/?C3// .5^^ intif(!Ettpofllrttigork College ot $ii|)sitctanfii anb ^urseons; Hihvavy Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatiseonpulmonOOsand v> TREATISE ON PULMONARY CONSUMPTION, IN WHICH A NEW VIEW OF THE ■ PRINCIPLES OP ITS TREATMENT IS SUPPORTED BY ORIGINAL OBSERVATIONS ON" EVERY PERIOD OF THE DISEASE. TO WHICH IS ADDED, AN INQUIRY, PROVING, THAT THE MEDICINAL PROPERTIES OF THE DIGITALIS, OR FOX-GLOVE, ARE DIAMETRICALLY OPPOSITE TO WHAT THEY ARE BELIEVED TO BE. BY JAMES SANDERS, M.D. ONE OF THE PRESIDENTS OF THE ROYAL MEDICAL AND ROYAL PHYSICAL SOCIETIES Of EDINBURGH. ^ • PRINTED BY WALKER AND GREIG; FOR LONGMAN, IIURST, REES, AND ORME, LONDON; BELL AND BRADFUTE, MANNERS AND MILLER, AND JOHN ANDERSON, EDINBURGH. 1808, Pr. R w TO JOHN HEPBURN, Esq. of Sideserf. Dear Sir, I address this Work to you, because, investigating the Subjects of which it treats, I have been animated by that sentiment, w^hich I, at an early period of life, heard you inculcate in a manner that did honour to your judgment, and made an indelible impression on my mind : you maintained, that ignorance is a crime of enormous magnitude, and that a blind con- IV fidence in the authority of great names, is the most contemptible species of it. I am. S1R5 Your sincere Friend^ Edi7iburgh, 12. James's Square.li Bee. 15. I8O7. S James Sanders. ; INTRODUCTION. Consumption of the Lungs was the first disease which I wished to understand > for this purpose I appHed to authors, Httle suspecting, that a malady coeval with the, human race, and so generally pernicious, had not been amply explored, its nature as definitely as possible explained, and its treat- ment conducted on some well established principle ; I was consequently much disap- pointed, when I found, that every thing re- lative, to this affection was involved in ob- scurity and confusion. One could scarcely perceive from their writings, that authors had ever attempted to relate the symptoms in the order of their occurrence and consistently with the changes which succeed in the constitution ; and this probably is the chief cause, that VI ^they do not agree with regard to its nature, though of bodies deprived of hfe by con- sumption an infinite number has been ex- amined with great patience and anatomical discrimination. The nature of the disease not being as- certained, its causes, and the relation which it bears to other diseases, could hardly be pointed out with precision ; accordingly, the causes of consumption have been con- founded with consumption itself; and there is not one nosologist who has reason to be satisfied with the place assigned to it even in his own arrangement. Where science is imperfect, specious opi- nions too often usurp the authority of sound principles, and the proceedings of the artist are dictated by caprice, supposition, or fan- cy. This is strikingly exemplified in the treatment of phthisis pulmonalis. Here every one has some favourite remedy, which he prescribes without regard to age, sex, peculiarity of constitution, or period of the disease. ' • Vll The Author of the present Treatise is far from presuming, that he can accomphsh the necessary reformation ; but, that the affec- tion be systematically investigated, that the more important doctrines and opinions of physicians concerning the nature of it be examined with the most candid freedoni, and that the treatment of, it be improved, is what he most solicitously desires ; and if his feeble efforts have even any influence in directing the attention of men of genius and learning, or contribute in any way to the attainment of this object, most interest- ing to humanity, he will not have labour- ed in vain. For reasons which will appear on perusal, this Work is divided into two parts: in both, I have occasionally used freedom with great and venerable names, but never with any intention to diminish their lustre ; if, in- deed, assisted and guided by that light which they afford, I have sometimes dis- cerned their imperfections, I would no more presume to blame them, than to blame the vin glorious sun, because by his rays I wasien- abled to discern spots on his disk. I esteem it the highest honour that can be done to a great man, to study his works with the stern severity of criticism, in or- tier that, unretarded by error or prejudice, the truths in which they abound may pro- ceed to augment the happiness of mankind. The First Part treats of Consumption of the Lungs. The Second Part is an experimental In- quiry concerning the Digitalis or Fox-Glove, one of the most important of those substan- ces which have been employed as remedies in consumption. This plant, according to Linnaeus, of the class didynamia ; order, angiospermia ; na- tural order, solanaceae ; has but lately been added to the Ust of remedies ; it is how- ever, not requisite to enter here, either into the botanical or medical history of it, as both are well detailed in the account of fox- glove given by Dr Withering, and in other medical and botanical-. books. IX The object of this part of the Work is to prove, that the powers of this substance on the hving body are misunderstood, and that it is in general administered for purposes which it tends to frustrate, but never can fulfil. To this Inquiry I have devoted much time and attention ; I have watched its effects in those of every period of life, and of every degree which the inequality of wealth can create in artificial society ; in persons en- joying health of every temperament or habit of body, and in those labouring under every state of disease. In ascertaining the facts, I had the assistance of a number of well- informed and ingenious . gentlemen, some of whom are already well known in the re- public of literature and science, and others of whom we shall soon see ranked among the most eminent of the medical profession. In short, I have observed its effects in all the variety of circumstances which I could devise, and have used all the means in my X power that I might not be deceived con- cerning it. The cases detailed and opinions advanced, have, in their progress, been annually dis- cussed in the Royal Medical and Physical Societies of this city ; during which oppor- tunities, I availed myself of every useful sug- gestion made by any of the ingenious mem- bers of those invaluable institutions. While occupied with this Inquiry, facts presented themselves which seemed to me not only to improve our knowledge of the nature and treatment of consumption, and explain several paradoxical tenets in physio- logy and pathology, but to be importantly illustrative of the nature of haemoptysis, hydrocephalus, anasarca of the lungs, and dropsy in general. These latter affections are reserved as the subjects of separate publication; the one concerning which I intend next to address medical men, is the hydrocephalus. I think it may be proved^ that the com- mencement of this disease is, in general, XI more evident, and its progress more easily- arrested, than they are understood to be. Were I permitted to advise, there is no af- fection that I would more earnestly recom- mend to the attention of the zealous stu- dent of pathology ; for certainly that man, who shall have the good fortune to discover a method of completely preventing or cur- ing hydrocephalus, will do a service to the most innocent and helpless of our species, equal to the discovery of the vaccine inno- culation, which, during these ten years, has preserved more lives than the most bloody and ruinous war that ever infested the earth, has destroyed. The facts contained in this Work, have been both selected and ascertained with great care. The Author avers, with the firmness of conscious rectitude, that he has been more anxious to know the truth, than to promulgate novelty ; he chuses no infer- ence that does not seem to flow sponta- neously from the facts. He has however, committed and witnessed too many mis- takes, not to know, that error is the infir- mity of our nature, and has seen too much reason to deprecate the consequences df perseverance in error, not to deem himself guihy of treason against the majesty of truth, if he wielded the arms of sophistry even in his own defence ; but, whatever inaccuracy there may be found in the rea- sonings whatever faults in the composition, which neither time allowed, nor experience qualified him to polisji, he trusts, that the experiments and the results of observation here related, can bear the strictest scru- tiny ; and hopes, that no one will condemn him on their account, till they have been, with equal care and patience, repeated ; when it will be the pride of the Author to confess obligation to him by whom he shall be corrected in this only instructive and philosophic manner. CONTENTS. PART I. TREATISE ON PULMONARY CONSUMPTION. CHAPTER I. HISTORY OF PHTHISIS PULMONALIS. Page Sect. I. Incipient Phthisis, or a Detail of those Sym- ptoms which precede Distinct Inflammatory Action 1 