a healthy
state.  The psoas muscle had been formed into a fun-
nel, fo* the reception of about three quarts of cream-col-
oured  pus.  Solid  flakes  of considerable magnitude
were deposited at the bottom of the abcess  ; and would
have effectually prevented the matter from passing thro'
thecanula  of a trocar, had one been introduced into the
tumor /or  the  purpose of evacuating it.   The lumbar
vertebra were all in a diseased state, and  large  pieces
were easily chipped from them  with  a  common scalpel.
There had likewise been considerable absorption of the
bones  of  the  sacrum.   There was no  projection of the
spinous processes  externally,  nor  did  they  deviate
from the  straight line.   When pressure  was   firmly
made upon them, the boy, at his first admission into the
hospital, said it gave him considerable pain. 
Hydrocephalus Internus.            17
                     Observations.
   The unfortunate termination of four out of five cases,
although what have been generally conceived to be ac-
tive remedies were employed, naturally leads  to an in-
quiry in the cause  of their failure.  Are the medicines
themselves improper, or does the nature of the disease
for the most part  preclude the possibility of  relief?  I
much fear that we must attribute its fatality to the latter
circumstance.
   It is well worthy of remark that all the patients whose
cases I have related were highly tainted with scrophula,
and it is in scrophulous  habits  that I have uniformly
observed the disease to occur.
   In scrophulous patients, a peculiar sensibility or irri-
tability of mind is  very observable, and to this irritabil-
ity of mind, I am inclined to attribute the susceptibility
of these  patients to the disease.  It may perhaps be con-
sidered the predisposing cause.
   Parts  predisposed to disease, are  more easily excited
into sympathetic  action  with diseased parts,  however
remote they may be from them,  than healthy  parts al-
though placed in their immediate vicinity.   It is on this
account, that local irritation proves so frequently the
cause of Hydrocephalus Internus.
   Hydrocephalus Internus is rarely an idiopathic dis-
ease.  1 have been induced to relate so many cases  with
a view of establishing this fact;  they form however but
a small proportion  of those which have fallen under my
observation.
   The deposition  of the serous fluid I conceive to be
the consequence  of sympathetic inflammation of the
brain ; the predisposing cause to this sympathetic in-
flammation, an irritability of mind ; and this irritability
of mind  is most frequently  met with in scrophulous
habits.   Local irritation is the  immediate cause of the
disease.  In all the cases related, there was local irrita-
           3 
 18           Hydrocephalus Internus.

 tion.   Jesse  Clissold  had been severely  beaten and
 much  bruised; added to which his mind at the time
 was thrown into a violent state of perturbation.  In the
 second case, the stump ; in the third, the operation for
 the harelip and the pins ; in the fourth, the worms; and
 in the  last the diseased vertebrae, with the fluid collect-
 ed beneath the psoas muscle, were the sources of local
 irritation.
                     Treatment.
  By regarding  Hydrocephalus Internus as a disease
 arising from sympathy, we shall perhaps be enabled to
 treat it more satisfactorily, if not more successfully.
  The mind of the patient should be kept in as tranquil
 a  state as possible,  in order to prevent  the brain from
 taking on a predisposition to the disease;  and we should
 endeavor as far as we  are able to improve the constitu-
tion of the patient.
  For this purpose, we should direct much of our at-
tention to the alimentary canal, but  more especially to
those parts of it, to which the process of  digestion is
more immediately consigned.
  The inability  of the stomach  to convert  the food re-
 ceived into it,  to a nutritious chyme is, perhaps, the ori-
ginal cause of scrophula.  Although the absorbents  of
the intestines in all probability possess to a certain extent
the power  to receive or refuse what may be presented
to their mouths,  if only an imperfect chyme be formed
they will be necessitated to take it up.   The imperfect
chyme (or rather chyle)  thus taken up, acts upon their
inner surfaces as an extraneous body.   They, as well
as the glands attached  to them,  become  inflamed, and
thus is produced the disease termed Tabes Mesenterica.
  Food  easily digested  should  be given, and all that
avoided  in which animalculae are  known  to exist; it
 should likewise be eaten at stated periods, and in small-
er quantity than is usually supposed to  be necessary. 
Hydrocephalus Internus.               19
If the stomach be overloaded, it must perform its offices
imperfectly.
  I have been induced to write thus much,  because I
feel firmly persuaded, that Hydrocephalus Internus may
often be prevented from arising;  I will now endeavor
to ascertain what  will be the practice most likely to be
attended with success,  when the  disease  has  actually
taken place.
  The cure cannot I fear be effected, unless we possess
the ability to remove  the local irritation.  If the irrita-
tion be produced by worms or by dentition, by speedily
expelling  the former,  or by freely  dividing the  gums in
the latter case, Ve may reasonably hope to put a stop to
the disease.  If however proper means  be not taken be-
fore there has been much  effusion into the  ventricles,
the termination will be fatal.
   It must be recollected that  although the  disease is
originally excited  by  local irritation, unless that  irrita-
tion be  speedily removed,  the brain will acquire  the
power of acting independent of it.   It is on this account
that the speedy removal of the local affection  is so de-
sirable.   If the local  disease be externally situated wre
must endeavor to lessen it by such applications as have
a tendency to allay irritation.  It may sometimes be ad-
viseable to remove the diseased part, provided it can be
effected without making any violent impression upon the
system, or without materially disturbing the mind of the
patient.   Where however these results are to be appre-
hended, the palliative treatment will be preferable ; in
two of the cases I  have related, it must be admitted, that
the disease was induced by the operations.
   Our next object should be to diminish arterial action.
   Although the blood seldom  exhibits  the buffy crust,
it is unquestionably an inflammatory disease.  The ra-
pidity and hardness of the pulse; the  strong pulsation
of the carotid arteries, which sometimes is observable ;
the acute pain in the  head ; the irritability of mind, by 
20            Hydrocephalus  Internus.
which, in its early stages, it is accompanied ;  all clearly
evince an inflammatory process.
  To diminish this vascular action we must rely princi-
pally upon bleeding from the jugular veins or temporal
arteries; I am inclined  to prefer the former situation.
Blood can be  taken  away more  freely and in larger
quantities  from those vessels.
  After the venesection, the patient should be placed in
nearly an  erect position, his head shaved, and an evap-
orating lotion applied to the scalp.
  The next thing to be attended  to is the intestinal ca-
nal.   Copious and frequent evacuations should be ob-
tained from it.
  If worms be suspected to exist, large doses of calomel
should be  given every four or six hours, and their  ope-
ration assisted by  exhibiting some infusion of senna?
combined  with sulphate  of magnesia.   If it  be desired
merely to  procure  stools, the ol.  ricini will perhaps be
the best medicine for that purpose.
  If,  in spite  of this treatment,  effusion take place,
(which  may generally be known by the further dilata-
tion of  the pupil, or by  its becoming  insensible to the
stimulus of light) mercurial friction to  a  great extent
may be employed.
  In the first  stage of this disease  I  apprehend  that
mercury is very injurious ; it only serves to increase the
febrile symptoms.
  It appears to me, that the deposition of water in the
ventricles is effected by a process somewhat  similar to
a deposition of pus within the cavity of an abscess.
  Inflammation exists for a considerable time before se-
cretion takes place. Mercury, I apprehend, is prescrib-
ed with a  view of exciting the absorbents to take up the
fluid; to exhibit  it therefore before  the fluid has been
deposited must be useless.
  It seems probable that the absorbent  system is  in a 
Apoplexia.
21
state of quiescence during the increased action of the
arterial;  at the precise moment the minute branches of
the arteries are about to secrete* the absorbents acquire
a disposition to act. They remove the surrounding solid
substance to form a receptacle for the fluid.  In the brain
however there is not that necessity  for their immediate
action upon the solid parts, as a natural cavity exists ;
but they in all probability possess the disposition to act,
and will act, as soon as the deposited  fluid presses up-
on  them ; more especially if they be  at  the same time
stimulated by mercury.  They will relieve compression
both by taking up the  fluid and by  enlarging the cavity
of the ventricle.  Many may be inclined to doubt their
ability to effect this, but patients could not exist so long
as they frequently do under the disease, unless  a por-
tion of the brain were removed.  In the case last related,
the ventricles did not appear to be nearly filled, and I
hazarded an opinion that a part of the water had been
absorbed.  After remaining two days in a state  of in-
sensibility, this patient on  the third could be made to
answer questions distinctly.   The salivary glands were
at the same time affected.
                     CHAPTER V.

                      Apoplexia.

   Motue voluntarii fere omnes imminuti cum sopore plus minus profundo.
                  CI. i. O. i. G. xl. Ctjlleni.

  In the treatment  of Apoplexy we must  in  a great
measure be guided by the state of  the pulse.   If it be
full and slow with an evident determination of blood to

  * Whenever the arterial system acts either with  too great or too little energy,
there will be a deficient secretion ; my opinion therefore is, that a diminution in
its action precedes the deposition of tbe fluid. 
22
Hemiplegia.
to the head, (which  may be known by a redness and
bloatedness of the face, strong action of the carotid arte-
ries, and fulness in the jugular veins) we may bleed im-
mediately and freely, with evident advantage; but  if
the surface of the body be cold, the pulse languid, or
imperceptible, by drawing blood  from the patient Ave
run a great risk of extinguishing the vital spark alto-
gether.
  That species of apoplexy which  depends upon  the
extravasation of blood upon the brain or within its ven-
tricles, will generally be benefited  by venesection to a
considerable  extent; recourse should however be  had
to it as  soon after the seizure as possible,  or it  will a-
vail but little.
  When apoplexy arises from the  reception of opium,
vinous spirit, or other pernicious ingredient into the stom-
ach, I have almost invariably seen bleeding prejudicial.
In these cases we must, by every  possible  means, ex-
cite free and copious vomiting.   Upon our  ability to do
this, will a successful termination principally depend.
                   CHAPTER VI.

                    Hemiplegia.

  Nothing more forcibly characterises  the perversity
of some professional men than the practice they pursue
in Hemiplegia.  Although dissection has repeatedly de-
monstrated, that the paralysis depends upon  the press-
ure made  by blood or  serum effused  upon the brain,
they still persist in administering stimulating medicines
internally, and in applying rubefacients, electric sparks,
&c. to the parts  deprived of muscular power.   By the
former,  they  often induce a recurrence of the effusion ;
by  the latter,  they  injuriously exhaust what little ner-
vous energy may have accumulated in the affected ex- 
Hemiplegia.
23
tremities.   As  reasonably might they expect by  such
means to relieve a patient  laboring under symptoms of
a compressed brain, from a portion of the inner table of
the scull, or other extraneous body being driven upon it.
Why w ill they  tread in the intricate, dark, and  often
dangerous paths of their forefathers, instead of availing
themselves of the light which anatomical investigations
afford them, to form for themselves and for their success-
ors, new, more sure, and safer roads ?
                  Treatment.
   In  Hemiplegia our efforts must be directed to the re-
moval of the whole or a part of the  effused fluid ; what-
ever therefore has the power to increase the  energies of
the absorbent system, will be found beneficial  in this
disease.
   When there is nothing in the pulse or in the constitu-
tion of the patient decidedly to contradict it, the abstrac-
tion of blood from the arm or jugular vein will be prop-
er.  Large  bleedings are not requisite ; only  enough
blood should be taken to reduce the impetus of the heart
and arterial system, and to keep it in a state of  dimin-
ished activity.   This can be better done by  abstracting
frequently small quantities of blood from a large orifice,
than  by having recourse to occasional copious bleedings.
   Whatever produces nausea has a tendency to  excite
absorption.  Upon  this principle the administration of
emetic tartar in nauseating doses will be found  highly
serviceable.
   We are not to content ourselves  with exciting a dis-
position to  vomit, for a few hours  ; we  must persist in
giving the antimonial for days, and even weeks, if we
can prevail upon the  patient to take it.  As, however,
a state of continued nausea is of all others the most dis-
tressing, we shall often be obliged to suspend its use.
   The scalp should be frequently blistered and dressed
with  mercurial  ointment.   Once a week,, or oftener, if 
24
Hemiplegia.
 it should  be necessary, a  brisk purgative  must  be
 given.
   The practice above recommended I have seen in sev-
 eral instances attended with complete success ; from the
 measures reprobated 1 have never witnessed any good,
 but very often mischief to arise.
   I shall conclude these observations upon Hemiplegia,
 by giving the history of a case which terminated unfor-
 tunately.   The appearances after death will shew, that
 there is nothing in the  nature of the disease which pre-
 cludes the  possibility of relief being obtained from the
 plan of treatment I have recommended.

                    CASE VI.

   William Ryall, aged 55 years, was  admitted on the
 9th of June, 1814.  He laboured under  considerable
 weakness of the right side,  the  consequence of an at-
 tack of Hemiplegia,  which happened three years since.
 His speech was imperfect, but this seemed to depend as
 much upon a malformation of the palate as upon a par-
 tial paralysis of  the lingual muscles.   There was some
 degree of stertor,  with determination  of  blood  to the
 head;  his pulse wras full and rather frequent, and he
 complained  of headach ; his lower extremities  were
 oedematous.
  Purgatives were diligently administered, and blood
 to the amount of forty ounces was drawn from the arm
 at three different times.   Under this treatment he rapid-
 ly improved, and was about to be discharged convales-
 cent, when he was visited by another  hemiplegic attack.
Twelve ounces of blood were drawn from  the temporal
 artery, which afforded  much relief.  The use of the
limbs in some measure returned; in this last attack
however there was not  that decided paralysis of one
 side, which is generally occasioned by an effusion of
Mood from the vessels of the brain in such quantity as 
Hemiplegia.
25
to cause compression.*   On  account of his continuing
very lethargic, a seton was cut in the nape of the neck ;
it discharged freely for some days ;  his spirits however
daily grew worse ; his appetite and strength failed him;
his voice was  at times very indistinct; he became more
drowsy; some difficulty was experienced in respiration;
his cheeks and  lips assumed a purplish, and his com-
plexion an extremely sallow hue.  He died on the 13th
of August.

                    Examination.
   After death the brain was examined, and the  follow-
ing morbid appearances discovered.
   Between the dura mater  and arachnoid tunic, there
was an accumulation of  a serous fluid,  particularly at
the basis of the cranium,  where  it amounted to  nearly
three ounces ; the  veins of the pia  mater were much
distended with  blood ; the lateral ventricles contained
about an  ounce of water;  the choroid plexuses were
very small, and in the right there  were found three hy-
datids, the largest of the size of a pea.
   At the basis of the brain, the tunica arachnoides had
acquired a very unusual degree of density  and opacity.
Where it passed under the  inferior  surface of the left
lobe of the cerebellum, it formed an extensive bag; upon
cutting this  open,  a considerable excavation  presented
itself.   This cavity was lined with a thick stratum of a
yellowish gelatinous substance.   Upon scraping this
away with the back of a scalpel,  it was found that the
pia mater had been absorbed, and iu its stead that pe-
culiar appearance,  denominated  arbor vitae,  was seen
almost as  distinctly as if an incision had been made into
a  healthy  part  of the cerebellum,  to demonstrate  it.
There was scarcely any fluid in the cell.

  * When serum is effused, the paralysis will seldom be so perfect as when it de-
pends upon extravasation of blood.
1 
26
Phrenitis.
                   CHAPTER VIr.

                     Phrenitis.

   Several violent cases of Phrenitis have fallen under
my observation.  They all terminated favourably.
                  Treatment.
   Bleeding was employed to a very great extent.   Sel-
dom less than twenty ounces of blood were drawn from
the arm or jugular vein twice, sometimes three times a
day, for four or five days in succession.
   No regard was paid to the quantity taken ; an abate-
ment in the violence of the phrenetic symptoms formed
the criterion by which the flow of the sanguineous  fluid
was regulated.
   A strict antiphlogistic  regimen was enjoined ; active
purgatives  administered;  the head shaved,  and  kept
constantly  enveloped in  cloths,  thoroughly moistened
with cold spirituous lotion.   The most decided benefit
was derived from this application.
                     Remarks.
   I am persuaded that venesection frequently  fails in
affording the  expected relief, in active inflammatory dis-
eases, from Physicians  directing a limited quantity of
blood to be taken away, instead of desiring it to be con-
tinued until a mitigation in the violence of the symptoms
be effected.
   Phrenitis,  Pneumonia,  and Peritonitis, may be ar-
rested almost to a moral certainty in their early stages,
by one or two copious evacuations of blood.
   Thirty or forty ounces taken  at  one operation will
more decidedly stop their progress than sixty or eighty
drawn off by driblets of fourteen or sixteen ounces at a
time.  It will be  found  that persons  bear the loss of
blood well or ill in proportion to the degree of inflam-
matory action which exists. 
Inflammation of the Pia Mater.        27
   A man, who in a state of health would faint from the
abstraction of a pound of blood, will, when an  inflam-
matory  diathesis is  present, part with two  or three
pounds, without  any, or but trifling inconvenience.
                   CHAPTER VIII.

           Inflammation of the Pia Mater.

  The following case, although  in its  symptoms and
progress it bears a strong  analogy  to  Hydrocephalus
Internus, presents some peculiarities which it  may  be
useful to record.

                    CASE VII.

  Diana Lovell, aged 22 years,  was admitted into the
Infirmary, on the 18th March, 1815.
  For fourteen  days previous to her  application she
complained of constant and violent headach.   In addi-
tion to this symptom she had a dry skin, frequent pulse,
and a furred tongue ;  the fur nearly approached to the
colour of lemon-peel.  An uneasiness was occasioned
by the admission of light to her eyes, and large and nu-
merous blood vessels  were seen ramifying upon the tu-
nica conjunctivae.
  14th. She  passed a restless night; pulse rather more
frequent, skin hot,  tongue  foul, bowels confined; she
could not move her  head  without  suffering excessive
pain.
  15th. Delirium came on in the evening and continued
throughout the night.
  16th. In nearly the same state ;  muttered incessantly.
  17th. Lay  upon her right side;  fixed her hands pow-
erfully between  her thighs, and  moved in a peculiar
manner,  a  manner  extremely difficult to describe.   I 
28         Inflammation of the Pia Mater.

know not how to  convey au idea of it better than by
stating, that  she  rocked herself upon her side.   She
screamed when her head was touched.
  18th. Comatose, faeces and urine passed involuntari-
ly ; seesaw motion of the body continued.
  19th. In the same state.
  20th and 21st.  Perfectly sensible ; pulse very rapid
and full; tongue foul;  skin dry.
  22nd. A strong epileptic fit terminated her sufferings.

                   Examination.

  The sinuses of the dura mater were full of blood, but
neither that membrane, the pia mater, nor the substance
of the hemispheres  exhibited any marks of disease.
About half an ounce of serous fluid was  found in the
lateral ventricles.
  At the basis of the cranium a large quantity of serum,
slightly tinged with the red particles of blood, had been
deposited.  The arachnoid coat was destitute of transpa-
rency, and much thickened.   The almost  triangular
compartment, formed by the converging  optic nerves,
was filled  up with a jelly-like  substance.  The tuber
annulare, crura cerebri et  cerebelli, were almost veiled
from the eye.
   This obscurity  was occasioned by the pia  mater,
which, (where it is passing over  the tuber annulare, cru-
ra cerebelli, and parts adjacent.) was in a high state of
inflammation. Its vessels were extremely numerous and
had  acquired an  undue magnitude.  The increase of
vascularity extended upon each side of the medulla ob-
longata, and probably was continued for a considerable
 distance along the medulla  spinalis.  That projecting
ridge formed  at the superior part of the cerebellum by
the union of its two lobes, had undergone some change
 in its appearance, but there was no perceptible altera-
 tion in its  structure; it looked as though  pus were de- 
Cerebri Abscessus.
29
posited beneath  the pia mater.  I have observed the
same change in the brains of several epileptic patients.
  The deposition of  fluid  at the basis of the  cranium
undoubtedly took place from the inflamed portion of the
pia mater.   Was the  peculiar motion to which 1 allud-
ed, occasioned by the tuber annulare and its continua-
tions  participating in the  inflammatory process with
which the pia mater investing them was attacked ?
  The effusion of the  fluid into the ventricles  is to be
regarded as symptomatic of the disease  at the basis of
the brains
  The treatment employed in this case, consisted in the
abstraction of blood from the  arm and temporal artery,
the administration of active purgatives, antimonials, &c.
as circumstances indicated.   Cold  Lotions were appli-
ed to the head, and a blister to the nape  of the neck.
                    CHAPTER IX.

                 Cerebri Abscessus.

  The following case will perhaps be found to possess
a sufficient degree of interest to render it worthy of pe-
rusal.  How is it that the slightest injury inflicted upon
the brain will sometimes terminate fatally  in a few
hours; while at other times extensive lesion will  exist
for weeks, months, even years, without destroying life
or materially disturbing  the  functions of the animal
economy.

                    case  vni.

  Jane Bevan, aged 36, was admitted on the 18th of
November, 1813.  Three weeks previous to her admis-
sion she miscarried.   Nothing remarkable occurred.
  At the time she presented herself to the  Physician 
30
Cerebri Abscessus.
her head was  drawn towards the right side, she  had
however power to turn it partially towards the left; a
considerable degree of stupor was observable, but upon
being roused, she gave reasonable answers to such ques-
tions as were proposed to her.  She complained of great
pain in the head ; the pupils were considerably dilated,
more  particularly that of the right eye, the globe of
which was drawn  towards the nose, inducing strabis-
mus ; the bowels were constipated,  pulse natural;  that
is to say it was soft, regular, destitute  of undue force?
and about seventy in the minute.  Purgative medicines
were administered  and a blister applied to the nape of
the neck.
  13th. More comatose, but still could  be made to un-
derstand what wras said to her;  the pupils were more
dilated.  It was evident that there was considerable
pressure upon the brain, but there was almost a total
absence o( that stertorous breathing which for the  most
part attends a state  of  apoplexy.  Bowels slightly re-
lieved, a plentiful secretion of urine, pulse distinct, slow
and regular.   The  purgative medicines were directed
to be continued,  and a blister was applied to  the calf of
each leg.
  14th. Still able to reply to questions proposed to her ;
pulse somewhat  more full, the spasm affecting the mus-
cles of the neck had subsided.   In the afternoon twelve
ounces of blood were drawn from the temporal artery ;
she died about an hour after the evacuation.
                   Examination.
  Upon examination the following were  the appearan-
ces which the brain exhibited.
  The dura mater adhered so firmly and universally to
the bones of the  cranium that it could only be separated
from them w ith  extreme  difficulty ;  the vessels of the
pia mater were minutely  injected; the  cortical  part of
the cerebrum had  a yellowish  hue as  though it were 
Cerebri Abscessus.
31
tinged with bile.  The structure of a portion of the mid-
dle of the right hemisphere of the cerebrum  was com-
pletely  destroyed ; a considerable excavation of that
part of it which is opposed to the squamous plate of the
temporal bone had been effected by the absorbents.   A
loss of substance had likewise occurred in the anterior
and posterior lobes, but the mischief was more superfi-
cial.  The walls of the cavity seemed to be without or-
ganization, the slightest force being  sufficient to break
them  down.  Tliey had a pulpy feel, and wrere of a red-
dish brown colour.  It seemed  to me that an abscess
having the middle lobe  of the cerebrum for its centre
had   extended  itself  upon the  anterior  and  posterior
lobes ; in fact the whole lateral part of the right hemis-
phere of the brain was in a diseased  state.  There was
no pus or other fluid in the cavity of the abscess.   The
right  lobe of the cerebellum was perfectly healthy,  but
the texture of the left was completely altered ; it was
pulpy, of a dark red colour, and almost  as destitute of
regular organization as the parietes of the abscess.
   The ventricles were distended with an immense quan-
tity of water ; the different parts contained within them
had in consequence  been rendered more than usually
distinct.   The foramen commune anterius was almost
large enough to admit the point of the little finger and a
large goose-quill  would readily have passed through
the foramen of Monro.
   This patient had complained of occasional indisposi-
tion for a year and a half.  She was affected with  but
little  stertor throughout the disease.  Only  two hours
before her death she could be made to answer questions,
thrust out her  tongue, and stretch forth  her hand, for
the purpose of having the pulse examined. 
32
Epilepsia.
                    CHAPTER X.

                     Epilepsia.

     Musculorum convulsio cum sopore.—CI ii. O. iii. G. 1. Culleni.

  Most sincerely do I lament my inability to furnish a
successful method of treating this formidable malady,
but I have  known every measure which consummate
ability and ingenuity could  devise, rendered perfectly
abortive when it has been of long duration.
  By far the  greater number of epileptic cases arise
from causes  which we cannot  ascertain, or which if as-
certained, perhaps,  we  do  not  possess the  power  to
remedy.
                     Treatment.
  The treatment  I  have seen upon the whole the most
efficacious was the following.
  The force of the  arterial system was diminished by
drawing blood from the  arm in small quantities, as fre-
quently as circumstances indicated ; an active purgative
was given once or twice a week, and on the intermediate
days, the oxid of zinc in sufficient  doses to excite nau-
sea.
  To adults were usually prescribed five grains three
or four times  a day, gradually increasing the quantity
to a scruple.  It will seldom be found necessary to give
a larger dose than this, although a larger may be taken
without injury.   With children it will be adviseable to
begin with one or two grains.
  By persisting in these measures for a length of time,
in several cases of extreme obstinacy and violence, the
disease was  suspended;  upon laying them aside it re-
turned, and  generally terminated in fatuity or death.
  I have given the spirit of turpentine in large as well
as in small doses, but no decided benefit accrued from
its exhibition. 
Epilepsia.
33
   In incipient cases, where the disease depended upon
the retention, suppression, or imperfect flow of the cata-
menial discharge, venesection employed monthly,  with
active purgatives and electric shocks applied to the pub-
lic and lumbar regions has been decidedly useful. Bleed-
ing, instead of diminishing the interval between the pa-
roxysms has always appeared to me to increase it.*
   When epileptic fits depend upon the presence of worms
in  the intestines, means must be  resorted to  for their
speedy expulsion.
   Sometimes  epileptic fits are excited by the  pressure
of an extraneous body upon the brain,  as a spiculum of
bone.   If we should be fortunate enough to discover its
situation, we  must remove it with a trephine.   A slight
depression  upon the surface of the cranium  will some-
times lead to a detection of the injured part.
   The  brains of epileptic  patients will  be  generally
found to present the  same diseased  appearances as are
met with in persons who die of serous  apoplexy; in ad-
dition to these, I have sometimes observed that change
in the colour of the superior part of the cerebellum no-
ticed in Case 7th.          *

  Note.—This work had thus far passed through the press, before I discovered
♦hat I had inadvertently  made extracts from one of the earliest editions of Dr-
Cullen's Nosology; those which follow are made from his fifth edition, printed
in 1792.

  * This observation is I believe in opposition to generally received opinion.
  A few months ago I bled a patient while labouring under an epileptic parox-
ysm with manifest advantage. In this case the heart and carotid arteries throb-
bed with great violence, ap»plectic stertor had commenced, and I am strongly
inclined to suspect, that, had not thirty ounces of blood been speedily drawn
away, effusion upon the brain would have taken place.  For several days after
the attack  the mental faculties were much impaired,  and it was apprehended
that the case would terminate in complete fatuity ; the powers of the mind how-
ever gradually returned, and the patient is now in a fair way of recovery. Jan-
uary, 1816.
5 
Si
Chorea Sancti Viti.
                     CHAPTER XI.

                  Chorea Sancti Viti.

  Impuberis utriusque sexus, ut plurimum intra decimum et decimum quartum
 ietatis annum adoriente?, motus convulsivi  ex parte voluntarii, plerumque alte"
 rius lateris, in brachiorum et manuum motu, histrionum gesticulations referen-
 tes ; in gressu, pedem alterum saepius trahentes quam attollentes.—CI. ii. O. in.
 G. Ii. Cplleni.

   Upwards of forty cases of this disease have present-
 ed themselves at this Infirmary within the last five years.
 With one exception they were all cured by  the oxid of
 zinc, given in the manner recommended  for epilepsy ;
 in fact, so speedily and decidedly did this remedy put a
 stop to the disease, that I cannot avoid regarding it as a
 specific for it.   Why it  has so frequently failed in the
 hands of other practitioners  I cannot tell ; probably
 however the failure arose from its not having been given
 with sufficient regularity, and in sufficient  doses to ex-
 cite nausea.   In some patients this oxid cured the dis-
 ease without producing  a nauseating  effect,  but these
 cases were of short duration, and not very violent.
   Perhaps tartarized  antimony would cure the disease
 with equal certainty, but it is  a less manageable medi-
 cine, and the nausea it induces is of a more  distressing
 nature.   When the cases were of extreme obstinacy and
 violence, the cold shower  was directed in  conjunction
 with the zinc,  and sometimes  with advantage.   When
 the disease seemed to depend  upon the retention of the
 menses, electricity was found  useful.  Occasional pur-
gatives were employed,  but I  do not recollect any case
in which constipation formed a prominent symptom.
   The subjects of this disease were mostly between the
 ages of seven and nine, and twelve and fifteen years ; in
 one case only had the patient reached her eighteenth
 year.  This patient was more decidedly  benefited  by
 electricity than any other. 
Tetanus.
35
  The disease sometimes  arose spontaneously; in by
far the greater number of instances, however, it was in-
duced by the children having been frightened.  Reten-
tion  of the  menses formed another  frequent exciting
cause.   The case wrhich resisted the long-continued ex-
hibition of the oxid of zinc  was finally cured by the fol-
lowing combination.
  JR. Tinct. Opii dr. ij. Liq. Ant. Tartariz. dr. vi. M.
  Of this, thirty drops were taken three times a day.
  The patient, a boy, was  twelve years of age.
                   CHAPTER XII.

                      Tetanus.

  Plurium musculorum rigiditas spastica.—CI. ii. O. iii. G. xlviii. Culleni.

  I have only witnessed one decidedly tetanic case ; it
was induced by an extensive laceration of the  sole of
the foot.  The patient died on the fourth day after the
attack, and the 12th after the accident.
                   Examination.
  The brain was examined but it presented no morbid
appearances.  I traced the posterior tibial nerve to some
distance under a suspicion that it might be in an inflam-
ed state.  Instead of exhibiting any marks of inflamma-
tion it was exceedingly white.
  A short time previous to my appointment to this hos-
pital, several cases had been successfully treated by
giving opium  and antimonial powder in combination.
The  quantity directed  was half a grain of opium and
five grains of antimonial powder every two hours.
  It ought to be observed, that in these cases the tetanic
symptoms were not induced by irritation from a wound.
1 could  not learn their exciting causes. 
36
Tetanus.
  As the case above alluded to forms a tolerably accu-
rate history of the symptoms and progress of this formi-
dable and inexplicable affection, I subjoin it.

                    CASE IX.

  Mary Timmins, aged  17 years, was brought into the
Infirmary  with  a lacerated wound  of the foot, on the
28th  February, 1815.   The part  was highly irritable
and painful to the touch.   It was dressed superficially ;
a cathartic powder administered, and twenty-five drops
of the tincture of opium directed to be taken at bedtime.
  March 1st. She slept well; the  foot not very painful;
the cathartic operated.  The  foot was  directed to be
kept constantly  wet with a saturnine lotion.
  2nd. Continued in good health ;  slept well.
  3rd.  From this day to the 8th,  she progressively im-
proved ; when she complained of general uneasiness.
   9th.  At ten A. M. The muscles  of  the  lower  jaw
 contracted powerfully, and the mouth was only prevent-
 ed from entirely closing, by  a piece of wood introduced
 by the nurse between the teeth ;* the pulse quick; slight
 pain in the neck and between the shoulders.
   Nine, P. M. The  pain between  the  shoulders  very
 distressing;  occasional spasmodic action of the muscles ;
 the feet and  hands cold.   She was directed a grain of
 opium and a quarter of a grain of tartarized antimony
 every fourth hour.
   10th. Ten, A. M. Passed a very bad  night; took
 only one pill, not being able to swallow ; bowels open ;
 pulse full, and  124 in a minute.
   Thirty-two ounces of blood were taken from the  arm ;
 an enema, composed of four ounces of  gruel and  three
 ounces of oil of turpentine, was injected;  she  was de-

    This is a precaution which never ought to be neglected in cases where ap-
 prehensions of trismus are entertained, as it very much facilitates the exhibition
 of remedies. 
Tic Houloureux.
37
sired to continue the pills if possible.  She fainted from
the bleeding.
  Eight, P. M. The spasms made her shriek frequent-
ly ; she said, " she felt hungry, but had no power to
swallow."   The enema was returned in a quarter of an
hour and procured three evacuations ; the crassamentum
of the blood was firm, but no buff was seen upon its sur-
face ;  some difficulty wras experienced in respiration.
   11th. At  twelve o'clock she  seemed  rather better;
her breathing was more  free; the spasms and pain in
the back less violent; pulse 130, aud full; when food
was introduced into the mouth she swallowed it  with
less difficulty, but her jaw continued firmly closed.
   She was directed another enema, to be bled ad  deli-
quium, and to take four grains  of antimonial  powder,
and one grain of opium every four hours.  The foot was
enveloped  in a poultice of linseed meal;  the  wound
looked healthy.  Thirty-six ounces of blood were taken
away.
   Nine, P.  M. She was relieved  for a  short time by
the bleeding, but the spasms returned again.
   12th.  Passed a dreadful night; the muscles of the
back and neck rigidly contracted, felt as firm as boards;
pulse 160.  The enema was retained an hour but failed
in procuring any  evacuation ;  she  rapidly grew worse;
dreaded even the thought of  swallowing; all the mus-
cles of the body  affected with violent spasms.  About
ten o'clock, P. M. she expired.
   She  remained perfectly sensible almost  to the last
minute of her existence.
                  CHAPTER XIII.

                  Tic Houloureux.

