■TH'3Usr-rhf*^ ilia ^s si.'&ftSi UNITED STATES OF AMERICA WASHINGTON, D. C. GPO 16—67244-1 ' « . • » 7 foV A PRACTICE OF PHYSIC, COMPRISING MOST OF THE DISEASES NOT TREATED OF "DISEASES OF FEMALES," "DISEASES OF CHILDREN." BY WILLIAM P. DEWEES, M. D. ♦ *♦ ADJUNCT PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVAWIA J MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; MEMBER OF THE PHILADELPHIA MEDICAL SOCIETY, &C. " We live in an age in which the fear of debility, causes a prodigal use of stimulants; and this too often, at the expense of the health, and the life of the patient."—Broussais, Pkleg. Chron. Vol. II. p. 82. " Had I dared to bleed freely, and'especially by means of leeches, the pa- tient might have been saved; but I was afraid of debility. But, who is to blame!" —lb. p. 178. IN TWO VOLUMES. :tf> '^ £\ c VOL. I. \ W^ 4 4 PHILADELPHIA: CAREY & LEA 1830. EASTERN DISTRICT OF PENNSYLVANIA, to wit: BE IT REMEMBERED, That on the twenty-second day of December, in the fifty-fourth year of the independence of the United States of America, A. D. 1829, William P. Dewf.es, M. D. of the said district, hath deposited in this office the title of a book, the right whereof he claims as Author, in the wtords following, to wit: " A Practice of Physic, comprising most of the Diseases not Treated of in " * Diseases of Females,' and ' Diseases of Children.' By William P. De- "wees, M. D. Adjunct Professor of Midwifery in the University of Penn- sylvania; Member of the American Philosophical Society; Member of fhe " Philadelphia Medical Society, &c. " * We live in an age in which the fear of debility, causes a prodigal use of " stimulants; and this too often, at the expense of the" health, and the life of the "patient.'—Broussais, Phleg. Chron. Vol. II.p. 82. " * Had I dared to bleed freely, and especially by means of leeches, the pa- " tient might have been saved; but I was afraid of debility. But, who is to "blame!'—lb. p. 178.—In two volumes." In conformity to the act of the Congress of the United States, entitled " 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 also to the act, entitled, " An act supplementary to an act, entided, ' An act for the encouragement of learning, by securing the co- pies 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 designing, engraving, and etching historical and other prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. SKF.RRETT--NINTH STREET, PHILADELPHIA. TO SAMUEL. JACKSON, M. D. Q-c. fyc. THIS WORK IS INSCRIBED, AS A MARK OF LONG-CHERISHED ESTEEM, BY HIS SINCERE FRIEND, WILLIAM P. DEWEES. Philadelphia, ~) Dec. 19, 1829. 5 CONTENTS OF VOL. I. Page. General Observations,.......... 9 1. Of the Qualifications of a Nurse,.....21 2. Of the Faithful Administration of Medicine, ... 24 3. Of giving Drinks and Nourishment,.....25 4. Of Cleanliness in the Sick Room, - . - - - 27 5. Of Quiet in the Sick Room, -.....28 6. Of the Ventilation of the Sick Chamber, .... 30 7. Of the Temperature of the Sick Room, .... 32 8. Regulating the Warmth of the Patient, .... 33 9. The Examination and Preservation of the Excretfons, - 34 10. Of the Patient's sitting up,......35 11. Of the Making of the.Bed,......38 12. Of the Proper Using of the Utensils for Evacuations, 40 13. Of Skill in Applying and Dressing of Blisters, ... 41 14. Of administering Injections, &c......50 15. Of the Management of the Convalescent, .... 52 Relapse,.........ib. CHAPTER I. Of Fever in General,.........64 General Plan of Cure, - .....71 A. Of Cool Air and Drinks,......ib. B. Of Bleeding,........74 C. Sweating,........77 D. Purging,.........81 E. OfBlisters,........84 a. Of the Period of the Disease, or* State of the Arte- terial System,......ib. b. Of the Part to which they are Applied, - - 85 c. Of the Duration of their Application, - - 86 d. Of the Peculiarities of the Patient as regards their remote effect, ...... ib. F. Tonics,.........ib. CHAPTER II. Intermittent Fever,..........88 CHAPTER III. Remittent Fever and Treatment,.......109 1. Of the state of Pulse,.......118 2. Of the Greater or Less Violence of Symptoms, - - 120 3. Of the Effects of Remedies,......ib. 4. Of the Peculiarities of Constitution,...... ib. 5. The Character of the other Prevailing Diseases, - - 121 CHAPTER IV. Yellow Fever,..........124 Treatment,.........133 VI CONTENTS. Page. CHAPTER V. 143 Gontinued Fever, - -....... Synochus Form, ------- Typhus Form, --'-'' CHAPTER VI. » Typhus,............166 " Of the Way of Attack without an Accidental Cause," - 172 "Of the Way of Attack with,an Accidental Cause," - - 1(3 "Of the First Degree,".......*£ "Of the Second Degree,"......*°- "Of the Third Degree,".......J7* "Of the Fourth Degree,"......- 175 "Treatment of the First Degree," - - - - 176 "Treatment of the Second Degree," - W, "Treatment of the Third Degree," ... - 177 "Treatment of the Fourth Degree," - - - - 178 CHAPTER VII. Rubeola, or Measles,.........1'9 CHAPTER VIII. Apoplexy,........... 190 Predisposing Causes,.......197 Exciting Causes, -.......198 Pathology of Apoplexy,.......199 Proximate Cause, - - - -- - - - 200 Of the Treatment of Apoplexy,.....210 1. Of the Prophylactic Treatment, .... ib. 2. Treatment during the Paroxysm, - 212 CHAPTER IX. Of Scarlatina, or Scarlet Fever,.......216 "Belladonna as a Preventive of Scarlet Fever," - - 224 "Belladonna in Scarlatina,"......225 CHAPTER X. Urticaria, or Nettle Rash,.........ib. CHAPTER XL Phrenitis,............230 CHAPTER XH. Hydrocephalus Internus,........ 241 Dissection,.........247 Acute Symptomatic Hydrocephalus,.....248 Chronic Idiopathic Hydrocephalus, - 249 Chronic Symptomatic Hydrocephalus, .... 250 Of the Treatment,.......251 1. Bleeding,........ j0. 2. Purging,........252 3. Sweating,........353 4. Topical Applications, and Blistering, - - . 254 CHAPTER XHI. Diseases of the Eyes,.........255 General Observations,....... t-$ CONTENTS. Vii Page. Sect. I. Conjunctivitis.—Inflammation of the Conjunctiva, - - 256 Anatomical Characters of the Conjunctiva, - - - ib. Physiological Characters, - - .. - - - - 257 Pathological Characters, ...... ib. Causes,..........258 Symptoms of Acute Inflammation,.....265 Symptoms of Chronic Inflammation, .... 268 Inflammation of the Conjunctiva in Irritable Constitutions, 269 Pustular Conjunctival Inflammation, .... 270 Treatment,.........ib. 1. Blood-letting,.......ib. 2. Purgatives,........274 3. Emetics,........275 4. Nauseating Doses of Antimonials, - ib. 5. Diaphoretics,.......276 6. Tonics,.........ib. 7. Diet,.........ib. 8. Blisters,........277 9. Local Applications,......ib. Treatment of Chronic Conjunctivitis, .... 281 Treatment of Conjunctivitis in New-born Children, - 282 Treatment of Irritable Conjunctivitis, .... 283 Treatment of Pustular Conjunctivitis, .... 284 Foreign Bodies in the Eve,.....ib. Sect. II. Sclerotitis.—Inflammation of the Sclerotica, - - - 286 Anatomical Characters of the Sclerotica, ... ib. Physiological Characters,......287 Pathological Characters,......ib. Causes,........- - 288 Symptoms, - - ......292 Diagnosis,......... 294 Treatment,.........ib. Purgatives,.......•- 295 Emetics,.........ib. Diaphoretics,........296 Tonics,.........298 Local Applications,.......ib. Regimen,.........299 Sect. HI. Corneitis.—Inflammation of the Cornea, .... 301 Anatomical Structure, and Physiological Characters, - ib. § I. Inflammation of the Mucous Covering Membrane, - - 303 1. Acute Inflammation, ......ib. Treatment,........ib. 2. Chronic Inflammation,......305 Treatment,........306 3. Vesicular Inflammation, - - - % - - - 307 Treatment,........ib. 4. Pustular Inflammation,.......ib. Treatment,........309 5. Ulcerative Inflammation,......310 Treatment,........311 § II. Inflammation of the Proper Tissue of the Cornea, - - 312 1. Acute Inflammation,.......ib. Treatment, -------- 313 2. Chronic Inflammation,......315 3. Suppurative Inflammation,.....316 Treatment, -.......**■ 4. Ulcerative Inflammation,......317 Treatment,........320 viii CONTENTS. Page. 5. Conical Cornea,......- 322 6. Encysted Tumours in the Lamellae of the Cornea, - 323 7. Ossification of the Cornea, ..... ib. § III. Inflammation of the Serous Lining Membrane of the Cornea, 324 Treatment,........ib. CHAPTER XIV. Of Catarrh, -.„..---..- 325 CHAPTER XV. Cynanche Tonsillaris,.........338 CHAPTER XVI. Cynanche Parotidaea, or Mumps,.......342 CHAPTER XVII. Cynanche Trachealis, or Croup,.......345 Of the First Stage,........350 Second Stage, or that in which the Disease is completely formed, 352 Third or Congestive Stage,......353 Treatment of the First Stage, - - - - • - - 358 Second Stage,.....360 Third Stage, .....368 CHAPTER XVDX Pertussis, or Hooping Cough,........371 ADVERTISEMENTS Would it be either sufficient, or satisfactory, were the ques- tion asked, "why has this work been given to the public?" to merely answer, because we were of opinion, that it was wanted? Will the necessity for such a work, insure its faithful, or best execution? Certainly it will not. It may therefore be pro- per to add, that we have brought to our aid in this compila- tion, (for what practical work can pretend to originality,) the experience of more than forty years; and if this has been im- portant upon the other occasions on which we troubled the pub- lic, it must be no less useful now, as it has been no less exten- sive. We have therefore attempted by means of our own ob- servations, together with those of others, as collected from pretty constant and extensive reading, to make this work useful and acceptable to the student, and the inexperienced practitioner. If this wish be ever realized, our object will be abundantly answer- , ed; and if it be not, we must derive comfort from the conviction, that we shall not have left the practical part of medicine, in a worse condition than we found it. We have dwelt upon certain points, which we have thought important to successful practice, with more than necessary detail perhaps, to the experienced physician; but we are persuaded he will forgive this minuteness, when he reverts to that period of destitution of practical detail in his own life, which every phy- sician must have felt once, and at which, he would so gladly have availed himself of the experience of another, could he have com- manded it. We now allude to the chapters, which treat of the generaj management of diseases, and on the duties, importance, li X ADVERTISEMENT. and qualifications of the tenders upon the sick, whether they be "nurses" by profession, by accident, by necessity, or by courtesy. We have attempted to elicit a more extensive and strict atten- tion to the diseases of the chest, than has been generally bestow- ed upon them, by earnestly recommending the practice of its exploration by the stethoscope and percussion, agreeably to the rules laid clown by Laennec in his inimitable, as well as invalu- able work upon this subject. We would moreover recommend a faithful study of this truly authentic author, if the practitioner wish to arrive at accuracy of diagnosis in the diseases of the lungs, the heart, &c. We would also take the liberty at the same mo- ment, of directing the attention of the young practitioner, to the study of the works of Forbes, Williams, Andral, Bayle, Louis, Broussais, &c. who have so rapidly and so successfully advanc- ed our knowledge of diagnosis, as well as the pathology of the diseases of the several viscera of the thorax, and other portions of the body. In treating the various diseases which we have at present sub- jected to our consideration, we have been particular, whenever practicable, to dwell upon their pathology as long and as minute- ly as was consistent with our present design; believing, most firmly ourselves, however incredulous or indifferent others may be upon this point, that it is the only true foundation to rest prac- tical medicine upon. The diseases, or affections of the eyes, we felt too important to trust their pathology and mode of treatment, to our own ex- perience; we are therefore indebted to our friend, Dr. Hays, for the chapter upon this subject—his long and attentive study of the subject, together with his experience in this branch of prac- tical medicine, has amply fitted him for the task. It will be seen, that the present work does not comprise the history and treatment of every disease that "flesh is heir to;" our reasons for omission are, first, that we have already treated ADVERTISEMENT. xi «■ of many, in the "Diseases of Females," and in the "Diseases of Children." Second, that many of the minor diseases described by authors, we have never seen; for all are not the diseases of our country. Third, that in some few cases, we have neither been sufficiently well satisfied with the investigations of others, nor with our own proper experience to the present moment, to give them a place here. Of this kind are jaundice, tetanus, hy- drophobia, rickets, and all the neuralgias almost. We however trust, should opportunity be given us, to treat of them more sa- tisfactory at another time. To conclude; we have avoided throughout all unnecessary theo- retical discussion; nor have we in any instance, attempted to make facts square with preconceived notions—or in other words, we have not attempted to build a system. On the contrary, we have care- fully studied the constitutional symptoms, and attempted to trace their origin to the pathological condition of the parts primarily involved, so far as they have yet been discovered. Moreover, we have not in any instance yielded our assent to authority, however high, when it has been contradicted by our own expe- rience; nor have we at any time obtruded our opinions upon points, when we had reason to believe, that the observations of others had superior claims; intending by this, to make our own experience as available as we honestly could, but never offering it as a substitute for that of others, when they appeared to have the best right to the preference. It may be proper to account, for the paging of the two vo- lumes being consecutive, instead of each having its own nume- rical commencement and termination. It was originally intended that this work should be comprised in one volume; but its size was found to exceed the first calculation—it was therefore thought best to divide it into two parts. GENERAL OBSERVATIONS. 1. THE great light which the French pathologists have shed upon the nature of fever, has enabled us in a very remarkable manner, to curtail its course, and to lessen its danger. The pre- sent work is not one, in which it would be either necessary or proper, to discuss the nature of this class of diseases—we shall therefore not attempt it. It will be every way sufficient for our purpose to state, that the variety of fevers formerly made by some nosologists, is now very much diminished; and the mode of treatment, founded upon examinations after death, has been very much simplified. 2. Nothing has retarded success in the treatment of fevers so much, as the almost endless variety, some nosologists have made; and each of which, agreeably to such distinctions, requiring a different mode of treatment. Thus Sauvages gives no less than one hundred and fifty varieties of fever; and almost all the noso- logists since his time, though they have not gone to the same length, have nevertheless recognised so many, as to become every way dangerous in practice. 3. In many instances, a single symptom in fever, has been sufficient to establish a variety, and a consequent difference in treatment—thus, we hear of a mucous fever, because the tongue has happened to be very white; of a bilious fever, because it has chanced to be yellow; or a putrid, or typhus fever, because this organ had become black, dry, or brown, &c. Now, in all these instances, the state of the stomach was, most probably, positively the same; differing only in the degree, or in the acti- vity of the inflammation, which was the original cause of the constitutional symptoms; and which has these various states of the tongue, very constantly, if not invariably, as attendants. H this be true, and we think it cannot well be disputed, is it not worse than idle, to make distinctions, where there are no impor- tant or essential differences? or to institute a variety in treatment, 2 10 GENERAL OBSERVATIONS. where one plan, if the right one, and properly pursued, is every way sufficient for the end proposed! 4. It appears to be at this time settled, at least as far as unani- mity can prevail upon a subject not susceptible of absolute or rigid demonstration, that, in all the supposed varieties of fever as recognised by some writers, (but which by very many of the best informed of the present day, are looked upon almost as gra- tuitous,) the lining membrane of the stomach is constantly found after death to be in a state of inflammation, (more or less;) and that all the constitutional symptoms, or the phenomena of fever, depend upon the altered condition of this organ; and con- sequently, that all the remedial means are such, and such only, as are calculated to diminish, or remove it. And farther, that every thing which has not this tendency, is not only useless, but is injurious. 5. We are aware, that every favourite theory, may be acted upon too exclusively, in a practical sense; and we are even wil- ling to admit, that the celebrated author of the doctrine just glanced at, pushes his practical precepts beyond, what we at this moment believe, is warranted by general experience. Thus he confines his treatment, so exclusively to the reduction of the inflammation of the stomach by leeches, and absolute starvation; that he loses sight, in his plan of cure, of the necessity of re- moving the extraneous substances, which almost always occupy this organ, or the bowels; and which cannot fail by their pre- sence, in our opinion, to become irritants, and every way able to perpetuate, if not to augment, the existing evil. 6. But on the other hand, we are ever disposed to exercise equal candour, and to acknowledge, that much mischief is con- stantly done, by the employment of means, altogether dispro- portionate to the mere removal of foreign substances from the alimentary canal, or from the stomach itself. And we farther admit, (but at the same time let us be understood to reprehend the mistake, while we deplore its consequences,) that the preva- lent idea upon the subject of clearing the first passages in fever is, that it requires remedies, active in proportion, to the violence of the constitutional symptoms; the very reverse of which is the fact, if the opinions we have adopted of the cause and for the cure of fever be true. GENERAL OBSERVATIONS. 11 7. For it must be evident that if the cause of fever consist in an inflammation of the mucous coat of the stomach, it is every way certain that violent emetics, or very active purgatives, will not have a tendency to remove this cause, however successful or sure they may be, of carrying off from both stomach and bowels, the impurities that may have occupied them. In such cases then, no greater error can well be committed, than to em- ploy them. We are convinced, that it is within the recollec- tion of almost every observing physician, the surprise he felt when the more active forms of fever did not yield to the very powerful cathartics he employed to subdue it; and that he constantly attributed his want of success to the indomitable na- ture of the disease, rather than to the ineligible nature of the means he had had recourse to. He never dreamed that the sto- mach was in a state of high excitement; and that the stimulating remedies that he made use of, were better calculated to aug- ment, than to sooth the condition of the organ on which they primarily acted. 8. It is to the French pathologists chiefly, but especially to Broussais, and his friends, that we are indebted for the late im- portant discoveries in morbid or pathological anatomy; and for the great improvement in the mode of treating almost every fe- brile affection founded upon these researches. And though we admit without hesitation, that they have in some instances run into an ultra mode of treatment, yet we are in truth obliged to acknowledge the value of their discoveries. 9. The premises and deductions of Broussais, we are aware, are not universally admitted; but in this he shares but the fate of all who have made valuable contributions to medical science. Some pass over his suggestions even without notice; while others furiously dispute the condition of the organs on which they are based. The one, is a reprehensible indifference; the other, too often is an uncandid examination. 10. Upon this point Dr. Johnson makes the following judicious and emphatic remarks. " If it be true, and we believe it is as good as proved, that all the symptoms known to accompany Eu- ropean fevers at least, also accompany the disease we are treat- ing of, (gastro-enteritis,) in its acute form—if it be true that in nine-tenths of these fevers there are signs of gastro-enteritic in- 12 GENERAL OBSERVATIONS. flammation during life, and that unequivocal traces of its having existed are found after death—if it be true, that this connexion of fever with the phlogosed state of the digestive organs was not efficiently noticed before the time of Broussais, then must it be also true, that this pathologist has conferred an incalculable be- nefit on the healing art, by calling the attention of those that exercise it, to this important, and hitherto neglected coinci- dence."* 11. The discovery of the inflamed condition of the stomach in fever, leads to many highly important therapeutical observances in the choice, and in the administration of remedies; this both regards their qualities, and quantities; and will very emphati- cally account for the many failures in their cure, before this va- luable pathological fact was thoroughly established. It also points out the value of local depletion, by either leeches or by cups; and satisfactorily accounts for the frequent success that follows the loss of a comparatively small quantity of blood, when abstracted by these means, from the region of the sto- mach. 12. We do not, however, yield entire faith to the French pa- thology upon the subject of fever; namely, that its seat is always in the stomach. For so far we have not had sufficient proof, that an inflamed condition of the mucous membrane of this or- gan is the true cause of adynamic, or typhus fever. So far as dissections can be relied on, this organ has very often been found in a normal state in patients who have died of this fever. The brain, the liver, the spleen, have all been observed to have borne marks of inflammation in the adynamic fevers; and in some other instances, dissection did not appear to reveal any thing that was conclusive upon this point. In all fevers that may have marsh miasma for their remote cause, the stomach we be- lieve will almost always be found to be the seat of the affection. 13. It moreover directs the choice of both diet and drinks in cases of fever—for it at once admonishes us to the cautious use of all; and imperiously forbids the employment of any which may belong to the class of stimulants. The cautions suggested in the use of food and drinks, are perhaps more extensively va- • Med. Chir. Review, April, 1828. GENERAL OBSERVATIONS. 13 Juable, than those for the administration of remedies; for the use of the first appears to be more frequently delegated to the nurse or attendants upon the sick, than to form a part of the regular, and necessary prescription of the physician; while the latter forms the more direct province of the medical attendant, and is usually conformed to by those who have charge of the sick.* 14. It is intended, by what we have just declared, to convey a direct, and severe censure, to every practitioner who neglects to prescribe, with rigorous care, every article of food or drink his patient may require. And at the same time, we recommend to him to jealously watch, that it has neither been altered in qua- lity, nor exceeded in quantity. We regret that this all-important vigilance is not sufficiently often exerted by the medical attend- ant; and that so much latitude is given to those, who, from the very nature of things, can neither comprehend the nature of the disease, nor be acquainted with the best mode of treating it. 15. From what has been said, it would appear, that, in the cure of fevers, much will depend upon the choice, and the due administration of drinks and food; and, moreover, we hesitate not to say, that all well-regulated experience is in its favour. Thousands have been called to an untimely grave, by the over- officiousness of the nurse, and the overweening anxiety of friends; for both too often and too certainly conspire, against the best interests-of the patient, by acting independently of the sug- gestions of the physician, or by running counter to his most po- sitive directions. 16. The office of " /Vwr*e"t is one of awful responsibility when its duties are properly considered; for on the faithful dis- charge of them, the life of a fellow being in very many instances * A physician cannot commit a greater mistake, than to leave the choice of drinks to the attendants upon the sick; this should be one of his unalienable rights, and one of his most positive duties; nor should he ever dispose of them. The directions for the drink of the patient, is oftentimes of more value than the prescription for medicine; and that practitioner is highly culpable, who neglects to specify both the kind of drink, and the nature of the aliment, be- fore he leaves the sick room. And we are sorry to be obliged to acknowledge it as a fact, that we have known many instances where neither diet nor drinks were specified by the physician, though the patients were labouring under diseases of an acute form. •j- Of this we shall speak more at large presently. 14 GENERAL OBSERVATIONS. depends. How much intelligence, good sense, and fidelity are required, that the patient may profit by her attentions; or that he may not be injured by her self-willedness or neglect! Where there is a medical attendant, the duties of the nurse are reduced to two simple, but highly important rules; and the observance of which should be most rigidly insisted upon. First, to do every thing that the physician orders to be done, and this in the strict letter of his commands. Second, to do nothing herself, nor per- mit any one else to do that which he has not ordered; for it is fairly to be presumed, that the physician will direct, to the best of his knowledge, whatever he may think is essential to the welfare of his patient; therefore, for a nurse to put her judg- ment in opposition to that of the physician, is both arrogant and dangerous. 17. Unfortunately, for the welfare of the sick, it too often happens, that the nurse, when about to oppose the judgment, or disobey orders, enlists on her side, the immediate friends of the patient, by unnecessarily rousing their fears for his safety, or still more reprehensibly, by diminishing their confidence in the skill and experience of the medical attendant. When this hap- pens, the suffering patient is left to the management of a disin- genuous and ignorant nurse; while the physician is charged with the entire responsibility of his recovery. Could ajl the conse- quences of the backslidings of nurses be made to meet the public eye, they would exhibit one of the most appalling pic- tures, that could be imagined, where absolute turpitude was not concerned in its production. IS. But in making this charge against this very important class of people, we mean not too generally to impugn their in- tentions—we are convinced they act from an honest, though a dreadfully mistaken notion, even in their greatest deviations. For it unfortunately happens that most nurses have their own notions of the nature and cure of every disease they may be called upon to watch; and but too often act upon their own the- ories, to the subversion of the plans of the physician; and not unfrequently, to the destruction of the patient. 19. Now, can it be for a moment supposed, that an ignorant, uneducated woman, (be her experience what it may,) shall be as well qualified to judge of the condition of a patient, as the man GENERAL OBSERVATIONS. 15 who has devoted the better portion of his life to the investiga- tion of diseases? This, we are persuaded, will be answered by every thinking being, in the negative; yet, is there a physician living, who has not seen, in many instances, the opinion of a nurse preferred to his, during his attendance upon the sick! As a mere matter of calculation, and to which every school-boy is altogether competent, it will be found, that in no instance can the judgment of the nurse be equal to that of a well-instructed practitioner, of even moderate practice. For a nurse cannot for the most part, attend but to a single patient at a time; and the whole that may fall under her charge, amount to a very few; consequently, her observations, must from the very nature of things, be very limited; while the physician, in the same pe- riod, may see hundreds; and of the condition of which, from his education, habits of thinking, and talent for observation, is in- finitely better qualified to decide upon the nature of the disease, and its mode of treatment. 20. Though the evils of which the physician has so much cause to complain, arise almost always from the direct agency of the nurse, yet they are less to blame in some other instances than the immediate relations and friends of the patient. For did not the latter consent to become faithless to their duty; a duty rendered sacred by every tie, and by every law, the nurse could not, perhaps would dare not, act contrary to the most abso- lute, and well-defined directions, of the physician. It is quite time that this grievance should be redressed—it is the bounden duty of every individual in society to aid in this all-important change; nor is the remedy difficult to find—for it consists sim- ply, in each individual determining to become faithful to his own interests, and consequently disregarding the crude opinions of a nurse. 21. The injuries which the sick receive from improper nurs- ing, are not always chargeable, as we have just hinted, to the nurse, properly so called—the near friends of the patient, from whom we have a right to expect better things, are equally, and sometimes solely culpable; for they, like the nurse, have their own notions to support; and unfortunately they do support them; and this, too often, at the sacrifice of the patient. 22. There are two consequences always dreaded by the ill- 16 GENERAL OBSERVATIONS. instructed, in almost every case of acute disease—namely, de- bility, and typhus. These phantoms, haunt the imagination with such frightful constancy, as to dethrone reason and to an- nihilate judgment. They are the dreaded, and constantly-rung tocsins in the ears of the physician; and unfortunately, if he be not a man of marked moral courage, and have not proper confi- dence in himself, he becomes so appalled and overpowered by this din, as to yield up his judgment; and this, to the destruc- tion perhaps of the life entrusted to his care. 23. The friends, with a view to destroy these bugbears of the imagination, (debility and typhus,) insist upon the use of im- proper remedies, but more especially upon improper diet, and drinks, which, if yielded to, is sure to injure, if not to destroy the patient. Inflammation, and its consequences, must, in the opinion of these alarmists, be suffered to run on, or to increase, because, the remedies most suitable to relieve them, are suppos- ed only calculated to increase the dreaded debility, or to bring on horrid typhus. Hence, the destructive administration of bark, volatile alkali, wine, &c. or the almost equally destructive use of broths, chicken water, or animal food, in one form or other, during the continuance of fever. And we may here declare, once for all, that it is our most solemn and deliberate opinion, that the apprehension of debility, and of typhus, has caused more deaths, than the unrestrained Plague, or the much-feared yellow fever. 24„ We have dwelt upon this subject, perhaps beyond the pa- tience of the reader; but certainly not longer than the subject demands, or its importance merits; and especially by those, for whose more immediate use, this work was undertaken. The di- rections for the management of the various diseases, must be re- garded as the opinions of the physican, by those not connect- ed with the profession, and consequently, general rules, must not be deviated from, without great and well-weighed cause, if success is to follow the plans of treatment laid down in these pages. For due consideration has been given to every portion of the work; and every direction given for the management of the various diseases treated of, is the result of the experience of the most approved authorities, aided by that of the author. 25. We cannot, however, yet dismiss this subject; we feel it GENERAL OBSERVATIONS. 17 important, again to recur to the vulgar errors on the hackneyed points of debility, and typhus. 26. Weakness, or debility, is the necessary consequence of disease, whether it be suffered to run its course without inter- ference, or has been treated agreeably to the rules of art. The patient and the disease, therefore, must be looked upon as a unit; and consequently, whatever abates the one, must necessa- rily diminish the other; and in most instances of acute, and con- tinued disease, there is no removing the one, but at the expense of the other. This fact should constantly be borne in mind; be- cause, as a great practical truth, it may tend to diminish the ap- prehensions just named, as well as give the best possible chance for the patient's recovery. 27. It should also be recollected, that debility is not disease; it is only one of its insuperable attendants; and is never, or but very rarely, of itself, the cause of death; for we may from long experience very safely say, where one dies from pure debility, an hundred perish from over-stimulation, or from the remedies purporting to counteract weakness. 28. The proper plan then to remove debility, must be to cure the disease; but the contrary course is almost constantly pur- sued; the consequences, we shall not repeat. Let us for a mo- ment, look at the means usually employed, to support strength, or to prevent typhus. They will be found to consist of all the more powerful stimulants in our possession; and whether they range under the head of medicines, or are regarded as articles of diet, they are for the most part, equally improper. Under the former, the bark, volatile alkali, opium, aether, phosphorus, and all the bitters, may be classed; and under the latter, brandy, wine, porter, ale, alcohol, animal food, broths, and jellies, may be ranked. 29. It is a fact generally admitted, that, the remedy which is not calculated to diminish or overcome a disease, is almost sure to increase it—now, fever for the most part has for its cause, a local inflammation; and that inflammation, seated in one of the most important organs of the body; namely, the stomach; if this be admitted, and admitted it is, by all the most enlightened of the profession, will not the common'sense of mankind revolt at 3 18 GENERAL OBSERVATIONS. the idea, that this formidable condition of the system, is to be overcome by means like those just enumerated? 30. Let it not, however, be imagined, that our treatment of acute diseases, excludes every kind of nourishment, or of stimu- lant, from its plan. On the contrary, it will be seen, that both one and the other are employed; and that we only insist upon the proper selection, quantities, and periods of exhibition. Our nourishments will be derived almost exclusively from vegetable substances; and our stimulants, will be mainly confined to exter- nal application. We must attempt to remove another vulgar error; one which has unfortunately an application as extensive, as it is mistaken, and mischievous; namely, that all stimulants, (whether durable or diffusible,) are tonic and bracing, and con- sequently calculated to prevent, or remove the monster debility, and thus secure the patient against the other dreaded consequence, typhus. 31. Hence, alcohol, whether in the form of brandy, wine, &c, is considered, and by too many, is emphatically called, strength- ening—and hence, its almost universal employment, in the de- cline, and in some instances, at the very acme of the disease, by those, whose imaginations teem with the fear of debility, and typhus; and hence, as we have too often witnessed, the too cer- tain production of the very conditions, so much held in dread. 32. This last assertion is not a creature of the imagination; it is too truly founded in fact; and we pledge our best hopes upon its truth. Nay farther, we have many times seen, a simple in- termittent, with well-marked intervals, converted into a highly dangerous remittent; and have more than once witnessed the latter, goaded into, what is usually termed typhus, by the too early or too powerful application, of stimuli. And we now in- sist once for all, that debility never was, nor never can be re- moved by diffusible stimuli, alone. As well might the unmerci- ful rider expect the renovation of the flagging strength of his sinking horse by the application of his spurs, as for us to attempt the restoration of strength to the human body, by the mere ex- hibition of alcohol, in any shape or form, whatever. Let it be remembered, that under the best circumstances it is rarely use- ful; and to be so, requires, that its exhibition should be most GENERAL OBSERVATIONS;. ID nicely timed as well as regulated by the soundest judgment. Let it also be borne in mind, that where it is once fortunately employed, it is an hundred times improperly applied. Indeed, the same may be said of substances which are usually termed very innocent; namely, the solution of animal jellies, in the form of broths, as beef tea, chicken water, &c. 33. We feel it highly proper to be more explicit upon the subject of animal jellies; and in so many words declare, we know of no period in the continuance of any acute disease or fever, where they are admissible; or rather, where they will not do, positive harm.- We are truly of opinion, that " chicken water,'''' that simple, innocent substance, as it is usually called, has done more mischief in acute diseases, than even the ill-judged use of the lancet, or the too freely urged mercury. For the " chicken water" is every day, and even very often in the same day, pro- ducing its mischief; while that from bleeding and mercury, under the circumstances stated, is of comparatively rare occurrence— yet so common and inveterate are the prejudices in its favour, that we fear we shall be too rarely believed, and too seldom aided in its proscription. 34. We are seriously of the opinion, that a majority of, the relapses in acute diseases, is owing to the injudicious employment of the " innocent chicken water.,y We well remember an in- stance, where only three table-spoonsful of this animal solution, created so much fever, and so severe a renewal of the pain of pleurisy, that seven bleedings were required to subdue them; though at the moment of its exhibition, the friends of the patient, and her physician, thought her in a state of convalescence. 35. It is in the unadvised and injudicious use of animal sub- stances, either entire, or in solution, that nurses most frequently effect the mischief complained of above. They cannot compre- hend, how a small piece of meat, a little broth, or a few spoon- fuls of chicken water, shall do harm to a patient who is labouring under fever, and who is confessedly very weak; and though they quickly after its exhibition witness an aggravation of every symptom, they never charge the improper food with the mis- chief; and therefore they do not profit, even by experience. 36. In the same way, and with similar results, do they venture upon "seasoning the victuals with a little dash of wine or 20 GENERAL OBSERVATIONS. brandy," contrary to the most positive prohibitions of the phy- sician. Is it then surprising, that fever should have so many victims, when the force of the disease is aided by the covert conspiracies of the attendants upon the sick! It were devoutly to be wished, that the duties of the nurse could be fulfilled, but by the exercise of conscience. For were this the case, they would most probably pause, and possibly cease to act, upon their own responsibility. 37. Hitherto, we have only adverted to the errors committed by the attendants upon the sick; and exposed a few of the more prominent sources from which they, arise. We shall now lay down a few rules for the government of the sick room, believ- ing that a work strictly practical like the present, would be very defective without them. 38. It is universally admitted, that " good nursing is half the cure;" yet there are but few who understand, in what this really important art, consists. And were we to describe it by nega- tive, we should almost be tempted to say, that it consists, in almost every thing, but that which is absolutely done. But as this brevity would not serve the purposes we aim at, we shall descend to some general principles, and the rules resulting from them. 39. In the first place, the physician has to acknowledge, that his attentions upon the sick, would be altogether unavailing, were his directions not obeyed by the nurse, and this, in the most faithful manner; the rule to be followed by the nurse must therefore be obvious; namely, to follow them, most implicitly. But the duties of the nurse are various as well as important; and consist of her qualifications for her office; the faithful admi- nistration of medicines; the giving of drinks and nourishment; attention to cleanliness; keeping the room quiet; procuring its proper ventilation; preserving a proper temperature of the air of the room; regulating the warmth of the patient; the examina- tion and preservation of his excretions; her management of his sitting up; making of the bed; the proper use of the utensils for the evacuations; the mode of giving him drinks; the applica- tion and dressing of blisters; the administration of encmata- and management of the patient during convalescence. GENERAL OBSERVATIONS. n l. Of her Qualifications as a Nurse. 40. In every department of life, however humble, or how- ever dignified, it will be found, that certain qualities are essen- tial to the best fulfilment of the duties belonging to each. To the one we are now considering, too little consequence has hitherto attached; it has been imagined, that any female was competent to this end, provided she had no absolute or physical incompatibility; than which, no greater error can well exist. 41. Both mental and physical powers are essential to a good nurse; without the first, she will lack a most important quality, namely, judgment; and without this she would be unable to pro- fit even by experience. She may possibly be competent to fol- low a particular, or a strictly marked out routine; but will rarely be able to generalize her duties, so as to make them available to the best interests of her patient. She could not be trusted with safety to execute a general order, by which remedies are to be persevered in, or withheld, agreeably to the varying condition of the disease. She cannot make herself mistress of the import of symptoms; or become familiar with the several states of the pulse. In a word, she would want the happy faculty of combi- nation, so often, all-important to the sick. The reverse of all this may rationally be expected from one who has cultivated, to a certain extent, a naturally good understanding, and who has made herself mistress of her duties. 42. She should be a woman of close observation, and of strict veracity; the first will enable" her to detail to the medical attend- ant the various changes of the disease; or it will instruct her in the application, or the withholding of the different remedies, as may be pointed out by the physician, or by the books of instruc- tion she may be obliged to follow. The second is eminently re- quired, that no exaggerated statement, nor suppressed truth, may mislead the judgment of the medical attendant in forming his plan of treatment. 43. She should possess no small share of both moral and ani- mal courage, that no condition of the patient may make her flee the bed side, or permit him to rise at an improper moment, or to commit acts of violence upon himself; and that she may be 22 GENERAL OBSERVATIONS. able to withstand his solicitations for things that are improper, or that have been forbidden. Yet must, she be all gentleness in manner; or soothing, or commanding in tone, as circumstances may require. She should possess feeling; that she may the more readily be prompted to her duties; but she must not be so far led astray by it as to betray alarm, where there is even just cause for it; but she should especially guard against it, when there is none. 44. She should possess moral honesty, that she. may com- pletely understand her situation as regards those, whose orders, from the nature of her office, she has voluntarily bound herself to obey. Her duty is passive obedience; and when she refuses this, she breaks a contract; and if she follows her own prompt- ings in the management of the patient, she betrays a sacred trust, by which she may counteract the best devised plan of treatment; or may heedlessly destroy a fellow being, by a de- # parture from her prescribed duty. 45. It is at once obvious she should possess sufficient physical powers, that she may not sink under the weight of her duties; and that she may be able to give every neeessary aid to the pa- tient, where his own strength is incompetent; or where it would be exhausted were it employed. And with a view to maintain her strength, she should be supported by a proper diet, and such occasional rest, as the exigences of the case may require. The comfort of the patient is very often dependant upon the physical powers of the nurse; the weariness arising from too long a con- tinued position; or the restlessness consequent upon sickness can only at times be relieved by changes of posture; and for these changes, he must be dependant upon the physical powers of the nurse. 46. To effect these changes, requires, on the partx)f the attend- ant, not only the physical powers insisted upon as essential to this character, but also an entire willingness to perform these duties in the best manner, and as often as may be demanded; amia- bility, and goodness of temper, are therefore also required. Every body that has been prostrated upon the bed of sickness knows full well how eminently it is in the power of the nurse to render it more supportable, by a kind, willing, and amiable deportment. And the obligations which an affectionate carriage GENERAL OBSERVATIONS. 23 imposes upon the sick, is ever after acknowledged by a grateful recollection of it. So important,.indeed, is the mild and atten- tive conduct of the nurse in some instances, that it contributes largely towards recovery. And so decidedly injurious, in some instances, is a contrary conduct, that it is sure to render suffer- ings more intense, if not, to augment danger; while in others, it has been too certainly destroyed. 47. Much depends upon the mode of exhibition, that medi- cines may be faithfully swallowed; or that they be not con- stantly rejected, A cheerful, persuasive manner on the part of the nurse, will often conquer a disgust that is almost consequent upon remedies being presented; and they are almost sure to be taken, even by children, if she administer them with delicacy, and choses the proper moment for their exhibition. She should therefore possess so much prudence, as not to excite aversion, by talking of their ungrateful taste, or their forbidding effects; and she should have so much tact, as to seize upon the instant at which they will be taken. And upon the importance of the regular administration of medicine, every body is agreed. 48. Nature appears to have endowed the female in an especial manner, with a capacity to support fatigue, and to endure priva- tions; hence, their peculiar fitness for the duties of nurses. And should one not possess these qualities, she is altogether disquali- fied for the important office of a "good nurse." The sick, re- quire the utmost vigilance of the nurse; she should therefore, not be a heavy sleeper; nor even be unusually prone to sleep, lest he may suffer from the want of her attentions. This is par- ticularly the case, where the patient is much exhausted; for sometimes he is unable from weakness to rouse her, when he may much require her care.* 49. But as no one can endure the loss, of but a certain portion • Some nurses not only sleep profoundly, but also snore loudly,- serious, and double disadvantages. We visited a gentleman who had the misfortune to be attended by one of these unmusical nurses; on one occasion upon my inquiring of her how Mr.----had slept, she answered " delightfully; he did not wake once the whole night." The gentleman on the other hand assured me, in a faint and exhausted voice, that he had not closed his eyes during the night; nor could he, for the loud snoring of the nurse. Nor could he rouse her, by any effort his feeble powers permitted him to make; in consequence of whicli, he suffered much for drink, &c. during the whole time. 24 GENERAL OBSERVATIONS. of sleep, the nurse should be indulged to take a nap during the { day, at a time she can be best spared from the sick room, that she may be able to resume her watch at night. To more effec- tually insure vigilance, the nurse should abstain from every species of liquor, unless it may be an occasional small quantity, if really exhausted by long watching, or over-exertion; sobriety is a sine qua non to a nurse. 50. Cleanliness in habits, is of immense consequence to a nurse; she should pay scrupulous attention to her clothes being frequent- ly changed, and always clean. Her hands should be frequently washed; and she should not use tobacco in any shape whatever; if she snuff, her fingers, by which she is to prepare the nourish- ment of the patient, will be always begrimed with this disgust- ing article; if she chew, or smoke, her breath will be highly offensive. And, indeed it would always be a good practice for her to carefully rince her mouth after each meal; as the stomach of the patient is often made to revolt, from the impression of dis- agreeable odours, upon the nose. 51. Let it be borne in mind however, that too much duty should not be imposed upon the nurse; for if this be done, she may fail at a moment, when of all others, her services may be required. To prevent such an accident, her strength of consti- tution should be consulted; that no more may be put upon it than it is well able to bear. In cases of long-protracted illness therefore, other assistance should be added, so as to afford her an opportunity for proper rest, or if much exhausted, for entire renovation. This is a matter of much consequence to the patient in many instances; for the one who has been long about his per- son becomes familiar with his habits, as well as those of the disease. 2. Of the Faithful Administration of Medicine. 52. If there be any power in medicine over disease, it must be owing to its proper selection, and its well-timed exhibition. It is left for the physician to make the choice of the remedy; but it depends too often upon the nurse, whether it be efficacious or otherwise. It is in vain that remedies are procured, or by what- ever experience, or talent they may be prescribed, if they be not GENERAL OBSERVATIONS. 25 applied, as directed. A nurse therefore, assumes an awful re- sponsibility, when she departs from her absolute province, and undertakes to differ in opinion with the physician, or neglects his orders. 53. On the regular exhibition of medicine, the cure very often depends; this is so generally admitted, that it needs no illustra- tion. In many cases, life itself is at the mercy of the nurse, as she may faithfully, or negligently perform her duty. How ne- cessary is it then, that this important personage, should feel the responsibility attached to her situation; and be influenced by a conscientious regard, for the proper fulfilment of the duties, her undertaking has imposed upon her? 54. In insisting on the entire conformity of the nurse to the directions of the physician, we do not wish to be understood as declaring, there is no exception to the rule. On the contrary, the patient, as well as the physician, are occasionally indebted to the nurse, for a judicious suspension; or perseverance in re- medies, beyond the strict letter of her orders; and especially, when such departures have proceeded, from a genuine exercise of judgment; and not from a wayward determination to disobey. Now, as there must necessarily exist every variety of constitu- tion, as well as very many peculiarities, or idiosyncrasies, no one can be certain, that the remedy ordered, shall act precisely as desired; consequently the departures from such expectations may be great; and were the medicine not suspended, or some- times urged, beyond the common direction, much injury might insue. In such cases, the judicious interference of the nurse, may be highly valuable, and fortunate. 55. But these cases, rare in occurrence, are'but the exceptions, and do not in the least interfere with the general rule; and to which, it is the bounden duty of the nurse, most scrupulously to adhere. She is therefore not only bound to do, most exactly, what she is ordered to do, but also, to do nothing, she is not or- dered to do; for as much mischief may result from the one, as from the other. 3. Of giving Drinks and Nourishment. 56. Greater errors are generally committed in the use of drinks and nourishment, than in the neglect, or mal-administra- 4 26 GENERAL OBSERVATIONS. tion of medicine. It is supposed, that thirst must be allayed whenever importunate; and that this can only be done, by pour- < ing down fluids, without regard to either quantity or quality. This error is sometimes of serious moment, as it not only over- loads the stomach, hut also forces it to regurgitate the supera- bundant draughts, to the great inconvenience or injury of the patient. An over-quantity causes oppression and restlessness; an improper quality may seriously injure from its entire incom- patibility. On these accounts, the nurse should never depart from the quality of the drink, nor ever exceed the due or pre- scribed quantity. 57. Upon these points, the nurse should never deviate from express directions; for should she, she cannot answer that im- mediate mischief may not ensue. Drinks have a more decided influence upon the system than is generally admitted; they should therefore be subject to the direction of the physician, as much as medicine and food. 58. From a vulgar belief, that all the " herb teas," as they are called, are perfectly innocent, we find nurses in the constant habit of employing them, without the sanction of the physician; by which the most serious evils oftentimes arise. It should be recollected, that whatever substance possesses a power to do good, may also have a power to do injury, if it be injudi- ciously administered; therefore, the whole class of these teas . should be proscribed, unless expressly ordered by the medical attendant, as they are all, to a greater or less extent, heating or of a stimulating character. 59. Popular feeling is in favour of warm or hot drinks, with the generality of nurses; they are therefore almost constantly exhibited in this condition, especially in fever; because they promote perspiration, as they suppose. This error should be done away with; and a bare statement of a fact, namely, experience has proved, that as a general rule, they are hurtful. A nurse should therefore never be permitted to prescribe drinks, any more than a medicine; for wc cannot but regard them as efficient, or inju- rious, as they may be properly or improperly ordered. 60. We may make similar objections to the manner of giving, as well as of the quality of the food offered to a patient. It is almost always given in too large quantities; too frequently re- GENERAL OBSERVATIONS. 27 peated, and but too often of an improper quality. The physician alone should be the judge of these matters; and his orders should be obeyed, most strictly, and literally. The nurse should never for an instant depart from his directions upon this point; she should not upon this subject be permitted to think for herself. An error in quantity, it should be remembered, is almost equal to an error in quality; for every particle that remains unsubdued by the stomach, becomes offensive, because it remains unsubdued. Or if it be subdued, it may be extremely injurious, by affording too much nutriment to the system, at a moment when it requires absolute reduction. So important then is the due administration of nourishment, that the nurse should never be left to her own discretion. 4. Of Cleanliness in the Sick Room. 61. No single agent is of more importance in a sick chamber, than pure air; therefore, to prevent its becoming foul, every source by which it may be deteriorated should be removed in- stantly, when practicable; and when not, it must be compensated for, in the best manner attainable. On the nurse, this task will almost exclusively devolve; she must therefore be mindful not to neglect this important part of her duty, whenever there is a necessity. To accomplish this, everything that can emit an un- pleasant smell, or shall ovolve an injurious gas, must be taken away with all convenient speed. The evacuations should be re- moved instantly from the room; the body, and the bed-clothes, should be as frequently changed as circumstances will allow, Fresh air should be freely admitted into the room; no filth should be permitted to accumulate upon the floor, the tables, the bed, or the hearth. 62 All the vessels employed, either for medicine, drinks, or nourishment, should be cleaned the instant they are used; con- sequently, the same vessel or spoon should never be used twice without cleaning, unless the substance for which it has been used is not of a nature to become offensive to any one sense, 63. The patient's hands and face should be frequently cleansed; and especially when warm, by wiping them with a towel or napkin, wetted with cold water or vinegar and water, unless 28 GENERAL OBSERVATIONS. there be chilliness present, or is easily excited by the application of any thing cold. In a word, every thing should be kept as clean and as sweet as the nature of things will permit. With the same view to comfort, the patient should have his mouth fre- quently cleansed; by himself, if his strength will permit; and by the nurse, when this fail. This attention is particularly grateful in the decline of such fevers as assume what is called the typhus type; that is, where the tongue becomes dry, and the teeth en- crusted. For this purpose, yeast and water is very effectual; or a wash made of a tea-spoonful of the sweet spirit of nitre, and a table-spoonful of water. The latter is particularly acceptable to the mouth, in the beginning of active fevers; when the tongue becomes loaded with a white dense fur, or is coated with a tena- cious slime. The patient, when able, finds both comfort and amusement, while performing this office himself, by means of a tooth-brush. 5. Of quiet in the Sick Boom. 64. There is scarcely any thing so distressing to the sick, as noise. It should therefore be the nurse's particular study to pre- vent disturbance from this cause. She should not only be of quiet habits herself, but she must make every body else conform to this regulation. A talkative nurse, is a great evil; indeed it is one, that can only be removed sometimes, by the removal of the nurse herself; and it were always better to do so than to have the patient exposed to the inconvenience of her loquacity. 65. A talkative nurse, is almost sure to be a superstitious one; and if so, she will deal out her forebodings so liberally as to do decided injury to the patient. In the sick room, no signs should be enumerated, but good ones; therefore all gossiping recitals of similar cases having had an unfortunate termination, should be most- carefully prohibited. All unnecessary conversation should be avoided; therefore the sick room is not the place for idle col- loquies. If conversation must be carried on, let its character be of the cheerful kind ; and in a tone of sufficient elevation, that the patient may, if he become interested, thoroughly compre- hend it. This should always be remembered. But as a general rule, the less conversation is indulged in, the better; especially when the disease is of the acute kind. GENERAL OBSERVATIONS. 29 66. In certain conditions of the nervous system, cheerful con- versation is frequently highly beneficial—and in such cases, an agreeable, chatty, and well-instructed nurse, is of immense value. But even in such cases, the topics of conversation should be ju- diciously chosen, and their duration, properly regulated. 67. A nurse however, may be annoying to the patient if she be not over-talkative; for there are your bustling nurses, who are forever putting " things to rights," without ever effecting the object; and who during the whole time make so much clatter, that the patient gets no sleep, however strong his desire; or else is as constantly disturbed, by the officious employment of shovel, tongs, or dusting brush.. 68. We are aware that the use of these implements, cannot altogether be dispensed with; but their employment can certainly be properly timed. 69. It were better, that the hearth remained unswept; or the fire unrenewed, than that the patient should be prevented from taking his nap, or that he should be roused from a sleep, that might be highly instrumental to his recovery, in effecting either the one or the other. 70. Indeed, a judicious well-instructed nurse, knows how to take advantage of the times, that will be least annoying to her patient. There should therefore, be no absolute or fixed time, for " clearing up the room;" the moment that will create the least annoyance to the sick, should be the only one selected. We have seen your nurses of absolute routine, do much injury by the performance of this office, at ill-chosen periods. The con- dition, and comfort of the sick, are always to be taken into consi- deration; and the ringing the changes upon the unstable shovel, tongs, and andirons, should be postponed, until the instant, at which the patient would be the least annoyed by it. 71. There is another very fruitful source of noise, and annoy- ance in the sick room, and which is very rarely attended to; namely, the noise of a creaking shoe. A nurse during her at- tendance upon the sick, should not wear a shoe that will yield the slightest sound; for she can always command such as will not; or.if she cannot, socks can constantly be procured; and with these her feet should be cloathed. 72. We may enumerate several other sources of unnecessary 30 GENERAL OBSERVATIONS. and vexatious noises in the sick room, either of which is capable of preventing or disturbing sleep; namely, the rattling of knives and forks, the jingling of glasses; and the clatter of spoons, and plates. Now, as these can never be necessary, they should al- ways be eschewed. And " though last, not least," in this ample enumeration, is the frequent opening and shutting of the door of the sick room. This common and certain annoyance, can always be avoided by the following observances. 73. 1st. Let the door be kept open, whenever it will not be desirable, or necessary to have it shut. 74. 2d. If unavoidably.it must be kept shut, let its being opened be productive of as little noise as possible; 1st, by having the locks in good repair; and 2d, having them to open easily; and 3d, by having the hinges well oiled. 75. 3d. Let the door be opened, only when it is absolutely necessary for the comfort or necessities of the patient; to avoid unnecessary openings, permit no more to enter the room than is essential to the nursing of the patient; because you will have to let all go out that come in; and each, will be a fresh distur- bance. 76. 4th. Never permit the door to be opened, while the pat tient is sleeping; to command this, we are told, that in London, . they have a very simple mode of communicating the informa-- tion, "that the patient is asleep," by thrusting the feathered end of a quill through the key-hole. It would be highly useful tq ftdopt this contrivance in this country. 77. 5th. Exclude all visitors from the sick room, however nearly they may be related by blood, or connected by friend- ship, whenever such prohibition shall be essential to the con> fort or safety of the patient; for it is better to give temporary pffence, than to produce permanent mischief. 6. Of the Ventilation of the Sick Chamber. 78. One of the most important attentions a nurse can bestow Upon the sick room, is, its proper ventilation. As regards this essential observance itself, it matters not, whether the season be hot or cold; for, in this instance, we merely, but distinctly mean changing the air pf the room—that is, the removal of that, which GENERAL OBSERVATIONS. 31 has become impure, for that which is pure. This can only be done with certainty, by establishing a current of the external air through the sick room, by the doors or windows being open- ed to a sufficient extent, and for a sufficient length of time. 79. As this can always be effected by proper management without risk; and as it is of the first consequence to the patient, it should never be neglected. The frequency of this renovation, or rather this exchange of air, must be regulated, 1st, by the season of the year; 2d, by the state of the weather; and 3d, the nature of the disease. 80. 1st. The season of the year will influence the necessity of ventilation; thus, in cold weather, or in winter, the air of the room does not so soon become vitiated as in warm weather, or in summer. For the substances capable of deteriorating the air, do not so readily become decomposed; and the circulation of the air in the room is much more rapid in consequence of fire; and, consequently, more frequently changed. Whereas, in summer, the contrary constantly obtains; hence, the greater necessity of giving air entrance from without, by means of the windows and doors. 81. 2d. The state of the weather, as regards its moisture or dry- ness, will necessarily influence ventilation. If wet, whether it be hot or cold, it will never be proper to admit the external air immediately into the sick room suddenly, or in large quantities^ at a time. The capacity to ventilate a room properly, under such circumstances, will necessarily be subject to many contingencies, as fortune, or poverty may prevail. The best mode of perform-1 ing this, under every circumstance, cannot be laid down; much must be left to the discretion, and good sense of the attendants. S2. 3d. The disease under which the patient may be suffering, will also have its influence upon the air of his chamber; and as a general rule we may lay it down, that fever, and every other acute disease, will require more frequent ventilation, than in chronic affections. Unless the latter have as an attendant, pro- fuse, or offensive discharges; in this case, it may be necessary to change the air more frequently than even in fevers, or other acute diseases. 83. Every body seems to be aware of the usefulness of changing, or purifying the air of a sick chamber; some arrive at 32 GENERAL OBSERVATIONS. this desirable end by the shortest and most effectual road; name- ly, by the admission of fresh air from without; while others suppose they attain this change by chemical decomposition.^ Hence, we have open window and doors in 'the one instance; * and suffocating vapours in the other. 84. We need not say more upon the first of these modes than • we have already done; on the latter, it may be well to offer a few observations, as its effects are not well understood; or they certainly would not continue to be resorted to. Combustion of every kind necessarily destroys, in proportion to its extent and continuance, a quantity of oxygen, or the vital principle of the atmosphere; consequently, wherever this process is performed, the air in which it was carried on, is less pure, by all the oxy- gen, the combustion required, to carry it on. Now, when sweet herbs, as they are called, rosin, sugar, tar, frankincense, &c. are burnt in the sick room, the air of that room loses a certain part of its vital air; and is, from this cause alone, less pure than it was before the burning was performed. But this is not all—for the air now has in it, in exchange for the oxygen with which it parted, a quantity of that irrespirable air, called, by the che- mists, carbonic acid gas, or fixed air, besides, a disagreeable odour, and other gases that arennfit for respiration. And nearly the same maybe said of decomposing vinegar upon a hot shovel, or upon live coals. These methods of purifying the air of a sick room, should therefore be strictly prohibited. 7. Of the Temperature of the Sick Room. 85. There is no fault in nursingmore common than over-heating the room of the sick. The dread, thaUhe patient will take cold, unless.his chamber be heated almost'to suffocation, is no less common than the fear of typhus, and the apprehension of de- bility. And like both these latter terrors, it has its own penal- ties. For in almost all acute diseases, it is erring on the wrong side; for very many more- suffer from too much heat, than do from too little. Light should be constantly excluded; at least as much as is compatible, with proper temperature, and venti- lation. 86. To fever patients, nothing is so grateful, as a reduced GENERAL OBSERVATIONS. 33 temperature; nor can any thing be more proper. One of the great efforts of the physician in fever, is the reduction of the ac- cumulated heat of the patient's body; and one of the best agents for this purpose, is the application of air to the surface of the skin, as well as that of the lungs, when it is of a lesser tempera- ture than the body. The advantage of this application is quickly perceived, by its tranquillizing influence upon the restless and agitated patient; by his skin becoming cooler; his breathing less hurried, and his pulse less frequent; or, perhaps, by his quickly falling into a refreshing sleep, or breaking out in a universal perspiration. 87. But on the other hand, if the heat of the room be equal, or nearly equal to the temperature of his skin, the reverse of all this is sure to happen—an aggravation of every symptom will certainly follow. It therefore becomes the bounden duty of the nurse, to so regulate the heat of the room, as it shall be con- stantly below, by a number of degrees, that of the patient's skin. We look upon a thermometer to be a necessary appendage to a sick room—for by this instrument alone, can we be certain of either an increase, or decrease of temperature; our feelings are fallacious guides. 88. At a season when fires are not in requisition, an attempt is frequently made to warm the room upon any sudden reduc- tion of atmospheric temperature, by burning of charcoal in the room. Let this never be practised; it is a plan replete with in- stant, and imminent danger. 8. Regulating the Warmth of the Patient. 89. At first sight it might be supposed, that this part of a nurse's duty would regulate itself—but it is not so. There is no one point in nursing, that has so little system, or that is di- rected with so little judgment as the warmth of the patient. Nurses upon this point, have no principles to direct them; or none at least, that are conformable to the proper treatment of the patient. It never becomes a subject of thought, that the patient can be benefited or injured by a particular quantity of bed-clothes, or by any particular temperature of his body, provided he does not complain of feeling cold. 5 34 GENERAL OBSERVATIONS. 90. If the patient declare he feels too cool, more covering is heaped upon him; and sometimes, without mercy. To relieve the sensation of cold by additional clothes, is always proper in acute diseases; and the nurse in her attempt to restore pleasurable sensation by this means, acts in strict conformity to principle, but without knowing it; and so far so good. But here her anxiety ceases, and her judgment is no longer exercised; for after reac- tion has taken place, and the heat upon the surface has become excessive, she never dreams, that it is as beneficial to lower the temperature, as it was proper and grateful to raise it, when it was too low! 91. She refuses to comply with the earnest prayer of the al- most burnt up patient, to "remove some of his covering;" but on the contrary, insists it would be his death were she to do so, or he would take cold. He is therefore obliged to submit, until the heat becomes so intolerable, that he bids defiance to re- straint, and removes the offending covering by main force; and he effects by this independence, such a reduction of temperature, as will perhaps now induce the skin to throw out a free perspi- ration. 92. It is true, that the poor nurse was anxious for this very result; and the very object of her refusal to remove the super- fluous bed-clothes, was to induce the sweating, so quickly effected by the very opposite means. She is not aware, that there is a sweating temperature; and that when this is exceeded, perspira- tion will cease if it have been present; or that it will not take place during its continuance. The rule therefore upon this point is plain ; that the patient should no more be allowed to complain of too much heat, without an attempt at its reduction, than he should be permitted to remain chilly, when it is possible to remove it. In a word, we should try to create the pleasurable sensation of healthy temperature; and this can very often be done by the proper adjustment of the covering; and this without incurring the smallest risk. Therefore, the quantity of covering, should always be made subservient to the sensations of the patient. 9. The Examination and Preservation of the Excretions. 93. This duty is almost constantly neglected; not being ca- GENERAL OBSERVATIONS. 35 pable herself of drawing conclusions from the varied appearances of the evacuations, the nurse very often does not even inspect them, much more preserve them for the physician.* Or if she have seen them, her account of their appearance is expressed so vaguely, that no satisfaction can be obtained, by any extent or ingenuity of interrogation. They have for the most part, a set of terms to express the colours of the stools, and which may be every way satisfactory to themselves, but which are altogether unintelligible to the physician; such as "natural;" "very healthy;" "very heavy;" "very slimy;" "very black," &c. &c. Now, we have frequently found by inspection, that their " natural" and " very healthy," were highly bilious; their" very heavy," to mean no more than very offensive; their" very slimy," to be pure bile, without a particle of the mucus of the bowels, which you were from their description, prepared to meet; and their " Very black," is almost sure to prove brown, &c. 94. The same or similiar errors are constantly committed in their accounts of the appearance of the urine, when enquired for. It is " very white;" " very red;" " very black;" " very thick," &c. The very white, means transparent, or of the colour of water; very red means that it has deposited a red sediment; " very black," means, when it is highly charged with bile; and "verythick," means, that after standing it has become turbid, though perfectly clear and thin, when it was evacuated. 95. On this account, we never depend upon their descriptions of the excretions; and we are in the constant habit of ordering them to be preserved that we may judge for ourselves; but we are constrained to say, that two little regard is paid to such or- ders, though the absolute duty of the nurse is to obey them, as the inspection of them is highly important. 10. Of the Patienfs sitting up. 96. An overweening anxiety on the part of the nurse to have the patient sit up, is often productive of serious consequences. It is imagined and "declared, that " the patient can never gain * We almost constantly direct the keeping' of the evacuations; but for this purpose they should not be retained in the sick room. 36 GENERAL OBSERVATIONS. strength while he lies in bed"—hence, he is forced to this ill-timed exertion by the importunity of the nurse, or of his friends, at a time that may occasion him to faint, or to endanger a relapse. They seem to forget, that this change of position requires a certain quantum of strength to perform it; and that it cannot be done if that be absent. Now, in cases of long, or even of short, very en- feebling diseases, the strength is oftentimes so prostrated, as to require much care, to either husband, or improve, the remain- ing little. Yet the patient is often required to expend his little stock, to gratify a false theory of the nurse, or friends. In this, they are only directed by a popular and vulgar error; for it is evident, that if the patient's strength has been so prostrated at a certain period, that even the nurse would have deemed it im- prudent to have attempted it, it would be madness, to insist upon its performance, if it had not improved; while on the other hand, it is equally clear, that if he be able to do this after a short interval by care, that he must have acquired some strength; con- sequently, it gives contradiction to the position, that " the pa- tient cannot gather strength, while he lies in bed." 97. Sitting up after illness, is, to all intents and purposes, ex- ercise. Now, during an approaching, or even during a confirm- ed convalescence, exercise to be useful, must be most carefully employed; lest its excess, and this even in a trifling degree, be productive of the most serious consequences. For exercise is a remedy; and a remedy of great power; consequently, if its dose be not properly, and opportunely prescribed, its effects may, like an over dose of any other active remedy, be followed by irre- mediable evils. We wish we could persuade the advocates for this hap hazard sitting up, to view it in this light; for did they much mischief would be saved. 