Sect. II. A Detail of the Inflammatory Symptoms which terminate in and" accompany Suppuration - 9 Sect. III. A Detail of the Symptoms indicating the Presence of Pus, &c. - - - 12 Sect. IV. A Detail of the Symptoms indicajing the Pre- sence of Mortification - - 22 Sect. V. Account of several Circumstances attending the Disease, and Varieties which occur in the Sym- ptoms, but which could not be easily comprised in the General History - - - - 25 Sect. VI. State of the Mind, and Emaciation in Phthisis 32 CHAPTER H. CONCERNING THE NATURE OF PHTHISIS PULMONALIS. Sect. I. Explains how the Nature of Phthisis Pulmo- nalis is to be ascertained, and details the Morbid Changes which the Lungs suffer •, 41 XlV Page Sect. II. The Nature of the Disease, and some of the Discordant Notions of Authors concemiitg it 45 Sect. III. Inquiry concerning the signification of the name Phthisis Pulmonalis, in which the bad conse- quences of its indefinite and vague application are pointed out, and a precise and unambiguous significa- tion assigned to it - - - 49 CHAPTER III. PREDISPOSITION TO, AND CAUSES OF IN- FLAMMATORY PHTHISIS PULMONALIS. Sect. I. Predisposition to Phthisis Pulmonalis 62 Sect. II. Causes of Phthisis Pulmonalis - 66 CHAPTER IV. ON THE DIAGNOSIS OF PHTHISIS PULMONALIS. Sect. I. The chief Affections, which in their Symptoms resemble Phthisis Pulmonalis - - "71 Sect. II. Whether the Disease may be known from the Expectoration pf Pus, &.c, - - 78 Sect. III. Whether Hectic Fever is a decisive proof of the existence of Phthisis - - 83 CHAPTER V. NOSOLOGICAL ARRANGEMENT. Sect. I. Errors in the Judgment of Authors with re- gard to the Place which they have assigned to Phthi- sis Pulmonalis in Nosological Arrangement - 85 Sect. II. General Observations on the Principles of Classification - - - 92 XV CHAPTER VI. VIEW OF THE NATURE AND TREATMENT PRIN- CIPALLY OF PHTHISICAL AFFECTIONS NOT TO BE CONSIPERED AS INFLAMMATORY. Page Sect. I. Phthisical Affections independent of Inflam- mation, with the different Species of Phthisis Pul- monalis - - - 100 Sect. II. In which are chiefly considered the Sym- ptoms and Treatment of the Second Species, or that which is independent of Inflammation - 104 Sect. III. Phthisical Affections commencing without Inflammation - _ _ 109 CHAPTER VII. TREATMENT OF THE FIRST STAGE. Sect. I. General Observations concerning the Treat- ment of Inflammatory Consumptions of the Lungs, from their commencement to their termination 12Q Sect. II. Treatment during the Inflammatory Sym- ptoms which terminate in and accompany Suppuration 127 CHAPTER VIII. TREATMENT OF THE SECOND OR SUPPURA- TIVE STAGE. Sect. I. Treatment according to the Different Ap- pearances of the Sputa - - 134 Sect. II. Treatment as regulated by the various Phe- nomena of the Fever which attends Ulceration 142 XVI Page Sect. III. Account and Explanation of the EiFects of Posture on the Heart and Arteries, in Health and Disease, and the Reason assigned why a certain Po- sition is easiest for the body of an enfeebled Person 149 Sect. IV. What Kinds of Exercise, and when Sea Air and Change of Climate are to be advised 155 Sect. V. Utility of inhaling certain Substances to promote the healing of Ulceration in the Lungs 161 Sect. VI. Utility of administering Digitalis in the Suppurative Stage _ _ _ 174. Sect. VII. New Modes of Treatment proposed for the removal of Air or of Puritorm Matter from the Ca- vities of the Chest - - - 176 - CHAPTER IX. TfREATMENT OF THE THIRD STAGE 184 PART II. INQUIRY CONCERNING THE MEDICINAL PROPERTIES OF THE DIGITALIS. CHAPTER I. EXPERIMENTAL PART OF THE INQUIRY. Sect. I. Preliminary Observations - 180 Sect., II. Concerning the Effects of Digitalis on the Pulse of Healthy Persons - - 192 Sect. III. Reasons for believing that the Digitalis is administered on False Principles - 200 Sect. IV. Demonstrates, that the Digitalis is admi- nistered on False Principles, and that its Primary Operation is powerfully Stimulant ' - 213 xvii Page. Sect. V. Shows, that the Digitalis may be success- fully administered, and in such a manner as to avoid that Debility which has been reckoned its Proper Effect . - - - 244 Sect. VI. Communication on the Powers of the Digi- talis, from Mr J. De Courcy Laffan, one of the Pre- sidents of the Royal Physical Society of Edinburgh 270 CHAPTER II. THE FACTS ASCERTAINED CONCERNING THE OPERATION OF THE DIGITALIS APPLIED TO THE EXPLANATION OF THOSE CIRCUMSTANCES WHICH HAVE LED TO THE MISTAKEN OPINIONS PREVALENT ON THIS SUB- JECT ; AND THE NEW PRINCIPLE FOR THE ADMI- NISTRATION OF THE REMEDY FURTHER ILLUS- TRATED, SsCT. I. OfJcration of Digitalis, with some Observa- tions on the Natpre and the Manner of Action of those Powers which maintain the Vital Phenomena 274.' Sect. II. Opinions of Authors examined, and their Inconsistencies pointed out - - 284 Sect. III. Endeavours to show those Occurrences which misled Physicians in forming their Opinion concerning the Powers of Digitalis - 291 Sect. IV. Comparative Effects of the Digitalis 303 Sect, V. Administration of the Digitalis - 311 PART I. TREATISE ON PULMONARY CONSUMPTION, TREATISE, &c. CHAPTER L HISTORY OF PHTHISIS PULMONALIS, SILCTION I. Incipient Phthisis, or a Detail of those Symptoms zvhich precede Distinct Inflammatory Action. IN certain persons, at an early period of life, but most remarkably about the age of puberty, occur tension and pain of chest, more or less severe, with titillation of the fauces, and slight short dry cough, readily excited by hot drink, especially if it con- tains ardent spirits ; to which are frequently added drowsiness, and a sense of weight irt the head ; occasionally, headach is the only thing which distresses them. All of these symptoms are often relieved by a sponta- neous epistaxis, or haemoptysis. A 2 . Whoever is so affected can neither run nor cHmb with the same ease of respiration as others ; without incurring greater danger than others indeed, or often without imme- diately increasing the complaint, he can, neither exert his voice, nor forcibly retain the air in his lungs ; he cannot inhale acrid fumes, as of coals, metals, and acids ; he cannot live in a marshy country ; he cannot expose himself to the extremes of heat and cold, to showers, to an atmosphere loaded with moisture, nor to any great vicissitudes of weather ; he can neither neglect the na- tural evacuations, nor omit the artificial, such as vensesection ; he can neither be greatly grieved nor greatly exhilarated ; he cannot devote himself to excess of study, to long watching, to abstinence, nor to any privation ; he can neither indulge in- dolence, nor enjoy the gratification of ac- tive amusement ; he cannot, in eating or drinking, exercising or resting, nor, finally, dare he, in obedience to the dictates of ap- petite or passion, deviate from the golden rule of mediocrity. Sometimes he heaves a deep involuntary sigh ; he may be surprised by a dyspnoea, for the attack of which no reason can be 3 assigned ; by an uncommon degree of pale- ness of countenance with a sense of feeble- ness ; or even by nausea, when he thinks himself in the best health : this dyspnoea is often of a spasmodic nature, and alternates with spasmodic affections of the urinary organs, which has induced some to believe that they were threatened with urinary cal- culus. During autumn, winter, spring, he is very liable to catarrh with a copious saltish expectoration of various consistence and co- lour. In these seasons the plurality of the above symptoms is much aggravated, and very grievously in a rainy autumn, if pre- ceded by an exceedingly hot and dry sum- mer * ; the cough, in particular, is often so severe as to excite vomiting with pain of chest usually referred to one of the sides, and the most excruciating headach. Not unfrequently such persons are asth- matical ; to them, frightful dreams with muttering or even walking in sleep, and , incubus, are not unusual. They are whim- sical, naturally generous, sometimes prodi- gal ; they are often remarkable for the * Hippoc. aph. 13. and 22. sect. 2. 