  No very severe cases of this distressing affection have
fallen under ray observation. Such as I have seen have 
38
Tic Houloureux.
readily yielded to the regular administration  of the ar-
senical solution, conjoined with a proper  attention to
the state of the digestive organs.
  I was sometime  ago informed of a new and success-
ful method of  treating this disease, which,  as I am not
aware that it has ever been  made public, I  shall take
the liberty to insert.  I regret that I  am unable to give
the name of its ingenious proposer with it.
                    CASE X.
  " In the month of December 1813, a man was ad-
mitted into (ruy's Hospital with Tic Douloureux.   He
had the infra-orbitar nerve twice divided without any
good effect; he had taken the liq. arsenicalis with  as
little benefit; when one of Mr. A. Cooper's dressers
suggested to  him  the  probability  of  paralysing the
nerves  by the application of  Cerussa.  Accordingly,
two scruples, formed into an ointment, were rubbed in
the morning on the affected cheek, about an hour before
the paroxysm  of the disease was expected.  This appli-
cation  was continued for a month or more and the man
left the Hospital apparently perfectly cured.
  u Should you not be inclined to fear a recurrence of
the disease, upon the recovery of the nerve from the se-
dative effects of the lead ?
  " The effect of the lead was rapid and striking, and
the patient, from a state of excruciating torment, was
rendered comparatively comfortable, in a short time.
  " A knowledge of the remedy is valuable as procur-
ing even  temporary  relief.   Its effect upon the bowels
was very  slight, the system but little deranged,  the
pulse rather diminished in frequency.
  " The young man's idea of the application  of lead to
relieve pain by its action on the nerves is by no means
original, but in this particular instance I believe it to be
strictly so, and as such, he is undoubtedly  entitled to
considerable credit." 
The Functions of the Brain.           39
  The above is extracted from a letter with which I was
favoured by a friend.  With respect to the query con-
tained in it; I am inclined to think that the paralysis of
the nerve will remain.  How often  do we see  perma-
nent paralysis  induced by the application of lead; a
paralysis which baffles all our attempts to relieve ?
                    CHAPTER XIV.

             The Functions of the Brain.

  Every attempt which has been hitherto made to ex-
plain the functions of the brain has been defeated, nor is
it probable, that, where so much must be founded upon
conjecture,  any incontrovertible  conclusions  can be
drawn.
  The following  are  the conjectures which  I have
adopted respecting them:* That the  office of the brain
is to convert a portion of the blood sent to it, into a fluid,
in which  the living principle  essentially  resides; that
this fluid is distributed by the nerves to  every part of
the body ;  and that it forms the connecting medium be-
tween the soul and the body.
  In support of this theory, I have first to endeavour to
prove, that  the brain is  a glandular organ.
  Blood is  distributed to the different parts of the body
for its nourishment,  or that it  may be converted into  a
fluid to answer some purpose in the animal economy.
  We find  that the quantity of blood conveyed,  and the
vessel conveying it, are  proportioned to the size of the

 * In the manuscript copy of this Volume I had employed the word formed ;
for, at the time  of writing it, I had neither heard nor read that the brain had
been regarded as a glandular organ.  I have since discovered that I have been
anticipated in many of my conjectures; firmly persuaded however  that many
diseases can be more successfully treated by regarding the brain as a gland than
by suffering our  practice  to be influenced by any other theory which has yet
been advanced concerning its functions, I again present them to the  public eye. 
40           The Functions of the Brain.
body which it is destined to nourish, or to the function
it has to perform.  Thus, the kidney has a much larger
artery distributed to it than is necessary merely for its
nourishment, but it is employed in converting a quantity
of blood into urine.  So it is with the brain.  The blood
which the carotid and vertebral arteries convey, is infi-
nitely greater than is necessary for its developement and
support; it is, therefore, fair to conclude, that it is des-
tined to answer some other purpose.
  Glands are the most vascular organs in the body; the
brain is the most vascular  of all organs ; for we are not
to judge of the vascularity  of a body by its redness on-
ly ; the division of the arterial branches  of the brain is
too minute to allow of the  passage  of the red particles
of the blood through them ; the absence therefore of
vessels containing red blood within  its medullary por-
tion, is to be considered as a mark of the extreme mi-
nuteness of their division.
  Having thus made it appear probable that the  brain
is by its structure calculated to perform the functions of
a gland,  and that it is furnished with a sufficient quan-
tity of blood for the purpose of conversion ;  I have sec-
ondly to endeavour to prove, that it does convert it into
a peculiar fluid.
  All the other glands  of  the  body convert the blood
sent to them into fluids.   To this  law of  the  animal
economy I do not know that there exists one exception.
Even the earthy  parts of bones are deposited in a state
of solution ;  they afterwards acquire their  solidity, ei-
ther by a chemical attraction which exists between their
particles, or by the removal of the fluid which held them
in a soluble state, by the absorbents.
  From  analogy, therefore, we are justified in conclud-
ing, that as  all the glands  of the body convert a  portion
of the blood propelled through them into fluids, that the
brain does the same. 
Tlie Functions of the Brain.           41
  I am next to investigate the nature and properties of
this fluid.
  That the fluid must be of the most subtle description
is demonstrated by the extreme minuteness « f the divis-
ion of the arteries of the brain.  It probably is the most
subtle of all fluids.   In many of its properties it resem-
bles  electric matter; its essential  difference seems  to
consist  in its being  endowed with the principle of vi-
tality.
  That it possesses this principle I trust I shall be able
to give  satisfactory reasons  for believing; it  is in the
first place necessary  to point  out the manner in which it
is distributed to every part of the body.
  All the glands of the body are furnished with excre-
tory ducts ; I do not think that even the spleen, thymus,
and thyroid glands,  form exceptions to this  law of the
animal economy.  Anatomists* in  their search after the
excretory ducts  of these glands,  appear to have disre-
garded the absorbent vessels as such.  The absorbent
vessels  are the excretory ducts of the absorbent glands;
they probably  perform the same office to the thymus and
thyroid  glands.   The thymus and thyroid glands are
perhaps nothing more than  modifications of absorbent
glands.
  That every gland  should be furnished with an excre-
tory duct is absolutely necessary for the preservation of
parts in a natural and healthy state ; the deposited fluid,
would, but for this provision, by its accumulation simply,
prove destructive to all organization.
  Equally destructive to the brain would be the accu-
mulation of the fluid which it forms, if it were not pro-
vided with excretory ducts.  These excretory ducts are
the nerves which proceed from it.
•  * I must beg leave to make an exception in favour of Mr. Thomas Shute, an
excellent anatomist in this City.  This gentleman has for several years, m his
leXres, expressed  his opinion that the absorbent vessels were the excretory
ducts of the spleen, and other glandular organs.
            6 
42
The Functions of the Brain.
  That the nerves are by their  structure admirably cal-
culated to conduct a subtle fluid, the  phenomena which
they exhibit upon the application  of the electric or gal-
vanic fluid, clearly demonstrate.
  In a manner precisely similar to that in which electric
matter passes along a metallic chain, I conceive the ner-
vous fluid to be conveyed by the nerves to every part
of the body, and to be expended in its preservation, and
in enabling it to  perform its various functions.  Those
parts of the  body, destitute of nervous fibre, are not ca-
pable Lof conveying  this fluid, neither do  they present
any greater  obstacle to its passage than the atmospheric
air  does to the transmission of electric matter along  a
wire.
  That this fluid possesses the principle  of vitality, is
also evidenced by the effects of electricity upon an ani-
mal recently killed.   So long as any of it  remains the
muscles will be  thrown into violent contractions; upon
its exhaustion, or  destruction, the further application of
electric stimulus produces  no sensible effect, although
the nerves remain in their structure unimpaired.
  This property, which electric matter possesses, of
exhausting or  destroying the nervous fluid, satisfactorily
explains the reason, why persons are so instantaneously
deprived of  their existence, when  struck with lightning.
Again,  the  rapid  decomposition of animal bodies  de-
stroyed by  lightning,  clearly  evinces, that they have
been entirely deprived of the principle upon which their
vitality and consequent ability to resist putrefaction de-
pended.
  The  necessity for the existence of such a fluid as I
have described,  will be readily admitted, if it be consid-
ered, that in the performance of all the motions of the
body, whether voluntary or involuntary, there must be
an expenditure of vital power ; unless therefore an or-
gan existed  capable of  furnishiug this vital  principle, 
The Functions of the Brain.           43
life would soon become extinct.   Who will say  that
the powers of life are not enfeebled, may not even be de-
stroyed by exertion ? who does not feel that they are in-
creased by occasional rest ? During the  active state  of
the body there is an expenditure of the vital power, in a
state of quiescence there is an accumulation of it.*
   One of the strongest proofs which can be adduced
that vitality does  depend upon the due performance  of
the functions of the  brain, is the debility which is al-
most  instantaneously brought on  when any accidental
circumstance  arises to interrupt them.  A robust man
in perfect health exposes  his head to  the  action  of a
tropical sun; he immediately falls upon the ground des-
titute of power  to raise himself again.   Unless speedy
relief be afforded him, all the functions of the body be-
come deranged, and a  rapid tendency  to  putrefaction
manifests  itself.  Take from the brain the superabund-
ance of blood which has been driven into  it by a copi-
ous bleeding from the arm or jugular vein ; it resumes
its functions,  and the man  recovers his strength,  with
almost as much rapidity as he was deprived of it.
   In order not to be misunderstood, I beg leave to state
that I consider the Tuber Annulare, Medulla Oblonga-
ta, and Medulla Spinalis,  to constitute  parts  of the
brain, f
   Having from strong analogy  endeavoured to shew
that the brain is a glandular organ ; that it forms a fluid
in which the living  principle resides, and that this fluid
is distributed to every part of the body through the me-
dium of the nerves,  it remains for me to offer an  expla-
nation of the manner in which it  forms the connecting
medium between the soul and the body.

  * Darwin's Zoonomia.      fe
  t The nervous ganglia are perhaps reservoirs in which the nervous fluid accu-
mulates, and passes off, as occasion requires. But for the existence of such an
apparatus it would be difficult to account for the sudden and almost irresistible
force which maniac* or persons under some mental affections sometimes exert. 
44           The Functions of the Brain.

  Of the properties of the soul, or of the peculiar manner
in which it is united to the body, we must ever remain
ignorant; it is however impossible to conceive that so
pure a spirit as it unquestionably is,  a spirit emanating
from the bosom of the Deity, can form  an intimate un-
ion, or  come in immediate contact  with gross animal
fibre.  It is much more  probable that it is connected
with it through the medium of some subtle fluid.  That
the nervous fluid in which the living principle resides,
approaches nearer  in  its  properties to those of the soul
than any other is also  extremely probable ; to me there-
fore it seems  to be best calculated  for conveying im-
pressions made upon the body by external objects to the
soul.
  Suppose an irritating substance applied to any part
of the body ;  the consequence is an exhaustion or pass-
ing off of a quantity of nervous fluid.   The expenditure
of this fluid makes an  impression upon the soul and pro-
duces that  sensation  which  we denominate  conscious-
ness.
  The soul resides not in the brain only, but pervades
every part of the body ;  it is however most intimately
connected with the nervous system, through the medi-
um of the nervous fluid.
  The soul  with  its  appendage, the nervous  system,
may  be aptly compared  to a  spider upon  its web.
Touch the web ever  so lightly the animal is conscious
of it; make an impression upon  a nerve, a quantity  of
fluid passes off; by the escape of the  fluid the soul is
informed that an impression has been made.
  Place a person  upon  an insulated stool  and charge
him from an electrical machine; he is unconscious  of
the presence of electric matter till something which has
an  attraction for it is  brought in  contact  with his body.
We are all charged with nervous fluid, and should re-
main unconscious of its  existence, if external objects 
              The functions of the brain.           45

did not, when brought in contact with it, occasion its
partial expenditure.
  I am fully aware that many objections may be urged
against this theory ; it is impossible for me to anticipate
them all.   When they are  brought forward, I shall, at
some  future  period, feel  great  pleasure  in answering
them, or in admitting of their validity  if they appear
unanswerable.
  Throughout the whole of this dissertation upon the
functions  of the brain, I have  studiously avoided em-
ploying the word secretion.  This term  has  probably
led many to form an  inaccurate  conception of the func-
tion of glands.
  The glands do not  separate their fluids  from the gen-
eral mass of blood as the term secretion implies, but
they convert it into fluids possessing distinct properties.
The same blood which in passing through the kidney
was converted into urine, would, if  it had been sent to
some other organ, have been converted into the fluid pe-
culiar to that organ.   The emulgent and spermatic arte-
ries arise nearly together from the aorta;  the  blood
which they  receive  must  therefore possess  the same
properties, but the living principle resident in each gland
changes  it, not in its elementary principles, but in its
sensible properties.   The  gland is  merely the instru-
ment  by means of which the living principle  is enabled
to effect its purposes.   Let the deadly nightshade  and
the succulent endive  be planted in  the same  soil and
their roots nurtured by the same water.   The former
will convert the w ater into a deadly poison,  the latter
into a  nutritious juice.  Will it  be said that  the night-
shade separates  the poison from  the fluid with which
its roots are cherished ? Attaching to the terra secretion
the idea of conversion, I shall throughout this work em-
ploy the two words indiscriminately. 
           SECTION II.

ON DISEASES OF THE FAUCES, TRACHEA, &c.
                    CHAPTER I.

                    Ophthalmia.

  Rubor et dolor oculi; lucis intolerantia ; plerumque cum lachrymatione.
                CI. i. O. ii. G. viii. Cpli.kni.

  I have found nothing so  completely and effectually
relieve  inflammation of the  eyes as frequent scarifica-
tions.  Merely dividing the  enlarged vessels which are
ramifying upon the surface  of the eye-balls is not suffi-
cient ; the lancet must be  also passed freely over that
part of the tunica conjunctiva which is spread upon the
inner surfaces  of  the eyelids.   The operation can be
more easily  and effectually performed with a round lan-
cet than with the shoulder or point of the lancet in gen-
eral  use.  A small quantity of blood thus abstracted
from the eye and  eyelids will  be productive of much
more benefit than many  ounces  drawn from the temples
or parts in the proximity of the eyes by means of leech-
es.  The scarifications should be made daily, and after
the parts have ceased to bleed, the eyes should be kept
constantly moistened with an aqueous solution of opium.
From one to two  grains of  the extract  should be dis-
solved in an ounce of water.  It should either be appli-
ed cold, or made warm, as the feelings of the  patient
indicate.
   When with the  local  affection there exists pain in the
head,  symptomatic fever, &c. general  as well as local
depletion must  be employed.   In addition to bleeding
from the arm and brisk purgatives, an antiphlogistic regi-
men should be attended to,  and light must be  carefully
excluded from the eyes. 
Hentitio.
47
                    CHAPTER II.

                      Hentitio.

   There is no process which requires greater attention
than that of dentition,  as,  when disregarded, it often
lays the foundation for  diseases in their nature the most
formidable.  Among these, hydrocephalus internus, con-
vulsions, and tabes  mesenterica, hold the first rank;
symptomatic fever, a deranged state of the stomach and
bowels, eruptions upon  the head, face,  and neck, and
sometimes over the whole body, are next in order.
   As soon as swelling of the gums,  an undue degree  of
heat in the mouth, and  attendant symptoms of irritation
arise, we ought to employ every  means  we possess to
expedite and facilitate the progress of the teeth ; this is
more particularly necessary when there is reason to sus-
pect the existence of a scrophulous  diathesis in the in-
fant.  When treating of hydrocephalus  internus, I ob-
served "that I  had  uniformly seen  the disease  in
scrophulous subjects."   It arises  from  no  source  of
irritation more  frequently than from  painful and pro-
tracted dentition.
   Upon a free division of the gums we must chiefly rely
for the prevention or removal of the diseases to  which
the process  renders children liable.   In less  than  two
hours after  the operation, 1  have  frequently seen the
most violent symptoms  diminished, hydrocephalus in-
ternus arrested in its progress, convulsions cease, symp-
tomatic fever subside, and, in  a few  days, cutaneous
eruptions disappear.
   Even were there nothing to apprehend from allowing
the process to be completed by natural means, we should
be justified in lancing the gums, for we  thereby spare
the little  sufferers many painful, restless moments. The
pain which the instrument inflicts  in dividing the gums,
is trifling when compared with that  occasioned by con- 
48
Odontalgia.
 stant pressure  and distention from a tooth.   A gentle-
 man  declared  to  me that one of  the most  pleasurable
 sensations he ever experienced, was that which immedi-
 ately succeeded the division of the gum distended by a
 dens  sapientiae.
   In  performing the operation, care should be taken that
 the edge of  the instrument comes in contact with the
 teeth  or but little benefit will be derived.
   I have heard the  operation  objected  to, upon the
ground that when  the teeth are deeply seated, a hard
cicatrix will be formed over them,  which will be absorb-
ed with  more difficulty than the original gum; the re-
verse however happens.
   It is now I believe almost universally admitted,  that
the absorbents act with much greater facility upon parts
which have been deposited for the purpose of  repairing
a breach of continuity, than they do upon  parts origin-
ally formed.*  It is upon this principle that the opera-
tion is recommended.
                    CHAPTER HI.

                     Odontalgia.

  The toothach is sometimes permanently relieved by
the application  of the fumes  of henbane seed.   The
smoke may  be directed to the affected tooth by being
drawn through a tobacco pipe;  this method however
will upon some persons produce extreme nausea.   The
following process will be found more eligible and equal-
ly efficacious.
  Put from one to two drachms of the seed upon a  red
hot iron or some lighted cinders and  immediately cover
them over with a bason.   As  soon as you suppose the
  * A similar opinion is expressed by Mr. Fox, in his excellent Treatise on Dis-
eases of the Teeth.—See second edition, pages 86 and 87. 
Odontalgia.
49
seed to  be consumed  and the vessel impregnated with
the fumes ; place it upon its bottom and fill it with boil-
ing water.  The person affected with the  toothach is
then to  inhale the vapour for twenty  minutes or half an
hour, a  blanket or some other  covering being previous-
ly thrown over the head and shoulders to prevent its es-
cape.   It will be advisable  to go to bed immediately
afterwards, as it often induces profuse perspiration.
   Should this seed fail of producing its  desired effect,
if the tooth be much decayed, its extraction  ought to be
recommended ; if however  it has only a small foramen
in it, its removal will not be advisable.   By  simply ap-
plying the odontagra to it with some degree of force, a
force sufficient to effect a partial destruction  of its natu-
ral adhesions, but not violent enough to  remove it from
its alveolar processes, the tooth may be sometimes pre-
served  without ever again proving painful.  When the
pain induced by the operation has subsided, the hollow
should  be filled up by the Dentist.
   French bole finely levigated, forms the best dentrifice.
It may  be deprived of its disagreeable earthy taste by
having  a small quantity of the essential oil of cinnamon
added to it.   It  may be prevented  from dashing sur-
rounding objects and its powers  as a dentrifice increas-
ed by previously rubbing the brush dipped in warm wa-
ter upon  a square of Windsor soap.  Whether in the
summer or winter season the teeth should always be
washed with luke-warm water.
i 
50
Cynanche.
                    CHAPTER IV.

                      Cynanche.

Pyrexia aliquaudo lyphodes; rubor ct dolor  faucium;  deglutitio et spiratio
   difficiles, cum angustiue iu fy.ucibus sensu.—CI. i. O. ii. G. x. Ci'LLEM.

   Cynanche from  whatever cause proceeding is more
frequently aggravated  than relieved by  gargles.   The
force which the neighbouring muscles are obliged to ex-
ert to perform the process, often occasions great  pain
and  sometimes increases the inflammation.  The inhala-
tion  of the steam of hot vinegar or the gradual degluti-
tion  of small quantities of honey acidulated with muri-
atic  acid will be found  more effectual in allaying irrita-
tion or in giving tone to whatever parts may be in a  state
of relaxation.
   When suppuration has commenced in the tonsils the
steam of vinegar will  be peculiarly serviceable by ac-
celerating its progress.   As. soon as it is evident  that
pus  is formed, if the tonsils are much enlarged and de-
glutition or  respiration thereby impeded, we must not
wait for their bursting spontaneously, but pass a lancet
into  them, bearing in our recollection however the im-
portance of the parts* in their vicinity.
   In syphilitic  sore throats fumigations with  cinnabar
will  be found highly useful, particularly when the dis-
ease is extending itself with great rapidity.   If the su-
perior part of the soft palate be affected, advantage  w ill
sometimes be derived from drawing a weak solution of
muriate of mercury through the nostrils into the throat.
In this w ay  the lotion  will be applied to the  diseased
parts with a  greater degree of certainty.
* The internal carotid arteries pass very near the tonsils. 
                Pharyngis  Ulceratio.             -51

                    CHAPTER V.

                Pharyngis  Ulceratio.

                    CASE IX.

  Margaret Semay, aged 30 years, was admitted on
the 14th of December, 1814, with the usual symptoms
of Pneumonia.   For their relief she was bled, antimo-
nial medicines prescribed,  and a strict antiphlogistic
regimen enjoined.
  Under this treatment, persisted in for fourteen days,
she appeared to  be nearly recovered ; when she began
to complain of a disagreeable sensation about the throat,
attended with a disposition to cough, and a frequent dis-
charge  of  frothy mucus.  These symptoms gradually
became more urgent and distressing; a disagreeable
hoarseness succeeded, which sometimes was so great as
to prevent what she said from being understood ; at oth-
er times she could only whisper faintly and indistinctly.
  Difficulty in deglutition and respiration was next ex-
perienced ; deglutition occasioned much pain; the in-
halation and expulsion of the air, produced a peculiar
and disagreeable sound.  A sound  somewhat similar
may be feigned  by  drawing air quickly and forcibly
down the trachea, at the same  time contracting the glot-
tis, and making an effort to form the guttural sound
ur-r-rh-r.  Instead of this noise,  occasionally  an un-
pleasant whistling prevailed.
  These symptoms evidently pointed out a diminution,
from some cause, in the  capacity  of the glottis or tra-
chea ; while the incessant cough, copious expectoration
of frothy mucus, and pain felt upon handling or pressing
upon the sides of the thyroid cartilage, seemed to indi-
cate that ulceration  existed upon some  portion of the
membrane  lining the larynx.
  Upon inspection of the posterior parts of  the fauces 
52           '  Pharyngis  Ulceratio.
and pharynx, no trace  of disease could be discovered ;
but the difficulty and pain experienced in swallowing,
rendered it probable that some morbid change of struc-
ture existed out of sight.
  The patient remained in this state for twelve weeks,
when the powers of life rapidly declined.   Her pulse
became almost imperceptible;  respiration  laborious ;
deglutition nearly stopped.  In this state she continued
four days, when she suddenly threw up a large quantity
of blood from the lungs which threatened instant  suffo-
cation.   She expired within a few  hours  after this oc-
currence.
                   Examination.
  The appearances, which the parts exhibited upon dis-
section, afforded a satisfactory elucidation of the symp-
toms which existed during the life of the patient.
  In consequence of a thickening of the  membrane of
the larynx, the rima glottidis was considerably dimin-
ished in its diameter; this,  in addition to the smallest
trachea, I ever met with in  an adult,  will  explain the
cause of the difficulty which was experienced in respira-
tion.   The trachea Avas  not  larger than we generally
meet with it in a child of twelve years of age. The bron-
chia^ were proportionately small; they would not allow
of the introduction of the first joint of the little finger.
A full sized urethral bougie would  have passed with a
tolerable degree of facility. In a trachea so much small-
er than is ordinarily met with,  it is evident  that even a
slight diminution of its capacity  must be productive of
serious inconvenience.
   Just below  the arytenoid cartilages,  a considerable
degree of inflammation had existed. Marks  of increased
vascularity were very  apparent;  a redness extended it-
self for the distance of an inch and an half along the
posterior part of the trachea.  I shall have occasion again 
Pharyngis Ulceratio.             53
to notice this circumstance, when the disease which ex-
isted in the pharynx is described.
  At the anterior part of the pharynx, just below the
rima glottidis, a tumor in shape  and size resembling a
filbert, was  situated.  Its external surface,  or that part
looking towards the back of the  pharynx was smooth,
and it had the appearance of an  absorbent gland; that
portion of it (its basis) which was opposed to the ante-
rior part of  the pharynx was in a state  of ulceration.
By its  pressure it had  likewise  produced an ulceration
of the membrane of the pharynx  and the adjacent mus-
cles.
   This ulceration  extended for  a  considerable way
downwards, and by it an excavation had been effected,
which, had the patient lived a short time  longer, would
have formed  a communication  between  the pharynx,
larynx, and superior part of the trachea;  the membrane
spread upon those parts forming the only  barrier be-
tween  them.  This is the spot to which I  alluded as be-
ing in  an  inflamed state.  This  inflammation probably
induced the incessant cough with which this woman was
harrassed.
   The slight partition, which existed between the pha-
rynx and larynx, and  the superior parts  of  the trachea
and oesophagus, could not be discovered,  until a consid-
erable  quantity of curd-like scrophulous  matter had
been dislodged from the excavation.
   Several scrophulous tumours, about the size of large
glandular Pacchioni  were met with upon the inner sur-
face of the  oesophagus.  No disease  was found in the
lungs  or abdominal viscera. 
54
Laryngis  Ulceratio.
                   CHAPTER VI.

                Laryngis Ulceratio.

  This disease is of more frequent occurrence than is
generally suspected.   It is often mistaken for phthisis
pulmonalis; but the  peculiar hoarseness and the diffi-
culty of respiration with which it is attended, together
with an almost total exemption from hectic paroxysms,
are circumstances  which will enable us to distinguish
them from each  other.  Its precise nature will be best
elucidated by a narration of one or two cases.

                    CASE XII.

  William Birch, aged thirty-nine  years, was  several
times admitted into the Infirmary in the course  of three
years, labouring under symptoms of pneumonia.  These
symptoms were uniformly relieved by venesection, blis-
ters upon the chest, and low diet; he complained how-
ever of a " tickling sensation about the upper part of the
throat with a constant desire to cough," and his voice
gradually underwent  considerable alteration.   At first
it was only thick, but it became by degrees exceedingly
hoarse and disagreeable.
  At the last time of his admission, the symptoms were
the following.   Hoarseness, a harrassing and  almost
incessant cough, with a very copious expectoration of a
frothy mucus, in which purulent particles were  plenti-
fully interspersed; the expectorated fluid had some-
times rather the appearance of pus distended with min-
ute.air bubbles, than simple mucus.
  The pulse was  frequent and rather full; the tongue
generally white in its centre and florid at its edges ; the
uvula  was seen to be elongated; the back part of the
fauces  very red, and  the  tonsils somewhat  enlarged;
appetite and spirits good; no other feeling of indisposi- 
           Laryngis et Tracheae Ulceratio.         55

lion than that of lassitude, which a want of natural rest
induced; for during  the night the cough was so inces-
sant as  frequently to preclude sleep altogether.   The
body was much emaciated ; the skin was sometimes dry
and rather hot and the  cheeks a little flushed, but he
never perspired profusely.  He continued in this  state
four months when the powers of life became utterly ex-
hausted.
                   Examination.
  A diminution existed in the superior aperture of the
larynx, and its membrane was thickened and vascular;
more particularly about the edges of an ulcer, by which
one of the arytenoid cartilages had been completely de-
stroyed, and a large portion of the other removed. There
were no marks of disease in the trachea, and as the  ul-
ceration within the larynx so  satisfactorily accounted
for the  symptoms  which  had existed  during  life, the
lungs were not examined; from having however  in-
spected several similar  cases in which no disease  of
those  organs existed, I am inclined to  believe that in
this case they were but little, if at all affected.
                   CHAPTER VII.

           Laryngis et Tracheae Ulceratio.

                   case xni.

  Sarah Hopkins, aged nineteen  years, was admitted
on the 2nd of June, 1814, affected with difficult respira-
tion accompanied  by a peculiar noise  in the trachea
somewhat resembling croup; a  cough; and a soreness
of the throat.  Upon inspection  of  the fauces the uvula.
was observed to be elongated and the tonsils enlarged.
She exhibited no marks of constitutional disease nor of 
56         Laryngis et Tracheae Ulceratio.

debility ; her pulse was perfectly natural, and she was
entirely free from pain in the chest.  According  to her
own account,  she had been in the state above described
three months.
                     Treatment.
  Twelve ounces of blood were  taken from the  arm ;
a blister applied to the chest; a saline antimonial mix-
ture taken  every  six hours ;  and a lohoc whenever the
cough was  troublesome.
  June 4th. The same difficulty of respiration ; bowels
confined.   A cathartic powder was ordered to be  taken
immediately; and twenty  drops  of  tincture  of opium
mixed with forty drops of tartarized antimonial wine at
bed time.
  Early in the morning of the 5th, she  died suddenly.
Her breathing had become more laborious the preceding
evening.
                    Examination.
  The rima glottidis was very much contracted and the
epiglottis abraded upon its sides and concave surface.
  An ulcerated surface commencing at the superior and
posterior part of the larynx extended downwards to  a
small distance below the ventricles of Gralen.
  The trachea was filled with purulent matter.   Upon
this being sponged away, an extensive and deep ulcera-
tion was discovered upon its  posterior part, about half
an inch below the inferior aperture of the larynx. About
a quarter  of an inch below this,  upon the anterior part
of the membrane another ulcer was situated.  This ulcer
spread  in a circular direction and nearly embraced the
whole circumference of the  trachea for the space of the
third of an inch.   In short the whole surface of the tra-
chea was more or less destroyed by the disease, to with-
in about half an inch of its division into  the bronchia^.
Upon this  small portion there were slight traces of in- 
Laryngis et Tracheae Ulceratio.        -57
 flammation, and its follicular structure was very appa-
 rent.
   The membrane lining the bronchia was highly vascu-
 lar, but no disease  existed in the  lungs, heart,  or ab-
 dominal viscera.

                      Remarks.
   Every case of ulcerated pharynx, larynx, and trachea,
 which has fallen under my observation, has  terminated
 fatally, and I feel myself incapable of suggesting any
 perfectly satisfactory or  successful mode of treatment;
 I suspect however that much time is  lost in  having re-
 course to constitutional remedies,  instead of regarding
 it as a local affection.
   The disease is extremely insidious in its  approaches
 and progress,  and will often commit extensive  and ir-
 remediable ravages before its existence or nature can be
 ascertained.
  From the frequent application of blisters along the
 larynx, trachea, and parts adjacent, some advantage will
 be derived ; blood ought also to be often drawn from the
 same parts  by means  of leeches.  I have  never seen
 much benefit result from  the inhalation of any vapour.
 In Birch's case, which was suspected to have a syphil-
 itic origin, mercury was exhibited and the fumes of  cin-
 nabar  inhaled.   Where such a  suspicion  exists, no
 doubt can arise as to the propriety of this practice.
  Query ?  Would it be  advisable to  make an opening
 into the trachea or  larynx, and apply such  substances
 to the ulcer as would  have the effect  of  exciting  a
 healthy action upon its surface ? I have seen several ul-
 cers upon the surface of the body, bearing a very strong
resemblance to ulcers of the larynx, cured  by one or two
 applications of nitrated silver.
  That this is a hazardous operation,  I am ready to
admit, but perhaps the fatality of the disease fully justi-
fies its being resorted to.   Ample experience has shewn
            8 
58
Bronchitis.
that, if the disease be left to itself, or combated only by
internal remedies, it will uniformly prove, sooner or la-
ter, fatal.
  There are many chronic affections, which, to be con-
ducted to a happy termination, require as prompt and
active assistance as the most acute.  Until professional
men arouse themselves from that apathy  with which
they too frequently  contemplate danger at a  distance,
the practice of medicine will be unsatisfactory  and inef-
ficient, and  many valuable lives will be sacrificed to
their supineness.
                  CHAPTER VIII.

                    Bronchitis.

                   CASE  XIV.

  George Carter, aged forty years, on  the  6th of
December, 1813, from exposure to great heat in a sugar-
house, to which he was not accustomed, and afterwards
going into the open air, was attacked with what seemed
to be  symptoms  of pneumonia.   These  symptoms be-
coming daily more severe, he was compelled to  relin-
quish his occupation, and on the 20th of the same month
applied for relief.
  Upon his admission, he laboured under the following
symptoms :
  Great pain in the chest, and  about the  scrobiculus
cordis ; dyspnoea; an inability to lie on  either side, or
on the back; he could only remain in bed in an upright
posture, or while resting his head upon his  hands  and
knees, with  the  trunk bent forwards ; he had a violent
cough, and spat a quantity  of mucus, of  a purulent
appearance ; he  passed but  little urine, the pulse was
extremely rapid and  full, and his countenance indica-
tive of effusion into the thorax. 
Bronchitis.                  59
  Dec. 23. On the 21st and22dhe  was bled, and from
sixteen to twenty ounces of blood taken away at each op-
eration ;  a blister was also applied to the chest; purga-
tives administered ; six drops of the tincture of digitalis
taken three times a day, and a lohoc to relieve the cough.
The blood exhibited no buffy appearance.
  He found but little benefit from  this  treatment, the
symptoms  continued nearly  as violent, and he  was
obliged to sit in a chair through the night, as in  a re-
cumbent posture he was threatened with suftbcation;  so
laborious and difficult was his respiration.  Pulse 130,
but not so full; tongue white.
   He was directed to take one grain of calomel and two
grains of powdered squills at bedtime, and eight drops
of the tincture of digitalis every eight hours.
   Dec. 24th.  Felt fatigued last night and desired to go
to bed;  he expired  very  shortly  afterwards, and was
found lying on his side.
                    Examination.
   On opening the chest, the lungs with  the other thora-
cic viscera, presented externally a most healthy appear-
ance ; the pleura costalis and pulmonalis had no  in-
flammatory appearance; no adhesions were formed, nor
was there any effusion into the cavity of the chest.  The
structure of the lungs, when examined by the hand felt
natural.
   The pericardium  contained about an ounce of fluid of
 a red tint; no peculiarity existed either  in the structure
 of the pericardium or heart.  The liver, with the chy-
lopoietic and other  assistant chylopoietic viscera, pre
 sented every mark of health.
   The symptoms which existed previous to dissolution
making  this appear  remarkable,  an investigation of  the
 internal lining of the trachea, bronchise, and their rami-
fications was instituted.  Their membrane was found to
 be inflamed to a high degree ; a purulent secretion had 
60
Bronchitis.
 been the consequence  of this  inflammation,  and the
 bronchial were filled with the fluid.  Throughout  all
 their ramifications which could be traced, the same ap-
 pearances were met with.
   That this pus was thrown out from the membrane of
 the Bronchia  is evident, as there  was not the slightest
 vestige of ah abscess in the substance of the lungs.
                    Observations.
   There  is no disease  to which  the lungs are liable,
 more formidable in its appearance, or dangerous in its
 nature than bronchitis.   To treat it successfully,  we
must attack it in its earliest stages with the lancet.  We
 ought not to be satisfied with the abstraction of sixteen
 or twenty ounces of  blood in the course of  twenty-four
 hours ; we must take away thirty, forty, fifty,  or even
 more, if the patient be not relieved.
   The patient whose case is above related, had labour-
 ed under  the  malady fourteen days before he applied
for medical assistance ;  it was then fully formed;  effu-
 sion into the bronchise had taken place.  Venesection,
or any other remedy could avail but little.
   In addition  to general depletion, a great number  of
leeches ought  to be applied along the course of the tra-
chea, but  more particularly in the vicinity of its bifurca-
tion.  Blisters, an antiphlogistic regimen, &c. are  indi-
 cated, but nothing  is to be relied upon except the copious
general, and local evacuation of blood.
   The disease,  in its latter stages, may be sometimes
mistaken for hydrothorax, but the expectoration of pur-
ulent matter,  together with the inflammatory diathesis,- ,l
 which, even in its latter stages  prevails, constitute^ a   ^
 striking difference.
   Delirium  is frequently  a symptom  attendant  upon
 bronchitis. 
Haemoptysis.                  61
                    CHAPTER IX.