98. The rules for sitting up, are in strict conformity with those, which govern every other remedy; namely, that its dose, is to be regulated, by its necessity; the strength of the patient;' and its effects. It must generally be looked upon as a stimulant of great power; and consequently, must be used as such. To prove this, it is only necessary to examine the patient's pulse under its influence, and it will be constantly found, when em- ployed at the time of great vascular excitement, to be from ten GENERAL OBSERVATIONS. 37 to twenty strokes in the minute more, in the sitting up, than in the supine position of the body; consequently, proving its stimulant power, and oftentimes, its unfriendly effects in fever. 99. And when resorted to in cases of great debility, the heart performs its functions with such rapidity, but with such speedy exhaustion, that fainting is often induced in a very few minutes.* But this condition of the system may be produced, by the dose being ill-timed, or too long continued. Now in either case, mis- chief, and sometimes, very lasting mischief, ensues. It there- fore follows, that much care is required, in getting the patient out of his bed; and that it should be considered as a great quali- fication in that nurse, who can prescribe this remedy advantage- ously, to her patient. 100. It is a very common error with nurses, to permit their patients to sit up too long at a time; indeed, in general they seem to have no other rule upon this point, than to let them re- main as long as they can support the fatigue; consequently, all the good, that might have been derived from the change of po- sition, is defeated in an instant, by a state of faintness being in- duced. The patient should therefore never remain sitting up one moment longer, than while his sensations continue to be agreea- ble; for if he be not instantly replaced in his bed when these pleasurable feelings cease, he will be sure to suffer from exhaus- tion, if not from fainting. It is therefore very much better that the patient sit up several times during the day, when he can support it, than that he should sit up one minute after he finds his strength flagging. 101. There is another error committed during the sitting up of the patient, which is every way calculated to destroy any good the getting out of bed promises; namely,surroundinghim withbed- clothes in such quantities as to oppress him with their weight, as well as to exhaust him, by their heat. This practice should be carefully avoided, if any good is to result from his change of position. Again, the fear of his "catching cold," which induc- ed the nurse to stifle him with bed-clothes, also leads her to the shutting out from the room every particle of fresh air, by block- * The fainting is also produced, by the blood retiring from the brain upon the patient being placed in an erect position; leaving too little in this organ for the purposes of due stimulation of the nervous system. 38 GENERAL OBSERVATIONS. ing up every avenue to its admission. The patient, in conse- quence, is obliged to breathe both a heated and impure atmos- phere, which quickly exhausts him, and he soon begs to be re- stored to his bed. There is no possible necessity for this over- caution; all that it is proper to guard against, is a current of cold air immediately upon the patient, and preventing chilliness. 11. Of the Making of the Bed. 102. This necessary arrangement, is almost always badly con- ducted. It is seldom performed with either comfort or advan- tage to the patient; for his condition, is too often lost sight of. He is frequently taken out of bed, and made to sit in a chair, while the bed is beating up, and the clothes are spreading. Dur- ing this period, he either becomes much exhausted, or absolutely faints.* * The following instance of this kind, was so extensive in mischief, that we think it proper to relate it, as it may perchance serve as a warning to the in- discreet nurse, or to the officious friend. In the summer of 1825, we attend- ed a young gentleman with a high grade of bilious fever, and from which he was slowly but certainly recovering. He however was still extremely weak; though now permitted to use a more nourishing diet than he had been hitherto been allowed, and with the most marked advantage. Quiet and rest were still recommended, though allowed to be shifted to different portions of his mattress, whenever the part he was lying on, became unpleasantly warm, as the weather was very hot. A friend called to see him; and finding him still weak, and very much re- duced, declared that unless he were taken out of bed, and permitted to have the air circulate around him, he could never expect to gain strength; his nurse was of the same sentiment, and unitedly urged their opinions so strongly, that his mother yielded, though, very reluctantly, as it was contrary to the express commands we had given but a few hours before, and which she was every way willing to obey. Accordingly arrangements were immediately made for the sitting up of the patient; he was lifted out of bed, and placed in an easy chair, where he had not been more than five minutes, before he fainted. His syncope was so ex- treme, and so long-continued, that he was considered as absolutely dead; for on our arrival to his assistance, we were informed before we went up stairs, that this was the case. We gave into the belief, ourselves for a moment, and looked upon the case as altogether hopeless. Yet we thought it proper to try means, though a full half hour had elapsed from the first moment of fainting. Accordingly, hot wrappers, bricks, jugs of warm water, volatile alkali to the Schneiderian membrane and lips, as well as to the rectum by an enema &c. GENERAL OBSERVATIONS. 39 103. It should therefore be a constant, and a never to be de- parted from, rule; that the patient should not be taken up, at the risk of fainting; more especially as this is never necessary. For if the patient is obliged to be moved for the purpose of refresh- ing his bed by a change of its linen, &c. he should he lifted care- fully from it, and placed upon one adjusted by its side; or in cases of still greater debility, he should only be removed to the other side of the bed, while the one he has just left is undergoing the necessary change; but to which he may be soon restored, to enjoy the alteration just effected. 104. It would be a most profitable arrangement for the sick with fever, or other acute diseases, if a mattress could be substi- tuted for the feather bed; than which there is nothing more un- friendly to the disease, or more destructive to the comfort of the patient. The advantages of the mattress over the bed, are as evident to those who will reflect upon the subject, as the incon- veniences of the latter are notorious; but so inveterate is habit, that substituting one for the other, with the generality of the people in this country, is rarely to be accomplished. Besides the obvious advantages of the mattress to the patient, we may reckon the facilities it would afford to the nurse; to her, much trouble would be saved by its general adoption; yet strange to say, she almost always gives the preference to the feather bed. And it is one of our tests, of a well-instructed and reasoning nurse, when she decides in favour of the mattress. 105. The necessity of beating up the bed, or newly-spreading the mattress, must be regulated, by the nature of the disease, and by the strength of the patient. In fevers it should be done were instantly resorted to; and after about twenty minutes of uninterrupted exertions had been employed, we had the pleasure to hear him make a deep inspiration and expiration. These were repeated, and soon followed by an evident pulsation of the heart. But not to dwell, he gradually gave evidences of returning animation; and eventually life was restored. He remained after this in a state of great feebleness for a long time; but eventually recovered entirely. In this case I attributed much efficacy to the injection; consisting of two tea- spoonsful of the pure ammonia water, and a pint of warm watec; as the favoura- ble signs took place almost immediately after. My present impression is, that this use of the aq. ammon. purae, has not heretofore been resorted to, in cases of extreme syncope, or of asphyxia, and it may deserve further trials. 40 GENERAL OBSERVATIONS. twice a day, if the patient have sufficient strength to bear it with- out risk; more seldom as this may be upon the wane. But when unable to leave his bed for this purpose, he may be shifted from side to side, as directed above; (especially in warm or hot weather,) as often as his inclination may prompt, or his strength will permit; provided this be not performed while he is sweating. 12. Of the Proper Using of the Utensils for Evacuations. 106. On the proper employment of the several utensils es- sential to the sick room, much of the comfort of the patient will depend, if it be not also instrumental to his recovery. One of the cardinal points in the management of the sick, is, to avoid all unnecessary fatigue; and this should never be lost sight of, even in the smallest details of the art. One great source of fatigue, is the management of the patient during his evacuations. He is obliged to rise from his bed, for the performance of these neces- sities, at a time he can but ill support the expense of strength it will require; and sometimes it is completely exhausted, before it is completed. 107. To prevent as much as possible inconveniences so se- rious, and so constantly recurring, requires on the part of the nurse, an entire acquaintance with her duties, and the best mode of performing them; and more rests with her in this particular than is commonly imagined. Some of them require every exer- tion to come from the patient; while others manage the various operations with great dexterity, and at a small expense of his strength. The latter class possess feeling, knowledge, and ex- perience; for it requires all to perform these offices, to the greatest advantage. Hence, the immense value of some nurses over others. 108. As a general rule, the patient when feeble should not be made to leave his bed, when he can without much inconvenience perform his offices in the bed. For this purpose, a bed-pan, and an urinal are very necessary appendages to the sick chamber; indeed it is not properly furnished without them. We are aware that the nurse will plead in extenuation, for the patient getting up, that he neither can nor will, use the pan in bed—indeed we GENERAL OBSERVATIONS. 41- have witnessed this opposition in many instances; but at the same time we scarcely ever failed to find, that it was owing to the mal- adroitness of the nurse, rather than to a rebellious disposition on the part of the patient. With a little management and perse- verance, this difficulty is almost always surmounted. 109. Before the pan is offered to the patient, a pillow should be placed under his back, so as to prevent its becoming hollow, and consequently unsupported. We have almost constantly found this want of support to be the ground of complaint against the pan; and it is as certainly remedied in this way. 110. For the purpose of passing urine, the patient, (male or female,) should never be permitted to rise, when strength is upon the wane, or when it is much exhausted, if the proper utensils can be procured. And this can almost always be done, if due attention be paid for this purpose. 111. Of apparently minor consequence, though of equal im- port, is the manner in which the patient is forced to receive his drinks; for though no single effort to receive drink, is equal to the exertion of using the pan, it is nevertheless oftentimes very distressing to the patient from the manner in which it is given; and as this is repeated very frequently in fever, and other acute diseases, the sum of exertion after a little while, will be found very considerable, and highly injurious to the patient. 112. A very large majority of nurses, oblige their patients to rise in the bed to receive their drinks; this is owing to the im- proper form of the vessel from which they receive it; for did they not raise themselves or suffer themselves to be raised, the clothes would receive as much of the fluid, as the patient. A tumbler, a wine-glass, a bowl, or a cup, are the common vehicles of drink; neither of which, should ever be employed in a well regulated sick room, while the patient is confined to his bed. The sick-cup, as it is called, should alone convey drink to him; by it all fatigue is spared; and he can receive it in any position of his body, without the slightest exertion. They can be pro- cured from almost any china store. 13. Of Skill in Applying and Dressing of Blisters. 113. This is a most useful, and important part of a nurse's duty; and it is one, of which she should never be ignorant. 42 GENERAL OBSERVATIONS. especially, as the efficacy and success of the application, as well as the comfort of the patient are all concerned in it. It is not the mere application of the plaster to the indicated spot, that en- sures the best effects of this remedy—something more is re- quired; and this something the nurse should be acquainted with. Thus, when the circulation is languid, and the sensibility much diminished in the part, it would be almost idle to bind the plas- ter to the part in the common way, or without preparation of the spot to which it is affixed, by first rubbing it well with some highly stimulating substance. 114. But this is not all that is required, to secure the best offices of blisters. Dr. Watt* tells us " that when a blister is to be applied, it ought to be large and spread so thick as to rise in as short a period as possible. In this respect, practitioners them- selves commit very great errors. If a blister rise at all, they think every purpose is served that a blister can accomplish; but this is by no means the case. A blister made too weak or spread too thin, soon dries, and merely raises the cuticle, and even to do this, requires a considerable length of time; whereas one thickly spread, with well made plaster, raises not only the cu- ticle, but also the rete mucosum, and does it too in a much shorter period." "I am fully convinced, from long experience, that there is a very great difference in blisters according to the manner in which they are made up and applied. The practice of putting dry flies on the surface of the blister, is also a bad one. If the flies be good, and the plaster well prepared, it requires no such assistance. Besides, the loose particles of the flies are apt to insinuate themselves into the skin and adhere to the sore after the blister is removed, giving the patient very unnecessary un- easiness and often producing strangury." 115. It must therefore be looked upon as rule, that this opera- tion be always performed, under such circumstances ; and that it is the province of every nurse, properly so called, to be ac- quainted with it, and to comply with it. If she be well instructed in her art, she will at once select, and apply, the proper sub- stances. If she be not, she must be directed to the use of the spirit of turpentine; of hartshorn; or Cayenne pepper and brandy, " • Treaties on Chincough, &c. p. 244. GENERAL OBSERVATIONS. 43 &.c. for this purpose; with either of these, the part on which it is designed to place the blister, should be well rubbed, for four or five minutes before it is bound on. 116. But on the other hand, an ignorant nurse will sometimes do mischief, by employing these substances, where the circula- tion is active, and where the sensibility is perhaps even exalted; merely, because she has seen them do good where they were ne- cessary; and thus proving herself altogether unacquainted with the reason for their application—we have witnessed several mis- takes of this kind, to the great annoyance of the patient. 117. An improvement of great consequence in the application of blisters, has lately been made, by substituting adhesive plas- ter for bandages. This mode, is particularly valuable, when the blister is to be applied to any other part, than the extremi- ties. Thus, all the inconveniences, and the confinement which attach to bandages, is entirely avoided when the plaster is to be applied to the chest, abdomen, back, or between the shoulders. Simple as the method is, when sticking plaster is used, we have found its utility entirely defeated, by the mere routine nurse, not understanding its proper management. This has happened from the almost universal belief, that a bister will not draw without the part on which it is to be placed, is previously wetted with vinegar—this therefore is done; and the plaster is applied, and all is supposed to be right. But upon the examination of the blister, at the alloted time for its drawing, it is found any where, but where it was designed to have been placed ; for the part being wet, the adhesive plaster would not stick; and the blister became at the merey of every motion of the patient. And time, perhaps precious time, has been lost;.or a part not intend- ed to be subjected to its operation, been made to endure the pain, but without the smallest advantage to the complaint for which it was designed to relieve. 118. It may be proper to remark, that with grown people, but especially with males, it would always be best to remove by shaving the hair from the part designed to be the seat of the blis- ter, even when the common mode of applying it is adopted ; but that it becomes absolutely necessary, when the sticking plaster is used, if the part be supplied with it. 119. As we consider the use of the adhesive plaster to have 44 GENERAL OBSERVATIONS. great advantages over bandaging the part, to confine a blister, we will detail the two modes of employing it. The first, and most common, though not always the best, is to have the margin of the plaster spread from half to three-quarters of an inch, with the adhesive plaster. If the blister be small, half an inch, (as with chil- dren,) will generally be sufficient; if larger, three-quarters may be necessary; but if very large, it may require an inch of margin. When thus prepared, its edges are to be snipped by scissors in a number of places, to the depth of the sticking plaster, to secure its sitting better on the part It must then be held over a few hot coals, until the adhesive plaster becomes sufficiently softened, to insure its sticking well to the skin. 120. The other plan is, to have strips of spread sticking plas- ter, of such lengths as shall extend two inches at least over each margin of the blister after it is applied to the part; the breadth may be three-quarters of an inch. In this case the blistering ointment covers the whole surface of the plaster. The mode of applying the adhesive strips, is by warming them well, and then making them cross the blister, either directly across each end, or in the direction of its two diagonals. If the plaster be very large, or the patient very restless, three, or even four strips, may be necessary. To secure the adhesion of the plaster, the skin upon which it is to be applied, should be perfectly dry; if it be moist with perspiration, a little com,mon flour dusted upon it, and wiped off, will effectually serve the purpose proposed. Should the blis- tering part of the plaster be made of the dry flies, it is best to moisten its surface carefully with a little warm vinegar or brandy; taking care not to touch the margin with it, if it be spread with adhesive plaster, or-you would prevent its sticking. 121. When blisters are applied to the legs, it is best, especially if the patient be restless, to draw stockings over them, which will effectually prevent their being disturbed. 122. The period commonly allowed for the drawing of a blis- ter is twelve hours; and, as a general rule, it is sufficient But as there are many deviations from this rule, it will be well to notice them. These departures from the general law, are found. to consist in, 1st, the anticipation of the period of twelve hours; as in children, and with skins of peculiar susceptibilities. With the first, under common circumstances, the blister is frequently GENERAL OBSERVATIONS. 45 found to have performed its duty in eight hours; and very often in six. It should, therefore, always be examined at these pe- riods, and dressed, if sufficiently drawn; if not, it should be suffered to remain, until this take place. With the second, the same rule should be observed; and we are directed to this, in the adult, by the peculiar burning sensations he may com- plain of. It may be remarked, as a general rule, that children, (contrary to what we would suppose,) suffer much less than the adult, from the action of cantharides. 123. 2d. The period of twelve hours is sometimes exceeded; owing, first, to the plaster not being well applied; that is, to its being bound either too tightly, or too loosely. This is no unusual fault of a nurse, where the bandage is used instead of the sticking plaster. If it be bound negligently, it soon loses its contact with the skin; and, consequently, cannot act upon a part it does not touch; if bound too strictly, the effusion of seriyn between the true and false skin, cannot take place; for the latter cannot sepa- rate from the former, from the mechanical force exerted by the bandage being too great. A well-skilled nurse is aware of this; and will bind the plaster only tight enough to secure its contact with the surface over which it is placed. 124. Or it may proceed from the exhausted state of the skin itself, as intimated above. This is no uncommon condition of the skin in fevers, that often terminate speedily in death; as is witnessed in the yellow fever, or in high grades of bilious fevers. It also takes place in long-protracted fevers; especially, where the nervous energy is much exhausted. And it also hap- pens from a rare, though not without example, indifference, or want of susceptibility, to the action of cantharides.* In either of these cases, the cause should be sought for, and removed if possible. In the first case, the remedy is as easy, as it is ob- vious; in the second, an attempt should be made to restore, or to * We once attended a young lady, on whose skin we were very desirous of exciting vesication; we tried, for this purpose, every form of blistering oint- ment or plasters we could devise; we permitted them to remain upon the part forty-eight hours at a time; we excited redness and irritation, by the spirit of turpentine, and by mustard, and then applied cantharides, but all to no pur- pose; vesication could not be produced. This was not the result of a single trial; for we persevered in our endeavours, altering the combination of the can- tharides, and the preparation of the skin, every day or two, for a fortnight. 46 GENERAL OBSERVATIONS. create in the pan, a brisker circulation, or an improved state of sensibility, by frictions, with the substances named above; in the third, there is no remedy that we know of; we can only substitute the pure ammoniated water, spirit of turpentine, mus- tard, or Cayenne pepper. 125. Many nurses are in the habit of placing a piece of gauze, or very fine muslin, between the blister and the skin. We have never perceived the advantage of this plan, though there is no- thing objectionable in it, provided the interposing substance is sufficiently thin, and the surface of the plaster sufficiently moist, to permit the cantharides to come in contact with the skin. The reason assigned for this practice, is, that it prevents strangury; but this is certainly a mistake. 126. It will be well to remark, that in fevers, without any apparent local inflammation, that the good effects of blisters, arise more from their effect upon the nervous, than upon the sanguiferous system; consequently, that their peculiar irritation . is more valuable than the discharge they produce. It will, therefore, happen, occasionally, that we desire only the inflam- mation they may excite; as in cases of great debility, or of pe- riodical pain. To insure this, the blister is to be examined from time to time, and removed as soon as the skin is well reddened. In the first case, it should be tightly bandaged upon the part, when the part or parts are either the upper or lower extre- mities. 127. It may also be important to remark, that in cases where blisters excite so much local inflammation and irritation, before the usual period for their drawing, as to render it desirable to interrupt them, that the plaster can be removed as soon as this condition of the skin is well established; and that the effusion of serum be insured by dressing them with basilicon ointment, or even by the application of a soft bread and milk poultice. 128. When blistering is prescribed for. the legs, it must be understood, that it is the calves of the legs that is meant; and the particular spots of them, are the insides of them. Blisters intended for any part of the extremities, should always be longer than broad; and the length of the blister, made to correspond with the length of the limb, when applied. When the thighs are named, the central portion of their inner surface is to be con- ■GENERAL OBSERVATIONS. 47 sidered the spots. When the arms are designated, the inner part, extending from below the flexure of the joint, to a sufficient distance above the hand, to allow the pulse to be examined with ease, are the places intended to be blistered. 129. When ordered for the chest, the place Will be indicated by the seat of pain, when local affections are present—when the chest generally is involved, the anterior portion of the thorax is the place. The extent of surface to be occupied by the blister, will depend upon the extent and force of the disease. 130. When a blister is designed for the neck, all that portion of its back part, from an inch, or little more sometimes below the hair, to nearly the lower extremities of the scapulae or shoul- der-blades, is the part intended. When for the ears, the hinder and inferior portion of them are to be understood. When for the region of the stomach, all the space below the extremity of the sternum or breast bone, (but inclining to the left side,) to near the umbilicus or navel is the part When for the abdomen, nearly the whole of the surface, or in local affections, only a por- tion of it is to be understood. When for the temples, the space immediately posterior to the termination of the eye-brows are to be selected. 131. The shape of blisters, vary as much as their size; the lat- ter will always be determined by the size and age of the patient; comparatively small in very young children; larger in those more advanced, and so on; the former must in some measure be deter- mined by the part designed for their action. 132. As it is important that some general rule should be fol- lowed, we will lay down the following measurements as guides for the size of blisters; remarking, however, that a large blister gives scarcely any more pain than a small one, but is oftentimes more efficacious. 133. For the legs or thighs, from 7 to 8 inches long—from 3 to 3$ broad. 134. For the back, from 7 to 8 inches long—from 4 to 4$ broad. 135. For portions of the chest, from 7 to 8 inches long— from 6 to 7 broad. 136. For the thorax, from 8 to 9 inches long—from 7 to 8 broad. 48 GENERAL OBSERVATIONS. 137. For the stomach, from 8 to 9 inches long—from 6 to 7 broad. For the stomach, the greatest measurement must be placed from side to side. 138. For the abdomen, from 10 to 11 inches long—from 8 to 10 broad, if the whole is to be covered; of proportionably less dimensions if the application is to be partial. 139. For the ears, the size cannot well be defined, as their shape is peculiar. • 140. For the temples, from an inch to an inch and an half in diameter; these are generally made circular. 141. These proportions, are the sizes for adults—they must be reduced for younger people, or small children. As the shapes of blisters differ, we shall give drawings of them, (see Plate I.) which will remove every difficulty. 142. Dressing of the blister after it has drawn, forms another of the duties of the nurse; much of the pain and inconvenience of this operation will depend upon the skill and dexterity of the dresser. But before this operation is proceeded upon, every thing necessary to the purpose should be in complete readiness. The plasters should be spread; the bandages ready; a pair of well- cutting, sharp-pointed scissors should be provided, as well as a quantity of soft linen rags at command. 143. Every vesicle upon the blistered surface should be care- fully snipped with the points of the scissors, unless they are very small and numerous; if this be the case, let only the larger be opened, as the small ones will most probably increase in size by the next dressing, and will then give less trouble. The skin should never be removed from the surface of the blistered part in acute diseases, however desirable it may be to keep up a dis- charge for a short time; for the irritation and pain which this creates, is but ill compensated for, by the increase or continuance, of the discharge it may excite—it is much better to reapply the blister for this purpose immediately after the part has healed, than to remove the cuticle. 144. A blister should never, or extremely rarely, be washed, though a very frequent practice among nurses. It is very apt to produce chilliness; it exposes the denuded part to the air too long; it is fatiguing to the patient, as it is always a tedious pro- cess; and above all, it never does good. At the first dressings GENERAL OBSERVATIONS. 49 the professed object, is the removal of any particles of the flies that may adhere to the surface; but if there do remain some few, they are almost certain to be attached to the dead skin, to which they can do no harm, and will be removed atthe subsequent dress- ings. If the blister has suppurated, the excuse is to remove the matter from it; than which there can be no worse practice; as by the operation of washing, the new and tender granulations which this matter was to protect, is removed, and the place kept an open sore much longer than is desirable. 145. The dressings for blisters, will consist of either stimu- lating or soothing applications, as it may be the object of the prescriber. If it be desirable to keep up a discharge, the surface may be dressed with the basilicon ointment—if this be not in view, simple cerate is to be used.* Either of these is to be thinly^ spread upon soft, fine linen rags, and repeated twice in the twenty-four hours; or only once if the discharge be small. It is alway best to let plasters or dressings, be cut into several pieces, when the surface of the sore is considerable, as they will set much better than a single piece, and not get into folds; the plaster should very little exceed in size the surface of the wound. 146. Blisters now and then become extremely painful and in- flamed; this condition is generally best subdued by a soft bread and milk poultice, in which is melted a small portion of fresh hog's lard, or newly-churned butter, before salt has been added. Or linseed oil and lime-water may be tried if the poultice fail. They also become extremely itchy, and thus prevent sleep—but this only takes place during the healing process; that which has succeeded best with me for this itching, is a strong infusion of the slippery elm bark, or flaxseed; or very fresh hog's lard in which some laudanum is incorporated. The part to be washed with either of the former when the itching is troublesome, and * Wilted cabbage leaves are the most common dressings out of large cities —hut they should never be amployed, as they become extremely offensive and annoy the patient very much—we have known fainting to be produced by a dressing of cabbage leaves. f A great error is generally committed in spreading all plasters"for sores; it is supposed the thicker the better. Much inconvenience is created by this, as a large proportion of the plaster is sure to adhere to the sore surface, from which it is detached with much difficulty. 7 50 GENERAL OBSERVATIONS. to be covered with the last by having a rag well imbued with it. Strangury is another consequence of the action of a blister; in some constitutions, this almost always takes place. We shall treat of this affection in another place. 14. Of administering Injections, fyc. 147. The value of these remedies are only beginning to be properly appreciated in this country. They have had to contend against much prejudice to gain their present consideration. An injurious and fastidious delicacy has prevented their general em- ployment, especially out of our cities; and it is only within a few years even in our cities, that they have been looked upon as prompt and efficient remedial applications. They have been regarded as extreme means; and by some, even more so than blisters; and others will not submit to them, however necessary, or however certain their utility might be. 148. For the good of the.afflicted, we hope this prejudice will soon wear away; and that they will be looked upon as indispen- sable domestic remedies. 149. Much of the objection to injections has arisen from the incompleteness of the apparatus for their administration; from the mal-adroitness of the operator, and from the disgusting ma- terials in many instances of which they have been composed. 150. The first of these objections is now entirely removed, by the improved method of constructing them; and though this improvement has in a small degree increased the price, they are nevertheless very much cheaper in the end than those of com- mon fabric. We would therefore recommend in the most posi- tive terms the purchase of the improved patent injection syringe. They are so well constructed in all their parts, as never to dis- appoint in their operation, or scarcely ever get out of repair— whereas with the common, the reverse is constantly taking place. It would be best to procure the two sizes, though this is not absolutely necessary in skilful hands; for we have seen an injection administered to a child from a large syringe, with as much address and certainty as if it were of the smaller size; for the piston and cylinder are fitted so exactly to each other, 'that GENERAL OBSERVATIONS. 51 an injection of no greater volume than a table-spoonful can be as certainly administered, as one of larger size.* 151. The second objection to injections should never exist, if a professed nurse is to be the operator; for it is as much a part of her business as any other belonging to her art; and she had as well be ignorant of any other important detail as this. Her want of cleverness in this particular, should have no other excuse, than a want of experience; and if she lack this, she is an impro- per nurse, and should only be employed as a dernier resource. Besides, there is no excuse for ignorance upon this point; for it is the simplest of all operations; and once having performed it, it can always be performed. 152. The third objection is fast wearing away; as enemata are now for the most part made to consist of but few, and oftentimes of but very simple materials. Soot, soft soap, fish brine, train oil, and other disgusting substances, arc now yielding to plain water and salt, flaxseed tea, starch, &c. &c. It is now no longer considered necessary to make them very complicated, as was sometimes formerly done, and is,even now, in some places. We were informed, and by good authority, that a European practi- tioner had an injection made of no less than two-and-thirty arti- cles; an half day was nearly spent in collecting the ingredients, and it required a preparation of several hours before it could be administered. 153. The importance of injections is never more manifest than in cases where it is every way important that a sudden dis- charge from the bowels is necessary; where the stomach is too irritable to retain any thing; where it is desirable to make an impression upon the nervous system without disturbing the sto- mach; where a direct application is to be made to the affected part, as in dysentery and diarrhoea; or as near to the part as pos- sible, as affections of the uterus, &c. 154. The purgative medicines are sometimes most successfully administered in this way; and the anodyne and antispasmodic, * These improved syringes can be procured at J. Rorer's, No. 26, north Sixth street, and at G. W. Carpenter's Drug Store, No. 221, Market street. There may be other places; if so, we do not know of them. We think tlie French syringes as sold by Carpenter, are rather better than those madcit Hcthlehem and sold by Korcr. 02 GENERAL OBSERVATIONS. with great certainty. As a general rule, the two last must be used in triple quantities by injection. Besides the qualifications enumerated above, the professed nurse should also be well skill- ed in certain parts of cookery; especially such as arc proper for the patient during the continuance of the disease. We shall in another part of this work give recipes for all the more important articles of food and drink; for on their proper manipulation much of the comfort of the patient will depend. 15. Of the Management of Convalescence. 155. The management of the patient after the cessation of fever, or the commencement of, and during convalescence, is one of the most important points in the treatment of disease; yet, unfortunately, it is one that is the most neglected; or to which, the least attention is given. A neglect of the proper observances at this time, has been but too often productive of the most seri- ous injuries; either by producing a relapse; or the production of a new disease. And, first, of a Relapse. 156. The highly excitable condition in which the system is always left after an attack of any acute disease, renders it ex- tremely liable to its renewal from very slight provocations; it is, therefore, of the utmost consequence to become well ac- quainted witn the causes that may be capable of this effect. These will be found to consist of the administration of either improper articles of food, and drinks; or in the too early, or improper exposure to the weather, &c. 157. The extreme anxiety to prevent, or to overcome "de- bility,"^) as we have observed before, has been, without the slightest exaggeration, the death of thousands—upon this point, we have no mental reservations; we mean, what we have de- clared upon this subject, should be understood in the most literal sense of our words; for nothing can exceed the sincerity of our belief, in what we have advanced. To the want of caution on the part of the nurse, or to the importunities and suggestions of friends, or by people out of the profession, we may look for GENERAL OBSERVATIONS. 53 the cause of the solemn, and dreadful truth, we have just ad- vanced. 158. It has ever struck us with surprise, that people who are altogether unacquainted with the structure of the human body, or with the laws which govern it, either in a state of health, and more especially, when labouring under disease, should take the awful responsibility upon themselves, to direct, what is sup- posed by them to be proper, during the existence of disease, or when the system has just struggled through it. They cannot have weighed the extent of injury, that might arise from their advice; or they would not thus voluntarily assume the responsi- bility, of either immediately, or remotely, causing death, or lin- gering disease. Yet, no one can offer opinions upon the state of a patient, or suggest means for benefiting it, without incurring this terrible risk. (16) 159. So nice a point is this sometimes, that the physician himself does not choose to act upon his own individual judg- ment; on the contrary, he solicits the aid of a brother practi- tioner, to aid it, and to divide responsibility. Yet, at this very moment of doubt and uncertainty; where the very life of the pa- tient will depend upon correct views being taken of his situa- tion, we find people flocking to the bed side, and fearlessly di- recting, that, which may cause death, if their instructions be fol- lowed. This is no false picture;.it has been witnessed by thou- sands, though it has effected no beneficial change in the sick room. 160. But strange to tell, there is no one who does not depre- cate this interference in the abstract; yet every body at the mo- ment they have the opportunity to infringe it, flatter themselves that they become exceptions to the rule, and that, what they say or do, cannot be otherwise than right; or at least, that it cannot do harm. In no other concern of life, does the same docility occur—if the distribution of property, or the employment of money become the subject of advisement, much hesitation, and deliberation is exercised, before the sought for, or proffered ad- vice, is followed. If a coat is to be cut, or a pair of shoes or boots are to be made, the qualifications of the recommended, are carefully scanned, before they are trusted; but the business of sickness, or health; or of life, or death; are dismissed, with the 54 GENERAL OBSERVATIONS. most frigid indifference; and too often, the advice of one, totally incompetent to the task, is promptly adopted, to the neglect of that, given by one, who was every way able to direct. 161. We could wish that this subject should receive more at- tention than it has hitherto done; it every way merits the most profound attention; the public weal demands it; and it is the bounden duty of every individual to act up to the principles we are endeavouring to establish—namely, that all advice, and every departure from the directions of the physician, or the general rules established by him, is replete with mischief; and involves all who may advise, or who may depart, in a dangerous enter- prise, or in an awful responsibility. How many orphans, widows, or desolated husbands, have to thank the officiousness of friends, for their sad condition—for to the advice, or the in- terference of those who had neither right, nor talent to direct, may they too justly look, for their misfortunes. 162. We are willing, however, to believe, that the interfer- ence complained of, does not arise from any evil intention, or any absolute design, to thwart the plans of the medical attend- ant; but at the same time we feel, that the plea, of "no harm being intended," is not sufficient to prevent mischief from fol- lowing the interference; and, that it is certainly altogether in- adequate to the repair of it, after it has been done. In such cases, every body should feel, that injury may arise from their advice, or opinions. 163. But to return. We agree, with the most inveterate "feeders," that the ravages of disease should be repaired as speedily as is consistent with the safety of the patient; and con- sequently, every way willing that strength should be restored. We only differ in a most essential point; namely, in the means. Those against whom we are contending, suppose the more promptly the restoration of strength is attempted, the better; to effect this, they imagine that the most nourishing animal sub- stances and stimulating diet are required. While we on the other hand insist, that the blood-vessels cannot well be filled too slowly; and that the nervous system cannot well be treated too kindly; for neither will bear but very little stimulation with profit, after they have been deranged, and perhaps severely de- ranged, by disease, and its necessary treatment. Hence, the GENERAL OBSERVATIONS. 55 necessity for some time, of the most bland or even vegetable diet. 164. With a view to illustrate this the better, we will very briefly describe the condition of the body after a severe attack of a febrile, or any other acute disease, that the application of stimulating food and drinks may be the better comprehended. 165. First, there must necessarily be, after illness, a great re- duction of both the solids and fluids, of the body; and conse- quently, that the first must be left in a state of great weakness; and that the vessels containing the latter, must be comparatively empty, as well as weak. Now, strength cannot be imparted to the solids, but through the medium of the nervous system, and of the vessels conveying fluids; the nervous system and blood- vessels can only do this, when their actions are healthily per- formed; and their actions can only be healthily performed, when they are properly filled, and duly stimulated. Therefore, any excess of stimulation will, from the increase of irritability, (which is always consequent upon a sudden reduction of the force of the body,) urge them to inordinate action. It will therefore follow, that over-nutritious food, or too great a quantity of that which is less so, will always endanger a return of fever, if given too early in convalescence; hence, the frequency of re- lapses after a full meal. 166. If this be true, it will follow as a legitimate consequence, that strength cannot be imparted to the solids, while the blood- vessels and nervous system are goaded to inordinate action; or to that degree of action, which is beyond the healthy bound; this condition will necessarily be followed by a state of inertia, or weakness; and this in the precise ratio of the over-action; therefore, instead of strength being increased by this plan, it is constantly found to be diminished. But this is not all; it too frequently happens that fever is recalled, and a comple relapse is established. 167. Second. The stomach, like every other portion of the body, suffers a loss of vigour from illness; consequently, its digestive powers are diminished; therefore, when food of too nutritive a kind is offered to it, one of two evils must necessarily urise. First, that the stomach, from the reduction of its powers, may not be able to convert it into nourishment; and if it do not, 56 GENERAL OBSERVATIONS. it remains an undigested mass within it, which sooner or later must, and will be disposed of, either by vomiting, or by diarrhcea; neither of which will contribute towards the strength of the pa- tient. Or, what virtually amounts to the same thing, if too much of a substance less nutritive be given, the same consequences are sure to follow. On the other hand, if the stomach has been capa- ble of mastering the whole of the mass offered to it, too much nourishment is formed; and which is introduced too suddenly into the weakened, irritable, and the too distensible blood-vessels; in consequence of which, fever is for the most part rekindled. 168. Equally, but more suddenly injurious, is the exhibition of stimulating drinks of every kind; they excite to inordinate action, both the nervous and sanguiferous systems; and too cer- tainly reproduce the disease of which the system has just been freed. On account of the certainty and suddenness of their in- fluence, they are more decidedly injurious than animal food; and therefore should be still more cautiously withheld. 169. Third. Illnesses of the acute kind, are constantly fol- lowed by a weakened tone of the whole circulating system; hence, we find a smaller, but a quicker pulse; the quickness ap- pearing to be a constant attendant upon the diminution of power. Hence, one of the surest presages of returning power is, the diminution of the frequency of the pulse, and an increase of vo- lume in the artery. From this it would appear, that an increase of the circulation is not favourable to the state of convalescence; for that strength is not acquired during its continuance. Animal food, or other stimulants, when improperly exhibited, increase the circulation; therefore animal food and other stimulants must be injurious; because, they increase the rapidity of the circula- tion. 170. It is true, that the too early use of animal substances, or of stimulating drinks, do not always occasion a relapse; but when they even do not this, they are very often far from being harm- less; for effusions in various parts of the cellular membrane are very sure to follow, if a genuine dropsy be not the consequence. 171. This is not the proper place to explain at length, the cause of this swelling; we shall merely observe, that it is an almost con- stant law of the sanguiferous system, to unload itself when op- pressed by too great a quantity of fluid, by pouring out a part, GENERAL OBSERVATIONS. 57 into the interstices formed by the cellular membrane. This is witnessed in the drawing of blisters; in dropsy of the brain; dropsy of the chest, &c. &c. Now the same thing takes place, when the blood-vessels are suddenly over-charged by any cause; and it is perfectly familiar to every observing person, that it happens to those who have been too quickly put upon an over- nutritious or stimulating diet, when recovering from illness. 172. We are not ignorant, that it is altogether contrary to common opinion, that dropsy or dropsical swellings, can be produced by any other cause than weakness—hence, we hear of people being purged, dieted, or bled, into a dropsy; but never that they have been fed into one. Yet the latter is a solemn truth; as the following little history will clearly prove. 173. A most amiable and worthy young gentleman, a parti- cular friend of the author's, had been most severely attacked with pleurisy, for the cure of which he had been pretty exten- sively bled, and was of course much reduced in strength. So soon as his fever had left him, he was permitted to sit up; and as soon as he was able, he was permitted to walk about his cham- ber; so far so good. His appetite was feeble; and he remained satisfied with the very moderate diet, that had been prescribed for him during the continuance of the disease. He was now rapidly recovering strength; and was thought by his medical attendant to be in a state of happy convalescence. At this time, his kind and attentive physician, was under the necessity of leaving the city for some days, and as he was gaining strength, and flesh, as fast as was, (rationally,) desirable, he was left to the care of his nurse, with directions that his diet should be a little more generous. 174. The nurse thought, that the patient now only required the cook, as the doctor had taken his leave; and to prove her- self faithful to her own opinions, commenced forthwith, with a well-seasoned beef-steak, and a glass of porter. At this time the author called on his friend to offer him his congratulations; etiquette having forbid before, any thing but enquiries at the door He found him in high spirits; as the visit was very soon after the meal of beef-steak, and porter; he declared himself never better, and asked of the author, if he did not think, he 8 58 GENERAL OBSERVATIONS. would soon be perfectly restored—the only reply was, that he would do very well, if he took care not to eat himself into a dropsy; at which he laughed very heartily; at the same time de- claring, it was for the first time in his life, that he had heard, that a man could eat himself into a dropsy. The caution was repeated; but it could not be enforced; for he was not our patient. 175. Soon after this he left the city for the benefit of country air; and in about three months returned to it, with confirm- ed dropsies of the abdomen, and chest, of which he soon after died. He informed us that he pursued the full diet, until he was brought to the state in which he was now found; and that after dropsy showed itself, it was thought proper to persevere in it; as dropsy only could arise from debility. To understand how great this error is, see Chapter on Dropsy 176. To those who are disposed to listen, this case speaks volumes; and if practically acted upon, will be most useful. It clearly shows the certain, and terrible consequences of impro- prieties in diet, after the system has been reduced by an acute disease, and the active treatment essential to its removal. With these preliminary observations in view, we will lay down a few rules in conformity with them, for the government of the nurse. 177. First. That no animal substance, in any shape or form, should be given during the continuance of fever; nor very im- mediately after its cessation; lest it be invited to return by the over-stimulating quality of this substance. 178. Secondly. That after the cessation of fever of any deno- mination, a sufficient time should be given, (before any altera- tion be made in the diet,) for the system to recover from the habit, if we may so express ourselves, of forming it. For if this be not heeded, fever will almost constantly be reproduced; even by a small change in the articles of food. 179. Thirdly. Such fevers as have manifested a periodical movement, should be particularly attended to; because, there is no certainty that there will not be a return upon the next pa- roxysmal day; though it may have passed one period. Thus with a quotidian, after the paroxysms has stopped, at least three consecutive days should be permitted to pass, lest it may return; either from the disease not having been subdued, or from the GENERAL OBSERVATIONS. 59 alteration in the quality of the food. In the tertian, two pa- roxysmal days should be allowed'to pass. In the quartan, one will be generally sufficient 180. Fourthly. When a change in the food, agreeably to these rules, is decided upon, the choice at first should be of such articles as possess the least possible stimulus of their class—or in other words, the transition from a mild vegetable, to an animal diet, should be as slight as the nature of things will permit. Thus, weak chicken water; weaker beef, or veal tea; or the diluted juice of oysters, should first be resorted to. 181. Fifthly. That the above enumerated articles should be given in small quantities at a time, and repeated at stated inter- vals, both by day and night, if the patient be very feeble, pro- vided, it will not too certainly interrupt important sleep. But care should be taken, in highly excitable systems, to withhold, for a few days, the animal sustenance, during the period the fever was wont to appear, in its greatest force. * 182. Sixthly. That the patient should be confined, for at least three days, to the above prescribed articles, before the power of the food be increased; and when this is determined on, such substances should be selected, as will very little exceed in strength those already exhibited. These'will consist of the soft ends of five or six oysters; a soft boiled egg; a small piece of boiled fish, or the cold custard. (See Art. Cold Custard.) 183. Seventhly. After this plan has been persisted in for three or four days, the patient may be indulged in a small piece of boiled mutton; the breast of partridge or pheasant; turkey, or chicken. And after as many more, he may be allowed, a small piece of rare done beef or venison steak; mutton chop,or sweet bread. At this latter period, a tumbler of ale, or porter and wa- ter, may be given at noon, with the meal intended for this hour; * By this we would wish to be understood, the time of day, at which the exacerbation was wont to take place. The reason for this caution is, that not- withstanding the fever has ceased to appear, yet there is a disposition in the system to be more readily affected by stimuli, at the time of day, at which the fever was accustomed to be the highest; and this condition will remain for se- veral days sometimes. On this account, it is always best to give at these pe- riods, the mild vegetable substances, the patient has been in the use of, dur- ing the existence of the disease, instead of the more itimulating articles, lately employed. 60 GENERAL OBSERVATIONS. provided, no other circumstance exist to render this improper; such as, its causing head-ache; flatulency; or sourness of sto- mach. Many are of opinion, that Port wine is always admissible after fever; especially after those of an intermittent kind; this is one of the many vulgar errors that the physician has to contend against; and the sooner this prejudice is destroyed, the better. We have never seen the slightest good follow its use; though we have often known much mischief to be the consequence of its employment* 184. Eighthly. During the whole period of convalescence, the bowels should be most strictly attended to—one evacuation daily is absolutely necessary; if this does not take place sponta- neously, it must be procured, by a simple rhubarb pill taken every night at bed time, (see Art Rhubarb pills.) But purging must be avoided most carefully. 185. Ninthly. The quantity of exercise should also be very strictly regulated; for there is no opinion more general, than, that the patient should take as much at a time as he can possibly endure; than which, there cannot well be a more dangerous er- ror. It is admitted, that a well-regulated plan of exercise will be highly serviceable, when the strength of the patient is such as to render it profitable; that is, when he can perform a certain quan- tity of motion, without producing fatigue. And the effect of motion, must always be the guide for both the repetition, and the degree to which it may be carried; for, if very little exhaust, that very little is too much. Therefore, when it is again attempt- ed, it should be less than that, which had previously been fol- lowed by fatigue. This degree should be persisted in, until the muscles acquire sufficient tone to bear more; and when an addi- tional quantity can be supported well, an increase should be ad- * By this declaration, we wish to convey the idea, that in our opinion, there is no particular virtue in Port wine, that would remove it from the ban under which we have put the whole class of diffusible stimuli at too early a period of convalescence. And that when it has been employed too early, under the impression that it possessed some specific quality favourable to that particu- lar, and highly excitable condition of the system, that we have witnessed much injury to arise from its use. We do not wish to withhold this article from the invalid, at the time wine of any denomination might be proper; for if he pre- fer it, he should be indulged in his choice. It may not be amiss, however, to remark, that there is no wine that comes to this, or any other market that is so uniformly adulterated, or so rarely found good. GENERAL OBSERVATIONS. 61 mitted; and so on, until strength is established. By observing these rules, we are certain, that vigour, will be much more cer- tainly, and speedily acquired, than if the contrary plan be fol- lowed. The exercise here alluded to, refers entirely to that, which can, and must be performed, within doors. For the inva- lid must commence with exercise in the house, before he can be eligible for exercise out of doors. 186. Tenthly. As it is every way important, that the patient should have the benefit of fresh air as early as possible, we will attempt to lay down a few rules for his indulging in it. 187. 1. The patient should never be allowed to exercise out of doors, before he is capable of walking about his floor for some minutes without any great fatigue; or in other words, until he has complied with the regulations of direction ninth. It is al- ways well to destroy, as early and as effectually as possible, every unpleasant association connected with the suffering of the patient; therefore, as soon as he is able, it is proper to remove him during the day into another room; while the one he was confined in is refreshed by cleansing and the admission of fresh air. Even the vials, pill-boxes, &c. which have accumulated during illness, should be removed from the sick room, the moment there is no farther use for them; and the whole appearance of the room should be changed as much as practicable, that the patient may not have gloomy, or painful associations, connected with the things with which he had become so familiar during his illness. 188. 2. The weather should always regulate every attempt at exercise without doors; for if it be bad, that is, windy, cold, very hot, extremely wet, or very dusty, the invalid should not ven- ture abroad during the continuance of either of these states of the atmosphere or roads. 189. 3. When strength will justify exercise abroad, it should always, when practicable, be first performed in a close carriage; regulating its closeness, by circumstances, that will at once pre- sent themselves. 190. 4. It should constantly be borne in mind, that when exercise is carried to fatigue, that injury, instead of benefit, is constantly the consequence—and this is almost sure to' happen in the first attempts. This arises in most instances, from its not occurring to those who may have charge of the invalid, that he has to return over every inch of ground that he has already pass- 62 GENERAL OBSERVATIONS. ed, which in the outward progress was not thought of. We have seen from this cause many instances of great suffering from ex- haustion; and thus, every advantage which well-regulated exer- cise had promised, has been entirely defeated. 191. 5. The invalid should, upon every occasion of this kind, be carefully provided with additional covering; lest, in our fitful climate, a sudden transition, from a higher to a lower tempera- ture take place during his absence, and thus be exposed to the risk of taking cold. 192. 6. As soon as renovated strength will permit, the patient should, in properly selected weather, use the best of all exercises __namely, walking. By this, every muscle of the body, is made to bear its proportion of expenditure; and at the same time re- ceive, its proper quantum of benefit. This kind of exercise is particularly valuable to those, who have tardy bowels; (a condi- tion by the by, common to almost all, who are recovering from acute diseases,) for the employment of the lower limbs, and of the abdominal muscles, gives the intestines a more certain, and uniform action, by their mechanical pressure upon them. 193. 7. The utmost vigilance should be exercised, that the invalid does not expose himself to currents of cold, or damp air; and that he be made to avoid sitting, or going into damp places, especially if his skin be disposed to moisture, from, either re- maining weakness, or from its having been excited by exercise. He should not take a full draught, of the most grateful of all beverages, to the convalescent, namely, cold water. 194. 8. A convalescent should pay strict attention to the fol- lowing important, though apparently insignificant rules of con- duct during, and after eating; first, not to take but little fluid of any kind into his stomach during his meals, nor immediately after; second, occupy as much time as can reasonably be spent, in the mastication of his food; third, not to exercise too soon after any repast; but especially after dinner; and fourth, not to sleep either too soon or too long, after either dinner, or his after- noon meal; fifth, to eat no supper. 195. 9. If the patient is recovering from illness in the fall of the year, or in early spring, let him wear flannel next to his skin, if he has not already been in the habit of doing so; but especially, let him protect his lower extremities well, by warm stockings, and sufficiently thick boots or shoes—the former however, arc GENERAL OBSERVATIONS. 63 always to be considered preferable to the latter; as they more effectively protect from cold, a very sensitive part of the body; namely, the ankles. 196. 10. Let him avoid with the greatest care, the several substances, almost constantly presented to the invalid, because they are thought to be highly nourishing; and most easy of di- gestion ; such as calve's feet, hartshorn, chicken and beef jellies. The nicety with which these articles are prepared; and the sa- voury nature of the ingredients which enter into their-composi- tions, are sure to render them favourite articles with the sick; on whom, they are most indiscreetly always, and very often, most injuriously urged. 197. When the composition of these jellies, is examined, it becomes a matter of extreme surprise, that they can be presented to the sick, by any rational or thinking being, with the most re- mote prospect of their being useful. In the first place, the most insoluble portion of animal composition, forms the bases of these jellies; the smallest portion of which, in some cases is sufficient, as we have before declared, (177,) to recal fever and every other terrible consequence attendant upon it—this it will do from its mere animal nature. But what is superadded to this glue, for such it literally is? wine, and highly stimulating spices; besides, the more innocent sugar, and acid. Now, can -any one with the slightest pretension to observation, believe, that this can be a proper compound for a patient labouring under fever, (be the reduction of strength what it may,) or for one, just recovering from it? we think there is no one. 198. But this is not all; we have only spoken of the highly stimulating qualities of the jellies—anotherTery serious objection attaches to them; (one however, we shall not be able to persuade some to believe they deserve,) namely, their great indigestibility. We are aware in this assertion, we are running counter to all belief upon this point; but it is nevertheless no less true. We say and declare it, without the fear of contradiction from those, who are qualified to investigate the point, that the food in question is one of the most insoluble substances that can tax the powers of even a hale stomach; what then must be the difficulty to one, enfeebled by disease, and the operation of medicine? It were consumately to be wished, that these baneful articles, could be forever banished from the sick room. CHAPTER I. OF FEVER IN GENERAL. 199. HITHERTO no definition of fever has been given, which is free from all uncertainty, or ambiguity. It has always been so constructed as to make its essence consist of some one circumstance, or symptom, which rather betrays an hypothesis of the author, than an essential, on which we may implicitly rely. Strictly speaking, the term fever implies heat; but a mere increase of heat does not constitute fever; since, we may have a considerable augmentation of heat without the system labouring. under this affection; and, on the other hand, we may have fever with a cool, nay, a partial cold skin; as sometimes happens in yellow fever. 200. Dr. Cullen says, in fever there is a sensation of chilli- ness, followed by an increase of heat; the pulse gives a greater number of strokes in a given time; while several functions of the body are more or less impaired, and the strength of the limbs, particularly, is diminished. 201. Many objections have been raised by various writers to this definition of fever; and especially, by Dr. Fordyce; but his cavillings have ended in a refinement, that rather perplexes, than elucidates. We are, therefore, rather disposed to adopt Dr. Cul- len's definition, though confessedly imperfect This disease pre- sents itself under so varied a form, that we are obliged in many instances to abandon a great part of the best devised definition, and to rely upon the impression the bed-side examination makes upon certain of the senses, (as the sight and touch,) for a know- ledge of its presence. 202. We may, however, in general remark in this class of diseases, that there are certain departures from what is termed the healthy standard; and that, though in fever there may not be an increase of heat over the whole body, we can rarely find a case in which there does not exist a partial augmentation; thus, we find certain derangements of the system, (which we believe the most fastidious stickler for definition, would consent to call OV FEVER IN GENERAL. 65 fever,) attended with cold hands and feet, nay, perhaps even cold legs and arms, while the1 head, the chest, and abdomen, may be preternaturally warm; or it may possibly happen that only one of these parts shall have this increase of heat The same uncertainty may happen with the pulse; its frequency by no means establishes fever; we may have a very frequent pulse without fever, or an unusually slow one when it is confessedly present; and this may, or may not be, accompanied by an in- crease of temperature. The pulse may, therefore, be slow or frequent; strong or weak; hard or soft, with or without fever. 203. Lassitude, with more or less disturbance of the mind, almost invariably attend fever—and some evidences of debility almost always manifest themselves a short time before its regular formation; the last never fails to accompany fever; but its de- gree seems rather to depend upon the nature of the agent giving rise to fever, than upon the violence of the symptoms which may attend it This can easily be illustrated, by comparing pleurisy with the typhus of Cullen, and other writers. 204. The order of the symptoms which attend fever, has given rise to the division of them into several kinds; and it is by observ- ing the succession and continuance of their phenomena, that we are enabled to declare to what particular variety the fever in question may belong. Each of these varieties may require some difference of treatment, as shall be observed whan treating of fevers individually. 205. But, notwithstanding the many kinds, or varieties of fever* made by some, they all have a general, as well as a par- ticular plan of treatment; we shall, therefore, point out several important directions which will apply to every species, or va- riety. 206. As there is for the most part an augmentation of heat, it becomes highly useful to preserve a proper temperature in the sick chamber. (See p. 32.) Artificial heat should not be added to the patient through the medium of the air; therefore the fire, * We have already remarked upon the absurdity of multiplying the varie- ties of fever to the extent which some have done; especially, as practical utility is not advanced by it; for in the cure of fevers, all have to be treat- ed more or less upon the same general principles; though certain of them, may exact a specific management. 9 66 OP FEVER IN GENERAL. if in winter, or cool weather, should be so regulated, as not to raise the temperature of the chamber equal to that of the pa- tient's body; by this means there will be a gradual subtraction of caloric; which will not only be very comforting to the sick, but very useful as a remedy. Artificial heat may frequently be very advantageously employed in such fevers, or periods of fevers, as are accompanied with a partial diminution of it—as in the feet, legs> hands, arms, &c. For, though we should deprecate its em- ployment when a generally diffused increase of temperature ex- isted, yet we shall find it very beneficial where the contrary ob- tains. For this purpose, warmed flannels, jugs or bottles filled with warm water, heated bricks, &c. may be used to the parts that are preternaturally cold, with decided advantage. 207. It is not only important to attend to the temperature of the room, so that the air be not over-heated, but also, that this air is frequently renewed. (Seep. 30.) This in many situations requires considerable caution, that the patient may not be ex- posed to a direct current of it—this of course must be guarded against in the best manner circumstances will permit—a door, or a window, or both, may advantageously be left open with a view to refresh the room; and this may be done even in cold weather^ provided the patient be protected from its direct influence. This ventillation is especially necessary in small and confined rooms; and in warm weather. 208. The air of the room should be so regulated as not to have its temperature too much increased ; nor to become stagnant, and loaded with the emanations from the patient's body; to guard more effectually against the latter, there should be no curtains to the sick bed. Should the situation of the patient's bed be such, as unavoidably to be exposed to a current of air, when about to ventilate the chamber, a partial drapery may be given to the bedstead, by hanging up a sheet, so as to intercept the draught— and this will always be sufficient* And to preserve the air as * Great care should be taken, that the patient be not exposed to a draught of air, while he is sweating, or even when his skin is moist, or when the tem- perature of his body is below the natural standard, and these perhaps are the only reasons for being particular upon this point. For when the temperature of the patient's skin is very much exalted, we do not see that injury can arise from cool air passing over the body, more than shall follow the sponging of it with OF FEVER IN GENERAL. 67 much as possible from contamination, nothing that could do mis- chief to it, should be suffered to remain—therefore the evacua- tions of every kind should be removed as speedily as possible. No culinary operations should be performed in the room when it can be ordered otherwise—as all strong smells, especially those arising from cooking, are extremely offensive, as well as injurious, to the sick. 209. The floor of the room in warm weather should be kept clean and sweet, by passing a wet cloth over it once or twice a day—but the room is not to be flooded with water, for the pur- pose of scrubbing—the room may be much refreshed by having the floor frequently sprinkled with pure vinegar. Carpets,* es- pecially in hot weather, should be removed from the floor; and when practicable, may be replaced by mats—even in winter, the carpet should be removed occasionally, and exposed to the fresh air—this in certain fevers becomes highly important, nay indis- pensable; for we should be mindful to remove every thing from the room that may be injurious. This is particularly important in dysentery, or other affections of the bowels, as these articles'* retain the smell from the evacuations for a long time. * 210. As there is in almost all cases of fever, a strong determi- nation to the head, or head-ache, we should be careful to keep the patient as quiet as possible ; and should delirium attend, we should guard with all possible care, against company, or any other circumstance, that might tend to augment it. To aid in this intention, the room should be kept as dark as proper venti- lation will permit, and all objects should be removed, that par- ticularly challenge the patient's attention. He must not see com- pany; and as few new faces should present themselves, as is com- patible with proper and careful nursing. No unnecessary con- versation should be indulged in ; and above all, low whisperings must be strictly forbidden. When conversation is necessary, cold fluids. Yet it is well to suggest the caution; as it will perhaps prevent the application of cold air, when it might be injurious, from the moist condition of the skin; or when the surface of the skin is too low in temperature. * In cases, attended by delirium, or extreme head-aches, it may be useful to have the floor carpetted, as it diminishes the noise from walking. Indeed it is in all cases of fever, desirable, that the patient should be disturbed as little as possible by noise; that which might arise from walking, can always be obvin 'ed, by the attendants wearing socks, or very soft slippers, 68 OF FEVER IN GENERAL. it should be carried on in a tone of voice, that will enable the pa- tient, if he chose to listen, to easily comprehend it—this will save him much exertion, and will prevent much solicitude. As the patient always imagines himself to be the subject of the confer- ences, that take place in the sick room, it will readily suggest itself that, all unpleasant anticipations of the event of the patient's disease, must be avoided in his presence. (See p. 28, par. 65.) 211. It is erroneously imagined, that people labouring under fever, are extremely liable to " catch cold," as it is termed; to prevent this, bed-clothes are heaped upon him almost to suffo- cation—this mistake should be carefully guarded against; and the patient should have no more clothing than is absolutely ne- cessary to prevent his feeling chilly—all covering beyond this is both useless and injurious. The bed-clothing therefore should be constantly regulated by the feelings of the patient. (See p. 33, par. 89.) 212. To patients, labouring under fever, nothing is more ac- ceptable than cool drinks, nor is there any thing more proper. A vulgar error prevails on this head, that should be done away with as speedily as possible. It is imagined that all the drinks of a patient in fever should be warm; with a view, as they say, of disposing to, or provoking perspiration; by this reasoning, the patient is deprived of almost the only luxury he dare indulge in; and this without the smallest benefit. We would therefore re- commend that all the drinks of the patient should be cool; nay, sometimes cold—and this is easily regulated; as the degree of external heat of the patient should be the uniform guide. Nor are we aware, that there is an exception to this, but where the skin is moist, or disposed to be so. Where perspiration has taken place, or is just about to take place, the liquids should not be cold, although they may be cool. 213. Indeed, we have very often seen a profuse perspiration immediately follow a drink of cold water; and we never hesi- tate to administer it, when the skin is hot and dry, and the thirst great; nor even to repeat it from time to time under like cir- cumstances. It however very often happens in the higher grades of fever, that the thirst demands more drink than the stomach can well support—for if cold drinks be too much indulged in, the stomach revolts, and a vomiting ensues. To prevent i\\\< OF FEVER IN GENERAL. 69 we are in the habit of giving small portions of ice* from time to time. By this plan we secure to the patient, a more permanently cold application to the mouth; while the stomach enjoys all the advantages of cold water, without its oppressive weight and bulk.( Or if ice cannot be commanded, cold water may be given by the spoonful, and repeated more frequently. 