4 finer sympathies, are sometimes adorned by nature with personal grace and intellec- tual superiority ; they are generally addicted to the pleasures of love, are of acute sensi- bility and irascible, they often abound in mirth and fancy, but are more often af-^ fected with melancholy. Very many of them become fond of con- vivial intercourse and intoxication, as a re- fuge from that occasional despondency to which they are particularly liable. Some of them, for perhaps several months, proceed in an almost uninterrupted course of asto- nishing dissipation, by which they may even seem to have meliorated their health, though, even during this, the greater num- ber is often awaked by short but dreadful menaces of instant suffocation ; and poign- ant regret, languor, mental and corporeal infirmity most certainly overtake all of them, when the disease may make uncon- querable progress. Such individuals are known to have been affected with great disorder of mind, for the most part of the gloomy character. They supposed themselves betrayed and surround- ed with enemies, and persons formerly lov- ed or admired were the chief objects of resentment. In this state suicide is threat- ened, and, we have reason to suspect, not rarely perpetrated. The paroxysm of fren- zy generally succeeds indulgence in the use of strong drink ; it continues for perhaps a day or two, after which the mind becomes sound, and the person is happy at the escape which he has effected from himself. There are intervals of entire immunity from suffering, even for the space of a year or two, but these are generally confined to the warmer and more uniform seasons ; and, in the colder months, a similar series of complaint is repeated annually, v/ith dif- ferent degrees of severity, in some instances for twenty or more years ; during which time there has often been felt a trouble- some chronic heat in the extremities. Disease and time (what in nature do they spare ! ) have gradually undermined the constitution ; the patient is convinced, that the affection has imperceptibly be- come worse, and that his life is now in danger. The appetite is impaired, and food received into the stomach creates uneasi- ness or squeamishness, relieved by eructa- tions and discharges of flatus ; this squeam- ishness comes on with a sense of weakness referred to the breast, and is accompanied with a flow of a warm sahish Uquid into the mouth ; the bowels are obstinately- constipated ; there are sometimes very co- pious discharges of limpid urine ; headachs are more frequent and acute ; he is benumb- ed, sluggish and drowsy ; he feels his eye-^ lids stiffened and agglutinated, and has a bad taste in the mornings ; the lips are often dry ; the tongue is in general moist, its superior surface is covered with some- thing white and brown in the middle to- wards the root ; his cough, which was for- merly more noticed by his friends and re- lations than himself, and the titillation of the larynx are now very distressing, parti- cularly in the evening, morning, and fre- quently on awakening in the night : the dyspnoea is often very oppressive, aggrava- ted by the least motion, and in sleep im- presses the mind with the most hideous im- ages, difficulties insurmountable and situa- tions of instant peril ; if he walk much or stand, he is first sensible that his shoes be- come too tight, and next, he feels pains in his ankles with a teasing uneasiness in his feet, as if they were punctured by a great number of needles, and now he observes that his feet always swell toward night ; the pulse is nearly of the usual number, and, like that of a healthy person, increases about five beats per minute on changing from the lying to the sitting posture, and five more on standing ; but is much more readily accelerated by more active exercise, by which also his body is sooner heated. Emaciation makes evident progress ; cold air, dampness, wet feet, or cold any how applied, produces an uncommon degree of chilliness, attended always with an instan- taneous paleness and sharpening of the features, corrugation of the skin all over the body, and some peculiarly uneasy sen- sations, and often with a very disagree- able stifling and hoarseness ; vomiting, par- ticularly in the morning on taking tea, is very frequent, and at last becomes con- stant on taking the usual food, for which invincible disgust soon supervenes ; the face becomes pale or yellowish, except that an inconstant redness occasionally enlivens the countenance ; the eyes put on a pearly whiteness, sometimes beautifully variegated with red streaks ; the teeth also whiten ; the skin is often hot ; the lips, tongue and fauces, dry ; often an unaccountable chil- liness with shivering, intervenes ; there is a sense of feebleness about the praecordia, and acute pains dart in the head and in the thorax ; severe pain is sometimes fixed about the scrobiculus cordis, or between the shoulders ; at which time the breathing is quick and short, and the face flushed ; tor- mina affect the bowels, which rather tend to constipation ; the urine begins to redden, and is discharged sometimes with pain ; un- easiness and slight pains impede the move- ment of the back, and of the joints of the extremities ; the pulse is variable, has im- perceptibly increased in number to about ninety, is rather stronger, and more evi- dently influenced by exercise, even of so mild a kind as change of posture ; and, at the same time, the nurnber of pulsations, and the heat of the body, are much in- creased by food ; bodily weakness is now very great ; fretfulness, peevishness and ap-^ prehensiveness of danger, are the charac- teristics of the mind. 9 SECTION 11. A Detail of the Inflammatory Symptoms which terminate in and accompany Suppuration, SOON, however, the pulsations and the motions of respiration begin to increase most remarkably in number ; the patient com- monly lies on his right side, unless, as hap- pens to many, there be a constant pain in it ; he cannot sleep ; is sometimes cold, some- times hot, during the night, and often shi- vers with cold when the skin glows, or thinks himself oppressed with heat when the surface of the body is cold ; the ears and face are often disagreeably hot, parti- cularly after exposure to cold air ; the heat of the palms, soles, and trunk, with general itching of the skin, is very troublesome ; pains more severe than ever infest the chest; the cough is almost constant, it is short and dry, or accompanied with mucous sputa ; he is attacked by severe paroxysms of asth- ma, which are terminated and relieved by copious expectoration of various consistence, sometimes transparent, sometimes yellow ; 10 the patient cannot lie with equal ease on both sides, nor on any account make a full inspiration ; some degree of dyspnoea is per- manent ; and his voice sometimes imitates the sound of a brazen trumpet ; the tongue is foul and red, the fauces also redden ; thirst is increased, appetite much diminish- ed, and a thin sahne fluid often collects in the mouth. But these distressing sensations may be very much mitigated, and the person will, for weeks or even months, be able to per- form all the common offices of life without much uneasiness from debility or emacia- tion, while the pulse beats in general from thirty to forty above the medium number of health ; when he sits before dinner or any other meal, it will beat from ninety to a hundred ; after a dinner of animal food, from a hundred and ten to a hundred and twenty ; and it will be increased by from twelve to twenty beats per minute at any time when he stands or walks. The quicker the pulse is when one sits, the great- er is the increase of its velocity when one assumes the standing posture, and the great- er is the diminution when one lays ones self in the horizontal posture ; the weaker XI one is, the greater is the increase of the number of pulsations by bodily motion of any kind, and the greater is the diminution of their number when the motion is inter- mitted. After no certain length of time the dis- ease proceeds with rapid aggravation of all the symptoms ; there is a perception of an uninterrupted tingling sound attended with vertigo, particularly if he attempt to sit ; the smallest degree of noise, even that of walking or speaking gently, disturbs him ; the eyes are suffused with red, and are acutely sensible to light ; the heat of skin, the dyspnoea, the pains and burning with beating in the breast, become nearly intole- rable ; pains are, at the same time, felt in the limbs, or even over all the body ; the bowels are very costive, the urine is red, and deposits a lateritious sediment ; the cedema- tous swelling of the feet disappears ; the suf-^ ferer is extremely restless ; there is a sense of great heat in the fauces ; the whole face is of a florid redness, changing to purple when the difficulty of breathing is very great ; extreme anxiety is depicted in the countenance ; the pulsations are strong and rapid, producing violent throbbing at the 12 temples, and headachs of indescribable tor- ture, which may even induce wild delirium. SECTION III. A Detail of the Symptoms indicating the Presence of Pus, ^c. AFTER these symptoms have conti- nued some time, there commences copious warm sweating, followed by severe cold shiverings ; the pulse generally becomes softer, milder and slower, or may even in- termit a little ; to these symptoms succeed severe sickness, with a certain sensation of a tendency to faint, which terminates in vomiting of puriform matter, tinged perhaps with blood ; now some degree of relief ar- rives. In many, indeed, the relief is so flat- tering, that for a week, or even a month, they think themselves nearly well, fever is scarcely perceptible, respiration easy, sleep sound, cough very mild, sputa in little quan- tity, white, smooth