                    Haemoptysis.

  Genarum rubor; molestiae aut doloris, et aliquando caloris, in pectore sensu?;
dyspncea; titillatio faucium; tusis aut tussicula sangumeum floridnm saepe spu
mosum rejiciens.—CI. i. O. iv. G. xxxvii. Culleni.

  The propriety of venesection in this disease has been
disputed by some medical writers.   I know of no other
remedy upon which we can rely ;  of nothing which so
effectually restrains the hemorrhage, lessens the force of
the circulation, or prevents the disease from terminating
in phthisis.
  We are  often reduced to  the  alternative of taking
blood from the arm,  or of allowing it to rush from the
lungs.  Which mode I would enquire is attended with
the greater hazard and inconvenience to  the patient ?
  After proper bleeding, digitalis may be sometimes ad-
vantageously exhibited;  I must confess, however, that
this medicine is not a favourite article with me.  I have
certainly seen it of service ; but in my opinion the good
which has been derived  from it, bears no proportion to
the mischief it has produced.   Unless given in sufficient
doses to produce its specific effects, it frequently increas-
es the force of the pulse  and the rapidity of the circula-
tion ; if administered in quantities large enough to bring
the system under its influence, it will sometimes, in spite
of all our vigilance, destroy life.   I could  instance ma-
ny cases of its deleterious and even fatal effects ; one or
two shall suffice.

                     CASE  XV.

   A woman, twenty two years, of age, labouring under
symptoms of acute pneumonia,  and a supposed effusion
into the cavity of the thorax,  after a moderate bleeding,
was  directed to  take half an ounce of the infusion of 
62
Haemoptysis.
digitalis every six hours. She took three doses and died
at the end of twenty four hours in the act of raising her-
self from the pillow.  Upon dissection, traces of inflam-
mation were found within the lungs, and upon the pleu-
ra, but they were not at all sufficient to account for the
death of the patient.   No effusion into the thoracic cav-
ity had taken place.
  The inner coat of the stomach was free from any pe-
culiar or diseased appearance.  All the abdominal vis-
cera were perfectly sound.

                    CASE XVI.

  A man, aged twenty three years, was affected with
excessive pain in the right  hip joint, attended  with a
high degree of symptomatic fever.  Twenty-five  ounces
of blood were taken from the arm, and some leeches ap-
plied over the inflamed joint.  The blood  upon separa-
tion exhibited upon the surface of its crassamentum a
thick  inflammatory  crust;  its serum  was  beautifully
transparent.
   On the following day, the pulse continuing strong
and rapid, he was directed  to take half an ounce of the
infusion of digitalis every six hours.   He took this
quantity only four times  before an intermission in his
pulse became very evident,  and he complained of slight
vertigo.  He was desired to discontinue  the  medicine
and keep in bed.  At the end of twelve hours from this
time ; a nurse came and informed  me of his  dissolution.
   All the thoracic and abdominal viscera were free from
 disease.  The hip-joint was not examined.
   These are the only cases  in which I have  seen digita-
 lis act as a  direct poison,  and prove rapidly fatal; I
 could  however cite others  in which it  destroyed after
 being continued for a longer period; and many, very
 many, in which the patients narrowly escaped.
    Even in several of the cases in which I have seen it 
                    Haemoptysis.                  63

of service, I feel persuaded that milder and less danger-
ous medicines would have been equally beneficial.   I
have to add that I have seen it given in large  doses  for
a great length of time without its producing the slightest
effect.
   I will briefly recapitulate my objections to the medi-
cinal employment of this plant.
   Upon some persons it acts as a powerful and deadly
poison ; but upon what peculiarities of constitution this
depends, we are at present ignorant.
   If not given in sufficient quantity to produce its spe-
cific effects, it frequently increases the inflammatory  di-
athesis.
   When the habit is once brought under its influence, it
will continue for aiv indefinite period.
   Should the effect produced be  too powerful, we  are
without ability to moderate it.
   The life of a man under  the  influence of this  medi-
©ine, is in perpetual jeopardy ; the incautious  or acci-
dental elevation of his body may destroy him.
   It may sometimes be given to a  great extent before it
produces any effect; its presence will then be suddenly
manifested, and perhaps so powerfully as to extinguish
the vital spark.
   Lastly, I object to digitalis,  because I firmly believe
that  all its beneficial effects may be derived from less
powerful and less dangerous ingredients ; among these
I number ipecacuanha, squills, and tartarized antimo-
ny, given in nauseating doses.
   I hope the importance of the  subject will be accepted
as an  apology  for this long digression.  I should  not
have acted conscientiously  if I  had not entered my pro-
test against the incautious, indiscriminate, or fashiona-
ble exhibition of a medicine, which has hurried thou-
sands to their graves.
   Digitalis ought  only to be prescribed  in ca«es of ex-
treme danger. 
64
Haemoptysis.
   To return to the treatment of Haemoptysis.  Bleeding
 is our sheet anchor; we must from time to time recur to
 it, so long as sanguineous expectoration, or an inflamma*
 tory diathesis prevails.
   The best time for taking away blood is towards even-
 ing, more particularly if a tendency to evening exacer-
 bations can be observed.  The patient must be enjoined
 absolute exemption from personal exertion, and rigid
 abstinence from  stimulating  liquors, or highly nutritive
 food.   Cool air must be admitted into his apartment,
 and cool acidulated fluids freely allowed.
  A small quantity of syrup of opium, or  white poppies,
 held in the mouth  for  a length of time, and swallowed
 very gradually,  will allay irritation at the upper part of
 the trachea, and a disposition to  cough more effectually
 than  if it be immediately received  into the stomach.
 The infusion of roses, strongly acidulated may be taken
 every three or four hours, and  twice  or  three times a
 day, from half a grain  to a grain of the acetate of lead.
 Independently of the  styptic property which the lead
 possesses, it will sometimes materially diminish the fre-
 quency of the pulse.
  Whether or not pain be felt in the chest, a blister may
 be advantageously applied to the sternum.
  If this plan, persisted in for a few days, does not suc-
 ceed, full vomiting should be induced with ipecacuanha,
 and afterwards  a  constant  state of nausea should be
 kept up with small doses of the  same root, with emetic
 tartar,  or  with,  what will in  some cases  be found more
 serviceable,  a combination of  squills and  antimonial
 powder.  With  these remedies, aided  by occasional
venesection, haemoptysis may be generally conducted to
 a happy termination, provided a strong predisposition to
 phthisis does not exist.
  I have sometimes seen benefit derived from keeping a
 piece of sulphate of  aluinine  constantly  in the mouth. 
Phthisis Pulmonalis.              65
It would appear that the astringent effects of the  alum
upon the fauces  are continued along the membrane of
the trachea ; whether directly or sympathetically is not
very evident.  Upon the same principle we must account
for the relief obtained by  the gradual deglutition of the
syrup of opium.
                     CHAPTER X.

                 Phthisis Pulmonalis.

  C orporis emaciatio et debilitas, cum tussi, febre hectica, et plerumque expec-
toratione purulenta.—CI. i. O. iv. G. xxxvii. Culleni.

   Phthisis, in. this infirmary,  almost uniformly proves
fatal.  Some few cases, indeed, of supposed phthisis re-
cover, in which even hectic paroxysms and the expecto-
ration of pus are  present; but these symptoms are not to
be considered as  decisive of the character of the disease.
An expectoration of pus may, and often does occur where
there is no derangement in the structure of the lungs.—
In the case last related the secretion of a  large quantity
of pus from the surface of the bronchia was pointed out;
a less active secretion is often mistaken for phthisis.
   In cases  of  this description,  moderate  venesection,
emetics, the judicious administration of opium, an anti-
phlogistic regimen, change of  air, and more especially a
sea voyage,  sometimes preserve the patient; but where
scrophulous abscesses or tubercles have formed, the dis-
ease is, and it is much to be apprehended, ever will re-
main without a  remedy.  I think it will  be found that,
however sanguine a man's expectation of curing it may
be, the deliberate examination of the lungs of a few con-
sumptive patients,  will thoroughly  convince him of its
entire impracticability ; that  the ravages committed are
of such a'description as neither nature nor  art can repair.
            9 
66
Phthisis Pulmonalis.
   The structure and functions  of  the  lungs  oppose to
 the  recovery of phthisical  patients impediments truly
formidable.  What can be conceived greater obstacles
to the  healing process, than the constant motion or dis-
tention of a diseased part, exposed to  innumerable vi-
cissitudes of temperature, and in actual  contact with at-
mospheric air ?
   When cartilage upon the extremities  of  bones is de-
stroyed, its place is sometimes supplied by a deposition
of earthy particles, but cartilaginous  matter is rarely if
ever reproduced ; in fact a constitutional  power to form
it anew does not exist.*   The lungs contain a vast pro-
portion of cartilaginous matter ; to the destruction  of
this matter, the almost uniform fatality of the disease is
in a great measure to be ascribed.
   Can any reasonable man  believe that he  can by the
exhibition of a few grains of digitalis, or a few grains of
any  vegetable or mineral production, impart a power to
the animal machine of which it is destitute  ab origine f
or that with such  feeble instruments he  can effectually
oppose the destructive processes which have been estab-
lished  ? As well  might  he  pretend to  hush the whirl-
wind,  or u direct the storm."
   My professional Brethren, let us no longer  deceive
mankind ; let us candidly acknowledge that there  are
diseases which cannot be cured.  Were  this generous
confession universally made, the world would more ear-
nestly  adopt preventive measures. So long as we promul-
gate opposite doctrines,  we are no  better than empirics  ;
we are destitute of honor, of humanity.*   Rather would
1 be  exposed to the chances of war, pestilence and fam-
ine,  than become the subject of phthisis pulmonalis.

  * Perhaps it ought rather to be said, that the vessels capable of forming carti-
lage being destroyed, there does not appear to be a power in the constitution ca-
pable  of re-producing those vessels.
  t Empiricism and falsehood if not twin-brothers are certainly very nearly allied. 
Pneumonia.
67
                      CHAPTER XI.

                       Pneumonia.

  Pyrexia; dolor in qnadam thoracis parte ; respiratio difficilis; tussis.
  Species sunt,
  1. Pneumonia ("peripneumonia) pulsu non semper duro, aliquando molli;
dolore thoracis obtuso ; respiratione perpetuo difficili, ssepe  non nisi trunco cor-
poris erecto exercenda; faciei tumidae colore purpureo ; tussi plerumque humi-
da, saepe cruenta.
  2. Pneumonia (pleuritis) pulso duro ; dolore, plerumque lateris, pungente, sub
inspiration^ praesertim aucto ; decubitu in latus molesto ; tussi dolentissima, ini-
tio sicca, postea humida, saepe cruenta.—CI. i. O. ii. G. xi.  Culleni.

   The  necessity for  an immediate and free evacuation
of the blood in  pneumonia,  is now almost universally
admitted ; the manner in which  the process  is conduct-
ed, however, not unfrequently aggravates  the disease.
   In inflammation of the lungs it is for the most part ne-
cessary, not only to diminish the force of  the heart and
arteries, but likewise  to lessen considerably the quanti-
ty of blood circulating in the system.   Our endeavours
are often frustrated by following the directions usually
given.
  We are told that  to induce the full effects of venesec-
tion,  we must bleed from a large orifice ;  there is how-
ever reason  to suspect, that this opinion is erroneous.
  A  physician  desires  sixteen  or eighteen  ounces of
blood  to  be  taken  pleno rivo.   The  consequence fre-
quently is, that the patient faints before  two  thirds of
the quantity directed,  aie  evacuated; the  physician,
satisfied with having reduced the  force of the circulation,
leaves  his patient for  twelve,  sixteen, or twenty-four
hours.
  By  such  a mode of proceeding the disease will  be
rendered more formidable.   Just  enough blood  is  re-
moved to relieve the vessels from that state of over-dis-
tention by which their force and activity was restrained,
and their ability to  do mischief in a great measure pre 
68
Pleuritis.
 vented.   The temporary debility induced by the opera-
 tion is soon recovered from; the  vessels  speedily ac-
 commodate themselves to their contents;  when, freed
 from their previous state of distention, they are enabled
 to act with a degree of violence which, in the course of
 a few hours, often proves destructive to the organization
 of the lungs, and lays the foundation for imposthume or
 effusion.
   It has already been stated that, in pneumonia, it is
 peculiarly desirable to lessen considerably the volume
 of blood, as well as to diminish the  rapidity of its cir-
 culation.   By inducing  syncope  by the abstraction of
 blood from a small orifice, both these objects are with
 facility accomplished.  It will be  found that this is the
 most effectual way of arresting the progress of all active
 inflammatory  diseases, more particularly if it be resort-
 ed to in their  early stages.  By it, decided and perma-
 nent relief will be obtained, and the necessity for such
 repeated venesection as is often demanded when an op-
 posite line of practice is adopted, in a great measure ob-
 viated.
   Debilitated persons are occasionally the subjects of
 inflammatory  affections.   It  can  scarcely be necessary
 to observe, that the practice here recommended  is not
 adapted to them ; it is only calculated for  the vigorous
 and plethoric.
   In weak habits, we may advantageously abstract a
 small quantity of blood  from a large orifice.   In con-
junction with  venesection, an antiphlogistic regimen, &c.
 is of course to be enjoined.
  Pleuritis  requires the same treatment as pneumo-
 nia ; in this form of the disease, however, the  applica-
 tion of leeches and blisters to the chest will be attended
 with more advantage than in simple inflammation of the
 lungs. 
Empyema.                   69
                    CHAPTER XII.

                      Empyema.

  Post pneumoniam suppuratione terminatam, saepe post vomicam, femissio do-
loris, dum perstant dyspnoea, tussis, decubitus difficilis, et febris hectica, saepe
cum sensu hquoris in pectore fluctuantis, et signis nydrothoracis.—CI. i. O. ii. G.
xii. Culleni.

                    CASE  XVII.

  John Naish, aged thirty-seven years, by trade a car-
penter, related that, about August, 1812, while  in the
pursuit of his daily avocations, he was almost instanta-
neously seized with lassitude, coldness of the extremi-
ties, and rigors of the trunk, which, in a few hours were
succeeded by a preternatural degree of heat.   A cough,
which he had considered as trivial, became  now more
violent, and was attended with a copious expectoration.
His nights,  for the most part, were restless, his extremi-
ties feeling  generally  cold,  and his body being covered
wtth a profuse and clammy perspiration.  His diet was
strictly antiphlogistic, and he persevered in  the  use  of
such medicines  as the practitioner prescribed for him,
until he was informed that  medicine  was superfluous,
there being no chance of recovery.
  Thus abandoned,  he  resolved to go into the country
and try a change of air.   By  this change he regained
his health so rapidly, that at the expiration of six months
from the  commencement of  the attack, he was enabled
to return to  his labour.   During these six months  he ex-
perienced no pain in the thorax, but from the commence-
ment, a sensation of weight and occasionally  some diffi-
culty of breathing.   The cough continued troublesome
until he went into the country, when it gradually de-
creased.  He continued uninterruptedly in the pursuit
of his daily labours for four months, at  the  expiration
of which time, symptoms  exactly similar  to those al-
ready described,  again  affected him,  with these  differ- 
70
Empyema.
ences only; that the cough was more troublesome, and
the expectoration less copious.  After five months from
the commencement of this second attack, with the ex-
ception of a slight  cough, he  found himself once more
restored to health.   He again renewed his trade, and
followed it to the commencement of May, 1814,  when
he was  visited  by  a third  attack,  much more violent
than those which preceded it.  He now, also, felt con-
siderable pain in the left side, and oppression at the
scrobiculus cordis.   Little  variation in the  symptoms
occurred during this month.
  Early in June he discovered, upon moving  his body
backwards and forwards, a fluctuation of something in
the left side of his chest, which daily became more evi-
dent and ascended  upwards,  until it could  be distin-
guished above the clavicle. An enlargement of the left
side of the thorax  next  took  place, and the fluid  sub
sided,
  On the  17th of October,  he became a patient  at thi.»
Infirmary.  The symptoms of disease which were at
this time  present,  were the following.   A troublesome
cough ; difficult breathing; little expectoration ; an evi-
dent fluctuation of fluid in the left  side of the thorax.
The noise produced when  the fluid struck against the
parietes of the chest, could be heard at a considerable
distance.  To the  feeling, it conveyed  the idea, not of
an agi tuted watery  fluid, but of a thick  oleaginous mat-
ter, shaken  in a cask partly  empty.  When  he lay on
the side  affected,  a palpitation of the heart ensued;
when lie elevated the left  arm he experienced great pain
in that side; his pulse was rather  full and accelerated ;
his nights were rendered restless by  the  cough; his
right  shoulder  was evidently higher than the left; on
striking the diseased side with the hand, it sounded
heavily  and obscurely.   He was someAvhat emaciated,
but his countenance had a healthy aspect; his constitu-
te :;n seemed to be but little impaired. 
Empyema.
71
   26th.  This day in consultation the Physicians and
 Surgeons of the House determined upon evacuating the
 fluid.  Since his  admission no  alteration had taken
 place in  the symptoms.
   29th.  An  incision was made between the sixth and
 seventh ribs ; a female catheter passed into the wound,
 and thirty-six ounces of imperfectly formed pus, slightly
 tinged with blood,  evacuated.  As the pus passed off,
 his breathing was relieved.  Immediately after the ope-
 ration, his pulse was weak, but in the course of an hour,
 became tolerably good; he felt no pain in the chest;
 the edges of the  wound  were dressed with adhesive
 plaister.
   30th.  He passed a tolerably comfortable night; pulse
 rather full, and eighty-six in a minute ;  tongue white ;
 bowels not relieved since the operation ; breathing con-
 tinued free ;  did not complain of any pain in the chest.
   31st. Pulse  good; tongue not  so  white; bowels re-
 lieved ; slept well; had  no pain  in the chest, except
 when he coughed.   There  still  remained  an  evident
 fluctuation.
   November 4th. The fluctuation could still be distin
 guished.
   8th. The  pulse full  and frequent;  tongue  white;
 bowels open ; had some  degree of heat on the surface ;
 his breathing was more difficult.
   Five o'clock, P. M. A pint of fluid was discharged
 from the wound, which greatly relieved him.
   9th. Nine o'clock, A. M.  About one pint and a half
 of fluid was evacuated; fluctuation still evident.  Two
 flakes of coagulable lymph passed through the wound.
   10th. At eleven  o'clock,  P. M.  The wound  burst
 open and discharged twenty-four ounces of pus.
   11th. No fluctuation  perceptible; his breathing re-
lieved materially.
   13th. No fluctuation evident: about four ounces of 
72                  Empyema.

matter evacuated in the course of twenty-four hours; no
disposition in  the  wound to heal; general health not
much affected.
  17th.  Large flakes of coagulated lymph continually
escaped ; when he rested on the right side, air passed
through the wound.
  22nd. Pulse full and frequent; breathing excessively
laborious ; he complained of pain in the chest,  and had
hectic flushes.
  Twelve ounces of blood were taken from the arm.
  December 6th.  The quantity of fluid lessened.
  18th. The fluid discharged, varied in  quantity, from
two to five ounces daily.
  23rd. He progressively improved; the discharge from
the side lessened ; he slept well at night, and  was free
from pain.
  25th. No fluctuation evident.
  February 19th.  Throughout the month of January
to the present day, he appeared to be convalescent;
when on the evening he expectorated about two ounces
of blood combined with pus.   The pulse being  rather
full and somewhat accelerated, ten ounces of blood were
taken from the  arm.   He expired half an hour after-
wards.
                   Examination.
   Upon examining the thorax, the following appearan-
ces presented  themselves.  The costal and pulmonary
pleura, on the left side, were much thickened, and their
surfaces covered with a purulent secretion.  They form-
ed the sac in which the fluid had been contained.  The
left lung was diminished in size, flattened, and so much
compressed as to have become perfectly useless.
   Upon its anterior surface, a foramen as large as a six-
pence, was situated.  This opening had communication
 with an abscess of considerable magnitude, and this ab-
 scess with the left bronchia.   A bougie could be readily 
Empyema.                  73
passed from the bronchia into the chest, or from the chest
into the bronchia.   This circumstance satisfactorily ac-
counted for the passage of air through the wound in the
side, during the life of the patient.   In the cavity of the
chest, about three ounces of imperfectly formed pus were
met with.  The right lung had formed a few inconsid-
erable adhesions, and had some tubercles here and there
scattered throughout its substance, but was not so much
diseased as in any respect to incapacitate it for perform-
ing its proper functions.   The heart was small, but free
from any morbid appearances.  A small quantity of fat
was situated  at its basis and apex.  The viscera of the
abdomen were all perfectly healthy.
                    Observations.
   I have found considerable  difficulty  in  compressing
this case ;  and even in its present abridged state, it will
perhaps appear tedious.   I was led into a narration of
it, from a desire to shew that a large quantity of fluid
may from time to time be removed  from  the thoracic
cavity, not only with  perfect safety  to the patient, but
without  interfering  in  the slightest degree with the ac-
tion of the heart.  The dread of inducing a fatal syn-
cope has, perhaps, deterred many from venturing  upon
paracentesis of the thorax, in this disease, as well as in
hydrothorax.
   Under several  disadvantageous circumstances,  the
operation, as far as it was concerned, fully  succeeded.
In the first place,  it was too long deferred ; the pus had
by its pressure, completely destroyed the organization
of the left lung; upon its removal the lung was incapa-
ble of expanding and filling up the space which  it had
occupied.  In spite of this obstacle to a perfect restora-
tion of parts  to  their natural state, the quantity of fluid
gradually diminished, and had for some days before the
death  of the patient entirely ceased.   Had the fluid been
evacuated at an earlier period, it is more than probable,
            10 
74                  Empyema.
that the lung would have expanded, and have come in
contact and formed  adhesions  with  the  costal pleura.
That an effort to establish such adhesions was made, is
evident from the quantity of coagulated lymph thrown
out.
  In the second place, an abscess situated at the root of
the lung had communication with the thorax; by which
air  was admitted, and formed another impediment to the
recovery of the patient.   I do not apprehend, however,
that much pus escaped from this abscess into the chest;
almost the  whole of it was probably secreted from the
surfaces of the pleura.
  It is difficult to account satisfactorily for the sudden
death of this man.  The quantity of blood ejected was
very small; it did not appear that it occasioned any in-
terruption  to the function of respiration.  The abscess
was probably a source of some irritation, but as the left
lung had for a length of time ceased to perform its office,
no  great degree of importance can  be  attached to it.
The right lung contained  some  tubercles, but  none  of
them were  in  a state of ulceration; the pulse, not half
an  hour before his death, was strong, full, and natural;
the body was  somewhat emaciated,  but the powers  of
the constitution were  not so much impaired as might be
supposed.   Just before his  dissolution, he appeared to
be the subject of incipient,  rather than of the last stage
of phtisis pulmonalis.
  I have seen one case of empyema in which an abscess
formed by  the side  of the inferior bones of the sternum ;
an  immense quantity of pus escaped  upon its bursting,
and the patient recovered.  Previous to this event the
action of the heart  and lungs was almost entirely sus-
pended and the patient seemed  to be  in articulo mortis. 
Hydrothorax.
75
                   CHAPTER XIII.

                    Hydrothorax.

  Dyspnoea; faciei pallor ; pedum oedemata ; urina parca ; decubitus difficilis;
subita et spontanea ex somno cum palpitatione excitatio ; aqua in pectore fluc-
tuans.—CI. iii. O. ii. G. lxxviii. Culleni.

   If  squills, digitalis, elaterium,  mercury, &c.  fail in
exciting an  absorption of the fluid in this  disease, the
subject of it is abandoned to his fate.  In ascites, where
no immediate necessity lor an operation exists, the tro-
car is unhesitatingly plunged into the abdomen, but, al-
though the water in the thorax threatens instant suffoca-
tion, an  attempt to relieve the patient, by making  an
opening into the thorax, is rarely resorted to.
   The case of empyema,  just  related,  satisfactorily
shews that the operation  may be performed with  perfect
safety ; let us examine then the  grounds upon which
professional men oppose it.
   In the first place,  it is objected that hydrothorax is
most frequently combined  with  some disease  of the
lungs, heart, or abdominal viscera; that an evacuation
of the fluid,  is therefore merely palliative.  Viewing it
only  in this light, I still  contend for the propriety of the
operation.   It often happens that  we are reduced to the
alternative  of allowing  the accumulated  water, by its
pressure, to destroy life; or, of  enabling the heart and
lungs to continue  their action for an indeterminate pe-
riod, by its evacuation.  That period may be, and  often
will  prove  short;  but the evacuation of the fluid  rescues
the patient  from the instant  danger, and affords us fur-
ther  opportunity of employing other remedies.
   The objection to the operation because it is  only pal-
liative applies equally to paracentesis of the abdomen ;
but hydrothorax is not always combined with  organic
affections.   I have met  with several cases in which  no
trace of disease either in the lungs, heart, or abdominal 
76
Hydrothorax.
viscera could be discovered, not even so much as an ad-
hesion between the opposed portions of the pleura.   In
these cases the accumulation of water was very  rapid,
and the patients died before the action of the absorbents
could be sufficiently increased to enable them to remove
the fluid.   My mind is forcibly impressed with the be-
lief that, had an opening been made into the thorax and
the water drawn off', these persons would have been
Saved.  So firmly convinced am I of it, that, if I were
labouring under the disease, I should earnestly request
and confidently submit to the operation.
   Secondly.  An objection is urged  against the opera-
tion, on account of the  uncertainty with which it is at-
tended.   To this I reply, that the symptoms of the dis-
ease, together with an attentive examination of the chest
in the manner directed  by Corvisart, will, for the most
part enable us to  determine  whether  or  not  water be
present, as well as the  point at which the opening may
be most advantageously made.
   Upon the sound produced by percussion of the chest,
we are not how ever  solely to form our judgment.  It
may, and  often does  happen, that extensive adhesions
between the lungs and the parietes of the thorax take
place.  If this be the case, an indistinct noise somewhat
similar to  that  emitted when water is present, will be
produced.
   Again ;  if the heart be very large, the left side of  the
chest will sound much  less than  the right, although the
latter may be full of fluid.  If the sound of this right side
were contrasted with the noise produced upon striking a
healthy chest, the existence of fluid would be manifest;
but by being compared with that  induced by striking
upon the side in which an enlarged heart is situated, an
erroneous conclusion may be drawn.
   One of the greatest obstacles to the free discharge of
the fluid arises from the adhesions which the lungs form 
Hydrothorax.                 77
with the ribs.  Those who have been in the habit of ex-
amining bodies, must have observed that these adhesions
are more universal at  the anterior than  at the posterior
part of the chest.   In hydrothoracic patients  more par-
ticularly, 1  have found that, after breaking them down
for a  short distance from the sternal extremities of the
ribs, my fingers have  come  in  immediate contact with
the surface of the water.   In order therefore to prevent
our attempts to evacuate the fluid from being frustrated
by any adhesions which  may exist, the opening should
be made in the posterior part of the thorax. As conven-
ient a point as any,  is probably between the sixth and
seventh ribs, about an inch and a half anterior to their
angles.  An opening in this situation will allow of the
ready escape of the fluid, whether the patient be placed
upon the back, or upon the side affected.
   Although I thus strenuously contend for the propriety
of an operation, I would not have it supposed that it is
to be performed before other means have been ineffectu-
ally employed.  The absorbents opening upon the sur-
faces of the pleura possess a considerable degree of ac-
tivity ; this activity may  be often  much  increased by
proper medicines.  Squills in nauseating doses will be
found serviceable; but elaterium, administered in suffi-
cient quantities to excite frequent, copious, and watery
evacuations from the intestines, will be found more ben-
eficial.  In the early  stages of the disease, venesection
will be, not merely proper, but indispensable.
  Although disapprobation of the indiscriminate exhibi
tion of digitalis was  so  unequivocally expressed, when
treating of hamoptysis, it  was admitted that it had in
some cases been  beneficial, and that, when imminent
danger threatened, we were justified in making use of it.
While allowing this, I had in recollection the advantages
which  I have twice seen derived from it in combination
with nitrate of potash, in hydrothorax, and with opium, 
78
Hydrothorax.
in carditis.  A quarter of a grain of the powdered leaf,
united with ten grains  of nitre,  in the former disease ;
and the same quantity  every four or six hours, with a
full dose of opium every twenty-four hours, in the Latter,
may,  when other means fail, be administered. 
      SECTION III.

ON DISEASES OF THE HEART, &c.
                     CHAPTER I.

                      Carditis.

Pyrexia; dolor in regione cordis;  anxietas; spiritus difficilis; tussis; pulsus
     inaequalis ; palpitatio: syncope.—CI. i. O. ii. G. xiii. Culleni.

  Inflammation of the heart has lately become a very
prevalent affection.   In almost all the cases I have seen,
it has either been combined, or has alternated  with se-
vere rheumatic attacks.
  In the following  case, a history of the disease in its
different stages, is preserved with a sufficient degree of
minuteness, to enable any one to distinguish it from oth-
er affections of the heart.
                   CASE XVIII.
  A baker, by the name of Rider, aged  eighteen years,
on Wednesday, the 10th of December,  1810, as he was
going to bed, felt a violent fluttering at his heart.  It ap-
peared to him to pulsate twenty times where it should
beat only once.  This increased action was  attended
with violent pain  in  the chest, spitting of blood,  and
sickness.  On  Thursday, Friday,  Saturday, and Sun-
day, his limbs  became stiff, cold, and painful, his legs
swelled, and his fingers contracted.
   On Monday, December 17th, he  was admitted into
this Infirmary.   His symptoms at this time were the
following: Great fluttering of the heart,  attended with a
rapid, irregular,  and scarcely  distinguishable pulse; the
breathing was extremely laborious,  and there was an
expectoration of mucus tinged with blood :  the bowels
were confined. 
80
Carditis.
   A blister was ordered to the chest;  two grains of .
 digitalis every night; and  a saline antimonial mixture
 with syrup of white poppies in the day time.
   18th. The digitalis excited great nausea, it was there-
 fore omitted, and the mixture alone continued.
   19th. The increased action of the heart continued;
 pulse full and  irregular; constipation  of the bowels.
 Another blister was applied to the chest;  ten ounces of
 blood were taken from the arm,  and a purgative enema
 injected.
   20th. The blood was rather huffy; the enema  ope-
 rated ; a vein was again opened, and sixteen ounces of
 blood taken away.
   21st.  Blood not at all buffed.   The pulse was hard,
 quick, irregular, and 160  in a minute.   A grain and a
 half of powdered digitalis  was directed to be taken  eve-
 ry four hours, with the saline mixture.
   22nd. The digitalis was ordered to be continued, and
 a bolus containing eight grains of aloes, and a grain and
 a  half of opium was  administered at bedtime.   The
 symptoms as yesterday.
   23rd. An astonishing  abatement of all the violent
 symptoms.  The pulse was  found to be regular  and
rather full, but not more than eighty in a minute ; the
respiration became easy ; tongue rather dry;  he com-
plained of much pain in the shoulder-blades, which he
said he Ead felt throughout the whole attack,  although
he had not spoken of it before.
   24th.  Pain in the shoulder-blades continued ; pulse
regular, ninety in a minute, and not so  full as yester-
 day ;  one alvine evacuation of a natural consistence and
colour.  The digitalis  was ordered to be continued, and
the aloetic pill, containing only a grain of opium, was
 taken at bedtime.
   25th. Pain in the  shoulders and  back somewhat re-
 lieved ;  digitalis continued.
   26th. Better ; pulse eighty-eight. 
Carditis.
81
   27th.  As yesterday.
   28th.  Pulse ninety, and stronger; tongue clean; bow-
 els open : digitalis continued.   He complained  of great
 pain in the lower extremities, particularly about the gas-
 trocnemii muscles.
   29th.  Better ; pain in the extremities abated.
   30th.  As yesterday.
   31st.  Daily improving.
   January 6th, 1811. He left the Infirmary in a state of
 convalescence.  The increased action  of the heart had
 completely subsided, and all he complained of was pain
 in the legs ; the pain in the shoulder-blades was entire-
 ly removed.
                    Observations.
   Although this case terminated favourably, it is proba-
 ble that its duration  might have been shortened, if in-
 stead of  twenty-six,  sixty, eighty,  or a hundred ounces
 of blood had been taken away.
   In carditis  we must endeavour  not  only to diminish
 the inflammatory symptoms, but likewise to put a speedy
 termination to the increased action of the heart.
   To effect these objects we must principally rely upon
 copious venesection,  and opium.
   When by the loss of blood, the action of the heart is
 moderated,  a large  dose of opium may be taken, with
 decided benefit.  In  the case above related, I am in-
 clined to attribute  its successful termination almost en-
 tirely to the opium.   The digitalis might likewise be of
 some service.
   This patient had a somewhat similar, but less violent
 attack three months  previous to his being admitted into
 the Hospital.   With the treatment to which  he was
then subjected, I am unacquainted.  He was of a robust
habit, and tolerably healthy countenance;  his blood,
 however, did not appear to be very well decarbonized ;
 his cheeks, lips, and finger-nails, had a bluish cast,
            11 
82              Hydrops Pericardii.

  A case of carditis has fallen under my observation, in
which the whole arterial system seemed to participate.
A violent and rapid pulsation could be seen, as Avell a«
felt, in its minute ramifications.   It was peculiarly dis-
tinguishable in the labial and digital arteries.  This man
lost in twelve  days, two hundred and sixty  ounces of
blood.  For  eleven days  in  succession,  twenty ounces
were abstracted, and on the 12th  forty at one operation.
From this last bleeding, he derived more advantage than
from all those which preceded it.  Syncope was induced
by  it, and  a  permanent diminution in the force of the
heart and arteries,  was  effected.   He recovered  more
speedily than could reasonably have been expected, and
is at this time in perfect health.
  This  man  sometimes perspired so profusely,  that it
became necessary to place vessels under the bed to catch
the fluid as it trickled through the bedclothes and sack-
ing.
                    CHAPTER II.

                 Hydrops Pericardii.