214. The drinks of fever patients should consist of such arti- cles as are most palatable; but, at the same time they should be such, as are free from all stimulus, unless the latter comports with the particular situation of the patient; in this case it forms rather an exception, than a rule.t We should therefore say, that in all cases which do not require such stimulating articles, as wine, brandy, &c. to be added, (and these are almost all cases of fever,) the drink should consist of toast water, baum tea, le- monade, currant jelly and water, molasses and water with a lit- • tie vinegar, the water off of dried cherries, very weak milk and water, barley water, flaxseed tea, either with or without lemon juice, iorrel water, &c. &c. We have purposely enumerated a variety of drinks, that the invalid may have a choice. But sim- ple cold water, as just noticed, is almost always admissible; es- pecially when there is great heat. 215. Food should be administered with the greatest caution; and this will refer not only to the quantity, but also to the qua- lity—it should be of the lightest kind, especially in the inflam- matory stages of the disease. Indeed, the patient frequently pro- fits by the kind interference of nature, when she deprives him of all inclination to receive it. In this country, we are subject to many highly inflammatory diseases, in which, the more com- plete the abstinence, the more the patient profits. There can be no error more injurious, than the belief, that the sick are in con- stant need of nourishment. This prejudice has destroyed its thousands—and it is one of the first and most important rules to be learnt by those who have charge of the sick, that in the com- mencement of any acute disease, little or no food is required. 216. In no instance of fever, or any other disease of high ' The ice should be broken into pieces of the size of a filbert, and placed at the command of the patient. f It will be seen, by the* sequel, how very few the exceptions are to this rufe. 70 OF FEVER IN GENERAL action, is animal food, in any possible shape or disguise, as broths, &c. admissible—during convalescence, it may be useful. 217. When it is proper to administer nourishment in fever, it should always be given in small quantities at a time—say three or four spoonfuls either large or small, as the patient may be either large or small. It should consist of weak milk and water; thin tapioca; sago or arrow root; gruel, either of Indian meal or oat meal; ripe fruits in moderate quantities, when in season, such as oranges, grapes, or roasted apples, may also be given. Gum Arabic water, is perhaps one of the least excep- tionable articles of diet we can recommend. A cup of weak tea or coffee is frequently extremely grateful to the sick; and may almost always be permitted. 21S. We can scarcely be too particular in the body-clothes •of the patient; they should be daily changed when the patient is not too much exhausted to permit this—the bed-linen should also undergo a daily change whenever it is practicable; and es- pecially in those fevers that end their paroxysms by sweat. 219. We have already intimated that much of the success in the cure of fevers will depend upon the promptitude with which remedies may be had recourse to; and upon the fidelity with which they may be administered; and these must be aided by the strictest attention to the proper regimen. Indeed, without the latter, the former would for the most part be entirely un- availing—much then depends upon the nursing as it is termed. (See p. 25, par. 56, &c.) The intervals at which medicine is di- rected to be exhibited, should be carefully attended to, as, a fail- ure in this, has frequently defeated a well-devised plan of cure. A mistaken tenderness should not interfere with a prescribed or an imperious duty; nor should it interrupt the application of an im- portant, though perhaps a painful remedy. There is a time or period in almost every disease, at which a remedy is the most im- portant; but if this time be allowed to pass, from mistaken kind- ness, indecision, or neglect, it may perhaps never return. There- fore remedies, to be efficacious, must be promptly applied, and rigorously persevered in. OF FEVER IN GENERAT "1 General Plan of Cure. 220. In fevers of almost every description, (as we have be- fore declared,) that state of the system called inflammatory, prevails; and in the commencement of all, it would scarcely be too much to say that, a preternatural fulness exists; so that we rarely meet with a fever, on the outset of which, we do not find the blood-vessels more than naturally active. When the contrary obtains, it is almost always in some uncommon epidemic or southern endemic; and these only form exceptions to the rule. We have therefore almost always to contend in the early stage of fever with an augmented heat; increased pulse; per- haps with loaded stomach and bowels; our remedies must there- fore be calculated to diminish the two first, and remove the latter. 221. These intentions are to be fulfilled by, 1st, cool or cold air; cool or cold drinks; and by such remedies, as are indirectly calculated to produce this end; 2d, bleeding; 3d, sweating; 4th, purging; 5th, blistering; 6th, tonics, &c. A. Of Cool Air and Drinks. * 222. We have already noticed the importance of fresh and cool air to the body of a patient labouring under fever, and we now wish to be understood to consider this as not only highly refreshing to the patient, but as a valuable and ac- tive remedy. Whenever therefore the surface of the body is above the natural temperature, we should so employ this * As the terms hot and cold; warm and cool, are relative, it may be well to offer a more precise meaning to them in this place. When speaking of cold or cool air, we should wish to be understood, that degree of it which would excite these sensations in the patient; thus when the body is heated to 108° or 110°, diminution of 15° would appear cold—should it be at 100° it will bear a greater reduction, before the sensation would be called cold; it would follow then of course that, the intermediate degrees would be called cool—when speaking of cold or cool drinks, we must be understood to mean in general from 40° to 57^° for the first; and for the second from 57° to 60°. And farther we would wish it to be understood, when we speak of the tem- perature of the air of a sick chamber, to mean that it should never exceed 62°, where practicable to keep it in this condition, during the hot stage of fever. If chill exist, there is no objection to a more exalted temperature for the time being. i 72 OF FEVER IN GENERAL. remedy as to remove this superfluous heat. To do this in the safest and most efficacious manner, we should permit the constant introduction of fresh air into the chamber; and the pa- tient should be so situated as to derive full advantage from it, but without incurring the risk of a full stream directed imme- diately upon him, if his skin be moist. In hot weather however, this will require but few precautions; as the external air in some of our hottest days, is perhaps but little below the heat of the patienf; in this case, no risk is run, in having a current di- rected immediately over him. To obtain this advantage, his bed should be removed to the most open part of the room; and his covering be as thin as possible. Where the temperature of the external air is considerably lower than the heat of the pa- tient, it must be applied in such a manner as not to induce a sud- den chilliness—and this can always be effected by giving a pro- per direction to the aii> and accommodating the bed-cloathing to the state of the atmosphere. The sensation this regulation produces in the patient when properly managed, is that of the most delightful cordial. The degree of cold therefore, must be commensurate with the degree of heat, the patient has to spare. 223, In situations where cold air cannot be commanded, the application of cool or cold water to the arms, head, and body of the patient, by means of a sponge passed over them, will be found highly refreshing, as well as useful. But in the employ- ment of these remedies, it must be recollected, it is never to be had recourse to while the body is sweating, or when the tem- perature of the body has been reduced by cool applications, (as sometimes happens,) so as to induce perspiration. The sponging must be now desisted from, until the perspiration disappear, and until a re-accumulation of heat make it again necessary. Should cough, or other affections of the chest attend, .the sponging must not be thought of. 224. Cool, or even cold drinks, we have said, are most grate- ful and most useful in fever. In very hot weather, their tempe- rature can be speedily and advantageously reduced by ice. In this state, they may with great propriety be employed, if they be ex- hibited in small quantities at a time, as has already been observ- ed; the quantity, however, may be frequently repeated. The kind of drink has already been pointed out. The same precautions OF FEVER IN GENERAL. 73 should be observed with cold drinks as with cold air, when the body is in a state of moisture from perspiration; but we need not withhold cold drinks if cough alone be present 225. Fevers of every denomination, be their types what they may, frequently have sickness of stomach as an attendant. This nausea, or it may amount occasionally to vomiting, is always attributed by the attendants upon the sick, to " a foul stomach" and in their opinions, decidedly calls for an emetic. This, nine times out of ten, is an error; for this sickness, &c. only points out a state of irritation of this organ; and so far from its being relieved by an emetic, is almost certainly aggravated by it In such cases, cathartic medicines of a moderately active kind should first be given; and if these do not afford relief, try, 2d, the direct application of such remedies as are known for their efficacy in such cases; and 3d, if these fail, counter-irritants must be used. 226. The first will consist of small quantities of calomel, fol- lowed if necessary by magnesia. For much advantage is derived in this condition of the stomach from small portions of calomel, repeated at short intervals, viz. R. Calom. ppt. - gr. viij. Take Calomel - - 8 grains. Sacch. alb. - gr. viij. White sugar - 8 grains. M. div. in viij. Mix, divide in 8 parts. One of these should be given every hour in a drop of syrup of any kind, or a little scraped apple, until they move the bowels. 227. But should this quantity not stir the bowels, and relieve the sickness, let two or three tea-spoonfuls of calcined magnesia in a little sweetened milk be given; or else, give an enema; in- deed this may be profitably employed whenever the stomach is thus irritable, and the bowels tardy. It may consist simply of hot water and common salt, in the proportion of a pint of the former to a large table-spoonful of the latter, This may be re- peated as necessity may require. Should this fail, it will be pro- per to employ the second set of remedies, and the milder of these should be tried first; these will consist, of small quantities at a time, of pretty rich gum arabic water, (cold,) milk and wa- ter, in- small quantities—that is, a table-spoonful every fifteen or twenty minutes; or we may use with almost a certainty of 10 74 OF FEVER IN GENERAL. success the following more complicated, but very successful julep. R. Bis-carbon soda - jiss. Pulv. gum arab. - 3'J- 01. minthx - gut. iv. Sacch. alb. - - 3»'vj- Aq. seltzer - - £1V- Take super-saturated soda 1£ drachm. Powdered gum arabic 2 do. Oil of mint - 4 drops. White sugar - 2 drachms. Seltzer water - 4 ounces. Of this, a table-spoonful may be taken every half hour or hour, as the necessity may be more or less urgent. If the seltzer water cannot be commanded, simple water will answer. 228. Should neither of these answer, we must have recourse to the third set of remedies; and a few ounces of blood drawn from the region of the stomach, by leeches, will be found to be of decided use. This may, if necessary, be followed or preceded by a plaster of the flower of mustard and vinegar to the stomach until it tingles the skin smartly; or this may be followed by a blister after depletion, if the vomiting be obstinate. B. Of Bleeding. 229. The employment of this valuable remedy in the com- mencement of fevers, is now so universal, that it has al- most become a domestic remedy; and the number of cases in which it is useful, nay, essential, is so great that we may look upon it as almost indispensable. The prejudices which were so long entertained against it, have given place to a com- pliance, which experience has shown, it merited; and it is now in such general acceptance, that it is very frequently the initia- tory remedy. The cases of fever in which this mode of deple- tion is inadmissible, are so few, that we find almost a difficulty in pointing them out—at least in the commencement; and it is at this period, we are always presumed to refer, whenever we speak of remedies in general, unless the contrary is expressly declared. The cases for the proscription of the lancet are so few, as to constitute only rare exceptions. 230. Although blood-letting is almost universally prescribed for fevers in this country, it must, nevertheless, be looked upon as a remedy of great power; and of course must be judiciously directed. For, that it may be employed advantageously, it must OF FEVER IN GENERAL. 75 be used at proper times, in proper quantity, and under proper circumstances. 231. The proper time for bleeding, is for the most part at the period at which the hot stage of fever is completely formed—it should, therefore, never be used in the cold stage of fever;* nor when the paroxysm has subdued, or is about to subside. As a general rule, it should not be used during the sweating stage; there are, however, exceptions to this—as in certain cases of yellow fever; and also in some instances of common remittents, where the sweating does not mitigate the symptoms, or lower the pulse. 232. The quantity to be drawn is of much importance—on this, almost every thing depends; for if too little be drawn, which is by far the more common error, very little advantage is derived; and if too much be taken, mischief must necessarily follow. The latter, however, as far as our experience goes, is an accident of rare occurrence; and when it does happen, is much more easily remedied, in very severe diseases, than where too little has been taken at an important period of the complaint. As a common practice, where this remedy is necessary, we should permit the blood to flow, until it produces a manifest change in the feel of the pulse—the pulse should become quicker, smaller, softer, and fluttering, as it were, under the finger. It is to be remarked here, however, that, in this direction, we have reference to the intense forms of disease. 233. In the milder forms of fever, where the pulse is not much excited, but yet requiring the loss of blood from local determi- nation, and especially, when this is to the head, we may content ourselves with a quantity, which shall merely diminish the strength and fulness of the pulse. But in cases in which the head is very much affected, it is for the most part a good rule, to allow the blood to flow, until relief is experienced. From this it will be perceived, that it is very difficult to direct the precise quantity of blood to be subtracted, by any fixed number of ounces. • The contrary of this has lately been recommended in strong terms, by a physician in Great Britain; that our opposition is something diminished, yet it is not so muchso, as to induce us to give it our concurrence. We are w.lhng to acknowledge, that this may be prejudice; but until more experience shall establish its utility, we must abide by our present prepossessions. 76 OF FEVER IN GENERAL. 234. As a general rule, the blood should be drawn from a large orifice; in many instances, by an observance of this, less blood is found to answer; as the effects upon the system are much more decided; this is especially important in the commence- ment of the disease; and where it is presumable from its force, that much blood will be required. With such "as may he dis- posed to faint, from the mere operation of bleeding, the precau- tion should be taken to bleed in a recumbent posture. But when this is not the case, and it is desirable to make a considerable impression on the sanguiferous system, the contrary should be observed, as the tendency to faint, is at times highly useful; es- pecially, in those fevers in which there is very strong arterial action, with great determination to the head.* 235. The number of times a patient may be bled for the cure of fever, can never be pointed out in round numbers—the repe- tition must depend upon the force with which the disease mani- fests itself in the sanguiferous system—and this for the most part the pulse will indicate. 236. But the pulse is not always to be the guide, especially in fevers of regular paroxysms; for in these, the pulse might in- dicate in many instances the abstraction of more blood, when it might be safely dispensed with. But, if in these very fevers, there occurs strong local determination, and especially if this be to the head, as becomes evident by head-ache, or delirium, we should bleed again and again, if the force of the disease con- tinue, or is but little abated; provided the pulse maintains a suf- ficient force and vigour, to justify the operation. 237. The circumstances under which we should not bleed, are those, in which the system is depressed by the cold stage of fever; or temporarily prostrated, by excessive evacuation. In the first case, the cold stage would be much protracted by bleed- * In general, in fevers, when either, from the peculiar nature of the disease, as an epidemic; or from the particular constitution of the patient, the determi- nation of blood to the head is strongly marked by head-ache, or delirium, the position of the patient is no mean point to be observed. He should always have his head and shoulders so much elevated, as will bring the blood within the certain influence of gravitation. Indeed, this rule should always be ob- served in such affections of the brain, or its appendages, as betray an excess of blood in these parts. OF FEVER IN GENERAL. 77 ing; and the reaction of the system would be much delayed; or the powers of the system might so sink, by an ill-timed bleed- ing, as to be unable to react. In the second, the powersof life may be so reduced, that a fatal syncope might follow. Of so much consequence is it then, to attend to the circumstances un- der which we bleed. The accidents we have just noticed, might take place in cases, where bleeding might again and again be ne- cessary, were the system allowed to react, or when not prevented from reacting, by the injudicious employment of this remedy. C. Siveating. 238. There is no remedy so decidedly popular for the cure of fever, as sweating; and none, perhaps, been more abused. As the healthy solution of almost all fevers has been ef- fected by this process, when allowed uninterruptedly to run their course; and as almost all fevers of regular paroxysms ter- minate by this discharge—it naturally suggested itself that, if we could imitate this process, we should sooner, and more cer- tainly cure this disease. Accordingly,from time immemorial, this mode of cure has been attempted, but not always with the same success. It has always been a popular belief that, in proportion to the quantity evacuated by the skin, would be the efficacy of the process; than which nothing can be farther from the truth. 239. This vulgar error has proceeded from not discriminating, between the insensible perspiration, and that collection of fluid upon the surface, called sweat It is not our intention to enter minutely into these differences, by giving their history or by enquiring into their causes; but simply to state that, while in many instances, a pleasant, soft, silky feel of the skin, by hav- ing the insensible perspiration increased, shall relieve a patient in fever, a profuse and deluging sweat, shall totally fail of this end. In a number of instances we have known an overwhelming sweat to be followed by a hard, rigid skin, and without the smallest diminution of the force of the arterial system, or the least abate- ment of the distressing and threatening symptoms. On the other hand, we have seen the whole system tranquillized and relieved by a gentle moisture breaking out spontaneously, or when pro- duced by the exhibition of some proper remedy for this end. 78 OF FEVER IN GENERAL. We may therefore lay it down as an invariable rule, as far as our experience justifies us in the assertion, that in no instance of fe- ver, simply so called,* does profuse sweating relieve, as much as gentle perspiration. It follows, then, that this evacuation has been in too many instances indiscreetly urged. 240. In employing remedies with a view to promote perspi- ration, (for this is all that should be attempted,) we must regard with attentive care, 1st, the period; 2d, the state of the body as regards temperature; and 3d, the agents, themselves. 241. 1st. The period of the febrile paroxysm at which we at- tempt its solution by this remedy, is a matter of great moment; we must, therefore, not commence our operation in the cold stage; nor should we be more successful at the formation of the hot stage, nor at its height, unless proper evacuations have so much reduced the vigourof the pulse, as to render the operation of the medicine probable; or unless the fever itself, is of so mild a grade, that an impression can be made upon it by the exhibi- tion of diaphoretics. It therefore follows, that, we should not exhibit any one of this class of medicines, while the pulse is full, hard, and frequent—for were we to do so, we should not only be foiled in our attempts, but have the mortification to see every symptom aggravated; for there is a "sweating point" of the ar- terial system, as well as a "sweating point" of temperature. 242. 2d. The state of the body as regards temperature.— From the well-conducted and conclusive experiments of Dr. Alexander, it appears that the heat of the body can transcend the "sweating point;" and that, when this is the case, it re- quires a reduction of temperature, before the sweating process can commence. He fixes this point at 108°, but we have reason to believe this too high, say 100° or 102°. It therefore follows, that to procure perspiration, the heat of the body must not ex- ceed this degree of temperature; and hence it is, that many have been defeated in their attempts by increasing the heat by stimu- lating drinks, and by additional bed-clothes, beyond the " sweat- ing point" And hence it is, that, a drink of cold water, has many times proved the best diaphoretic, by suddenly bringing * In acute rheumatism, sweating is sometimes highly useful, but not always; but this is a disease very different from fevers arising from marsh effluvia, or other causes capable of producing simple fever. OF FEVER IN GENERAL. 79 down, or reducing the heat of the body to the " sweating point;" and that, by sponging the body with cold water or vinegar, per- spiration has been immediately excited. It may, therefore, be laid down as a rule, that, all attempts to procure perspiration will be unavailing, if the heat of the body exceed 102°. 243. 3d. As regards the agents, they must be accommodated to the state of the system itself—and this will refer both to arterial action, and temperature. We have already noticed that, there is a choice of period in the paroxysms; and also, that re- gard must be paid, to the condition of the pulse; and we will now add, that, whenever the hot stage is attended by a vigorous pulse, and strong local determination, especially to the head, every attempt to procure a diaphoresis will not only be unavail- ing, but injurious; and that the system must be properly pre- pared, (if we may so express ourselves,) by bleeding, purging, &c. before an attempt of this kind be made. As a general rule, then, when there is considerable vigour in the system, the anti- monial preparations will be the most eligible; and if accompa- nied with much heat, nitre will sometimes be an useful addi- tion.* 244. If there be but a moderate degree of vigour in the pulse, or if it be soft, opium is a highly important drug. This medi- cine seems to merit a decided preference in all the more pro- tracted forms of fever, or where the powers of the system have been pretty much expended; and in all those of weak action, • The combination of nitre and tartar emetic, is sometimes employed with great advantage in cases, where there is a hot dry skin; much thirst, and head- ache; and where the pulse is yet too high for the exhibition of opium, but not sufficiently so, as to render blood-letting necessary. And it is especially pro- per, when the bowels are tardy; as the addition of a little calomel, gives great efficacy to its power over the bowels; particularly, where it might be objec- tionable to give a cathartic expressly. The following formula is one in com- mon use:— R. Sal. nitri - - ^iss. Take Nitre or saltpetre 1$ drachm. Emet. tart. - - gr. j. Tartar emetic - 1 grain. Calom. ppt. - gr. viij. Prepared calomel 8 grains. M. et div. in viij. Mix, and divide in 8 parts. One of these powders to be given every two hours, mixed in a little roasted apple, or syrup of any kind. If they operate on the bowels too much, they must be suspended, 80 or FEVER IN GENERAL. even in the commencement. The proper time for its exhibition is at the early part of the hot stage. It should be given in sucli quantities, and at such intervals as to make a decided impres- sion; but nor so much as to have its narcotic effects prodominate; nor should the frequency of exhibition be such, as to subject the system to this part of its influence. We therefore hold it wrong to give it, either in such a dose or doses, as will subject the brain to its anodyne powers; for whenever we induce this tendency to coma, we unnecessarily prostrate the system. The powers of opium, when administered with a view to produce perspiration, are decidedly augmented by the addition of some other sub- stances; and perhaps one of the very best forms, is that of Do- ver's powder.* 245. We have, however, seen cases, in which the internal exhibition of remedies have failed to procure perspiration, how- ever eligible in kind, or however faithfully persevered in; yet it has been quickly excited, by external applications. One of the simplest, and at the same time, one to be most relied on is, the vinegar vapour. This appears to be particularly successful in those cases, where there is a dry, hard skin, without excessive external heat—for we have known it to be a powerful auxiliary to opium, when there has not been a sufficient or regular distri- bution of heat to the surface. It should never, however, be used when the temperature is above the " sweating point," nor where the external heat is easily augmented, by any additional sti- mulus. 246. In conducting the sweating, no inconsiderable care is re- quired, that its utility may not be defeated. We have already said, our aim should be, to produce a gentle transpiration, but not a profuse sweat Therefore whenever we find it is tran- scending this condition, we should abate it, by the removal of some of the covering. And when we find this sweating is not produced, pretty soon after the exhibition of medicine; or by ex- * Recipe for Dover's powder:— R. Pulv. ipecac, Pulv. opii., 5a. gj. Sulph. potassa - - - JJviij. M. Ten grains of this powder is considered a dose—it should be mixed in a httle syrup or gruel, and the patient should not drink any thing for an hour after its exhibition. OF FEVER IN GENERAL. 31 ternal applications, we should carefully examine the state of heat of the patient's skin—if this be very hot, we can only induce perspiration by its reduction; this must be attempted, either by a removal of the bed-clothes; by the use of a large draught of cold water, or by sponging. 247. The length of time that sweating should be kept up, must depend very much upon its quantity; by its effect on the pulse; or the sensations of the patient. We have noticed that, a profuse sweat is not desirable, and therefore,' when this happens, either from the bad manner in which it has been conducted, or from some peculiarity of the patient, we should endeavour to check it by a removal of some of the bed-clothes; by the admis- sion of cooler air into the room; or by taking away the external means, if any should have been employed to excite it, and by abstaining from warm or hot drinks. 248. Should the pulse be much reduced in force and frequency by this means, even soon after the breaking out of the perspira- tion, we may prepare to check it by the plan already suggested. Or should the patient become very faint, exhausted, or extremely restless under its influence, we should not persist in its continu- ance. 249. After the patient has been subjected to the sweating pro- cess, all the clothes which surrounded him should be removed and replaced by fresh linen, &c. as soon as he is dry. This is a matter of considerable importance, and where practicable, it should always be complied with. D. Purging. 250. In fevers of almost every description, purging is not only useful, but in many, is indispensable. There exists con- stantly a want of equilibrium in the circulatory system, when- ever the body is attacked with fever—and the determination for the most part is, to the brain, the liver, the spleen, or to the lungs ; and few remedies are found so effectual in restoring this want of balance, as well chosen, and properly adopted aperients. Besides the determinations just mentioned, fecal matter in the bowels, is constantly accumulating, which it is of much conse- quence to remove. Occasionally there will be a redundancy of 11 82 OF FEVER IN GENERAL. bile; at other times a deficiency; and we are obliged sometimes to remove the one, or to solicit the other; and both of these ends are answered by the proper choice, and exhibition of cathartics, of the aperient or laxative kind.* 251. Purges, besides cleaning the bowels of offensive matters, cause to be discharged into the bowels, a considerable quantity of the fluids, natural to these parts; and thus serve the double purpose of removing their fecal contents, as well as evacuating from the general system. For effecting these purposes however, some cathartics are much more valuable than others; conse- quently there is a considerable choice. We shall not enter here more fully than we have into a detail of them; designing, in the treatment of each disease, as they may be necessary, to point out the proper ones. 252. The management of cathartics must be regulated, 1st, by the state of the system in general, and of the bowels in par- ticular; they are indicated when the system maintains its general vigour, and where the bowels are still loaded, or not sufficiently cleansed—the pulse will direct in the one instance, and the ap- pearance of the evacuations in the other. The regular inspection therefore, of these discharges is a matter of much moment; and should never be neglected by those who may have the care of the sick—for it is not sufficient for all valuable purposes, that the patient should frequently require the pan; for these calls may be for the discharge of thin, watery fluids, and not for the evacuations of the feces—and sometimes such is the effect of pur- gative medicines that they excite the bowels to frequent action, yet do not effectually remove the offensive matters contained in them. On this account we recommend the regular inspection of these discharges, that we may not be deceived in a matter of such moment (See par. 93, &c.) There is a popular prejudice against purging, that we should be glad to remove, namely, that they are "very weakening." Purging, like every other evacuation, may be carried too far; and then with strict propriety it may be * Cathartics, signify such medicines as quicken the peristaltic motion, there- by inducing a more free evacuation of the bowels. But as this class of medi- cines differ very much in the capacity to provoke this increase of motion of the intestines, they have been very properly divided into laxatives or aperients, and purgatives. The former are such as act mildly upon the bowels, as castor OF FEVER IN GENERAL. 83 said, to be " very weakening"—but this is only the abuse, or mal-administration of a remedy. In many instances of fever, the patient is so far from being weakened by being purged, that he is absolutely strengthened by it* And again, it is fre- quently said, when these medicines are about to be administer- ed, that they "cannot be necessary, for there is nothing inside of the patient to bring away;" and as a proof of this, they will declare " the patient has eaten nothing for a number of days." 253. This popular language and feeling, must be disregarded, if we do not mean to injure the patient; especially, where atten- tion has been paid to the quantity and nature of the discharges; and where we are convinced, from these inspections, that much remains to be removed. For we have frequently seen, after the purging process has been continued for a considerable time, and where the friends of the patient were convinced there was " no- thing inside," large, hard, and fetid evacuations have succeeded those " watery stools," and the patient has been almost imme- diately restored to health. We could say much upon this im- portant subject, but our limits will not permit us. 254. 2d. Attention should be paid to the time they are admi- nistered—they should not be given, (unless it would be the loss of precious time to procrastinate,) so as to interfere with the night's rest of the patient; nor should they be used, so that they shall interfere with the "sweating period of fever;" nor with- out previous preparation by bleeding, in the more concentrated form of fever. 255. 3d. They should not be given in the decline of fevers, where the patient is rapidly convalescing, lest they produce a relapse—but this is not intended to prevent proper attention to the bowels at this time; for costiveness might be as injurious as purging. Nor must we use them when the patient is much ex- oil, magnesia, rhubarb, neutral salts, as Epsom or Glauber, &c. The latter are such, as act with more violence upon the bowels, as calomel, jalap, senna, &c. * This has been repeatedly exemplified in yellow fever. We have known patients nearly faint, when labouring under this disease, upon being merely put in an upright position; yet after a free purging, and other evacuations, they have been able to get out of bed, and walk the floor. Now, were these remedies directly weakening, the contrary of this should have happened 81 OF FEVER IN GENERAL. hausted by colliquative diarrhoea; nor near the decline of a fe- brile paroxysm. 256. 4th. The operation should be so managed, that the pa- tient need not unnecessarily expend his strength in complying with its demands—he should, therefore, never be permitted to get out of bed for this purpose, when he is so weakened, as to be in danger of fainting, or of even being much exhausted. A bed pan should always be used; and although it may at first be a little awkward for the patient, a little practice would reconcile him to it. (See p. 40.) 257. 5th. The patient should be so protected by clothing, when obeying these calls, in cool or cold weather, that he may run no risk of taking cold, or provoking chill—on this account also, we should guard against his getting out of bed, when it is practicable to confine him—he should have his stockings drawn on, and a pair of warm slippers ready for him to step into—and he should also be carefully covered with a blanket, during the time he is sitting upon the pan. E. Of Blisters. 258. One of the most common resources in fevers of every description, is blistering; nor is any remedy more abused; be- cause no one is so empirically prescribed. The employment of blisters, in the cure of fevers, must be governed by strict, and decided laws, or very certain injury will ensue. Therefore, in using them, reference must be had, 1st, to the period of the dis- ease, or rather to the state of the arterial system; 2d, to the part to which they are applied; 3d, to the duration of their applica- tion ; 4th, to the peculiarities of the patient, as regards the more remote effects of this remedy. a. Of the Period of the Disease, or State of the Arterial System. 259. The discrepant accounts of the febrifuge effects of blis- ters, have arisen, we are disposed to believe, from the little re- gard paid to the state of the system, at the time of their appli- cation, by those who look upon such application as mischievous; OF FEVER IN GENERAL. 85 while they are recommended in terms of the strongest confi- dence by others, who have been more attentive to this great practical distinction. It is, therefore, justly inferable, that both parties were right as regarded effects; but only one was right as regarded the usefulness of blisters; as only one was directed by principles, in their user. 260. It is now well ascertained, that blisters have as decided, and as well characterized a period for application, as blood- letting, cathartics, or emetics; and when used at improper times, they will, like each of the remedies just named, do mischief. It is therefore important, that the pulse be in a proper condition; that is, of very moderate force, at the time of their application; for if it be not in this reduced state, blisters will, like wine and other stimuli, but increase the state of arterial action. The blistering point therefore always means, when the arterial force is rather below par, as it is termed. Or in other words, where the artery can be easily compressed, or is soft When employed in this state of the system, we are very sure they will do no mis- chief; but, on the contrary, we have every reason to anticipate a favourable result, if the case has been a fair one for their appli- cation; for it must be recollected, that blistering will not relieve every state of disease, that may be attended by a soft or yielding pulse. b. Of the Part to which they are Applied. 261. It is a matter of some moment to select the proper seat for the blister or blisters. Therefore, as a general rule, we may say, that in such fevers as are not marked by local affections, as in pleurisy, inflammation of the liver, or other partial inflamma- tions, that the extremities are the best locations for them. On the calves of the legs, when the circulation in these parts is not too languid, as may be determined by their coldness and insen- sibility; and on the inside of the thighs, when this is the case. The application to the arms may be regulated, by the same state of the parts, to the forearm, when its sensibility is sufficient for the purpose; and above the elbow, when it is not. 262. It will not be necessary to extend the subject-here, as we have already adverted to this subject before, at page 41; and 86 OF FEVER IN GENERAL. especially as we shall in each separate disease, point out the part to which they shall be applied, when these remedies are indi- cated. ■ 263. In remittent and intermittent fevers, blisters are almost always applied to the extremities; and are indicated, whenever it is necessary to make a strong impression upon the system, for the purpose of procuring a more decided remission, or a more distinct intermission, after the force of the pulse has been abated, by antecedent remedies; or is already so, by the type of the fever itself. c. Of the Duration of their Application. 264. In general, blisters are permitted to remain on twelve hours. If they have not produced their effect in that time, an hour or two more should be allowed them. But if the inquietude of the patient, or other signs, give evidence that they have drawn at an earlier period, they may be examined sooner, and dressed, if they have performed their office. d. Of the Peculiarities of the Patient as regards their remote effect. 265. We have seen several instances of adults who could not bear the irritation of a blister, without the most exquisite pain, as well as the most manifest aggravation of existing symptoms. In such cases, we must yield to the idiosyncrasy, by removing these applications; for no possible good can result from a con- tinuance. Others are so liable to severe stranguary upon every occasion of their application, that we should not insist upon their employment, but when compelled by the severest necessity. F. Tonics. 266. There is no dread in fever so universal as that of weak- ness; nor is there a circumstance connected with disease so se- dulously attempted to be guarded against; nor one that has been so uniformly mischievous. Under the influence of this appre- OF FEVER IN GENERAL. 87 hension, proper remedies are withheld, and their places supplied by such as are injurious, because the patient is supposed to be " too weak" to bear the appropriate ones; and consequently, that he absolutely requires the others. Hence the too early and mischievous, or perhaps fatal use, of improper diet and drinks, and the injudicious administration of tonics. We are of opinion, that in our climate, this class of medicines should be exhibited with great caution; and that they have, in very many instances, contributed from their ill-timed use, to protract disease; created others, or have destroyed the patient. To the too early use of the bark, one of the best known and most celebrated tonics we have, we may but too often attribute the visceral obstructions which follow fevers; and from its too early employment, intermittents have often been rendered more intractable, or have been con- verted into other more obstinate or dangerous diseases. Let me therefore caution against all unnecessary fears for the strength of the patient; and the too early use of tonics. 267. Against the too early administration of bark, we can hardly recommend too much caution; nor do we know how, in adequate terms, to warn against a popular delusion that has been the death of thousands. We here allude to certain symptoms common to most fevers, (when a little protracted, or when in their early stage, bleeding and purging, have either been alto- gether neglected, or but inadequately performed,) such as a dry, brown tongue; flushed face; quick pulse; red and scanty urine; dark offensive stools ; dry skin; black lips; high delirium; drow- siness or stupor; trembling or unsteady action of the arms when about to be used, &c. These, with many practitioners, are look- ed upon as signs of typhus; and for the relief of which, bark, wine, nay, the whole list of stimulants, are put into immediate and fatal requisition. Under such circumstances, with even a pretty decided remission, neither the bark nor any other sti- mulant is proper. When we treat of typhus, we shall have oc- casion to advert to this bad and dangerous practice.* 268. Of tonics, there is a great variety, some decidedly pre- ferable to others; but the choice of them in each individual case where indicated, cannot be pointed out here. We shall, there * See Chapter on Continued Fever and Typhus. 88 INTERMITTENT FEVER. fore, as we proceed in the history and cure of diseases, direct the substances of this class the most proper to be employed, in the individual case that may require them. 269. Having thus spoken of fever, and its cure in general, we shall proceed to consider fevers in particular; and first of CHAPTER II. INTERMITTENT FEVER. 270. An intermittent fever is a disease in which there are distinct paroxysms, with a state of apyrexia, or intervals which are perfectly free from fever. This fever receives a name from the different periods at which its paroxysms or its febrile states return. As, quotidian, if the renewal of the paroxysm be every day; a tertian, if every other day; a quartan, if every fourth day, or after the lapse of seventy-two hours, &c. &c. 271. This fever is supposed for the most part to arise from marsh miasma,* and is most frequent in the spring, (then term- ed vernal,) and in the fall, (then called autumnal,) intermit- tents. The latter is the more common and the severer of the two. 272. They commence by a chill of greater or less severity, which lasts a longer or shorter time, according to circumstances. The chill is followed by heat of more or less intensity; and is occasioned by what is called the " reaction of the system;" this reaction, or hot stage, terminates after a certain duration, by a sweat—and when this last symptom subsides, the patient is left * Of this agent, Dr. Johnson, (Influence of Tropical Climates, &c.) very properly observes, "the term marsh, is not so proper as vegeto-animal effluvium" or miasma; since experience and observation have proved, that these febrile exhalations arise from the summits of mountains as well as from the surface of swamps. The mountains of Ceylon, covered with woods and jungle, and the Fast ghauts themselves, give origin to miasmata, that occasion precisely the same fever as we witness on the marshy plains of Bengal." INTERMITTENT FEVER. 89 apparently free from disease, until the period of twenty-four hours from the commencement of the chill, again comes round; and then the attack is renewed, if it be of the quotidian type. In this form, the interval is short; sometimes not exceeding four hours. In the other forms, the intervals are proportionably longer. 273. The paroxysm of an intermittent is divided, therefore, into three stages; 1st, the cold; 2d, the hot; 3d, the sweating stages. 274. Before the first stage takes place, the patient for the most part feels languid and weak; is indisposed to motion; is prone to stretch and yawn, and generally has a complete aver- sion from food. The whole body becomes pale, and evidently diminished in bulk, especially the extremities; for rings will of- tentimes fall from the fingers. Sometimes the cold sensation is intense, and the patient will shake severely; at other times, the coldness is more moderate, and some trifling trembling is all that is experienced. 275. After this sense of coldness has been endured for some time, its intensity begins to abate gradually, and is succeeded by a glow, that spreads itself successively over the whole body; and after a small interval, is converted into a heat of greater or less intensity; the face and other parts of the body redden; the skin becomes dry; the thirst intense; the head-ache, anxiety, and restlessness excessive; the tongue is furred; the pulse frequent, and for the most part hard and full. This stage is sometimes attended with stupor, delirium, convulsions, coma, or apoplexy. 276. After the hot stage has continued its period, a moisture is discoverable upon the forehead, which gradually spreads it- self over the whole surface of the body, and eventually is con- verted into a sweat—when this takes place, there is almost al- ways an abatement of the most distressing symptoms; and after a while, most of the functions are restored to their natural state, and little inconvenience is experienced, except debility. In this stage it is well to remark, the urine deposites a sediment, where- as in the former stage, it is almost always colourless. The en- tire series of symptoms just enumerated, is again and again re- peated; and the interval between each, depends upon the speci- fic type of the intermittent. 12 90 INTERMITTENT FEVER. 277. The chance of recovery is in proportion to the mildness of the symptoms; the shortness of the paroxysms; and the free- dom from complaint in the intervals. Agues rarely destroy by true inflammatory determinations to the head or the chest. When they are fatal, it is for the most part by inducing disease in other parts of the body, as in the liver or spleen; or by a drop- sical affection of the abdomen. They are more fatal in hot, than in cold climates. 278. In the cure of intermittents there are three principal ob- jects to be attempted; 1st, to shorten the fit; 2d, to interrupt the return of it; 3d, to prevent the recurrence of the disease, after it has ceased a certain time. 279. To fulfil the first object, the application of warm things to the whole body; but to the feet, legs, and pit of the stomach, in particular, is of primary consequence—this may be aided by draughts of warm baum tea, lemonade, or common tea. A jug of warm water to the pit of the stomach is not only very grate- ful, but very efficient in shortening the cold fit. Dr. Trotter found thirty drops of laudanum of great use in shortening the cold stage of intermittents—it was given as soon as the patient could discover any sign of its approach, and if in fifteen minutes after its exhibition, a sensation of warmth was not felt, the dose was repeated. This plan was pursued for several periods con- secutively at the time of expected attack; this being regulated by the type of the ague—if a quotidian, every day; if a tertian, every other day, and so on. 280. After the hot stage commences, we should endeavour to abridge its duration as much as possible—for this purpose the warm applications must be removed—the bed-clothing diminish- ed—cool air admitted—cool or cold drinks administered—and should much head-ache be present, the pulse active and firm, much relief is experienced by the loss of a few ounces of blood. In prescribing blood-letting in ague, we do not offer it as a re- medy that will of itself cure the disease; but we can from consider- able experience recommend it as one, that affords very imme- diate relief in most cases; and in all, where its use is justified by the pulse, shortens the hot, and hastens the sweating stao-e; and moreover it prepares in a very certain manner, the system, for the exhibition of tonics. The importance of the last effect is of INTERMITTENT FEVER. 91 much moment, but we fear not sufficiently appreciated—had this remedy been more frequently resorted to, we are of opinion that the duration of agues with their melancholy suite, would have been much more rare. 281. Opium during the hot stage is highly extolled, and boldly recommended by several high authorities; especially Dr. Lind. In this particular district of country we are of opinion, it should be given with caution, where bleeding, purging, and other de- pleting remedies, have not preceded its use. WTe have seen* the most decided good effects of this remedy after a sufficient bleed- ing, and would never hesitate to exhibit it, where this evacua- tion had diminished the force of the pulse; and where there was no marked determination to the head. In the warmer parts of our country, we need not perhaps be so cautious—as there, the disposition to inflammatory diathesis is less; and opium can be given both earlier, and with greater freedom. Besides, they re- semble more the climates in which Dr. Lind found opium so useful. 282. If then the pulse be moderately soft, either from the dis- ease not being much disposed to inflammation ; or from previous depletion, a grain of opium with a quarter of a grain of the tar- trate of antimony, may be given at the commencement of the hot fit; and if it act favourably, it will procure a free perspira- tion over the whole body—but if instead of this, we find the hot stage protracted, or all the symptoms aggravated, it should not be again given, until the activity of the blood-vessels is more effectually subdued. 283. It may not be amiss to say, that the epidemic character of intermittents, should always be consulted when we propose to use opium in any shape, for it is one of those remedies which has a very decided agency upon the nervous system; and when exhibited in any acute disease, without immediate benefit, it rarely fails to do harm—therefore, the influence of the epidemic upon the force, and vigour of the pulse, must always be taken into consideration. And as a general rule we may with safety, declare, that the usefulness of opium in arresting the paroxysms of intermittents, will be almost in proportion to the reduction of the pulse. 284. Should pain in the side, or any other local affection ac- 92 INTERMITTENT FEVER. company this disease, much relief will be found from cupping, or blistering; and should cough attend, fifteen or twenty drops of laudanum at bed-time will be found very useful.* 285. When sweat breaks out, it should be gently encouraged by mild warm drinks; but it is never necessary to force a profuse sweat. 286. Secondly, to prevent the return of the fit. This is a most important object; and is attempted in two ways; first by the exhibition of some remedy, which shall by its immediate action, prevent the febrile one taking place. Very many ar- ticles have been proposed to fulfil this intention| but it would be useless to repeat them. They may now be considered as con- fined to emetics, and opium. 1st, if an emetic be exhibited about an hour before the expected chill, it will sometimes prevent its occurrence—when then, there is no peculiarity in the constitu- tion of the patient, that would prevent the employment of the emetic; as when there is no great determination to the head, aa is evidenced by considerable head-ache, and red eyes,this remedy may be used with a prospect of success, especially if much nausea, and bilious throwing up, attend the disease, t And should it fail * Intermittents, within the last few years, have been more extensively epi- demic than formerly; and each, seems to be marked by its own peculiarities. Sometimes it is accompanied by pleuretic, and others with pneumonic symp- toms; and these almost constantly oblige us to vary the treatment; for the local affections, are pretty sure to interrupt the regular, and common routine pf treatment of the fever. Thus, if pleuretic symptoms show themselves, we are necessitated to bleed from the arm, or to cup, leech, or blister the affected side, before bark, or other tonics can be given. If cough accompany, it also interferes with the use of tonics, especially bark; unless the cough should be purely paroxysmal, like the chill itself; as happened in very many of our in- termittents this fall, (1828.) In these cases the quinine, or Wetherill's ex- tract of bark, was as certain to stop the cough, as it was the febrile paroxysm itself. f It is commonly supposed, if sickness or a disposition to vomit attend the course of the paroxysm, that it is caused by bile, or some other crude sub- stance in the stomach; and that this, clearly indicates the necessity of an emetic; but as this may lead to great error in practice, it is well to observe, that mere nausea, even with a discharge of some fluid from the stomach, does not prove the propriety of an emetic; but on the contrary, it may be, and is very often injurious. If what is discharged from the stomach be really bile; that is, a pure bitter, yellow substance, afew grains of ipecacuhana may be useful. But if the substance be thin, watery, and nearly tasteless, it will be injurious. We INTERMITTENT FEVER. 93 in this intention, it will be at least useful as an evacuant We could therefore recommend its employment in the commence- ment of the disease, if its form be a very mild one, but not otherwise; for if the chill be of long duration, and the reaction or the hot stage violent, an emetic should not be used; particu- larly if head-ache, or delirium attend ; or if a complete solution of the fever does not take place, by the hot stage terminating in a general, and sufficiently copious perspiration. 2d, opium, when given in a proper quantity, and under proper circum- stances, is likewise very powerful in preventing the accession of an intermittent; but of this we have already spoken. 287. The second mode, is by the use of such remedies as make an impression, during the interval. These are classed under the general head of tonics. The most noted of these, is the Peruvian bark. This medicine is given in a great variety of forms, and in very different doses, but it is now very well ascertained, that there is too much fancy in the varied form; and very little ad- vantage in the excessive dose. When given in drachm doses, it has been more successful, than when extended to two, three, or four. 288. We mention the bark, and its dose, because some prefer it in substance, to the sulphate of quinine, which has almost al- together superceded it. We do not, however, cherish this pre- dilection for the bark in substance—on the contrary, we could wish it were entirely abandoned, as the quinine, (caeteris pari- bus,) is equally certain, to say the least; and is, unquestionably, much more acceptable to the palate, and to the stomach. One grain of the quinine is equal to one drachm of the bark in sub- stance. It is best administered in solution; and may be prepared as follows:—Sixteen grains of the quinine; four drops of sul- phuric acid ; two drachms of powdered gum Arabic; and three drachms of sugar, are to be dissolved in two ounces of water— of this, a tea-spoonful is to be given every hour, while free from would therefore lay it down as a general rule, that the antimonial emetic is rarely so safe, even where there is strong evidences of bile, as the ipecacuhana in fevers of high action, or of strong' paroxysms. The reason of this is at once obvious, (if the most modern, and approved pathology of fevers be admitted, or if any reliance can be placed upon experience,) namely, that they are caused by an irritation or inflammation of the mucous membrane of the stomach, 94, INTERMITTENT FEVER- fever. * We have been much in the habit of late of employing Wetherill's extract of bark. This preparation contains the qui- nine in the state of a super-sulphate, combined with the whole of the extractive matter of the cinchona. It is more certain in arresting the paroxysms than the sulphate of quinine, if our ob- servations have not grossly deceived us; and the disposition to the recurrence of them, seems to be much lessened. 289. It is usually prescribed in doses of one grain in the form of a pill; one is given every hour, while free from fever; for, like the quinine, this is the time for its exhibition. 290. After suitable evacuations, by purgatives, and bleeding, (or an emetic if it has been thought advisable,) and where there is distinct, and decided intermissions, we should commence with the bark or quinine, as soon as the paroxysm has completely subsided; or in other words, when there is no longer any fever remaining. It is too common to order the bark, as soon as the sweating declines; and mischief many times has resulted from obeying it; for very often "there is still remaining a vestige of fever, even after the perspiration has gone off. The pulse should therefore be examined; and if it be found still active, the use of * It will be perceived that, a drachm of the solution, or one grain of the qui- nine itself is intended to be given at a dose by this formula, as a tea-spoon is supposed to hold one drachm. In the Annali Universali di Medicina, for Novem- ber and December, 1828, Dr. Speranza gives an account of a successful mode of treating tertian fever, by the endermic method of applying the sulphate of quinine. In fifteen cases, the fever had appeared some days before he pre- scribed for them. With the exception of two there was no very manifest local irritation; and in these the symptoms were gastric. Without giving purgative medicines to any of them, he had a blister applied immediately, and in most instance on the day of the febrile paroxysm; the sulphate of quinia was put on at the end of the fit, or the beginning of the apyrexia. The arm was selected for the application of the blister, as the most convenient for dressing. Con- centrated vinegar was first rubbed strongly on the part to hasten the produc- tion of a vesicle by the blister. After removing the epidermis, eight or ten grains of the sulphate mixed with a small portion of ointment, was placed upon it. The wound was dressed on the second day, and every thing that remained upon its surface was removed. From appearances one-half of the sulphate was absorbed. In most cases the fever did not return even after the first applica- tion; nor was it necessary to repeat it. Not only primative tertians were treated in this manner, but also those that were at first continued. No case of relapse was known. But in some cases, the inflammation of the arm required topical remedies. INTERMITTENT FEVER. 95 the bark should be suspended until this subside. A want of at- tention to this circumstance, has frequently defeated the best powers of this medicine. But when the system is in a proper condition to profit by its exhibition, we should give a drachm, every hour in milk, or thin molasses; or a grain of quinine, un- til within an hour of the time of the expected return of the fit, if*it be a quotidian; but if a tertian, or quartan, it may be given every two hours—but this must be done with persevering fide- lity during the day and night We object to excessive doses being taken immediately before the returning fit; we have never seen it decidedly useful in any one instance; and we believe we have seen it unequivocally mischievous, many times. 291. There is a great variety of substances purporting to be substitutes for the bark; but as far as our experience, or informa- tion goes, there are none of equal value. The one of the vege- table class that approaches nearest to it, in our estimation, is the cascarilla bark, (cortex eleutheria,) treated pretty much after the same manner as the bark itself; or what perhaps is a more eligi-' ble form for this drug, is that of a decoction. In some cases, as in those which may be accompanied by cough, or purulent ex- pectoration from the lungs, it has a decided advantage over bark in any form. 292. Neither the bark nor quinine can be used without in- jury in intermittents, that are accompanied by cough; (see note to par. 284) or any congestion of the lungs; nor has it ever been useful, when this disease has been complicated with extensive visceral obstructions. 293. Both the bark, and the quinine, run off by stool some- times, where its exhibition would otherwise be most proper; to prevent this, eight or ten drops of laudanum should be occasion- ally added to the dose—or the patient may drink now and then a wine-glassful of tea made from the ground allspice—this to be useful must be strong—at other times the bark produces obsti- nate costiveness—to obviate this, the patient should take a few pills made of rhubarb and soap, or aloes and soap, at bed time.* 294. There is another remedy which is much, and justly ex- • The following pills answer this purpose admirably well; and when it be- comes necessary to persevere in any laxative, to overcome costiveness, for a 96 INTERMITTENT FEVEK. tolled, for the cure of intermittents; namely, arsenic—as far as our experience enables us to institute a comparison between it and the bark, we should say, it is fully as certain, and without some of its inconveniences. The only objection that we believe can be urged against it, is, that it is a medicine of most deadly power when improperly used. But when properly exhibited, it is as safe as opium, or any other medicine in daily use. We have never seen the least injury result from it—itj sometimes sickens the stomach, and occasionally, even to vomiting—but of what medicine of any power may not the same be said.* 295. The arsenical solution has a decided advantage over any preparation of bark, when children are the subjects for its exhi- bition—to them it can be administered with the fullest effect, without their being aware they have taken anything. It maybe given when the system cannot receive the bark, or even when the pulse is too full to bear its use.t It must be given in doses of six or eight drops every three, four, or six hours, to adults. Should this quantity sicken too much, or be rejected, smaller doses must be tried; and this will very rarely fail to sit well. To children from one to two years old, one drop or a drop and a half may be given every four or six hours—to those of two or six, two drops; from six to twelve, three drops; and from twelve long time they have the advantage over every other that we are acquainted with:— R. Gum. aloes sue. 3J- Take of Socotorine aloes 1 drachm. Pulv. rh?ei • 5'j- Powdered rhubarb 2 drachms 01. caryoph. gUt. Yj. Oil of cloves - 6 drops. Sapo venet. gr. viij. Castile soap - 8 grains. Syr. rhsei q. s. Syrup of rhubarb sufficient. M. f. pil. Ix. Make 60 pills. One, two, or three, of these may be taken at bed time when necessary, as the constitutional condition of the bowels may require, a small or large dose. • When we have witnessed the most decided good effects from this medi- cine, it has always been in recent, or at least, not in very long-standing cases -and we think it more successful in young, than in old subjects. f The arsenic, like every other .tonic or stimulant, employed for the cure of fever, must have the system prepared for its reception; but we think it can be given earlier, and with less depletion, than the bark. Nor is it a matter of any consequence, so far as we have observed, if the fever be not absolutely sub- dued at the time of its commencement. Indeed, some are of opinion, that this medicine can be given during the whole march of the disease. As regards our own experience, we confess it to be at variance with this declaration. INTERMITTENT FEVER. 97 to adult age, four drops may be used. Should it prove unplea- sant to the stomach, let it be given with a drop or two of the essence of peppermint and water, which will almost always cor- rect this tendency to sickness. The only obvious effect we have witnessed from this drug beside sickness, is a swelling of the eye- lids; especially in the morning; but this soon goes off, if the medi- cine be intermitted for two or three days; nor is it of any con- sequence if it continue a short time; for it appears only as an evidence that, the medicine has had a constitutional effect We have never known it but once to affect the bowels; and then, only very temporarily. After it has been used for a few days, and has not affected the stomach, the dose if necessary, can be increased very safely two or three drops for a grown person, and proportionably for children. 296. The third great object in the treatment of intermittents, is to prevent a relapse after the fits have ceased a certain time. There is no disease to which the human body is obnoxious, that is so easily provoked to return, or so difficult to prevent from reappearing, as agues. It therefore becomes a matter of great consideration with the patient to know how he shall be protect- ed against its renewal. The seventh, ninth, and thirteenth days, appear to be the most frequent periods of return; but agreeable to our own observation, the thirteenth is the most common. Therefore, to prevent this, the patient should be particularly guard- ed against exposure,on the days designated above—he should two days before each of these periods take a few doses of his medicine; either the bark, quinine, or arsenic, whichever he may have em- ployed—he should avoid all exposure to damp, cold, or heated air—he should preserve his bowels in a soluble state; but they must not be purged; and most carefully avoid fatigue of body, or emotions of mind. But above all, when practicable, he should remove from the place where it originated, and remain from it, until his health be firmly established. 297. As this disease is generally supposed to arise from an excess of bile, purgatives are too often employed during conva- lescence, with a view to its removal; than which a greater error can hardly be committed. We are certain that we have seen re- lapses produced by the administration of a brisk cathartic, though given with a prophylactic view. We would therefore earnestly caution against this plan of treatment. 13 98 INTERMITTENT FEVER. 298. We have admitted it to be every way proper, to keep the bowels soluble; but they must be purged with great caution, during convalescence. And it may be useful farther to suggest, that much care is required, that purging shall not be carried too far, even when there may be a renewal of the paroxysms, espe- cially, if the interval has not been very long; or if the returns have been previously pretty frequent Nor, is it a matter of in- difference which of the cathartics we employ. Calomel in divi- ded doses, say a grain every hour, until five or six grains are taken, is the best; and should not this operate in two hours after the last portion has been taken, it should be carried through the bowels by a dose of castor oil, or magnesia. But even this cau- tious use of purgative medicines, has its rules; and against which it would not be safe to sin. Calomel, as above directed, should be given only during the appearance of unhealthy, bilious dis- charges; for as soon as the feces assume their natural looks, it should be desisted from. The neutral salts are always improper, under the circumstances just stated. 299. Should the ague be of long standing, and the stomach much affected; and especially with people advanced in life, it becomes very important, that some aromatic should be joined with the remedies just recommended. The Virginia snake-root in form of a strong tea, where sickness attends, is of great value —but where the stomach is merely feeble, and flatulent, cloves becomes an important addition to the bark. Indeed, in many ob- stinate cases which we have witnessed, the addition of cloves, was found to be essential to the cure. We have oftentimes suc- ceeded with this remedy joined to the bark, in form of an elec- tuary, when every other we had employed; even the quinine, had proved unavailing. We can therefore recommend this mode of exhibiting the bark, with great confidence.* 300. Blisters are very often powerful auxiliaries in the cure * The following formula is the one we are in the habit of using:— R. Pulv. C. Peruv. opt. - §ij. Take Best powdered bark 2 ounces. Pulv. caryoph. - - 3J. • Powdered cloves 1 drachm. Syr. commun. - - q.s. And as much molasses or any M. f. elect. other syrup as will make it into a pretty stiff paste. Of this the size of a nutmeg must be taken every two hours, when free from fever. INTERMITTENT FEVER. 99 of intermittents—but they should not be employed too early— the pulse should have lost considerably of its vigour, before they be had recourse to. In protracted cases, and especially in aged people, they may be used with great advantage, applied to the inner side of the calves of the legs, or above the wrists, on the arms. They should be of as large a size as the place on which they are to be applied will admit of; for it must be recollected, that a large blister gives no more pain while drawing than a small one. (See par. 114.) They should be applied at such a period as to secure their drawing at about the time the fit is expected. 301. Should the stomach be much affected, a blister can be applied over its region with much advantage—this should be in size at least eight inches by -nine. Should the head particularly suffer, the blister should be applied between the shoulders, and of such dimensions as will pretty nearly occupy the space of half each shoulder blade, both in depth and breadth, up to the nape of the neck. 302. In our account of fevers in general, we have said enough to direct the diet and drinks in these particular fevers. Should our rules on this subject be adhered to, we believe it will be of advantage to the patient, although we differ in some respects on this subject, from authors of great experience and celebrity; and especially the European writers. We find in most of them a disposition to alter the diet on the days of interval, by permitting an indulgence in more generous food, than we have directed. This may be right in their climate, and in the diseases of them; but in this country, and especially in the middle and north- eastern states, the plan we have laid down we are persuaded is right; and we must insist, it should be persevered in, until the ' paroxysms cease to return, or until such a state of debility super- venes as will call for this charge. 303. After the fits have been interrupted for several days, the patient may be permitted to eat of light but nourishing food; and in indulging in this, he should be cautious not to go too far at once. He may now be permitted to eat moderately of oysters, soft boiled eggs, chicken broth, beef tea, or thin chocolate. In a few days more, he may indulge in beef-steak or mutton chop; and these may be accompanied by a tumbler of good ale and wa- ter, or porter and water—and after a few days more of exemp- 100 INTERMITTENT FEVER. tion, he may return to his usual habits of eating, except upon the days pointed out for his guarding against a relapse. 304. The anxiety to arrest the returns of ague is sometimes so strong, as to lead to the most disastrous means of effecting it. Thus, we have frequently known people in common life, (and occasionally, indeed, people who should have known better,) take large quantities of ardent spirits; and this sometimes ren- dered more stimulating by the addition of pepper, just before the expected period of a fit, or at its commencement, with the most baneful result. We once knew death to ensue very shortly after this vile potation had been swallowed; and we have wit- nessed a number of instances of intermittents being converted into continued fevers by the same means. But candour obliges us to confess, w» have also known it to succeed sometimes; but not oftener, nor perhaps so often, as by the use of the remedies we have proposed for this end, and from which no mischief can result. We should be glad, could we but induce those who may be affected with this, but too often tedious and obstinate disease, to give to milder, and more rational means, a fair trial, before they proceed^o use remedies rarely successful, very often de- cidedly injurious, and sometimes dangerous. 305. As intermittents for the most part have marsh miasma, for their remote cause, we cannot be surprised that they should be protracted to almost an indefinite period, so long as the pa- tient continues to have these causes operating in him. Accord- ingly, many are doomed to be victims to these distressing com- plaints for many consecutive months, notwithstanding all the ''appliances and means, to boot," have been industriously employ- ed. It is therefore in many instances a chronic affection, and is perpetuated to "immeasurable length," by the force of habit. • Patients so situated, drag on a miserable existence, until some fortunate application may break the spell, and restore them to tolerable health. 306. It is a desideratum of great magnitude, to find a remedy which shall destroy the morbid associations which give rise to these repeated and long-protracted paroxysms. So far we are not in possession of such a remedy, although we have several which scarcely fail. The treatment of agues in the southern states, is different from that of the middle and eastern states; this arises INTERMITTENT FEVER. 101 almost exclusively from certain localities, and the influence of climate. In the southern portions of our union, there is much more extensive, as well as much longer application of the causes which produce them; this gives to the disease a force and a fixedness, that is rarely known, in other parts of the United States. 307. From constant exposure to the remote causes, the pa- tient has but small chance of a speedy cure; accordingly, he is rarely benefited until frost has destroyed the effluvia that gave rise to the complaint By the time spring returns, he is but barely relieved from the effects of his summer disease; and be- fore his constitution has recovered from the previous shock, he is again visited by his ague. Weakened by former indispositions, the noxious causes continue to operate on him with as much cer- tainty, if not with equal force as before; while the remedies, which had formerly been employed with success, ^iave now lost in great measure their power, and the disease can no longer be held in check; consequently he is subject to it, the greater part of the year—visceral obstructions form; and these are succeeded by dropsy—he crawls a living spectre, until he is relieved by the kind stroke of death. 308. This is but too frequently the melancholy progress and termination of intermittents in certain districts of our country; to arrest them early, and permanently keep them at bay, is more to be coveted than expected; at least so long as the patient remain on the spot from whence the cause proceeds. To remove him then is a matter of primary importance when practicable; and where not, we are of opinion that much of the obstinacy of the disease might be subdued, if proper and efficient means were em- ployed in the commencement of the attack. By efficient means we wish to be understood, the proper exhibition of cathartics; blood-letting; and occasionally emetics when the liver is goaded to excessive action. 309. By the constant operation of the remote causes in such locations, there will be frequently, an unusual secretion of bile; and although we are by no means of the opinion, that bile is the cause of intermittents, yet we are fully persuaded, nay certain, that it may aggravate the disease when existing in excess, in the stomach and duodenum. It is therefore far from unusual 102 INTERMITTENT FEVER. that the patient discharges large quantities of this fluid during the whole continuance of the disease; which, if it do no other injury, will very frequently prevent the employment of the bark, and other medicine given with the view to interrupt the paroxysms. 310. It has therefore been found an excellent practice in such cases, to repeat the exhibition of emetics; and occasionally dur- ing the paroxysm, to have the bowels unloaded by mercurial cathartics. In the southern states, where they are much expe- rienced in this disease, the use of emetics is had much recourse to, and it is said with decided advantage; but we fear they err in not using laxatives as freely as they should; and almost entirely withholding the lancet, even where there is unequivocal evi- dence of a phlogistic diathesis present. The fear of inducing weakness, has led to this reserved use of the lancet; and thus a contingent debility, is compounded for, by the certain induction, of obstructed abdominal viscera. 