and easily expectorated, appetite improved, evacuations pretty natu- ral ; but in the greater number perhaps, the difficulty of respiration is rather in- 13 treased, and ihe other distressing sensations are only mitigated ;, severe dyspnoea with hoarseness may attack and go off sponta- neously, often to be succeeded by strangury or even complete retention ; there is a sense of weight and oppression in the breast, and sometimes a very acute pain in the side ; the eyes are pearly again ; the face more yellow and meagre ; the temples collapsed ; emaciation increased : and there is now very copious purulent expectoration. . After a species of smart continued fever may have proceeded for a few days, alter- nate accessions of heat and cold arrive, "which gradually assume a certain regula- rity, and the cold seems to introduce the heat. The cold fit approaches, accompanied with rigor, sweating, fluid, sputa, sickness, vomiting, disgust of life, the most piteous looks, and not rarely low delirium. The hot fit approaches, accompanied sometimes with desire of food, but when taken, the food may induce such cardialgia, pain and disturbance in the stomach and bowels, as to deter him from again indul- ging his appetite ; this fit is, at the same time, most frequently accompanied with 14 expectoration less fluid, with hilarity and activity of mind, and not rarely with wild delirium ; which exacerbation terminates in the effusion of copious sweats, first succeed- ed by an interval of remission, and next by all the phenomena of the cold fit. In the cold fit the pulse is as quick, or even more so than in the hot, but is re- markably feeble, intermits, and sometimes flutters ; the urine is generally copious and limpid, or contains a white sediment ; though on many occasions, without any regularity, it is oily of surface, pale, reddish, muddy or transparent, in the cold, in the hot fits, and in the intervals ; there is some- times great uneasiness at stomach, relieved by discharges of flatus ; matters discharged by the mouth soon begin to be of various colours, and exceedingly offensive ; the breath is at the same time very noisome ; the muscles of the thorax become relaxed, and the expectoration difficult : there may now supervene acute pains in the parietes of the breast during inspiration, while the intercostal muscles make impotent exer- tions to perform their duty, and also acute pains at the scrobiculus cordis from a simi- lar affection of the diaphragm. 15 In the remission the pulse is almost as quick as in the hot fit, but is less variable, in*- termittent and feeble than in the cold ; and, like that of all debilitated persons, will ob- serve a range of from twenty to forty beats per minute of increase or diminution, when he changes from the horizontal to the erect posture, or the contrary. Sometimes the chilliness of a new fit will instantly succeed the sweating of the former, nor is there ever any remission, however complete, in which the pulse is not morbidly quick and morbidly excitable by every kind of exer- cise. At some calm moment of the time w^hich intervenes between the hot exacerbations, the patient is commonly overtaken by sleep, during which the mouth is open, and if much matter is collected in the bronchia, the respiration is very laborious and noisy ; the nostrils expand and close, the pupils are turned upwards, and he often complains, groans, is oppressed, and awakes frighten- ed ; occasionally however, particularly af- ter a copious expectoration, he may have a pretty tranquil, though very seldom re- freshing sleep ; he inclines to lie on his back, with his head and shoulders high, 16 . and sometimes with his knees drawn up ; the tongue is moist, and often of natural appearance ; in this interval the sponta- neous alvine evacuations occur ; by cold drink the cough is excited or increased, and a spasmodic affection of the fauces and re- spiratory organs is induced. In the hot stage the pulse is pretty re- gular and sharp, occasionally even very strong ; the patient very seldom sleeps, and when he does, he speaks all the time of it, tosses and often exerts as if he were fight- ing ; but if sleep entirely forsake him, if his face flush, if he be restless and uneasy night and day, if he be very irritable, start, stare and speak angrily, complain of head- ach, and be affected with strange fancies, it is to be dreaded, that an attack of furor, like that of phrenitis, will succeed. The tongue reddens and becomes sordid ; the urine, though it is generally red, and depo- sits a lateritious branny sediment, is some- times palish, and deposits a white sediment j though the bowels may be easily moved, they seldom have spontaneous evacuation. The accession and continuance of the sweating which terminates the hot fit, sel- dom afford m-uch relief; this sweating some- 17 times alternates with diarrhoea ; the matter perspired is generally warm, but soon be- comes cold ; that which is perspired during the remission, is always cold. The heart beats with great force in the hot stage, nor does it much abate either in the cold or in the remission, nay, the breast may sometimes be seen elevated by every contraction of the heart, and the neck swelled by every pulsation of the carotid arteries, when the extremities are cold, and their arteries nearly reduced to silence. Mid-day and evening are the times of the hot exacerbation ; the sweats are ge- nerally most severe during the night ; some degree of relief, accompanied with great languor and debility, arrives in the morn- ing, and a permanent circumscribed redness partially occupies the cheeks. This com- bination of symptoms, with no important alteration in the statement, has been con- sidered of late to characterise the proper hectic* The hectic fits rarely occur in the same manner more than thrice in succession ; * Vide Cullen Synop. Nosolog. Method. Heclicse Defini- ionem. 1^ on some days there are many hot exace^rba* tions, or there may be several attacks of cold even in a few hours : the former are gene- rally succeeded, the latter attended by an increased expectoration. Chilliness may be experienced for about half an hour in the midst of apparent febrile activity ; there may be chilliness succeeded neither by heat nor sweating ; cold shivering and sweating without any intervening heat ; heat and sweating together not preceded by cold.* The hectic, or perhaps more properly the ulcerative fever, does not rage long be- fore there recurs the cedematous swelling with pains of the ankles and feet, especially toward night ; some considerable time after which, small aphthous sores cover the lips, the tongue, the inside of the mouth and fau- ces, most disagreeably tainting the breath, and rendering speech and deglutition very difficult ; if he attempt to show his tongue it trembles in his mouth ; at the same time, livid spots- or petechiae appear all over the surface of the body. Often about this period there are great noise and commotion in the bowels ; the * Vide Heberden Comment, de Febre Hectica. 19 contents of the intestinal canal become cof- fee-coloured, and the stools, though volun- tary, are loose and too frequent, indicating the approach of colliquative diarrhoea. In a short time after this the more pro- minent parts of the body, which chiefly sustain its pressure in bed, run into very dis- tressing gangrenous and sphacelating sores. The hands next, and face, but very re- markably the eye-lids, tumefy ; in such de- bility, besides, there has occurred a sudden, great and unaccountable tumefaction, most remarkable in the abdomen, which va- nished spontaneously. In its duration, also, the violence of the fever increases, and its effects become still more alarming. In the occasional intervals of relief, he feels himself giddy, thinks that he sees insects flying before him, and knows that his memory and judgment are im- paired. There occur subsultus tendinum or spasmodic motions, particularly of the muscles of the face and extremities ; the legs and feet may become and continue to be spasmodically stretched and very pain- ful. In the midst of a hot exacerbation, when the pulse is pretty strong and very ra- pid, the heart will suddenly cease to move. 20 and, after a few moments of fainting^ will resume its activity. The minds of many become, with short interruptions, quite in- coherent, through all the varieties of the hot and the cold ; the person will sit up, and pick the bed-clothes, feel every thing near him very minutely, and move his fin-' gers on the wall as if he were touching the strings of a harp ; at another time, he will rise, and either not notice^ or misname all those in his view ; he will embrace imagi- nary visitors, and express himself happy to see those who have perhaps been long out of the number of the living j he will won- der, that he is so well, and promise himself much pleasure, when a transient return of reason dissipates the vision. — Kind delusion ! one of those inventions of nature which, for some time, divest impending dissolu- tion of her horrors ! In their turn, however, even the morbid powers of vitality exhaust themselves, the rage of the fever abates, the mind becomes consistent, the eyes are almost insensible to light, even very great noise excites no alarm, and now intervene drowsiness, torpor and unwillingness to be roused. 