  This disease  is almost  always  the  consequence of
some derangement iu the structure of the heart.  Dila-
tation of the auricles or ventricles; contraction of the
auriculo- ventricular apertures ; ossification of the valves ;
and ulceiation upon the surface of the heart are its most
frequent exciting causes.  It is likewise  frequently com-
bined with aneurism of the aorta.
  It may continue for a length of time and  water accu-
mulate in great quantity without exciting any symptoms
by which its existence can be decidedly known, as the
case about to be  related will evidence.
  To distinguish hydrops pericardii from hydrothorax 
Hydrops Pericardii.              83
is extremely difficult; in some cases impossible.   It
frequently  happens that they  are united.   It requires
the same medical treatment.  An operation is not admis-
sible.

                   CASE  XIX.

  A woman, aged  twenty-nine years, applied on  the
27th of June, 1811, for admission into the  Bristol  In-
firmary.
  She was led into the room by two persons.  She was
incapable of supporting herself, and her spirits were so
much depressed, that she seemed indifferent to the ques-
tions asked, and unwillingly returned answers to  them.
Her friends stated, that she had been ill many months,
and that she had been taking medicines.
  The fetor exhaling from her, was so extremely un-
pleasant that none but those  whom necessity compelled
would venture near her.  The gums were absorbed, and
it was evident a large quantity of mercury had been giv-
en to her.  She said she had the dropsy, but observing
that the tumor of the abdomen was much more circum-
scribed than it usually appears under that  disease, it
was suspected that the tumor had been produced by a
more natural cause.
  She was asked if she had any reason to suspect that
she was pregnant. She replied, " I do not know wheth-
er I am or not;  some people say I am, others, that I am
not;  I however never feel as though  I were  with child.
My courses have disappeared for seven or eight months.
My husband has not been  with me for three years; but
still I cannot be certain that I am not with child."
  She was ordered to be put in the warm bath, merely
with a view of rendering her  less offensive.  A scruple
of jalap was given  to  her  in the evening, and a gargle
was ordered her to cleanse her mouth. 
84
Hydrops Pericardii.
  On the  following morning, her skin was rather dry
and hot, tongue foul, pulse ninety, somewhat oppressed,
but perfectly regular ;  there was however nothing in the
state of it  which  would have  led any one to suspect
much disease about the heart or lungs.  Her breathing
was rather difficult,  but she did not complain of it.
  Upon examining the abdomen, a circumscribed tumor
was found extending upwards  from  the pubes to mid-
way,  between  the  umbilicus  and scrobiculus  cordis.
This tumor was extremely firm and communicated the
sensation of a solid body to the touch.   It was endeav-
oured, but in  vain,  to distinguish  a fluid.   The urine
was evacuated freely, regularly, and in large  quantity.
She complained of  her mouth  very much, but felt no
pain in any part of the body.
  All  these  circumstances in combination,  led to an
opinion, that  the woman  was in the seventh  or eighth
month of pregnancy.  Nothing but the introduction of a
catheter into  the bladder,  or an examination per vagi-
nam could have detected the fallacy of this conclusion.
  She was discharged under a suspicion of pregnancy,
and died in the course of the folloAvins; week.
                    Hissection.
  I am not acquainted with the minutia of the dissec-
tion, neither have I  been very  anxious to obtain them,
as a  Gentleman in this city has it in  contemplation to
publish the case with a plate representing some ulcera-
tions which existe: upon the surface of the heart.
  These ulcerations were of  considerable extent and
nine ounces of fluid had been deposited within the peri-
cardium.
  The tumor in the abdomen  was occasioned by an
enormously  distended bladder.  Upwards of two gal-
lons ol urine were  discharged upon an  incision being
made through its parietes. 
Hydrops Pericardii.              85
                     Remarks.
  Although there was so much disease about the heart,
1 cannot learn that any symptoms ever manifested them-
selves by which its existence could be decidedly known.
It may be proper  to state that, nine months previous to
her admission, upon  going hastily up  stairs, she  was
twice in the same week suddenly attacked with a flut-
tering at the heart, which was followed by an alarming
and  long  continued  syncope.  It is probable that the
disease commenced nearly at this period.
  Perhaps a greater number of circumstances scarcely
ever occurred in any one case to deceive medical Men,
as to the real condition of the sanguiferous, uterine, and
urinary systems.   With a regular and  natural pulse;
with respiration but little impaired, who would have
suspected the presence of nine ounces of fluid within the
pericardium?  or extensive ulcerations upon the surface
of the heart ? With the discharge of the contents of the
bladder without difficulty, and in large quantities, who
would  have divined  that the tumor was  occasioned by
its over distention ? On the other hand, the suppression
of the catamenia ; the gradual ascent of the tumor from
the pelvis to between the umbilicus and scrobiculus cor-
dis ; its firmness, its form;  the woman's indirect admis-
sion of the possibility of her being pregnant; with other
collateral  evidence,  were  circumstances sufficiently
strong to induce a belief in the gravid state of the uterus.
  This erroneous opinion could only have been correct-
ed by the introduction of a catheter  into the bladder or
by  an examination per vaginam.   Professional Men
ought never to hazard an opinion, as to the condition of
the uterus, without being first permitted to make  such
an examination.
  The  contractile power of the  coats of the bladder
must have been in a great  measure destroyed ; we can
therefore  only account for the  partial evacuation of the 
86       Ventriculorum Cordis Inflammatio.
urine, by supposing that, when extreme distention pro-
duced uneasiness,  the abdominal  muscles were called
into action, and effected its expulsion.
                   CHAPTER III.

          Ventriculorum Cordis Inflammatio.

  I do not remember to have seen any where recorded
a case precisely like the following :  I suspect however
that it is by no means of infrequent occurrence, and that,
in a less aggravated state than is here related, it is often
the cause of those palpitations of the heart which have
lately become so very prevalent.  Nearly as many cases
of increased action of the heart as of phthisis, have been
admitted into this infirmary within  the last five  years.
Scarcely a female applies for the removal of hysterical
symptoms, or labouring under amenorrhcea, but, in ad-
dition, she is affected with increased and inordinate ac-
tion of the heart and  carotid arteries.   Amongst  men
likewise this affection is become very common.   The
metastasis of rheumatic inflammation from the extremi-
ties to the  heart, often gives rise to it, particularly when
venesection has been omitted or but sparingly employed.

                    CASE XX.

  William Trick, a native of Wales,  applied  for ad-
mission on Thursday,  January  10th,  1811.  He was
twenty-five years old, of a moderate size; his  counte-
nance indicating  much disease.  He stated, that he had
been ill about  six months; and that he  conceived his
malady Avas brought on by violent exertion, while work-
ing in a coal pit.
  In the month of July,  1810, upon straining to lift up
a heavy weight,  he was seized with a violent  cough, 
         Ventriculorum Cordis Inflammatio.       87

and threw up a considerable quantity of blood from the
lungs, the discharge of which continued for  a few days
and then subsided.  Since that time  he had been la-
bouring under violent palpitation of the heart, attended
with  difficulty  of  breathing and  an occasional  cough.
His strength gradually failed him; he became emaciat-
ed ; he had resorted to medicine without deriving any
benefit from it.
   Upon making this  statement, the Physician of the
week gave it as his opinion, that there was some organic
affection of the heart for which there was  no remedy.
He prescribed  some saline antimonial medicine, and a
lohoc for the cough.
   As he did not appear to be  in any immediate danger,
he was  directed to apply again for admission on  the fol-
lowing Monday,  and in the mean time to keep  himself
quiet.
   On the Monday he came, but with all his symptoms
of indisposition aggravated.   He was scarcely  able to
walk ; his breathing was very laborious ; his heart pal-
pitated violently ; his  pulse was hurried, irregular, and
intermitting ; and there was extreme anxiety of counte-
nance.
   It  was observed that  the action of the heart was fee-
ble at its apex, but that at its basis it was very strong.
A belief was induced, that a dilatation  of  the  aorta at
its origin was the cause of its irregular and convulsive
efforts.   It was deemed expedient to endeavour to di-
minish its  impetus, by the exhibition of opium. A grain
of that narcotic was administered, with directions to  re-
peat  the dose as occasion might require.  At six o'clock
in the evening, I  was requested to  see  him.  I found
the heart  throbbing against the  parietes of the chest,
with astonishing velocity, irregularity, and  almost un-
precedented violence.   The pulsations of the radial
 artery could not  be numbered.   His  breathing was so 
 88       Ventriculorum Cordis Inflammatio.

 laborious that it was expected instant suffocation wrould
 ensue.
   Twelve ounces of blood were drawn from the exter-
 nal jugular vein.   This evacuation seemed to afford
 some relief;  his breathing became less difficult, and his
 pulse more regular.  After the  evacuation, sixty drops
 of laudanum were administered.
   At eleven  o'clock he complained of giddiness  and
 loss of sight;  the surface of the body became cold.   At
 two o'clock, on the following morning he  died, without
 any previous increase of the symptoms above  enume-
 rated.
                    Examination.
  The pericardium was in a  healthy state, nor did it
 contain  more  than  its  usual quantity of water.  The
 heart itself was rather of a large ssze ;  it was coated  at
 its basis, and upon its under surface, with  a larger quan-
 tity of adipose substance, than is ordinarily met with in
 persons of the patient's age.
  The  auricles presented no unusual  appearance, but
 the inner surfaces of the ventricles were highly vascular.
 The tricuspid and  mitral valves  were evidently in an
 inflamed state.
  The outer coats of the aorta and  pulmonary artery
 were rather red; their internal linings looked precisely
like a highly inflamed tunica  conjunctiva.   The pul-
monary artery was much more  vascular than the aorta.
 There were slight adhesions between the pleura and its
reflected portion, but the lungs did not appear  to be in
the slightest degree diseased.
                     Remarks.
  The death of this  man was,  perhaps, occasioned by
 a rapid increase of the inflammation upon the inner sur-
 face of the pulmonary artery ; in consequence of which. 
On the Action of the Heart.           89
that important vessel was rendered incapable of supply-
ing the lungs with sufficient regularity.
  The  inflamed  state of the  ventricles, must likewise
have materially diminished their powers of contraction.
As, during the life of the patient, the  auricles  could be
distinguished to act with so much greater violence  than
the ventricles, it is probable that the blood was propell-
ed in a great measure by them into the aorta and arteria
pulmonalis.
  The arch of the aorta was slightly enlarged,  but no
aneurismal tumor existed, either upon it, or the neigh-
bouring large vessels.
                    CHAPTER IV.

 On the Velocity and Inequality of the Action of the Heart.

                    CASE  XXI.

   John Ferrol, aged twenty-three years,  by trade a
cooper, had been indisposed about twelve months pre-
viously to his admission on the 16th of December, 1811.
He stated that he was first seized with a cold chill, since
which time he had  been labouring under more or less
difficulty of breathing,  with  violent palpitation of the
heart.
   The symptoms of disease at the time of his admission,
were the following.   He was attacked every morning
and  evening with  palpitation of the  heart.  At these
times it acted with great force and rapidity. It pulsated
212 times in a minute.   During this increased  action,
no pulsation of the radial artery could  be discovered,
nor was the action  of the carotid arteries very evident.
He was in no  pain, but was under continual dread of
suffocation.   His breathing  was  very  laborious; his
           12 
90           On the Action of the Heart.
countenance  bloated, and of  a dark blue colour,  more
particularly when he was in a recumbent posture.
  This action would continue one hour, when another
equally curious would  take  place.   The radial artery
struck  the  finger  feebly but  regularly about  seventy
times in a minule, and the heart was distinctly felt beat-
ing against  the  parietes of the chest  140 times in the
same space of time ; that is to say there were two pulsa-
tions of the  heart for one of the artery.  This state of
the pulse likewise  continued about an hour, Allien the
heart and arteries would move in unison about ninety-
five times in a minute.
  The evening paroxysms were  more  distressing than
those  of the morning ;  the duration of both could be
somewhat shortened by giving a drachm of ather, and
twenty drops of laudanum.   He  had been taking for  a
fortnight a saline mixture with a  small quantity of digi-
talis, a pill composed of one grain of calomel, and three
grains of powered squills every morning, and ten grains
of the compound powder of ipecacuanha  every night.
 Occasionally a cathartic powder  was given.
  By this treatment he was somewhat  relieved, but  as
he was prepossessed with an idea, that in the event of
his dying in the house  he would  be examined, he insist-
ed upon leaving it.  He died about three weeks after-
wards.
                       Remarks.
  I regretted extremely not being able to  examine the
 state of the thoracic viscera in this case, as  perhaps they
would have afforded some explanation of the extraordi-
nary pulsation of the heart and arteries.
   That the heart did actually strike against the parietes
 of the chest 212 times in a minute, I positively affirm.*
  * I am pointed in making this asseveration, because a man, more celebrated
 for height of impudence  than profundity of physical and physilogical science,
threw out insinuations against the veracity of this statement. 
On the Action of the Heart.           91
I counted them every day for a fortnight, with a stop
watch in my hand.  I not only reckoned them myself,
but I requested one of my pupils to do the same ; and
that without  previously informing  him of the result of
my examination.  When I asked him how many strokes
he  could number, he  unhesitatingly  replied, " Two
hundred and ten."
  Some men have denied the  possibility of distinguish-
ing so great a number of strokes  in the space of a min-
ute.  Of the fallacy oi this opinion, any one may con-
vince himself.  Let him place a watch before him, and
at the same time allow 1, 2, 3, 4, 5, 6,  7, 8, 9,  10, to
pass rapidly through his mind : he will find that he can
distinctly count ten, twenty times over  in  the  space of
fifteen seconds.   If then,  800 can be counted  in a min-
ute, why should it be deemed impossible to number 212
strong,  regular and, distinct pulsations of the heart  in
the same space of time.  A  difficulty in numbering the
pulse will be experienced only, when to velocity, is con-
joined irregularity or intermission.
  I do  not imagine that the  heart propelled blood into
the aorta every time it wras felt to pulsate.  There was
probably some impediment  to the  free passage of the
blood from the auricles to the ventricles,  and from the
ventricles into the aorta and pulmonary artery.   In con-
sequence of this obstruction,  the action of the  heart  at
its basis, was rendered as distinct as at its apex.
  When the hand was applied to the chest,  I think the
dilatation of the  auricles, as well  as  of  the ventricles
was perceptible,  an instantaneous intermission  being
observable between the dilatation  of each ; I conceive
therefore that blood was only sent into the aorta at eve-
ry alternate  pulsation of the heart.  That this was the
case, further appears from the circumstance of there be-
ing, during one period  of the paroxysm, only seventy
pulsations of the  radial artery, when 140  strokes were
given to the hand applied to the parietes of the chest. 
92
Polypi of the Heart.
  Why was it, when  the ventricles were acting with so
much violence and rapidity, that no action could be ob-
served either in the carotid or radial arteries ?  Such an
occurrence is by no means unfrequent.   I can only ac-
count for it by supposing that some impediment existed
at the mouth of the aorta, inconsequence of which  the
ventricles not being able to empty themselves of their
contents per saltum, pressed them forward in a continu-
ed stream.  Under these circumstances the blood is af-
terwards  carried on  by the arteries unassisted  by the
heart, in the same  manner as it is by the veins.  I am
confirmed in this  suspicion from having examined  a
young man,  in  whom no action of the  radial  arteries
could be felt for three  weeks previous to his dissolution.
In this lad the left auriculo-ventricular aperture, and the
orifice of the aorta were so much contracted, that the first
phalanx of the little finger could not be passed through
them.  Several polypus-like concretions  were  likewise
met with in the left ventricle, which must have still fur-
ther impeded the passage of the blood.
                    CHAPTER V.

                 Polypi of the Heart.

  A difference of opinion with  respect to polypi of
the heart has long existed among professional  Men.
Some have contended that they often exist long before
life is extinct; others, that they are formed immediately
before or soon after death.
  In these polypi, as they are called, a great variety of
structure and appearance is  observable.  Some will  be
found to be constituted of layers of coagulable lymph
regularly deposited upon each  other, and intimately
united, or as it were kneaded together by the long con-
tinued contractions of the heart;  others are but loosely 
Polypi of the Heart.
93
connected ; have the red particles of the blood in greater
or smaller quantities blended with them; are in short a
mass destitute of any resemblance to organized matter.
They are evidently nothing more than portions of blood
rendered somewhat firm by the  separation  of its serous
parts, and the slight pressure to which they were a short
time before  death subjected.  They are attached but
feebly to the sides of the cavities  of the heart, aud are
easily separated from them ; whereas  the  first species
adhere with great pertinacity, and are with difficulty re-
moved.  So  intimate is  the union which exists, that I
have sometimes suspected blood vessels were  passing
into them from the  membrane lining the cavities of the
heart.
  I am  inclined to think that they are often  the conse-
quence of inflammation upon this membrane, and would
beg leave to submit  the following conjecture,  relative to
their formation.
  It is well  known that, if blood received  into a vessel
be kept in motion with an unpolished piece of wood, the
coagulable lymph will collect around it. In a  manner
precisely similar, I  conceive the  coagulable lymph  to
accumulate within the auricles  and ventricles.  From
some accidental cause,  as inflammation of one of the
carnea  columna,  the membrane is  by the  coagulable
lymph thrown out deprived of its polished surface. The
roughness thus produced,  serves for a nucleus  around
which the coagulable lymph contained in the circulating
blood gathers, and by degrees forms those extraneous
bodies which are usually denominated polypi.
  These concretions are  occasionally productive  of
much inconvenience.  Sometimes they are driven before
the  openings  of the aorta and  pulminary artery,  by
which the passage of the blood becomes interrupted, and
syncope, palpitation of the heart,  irregularity  of the
pulse, &c. are induced.
  By partially occupying the cavities of the heart, they 
94             Aueurism of the Aorta.
may also occasion their enlargement; 1 suspect, howev-
er, that dilatation of these  cavities  is much more fre-
quently produced by violent and long continued  exer-
tion, or by  painful mental  affections.  In persons  who
die of what is called a broken heart, the auricles Avill
sometimes be found much distended.  I remember ex-
amining a case of this  description, in which no trace of
disease could be detected except in the right auricle of
the heart.  This  compartment was of three  times its
natural dimensions.  It contained a large quantity of
blood which  had separated into serum, crassamentum,
and coagulable lymph,  as perfectly  as inflamed blood
does when drawn from a vein.
  Scorbuticising  the  system would,  perhaps, prevent
the formation of these  polypi, but could  effect but little
change upon them when fully formed.
                   CHAPTER VI.

              Aneurism of the Aorta.

                  CASE  XXII.

  Mary Townsend, aged thirty years, of a dark com-
plexion, disagreeable Mulatto features,  and  emaciated
form, was admitted on the 24th of February, 1814. She
complained of frequent cough, and  slight pain  in the
left side, but the  most distressing symptom was occa-
sioned by a violent palpitation of the heart.  Sometimes
this increased action would  not come on for many days;
even a week would elapse without her being affected by
it; generally speaking, however,  she had one or  two
attacks every day, more particularly upon making  any
unusual or violent exertion.   It would sometimes con-
tinue for several  hours, at other times it would subside
in the course of forty minutes.  The paroxysms could 
Aneurism of the Aorta.            95
for  the most  part be shortened by administering lauda-
num and ather in the proportions specified in case XXI.
Whenever respiration  was  impeded, painful, or diffi-
cult, a few  ounces of blood were abstracted from the
arm.  As soon as the violent action of the heart subsid-
ed,  the pulse became  soft, regular, and about eighty in
the  minnte ; but while she was labouring under it,  it
was excessively rapid and indistinct.
  She had previously to her admission, led a very dis-
sipated life,  and had suffered for nearly two years in
the manner above stated.  Recourse was had to a vari-
ety of remedies ; amongst the rest,  small doses of mer-
cury, opium, and digitalis, opium and digitalis combin-
ed, ather and camphor ; and three or four times,  during
the three months she was in  the house, she was bled to
twelve ounces.  She appeared once or twice to be very
nearly recovered,  but upon  using exertion the palpita-
tion returned ; and from  its violence one  would have
imagined she had but a few hours to live.
  Three days before her dissolution, she requested per-
mission  to  walk out.   On the same evening she had  a
return of the palpitation, attended with great pain in the
chest; laborious respiration, &c. and she spat up about
an  ounce of blood.
  Twelve ounces of blood  were  taken from  the arm,
and at night the opiate was  administered.  The bleed-
ing afforded much relief; the blood was devoid  of any
unhealthy appearance.
  On Saturday  morning, (the day before her death) she
coughed up  nearly a  quart  of blood, and became ex-
tremely  faint; the radial artery was destitute of pulsa-
tion, but the vessels about the neck throbbed vehement-
ly.  Two ounces of the infusion of roses strongly acidu-
lated, were administered instantly.   Towards the even-
ing the  pulse at the  wrist  returned: the  action of the
heart was moderated : but she complained of great pain 
  96             Aneurism of the Aorta.

  in the chest, attended with difficult respiration.   The
  opiate was taken at bedtime.
    Sunday.  She rested  tolerably well, but  about ten
  o'clock,  A. M. the hemorrhage returned;  the blood
  gushed in a full and uninterrupted stream from the mouth
  till nearly five pints were evacuated ; she then sunk back
  and expired.
                      Hissection.
   The first thing which attracted attention upon reflect-
 ing back  the abdominal parieties, was the unusual posi-
 tion of the stomach.  Instead of stretching  obliquely
 across the  upper part of the abdominal cavity, it  was
 placed longitudinally, that is to say, parallel with the
 linea alba.
   Its  cardiac extremity was opposed to the diaphragm,
 its pyloric end nearly reached the  brim of the pelvis.
 The duodenum passed  upwards and behind it, to be
 joined by the pancreatic and bilary ducts in  the usual
 situation.
   The stomach  was of a pale colour.   Towards  its
 upper extremity a hole  was situated, through which a
 quantity of grumous blood  escaped upon  the viscus  be-
 ing slightly pressed.  It was but moderately distended.
   The colon, upon  the right side, was filled  with air;
 its descending portion was less inflated ;  its transverse
 portion passed behind the stomach.   The gall-bladder
 projected  above it, and its fundus rested upon the  stom-
 ach which was stained with  transuded bile.   In short,
 the only things which presented themselves on first turn-
 ing back the abdominal muscles were, the stomach,  oc-
 cupying the centre;  the ascending colon distended ;  the
 descending colon less distended; a small  portion  of
 omentum,  and the fundus of the gall-bladder.
  The liver had no left lobe.  The right lobe was per-
fectly healthy, though rather small.   Upon the left side
of the ligamentum suspensorium, instead of a lobe, there 
Aneurism of the Aorta.            97
was merely a small fleshy portion about the width, and
half the length of the little finger.
  The bile contained in the gall-bladder was of rather
a pale straw colour.
  The stomach contained large  pieces  of coagulated
blood, with a considerable quantity of a coffee coloured
fluid.   Its inner surface was  very much discoloured,
more especially  about the hole before alluded to.   At
this part, as well as in the other places, it had a dusky
red aspect.
  The small intestines were chiefly lying in the pelvis,
and were contracted in their diameters.
  On opening the thoracic  cavity and separating the
sternum from its clavicular attachments, a mass of coag-
ulated  blood was  exposed to view.  Upon feeling the
inner surface of the first bone of the sternum, it was dis-
covered that it had been rendered rough.  It was conjec-
tured that this roughness had been occasioned by press-
ure from an aneurism formed upon the arch of the aorta.
Further search confirmed the conjecture.
  The coagulated  blood was carefully removed and the
sac exposed.  Its coats were very thin, and the layers of
coagulable lymph which were deposited on its sides, ad-
hered very slightly to each other.  „ Within the sac there
was likewise found a ball of coagulable lymph.  It was
of the size and consistence of the yolk of a hen's egg ;
in colour it resembled albumen.
  Upon the under and anterior part of the sac, two ten-
dinous bands were stretched and inserted into the upper
part of the arch of the aorta.  They resembled chorda
tendinea but were destitute of muscular fibres.  The
under part of the  sac was  resting upon  the bronchia.
The trachea was  full of  blood.   The aneurismal sac
was somewhat larger than a Turkey's egg.  The arch
of the  aorta had undergone  an enormous distention, its
diameter was greater than that of the sac.  Between its
            13 
98             Aueurism of the Aorta.
coats there were large flakes of ossifit matter, some of
them nearly half an inch in diameter.
   The pulmonary  artery did not appear to have under-
gone any change.   The pericardium contained about
three ounces  of serum.  The heart itself was not unu
sually large, but very fat.   Its cavities were not opened.
   The right  lung was perfectly healthy,  and  free from
adhesions with the costal portion of the pleura.  It was
beautifully streaked with depositions of carbon.
   The structure of the left lung  seemed to have under-
gone some alteration;  it was disproportionately  smaller
than the right,  and adhered very closely at its root to
the dorsal vertebra.   The  pleura  was much thickened,
and broke down easily.   There was scarcely any fluid
in the cavity of the chest.
   Many of the bronchial glands were very large;  and
loaded with the same black deposit, which had so beau-
tifully marked the lungs.
                    Observations.
   The subjects  of aneurisms will, for the most part, be
found to be intemperate or irregular in their habits, and
I am inclined to suspect  that they are  produced more
frequently by the  excessive use of spirituous  liquors
than any other cause.*
  Diseased or increased  action cannot exist for  any
length of time, without inducing  an alteration in  the
healthy structure of parts.   It is scarcely possible  that
the heart and arterial system can be stimulated into ex-
cessive action, by the repeated use  of large quantities of
spirit without exciting at least a  disposition to disease.
   Perhaps the frequent introduction of alcohol into the
system impairs the  structure of the  coats of the arteries.

 * Gout is frequently produced by  excessive indulgence in spirituous liquors
Are gouty concretions, and the depositions of ossific matter within the coats oi
arteries constituted of the same materials ? 
Aneurism of the Aorta.             99
Its pernicious influence upon the stomach, liver, &c. is
now generally admitted.
   When speaking of the appearances of the lungs and
bronchial glands, I stated that they were loaded with
what seemed to be carbonaceous matter.  Dr. Bostock
has ascertained by direct experiment, that this matter is
carbon, but I do not think he has accounted very satis-
factorily for the manner in which it is deposited.  He
conceives that it is taken up from the surface of the air
vessels by  the absorbents,  and carried to these parts.
He seems either to have forgotten, or not to be aware of
the incapability of these vessels to take up carbon.  Car-
bon, or any other body which will not undergo solution
in the animal fluids, cannot be acted upon by  the ab-
sorbent vessels, but will remain unchanged for many
years ; even from infancy to old age.  Marks inflicted
by tatooing,  &c. can never be removed but by the entire
destruction of the parts in w hich they are situated.  It
seems to me much more reasonable to suppose, that these
particles of carbon are the product of arterial action.
The vessels  distributed to the glands and surface of the
lungs, convert  a portion of the blood  which is sent to
them into  carbon.  By a similar process it is that the
pulmonary artery decarbonizes the blood.
   When an  unusual  disposition of the abdominal vis-
cera is met with, it is extremely  difficult to convey by
verbal description only,  a  distinct idea of their relative
situation.  I trust, however, that I have rendered my-
self intelligible.
   This is  the only case in which I have heard of the
liver in the human subject,  being constituted of only one
 lobe.   This peculiarity might, perhaps, prove indirect-
ly one of  the exciting causes of aneurism in this case;
for the blood not having so large a space to be distrib-
ited through, would be returned  from the intestines to
the heart sooner than it is under ordinary circumstances; 
100    The Functions of the Pulmonary Artery.

by which, accumulation, consequent distention, and in-
crease of muscular force in that organ would be produc-
ed.   Of this I shall, however, speak more at large when
I offer some conjectures  relative to the  functions  of the
liver.
                   CHAPTER VII.

       The Functions of the Pulmonary Artery.

  That blood  is formed from chyle is universally ad-
mitted, but as to the peculiar mode in which the change
is effected, or by  what organ, has hitherto been imper-
fectly explained.
  It may  appear  presumptuous in me  to attempt at an
explanation of a subject of such difficult solution, a sub-
ject which the  researches  and experiments of the most
distinguished physiologists have been  found insufficient
to elucidate.  Its  immense importance, with the unsatis-
factory manner  in which it has been hitherto accounted
for will I hope plead my excuse.
  I am  of opinion that the power of  converting  chyle
into blood is resident in the pulmonary artery.
  The chyle, conveyed by the thoracic duct to the an-
gle formed by the union of the jugular and subclavian
veins, passes with the refluent blood almost immediately
into the pulmonary artery : it returns by the pulmonary
veins, not in the state of chyle, but in  the form of pure
arterial blood.  By what agent can such a change be ef-
fected ?  The answer  must be by means of an artery ;
for  a change in the sensible  properties of  the fluids o
the body can be effected only through the medium of an
artery.  The mere admixture of chyle with refluent
blood cannot possibly convert it into blood, neither can
it be effected by the muscular action of the  right side of
the heart.   As therefore no instrument  exists by which a 
       The Functions of the Pulmonary Artery.   101

conversion of chyle into blood can be accomplished pre-
viously to  its  reaching the pulmonary artery, and as it
issues from the minute branches of that vessel  in  the
form of pure arterial blood, it is self-evident that it must
have been converted into blood by the peculiar action of
that vessel.  How this circumstance could have been so
long overlooked appears extraordinary; perhaps  the
oversight was occasioned by physiologists having as-
signed  to the  pulmonary artery, the exclusive  property
of oxygenating or decarbonizing the blood.   The aorta,
with its branches, performs many functions;  can any
physiological  reason be assigned why the pulmonary
artery with its  branches should not perforin three  or
four ?  or why that  vessel should not be  as capable of
converting chyle into blood, as the spermatic arteries
are of converting blood into  semen ?
   It has been often  said that the whitish fluid which is
sometimes seen floating in the serum of blood,  is chyle;
I must confess myself of an  opposite opinion.   My rea-
sons for thinking otherwise,  are the following.
  If it were chyle, we should uniformly meet with it an
hour or two after food had been taken, or probably in a
much shorter space of time ; the reverse however hap-
pens.
  We sometimes meet with  the  appearance which has
been attributed to the presence of chyle after an  animal
has been deprived of sustenance for many hours.
  If it were chyle we should as frequently meet with
turbid serum in arterial as in venous blood, and in arte-
rial blood, it would  first be seen; this  however  is  far
from being the case.  I do not recollect ever to have
seen it in arterial blood more than six times.   In these
cases the appearance was  probably  depending upon
some other cause ; a cause to  which I shall i presently
advert.
  The chyle of geese is perfectly transparent;  whereas 
102    The Functions of the Pulmonary Artery.

the serum of their blood is said, by Hewson, to be more
milky than that of almost any other animal.
  If it were necessary, many other arguments might be
advanced to shew how improbable  it  is that  chyle
should  pass  through  the lungs  unaltered, and be dis-
tributed  by the aorta to every part of the body.   How
unfit this fluid is  for an extensive circulation, must be
apparent to every one.
  If then it be admitted that the  arteries perform the
function  of secretion,  and if it be allowed that a fluid
called chyle passes into the pulmonary artery, and is-
sues from it,  not  in the form of chyle,  but in  that of
blood, it is evident that chyle is converted into blood by
an action peculiar to that artery.
  Every part of the body, whether solid or fluid,  is the
product of secretion.   Is it probable that so  important
a fluid as blood should be without an appropriate organ
for its secretion ?
  The centrical situation of the pulmonary artery ; its
proximity to the thoracic duct and to the aorta; renders'
it peculiarly  eligible for the purpose of secreting blood.
It almost immediately receives its heterogeneous con-
tents, aud converts them into a fluid proper for the aorta
to distribute to every part of the body.
   That the pulmonary artery performs other  important
functions I am ready to admit.  As I before observed,
the aorta, with its ramifications, serves many  purposes ;
the  pulmonary artery  may, and does  answer several.
Some of its branches decarbonize*  the refluent blood ;
others secrete a fluid upon the surfaces of the bronchia,
by means of which they are preserved in an open state;
a third set terminates at the commencement  of the pul-
monary veins; a fourth, converts the chyle  into blood,
and terminates in the same manner.
  * Carbon in a palpable form, during  profound sleep, is sometimes  deposited
 upon the lining membrane of the bronchiae, and is coughed up  in combination
 with a very viscid mucus.  The mucus is literally rendered by  it. " as black as
 h cro'.v." 
       The Functions of the Pulmonary Artery.    103

  One circumstance remains to which I promised to di-
rect the attention.
  To me it seems probable, that the .white appearance
of the serum depends upon an action of the sanguiferous
system, somewhat similar to that  by which the buffy
coat is produced upon inflamed blood.
  It is stated, that  this white serum  is frequently met
with soon after eating; in other words, when the circu-
lation of the blood has been rendered more rapid by the
stimulus of food.
  We seldom meet with buff except  when there is an
increase of vascular action.   When the buff is perfectly
formed, we generally have a very transparent serum.
We now and then meet  with a little buff upon  arterial
blood.  We sometimes, but more rarely, see the serum
of arterial blood a little white.  I therefore am inclined
to attribute the white appearance of the serum, and the
buffy state  of the crassamentum to an increase of vascu-
lar action; the difference of the  appearance depending
upon a modification of that action.   In other  words,  if
the stimulus of food were  sufficient to produce inflam-
matory action, instead of a white serum, we should have
a huffy crassamentum.  Whenever, therefore, I observe
a white serum, I infer that  more or less  of  increased
vascular  action  exists.  Perhaps I shall be better un-
derstood if I state, that under a moderate increase of ac-
tion a turbid serum will be formed ; under an excess of
that action  a buffy  crassamentum,  with  a transparent
serum.
  Buff, or coagulable  lymph, and  the particles which
render the serum turbid, are probably formed at the ex-
tremest points of the arterial  ramifications.
  Should these conjectures receive  support or confirma-
tion from the experiments, or the observations of others,
some important improvements in the practice of medi
cine may be founded upon them. 
         SECTION IV.

0N THE DISEASES OF THE STOMACH, &c.
                     CHAPTER I.

                     Hyspepsiu.

  Anorexia, nausea, vomitus, inflatio, ructus, ruminatio, cardialgia, gastrodynia,
pauciora saltern vel plura horum simul concurrentia, plerumque cuia a;<o ad-
stricta, et sine alio vel ventriculi ipsius, vel aliarum partium, morbo.-^-Cl. ii. O.
ii. G. xlv. Cclleni.