311. The bark in almost all its forms as a remedy in inter- mittents, is admitted by every body to be of extraordinary effi- cacy; but it is equally true, that it requires a certain condition of the system to ensure its success; and that condition, is, an en- tire freedom from inflammatory action. Therefore, when this state of the system has been overlooked, or not sufficiently at- tended to, we find intermittents very often converted into re- mittents; or the force of the disease falls upon the abdominal viscera, to the ultimate destruction of the patient—hencej as we have already observed, it is one of the most common causes of obstructed liver, or spleen, or both. 312. So soon then as there is a determination to these parts, we cease to find much good from the bark—the practitioner is surprised at his want of success; and attributes his failures to the niggardly doses in which he has given the medicines; to remedy which, he doubles, nay, sometimes trebles the quantity, with no better, or perhaps, with even worse effects. The disease now becomes habitual; and will no longer yield to common remedies —an empirical practice is now adopted; which may either suc- ceed, or destroy, as chance may have it. 313. One of the most deplorable circumstances, connected with the history of intermittents, as we have already observed, INTERMITTENT FEVER. 103 is, their liability to return, after the paroxysms have been sus- pended for days, weeks, nay, months; even when the patient has been removed from the place, and where the remote causes have ceased to act There is something peculiar in the nature of this form of fever; since it creates a liability to return, which no other form of fever does. A remittent passes off without leaving this disposition behind it; provided it has not terminated in the intermittent form: when this happens, there is certainly a risk, that the paroxysms of the intermittent may be repeated; but the danger is less than when the fever presented itself ori- ginally as an intermittent 314. To protect the system against this liability, or to destroy the disposition to it, has long been a desideratum, as we ob- served above; and many substances have been recommended, and various plans proposed for this purpose; but on none of them, so far as we know, can implicit reliance be placed. The plan which often succeeded with us, within the last few years, is, the persevering use of the black pepper corns. Six or eight are to be swallowed, three times a day, about fifteen minutes be- fore each meal, and continued for twenty days; the taking of them should be commenced as soon as the febrile paroxysms have been suspended. 315. We have lately adopted an easier method of exhibiting this substance, and with equal success; which is in pills made of the piperine. * A grain of this substance, in a pill, is to be taken as directed for the pepper corns. It can now be procured in this city without difficulty. The dose of the pepper corns, or of the piperine, is for an adult—so far we have only witnessed the efficacy of this remedy, with them; we are yet to learn its powers with children. 316. If the patient, who may be labouring under the pro- tracted form of ague, can be removed from the spot on which the disease originated, he may speedily recover, by the use of the very remedies, which before his removal had altogether failed. But if a change of place be impracticable, we are obliged to combat the complaint in the best manner we can, though this be at fearful odds. * The piperine is the proximate principle of the black pepper; and bears the same relation to it, as the quinine does to the bark. 104 INTERMITTENT FEVER. 317. Sometimes by new combinations the same remedies will prove successful, that had before failed even in large doses; thus bark in combination with certain aromatics will stop an ague, (as we have noticed above,) that would not yield to any quan- tity administered alone. The prescriptions in the margin, be- side the one just mentioned, are of this kind;* and from repeat- ed experience of their efficacy, we can safely, and confidently recommend them. My friend, Dr. Chapman, speaks highly of the blue vitriol, (sulphate of copper,) and opium, in the pro- tracted form of this complaint; and his authority for its useful- ness is sufficient to inspire confidence. His formula is noticed below. It is also extolled by several European writers.! 318. When visceral obstructions exist, mercury must be had recourse to. In advising this, we are not to be understood, that it should be exclusively employed; we mean it as a powerful auxiliary to the tonics which must now be substituted for the bark—such as Fowler's solution; sulphate of zinc; sulphate of copper; the decoction of cascarilla, (cortex eleutheria,) &c. for we must suspend the bark, as we are persuaded it is an improper • R. Pulv. cort. Peruv. opt. Jvj. Theriaca androm. - sjiij. Pulv. crem. tart. , - gij. Aq. font. - - - gvj. M. Take Best powdered bark 6 drachms. Venice treacle - 3 drachms. Cremor tartar - 2 drachms. Water - - 6 ounces. Mix. Of this, when practicable, a table-spoonful is to be taken for twelve consecu- tive hours before the chill is expected. Or, R. Pulv. cort. Peruv. opt. Rad. serp. virg. Cort. aurant. Pulv. caryoph. - Carbon, sods - M. gss. S3- 3J- Take Best powdered bark 1 ounce. Virginia snake-root $ ounce. Orange peel - 2 drachms. Powdered cloves 1 drachm. Potash or soda - 1 drachm. Mix. This powder is to be put in a clean earthen vessel, with three half pints of boiling water—and simmered gently until it is reduced to a pint—allow it to settle; pour off from the sediment, a wine-glassful every hour, for eight hours, before the chill is expected. f R. Sulph. cupri. - gr. ij. Take Gum. opii - Conserv. rosar. M. f. pil. xvj. One every morning, noon, and evening.' gr. ij. gr. iv. q. s. Sulphate of copper 2 grains. Opium - . 4 grains. Conserve of roses, enough to make in sixteen pills. INTERMITTENT FEVER. 105 remedy under such circumstances. The best modes of introduc- ing mercury, is either by friction, or by the blue pill—two drachms of the former may be rubbed in, morning and evening, over the region of the liver, spleen, or the inside of the thighs, until two ounces are expended; unless a lesser quantity has given evidence of its constitutional action. Should the mouth not be- come affected after a lapse of four or five days, another ounce, in drachm quantities, may be rubbed, as before. We believe these quantities will be every way sufficient for the object, for which they are prescribed; that is, rather as an alterative, than as a syllagogue. When this plan is inconvenient, or is objected to, the blue pill, (pil. hydragr.) may be given, in three or four grain doses, morning and evening, until the mouth becomes slightly affected. Should they run off by stool, each dose must be guarded by a quarter or half a grain of opium. 319. A patient subject to frequent returns of this fitful dis- ease, should be careful about his clothing, especially on sudden changes of the weather from hot to cold, and from dry to wet. To ward off the ill effects of these transitions, he should never be without flannel next his skin; and this should frequently be changed; much depends upon an attention to this point; and no one perhaps is more neglected. It is too commonly believed, that there is very little if any necessity, for changing of the flan- nel ; and it is worn by some, for months together, without this being done; whereas, it should be renewed, when practicable, fre- quently, (that is, at least twice a week,) especially by those who perspire much. 320. Another precaution should be taken by invalids of this description, (as well as of every other indeed,) which is, never to go out in the morning without having taken food previously. We may with propriety in this place suggest another caution; never to take any liquor with a view of "fortifying the stomach." If such a habit has been indulged in, the sooner it is broken the better; and this may be done both successfully, and advantage- ously, by substituting a gill of strong ginger, or calamus tea, for the usual spirituous potation. 321. The system is very liable to lose its susceptibility to me- dicine, and stimuli of every kind when long continued; it is therefore of consequence not to persevere too long with any one 14 106 INTERMITTENT FEVER. remedy; and this is especially the case with bark;* therefore when it is not successful in arresting the paroxysms by a fort- night's perseverance, it should be discontinued, and some other remedy tried; or else alter its form, which sometimes proves highly efficacious. 322. But we should, in making our estimate of the power of the bark, be certain that its failure is owing to the system losing its susceptibility to its action; or we may confound it with the .phlogistic condition of the body—this is particularly to be at- tended to in the earlier stages of the disease; and especially with such patients as have it for the first time. It is sometimes surpris- ing to see how much the powers of the bark are augmented by certain combinations; and at times truly astonishing how speedily an inveterate ague will yield to them; thus we have seen the forms mentioned above relieve like magic, after the patient had for weeks, most industriously swallowed large doses of this me- dicine, in its simple form. 323. In dismissing this subject we cannot refrain from re- peating, how truly essential a proper and effectual prepa- ration of the system, is, for the best effects of the bark. We are persuaded this has not been attended to with the care its usefulness demands. We again declare, that in our opinion, that most of the failures with the bark, have arisen from this cause. It may not however, be amiss to remark that, much also will de- pend upon the quality of this drug. For in no one article per- haps of the materia medica, are we so likely to be imposed upon, as with this—it is either weakened by improper mixture, or a kind is substituted, that is entirely inert The same almost, may now be said of the quinine. 324. Within the last few years, the bark in substance, has been almost altogether superceded by the quinine, and Wethe- rill's extract; which when pure, are the most valuable acquisitions, presented to us by modern chemistry; and are truly, two of the most certain of the preparations, of this extraordinary medicine. We have already glanced at some of their advantages over the • With the bark, we mean to include the quinine and Wetherill's extract, of course; as all have been found to lose their powers in about the same period. And whenever we name bark, its preparations are also to be supposed in- cluded, unless otherways expressed. INTERMITTENT FEVER. 107 bark in substance, and we shall now add, that their exhibition is more generally certain, than the substance from which they are derived. They are much less offensive to the taste, though in- tensely bitter; they sit better upon the stomach; and they are not so much disposed to run off by the bowels. Besides, their bulk may be reduced to almost nothing; the grain pills, make very little bulk; and the quinine in solution need not exceed a tea-spoonful at a dose. 325. Many are in the habit of exhibiting the quinine in pills; but we are persuaded from repeated experience, that it often fails when given in this form; this arises perhaps from its great in- solubility; indeed on this account much care is required to pre- pare it in a liquid form. The best formula is recorded at par. 288. 326. The quinine is a costly medicine at first sight; but from all the estimates we can make, we are persuaded, that in the main, it is cheaper than the bark itself. Its high price, and the great demand for it, has unfortunately led to its adulteration. The genuine quinine is a little yellowish. 327. A medicine of great efficacy, if we believe Dr. Jackson, (and perhaps no one is better entitled to credence,) is found in the cob-web; which he assures us " is more effectual in prevent- ing the return of febrile paroxysms, than any other remedy, of which he had knowledge," he farther adds, "I think I may ven- ture to say that it prevents the recurrence of febrile paroxysms more abruptly, and more effectually than the bark or arsenic, or any other remedy employed for that purpose with which I am acquainted; that, like all other remedies of the kind, it is only effectual as applied under a certain .condition of habit; but that the condition of susceptibility for cob-web is, at the same time of more latitude than for any other of the known remedies. The cob-web was rarely given until the subject was prepared by bleeding, emetic, or purgative, and, given to a subject so pre- pared, has seldom failed to effect a cure comparatively permanent; relapse or conversion into another form of disease, being upon the whole a rare occurrence, where the disease had been sus- pended by this remedy. If the cob-web was given in the time of perfect intermission, the return of the paroxysm was pre- vented; if given under the first symptoms of a commencing pa- roxysm, the symptoms were suppressed, and the course of pa- 108 INTERMITTENT FEVER. roxysm was so much interrupted, that the disease for the most part lost its characteristic symptoms. If it was not given until the paroxysm was advanced in progress, the symptoms of irri- tation, viz, tremors, startings, spasms, and delirium—if such ex- isted in forms of febrile action, were usually reduced in vio- lence, sometimes entirely removed. In this case sleep—calm and refreshing, usually followed the sudden and perfect removal of pain and irritation. Vomiting, spasms, and twisting in the bowels, appearing as modes of febrile irritation, were also usually allayed by it; there was no effect from it where the vomiting or pain were connected with real inflammation, or progress to dis- organization." 328. The Dr. farther adds, "the cob-web may perhaps be thought to belong to the class of poisons; but it is somewhat sin- gular that I have never been able to discover much difference of effect from a dose of ten grains and from a dose of twenty. The changes induced on the existing state of the system, as the effects of its operation, characterize a powerful stimulant 1. Where the pulses of the arteries are quick, frequent, irregular and irri- tated; they become calm, regular and slow. Almost instanta- neously after the cob-web has passed into the stomach, the effect is moreover accompanied, for the most part, with perspiration, and a perfect relaxation of the surface. 2. Where the pulses are slow, regular, and nearly natural, they usually become frequent, small, irregular—sometimes intermitting. 3. Where languor and depression characterize the disease, sensations of warmth and comfort are diffused about the stomach, and increased ani- mation is conspicuous in the appearance of the eye and counte- nance." Dr. Jackson then specifies the particular spider from which the web should be procured, by saying, "the cob-web here recommended is a product of the black spider, which inha- bits cellars, barns, and stables; that which is found upon the hedges in autumn, does not possess the same power, if it be ac- tually of the same nature." 329. The high encomiums thus bestowed upon this curious substance, should tempt us to fair and unprejudiced trials of it__ and as far as our own experience goes, it is much in favour of this medicine, and is very analogous to that of Dr. Jackson's— we however confess, that our experience is limited. REMITTENT FEVER. 109 CHAPTER III. REMITTENT FEVER. 330. When a fever consists of repeated paroxysms, (that is, regular exacerbations and declines,) but without a distinct inter- mission between the paroxysms, it is called a remittent fever. In these cases, it is observed that, though the hot and sweating stages* do not entirely cease before the twenty-four hours have expired from the beginning of the paroxysm, the fever is found to have suffered considerable abatement, or a remission of their violence; but at the return of the quotidian period, the paroxysm is again renewed, and runs the same course as before. This form has therefore no absolute apyrexia, nor is it necessarily preceded in its onset, by chill, nor the succeeding exacerbations anticipated by a sense of cold. 331. This fever commences very much like an intermittent; it is preceded by languor and anxiety, listlessness, yawning, and sometimes by alternate fits of heat and cold; pain in the head or back, of greater or less intensity; the heat over the whole body is much augmented;t thirst; more or less difficulty of breathing; * A sweating stage does not always belong to this form of fever—we have seen many instances to the contrary of this; and never more frequently, per- haps, than in the fevers of this fall, (1828,) when they assumed the remittent form. In almost all these cases, there were two exacerbations in twenty-four hours, at about twelve hours interval. The first, at seven or eight o'clock in the morning, and the other about the same hour in the evening. These con- ditions would continue for three or four days, before any marked solution of the fever would take place by sweating. A partial moisture was sometimes, however, observed, upon the decline of the heat of the body. f This is not universally the case; this form of fever has its characters to vary like all others, and by causes altogether inscrutable; and especially when it becomes epidemic. In many instances of this fever this fall, (1828,) the ex- tremities would remain cold, and especially the lower, for many hours toge- ther; while the other parts of the body, and the head particularly, would be excessively hot. Indeed, the feet and legs were difficult to warm, even by the repeated application of hot things; as heated bricks, or bottles of hot water. When this disposition to become cold prevails, we should never fail to attempt its removal, by the means just named. In some cases we were obliged to have recourse to hot brandy and Cayenne pepper for this purpose. 110 REMITTENT FEVER. tongue for the most part white; spirits dejected; and frequently, the skin and eyes have a tinge of yellow; sometimes nausea, and vomiting of bilious matter; pulse frequent, full or small, tense or soft, as the constitution may be affected by the remote causes. After these symptoms have continued for some time, the fever is found to abate considerably; or there is an attempt at perfect solution by partial sweats breaking out, but it is rarely completed; for after a lapse of a few hours, the same routine of symptoms are again observed. After a continuance for some time of alter- nate remissions and exacerbations, a crisis takes place; or if the disease has been neglected, or improperly treated, it may be converted into a fever of the continued type. 332. There is no inconsiderable difference in the grades of this fever, as constitution, seasons of the year, and climate, may modify the force of the remote causes, &c. In the milder forms of this disease, delirium for the most part is absent; but in the more exalted, it comes on with the first symptoms, and per- tinaciously continues through the whole course of the complaint When this obtains, we may remark an aggravation of all the other symptoms; but these, like the former, suffer a small abate- ment at the period of remission; but for the most part, the pa- tient profits very little by this partial truce, as the succeeding exacerbations are attended by aggravated symptoms, and some- times even death ensues. When about to terminate favourably, the contrary, to what has just been mentioned takes place; the remission is of longer continuance, and the state of the disease during this reduction is milder; the exacerbation which follows is of less intensity than the former; the sweat, before partial, now becomes general; the delirium less ferocious; the pulse softer and more tranquil; the breathing less oppressive; and even- tually a crisis take place on the tenth or twelfth day, or in hot climates, on the fifth, perhaps. 333. We should not ever persuade ourselves, that this disease is not, or may not be dangerous; for it sometimes has a fatal ter- mination,- even under the best treatment. This, however, more certainly happens, when the remedies have been either injudi- ciously, or feebly administered; or where they have not been applied, until the patient was already in jeopardy. As a gene- ral rule, we may say of it, that, in proportion to the distinctness REMITTENT FEVER. Ill of the remission; or, in other words, the nearer it approaches to the intermittent form, will be the exemption from danger; while on the other hand, the shorter and more obscure the remission, the greater will be the danger. 334. Dissections prove that, (at least in almost all the fatal cases which have been noticed,) there are strong local determinations of blood especially to the stomach, head, and liver; and that very often there is an inflammation of these parts. In this country this obtains with almost as much certainty, as within the tro- pics;* and the disease very frequently runs its course with the same appalling rapidity. We should therefore attend to this dis- ease with a watchful eye, and rejoice, when it does not elude our vigilance. The treatment of it must be both prompt, and de- cisive; half-way measures will rarely succeed, unless it be in its very mildest form. 335. The treatment of this disease differs very much from that of an intermittent We rarely dare commence with an eme- tic; indeed only, when this complaint assumes its very mildest appearance; and when the stomach is evidently irritated by bile.t We mention this, and we wish to be understood as lay- ing some stress upon it, because it is a prevailing error, that " all fevers are accompanied by a copious secretion of bile; there- * We have already acknowledged our obligations to the French patholo- gists, for the extent, and precision of their remarks upon the dead, fever sub- jects—indeed, they seem to have done almost every thing which is required upon this point; and the truth of their observations, as regard the condition of the stomach; as well as the practical conclusions deduced from them, are now almost as universally as well as profitably admitted. Yet it is due to Dr. Phy- sick to say, that he made like discoveries as early as 1793, when the yellow fever, was epidemic in this city. And we may add, with a view to show how slowly new truths are received, when such truths are calculated to destroy old prejudices, that his skill as a physician, as well as that of an anatomist, were called in question, the instant he published his discoveries to the world. f It now and then happens, that a fever of a remittent form, is, in its onset, accompanied by a vomiting of a bilious matter. The stomach in this case is extremely irritable, and refuses to retain any thing offered it—neither food nor medicine, will lie upon it an instant when this happens; occasionally, ad* vantage is found from emptying this viscus, by the exhibition of ipecacuanha. We rarely venture upon the antimonial preparations; as we are of opinion, that much mischief has followed their operation. This is, perhaps, not of diffi- cult explanation, if the pathology we have adopted of this disease, be correct. 112 REMITTENT FEVER. fore, the attempts at cure should be premised by an emetic." We are persuaded that in several instances within our own ob- servation, an emetic had a decidedly mischievous, if not a fatal tendency. From the force of arterial action, arising from the phlogosed state of the stomach, and the constant tendency to lo- cal determinations, bleeding* must be had recourse to as early as possible; and the quantity to be drawn must be regulated by the intensity of the symptoms. The regulations we have already laid down for this remedy must be strictly complied with; espe- cially the one which refers to the change which must be induced on the pulse. Without changingthe force or nature of the action of the circulatory system, we do little, perhaps nothing, nay, some- times mischief. Therefore, where pain in the back and head are severe, we should not stop the flow of blood, until they are re- lieved, or much mitigated; and this rarely ever will be the case, before the pulse is reduced in a very evident manner. We are to decide upon the quantity to be drawn, entirely by the effects it produces upon the pulse; and not by either weight or measure. In some cases a very few ounces will afford instant relief, while others may require the loss of many. We have frequently seen a large bleeding, immediately followed by a profuse perspira- tion, much to the relief of the patient, and we were persuaded, at the moment, that a small one would not have produced such an effect. 336. We have several times declared, that dissections have proved that the stomach is in a state of greater or less inflamma- tion, in perhaps every form of fever; and this is so readily de- tected in most instances by pressure made over its region, that we may almost constantly satisfy ourselves of the fact. In mak- ing this examination, and it should never be omitted, we must take care not to apply a force, that would of itself create pain, independently of the diseased condition of the stomach, just spoken of. The part most sensitive in general, is the hollow space at the lower extremity of the sternum, or breastbone. If two or three fingers be made to press gently and gradually upon this part, and the patient evince or acknowledge that he expe- * We would wish to be understood here, to mean local bleeding, if neces- sary, as well as general."The general bleeding, as a common rule, should first be had recourse to. REMITTENT FEVER. 113 riences pain from the trial, we are assured almost beyond a doubt, that the stomach is labouring under a greater or lesser degree of inflammation. Hence the propriety and oftentimes the absolute necessity, of having recourse to topical bleeding, either by the means of leeches or cups; especially after a bleeding, or bleed- ings from the^arm, have been performed. In a number of in- stances, we have seen a complete intermission instantly procur- ed by the loss of five or six ounces of blood by leeches from the region of the stomach. Nor do we always require the presence of tenderness from pressure, to induce us to have recourse to leeches. On the contrary, we have known this to be absent; yet the most decided benefit to follow their use. Therefore whenever the fever is obstinate, they should be employed with- out farther loss of time. 337. After having bled the patient, we should attend to the state of the bowels—they should be promptly and freely evacuated; ■for this purpose, a small dose of calomel, say six grains, should be given, and this followed in two hours by an ounce of castor oil; which must be repeated, if it does not act sufficiently in two or three hours. We rarely repeat the calomel the same day. Or we may use with much advantage, the Epsom salts and calcined magnesia; or castor oil alone. The salts and magnesia are given in the following proportions. &. Sulph. magnes. Take Epsom salts, Magnes. alb. ust., aa. - Jiij. Calcined magnesia, M. et div. in Lij. each, - - 3 drachms. Mix and divide in 3 parts. One to be taken every hour, mixed in sweetened water or lemonade, until they operate freely. 338. The castor oil should be given in ounce doses, every two or three hours until it operate. It is always best to make the oil very thin, by warming it. 339. Generally it is best to give these medicines in divided doses, and repeat them until a full effect be produced—the inter- vals at which they shall be given are indicated by the prescrip- tion. If a copious perspiration ensue, we may be assured we have lessened the force of the exacerbation; and that the succeed- ing one will be milder; but we must not be lulled into the belief that it will require no farther care—on the contrary, it should be 15 114 REMITTENT FEVER. watched with attention, and made to undergo a discipline pre- cisely similar to the one just mentioned; provided, the force of the pulse, head-ache, &c. make it proper to lose more blood— the quantity now to be drawn may be less; but the lancet must not be withheld, if pain attend, and the pulse be still active. The bowels must again be opened by the same means as before; but not to the same extent, unless the evacuations are decidedly bili- ous, very dark coloured, and offensive. Should perspiration ensue, and terminate the paroxysm, we may perhaps, gain a com- plete intermission, and the disease change its type to that of in- termittent; in this event, it must be treated as already directed for that fever. 340. It is not a matter of indifference, at what part of the pa- roxysm we abstract blood, either from the arm, or from the skin over the stomach by leeches, or cups. We are of opinion, and think we are not mistaken when we say mischief has followed the loss of blood, when it has been abstracted near the end of the ' paroxysm; especially, when the habit of thp fever is, to termi- nate by sweat. We are therefore constantly careful to direct this operation some time before the exacerbation is about to decline. 341. If the paroxysm does not terminate by perspiration; and the patient continue restless, hot, and thirsty, with very little or no abatement of fever, we may be pretty certain, that the re- medies have not diminished the force of the disease; and especi- ally, if delirium should now attend, or become augmented. In this case, we must disregard what has already been done for the patient; and industriously apply ourselves toward off the threaten- ing mischief—with a view to this, wc must carefully consult the pulse, and the attending symptoms, as to the propriety of the farther abstraction of blood—should the pulse be still active, the head-ache severe, or other pain continue, we should again tie up the arm, and allow more blood to escape—the quantity must be regulated by existing circumstances, that is, by the reduction of the pulse, or by the alleviation of symptoms. Should the pulse not be so active, (which by the by, will, rarely happen at this period of this disease,) as to justify farther depletion from the arm; if head-ache, and other evidences of local determination exist, or the tenderness in the epigastric region be undiminished, or augmented, we may take away blood by leeching, or cupping, REMITTENT FEVER. 115 and may again deplete from the bowels. In this state of things, the latter object is admirably obtained very often by the use of the nitro-antimonial powders. * Or should the disease suffer some mitigation, that is, the abatement of the symptoms just enume- rated, we may employ the same powders, with great advantage, or simply the neutral mixture.! It may be well to remark here that, in remittents of very active stages, the utmost advantage is derived from carefuHy watching the exacerbations, and by never suffering a paroxysm to pass without the abstraction of blood so long as the pulse is active, the face much flushed, the skin very hot, and the head-ache severe. Some years ago, in some of our autumnal remittents, so mischievous was the neglect of this rule, that with a number of practitioners it became an aphorism that, " to lose a paroxysm was to lose a patient." 342. As our remittents are very much influenced by causes which we neither see nor have controul over, we shall find their force very different, in different years. In our directions for their treatment, which necessarily must be general, we must con- stantly be understood to mean, that the remedies are to be adapted to the force with which the disease attacks; the period * The following is the formula for these powders. £. Nitrate of potash, - - giss. Take Nitre, - - 1£ drachm. Tartrate of antimony, - gr. j. Tartar emetic, - 1 grain. Calom. ppt. - - gr. iv. Calomel, 4 grains. M. div. in viij. Mix and divide in 8 parts. One of these to be given every two hours mixed in a little syrup of any kind. The number to be given must be determined by their effects upon the bowels. If they purge too freely they must be suspended, until farther necessity. f Formula for the neutral mixture. R. Mixt. neutral, Take Carbonate of soda Aqua font. aa. - - §iij. or potash, - 2 drachms. Tart, antim., - - gr-j- Lemon juice, - 3 ounces. M. f. sol. Tartar emetic, - 1 grain. Water, - - 3 ounces. M. and dissolve, a A table spoonful to be given every hour or two, during the active state of the fever. a When making this mixture, care should be taken to first strain the lemon juice, then add it very gradually to the soda or potash until the effervescence ceases. Let the tartar emetic be dissolved in the water before it is mixed with the neutral mixture. Sugar may be added to the taste if required. 116 REMITTENT FEVER. to which they run, and the particular character they may assume. Thus we find, in some years they are mild, tractable, and of considerable duration; in others they are fierce, rapid, and quickly terminate in health or death. The remedies must therefore be regulated by these modifications. 343. If, after due depletion, we find a disposition to crisis by perspiration, we should endeavour to encourage it by such mild diaphoretics as will create no disturbance in the system, if they fail to procure sweat. For this purpose we may exhibit small doses of tartar emetic, as directed above in the neutral mix- ture; warm lemonade, or baum tea, with forty or fifty drops of the sweet spirit of nitre; or apply the vapour of vinegar, by means of heated bricks, saturated with this substance. Should the external application fail to produce perspiration in half an hour, it should be desisted from; for farther perseverance will not only be unavailing, but even injurious. This indisposi- tion to moisture is almost always owing to too active a state of the pulse, or too high a temperature of the skin—if the first, we must deplete more; if the latter, we must reduce the excess of heat by cool drinks, cool air, and by sponging the body with cool water, or vinegar—but should there be a disposition at this time to chilliness, warm vinegar or warm whiskey may be em- ployed; for notwithstanding this high temperature, the skin when exposed, is sometimes very sensible to the application c i any substance below its own heat We need not, however, always wait for an appearance of moisture on the skin, before we employ diaphoretic remedies; we may have recourse to them when the violence of the disease is so much subdued, as to pre- sent a soft and yielding pulse. 344. The nights of fever patients are, for the most part, those of great restlessness and disquietude; and the practitioner is much importuned by the nurse or friends of the patient i >r "some- thing to make him sleep." But beware how you ) teld to this request; for an ill-timed exhibition of opium in certain states of the remittent form of fever, is almost always mischievous; and we are sorry to add, has been too often fatal. We have seen without the smallest doubt, several instances of heavy stupor and apoplexy, produced by even a moderate dose of laudanum. 345. On this account we are extremely reluctant to give it, REMITTENT FEVER. 117 at almost any period of a remittent; and more especially to a yellow fever patient, whatever may be the degree of sleepless- ness, or agitation. Under such circumstances, we have found, almost constantly, that there was either a general or partial ac- cumulation of heat, especially of the head, a dry skin, bowels rather tardy, or very offensive evacuations, to be the cause. Or it has been found owing to a dull but pretty constant pain in the head, attended sometimes by slight delirium; and other times^ vith a slight stupor, alternating with distressing watchfulness. Pulse either too quick or lagging. 346. In these cases, we are certain that opium would be in- jurious, if not fatal. Instead, therefore, of it, in such cases, cold applications to the heated parts of the body and extremities, by sponging; to the head by wetted cloths, or a bladder of cold water; a few leeches should be applied to the temples; a mild purge should be exhibited, as castor oil; a free ventillation of "the room should be made, together with a decided reduction of the bed-clothes. This mode of treatment is almost sure to pro- cure sleep. Or if, as has occasionally happened, especially in our late epidemic remittent, (1828,) the feet and legs be cold, to have them well warmed, by a foot bath, or the application of dry heat. 347. Affusions of cold water are spoken of with high enco- miums by writers of great practical eminence, in this species of fever—but we hesitate to recommend them in this place, as their usefulness is entirely governed by a particular state of the sys- tem, which it is difficult to procure or to seize. It is agreed on all hands, that cold water applied to the booy, is an agent of great power; and that it is only useful where the condition just alluded to, but which we shall not repeat, exists, and where all the requisites for its exhibition, can be complied with. But these conditions are so numerous, and so difficult to designate, that £cw would be tempted to employ this remedy, after having heard them detailed. But independently of these considerations, great inconveniences attach to this remedy in private practice; in hospitals alone it can be used with advantage, for in them every contrivance for its application is at hand, and ready at a moment's warning. 348. Blisters are very often advantageously employed in these 118 REMITTENT FEVER. fevers; but there are few remedies, in the use of which so much discrimination is required. They should never be used in the early part of the disease; that is, never before the pulse is suf- ficiently reduced. Should we use them too early, they do harm instead of affording relief—for there is truly a " blistering point." But when the system is properly prepared, few remedies are of more decided efficacy. • 349. Blisters are employed with two views. 1. To relieve pain, by being applied immediately over, or as near as possible to the part pained—thus, when head-ache is severe, or delirium is present, they are most successfully applied to the nape of the neck, and. shoulders; if the pain be in the chest, stomach, or side, they should be applied to these parts respectively. 2. They are used with a view of making a counter-impression, or revulsion. When used for this purpose, they are generally fixed upon the inside of the calves of the legs, or above the wrists upon the arms, or upon both. We may here remark upon the use of blisters, that, to be useful, they must be of sufficient size; for we have before observed, that a large blister gives little or no more pain than a smaller one, but is much more useful. (See par. 132.) 350. It sometimes happens, that remittents do not require, or will not bear large evacuations, especially by bleeding, even in this portion of our country, but more especially in the south— this is occasioned by several causes; but over which, we have no controul. We have already noticed this diversity, but this will occasion very little embarrassment in practice, as the character of the disease will .readily be learnt; 1st, by the state of pulse; 2d, by the greater or less violence of the symptoms; 3d, by the effects of remedies; 4th, by the peculiarities of constitution of the patient; 5th, by the general character of the other prevailing diseases. 1. By the State of Pulse. 351. The pulse in fevers is a more certain guide than in al- most any other form of disease—it must therefore be strictly at- tended to, and all its different varieties, should if possible be un- derstood. We shall endeavour to convey an idea of the states REMITTENT FEVER. 119 of the pulse; but are thoroughly sensible of the difficulty which attends the subject—for experience must do much towards its being well comprehended. We shall therefore merely state here the conditions of pulse which require and justify the abstraction of blood in fevers, a. Where it is hard and full. b. Where it is preternaturally slow or sluggish, with tension and firmness, c. Where it is frequent and tense, d. Where it is quick and cord- ed, e. Where it is oppressed and labouring. * Where either of * The hardness of the pulse, is to be ascertained, by the sensation it conveys to the mind when felt by the finger. Hard and soft, are merely relative terms; and are simple ideas. But an inference is instantly drawn, when the finger touches a body; and when the mind is directed to determine its quali- ties, it concludes, that it is either hard or soft. But the degree of either, is only ascertained, by a comparison with other bodies; or with the same body, under different circumstances; thus heat and a variety of other causes, may affect a body, so as to render it comparatively, harder or softer, when compared with itself. So with the artery; for causes may render it, capable of resisting the pressure of the finger, to a greater or lesser degree. To become acquainted with the relative conditions of the pulse, it is very useful to examine carefully and frequently, the degree of pressure the young, and adult artery will bear, in a state of acknowledged health; and when it is altered by disease, to en- deavour to detect the difference, by comparing the present, or deranged con- dition, widi the sensation it formerly excited, when it possessed its healthy tone. If it convey the idea of greater firmness, it is to be concluded that it is harder than natural; but if on the contrary, it give the sensation of bearing less pressure, it is to be considered as softer, than the natural standard. You have then presented to you, a hard or a soft pulse. But it may be well to remark, there are even degrees of these two qualities of the pulse, but which can only be learnt by experience. A full pulse conveys the sensation of the ves- sel being distended, or filled with a fluid, to as great an extent as it will bear: and to such nicety of discrimination does the experienced finger arrive some- times, that in the full or contracted pulse, it can determine the thickness of the arterial parietes. The preternaturally slow or sluggish pulse must be determined by the beats being fewer than the natural standard; and giving the idea of an unwillingness to perform its assigned duty. This pulse is more common with such patients, as have great cerebral determination; amounting even to coma sometimes. The tension of the pulse is ascertained, by imagining the arteiy to be stretched by two contrary powers; and the degree of force that would be required, to make it depart from a straight line; this state of the artery, we believe, is always hard; the mode of determining its firmness, we have just explained; and it may be considered as synonymus with the "hard pulse." The frequency of the pulse, is determined by the excess of strokes beyond the natural standard, in a given time, this pulse may be attended by tension; if so, it is always hard. The 120 REMITTENT FEVER. these state of pulse obtains, we are justified, (if other symptoms, such as pain, oppression, delirium, &c. be present,) to abstract blood; and repeat it, so long as these marks of disease continue. But on the contrary, we are not warranted to draw blood where the pulses are in an opposite condition to those we have just stat- ed. It, however, frequently happens, that we may safely and advantageously employ local blood-letting, by cups or leeches, when we should not dare to abstract blood from the arm. 2. By the Greater or Less Violence of Symptoms. 352. It obtains in many instances of remittents, that very few distressing symptoms accompany it—the fever, not excessive, and the remissions strongly marked; head-ache, or other pains, very moderate; and no delirium. In these cases it is not neces- sary to bleed largely. 3. By the Effects of Remedies. 353. This should always be kept in view; for the loss of a few ounces of blood, or other evacuations, will have a much greater effect at one time, than at another, and upon different in- dividuals. We should, therefore, apportion our remedies to their effects. 4. By the Peculiarities of Constitution. 354. Almost every individual has his peculiarities, as regards remedies—some requiring large, and others, smaller doses, of quickness of the pulse is determined by the time it employs in performing its strokes, and has no relation to the period which elapses, between the se- veral strokes; consequently, is not synonymus with the "frequent pulse." This pulse may be tense, hard, or corded; for the tense, hard, or corded pulse, may be looked upon as the same. The oppressed, or labouring pulse; or as it is fre- quently termed, the "depressed pulse," conveys the idea, that the artery is raising a weight in distending itself, (that is, while it is performing its beat,) almost equal to its powers. In attempting to convey an idea of the different states of pulse, we are fully aware of its extreme difficulty and of the inadequacy of words to effect this: we thought it right how ever to attempt it—and if we have been able to make an approach towards explaining of them, wc shall Uiink wc have gained by it. REMITTENT FEVER. 121 even the same medicine. We should, therefore, always be at- tentive to this peculiarity, and act as this will point out. It is highly important to study the habits of patients, that it may be known how they may be effected by particular agents; for many times mischief would ensue without this information, from the exhibition of very common remedies. Some cannot bear the loss of even a very few ounces of blood without fainting; while others can bear their vessels almost drained, without such an ef- fect ensuing. But in deciding how we are to act in the first case, it is important to know, that this circumstance does not always justify withholding the lancet; but in this case, much less blood will suffice, than if this did not obtain. Others cannot be af- fected by certain remedies, at least in a degree to be any way useful, without much difficulty—thus we have seen some pa- tients take, without effect, three or four times the quantity that would answer for others; while, on the other hand, we have known some, so extremely susceptible to the action of certain articles, that it would really be unsafe to exhibit them in almost any quantity. These deviations should always be kept in view, lest we should attribute to the disease, that which properly be- longs, to idiosyncrasy. 5. The Character of the other Prevailing Diseases. 355. If it should be at a season of the year when other dis- eases be rife, we may learn much by attending to their general character—if this should be inflammatory, the remittents will partake, to a greater or less extent, of this character—on the other hand, should the contrary be their disposition, we must employ less bleeding, or none, and more moderate purging: in a word, a modified treatment will then be required; which we trust can be learned by paying attention to the general doctrine of fever. 356. That occult cause, which determines the character of every epidemic, operates by laws, of which we are entirely ig- norant; its power is only made known to us by the peculiarities it imposes upon the prevailing disease. These peculiarities are never to be lost sight of. They are of the greatest practical im- portance; since, the neglect or observance of them, will render 16 122 REMITTENT FEVER the treatment either successful, or otherwise. And the fact can- not be too early suggested, or too strongly enforced, that there are shades of difference in every disease of an epidemic charac- ter, however frequently or seldom, it may renew its visitations. This has been well demonstrated in the various returns of the " yellow fever" in this city; and has been no less evident in the recurrences of the intermittent and remittent fevers, in the neighbourhood of Philadelphia, for the last six, or seven years. The last, that is, the one of this fall, (1828,) has in several very important particulars, differed from every preceding one; and, consequently, required a difference in the mode of treatment. 357. When the disease was of the remittent form, it was fre- quently ushered in by a sense of cold, pretty long in duration, rather than by a manifest chill. The reaction was generally ex- cessive, and constantly attended by severe head-ache, and often- times with delirium. The hot stage decreased very slowly, and sometimes the period of its remission was marked by a partial sweat. It observed almost constantly the tertian type; and the third day was sure to be marked by an increased severity of the exacerbation. It sometimes required ample depletion; both by general and local means; purging by the milder cathartics; blis- tering, &c. 358. Should the investigations just recommended lead to the persuasion that the character of the disease is one of but mode- rate, or feeble excitement, we must be regulated in the use of remedies by this impression. But we should not let ill-grounded fears so pervert our judgment, as to make us plunge ourselves into the opposite extreme. The dread of a low, or typhus state, has too frequently suspended the use of the only remedies which could have prevented it, or saved the patient; and thus, depletion, to a proper extent, has been neglected, or feared, and stimulants made to usurp its place. Against an error of this kind, we can- not guard too carefully; for even typhus, (as it is called,) as we shall hereafter say, can only be cured by premised bleeding and purging. We should, therefore, never neglect these reme- dies when indicated in the commencement of a disease, because this disease may eventuate in the condition called typhus. It, however, behoves us to watch carefully the tendency of the fever, If it be disposed to run into one of feeble action, after REMITTENT FEVER. 123 a few days continuance, we should take care not to push deple- tion beyond its proper bound; the pulse, and other symptoms, will direct us when to withhold it, if properly studied. But it must be recollected, that, when fever does not require deple- tion, it does not necessarily require stimulation—that there is a period in such fevers as are disposed to run into a low state, at which we must withhold evacuants, we grant; but we must in- sist, that it requires much judgment when to exchange them for tonics, or stimulants, should these ever be necessary. 359. There is no term in medical nomenclature, that is so ill- defined, or understood, as typhus; according to our observations, it is almost constantly made to consist in a set of symptoms that have two opposite conditions of the system for their origin, yet both treated as if they were one and the same. We shall at- tempt to prove this by and by. 360. During the whole continuation of fever, too much regard cannot be paid to the articles of diet and drink; we have dwelt upon this in our general observations on fever; and a long ex- perience convinces us, that the rules laid down, cannot be dispensed with, without incurring a risk of mischief to the patient. 361. It will be observed, that we have hitherto not prescribed that supposed innocent cordial and beverage, "wine whey," in any one instance; not even in such cases as are too generally supposed to require it—namely, where the tongue is black or brown, &c, we have done this, from a conviction, that these symptoms do not require such a remedy; and which in itself would do mischief, were it employed, since, these very symp- toms are almost sure to be removed, (especially, when they ap- pear after the few first days of the disease,) by a contrary plan; and when they show themselves in long-protracted fevers, it is totally inefficient. But more of this by and by. 124 YELLOW FEVER CHAPTER IV. YELLOW FEVER. 362. By yellow fever we mean a disease of specific character, one that differs from the endemic remittents of tropical climates-, and from those of the southern portions of our continent This disease, by some, has been considered as only an exalted form of the bilious remittent; but there are peculiarities in its history that show it to be a distinct disease. We shall therefore enume- rate the several remarkable circumstances connected with it, which have led us to adopt the opinion of Jackson and some others on this subject, and which in our opinion are conclusive. 363. 1. It has been remarked by many of the physicians and inhabitants of the West Indies, that the negroes immediately from the coast of Africa are never attacked with this disease, and the native West Indian, or Creole, is likewise exempt from it, provided he uninterruptedly remain in the place of his nati- vity; but should he or the negro pass a year or two in Europe, or in the higher latitudes of America, they would be liable to this complaint. 364. 2. Strangers are particularly liable to this disease on their arrival in the West Indies, or on certain portions of our conti- nent. But should they escape it for the first or second year, they will most probably be exempt from its attack; and more certainly, if they had suffered from the endemical fever of these climates. This is what is familiarly termed "the seasoning." 365. 3. It has been very rarely found to attack the same per- son a second time, while the endemial fever may be repeated several times. 366. Some of these facts are well established, and seem deci- dedly to mark a difference between the bilious remittent and yellow fever. Nor are we entirely indebted to the writers on tropical diseases for these marked peculiarities of the yellow fever; for the same has been observed, and recorded in part, if not entirely, in our own country. YELLOW FEVER. 125 367. The first visit this formidable disease paid us, which is still fresh in our memories, was in 1793; and it was then fre- quently observed, that the Creole population, which was at that time considerable, was almost entirely exempt from its attacks;* and more especially the coloured part of it. It must be remarked that there was at this period a large influx of West India inhabi- tants into our city, and chiefly French. But after they had re- mained, here a few years, they seemed to lose in a degree their immunity from attack; accordingly, instances of this disease occurred among them, as well as among the native inhabitants. 368. It was also remarked at this and at subsequent periods, that the transient visitors from the surrounding country, were more obnoxious to this disease than those who permanently re- sided in this city, provided they visited certain portions of the town. And if we can trust to observation, the fact of a person " not being liable to a second attack," was confirmed by the sub- sequent visitation of this terrible scourge, and which we think put the circumstance to as fair an issue as negative proof could do. 369. From these considerations, we think we are warranted in the conclusion, that " the yellow fever, and an exalled form of bilious-remittent, are not one and the same disease." How far a distinction between them may lead to any practical utility, we are not at present prepared to say; but that it may at some future time, we do not hesitate to believe. At present we treat the two diseases pretty much after the same manner; differing more in the rigour of application than in the routine and nature of the agents employed. 370. This disease either attacks variously, insidiously, openly, or ferociously. In this particular it differs perhaps from almost every other febrile disease—for in these, the danger is generally in proportion to the intensity of the symptoms; but yellow fever when masked under an apparently mild form, is dangerous in the extreme. In general we have remarked more instances of • We say "almost entirely exempt from its attacks." We choose to employ this cautious language, because we could not say there was no such exception to the rule; but we can very confidently declare that we did not hear of an exception; for at this period, they had been but a very short time from St. Do- mingo. 126 YELLOW FEVER. recovery where the disease assumed an open, severe, but tangi- ble form, than where neither the pulse nor other symptoms be- trayed the ravages the disease was making. The whole system appeared to be prostrated beyond the power of reaction; and death was frequently at hand, when the patient was perhaps walking the floor, or but occasionally indulging himself in his bed. We have known more than once a patient declare himself entirely free from disease, at a moment when he was without pulse* and within a very short period of dissolution. In these cases the foundation of the healthy play of every organ of the body seems to be silently undermined; and though slowly, it is not the less certain or extensive ; indeed every function appears to be gradually but eventually diminished to an extent, that cannot be recalled, as the bane has silently stolen to the very fountain of life, and so polluted its streams, as to render them no longer fit for the purposes of the system; and before the enemy is suspected, the citadel is on the point of a surrender. This peculiarity, for such it is, may also serve to distinguish this formidable disease, from the highly bilious endemic fever of the West Indies, or of America. 371. Three distinct modes of attack may be observed in the yellow fever, as we have just observed; each of which has some- thing peculiar to itself; this variety must arise from 1. The greater or less degree of concentration of the remote cause, or marsh miasma. 2. To the peculiarity of constitution. 3. Or to the nature and degree of the exciting cause. Each of these cir- cumstances will necessarily modify to a certain extent, the form, or force of the disease; accordingly we find it presenting itself, 1. Where the disease rapidly runs on to dissolution, and is ac- companied by black vomit—this form has often terminated its career within three days, and never exceeding the fifth day. 2. • In no disease with which we are acquainted, does this circumstance ob- tain to the same extent as in yellow fever—we have in a number of cases known this state of things to exist for many hours before death. During this period it was not unusual for the patient to be in full possession of his senses; some- times even without pain, or the smallest anxiety for his situation—nay, when interrogated as to his feelings, he would declare, "he was very well, much better, or expected he would soon be well, as only a little weakness remained." If we are correct in our observations, this more especially happened, where this disease killed without the intervention of black vomit. YELLOW FEVER. 127 Where the disease was without remissions, or when they were so indistinct, as scarcely to be observed. In this form of the disease, the course is not run with so much rapidity as the first; but for the most part the sufferings of the patient are greater—there is no perceptible attempt at crisis, and where it terminates fatally, it is for the most part from the fifth to the seventh day, and is not necessarily attended with black vomit. * 3. Where the paroxysms can be pretty regularly traced, or where the periods of exacerba- tion are not so entirely uncertain; but where there is stronger evidences of an inflammatory diathesis, than in either of the for- mer; but which may rapidly change if not arrested by proper remedies, into an opposite state, and terminate either in the black, or the coffee-ground vomit—this form may terminate within five days, or if checked, may run on to the seventh, ninth, or eleventh day. 372. The first form observes no regular period of attack,though the evening is the most common. It invades by an unusual degree of languor and debility; head-ache more or less intense; a most distressing and indiscribable sensation about the region of the stomach. It is rarely preceded by severe rigour, but it is often- times of long continuance; it is not followed by great reaction; the heat of the body is rarely great, but is of a peculiar kind, giving the idea of acridity or pungency to the hand that feels it. The pulse is apparently weak, t confined, and giving the sensa- tion of creeping. The face assumes a character and expression that belongs exclusively we believe, to this disease; the eyes are inflamed, or rather severely blood-shotten, as it is called; and have a look of peculiar sadness, anxiety, and anguish ; a flushing of the face of a truly characteristic hue, and of a singular tone— a reddish-brown not unlike the colour of mahogany, mixed with a lividity, especially its own. It is difficult, if not impossible, to * This form of the disease has been known to terminate without black vomit; but dissection has shown that this fluid has been formed, though not re- jected. It was also observed in these cases, that the inflammation of the sto- mach was more decided and extensive, than where black vomit had been thrown off. Was the stomach prostrated beyond the power of vomiting? f This state of pulse has led to great error in perscriptions—for this "ap- parently weak pulse," has been mistaken for an absolutely weak pulse; whereas it is only the "depressed pulse," and requires a diametrically oppo- site treatment. This fact should be kept in mind. 128 YELLOW FEVER. convey an accurate idea of this appearance of the face; but so im- pressive are its characters that they are never forgotten, after having once been seen. So truly does it indicate yellow fever of a high grade that, we believe with people familiar with it, it would be sufficient to designate the disease. The tongue for the most part is moist, but foul; the thirst in the beginning not great, at least rarely severe. As the disease advances, the breathing is oftentimes disturbed; becomes hurried, and ap- pears to be performed with a distress about the precordia. No remission takes place, although a trifling abatement of symp- toms is observed, sometimes about ten or twelve hours from the commencement of the disease; but this is transient; and seems only a prelude to an increased severity of symptoms; for an aggravation of all that we have enumerated, immediately succeed this attempt at remission. The eye increases in sad- ness of expression—it is the eye of complete hopelessness— a burning sensation is now felt about the stomach, and the pa- tient suddenly flinches from the slightest pressure being made upon it, which emphatically, locates the seat of mischief; head- ache is augmented, sometimes to an intense degree; the counte- nance becomes haggard, and of most sad expression—marks of inflammation are now more decided; the gums begin to swell and to become engorged with blood, and easily provoked to bleed. The condition of the tongue now is variable; sometimes moist, some- times dry, but always, or with very few exceptions, foul or very red. Thirst either moderate or intense. Nausea, which per- haps may have existed from the beginning, is now increased; but there is rarely a steady vomiting for the first day or two, or even perhaps sometimes longer. The discharges from the sto- mach, when vomiting occurs, are rarely bilious; though some- times porracious.* 373. The fluids discharged are for the most part clear, or par- take simply of the colour of the liquids drank; but a change is soon perceived as the disease advances; they become thick and • In some few instances of the mild form of this disease, bilious vomitings occurred—they for the most part afforded relief, and always decidedly marked a disease of a milder and more tractable kind, than where this did not occur— in some rare instances, a vomiting of very dark or black coloured bile accom- panied the first symptoms of the disease; almost all of these recovered. YELLOW FEVER. 129 ropy, and have mixed with them, a dark-coloured flaky sub- stance, which gives the first intimation, that the stomach is about to yield to the force of the disease; for these flakes are part of the villous coat of this organ.* The patient now becomes rest- less and anxious in the extreme; he throws himself incessantly about, as if in the hope that a change of place would procure a temporary suspension of misery. He is watchful—sleep seems to have forsaken him; or should he chance to slumber, he is sud- denly disturbed by internal disquietudes, and awakes to renewed and increased sufferings. His respiration is deep, hurried, and to appearance painful. He sighs deeply and frequently,t and is disposed to faint upon the smallest disturbance, or the slightest elevation of his head. A clammy sweat breaks out sometimes about the head and neck; which neither affords relief, nor be- comes a favourable prognosis. 374. The heat of the body is rarely increased; and the pulse even abates in frequency; in the commencement of the attack, the bowels are usually confined; the urine high-coloured, turbid, and in small quantity—indeed, in many instances, it seems gra- dually to diminish as the disease advances; so much so some- times, as to be entirely wanting at last—where this has obtain- ed, we do not recollect a single instance of recovery. 375. Delirium is by no means an usual symptom of yellow fever; it however occasionally presents itself; sometimes in a very mild, at other times in a most ferocious degree—when it does occur, it is rarely before the third day, and it may then be transient. 376. About this period, (that is, of three days,) the patients' sufferings appear to diminish, and the system to undergo an in- sidious change—a change, which has but too often imposed upon * W*e have seen these dark spots diffused, immediately after vomiting, in a large quantity of almost transparent fluids; but when suffered for a time to be at rest, they would rise and float upon the surface. f Dr. Physick has observed that the following symptoms in yellow fever were always fatal. 1st, those patients who sighed deeply immediately after waking, and before they had recovered the power of speech; 2d, those, who complained of soreness and pain, without this part having any morbid appear- ance; 3d, those, whose arms became rigid; and 4th, those, who had an entire suppression of urine. 17 130 YELLOW FEVER. the inexperienced in this disease—the eye now nearly regains its accustomed brightness, and the countenance assumes its usual cheerfulness and serenity; but the practised observer is but too well acquainted with the treachery of these appearances; he ob- serves a yellowness spread itself over the body and neck, which too emphatically bespeaks a fatal issue to the disease. The fever. and external heat now subside; the pulse even becomes fuller, and slower; and were the wrist presented for the examination of one unacquainted with the other circumstances connected with the case, he would most probably declare it to be in a natural state. 377. The skin is dry, and of a peculiar feel; a roughness or harshness possesses it, that would seem to declare that sweating was not one of its functions—the gums increase in intensity of colour, become spongy, and occasionally bleed—the vomiting is more troublesome, and continues to show still jnore decidedly, that the villous coat is separating; the distress at stomach is re- newed with augmented force; and the patient discovers the ut- most misery and wretchedness. This state of things may remain for one, two, or even three days, without much alleviation or change—but at the end of this time, without a favourable altera- tion take place, the heat of the body, and especially that of the extremities, is found to be dissipated; the pulse is either almost, strictly speaking, natural, or is slow and regular—the yellowness increases—the anxiety becomes extreme and inexpressible—the vomiting is now indomitable; and the long looked for, and ter- rible black vomit, at last appears. 378. There are shades of colour in this black discharge, de- pending chiefly, we believe, on the speed with which this dis- ease runs its course—when its progress is rapid, the matter of the vomit will be very black, and resemble a strong mixture of soot and water; when less so, it will appear like the grounds of coffee; and when still slower, the black will be less intense, or consist sometimes of merely dark-coloured mucous flakes. When these flakes appear early in the disease, it always presages a se- vere one; and they always increase when the disease is making a fatal, or even a highly dangerous progress. Blood is sometimes found with the fluids thrown from the stomach, which may pro- ceed either from the stomach itself, or from the throat or gums. YELLOW FEVER. 131 At times, the quantity of fluid vomit is truly surprising, and would appear much to exceed that taken down; and towards the close of the disease it seems to be ejected almost without effort. This discharge for a moment seems to bring some relief; but it is very transitory; for the stomach is obliged again to empty it- self, so soon as it is again distended. The stomach appears at this time too much prostrated to experience the sensation of nausea—at least we have known patients declare they were not sick at stomach, the moment before they would vomit. There is almost always a " vomiting of wind,"* before black vomit makes its appearance—this we believe to be owing to the extrication or secretion of gas within the stomach, which by distending it, causes an effort similar to vomiting. We have almost invariably observed the disease to terminate in black vomit, or fatally, where this symptom, was present. It is a most distressing con- dition of the stomach, and evidences a severe inflammation of this organ. 379. At this stage of the disease, that is, at the time when black vomit is about to appear, the bowels almost always become loose; the evacuations are tenacious, and much resemble tar, both in colour and consistence. In our early acquaintance with this disease, in our city, this appearance of the stools was by some considered favourable, as it looked like getting rid of a highly irritating and offensive matter; purging was immediately instituted, and the patient sometimes expired under the opera- tion. 380. The gums are now extremely soft, and discharge, or ra- ther there oozes from them blood, which has lost the power of coagulation; this oozing, however, is not always confined to the gums; the nose, ears, arms, and various other parts of the body, sometimes participate in it Sordes now encrust the teeth; the pulse may either cease altogether, or become so frequent and feeble, as scarcely to be counted; a low muttering delirium, coma, or convulsion, may close the scene. * This may appear an awkward expression, but it is truly characteristic, and exist as a fact; for the stomach discharges at this time a considerable quan- tity of gas, (the nature of which we believe has never been ascertained,) by the same mechanism it does fluids or solids upon other occasions, 132 YELLOW FEVER. 381. Wc ffave endeavoured in the history of the symptoms of yellow fever, to give a detail of its ordinary march to a fatal issue, where the disease was allowed to run its own course. We do not pretend to enumerate all the symptoms which may occur, as they will necessarily be modified by contingencies. We trust we have kept pretty faithfully to the order of progress; though we are sensible they do not invariably observe the same succes- sion—for instance, we have known the black vomit precede the general diffusion of yellowness—but we have just observed such cases are rare; and even when they do occur, a.tinge of yellow about the corners of the mouth and neck may be observed, be- fore the vomiting of black matter comes on, if they be carefully observed in a strong light; and as far as our observations have extended, they mark the approach of the event as decidedly, as when the diffusion is more general—especially, if the skin of the forehead be tinged; is drawn tightly over the frontal bone; and is shining. Again we have seen an increase of restless- ness after black vomit has commenced, though it is generally the reverse, &c. 382. It may not be amiss to remark here, that fatal as the symptom of black vomit is, it is not invariably so—for we have seen more than one instance of recovery after this had taken place; this has been more frequently witnessed in children than in adults. Bleeding from various parts of the body is also a ter- rible symptom; but instances of recovery from this have much more frequently occurred than from black vomit—indeed, in several instances, in 179S, it appeared useful; at least there was from the moment of its taking place an evident amendment, and finally recovery. The recoveries after the black vomit are both rare, and slow—the abatement of the puking is gradual; the black matter ceases to be thrown up, but the stomach continues to dislodge other matters from it for some time; and a long period before this organ recovers its tone—in one instance which we witnessed, more than three months elapsed before it could bear the ordinary food of the table. The patient being many hours without pulse, is not necessarily a fatal symptom; we have seen instances of recovery where this had obtained. YELLOW FEVER. 133 Treatment. 383. Having thus given as condensed a history of yellow fever as we were capable of, we shall proceed to consider the method of cure. In doing so we must remark, that this dis- ease in a most especial manner calls, not only for appropriate remedies, but also for the most prompt application of them. And we have authority to say, that where the patient does not delay too long before he seeks advice, that it is a manageable disease, in more instances than is generally supposed. But to render it so no time must be lost—it must be instantly subjected to a ri- gorous discipline; or it soon becomes so intractable as to bid de- fiance to every attempt at subjugation. We have noticed three different forms under which this disease presents itself; this how- ever will not embarrass the method of cure; as each of these is virtually the same disease, and require almost the same remedies —the difference consisting chiefly in the extent to which the re- medies must be carried, rather than a difference in the remedy. In the first form there is more likelihood of error than in the other two; and which if committed, will at once seal the patient's doom. 384. In our description of this form, we noticed two circum- stances, which we here repeat, that they may not be lost sight of: 1st, the appearance of weakness in the pulse;* 2d, the dis- ease not being ushered in by a regular chill; but rather a cold- ness of long continuance sometimes, and which is not followed by violent reaction. From the two circumstances just stated obtaining in this form, a wrong conclusion has been drawn as to * We have before remarked, that the pulse of this form of yellow fever is what we have termed upon good authority, the oppressed or depressed pulse; a condition of the artery which requires depletion even more certainly than the strong full pulse. It requires however to be understood; we have at- tempted some explanation of it at par. 351. This pulse is sure to be convert- ed by depletion, into the strong, full pulse, in a few minutes; hence we have directed, that after this ensues, the abstraction of blood must be continued, until the force of the artery is positively weak; for it was only relatively so before. This kind of pulse is felt in apoplexy, and in phlogosis of the lungs; or sometimes even in violent fits of asthma. 134 YELLOW FEVER. the state of the system; and stimulants have been employed; or if not, proper depletion had not been resorted to, to the certain destruction of the patient We must not therefore be deceived as to the proper remedies, for they must consist of bleeding and purging, and powerfully exciting the skin, when its temperature is below the natural standard—this is best done by the applica- tion of external warmth in the usual various ways—as bottles of hot water, hot bricks, warm blankets, &c. 385. The patient should be supported during the chilly state, by artificial heat, applied to his body by means of heated blan- kets, &c. as just stated, until the system begins to react; the warm bath, when practicable, and when it will not occasion too much delay, may be advantageously employed—a vein should then be opened, and as much blood should be taken as the pa- tient can well spare at the moment—the quantity should be very much regulated by the effects—that is, where a few ounces have been lost, and the pulse is found to rise, and become more ac- tive, we should permit the blood to flow until a decided reduc- tion is made of its lately acquired force—that is, until it becomes really feeble; or there is a regular abatement of symptoms. If the pain attending the disease, especially head-ache, be very se- vere, we shall find it relieved in proportion sometimes, to the flowing of the blood. But if we have an obscure head-ache with very red eyes; with this depressed state of the pulse, it is very possible, we shall convert a dull obtuse pain into a very acute one. This change was far from being unusual in the yellow fevers which visited Philadelphia in the various years in which it made its appearance. And in 1793, especially, it had an un- favourable effect upon the public mind; for it made it hostile to depleting remedies—this prejudice was however but transitory; it yielded as soon as the cause was understood. 386. We have noticed, that the bleeding would very often procure an abatement of the most distressing symptoms, when early resorted to, and sufficiently employed; nor was this all; it also disposed the disease to assume a greater regularity of pa- roxysm; or in other words, procured a disposition to remission; and although there was not much regularity in the accessions, still they were sufficiently marked, as to lead to the hope, of YELLOW FEVER. 135 converting this disease into one of more regular type, and of milder grade—and this sometimes very early took place. It was therefore, always looked upon as favourable, where there was strong exacerbations, with decided remissions, after the de- pressed state with which it commenced. In this form the dis- ease was more palpable, and open; and although it would re- quire the use of the lancet many times, before it could be sub- dued, yet it was in a form that was much more manageable, than where the bleeding and other remedies failed to give the disease this new character. 