21 At -such a time, may be presented to us a truly humiliating image of miserable exte- nuation. The bones which support the superstructure are greatly wasted ; the soft investment which gave symmetry, grace and elegance, to the whole figure, has near- ly abandoned the bones ; the shoulders are extended like wings, and the inferior terr- mination of the trunk seems to be elon- gated ; the extremities also, with the incur^ vated fingers and toes, seem of unusual length ; all the articulations of the joints seem swelled, the various portions of the stiffened spine, the ribs and their junc- tures, are distinctly perceptible ; that soft covering., with which careful nature had anteriorly protected the admirably delicate organs of nourishment and of life, now forms a vast concavity in the middle of the body, and seems to be almost in contact with the posterior half of the circumfer- ence ; the features are astonishingly sharp- ened ; the eyes are hollow, clear and spark- ling ; the superior portions of the cheeks project, and, while the rest of the face is pale or livid, are covered with a florid redness ; their soft parts are fallen in close on the teeth ; the gums are shrivelled ; teeth ap- 22 patently lengthened ; and the open mouth imitates a ghastly smile ! — who can behold this and not exclaim, What is man ! SECTION IV. A Detail of the Symptoms indicating the presence of Mortyication. AT length, contrary to expectation, all pain and uneasiness suddenly cease ; the re- spiration becomes easy, the mind tranquil ; the patient believes recovery and health not far distant ; this event indeed presages a speedy termination of suffering, but one far different from what most fallacious hope presents to the fancy 9f the victim. Soon the charm vanishes ; a universal - tremor with a sensation of internal cold, fainting, hiccough, severe retching, unavail- ing desire to vomit, complete failure of the expectoration, consciousness of inability to perform any Voluntary fuipiction, undeceive him : the pulse is very quick, feeble, irre- gular, intermitting, accelerated by the least 23 motion, and in the extremities scarcely per- ceptible. On his attempting to raise him- self, the heart palpitates and flutters, or is quieted by fainting. He now lies on his back with his limbs stretched out. The skin is permanently moist, and, except on the chest, scarcely warm, though transient flushes frequently intervene ; there are many attacks of cold shivering with copious effusion of moisture, somewhat warm on the breast and fore- head ; the urine is pale, and the stools fetid, greenish, or black, and very frequent. There often occurs an inconsistency of judgment, very different from the delirium either of the hot or cold stage : the person knows where he is, and can distinguish those near him, but yet seems bewildered, and, at intervals, makes childish incon- sistent remarks. The voice entirely changes, and the movement of its organ seems to be quite a mechanical operation, by means of inani- mate soft substance ; deglutition is nearly at an end, the greater part of the liquids put into the mouth is returned after some convulsive attempts to swallow ; the hair 24 drops off; the volar* surface of the fin- gers and plantar surface of the toes are flat- tened, and the skin on them corrugated ; the nails become incurvated, whigh, as well as the fingers and toes, are purple or livid ; the eyes, now glassy, sink ; the features are still more collapsed ; not only the general countenance, but the lips, become deadly pale ; he is much inclined to sleep, in which the inferior jaw separates from the superior spontaneously, and occasions a truly hideous appearance, which is increased by the pe- culiar sound of the breathing ; not only the mouth, but the whole body, emits a sickening fetid odor ; deglutition and voice are now entirely gone ; pulsation gradually abandons the cold, the frigid extremities ; the breast at intervals heaves with agoniz- ing toil ; the heart, convulsed, beats at the same time as if to burst its confines : the breath is cold and extremely fetid ; sweats, cold and clammy, cover the forehead, face and neck, and are often very profuse, but still less cold about the middle of the trunk ; the stools and discharge of urine are invo- * "Vide Noiuenclature of Dr John Barclay, Lecturer ors Anatomy, Edinburgli. 25 luntary, the former of a horrid appearance and smell — evident effects of extreme pu- trescence and debility : every thing an- nounces the appalling departure of life ; the dire commotion in the breast has ceas- ed ; the countenance is involved in a deep- er shade ; the eyes are sunk and circled with blackness ; the subtile principle of mind va- nishes ; corruption and ruin have already seized their prey, and turned it into horror unutterable. SECTION V. Account of several Circumstances attending the Disease, and Varieties which occur in the Symptoms, but which could not be easily com- prised in the General History. THIS section is devoted to the relation of many interesting particulars, vi^hich could not be introduced into the general history. . The disease w^hich we have been consi- dering, occurs in every region of the world, and at every period of life ; but it is most destructive and frequent in the colder lati- 26 tudes, where the atmosphere is moist, an4 weather inconstant ; persons are in the greatest danger of it from puberty to about thirty-five years of age, though consump^ tion has fatally terminated the career of many, in whom its approach had not been perceptible, in any form, before the fortieth year. Males are less liable to it than females ; the latter at puberty, in whom this disease has begun, are much more languid, pale, and enfeebled than the former. Some of the phthisical are ruddy, others- of sallow complexion ; in the former of whom the symptoms, from the commence- ment, are generally violent. Phthisis pulmonalis is frequently com- bined or connected with morbid affections of external and internal parts, but most fre- quently perhaps With those of the liver ; in women it is often accompanied with violent hysterical affections, and has been preceded by amenorrhoea, or chlorosis ; in most of them, however, menstruation ceases soon after purulent expectoration is begun. Abortion often interrupts the pregnancy df the consumptive ; though it is not un- common for a mother to think her health 27 improved by that state, who, after having carried the child to the full time, presents it with sorrow to a world, which she feels she must soon leave for ever. There is a great general resemblance in almost all instances, yet there is scarcely one symptom which can be affirmed to have been uniformly present at any period of the disease. Smart transitory pains first attack the breast at uncertain intervals, or there is a general and permanent soreness, which is rendered severe by violent fits of coughing. The coughing and dyspnoea occur in pa- roxysms, like the asthmatical, during the whole course of many consumptions. Phthisical symptoms may occasionally appear to have been quite removed by a copious menstruation ; likewise, in either sex, unusually copious discharges of diffe- rent kinds, as the cuticular, urinary, alvine, hoemorrhoidal, of blood from the internal parts, or even the suppuration of a tumor externally, may be immediately followed by the restoration of health. Certain individuals have been afflicted with a cough and other signs of pulmonary affection, from which in a few years they 28 have unexpectedly had an entire recovery ; others, less fortunate, after several pretty long intermissions of the cough and con- comitant complaint, have at last been the victims of consumption— their insidious and inveterate enemy. Sometimes the disease commences with fierce inflammatory symptoms, and is ra- pidly fatal ; sometimes this fury abates, and the body wastes slowly. Hectic fever often occurs in scrofulous persons, who are much enfeebled even be- fore ulcers form, is converted . into the in- flamatory >vhen the glands form abscesses of an active kind, and becomes an ulcera- tive rather than a hectic fever when the sores degenerate. The purulent expectoration may cease, and the person seem entirely recovered, when unexpectedly the disease will resume the same course, and have again a similar termination ; this has been more than once repeated in the same individual. In the Journal de Medicine »f it is related, that a man regained a tolerable state of health after having for many months ex- * Tome \i. p. 216. 