  So universal is the sympathy between the  stomach
and the other parts of the body, that it is almost impos-
sible for disease to exist in any part, without the stom-
ach being more or less affected by it.
  Dyspepsia is generally described as a distinct disease,
and many symptoms  characteristic of  it, such as heart-
burn, flatulent  and acid  eructations,  constipation, &c.
are enumerated; these symptoms are however more fre-
quently sympathetically excited by disease in some oth-
er organ, and ought rather to be considersd as symptoms
of that disease, than  regarded as constituting a disease
of the stomach itself.
  For the  removal therefore of what  are called symp-
toms of dyspepsia, instead of wasting our time and dis-
gusting our patients,  by the administration of palliative^
remedies, we must direct our whole  attention  to their
exciting causes.
  Dyspeptic symptoms will be found  for the most part
to arise from a derangement in the structure or functions
of the brain, liver, pancreas,  uterus,  and  kidneys ;  in
the uterus and pancreas more particularly.
  An enlargement of the duodenal extremity of the pan-
creas is a very frequent exciting cause.
  Unless we can remove these affections, we shall  in 
Dyspepsia.
105
 vain ransack the materia medica for remedies calculated
 to give tone to or allay irritation in the stomach.
   I have been thus particular in enumerating the sources
 from  whence dyspeptic  symptoms arise,  because they
 are so frequently disregarded in practice, and effervesc-
 ing draughts by the gallon and magnesia by the pound
 are consumed,  not only without benefit, but  with  evi-
 dent prejudice.
   I do not intend however to deny that dyspeptic symp-
 toms are sometimes excited by a  diseased  state of  the
 stomach itself.   From the  admission of improper sub-
 stances, or from the immoderate use of proper food,  its
 coats become impaired and its  functions  disordered.
   Dyspepsia, depending upon  such causes, may be most
 effectually remedied by a rigid adherence  to an abste-
 mious diet; an entire abstinence from every thing which
 the patient from repeated experience has found  to disa-
 gree with him, or to be difficult of digestion ; occasion-
 ally an emetic; from forty drops to  a  drachm of  the
 volatile spirits of ammonia three times a day in a glass
 of water,  or moderately bitter  infusion of gentian; and
 every alternate evening five grains of the blue mercurial
 mass.  Against a constipated  state of the bowels  we
 must likewise carefully guard.
  The following most obstinate case of dyspepsia, sub-
 mitted to the continued use of the mercurial  pill after
 every other  remedy  which  could be devised had been
 tried in vain.

                  CASE XXIII.

  Thomas Bush, aged  twenty-nine years, by  trade a
painter, was admitted in the month of November, 1810,
labouring  under all  the symptoms of colica pictonum,
with paralysis of the muscles of the fore-arms,  and an
excessive  irritability of stomach.
  After constipation was removed, his hands were  ex-
           14 
106
Hyspepsia
tended upon splints,  and opium, rhubarb, ipecacuanha,
bitter infusions, magnesia,  fixed  and volatile alkalies,
in large as well as in small doses, were exhibited, but
they all appeared to  aggravate rather than relieve the
cardialgia, nausea,  and  sickness, with which he was
perpetually tormented.
   The stomach w as incapable of digesting  any thing.
Whatever was received into it was ejected from it in the
course of  one or two hours, without having  undergone
any sensible alteration.
   Under  these circumstances, five  grains of the blue
pill, combined with half a grain of  opium, were taken
every night.   Within a week after its exhibition, he re-
tained food upon his stomach without much difficulty;
in a fortnight his gums became affected ; the dyspeptic
symptoms  were nearly removed, and the  wrists were
evidently  stronger.   At  the  end  of three weeks, the
dyspeptic symptoms had entirely subsided ;  the exten-
sor muscles of the fore-arms  became perfectly obedient
to the will, but their action was feeble; it was sufficient-
ly powerful however, to enable him to extend the hands
;md keep them in a straight line with the arms.
   He was discharged in a state of convalescence and re-
commended to use the Bath waters, under an impression
that they would confirm a cure so happily brought about
by the use of the mercurial mass.
   This case not only shews the advantages which may
be derived from the  exhibition of mercury in some af-
fections of the stomach;  but it proves that that metal is
eminently powerful in counteracting the baneful influence
of lead.
                      Pyrosis.
Epig^strii dolor urens, cum copia humoris aquei, plerumque insipidi, aliquando
          acris eructata.—CI.  ii. O. iii. G. lviii.—Culleni.
   Pyrosis will be most  effectually relieved by the prac-
tice recommended when treating of dyspepsia. 
                    Haematemesis.                107

                    CHAPTER II.

                    Haematemesis.

   Except where  hamatemesis was occasioned by ex-
ternal violence, or took place in consequence of a partial
destruction of the stomach itself by ulceration, I have
never known it to terminate fatally.  It is for the most
part induced by the suppression of some natural or long
accustomed evacuation, and we must direct our curative
intentions to the re-establishment of this  evacuation, or
the introduction of some substitute for it.
   I have known women labouring under suppresssion of
the menses lose blood every month with great regularity,
from  the stomach,  lungs, nose, and open ulcers.
   Under these circumstances it will be useless for us to
attempt to restrain the hemorrhage from the parts them-
selves ; it can only be affected by restoring to the uterus
its natural  healthy action.   The  most powerful means
we possess to attain this object are, periodical venesec-
tion,  and active purgatives: upon  the former however
we must chiefly rely.
   Hamatemesis frequently occurs in consequence of an
over-distended state of the blood-vessels of  the messen-
tary or liver.  When originating from such a cause, ac-
tive purgatives will be found of most  avail.   Bloodlet-
ting will likewise be sometimes demanded.
   When the disease is brought on by the sudden sup-
pression of a  hamorrhoidal defluction,  leeches should
be from time to time applied about the verge of the rec-
tum ;  aloetic purges administered, and such other means
employed as  are  calculated to restore the discharge,
which is afterwards to be diminished gradually and wi(h
great  caution.
   Although blood may be, and frequently is,  thrown
from the stomach in immense quantities and  for a great
length of time, without materially injuring the  patient. 
108          Ulceration of the Stomach.

hamatemesis must  not be  regarded as an insignificant
disease.
                   CHAPTER III.

              Ulceration of the Stomach.

  With the exception of the female breast, there is no
part of the body more frequently  the seat of  scirrhous
induration and subsequent ulceration, than the pyloric
extremity of the stomach.  It is  one of the  most de-
plorable diseases  to which the human frame is liable.
Its wretched victim is  doomed to  drag out a protracted
and miserable existence without a prospect of cure, or
even a suspension of suffering for any length of time.
  A clear conception of  its irremediable nature will be
most readily acquired by a description of the destruction
which it sometimes occasions.

                  CASE XXIV.

  A poor emaciated creature, aged fifty-two years, was
admitted, after having for more than two years suffered
excruciating pain  in  the stomach, attended sometimes
with a total inability to retain food.
  The disease commenced with all the symptoms usual-
ly termed dyspeptic.   I could not learn that at any time
she had vomited pure  blood.
  After remaining in the Hospital six weeks  she died.
During this period, she complained of excessive pain in
the epigastric region,  and threw up  almost every thing
she swallowed mixed with a sanious fluid.  The only
thing she could keep upon the stomach was oil of cinna-
mon given upon pieces of refined sugar. 
Ulceration of the Stomach.          109
                   Examination.
   A firm, thickened, inflamed ridge, extending along
the upper surface of the stomach, and pursuing the  di-
rection of the edge of the left lobe of the liver,  was the
first diseased appearance which attracted attention.
   It was found that the stomach had formed adhesions
with this edge.   But for this circumstance  its contents
would have escaped into the abdomen ;  for upon  mak-
ing use of slight force to  separate the liver from  the
stomach, the fingers passed directly into the cavity of
the latter.   The liver, stomach, spleen, and pancreas
were removed together from the body, that they might
be examined more at leisure.
   The pancreas was very much enlarged and indurated
at its duodenal portion;  and by its pressure must have
retarded,  or  even almost prevented the passage of food
along the first intestine.
   The spleen was free from disease.   The liver had
externally a healthy appearance.  The stomach was
very much distended with fluids.  Upon cutting it open
in the course of its greater curvature,  more than one
third of its inner surface was discovered to be in a state
of ulceration.   At its upper part its coats had been en-
tirely removed and an extensive cavity made in the sub-
stance of the liver.  The excavaled  liver truly formed
at this place a substitute for the stomach.   The pyloric
extremity of this  organ was much  thickened,  and its
opening into the duodenum nearly closed.  The  car-
diac extremity was perfectly healty.   A few patches of
a dusky hue  were here and there scattered upon such
parts of the inner surface as had escaped the ulcerative
process. 
110
Gastritis.
                   CHAPTER IV.

                     Gastritis.
  Pyrexia typhodes; anxietas; in epigastrio ardor et dolor, ingestis quibuslibet
auctus ; vomendi cupiditas, et ingesta protinus rejecta ; singultus.  CI. i. 0. ii.
G. XV.—CCLLEJVI.

  Gastritis is for the most part attended with symptoms
which clearly point out. the  nature of the affection;
sometimes however, in its attack and progress,  it is but
imperfectly marked.   I have  seen it destroy life with-
out a single circumstance occurring by which its exist-
ence could be known, or even suspected, till within a
few  hours of dissolution.  The following case illus-
trates this statement.

                   CASE XXV.

  Henry Hancock, aged twenty years, was admitted
on Monday, the 28th of August, 1815,  labouring under
symptoms of slight pyrexia.   His pulse was moderate
ly full and frequent; his skin rather dry; and his tongue
white at its centre, and red at  its edges.  He icomplain-
ed of no particular pain; the  epigastric and abdominal
regions were  destitute  of tenderness;  he felt neither
nausea  nor sickness.   A cathartic powder, and some
saline medicines were directed.
  During Tuesday and Wednesday he continued nearly
in the  same state.  On Thursday  the limbs became
swollen and extremely painful; in short all the symp-
toms of acute rheumatism manifested themselves.
  He was directed another cathartic powder, and  six-
teen  ounces of blood were taken from the arm.  The
blood speedily  exhibited the buffy coat;  the  crassa-
mentum was in full proportion; the serum very transpa-
rent.
   On Friday morning he appeared much relieved ;  his
joints were less painful and inflamed ; but the pulse con- 
                     Gastritis.                  Ill

tinned full and frequent.  Sixteen ounces of blood were
again drawn away, which were likewise much buffed
and cupped.
  On Saturday morning a most extraordinary, unex-
pected,  and inexplicable  alteration had  taken place.
His features had assumed the complete Hippocratic as-
pect ; his tongue was dry and brown ; his skin covered
with a cold clammy prespiration ; and his pulse scarcely
perceptible.   It  was  evident that he  had only a few
hours to live.
  Had a person unacquainted with his previous history
been asked his opinion of him, he would have unhesitat-
ingly pronounced that he was in the last stage of typhus
gravior.  I knew not what to think ; I suspected how-
ever that some blood vessel had  suddenly given way,
and that he was  dying from internal hamorrhage.
                 Examination.
  The whole surface of the peritonaum exhibited traces
of inflammation.   In some parts this increase of action
had been excessive and the coats of the intestines were
involved in it.   The pelvis was full of serum  and flakes
of coagulable  lymph; and the small  intestines were
almost inseperably united by  the adhesive  process.
Some lymph and serum was likewise met with in  the
abdomen.
  The stomach was  remarkaaly small, but  externally
presented no diseased appearance.   Nearly one half of
its inner surface however was found to be in the highest
possible state of inflammation.  At the pyloric extremity
it was  of a  deep red colour, which became gradually
brighter as it diffused itself upon the coats.  The duo-
denum for a short distance partook of the disease.
  Queries.   Did inflammation of the stomach and intes-
tines exist at the time  this  patient was admitted, and
increase so gradually as not to excite the symptoms by 
112  On the Effects of Ardent Spirit upon the Stomach.

which its existence may for  the most part be certainly
known ? or did it attack these organs suddenly, and ac-
quire its fatal height in the course of fourteen or sixteen
hours.
  I am inclined to think that its increase was  gradual.
I have seen cases of long continued peritonitis, in which
the symptoms were at first so mild, that, till  within a
few  hours of dissolution, no apprehension of danger
was excited by them.
                     Treatment.
  We must have recourse to the most prompt and ener-
getic measures.   Blood  must be taken largely  from the
arm:  and twenty or thirty  leeches, and  afterwards a
blister, applied to the epigastrium.
  Enemas may be thrown up  frequently with advan-
tage, but,  before the inflammatory symptoms have been
removed,  and the irritability of the  stomach  allayed,
neither food nor medicine ought to be swallowed. They
will only add to the sufferings of the patient and aggra-
vate the disease.
                    CHAPTER V.

   On the Effects of Ardent Spirit upon the Stomach.

   Upon the  first  arrival of the  fleets from the West-
Indies men are frequently brought  into this Hospital,
in a state  of  total insensibility produced by  drinking
rum.   The precise quantity  swallowed can seldom be
ascertained, as it is procured by boring holes into the
casks, and sucking the liquor through straws  or small
reeds.
   The degree of danger  arising from intoxication, may
be best estimated by the irritability of the iris.   If the
iris retain its contractile power, the patient will generally 
On the Effects of Ardent Spirit upon the Stomach.  113

recover, however overpowered his senses may be; if, on
the contrary,  it remain in a state of extreme dilatation
when a strong light is directed upon it, but a feeble hope
of recovery must be entertained.
   The paralysis, or immovable dilatation of the iris, is,
for the most part attended with apoplectic stertor;  la-
boured and imperfect respiration ; and a slow, oppress-
ed pulse.  The power  of  the  stomach is also lost, the
strongest emetics being insufficient to excite it into action.
Next to the insensibility of  the iris, want of energy in
the stomach indicates the greatest danger.
                     Treatment.
   We must use all our  efforts to excite vomiting.   Ipe-
cacuanha and sulphate of zinc or copper, in large doses,
should be given, and the patient compelled  to swallow
as much warm water as possible.   The expulsive force
of the stomach should likewise be solicited by irritating
the fauces with a feather.
  If we  can make  the  stomach eject its contents, the
patient may be considered out of danger.
  As soon as  re-action  in  the  system takes place,  he
should be put under a copious shower-bath.   The ap-
plication of cold water will often restore him instanta-
neously.   On  the following day, if  any preternatural
fulness of the vascular system be present, blood should
be abstracted from the arm, and an active purgative ad-
ministered.
   Venesection, in the early stages of the affection, seems
to be especially indicated, as there is always a consider-
able determination of blood to the brain; I have how-
ever seen it employed to a great extent without any mani-
fest advantage; more frequently it has proved injurious.
From all that I have observed, I am  arrived at the fol-
lowing conclusions.  If we can excite full vomiting, we
shall save our patient; if we cannot, he will have a bet-
            15 
114    On the Effects of Arsenic upon the Stomach.

ter chance of recovery, if Ave leave  him to  the  opera-
tions of nature, than if we bleed him, agitate him, en-
deavour to make him walk, or in any other way disturb
him.
  I have had several opportunities afforded me of ex-
amining the brains and stomachs of persons who died
intoxicated. The appearances I have met with have been
uniformly the the same.   The vessels of the brain were
gorged with blood, and a quantity  of serum deposited
in the lateral ventricles.   In the stomach I have never
been able to discover any  deviations from a healthy
state, but a quantity of the pernicious spirit  is generally
to be detected.
   The brain of a person who was destroyed by a large
dose of laudanum  exhibited the same marks of increas-
ed vascularity; some serum was effused within the ven-
tricles  ; and some  of the narcotic was likewise found in
the stomach.
   The practice which has been here recommended and
successfully adopted for the  relief of persons under the
influence of ardent spirit,  I  conceive to be equally ap-
plicable to those Avho have taken  opium, but my actual
 experience in this  respect has been very limited.
                   CHAPTER VI.

    On the Effects of Arsenic upon the Stomach.

  Only one person who had taken an undue quantity
of arsenic has fallen under my observation.
  The sAvalloAving of the poison in this case, was suc-
ceeded by symptoms so peculiar,  that I do not think a
concise narration of them will be found uninteresting. 
     On the Effects of Arsenic upon the Stomach.  115

                  CASE XXVI.

  Mary Pearce, a healthy young  woman,  was admit-
ted in the month of January, 1812, in consequence of
having accidentally taken a  quantity of arsenic upon
bread and butter.  A powerful emetic was immediately
administered, and after its operation a combination of
sulphur and oil.
  When pressure was made upon the epigastric region,
she complained of pain, but  for ten days experienced
no other inconvenience.  At the expiration of this time,
her appetite became impaired  ; her skin hot and remark-
ably dry; her pulse frequent and feeble; and her tongue
covered with  a thick white fur.
   At the end of five-weeks she was universally emaci-
ated, and lost the use of her  loAver extremities.  From
this time a progressive amendment was perceptible; the
febrile symptoms gradually subsided ;  her appetite and
strength  returned; but  her lower extremities remained
paralysed.
   In October the  paralysis was only partial; she was
able to move  her thighs  and legs, but her feet were in a
state very similar to that so frequently produced by lead
upon the muscles of the  fore-arm.   During her stay
here, antimonials, mercury,  bark, friction,  electricity,
galvanism, warm-bathing, &c.  were  successively  em-
ployed.
   From this Hospital she went  to Bath.  I have been
informed that she was materially benefited by the use of
the waters of that city.  With  her medical treatment I
am unacquainted. 
116       On the Structure of the Pylorus.
                      CHAPTER VII.

             On the Structure of the Pylorus.

     There is a peculiarity in the structure of the pyloric
   extremity of the stomach,  which I  do not recollect to
   have seen any Avhere noticed.  It consists in the inter-
   position of a valve between the pylorus and duodenum.
   This valve cannot be satisfactorily seen either upon the
   recent subject, or on a wet preparation of the stomach.
   The best mode  of  shewing it, is to inflate the stomach
   with a portion of the duodenum,  and allow them to be-
   come perfectly  dry.  In this  state, if  an opening be
   made into the stomach  or  duodenum, a valve attached
   at its basis to the whole circumference of the pyloric ex-
'   tremity of the stomach, with an almost circular opening
   in its centre will be seen.   The diameter of the opening
   bears about  the proportion  of one-third to  the whole
   valve.
     By a similar preparation of a portion of the ilium and
   cacutn, the manner in which  the former intestine termi-
   nates in the latter, will be best elucidated.
     The ilium will be found to end in two crescent-shaped
   valves.   The elliptical  space left between the horns of
   the valves is very considerable.  The opening is suffici-
   ently ample to allow of  the ready passage of fluids from
   the colon and cacum into the ilium.   With a Avell-con-
   structed apparatus, I feel persuaded  that enough warm
   water might  be injected into the intestines  to effect the
   reduction of strangulated hernia.  A small equable force
   applied behind the stricture, would act much more ad-
   vantageously than pressure, made upon the protrusion
   itself, however judiciously directed.
     A difference in the form of the cacum of the adult and
   the infant will sometimes, if not  universally, be found
   to exist.  The cacum of the adult generally forms an
   irregular bag.  To this bag the appendix vermiformis is 
Splenitis.
117
 attached, but has no definite point of connexion.   The
 cacum of the infant tapers toAvards  a point, and  from
 this point the appendix vermiformis is depending.  The
 cacum,  with its appendix, bears a very strong  resem-
 blance to the posteriors and tail of a very young suck-
 ing pig.   From the appendix vermiformis a secretion of
 fluid takes place, Avhich is probably intended to facili-
 tate the passage and to prevent the accumulation of fecu-
 lent matter in the cacum.


                   CHAPTER  VIII.

                      Splenitis.

 Pyrexia; hypochondrii sinistri tensio, calor, tumor et dolor pressu auctus
       absque signis nephritidis.—CI. i. O. ii. G. xviii.—Culleni.

   Acute inflammation of the spleen is of comparatively
 rare occurrence.   When it does arise, it requires for its
 removal the depleting and  antiphlogistic system so often
 recommended in this volume.
   Indurated or enlarged spleens must, when productive
 of  inconvenience, be reduced by mercurial frictions car-
 ried to a considerable extent.   Brisk cathartics  will be
 found useful adjuncts.
   The entire removal of the spleen from the body with-
 out its being succeeded by  any perceptible derangement
 in the animal economy, satisfactorily demonstrates that
 its function (whatever its function may be) is not of pri-
 mary importance.  To me, it seems  probable that it is
 intended to regulate the quantity of blood, and the force
 of its circulation through the coats of the stomach.  The
 communication which the  stomach has with  the spleen
 through the medium of the vasa brevia, must materially
 contribute to prevent an accumulation of blood within its
 coats.  But for  such a provision, hamatemesis would,
perhaps, more frequently occur. 
lib          Induration of the Pancreas.
                    CHAPTER IX.

             Induration of the Pancreas.

   Several cases of extraordinary enlargement and in-
duration of  the pancreas have been  admitted since my
residence at this hospital.  They commenced with all
the symptoms of dyspepsia.   As they advanced a most
distressing sense of  weight was  felt in the epigastric
region; food was with  difficulty retained ;  was some-
times ejected from the stomach; and the bowels were
obstinately constipated.
   When the disease had  made further progress,  the
skin and tunica conjunctiva became deeply and perma-
nently tinged with  bile,  and  a large  quantity of the
same secretion Avas seen in the urine.  Great irritability
in the stomach was next experienced ; bile was frequent-
ly cast from it, but it rarely happened that any  passed
into the intestines.   A pain  similar to, but less  violent
than that occasioned  by gall-stones in the biliary ducts,
was likewise felt.  Upon pressure being made  in the
epigastrium a hard tumor could be distinguished.
   The disease is often of many years duration, but the
patient seldom survives its last, and what may be called
its acute stage, more than three or four months.
                     Dissection.
   Dissection shows the Pancreas enormously enlarged
and extremely hard :  it sometimes acquires six times its
natural bulk.  By its pressure upon the duodenum and
biliary ducts, it prevents the passage of food and  bile
along the intestinal canal.   The retention of the bile ap-
pears to me to give rise to derangement  in the structure
of the liver.  That viscus becomes both internally and
externally studded with circular tubercles with depressed
surfaces, some rather larger, others somewhat smaller
than a six-pence.   The curd-like matter they contain is
deeply coloured with bile, which gives to them a singu- 
Biliary  Calculi.
119
larly beautiful  appearance.   I have several times en-
deavoured to preserve specimens  of the disease, but the
liver was  so  completely  saturated with bile, that the
spirit, however frequently renewed, was discoloured by
it.
   The  gall-bladder  is always  greatly  distended.   I
have seen it contain from four to six ounces of dark in-
spissated  bile.   To this over-distention of the bladder,
is to be attributed that pain felt and described by the
patient  as  similar to  that produced by the passage  of
gall-stones.
                        Treatment.
   The treatment can be merely palliative.  The  disease
is, and perhaps ever will remain without a remedy.   I
cannot learn that  a scirrhous pancreas  ever undergoes
the ulcerative process.
                       CHAPTER X.

                     Biliary Calculi.

  I have seen many cases in which biliary calculi were
supposed to exist;  dissection however almost uniformly
detected  the inaccuracy of the diagnosis.   I have exam-
ined nearly two hundred subjects,* and never  but once

  * A circumstance, disgraceful to the age in which it happened, occurred a few
weeks ago.
  A Mr. Cassan, of Hull, was fined one hundred pounds, and imprisoned (with
his apprentices) one month,  for having disinterred a human body.  Since the
Legislature has thought proper to constitute the removal of a body which in the
course of a few weeks would otherwise become
            -------------------" A nauseous mass
           " Of all obscene, corrupt, offensive things -,11
into an act of felony, it will not surprise me to hear of the embarkation for Bota-
ny Bay, of our Coopers, Abernethy*, Clines, in short, of every individual who is
desirous of  benefiting mankind by anatomical investigations. Surely an act
which strikes at the very root of medical science, and presents so formidable a
barrier to its advancement, ought to be petitioned against by Physicians, Sur-
geons, Apothecaries, by enlightened men of every denomination, by every real
friend ot humaHitv. 
120
Icterus.
found  concretions in the gall-bladder.  In this person
their presence was not suspected.  The symptoms which
have given rise to the opinion of their  being present,
have been almost uniformly found to  be  excited by an
enlargement of the duodenal extremity of the pancreas.
  However frequent these calculi may be in other places,
I think my extensive opportunities of  making examina-
tions after death,  will warrant the conclusion, that, in
this city, they are of rare formation.
                     Treatment.
  For the expulsion of biliary calculi, we must princi-
pally depend  upon the friendly efforts of nature.   So
dreadfully  acute are the sufferings of the  patient during
the paroxysms, that large doses of opium, preceded by
venesection, are sometimes imperiously demanded.
                    CHAPTER XI.

                       Icterus.

FJavedo cutis et oculorum; faeces albidae ; urina obscure rubra, immisa colore
          luteo tingens. CI. iii. O. iii. G. xci.—Culleni.

  Jaundice is generally  occasioned by pressure upon,
or an obstruction in the hepatic  duct; sometimes how-
ever bile'is  carried into the circulation without any as-
signable cause.  In these cases the health is not materi-
ally affected ; the symptom of which the patient princi-
pally complains,  is an irresistible disposition to sleep.
                     Treatment.
  This last named affection  may be speedily removed
and the bile restored to its natural channel by  adminis-
tering an emetic, and afterwards brisk cathartics for two
or three  mornings in succession.   Should these medi-
cines fail in producing  the desired effect, five grains of 
Hepatitis.
121
the mercurial mass,  or what will be sometimes found to
answer better, one grain of calomel with two grains of
powdered  squils, should  be  given every night and
morning.


                    CHAPTER XII.

                      Hepatitis.

  Pyrexia; hypochondrii dextri tensio et dolor; ssepe pungens pleuritici instar,
ssepius obtusus ; dolor ad claviculam et summum humeri dextri; decubitus in
sinistrum latus difficilis ; dyspnoea; tussis sicca; vomitus ; singultus.—CI. i. O.
ii. G. xvii. Culleni.

   If copious venesection be employed in the early stages
 of this disease, it may in this climate, (and I am strong-
 ly inclined to  believe in any other) be for the most part
 conducted to a favourable termination.   Where  this is
 neglected, abscesses will form, and often sooner or later
 destroy life.
   These abscesses point and burst in various directions;
 I believe, however, that they most frequently make their
 way  through  the diaphragm into the thorax.   I have
 met with several cases in  which they thus  terminated.

                    CASE XXVII.

    Francisco Fernandes, a Spaniard, aged twenty-nine
 years was admitted on the  20th of  December, 1810.
 He coughed up every day blood blended with pus.  All
 the symptoms of phthisis pulmonalis  came  on  in rapid
 succession and put an end  to a miserable  existence at
 the expiration of three  months.
                     Examination.
    The liver  was  enlarged  and  of a  whitish  colour.
  Within its substance were many tubercles,  and several
  small abscesses.   These small abscesses  had communi-
             16 
122                  Hepatitis.

cation with a large one situated  on its convex surface.
This abscess extended through the diaphragm and pour-
ed its contents into the cavity of the thorax.  About two
quarts of pus, mixed with blood, were found in the chest.
The under surface of the lungs was abraded, and there
can be no doubt of pus having been taken up by them
and carried out by the trachea.  The texture of the dia-
phragm was universally altered, and its muscular fibres
had lost their redness.  The lungs adhered to the pleu-
ra, and the heart to the pericardium.
                     Remarks.
  During the illness  of this patient, he was never sus-
pected to have any disease of the liver, as that organ per-
formed all its functions with regularity; neither was he
at any  time heard to  complain of the sympathetic pain
in the shoulder, which so frequently occurs in a diseased
state of that viscus.  I am inclined to think  that an ab-
scess, seated in the liver and extending itself through
the diaphragm  into the thoracic cavity, much more fre-
quently occurs  than is suspected ; and that many of the
cases, which have been considered truly pulmonic, ori-
ginated in the liver.   I have since met with a case in its
progress and termination very much resembling the case
above  related.   Its precise nature however was clearly
pointed out  by the additional  circumstance of a large
quantity of bile being mixed with the expectorated blood
and pus.
   Upon examination  after death,  it  was found that the
right lung had an immediate communication Avith a large
abscess situated in the liver, the interposing diaphragm
having been removed by the absorbents.  Upon pressing
the gall-bladder, bile floAved  freely and copiously into
the cavity of the abscess.
   Bile was likewise ejected from the stomach  in im-
mense quantity,  distressing the patient exceedingly; it 
On the Function of the Liver.         123
was also universally diffused through the  circulating
system.
  In cases  where disease of the liver has extended itself
into the lungs, the expectorated matter has often assum-
ed a reddish fleshy aspect.  This appearance of the dis-
charged fluid  may  sometimes enable us to  distinguish
the disease from true phthisis pulmonalis.

                 Chronic Hepatitis.

  Chronic Hepatitis requires a judicious administra-
tion of mercury for  its removal.   Blood may likeAvise
be from time to time advantageously taken  away from
the hypochondria by  means  of leeches or cupping-
glasses.
   Where an indurated or enlarged state of the liver can
be distinguished mercurial  frictions over it  must be di-
rected.
                   CHAPTER XIII.

            On the Function of the Liver.

  The  anatomical researches of Mr. Abernethy and
Mr. Laurance, have confirmed an opinion I have for a
great  length of time  entertained.   These Gentlemen
found two children, in Avhom the vena portae instead of
ramifying through the substance of the liver, terminated
immediately in  the vena cava.  In these subjects, bile
was met with in the gall-bladder; and there was reason
to believe that it had been regularly secreted during life.
These cases indisputably prove that the hepatic artery
is destined for the secretion of bile, as well as for  the
nourishment of the liver.
  To affirm that bile is formed by a vein, is so directly
in opposition to the general and known laws of the ani- 
124
Peritonitis.
mal economy, that it is a  matter of surprise how  such
an assertion  should have  gained almost universal cre-
dence.
  It appears to  me that the vena porta is intended to
preserve an equilibrium in the circulation of the blood.
If the blood which  is sent to the abdominal viscera were
returned immediately  to the  heart, instead  of passing
through the liver, the same inconveniences would result
from it as arise from a too rapid circulation; whereas
by being compelled to pass through the liver, about the
same space of time  is  occupied as is taken up for the re-
turn of blood from  the extremities.  In  this manner  I
conceive an equilibrium  in  the  circulation  to be pre-
served.
  The  idea of a  balance in the circulation has  been
treated with levity by some  authors, by others it has
been  seriously entertained.   My own opinion is, that
upon its preservation  health depends; that from its gen-
eral or partial destruction many diseases originate ; and
that  our curative  intentions must be  directed  to its re-
establishment.   The occurrences  of  every day confirm
this opinion, and until I discover something in the  great
volume of nature in opposition to it, I shall cherish it.
                   CHAPTER XIV.

                     Peritonitis.

Pyrexia; dolor abdominis, corpore erecto auctus;  absque propriis aliarum
    phlegmasiarum abdominalium signis.—CI. i. O. ii. G. xiv. Culleni.

  The most vigorous and  decisive practice ought to. be
adopted in the early stages of this disease.  We must
use the lancet  with an unsparing hand,  and cover the
abdomen  with leeches.   These remedies must be per- 
Peritonitis.
125
 sisted in as long  as the patient complains of excessive
 pain or tenderness in the abdomen.
   The superiority of this  practice over the inert, half
 measures but too frequently relied upon, was strikingly
 exemplified a short time since.

                  CASE XXVIII.

   A young woman, eighteen years of age, was sudden-
 ly attaked with the symptoms of acute peritonitis.  She
 complained of extreme pain over the whole abdomen,
 which was greatly aggravated by pressure.  Her pulse
 was hard, small, and  frequent; her countenance  anx-
 ious ; her tongue  white,  her skin hot and dry.  From
 thirty to forty ounces of blood were taken away for five
 days  in succession, and afterwards a few ounces occa-
 sionally, when a febrile disposition was  perceptible.
 The total quantity of blood abstracted was two hundred
 and forty ounces.
   She remained in a debilitated state for some weeks,
 but ultimately perfectly recovered.

                  CASE XXIX.

  A boy aged  seventeen years, labouring  under pre-
 cisely similar  symptoms, had fallen under my observa-
tion a short time previously.   I never  saw tAvo  cases
 bear a more striking resemblance to each other.
  Sixteen ounces of blood were taken from his arm;
 some  leeches applied to the abdomen, and half an ounce
 of the infusion of digitalis was directed  every six hours.
The boy died at the end of three days from his first sei-
zure.   The digitalis produced no  effect either upon the
head, pulse, or stomach.
  The peritonaum and intestines exhibited traces of the
 most active inflammation. The intestines were glued to-
 gether ; flakes of coagulable lymph were deposited upon 
126
Peritonitis.
their surfaces; and nearly a gallon of serum  had been
poured into the cavity of the abdomen, in which globu-
lar transparent pieces of lymph were also floating.
                      Remarks.
   The violence of the pain, tenderness, &c. form the
best criteria for estimating the danger of the patient; and
our practice must be regulated by their intensity.   If we
pay  any regard to the pulse, we shall be more frequent-
ly deceived than  assisted by it.  I  have  seen  cases of
peritonitis,  in which it  remained perfectly natural;
others, in which it was as strong and full as in pneumo-
nia,  acute rheumatism, or any active inflammatory  dis-
ease ;  others in which  it  was small,  feeble, fluttering,
and  almost imperceptible.
   A remarkable instance of the insidious nature of the
disease happened about two years ago.

                    CASE XXX.

   A young woman, for five days after a natural labour,
appeared to be getting well without the occurrence of one
unpleasant symptom.*
   On the evening of the fifth day,  she complained of a
little tenderness above the pubes, slight nausea, and the
abdomen  felt rather tense.  The  pulse  was soft and
equal; the  tongue clean; the skin moist;  the bowels
confined.   She was directed to take an aperient.  For
three succeeding days she remained in nearly the same
state ; her pulse then sunk so low as to be scarcely per-
ceptible ;  the surface of  the body became  cold, and cov-
ered with a clammy perspiration;  the abdomen tense
and  inflated;  and  the  stomach rejected every thing.

  * After delivery, the uterus did not contract upon the placenta with sufficient
force  to effect its expulsion ; and the funis was so very slender that it would
have given way, had efforts for the extraction of the placenta been made with
it; I was therefore under the necessity of detaching it with my fingers from the
nterus. 
Peritonitis.                  127
Cordials were directed for her, but she died in thirty-
six hours.
                   Examination.
  The left  appendages of the uterus were  found in a
sphacelated state;  sphacelated spots were seen upon va-
rious parts of the intestines, the peritonaum was almost
universally inflamed, coagulable lymph thrown out, and
several quarts of serum were in the cavity of the abdo-
men.  No disease  of  the  uterus existed; it had not,
however returned to its natural dimensions in the unim-
pregnated state.