387. Where bleeding failed to give immediate, though tempo- rary relief, or to unload the system so that it could pretty freely react, the disease scarcely ever failed to run its course in a short time in spite of every other attempt at opposition. The stomach would soon give way; and be ushered in by black vomit Some of the West India practitioners, especially Jackson, carried bleeding to a much greater extent than has been ventured upon in this country—he almost always bled to fainting, when he saw the patient after the first, six or eight hours after the attack, and he declares, with the most happy and decided advantage. In directing bleeding in the form of the disease under consideration, we must be understood as having in view, its commencement —as for the most part, if the patient had been ill with it for twenty-four, or thirty hours, it was truly a forlorn hope to at- tack it. For after this period the debility and disorganization become so decided, and irreclaimable, that every effort to arrest their farther progress was totally unavailing. It is vain we give tonics, or urge stimulants; they both, indeed appear to hasten the catastrophy. 388. After taking as much blood as the state of the system will justify, or the exigency of the existing symptoms require, we are strictly to put in use all the rules we have laid down for the ge- neral management of fever; in no kind are they more neces- sary or decidedly useful than in this. We must next pay at- tention to the state of the bowels; we have said that for the most part they are costive or tardy in this disease—we should select for exhibition the most certain of the purgatives; and they should be exhibited in divided doses, rathar than in large ones. In this 136 YELLOW FEVER. way they are not only more certain, but also less offensive. Calomel* in form of pills is perhaps the least exceptionable, and of the most decided efficacy-—should the)7- fail after a few hours, of procuring copious evacuations, they may be followed by castor oil, or calcined magnesia, drinking after it lemonade; or magnesia, and Epsom salts, until the effect be produced; and these may very often be advantageously aided by stimulating injections, t It must be remarked, we are not to be deterred from giving purgatives be- cause a moderate sickness of stomach may accompany the dis- ease; for should we yield even for a few hours to this symptom, we should have the mortification of seeing it augment without the advantage of having the purgative in possession of the bowels—we have rarely found the nausea of this disease en- creased by these medicines. The only difference we would ad- vise, is, the use of the calomel alone in grain doses, aided by re- peated injections. 389. When the bowels are freely purged, we may desist from large doses of medicine; but we must be careful to maintain the operation by occasional exhibitions of it—for this purpose a pill of calomel may be given once in four or six hours; or small doses of castor oil, with great benefit. Upon bleeding, and a lax con- dition of the bowels, we must place our chief reliance; and they must be employed whenever the system either reacts in form of regular paroxysms, or in occasional exacerbations. We must not limit the time of repetition of this remedy by its use in or- dinary diseases; we must be governed by violence of symptoms, and by the period in which the fever runs its course—the pro- crastination of a single hour may have important consequences attached to it. We, therefore, bleed whenever the symptoms increase in violence, (other things being equal,) if that be every few hours—we well remember a case where twenty-three bleed- • R. Calomel ppt. - - gr. x. Take Calomel, - - 10 grains. Conserv. rosar. - q. s. Conserve of roses, sufficient to M. f. pil. iij. make three pills. One of these to be taken every hour. ■j- One of the simplest and best we believe at this time, is, a pint of luke- warm water, and a large table-spoonful of common salt. Should this fail in ope- rating for twenty minutes, it may be repeated. YELLOW FEVER. 137 ings were performed in five days with the happiest effect. And we have witnessed where the blood first drawn was dissolved,* yet the subsequent bleedings showed decided marks of inflam- mation. One instance is still fresh in our memory, where six ounces of dissolved blood were drawn at the first bleeding, on-the first day of the disease; yet after this the system reacted so powerfully, as to require twelve more bleedings to tranquillize it; the patient recovered rapidly. 390. We must not be deterred from the employment of de- pleting remedies by the semblance of weakness—it is a most fal- lacious sign; and when respected in the commencement of the disease, has, and will be the death of thousands. There is great debility in yellow fever; the patient is wont to faint early in the attack, when disturbed, or placed in an erect position; but this, instead of forbidding bleeding, calls loudly for it—we have very many times witnessed the patient strengthened by the loss of a large quantity of blood, and free purging. So long then as the pulse is either depressed and tense, preternaturally firm and slow, or very active and chorded, we are imperiously called upon to deplete. In the first instance, the pulse will rise, and be invigorated; in the second, it will increase in frequency, and become softer; and in the third, it will become less quick, and more open. There is something remarkable in the strong ten- dency which this disease has to disorganization when permitted to run its course, which we have said was from three to five days—it marks the highest grade of inflammatory action; and which, if not subdued by prompt and appropriate remedies, will end most speedily in death. The employment of proper eva- * Dissolved blood, is that condition of this fluid, in which no separation of its constituent parts take place; and where the coagulated lymph has lost its power of coagulation. The whole mass after standing for some hours can be poured from one vessel into another, like thick molasses. This state of the blood was looked upon by Dr. Rush as a mark of the highest inflammation to which the system could go, without being in a state of gangrene. If this ob- servation be confined to the early part of this disease, we have reason to be- lieve his observation correct, as the case alluded to in the text, seems to con- firm it. But it must not always be regarded as a sign, that blood-letting is the proper remedy in the disease in which it may appear; for in the last stages of yellow fever, the blood will exhibit the same phenomenon: and also in scurvy. IS 138 YELLOW FEVER. cuations will almost always protract the hour of dissolution; by which means we are sometimes enabled to gain a victory over the disease—for if it moderates in yiolence, we have a greater op- portunity afforded us, to yield needed succour. While, on the contrary, if the patient has been entirely neglected, or what is worse, if he has been treated with cordial or stimulating reme- dies, he has rarely lived to see the fifth day, and very often has expired on the third. 391. If it has so happened that a day, or two at farthest, has been lost to the application of remedies, we very rarely, (in this form of the disease,) have it in our power to retrieve them —but, although the chance of success is very slender, the pa- tient must not be abandoned. We are, however, persuaded, that even here the same kind of remedies are necessary, though inji much less active, or extensive degree; very small bleedings, with gentle purging, have succeeded sometimes when the sys- tem seemed fast hurrying to dissolution. We should, therefore, employ them as long as there is the .least vigour in the arterial system, only proportioning the quantity of the bleeding, and the extent of the purging to the existing state of the system. Sometimes two or three ounces of blood have been drawn with evident advantage; and this has several times been repeated at two, three, or four hours interval, until the system has reacted with renewed force, and the patient has escaped from death, by these small, and well-timed bleedings—what led to this practice was observing recoveries, after haemorrhages from various parts of the body had taken place. 392. Although the pathology of this disease, was in part un- derstood in 1793, and clearly in 1798, yet it did not lead to the free use of leeches. The numerous post mortem examinations made by Dr. Physick in the Yellow Fever Hospital, at Bush- hill in 1793, and at the City Hospital in 1798, convinced almost every body, that a high grade of inflammation of the mucous membrane of the stomach, was the true cause of the disease. Hence the almost universal employment of the lancet, and of purging in this complaint. Notwithstanding the importance of these facts, and the general truth of the indications they led to, we had yet to learn, that many of the remedies employed to ful- fil them, tended rather to aggravate, than to abate the inflamma- YELLOW FEVER. 139 tion of the stomach; such for instance, as all the very active, or rather drastic purgatives, so liberally employed. But more es- pecially, the directly stimulating articles resorted to by some, under the impression it was a form of typhus, and-required bark, wine, ammonia, &c. &c. 393. But we may here ask if this practice be not adopted, to what shall we have recourse? There are but two other choices, either to do nothing, or what is still more decidedly mischiev- ous, to stimulate with wine, brandy, or volatile alkali. Exter- nal stimuli may be advantageously used, however, at this pe- riod ; one of the best of these is heat—this may be applied in various ways—by warmed articles of covering, heated bricks, jugs or bottles of warm water, &c.—sinapisms to the feet and ankles,* legs wrapped in flannels we,tted with warm spirit of tur- pentine, &c. 394. We are of opinion, (which however we confess to have derived only from analogy,) that the occasional loss of a few ounces of blood from the region of the stomach by leeches, would be of the most prompt, and extensive benefit. The al- most certainty in cutting short the paroxysms of the remittent form of fever by leeching over the stomach, lead to the persua- sion that it would be as useful in yellow fever; especially when as large draughts have been made from the general system as it would well bear; or where the disease had been neglected, and the abstraction of blood from the arm might be thought ineli- gible; or where it presented itself in a milder form. After this we might blister over the stomach, or what is as effectual, and more prompt, a plaster composed oi ground mustard and spirit of turpentine; this must be permitted to remain, until the patient complain of the intensity of its action. The bowels must be evacuated by mild purgatives, as castor oil, weak solution of Epsom salt, or magnesia in milk—these to be aided by injec- tions. 395^ As the stomach is very frequently sick in the early part of the disease, care should be taken not to increase it by the ex- hibition of improper articles, with a view to relieve it—all sti- * In the use of these articles great care should be taken, that they do not remain on the part longer than to exert a rubefacient effect. For if permitted to stay too long, a gangrene of the part may ensue. 140 YELLOW FEVER. mulating teas should be avoided ; such as the mint, ginger, or chamomile; the surest relief obtained in general is not allowing the patient to fill his stomach with, any fluid—cold water, one of the best drinks, is rejected very often with great violence, when given in a large quantity; it should therefore be given by the spoonful—indeed, any very cold drink seems to disagree with the patient, if given too freely, or in too great quantities; while tepid or lukewarm, will be retained. We found nothing so uni- formly agree with the stomach as a pretty strong solution of gum Arabic in water in small quantities at a time; small quan- tities of milk and water, frequently repeated; rich toast tea; or lime water and milk. 396. When head-ache is severe, cold applications have been found very serviceable; they may be frequently renewed, or permanently maintained on the head.* The best mode of con- ducting this is by filling a large bladder two-thirds full with cold water, to which, if necessary, a lump of ice may be added— the bladder is then tied and placed on the head—should the hair be thick, it may be well to thin it. Should there be great heat of skin, which is sometimes the case even in this form of the disease, especially after depletion has been freely employed; and the fever assuming a more regular form, great comfort as well as advantage is found from sponging the body and arms with cold water, or should there be great sensibility of skin, with tepid water. And we have seen in this state of the system much benefit, from having the hands of the patient kept in basons of cold water, until their temperature has been well reduced by it—this can be repeated as the occasion may re- quire—by this process, indeed, the heat of the whole body ap- pears to be reduced. 397. In the other two forms of the disease which we have noticed, the plan of cure is so conformable to the first, that we need not enter into a detailed account of it—we must, how- ever, observe, that like the former, almost every thing de- pends upon the promptitude with which the remedies are em- * The benefit of this valuable application is oftentimes destroyed, by not having it properly employed. It is almost always kept too long at a time upon the head; whereas, it should be removed as soon as the head becomes cold; and only renewed when the head becomes again hot, or the pain severe. YELLOW FEVER 141 ployed. In the second form the alleviation of the symptoms is more manifest, than in the first, that is, it is easier to procure re- missions—the heat of the skin is in general more intense, and the patient bears bleeding and other depleting remedies better than in the first; and when an impression is made upon the dis- ease it is more easily maintained—the disease may be protract- ed until the seventh, ninth, or eleventh day, or even longer, and may at these advanced periods terminate by a regular crisis, or in death. In this form the good effects of cool air, sponging, and the application of cold water to the hands and head, are more evident than in the former. The stomach does not yield so soon; and the issue by black vomit, is either longer protracted, or does not take place, though death may ensue. This form also requires more extensive purging; and the evacuations are frequently bilious. Haemorrhages are not so frequent. 398. In the third form we have said, the inflammatory symp- toms are evident; that is, there is considerable heat of skin, strong, firm, full pulse, flushed face, red eyes, tongue white and furred, and great soreness over the region of the stomach when pressed; more certainty in the periods of exacerbation, or more distinct remissions. This form seems more open and of easier management than the two former, and resembles more the high grade of a regular bilious remittent But if the first two or three paroxysms be allowed to pass without opposition, the system may be prostrated—the pulse becomes slower, softer, and weaker —the blood seems to retire from the surface—the body becomes cool and pale; the face assumes a leaden hue; the eyes remain injected, with also a strong tinge of yellow; the tongue dry and brown; the stomach sick and disposed to vomit; the matters thrown up have the dark mucous flakes mixed with them; hic- cough, cold extremities, and black vomit—the bowels become loose, and the evacuations are sometimes passed involuntarily— coma, and slight delirium. Notwithstanding this terrible train of symptoms, the disease runs a longer course than the two for- mer—and although the tendency to disorganization is equally certain, it is not equally rapid—the inflammation which attends is not so excessive though more evident and palpable; and the system seems to lose its powers more from excessive action, than 142 VELLOW FEVER. from a higher degree of inflammation suddenly ending in gan- grene. 399. When proper depletion is employed early in this form, it is sometimes changed into a regular remittent, and sometimes ends in an intermittent* The same remedies must be employ- ed in this, as in the other forms; but with difference; bleeding and purging not to be carried to the same extent, though indis- pensably necessary—a much smaller quantity of blood will di- minish the force of the circulation; but the reaction after it, is more prompt and certain. Emetics and sweating have been some- times advantageously employed after due depletion about the third or fourth day, where the stomach would reject its contents mix- ed with bile; and blisters have a decidedly good effect in remov- ing the disposition to coma, and relieving delirium; they should be applied first to the legs, and then a large one to the nape of the neck, and extend down between the shoulders. 400. Should the inflammatory stage pass over without an at- tempt to moderate it, the system becomes so prostrated that no- thing can again invigorate it—it must be left like a wreck, pretty much to the mercy of the wind and waves that have overwhelmed it—it may float to shore, but it cannot be navigated there. 401. We may, however, in this, as well as the two other forms, alleviate certain symptoms; or so controul them, that they shall be less mischievous—the nausea may sometimes be relieved by the seltzer or soda-water, or by the effervescing mixture—by lime-water and milk, and in the last stage, even where black vomit is present, the spirit of turpentine has been successfully employed—a strong infusion of cloves has also been used with advantage in the severe vomitings that take place in the decline of the system—a blister over the stomach may also be useful. A distressing hiccough sometimes attends; this has been found to • This last change only takes place in the later part of the season, after the weather becomes cooler. That is, it has happened pretty late in the fall, to see this change; but whether these cases were genuine cases of yellow fever may be doubted. For when this disease is epidemic, every fever in the vici- nity of its visitation is thought to be yellow fever; yet the circumstance is noted by most modern writers upon tropical diseases. CONTINUED FEVER. 143 yield best to large doses of camphor. Should a weakening diar- rhoea supervene, the chalk julep should be given until it be suffi- ciently restrained, or very strong allspice tea. 402. Porter and water after the inflammatory symptoms have yielded to remedies or passed away, has almost always been found a most grateful beverage, as well as being very often suc- cessful in quieting nausea or arresting vomiting. 403. We may here remark that, as the season advances this disease bears more bleeding than in the very hot weather. CHAPTER V. CONTINUED FEVER. 404. This form of fever, allows us but little to say in parti- cular; as it is one that rarely appears among us, unmixed with symptoms, that belong to the remittent of this climate. We have of late years paid some attention to this form of fever; because it is recognised by almost all the writers upon this subject, and made by some to be essentially different from the remittent We have however, never satisfied ourselves, that there is good grounds for such a distinction; at least so far as it is just to con- sider similar remote causes. 405. The continued fever runs its course, without intermis- sions, and with but very slight remissions. Good makes this fever, consist of "one series of increase, and decrease; with a tendency to exacerbation and remission, for the most part ap- pearing twice every twenty-four hours."—Study of Med. Vol. II. p. 116. Amer. edit* He divides it into three species; 1, in- flammatory fever; 2, typhous fever; 3, synochal fever. 406. For the purpose of practice, this division into species is • In what does this definition of continued fever differ from that of our ordi- nary remittent? in the mere circumstance of the latter being "strikingly ex- acerbating and remitting." Good, vol. 2d, p. 21. Does this mark any essential difference between the two, except what may be purely accidental, or de- rived from the previous state of the system> for we have seen remittents, pro- 144 CONTINUED FEVER. not essential; for the duration and force, of the inflammatory symptoms, are altogether uncertain; for the continuance, and perhaps existence of this condition of the system, will depend upon the power of the remote cause or causes; constitution of the patient; location; and the mode of treatment. If the inflam- matory symptoms are high, we have the first species, or the in- flammatory fever; but if they be not high, yet will bear mode- rate depletion, the synochal fever may be considered as present; and if the reduction of the phlogistic state be still more evident, typhus according to some writers and practitioners, will be formed. So that the three species of Good, may consist only of modifications of his continued fever; and these forms be de- pendant upon the contingencies above named. 407. Thus it would appear, that the same remote cause or causes, may produce the three species of continued fever of Good, in different individuals; or they may follow each other in the same person, from the same remote, and exciting causes. 408. This form of fever, commences like most other fevers; that is, with languor, or a feeling of weakness ; indisposition to motion; yawning and stretching; paleness, or shrinking of the extremities; rarely a well-defined chill; but at first, a sensa- tion is felt down the back, as if cold water were poured upon it, which sometimes extends to the whole body; head-ache; red eyes; disagreeable taste in the mouth; loss of appetite ; pain in the back and loins, with a short breathing. 409. These symptoms, after a shorter or longer time, are fol- lowed by a glow or heat over the whole body; flushed face; anxious expression of the eye; restlessness; increased head-ache, perhaps delirium; oppression about the precordia; nausea, and sometimes vomiting of pure bilious matter; red eyes; and very dry skin; bowels almost always constipated; deficiency of urine, &c. perly so called, have " one series of increase," and with very little tendency to marked exacerbation or remission. Indeed, in a practical point of view, but little is, or can be gained by distinctions, without essential differences. For our curative intentions are derived from, (or always should be,) the state of the circulatory and nervous systems; and not from the period of exacerbation, or the time of remission, or the one being more intense, and the other a little more perfect. The remote causes appear to be the same. CONTINUED FEVER. 145 410. The pulse, not extremely frequent; rarely amounting to a hundred in the beginning of the disease; but may rise to one hundred and twenty as it progresses; always hard and full, re- sisting a considerable compressing force. 411. The causes of this fever, are bodily fatigue; great men- tal exertion; anxiety; long watching; passions and emotions of the mind; cold long applied to the body; checked perspiration; &c. &c* (marsh miasma?) Some of the British writers look upon this fever as contagious; but there is not the slightest ground for this belief; at least not in this country. Marsh mi- asma and excessive heat however, may be looked upon as the most frequent causes in autumn. 412. The exacerbations of this fever are almost always in the evening; in the morning an abatement of the frequency of the pulse; a diminished temperature of the skin, and a partial or ge- neral attempt at a solution of the paroxysm by sweat may be ob- served. But this, when not complete, is of short duration; for the fever becomes again very quickly, and sometimes, greatly aug- mented. 413. If this fever continue beyond the fifth or sixth day, without a tendency to amendment or crisis, we for the most part find the strength of the patient to fail with considerable rapidity; the pulse to increase in frequency; but is weaker, smaller, and perhaps irregular. The mind becomes more certainly unsettled; the tongue may now be dry; or brown, with a tenacious moisture; the heat of the body irregularly diffused; some portions more than ordinarily hot, as the head, chest, abdomen, and back; while the hands and arms; and the legs and feet, are preternatu- rally cold. Now and then, a cold sweat bedews the whole body; or it stands in detached portions, upon the marble-cold skin. 414. The urine for the most part, is scantily secreted, and is of a very high colour; or it may be unusually abundant, and of watery transparency, without a deposition. This fever, as no- * These are the common causes assigned for the production of continued fever—we should regard them in general as but the exciting causes. Marsh miasma may, we know, remain dormant in the system for a long time—so long indeed in some instances as to be lost sight of, though it was the verita- ble cause of the disease. 19 146 CONTINUED FEVER. ticed above, may degenerate into what is commonly called ty- phus; and it may pass off in an intermittent form. From this it appears, that it differs but little in essentials, from the com- mon remittent; and this variation may be looked upon, as rather accidental than necessary or constant. Location perhaps may have considerable influence in modifying the type of this form of continued fever; as it is found most frequently in marshy and wet situations. It was very frequently met with in the epidemic of this fall, 1828. 415. This fever differs from the ordinary form of the remit- tent common to our country, principally in, 1st, the exacerba- tions being less regular; 2d, the remissions more obscure, or less tendency to useful, or critical perspiration; 3d, greater discharges of pure bile; 4th, less equality in the general temperature of the body; 5th, more decided tendency in the extremities to become cold; 6th, cold colliquative sweats, stronger disposition to deli- rium, and a dry state of the tongue. But all of these variations are merely modifications of force in the disease. 416. The favourable signs in this fever, are a more equal dif- fusion of heat; a tendency to a general, warm perspiration ; di- minished frequency of pulse; less restlessness of body; more clearness, and steadiness of mind; tongue changing its dark, to a light, moist coat; diminished thirst; the free secretion of a urine that will yield a deposit of a brick-dust colour; and some- times a diarrhoea. 417. The unfavourable signs are irreclaimably cold extremi- ties; a profuse cold sweat, either general, or partial; increased frequency of the pulse, with an abatement of its strength ; great jactitation; muttering low delirium; picking of the bed-clothes; twitching of the nerves; increase of dryness of the tongue, and blackness of the teeth; hiccup; a suppression of urine; and above all, the patient not feeling the necessity, or possessing the abi- lity, to retract the tongue, after it has been thrust beyond the teeth,* for the purpose of examination; involuntary stools; apo- plexy; convulsions; death. 418. The mode of treatment of this fever is very analogous to that of the remittent, of which we have already spoken. The • We have been very attentive to this symptom for the last few years; and so far, we have not seen a recovery, where it had existed. CONTINUED FEVER. 147 nature and extent of the remedies will in great measure de- pend upon the force, and period of the disease. If in the com- mencement, while the pulse manifests vigour and activity in the vascular system; and especially, if much head-ache be present, bleeding should be resorted to, to an extent that will insure an abatement of the head-ache, and a decided reduction of the pulse. We cannot determine by figures, the number of ounces that should be taken; the effects above stated, as necessary to take place from the bleeding, should alone be the guide, as re- gards the quantity, and for the repetition of the operation. If the loss of ten ounces, or even less, produce the changes insisted on, the blood may be stopped; but if several ounces more are re- quired for this end, they must be drawn. 419. If there be less vigour of pulse, or so little as not to jus- tify the drawing of blood from the arm, either, after having been reduced by a previous bleeding, or from any other cause, it may be abstracted by leeches, or cupping, from the head, when this part is acknowledged to be a seat of pain; or if there be delirium, or stupor, a flushed face, and loud breathing, it should also be done. If there be much heat in the head, cold applications must not be omitted. 420. Should there be pain, or even considerable tenderness upon pressing the region of the stomach after depleting as above directed, or where there is no great embarrassment in the head, four or five ounces of blood should be drawn from this part, by the same means. 421. The alimentary canal must now be evacuated, after the same manner as has been directed, at page 81; and should these means produce a tendency to perspiration, it should be encou- raged by drinking of warm, weak lemonade, baum tea, or weak common tea. Should these means have been faithfully followed in the beginning, it will rarely be necessary to repeat them. But should the symptoms continue, and the pulse still be full and active, the lancet, and other evacuations must again be resort- ed to. 422. If the feet become cold, they should not be permitted to remain so a moment longer than proper applications can be made to them. These applications may be warm vinegar and mustard, or heated bricks; jugs of warm water, or the feet placed in a pail 148 CONTINUED FEVER. of warm water, in which salt, or mustard, is mingled. The first is to be preferred when the system appears rather prostrated; and they should be suffered to remain on until they produce redness, and pain. The second where the coldness is tempo- rary, and where the action of the skin is easily excited: and the third, when there is headache, delirium, and great rest- lessness. 423. During the continuance of the fever, the bowels are to be kept free after the first or second day, by the more mild pur- gatives; such as the castor oil, magnesia and salts; rhubarb and magnesia; Rochelle salts, and the Seidlitz powders. Should the evacuations, however, become very dark-coloured without odour, or very offensive, with a frequent inclination to use the pan without much passing from the bowels at a time,* small doses of calomel should be given, and continued, until they procure a change in the appearance, odour, and quantity of the feces.! 424- Should the bowels not be speedily or sufficiently obe- dient to the medicines exhibited, but become painful and tumid, they should be excited to discharge themselves by means of a simple injection. J If the stomach become very sick, and throw up bile, twenty grains of ipecacuanha should be given in a table- spoonful of lukewarm water; and its operation encouraged by draughts of warm water. But if the stomach be merely sick, or rejects a colourless, or a pea-green fluid, the emetic should not be given; especially, if there be a tendency to dryness of the tongue, or much tenderness at the pit of the stomach. • Great mischief is sometimes done, when this state of bowels exists, by the exhibition of laudanum, or other astringents, with a view to arrest their mo- tions; nothing can be more ill-judged than this. For it is every way certain, that this condition of the bowels arises from putrid bile, or other offensive matters, which have been thrown into the alimentary canal, and which require to be carried off by calomel and other purgatives. j- A grain of calomel should be given every hour, until five or six grains are taken; if these do not operate freely, let an half ounce of castor oil be given; and should this not produce the desired effect in two hours, let it be repeated. Or should the oil be offensive to the stomach, two or three tea-spoonfuls of calcined magnesia may be given. Under the circumstances above described, the purging should be continued until this dark and offensive matter be re^ moved; this will be known by a change of appearance in the evacuations. * For this purpose, one of the best Is a pint of warm water, and a table-spoon- ful of table salt. CONTINUED FEVER. 149 425. Blisters are highly useful in a certain stage of this fever; that is, after the more active and inflammatory stage has passed. At this period, if there.be a disposition in the feet and legs to become cold; if the remissions continue to be obscure; if there be no disposition in the skin to furnish a warm, gentle, and ge- neral perspiration; a tendency of the tongue to become dark and dry; blisters should be applied to the calves of the legs, and suf- fered to remain until they irritate the skin in a decided manner. This will be ascertained by the patient complaining of pain; and by the inspection of the parts to which the blisters were applied. Should they neither have drawn, nor have reddened the skin, they should be kept on until either of these changes take place; we say either, for if they have blistered, nothing more can be expected; or if they have well reddened the surface on which they have been applied, vesication will be sure to follow, if the part be dressed with basilicon ointment. (See Art. Basilicon Ointment.) 426. These applications may be repeated if the disease still persists in its course, or if the system appears reluctant to pro- duce a crisis, either by the skin, or by the bowels. If a crisis take place by the skin, the transpiration will be general; more or less profuse; the skin will become cooler, but still a little warm; that is, rather above the natural temperature; thirst will diminish; the head will be relieved; delirium, if it had been pre- sent, will abate; and the pulse become less frequent, more full and softer. If by the bowels, the same reduction of the unplea- sant symptoms will take place, with the exception of the state of the skin; this will not transmit so much fluid, though it will be inclined to moisture; and the reduction of its heat will not be so rapid. 427. But if neither of these events happen, a pair of blisters to the arms may be of great importance. Or, if the tenderness remain at the pit of the stomach, abstracting three or four ounces of blood by leeches, will sometimes produce the desirable changes above stated, in a very short time after the operation. 428. We do not think that Dr. Good has followed the most natural arrangement for his three species of continued fever. The typhus and the synochus should have changed places—at 150 CONTINUED FEVER. least it would be so in this country. We shall, therefore, fol- low the latter arrangement. Synochus Form. 429. The synochus fever does not differ from the one just de- scribed, in either its causes, or its general phenomena. The only essential difference that can be detected, perhaps, is a lesser de- gree of inflammation. With this in view, the treatment will be as easily conducted as the one just noticed. It will be proper, however, to bear in mind the following modifications of the practice detailed above. 430. First. That, as there is less inflammatory action in this form of the disease, a lesser quantity of blood will be required to be drawn. 431. Second. That the want of vigour of the arterial system may be such, as to render bleeding from the arm altogether un- necessary. 432. Third. Though this may be true in some instances as regards general bleeding, still, it hardly ever occurs, that the to- pical abstraction of blood is not absolutely necessary—for, where there is head-ache, red eyes, flushed cheeks, a hot skin, and perhaps delirium, blood taken from the temples, by leeches, or cupping, forms an essential part of the treatment. 433. Fourth. If, under such circumstances, there be tender- ness at the pit of the stomach, nausea, and vomiting of thin fluids, or glairy mucus, the blood should be abstracted from the tender part, by either leeches, or cups. 434. Fifth. Though the system may permit only a moderate expenditure of blood, yet the bowels will almost constantly re- quire to be free; the extent, however, to which this action must be carried, will very much depend upon the appearances of the evacuations themselves; recollecting, that while the stools are dark, offensive, and bilious, the bowels should be kept constantly open by the milder purgatives,* and the occasional employment of calomel, after the manner already directed. * There is no practical error greater, than the one, that supposes, there is a necessity of employing the most active purgatives, in the treatment of fevers. As the bowels are sometimes tardy, and as the relief, when this reluctance is CONTINUED FEVER. 151 435. Sixth. That the purging must be withheld, for a time, if the stools are very sparing, watery, and mixed with the white mucus of the bowels, or blood; or urged less freely, if bile of a healthy bright yellow colour appear. 436. Seventh. Should the skin continue to be dry, and hot; if the pulse be frequent, and even but moderately tense, the neu- tral mixture, with tartar emetic, should be given every two hours; (see p. 341) provided the stomach is not nauseated, or too irritable, to bear the tartar emetic. In this case, the neutral mixture alone should be administered. The application of blis- ters will be regulated by the rules laid down above. 437. In this, as well as in every other form of continued fever, much benefit is derived from sponging the body with cool, or cold water, whenever the skin is hot; provided there be no moisture upon the surface at the time, or no cough, or other pneumonic symptoms attend, as has already been directed under the head of " Remittent Fever," page 109. 438. During the whole course of the disease, the diet should be strictly antiphlogistic; and the drinks the same as before re- commended. (See par. 214.) overcome, is both striking and salutary, it has been imagined, that the more certainly, and speedily, this could be effected, the better for the patient; hence the almost universal use of the drastic purgatives, as calomel and jalap; senna; scammony; gamboge, &c. &c. Now, let it be again repeated, that in all fevers there is a constant liability, (if it does not always exist,) of the mucous mem- brane of the stomach and bowels to become inflamed; and, consequently, that all irritating substances must be highly prejudicial to this condition of this very important surface. This is not a refinement in doctrine; nor an instance of pa- thological theorizing; it is a constant, and valuable practical fact, and must never be lost sight of. The evidence of the mischievous effects of the drastic purgatives might be constantly observed, were practitioners as attentive to the phenomena presented by an inflamed, or highly-irritated mucous membrane, as they should be. They might see the mucus of the intestines coming away in quantities, with little or no fecal matter, when the mucous membrane was only severely irritated; this may be either marked with streaks, or accompa- nied by a greater or less quantity of blood; or when this coat is inflamed, they might witness profuse, watery discharges—let either of these signs be a warn- ing, not to employ such active medicines, or to withhold every kind, for a while. 152 CONTINUED FEVER. Typhus Form.* 439. The typhus species, of continued fever, seems to be al- together misplaced, if it be looked upon as a consequence of in- flammatory fever. For a typhus fever, properly so called, may be regarded, as a distinct and peculiar form of fever; for it has not the same general causes for its production; it does not exhi- bit the same phenomena; nor does it yield exactly to the same mode of treatment. 440. The form of fever which we are now to consider, de- pends for its existence upon a state of previous high excitement, and is always a consequence of that condition. And though it shows a number of symptoms, extremely analogous to an origi- nal typhus, yet it does not bear with success the same kind of treatment, if we are to credit the cases of many of the European writers. (See Chap, on Typhus.) 441. We consider the typhus tendency after an inflammatory or even the synochus fever, to be altogether contingent; at least we have never seen an instance in which we thought it was ab- solutely and essentially consequent We have been called upon to witness this state of the system, where the disease had been either neglected or badly treated; but we can with the most per- fect truth declare, that this condition has never happened in our hands, where the patient was under our care in the early stage of his disease, or where our plan of treatment has not been in- terrupted, by the improper interference of friends—that is, we never have seen in our practice, that state of fever called typhus by many, and which agreeably to them, requires stimulation for its cure, but under the circumstances just named.' 442. We are perfectly persuaded from long, and carefully made observation, that the fever almost universally called ty- * We are perfectly aware of the impropriety of this term in this place; (see Chap, on Typhus,) but we make use of it because it is familiarly employed in this country to denote the state of the system now to be described. And were we to reject it for a more appropriate term, we fear the condition of the sys- tem about to be noticed, would be less vividly conveyed to the mind of the reader, who had become familiar with the appearances in question, and who had been in the habit of regarding this state of fever, as a real, or genuine ty- phus. CONTINUED FEVER. 153 phus, for the most part is of artificial origin;* and farther, that it is constantly in the power of improper management to con- vert the most inflammatory fever .into this much-dreaded state of the sytem; and this by the most simple and easy process ima- ginable. To effect this terrible change, for such it really is, it is only necessary to deplete insufficiently; or to over-stimulate, during the phlogistic state of the system. 443. What we have just advanced, we believe to be most strictly true; and this convertibility being observed in this dis- ease, though it had an artificial, or contingent cause, it has been mistaken for an inevitable consequence; to guard against which, means are employed, which only hastens, and makes sure, the evil. A dry, dark tongue; a hot skin; a flushed face; a tendency to delirium; and an irritated pulse, are sure to be called typhus, and is too constantly treated as a disease of absolute weakness. Stimulating and tonic remedies are resorted to, and the system is goaded into gangrene, and the patient into the grave, in the course of a short time. 444. Now, we are of opinion, that the above-named train of symptoms do not constitute a typhus fever, in its true meaning, though typhus, has all of them as attendant symptoms; for they will seldom, or never yield to the stimulant plan of treatment; while we are told, and perhaps bound to believe, by the greater part of the writers, that typhus is sometimes cured by bark, wine, volatile alkali, &c. (See Chap, on Typhus.) 445. Our experience is decidedly against this mode of prac- tice; for we have not unfrequently, when called upon to pre- scribe for this artificial disease, witnessed that it would yield, with pretty constant certainty, to a perseverance in the anti- phlogistic and temporizing plan of treatment. We have often ab- stracted blood, both from the general system, as well as topi- cally, when all the symptoms enumerated, and which are sup- posed to constitute typhus, were present; and we have witnessed them to change their aspects immediately. For by these means, the dry dark tongue, we have had, (sometimes in the course of • We may with much propriety call the cases, now under consideration, that is, such as have been neglected in the early stage of the disease, "accidental typhus," since we have agreed to retain the term typhus, for the reasons just stated. 20 154 CONTINUED FEVER. an hour,) a moist, whitish one; for the dry, hot skin, we have had a cool, moist one; for the flushed face, we have had a pale one; delirium has been arrested; and the irritated pulse, has been converted into one of a mild, and open character. 446. One of the most dangerous errors in the practice of me- dicine, is prescribing for the name of the disease, instead of at- tending to the state of the system—that is, paying a strict atten- tion to the state of the pulse; the degree, and seat of pain; and the state of skin. For if the pulse be tense and active; pain acute; especially, if in the head, chest, or region of the stomach; the skin hot, and dry; the tongue dry; the teeth encrusted, and the mouth black; the fingers employed in picking the bed-clothes, or the arms twitching with subsultus tendinum, we would not hesitate to abstract blood in one way or other, be the period of the disease what it may. 447. Nor would this be all; we would purge as just directed, (page 81,) and observe a rigid antiphlogistic regimen through- out We would do this, because we could appeal to our experi- ence for the comparative success of the two methods; for the time was, when we went with the current; stimulated as fear- lessly as any one; and lost patients as certainly as any other practitioner. But for the last ten years we have abandoned this mode of treatment; and by doing so, if we do not.deceive our- selves, we have carried patients through, that would, we sin- cerely believe, have succumbed under the other plan. 448. If then, we have the misfortune to meet with this artifi- cial disease, we treat it, as if there were still a lurking inflamma- tion present in some one of the viscera; or as if the morbid irri- tation of the pulse could only be subdued by a sedative, or tran- quillizing mode of Treatment. That is, by aperient medicine; the (perhaps) loss of blood; a mild regimen, and the total ab- straction of all stimuli, either in the form of food, or medicine, if we except the occasional employment of blisters; or now and then, perhaps the use of laudanum. To be successful therefore in this state of fever, only requires, that the evacuations should be suited to the condition of the system, for evacuants must be em- ployed. 449. But let us not, however, be understood to insinuate,that no recoveries take place under the stimulant plan of treat- CONTINUED FEVER. 155 ment; for certainly there are instances of this kind; so there have been escapes from shipwreck, or the carnage of battle; or from the deadly plague itself, under the most preposterous treatment possible, or under no treatment whatever. But can any one flat- ter himself, that the recovery of a patient from typhus, after the use of stimulants, is an instance of the triumph of remedies ? Have not the natural energies of the system done most in ef- fecting the cure? 450. Let us now consider the state of the system; while labouring under a fever so commonly, though so wrongly, called typhus; and in doing so, let us fairly and without preju- dice, endeavour to ascertain the precise state of the arterial, and nervous systems, at this time; and from this examination, see whether, a stimulating plan of treatment, is fairly deducible. 451. In all the cases we have witnessed of this disease, symp- toms, decidedly marking, an inflammatory state of the system, had been present, to a greater or less extent; or for a shorter or a longer period—that is, there had existed, a hot dry skin; a pulse full and hard; head-ache, of more or less severity; high-coloured, or very pale, crude urine; a white slimy tongue, and sometimes local determinations, manifested by acute pain, &c. Now if these symptoms do not betray a phlogosed condition of some one of the viscera, we should be at a loss to determine, an inflamma- tory state of the system under any circumstance, and if they do not call for the employment of the lancet, or other depletory means, we do not understand in any case whatever, where they are indicated. 452. But should these means be neglected, inadequately urged, or too soon withheld; we shall find, a change in several of the phenomena; but none in the general character, or type of the - fever. There will as certainly be present, an inflammatory con- dition of the system, as there was before the change took place, either by neglect, timidity, or improper views. And though the system will not bear depletion to the extent, it would have done before the vessels had in part destroyed their own powers by excessive previous action, it nevertheless requires it to an ex- tent, that must be regulated by the apparent force of the symp- toms at the moment—at all events, tonics and stimulants, will be destructive. 156 CONTINUED FEVER. 453. The pulse, and the local determinations, will be never- failing guides upon such occasions to the attentive observer; especially, when combined, with several other of the pheno- mena above enumerated; as the flushed*face, hot skin, deli- rium, &c. &c. 454. The pulse in such cases, will constantly declare its irri- tation ; that is, it will be both quick, and frequent; (see p, 351,) with a marked degree of incoiaipressibility, though small in point of volume; and these are never-failing marks, that the system is labouring under phlogosis, in some one part or other; and from which, it cannot be relieved, but by adequate, and well-directed evacuations. 455. Now, the great error in practice lies, in mistaking this state of pulse, for a pulse of debility; because, it is accompanied by certain changes in the febrile phenomena, which have been too constantly and wrongly associated, with a state of debility, and which it is supposed, requires for its removal, tonics and stimulants. The other symptoms accompanying the state of pulse just described, unfortunately, from mere association, lead to the same conclusion. Such are the dry, and loaded, or the dry, and polished tongue; a circumscribed red, or hectical check; con- fusion of intellect; a hot, parched skin, and more or less of sub- sultus tendinum. We-would now ask, is there any thing within the range of pathological research, or practical observation, that countenances the belief, or that establishes the fact, that the symptoms above enumerated, are proofs of an over-prevailing debility, which can only be removed by tonics and stimulants? 456. We hesitate not, to say, there is no observations, either pathological, or practical, that can lead to such copclusions. On the contrary, we can with the utmost confidence declare, that we have seen all these symptoms vanish, by general or topical bleeding; by purging; by a strict antiphlogistic regimen; by sponging the body; by cold local applications, and by sudorifics. And farther, that we have almost invariably seen them aggra- vated, by the tonic, and stimulating modes of treatment. 457. There seems to be a species of infatuation upon the sub- ject of typhus, that is no less surprising, than mischievous. Sur- prising, because, no adequate cause can be assigned for it; and mischievous, because, it leads to the employment of remedies CONTINUED FEVER. 157 which are decidedly destructive of human life; for the appre- hension of an event, which in itself, is altogether contingent, leads to a practice, that seems the absolute production, of this ar- tificial species of typhus. Thus, .the fear of debility, and its sup- posed inseparable attendant, (typhus,) are attempted to be guard- ed against, by the administration of remedies, altogether unsuited to the nature of the disease; or rather, to the condition of the system. The nervous and vascular system, have now to contend with the force of the remote cause, as well as to bear with the stimulation, which a narrow pathological view, has called into requisition. 458. The disease in question, ruas an anatomical character without doubt; and though, we do not consent either to Brous- sais, or Clutterbuck's exclusive locations, for this character, (as both are certainly right at times,) yet we are persuaded, that in every instance of this disease, some one portion of the system, has been acted upon in an especial manner by the remote cause; which will have the effect perhaps, of modifying the force, and perhaps the succession of phenomena attendant upon the disease when about to be developed, or after this has fully taken place. 459. We cannot well be certain that there is not a phlogistic state of some one portion of the system; and which may be the cause of the irritated pulse, and the other symptoms attendant upon this state of fever; for sometimes we have no other evi- dence of its existence than the pulse; as there may be no local pain to detect the lurking mischief. In this situation of things, that is, of local inflammation, stimulants would be highly inju- rious; for they would with the utmost certainty increase the mis- chief they were intended to remove. 460. It is therefore always safest to trust to the mildest, and most temporising plan of treatment; by this we give the recu- perative powers of the system a chance of doing something in favour of the patient. On this account we pay attention, first to the state of the alimentary canal; and if this be affected by loose, black,-fetid stools, we give mild aperients until their cha- racter change; for it is in vain to attempt the relief of the sys- tem, while these stimulating substances occupy the intestines. Second; we pay a great regard to the condition of the skin; if this be dry and hot, we cause it to be sponged with cold water, 158 CONTINUED FEVER. and give the neutral mixture, or the sweet spirit of nitre;* if partially cold, we endeavour to establish an equality of tempe- rature, by warm applications. Third, to the state of the lower extremities, and the degree of intellectual sensibility. If the legs are disposed to become cold; and there be delirium or stu- por, we apply blisters to the calves of the legs. If there be no unusual tendency to coldness in the limbs, and if the mind be much affected, we have the blister applied between the shoulders and down the spine. Fourth; we attentively watch for the ap- pearance of local inflammations, or determinations. The ex- istence of these, are sometimes, it must be confessed, sufficiently obscure, if no other symptom than pain is to be regarded as evidence of them; but in this we must not be mislead; since pain is not the constant attendant upon these conditions; the pulse must be attentively examined. It will be well to bear in mind, that both inflammation, and congestion or engorgement, may hap- pen at any period of the disease; and when extensive, will very much influence the treatment. For though inflammation may really exist during the whole progress of the disease, or super- vene at any period of it, yet its character will in great measure be determined, as it may be initial, or secondary. In the first * There are few articles which are so decidedly refreshing to the over-heat- ed system, and the parched mouth, as the sweet spirit of nitre; it may be given in forty-drop doses in a little sugar and water, or combined in a smaller proportion with the neutral mixture, or Mindererus' spirit, (see Art. Spirit of Mindererus. We may here however make a few observations upon the sweet spirit of nitre, that are of great practical import. This medicine is by most practitioners looked upon as possessing very few positive powers, or active properties—it has therefore been most negligently prescribed, and has in con- sequence often disappointed expectation, for which it has been as loudly as unjustly condemned. This discrepancy has arisen, from improper doses hav- ing been given; for it is commonly received as a mere placebo; this is a mis- take. This medicine when given in small doses, (that is, doses not exceeding forty drops once in two hours for an adult, and in proportion for children,) has a most tranquillizing influence upon the system when it is labouring under fever of feeble action, and dry skin. It also disposes with considerable cer- tainty to the surface; especially, when combined with the neutral mixtures, and antimony. And it contributes very happily to diminish the unpleasant after effects of laudanum; we have known patients most pleasantly influenced by this combination, that would have suffered, (if they could trust their former experience,) very much, had they taken the laudanum alone. CONTINUED FEVER. 159 instance, it will bear a greater loss of blood, than in the seoond; and the loss of blood, either directly or indirectly, is absolutely necessary. In the first case, especially in the early part of it, bleeding from the arm may be essential, and which will be clearly indicated by a full, tense pulse; in the second, leeching or cup- ping the part, which is the seat of the local aberration, will be all that may be required; or that the system will bear. 461. We have said that pain does not always betray the exact seat of the inflammation, or engorgement; this is strictly true; but the spot or viscera, may be known with considerable accu- racy, by certain embarrassments in the functions of such viscera as may be affected. Thus by delirium, we may declare with almost a certainty, that the seat of the local affection, is in the brain or its appendages; a hurried, very slow, or a laborious breathing, may detect its seat in the lungs, or pleura; by a sore- ness, fulness, and a desire to lie upon the right side, we may have a just suspicion that the liver is its location; by a very scanty supply of a very high-coloured urine, or an entire sup- pression of it, we may declare the kidneys to be involved. 462. This being determined with as much certainty as the na- ture of the case will permit; the proper remedies immediately present themselves; namely, bleeding, followed in many instances by blistering. In the first case, blood may be abstracted from the forehead, by leeching, cupping, or by the division of the temporal artery. The quantity to be drawn must always be de- termined by the violence of the symptoms, and the state of the pulse. In the second, cupping or leeching should be performed from the lower part of the neck, and from between the upper portions of the shoulder blades. In the third, from immedi- ately over the region of the liver, and by the same means. In either of these cases, the loss of blood may be followed by a blister; a, when the head is affected, upon the neck over the parts pointed out for the cupping or leeching; b, when the chest is affected, to the same part; c, over the region of the liver, when that organ is the seat; d, by leeching or cupping, from immediately over the kidneys. (See pars, 418, 419, 420.) 463. We order as drinks barley water, gum Arabic water, tamarind water, toast water, or weak lemonade, to be given cold; in small quantities; but to be frequently repeated; and the thin 160 CONTINUED FEVER. jellies of tapioca, rice, or sago sweetened, and rendered pleasant by lemon juice, to be given from time to time, in very mode- rate quantities, as nourishment. We prohibit in the strongest, and most unequivocal language, the use of any animal juice, or jelly, in any shape or form whatever; as well as every stimulat- ing drink, or liquor, either fermented or distilled. The free ventilation of the room, by the constant admission of fresh air, is an indispensable attention in this form; therefore all the means and cautions suggested in page 30, must be faithfully at- tended to. Also changing the body, and bed-clothes, as often as circumstances will permit; especially, if the weather be warm. We must never listen to the idle prejudice of many, that "chang- ing the clothes often, is weakening." 464. Let us now enquire into the state of the nervous system, in this fever. In doing this it will be well to consider, first, the remote, or morbid agents; second, the part of the system on which they exert their, influence; and third, the phenomena re- sulting from their application. In pursuing these enquiries, it may be well to suggest, that the nature of the present work, will only permit us to glance at each of these subjects. 465. First. The remote, or morbid agents, capable of causing fever, may be, a, marsh miasmata; of these effluvia, we know nothing; either chemically, or physically. They have eluded every attempt at examination hitherto made; nor is it probable, that either chemical tests, or analysis, will ever instruct us in their absolute nature. The spots from whence they emanate, are well known; but the causes necessary or accessary to their formation, as poisons, are at present altogether inscrutable. It is true, we are acquainted with certain physical agents that are essential to their existence; as heat, moisture, and vegetable pro- ductions; but more is required than these, for the formation of the remote cause of fevers; as we see these three agents united frequently without the production of malaria. As regards the mere physical properties of the air, it is not necessary to the production of malaria, that they should be in the slightest degree deteriorated, if we can place any reliance upon the experiments performed with a view to determine this point For the causes of malaria exist without the possibility of detection in an atmos- phere, that offers to the tests of the philosopher, proofs of the CONTINUED FEVER. 1 (i 1 most entire salubrity. We therefore shall lose nothing by con- fessing our most entire ignorance as to the nature of such miasms, as are capable of causing fever; with their effects only are we familiar. 466. These remote agents may exist however, in different degrees of concentration, or dilution; and on these degrees, will the nature of the fever, or rather will the different phenomena and type of fever depend; making at the same time allowance for individual susceptibilities. 467. b. These agents may be a product, sui generis perhaps; arising from the combination of bad ventilation; effluvia from human bodies when too closely confined, or too closely crowded together; with a deficiency of wholesome food and drinks. 468. c. They may arise from a diseased body; and thus pro- pagate themselves by sending forth noxious emanations, which when received in the healthy body, are capable of exciting in it the same kind of action, by which they themselves were produc- ed—that is, by contagion. 469. Second. The part of the system on which these morbific agents act, must necessarily be the nervous system, as we know of no other that gives susceptibility. Their action upon this system will be in different degrees, as the poison may be more or less concentrated, as the dose may be larger or smaller, or as the susceptibility may be more or less exalted. The particular part of the body to which these remote causes are applied, so as to act upon the nervous system, is not so settled by physicians as to be beyond the power of controversy—the greater number of pathologists, however, incline to fixing the seat in the sto- mach. 470. Third. If the remote causes be susceptible of the modi- fications above named, and the nervous system liable to the different degrees of susceptibility just spoken of, it will follow, that the influence of the remote cause will be in strict obedience to these conditions; and hence the different character or type of fever. It will, therefore, happen, that a certain dose of the poi- son, with a given degree of nervous susceptibility, will in one instance produce fever, the character of which shall be highly phlogistic; another as strictly inflammatory, but not as highly so; another with still less of the inflammatory type; and with a 21 I 63 CONTINUED FEVER. fourth, the nervous power may be so prostrated by the strength, or concentration, or peculiarity of the poison, or the remote cause, that no febrile reaction wjll take place. 471. It will then be evident, if this be true, that all fevers may be comprised under two general heads, namely; 1st, those in which there is a greater or lesser degree of inflammation; 2d, those in which inflammation does not exist; as in the worst forms oipure typhus. (See Chapter on Typhus.) 472. The first effect of the remote cause we have observed, we is upon the nervous system; to which, however, it is but a short time confined; for such is the nature of the arrangement, and of the mutual relation between it and the circulating system, that the latter is soon called into action; and the quality of this sym- pathetic action will be determined altogether perhaps by the de- gree of impression made upon the former. So intimate and in- separable are the relations between these two systems, that the one cannot be acted upon with any force by the remote causes just named, without exciting the other to inordinate action, or prostrating it below the power of action. 473. The circulatory system, however, is evidently dependent upon the nervous, for the various modifications of its action; while on the other hand, the nervous system is reciprocally de- pendent upon the circulatory. 474. Thus, the circulatory system could not have its action maintained without the aid of the nervous; nor could the latter perform its functions longer than the former continued to circu- late a healthy blood. For the instant that venous or unoxygenated blood is made to circulate in any part or portion of the nervous system, that instant that part or portion has its actions to abate materially, or altogether to cease. If this should be in the brain, or the medulla oblongata, respiration would be very imperfectly performed, or death would ensue, from this process being stopped. If there be only a small deficiency of oxygen in the blood, the circulatory system will feel the loss of this abstraction; but the change will be less marked. If the blood be more than ordina- rily charged with oxygen, the circulatory system will present phenomena that mark that form of fever called inflammatory; and the nervous will be exalted to great sensibility, or extreme mobility. CONTINUED FEVER. 163 475. It will therefore follow from what has been said, that the character of febrile phenomena will almost exclusively de- pend upon the impression made by the remote cause upon the nervous system, be the nature of that remote cause what it may. —hence the variety of types in fever. 476. The blood itself, while circulating, is also subject to changes in its structure, if we may so term it; and from these changes, some of which are made evident to our senses, much is inferred in the treatment of diseases of the febrile kind. To be acquainted with the more evident sensible properties of the blood, is very satisfactory, but not always so important as is generally imagined. For from the appearance of the blood alone, we should not deduce, either the necessity for its farther abstrac- tion, or for our withholding the lancet. If we did so always, we should sometimes abstain, when its loss would be all-important— for instance, when it is in the condition called dissolved; as is the case sometimes in the commencement of violent onsets of yellow fever; (see par. 389,) or, we should continue to draw it, ' when each loss would be but to hasten the death of the patient; as in hectic and in rheumatic fevers; for here we have seen it cupped or sizy, but a short time before death. 477. Now all the varied appearances of the blood are caused by the particular actions of the heart and arteries; and the heart and arteries must necessarily depend upon the state of the nervous system, for their peculiar mode of action. Changes are therefore effected upon 'the whole mass of circulating fluids in the course of a very short time. And these changes are not less remarkable than sudden sometimes; thus death, from a blow upon the sto- mach, or from lightning, are said to prevent the coagulation of the blood. 478. From this view of the subject, the nature or quality of the remote cause is not a matter of indifference, at least as re- gards the phenomena and type of fever. Those arising from marsh miasma, in otherwise a healthy or a duly oxygenated at- mosphere, are generally fevers of the sthenic or inflammatory kind, provided the poison be not too much concentrated, or the dose too large; for the mere presence.of oxygen does not destroy the cause of malaria. But the absence of this important principle renders, (perhaps miasmata,) but certainly the combinations of 164 CONTINUED FEVER. the various exhalations arising from filth, and from human bo- dies in crowded places, much more active or virulent. 479. Of this, however, we have few opportunities to witness, in this country, though some of our public institutions, when "unusually crowded, bear testimony to the truth of the statements of the European writers upon this subject. It seems to be agreed that the character of a fever generated in an impure atmosphere, will be quickly altered, by a change to a more pure situation. By this change, two very important circumstances take place, both of which doubtless contribute to the alteration in the cha- racter of the fever generated in the impure atmosphere—namely, a due and healthy supply of oxygen, and the removal from the impurities to which the location was liable. 480.. So marked, indeed, is the influence of this change some- times, that we are informed by Dr. Burne, that " patients in whom, in their own habitations, the powers of life were very low, and indicating cordials, became so altered after the removal, as to have a vigorous circulation, and signs of inflammation, which call for the abstraction of blood."* 481. In these cases, and in all others of the same character, the inflammatory nature of the disease was only masked by the impression made upon the nervous system by the remote cause or causes; giving to the system a fallacious appearance of pros- tration and feebleness, which would be as certainly augmented by stimulants, as it would be diminished by well proportioned depletion. How depletion acts in such cases to remove or dimi- nish the force of the remote causes, our limits will not permit us to enquire. All that is necessary to understand is, that it is a practical truth, or else all the latest and best writers upon the subject are greatly deceived. And this similated or indirect weakness, must not be mistaken for an absolute exhaustion, and be supposed to require for its removal, cordial and stimulating remedies. 482. The disposition which certain continued fevers discover, sometimes even in the early part of their course, to take on, or similate the typhus type, has too frequently led to the most de- structive practices for its cure. We have inculcated this belief • Burne on Typhus or Adynamic Fever, p. 43. CONTINUED FEVER. 165 on our part, again, and again; in the hope, th'at those who may have the management of fevers under their care, may at least pause, before they decide against a plan of treatment, opposite to their usual routine, but which we most sincerely think has both reason and experience on its side. The best, and latest Euro- pean writers upon the subject in question agree, without a dis- sentient voice, upon the following general principles. 483. First That in all adynamic fevers, there is more or less inflammation almost constantly present, either general, or local. 484. Second. That even during this more or less inflamma- tory condition of the system in general, or in portions of it, that the most unequivocal evidence exists, that, a certain combina- tion of symptoms will present themselves; such as a dry parched tongue, and lips; flushed cheeks; low, muttering delirium; a dry, rough, unrelenting skin; lying upon the back, with the legs drawn up; high-coloured, scanty urine; subsultus tendinum, picking of the bed-clothes; and which symptoms, have constantly, or with very few exceptions, been called typhus, or typhoid symptoms. 485. Third. That the symptoms just enumerated, do not give evidence, that all inflammation is at an end, when they make their appearance, as is generally supposed. 486. Fourth. And that when the treatment is made to con- firm to such opinion, by the employment of tonics, and stimu- lants, that the most serious consequences have followed the prac- tice. 487. Fifth. That though the symptoms mark a less active state of inflammatory action, yet that the action present, never- theless is of the phlogistic kind; and cannot be relieved by a stimulating plan of treatment 488. Sixth. That nothing in practice, is more decidedly wrong, or more actively mischievous, than the belief, that, when the system will not bear active depletion, that it necessarily calls for the opposite mode of treatment. 489. Seventh. That it is now agreeable to the best experience, that, the employment of stimulants, is sure to be followed by a marked increase of every bad symptom; and that when reco- veries have taken place under the stimulating plan of cure, they 166 TYmus. have only marked the strength of the recuperative powers of the r .system, and not the elegibility of the plan adopted. 490. Eighth. That when the system is in that forlorn condi- tion, in which we dare not deplete; and that we must not stimu- late, it is the best, and most successful practice, to remove all the physical causes in our power, that may have a tendency to de- press the oppressed system; such as impure air; offensive smells; soiled clothes; too much heat; too low a temperature; too great a weight of bed-clothes; and too much company. To adminis- ter such kind, and quantity of nourishment, from time to time, as will offer the least trouble to the feeble digestive powers; (such as has already been specified at par. 217,) and such drinks, as will make an agreeable impression upon the gustatory nerves; but which shall not convey to the stomach, any decided stimu- lating agency. To promote to the last, the alvine discharges; either by injections, or by the mildest aperients;* to effect, (and if necessary by even artificial means,) the flow of urine. CHAPTER VI. TYPHUS. 491. The disease, strictly called typhus, we have never wit- nessed, though we have strong ground for the belief, that it has occasionally appeared in the alms-house of this city. The disease bearing this name, has several very important, and remarkable peculiarities, which serve to distinguish it from every other form of fever; and which has induced Dr. Bancroft to say— • In the last stage of the fever under consideration, it is a matter of great consequence to secure a regular daily discharge from the bowels; for this pur- pose we have proposed the mildest aperients, and injections. Of the former, the simple syrup of rhubarb is one of the best—a tea-spoonful of this may be given once in an hour or two, until the effect is produced; or simply a solu- tion of manna in the drinks of the patient, will often be sufficient. The in- jections at this period, may be simply, warm molasses and water. If diarrhoea (but not if it be of the critical kind,) attend, it should be moderated by the chalk julep; or by small doses of laudanum. (See Chalk Julep.) TYPHUS. 167 492. " I believe in the existence of a fever, sui generis, strictly contagious, (unconnected with any of the exanthematous dis- eases,) and, therefore according to my view of the subject, de- rived exclusively from its own specific cause, or contagion. In this, which I consider as the only contagious fever, there are I think, some varieties; but without any differences sufficient to form more than one species."* 493. The opinions of Dr. Bancroft, upon this subject, are very valuable, as every reliance may be placed upon his facts. They are for the most part derived from his own observations, for which he had frequent opportunities, as well as large sources to collect from; we shall therefore, cite in his own words the reasons for the opinions, just stated. 494. He says, p. 89, et seq. "Every thing which I have been able to discovery or ascertain, respecting the nature and proper- ties of contagion, induces me to consider each of its several spe- cies as a peculiar morbid quality or power, imparted to certain animal secretions, in consequence of some particular, though un- known, actions excited in the living body, when actually dis- ordered, by the very same species of contagion previously, and in like manner, elaborated in another body whilst labouring un- der a similar disorder from a similar cause; and therefore, though we ar& unacquainted with the origin of any one. species of con- tagion, yet, considering the properties manifested by all, ever since they have been known to exist, we may conclude, that being thus produced, exclusively by, and within the living body, each is capable of exciting, in other bodies, the same morbid ac- tion, or disease, which occasioned its own production, and of thus maintaining and propagating itself, indefinitely; and conse- quently, that though contagion be a morbid and morbific secre- tion or production, it is also, a natural one, wholly, inimitable, either by accident or art. If this be true, it must follow that, though noxious vapours should result from those fortuitous, and ever-varying, collections of unclean or putrifying matters com- monly denominated filth, which as in the instance of marsh efflu- via, may produce diseases, including fever, yet the diseases so produced will be incapable of exciting similar diseases in other • Bancroft on Yellow Fever, &c. Davidge's Ed. p. 337. 168 TYPHUS. persons, and will therefore be destitute of the most essential pro- perty of contagion.'' 495. From these facts, the following important conclusions may be drawn ; first, that typhus fever is a contagious fever; that is, it is capable of propagating itself; second, that it is the only fever that possesses this quality, if the exanthemata be excepted; third, that the contagion or poison of typhus, is suigeneris; and bears no analogy to the emanations from fevers, which have con- fessedly other causes, than the contagion, or poison of typhus for their production; fourth, that exhalations, from any putrifying masses, whether animal or vegetable, are incapable of producing typhus. 