29 pectorated enormous quantities of puriform matter, in which, before convalescence, there came up certain substances of a membranous appearance. " A youth of sixteen, (says Heberden*) after having the usual signs of a phthisis for many months, and being apparently in the last stage of it, was almost suffocated by bringing up at once a great quantity of matter, and, after a few days, the bag in which it had probably been contained. He soon recovered his flesh and strength, became a strong man, and lived to old age, with a family of robust children and grand-^ children. Yet he was remarkably subject to a cough upon every slight cold, and had returns of spitting of blood several times every year." Some persons, who have been very much reduced by ulceration of the lungs, as indi^ cated by all the proper and usual symptoms, have had an entire recovery. Others have had portions of their lungs destroyed by ulceration, who had not been very percep- tibly affected with fever, had not evinced any degree of emaciation, nor, within a few hours of death, lost their appetite. * De Phllilsi, p. .179. 30 In one, the disease has a short and violent course, even without any purulent expec- toration ; in another, it glides on a long time almost imperceptibly, or without be- ing decisively marked by any symptom ; a third has been affected with some pectoral uneasiness and slight cough from infancy to above fifty years of age, whom the most violent symptoms of it have then suddenly seized, and speedily destroyed. The mildest consumptions often proceed with the most pertinacious constancy in de- fiance of art ; sometimes a complete reco- very arrives, which the most mature judg- ment could hardly have deemed possible. In many persons, spitting of blood both precedes and accompanies the disease, or occurs some time or other during it ; but in an equal number perhaps this symptom never appears. Very oppressive sickness generally attends the vomiting of blood, along with which various other matters are often ejected. The expectoration is often observed to be very thick and viscid, of an ash colour with a slight tinge of green, and to contain many air-bubbles ; sometimes it is white or yellow^ish, and in small round globules ', 31 in it, gelatinous, sandy, calcareous, Osseous and carneous substances, or even portions of the lungs, appear. Before the fatal termination, particularly of the slower consumptions, there often su- pervenes hydrothorax, dr universal dropsy. The senses of one remain undisturbed, those of another are long incoherent. One bears the disease with great good nature and resignation ; another is fretful, capricious, hypochondriacal, and in horror on the slightest ungrateful change in his sensations ; this last I have observed to be remarkably and invariably, in those to "Whom any great degree of haemoptysis has happened. " It strikes terror," says an- cient Aretaeus, " to perceive, flowing by " the mouth, that blood, whence all of " mortal race derive their colour, their " heat, their nourishment*." The life of some of the phthisical lin- gers, protracted beyond all expectation ; but by the effusion of blood, purulent matter, or air, many are precipitated into eternity. * De Morb. Acut, 1. ii. c- 2. 32 SECTION VI. State of the mind, and Emaciation in Phthisis. IT would be superfluous to endeavour to explain the different symptoms, which the appearances on dissection will elucidate more amply and eloquently than any words ; I shall only take the liberty to make some rather desultory remarks on the state of the mind, and the nature of emaciation which occur in this disease, solely with the view of suggesting the uti- lity of such inquiries. In order to arrive at any solid knowledge on such subjects, we must agree with Hip- pocrates, that the basis of all reasoning in medicine is the nature of the human bo- dy ; * or, in other words, that the princi- ples of Hfe and of health, of disease and of cure, are implanted in the animate system, and by the exploring of it only, are dis- coverable. From the most remote antiquity, it has been perceived, that not only the general * Lib. de Loc. in homine, sect. 4. 33 actions of our bodies were excited, but that the viscera were affected by the passions, whence particular organs have been deem- ed the seat of particular passions, as the heart of courage, &c. which consideration alone seems to me completely subversive of the very ingenious opinion introduced as a theory by Bichat, that the voluntary and involuntary motions and organs are inde- pendent of each other ; or, as he expresses it, that the animal life is quite independent of the organic. Many observations indeed have been made, and many things have been ascer- tained, which demonstrate the reciprocal influence and dependence subsisting be- tween the mind and body. Reflecting fur- ther, that every expression of voice, every change of feature or look, indicate both some operation of the mind and a degree of vital energy, we indulge the pleasing hope, that much valuable information may be obtained, when the revolutions of the mind, corresponding with the changes in the condition of the body, shall have been investigated with the scrupulous minuteness of scientific comparison. 34 it was to me an object of peculiar care to mark the state of the mind, both as mo- dified during the progress of the disease and as influenced by those alternations which signalize the concomitant fever ; in addition to which we may here observe, that during the milder exacerbations of the fever, or when it is of a gentle continued type, the mind is somewhat active and lively, but is still impressed with a sort of complacent me- lancholy, possibly from this, that the patient does not suffer acute pain, nor dread imme- diate danger, though, in the mean time, he is sensible of his increasing weakness, and is seldom diverted from thinking of his steadily approaching fate ; but when the cold stage comes with shivering, vomiting, &c. his spirits sink to the lowest degree, and he often wishes that life would quit his wretched body. I have never seen an instance of far advanced consumption which warranted the account generally gi- ven, of the uninterruptedly high hopes of recovery, which delude the minds of per- sons labouring under this disease. The emaciation is in phthisis accom- panied with the general depravation of the digestive and assimilatory functions and 35 most frequently with a certain fever. In- deed any fever never fails to have ghastly emaciation as a companion, and the mea- gerness of the one is always proportioned to the fury of the other. Considering the phenomena of this pro- cess, may one not suppose, that it is the immediate effect of a great alteration in the affinities of the body in relation to the ma- terials conveyed to its different parts ; and that, because no part undergoing decompo- sition selects for itself from the circulating mass, those particles which are necessary to supply the deficiency, the whole body- diminishes in bulk ? To know, however, the disposition of the body necessary to the progress of emacia- tion, is not so important as to know the nature of those powers by which such dis- position is induced, and the means or cir- cumstances by which they are influenced. It will perhaps be found, on comparing the effects of the powers which operate in health with the effects of those which ope- rate in disease, that, contrary to the opi- nion of Brown,* they often differ in the * Vide Elementa Medicinae. 36 kind, and not always in the degree only, of their operation. A change of quality in the exciting power may occasion a dif- ference in the combination of parts, as real- ly as an excess of action may destroy their excitability or susceptibility of action ; a difference, for example, induced in the af- finities, may occasion the concretions of gout, those found in the different fluids and the morbid changes in the consistence and structure of parts, as certainly as an excessive exertion of that power, by which our muscles contract, may shatter, or com- J)letely destroy the animal machine. Leaving this intricate subject to future experience, let me here point out a few changes, which' are induced in the body by certain means, the knowledge of which would incalculably strengthen the efficien- cy of the art of medicine. To recommence then, it were truly dif- ficult to conceive, that emaciation should not ensue, when fever devastates, and the depraved nutrition cannot supply the body; but though emaciation always attends fever and morbidly diminished nutrition, yet the converse of the proposition is not true, for the body often diminishes as well as in- 37 creases in bulk, when infested by no such disorder. The size of the body may not only be greatly influenced, at any period of its du- ration, by food, exercise, rest and the va- rious avocations of life, but does, at fixed times, undergo very considerable spontane- ous changes