                    Observations.
  This unfortunate case ought to teach us to give our
utmost heed to any tenderness or pain complained of in
the abdomen after  delivery, however slight it may be.
As  a precautionary measure, we shall do well to  make
use of frequent gentle pressure, to ascertain  whether or
not there  be any tendency towards inflammation.  This
woman, previously to her confinement, had  been  much
debilitated by excessive discharges from the vagina, and
from the ulcerated surface of a large Avarty excressence
upon the  pudenda.  This consideration, together with
the total absence of inflammatory symptoms, forbade the
use of the lancet;  or perhaps I ought rather to say, de-
terred her attendants from having recourse to it, or from
supposing that any necessity for it existed.
            Treatment of acute Peritonitis.
  When by the practice already recommended in the
early stages of the disease, the inflammatory symptoms
are subdued, a large blister over the abdomen will be
serviceable.  There is, however, one inconvenience at-
tending the  application of a blister:  it prevents us from
accurately ascertaining, by pressure, the degree of ten-
derness which exists;  consequently  we cannot so well 
128              Peritonitis Chronica.

determine how far it may be necessary to employ further
venesection.
  Much medicine ought not to be exhibited in this com-
plaint;  the frequent injection of enemas will be found
more  serviceable.  It is  to be regretted that the appa-
ratus in general use for throwing up injections is  so de-
fective.
  If there be not great  irritability of  stomach, and the
injections are insufficient to overcome  the  constipation,
calomel by itself, or conjoined with extract of colocynth
must be given.
  When peritonitis is induced by colica pictonum, mer-
cury either internally or externally is  absolutely requir-
ed.  It will sometimes be necessary to combine it with
opium.   Copious venesection  must,  however, always
precede the use of these remedies.
                   CHAPTER XV.

               Peritonitis Chronica.

  Active  Peritonitis  frequently  becomes  chronic.
This is particularly liable to occur when the depleting
and  antiphlogistic systems have not, been early and
vigorously adopted.
                     Treatment.
  A fewr ounces of blood must be taken from  the arm
whenever a febrile or inflammatory diathesis prevails ;
leeches and blisters must be frequently  applied to the
abdomen, and small doses of calomel given.  An active
cathartic administered once or  twice a  week, will be
found of the utmost service.  I have generally found five
grains of calomel, and five grains of antimonial powder
at bedtime, and on  the folloAving morning some castor 
                        Ascites.                    129

 oil, or sulphate of magnesia largely diluted, the most
 efficacious remedies.
   Chronic Peritonitis sometimes arises from, or depends
 upon a diseased state of the mesenteric  glands   If not
 removed by the remedies above directed,  after continu-
 ing for many  months, it sometimes assumes an active
 lorm, and must then be treated accordingly.


                    CHAPTER XVI.

                      Enteritis.

 Pyrexia typhodes ; dolor abdominis pungens, tendens, circa umbilicum torquens,
    vomitus ; alvus pertinacitur adstricta.-Cl. i. O. ii. G. xvi. Culleni.

   In Enteritis the remedies proposed for acute peritonitis
 must be employed.   In this disease the pulse is general-
 ly from the very beginning exceedingly feeble and hur-
 ried; and sinks  more suddenly; the anxiety of counte-
 nance is greater ; the bowels are more obstinately  con-
 stipated ; the stomach more irritable ; and stercoraceous
 vomiting often  superadded.  It  is  in reality,  a more
 dangerous  disease, and demands  proportional energy
on the part of the practitioner.
                    CHAPTER XVII.

                        Ascites.

Abdominis intumescentia tensa, vix elastica, sed fluctuosa.—CI. iii. O. ii. G.
                      IXXJX. CCLLENI.

  An immense number of ascitic patients have been ad-
mitted into this Hospital within  the last five years, and
various measures have been resorted to for their relief.
In a great majority of these cases, more advantage was
            17 
130
Ascites.
gained from mercurial friction, and an occasional dras-
tic purgative, than from any other remedies.  From a
scruple to half a  drachm of mercurial ointment was di-
rected to be rubbed over the abdomen every  night till
the mouth became  slightly affected.   In such cases as
it was found difficult to excite the mercurial action when
the friction was confined to the abdomen, it was applied
to the thighs.  Mercury when thus introduced into the
system will almost uniformly be more  beneficial  in as-
cites than aa hen taken into the stomach.  The purgative
employed  was elaterium.   From  two to five grains of
that most poAverful and most efficacious of all purgatives
were given once or twice a week.   The frequency of its
exhibition was of course regulated by the strength ef
the patient, and by  the effect it produced.  When the
patient is much debilitated, instead of large doses, the
quantity ordered  must be very small; not more than a
quarter of a grain daily, combined with five grains of the
squill pill.
  For the more robust, the same quantity may be taken
night and morning  on the days  when the  larger doses
are not administered, and  will be  eminently  useful.
They may likewise be alloAved to drink freely of a solu-
tion of supertartrate of  potash.   If these remedies are
firmly and judiciously persevered in, they will often re-
move ascites ; provided it has not been of such long con-
tinuance as to have destroyed the vigour  of the consti-
tution, or that no irreducible enlargement, or incurable
disease in the liver exists.
   The distention produced by the accumulated fluid is
sometimes very great, and  the pain and  inconvenience
so considerable, that it  becomes necessary  to resort to
paracentesis.  No permanent advantage is to be expect-
ed from  the operation, and when  it can  be avoided, it
ought not to be performed.  It must be likewise recol-
lected that it is not altogether unattended with danger
for a fatal peritonitis sometimes succeeds it. 
Ascites.
131
  When the operation is determined upon, I am inclin-
ed to think that the most favourable period for perform'
ing it is when the system is under slight mercurial influ-
ence ;  an influence, however,  which has  been found
insufficient to effect the  removal of the fluid by the ab-
sorbents.   Although the absorbents may not be able to
take up  all the fluid, they are unquestionably at this
time in a state of increased excitement, and if the fluid
then present be evacuated, they probably possess enough
activity to  prevent its quick re-accumulation.  In  their
endeavours they will derive  material assistance from
the kidneys, for  if I mistake not, the function of those
organs is impeded, if not almost entirely stopped by the
pressure of the fluid in  the abdomen.  Every one  must
have observed, that after the operation a large  quantity
of urine is formed, and  continues to be formed until the
fluid again accumulates.  This is more particularly to
be noticed in dropsy of  the ovaria.
   The injection of some fluid into the  abdomen with a
view of  producing such a degree of inflammation  upon
the peritonaum,  as should be sufficient to excite univer-
sal adhesion between its opposed surf ices has been pro-
posed, and in one or two instances  successfully prac-
tised.   I must confess,  however, that it appears a pro-
cess so fraught  with hazard, that I could not conscien-
tiously carry  it into execution.  To make use of a very
common, but  an  apposite expression,  peritonaal in-
flammation once excited,  spreads like  wildfire.   We
cannot say to it, "Thus  far shalt thou go, and no far-
ther."   I feel persuaded, that in nine hundred and nine-
ty-nine cases out of a thousand, the degree of inflamma-
tion necessary to effect the requisite adhesions, a\ ould
destroy life.  I have seen  water, and Avine and water,
injected without success.  It is, however, proper to state,
that the cases were extremely unfavourable for the op-
 eration; the  patients would,  in  all probability,  have
 died in a few days, under any treatment. 
132
Ascites.
  Another  reason why the  injection  of fluids  cannot
succeed, is, that ascites very rarely arises from a diseas-
ed state of the peritonaum,  but more  commonly is the
consequence of an enlarged liver ;  mechanical pressure,
from some other cause, upon the absorbent vessels ; or
some defect in the absorbent system itself.
  The following case will be found to possess some in-
terest.

                  CASE XXXI.

  A man, aged thirty-three years, came into the Infirm-
ary on the 31st of March, 1814.   He had been  affected
with dropsy nearly  two years.   His  countenance was
sallow, and indicative of  much visceral disease.  The
abdomen was not very large, but tense, and evident fluc-
tuation  could be perceived.   Great pain was  felt on
pressure being made in the region of the liver, and that
organ, as far as could  be ascertained by external exam-
ination, was  considerably enlarged.   He was  directed
to take the squill pill, with calomel, night and morning,
and the saline antimonial mixture, every six hours. He
also applied a scruple of mercurial ointment to the right
side every night.
   The mouth became speedily, and in so high a degree
affected by the mercury, that it  was suspected  he had
been taking some preparation of it before his admission.
He discontinued it on the third day, and had prescribed
for him an infusion of gentian.
   He persisted in the use of this  medicine till the 13th
of April when the operation of paracentesis  abdominis
was performed,  and  about two gallons of a straw-col-
oured fluid drawn off.  It was desired that the canula
should be allowed to remain in the wound.  A flannel
bandage was  applied to secure it, through which, fluid
continued to exude in considerable quantity.   He passed
the night comfortably. 
Tabes Mesenterica.
183
  14th. He complained of pain in the abdomen; pulse
thready and accellerated ; countenance expressed much
anxiety.   In the evening,  these  symptoms  became  ag-
gravated.   He was directed to take an anodyne draught.
  15th. Passed a restless night;  the whole  surface of
the abdomen extremely tense and  tender; the pulse so
feeble  as  scarcely to be perceptible.  The canula pro-
duced such excruciating pain, that it was deemed advis-
able to remove it.
  He died at seven o'clock this  evening.  No opportu-
nity of examining the abdominal viscera was  afforded.
                .  CHAPTER XVIII.

                 Tabes Mesenterica.

   Marcor ; asthenia; pyrexia hectica.—CI. iii. O. i. G. Ixix. Cclleni.

  When treating of hydrocephalus internus, I offered
an explanation of the manner in which I conceived tabes
mesenterica to be produced,
                     Treatment.
  The patient  should be suffered  to  partake of only
light nutritive food, and the digestive powers of the stom-
ach must be improved, by exhibiting the decoction of
bark made gratefully  acid, and by giving small doses of
mercury.   For children, the hydrarg. cum creta,  given
nightly, in doses of from three to fifteen grains, is the
best preparation.
  If these remedies be employed in the early stages of
the disease, we may anticipate a favourable termination
with some degree of confidence.  In adults, the disease
is more formidable and fatal than in children, fortunate-
ly, however, they are rarely the subjects of its attack. 
134
Tympanites.
                    CHAPTER XIX.

                      Diarrhoea.

Dejectio frequent; morbus non contagiosus ; pyrexia nulla primaria.—CI. ii. O.
                    iii. G. lxi. Cplleni.

                      Treatment.
  For one, two, or three  nights in succession,  as  cir-
cumstances may indicate,  from three to five grains of
calomel, with one grain of opium, should be given.  On
the following morning it may sometimes be proper to di-
rect half an ounce of castor oil.
  If it were necessary, I could safely state that at least
fifty violent cases of diarrhoea have been  speedily re-
lieved by this practice at this Hospital.
  Preparations of chalk, kino,  catechu, &c.  must only
be  used after the alimentary canal  has been freed from
offending matters.   If exhibited in the early stages of
the disease they almost invariably prove hurtful.
                    CHAPTER XX.

                     Tympanites.

Abdominis intumescentia tensa, elastica, sonora; alvus adstricta; ceeteraruiH
          partium macies.—CI. iii. O. ii. G. lxxiii. Cui.leni.

   Active  purgatives  and mercurial  frictions,  either
upon the surface of the abdomen  or thighs,  will more
frequently remove this affection than any other remedies
which I have seen prescribed.
   The facility with which the absorbents take  up air  is
every day evidenced.   If  air,  accumulated  within the
large intestines, be forcibly retained  by the sphincter
muscles attached to the extremity of the rectum, instead
of being  allowed to escape, the absorbents quickly re-
move it; and thus  the necessity  for  a breach of good 
On  Worms.
135
manners is obviated.   By subjecting the absorbent sys-
tem to mercurial stimulus, its activity is increased;  and
thus the removal of accumulated air, either within the
intestines, or between the duplicatures of the peritona-
um,  may be sometimes accomplished.
  Query.  When the air is confined within the general
cavity of the abdomen,  and the absorbents  have been
found insufficient to  effect  its removal, would there be
any  impropriety in discharging it by means of  a trocar
and  canula?
                   CHAPTER XXI.

                      On Worms.

                      TAENIA.

  Rectified oil of turpentine  is certainly the best re-
medy which has hitherto been discovered for the expul-
sion of the tape-worm.  It has been administered at this
Hospital with  almost  uniform  success.  In  some few
cases in which it has not succeeded,  its failure was pro-
bably attributable  to  its not being given  in sufficient
doses.   Less than an ounce  of it will seldom have the
desired  effect.   The proper doses will be found to be,
for a delicate female, an ounce; for a robust female or a
small man, an ounce and a half;  for a robust man, two
ounces.   The best vehicle for it, is milk.   It should be
taken early in a morning, upon an empty stomach.
   Independently of the inefficacy of  small doses they
excite more nausea, vertigo, and other disagreeable feel-
ings, than large ones.  The greater distress occasioned
by small than by large doses is not confined to the action
of oil of turpentine.  Three grains of calomel will often
act as a violent purgative, whereas a scruple of  it (par-
ticularly a second  dose) is one of the mildest aperients
that can be given. 
136        Aortas Descendentis  Ulceratio.
                     Lumbrici.

  Fifteen grains of jalap, the same quantity of rheubarb,
and five grains of calomel, given for three or four morn-
ings in succession, will generally expel lumbrici.
  The same ingredients will be found serviceable for the
destruction of ascarides.   For the rheubarb,  tin-filings
may be sometimes substituted.  As the seat of ascarides
is generally the lower part of the intestinal canal,  it is
probable,  that these  worms might be more speedily re-
moved by the frequent injection of purgative or terebin-
thinate enemas.
  Where the powers of the digestive organs are perfect,
worms of any description cannot  exist; we  must not
therefore confine ourselves to the mere expulsion of the
worms, but endeavour to give tone to the stomach  and
chylo-poietic viscera  by the exhibition of cinchona, gen-
tian, and small doses of mercury.
                  CHAPTER XXII.

           Aortas Descendentis  Ulceratio.

  Mary  Strange,  aged twenty-nine years,  in  the
month of December, 1810, in  consequence  of a  fall,
miscarried;  she lost at  the time, about three pints of
blood.
  She never, afterwards, menstruated regularly.  The
menses would disappear for two or three months in suc-
cession, and then flow profusely for two or three weeks.
The discharge was \Tiscid, and of a dark mahogany co-
lour.  She experienced occasional difficulty in discharg-
ing her urine, which sometimes resembled curdled milk;
at other times it was very highly coloured, and appear-
ed to contain blood.
  About five months after her miscarriage, she  complain- 
           Aortas Descendentis  Ulceratio.        137

ed of violent pain  in  the back and loins, which  was
greatly exasperated during the periods of menstruation.
This pain was accompanied  with Aiolent palpitation of
the heart,  which continued from tAventy-four to forty-
eight hours after the pain had abated.   With the palpi-
tation, the patient experienced great nausea and sickness,
the stomach rejecting every thing received into  it; and
sometimes she threw up a quantity of viscid mucus.
   She was frequently  bled and blistered;  but seldom
derived,  from the use of these remedies, any mitigation
of suffering.
   In the month of January, 1811,  she had a very vio-
lent attack.  From this time,  to the beginning of Sep-
tember, she gradually recovered, and was  able to  go
about her ordinary business.
   In the last named month she was seized with violent
pain in the left  hip ;  which extended across the bowels
to the back, and from thence to the pit of the stomach.
The heart palpitated with increased power, and induced
fainting for three or four hours; her  breathing was some-
times loud and laboured; at other times it was  scarcely
perceptible ; the superficial veins of the head, neck, and
upper extremities,  became  greatly distended.   These
paroxysms occurred four or five days in the week;  they
subsided  very gradually, and with hysterical sobbing
and crying ;  the urine still continuing turbid.
   In  the month of November she had a return of the
uterine discharge,  which continued for ten or twelve
days; it was very profuse, and of a dark colour.  She
felt great tenderness in the hypogastric region.  She con-
tinued nearly in  this state till July the 12th, 1812 ; at
which time she was admitted into this Hospital.
   The above is a compressed narrative of her suffer-
ings,  as  they were related  by her  husband.   The pa-
tient  was  too ill and too  exhausted to be able  to afford
much information.   She appeared to be labouring under
            18 
138        Aortas  Descendentis  Ulceratio.
inflammation of the peritonaum.   There was consider-
able tumefaction of the abdomen; pressure upon it oc-
casioned great pain ; her pulse Avas  thready and rapid;
her tongue dry;  her countenance expressive of anxiety;
her respiration hurried.   At the pit of  the stomach a
remarkable depression Avas evident.
  A feAV ounces of blood Avere abstracted from the arm,
which speedily became buffed.  A blister Avas applied
to the chest, and some saline medicines prescribed.
  On the following morning, she reported  that she expe-
rienced relief from  the bleeding; it was therefore ordered
to be repeated : it was evident, however, that nothing
could be of permanent service.  A few days preceding
her dissolution, Avhich took place on the 29th of August,
a pulsatory motion Avas felt upon the application of the
hand to the abdomen.

                   Examination.
  When the abdominal muscles were turned back, an
immense tumor was exposed.  It  occupied almost en-
tirely the left side of the cavity of the abdomen. Through
the peritonaum which invested  it, it looked very much
like the uterine  surface of a placenta.  Upon dividing
the peritonaum, the tumor was found to consist of coag-
ulated blood.  After six or seven handfuls of this coa«--
ulum were removed, the  left kidney presented itself.
It occupied nearly the centre of the tumor; as much
blood was behind  it, as had been  taken from  its upper
surface.   The emulgent vessels were much elongated.
Probably they had been rendered so by the mechanical
force applied  to them.  The fore-finger, passed upon
them to their origins,  and then directed a little upAvards,
went immediately into the cavity of the descending aorta.
It appeared that a  circular piece of  the artery had been
removed by the absorbents.  Upon the inner surface of the
peritonaum, no layers of coagulable  lymph had been de- 
portae Descendentis  Ulceratio.         139
posited;  then was not, in fact, any thing which resem-
bled an aneurismal sac.
  The other abdominal, as well as the thoracic viscera*
were inspected, but no disease Avas detected in them.
                      Remarks.
  This case differs from any other with which 1 am ac-
quainted, in as much as no aneurismal sac existed, the
peritonaum investing the aorta forming  the only obsta-
cle to the effusion of  the blood into the general cavity of
the abdomen.
  That a diseased action, capable of destroying the coats
of the aorta,  should take  place  without inclosing the
peritonaum is truly extraordinary; and it is no less sur-
prising that the peritonaum should be subjected  to so
much distention, and yet be capable of resisting the im-
petus with Avhicli  the blood must have  been  from time
to time driven against it.
  The symptoms, attendant upon this peculiar state of
the artery, probably do not differ materially from those
excited by a perfectly  formed aneurism  of the vessel in
a similar situation.  The constant pain in the  back, pro-
duced by the distended state of the peritonaum; the
derangement in  the uterine and urinary secretions ; the
syncope  and palpitation, Avhich we must conclude were
produced by the escape of blood from  the aorta; the
tumor of the abdomen ; and lastly,  the pulsating mo-
tion felt a few days before the death of the patient; I
think, point out the  nature of the disease with a suffi-
cient degree of precision to enable us to distinguish anal-
ogous cases. I have much  to regret, that an opportunity
was not  afforded me of minutely  inspecting the coats of
the aorta. 
140
Nephritis.
                   CHAPTER  XXIII.

                      Nephritis.

  Pyrexia; dolor in regione renis, saepe ureteris iter sequens ; mictio frequena
urinae, vel tenuis decoloris, vel ruberrimae;  vomitus;  cruris stupor; testiculi
ejusdem lateris retractio aut dolor.—CI. i. O. ii. G. xix.  Cullewi.

   The remedies which will be found the most efficacious
in this disease are, venesection  from a small orifice, ad
deliquium; cupping;  leeches and  blisters  about  the
lumbar regions ; and warm bathing.
   Warm bathing will produce a powerful determination
of blood to the surface of the body, and greatly increase
the action of the cutaneous  exhalant vessels ;  two pur-
poses  which  it is peculiarly desirable  to effect in this
affection.
   Blisters are not so liable to excite  strangury,  when
applied in the immediate vicinity of the urinary organs,
as when they are placed upon parts remote from them.
   A  constipated state of the intestinal  canal is to be
guarded against; but before the inflammatory symptoms
have been subdued, any other class of medicines  than
aperients will be not only useless, but prejudicial; par-
ticularly if they possess diuretic properties.  Diuretics,
by determining a larger quantity of blood to  the  kid-
neys,  must, of necessity, aggravate the disease.
                   CHAPTER XXIV.

                       Diabetes.

   Urinae plerumque praeternaturalis, copia immodica, profusio chronica.
                 CI. ii* O. iii. G. Ixii. Culleni.

  In this disease,  more benefit has  resulted from the
treatment recommended by Dr. Watt, of Glasgow, than
from any other which I have seen employed.   In one 
Diabetes.
141
case, it promised  to be attended with complete success,
when an untoward accident disappointed well  founded
and sanguine expectations.

                 CASE XXXII.
  Mary Phipps,  aged fifty-two years, a small woman,
and much emaciated at the time of her admission, made
daily from six to seven pints of nearly colourless urine,
strongly flavoured with saccharine matter.
   For  some weeks  she was confined to animal food,
and  restricted as much as possible in the use  of fluids.
No advantage resulting from this regimen, she was di-
rected to lose from ten to twelve ounces of blood three
times a week. The blood presented all the appearances
so accurately described by Dr. Watt; the crassamentum
 was at  first almost destitute of tenacity,  and  of a dark
 colour; after the fourth bleeding, it became firmer, and
soon afterwards exhibited a layer of deeply cupped  co-
agulable lymph upon its surface.
   This plan was persisted in for three weeks ; the urine
 gradually diminished in  quantity; it  was reduced to
three pints  in  twenty-four  hours, and reacquired  its
proper odour and taste.   When things  were brought to
 this favourable state, she unfortunately purloined nearly
 a pint of rectified spirit of wine, which she drank in an
 undiluted state.  Almost immediate intoxication came
 on, which, in less  than an hour, Avas succeeded by a
 state of apoplexy, and she died in four  hours.  Power-
 ful emetics were administered  very soon after she had
 taken the spirit,  but vomiting was not excited by them.
                     Examination.
   The vessels of the dura and pia mater were gorged
 with blood, and a small quantity of serum was found in
 the lateral ventricles, and at the basis of the brain.
   The kidneys were large and rather flaccid.   In the
 right kidney there was a hydatid, of the size of a hazel
 nut. 
142       On the Function of the Kidneys.

  As the general evacuation of blood is found so benefi-
cial in this disease,  it is extremely probable that its fre-
quent topical abstraction, by means of leeches and cup-
ping-glasses, from  the  lumbar  region, would be also
eminently advantageous.
  The excessive thirst of which diabetic  patients often
complain, is much ameliorated,  and the patients  them-
selves are benefited, by drinking freely of sulphuric acid,
copiously diluted with water.
  Query.  How far might the hydatid, in the right kid-
ney, prove  an exciting  cause of  the disease?   Dogs
make a very large quantity of  urine.  The kidneys of a
dog I examined a short time since, were full of hydatids.
Are these animals particularly subject to this  species of
animalcula ?
                  CHAPTER XXV.

           On the Function of the Kidneys.

  The urine is generally regarded as  an excremehti-
tious fluid.   If it  be so, it is the only animal fluid which
can be considered as such.  All the other secretions an-
sAver  some purpose  after their  deposition.  The tears
lubricate the  eye-balls; the  synovia facilitates the mo-
tions of the joints ;  the saliva assists digestion, &c. it is
difficult therefore to conceive that the secretion of the
kidneys can form an exception to this general law of the
animal economy.
  In the month of October, 1815,1 injected rather more
than a pint of warm milk and Avater into the bladder of
a patient who had been for some years suffering from an
ulceration of the  inner membrane of that reservoir. The
fluid for a feAV minutes occasioned uneasiness ; an unea-
siness which the patient imputed entirely to over-disten-
tion.   This unpleasant feeling gradually subsided, and 
On the Function of the Kidneys.        143
at the expiration of half an hour,  he said that  he was
certain his bladder  was  perfectly empty.   Upon  de-
siring him to  allow any fluid that might be in the blad-
der to pass through the  catheter,  about two ounces of
highly fetid pus mixed with a very small quantity of the
milk and water came away.
  The removal of the injected fluid could only have been
effected by the absorbents.   This circumstance gavTe rise
to a suspicion, that the absorbents upon the inner  sur-
face of the bladder were destined to reconvey the purer
portion of the urine  into the system, leaving  only the
more  acrid part  to be expelled.   What purposes the
fluid  taken up may answer, it  is difficult to determine;
it is possible,  however, that it  may contribute towards
the formation  of the tears, the saliva , the perspiration;
and several other secretions.  Of  this I feel persuaded,
that an infinitely larger quantity of fluid is deposited in
the bladder than is expelled from it; and a strong anal-
ogy justifies the conclusion, that urine is not purely ex-
crementitious.
   I have  the kidney and ureter of a patient who died of
phthisis.   The kidney is free  from disease; the ureter
is distended with  urine to about three times  its natural
size.   The urine it contains is prevented from  escaping
by an impervious stricture in the ureter.  The stricture
is placed at the inferior part of the  ureter, just  before it
terminates in  the coats of the bladder.
   The patient, from whom this preparation  Avas taken,
was never known to be labouring under any disease of, or
derangement  in, the  functions of the urinary organs.
Had  not  the  absorbents possessed the power of remov-
ing the urine  from the ureter, as it was secreted from the
kidney,  the tube must have been ruptured by its exces-
sive accumulation.   This case comes strongly in support
of the theory  I have advanced.   Dr. Darwin has insist-
ed upon  the existence of what  he calls the retrograde
motion of the  absorbents of the bladder. 
         SECTION  "V.
ON diseases of the pelvic viscera.
                     CHAPTER I.

               Affections of the Bladder.

   I am inclined to think that almost all the diseases to
 which the bladder is liable arise from suffering it to  be
 frequently in  a state of extreme distention.   Fema les
 from motives of false delicacy, often entail  upon them-
 selves loathsome, painful, and incurable affections of this
 organ.  Inflammation of the bladder; an extreme  irri-
 tability, and  subsequent ulceration of its  inner mem-
 brane; an incontinence of urine,  and an  inability  to
 evacuate it; may be generally traced to the foolish habit
 of retaining it for hours after it  ought to have been ex-
 pelled.
  If the urine were  discharged  whenever it,  either by
 its accumulation or acrimony, excited uneasiness, nuclei
 for calculous concretions would have no opportunity  of
 forming.
                     Treatment.
  For the removal  of inflammation of the bladder we
 must resort to  copious general, and topical blood-letting;
 fomentations to the hypogastric region ; and warm bath-
ing.   Distention  must be carefully guarded against by
the occasional introduction of  the catheter.
  An  irritable state of the  inner membrane of the
 bladder will be much alleviated, and sometimes remov-
 ed, by the frequent application of leeches to the perina-
um and pubes, and by the warm bath.   Alcaline prepa-
rations, exhibited internally,  afford great relief.   The
most efficacious medicine of this class  is the aqua kali 
Affections of the Bladder.          145
puri (liquor  potassa)  in  doses of from six  to tAventy
drops, three times a day.   The same preparation Avill
be  found useful  in  ulceration of  the  inner membrane.
Much benefit is also to be derived  from the injection of
tepid milk and Avater into the bladder.
  Incontinence of urine, when depending upon a para-
lysis of the sphincter muscles of the neck of the blad-
der, may be sometimes remedied  by the application of
blisters to the perinaum, pubes, and sacrum, and by the
internal exhibition of the tincture of cantharides.
  An inability to expel the urine (which appears to de-
pend upon a paralysis  of the muscular coat of the blad-
der, while the sphincter muscles retain their contractile
power) requires  the same treatment.   In addition to
these, it will be absolutely necessary to keep the bladder
empty by introducing the catheter three or four times
every day.  A great number of females have been ad-
mitted into this Hospital,  labouring under this affection
of the bladder; and they all attributed it to the practice
of improperly retaining its contents.
  When calculi form in the bladder of a male, they can
only be removed  by the operation of lithotomy ;  in the
female, however,  before the operation is resorted to, a
gradual dilation of the urethra, by means of bougies,
ought to be attempted, particularly  if it can be ascertain-
ed that the stone is of  small dimensions.  The urethra
of the female is capable of very Considerable dilation ;
and if by the means above recommended the removal of
the stone can be effected,  there will be less danger of a
permanent and incurable incontinence of urine, than is
incurred by the ordinary operation.
  As an inability to retain the urine so generally results
from the usual operation upon females, would it not be
advisable to operate upon them above the pubes ?  I am
one of the few who still think  that  the higher  operation,
as it has been denominated,  whether for the male  or fe-
           19 
146         On Affections of the Rectum.
 male, is the best.  If the bladder be allowed to become
 completely distended before the incision is made, there
 will be but little danger of wounding the peritonam, and
 all risk of effusion of urine into the cellular  membrane
 may be effectually guarded against, by keeping an elas-
 tic gum-catheter (introduced by the urethra)  constantly
 in the bladder, for a few days after the operation.
   As a proof of the practicability of this measure, I shall
 make an extract from page 121, of the £i Sketches of the
 Medical Schools of Paris," by Mr. John Cross.
   "  It is astonishing with how little inconvenience  pa-
 tients kept in bed submit to the presence of this instru-
 ment (the gum-catheter) in  the  canal, which is changed
 every four or six days, for the sake of introducing  a
larger one;  and but for this reason, it might be left in a
fortnight or three weeks without being renewed, the only
thing requiring  attention  being the incrustation upon
the extremity of the instrument, which sometimes forms
in seven  or eight days,  and at others, not in as many
 weeks."
   If then, in a diseased urethra, an elastic  gum-catheter
can  be retained for  many weeks,  with how  much ease
 might it be kept in a healthy canal.
                   CHAPTER II.

            On Affections of the Rectum.

  To the improper practice of retaining the contents of
the rectum, after they have,  by accumulation,  excited
uneasiness, many of the diseases of that intestine may
be referred.
  The absorbent vessels opening upon the inner surface
of the rectum are numerous, and extremely  active.  If
the feculent matter protruded into it by the  peristaltic 
On Affections of the Rectum.         147
motion of the intestinal canal be not speedily expelled,
tue absorbents  remove its watery particles, and conse-
quently render its exit very difficult.   For the removal
of hardened faces, the action of the muscles  affixed to
the rectum is insufficient; the abdominal muscles must
therefore be put in requisition.  These muscles,  by their
pressure upon the abdominal viscera, propel  ah undue
quantity of blood into the rectum, and other pelvic vis-
cera.  The coats of the vessels thus over-distended, by
degrees become weakened and varicose.   Hence arise
hamorrhoidal tumors, and effusions of blood.
   Hardened faces are not only productive of mischief,
by requiring an improper degree of muscular force for
their expulsion, but in their passage along the rectum,
they frequently  abrade  its lining membrane.   These
abrasions  lay the foundation of fistulous openings  and
strictures.
   Indurated faces irritate  the rectum, and excite  a
spasmodic contraction of the sphincter  muscles, thereby
producing another  serious impediment  to their expul-
sion.
   Prolapsus of the  rectum is another consequence of
the improper retention of the feculent matter.
                     Treatment.
   The cure of all diseases of the rectum will  be  facili-
tated, by expelling its contents as soon as they  excite
disagreeable feelings.  If these feelings  were carefully
attended to,  the  muscles belonging to the rectum,  and
intended by nature for the expulsion of the faces, would
be found perfectly sufficient for that purpose.
   Hamorrhoids of recent formation, may  be generally
cured by the regular administration of some mild aperi-
ent.  The confection of senna, combined Avith a portion
of sulphur, will be found as convenient and efficacious a
medicine as  can be employed.   The pasta piperis com-
posita is also a useful medicine. 
148          On Affections of the Uterus.
   When the tumors have been formed for a length of
time, and are exceedingly painful,  nothing will afford
so much relief as the frequent application of leeches.
Much ease is  also  often  experienced  from the use of
henbane ointment.  Sometimes (but not very frequently)
it may be proper to  remove some of the tumors, either
by ligature, or Avith the knife.
   Strictures of the rectum, and  spasmodic contractions
of its sphincter muscles, are best treated by the frequent
inrroduction of bougies.*  When fistulous  communi-
cations  between the  rectum and an external part  have
been established, I knoAv of no other remedy than an
operation.
  I have met Avith several cases of diseased rectum, in
which an opening into the cavity of the pelvis existed.
Through this opening I have withdrawn some lumbrici.
A fistulous opening  of this description, as well as the
more common forms of fistula in  ano, will often be met
with  in phthisical  patients.   Fools, madmen, or bad
men only, will operate upon such patients.
   Whenever a prolapsus  of the rectum occurs, the in-
testine  should be washed with a solution of sulphate of
alumine, with a decoction  of bark, or some other astrin-
gent, and immediately replaced,
                    CHAPTER III.

             On Affections of the Uterus.

                      hysteria.

  Ventris murmura; sensus globi in abdomine se volventis, ad ventriculum et
fauces ascendentis, ibique  strangulantis; sopor ; convulsiones ; urinae limpidas
copia profusa ; animus, nee sponte, varius  et mutabilis.—CI. ii. O. iii. G. lxiii.
Cplleni.

  As hysterical symptoms  are generally supposed to
be excited by a  peculiar state of the uterus, 1 have plac-
     * See Mr. Coupland's excellent Work on diseases of the Rectum. 
On Affections of the Uterus.         149
ed the disease under affections of that organ ;  I am in-
clined to believe, however, that the brain is the real seat
of the disease, and that the uterus is only  sympathetic-
ally affected.
  The laws of well-regulated  society (as applied to un-
married persons,) and the laws of Nature,  are opposed
to each other.  The former are, for the most part, suffi-
ciently powerful to prevent a compliance with the dic-
tates of the latter ; but in the conflict, both  mind and
body sometimes suffer.
  A natural desire to possess  that which the laws of
society forbid, produces an irritability of mind, and a
consequent  determination  of blood  to the brain ; the
sympathy between the brain and the generative system.,
although inexplicable, is well known to be direct.

                      Treatment.

  We shall find nothing so effectual for the relief of
hysteria, as venesection.   In plethoric habits, it  is ab-
solutely demanded ; in the most delicate, its occasional
employment is highly necessary. The quantity of blood
taken away must  of course  be proportioned to the
strength of the patient.
  When, with hysteria, there is a deficiency of the cata-
menial discharge, blood should be regularly taken away
every month at the  time,  or shortly  before the menses
make their appearance.  A spare diet and exercise must
be directed, and a proper attention paid to the state of
the intestinal canal.   The whole class of stimulants, so
generally employed,  must be  studiously  avoided. A
great majority of the cases of hysteria, which  have  pre-
sented themselves at this Hospital, have been  combined
Avith increased action of the heart, inordinate  throbbing
of the carotid arteries, and not  unfrequently with strong
pulsations of the descending aorta, or caliac artery. 
150
Leucorrhoza.
                 Emansio Mensium.
  When the menses do not  make their appearance  at
the proper ago ;  venesection employed monthly; elec-
tric shocks applied to the pubic, hypogastric, and lum-
bar regions, and the administration of aloetics, will often
succeed in exciting the uterus into the desired action.
                    CHAPTER IV.