496. We learn also from the same source, that typhus is very much confined to Great Britain; and that when it has become prevalent in other places, it was constantly introduced into such places from Great Britain, if we except Holstein and Denmark, where typhus is a frequent disease; and such an introduction took place in the year 1809, by the Spanish army under the Marquis de Romana. 497. Dr. Bancroft has proved beyond all controversy, that neither moisture alone; putrifying animal or vegetable matter, nor both; nor crowding the sick in ill-aired hospitals; or the well, in a confined space, as the black hole of Calcutta, has ever in a single instance produced typhus. The proofs offered by this candid, and enlightened writer, are so numerous, that our limits, will not even permit an analysis of them; we must therefore re- fer the curious, to the work itself. 498. We have already in several places, borne testimony against confounding a certain condition of the system, in the yellow, the continued, and the remittent fevers, with typhus; because they bear no analogy to it, as they all want the power of propagating themselves, by contagion. This confusion in terms, has necessarily led to injurious practice; and when mischief re- sults from this want of discrimination, it becomes the duty of every physician to oppose such an amalgamation. But Dr. Ban- croft does not stand alone in what he has advanced on the sub- ject of typhus; he is supported by several other writers of emi- nence, and especially, by Armstrong, who has professedly treated of this subject. He says, "it strikes me, that to call any spe- TYPHUS. 169 cies of fever, typhus, which has not the contagious essence, ca- pable of producing an unequivocal typhus, is equally incorrect in logic as in language." He therefore informs us in his valu- able essay upon this subject, that " the word typhus shall be limited to the peculiar disease, which is allowed to originate from a specific contagion, and which doubtless, has the power of producing an affection of its own nature, in individuals -ex- posed to its influence." p. 7. 499. Dr. Davidge says, " the typhus is not, so far as my ob- servations have extended, a disease of Maryland, perhaps not of America; at any rate, not south of the New England states. And since, as Armstrong and Bancroft, and most other enlight- ened physicians, admit contagion as essential to typhus, (I here refer to the typhus of Britain and Ireland,) it must be highly absurd to speak of the typhoid condition of diseases, in regard to those diseases that are not admitted to be contagious in any stage. For surely, no disease can be said to be like another, that is deficient in an essential quality. Hence, it appears, how unphilosophic the language is, that states the low and collapsed condition of the body, in remittent bilious fever, synocha of the winter, or pneumonia, to be typhoid. These diseases are wholly distinct from typhus, in all their stages, cause, and sensible phe- nomena."* 500. Typhus is a disease of cold weather exclusively; and its progress is as certainly as constantly arrested by hot, or even by warm weather, as yellow fever is by cold weather, or frost. This is a remarkable and an important circumstance in the his- tory of this disease; and there is perhaps no one fact in medical history more cordially and generally acknowledged by all wri- ters upon fevers. Dr. Bancroft says, that "typhus is properly a disease of cold climates." p. 342. 501. Dr. John Hunter says, "I have never seen the fever earlier than the month of November, and I believe it seldom appears so soon. It becomes frequent about Christmas, and in- creases during the months of January and February; but if they are cold, it continues nearly as common as in the preceding * Davidge's Edition of Bancroft, p. 518. 22 170 TYPHUS. months." He adds, "the heat proves a prevention to the dis- ease, as much as cold forwards its production."* 502. Drs. Trotter, Blane, Lind, &c. all confirm, by their ob- servations, the same thing. With these facts before us, how can typhus be talked of as a disease of warm weather, nay, of sum- mer! 503. Another'very remarkable circumstance attends the .his- tory of typhus; namely, that it never becomes epidemic, like fevers arising from miasmata; and that when simple, it is always of the continued form. Should the patient, however, have been exposed to miasm, it may cause typhus to assume a disposition to remit, but not without. This disease, therefore, must not be confounded with fevers that may have marsh miasmata for their remote causes, nor with those which may arise "from fatigue, damp habitations, unwholesome or insufficient food, anxiety, grief, fear, and other depressing passions and debilitating causes, which have no connection with contagion, nor any power of producing a contagious disease." 504. We trust we have said enough on the authority of those who have had the best opportunities to observe the origin, ha- bits, and phenomena of typhus to prove, that it is not a disease of the American climate, or but very partially so; and that when it has appeared in our city, if it ever have appeared, it has always been confined to our poor-house. Yet we hear constantly of typhus; and our bills of mortality never fail to record deaths from this fever. We have already confessed we have never had an opportunity of seeing a single case of this disease; nor do we believe it can exist, if its history be truly given by the highly respectable gentleman above named, in our more southern states. 505. It certainly never prevails within the tropics, if reliance can be placed upon the writers on tropical diseases. Dr. John Hunter assures us, " that during more than two years that he remained in Jamaica, he never saw one instance of the hospital fever, though the military hospitals were as much crowded as in Europe." loc. cit These places owe their exemption from typhus, to the heat of the atmosphere; as heat and typhus toge- » Med. Trans. Vol. HI. p. 348, &c. TYPHUS. 171 ther are incompatibilities. Dr. Bancroft says, that " the influence of heat in mitigating, and finally extinguishing contagious fever, was very fully manifested in regard to the troops which sailed from Cork, under the command of Major-General White, for St. Domingo, in February, 1796. Two hospital ships, in which I had embarked, and sailed from England with the army, under Sir Ralph Abercrombie, having by storms been rendered unable to continue the voyage, and the last of them having landed me on the south-west coast of Ire, I embarked on board a very large hospital ship, the Bridge water, (formerly an Indiaman,) destined to receive the sick of General White's division, among which a severe typhus fever had prevailed to a great extent, and with great mortality, previous to our sailing from Cork, where most of the sick were left at our departure; but many of the soldiers, apparently well, being exposed to the contagion which existed in many of the transports, or having imbibed it previously, while detained at Cork, fell sick on the passage, and were from time to time removed into the Bridgewater, which soon became full of patients, under typhus fever, which was communicated to several of the orderly men, and nurses, to some of which it proved fatal. It became evident, however, that as wre reached, and proceeded in the warmer latitudes, the cases of fever gra- dually diminished in number, and became much milder; though from the shortness of our passage, and the cool season in which it was made, the full effect of heat in extinguishing contagious fever could not have been produced; and, therefore, it was not surprising that a few patients with the same fever, in a milder form, and apparently divested of its contagious power, were sent on shore to the hospitals, immediately after our arrival at Barbadoes. These had probably imbibed the contagion before our arrival within the tropics^ and its effects, though moderated, were not wholly prevented by a change of temperature." p. 343. 506. Similar facts could be easily added, were it necessary to, or compatible with, our plan—enough has been shown to prove, that typhus fever has its own peculiar laws, and phenomena; but none of which belong to any of the fevers of our seasons; consequently, none of such fevers can be typhus. 507. As we have never had an opportunity of seeing a case of typhus, as we have already declared, we shall be indebted to 172 v TTPHUS. others for a description of this fever. The latest, and perhaps the most approved account we have of typhus as it exists, in Great Britain in general, and London in particular, is that of Dr. Burne, in his Treatise on the Typhus or Adynamic Fever. 508. He says there are two modes of attack. " The adynamic fever frequently attacks young persons in the vigour of youth, between the age of eighteen and twenty-five, having robust con- stitutions, and who had enjoyed good health up to the invasion of the disease. These peculiarities are remarkable. In order to the production of the adynamic fever, it is necessary that there be a certain state of system; which state depends, in most instances, on a continued exposure to a poisoned, or contami- nated atmosphere. This state then existing, it will be found that the adynamic fever attacks in two ways; and it is of great importance that these should be clearly understood, because they account for the presence, or supervention of inflammation in some cases, and the absence of it in others." p. 13. 509. " In one instance it acts by the intervention of an acci- dental cause; the other without. When without the intervention of an accidental cause, the condition of the body itself is suffi- cient to give rise to the phenomena of adynamic fever. When with an accidental cause, the condition of the body, though not sufficient of itself to produce the fever, is yet sufficient to give the fever thus accidentally produced, the peculiar adynamic type. In the one case, the development is slow and progressive, re- quiring many days, or even weeks; in the other, it is fully form- ed in a few hours." p. 14. (i Of the Way of Attack without an Accidental Cause." 510. The signs of this mode, are disinclination to food, lassi- tude, weakness; to these are added slight head-ache, and chilli- ness. In a day or two these symptoms increase; together with pain in the back and limbs; shivering, followed by heat and sweat- ing; " so that a febrile paroxysm is established," p. 15. These recur daily; especially about noon. Others experience the exa- cerbation in the evening; others again, will be laid up from the very invasion—in these the symptoms run high. While some will complain for several days, and then be attacked suddenly; TYPHUS. 173 and this frequently after a meal. This attack is not commonly attended "by any organic inflammation." p. 17. " Of the Way of Attack with an Accidental Cause." 511. "That cause is generally a severe cold, from exposure to rain, wind, &c." The initial symptoms much the same, only perhaps more pronounced, and the chilliness, &c. will continue for two, three, or more hours; " when a violent reaction takes place, and the skin becomes hot and dry, the face suffused, with an increase of action of the heart and arteries." " When this fever attacks in this way, organic inflammations are apt to ac- company it from the beginning." p. 18. 512. " The adynamic fever being produced in one of the two ways just described, it will be found to differ very much in se- verity: for which reason, and for practical purposes, it is expe- dient to divide it into degrees; and these may with great pro- priety be limited to four." p. 19. " Of the First Degree." 513. This is mild; merely slight head-ache; sometimes none; some reaction. Appetite poor; tongue covered with a dirty white covering, except the end, which is red, with prominent papillse, and moist. Cheeks flushed, eyes rather suffused; senses dull; great prostration for the existing symptoms. Urine scanty and high-coloured; bowels sluggish; seldom delirium; refreshing sleep during the night, p. 19. " Of the Second Degree." 514. Considerable head-ache; sight and hearing less acute; noise and light unpleasant. Suffusion and fullness of face; bluish blush on the cheek. Considerable reaction; pulse frequent, rather full and strong, but compressible by moderate force; pulse deceptive; is open from want of tonicity, and may be mistaken for great fulness. Tongue the same, except that the coating is thicker and more dirty. Skin hot and somewhat tight; dusky suffusion on the skin. Bowels disposed to consti- 174 TYPHUS. pation; belly distended. Urine high-coloured, and scanty; strength greatly prostrated. The patient on the side sometimes, and sometimes on the back. During the day drowsy; during the night delirious, p. 20. " Of the Third Degree." 515. Third degree severe; great prostration; patient lies on his back; breathes slowly and deeply, as one in a lethargic sleep. Unable to turn, and averse from motion. Can speak only in broken sentences. Tremors and twitchings of the muscles. Can- not stand if taken out of bed. Dullness and torpor of all the senses; obliged to repeat questions before an answer is obtained; complains of a dull pain in the head; great thirst 516. Face void of expression;* every feature relaxed; skin dusky; purplish, circumscribed flush on the cheek; eyes suffused and glassy, with shreds of mucous matter floating in them. Lips blue; teeth dry and shining; viscid mucus in the corners of the mouth, which is drawn into filaments when the tongue is protrud- ed; this mucus dries, and covers the teeth and lips with blackish sordes. Breath peculiarly offensive. Tongue thickly coated; brown and dry in the middle; red and dry at the tip; whitish and moist at the sides. The pulse seldom exceeding 90; some- times not above the natural standard; fullish, sometimes rather firm, but always more or less compressible. The skin dry and rather harsh; temperature variable; at one moment high, at an- other not much increased. Urine always scanty and high-colour- ed, and becomes turbid on standing. Belly full; tender on heavy pressure. Bowels generally sluggish; sometimes relaxed; de- jections dark and offensive; restlessness; constant delirium through the night; frequent attempts to get out of bed; delirium some- times in the day. 517. These symptoms change in a few days, for the better or worse. If for the better, prostration, lethargy, and dullness, • "Many of the characters of typhoid fever are unsusceptible of accurate description; and of these the most remarkable is the expression of countenance, so uniform as to make all typhoid patients, in a great degree, resemble each other."—Gregory's Elements of the Theory and Practice of Physic, 2d Jm. Ed. p. 66. TYPHUS. 175 diminish; patient turns upon his side; less viscidity about the mouth; tongue moistens, and commences cleaning; spontaneous diarrhoea of ochre-coloured stools; pulse natural; skin soft and moi^t; eyes brighten; skin clean; countenance more animated; delirium ceases; sleep refreshing; convalescence. If an unfa- vourable change takes place; there will be constant delirium; great jactitation; violent and frequent screaming, which only subsides with the powers of life—drowsiness increases; skin becomes purple; temperature sinks; extremities cold—death. p. 21, &c. - " Of the Fourth Degree." 518. Soon as fever begins, the symptoms become grave. Pa- tient lies upon his back, in nervous agitation, picking the bed- clothes; countenance haggard, and visage sharp; carotids vibrate; respiration quick; breath strong with the odour peculiar to this fever. The eyes suffused and sometimes convulsed, moving from side to side; eyelids depend, and there is a ghastly stare. Mouth parched; sooty coating on tongue, dry, hard; lips and teeth covered with black sordes. Skin hot, dry, harsh; fre- quently spotted with petechias. The pulse from 100, to 120; stroke unsteady, open; very compressible. Bowels relaxed; belly tender on pressure, and full; stools black and highly offen- sive, and passed with the urine involuntarily. Voice husky; articulation muttering; emaciation rapid. 519. Under these circumstances the disease frequently runs a rapid and fatal course. If the patient survive, recovery is slow. A favourable change is announced by the countenance improv- ing; abatement of the violence of all the symptoms; and by a return of sleep and consciousness. Secretions return; tongue clears; ochre-coloured frothy stools. Urine more abundant; de- posites a lateritious or brick-dust coloured sediment. Pulse less frequent, and gradually convalescence. 520. "When the secretions are re-established, and the tongue has cast off its fuliginous coat, the lips and tongue are left red, tender, and sore, and as it were raw. And this condition ex- tends throughout the mucous lining of the intestinal canal, caus- ing great soreness of the belly, keeping up the diarrhoea, and 176 TYPHUS. rendering the stomach and bowels highly sensible td the opera- tion of medicines, or the presence of undigested food; which makes it important to pay strict attention to this condition in the treatment of persons recovering from the adynamic fever." p. 26. 521. When it terminates fatally, all the symptoms are aggra- vated, strength diminishes; the patient continues supine, and motionless; the arms stretched out, or cross the chest; visage sharper; face sweaty and cadaverous; eyes fixed; eyelids nearly closed; belly tympanitic, temperature diminished, extremities cold; pulse rapid, small, and weak, faultering; life gradually ex- tinguished, p. 27. " Treatment of the First Degree." 522. " The character of this degree of the adynamic fever is so mild as to require very little medical aid." 523. " It is only necessary to supply the patient with good air and fresh linen; to keep the bowels rather freely open by any aperients; (as castor oil, rhubarb, magnesia, and senna and man- na, but Dr. B. prefers rhubarb,) and to give a simple saline, as the liq. ammon. acet in the dose of three drachms three times a day." 524. "No other food than gruel to be allowed till the head- ache and flushing of the face have subsided, and the tongue has become clean; when a nutritious diet may be gradually re- sumed."* p. 206. 11 Of the treatment in the Second Degree." 525. " The object is to moderate the symptoms, and to pro- tect the various organs against an undue momentum of blood, which may lead to inflammation in any organ so disposed." 526. " This end will be effected by the abstraction of six or eight ounces of blood from a vein, which may be repeated in forty-eight hours, if the first bleeding has been beneficial, and circumstances call for a second; but if the general febrile excite- * It may be useful to solicit the attention of the reader, to this mild mode of treating typhus—here no stimulants arc prescribed—no wine whey; no bark; no volatile alkali, are ordered. TYPHUS. 177 ment has been moderate, and the headache is still severe, two or three ounces may be taken from behind the ear, with the cup- ping-glass, with great advantage." 527. " The bowels are sluggish, and the belly often flatu- lent; which must be counteracted by aperients given every or every second day, so as to keep them freely open; and the more dark and offensive the dejections, the more are aperients to be persevered in." 528. Calomel in two grain doses with six or eight of rhubarb may also be given as an aperient, "but as the belly is flatulent, winch shows a disposition to the irritation and organic affection of the intestinal canal peculiar to this disease, it is prudent to use mercury sparingly, and towards the decline of the disease, dis- continue its use altogether." p. 208. 529. A three drachm dose of the liq. ammon. acet should also be given, every four hours. The night delirium requires no particular treatment. The hair should be cut close; and the head frequently sponged, p. 209. " Of the treatment of the Third Degree." 530. Blood is not to be taken from the arm; but much relief is afforded by taking three or four ounces from behind the ear, by cupping, and this may be repeated, in a day or two if the stupor continue. A blister of not a large size should be applied to the crown of the head, in preference to between the shoulders p. 211. 531. "It is in this degree of adynamic fever that the external use of mercury is so eminently serviceable; because of its un- rivalled power to bring about, speedily, a re-establishment of the secretions; the mercury is to be rubbed in on any convenient surface of the body, as the inside of the thigh, in the quantity of about half a drachm of the ung. hydrarg. fort, every night and morning, till it effects the desired purpose." p. 211. 532. The bowels are to be daily moved by aperients, though the bowels be relaxed, and continued until as long as the stools are dark and offensive—rhubarb is particularly appropriate in six - or eight grain doses. After the bowels have been well opened, and blood abstracted, a grain of opium, or hyosciamus may be given if the delirium and restlessness continue. 23 178 TYPHUS. 533. If the ochre-celoured diarrhoea supervene, it must be treated by " demulcent drinks, as barley water, rice water, gum water, and the like"—"as regards the diarrhoea no other treat- ment is called for, unless it be protracted and evidently affects the patient's strength; in which case the irritation of the bowels must be allayed by small and repeated doses of opium, as three drops of the tinct opii." 534. " Sometimes at the commencement of this diarrhoea, the belly will continue flatulent and the dejections offensive; in which case the tongue, though nearly clean, will be dry and of a light-brown, and the cheeks will be flushed." p. 234. 535. Aperients must here be used; but they must be given in very small doses. Rhubarb is to be preferred ; and five grains is a sufficient dose, and repeated every six hours, until the dejections lose their offensive smell, and the tongue becomes clean, p. 235. " Treatment of the Fourth Degree." 536. "The treatment should be directed particularly to the intestinal canal, as the nervous excitement and debility are kept up and augmented by any loitering or lodgment of the black offen- sive faeces. Rhubarb, is unquestionably the best aperient." Eight or ten grains of rhubarb with as much of the confect opii. and one drachm of syr. zinzeb. in cinnamon water;* and be re- peated every four or six hours until the bowels are satisfactorily emptied. Castor oil if preferred may be given in two or three drachm doses in a glass of Sherry wine. The hair to he clipped; the head sponged with cold water; and tepid or warm ablution of any part of the body where the skin is dry and harsh is very refreshing, p. 215. 537. Mercury, as before advised, should be had recourse to, a saline effervescing "draught of half its usual strength; as ten grains of the carbonate of potassa with two drachms of fresh lemon juice. As soon as the bowels are well cleansed, opium may be given as just directed, also a decoction of the bark, in • Take of Rhubarb, - - . 8 or 10 grains. Confection of opium, - 10 grains. Syrup of ginger, - - 1 drachm. Cinnamon water, . . Enough to make into a draught Mix together. RUBEOLA, OR MEASLES. 179 Ihe dose of one ounce and an half;* or the sulphate of quinine, in the dose of one grain, with one minim of the diluted sulphuric acid, and a drachm of the tincture of orange peel. The bark and effervescing mixture! to be given alternately, p. 216. 538. If the prostration be very great, and the bowels re- lieved, it must be supported by porter, or brandy and water; beginning with them very sparingly, and increasing according to necessity, p. 216. 539. We have thus given the general outline of Dr. Burne's account and treatment of typhus fever; it will be quickly per- ceived, that his plan is very different from that, which is gene- rally pursued in this country by many practitioners for this sup- posed disease as supervening upon our miasmatic fevers, and as we have had occasion to remark at p. 152 et seq. With those who dread the onset of typhus in every species of fever; this practice will not be altogether approved of—"what," say they, "bleed, cup, and purge, when typhus is impending!! No, no, give bark, wine, volatile alkali, brandy, ether, phosphorus, &c. &c. if you mean to cure the disease." CHAPTER VII. RUBEOLA, OR MEASLES. 540. This disease occurs for the most part in winter, and in the spring; at least its appearance is much more frequent at these periods, than at other portions of the year. It may, how- ever, prove epidemic in the summer. 541. This disease is evidently influenced by the state of the weather; it is more moderate in mild, than in severe weather. • Decoction of bark. Take one ounce of bark in powder. One pint of water. Mix, and let them simmer slowly for twenty minutes; permit it to settle, and give a wine-glassful every two hours. f For effervescing mixture, see Appendix, Art. Effervescing Mixture. 180 RUBEOLA, OR MEASLES. 542. It is the opinion of some, that measles is regular in its recurrence as an epidemic; the interval is said to be seven years. Whether this is rigidly the case, we are not prepared from pre- sent data to decide; it is, however, rendered probable, that there is either a regular return at this period, or at least, an approxi- mation to it It is said to be contagious; but this may be pretty fairly disputed, notwithstanding the imposing experiments of Dr. Home, who declared he propagated the disease by inoculation. An Italian physician, (Speranza,) declares he has succeeded in an attempt at inoculation by puncturing a full measle with a lancet, and inserting the blood that was yielded by the punc- ture; he declares he was successful in six cases. On the other hand, Dr. Chapman, (MS. Lectures,) says, upon this point, that " experiments of this nature were instituted in the practice of our Dispensary in 1801; in which the blood, the tears, the mucus of the nostrils, and bronchia, the eruptive matter in the cuticle, properly moistened, were all tried, and without success in any one instance." 543. Neither is it settled whether the constitution can be made to suffer the rubeolus action a second time; evidence is so en- tirely contradictory on this point, that it would not be safe to draw a positivj- Powdered gum Ara Elix. paregor. 3VJ- bic - 2 drachms Vin. antim. - gss. Paregoric elixir - 6 drachms Sacch. alb. 3'ij- Antimonial wine 4 drachms. Aqua font. - 3vj- White sugar 3 drachms M. Water Mix. 6 ounces. Of this a table-spoonful is to be given every two or three hours, until the cough is relieved. This dose is calculated for an adult—for children the quantity must be proportional. Note.—To make this mixture, the spermaceti and the yelk of the eggmust be first rubbed together until well incorporated—add then the gum Arabic and the other ingredients in succession; when these are well mixed together, let the water be added gradually—keep it in a cool place. •j-We are of opinion that too much care cannot be taken, not to confound what is termed a typhoid condition, with an existing inflammatory state of the system; witness the case related by Sydenham, p. 474, and also p. 564. RUBEOLA, OR MEASLES. 18.0 570. Emetics are also useful in this species of measles, and should be employed where there is great accumulation of phlegm, and the expectoration but inconsiderable. Mercurial purges are also to be given, even to plentiful purging. It is occasionally use- ful to employ the warm but not a hot bath; especially where the character of the eruption is not sufficiently healthy; looking either too pale or livid, provided the pulse is not so active as to require bleeding. 571. Should the appearance of exhaustion supervene, we must have recourse to the diffusible stimuli, as wine whey, and the volatile alkali; and these may be aided by blisters to the extre- mities, or by sinapisms to the soles of the feet. 572. It is of much consequence, throughout the whole course of this disease, that the temperature of the air of the patient's chamber should be regulated, and not made to exceed sixty-four or five; sixty perhaps would be the best standard. This tempe- rature would be warmer than would be useful for small-pox; measles however requires this; but it is never proper to keep the patient hot, either by a heated atmosphere or bed-clothes. The constant disposition to cough will readily explain, why measles requires a higher temperature than small-pox. Dr. Gre- gory observes that "it is well ascertained, that these, (the symp- toms of thoracic inflammation,) are often aggravated by a free exposure of the body to cold, either during or previous to the eruption; and some have remarked, that this aggravation of the catarrhal symptoms, is occasionally attended by a recession of the eruption; moderate warmth therefore, is on all accounts ad- viseable in measles." 573. Measles but too frequently leave disagreeable conse- quences behind them; especially cough. This secondary or su- pervening cough, is too often neglected, owing to the belief that more or less must necessarily follow this disease. This affec- tion takes place after the patient has gone through the eruptive stage; and dissection reveals, that it is owing to an inflamma- tion having attacked the mucous membrane of the bronchia. This complaint comes on sometimes so insidiously, that it makes a fatal progress before danger is apprehended; we should there- fore never trust to nature and time a patient, in whom a consi- derable difficulty of breathing exists, accompanied by a wheez- 190 APOrLEXY. ing; nor must we be deceived, because the cough is not severe; for in some of the worst cases, the cough is not always violent. 574. The cough for the most part is dry and fatiguing; and comes on by paroxysms. The pulse is hard for the most part, and always frequent; great thirst, tongue loaded, bowels consti- pated and a hot skin. This is a state of great danger; the bron- chia are soon filled with mucus, and the patient dies from the failure of the due oxygenation of the blood. This complaint must be treated as an acute bronchitis. 575. A deranged state of the bowels may also follow, parti- cularly if the disease has been ill-managed, by over-stimulation, exposure, or improper diet, too soon after the fever has passed away. On this account a patient recovering from this disease, must never be exposed to cold, or damp; should be confined for some time to a milk and vegetable diet; and made to wear in cold, or cool weather, flannel next the skin. 576. Sydenham informs us,that the diarrhceafollowing measles, has always been best relieved, by blood-letting. CHAPTER VIII. APOPLEXY. 577. This formidable disease early attracted the attention of medical writers; hence, we find it mentioned by almost every one of them from the time of Hippocrates to the present day. And in no other disease, perhaps, have descriptions been so ac- curate, or so uniform. But notwithstanding this harmony in the history of the symptoms of this disease, its pathology has not been ascertained until within (comparatively) a very short time. Mor- gagni, and his cotemporaries, were among the first cultivators of pathological anatomy; and the diseases of the head, from their se- verity and frequency, particularly attracted their attention; espe- cially Morgagni. In his great work, he has left us the dissections of a considerable number of apoplectics, agreeing in detail pretty APOPLEXY. 191 much with those of later observers, but without being arranged in such order as to enable us to draw any important practical distinctions from the varieties of appearance he discovered in the brain. Extravasations were met with in a great majority of instances, but without his coming to a conclusion that there was any coincidence between the part of the brain occupied by them and the symptoms that had preceded death. 578. Indeed, the presence of a foreign body within the cavity of the cranium, was held sufficient to account for all the pheno- mena of apoplexy; and here enquiry appeared to cease, until within a very short period. And it is to Serres that the honour is due, of having first suggested and traced the connection be- tween the accompanying symptoms of this disease, and the va- rious lesions of the brain and its appendages, which gave rise to them; but of this, more by and by. 579. Several definitions have been given of apoplexy, all of which agree in its principal phenomena, yet no one demon- strating its absolute character, as will be seen as we proceed. Apoplexy is said by Dr. Good to consist of " mental and corpo- real torpitude, with oppressive, mostly stertorous sleep."* This definition is concise, but fails perhaps in rigid accuracy. Dr. Cooke's is rather more comprehensive, and less objectionable. He very modestly says, "perhaps apoplexy may be thus defined —it is a disease in which the animal functions are suspended, while the vital and natural functions continue, respiration being generally laborious, and frequently attended with stertor."t 5S0. This disease sometimes takes place so suddenly, as to preclude all cognizable premonition; at others, there may be a short warning; while again, it may advertise its approach by a number of well marked and decided symptoms. These different onsets of apoplexy appear to be governed altogether by the con- dition of the brain itself, or of its meninges, at the moment of attack, or a short time previous to it. 581. When warning is given, the following circumstances generally obtain. A sense of heaviness, or weight, attended by pain in the head of less or greater intensity; vertigo, or only a • Study of Medicine, Am. Ed. Vol. HI. p. 394. f Dr. Cooke on Nervous Diseases, Vol. I. p. 166. 192 APOPLEXY slight dizziness; disposition to sleep; disturbed, and oppressed sleep, or nightmare; involuntary contractions of the muscles of jthe face, especially during sleep; spasmodic affections in various parts of the body; redness, and fulness of the face; injected eyes; inspiration more deep than natural; indistinctness of vision; ring- ing in the ears; bleeding from the nose; faultering of the speech, or employing inappropriate words; failure of memory, and dimi- nished sensibility of both body and mind. 582. After these symptoms have continued a longer or shorter time, or without any discoverable previous intimation, the pa- tient falls prostrate, and lies as if in a profound sleep, but from which he cannot be roused by any excitation. So analogous in appearance is apoplexy to profound sleep, that at first sight it might be difficult to distinguish them, and which led Boerhaave to declare it to be its true image. 583. Stertor is not a necessary attendant upon apoplexy, though it is of frequent occurrence; nor is the patient entirely deprived of all capacity of action, if it be admitted that he is of all sensation—for the application of powerful stimuli will pro- duce contractions of the muscles, though this may not be attend- ed by consciousness. Dr. Cooke says, " in the strong paroxysm, persons are said to be entirely deprived of sensation and motion; but the power of moving is occasionally apparent, and we can- not be certain that the power of feeling in these cases is wholly abolished. I have seen patients in this disease shrink on being cupped, and move their hands towards the head, as if feeling uneasiness there." p. 168. We have repeatedly witnessed the same thing, which has constantly led us to believe that all sen- sation was not destroyed, as the hand directed to the spot on which the stimulus was applied, cannot be regarded as a mere automatic motion. 584. Dr. Wilson Philip thinks, that the power of the volun- tary muscles remains; as he declares he had repeatedly examined the state of these muscles in apoplexy, both in warm and in cold blooded animals, and found their excitability unimpaired. He therefore is of opinion, that it is not their power, but the stimu- lus which excites them, that is lost in apoplexy. 585. Respiration, for the most part, is much affected in this disease, and seems to be laborious in proportion to the extent of APOPLEXY. 193 the proximate cause. It is not, however, suddenly embarrassed, as it gradually augments as the disease continues—thus, it is frequently slow and regular in the commencement, though it may be laborious; while towards its close, it may become ex- tremely slow, or very frequent, and irregular. It is said that the danger is in proportion to the derangement of this faculty; and that which is very laborious and irregular may be looked upon as one of the most unfavourable symptoms. It is observed by Dr. Cheyne, that " immediately before death, the respiration is irregular, and is performed not oftener perhaps than three or four times in a minute." 586. This slow and laborious breathing in generally accom- panied by stertor. And when the disease is attended by this symptom, both Boerhaave and Portal, consider it in its most aggravated form. There is also a quantity of saliva blown from the mouth in the form of foam, which also marks the intensity of the disease. 587. The pulse is constantly affected; in the beginning it is for the most part slow, regular, full, and hard; but in a few hours, M. Series informs us, both it and the respiration become much affected. He says, " in a few hours after the invasion (if the brain have not already suffered laceration on some point of its various surfaces,) the respiration becomes considerably slower than natural. The venous blood thus experiences a mechanical obstruction to its return to the heart, and the latter organ begins to react in proportion; the pulse accordingly becomes hard, and frequent; the artery vibrates as it were under the finger; in short, the action of the heart is quickened in proportion as the respi- ratory process is retarded. And agreeably to Dr. Cheyne, the irritability of the heart survives the respiration. " Sitting, with my finger over the artery of a person who died of apoplexy, I distinctly felt the pulse beat after the last expiration." (p. 14.) The pulse in the beginning of the attack, rarely exceeds fifty strokes in a minute. 588. Indeed, in one case, and that slight, as the patient re- covered his senses in a short time, the pulse was not more than thirty-four strokes in the minute; full, tense, and equal. We can- not say what was the state of the respiration, as we did not see him until he was able to give an account of himself. The attack 194 APOPLEXY. was sudden and without warning, according to his own statement —he was suddenly seized while walking in the garden at his country seat, and fell upon the ground. How long he remained in this situation he cannot tell; but it was a considerable time he thinks, by the apparent waste of the day. No one saw him in this situation; after this his head remained giddy and rather pain- ful, especially on the left side.* We saw him for the first time, the day after these events had taken place; he was much weak- ened; head always slightly painful, and occasionally, considerably so; his breathing pretty free, though the expiration was per- formed rather suddenly, especially after talking a little. The pulse was at thirty-four at most, occasionally as low as twenty- eight, indeed, a number of times not more than twenty-six strokes in a minute;! there was nothing like pjMjalysis in any portion of the body. Depletion was as frequentty employed during the period of three months, and in as liberal a manner, as was con- sistent with safety for one, who had exceeded seventy-three years, and who was naturally of a feeble constitution. 589. He gradually recovered nearly his usual state of health; and remained so until a few days over a year from the attack just spoken of. At this period he began to experience a heavi- ness and occasional pain in the head; his pulse keeping about thirty-two, tense, and full—he lost a few ounces of blood, was purged and kept upon a very abstemious diet for some time, by which means these symptoms disappeared. He remained in this situation for two months, when pretty soon after dinner, he fell suddenly from his chair upon the floor. We were instantly sent • This gentleman had for three or four weeks, five or six times a day, what he called "shocks," through the brain, especially upon the whole half of the leftside. These "shocks" would be both painful and astounding for some minutes together. f This patient was a remarkably close observer—he very frequently exa- mined his pulse by an accurate stop-watch with a quarter second movement— he recorded all the sensations he experienced, and marked each varying change—he was learned, and very studious, and consequently very seden- tary—a very moderate feeder, and never drank any thing stronger than a weak mixture of claret and water, and not much even of that, and this only at his dinner. His bowels always, very regular in their motions; indulged but little in bed, and habitually an early riser—not given to any sudden gusts of passion, and of a cheerful disposition. He had been subject many years however, to a catarrh of the bladder, and slight irregularities in his urinary discharges. APOPLEXY. 195 for; but living at a considerable distance from him, three-quarters of an hour had elapsed before we saw him. He was still lying on the floor, with his head elevated ; but pale; his mouth drawn to one side, and senseless. It was stated, that he was slightly con- vulsed; frothed at the mouth, and snored; his faeces and urine were discharged during the paroxysm. 590. His pulse was twenty-six strokes in the minute, and scarcely perceptible; his breathing not much affected; the skin bedewed with a cold clammy sweat; but little more of the eyes could be seen than the whites; strabismus; and a considerable quantity of a tenaceous saliva running from the mouth. 591. We caused his legs to be rubbed with hot brandy and mustard; spirit of turpentine was applied to the region of the stomach, and a number of hot bricks were placed at different parts of the body. Reaction soon after took place; the skin be- came warmer; the pulse more expanded, but not more frequent; the countenance more composed and less ghastly; the mouth however remained contracted; though the squinting was re- moved. He became gradually sensible of things around him, though he could not articulate when he attempted to answer any question. He now lost eight ounces of blood from the arm, with marked advantage, as his speech returned while the bleeding was performing. He gradually mended, and went to the country, and while there, was again assailed by similar apoplectic symp- toms; these were not of long continuance, or of great severity, but they were followed by a paralysis of the right side. He was cupped, and purged; and in a few days after, was put upon the use of the white mustard-seed, under the use of which, he is gradually acquiring the use of his arm and leg. His pulse, during the whole progress of this affection, never exceeded thirty-four strokes in a minute, but has been occasionally, as low as twenty- six. 592. This case is remarkable in several of its particulars; first, the mildness of the original attack—the second, being at- tended, with several threatening symptoms, such as the partial paralysis of the face; the distortion of the eyes, and the loss of speech, all of which disappearing, and the patient regaining, nearly his ordinary health—the third, being followed by a para- lysis of one side, without the loss of speech or drawing of the 196 APOPLEXY. mouth, but above all, the long-continued (nearly two years,) and uniform slowness, of the pulse. 593. The temperature of the skin is sometimes higher than natural; at other times, it is cold and sweaty—the latter some- times, even to profuseness; in other instances, a well-marked fe- brile condition of the system may be observed. Dr. Cooke says that " fever however is not generally mentioned in the history of apoplexy and I believe seldom accompanies it." (p. 173.) We do not ourselves think, that fever necessarily belongs to the history of this disease, but nevertheless we have seen it well marked in several instances. 594. The eyes in this disease, are generally injected, and rather prominent, sometimes they are only half closed, at other times completely shut. The pupil for the most part is dilated, and others greatly and permanently contracted. Dr. Cooke says, "in some instances I have seen the pupils contracted to a point, and a physician of eminence of my acquaintance has likewise ob- served this appearance of the eyes in apoplexy; yet although all writers on the subject mention the dilatation of the pupils, I do not find any one, (AretDSus among the ancients, and Dr. Cheyne among the moderns, excepted,) who has noticed the contracted pupil in these cases." p. 174. 595. The teeth are frequently clenched very firmly together; so much so sometimes as to render it extremely difficult, to get any liquid into the mouth; nor is it unusual in an attempt of this kind, to find it returned by the nostrils. 596. As this disease approaches to a fatal termination, the symptoms become more and more intense—the abolition of sense and motion becomes complete; the pulse becomes weak, very frequent, and indistinct, and these symptoms are sometimes fol- lowed by convulsions, which close the scene; at other times, the extinction of life is so gradual, and so tranquil as scarcely to be observed when it takes place. The duration of this disease, will be very much influenced by the force and number of the remote causes; and the extent and location of the lesion they may produce—thus, it may happen in a few minutes or within an hour, or it may persist for days. We agree with a number, who believe that many of those sudden deaths attributed to this disease, depend upon some disease of the heart, or of the large bloodvessels. APOPLEXY. • 197 Predisposing Causes. 597. Various causes have been assigned as predisposing to this disease; as hereditary transmission by conformation; this by some has been considered as well grounded; Forestus in con- firmation of this opinion, mentions a father and three sons dying of apoplexy;* old age is also said to be predisponent to this disease; Rochoux is of this opinion. The translation of gout; the suppression of accustomed evacuations; and the re- pelling of certain eruptive affections, have always been consider- ed with great propriety, as belonging to these causes. 598. But this must certainly be contingent, since we find no age exempt from it. Serres says, "it is an established fact that apoplexies may attack all ages—I have observed them in all the periods of life, from the age of three years, up to decrepid old age."t And Rochoux gives a statement of sixty-three cases, in the following order:— Age. Number of c From 20 to 30 years - 2 30 to 40 - - 7 8 40 to 50 - - - 7 50 to 60 - - - 10 60 to 70 - - - 23 70 to 80 - - - 12 80 to 90 Total, 1 63} 599. This table goes far to prove the accuracy of Hippocrates' statement, that apoplexies chiefly take place between the fortieth and sixtieth years; though not altogether confirmed by the ob- servations of Serres. Rochoux remarks upon these cases, that there are more people living of the age of sixty than of seventy; • Dr. Cooke on Nervous Diseases, Vol. I. p. 199. f Philadelphia Journal of the Medical and Physical Sciences, Vol. VIII. p. 294. * Recherches sur Apoplexie, p. 212. 198 APOPLEXY. but that he can hardly believe that the number is double, yet it is seen, that the age of sixty has furnished almost double the number of apoplectic subjects. Besides, if it be admitted, that there are more of the age of sixty than the age of seventy, there are also more of fifty, than of sixty, yet the latter age gives more than double the number of patients. By this it may be perceived, that the predisposition to apoplexy increases towards sixty, and diminishes towards seventy. That this disposition is but little, before thirty, and that the numher is extremely small before twenty; and the influence of temperament, is very far from fur- nishing the same results; the sanguine, sanguino-bilious, and the sanguino-lymphatic, furnish nearly an equal number of cases of this disease."* 600. Serres has declared that apoplexy may take place at any period of life; if this be so, dentition in children must be looked upon as a predisposing cause, with them. The sudden altera- tions in atmospheric temperature, as well as moisture have ever been looked upon as predisponents. Large heads and short necks; and, agreeably to Ponsart,t a small head equally disposes to apoplexy. Obesity, gluttony, drunkenness, &c. Tempera- ment, agreeably to Rochoux, seems to have no very marked influence. Exciting Causes. 601. Among the exciting causes, an over-charged stomach, is considered by many as the most common; excessive venery, especially in aged people; passions and emotions of the mind; labour in females, especially with the first child; sudden appli- cation of cold, &c. The mode of action of these causes, is, by increasing the force and rapidity of the circulation, as well as an especial determination to the head; yet it is evident, that there must be causes which constantly produce these effects, even in a more violent degree, yet they do not produce apoplexy. Rochoux directs our attention to tumblers and montebanks, who stand long upon their heads; who will place an anvil upon their belly, • Recherches sur Apoplexie, p. 213. ■j- Traite de 1'Apoplexie et de la Paralysie, p. 14, as quoted by Rochoux. APOPLEXY. 199 which they allow to be forcibly struck with a hammer, &c. If then apoplexy has taken place from apparently slight causes, we must attribute it to some alteration in the vessels of the head; their having become too weak to prevent the escape of the blood with which they are filled. Of this it might be easy to convince ourselves, by taking at random, a twentieth part of the histories of apoplexy; the three-fourths of which would be found to have had a paroxysm, without being able to suspect the cause. And is it not probable, that the other fourth, may assign causes for this disease, which were altogether fortuitous, and have had but a trifling agency in the production of it?" p. 218. The too fre- quent and long-continued use of the warm bath. We once wit- nessed this affection in a young lady, after having her feet and legs placed in very warm water; she fell suddenly from her chair, with all the usual marks of apoplexy attending—she was largely bled; and other means were liberally employed, before she recovered—she suffered with head-ache many months after this attack. * Pathology of Apoplexy. 602. " A man falls down with all the symptoms of apoplexy, but by bleeding, purging, and other means, he perfectly recovers. Another dies under apparently similar circumstances and treat- ment, and, on dissection, extravasation of blood is found within the head. A third dies of apoplexy, and only serum is effused. A fourth presents after death only a turgescency of the vascular system of the brain; while a fifth, who dies with every symptom of perfect apoplexy, presents on dissection, no cognizable trace of lesion in the brain, or any other organ of the body. These various and contradictory appearances, post mortem, would seem to offer an insuperable objection to any fixed pathology of apo- plexy; or at least, might apparently sanction a division of the disease into different species. Nevertheless, we will endeavour to maintain an identity of morbid state, or in other words, of • Fourcroy relates the case of a person, who immersed himself in a bath of 66° of Reaumer, equal to 180° of Fahrenheit, and who fell down an hour after- wards apoplectic. And Buchan gives an account of another who was seized with paralysis after having subjected himself to a very warm bath. 200 APOPLEXY. pathology in apoplexy, whatever may be the appearances after death. We consider pressure* on the cerebral mass, or its ap- pendages, as the real efficient cause of the apoplectic phenomena in every case."t Proximate Cause. 603. This opinion of the proximate cause of apoplexy has been almost universally adopted within the last few years; and the result of very many post mortem examinations would seem to confirm it. Its truth has, however, been lately called in question by M. Serres. He endeavours to prove that pressure is not the cause of apoplexy, and commences by asking, " are effusions the cause or the effect of apoplexies?" He determines this question in the negative, from the result of the following experiments. J They are first conducted on animals, and secondly upon the human subject. 604. Experiment I.—-An old dog was trepanned immediately over the superior longitudinal sinus—the sinus was opened by a bistoury its whole length, and the external wound was closed, that a sanguineous effusion might take place. In three hours its na- tural state was so little changed, it was doubted that effusion had taken place. 605. " On opening the cranium, we found a very considerable clot of blood between the lobes, and a second extended to the left hemisphere." 606. This experiment was repeated upon a young dog, lest it might be thought that in the old dog the sinking down of the brain might leave a void between it and the cranium. The result was the same. In neither instance was there the slightest appear- ance of apoplexy. Rabbits and birds were subjected to similar trials with like results—" no somnolency, none of the symptoms which accompany apoplexies." * We have taken for granted, that the word pressure, as employed in this quotation, referred to this mechanical act, from extravasations within the cra- nium—in this we may be wrong; and if so, we beg its author's pardon, for having mistaken his meaning. | Medico-Chirurg. Review, p. 7. Vol. I. for 1820. $ We have even abridged the short histories of M. Serres' experiments, by only retaining such parts as bear upon the points at issue. APOPLEXY. 201 607. "There was already strong presumption against the gene- rally received opinion; for I could compare this effusion to those which occur in the course of apoplexies between the dura mater and the arachnoid coat, or between this and the pia mater—apo- plexies in which the substance of the brain is not involved." 608. "Artificial Effusions in the Ventricles."—To deter- mine the effects of this, a number of experiments were inge- niously made, by penetrating them with a sharp instrument. The corpus callosum of a grown dog was pierced, and the point of the instrument made to enter the left ventricle. The instru- ment was withdrawn, and the wound closed. 609. "The animal had a vertigo of a minute's.duration—it was uncomfortable the whole day—had a little agitation in the pulse, and violent thirst, but there was no somnolency; his sleep in the night was troubled. In the morning, he walked about the laboratory. In three hours the cranium was opened; the effused blood had filled the great fissure between the lobes, and pene- trated the left ventricle, which contained an ounce and an half of it—a small cavity was foundjn the anterior part of the corpus callosum, (middle lobe.") This experiment was repeated upon a rabbit with a similar result. 610. " Artificial Excavations formed in the Cerebral Sub- stance."—An old dog was chosen for the experiment. Two drachms of the left hemisphere of the brain was removed, by a bistoury; no sleepiness or impeded respiration followed its re- moval. An excavation containing a coagulum of the size of a nut was situated in the middle of this lobe. On another animal a cavity was made in each lobe of the brain with like result__ no apoplectic symptoms. The same was performed on a pigeon —no somnolency. 611. Experiment Sixth.—" I made an artificial opening into the middle part of one of the hemispheres; I took away a certain quantity of the cerebral substance—I thrusted a cork into the aperture in the manner of a plug, so as to augment the pressure. There was a complete hemiplegia, but no apoplexy, no somno- lency." These experiments were repeated upon rabbits, birds, oxen, and horses, with like results. From these the following important deductions are made. 612. " Thus sanguineous effusions do not produce apoplexies, 26 202 APOPLEXY. whether they be lodged between the cranium and the dura mater, or between this membrane and the brain—whether they occupy the grand interlobulary fissure, and in this manner rest upon the corpus collosum—whether we have formed a cavity in the he- mispheres, before, behind, or in the middle, or pierced it from one side to the other—whether in fine, in traversing the corpus callosum, (middle lobe,) we had penetrated into the ventricles, and filled these cavities. The same result with rabbits, the same with birds, the same result upon dogs. The apoplexy of man, therefore, cannot be attributed to the presence of the effused blood, whatever place it may occupy; whether it be found out of the brain, or in the cavities of that organ, or lodged in its proper substance." , 613. "Experiments relative to man."—"Do the facts of pathological anatomy relative to the brain of apoplectic persons contradict my experiments?" He refers for the answer to this question " to the annals of our science." He cites a case from Vesalius, of a child of two years old, having nearly nine pounds of " serocity" in the circumvolutions, and ventricles of the brain, yet there was neither "somnolency, convulsions, or paralysis." Another from Wepfer, of a man of seventy, who died of con- sumption, and who " had spoken to the moment of his death," in whose " ventricles and between the meninges a great quan- tity of limpid serosity" was found. Another witnessed by himself, in which there was delirium to the moment of death; the brain was a little softened, and "an enormous quantity of serosity oc- cupying its infractuosities, the four ventricles, and the canal of the spine." In an old man of seventy, who died of dropsy, and who preserved his senses to the last moment, was found a sarr- guineous serosity in the left ventricle of the brain, and clotted blood in the right. 614. His seventh "observation," relates to a person who had been three weeks recovered from an apoplexy, but who died of a pleurisy on the seventeenth day of his new disease. " On opening the cranium, a clot of blood of the size of a small egg, was found lodged in the cortical substance of the great left lobe." The eighth, was a patient who sunk "into an adynamic state the eighth day after his entry into the hospital." "The apo- plectic attack which had produced hemiplegia, had taken place APOPLEXY. 203 six weeks before his death. Since that time no symptom of apo- plexy—on opening the head, a sanguineous effusion was found in the middle of the great lobe. The ninth, was a woman who died of puerperal fever. "A hard coagulum was lodged in the certical substance of the right lobe—this woman had a "coup de sang," two years before. His tenth, eleventh, and twelfth, are in the main of a similar character and go to prove the same posi- tion, that extravasated fluids may remain harmlessly in the brain after the symptoms of apoplexy have been removed, and conse- quently, that neither effusions in the venticles, or on, or in the substance of the brain, nor excavations of its medulla, are the causes of apoplexy." 615. Mr. Serres informs us, that the above observations were selected from twenty-two analogous cases, which he had col- lected in the hospital of " La Pitie." From these facts he decid- edly infers, " if compression by fluids be the cause of apoplexy a direct consequence is, that—no apoplexy can exist with- out effusion. Now I am only embarrassed" he says, " in the choice of authorities and facts to prove the contrary." And eventually declares from these premises, that there are apoplexies without effusions; and effusions without apoplexies; and that he is " led to a belief that the effusions are the effects, and not the cause of apoplexies." 616. He next attempts to ascertain, whether apoplexies offer any appreciable differences during their developement and con- tinuance; and whether these, have any constant relation to the seat of the disease, and whether this is supported by dissection; and lastly, whether the seat of apoplexies can be determined by the presence or absence of these certain symptoms, and thus establish a mode of treatment. During his endeavours to dis- tinguish sanguineous, from serous apoplexies, he discovered, that this disease presented two different forms—one simple, and the other always complicated with paralysis. 617. He now asks, "was this remarkable circumstance the effect of accident, or did it depend upon discoverable causes?" The answer he says " was given to me by the histories of an hundred apoplexies." 618. " Of this number, twenty-one were simple; seventy-nine were complicated with paralysis. Of the first, dissection gave 2.04 APOPLEXY. the following results—sixteen had collections of serum either in the ventricles and cerebral convolutions, or in the ventricles, or in the convolutions separately; one had a sero-sanguineous collection in the left ventricle; two had similar collections be- tween the arachnoides and pia mater in both hemispheres; and two were without any collection." In all these cases the brain was sound; but the membranes were affected in various degrees; the vessels were injected, thickened, opake, and sprinkled with miliary granulations. 619. From the constant correspondence between the altera- tions of the membranes, and the effusion, he was led to suppose there was some connection between them; he was therefore led to the conclusion, that in the meningeal apoplexy, the mem- branes are primarily and principally affected, and that the various effusions which are met with are nothing but the effects of these alterations. 620. Whereas, in apoplexies complicated with paralysis, there were no effusions, either serous or sanguineous in the natural cavi- ties of the brain, nor in the space between duplicatures; no altera- tion in the texture of the membranes—but the brain was mate- rially altered in structure—excavations were dug in its substance; the whole surrounding texture bore marks of irritation. The blood which was extravasated, was found to proceed from a rup- ture of a vessel, which was proved by filling the carotids with fine injection, and observing that it penetrated the cavities. 621. He now enquires, why all the cerebral apoplexies, (that is, apoplexies attended by lesions of the brain,) should be ac- companied by paralysis, while the meningeal, should not be at- tended by a loss of motion. He answers these questions by saying that apoplexies followed by paralysis, is the necessary effect of an organic alteration of the proper substance of the brain, while in meningeal, or simple apoplexies, the brain being sound the capacity for motion would remain unimpaired. 622. From these important, and interesting facts, he arrives at the following novel deductions:—1st. That, when apoplexy is not complicated by paralysis, the disease is seated in the mem- branes of the brain. 2d. That when attended by palsy, the brain is the seat of the irritation. 3d. That serous, or sero-san- guineous, bloody, or purulent collections, are effects of irrita- APOPLEXY. 205 tion of the membranes, or the brain, or of arterial, or venous rupture. 623. He thinks, from these considerations, apoplexies should be designated as follows:—1st. Meningeal apoplexy—is apo- plexy without palsy. 2d. Cerebral apoplexy—apoplexy with palsy. Thus he thinks we are enabled to determine the nature of the disease we have to contend with during the life of the pa- tient. If it be simple, the patient can move his limbs; the dis- ease is then in the membranes. If he cannot move his limbs, and the mouth distorted, it is a cerebral apoplexy, that we have to encounter. 624, " The meningeal apoplexy principally attacks youths from the age of fifteen, and old men past sixty—it generally affects females before the last named period." " Of forty meningeal apoplexies, there were thirty-two in females, and eight in males. 625. Attack.—" Physicians have differed greatly in the mode of attack in apoplexies. One party has said that they always come on suddenly—the other, that the attack is preceded by precur- sory symptoms, which manifest themselves many days previous. Both sides have been right, and both in a certain degree wrong, as the cases may have been meningeal or cerebral." • 626. The meningeal apoplexy is almost always slow; has pre- cursory symptoms, as torpor; difficulty in exercising the mind, and its becoming easily fatigued; perception blunted; drowsi- ness; respiration slower than ordinary—tardy circulation; less warmth than usual; secretions diminished; impaired digestion, ,and sometimes vomiting. 627. Mr. Serres asks, " what distinguishes apoplexy from sleep?" He answers the question by the following important observations. " In sleep the respiration is slow, and the circu- lation is in a relative proportion—in apoplexy the natural rela- tion is destroyed." 628. Whatever difference age and strength may make, in the number of pulses in a given time, the discordance between them and respiration never fails to show itself; and when this is at its maximum, the stupor is also. Thus Mr. S. relates a case in which the following extreme of disparity between the pulse and respiration existed—pulse, eighty-three strokes to eleven inspi- 206 APOPLEXY. rations. And, that the abolition of the natural and mental func- tions, are in the precise ratio to the loss of the healthy propor- tions, between the motions of the heart, and the lungs; and that these functions are restored, exactly in the degree, that the pulse and the breathing, approach the natural standard. 629. He also states this curious, and to diagnosis, valuable fact; that in meningeal apoplexy, respiration is always equal on both sides; that is, the thorax is equally dilated on the right and left sides, which is not the case in cerebral apoplexies. The mouth is not distorted; the body lies in a straight line; and if the patient be not in a state of stupor, he will present both hands —if he be somnolent, irritating the limbs will produce the same motions. The nervous and muscular systems preserve their powers on both sides. Though meningeal apoplexies present important varieties in the fluids effused, Mr. S. acknowledges, he has never been able to indicate them individually from the accompanying symptoms. 630. The varieties of meningeal apoplexies, are deduced from the nature of the fluid effused; by the absence of effusion, and the rupture of arteries or veins in the brain. Hence, there is, 1st, meningeal apoplexy without effusion; 2d, with effusion of simple serosity; 3d, with sero-sanguineous effusion; 4th, with arterial rupture, or aneurismal dilatation; 5th, with venous rupture. 631. Dissections.—In meningeal apoplexy without effusion, the pia mater is thickened, dry, and the vessels slightly dis- tended. 632. In var. 2d, the arteries and veins are distended, and^ all the pia mater is covered with a net-work of small vessels— the arachnoides opaque, thickened, and in places covered with a whitish exudation. The choroid plexus is generally injured; distended. 633. In var. 3d, the alteration very similar to those in var. 2d; but the arachnoides manifestly red and inflamed. It is prin- cipally in the lateral ventricles this irritation is observed.' 634. In var. 4th, all the arteries are distended; a rupture is found either in one of the trunks, or one of the branches. A part of an artery may be aneurismal. 635. In var. 5th, the veins are more frequently ruptured. APOPLEXY. 207 636. Whenever coagulated blood is found between the mem- branes and the ventricles, and the cerebral substance sound, we may be certain that the haemorrhage has been caused by the rup- ture of an'artery, or a vein. Venous rupture frequently occurs in the choroid plexus. The meningeal apoplexy with serous ef- fusion is the most frequent—they are as seven, to two. 637. Cerebral apoplexies and their varieties.—In describ- ing these, Mr. S. proposes to solve the following question:— " an apoplexy being given, to determine its seat by its symp- toms." 638. Attack.—The attack is often instantaneous, especially in men of plethoric habits, short necks, corpulent, and addicted to wine and women. Some moments before the attack, the mind is more than usually active. Sometimes a numbness of one side, one side of the face, or a fixed pain in the head, pre- cedes the attack; the tongue is sometimes embarrassed; a diffi- culty in pronouncing certain letters, or words—rarely stut- tering. 639. "But whether the fit has been preceded by these symp- toms or not, at the moment of attack, the face is coloured in an unusual manner; the cervical and facial veins swell; the tongue becomes embarrassed; the sight is imperfect; the. hearing im- paired; the sensibility and the faculties of the mind lost—and if the patient be erect, he falls upon the side which afterwards will be struck with apoplexy—this circumstance is of much importance to the physician when called to the patient." 640. " Some hours after the attack, if the brain has not already been destroyed at some part of its surface, respiration becomes slower, the venous blood suffers a mechanical obstruction, and requires an appropriate reaction of the breast. The pulse is strong, hard, and frequent—the action of the heart increases in propor- tion to the difficulty of respiration. The force and hardness of the pulse continue until the moment a vessel gives way in the brain—it then becomes suddenly small, concentrated, and fre- quent." 641. "Respiration is equal on both sides in the beginning of the attack, but the thorax and lungs are unequally dilated—one side of the chest becomes motionless, while the other seems to redouble its activity; on the side in which the action is diminish 208 APOPLEXY. ed, the ribs are flattened, but on the opposite side they are ele- vated; the two sides thus offering a very obvious contrast. This happens previously to the occurrence of the hemiplegia; and it is important to attend to this symptom, as it points out the side that will be paralyzed." 642. Coma and stupor extreme—sensibility diminished on both sides; sometimes remarkably so on the side about to be in- jured—at other times, sensibility remains, though paralysis is about to take place. The paralyzed member sometimes preserves its sensibility; but when it loses it, it is before the loss of the power of motion. 643. Varieties of Cerebral Apoplexy. —Observation has not furnished us in cerebral apoplexy with any decided marks or symptoms of each variety, any more than in the meningeal. Dissections have revealed the following forms of cerebral apo- plexies: 1st, cerebral apoplexy with hemiplegia; 2d, with para- lysis of one arm; 3d, with paralysis of one leg; 4th, with double hemiplegia; 5th, with complete paralysis from a single attack. 644. " These apoplexies have distinct and different seats in the brain, as will be seen by the following analysis of my dissec- tions." Mr. S.then says, 645. " I have opened and attentively dissected one hundred and seventy-one subjects, dead of cerebral apoplexy, with hemi- plegia of the arm and leg at the same time; and I have found, in one hundred and seventy-one, the hemisphere of the brain on the opoosite side materially affected in its structure. I have dis- sected the brains of forty-seven hemiplegics dead at the Hospital of Pity, and forty-seven times I found disorganization opposite to the palsied side. I have received, from the hospitals of the Bicetre and Salp6triere and Hie Hotel Dieu, about one hundred and fifty brains of hemiplegic patients, and always without ex- ception, the alteration of the brain was in the opposite lobe to the paralyzed side. May we not, after these facts, and by the aid of two or three thousand cases contained in the annals of science, establish it as a principle, that the cerebral disorganiza- tion constantly occupies the lobe opposite to the palsied side, or the side that has remained hemiplegic, during the cerebral apo- plexy." 646. Double hemiplegies may come on suddenly, or by two APOPLEXY. 209 distinct attacks. In this species, the mouth is not paralyzed, as is the case of single hemiplegia. In both, the seat is the same as in single apoplexy, with paralysis on one side; the two sides are successively affected. A single stroke may paralyze the whole body; neither of the limbs can be excited to motion by any sti- mulation. In this case the extravasation will be in the pons varolii or tuber annulare. Death always follows with frightful quickness. The patient dies of asphyxia, or like animals which have had both pneumo-gastric nerves cut. Such are the princi- pal varieties of cerebral apoplexies, and if " I mistake not, we may prognosticate the seat of the disease from the symptoms." 647. In all instances of apoplexy without paralysis, the brain itself is uninjured—but in these cases, the membranes are alter- ed in different degrees; but that each of these degrees has its peculiar character of effusion. Had the irritation been intense, sudden, and of short duration; were the membranes inflamed partially or universally, the fluid effused within the ventricles, between the convolutions, or in the commencement of the spinal canal, was always found to be either sanguineous or sero-sangui- neous. This effect was so uniform, that the effusion was only found where the irritation had existed previously—if this irrita- tion happened to the ventricles alone, the effusion was limited to them; if upon the exterior of the encephalon, the sanguineous fluid wa." only found there, for the ventricles in such a case would be found either empty, or contain nothing but simple serosity. 648. In apoplexies with paralysis, the disorganization of the encephalon was constant, as has been observed before. If there was nothing fortuitous in these coincidences, Mr. S. says it is easy "to assign to apoplexies their characters, place, and name." The apoplexies without palsy having their seat in the membranes, he thinks are properly designated by the term meningeal apo- plexies; while those complicated with paralysis, are called cere- bral apoplexies. 649. Our author denies the existence of serous and sansui- neous as separate species; and insists that all apoplexies are seat- ed in the brain and its appendages. And those recorded, pur- porting to be apoplexy of the stomach or intestinal canal in apo- plectic subjects were accidental, and derived their supposed 27 210 ArorLExv. existence from the irritation or inflammation excited by the emetics and cathartics administered for their relief. Of the Treatment of Apoplexy. 650. The treatment of apoplexy, will very properly divide itself into that which is prophylactic, and into that which is ne- cessary during the paroxysm. 1. Of the Prophylactic Treatment. 651. By glancing our eye upon the predisposing causes of this disease, it will be perceived, that bodily conformation, habits, period of life, and temperament, may one or all contribute to the production of apoplexy. That each of these conditions have some modifying influence upon either the formation or distribution of the blood, in such manner as to determine it in an unequal or in undue manner to the brain; consequently, to be useful to a con- stitution prone, from either or all of these causes, to apoplexy, their agency must be counteracted in the best manner in our power. We have a full belief in the existence of an apoplectic constitution; and of course, an entire conviction of the tendency, of certain causes to effect the transportation of an undue quantity of blood to the vessels of the brain, and thus indirectly, produce the disease in question. 652. If this be true, it will follow, that all our means must be directed to the prevention of the too great formation of blood, or divesting it from an unequal distribution. These means will necessarily consist in a proper observance of diet, in the ju- dicious employment of exercise, and the proper administration of remedies. 653. The first plan must be carried into execution, by recom- mending a diminished quantity of, or an entire abstinence from, animal food, at least so far as will be compatible with the safety of the stomach, and the general strength of the body. A diet consisting chiefly, if not altogether, of vegetables, should be ri- gorously adopted. Nothing but plain water should be used for drink—all distilled or fermented liquors being absolutely and APOPLEXF. 211 directly injurious. But care should be taken, in the selection of the quality, as well as caution exercised, in the use of the quantity—for error may be committed in either. 654. The quality should be that of easy digestion; or of such substances as experience had proved to be acceptable to the sto- mach; for in this particular individual differences will constantly present themselves. Rice, sago, arrow-root, tapioca, barley, oatmeal, potatoes, turnips, tomatoes, salsafee, parsnips, beets, ochres, and spinage, maybe looked upon as the most digestible; the ripe fruits of the season may alse be indulged in. Cabbage, beans, sallads, raddishes, onions, and cucumbers, are decidedly improper, from the difficulty almost constantly found in their assimilation. If animal food in any quantity be indulged in, it should be of the most digestible kind; or such as has been found by experiment to be speedily and easily digestible. Suppers of no kind should ever be indulged in. The quantity should be no more than the stomach can with facility and certainty digest. 655. Exercise should be regularly, and steadily pursued; but it should never consist of such exertions as have a tendency to force the blood into the head; such as are proscribed will easily present themselves to the mind, and should be carefully avoided. Exercise must never be performed in a hot or even a warm sun; nor should it be indulged in extremely cold weather or in damp places. Serres recommends exercise, even to fatigue, for those disposed to apoplexy. 