without the general health be- ing impaired. There are two remarkable stages in hu- man life, in both of which, consistently with health, the sanguiferous system evinces a determinate change ; in the one, which is from infancy to adult age, the pulsations diminish in velocity, while the body is en- larged and invigorated ; in the other, from the close of the middle period of life, till vi- tality ceases to actuate this admirable struc- ture, the pulsations become feeble, while the body gradually contracts and fades. Beside which general results of the laws of the animal economy, there are local changes, at certain periods, also consistent with health and with those laws. The head, the spinal marrow, the nerves, the heart and the liver increase, at their res- pective times, rapidly in proportion to the other parts of the body, and next the trunk 38 and extremities rapidly in proportion to them. In the infant, the cellular texture, which unites the skin to the external muscles, be- comes loaded with adipose substance, while very little collects interiorly either about the heart or in the omentum, and while several large blood vessels are shrinking into membranes, and the liver is diminish- ing in volume. The term puberty denotes an important epoch, and must suggest that interesting re- volution by which it is characterized. At this time fatty matters have collected, and continue to form in the interior of the body, particularly about the heart, the kid-t neys, and in the peritonaeum envelopping the intestines and composing the expan- sions of the mesenteria and omenta. It is worthy of remark, that, from this time to about forty years of age, there is a tendency to general plethora, to inflamrna- tory affections of the lungs and to obesity. To about the eighteenth year, the body increases in length, after which, to the thirtieth, in its other dimensions. In short, there is no interval in which some organ 39 or part does not vary in its relative pro- perties. These are tendencies and changes of the constitution resulting from the original and inherent principles of our nature, "which, ^thin certain limits, contribute to our welfare, all of which, on the contrary, may be counteracted by disease, or destroy us by excess, there are likewise occurrences of a morbid kind, not only manifested in the general frame, but in single parts or or- gans, by which they may be increased or diminished, softened or hardened, in short, undergo an infinite variety of alterations in their form, structure and other properties. From all these facts it appears, that there is a power in the system of altering the structure and of increasing or diminishing the magnitude of all or any of its parts se- perately or conjointly. Such events, mightily useful to the phi- losopher and to the physician, Bichat wish- es to explain to be the result of the peculiar distribution of the vital forces as inherent in his animal and organic systems ; * but if not more correct, would it not be more con- * Anatomic Gencrale, tomeiii. p. 408. 40 ducive to research, to maintain, that these are the effects of the particular distribution of the vital powers, or perhaps vital power, regulated in a manner which is not un- derstood, because unexplored ? But in whatever manner these phenome- na are conceived to be explicable, it is evi^ dent, that, if we could command the power, on which they depend, and direct its oper- ation to any single part or to the whole body at pleasure, we should possess an al- most unlimited control over an immense number of both local and general affections. I am convinced, that the changes from the healthy to the morbid actions of the body, their causes, concomitant circumstances and consequences, offer a vast field, the cultiva- tion of which would be succeeded by a sa*? lutary and most glorious harvest. 41 CHAPTER 11. CONCERNING THE NATURE OF PHTHISIS PULMONALIS. SECTION I. Ei'plains haw the Nature of Phthisis Pulmonalis is to be ascertained, and details the Morbid Changes "which the Lungs suffer. PHTHISIS Pulmonalis, as the name imports, is an affection of the lungs, the nature of which, as of every other incident to our bodies, is only to be deduced from a comparison of those signs which indicate the deviation from health, with the ap- pearances which are to be observed after death. Those signs, as detailed in the preceding history, are such as indicate a progressive local inflammation ; to which are added,* instances of destruction of the lungs, in * Chap. I. sect, 5. 42 which death was not preceded by any proofs of such action. I shall now, trust- ing that the reader is acquainted with the anatomy and physiology of the lungs, state summarily what is observed in the thoraj^ of the phthisical, after life has abandoned the body. Very numerous and different are the appearances which present themselves on the examination of the bodies of those who have died of pulmonary diseases. The lungs are in one wonderfully shri- velled, and in another enormously swelled ; the lung of one side is almost completely obliterated, while that of the other has ac- quired uncommon size, and seems, for a considerable time, to have alone supported the function of resphation ; even the air cells have been found prodigiously enlarg- ed. ^ The following case, of which I only give an abstract, is particularly worthy of atten- tion, f A lawyer, aet. 51. of good consti- tution, but subject to coryza, was suddenly * Morg. Ep. xxii. Art. 12. and Frid. Hoffmanni Oper. Tom. i. § 1. cap. xvii. p. 399. f Obs. d'un Emphyseme des poumons j par Taranget. Journal de Medicine^ Tome xi. p. 313* 43 affected with difficulty of speech, accom- panied with a disagreeable nasal sound. The uvula had assumed the form of a strawberry, and was amputated without af- fecting any change in the symptoms. He was sometimes surprised by deep and strong inspirations ; the nasal sound increased ; the voice became obscure ; there was dif- ficult deglutition ; the continual ejection of mucous viscid sputa ; the eye-lids and lips frequently convulsed, and he sometimes ex- perienced dreadful paroxysms of asthma ; there was no fever ; the emaciation was very remarkable, and he di^d seven months from the attack. On examination, the lungs were found quite impacted, as it were, in the thorax, and in the right side there were adhesions to the pleura ; when taken out they dis- tended themselves with the elasticity of sponge, to four times the size of their pre- vious inclosures ; when pressed there was great crepitation, and when cut at random black blood and air issued copiously. In different instances, the substance of the lungs has assumed the appearance of muscle or tendon ; is signally indurated with scirrhous, osseous, and calculous forma- 44 tions ; is softened into adipose or gelatinous matter, and is disfigured by hydatigenous productions. Though we learn from these appear- ances, that the lungs exhibit an infinite variety of change, which cannot be ascri- bed to any of the known effects of inflam- mation, it is sufficient for our present purpose, that the proofs of the ravages of local inflammation are quite convincing in the bodies of those who have during life been unequivocally afflicted with the vio- lence of local inflammation. Coagulating lymph is abundantly effused ; there are thickening and induration ; the mucous and serous membranes of the bron- chia and pleura are often greatly altered or destroyed ; adhesions are formed between the lungs and the surrounding parts, and between their different lobes ; abscesses con- taining pus are formed in their substance, and ulceration has often made tremendous havock. In the lungs of those in whom scrofula has exercised dominion, glandular swellings or tubercles present themselves, replete with matter of every colour and consistence, while part of the substance of the lungs 45 remains sound in the interstices ; some of the tubercles contain pus, and others appear as if they have been arrested in their pro- gress to suppuration ; very many of them are not larger than small seeds, and others are of incredible magnitude. In fine, every species of sore, from the minute pustular to the large cancerous, every form of inflam- mation and effect of diminished vitality are manifested, from simple redness to com- plete sphacelation.