                    Amenorrhea.

Menses tempore quo fluere solent, vel solito pareiores, vel non omino fluentes.
        citra graviditatem.—CI. iv. O. v. G. cxxvi. Cvllemi.

  The treatment recommended for retention is  equally
applicable to  suppression of the catamenial discharge.
It will frequently happen that the menses will flow at
the same time that the blood  is making its escape from
the arm, or immediately after the application of the elee
trie shock.
  Chorea, emansio mensium, and amonorrhcea, are the
only affections in which I have ever found electricity of
the slightest service.
                    CHAPTER V.

                    Leucorrhoza.

  It will be necessary to have recourse to occasional
blood-letting in plethoric habits for the cure of Leucor-
rhcea.   In such habits it will  not always be proper to
put an entire stop to  the discharge, but only to mode-
rate it.
  Debilitated patients  will require an opposite line of
treatment.   Bark, steel, or some other  tonic, must be 
                    Menorrhagia.                151
given, and  some astringent lotion injected into the va-
gina.  The application of cold water every morning, to
the loins, will be attended with great advantage.  When
the discharge is thin  or acrid, benefit will  be obtained
from giving nightly a grain of opium.  Violent exertion
should be avoided, and a  recumbent posture  inculcated,
particularly if procidentia or prolapsus uteri be  at the
same time present.
                     CHAPTER VI

                     Menorrhagia.

  Dorsi, lumborum, ventris, parturientium instar, dolores ; menstruorum copio-
sior, vel sanguinis e vagina praeter ordinem fluxus.—CI. i. O. iv. G. xxxix
CULLENI.

   Menorrhagia must be treated in the same manner
as leucorrhcea,  except that during  the  presence of the
discharge, injections, and the application of cold,  must
be abstained from.
               Ulceration of the Uterus.
   Ulceration of the cervix uteri, and consequent hemor-
rhage, is sometimes mistaken  for menorrhagia.   The
error will be easily detected, by an examination per va-
ginam : not only the os uteri will be wanting, but the
entire neck of the uterus  will  be  found to be  removed.
The body of the uterus itself undergoes  no  change, ei-
ther in size, form, or structure.
  The disease most commonly occurs between the ages
of forty-five  and fifty-five ; it uniformly proves, sooner
or later fatal.  Upon examination of the uterus, it looks
rather as if its neck  had been  eaten  by mice, than as  if
it had been taken away by the absorbents.
  It  has been my good fortune, never to meet with  a
cancer of the uterus. 
      SECTION  VI.
on affections of the SPINE, &c.
                    CHAPTER I.

                  Diseased Spine.

  Disease of the spine is said to be of very frequent
occurrence.   It may be so; but I feel persuaded that it
does not occur half so frequently as is imagined.  A del-
icate female cannot now complain of pain in the back,
but a Surgeon is immediately  sent for,  to examine the
spine.   If after thumbing it, and  striking it  with his
knuckles from  occiput to coccyx for half an  hour, one
part is discovered to  be, or has been rendered by the ex-
amination more tender than the rest, it is very gravely
pronounced  to  be diseased.  Incarceration,  for three
months, or sometimes  for three years, is immediately
directed, and setons or issues made in the back.  If by
this judicious treatment, aided by confinement, the health
of the patient be not destroyed, in a reasonable time she
is  declared  to be cured of the disease, and allowed to
get up.  I have known cases of this description kept " in
durance vile" three years, and ultimately recover ; the
recovery, however, did not take place till after  they had
escaped from under the hands of the Surgeon.  Impo-
sition, under any disguise, I detest; wherever I see it?
I will expose it.
                    Treatment.
  When the spine is actually diseased, absolute rest is
requisite.   Leeches should be frequently applied in the
vicinity of the diseased  vertebra,  and every  possible
means employed to improve the  constitution.  Bark,
Avith carbonate of ammonia, or muriate of lime,  will be
eminently useful. 
               Fracture of the Spine.            153

                   Psoas Abscess.
  I have never examined psoas abscess, without finding
it connected with disease of the vertebra ;  and I am in-
clined to think that it ought to be treated as such.
  For  an account of the appearances usually met Avith
on dissection, see Case V.
                    CHAPTER II.

               Fracture of the Spine.
                 CASE XXXIII.
  James Palmer, aged sixty-three years,  was admit-
ted into the Infirmary, on Wednesday, June 19th, 1812,
at ten  o'clock at night.   He  stated,  that about seven
o'clock, he fell from a load of hay, backwards, and that
he struck the back of his neck  violently against the
ground.
  When the head was  elevated, he complained of ex-
cruciating pain.   There appeared to be a slight depres-
sion in the integuments above the spinous process of the
fifth cervical vetebra; but whether it was the natural
conformation  of  the part, or the consequence of the in-
jury, could not at that time be determined.  His mental
faculties were not at  all  impaired, but his speech  was
rather indistinct.   His upper and lower extremities Avere
completely paralysed and destitute of sensation.  Vari-
ous parts of  his body were pinched, Avithout his being
at all conscious  of  the violence committed upon them.
His pulse Avas full and sIoav ; it did not beat more  than
fifty times in the minute.   TAvelve ounces of blood were
directed to be taken from his arm, and afterwards a ca-
thartic powder was given him.
  20th.  He appeared somewhat better;  his articulation
Avasmore distinct; his pulse eighty, and  regular; he
slept a little during the night.   As he Avas incapable of
           20 
154             Fracture of the Spine.

expelling his urine, a catheter Avas directed to be passed
twice a day.   The cathartic powder produced no faecal
evacuation.   Half an  ounce of castor oil Avas directed
every four hours.
   21st. In  the same state as yesterday.   He once felt
an inclination to go to the closet; but, Avhen  there, was
unable to expel any thing from  the intestinal canal.
   22. Pulse  diminished  in  frequency, not  more than
forty-eightinthe minute, and was weaker than upon his
first admission.   Voice feeble and indistinct.  He died
about nine o'clock at night.
                    Examination.
   Upon making an incision along the spinous processes
of the cervical vertebra, blood, in considerable quanti-
ties, was  observed  to have been  extra vasated.  The
spinous process  of the fourth cervical vertebra, reckon-
ing from the atlas, with that portion of the vertebra con-
stituting the  back part  of the medullary  canal, was
broken off" from  the  body of the vertebra.  It was quite
loose, and only required to  be dissected  from the sur-
rounding muscular  substance to be removed.  Its infe-
rior edge was advantageously  situated for making com-
pression upon the medulla spinalis, and probably was
driven upon it at the time the blow was inflicted.   The
medulla was  not at all lacerated, nor did it exhibit any
mi rk of long-continued compression.  Upon puncturing
its investing membrane, a quantity of serous fluid escap-
ed.   It could not be discovered that the body of the ver-
tebra was injured.
                    Observations.
   The most remarkable circumstance in this case is the
length of time the patient lived after the accident.  It
has been stated that a fracture  of the cervical vertebra,
 for the most pari, proved instantly fatal; whereas this
 man lived seventy-one hours.  The case warrants the 
Fracture of the Spine.
155
conclusion, that an operation would have saved the pa-
tient.  Where the medulla spinalis is simply compress-
ed, and w ithout having sustained any laceration or other
injury, I can see no reason why the removal of the com-
pression should not relieve as effectually as elevating a
portion of depressed bone from the cerebrum.
  It may, perhaps, be urged against an operation, that
it  is  impossible  to determine whether  the medulla be
torn or not.   It is a common practice, to destroy ani-
mals, by dividing the  medulla.   They die almost in-
stantaneously after the  operation.  Almost as  sudden
will be the  death of a  patient, w here the medulla (as it
is passing along the cervical vertebra) is wounded; but
where it is simply compressed, the patient may  survive
hours, or even days, as in the case above related.
  A force sufficient to  fracture  the body  of one of the
superior cervical vertebra, would inevitably destroy life
at the same time ; but a less degree of  force would be
capable of breaking off the processes of  the  vertebra,
and driving them upon the medulla.  If they be suffer-
ed  to  remain there, the patient will inevitably  die ; if
they be elevated, he  may live.   Whenever,  therefore,
a superior dorsal or ceivical vertebra  is  fractured, an
examination of the parts should be made, if the patieut
survives a few hours.   It cannot possibly  do harm, and
affords a prospect of  success.  The immense  mass of
muscular fibre which must be cut through, to expose the
vertebra completely, ought not to deter us from making
an incision through it.   No part of importance can be
wounded, even though the incision were  to be carried
through the whole length of the spine.   Generally, an
incision of five inches in extent will be sufficient.
   In a work professedly medical, perhaps 1 have erred,
by introducing a surgical case.   I  have,  however, so
frequently seen patients with injuries of  the  spine suf-
fered to perish, without a single effort being made for
(heir relief, that I trust the irregularity will be forgiven. 
SECTION VII.
                    CHAPTER I.

                  Theory of Fever.

  In what fever essentially consists, has baffled the pow-
ers of the  most distinguished medical philosophers to ex-
plain.   If it were possible  to discover  it, perhaps it
would not enable us to treat it more successfully.  It is
of greater importance that we should be  aware of its
exciting causes, and that we should be able to moderate
their baneful influence.
   Mental anxiety, the exposure of the body to a great
increase or  diminution of temperature ;  and  vegetable
and animal effluvia, are the most frequent exciting causes
of iever.  Mental anxiety produces a great determina-
tion jf  blood to the brain.   The  exposure of the head
to the rays of an intense sun, has the  same effect.  If a
great abstraction  of caloric take place  from  the surface
of the body, an undue quantity of blood will be propel-
led upon the brain, lungs, liver, or some other viscus.
The application of effluvia is productive of the same ef-
fect ;  more powerfully, and to a greater certainty, how-
ever, when the animal powers have been previously im-
paired by mental anxiety, or violent and long-continued
exertions, and a subsequent exposure to a great increase
or diminution of temperature.
   I have  never observed.fever of any description, with-
out being able to trace a determination of blood to some
particular organ.   Examination  after  death, whenever it
has  been resorted to,  has  confirmed the observation.
The uniformity of the occurrence has taught me to think,
with some other men, that fever is an effort of the vis
medicatrix  naturae,  to free the oppressed  organ  from
the superabundant blood.  In other words, by the ap- 
Typhus.                    157
plication of some direct or indirect stimulus, or sedative,
to the human body, the equilibrium of the circulation of
the blood is destroyed ; and that which we call  fever,
is an effort of the vis  medicatrix naturae, to re-estab-
lish this equilibrium.   If Nature be assisted in her ear-
liest endeavours, she  will often succeed ;  if left entirely
to herself,  the contest will  be  long  and doubtful; and
the destruction of the  structure of the organ in which the
accumulation has taken place,  and the death of the pa-
tient will be the consequence.
   During this reaction  of the system, a something capa-
ble of exciting a similar disease when applied to a per-
son in health, is  sometimes  formed.   What this some-
thing is, or upon what  peculiarity of action its elimina-
tion depends,  I  Avill  not pretend to explain : its pres-
ence, however, appears to constitute the principal differ-
ence betAveen  fevers which have been considered purely
symptomatic or inflammatory, and contagious or typhus
fever.   I have never known a fever prove contagious,
where the  brain has  not been the  organ  primarily af-
fected.
   All fevers are  inflammatory; the division of them in-
to inflammatory  and typhoid  is prejudicial; it  deters
many from employing  the  proper remedies.   A better,
more useful, and a more natural division of them, is into
contagious and non-contagious  inflammatory affections.
                     CHAPTER II.

                       Typhus.

  Morbus contagiosus ; calor parum auctus ; pulsus parvus, debilis, plenunque
liequens ; urina  parum mutata; sensorii functiones piurimum turbatas ; vires
multum imminutae.—CI. i. O. i. G. v. Ccllejvi.

  Although the theory of Fever,  advanced in the last
chapter, does  not explain all its phenomena, a success- 
158
Typhus.
ful practice may be founded upon it.  During  the last
five years  not more than twelve  patients have died  of
Typhus at this Infirmary ; the number admitted cannot
have been less than two hundred.*
   I am of opinion, with my kind friend and  preceptor,
Dr. Clutterbuck, that the seat of genuine Typhus  (a fe-
ver distinguished by being contagious) is the brain.   It
is true that I have seen  fever,  arising from inflam-
mation of the lungs,  liver,  and  internal coats of the
stomach,f bear a very strong resemblance  to genuine
Typhus.   So marked has the resemblance been in  the
last stages, that it would have been impossible for any
one, unacquainted with the previous history of the cases,
to have distinguished them  from Typhus.   In  these
cases,  hovvever, the brain was secondarily affected ; and
I do not remember a  single instance  in which  they
proved contagious.  Hoav often  is  the dissolution of
phthisical patients preceded  by all the symptoms usu-
ally considered typhoid : delirium; indistinct  articula-
tion ; parched brown  or black  furred tongue ;  hot, dry
skin;  feeble,  fluttering,  rapid  pulse; subsultus  tendi-
num, &c. ! but who thinks of calling the  disease Ty-
phus?
                      Treatment.
   In the first approaches of Typhus we shall frequently
be able to prevent  the disease from establishing  itself,
by administering an emetic.  Should this be found in-
sufficient to prevent the formation of afebrile  paroxysm,
as soon as the hot stage  of it is fully formed,  we must
  * The precise number of cases cannot be ascertained, as many patients, ad-
mitted with other diseases, were attacked with fever after their admission ; no
memoranda of which are kept in the Registers of the Hospital.
  The cases reported as typhus, were certuiuly characterized by the symptoms
of that disease; the brain, however, was only secondarily affected ; and it was
easy to distinguish a determination of blood to some other organ. Strictly speak-
ing, therefore, perhaps not more than ane hundred genuine osus of typhus Luv<
been admitted within the period mentioned.
  t See Case XXV. 
Typhus.
159
take away some blood from the arm,regulating the quan-
tity by the strength of the patient, and the violence of
the symptoms.   As a  general rule, we must be guided
in the quantity according to the force with Avhich  the
blood is driven towards the brain, and the consequent
disturbance of its functions.   The pulsations of the ca-
rotid artery will enable us to determine this point better
than if we trust to an examination of the pulse at  the
wrist.
   In the treatment of typhus fever we must be careful
not to mistake indirect for  direct debility. This we shall
be very liable to do, if we form our opinion by the state
of the pulse.  In the early stages of the disease, it will
be often found soft, slow, and feeble.  This state of the
pulse is not a mark of direct debility, but is the conse-
quence of an accumulation of blood within the  brain; by
which the energy of that organ is impaired.
   When  treating  of  the functions of the brain, it was
stated that the nervous fluid, in  which the living princi-
ple resides,  is formed by it.   If an interruption from
any cause be given to the due performance of  the func-
tions of the brain, debility,  or a diminution of the pow-
ers of life, must be the result.
   Instead therefore of inducing debility by the abstrac-
tion of blood in the early stages of typhus  fever, we
shall, by its  removal, enable the brain to reassume its
functions.
   Emetics and venesection will, if employed very early
in the disease, generally put a  stop to  its progress.  If
these remedies be omitted, and several febrile  parox-
ysms alloAved to form, all our endeavours to shorten the
disease  will prove abortive.  A  palliative treatment is
all we can employ with any advantage.  We must pre-
vent an accumulation of faces, by giving every night, or
every other night, five grains of antimonial powder, and
five grains of calomel.  This combination will generally
procure two or three dark, fetid stools; by their evacu- 
160
Typhus.
 ation, the patient will  be much  relieved.   The patient
 must be supplied freely with cool acidulated liquors;
 cool air must be admitted into the apartment, and when-
 ever the skin is hot or dry, it must  be sponged with
 either cold or tepid water.  I generally direct a small
 quantity of vinegar to be added to the water, to quiet (he
 apprehensions of the patient, or of  the attendants.  I
 have never seen cold affusion applied in the manner re-
 commended by  the late Dr. Currie,  of Liverpool.   Its
 efficacy in the early stages of the disease is well attest-
 ed ; in its second, or more advanced stage,  simple ablu-
 tion appears to me  preferable.   Relief will likewise be
 obtained by the frequent application of leeches to the
 temples.  In this, as well as in the first stage of the dis-
 ease, stimulants are to be abstained from.
  In the third, or last stage of Typhus, I scarcely know
 what line of treatment to recommend.   There is a point
 at which stimulants either   do  good, or accelerate the
 death of the patient.  I think, however, that they will
 be  more  frequently found   useful  than  prejudicial.
 The best  stimulant is  port  wine.   A table-spoonful of
 it may be given every hour ; nutritive broths,  from time
 to time administered, and a blister applied to the nape
 of the  neck, or  between the shoulders.  In  the early
 stages of the disease, blisters have appeared to  me some-
 what injurious, particularly  when applied  to the  scalp.
 In irritable habits, they  will sometimes accelerate the
pulse, and give to it a peculiarly thready feel.
                   Recapitulation.
  It will be seen that I have divided  the treatment of
 typhus fever into three  stages.  In the first stage, we are
 to administer emetics, and employ venesection.  In the
 second  stage,  we are  to moderate the reaction of the
 system, by the admission of cool air, sponging the body,
 fcc.;  and by emptying the bowels,  by administering
 calomel, in combination with  antimonial powder.   In 
                 Febres Intermittentes.             161
third and  last stage, we  shall more frequently benefit
than injure the patient, by giving him wine, broths, &c.
                       CHAPTER III.

                  Febres Intermittentes.

   Febres, miasmata paludum ortae, paroxysmis pluribus, apyrexia, saltern remis-
 sione evidente interposita, cum exacerbatione notabili, et plerumque cum horrore
 redeuntibus, constantes : Paroxysmo quovis die unico tantum.

                         Tertiana.

   Paroxysmi similes intervallo quadraginta octo circiter horarum: Accessioni-
 bus pomeridiannis.—CI. i. O. i. G. i. Cullejvi.

                        Quartana.

   Paroxysmi similes intervallo septuaginta duarum circiter horarum : Accessi-
 onibus pomeridianis.—CI. i. O. i. G. ii. Ctjllem.

                       Quotidiana.

  Paroxjsmi  similes intervallo viginti quatuor circiter  horarum: Paroxysmis
 matutinis.—CI. i. O. i. G. iii. Cplleni.

   Intermittents,  whether tertian, quartan, or quoti-
 dian, require  nearly the  same treatment.   The acces-
 sion  of the paroxysms may be, for the  most  part, pre-
 vented, by exhibiting an emetic about half an hour be-
fore its cold stage is expected.  In delicate habits, when
the emetic fails to  produce its intended effect, twenty
drops of the tincture of opium will sometimes  succeed.
   In plethoric habits, much advantage will be gained by
bleeding the patient in the hot stage.   We may succeed
in breaking  the diseased chain of action,  in obstinate
quartans,  by resorting to this practice, after every other
means  have proved insufficient.  In several  cases of ex-
treme obstinacy, the patients were put  under  a  copious
             21 
162
Scarlatina.
cold shower-bath, in the same stage of the paroxysm
with the best effect.
   Having  succeeded in preventing the accession of the
paroxysm, the usual practice is  to employ cinchona.
Bark will cure the disease, but  it will be found more
tardy in its operation than the arsenical solution.  I have
succeeded  with arsenic in  cases where bark had been
given in large quantities, for a great length of time, with-
out producing the slightest good effect.  1 have never
known arsenic to fail.
   Whether bark or arsenic be made use of, it will be
advisable to give nightly,  one or two grains  of calomel
with five grains of the squill pill;  more especially if any
induration, or enlargement of the spleen or liver can be
distinguished.
   It w ill  be found economical to make an addition of
some aromatic to the cinchona, and its powers are im-
proved  by the addition.  Fifteen grains of bark,  with
five grains of powdered ginger, will be found equivalent
to half a drachm of bark by itself.
   During  the  hot or sweating stages of the paroxysm,
the bark must of  course be laid aside.
                    CHAPTER IV.

                     Scarlatina.

  Synocha contagiosa.
  Quarto inorbi die, facies aliquantum tumens ; simul in cute passim rubor flor>-
dus, maculis amplis, tandem coalescentibus, post tres dies in squamulas furfura-
tvas abiens ; super veniente deiri saepe anasarca—CI*, i. O. iii. G. xxix. Cullexi.

   The treatment recommeuded for Typhus must be em-
ployed in Scarlatina.  Emetics  will be found useful by
clearing the prim* mas.   Venesection, employed at the
commencement of the disease, in cases where the symp- 
Scarlatina.                 igg
toms of reaction  are  violent,  will secure to the patient
a comparatively mild disease; neither of these remedies,
however,  possesses the power of preventing  its attack-
Sponging the skin, whenever  it is hot and dry, is very
beneficial, and will be found particularly grateful  to the
feelings of the patient.
   If the throat be inflamed, it must be  treated in the
manner recommended in the former part of this volume,
when writing on Cynanche.  If sloughs form  upon the
velum palati, tonsils, or back part of the fauces,  they
may be advantageously stimulated Avith  an infusion of
capsicum.
   It will generally be found most advisable to leave the
anasarca, by which the disease is  sometimes folloAved,
to itself.  A very malignant case of Scarlatina, attended
with some  peculiarities which it may be  proper to re-
cord, was admitted into this Hospital on the 30th of No-
vember, 1815.

                  CASE XXXIV.

   Ann Young, a very corpulent woman, twenty years of
age, at the  time of her  application had the face and
neck covered with a deep  scarlet eruption.   The same
kind of eruption was to be seen in patches upon the arms
and legs,  and various other parts  of the body.   The
face was very much swoln ;  the lips of a dark blue ; the
vessels upon the conjunctive coats of the eyes were like-
wise injected with blood of a purple colour.   The cutis
covering the ala nasi  vvas in a sphacelated state.   The
tongue  was  thickly incrusted upon its upper surface
with a dark broAvn fur; upon its sides, and on various
parts of the lining membrane of the fauces,  aphtha
were situated.  She complaiued of great soreness of the
throat; but  she experienced so much difficulty in open-
ing the mouth, that it could not be properly inspectd.
Swallowing  gave  much  pain.  Her breathing was ex~ 
164
Scarlatina.
tremely laborious ; she coughed incessantly, and expec-
torated pus blended with frothy mucus.  Her voice was
exceedingly hoarse, indistinct, and disagreeable.   The
pulse  was soft and natural,  and did not beat  more
than ninety times in a  minute.   She  had been  unwell
for a fortnight, and seriously ill a week.   The eruption
had been upon  the  skin three days.  She was directed
to take five grains of calomel and five grains of antimo-
nial  powder at bed-time,  and  to make use of  some
honey, acidulated with muriatic acid, for the throat and
aphtha.
   Dec. 1st. Delirium during the night. The legs, arms,
neck, and different parts of the body, were covered with
petechia of an unusual size.   The breathing was  more
laborious ; pulse less distinct.   A blister was directed
to be put upon the chest, but she died in the evening.
                   Examination.
   The  abdominal  viscera  were  all  found  perfectly
healthy.  The lungs were gorged with blood, and some
serum had been deposited  in the cavity of the thorax.
Tl<  lining membrane of the larynx Avas of a dark-brown
colour; it looked rather as  if it were lined with a  piece
of wetted broAvn paper than with a mucous membrane.
The same appearance  was  seen for a short distance up-
on the membrane of the oesophagus.  The membrane of
the trachea wras in the highest possible state of inflamma-
tion ; Avhicli  inflammation extended into the bronchia
as far as they could be traced.  The membrane of the
trachea was  of a deep brick-dust red, approaching  to
brown.  This  redness gradually assumed  a brighter
hue, as it extended itself upon the bronchia. The brain
 was not examined.
   This patient evidently fell a victim  to inflammation of
 the larynx, trachea, and bronchia, not to scarlatina. 
Rubeola.                   165
                    CHAPTER V.

                       Rubeola.

  Pynocha contagiosa cum sternutatione, epiphora et tussi sicca, rauca.
  Quarto die, vel paulo serius, erumpunt papulae exiguae, confertae, vix eminent
tes, et post tres dies in squamulas furfuraceas minimas abeuntes.—CI. i. O. iii.
G. xxviii. Culleni.

  An immense number of persons die annually of Mea-
sles.   This will continue to be the case  as long as it is
regarded by the parents  of children  as  so slight a dis-
ease as not to require  medical attendance,   if a  prepa-
ration for  the reception  of small-pox be necessary aiuT^
beneficial, it is, if possible, more imperiously required
for Measles.
   Whenever it is  known  to  be prevailing, children,
 who have  never had  it, should be instantly prohibited
 animal  food,  and  a  considerable reduction should be
made in the quantity of their other aliments.  In addi-
tion to this they should be obliged to take, two or three
times a week,  some mild aperient. If the disease attack
persons thus  prepared for it, they  will have it  in the
 mildest possible  manner.   I can pledge myself for the
 utility of this plan.
                      Treatment.
   In the first stage of the  disease, it will be proper to
 give an emetic.  The instant we discover too great a de-
 termination of blood to the lungs, we must employ vene-
 section, and apply leeches to the chest.   This  is the
 period of the  greatest danger; this  is  the  moment in
 which the foundation of all the miserable sequela of the
 disease is laid : if we  neglect it, evils will accrue which
 all our after-care  can never remedy.   We  must take
 away blood  from  time to time, so long as  difficulty of
 breathing, a troublesome cough,  or any other symptom,
 indicative of inflammatory action in the lungs,  exists.
 With very young children, leeches will be equally as 
166                   Pertussis.
serviceable as venesection; but in adults,  or children
above five years of age, w7e must not rely upon them.
They will be found useful adjuncts, but must not super-
sede the use of the lancet.  In this disease, as  well as
in all other affections of the lungs, it is of the utmost im-
portance that the cough should be kept quiet.  The
very effort to cough, propels an undue quantity of blood
into the lungs, by  which it  too often happens that their
structure is  impaired.  It is  stated in some other part
of this work, that  syrup of poppies,  swallowed  very
slowly, will allay Irritation of the  larynx and trachea,
more effectually than any other remedy.
                    CHAPTER VI.

                     Pertussis.

Morbus contagiosus; tussis convulsiva, strangulans, cum inspiratione sonoia,
        iterata ; »aepe vomitus.—CI, i'l. O. iii. G. lvii. Cullejvi.

  Although no  specific  for this  disease has yet been
discovered,  its violence may be much  diminished,  and
its duration shortened: too  frequently, however,  it is
allowed to pursue its natural  course, without an effort
being made  for its removal; and many become its  vic-
tims.   It is  so common a  thing for children to die of
small-pox, measles, and hooping cough, that it is scarce-
ly thought of; but if a child be cut off by some extraor-
dinary or uncommon  disease, the Avhole kingdom is
thrown into a state of alarm.   Men heave the sigh  of
sympathy over one untimely grave, but they every day
see the earth opened to receive thousands, whom they
Avilfully suffer to be the victims of diseases, which long
experience has shewn to be highly dangerous.   How
long will they continue to  sin against this experience !
There are no  diseases which more imperiously require 
Variola.
167
the aid of medicine than small-pox, hooping-cough, and
measles.
                       Treatment.
   The preparatory measures advised for measles should
be resorted to.   Emetics should be given twice or three
times  every  week ;  leeches and  blisters frequently ap-
plied to the sternum, and along the course of the trachea;
and the cough  quieted by the judicious use of syrup of
poppies.   When the inflammatory  symptoms run high,
venesection  will  be  requisite.   After  the disease  has
subsisted for a  few  weeks,  a change of air will be of
service.
                     CHAPTER VII.

                        Variola.

  Synocha contagiosa cum vomitu, et, ex epigastrio pVesso dolore.
  Tertio die incipit, et quinto finitu eruptio papularum phlegmonodearum, quae,
spatio octo dierum, in suppurationem et in crustas demum abeunt, saepe cicatri-
ces depressas, sive foveolas in cute, relinquentes.
  Species sunt,
  1. Variola (rfwcreta) pustulis paucis, discretis, circumscriptione circularibus,
turgidis ; febre, eruptione facta, protinus cessante.
  2. Variola (confluens) pustulis numerosis, confluentibus, circumscriptione ir-
regularibus, flaccidis, parum elevatis ; febre post eruptionem perstante.
                                  CI. i. O, iii. G. xxvi. Cdlleni.

   The treatment of  small-pox  must be very similar to
that recommended for typhus.  In the confluent species
of it, when  the  pustules look pale and  flaccid, Avine or
some other  cordial must be freely  administered.  The
preparation for  this disease was  formerly carried  to an
extravagaut extent; it Avas however an error on the right
side.   In the present times it is  too much neglected.
   The day will, I hope, arrive when this loathsome dis-
ease will be knoAvn only by  name ; but  this day  is far
distant, unless the Legislature will compel all those who 
168
Syphilis.
delight in the murder of their offspring, and in entailing
misery upon mankind,  to erect the altar of Moloch in a
place remote from the habitations of Humanity.
                   CHAPTER VIII.

                   Variola Vaccina.

  When groundless prejudice shall  cease to operate ;
when private emolument shall be sacrificed to the gen-
eral good; the name of Jenner will be pronounced with
rapture by a grateful world.  I  would  rather be Dr.
Jenner than any man who  has been born during the last
thousand years.
  My observation furnishes me with nothing to add  to
the many valuable works upon this disease which have
already appeared.
                    CHAPTER IX.

                       Syphilis.

  Morbus contagiosus, ppst concubitum impurum et genitalium rnorbum, ulcera
tonisllarum; cutis, praesertim ad marginem capillitii papulae corymbosae, in
crustas et in ulcera crustosa abeuntes ; dolores ostocopi; exostoses.
                               CI. iii. O. iii. G. lxxxv. Cullem.

   The remedy for syphilis is  well known.  Mercury,
judiciously administered, is an invaluable medicine, but
if given improperly, or in too  great quantity,  it is  fre-
quently productive of greater evils than it is intended to
remove.
   In a work professedly a  " Compendium," it cannot
be expected that I should enter into the history and de-
scription of a disease,  which  it would require volumes
properly and sufficiently to detail.  I shall therefore
content myself with a few general observations. 
Syphilis.
169
  Mercury is the only certain remedy for syphilis : but
I feel persuaded that ten times as much of it is frequently
given as is necessary for the cure of the disease in any
form.  If we excite and keep up a slight mercurial ac-
tion for a sufficient length of time, the disease  will be
certainly cured, without any injury to the constitution.
Violent  salivation is never  necessary,  is often prejudi-
cial, and not unfrequently destructive.   In scrophulous
habits,  more  particularly, we ought to  be very guarded
in our exhibition of it.   On some persons, a small quan-
tity of this metal will produce very violent effects.   As
we  are not  in possession of a knowledge of the peculi-
arity  of constitution upon which this  susceptibility de-
pends, after having slightly affected the mouth, we ought
to lay it aside for a few days,  till we have ascertained
that it will not  produce these powerful effects upon the
person under our care, before  we  venture to  proceed
with it.
  One of the most common injurious effects of too much
mercury,  is ulceration of the throat; with  destruction
of the palate, and of the bones  of the nose.  I believe
these parts are more frequently destroyed by mercury
than by the venereal virus.   Unfortunately, a syphilitic
ulcer in the throat,  and an  ulcer  produced  by  the ex-
cessive use of mercury, bear a very strong resemblance
to each other.   I know of no decisive marks of distinc-
tion.  As a general rule, if  an ulcerated throat  of long
standing presents itself,  where mercury has not been
given in excess, we may conclude that it is of venereal
origin; on the other hand, if we meet with it after mer-
cury has been largely and repeatedly used,  we  shall be
justified in suspending its further exhibition for a  sea-
sou.
  I have one remark to add, with respect to the use of
mercury.   Children will take an immense quantity of it,
without the salivary glands becoming affected: we ougitf
            22 
170
Erysipelas.
not, however,  on this account to give it incautiously;
for it will sometimes happen, that, without salivation,
the parotid duct will be excited by it into violent inflam-
matory action, in which the parotid gland and the whole
cheek will be  speedily involved, and sphacelus, or  a
rapid ulceration, will be the  consequence.   I have seen
both cheeks entirely removed by this process.  Nothing
with  which I am acquainted has the slightest tendency
to check its progress.

                       CHAPTER  X.

                       Erysipelas.

  Synocha duorum vel trium dierum, plerumque cum somnolentia, saepe cum
delirio.  In aliqua cutis parte, saepius in facie phlogosis erythema.
  Species sunt.
  1. Erysipelas (vesiculosum) erythemate. rubedine serpente, latum spatiumoc
cupante, et locis ejus quibusdam in vesiculas magnas  abeunte.
  2. Erysipelas (phlyclum-odes) erythemate ex papulis pluribus, trunci corporis
partes praecipue occupantibus, et protinus in phlyctaenas, sive vesiculas parvas
abeuntibus.—CI. i. O. iii. G.xxxi.  Culleni.