656. As it is every way desirable, that the circulation should not be hurried while the body is passive, the subject should avoid all crowded places, heated air, and too much warmth at night from sleeping upon a feather bed, or indulging in too much bed- covering. He should sleep in a well-ventilated room; should wear nothing tight round his neck, or waist. Dr. Donald Monro says he has known soldiers carried off by apoplexy, in conse- quence of the stricture of the veins of the neck; from being obliged to wear their cravats too tight. Winslow has also men- tioned the same thing.* Dr. Fothergill mentions the case of a gentleman who was predisposed to apoplexy being seized with a fit, by turning his head too far round to look at an object • Cooke on Nervous Disorders, Vol. I., p. 227. AVA APOPLEXY. rather behind him.* Now this position of the head could onlv have been mischievous by interrupting the descent of the blood from the head; acting as a partial ligature. 657. The utmost care should be taken against the suppression of any habitual evacuation; and if it happen, we should attempt its restoration as quickly as possible, and by the best means in our power. The menstrual evacuation, if arrested, should be recalled by the appropriate remedies; the hemorrhoidal flux, if interrupted, should be compensated for by the application of leeches to the anus; issues, or setons if they dry up, should be renewed, &c. 658. Bathing the head with cold water daily, would be a very good practice with persons of apoplectic tendencies—the hair should be kept cut short; the direct rays of the sun should be re- flected by a white hat; and the feet kept warm constantly. If the feet be habitually cold, the partial warm bath with the flower of mustard in it, should be used, whenever they feel uncom- fortably so, on going to bed. 659. It may, in addition to the means just suggested, be im- portant to employ remedies, for the immediate diminution of blood, and for the proper regulation of the bowels. For the first, the occasional loss of a few ounces of blood will be highly ser- viceable—this may be done by bleeding from the arm, or by ab- stracting blood from the head by cups or leeches; or according to Serres, from the anus, by the latter means. 660. Costiveness should be very carefully guarded against, either by diet, or medicine; or if necessary by both. For the first means, the bran bread should be used freely instead of other bread; ripe fruits, prunes, figs, &c. For the second, the aloetic and rhubarb pill will answer admirably, (see p. 96.) It may be proper also to purge occasionally, especially if there be slight head-ache, unquiet nights, and confined bowels. The pa- tient when in bed, should not fail to sleep with his head high, and uncovered by night-cap or handkerchief. 2. Treatment during the Paroxysm. 661. As it is agreed on all hands, that in apoplexy, there is an excess of blood occupying the vessels of the brain, or a quan- * Works, p. 214. Vol. III. APOPLEXY. 213 tity extravasated in either its cavities or substance, it would seem to follow as a necessary consequence, that nothing can take off the pressure caused by the distended vessels, or remove the dis- tention from them, but a reduction of the quantity of this fluid; and consequently, that our main dependence for this effect, must be by blood-letting. By this it will be perceived, that we re- nounce the distinction made by systematic writers, of "sangui- neous" and " serous apoplexy," though " educated" in its belief. We think indeed that no one will retain the distinction after a careful and dispassionate perusal of Serres's memoir upon this subject. Indeed the learned editor of the Medico-Chirurgical Review, calls it an ignis fatuus, though he does not feel himself authorized "to treat all cases of apoplexy in the same manner." 662. Notwithstanding our conviction of the absolute neces- sity of blood-letting in this disease, we are convinced, that both time and quantity must be regarded. With regard to time. It sometimes happens immediately after the apoplectic stroke, that the powers of the system are very much prostrated, from the sudden violence committed on the nervous system; the face is pale; the skin and extremities cold; the respiration slow and difficult; the pulse feeble and frequent, while both faeces and urine may be discharged involuntarily. Now, it must be evi- dent, that if we prescribe for the name of the disease, to the to- tal disregard of the state of the circulatory system, we should do much mischief, by the abstraction of blood. 663. It may be said, that this appearance is fallacious; and that the system is merely depressed, (see note to par. 351,) and that it will rise, if we take blood from it—this may be the case sometimes for aught we know; but we have never seen a case attended by the symptoms above detailed, especially in subjects advanced in life, in which the pulse was in a state of depression agreeably to the notions we have of that state of the arterial sys- tem. In cases of the kind under consideration, we have never ventured to abstract blood until we have enabled the system to react, by the use of external stimuli. We therefore direct the legs and feet to be placed if possible in warm water, in which there is a considerable quantity .of the flower of mustard min- gled. These parts are to be well rubbed with the hand while in the water for ten or fifteen minutes; they are then to be well 214 APOPLEXY. dried and wrapped in a warm blanket. Dr. Abercrombie speaks highly of strong frictions applied to the body. 664. Should it not be practicable to place the feet and legs in water as directed, these parts should be bathed with brandy and mustard or Cayenne pepper, until a rubefacient effect is pro- duced. At the same time mustard and vinegar or brandy, should be applied warm, to each forearm until they redden the skin; and the whole body should be warmed by heated blankets, bricks, or jugs of water. And if by these means reaction is established, then, and not until then, should we open a vein. But as soon as this has taken place, blood should be abstracted, with a freedom and to an extent commensurate with the powers of the system and the urgency of the paroxysm. It is impossible to give a definite direction as regards the quantity of blood that should be drawn at any one time, or during the course of the disease,* as this must depend upon the effects of that which is abstracting, or has been abstracted, upon the force of the symptoms, and the power of the pulse; remembering always, that bleeding is per-" formed to no valuable purpose, if it be not carried to an extent that will diminish the vigour of the arterial system. 665. In order however to ensure this desirable end, at the least possible expenditure of blood, it should be abstracted from a large vessel, and from a large orifice, and in as short a time as may be practicable. For this purpose the jugular vein or veins may be opened, sometimes, with great advantage—we say, some- times; because this cannot always be done. If this vein be se- lected, it must be opened without the use of a ligature; as this would be mischievous, by retarding the departure of blood from the head. We have never found it necessary to do more, than to compressthe vein, by the extremity of a finger. 666. If the jugular, cannot be commanded, we should bleed from the arm or arms, making large orifices, as just recommended. To aid the bleeding, we should have the bowels opened as speedily, and as copiously, as possible; this should be attempted by an injec- tion made of two ounces of senna and a pint of boiling water; and dissolving in it, after straining it, a table-spoonful of common * Dr. Cheyne says, " it ought to be known that from six to eight pounds of blood have been taken from a person by no means robust, before the disease, which ended favourably, began to yield." APOPLEXY. <. 215 salt. This must be repeated, from time to time, until the bowels are freely purged. If the patient be capable of swallowing, which is often the case, an infusion of senna like that just recommend- ed for the injection, should be given him frequently by spoon- fuls until the object for which it is given is accomplished. We prefer the senna to any other of the cathartic remedies; as it is always certain and prompt if the sensibility of the alimentary canal be not too much diminished, as is the case, sometimes. Indeed the griping effect of the senna appears to be useful in all the affections of the brain, that depend upon its repletion. 667. Cold applications should be made from time to time, under the precautions suggested, (par. 396,) for their employ- ment in fever.* The feet and legs should never be permitted to remain cold an instant, provided they can be made warm by ar- tificial means. The patient should be placed in as an erect a po- sition as possible, as every advantage should be taken of the be- nefit gravitation affords us. 668. As respects the propriety of repeating the bleeding, much must be left to the discretion of the medical attendant— for he must determine whether the state of the pulse and other symptoms will justify the farther abstraction of blood. Should it not be thought justifiable to bleed from the arm, yet the symp- toms persist, much advantage may be derived from local deple- tion; especially by cups—six, eight, or ten ounces may be rea- dily abstracted by these means from the temples, forehead, or behind the ears and neck. Cupping, is preferable to leeches, though we could abstract an equal quantity of blood by their ap- plication. Why this is so, is perhaps difficult to explain—but all experience seems to confirm it as a truth. Dr. Abercrombie seems to attach but little importance to local bleeding; at this we are not a little surprised; while Dr. Gregory, we are informed by Dr. Johnstone, used to declare in his lectures, he had seen the cupping-glasses rouse the patient, when general bleeding had produced no effect. 669. Of this fact we do not entertain a doubt; yet if it be re- • Cold water in a full stream upon the crown of the head, and received in a basin held under the chin, is recommended by Dr. Abercrombie in apoplexy. He gives an instance of a girl, who was quickly restored by this means, from a state, he believed to be, perfect apoplexy. 216 OF SCARLET FEVER. ceived as it stands, as a practical lesson, it might grossly mislead the inexperienced practitioner; for it appears to imply, what we presume Dr. Gregory did not mean should be understood by the observation,—namely, that cupping was preferable in apoplexy to general bleeding; and that it would succeed, where this had failed. The fact therefore should only be thus interpreted, that by the general bleeding, a sufficient quantity to relieve the pa- tient had not been drawn; but the additional abstraction of a few ounces by cupping, effected, just what was left undone, by the previous bleedings. For we will persist in the belief, that had not just so much blood been drawn by the general bleeding, that the local bleeding would not have been of the slightest avail. Indeed, topical bleeding should never be had recourse to, but after it was no longer proper to bleed, generally. 670. Of emetics in apoplexy, we can say nothing from our own experience, never having had courage, (from a pre-conceived notion we grant,) to employ them. Nor have we been seduced by all that has been said in their favour, by an ingenious writer in the 6th, and 7th vols, of the Medical and Physical Journal. To us there appears to be but one possible case in which they can be employed with the probability of advantage, and that is in crapulous apoplexy; and even here, we would not venture upon giving them, Tjut after pretty ample depletion. 671. Every thing that can act round the neck like a ligature, should be instantly removed ; nor should they be suffered to be reapplied while the disease continues. The patient should be placed in as airy a situation as circumstances will permit; and constantly kept in as moderate a temperature of atmosphere as can be commanded. CHAPTER IX. OF SCARLATINA, OR SCARLET FEVER. 672. This is so denominated, on account of the peculiarly florid appearance of the skin, by which it is accompanied. In some one of the several forms, which we shall presently see it OP SCARLET FEVER. 217 puts on, this complaint has, from an early period, occupied no inconsiderable share of attention. It is frequent in its occurrence, extensive in its prevalence, and, at times, exceedingly fatal in its terminations. The complaint prevails more in winter and spring, than in summer or autumn; attacking children, in preference to those who are more advanced in years.* By the nosological writers, it is divided into three forms; which are to be regarded, however, as nothing more than the same disease, marked by different degrees of violence:—the scarlatina simplex—scarla- tina anginosa—and scarlatina maligna. To many, the latter is more familiar under the name of the malignant, or putrid sore throat. 673. By scarlatina simplex, is to be understood, the simple constitutional disease, without any morbid affection of the throat. By scarlatina anginosa, a higher degree of the same complaint —the throat being at the same time inflamed and swollen. By scarlatina maligna, the same disease, in still greater violence —the throat being affected, or otherwise, and the symptoms ma- lignant. 674. It is unnecessary to enter into an elaborate discussion, to establish the identity of the diseases. 675. Like most other fevers, scarlatina commences with chil- liness, fulness of the head, and lassitude; to which succeed, pros- tration of strength, which at times is very great; and nausea, or vomiting. The surface soon becomes florid, and hot; and on examining the throat, it will sometimes be found inflamed; and the same red appearance extends to the tongue, t There is often at this time, more or less catarrhal affection; the head suffers severe pain, particularly about the frontal sinuses; and with which is sometimes associated, a disturbance of the intellectual faculties. .The degree of these symptoms, indicates with suf- ficient exactness, the strength and character of the forming dis- ease. Being very slight, the complaint will be simplex; if less * Sir Gilbert Blane says, that he never saw a person turned of forty, affected by it. f This last presents a very peculiar aspect. Through the fur with which it is covered, the elongated papillae project their points, and are of intensely deep scarlet hue. 218 OF SCARLET FEVER. so, the anginosa; and where they are severe and threatening, the maligna. 676. In the worst variety of scarlatina maligna, the com- mencing symptoms are alarmingly violent. The attack is, for the most part sudden; the patient becomes pale, sick, and faint; the head is giddy, heavy, and confused, rather than severely pained; the oppression about the praecordia, is extreme; the heart palpitates, and the stomach suffers great uneasiness, though there is no vomiting—this organ being probably prostrated be- low the power of reaction. The face is pale, or livid ; the eyes exhibit a glairy appearance, and are marked by a fatuitous or inebriated expression. "A remarkable tumefaction of the fingers sometimes takes place, which, with the erysipelatous tinge they soon acquire, is often of itself sufficient to characterize the dis- ease." Gregory. 677. On the second or third day from the commencement of the disease, the febrile symptoms are considerable; the skin be- comes morbidly sensible to the touch, and begins to be covered with an efflorescence, or florid eruption.* About the same time, a degree of redness and swelling appears in the fauces. The skin becomes excessively hot; more so perhaps than in any other form of febrile disease. The pulse is also very frequent, rarely being under one hundred and twenty strokes in a minute. 678. The reaction of the system being now completely de- veloped, the pulse exhibits the character which belongs to the existing form of the disease—preternaturally frequent, quick, and active, though still moderate, if the disease be simple—more frequent, irritated, and tense, if it be anginose—of greater fre- quency still, but not so full, resisting, and firm, if it be malig- nant. The temperature of the body, the thirst, the scurf on the tongue, are also graduated in the same way; each symptom in- creasing in intensity, according to the augmented violence of the case. 679. The eruption assumes, at times, the form of red points, though generally, that of red patches, which spread and unite, so as to cover the whole surface. It appears first on the face and * The tone of colour is said to be that of a boiled lobster. OF SCARLET FEVER. 219 neck; and in the course of a short time, spreads gradually to the lower extremities. The redness is often considerable about the loins, and the bendings of the joints, and on the hands, and ends of the fingers, which feel stiff and swollen. The eruption is not very regular, either as to the time of its appearance, its steadi- ness, or its duration. It usually continues about four days, and goes off with desquamation of the cuticle. As the disease pro- ceeds, the neck and lower jaw grow stiff, the tonsils swell, and become marked with specks, which degenerate into ulcers, cover- ed with superficial, ash-coloured sloughs. These sloughs, in fa- vourable cases, separate and come off, about the eighth or tenth day, when the ulcers underneath are fresh, and florid, and heal kindly. The fever, at the same time, gradually abates, and a great amendment becomes apparent. 680. But, in the more malignant cases, the course of the dis- ease is very different. The sloughs on the tonsils grow fouler; and the discharge from them, and the nostrils becomes exceed- in <»Iy acrid. The mouth assumes a dark colour, and is often encrusted with a black or brown fur. The breath is extremely offensive, a tenacious mucous secretion infests the fauces. The eyes and nostrils furnish an acrid serum. Haemorrhagies some- times take place from these parts, as also from the bowels; diar- rhoea of a severe kind is often found present; so also delirium or coma. If the throat be examined, it will be found studded with more or less sloughs, with dark or livid bases. The parotids are swelled and tender to the touch. Painful induration of the glands of the neck, which sometimes terminate in large suppurating abscesses; tenesmus, and diarrhoea; which sometimes speedily sink the patient, if not early removed. 681. This is reputed to be a contagious disease. On this point, however, the evidence, to say the least, is equivocal. The facts connected with the spreading of scarlatina, seem to be perfectly explicable, on the ground of its being epidemic, and not conta- gious.* In this country the belief that it is a contagious disease, » The weight of European authority is perhaps against us; and in actual practice, it will be safest to act under such a conviction. We are indeed told, that the power of infecting endures for a very considerable time—certainly for a week or two after the cessation of the efflorescence, and probably as long as the desquamation of the cuticle lasts. Persons who have been exposed to the contagion, have the disease, it is said, to break out on the fifth or sixth day. 220 OF SCARLET FEVEIt. is by no means so general as it is in Europe, and especially as it is in Great Britain. I have never seen so far, any decided proof, that it has communicated itself in any one instance. On the con- trary, I am strongly disposed to doubt its contagious quality. I attended a child with scarlatina anginosa, in a family of eight children; the child that was ill was constantly surrounded by the well children, yet not one of these sickened afterwards with this disease. The same thing precisely occurred in my own family; besides many less remarkable instances. Gregory says "the slowness of its diffusion is one of the most remarkable circum- stances in its history." Vol. I. p. 237. 6S2. As regards the prognosis, it is unfavourable in propor- tion to the malignant character of the disease. Thus great pros- tration of strength; delirium; or coma; extreme restlessness; a distillation of very acrid sanies from the nose; a purple or livid appearance of the fauces, without tumefaction, interspersed with white species, or dark sloughs, attended by diarrhoea of acrid matter; and above all, a change of the efflorescence to a mahogany colour, are mortal, or extremely alarming symptoms. The ter- mination of this disease is sometimes exceedingly abrupt, and unexpected. We have known death to take place, in several instances, and this most suddenly, where every hope was enter- tained of recovery,* but a short time before. The favourable signs in scarlet fever are, the patient surviving the ninth day, without any decided mortal symptoms; the intensity of the co- lour of the skin abating gradually; desquamation of the cuticle, and the departure of the swelling from every .portion of the body to which it had extended; the separation of the sloughs, with a healthy appearance of the parts from which they separated; pulse becoming slower and less irritated; heat abating; urine depo- siting a lateritious sediment, refreshing sleep, and return of ap- petite. 683. In its simple form, scarlet fever calls for very little me- dical aid. An emetic of ipecacuanha or antimony; purging with calomel, and afterwards with some one of the neutral salts; vene- • When the disease is very malignant, death sometimes takes place on the third or fourth day; while in its milder forms, it will linger on to the second, or even third week. Generally, however, the patient is safe after the ninth day, under either form of the disease. OF SCARLET FEVER. 221 section, in case of fulness and pain in the head; the mild diapho- retics, aided by diluting drinks; and a regulated diet,* are all^we need prescribe. But in the anginose state of the disease, more is required—the treatment, here, must be circumspect and vigor- ous; and much reliance is to be placed on the thorough evacua- tion of the alimentary canal. Unless, as is sometimes the case, the violence of the symptoms calls for the immediate use of the lancet, let the treatment commence by puking with ipecacuanha. Emetics are of the highest importance; and may sometimes be repeated during the course of the disease, should the symptoms be persevering. 684. The emetic should be followed by laxatives. Calomel would seem to be the most suitable, on account of its tendency to prevent, and remove congestions of the abdominal viscera, which are much to be dreaded, and vigilantly guarded against, in this disease. This is a disease in which congestions of the great viscera, are very apt to occur; and requires mercurial purging to unload the vessels, and restore the balance, which is thus destroyed in the circulation. In the more advanced stages of the disease, however, provided the bowels have been already fully evacuated, some of the milderpurgatives may be employed. The best mode of exhibiting calomel is in divided doses—say six or eight grains divided into six parts; one part to be given every hour, until the whole is taken; unless the previous quan- tity may have answered. Should this quantity however fail to move the bov/els, it must be followed by two or three tea-spoon- fuls of calcined magnesia, mixed in a little sweetened milk, and drinking after it, some lemonade. 6S5. In case the pulse be full, tense, or hard, immediate re- course is to be had to venesection. The quantity of blood drawn, and the repetitions of the operation, are to be directed of course, by the judgment and experience of the practitioner. The relief felt by the patient, the appearance of the blood, and the effect on the pulse, must determine, whether it shall be repeated—the bleeding must be followed by purging. In the early or inflam- • By a regulated diet, we mean, a strict antiphlogistic one; that is, an entire forbearance from animal food; from every kind of liquor, whether fermented or distilled; and from spices of every species. 222 OF SCARLET FEVER. matory condition of scarlatina, however, when there is consi- derable arterial action, and vast augmentation of heat on the sur- face, cold ablution, or sponging, gives great relief to the symp- toms, and is a most comfortable process. We prefer, however, sponging to ablutions. Some however are afraid of these cold applications, because the throat is sore; but this forms no excep- tion ; for it is not accompanied by cough or other pneumonic symptoms like measles; and the sponging, or even affusion has checked the sore throat most evidently. We would however make an exception to the employment of cold water, &c. when they produce chilliness; in this case tepid water may be substi- tuted. 686. We are told the warm bath is exceedingly efficacious, when the eruption imperfectly takes place, owing to general lan- guor; and especially when attended by coldness of the surface— or having appeared suddenly recedes, inducing great gastric distress, and other very unpleasant symptoms—to cleanse the foul ulcers of the throat, emetics are found most effectual—the emetic may be followed by the use of detergent gargles; the best of which are composed of Peruvian bark, with a portion of the tincture of myrrh—or, barley water, acidulated with the sul- phuric or muriatic acid, with the addition of honey. An infusion of Cayenne pepper, alone, or mixed with barley water, or the decoction of bark, is much, and we have reason to believe not too much, praised as a gargle,* as far as we can rely on our own observations. 687. In the malignant shape of this disease, the general prac- tice is nearly the same as in the preceding or anginose state. We rely mainly, on evacuations of the primae viae—first, by eme- tics, and next with the mercurial purges. 68S. Whatever may have been the primary form of the dis- ease, in the advanced stages, when appearances of great depres- sion supervene, we have recourse to nearly similar measures. The object is to support the enfeebled system, and which is best accomplished by the carbonate of ammonia, camphor, turpentine, * We are in the habit of using the Cayenne pepper gargle in the incipient stages of anginose affections, with the most decided advantage; and in the disease under consideration, it seems to us to be the only remedy that affords relief, if ulceration has not taken place. OF SCARLET FEVER. 223 bark, and wine—aided by the ordinary external irritant applica- tions. 689. Long after the cessation of the active symptoms, there are certain consequences show themselves, to which our atten- tion should be immediately called. Deafness is one of these; this proceeds from inflammation having invaded the Eustachian tube, and leaving it in a state of obstruction. It is an unpleasant affection, though we have never known any permanent mischief to result from it; it requires no treatment.* OZdematous swell- ings of the lower extremities, are a common, as well as a more serious inconvenience. The best treatment is to purge mode- rately, and afterwards exhibit the digitalis. It is here, that it sometimes proves pre-eminently beneficial. But in the removal of the effusion, it may be aided by frictions and bandages, if the swelling be large, and by exercise duly regulated, and persever- ing in a milk and vegetable diet. We have known the inflamed parotids run on to extensive suppuration, and require much time for healing. When this takes place during the continuance of considerable fever, and the parts exposed by sloughing look as if they had been carefully and beautifully dissected, death has constantly followed, as far as our observations have extended. 690. Dropsical affections frequently succeed to scarlet fever; this takes place after the mild, as well as after the severer form of this disease. We are inclined to believe, that this affection arises from the accompanying inflammation, not having been properly subdued by early depleting remedies. In consequence of this, the inflammation acquires a chronic, or a sub-acute form, which is only relieved by purging, even by blood-letting, and diuretics of the saline kind; as nitre, or nitre and squills. For children under seven years, and above three, we would give eight grains of nitre and one-fourth of a grain of squills three or four times a day. For those above seven to fifteen, twelve grains of nitre, and half a grain of squills may be given; from fifteen to adult age, from fifteen to twenty grains of nitre, and a grain of squills may be administered. * Dr. Gregory however states, that " not unfrequently permanent deafness is left by it." Vol. I. p. 240, Of this however we have never seen an ex- ample. 224 OF SCARLET FEVER. 691. Much has been said of the preventive powers of bella- donna in scarlet fever, in various parts of Europe, especially in Germany; and as every thing that can possibly diminish the frequency or abate the danger of this oftentimes formidable dis- ease is eagerly sought after, we have thought it proper to intro- duce in this place a summary of what has been urged in favour of the prophylactic powers of this active drug; and at the same time to contrast these newly raised expectations with what ap- pears to be a fair and candid, and at the same time a sufficiently extensive experience upon this point—at the same time declaring our entire want of confidence in this medicine, or perhaps any other, to prevent the accession of scarlet fever; especially when epidemic; a time of all others at which it would be useful. In matters of so much moment as the one under consideration, ne- gative proofs of the efficacy of any means are not always to be relied upon; we should always endeavour, in making proposi- tions in which the lives and happiness of our fellow creatures are involved, to arrive at absolute certainty, as far as this is prac- ticable, before they are confidently promulgated to the public to be acted upon. Had this plan been adopted as regards the pre- servative powers of the belladonna, we believe we should have heard of no positive testimony in its favour. "Belladonna a Preventive of Scarlet Fever." 692. " It has been long known that Dr. Hahnemann, of Leipsic, has asserted the above fact—but, since the year 1818, several practitioners in the north of Europe have repeated these experi- ments, and they find them founded on truth. The first of these, Dr. Brendt, of Custrin, affirms that all who employed this re- medy escaped the infection—and his account is corroborated by Dr. Mushbeck, of Demmin, in Western Pomerania, who says he has used it for seven years, and with equal success—and he administered it to all those who dwelt in the houses where scarlet fever prevailed, continuing its use until desquamation of the cuticle had taken place in those attacked. Dr. Dusterbourg, of Warbourg, has also published an account of a series of experi- ments, confirming those statements—and several subsequent me- moirs have appeared, all equally corroborative of this virtue in URTICARIA, OR NETTLE RASH. 225 the belladonna. The formula generally recommended, is a solu- tion of two grains of the extract in an ounce of some distilled water—and to children from one to ten years of age, from one to five drops of this solution is given four times in the day— from ten years of age and upwards, from six to ten drops is given, also four times in the twenty-four hours."* "Belladonna in Scarlatina." 693. "In the last volume of the Philadelphia Journal of the Medical and Physical Sciences, will be found some observations which are highly favourable to the efficacy of the belladonna as a preservative against scarlatina. Dr. Lehman has published, in the twenty-second volume of Rust's Magazine, a memoir, in which he observes that an epidemic scarlatina prevailed at Tor- gan, in 1825, of so violent a character, that one in eight of those afflicted with it died, and that thirty patients, all of tender age, fell victims to it. The belladonna was administered, with confi- dence, in many families in which the disease appeared, and there could be no doubt of the good quality of the extract employed; nevertheless it did not act either as a preseryative, nor did it mitigate the violence of the disease. Dr. L. did not perceive any difference either in the violence of the disease, or its results, when it attacked those who had taken the belladonna^ even for a long time and in large doses, and those who had never taken the medicine." CHAPTER X. URTICARIA, OR NETTLE RASH. 694. This very troublesome, and sometimes obstinate com- plaint,-is wont to attack children who are teething, or who in- dulge much in ascescent food, or fruits, in the summer season especially. • Philada. Med. 8: Phys. Journ. from the Revue Mcdicale, Juin. 29 226 URTICARIA, OR NETTLE HASH. 695. Dr. Good defines the idiopathic species to be—"rash in florid, itching, nettle sting weals, appearing about the second day; irregularly fading and reviving, or wandering from part to part: fever a mild remittent." Vol. II. p. 384. This defini- tion may be correct in what Dr. Good calls the idiopathic form of urticaria; but there are some remarkable deviations from it. We have seen many instances of this complaint come on very suddenly, when certain articles had been taken into the stomach, and which was only relieved, by these substances being again discharged from it. We knew a gentleman in whom this complaint has been several times produced by eating of very young boiled chickens; when roasted or broiled they would not affect him; by boiled young cabbage in the spring of the year; by a draft of cold lemonade when his body was over-heated. After either of these substances had been received into the sto- mach a few minutes, he would become violently sick; would vomit, and in a moment be covered with weals, which would remain until he would effectually cleanse his stomach from the offending matter. 696. Dr. Hewson mentions several cases of eruptions which arose from taking pf balsam copaiba; some resembled the weals of urticaria, others erythema, or roseola. Strawberries some- times gives rise to urticaria; we knew a lady who never fails to have it after eating this fruit. 697. This is a very troublesome complaint in consequence of the excessive itching which always attends it. It is almost always accompanied by sickness of stomach, head-ache, giddiness, and great disposition to become chilly, upon the slightest exposure of any portion of the body. The fever which attends, may be of greater or less violence; but it almost always observes an even- ing .exacerbation, at which time, all the symptoms are increased, and especially the itching. The weals which appear upon the skin are sometimes very extensively spread over the body; and at other, confined to certain portions of it, especially upon the inner surface of the forearms, and inside of the thighs. 698. From the surface of the weals there issues an acrid scrum, or lymph, which serves to perpetuate, or renew the troublesome itching; and such is the disposition of the skin, while labouring under this affection, that you may at pleasure, if the fever be con- siderable, produce a continued eruption, by drawing the nail URTICARIA, OR NETTLE "RASH. 227 forcibly over the skin, at almost any portion of it. This erup- tion sometimes disappears as suddenly as it had showed itself; and when this is the case, serious consequences have sometimes resulted, though the disease is very rarely fatal. We but once have witnessed danger from the retrocession of this eruption. In this case the patient had previously several attacks of an in- termittent, from which she had been relieved each time by the sulphate of quinine. Her health appeared to be rapidly mending for some time, and she had nearly acquired her wonted strength; when very early one morning she was attacked with urticaria to which she had been occasionally liable. 699. Soon after it made its appearance she became extremely sick, and vomited very freely; she complained of a severe pain in the head, which was quickly followed by delirium. At this time we saw her; besides the symptoms j'ust named, we found her ex- tremely restless, throwing herself into a variety of positions, as if unable to keep quiet for a moment. 700. The face was cadaverous, and evinced much uneasiness. Her intellect was not sufficiently collected to give any rational answer to our questions. 701. The extremities were cold, the pulse nearly extinct, and the breathing very laborious; in a word, her situation was truly alarming. Hot applications were made to the feet and legs; a very large warm sinapism was applied to the region of the sto- mach; and ten grains of the carbonate of ammonia were ordered every hour, together with a spoonful of hot brandy toddy every few minutes. 702. The parts of the body from which the eruption had dis- appeared exhibited a motled, livid hue; other portions of the skin were " goose-fleshed" to a great degree. The bowels were spontaneously opened, at the time the puking took place; and she passed a large quantity of urine. We saw our patient after an interval of two hours, and found her in rather a more favour- able situation, but very far from being relieved. 703. The legs and feet were a little warmer, but the mustard had scarcely acted upon the skin. The volatile alkali, and brandy toddy sat well upon her stomach ; the delirium somewhat abated, and the whole skin looked more natural. The remedies were ordered to be continued. 228 URTICARIA, OR NETTLE RASH. 704. At the end of two more hours, we again visited our pa- tient, and found her much amended—that is, the warmth of the body greater, and more natural; the delirium and j'actitation less; the pulse more open; the countenance more natural, and less dis- tressed; but no return of the eruption. Remedies were ordered to be continued. 705. In the evening, upon our return, we found a pretty plen- tiful crop of the eruptive weals, attended by much itching. The warmth of the skin rather above the natural standard; the deli- rium was gone; the inquietude over. The volatile alkali and brandy were suspended; a liberal dose of magnesia ordered, and a little chicken water, from time to time, was allowed. On our visit on the following morning we found our patient feeble, but relieved from the eruption, and free from fever. She was soon after restored to health. 706. It would be difficult to say what may be the cause of idiopathic urticaria; be this what it may, the force of the disease is chiefly spent upon the cutaneous system; but with which the stomach is sure to sympathize: or the stomach may be the seat of the affection, and the skin sympathize with it. It sometimes becomes chronic, and we have known several young people liable several times in the year to returns of it, without any evident exciting cause. 707. This disease, however, is much more frequently a sym- pathetic affection, arising sometimes from difficult dentition, and at others from some offensive substance taken into the stomach; this is especially the case with children until the age of puberty. Acids of every kind seem capable of producing it—hence the frequency of its appearance after crude fruit, cucumbers, young cabbage, lemonade, when the body is heated, &c. The plan of treating this complaint is in conformity to the condition of the stomach; for whether this disease be idiopathic or symptomatic, the stomach is sure to possess great acidity—to destroy this is essential, both to its alleviation and cure. 708. Magnesia should, therefore, be freely prescribed; lime- water and milk should also be given, particularly where the eruption has continued several days. A milk diet should be adhered to; and if no fever be present, chicken water and beef tea may be indulged in. URTICAniA, OR NETTLE RASH. 229 709. It is common in this disease to give saline purges; but this is decidedly inj'urious—there is no purgative so certain or proper, as magnesia, or magnesia and rhubarb. It is also com- mon to permit the patient to take lemonade; but this is still worse—plain water or toast water, not too cold, are the best drinks. Solid food should be avoided; as should damp places, or streams of cold air. 710. To relieve the excessive itching, the patient may be liberally dusted with well-toasted rye or wheat flour, from which much relief will be experienced. In the chronic form of this complaint, we have found a persevering use of small doses of Fowler's mineral solution to have succeeded in every case in which we have hitherto tried it. 711. A very interesting case of chronic urticaria is related by Cazenave. "In the Hospital of St. Louis, in a patient of Mr. Biett's wards," says Mr. C, "we have seen it, (urticaria,) ac- companying a quotidian intermitting fever, and after "having lasted for four years, finally induce swellings and great disten- tion, ecchymoses, ruptures, and ulcerations. In many paroxysms it was accompanied with a general tumefaction; sometimes to such a degree, that the patient was nearly suffocated; his respi- ration was hurried, the movement of the thorax very slight, the neck swelled, the face puffed up, and of a violet colour, the pul- sations of the heart intermitting, and at times scarce perceptible, and death, which appeared imminent, only prevented by large bleedings." 712. " This patient, who had passed through several hospitals, and in which every means of cure had failed, was at last restored to health by the use of Fowler's solution."* 713. We believe we were the first to recommend Fowler's solution, for the cure of chronic urticaria. 714. Children of from seven to fourteen years old, may take four drops every morning, noon, and evening, in sugar and wa- ter; or should this sicken, give but three. * Prac. Syn. of Cut. Dis. trans, p. 65. 230 threnitis. CHAPTER XI. PHRENITIS. 715. By this we understand an inflammation of the brain or of its appendages. So far as we are at present acquainted with this disease, and its symptoms, we are not able to say which por- tion of the cerebral system is particularly affected, though post mortem examination, declares that either the substance of the brain, or its coverings, or both may be involved. Much pains has been taken by late pathologists to distinguish the one affec- tion from the other; and some have thought they have been able to do so, and have enumerated a number of symptoms, which purport to point out the particular structure that is affected; but there is much doubt upon this point; but fortunately in a practi- cal point of view, it is of very little importance, since the know- ledge of the existence of either, would not influence our thera- peutical views. 716. Thus Dr. Fordyce says, "if the meninges are affected, the pain is acute; if the substance only, obtuse, and sometimes but j'ust sensible." Practice of Medicine. Dr. Cullen observes, " I am here as in other analogous cases, of opinion, that the symptoms above mentioned of an acute inflammation, always mark inflammations of membranous parts; and that an inflamma- tion of parenchyma, or substance of viscera exhibits, at least commonly, a more chronic inflammation." There is much rea- son to challenge the truth of these opinions; they certainly fail in pneumonia, and we believe we could prove they do not hold good in either the brain or its appendages, as we shall have oc- casion to say in its proper place. 717. We shall therefore comprehend under the term phrenitis the inflammation of the substance of the brain, or that of its ap- pendages, or both; as it is extremely doubtful whether we are in possession of any pathognomonic sign for either. Mr. Pinel* * Nosographie, Vol.11, p. 180. PHRENITIS. 231 censures Sauvages, for the confident manner in which he de- tails the symptoms belonging to each membrane of the brain, and the brain itself when labouring under inflammation. He de- clares this decision altogether premature; and thinks from our present state of knowledge, we have no right to make a distinc- tion between the one part and the other when in a state of phlo- gosis. We are decidedly of this belief; for we have never been satisfied, that any peculiar cognizable circumstance marked the seat of the inflammation. 718. As to the marks laid down by some authors, we are cer- tain they cannot be relied upon—more especially those which consist in the distinction of the quality, if we may so term it, of the attending pain. Acute and obtuse pain, the chief distinc- tions, are easily confounded, and we are certain they cannot be relied upon; for what, in a person with even a moderately clear intellect, would be called acute, might by another receive the epithet, obtuse; and it becomes still more uncertain, when the operations of the mind are disturbed, by an overwhelming in- flammation. 719. In treating this subject, we shall at this time confine the consideration to the idiopathic form of this disease; at least as far as circumstances will permit us to distinguish it from the symptomatic. At the bed-side this is not so easy as it might at first appear to be. Acute diseases of other viscera are very fre- quently attended with intellectual derangement—delirium is common to most fevers; the stomach, the intestines, the liver, the lungs, when inflamed, may, produce severe or mild mental aberations. In one of the most furious cases of delirium, I ever witnessed, and which bore the most unequivocal marks of cere- bral inflammation, Dr. Physick and myself found the brain upon examination to be healthy, while the stomach exhibited the highest grade of inflammation ; while on the other hand, WiJlis, Bonetus, Sarcone, &c. have observed inflammations of the brain, without delirium having preceded death.* Stollt has seen the brain and its membranes, inflamed, gangrenous, together with abscesses, in idiopathic phrenitis. MorgagniJ has seen a true • Pinel. Nosographie, Vol. II. p. 183. f Ibid. t Letter VII. Art. YT. 232 PHRENITI5. phrenitis, without leaving any marks of inflammation in either the brain or its appendages. 720. These are curious as well as important facts; apd should teach us caution in deciding upon the seat of a disease, espe- cially where the body may be inspected after death; and also should convince us, that there are no absolutely certain signs by which the condition of the brain or of its appendages can be recog- nised; for however advantageous a distinction might prove, yet it can rarely be made, but by opening the head. 721. The predisposing causes of phrenitis are pretty generally the same as those which give rise to the other phlegmasia?. The exciting causes may be insolation; immoderate mental excite- ment, as anger; the too free use of ardent spirits; errors in diet; metastases, as of gout, rheumatism, erysipelas; cuticular affec- tions, &c* 722. The premonitory signs of phrenitis, will vary both in intensity and duration, as the susceptibility of the body may be greater or less, or as the force of the exciting cause may be stronger or weaker, or perhaps as it may be one or other por- tion of the brain, or its appendages that may receive the shock, and perpetuate the impression. For the most part there is head- ache, and its seat maybe general, or confined; a sense of fulness, particularly if the head be placed a little depending, or suddenly moved; a throbbing within the cranium, communicating the idea that the pulses within the cranium can be\ heard. Disturbed sleep; startings; grinding of the teeth; frightful dreams; irasci- bility; unusual gaiety; redness of the eyes; face tumid and flush- ed; easily shedding tears, or perhaps they flow involuntarily; sensation of cold; extreme sensibility to light or to noise; bleed- ing at the nose; agitation ; limpid urine; costiveness, &c. 723. In the idiopathic form of phrenitis, the pulse betrays less disturbance than really exists; and this circumstance may serve with others to point out the independent nature of the affection. For when this disease is symptomatic, the pulse always partakes of the character it assumes, in the individual inflammation which • We do not enumerate among the causes of phrenitis, certain mechanical impressions or forces, such as blows, falls, or wounds of various kind, as the disease arising from such accidents, properly belongs to the care of the surgeon. PHRF.NITrs. 2JJ preceded the affection of the brain, and with which it is sympa- thizing. Dr. Wilson Philip says, and in this we fully agree, that "the hardness of the pulse is more remarkable, (in phrenitis,) than in synocha; sometimes it is both small and hard, and sometimes irregular; the pulse in synocha is always strong, full, and regu- lar."* 724. In no acute disease of the system, is there less evidence in some cases of local disturbance, than in inflammation of the appendages of the brain, or of even the substance of the brain itself. We have lately witnessed very remarkable derangements of this in two children, who died unquestionably from these af- fections, though in one the disease followed a mild case of measles, and the other a violent case of pneumonia. In neither instance was there the slightest delirium; in one there was a slight stra- bismus; yet in both there were marks of high previous inflam- mation. In one at least three ounces of serum escaped from be- tween the dura mater and the surface of the brain; the vessels of the brain itself were much enlarged; and its substance somewhat softened. In the other there was less serum, but a purulent substance spread itself over the whole of the superior surface of the brain, dipped between its hemispheres, and was even found at its base. The whole mass of brain, was of uncommon soft- ness. In both instances, the dura mater adhered so firmly, as not to be separated without tearing. One case terminated by- convulsions; the other with much apparent agony, but perfect consciousness. 725. Pinel says, "that coma may attend a true inflammation of the brain, without being preceded by phrenitis; in jjroof of which I will relate two instances in two children, one aged seven years the other eleven. On examining the first, the tunica arachnoides was found thickened in several places, and spread over with granulations; it was red, and adhered to the dura mater, and to a certain extent, a layer of albuminous matter was to be seen. In the other child, the inflamed condition of the tunica arachnoides was equally remarkable; it also adhered to the dura mater, and was occupied by a similar coat of albuminous matter. The right lateral ventricle was distended by a great quantity of serum, "t * Symptomatic Fevers, p. 81. f Nosographie, Vol. II. p. 189. 30 234 phrfxiti>. 726. M. Harpin has run a long parallel between the symp- toms of phrenitis and cephalitis; to which the author of the ar- ticle " Phrenitis," in the Diet, des Scien. Med. M. Vaidy, makes the following judicious remarks: "After reading this parallel, nothing appears to be easier than to distinguish cephalitis from phrenitis; but unfortunately it is not so at the bed side: for there is no characteristic symptom to distinguish these affections from each other, and they may be so entirely attended with the same signs, that experienced practitioners have mistaken one for the other." 727. The progress of this affection is no less constant than rapid; augmenting in intensity, until it is about to terminate fa- vourably or fatally. It has however its moments of remission and of exacerbation, like any other phlegmasia; and these maj be more or less regular. A treacherous calm sometimes takes place, only to be followed, by highly exasperated symptoms— even furious delirium. And such is the severity of the inflam- mation, and the importance of the parts involved in it, that it runs its course in a few days, if not arrested by prompt, and pro- perly adapted treatment. 728. It has always been looked upon as very difficult, to es- tablish the diagnosis of phrenitis; especially from that grade of fever called synocha or inflammatory fever. This difficulty con- sists chiefly in the want of pathognomonic signs for phrenitis; and from synocha almost always being attended by delirium. This however would not create much embarrassment, were the views taken of fever by Dr. Clutterbuck thoroughly established, or were they susceptible of it; as agreeably to him, phrenitis or inflammation of the brain, is the cause of fever, and consequently it, with all its phenomena, has a phlogosed state of the brain or its appendages for its origin. 729. " Sometimes nausea and a painful sense of weight in the stomach are among the earliest symptoms. In other cases the patient is attacked with vomiting, or complains of heart burn, and griping pains in the bowels. When the reader reflects on the intimate connection which subsists between the brain and every part of the system, he will not be surprised to find the symptoms attending the commencement of phrenitis so various, and that the stomach should in particular suffer, whicli so re- PHRENITIS. 235 markably sympathizes with the brain. These symptoms assist in forming the diagnosis between phrenitis and synocha.'" 730. The symptoms just enumerated we think are more com- mon to children or very young subjects, than to adults and elderly people. We have seen in several very strongly marked cases of this kind, in each of which the disease was supposed to be in the stomach, and to which all the remedies were unavailingly ad- dressed ; the post mortem examination proved the seat of the disease to be the brain. Perhaps the most certain diagnostic symptom in this disease, is the terrifying intolerance to light, when this symptom occurs, for it is not always present. We have seen the approach of a candle throw a child nearly into convulsions, and draw from it the most importunate supplica- tions to have it immediately removed. Dr. Philip justly ob- serves, "if in phrenitis we succeed in removing the delirium and other local symptoms, the febrile symptoms in general soon. abate; whereas, in synocha, though the delirium and head-ache be removed, the pulse continues frequent, and other marks of indisposition remain for a much longer time, and this serves to distinguish the two diseases, "t 731. "The eyes are incapable of bearing the light; and false vision, particularly that termed muscas volitantes, and the ap- pearance of false flashes of light passing before the eyes, are fre- quent symptoms. The hearing is often so acute, that the least noise is intolerable; sometimes, on the other hand, the patient becomes deaf; and the deafness Saalman observes, and morbid acuteness, now and then alternate."% 732.' " As the organs of sense are not frequently deranged in svnocha, the foregoing symptoms farther assist the diagnosis be- tween it and phrenitis."§ 733. The prognostic in this disease must always be uncertain, if not always unfavourable; for when we consider the importance of the parts involved in inflammation, the delicacy of their struc- ture, the great quantity of blood circulating through them, and the quantity required to be abstracted from the system in gene- ral before much impression can be made upon the contents of • Philip on Symptomatic fever, p. 79. * lb. p. 80. f Ib. p. 83. § Ib. p. 81. 23(i rilUENITI^. the cranium, and the changes effected in the remaining portion of blood, by the capillaries yielding their contents to the larger vessels after very large quantities have been abstracted, we shall cease to be surprised that phrenitis is constantly a disease of dif- ficult management, and of great danger. Yet these cases are not altogether hopeless. When this disease supervenes to other affections of an acute kind, as gastritis, enteritis, &c. the prog- nostic is almost always unfavourable, as we have two seats of inflammation now to contend with; and this at a period when the recuperative powers of the system are on the wane, if not very much exhausted. In general, the risk is in proportion to the violence of the symptoms; but this is far from always being the case, as the apparently milder forms have terminated fatally, though not equally rapidly. We have already declared, that this inflammation terminates sometimes in suppuration, effusion, and gangrene; in either of these, the case must be hopeless, though we have no absolutely certain signs that determine either has taken place, though either may be suspected, when coma, para- lysis, squinting, or convulsions follow the more acute and vio- lent symptoms. Also when the skin becomes cold, clammy, or rigid; the pulse creeping, very quick, small and feeble; respira- tion hurried; preternaturally slow, laborious, or stertorous, we may look upon death being near at hand. 734. As regards the alvine excretions, Dr. Philip says, that "instead of a superabundance of bile, there is sometimes a defi- ciency of it,* which seems to afford a still worse prognosis. The faeces being of a white colour, and a black cloud in the urine, are regarded by Lobb as fatal symptoms. The black cloud in the urine is owing to an admixture of blood." " There is often a remarkable tendency to the worst species of haemorrhagy to- wards the fatal termination of phrenitis." p. 82. 735. On the other hand, we may regard the following marks as constituting the favourable signs; a generally diffused warmth, without rising to a preternatural heat; warm and extended per- spiration; urine depositing a sediment; haemorrhage from the uterus, the nose, or the haemorrhoidal vessels in the more ad- vanced period of the disease; eruptions upon the skin, especially * Desault makes a bilious species of phrenitis. PHRENITIS. 237 of the inflammatory kind; the pulse becoming more voluminous, quicker, or less frequent; diminution of delirium and coma, &c. 736. The mode of treating this disease can almost be deduced from its history—it is essentially an inflammation of a highly sensible and vascular part, the organization of which is quickly liable to lesion, from causes that would scarcely disturb some other of the viscera. It must be evident that our chief reliance must be placed upon the abstraction of blood; and this will em- brace both general and local blood-letting. 737. The nearer to the head we can abstract blood, the better; but the most proper place cannot always be commanded, for this would be the jugular vein. There is much difficulty sometimes in drawing blood from the neck—the patient, unless it be a child, will not always submit to it, if he be even in his senses; and if he be delirious, it is almost impracticable. Hoffman and Cullen were both aware of the advantages that would result from draw- ing blood so directly, and at the same time so suddenly from the diseased part; and it is to be lamented, that their directions to this effect can so seldom be complied with. When, however, this can be done, it is certainly proper in violent cases, to give the jugular the preference. It nevertheless excites much alarm, when proposed, though there is neither disadvantage nor danger, from the operation—we have repeatedly performed it on children for convulsions, with the happiest results; nor have we ever wit- nessed any inconvenience from after-bleeding, as might reason- ably enough be expected. 738. But whether we select the jugular vein, or take the arm, sufficient quantity of blood should be drawn to produce a most decided impression on the pulse; nay, even to syncope would be desirable in some instances. These effects are best secured by placing the patient in an erect position, and drawing the blood from a large orifice. And this operation must be repeated as often as the symptoms and state of the pulse demand it. In this re- spect, and indeed in almost all, the treatment must be such as has been directed for fever of a high grade. And it must be borne in mind, that we have other resources in this disease, when the diminished force of the pulse might not justify the abstraction of blood from the arm. The application of leeches behind the cars, and angle of the jaw, or to the temples and forehead, will 238 PHRENITIS. be found highly useful in the idiopathic form of phrenitis; and if sympathetic, to the part nearest to the affected viscera. If it be gastritis, over the region of the stomach, &c. 739. Cupping may also be had recourse to, where leeches can- not be commanded; and the spots selected for their application, should be the same as directed for the leeches. And if neither cupping nor leeching can be done, much advantage may be de- rived by dividing the temporal artery, by the shoulder of a lan- cet, or by a scalpel. No difficulty attends this operation; nor is any thing to be apprehended from an artery being cut—a slight compression arrests the bleeding, nor is there the least risk that the bleeding will renew itself. 740. The head of the patient should always be elevated; and water of a low temperature, in a large bladder should be applied to it; but this must be under restrictions similar to those laid down for its use in fever. (Seep. 396.) The hair must be shaved off, or cut very close, that the eold may be quickly perceived. 741. It may however be proper to observe, that the propriety of applying ice to the head in cerebral inflammations is ques- tioned by Mr. Costa, in a memoir he read before the French " Academic Royale ,de Medicine" on this subject. He says, " would we found this treatment, (the application of ice to the head,) on the idea that the inflammation of organs contained within the brain is of a peculiar nature? But MM. Tomasin and Broussais, have sufficiently proved that inflammation wherever situated, and whatsoever its causes, is always the same. Now, then, if cerebral inflammations are the same as phlegmasiae of other organs, why treat them differently from the others? can we expect to oppose the flow of blood by the intensity of the cold?" 742. The author is of opinion, that by constrirrging the ves- sels of the scalp, we force the blood they contain to flow back on the brain. Under this impression, he proposes in idiopathic cerebral inflammations to shave the head, and to cover it with leeches in the course of the sagittal suture, and especially at its posterior extremity. He afterwards covers it with emollient poultices, which are to be renewed when necessary; and if re- quired he also has recourse to general bleedings. On the other hand, if the inflammation he sympathetic with gastro-enteritis, PHRENITIS. 239 which is frequently the case, especially in children, he directs his treatment to the state of the intestinal tube; unless the affec- tion of the brain greatly predominates; in which case he pro- ceeds as just mentioned. 743. He prefers the sinciput for the application of leeches, because the inflammation of the arachnoid, or encephalitis, usually occupies the anterior regions of the head, and by apply- ing leeches to the sinciput, he unloads the inflamed parts more directly, by acting on the longitudinal sinus, or rather on the veins which discharge themselves into it; and because there exists a sympathy between the skin which covers the splanchnic cavities and this part. 744. In aid of this, the stimulus of heat, light, and noise, must be removed as far as is practicable and proper for the season, and for the purposes of nursing. All conversation, or communi- cations whether of an agreeable kind or otherwise, must carefully be avoided—in a word, all the directions given for the manage- ment of fever in general, must be here put in practice. 745. Purging in idiopathic phrenitis is of much consequence; this should be performed by calomel, in doses suited to the age and situation of the patient; rendered active by an after-dose of the sulphate of magnesia or Epsom salts, or by magnesia, drinking lemonade after it. A free discharge must be maintained, by castor oil, magnesia, salts, either alone, or united. In the symp- tomatic affection, the purging must be regulated by the nature of the original affection.* The strictest antiphlogistic regimen must be insisted on. (See p. 214, 215, 216.) If the bowels are tardy, as they are wont to be, the operation of the medicines just named may be promoted by enemata of warm salt and water. • We would direct the attention of the practitioner when he determines on producing catharsis, that it is only in the idiopathic form of phrenitis that this operation can be valuable or sometimes perhaps even safe. For while he may derive prompt and decided advantage from purging in the idiopathic, he may do much mischief in symptomatic phrenitis; especially, when the original seat of disease is either in the stomach or intestines; or if he give in these cases, even the more active or drastic purgatives. In the latter form of phrenitis the milder laxatives should be employed; as castor oil, or weak solutions of the neutral salts; but in the former, from the direct communication of the vessels of the head and the abdomen, we may expect much advantage from the more active cathartics. 240 PHRENITIS. 746. Blisters as revulsives are highly useful when the system is reduced to the blistering point. (See p. 260.) They should be applied to the calves of the legs, to the inside of the thighs, or to the forearms. We have strong doubts of the propriety of blistering the head—indeed, we are of opinion that it is injurious ; to the shoulders, is less objectionable, though not a decidedly eligible spot. 747. Rubefacients may be also advantageously employed, after the circulation has been moderated, and especially when there is a tendency to congestion, as declares itself by an inequality of heat upon the surface, and especially when the feet and legs be- come cold. Mustard, Cayenne pepper, or the spirit of turpen- tine may be employed4or this purpose; and these may be aided by jugs of warm water, or heated bricks placed near the parts. Pediluvium may also be resorted to; provided the legs of the patient can be made to hang over the edge of the bed, without disturbing him too much, or obliging him to assume a horizontal position. His drinks should be the same as those directed for fever in general. (See p. 214.) 748. When phrenitis succeeds to the sudden suppression of any accustomed evacuation, as the menses, haemorrhoids, &c. though it must be looked upon as symptomatic, it will neverthe- less require almost always, active treatment. Bleeding, leeching, purging, &c. as already directed for the idiopathic species; and early attempts must be made to recall the habitual discharge. 749. After the disease has disappeared, the utmost caution should be exercised in returning to the ordinary mode of living— a moderate diet should be persevered in for some time after all febrile irritation has ceased, lest the disease be recalled. HYDROCEPHALUS INTERNUM. 241 CHAPTER XII. HYDROCEPHALUS INTERNUS. 750. It does not appear to be of much consequence in a prac- tical point of view, the place we give hydrocephalus internus; nor do we look upon as a matter of moment as a nosological arrange- ment; for two places perhaps may with equal propriety be as- signed it—first, either immediately following the acute affec- tions of the brain; or second, ranking it strictly with dropsy. And as we do not profess to be attentive to any strict nosologi- cal classification, we give it the place it is now found in; and more especially as it is not only an inflammatory affection, but one ex- clusively confined to the head, some of the diseases of which, we have been considering, and particularly phrenitis, to which it is occasionally without doubt, a sequel. 751. It would be altogether time ill-spent, in a work like the present, to enquire into the medical history of this disease; we refer those who are curious upon this point, to the works that treat professedly upon this subject. We shall only observe, that however familiar the ancients may be supposed to have been with hydrocephalus internus, it is every way certain, that its patho- logy was altogether perhaps unknown to them ; for it is only within a very few years, that it has been well understood even by the moderns. 752. By hydrocephalus internus, is to be understood a pre- ternatural turgescency of the vessels of the brain; a collection of serum, or serosity, within the ventricles, or upon the surface of the brain, or all; for dissection has discovered to us, that each of these circumstances may obtain at one and the same time. 753. Mr. Itard* with much propriety, and we think pathologi- cal truth, makes four species of this disease. 1st. Acute idio- pathic hydrocephalus. 2d. Acute symptomatic hydrocepha- lus. 3d. Chronic idiopathic hydrocephalus. 4th. Chronic symptomatic hydrocephalus. * Diet, des Sciences Med. Art. Ilydrocephale. 31 242 HYDROCEPHALUS INTERNUS. 754. The first species, is made to consist of serum suddenly effused by the tunica archnoides, in consequence of an idiopa- thic affection, within the ventricles, and upon the surface of the brain itself. It may be occasioned by external violence, as falls, and blows; or by sudden passions or emotions of the mind, as anger, fear, frights, &c. by the sudden arrest of habitual evacua- tions, as bleeding from the nose, the discharge from crusta lactea, sore ears; or the drying up of issues. It is most common with children; and particularly between the periods of the first and second dentition, among those of a robust constitution, and of florid complexions—at other times, it appears to be constitu- tional, and to run in families. We are at this moment attending a little girl of nine months old, with this species of complaint, who has lost, we are informed by the parents, five brothers and sis- ters of the same disease; and Cheyne mentions a much more nu- merous loss of this kind. In adults it is rare; yet with them, we have seen it in several instances prove fatal. Agreeably to Itard, epidemic peculiarity has an influence upon its prevalence. In one instance, an epidemic scarlatina; and in another, an ataxic fever, were followed by many cases of hydrocephalus. 755. The proximate cause of this disease appears to consist of an irritation or inflammation of the tunica arachnoides, which eventuates in an effusion of serum from such portions of this membrane, as may be subject to this irritation or inflammation; and which consequently may be, any portion of surface of the encephalon which this membrane covers. If this be true, it must be evident, that we must have at least three periods in the disease; each of which, during its continuance, must necessarily have its own characters. 756. Dr. Whytt, many years ago, divided this disease into three stages; but certainly without understanding its pathology. He has however notwithstanding this, proved himself to be a very accurate observer, and a faithful recorder of symptoms; for we very much doubt, whether a more accurate, general history could be given, especially of chronic hydrocephalus than he has left us. He certainly was unacquainted with the two states of mflammation now so generally acknowledged, as well, as so com- monly acted upon; though he has given evidence, that hydroce- phalus may be symptomatic; for in enumerating the causes, he HYDROCEPHALUS INTERNUS. 243 mentions, "ischuria," as giving rise to this eomplaint; and that " in tedious chronic diseases, water is often collected in the ven- tricles of the brain."* 757. The first period of the acute hydrocephalus, is generally marked by a more than usual reluctance in the child to talk; seeking the darker places of the room ; peevish much beyond its usual want; loss of appetite, or voraciousness; pretty sudden loss of strength; an unnatural heat of the skin, especially the head, though the exposed hands may be even cooler than natural; a contraction of the forehead and eyebrows; an intolerance of noise; a frequent pulse, especially towards evening; a flushed face, or only one cheek; heaviness of the eyes, and sometimes a dis- charge of water from them. If the child be old enough to be interrogated, it will declare its head to be the seat of its sufferings; if it be not, it will manifest this, by vague, and ill-directed at- tempts to place its hand upon it. These actions, especially in children under two years of age, are very often mistaken in what they mean—thus with some, attempts are made to put their fingers in the mouth, especially if they have not passed the first year; with others, beyond this period, the nose is frequently rubbed; with others, rather more advanced, the nostrils are picked, even to bleeding; while others, still younger, will roll their heads from side to side with fatiguing perseverance. The former of these symptoms are almost always attributed to wprms; while the latter always produces an apprehension, that "the head is affected." 758. The child for the most part is rather drowsy; that is, it lies with its eyes closed, and appears to sleep—but this is either merely an instinctive act, or the sensibility of the child is inor- dinately increased; for .the least noise, suddenly made, or the slighest touch, will excite an alarm, that is manifested, by sud- den startings. Or it will utter, during sound sleep, apparently piercing and fearful cries, without being able to state, that they were either alarmed, or in pain. Sometimes we have observed the head during several days together, carried first on one side and then on the other; and complaint is made with those suffi- ciently old, of a pain in the back of the neck. The secretion of * Works, p. 740. 244 HYDROCEPHALUS INTERNUS. the nostrils is almost always stopped altogether; and a dry, cha- racteristic cough, is almost certain to be present, and almost always continues through the whole course of the disease. We do not recollect an instance of idiopathic acute hydrocephalus, without this cough being present. 759. As the disease advances, and is about to form the second period, we find an aggravation of almost all the symptoms; the child now inclines to lie constantly, and may be observed to press its hind head forcibly against the pillow that supports it; or is much inclined to lie with it low. If it be raised, the head hangs motionless down, and the child betrays much uneasiness at the change of position; and if it can speak, desires to be laid down with an importunity and impatience that loudly proclaims its sufferings. When it is returned to its pillow, it is oftentimes pale, and apparently much exhausted by the effort it has made; it will sigh deeply, or scream violently. The face becomes more flushed, or there may be a deep-red spot only on one cheek, which will perhaps in the course of a few minutes shift itself to the other cheek. The lips are dry and parched; the tongue for the most part is clean; and there is either great thirst, or no demands are made for drink. The pulse now becomes slower and more con- tracted; the pupils widen, and an occasional obliquity in the eye may be observed; the forehead becomes permanently corrugated and the eyebrows contracted. 760. The mouth is kept in almost constant motion; the tongue is frequently thrust beyond the lips, and again suddenly retract- ed ; the eyes are now kept almost constantly open, if the room be dark; but if a strong light be suddenly admitted to them, the pain becomes so intense, that a violent scream is instantly given, accompanied by an earnest desire "to .take the frightful thing away." We have seen this repeated a number of times in the same individual; indeed, for a time, whenever a sudden light was admitted, and especially the light of a candle, when it was necessary to approach one, to give its medicines, or for other purposes. Indeed, the eye may almost be said to obtrude itself upon our notice; not only from the extreme sensibility it mani- fests to light for some time, but from the varying and pro- phetic changes it undergoes to the last moment of life. It is either steadfastly fixed, or constantly moving: now shrinking HYDROCEPHALUS INTERNUS. 245 from the light, from exquisite torture, or gazing upon the broad day, with the most perfect insensibility. Now convulsively drawn upwards under the eyelid, that nothing but the whites can be seen, even by separating the palpebrae; or their coloured portions sunk deep in the inner angles of the orbits—no visible part of the frame appears to undergo such decided changes as these little organs; nor from the condition of which can so much be learnt by the attentive observer. It is said, that a convulsive oscillation of the pupil may be observed upon the approach of light, which appearance is declared to be peculiar to the acute hydrocephalus. Now were this constant, which it is not, as M. Itard declares, it might be highly useful in diagnosis, as it would form a pathognomonic sign. 761. The bowels are for the most part constipated, and diffi- cult to move; the epigastrium more or less tender, and the abdo- men sunk; the urine scarce, and generally high-coloured, depo- siting a white mucilaginous substance, sometimes with shining particles floating in it; the hands and feet inclined to become cold, while sweat may be observed upon the forehead and about the neck. This state of things continue for an uncertain period, when the third period may be ushered in by convulsion or by a manifest squinting, with decided coma. Paralysis may now be added to the new symptoms, or a pretty constant twitching of the leg and arm of the same side, or a regular and constant mo- tion of them may be now kept up; the pulse is very frequent, small, and wiry—the face disfigured by a livid suffusion; a cold sweat bedews the whole body; the breathing becomes slow, and stertorous, until death closes the scene; or this event may be sadly hastened by convulsions. The bowels during this period reluctantly yield a dark, rue-coloured bile; and the urine often- times is entirely suppressed. This period is uncertain in its duration; it may continue several days, or it may terminate in a few hours. Indeed, we have seen a number of instances, where convulsion has not ceased, for a moment, for seven or eight hours together. We do not recollect having seen a single instance of convulsions that were not .preceded by strabismus, though we have often seen strabismus without convulsions. 