   This Hospital has,  during nearly five years, been oc-
casionally infested  with an  erysipelatous inflammation,
of a very malignant description.   In some cases it arises
without any assignable cause, and a few patients have
been admitted  with the disease  upon them; but by far
the greater number were attacked with it in the  surgical
wards after admission.  The patients most liable to its
attack are  those who have recently undergone opera-
tions : those with ulcered legs, or  any open wound or
ulcer, are,  however, liable  to it.  Patients in the medi-
 cal* wards are sometimes attacked with it  after  venesec-
 tion, bleeding  from the temporal artery, making of setons
 or issues, and the application of leeches.   1 believe the

  * The  medical and surgical patients are kept perfectly distinct from each
 other in this Hospital; an arrangement  so judicious, that it is to be regretted it
 is not universally adopted. 
                    Erpsipelas.                 171

first cause occurred in a medical ward.   The subject
was a young woman, by the  name of Grace Hansford,
who was bled in the temporal artery.  This girl was re-
moved to a  surgical ward,  for the purpose  of being
trephined*,  and very soon afterwards the disease made
its appearance among the surgical patients.
  The course which the disease usually observed is the
following.   Two or three days after an  operation, the
edges  of  the wound  became  thickened, and  slightly
elevated.  From these edges a dusky erythema spreads
with great rapidity, and speedily covers the whole limb,
or the greater part of it.   This redness is accompanied
by an intense degree of heat upon the surface of the body,
and great swelling of the whole limb.   When  the dis-
ease proceeds from an  incision made for the purpose of
opening the temporal artery, the  whole face is  in less
than  twenty-four hours, completely  disfigured  by  it-
The parts upon which the inflammation is seated feel
harsh, hard and unyielding.   Together with the local
inflammation, great constitutional irritation is experienc-
ed.  The pulse is full, hard, and rapid ;  the tongue be-
comes brown, and thickly coated ;  and towards evening,
and during  the  whole night,  there is delirium.   This
symptom  is  almost uniformly  present when the inflam-
mation is upon  the face, scalp,  or neck.
   The most common terminations of  this affection are,
resolution ;  a fever resembling typhus; gangrene and in-
ternal  hydrocephalus.   In a few cases it has  ended in
suppuration.  Vesicles rarely form.
   Examination after death shews that the inflammatory
process is not confined to the cutis.  It involves not only
the cellular membrane surrounding the limbs, but passes
with it between the muscles.  The muscles are in fact
dissected by it, and can be lifted from their nidus without
the assistance of a scalpel.   The brain always exhibits
* This is the case alluded to when treating of Affections of the Scalp. 
 172                 Erysipelas.

 traces of excessive vascular action.  Its vessels are over-
 distended  with blood; lymph and serum are deposited
 upon and  between the arachnoid coat and dura mater?
 and at the  basis of the brain; and sometimes the^lateral
 ventricles are filled with serum.
                     Treatment.
   Till the  great fatality* of the disease afforded frequent
 opportunities of ascertaining its nature, a very errone-
 ous treatment of it was adopted.   As in its latter stages
 it most commonly assumed a typhoid type,  it was re-
garded  as  a disease  of debility,  and  bark, wine, and
other stimulants were freely administered,  under an im-
 pression that by such means debility could be obviated.
Unfortunate mistake !  Three cases in succession hav-
ing terminated fatally, and an opportunity of ascertain-
ing the precise state  of the brain being afforded, an op-
posite line of treatment  was resorted to.  Blood was
taken largely from the arm, and active purgatives freely
administered.  The  present Matron to this institution is
a living witness of the efficacy  of  this treatment.  She
is the first person upon whom it was tried.   Since it has
been pursued in the medical wards, we have not lost a
single patient  by the disease.   Advantage will be de-
 rived from  keeping up a constant  evaporation from the
 inflamed parts by means of alcohol and water.
* Not less than thirty patients have fallen victims to it. 
 SECTION VIII.

GENERAL AFFECTIONS.
                     CHAPTER I.

                Diseases of the Skin.

   The works of the late Dr. Willan and of the present
Dr. Bateman  have almost superseded the necessity for
any further description of diseases of the skin.   Much
more has been written than is practically useful.   The
only distinction which I have found it necessary to make,
is between cutaneous eruptions of an indolent nature and
those which are active and irritable.  The former will
require stimulating applications; the  latter such appli-
cations as have a tendency to allay irritation.  Mercurial
preparations are best adapted for the former; for the lat-
ter nothing will be found more  efficacious than an oint-
ment Avhich has henbane for its basis.  Sulphur will not
only cure scabies,  but an immense number of anomalous
eruptions.   Alteratives (as they are called) are some-
times useful,  either by exciting an increase of action
upon the skin, or by increasing  the  secretion of the
liver.
                    CHAPTER II.

                      Anasarca.

  Corporis totals vel partis ejus intumescentia mollis, inelastica.
                            CI. iii. O. ii. G. lxxv. Culleivf.

  When cedematous swellings upon the extremities, are
the mere consequences of debility, at the same time that
we endeavour to renovate the system, advantage will be 
174
Sphacelus.
derived from the application of rollers to  the distended
limbs.  When it is a symptom of effusion into the abdo-
men, or thorax, or  some  visceral disease, it will be
found most advisable to leaA'e it to itself, and direct our
whole attention  to the cause  upon which  it depends.
Practitioners  should  be particularly cautious how  they
make scarifications,  more especially upon the scrotum.
I have never seen them upon any part of the  slightest
service; but when made upon the scrotum, they have
almost uniformly occasioned mortification, and the spee-
dy death of the patient.
                    CHAPTER III.                    V

                     Sphacelus.

  Post gangraenam pars nigricans, flaccida facile lacerabilis,  sine sensu vel
calore,. et cum fnetore carnis putridae ; vitio celeriter serpente.
                                CI. i. O, ii. G. vii. Culleku.

  Much  has been written with  respect  to  sphacelus,
and a great difference  of opinion still exists as to the
most judicious mode of treating it.  The stimulating plan
is that which has the greatest number of advocates.   No
sooner is  a  part threatened with  mortification, than the
patient  is desired to take bark,  wine, and a variety of
other stimulants, and the diseased part is often power-
fully  excited by irritating  applications.   Dreadful are
the evils Avhich  I have  seen occasioned by this practice.
It must be remembered that sphacelus, wheiher arising
in vigorous or debilitated patients, is the consequence of
previous excessive vascular action;  we  must therefore
endeavour to moderate the action of  the diseased part
itself, whether  in  vigorous or debilitated persons.
  The  constitutional treatment of the patient  must be
regulated by the degree of constitutional vigor or debil- 
                      Scrophula.                  175

lty.  When a patient of a vigorous habit is threatened
with mortification, there is always a powerful constitu-
tional reaction.   At the same time that we endeavour to
diminish the action  of the inflamed  part, Ave must have
recourse to blood-letting, and other means of general de-
pletion.   When persons whose habits  are much debil-
itated are threatened with it, at the same time that we
endeavour to diminish  the  local irritation, we must in-
vigorate the powers of the constitution.   This latter end
will be  best attained by giving jellies, broths,  and other
aliments, made  palatable only by wine or spices.   It is
the introduction of a nutritious food into the system, that
alone imparts  real  strength to it.   Alcohol,  instead  of
giving vigor, by its excessive excitement is  a certain
means of inducing indirect debility.
  In as few words as possible, I will sum up all that I
have seen it necessary to  observe  in the treatment of
sphacelus.  When  any part is threatened with it, in a
strong constitution, we  must allay the local inflamation,
and pursue a strictfantiphlogistic regimen ; in debilitated
habits, we must endeavour to impart vigor to the system,
at the same time that we allay the local irritation.
                    CHAPTER IV.

                      Scrophula.

  Glandularum conglobatarum, praesertim in collo, tumores;  labium superius et
columna nasi tumida ; facies florida, cutis levis ; tumidum abdomen.
                             CI. iii. O. iii. G. lxxxiv. Cullejvi.

  It has been stated  in the early part of  this volume,
that a scrophulous enlargement of the glands of the me-
sentery is occasioned  by the irritation produced  by an
impure or  imperfectly  formed  chyle.   If the materials
of which the whole animal fabric is constituted be of a 
176
Rheumatismus acutus.
bad quality,  when, in the ordinary course of solution
and absorption,  they are removed by the  absorbents,
they will again irritate  and  inflame these vessels, and
the glands attached to them.   Scrophula may therefore
be said to originate in an imperfectly formed chyle, or a
chyle constituted of improper materials.  The enlarge-
ment of the absorbent glands is merely a consequence of
irritation.
                     Treatment.
  The remedies  recommended under  the articles Hy-
drocephalus Internus, Tabes Mesenterica, and Diseased
Spine, for the purpose of improving the vigor of the con-
stitution, must be employed.
                     CHAPTER V.

                Rheumatismus acutus.

  Morbus ab externa, et pie rumque evidente causa -, pyrexia ; dolor circa ar-
Mculos, musculorum tractum sequens, genua et reliquos majores, potius quam
pedum vel manuum articulos, infestans, calore externo auctus .
                               CI. i. O. ii. G. xxii. Cullejvi.

   A  great number of cases of  acute rheumatism are
annually admitted into this Hospital.  Nothing has been
found so effectual for their relief, as  copious venesection.
When  twenty, thirty, or forty ounces of blood  have
been taken  away for three or four days  in  succession,
cases of the most  violent description have been  very
speedily cured.   Cases of the same  description, treated
with antimonials, the compound powder of ipecacuanha,
and other sudoriflcs,  have been as generally very slow
of recovery  ; and it not unfrequently has happened, that
there has been a metastasis of the disease to the heart.
  Besides venesection,  active purgatives have been em-
ployed.  The keeping the inflamed extremities moist- 
              Rheumatismus Chronicus.          177

oned with a cold acetous or spiritous lotion has in some
few cases been found of great service.   When cold ap-
plications are made use of, care must be  taken that the
evaporation be uniformly kept up.  If wet cloths be ap-
plied, and allowed to become frequently  dry, they will
be productive of much mischief.  As far  as my observa-
tion extends, bark has generally been injurious.

              Rheumatismus Chronicus.

  The  arsenical solution,  the  w arm bath,  and active
purgatives, have been found amongst the most powerful
remedies for the removal of chronic rheumatism. When
these means fail, the disease may be sometimes cured by
exciting a slight mercurial action in the system.
   Cases,  which  had long resisted  every plan of  treat-
ment that could be devised, have at length  been cured
by giving a scruple of calomel  tAvice a week.  I  never
saw any ill effects follow the  use of so large a dose of
this preparation.   The first and second  doses generally
operate as brisk purgatives, and will sometimes induce
a little vomiting;  the subsequent doses act as mild ape-
rients.  They seldom  procure more than two or three
evacuations ; but these are extremely fetid and of a dark
colour.   As soon  as the gums become slightly affected,
they must be discontinued for  a week or two.  It has
been before observed, that there are some habits  upon
which mercury  acts immediately  and powerfully, be-
fore we venture upon a  second dose, we ought therefore
to wait till we have ascertained that such a constitution-
al idiosyncracy does not exist.
23 
NOTES.
      Page 5.  Painful Affections of the Scalp.

   There are  no cases so insidious in their attack and
progress, as those from wounds and bruises of the scalp
and head.  The author has been much too  brief in  his
observations upon them and does not refer sufficiently to
the causes of them.   He very properly directs to the in-
valuable work of Abernethy on the constitutional origin
and treatment  of Local Injuries, for more full informa-
tion respecting them.  But these works  are  not in the
hands of every practitioner.   And, in a Avork of refer-
ence, like this, it will be expected  by the readers, that
some particular observation will be  made,  by which they
will be able accurately to determine the nature aud seat
of the complaint, as well as the treatment of it.
   A man receives  a severe blow  upon  his  head, ei-
ther by an obtuse instrument or a fall.  He may, at
the time, be seriously affected by it, or he may not.  If
he is much affected the  whole system may be throw n in-
to disorder by the shock ; a general state of  stupefaction
may follow; he may become comatose and lethargic ;
the pupils of his eyes may be dilated, and the  iris insen-
sible to the influx of light; his breathing may  be stertor-
ous, as in apoplexy; his pulse may be feeble, or it may
be irregular, or intermittent; he may have nausea and
vomiting, with all the train of symptoms attendant upon
concussion or  commotion of the brain.
   All these symptoms may folloAV a severe blow upon
the head, and  no external mark be found upon it.   After
the use of stimulants, if the above symptoms  are present,
to restore the  re-action of the  blood vessels and of the
nervous system, blood-letting almost ad libitum, should
be resorted to.  This sometimes restores the patient for
a season, and sometimes  permanently.   We may add
that active  cathartics may, at the same time, be had re- 
179
course to.  At other times, this treatment is of no avail,
and  he falls  a sacrifice to the  injury  received.   When
he has recovered from the shock, he feels safe, and goes
about his business.   Months,  and sometimes one, tAvo,
or three years elapse and no disease discovers itself in
the system.   But future danger  is to be apprehended.
The patient may be suddenly taken with violent pain in
the head, vertigo, nausea and vomiting, chills, and fever-
ish flushes, and a long train of symptoms, which, if not
immediately   attended  to will  speedily  terminate in
death.   Upon examining the  head, a small puffy tu-
mour, such as is described by the author,  will  be dis-
covered, which not unfrequently contains matter.  Now
is the time to take the alarm, for if the operation of tre-
phining be not immediately resorted to the patient is
gone.  Unfortunately it is often too  late to resort to the
operation with success after this puffy tumour is discov-
ered.  Upon dissecting into it,  the pericranium, imme-
diately under the scalp,  is found to  be destroyed ; the
external and internal tables of the  skull  are most fre-
quently found carious ; the dura mater detached, some-
times in a  state of decomposition ;  and sometimes the
brain  itself  immediately under the  tumour, is putrid.
Paw relates the case of a person, who was struck, while
drinking with another, with a  pewter pot, over  the right
parietal  bone.  He walked and was very well, till ten
months  afterwards he was  taken  with  a  vertigo, in
walking, and expired in a very little time.  After open-
ing the cranium in the affected  part, the  bone and the
dura mater was found perfectly rotten  and fetid.  Nu-
merous such instances are found in the records of Sur-
gery.
   I have recently prescribed for  a patient, who, two
years ago received a blow with an axe, upon the  frontal
bone, immediately  over the eyebrow.  His hat, iii some
measure, protected his  head, or he would, probably, 
180
have been killed by the blow.   He was stunned by it,
but soon  recovered from  it.  The wound was scarcely
perceptible.  He felt  no  bad effects from it, till a year
and a half afterwards, when taking  cold the  digestive
orgaus became  affected,  and soreness and  pain in the
wound folloAved.  Every time he takes cold, his head is
severely  affected, and once or twice great febrile action
has been excited, and derangement has followed. Bleed-
ing extensively, purgatives,  and the antiphlogistic regi-
men are the appropriate remedies.
  But these affections of the scalp often produce  this
direful train of symptoms, even when they  are  at  first
trivial.   The  pericranium  is often separated from the
bone, or the dura mater detached, which deprives the
bone  of  nourishment; it becomes dry and dies.   But
even if the pericranium be  not detached, matter from
bruises sometimes  forms between the external  integu-
ments and the pericranium.  This matter must discharge
itself somewhere, or affect the pericranium, the bones,
or the dura mater.
  Even the slightest wounds of the external  integuments
may produce the most alarming symptoms.  John Bell
says : - " life is more frequently endangered, by a lacer-
ation of the integuments,  by a mere contusion, or by an
imperceptible separation of the dura mater,  than by the
broadest  fractures.    From  the slightest injury of the
most remote of the integuments of the brain, there often
ensues, slowly, imperceptibly,  and at a distant and un-
suspected period, suppuration of the  brain itself.  A
wound of the  integuments, naturally  slight and void of
danger, may, by misconduct, cause, not merely caries of
the bone, but suppuration of the brain."
  From my manuscript lectures upon  Medical Jurispru-
dence, I  extract the following observations :—" Injuries
of the scalp are frequently dangerous  as they may affect
the important nerves, blood-vessels, the pericranium, &c. 
181
The pericranium sends vessels to the bones  ©f the era
nium, and also receives others from those bones Avhere-
by it is connected to them, so that the vital influx and af-
flux of the juices to and  from the bones of the cranium,
and especially their internal table, depends on a sound
state of the pericranium.   This membrane, therefore,
being injured, will readily communicate its. disorder to
the bones of the cranium, and also to the  dura mater,
especially  near the  sutures, where there is a manifest
and reciprocal intercourse of vessels betwixt those mem-
branes."  I have neATer seen these affections of the scalp,
which the  author mentions as  arising spontaneously
without any known cause.   From the manner in which
they present themselves, it  is probable they are in con-
sequence of some injury received at some distant period
from the time of the attack.
   From what has been said we may infer how manifest-
ly improper it is to divide the integuments of the skull,
in cases of injuries of the head,  unless there is a proba-
bility  that  the operation of trephining will be resorted
to.  The time, I trust, has passed away, when a simple
fracture of the skull, or even a fracture with considerable
depression, will alone justify the operation.  I know
there are those, who resert to the operation of trephining
in  every case of depression and even fracture of the
skull,  for fear of future danger.   I  have  seen several
large and deep depressions of the skull, Avhere the injury
was received twelve or fifteen years since, when the pa-
tients  had  nothing  more  done  for them than copious
bleeding, and powerful  evacuations at the time, and no
bad effects  have resulted from  the wounds.  The de-
pression still  remains.   Numerous such instances are
mentioned by surgical  writers.  I feel myself so  per-
fectly shielded by their, and my own observations, that
I am ready to meet  any gentleman in fair  debate,  avIio
chooses to take up the opposite side of the question. And
here 1 throw the gauntlet.   It is seasonably enough  to 
182
operate when alarming symptoms present themselves.
As the author has referred to the writings of Abernethy,
on this subject, I will take the liberty of referring to the
luminous writings of John Bell, on injuries of the head,
than which a more able treatise is not to be found in the
English language.   Even Van  Sweiten on injuries of
the head may be read with great advantage.

              Page 6.   Tinea  Capitis.
   It is highly  probable that this  complaint is many
times constitutional.   At least constitutional symptoms
often present  themselves, so that the complaint cannot
be removed without a resort to internal remedies. After
a thorough evacuation of the stomach and  bowels, I gen-
erally resort to antimonials,  and sometimes to mercury
in alterative doses, which I  sometimes continue till the
glands are affected.   Cleanliness is absolutely requisite.
After shaving  the head,  and washing it  frequently in
warm soap suds.  I know of no better local application
than the White Ointment, prepared according to the fol •
lowing formula:—
            R.  Merc. Praec. Alb.  dr. ii.
                Hydragyr.  Muriat. gr. x.
                Axung. Porcin. oz. iii.
                Essent. Burgam. dr. ii.
   An ointment prepared from the root of  the Phytolacca
decandra, or  poke  root,  is  said upon the authority of
Professor  Smith, of New-Haven, to be very efficacious.
As this disease is highly contagious, care should be ta-
ken that the heads of the uninfected should not be comb-
ed with the same comb that is used for the diseased,  as
the disorder is often communicated in this way.

        Page 8.  Hydrocephalus Externus.

   I have seen one case of this  complaint in an infant,
aged one year.  The head was  monstrously  enlarged. 
188
and all the sutures of the cranium were separated, some
of them to the distance of one or two inches, and the wa-
ter had  separated the external integuments of the head
from the skull.   The attending physician punctured the
skin with  a  lancet,  and suddenly  dreAV off the  water.
The child, I  understand, expired in 24  hours after the
operation.  This note is given to warn physicians of the
impropriety and danger of this operation.
  Quere.   Although this complaint has uniformly prov-
ed fatal, may not the operation of acupuncture,  with a
very fine  needle,  as in Hpdrocephalus  infantum,  and
spina bifida,  alleviate some of the  symptoms attendant
upon it, and prolong the life of the patient ?
  Since writing the  above I have perused the following
statement from  the  Salisbury  Journal, which I think
well worthy  of insertion in this place.  "An  extraordi-
nary case of Hydrocephalus or water of the brain is just
now exciting the interest of the medical gentlemen  of
Salisbury.   The head of an infant,  before any operation
was performed,  at the age of six months (now only sev-
en)  was  of  the following  extraordinary  dimensions:
Round the forehead  and back  part of the head  30 in-
ches, and from ear to ear, across the vertex 24 inches;
which measurement  will be better understood by stating
that the larger  circumference of the adult head  avera-
ges  but 22 inches,  and from ear to ear but 12 ;  and of
a healthy child  of six months  old the largest circumfer-
ence averages 16, and from ear to ear 9 inches.   The
infant, belonging to respectable parents, is under  the im-
mediate treatment of one of our surgeons, and is submit-
ted to a novel practice, viz.  the removal of the water by
degrees, through means of an operation, and at the same
time the employment of pressure.   The infant has un-
dergone the  operation five times, and 110 ounces of wa-
ter (nearly seven pints) have been removed.  The pres-
ent state of the  infant, and  the effects of the operation 
184
and treatment are such as afford well grounded hopes
that for this disease,  hitherto considered hopeless, a
remedy has at length been found."

 Page 61. et sequentia.  Digitalis in Haemoptysis and
               in Phthisis Pulmonalis.

  The medical world is much divided in opinion, in re-
gard to  this  powerful  article of the Materia Medica.
Many  of the observations of the author on this  subject
are judicious and pertinent, while some of them, in my
opinion, lead to an  excessive caution in the use of this
drug, and  may deter some from resorting to an  article,
which, in  many  cases, will be almost, as  he  says of
bloodletting,  a sheet-anchor.   I certainly have seen the
digitalis given in large, and increasing doses, for a great
length of time, in pulmonary phthisis, without the least
possible benefit, and this too in a great variety of cases.
I have no  faith to believe that it will ever cure consump-
tion, particularly the tincture of it, nor should I ever use
it in this affection.  It seemed to have been a favourite
remedy  with  one of the attending physicians of the New-
York Hospital in the year 1813—I  saw it pushed to its
greatest extent there in several patients, and for  a long
period, but I do  not recollect  to have seen  it produce
any effect  upon the pulse, certainly not towards dimin-
ishing it in frequency, or force.  Nor do I remember to
have seen any benefit  whatever resulting from  the use
of it.  Neither do I recollect  to have seen it produce
any deleterous  effect upon the system, notwithstanding
the long continuance of the use of it.
  It is a medicine, when the dose   is properly regulat-
ed, which may be given with the  greatest  safety, and
frequently  with the best effects in asthmatic and drop-
sical affections; and perhaps  the  administration of it
ought to be limited to these cases.  It is certainly a most
powerful diuretic, and combined with squills, and some- 
185
times with calomel.  I have seen it cause the discharge
of enormous quantities of water from the  abdomen,  in
cases of ascites, aud remove  every vestige of the com-
plaint, even when the water  had accumulated in suffi-
cient quantity to warrant the operation of paracentisis.
But I conceive that the best form of administration is  an
infusion of it, or the powder of the leaves, in substance.
   The author bears testimony in favour of it in dropsy;
but there is some reason to believe that all his observa-
tions upon it, are not founded  in fact.  The same objec-
tion may be brought against ipecacuanha, squills,  and
tartarized antimony,  which  he would substitute, and
there is as much reason to believe, that these have " hur-
ried  thousands  to  their graves," as that  digitalis has.
Yet, who would abandon these most useful  medicines,
because they have been abused.
   It is doubtful whether the  observation  is correct that
u when the habit is once brought under its influence, it
will  continue an indefinite period."  Many cases could
be mentioned  where  its influence subsided, soon  after
ceasing from the use of it.  Indeed, it is not believed,
that  its effects are so permanent as those from the use of
mercury.  The author says :—" Should  the effect pro-
duced be too powerful, we are without ability to mod-
erate it."  Paris,  who is the best authority to  whom
I can refer, says,  the distressing effects of an over-dose
may be counteracted by tincture of opium in brandy and
water, and by the application of a blister to the pit of
the stomach, and speaking of the infusion he observes,
* we shall counteract its effects by endeavouring to ob-
viate its nauseating tendency by brandy and water, &c."
Blackall agrees with Paris on this subject.
   Although I have been in  the habit of using digitalis
freely, I  have never seen any of the alarming  effects
mentioned by  him.  I have  one patient who has used
it, combined with  tincture of Lobelia inflata and Elixir
            24 
186
 Paregoric, for asthma, daily, for a year, and kept about
 his usual employments on  a farm, yet, I have not seen
 his life "in continual jeopardy,"  nor do I  believe that
 the u incautious or accidental elevation of his body will
 destroy him."   Neither do I fear in this case, although
 he has taken it so long, " its presence  will be suddenly
 manifested, and perhaps so powerfully, as to extinguish
 the vital spark."
   Dr. Withering, who has written an able treatise upon
 the digitalis, directs one drachm of the dried leaves of the
 digitalis,  purpurea to be infused four hours in a  half a
 pint of boiling water, adding to the strained liquor  half
 an ounce of any spirituous  w ater; and an ounce  of this
 infusion to be given twice a day to an adult.  If the pa-
 tient be stronger than usual, or the symptoms very urgent,
 the dose may be given once in eight hours.
   The following formula for a tincture of it, is highly
 recommended to the consideration of the learned College
 of Physicians, for insertion in  their Pharmacopea, by
 Dr. Maclean, of Sudbury,  (Eng.)
       R. Folior. digital, purpur. recent, oz. iv.
          Spts. Vin. rect.  oz. v.
          Digere dies septem leni calore, dein. cola.
   This makes a beautiful dark green tincture.
                        Or
     R.  Fol. digital, purpur. recent, exsic. oz. i.
         Spts. Vin. ten.  oz. vii. M.
        Digere leni calore per dies septem et cola.
   In Dropsy, a single grain of the powder, the fibres be-
 ing carefully excluded,  is a medium  dose for an adult
to begin with ;  and taken  morning and evening aa ith a
 a  little confect. aromat.  has frequently  evacuated  the
water in general anasarca, in 48 hours.  A grain  and a
half may, however in general be begun with, twice a
 day, increasing half a grain a dose every  second day.
until some  effect be obvious.  The leaves when dry. 
187
should appear green, and have a flavor like sound fresh
hay.
  Dr. Maclean has used the digitalis  in more than two
hundred cases, and he never observed  any fatal case, nor
any very "dangerous or deleterious" effects from it; nor
has he seen alarming symptoms from  it, except in two
instances, where from neglect it was increased  after the
habit was under its full  dominion.  He says  "I will
continue to affirm with confidence, that any serious con-
sequences that have arisen, or may arise from it, have
been or will be from inattention to its effects ; as it inva-
riably gives full warning of its deleterious qualities. The
most valuable medicines in our possession, or even the
most salutary substances will prove injurious, if admin-
istered to  excess.  It is unfair to argue of the use  of any
substance from  the abuse of it.   Opium,  tartar emetic,
the active preparations of mercury, and many other val-
uable remedies, are destructive  poisons  if administered
in undue  quantities.

     Page 114. Effects of Arsenic on the Stomach.

   Arsenic is  sometimes taken  in  large doses, for the
purpose of destroying  life, and sometimes people swal-
low it by mistake.  It is often extremely difficult  to de-
tect it, or to determine the cause of the complaint of the
patient, or his death.   As little can be determined in re-
lation to  this subject, from the case related by the au-
thor, I have thought it  advisable to give the  symptoms
resulting  from an overdose of this poison, the appear-
ance of the body after death, the remedies for it, and the
most certain test.  These are principally taken from my
lectures upon Forensic Medicine.
   The symptoms from the poison of arsenic  are great
heat in the mouth ; the teeth become  affected ; a  prick-
ing and burning sensation in the stomach; violent grip-
ings in the bowels ; vomiting succeeds, and the stomach 
188
and mouth become corrugated ; an unquenchable thirst ;
anxiety; strictures in the region of the prsecordia, and
restlessness.   In those Avho die, great fever, hiccup, in-
flammation of the stomach and intestines, terminating in
mortification.  The discharge from the stomach is black
and fetid, and death soon closes the scene.  From some
cause or other the genitals in men quickly mortify from
the poison of arsenic.  The time Avhich it takes for this
poison to destroy life, differs  in  different  subjects,  in
proportion to the quantity taken, the  predisposition  of
the system to disease or to the fulness or emptiness  of
the stomach.   Sometimes death is induced under all the
above excruciating agonies in four hours.   Oftentimes it
is 48 hours, and sometimes longer in bringing on the fa-
tal catastrophe.   From some  observations of Mr. Bro-
die, read before the Royal Society, it would seem that
death from arsenic is not induced, from inflammation  of
the stomach,  but that the symptoms to be referred to it
may be ascribed to the influence it has upon the nervous
system, upon the heart, and upon the alimentary canal;
and this opinion  seems to be corroborated  by numerous
dissections.
  According to Dease, the body of the  person who has
died from the poison of arsenic, "turns suddenly putrid,
and  becomes  horribly inflated; the head, tongue, and
fauces,   monstrously  swelled   and black;  the whole
carcase emits the most horrid stench, and the scarf-skin
peels off on touching it.  The stomach appears inflated,
often  inflamed, with  gangrenous spots, or rather  suffu-
sions,  here and  there spread over its  surface and the
blood-vessels  distended.   When  opened, the villous
coat has all the appearance of  having suffered great in-
flammation, often an eschar is observed, encircled  by an
inflammatory ring.  An inversion of the alimentary ca-
nal is also frequently seen.
  Remedies.—Professor  Stringham  relates the follow- 
189
ing anecdote, which  would seem to shew that spirit is
one of the best remedies for the poison of arsenic.   " A
person with the intention of poisoning his wife, infused
arsenic in her food.  Soon after eating, she complained
of intolerable thirst, and begged of her husband to give
her a glass of  spirit, which he did, and infused  more
arsenic in it.   She drank it and immediately her thirst
abated, and she soon recovered."—I have no experience
of the efficacy of this remedy.   The means on which I
should place the most dependence, are, an emetic of sul-
phate of zinc, followed by purgatives,  and a solution of
gum arabic or tragacanth.  After this, sulphuret of pot-
ash, or liver of sulphur, scr. i. dissolved in  a pint  of
water.  Some recommend in the second  stage, a milk
diet, electricity, and the mineral waters.
  Arsenic, although  one of the lightest of the metals, is
nevertheless ponderous,  and the white powder,  when
taken in  any quantity,  may sometimes be found adher-
ing to the villous coat of the stomach.  It may be wash-
ed from the other substances of the stomach and bowels,
by water, or by spirits.  When we  are called to exam-
ine the body of a person suspected to have been poison-
ed by arsenic, we should examine all the phials or ves-
sels, near the body, or in the house wdiere he is sick  or
where he  died, as  also  loose pieces of paper.   We
may sometimes discover some remains of the poison in
some of them.   We  should, if possible, save what was
ejected from the stomach, and what was discharged from
the bowels, in separate vessels.  We should likewise
separate  the more solid contents which may be found in
the stomach, from the liquid, and put them into separate
vessels, and repeatedly  wash them in cold water, and
filter them upon blotting paper, and subject the residuum
to chemical tests.
   Arsenic is a poison which has so frequently been em-
ployed for the commission of suicide and murder, that 
190
the attention of medical men and chemists has been di-
rected for centuries, towards the discovery of a test for
it;  and from the great variety which have been palmed
upon the world  as absolutely  certain, one would sup-
pose that there would be no difficulty in immediately de-
tecting it.  The reverse, hoAvever, is the fact; and not-
withstanding all that has been said upon the subject, we
have  not, till lately, absolutely known any infallible
tests which would detect it in small quantities, and in a
liquid form.   I  shall pass over the tests of Marat  and
Phillips, by means of the nitrate of  silver, and  several
others, as according to my apprehension,  they are not
so delicate and certain, as the one discovered by Judge
Cooper, and by him communicated to the American Phi-
losophical Society.  Here, perhaps it  may be  made  a
question, whether any thing ought to be received as pos-
itive proof,  but the production of arsenic in its metallic
form.  The contents of the stomach must be  repeatedly
washed in cold water, and the water suffered to remain
at rest.   The arsenic, from its gravity  and insolubility,
will subside to the bottom in white powder.   It requires
80  parts of cold water, completely to dissolve one part
of arsenic.  The water is carefully to be poured off, and
if the powder is in very  small quantity the water is to be
preserved for examination.
  The test of Cooper, which I consider the most perfect,
delicate and proper, is :—Take a conical wine-glass, or
watch-glass, or  a bright piece of a pane of glass.   Put
on  it the 16th of a grain of white arsenic, or any  portion
of  a grain that may be visible to the naked eye ; drop
on it one or two drops of chromate of potash, where the
excess of the alkali has  been neutralized by nitric or
acetic acid, according to the usual processes of the man-
ufacturers of  the chromate of lead.  In three hours the
arsenic will give a decided green tint.  The arsenious
acid, or white arsenic, attracts oxygen from the chromic 
191
acid, which is thus converted into a green oxyd and pre-
cipitates ; the alkali combines with the acid of arsenic.

   Several other topics might be enlarged upon.  It is
much to be regretted that the author has been so brief in
his observations on many important diseases.  Were he
to review his work,  and give us a second  edition, he
would  undoubtedly  improve  upon it.   So much more
might be said upon most of the subjects upon  which he
has treated, that I hardly knoAV where to begin, or Avhere
to stop.  It would be  easy  to enlarge upon them, and
swell our observations to the size of a volume, but per-
haps it is best to stop in limine.   We should have been
pleased to have seen his physiological  observations,  so
novel,  and yet so pertinent, extended.  Some farther ob-
servations on his practice, Avhich in some cases is new,
and  in others bold and decisive, would have been highly
satisfactory.
   We admire his candour in  his  closing observations
upon Phthisis Pulmonalis.   But  from this ingenuous
confession, which  is unquestionably true, let it  not be
supposed that nothing can be done to alleviate the symp-
toms attendant upon this most distressing disease.   It
is already too common to leave the unfortunate  sufferer
to his fate.   Much may be done in this respect  by the
judicious application of medicines.  Physicians may be
deceived in the time in which the lungs become ulcerat-
ed or tuberculated, and this opprobrium medicinas, may
often be warded  off by vigorous and active treatment at
the commencement of the complaint.
   We  had hoped  to have discovered a remedy in this
work for that most horrid complaint the epilepsy.  But
from our author's confession  we  are apprehensive that
we must long remain in the  dark on this point.  From
the favourable results which have folloAved the use of oil
of turpentine, in several cases, and the acetate of lead in
others, according to the suggestion of Dr. Rush, we can- 
192
 not but hope that this complaint is disarmed of many of
 its terrors; and  perhaps future trials will prove  they
 will  be prophylactic, especially  in those cases which
 are not in consequence of injuries of the head, or organ-
 ic affectious of the brain.
   We could have Avished that the observations upon di-
 abetes had been more full. Tlie practice of blood-letting
 in this complaint, we  believe, is of recent origin.   It is
 much to be hoped that it  will be extensively beneficial,
 but we have too much reason to fear that it must be rank-
 ed with the consumption, among the incurables.
   Had not his observations upon menstruation been so
 brief,  they would have  been more satisfactory.   The
 train  of diseases frequently following a derangement of
 this salutary discharge,  often baffles  all the skill and
 discernment of the most judicious  physicians.  These
 derangements are  very   frequently the  precursors of
 Phthisis Pulmonalis,  and  will probably explain the
 cause, why females are more subject to this complaint
 than men.  How frequently do we  see a suppression or
 retention of the  menstrual  flux, followed by  a severe
 cough and  haemoptysis, and if the  natural discharge is
 not soon restored, the lungs become permanently affect-
 ed.   We could dwell upon this point with pleasure, but
the limits allowed us will not permit.
  Let it not be thought,  from the  above observations,
that we are fastidious  and disposed only  to cavil with
 the author.   On the contrary, Ave consider his work the
 most  perfect compendium of  practical  facts, which has
 recently appeared, and which have  been noticed by an
 individual, and as such we heartily recommend it to the
 consideration of  the faculty, as a luminous  display of
 erudition, and profound practical knowledge.
  Errata.—For Hydrocephalus infantum, in page 183, of Notes, line 11 from
top, read Hydrocapitis infantum. 
 
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