762. The duration of an acute hydrocephalus is very uncer- tain, and dependent upon circumstances of cause, constitution, 24fi HYDROCEPHALUS INTERNUS. extent of effect, and the period of life. Nor is the succession of symptoms less variable, each individual case showing its own peculiarities. Its progress will therefore be sometimes sufficiently rapid and severe to destroy in a very few days; and other times it may occupy weeks before it shall terminate. The cases in which head-ache has been severe, and where squinting takes place early, are those that terminate the soonest. Again, if after the third or fourth day, the child looses its flesh rapidly, becomes very pale, and its features suddenly sink, it is pretty certain that the disease will run its course rapidly. At other times, the pro- gress is slow, and without much violence of symptoms; and thus runs into a chronic form. 763. There is a peculiarity in the character of this disease, that is truly distressing, and ever to be dreaded; because, so far as we have observed, it is always deceitful—what we allude to is, the promise of restoration, by apparently a real amendment. We have seen a number of cases, where almost every threaten- ing symptom had removed itself; and where the little patient, seemingly, was suddenly placed in a state of convalescence, and hope entertained that the danger was past—but in another in- stant every thing was reversed, and the child quickly destroyed, by a cruel convulsion. This calm was probably owing to the relief the vessels experienced from the act of effusion, and the subsequent and suddenly bad symptoms from the pressure the effused fluid caused. 764. The prognostic in hydrocephalus must, from the very nature of things, be unfavourable, whether it be idiopathic or symptomatic, under any hitherto proposed plan of treatment. This appears to be the uniform opinion of all the writers we have met with upon this subject. Whytt says, he never cured one that had the characteristic symptoms of this disease; while others, as Fothergill, Percival, &c. declare they have'succeeded in curing the disease. Brichteau says he has succeeded to cure one in six; while Odier states his success to have been one in five. M. Itard says he has not been any thing like so fortunate, though he employed every known remedy,.besides obtaining the advice of the best practitioners in Paris. But he adds, that within three years, after he had dared to introduce the vapour baths in the treatment of this complaint, that he had obtained much more HYDROCEPHALUS INTERNUS. 247 flattering results; that he had been able to save two out of three children he treated by this method. We will not pretend to fix the proportion of our success to our failures; but if we do not deceive ourselves, we may say, we have seen hydrocephalus cured in many instances—and some we have at least seen get well, under the most unpromising appearances. The symptoma- tic form of this disease is certainly more manageable than the idiopathic, as the disease from which it proceeds may be "medi- cable," and thus giving greater chance for the cure of the other. 765. The signs which announce a favourable change taking place, are first, an abatemenj. of vascular and cerebral excitement, together with a diminution of the squinting; 2d, the relaxation of the forehead and eyebrows; 3d, the stomach retaining its drinks, and the bowels discharging a newly-secreted and yellow bile; 4th, the urine depositing a lateritious or a heavy sediment; and less intensity of colour; 5th, a soft skin, from gentle trans- piration; 6th, "though last not least," in its favourable import, is the renewal of the secretions from the nostrils. 766. Hydrocephalus, it is said, may be similaled by a variety of other diseases, as phrenitis, ataxic fever, serous apoplexy, &c. Why need we say of the first of these, that it similates dropsy of the brain ? May we not declare, that inflammation or irritation is the absolute cause of both or either? And that the others can be the cause of symptomatic hydrocephalus, there can he but little doubt, if dissections prove any thing. Dissection. 767. Let us then enquire what the knife reveals to us, in those who have died of the acute hydrocephalus. 1st. "An extreme engorgement of the sinus of the dura mater, and of the blood- vessels spread upon the brain itself. 2d. The substance of the brain altered, and sometimes softened in its natural consistence, but most commonly firm, and very elastic, (renitent) often smeared with a transparent exudation, or an absolute layer of pus. 3d. Effusion of serum to a greater or less extent in the ventri- cles, or upon the surface of the encephalon. 4th. The brain embued with a serosity, that only becomes evident by cutting into the brain, and permitting the fluid to fill up the gashes. 5th, 248 HYDROCEPHALUS INTERNUS. Sometimes, however, no part of the brain appears to be moistened by any unusual portion of Serum." Itard. 768. M. Itard asks, " shall we from this condition of the brain, conclude that a hydrocephalus did not exist, though the disease was strongly marked by its appropriate symptoms? I think not" he answers, "for the effusion is not the disease; it is only the consequence; and even by opening the body we may not find an effusion, either because it may have been absorbed after death, or what is more likely, that the irritation of the tu- nica arachnoides may have been so intense, or sufficiently dele- terious, to cause death before the formation of the effusion. Now, we know that similar appearances, have followed from the other diseases just enumerated." 769. In the abdomen, lesions are also to be found; they are the result of a sympathetic influence, between the brain and sto- mach, &c. This viscus in an especial manner suffers from this cause, hence in hydrocephalus, it is found engorged, inflamed, or suppurating; its membrane softened, and easily destroyed by the finger. We may also observe the intestines, to be much dis- ordered, by inflammation, invagination, softened, or even, in a state of incipient gangrene; and almost always containing more or less worms. The liver also bears marks of recent engorgement. Acute Symptomatic Hydrocephalus. 770. This is only to be distinguished from the species just considered, by always being preceded or accompanied by some other acute idiopathic affection. This species is doubtless we believe very much more common, than the idiopathic species, as it appears to be the termination of many other diseases. 771. That fever may eventuate in hydrocephalus, we have no doubt, be its type what it may. The eruptive fevers, however, appear to be more special causes of this affection; scarlatina, when epidemic in Europe, we are informed is very prone to this termination. Cholera infantum, gastrites, and verminous fever,* are frequent causes of this sympathetic disease. Whytt • When worms infest the alimentary canal, a chronic fever or fcbricula is sometimes induced; this fever is almost always accompanied by drowsiness; flushed cheek or cheeks; hot head; paleness of face except when flushed; HYDROCEPHALUS INTERNUS. 249 says, "a scirrhous tumour of the glandula pituitaria," may pro- duce hydrocephalus internus."* Chronic Idiopathic Hydrocephalus. 772. We have already observed, that this may be the sequel to an acute hydrocephalus; or it may proceed from an hydropic diathesis without requiring any especial condition of the brain itself. This form of the disease has been subdivided, 1st, into idiopathic chronic hydrocephalus, properly so called. This dis- ease is said not to be very rare; and indeed if we take for granted, that every enlargement of the head which takes place after two years, and perhaps up to seven, it might seem to be proved. If this be so, certainly this complaint is not necessarily mortal; as we see children with heads of this kind, grow up to manhood; or we must suppose that the water is absorbed and the cure effected by the recuperative powers of the system alone; or that mere pressure from effused serum, is not necessarily productive of death. Sometimes however, this complaint extends itself, so as to render the head enormous, and at the same time truly hideous; eighteen pounds of water it is said have been found in heads of this kind. This complaint gives rise to various dis- turbances of the system, the cause of which is easily perceived, but it is not to be removed, with any thing like certainty in any case whatever. The other disease to which we now refer, is, 2d, one that is not unfrequently seen among children of an early emaciation; cold feet; enlarged abdomen; grinding of the teeth during sleep; startings; frequent application of the hands to the head; picking or rubbing the nose; and squinting more or less confirmed. In this account we see a very close resemblance to the more prominent symptoms of hydrocephalus, and with which it is of course often confounded. We remember a remarkable case of squinting from worms in a little girl of five or six years old. The parents were much alarmed at this occurrence, especially as it had made its appearance suddenly, and the child apparently but little indisposed. After enquiring into the history of the case, we were satisfied that all the symptoms justified the belief that they were occasioned by the presence of worms in the intestines—we ordered her the pink root, .(spigelia,) in appropriate doses, (see Chapter on Worms,) which brought away many lumbrici, and the squinting, and other symptoms, disappeared immediately. * Works, p. 736. 32 250 HYDROCEPHALUS INTERN US. age; commencing generally pretty soon after birth, and con- tinuing to an indefinite period. 773. This form of hydrocephalus indeed, was for a long time the only one that bore the name of chronic dropsy of the brain. Children are sometimes born with this complaint, though we have never ourselves witnessed an instance of it, in more than ten thousand cases of births, that we have attended; on two oc- casions, we were obliged to open hydropic heads, &c. before delivery could be effected. We have seen this complaint show itself a few weeks after birth, and have known it to proceed to a considerable length; but never to the extent recorded by se- veral writers. 774. This disease, we believe rarely admits of a cure; it is almost always mortal, for death takes place sooner or later perhaps in all cases. A variety of means have been proposed for its cure; piercing the cranium with a trocar; salivation; and bandaging. The first plan has nothing but its hardihood to recommend it; the second, it is said, has succeeded; this was first recommended by the British writers; Brichteau, by this means restored the ge- neral health of a child of four years old, but without diminishing in the slightest degree the size of the head. And the late Dr. Jenner spoke favourably of bandaging the head. We tried this plan in one case for a long time, but without the smallest advan- tage. The history of these two affections, will instantly suggest their own prognostics. Chronic Symptomatic Hydrocephalus. 775. This species of hydrocephalus is far from being rare; for independently of the affections which are proper to the brain itself, there are many chronic affections of other portions of the body, that call this mass into action, especially, when about to terminate unfavourably. Thus hooping cough, asthma, chronic catarrh, polypus of the heart, aneurisms of the great vessels, may eause a serous effusion within the ventricles of the brain, or upon its surface. Drying up old: sores suddenly, especially in aged people; and the sudden disappearance of a scrofulous tumour has been followed by a similar consequence. In addition to the remote causes of chronic hydrocephalus, many derangements HYDROCEPHALUS INTERNUS. 251 were it important to our subject, of the brain itself, might be mentfoned. Of the Treatment. 776. There are two principal indications to be fulfilled, in the treatment of the acute forms of hydrocephalus—namely, tp over- come the irritation or inflammation which has attacked the brain, so as to prevent effusion; and to endeavour to remove the serum, if effusion has taken place. 777. The first is to be answered by all the antiphlogistic means in our power; as bleeding, general and local; purging; sweating; topical applications; blistering, and mercury. 1. Bleeding. 778. We must have recourse to this remedy, so soon as the disease is sufficiently developed, to present us with an active and quickened pulse; or where, from the confession of the patient, when able to make the acknowledgment, that there is head-ache; where we see a corrugated forehead; observe an aversion to light, fretfulness, &c. We are aware that many practitioners are re- luctant to bleed in the beginning of this disease, because they have seen all these symptoms disappear upon the child being liberally purged, kept quiet, and uppn a strict regimen, with- out having had recourse to blood-letting. This we admit to have happened—but has it not also happened, that the con- trary of this has taken place? where the disease ran a rapid and fatal course; and gave the attendant cause to repent his having neglected this important remedy in the beginning—we at least acknowledge this to have happened with ourselves, and therefore suppose it may have taken place with others. 779. On this account we now rarely omit to have blood ab- stracted, cither by the lancet, or by leeches. From the arm, whenever there is much arterial action, with manifest cerebral irritation; by leeches when the symptoms are less palpable, or more moderate ; and governed by the same rules, we repeat it, pro re nata. Much importance is now attached, to the part on which leeches are to be placed; more perhaps sometimes, than the case really demands. On this point, our selection is usually 252 HYDROCEPHALUS INTERNUS. made, by the opinion we have formed, whether the symptoms arise from an idiopathic cause, or a sympathetic influence. If we believe it to be the first, we order them to the temples and behind the ears; if the second, we suppose them to arise from some irritation in the chylopoietic viscera, and direct them to be placed upon the epigastrium. Itard insists upon their superior usefulness when applied to the lower extremities; this may be so—but we fear there is more theory in this, than practical con- firmation. 780. In our employment of blood-letting in hydrocephalus, we are always governed by the actual state of the system; and never prescribe for the name of the disease. If the system be prostrated before any cerebral affection manifest itself, we never bleed from the arm; and we only use leeches, where we judge there is a farther reduction of arterial action absolutely necessary to the safety of the system. But at the same time, we are in the habit of using other remedies in conjunction with the bleeding; especially to the lower extremities—these remedies may be, warm water and mustard, sinapisms, or blisters. As regards the quantity of blood to be drawn, we can lay down but one fixed rule—namely, to accommodate the quantity by the exigency of the case, and the age and strength of the patient. 2. Purging. 781. This remedy cannot be dispensed with, in either form of hydrocephalus—in the acute, it is essential, as no other re- medy with which we are acquainted relieves the head of its superfluous blood like purging—this effect is not difficult to understand if we call to mind the direct communication of the blood-vessels of the abdomen and the head. Some indeed are of opinion that purging is more to be relied fopon than the abstrac- tion of blood—we are also of this opinion quo ad hoc; namely, where a morbid condition of any of the abdominal viscera give rise to the cerebral irritation; but where the affection of the brain is really idiopathic, we believe this is not the case. The case related by Cheyne where, "two chamber-potsful of the most extraordinary faeces," were brought away is a case in point. But notwithstanding our conviction of the efficacy of purging in HYDROCEPHALUS INTERNUS. 253 hydrocephalus, yet it must be understood, that it is only certain- ly, and extensively useful, in the idiopathic acute hydrocephalus, and after the system has been lowered by a previous bleeding, or bleedings. Not so, perhaps in the symptomatic species—in this variety, purging may be of paramount benefit to bleeding, as the case just cited appears to prove. 782. But in either case we purge—whether bleeding has been premised or not. For this purpose we prefer a few grains of calomel, followed in two or three hours by castor oil or mag- nesia, should the calomel not have operated sufficiently. We persist in this plan daily; unless we see some evidence, that this remedy has been carried far enough, by only very small, green, and frequent stools succeeding to their exhibition; or if the evacuations become watery, oraccompanied by some of the mucus from the bowels. After a free purging has been instituted, and we think it no longer desirable to persevere in it, we maintain a sufficient action of the bowels by very minute doses of calomel, that is, from a quarter to half a grain every two or three hours, or, by small doses of castor oil. It may be proper however, to suggest a caution to the young practitioner here, not to persist too long in cathartic medicines, by reminding him, that in most instances, the stools will appear of a dark-green colour, purge as we may; therefore that farther purging is not called for from the mere appearance of the evacuations. 3. Sweating. 783. By sweating, in this place, we would only wish to be un- derstood, the exhibition of such medicine as have a tendency to produce diaphoresis, without expecting a profuse discharge like that, which take place upon the solution of fever of regular type. For though fever is an almost constant attendant on the disease in question, yet it has no uniform termination; but notwith- standing this, we think we have seen advantage follow the exhi- bition of the tartrate of antimony in minute doses; that is, from the tenth to the twentieth part of a grain, exhibited every two or three hours—or the eighth or tenth of a grain of ipecacuhana at the same intervals. 251 HYDROCEPHALUS INTERNUS. 4. Topical Applications, and Blistering. 784. The topical applications besides blisters, are cold to the head; pediluvium; and sinapisms. For the first to be suc- cessful, the hair should be cut off, or the head shaved—the best mode of applying the water, is by a bladder of large size par- tially filled with cold water, or ice and water. These applications should not be continued too long at a time; therefore, when the temperature of the head is well reduced, they should be remov- ed, and not again applied until the head again becomes warm. 785. Sinapisms are only proper where there is a reduced pulse, and a tendency in the extremities to become cold—they may then be applied to these parts with advantage, until the skin be- comes red, but no longer. They may be renewed however, as occasion may require; or when the redness goes off. 786. Pediluvium may be had recourse to from time to time, especially if the determination to the head be strong, and the legs and feet rather cold; in the latter case, a little flour of mus- tard should be mingled with the water. 787. Blisters are to be applied to the legs and thighs alternately if necessary, as soon as the first stage threatens a conversion into the second; and they may be repeated to the end of the dis- ease. Many prefer the head; but this is certainly an inconve- nient part to blister, if it be not an improper one; and if we can place reliance upon our own experience, we have thought it in- jurious in many instances. To the nape of the neck, is much better as regards effects; but the position is certainly a most fa- tiguing one to the patient—we have therefore for the last thirty years, rarely applied them to this part; believing most firmly that more advantage is derived from their employment upon the extremities. 788. After effusion has certainly taken place, we have little to hope for, or to rely upon—absorption we have reason to believe, can rarely take place, from even the anatomical arrangement of the brain itself; and our means to aid this, with odr present li- mited knowledge, is almost confined to one article; namely, mercury, freely urged by the mouth, and by the skin. This DISEASES OF THE EYES. 255 remedy in such cases, certainly deserves a trial, for as far as the facts can be proved by our senses, and belief, a number have recovered under its use, since it was first recommended in 1775, by Dr. Dobson, of Liverpool. CHAPTER XIII. DISEASES OF THE EYES. General Observations. 789. The diseases of the eyes and their appendages, the brows, lids, and lachrymal organs and passages—form a class of affections so numerous, diversified and important, as to constitute in many parts of Europe, a separate branch of study and practice; and in the principal universities, their consideration is the province of an appropriate professorship. It will not, therefore, be expected in a treatise on the practice of physic, that we should enter into a particular investigation of these complaints; for even if they be not considered as belonging to a distinct division of our art, at least many of them appertain rather to the province of sur- gery than to that of physic; and moreover, to treat of them in detail would require more space than we can with any propriety allot for that purpose. All that we shall attempt, will be, to give a general and cursory sketch of the more prevalent and impor- tant derangements, or those which the medical practitioner is most frequently called upon to treat; referring those who desire more particular information to the professed works on the sub- ject. • 790. Several distinct structures enter into the formation of the eyes, some of which are entirely different from any of the other tis- sues of the body. The conjunctiva, or the membrane which lines the eyelids, and covers the anterior half of the globe of the eye, though villi cannot be seen on its free surface, may be consider- ed as a mucous membrane) except that portion covering the cor- nea, which exhibits a nearer approach to the character of serous 256 DISEASES OP THE EYBS. than to that of mucous tissues. The sclerotica is a fibrous tissue, except its anterior transparent portion, the cornea, which cannot with propriety be arranged in this class.* The membrane lining the chambers of the eye, and covering of the iris—called the membrane of the aqueous humour—the choroid and hyaloid membranes, may perhaps without any great error be considered as serous tissues. The retina is a nervous, and the iris an erectile tissue. The cornea and crystalline lenst differ from any other por- tions of the body in their structure. 791. These tissues are all liable to inflammation, which not only varies in violence, but presents a peculiar character in each class, and which even in the same class is modified by peculiarities of constitution in the patient. These variations have afforded to the nosologists an opportunity for the manufacture of species, and the construction of a nomenclature, of which they have not been neglectful; and accordingly we have a host of names, a re- petition of which we will spare the reader. Sect. I. Conjunctivitis.—Inflammation of the Con- junctiva. Anatomical Characters of the Conjunctiva. 792. The conjunctiva is the most delicate of all the mucous membranes; it is exceedingly thin, transparent, devoid of pa- pillae, colourless upon the globe, and of a rose colour upon the eyelids. That portion which^ covers the cornea is united to its subjacent coat so closely, that it is difficult to separate them. To the sclerotica and eyelids, it is loosely connected by a fine, cel- lular tissue; within which, between the conjunctiva and the car- tilages of the palpebrae, are a number of small whitish or yel- lowish glands, consisting of minute, very elongated, narrow, * Professor Mayer, of Bonn, in his classification of the organic tissues, places the cornea, crystalline lens, epidermis, hair, nails, teeth, &c. in a class to which he has given the name of Lamellar. It may be objected to this arrangement, that the structures he has thus grouped together differ as much from one an- other as they do from those with which they were formerly arranged. \ The aqueous and vitreous humours, though important parts of the organ of vision, cannot be considered as organic tissues—when they become morbid, it is the result of disease in the vessels by which they are secreted. DISEASES of the eyes. 237 tortuous sacs, which pour out their secretions through small openings, disposed in a regular arcuated line, just within the edge of the eyelids. Physiological Characters. 793. The conjunctiva, in a healthy state, secretes a mucous fluid, which is liable to be increased, altered, or suppressed by inflammation. It possesses a high degree of sensibility. Pathological Characters. 794. The susceptibility of parts to inflammation, the continu- ance and violence of the affeetion, and the facility with which restoration takes place, appear to be in direct proportion to the facility with which their vessels can be distended. From the looseness with which the conjunctiva is connected with the pal- pebrae and sclerotica, their vessels readily expand so as to admit red blood, and when the exciting cause is removed, unless the disease has been of very long duration, as speedily recover their tone, and contract to their original dimensions. Very different, however, is the case with respect to the corneal conjunctiva; it is united to the cornea by such a dense connecting texture, that its vessels are prevented enlarging themselves even during high degrees of inflammation, and red blood is only admitted into them when the inflammation is long-continued; but when once distended, their restoration is very difficult, and seldom effected without some derangement in structure and loss of transparency in the part. 795. Inflammation of the conjunctiva commences by dilata- tion of its white capillaries or serous vessels, which in a healthy state are not visible, but may now be seen conveying red blood, and as the disease advances, the number of these red vessels in- creases ; the sensibility of this membrane is exalted, and villi usually become apparent. The natural secretion is increased, afterwards altered, and finally pus is poured out, often very pro- fusely. In some rare instances coagulable lymph is secreted, completely agglutiaating the occular and palpebral conjunctiva; one case of this we have seen. A serous fluid and sometimes blood is effused in the cellular tissue beneath the conjunctiva. In the progress of the disease, coagulable lymph is effused in the 33 258' diseasks ok the eyes substance of the conjunctiva; this membrane becomes thickened, hardened, and sometimes on the globe assumes the appearance of tendon; fungous excrescences are at other times formed, espe- cially near the edge of the tarsi, which are sometimes of a fleshy appearance, at others of a hard cartilaginous pature resembling warts, and not unfrequently of a soft spongy texture and dark colour, resembling clots of blood. 796. Inflammation does not readily extend to the corneal con- junctiva, but in severe inflammation of the eye it becomes even- tually affected. This is first manifested by a slight haze or dim- ness produced by a fulness of its serous vessels; these in the pro- gress of the disease become so dilated as to convey red blood; coagulable lymph is thrown out, thickening this membrane, and rendering it opaque. The conjunctiva has little disposition to ulcerate; when ulceration occurs, it is usually the consequence of pustules or small abscesses beneath it. 797. When inflammation is kept up for a length of time, in the sclerotic conjunctiva, its blood-vessels become permanently enlarged, coagulable lymph is secreted around them, and a mem- brane is formed, which sometimes appears of a fleshy consist- ence>* at others like a delicate tissue of vessels, t Baron Larrey says that pterygium was one of the most frequent sequelae of Egyptian ophthalmia. 798. A nodule of fatty matter is sometimes formed under the conjunctiva, either in consequence of chronic inflammation or some derangement in the nutrition of the part. We have seen small hard bodies, perfectly transparent, in or upon the sclerotic conjunctiva, and which were probably the effect of a similar cause. 799. Sometimes tumours form on the conjunctiva, composed of a group of varicose veins; we have observed these only at the inner canthus. Causes. 800. Inflammation of the conjunctiva, may be excited by a variety of internal as well as external causes; among the former • Pannus of authors. f Pterygium. diseases of the eyes. 259 may be mentioned, the abuse of stimulating liquors or food, prolonged irritation of the stomach or alimentary canal, the sup- pression of perspiration, of the menstrual or haemorrhoidal dis- charge, of a periodical or chronic haemorrhage, or of an habitual sweat, metastasis of gonorrhoea, the retrocession of an exanthema- tous eruption, &c. To the latter may be referred foreign bodies introduced into the eye, and these may excite irritation either by their mechanical operation, as sand, spiculae of iron, &c. or by their corrosive or stimulating properties as lime, and different chemi- cal agents, smoke, irritating vapours, &c. 801. In children it is sometimes produced by the irritation of teething; and Mr. Ware says that he has seen it produced in old persons, by a decayed tooth. 802. It may also be produced by any cause which determines an unusual quantity of blood to the conjunctiva; or by tight ligatures around the neck interrupting the flow of venous blood from the head, as tight cravats; the tight inelastic stocks worn by soldiers was one of the causes of the conjunctivitis that pre- vailed so extensively in the army of the low countries a few years since.* Light, also, either direct or reflected from white or polished substances, produces a determination of blood to the eye, and thus excites inflammation of the conjunctiva. In the dif- ferent towns upon the coast of Barbary, subject to the Emperor of Morocco, where it is the practice to whitewash the walls of the houses externally, the inhabitants suffer greatly from this dis- ease, while on the opposite shores, where this practice does not prevail, the inhabitants are exempt from it. 803. Heat, by its direct stimulus,excites inflammation. Black- smiths, and those engaged in furnaces, suffer from the disease from this cause. 804. Cold acting either directly on the eye, or through the medium of the constitution, is a very frequent cause of the dis- ease, but it is sudden transitions from heat to cold, that is the most prolific source of the complaint. Soldiers on duty, in high latitudes, alternately exposed to the heat of the day and bright light of the sun, and to the cold and dews of the night are often * Vleminckx and Van Mons. Essai sur l'ophthalmie de l'armee des Pays. Has. p. 41. 260 DISEASES OP THE EYES seized with it. In the commencement of August, 1812, great numbers of the French arm}-, in its march upon Smolensk, were affected with ophthalmia, produced by these causes; and the Prus- sian corps d'armie, in 1813, and many regiments of the British army in 1815, suffered from the disease, arising from similar causes. The effects of cold are also very severe when combined with a current of wind. Dr. Smith states that of two detach- ments, of invalids sent from the Mediterranean, most of them were attacked with inflammation of the eyes upon reaching the windy latitudes of England. Mr. Reilly,* surgeon to the British ship Saturn, states that when off Brest, in October, 1797, when the weather was damp and the wind east, ophthalmia broke out among the crew, three hundred of whom were attacked with it, and he remarks that the sick list varied with the weather. Sol- diers on guard, during a stormy night, and individuals lying op- posite to open doors or windows, are exceedingly liable to be- come affected with the disease under consideration. In France, during the conscription, it was not uncommon for the young men to procure an habitual ophthalmia by exposing their eyes to a current of air from a key-hole or crack, and thus obtain a dis- charge, for which they often paid with the loss of an eye.t 805. Moisture exercises a very baneful influence over this af- fection. Dr. Vetch states that there was not a single case of the disease, in the 54th regiment, (in which it prevailed,) of a violent form until the 24th of September, when after a very heavy fall of rain during the night, to which the men affected with the ophthalmia were more particularly exposed, by being at the time under canvass, the whole number of patients, thirty-four, were found in the morning with their eyes completely closed by the swelling of the palpebrae, attended with the excruciating pain, the purulency, and other symptoms of the disease in its most alarming and inveterate form. He farther remarks, that the changes in the state of the disease were uniformly influenced by those of the weather, and afforded the most unequivocal proofs of the deleterious consequences which result from an increased humidity of the atmosphere. He adds, "the disease is so fre- * Trotter's Medicina Nautica. f Dictionaire des Sciences M having never lost a patient in the hooping cough." Dr. L. declares a similar success awaited his own trials of this medicine. Watt, p. 282. * 1247. But we never employed any remedy of equal efficacy with the garlic in substance, to relieve the cough of habit after hooping cough. We have very often used it; and we have rarely seen it fail. The objections arising from its smell, are, however, very great in the minds of some; so much so, that they cannot be prevailed upon to use it But children of six or seven years of age, or even older, can very often be prevailed upon to eat it, and become after a while very much attached to it A child of six or seven, may begin by taking a third of a common-sized clove, morning, noon, and evening; gradually in- creasing the dose as the system becomes accustomed to its ac- tion. One of ten years old, may take half a clove three times a day; increasing it as it may be necessary; and so on for greater ages. 124S. Desruelles condemns us for the employment of the gar- lic, either externally, or internally; indeed he goes so far as to say, we give a blind confidence in this substance. This affects us not; and so long as we continue to experience benefit from it, we shall persevere in recommending it under the restrictions* suggested above; namely, in the absence of all febrile excite- ment, and when the cough appears to be perpetuated by habit. The following case is highly deserving of attention. Miss M. W. aged twelve years, had the hooping cough in great seve- rity, notwithstanding she was subjected to a very active treat- ment in the early, or inflammatory stage of the disease. It be- gan in March, and the cough continued with great violence un- • " Specific for the Hooping Cough. In Rust's Mag. f. die Gesammt. Heilk. (No. 2, 1828,) it is stated that Dr. Meyer, of Menden, has in a few days been enabled to remove all the symptoms of pertussis, by the external application of morphia. He directs a small blister to be applied over the praecordia; the detached cuticle being removed, the exposed surface is to be sprinkled over with half a grain of morphia rubbed up with starch. The morphia to be re- peated every evening. The only internal remedy he employed was an eme- tic. If necessary, the blister may be reapplied every third day. In five cases, the disease was so diminished in eight days, that no farther treatment was con- sidered necessary."—North American Med. and Surg. Journ. No. XV. July, 1829. p. 197. 50 394 PERTUSSIS, OR HOOPING COUGH. til July, at which time we were requested to prescribe for her —at our first visit, we had an opportunity of witnessing two fits of coughing; both of which spells exceeded in severity any thing we had ever seen; she was literally black in the face, and was threatened with immediate suffocation. 1249. These paroxysms were repeated frequently; especially during the day; they left her weak, and exhausted; she lost flesh daily, and was so debilitated as scarcely to be able to walk. She was ordered to eat a small clove of garlic three times a day; in forty-eight hours these paroxysms left her entirely; a slight cough remained for a few days, and this soon ceased altogether. We can- not but believe it was the garlic which afforded such speedy and happy relief; particularly, as it has frequently proved as certainly, if not as extensively, serviceable, in other cases of hooping cough. 1250. Exactly on the same principle, the arsenical solution is employed; and we have the strong testimonies of Simmons and Ferriar in support of it. Each of these writers goes so far as to declare that it is the only medicine deserving of much confidence. 1251. On this point we can say nothing from our own expe- rience; as we do not deem the few trials we have given this medi- cine, entitled to much weight; our impressions of its efficacy are not strong. 1252. We have said nothing of the utility of topical remedies, in the acute stage of the disease; for they can rarely be useful: but in the one now under consideration, external applications may be advantageously resorted to; such as liniments of an irri- tating nature, as the volatile or camphorated; the spirit of tur- pentine mixed with olive oil; or the juice of garlic rubbed along the vertebral column. But we think we have observed more ad- vantage to result from the use of the tartar emetic ointment,* than * The following formula we are in the habit of using for children:— ft. Tartar, antimon. - gjss. Take Tartar emetic 1$ drachm. 01. lavend. vel ess. lem. gtt. xx. Oil of lavender, or es- Cerate simp. - - 3jj. sence of bergamot, 20 drops. M. Simple cerate 1 ounce. Mix. With this the part indicated above must be rubbed, three times a day, until it shows a number of small pimples upon it—dress with common cerate. If the irritation subside too soon, it must be re-excited by the ointment. PERTUSSIS, OR HOOPING COUGH. 395 from any other application—this should be applied high up be- tween the shoulders. 1253. It is well understood, how much the action of the lungs is dependent on a nervous influence from the spinal marrow; and it is probably on this principle, the efficacy of such embrocations is to be explained. The muscles of the chest, diaphragm, and scapulae, receive portions of the cervical and dorsal nerves; the accessory nerves of Willis form a part of the par vagum, and as- sist in giving rise to the cardiac and pulmonic plexus; hence the propriety of applications to the spine; and the popular opinion of the utility of a Burgundy pitch plaster between the shoulders, is accounted for, from anatomical arrangement. 1254. Of the efficacy of the change of residence, more par- ticularly to the country, and even of a frequent exposure to fresh air, every one is so fully persuaded, that the remedy is abused, by its general and indiscriminate adoption. It is by no means uncommon to see children exposed, in the coldest and most in- clement seasons; and this sometimes, by the order of the attend- ing physician. Nothing can be more pernicious and ill judged. 1255. On the subject of the change of air, Dr. Watt observes, p. 217, " I agree that pure air and change of air, are exceed- ingly necessary to bring round the patient from a convalescent to a confirmed state of health; but this is not the onhy period in which change of air may be useful. I have seen the disease kept re- markably mild in many individuals, and in several large families, by having the children almost constantly in the open air from the commencement; driving them about from place to place in carts and open carriages. I have known many where the dis- ease was very severe, on being taken out in the open air, getting better every hour as they proceeded on their journey, the pa- tients scarcely giving a cough, and the fever going off entirely." 1256. "It must be confessed, however, that on many occa- sions children have been worse on being freely exposed to the open air. I saw several remarkable instances of it last winter and spring. Some people, who had formerly experienced the benefit of change of air, were anxious to give it a trial, without reflecting sufficiently on the nature of the* case, and season of the year." p. 218. 1257. " I have never seen children in any state of the disease, 'iyt) FERTUSSIS, OR HOOPING COUGH- the worse for being taken out in the summer months, unless too much exposed to the sun in the middle of the day, or to the cold damp in the mornings and evenings." p. 218. 1258. "The great question then appears to be, what are the symptoms which most mark that state of the disease, when ex- posure will be useless if not injurious? To which I would re- ply, considerable fever, a strong, full, and frequent pulse, violent cough, pain in the breast, and above all, great oppression of breathing." p, 221. 1259. Dr. Ferriar is of opinion that soil may influence the surrounding atmosphere, so as to render it more valuable to the lungs in hooping cough, he instances the limestone soil of Der- byshire, which has been long celebrated for the cure of this dis- ease.* Of this we can say nothing from our own experience. 1260. In the inflammatory catarrh, we guard against cold, by keeping the patient in a room duly warmed; the same should be observed in the first stage of hooping cough. The lungs in this case are either inflamed or peculiarly susceptible of inflamma- tion, so that the slightest exposure brings on, renews, or vio- lently exasperates the attack. Catarrh, or active pneumony su- perinduced'on pertussis, constitutes a formidable case, and most frequently is the way in which the disease proves obstinate, or fatal. But, the inflammatory stage having passed, and the weather mild, much advantage may be derived from gentle ex- ercise in the open air—this may be by walking, or riding in a carriage. But completely to eradicate the disease, the child should be removed into the country, provided the season of the year will justify the change. 1261. During the summer months, we think our little patients have been much benefited by frequent excursions on the water, in the steam boat, and we constantly recommend this mode of exercise when the weather is propitious. * Med. Hist, and Refiec. Vol. III. p. 222, CAREY & LEA HAVE RECENTLY PUBLISHED THE FOLLOWING VALUABLE WORKS. 4> * I. The WATER WITCH, or the SKIMMER of • the SEAS. By the Author of the Pilot, Red Roveb, &c. 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The POETICAL WORKS of CAMPBELL, ROGERS, MONTGOMERY, LAMBE, and KIRKE WHITE, beautifully printed, lvol. 8vo. to match Byron, Scott, Moore, &c. With Portraits of the Authors. VII. The CHEMISTRY of the ARTS, on the Ba- sis of Gray's Operative Chemist, being1 an Exhibition of the Arts and Manufactures dependent on Chemical Principles, with numerous Engravings, by Arthur L. Porter, M. D. late Professor of Chemistry, &c. in the University of Vermont. In 8vo. With numerous plates. Thepopularand valuable English work of Mr. Gray, which forms the ground- work of the present volume, was published in London in 1829, and designed to exhibit a Systematic and Practical view of the numerous Arts and Manufactures which involve the application of Chemical Science. The author himself, a skilful, manufacturing, as well as an able, scientific chemist, enjoying the mul- tiplied advantages afforded by the metropolis of the greatest manufacturing na- tion on earth, was eminently qualified for so arduous an undertaking,and the popularity of the work in England, as well as its intrinsic merits attest the fidelity and success \\ ith which it has been executed. In the work now offered to the American public, the practical character of the Operative Chemist has been preserved, and much extended by the addition of a great variety of origi- nal matter, by numerous corrections of the original text, and the adaptation of the whole to the state and wants of the Aits and Manufactures of the United States; among the most considerable additions will be found full and extended treatises on the Bleaching of Cotton and Linen, on the various branches of Ca- lico Printing, on the Manufacture of the Chloride of Lime, or Bleaching Pow- der, and numerous Staple Articles used in the Arts of Dying, Calico Priming, and various other processes of Manufacture, such as the Salts of Tin, Lead, Manganese, and Antimony; the most recent Improvements on the Manufacture of the Muriatic, Nitric, and Sulphuric Acids, the Chromates of Potash, the latest information on the Comparative Value of Different Vaiieties of Fuel, on the Construction of Stoves, Fire-places, and Stoving Rooms, on the Ventilation of Apartments, Sec. Sec. To make room for the additional practical matter, and hot to enhance the price of the work to the American reader, between two and three hundred pages of the theoretical or doctrinal part of the original work have been omitted; indeed, most of the articles on the theory of chemistry, such as Electricity, Galvanism, Light, fee. which have little or no immediate ap- plication to the arts, and which the chemical student will find more fully discussed in almost ever)' elementary work on the science, have been either wholly omitted or abridged. Many obsolete processes in the pmctical part of the work, used in some instances, the description of arts not practised, and from Published by Carey fy Lea. 3 o^^"1* u ot ULelv to ^ Practised in the United States, have also been omuied; in snort, the leading object has been to improve and extend the prao ttcal character of the Operative Chemist, and to supply, as the publishers natter themselves, a deficiency which is felt by every artist and manufacturer, whose processes involve the principles of chemical science, the want of a Systematic worn wmcn should embody the most recent improvements in the chemical ara ana manufactures, whether derived from the researches of scientific men, ~1„ .Lexpe!,ments and observations of the operative manufacturer and arti- sans themselves. VIII. PATHOLOGICAL and PRACTICAL RE- SEARCHES on DISEASES of the BRAIN and SPINAL CORD. By John Abercrombie, M. D. (Nearly ready.) "We have here a work of authority, and one which does credit to the author and his country."—North Amer. Med. and Surg. Journ. By the same Author, IX. PATHOLOGICAL and PRACTICAL RE- SEARCHES on DISEASES of the STOMACH, the INTES- TINAL CANAL, the LIVER, and other VISCERA of the ABDOMEN. " We have now closed a very long review of a very valuable work, and, al- though we have endeavoured to condense into our pages a great mass of impor- tant matter, we feel that our author has not yet received justice."—Medico-Chv- rurgical Review. X. A RATIONAL EXPOSITION of the PHYSI- CAL SIGNS of DISEASES of the LUNGS and PLEURA; Il- lustrating their Pathology and Facilitating their Diagnosis. By Charles J. Williams, M. D. In 8vo. with plates. " If we are not greatly mistaken, it will lead to a better understanding, and a more correct estimate of the value of auscultation, dun any thing that has yet appeared."—Am. Med. Journ. XI ARNOTT'S ELEMENTS of PHYSICS. Vol. II. Part I. containing Light and Heat. XII. ELEMENTS of PHYSICS, or NATU- RAL PHILOSOPHY, GENERAL and MEDICAL, explained independently of TECHNICAL MATHEMATICS, and con- taining New Disquisitions and Practical Suggestions. By Neil Arnott, M. D. First American from the third London edition, with additions, by Isaac Hays, M. D. %* Of this work four editions have been printed in England in a very short time. All the Reviews speak of it in the highest terms. XIII. BECLARD'S GENERAL ANATOMY. Translated by J. Togtto, M. D. 8vo. XIV. A TREATISE on FEVER. By Southwood Smith, M. D. Physician to the London Fever Hospital. " There is no man in actual practice in this metropolis, who should not possess himself of Dr. Smith's work."— Land. Med. and Surg. Journ. Feb. " With a mind so framed to accurate observation, and logical deduction, Dr. Smith's delineations are peculiarly valuable."—Meclico-Ckir. Rev. March. " No work has been more lauded by the Reviews than the Treatise on Fevers, by Southwood Smith. Dr. Johnson, the editor of the Medico-Chirurgical Re- view, says,' It is the best we have ever perused on the subject of fever, and in our conscience, we believe it the best that ever flowed from the pen of physician in any age or in any country.' "—Am. Med. Journ. XV. SKETCHES of CHINA, with Illustrations from Original Drawings. By W. W. Wood, in 1 vol. 12mo. " The residence of the author in China, during the years 1826-7-8 and 9, has enabled him to collect much very curious information relative to this singular people, which he has embodied in his work; and will serve to gratify the curi- osity of many whose time or dispositions do not allow them to seek, in the volu- minous writings of the Jesuits and early travellers, the information contained in the present work. The recent discussion relative to the renewal of the East India Company's Charter, has excited much interest: and among ourselves, the desire to be further acquainted with the subjects of ' the Celestial.Empire' has been considerably augmented." 4 Valuable Works XVI. HISTORY OF ENGLAND, Br Sin JAMES MACKINTOSH, Vol. I. being a portion of The Cabinet History of the British Islands, EMBRACING HISTORY of ENGLAND. By Sir James Mackintosh, Vol. I. " Our anticipations of this volume were certainly very highly raised, and un- like such anticipations in general, they have not been disappointed. A philo- sophical spirit, a nervous style, and a full knowledge of the subject, acquired by considerable_ research into the works of preceding chroniclers and historians, eminently distinguish this popular abridgment, and cannot fail to recommend it to universal approbation. In continuing his work as he has begun, Sir James Mackintosh will confer a great benefit on his country."—Land. Lit. Gazette. HISTORY of SCOTLAND. By Sir Walter Scott, 2 vols. HISTORY of IRELAND. By Thomas Moore, 1 vol. XVII. HISTORY of SCOTLAND. By Sir Walter Scott, Bart, in 2 vols. 12mo. The History of Scotland, by Sir Walter Scott, we do not hesitate to declare, will be, if possible, more extensively read, than the most popular work of fiction, by the same prolific author, and for this obvious reason: it combines much of the brilliant colouring of the Ivanhoe pictures of by-gone manners, and all the graceful facility of style and picturesqueness of description of his other charm- ing romances, with a minute fidelity to the facts of history, and a searching scru- tiny into their authenticity and relative value, which might put to the blush Mr. Hume and other professed historians. Such is the magic charm of Sir Walter Scott's pen, it has only to touch the simplest incident of every day life, and it starts up invested with all the interest of a scene of romance; and yet such is his fidelity to the text of nature, that the knights, and serfs, and collared fools with whom his inventive genius has peopled so many volumes, are regarded by us as not mere creations of fancy, but as real flesh and blood existences, with all the virtues, feelings and errors of common place humanity."—Lit. Gaz. XVIII. CLARENCE j a Tale of our own Times. By the Author of Redwood, Hope Leslie, &c. In two volumes. XIX. FALKLAND, a Novel, by the Author of Pelham, &c. 1 vol. 12mo. XX. MEMOIR on the TREATMENT of VENE- REAL DISEASES WITHOUT MERCURY, employed at the Military Hospital of the Val-de-Grace. Translated from the French of H. M. J. Desruelles, M. D. &c. To which is added, Observations by G. J. Guthrie, Esq. and various documents, showing the results of this Mode of Treatment, in Great Bri- tain, France, Germany, and America, 1 vol. 8vo. XXI. PRINCIPLES ofMILITARY SURGERY, comprising1 Observations on the Arrangements, Police, and Practice of Hospitals, and on the History, Treatment, and Anomalies of Variola and Syphilis; illustrated with cases and dissections. By John Hexnen, M. D. F. R. S. E. Inspector of Military Hospitals—first American from the third London edi- tion, with Life of the Author, by his son, Dr. John Hennen. " The value of Dr. Hennen's work is too well appreciated to need any praise of ours. We were only required then, to bring the third edition before the no- tice of our readers; and having done this, we shall merely add, that the volume merits a place in every library, and that no military surgeon ought to be without it."—Medical Gazette. " It is a work of supererogation for us to eulogize Dr. Hennen's Military Sur- gery; there can be no second opinion on its merits. It is indispensable to the mi- litary and naval surgeon."—London Medical and Surgical Journal. XXII. A COLLECTION of COLLOQUIAL PHRASES on every Topic necessaiy to maintain Conversation, Published by Carey fy Lea. 5 arranged under different heads, with numerous remarks on the peculiar pronunciation and use of various words—the whole so disposed as considerably to facilitate the acquisition of a correct pronunciation of the French. By A. Bolmar. One vol. 18 mo. XXIII. A SELECTION^of ONE HUNDRED PERRIN'S FABLES, accompanied by a Key, containing the text, a literal and free translation, arranged in such a manner as to point -out the difference between the French and the English idiom, also a figured pronunciation of the French, ac- cording to the best French works extant on the subject; the whole preceded by a short treatise on the sounds of the French language, compared with those of the English. XXIV. A TREATISE on PATHOLOGICAL ANA- TOMY, by William E. Hobner, M. D. Adjunct Professor of Anatomy in the University of Pennsylvania. " We can conscientiously commend it to the members of the profession, as a satisfactory, interesting, and instructive view of the subjects discussed, and as well adapted to aid them in forming a correct appreciation of the diseased conditions they are called on to relieve."—American Journal of the Medical Sciences. No. 9. J XXV. A New Edition of a TREATISE of SPECIAL and GENERAL ANATOMY, by the same author, 2 vols. 8vo. XXVI. A New Edition of a TREATISE on PRAC- TICAL ANATOMY, by the same author. XXVII. COXE'S AMERICAN DISPENSATORY, Eighth Edition, Improved and greatly Enlarged. By John Redman Coxe, M. D. Professor of Materia Medica and Phar- macy in the University of Pennsylvania. In 1 vol. 8vo. XXVIII. An ESSAY on REMITTENTand INTER- MITTENT DISEASES, inoluding generically MarshFever and Neuralgia—comprising under the former, various anomalies, obscurities, and consequences, and under a new systematic view of the latter, treating of tic douloureux, sciatica, head- ache, ophthalmia, tooth-ache, palsy, and many other modes and consequences of this generic disease; by John Macculloch, M. D., F. R. S. &c. &c. Physician in Ordinary to his Royal Highness Prince Leopold, of Saxe Cobourg. " In rendering Dr. Macculloch's work more accessible to the profession, we are conscious that we are doing the state some service."—Med. Chtr. Review. u We most strongly recommend Dr. Macculloch's treatise to the attention of our medical brethren, as presenting a most valuable mass of information, on a most important subject."—K. A. Med. and Surg. Journal. XXIX. WISTAR'S ANATOMY, fifth edition, 2 vols. 8vo. XXX. The ANATOMY, PHYSIOLOGY, and DIS- EASES of the TEETH. By Thomas Bell, F. R. S., F. L. S. &c. In 1 vol. 8vo. with plates. " Mr. Bell has evidently endeavoured to construct a work of reference for the practitioner, and a text-book for the student, containing a ' plain and practical digest of the information at present possessed on the subject, and results of the author's own investigations and experience.'" • • * « We must now take leave of Mr. Bell, whose work we have no doubt will become a class, book on the im- portant subject of dental surgery."—Medico-Chirurgical Review. XXXI. MORALS of PLEASURE, illustrated by Stories designed for Young Persons, in 1 vol. 12mo. « The style of the (tones is no lex remarkable for its ease and gracefulnetj, 1* 6 Valuable Works than for the delicacy of iu humour, and its beautiful and at times affecting Sinn phcity. A lady must have written it—for it is from the bosom of woman alone, that such tenderness of feeling and such delicacy of sentiment—such sweet les- sons of morality—such deep and pure streams of virtue and piety, gush forth to cleanse the j uvenile mind from the grosser impurities of our nature,and prepare the young for lives of usefulness heoe. and happiness hereafter. We advise pa- rents of young families to procure This little book—assuring them that it will have a tendency to render their offspring as sweet as innocent, as innocent as eay, as gay as happy. It is deditigted by the author «to her young Bedford friends, Anna and Maria Jay'—buflfco this fair author is, we cannot even guess. We would advise some sensible educated bachelor to find out."—N. 7". Com. Adv. XXXII. The PRACTICE of PHYSIC, by W. P. Dewees, M. D. Adjunct Professor of Midwifery in the University of Pennsylvania, 2 vols. 8vo. " We have no hesitation in recommending it as decidedly one of the best systems of medicine extant. The tenor of the work in general reflects the high- est honourjon Dr. Dewees's talents, industry, and capacity, for the execution of the arduous task which he had undertaken. It is one of the most able and satisfactory- works which modern times have produced, and will be a standard authority."— Land. Med. and Surg. Journ. Aug. 1830. XXXIII. DEWEES on the DISEASES of CHIL- DREN. Third edition. In 8vo. The objects of this work are, 1st, to teach those who have the charge of chil- dren, either as parent or guardian, the most approved methods of securing and improving their physical powers. This is attempted by pointing out the du- ties which the parent or the guardian owes for this purpose, to this interesting, but helpless class of beings, and the manner by which their duties shall be ful- filled. And 2d, to render available a long experience to these objects of our af- fections, wheu they become diseased. In attempting this, the author has avoided as much as was possible," technicality;" and has given, if he does not flatter him- self too much, to each disease of which he treats, its appropriate and designat- ing characters, with a fidelity that will prevent any two being confounded, to- gether with the best mode of treating them, that either his own experience or that of others has suggested. XXXIV. DEWEES on the DISEASES of FE- MALES. Second edition with additions. In 8vo. XXXV. DEWEES'S SYSTEM of MIDWIFERY. Fourth edition, with additions. XXXVI. CHAPMAN'S THERAPEUTICS and MATERIA MEDICA. Fifth edition, with additions. XXXVII. A CHRONICLE of the CONQUEST of GRENADA, by Washington Irving, Esq. in 2 vols. " On the whole, this work will sustain the high fume of Washington Irving. It fills a blank in the historical library which ought not to have remained so long a blank. The language throughout is at once chaste and animated; and the narrative may be said, like Spencer's Fairy Queen, to present one long gal- lery of splendid pictures. Indeed, we know no pages from which the artist is more likely to derive inspiration, nor perhaps are there many incidents in lite- rary history more surprising than that this antique and chivalrous story should have been for the first time told worthily by the pen of an American and a re- publican."—London Literary Gazette. New Editions of the following works by the same Au- thor. THE SKETCH BOOK, 2 vols. 12mo. KNICKERBOCKER'S HISTORY of NEW YORK, 2 vols. 12mo. BRACEBRIDGE HALL, 2 vols. 12mo. TALES of a TRAVELLER, 2 vols. 12mo. XXXVIII. NEUMAN'S SPANISH and ENG- LISH DICTIONARY, new Edition. XXXIX. A TOUR in AMERICA, by Basil Hall, Captain, R. N. in 2 vols. 12mo. XL. AMERICAN ORNITHOLOGY, or NA- TURAL HISTORY of BIRDS inhabiting the UNITED Published by Carey fy Lea. 7 STATES, by Cuaiiles Ltjcian Bonapahte; designed as a continuation of Wilson's Ornithology, vols. I., II. and III. #* Gentlemen who possess Wilson, and are desirous of ren- dering the work complete, are informed that the edition of this work is very small, and that but a very limited number of copies remain unsold. XLI. The AMERICAN QUARTERLY RE- VIEW, No. XVI. Contents.—Buenos Ayres and the Pampas. —Internal Improvement.—Brown's Novels.—Watson's Annals of Philadelphia.—Wilson, the Ornithologist.—Longevity.— Juan Van Halen's Narrative.—Mirabeau.—Banks and Cur- rency.— Terms, Jive dollars per annum. XLII. The AMERICAN JOURNAL of the ME- DICAL sciences, No. XIIL for November, 1830. Amongthe Collaborators of this work are Professors Bigelow, Channing, Chapman, Coxe, Davidge, De Butts, Dewees, Dickson, Dud- ley, Francis, Gibson, Godman, Hare, Henderson, Horner, Hosack, Jackson, Macneven, Mott, Mussey, Physick, Potter, Sewall, Warren, and Worthington; Drs. Daniel], Emerson, Fearn, Griffith, Hays, Hayward, Ives, Jackson, King, Moultrie, Spence, Ware, and Wright.—Terms, Jive dollars per annum. XLIII. EVANS'S MILLWRIGHT and MIL- LER'S GUIDE. New edition with additions, by Dr. T. P. Jones. XLIV. HUTIN'S MANUAL of PHYSIO- LOGY, in 12mo. XLV. HISTORICAL, GEOGRAPHICAL, and STATISTICAL AMERICAN ATLAS, folio. XLVI. MANUAL of MATERIA MEDICA and PHARMACY. By H.M. Edwards, M.D. andP.VAVASSEUR, M. D. comprising a Concise Description of the Articles used m Medicine; their Physical and Chemical Properties; the Bo- tanical Characters of the Medicinal Plants; the Formulje for the Principal Officinal Preparations of the American, Parisian, Dublin, Edinburgh, &c. Pharmacopoeias; with Observations on the Proper Mode of Combining and Administering Remedies. Translated from the French, with numerous Additions and Corrections, and adapted to the Practice of Medicine and to the Art of Pharmacy in the United States. By Joseph Togno, M. D. Member of the Philadelphia Medical Society, and E. Durand, Member of the Philadelphia College of Pharmacy. " It contains all the pharmaceutical information that the physician can desire, and in addition, a larger mass of information, in relation to the properties, &c of the different articles and preparations employed in medicine, than any of the dispensatories, and we think will entirely supersede all these publications in the library of the physician.'1''—Am. Journ. of the Medical Sciences. XLVI1. An EPITOME of the PHYSIOLOGY, GENERAL ANATOMY, and PATHOLOGY of BICHAT, by Thomas Hexdeksox, M. D. Professor of the Theory and Prac- tice of Medicine in Columbia College, Washington City. 1 vol. 8vo. " The epitome of Dr. Henderson ought and must find a place in the library of every physician desirous of useful knowledge for himself, or of being instru- mental in imparting it to others, whose studies he is expected to superintend."— Worth American Medical and Surgical Journal, No. 15. XLVIII. ELLIS' MEDICAL FORMULARY. The 8 Valuable Works, fyc Medical Formulary, being a collection of prescriptions de- rived from the writings and practice of many of the most emi- nent physicians in America and Europe. By Benjamin Ellis, M. D. 2d edition, with additions. " A small and very useful volume has been recently published in this city, en- titled ' The Medical Formulary.' We believe that this volume will meet with a cordial welcome from the medical public. We would especially recommend it to our brethren in distant parts of the country, whose insulated situations may prevent them from having access to the many authorities which have been_con- sulted in arranging materials for this work."—Phil. Med. and Phys. Jour.' XLIX. Major LONG'S EXPEDITION to the ROCKY MOUNTAINS, 2 vols. 8vo. with 4to Atlas. L. Major LONG'S EXPEDITION to the SOURCES of the MISSISSIPPI, 2 vols. 8vo. with Plates. LI. The HISTORY of LOUISIANA, particu- larly of the Cession of that Colony to the United States of North America; with an introductory Essay on the Constitu- tion and Government of the United States, by M. deMahbois, Peer of France, translated from the French by an American citizen, in 1 vol. 8vo. PREPARING FOR PUBLICATION. I. FARRADAY'S CHEMICAL MANIPULA- TION. First American from the Second London edition. II. THOMPSON on INFLAMMATION. Second American from the Second London edition. III. ROBERT of PARIS, a Tale of the Lower Em- pire. By the Author of Waverlet. IV. TALES of a GRANDFATHER, being a Se- ries from French History. By the Author of Waverlet. V. DESTINY, a Novel. By the Author of Mar- riage and Inheritance. VI. The PHYSIOLOGICAL PRACTICE of ME- DICINE, by J. Costeh. Translated from the French, by Dr. Knox. VII. The PRINCIPLES and PRACTICE of ME- DICINE. By S. Jackson, M. D. (Nearly ready.) VIII. COLLES'S SURGICAL ANATOMY. Se- cond American edition. IX. BROUSSAIS on CHRONIC INFAMMA- TIONS. In8vo. X. BROUSSAIS'S EXAMINATION of MEDI- CAL DOCTRINES. In 2 vols. 8vo. XI. ENCYCLOPEDIA AMERICANA, Vol. V. (Will be ready in January.) XII. PRINCIPLES of GEOLOGY, being an At- tempt to Explain the Former Changes of the Earth's Surface by reference to Causes now in Operation. By Chables Ltell, Esq. F. R. S. XIII. ELEMENTS of MYOLOGY. By E. Ged- dings, M. D. In 4to. with numerous plates. XIV. AMERICAN ORNITHOLOGY. By Prince Charles Bohafabte. Vol. IV. Philadelphia, Nov. 1830. Just Published, by Carey <$• Lea, i A^d/°}^jn Philadelphia by E. L. Carey $ A. Hart; in New-York iJ ii-^rr' 7. H' Ca^^''">• "i Boston by Carter & Hendee—in Charleston by IV. H. Berrelt—in New-Orleans by W. M'Kean; by the principal booksellers throughout the Union, AND IN LONDON, BY JOHN MILLER, ST. JAMES'S STREET. VOLUME IV. CONTAINING ABOUT 1500 ARTICLES, {To be continued at intervals of three months,) OF THE ENCYCLOPEDIA AMERICANA: A POPULAR DICTIONARY OP ARTS, IJjLENCES, LITERATURE, HISTORY, AND POLITICS, BROUGHT DOWN TO THE PRESENT TIME AND INCLUDING A COPIOUS COLLECTION OP ORIGINAL ARTICLES IN AMERICAN BIOGRAPHY: On the feast's of the Seventh Edition of the German CONVERSATIONS-'LEXICON. Edited by Dr. FRANCIS LIEBER, Assisted by EDWARD WIGGLESWORTH, Esa. To be completed in twelve large volumes, octavo, price to subscribers, bound in cloth, two dollars and a half each. EACU VOLUME WILL CONTAIN BETWEEN 600 AND 700 PAGES. The Conversation Lexicon, of which the seventh edition in twelve volumes has lately been published in Germany, origin- ated about fifteen years since. It was intended to supply a want occasioned by the character of the age, in which the sciences, arts, trades, and the various forms of knowledge and of active life, had become so much extended and diversified, that no in- dividual engaged in business could become well acquainted with all subjects of general interest; while the wide diffusion of information rendered such knowledge essential to the charac- ter of an accomplished man. This want, no existing works were adequate to supply. Books treating of particular branch- es, such as gazetteers, &c. were too confined in character; while voluminous Encyclopaedias were too learned, scientific, 2 ENCYCLOPEDIA AMERICANA. and cumbrous, being usually elaborate treatises, requiring much study or previous acquaintance with the subject discussed. The conductors of the Conversation Lexicon endeavored to select from every branch of knowledge what was necessary to a well- informed mind, and to give popular views of the more abstruse branches of learning and science; that their readers might not be incommoded, and deprived of pleasure or improvement, by ignorance of facts or expressions used in books or conversation. Such a work must obviously be of great utility to every class of readers. It has been found so much so in Germany, that it is met with everywhere, among the learned, the lawyers, the military, artists, merchants, mechanics, and men of all stations. The reader may judge how well it is adapted to its object, from the circumstance, that though it now consists of twelve volumes, seven editions, comprising about one hundred thou- sand copies, have been printed in less than fifteen years. It has been translated into the Swedish, Danish and Dutch lan- guages, and a French translation is now preparing in £&ris. A great advantage of this work is ita liberal and impartial character; and there can be no doubt that a book like the En- CYCLOP2EDIA Americana will be found peculiarly useful in this country, where the wide diffusion of the blessings of education, and the constant intercourse of all classes, create a great de- mand for general information. In the preparation of the work thus far, the Editors have been aided by many gentlemen of distinguished ability; and for the continuation, no efforts shall be spared to secure the aid of all who can, in any way, contribute to render it worthy of patronage. The American Biography, which is very extensive, will be furnished by Mr. Walsh, who has long paid particular atten- tion to that branch of our literature, and from materials in the collection of which he has been engaged for some years. For obvious reasons, the notices of distinguished Americans will be confined to deceased individuals: the European biography con- tains notices of all distinguished living characters, as well as those of past times. The articles on Zoology have been written expressly for the present edition by Dr. John D. Godman ; those on Chemistry and Mineralogy, by a gentleman deeply versed in those de- partments of science. In relation to the Fine Arts, the work will be exceedingly rich. Great attention was given to this in the German work, and the Editors have been anxious to render it, by the necessary additions, as perfect as possible. To gentlemen of the Bar, the work will be peculiarly valua- ble, as in cases where legal subjects are treated, an account is ENCYCLOPAEDIA AMERICANA. 3 given of the provisions of American, English, French, Prussian, Austrian, and Civil Law. The Publisher^ believe it will be admitted, that this work is one of the cheapest ever published in this country. They have been desirous to render it worthy of a place in the best libraries, while at the same time they have fixed the price so low as to put it within the reach of all who read. Those who can. by any honest modes of economy, reserve the sum of two dollars and fifty cents quarterly, from their family expenses, may pay for this *vork as fast as it is published; and wo confidently believe that they will find at the end that they never purchased so much general, practical, useful infor- mation at so cheap a rate.—Journal of Education. If the encouragement to the publishers should correspond with the testimony in favor of their enterprise, and the beautiful and faithful style of its execu- tion, the hazard of the undertaking, bold as it was, will be well compensated; and our libraries will be enriched by the most generally useful encyclopedic dictionary that has been offered to the readers of the English language. Full enough for the general scholar, and plain enough for every capacity, it is*far more convenient, in every view and form, than its more expensive and ponder ous predecessors—American Farmer. The high reputation of the contributors to this work, will not fail to insure it a favorable reception, and its own merits will do the rest.—Silliman's Journ. The work will be a valuable possession to every family or individual that can afford to purchase it; and we take pleasure, therefore, in extending the knowledge of its merits.— National Intelligencer. The Encyclopaedia Americana is a prodigious improvement upon all that has gone before it; a thing for our country, as well as the country that gave it birth, to be proud of; an inexhaustible treasury of useful, pleasant and fa- miliar learning on every possible subject, so arranged as to be speedily and " safely referred to on emergency, as well as on deliberate inquiry; and better still, adapted to the understanding, and put within the reach of the multitude. * * * The Encyclopaedia Americana is a work without whicli no library worthy of the name can hereafter be made up.—Yankee. The copious information which, if a just idea of the whole may be formed from the first volume, this work affords on American subjects, fully justifies its title of an American Dictionary; while at the same time the extent, varie- ty, and felicitous disposition of its topics, make it the most convenient and , satisfactory Encyclopaedia that we have ever seen.—National Journal. # If the succeeding volumes shall equal in merit the one before us, we may confidently anticipate for the work a reputation and usefulness which ought to secure for it the most flattering encouragement and patronage.—Federal Qaiette. The variety of topics is of course vast, and they are treated in a manner which i3 at once so full of information and so interesting, that the work, in stead of being merely referred to, might be regularly perused with as much pleasure as profit.—Baltimore American. We view it as a publieation worthy of the age and of the country, and can- not but believe the discrimination'of our countrymen will sustain the publish- ers, and well reward them for this contribution to American Literature.— Baltimore Patriot. We cannot doubt that the succeeding volumes will equal the first, and we hence warmly recommend the work to the patronage of the public, as being by far the best work of the kind ever offered for sale in this country.— U. S. Gaz. Tt reflects the greatest credit on those who have been concerned in its pro- duction, and promises, in a variety of respects, to be the best as well as the most compendious dictionary of the arts, sciences, history, politics, biography, &c. which has yet been compiled. The style of the portion we have read is terse and perspicuous; and it is really curious how so much scientific and other information could have been so satisfactorily communicated in such brief limits.—M Y. Evening Post. A compendious library, and invaluable book of reference.—JV. Y. American 4 ENCYCLOPEDIA AMERICANA. This cannot but prove a valuable addition to the literature of the age.—Mcr Advertiser. The appearance of the first volume of this valuable work in this country, is an event not less creditable to its'enterprising publishers, than it is likely to prove lastingly beneficial to the public When completed, according to the model presented by the first volume, it will deserve to be regarded as the spirit of all the best Encyclopaedias, since it comprises whatever is really desirable and necessary in them, and in addition, a large proportion of articles entirely original,.or expressly written for its pages. This is the condition of all the articles of American Biography, by Mr. Wateh; those on Zoology, by Dr. God- man; and those on Mineralogy and Chemistry, by a gentleman of Boston, distinguished for his successful devotion to those studies. The work abounds with interesting and useful matter, presented in a condensed and perspicuous style; nor is it one of its least commendations that it is to lie comprised in twelve octavo volumes, which may be placed on an office table, or occupy a shelf in the parlor, ever ready for immediate reference, instead of requiring almost a room to itself, like its ponderous predecessors, the Britannica, Edin- burgensis, &c. The vast circulation this work has had in Europe, where it has Already been reprinted in four or five languages, not to speak of the numerous German edi- tions, of which seven have been published, speaks loudly in favor of its in- trinsic merit without which such a celebrity could never have been attained. To every iiu»n engaged in public business, who needs a correct and ample book . of reference on various topics of science and letters, the Encyclopaedia Ameri- cana will be almost invaluable, lo individuals obliged to goto situations where books are neither numerous nor easily procured, the rich contents of these twelve volumes will provi* a mine which will amply repay its purchaser, and be with difficulty exhausted, and we recommend it to their patronage in the full conviction of its worth. Indeed it is difficult to say to what class of readers such a book would not prove useful, nay, almost indispensable, since it combines a great amount of valuable matter in small compass, and at mode- rate expense, and is in every respect well suited to augment the reader's stock of ideas, and powers of conversation, without severely taxing time or fatiguing attention. These, at least, are our conclusions after a close and candid ex- amination of the first volume.—Am. Daily Advertiser. We have seen and carefully examined the first volume of the Encyclopedia Americana, just published by Carey, Lea and Carey, and think our readers may be congratulated upon the opportunity of making such a valuable accession to their libraries.—Aurora. The department of American Biography, a subject of which it should be disgraceful to be ignorant, to the degree that many are, is, in this work, a prominent feature, and has, received the attention of one of the most indefati- gable writers in this department of literature)'which the present age can fur- nish.—Boston Courier. According to the plan of Dr.-Lieber, a desideratum will be supplied; the sub- stance of contemporary knowledge will be brought within a small compass;— and the character and uses of a manual will be imparted to a kind of publica- tion heretofore reserved, on strong shelves, for occasional reference. By those who understand the German language, the Conversation Leiicon is consulted ten times for one application to any English Encyclopaedia.—National Gaz. The volume now published is not only highly honorable tu the taste, ability and industry of its editors and publishers, but furnishes a proud sample of the accuracy and elegance, with which the most elaborate and important literary enterprises may now be accomplished in our country. Of the manner in whicli the editors have thus far completed their task, it is impossible, in the course of a brief newspaper article, tSi speak with adequate justice.—Boston Bulletin. We have looked at the contents, generally, of the second volume of this work, and think it merits the encomiums which have been bestowed on it in the northern papers. It continues to be particularly rich in the departments of Biography and Natural History. When we look at the large mass of mis- cellaneous knowledge spread before the reader, in a form which has never been equalledsfcrits.condensatirn, and conveyed in a style that cannot be surpassed for propriety and perspicuity, we cannot but think that the American Ency- clopaedia deserves a place tn every collection, in which works of reference form a portion."—Southern Patriot. ^ ■ NLM032777968