* SECTION II. The Nature of the Disease, and some of the Dis- cordant Notions of Authjors conceming it. WHEN the symptoms during life warn us that local inflammation is present, and when in the dead bodies of those in whom such symptoms occurred, we discover the well known effects of inflammatory action, the inference is plain, that phthisis pulmo- nalis is an inflammatory affection of the lungs. * These facts are founded in the works of Plater, Frid. liofFman, Bonetus, Morgagni, Lieutaud, Baillle, &c. 4& But whatever be the state of the lungs after death, if the symptoms of inflamma- tion were not present during hfe, the disease cannot have been one of an inflammatory nature. Whether there are any other than in- flammatory consumptions of the lungs, shall be considered after we have inquired into some circumstances which principally con- cern that in which inflammation is cer- tainly present. That phthisis pulmonalis, however, is ge- nerally an inflammatory affection of the lungs, which produces the destruction of their substance, is an idea so definite and obvious, that one might have expected wri- ters to be almost unanimous concerning the nature of the common form of this pernicious malady, which must have arrest- ed the inquisitive attention of the wise, as well as interested the feelings of all man- kind from the first dawnings of sympathy and philosophy. But there is scarcely, in the records of science, a better instance of how far we may be led from the very object of our research by adventitious circumstances and the want of precise and definite terms. Though in- 47 deed every well educated person knows pretty precisely, that phthisis is a certain affection of the organs of respiration, yet, in the writings of physicians, the utmost confusion prevails with regard to all the circumstances of it : they scarcely, even now, agree that phthisis pulmonalis is a dis- ease of the lungs ! In the judgment of Dr Cullen, and, as far as I know, every other author of mo- dern times, no change, ulceration, abscess nor wasting of the substance of the lungs constitutes phthisis, unless hectic fever is present;* accordingly persons, as we have seenf, have died of consumed lungs with- out having been affected with pulmonary consumption ! Dr Brown, the celebrated antagonist of Dr Cullen, asserts, that persons have died oi pulmonary consumption^ though their lungs remained perfectly sound! % Dr Darwin, if I understand him, thinks consumption of the lungs a disease of in- creased sensation without j^/?///?^ / § * First lines, vol. i. p. 482 — 494, &c. f Ch. i. sect. 5. X Vol. iii. p. 217, 594. note m. § Vol. iii. cl. ii, ord. 1. gen. 6. sp. 7. p. 455, 464, &c. 48 Dr Rush of Philadelphia maintains, that consumption of the lungs is a primary dis- ease of the whole system.* But such conceits are not altogether of the present day ; Willis, a celebrated physician of the seventeenth century, as- serts, that pulmonary consumption is not the ulceration or corruption of the lungs, but a - general wasting of the body from their mal-conformation. f Argenterius, of the sixteenth century, as- serts, that great wasting of the body is only a tendency to consumption, unless the lungs are ulcerated ! J . And if we go back to records of ancient date, besides opinions similar to those now mentioned, we find, that consumption of the lungs is a distillation from the head ! || * Dr Duncan's Med. Com. Dec. ii. vol. x. p. 70. •{• De Medicament. Operat. sect. 1. c, v. p. 156. c. vi. p. 159. De phthisi proprie dicta, sive de tabe, pulmonurar vltio excitata. X In Aph. Hippoc.viii. p. 1322. II Hippoc. de Morbis, 1. 2. c. xvill. Celsi de Tabe, 1. 3* c. xxii. Aretaei 1. i. de Morb. Diut. c. viii. 49 SECTION III. Inquiry concerning the signification of the namt Phthisis Puimonalis, in, which the bad conse-^ quences of its indefinite and vague application are pointed out, and a precise and unambiguous signijication assigned to it. PHTHISIS, as derived from (p'^la a (p'^za-j generically signifies wasting or corruption, and seems from the earliest times of Gre- cian medicine, to have been generally ap- propriated to signify that wasting of the body which so frequently accompanies ul- ceration of the lungs ; and, though the lungs were ulcerated, phthisis was not con- sidered as constituted without progressive emaciation of the universal system i phthi- sis, in short, signifiedj not ulceration or wasting of the lungs, but wasting of the body from such ulceration. This term did not, however, signify consumption of the body solely as arising from ulceration of the lungs, but also from the disease of any other internal viscus or D 50 from any cause ; * it is of importance, therefore, to be aware, that Hippocrates did not mean an affection of the kmgs always when he employed, either in the singular or plural form, the word phthisis unqualified. In like manner, tabes among the Latins did not always signify consump- tion of the lungs, nor tabidi, those labour- ing under pulmonary complaints, but these words imply a general wasting of the body from whatever cause. Celsus enumerates three species of tabes,f the first called by the Greeks ar^ocp/a, aris- ing either from the deficiency or the super- abundance of food ; the second, ;ia»g|/a, in which the habit of body and function of digestion are depraved, a distinction, as is not uncommon, merely verbal ; the third is (p^/r;j, in which the lungs are ulcerated. I suspect that there is here some inaccura- cy, for though the commonalty in Greece, like that in Britain, might speak of con- sumptions indiscriminately, yet the com- mon Athenian term for this idea, if I mis- take not, would not be (p^/c/g but (p^o^, a * Etmulleri Operum torn, i, p. 280. De Nutritione. § Phthisis. f De Tabe, 1. 3. c. xxii. 51 word of the same ultimate origin. Nor did the most elegant and most eminent of the Greek medical writers exclusively charac- terize the ulceration of the lungs by the word (p^itri?, but, in the most complete in- stances of the destruction of the lungs, pre- ferred cp^ofj. In the work of Aretaeus there is, doubt- less from the ravages of time, something not very intelligible about the difference be- tween phthisis, empyema and phthoe ; but when he speaks of ulceration of the lungs, with the violence of fever and the most destructive symptoms of consumption, he distinguishes the affection by the word It has been observed, that Hippocrates did not always mean that the lungs were diseased, when he used the word phthisis ; of this we may readily satisfy ourselves by examining his prognostications and apho- risms ; here we may add, that he did not always use the word phthisis when he in- tended particularly to express consumption of the lungs. In his work Us^i 'Naa-uv, we find, the distinct properties of those parts, the connexion, intermixture and mutual influ- ence of which are not only not precisely dis- tinguished, but perhaps not distinguishable. There seems to be something fundamen- tally fictitious or artificial in the principles of most of our nosological arrangements : Cullen has given four classes \ the first three comprehend diseases of the general system, the pyrexiae or that of fevers ; the neuroses or nervous diseases ; the cachexiae or diseases of depraved habit ; the fourth class con- tains locales or local diseases, but these dis- tinctions are only nominal, since in each class, there are fevers, nervous affections, depraved habit and even local diseases , among the diseases of the whole body tooth- ach is given as an instance of fever ; dia- betes, as a nervous disease, and hydrocele as a depraved habit ; but nostalgia, or the desire of seeing a place, is, wittily enough, a local disease. As the principle of classification * Dr Darwin has chosen the proximate cause or the change in the system which immedi- # Preface to Zoononiia, vol. iii. 92 J ately precedes morbid action. His classes are likewise four, (p. l) 1st, diseases of irri- tation ', 2d, of sensation ; 3d, of volition ; 4th, of association : but irritation is a sen- sation accompanied with some degree of anger ; volition, is a sensation, with some wish ; association, is a combination of sen- sations ; all of these terms more or less in- volve the ideas of one another ; in all of them, is implied the action of sense and of mind. Some degree of philological dis- crimination is even required to give each its distinct and appropriate place in speech ; but in no acceptation connected with their radical, philosophical or common meaning, can they be made to denote the classes of disease. Indeed the proximate cause could only be the basis of a fanciful superstruc- ture. SECTION IL General Observations on the Principles of Classijication. FOR scientific classification it is indispen- sably requisite to discover one general prin- ciple to which all the phenomena as it were 93 voluntarily submit. This has long been desired in nosology, and no one seems to have approached the fountain of animate nature so closely as Dr John Brown, author of the Elementa Medicinae. This great genius contemning the igne- ous, ethereal and other favourite principles, which were so many centuries the vivify- ing powers chosen by philosophers, endea- voured to deduce some general laws from the phenomena of life. He selected a general truth which had been observed from the earliest ages by every man who contemplated the regions of the living world, but which before him, had never been applied as a fundamental principle according to which might be ex- plained the phenomena of health and of disease. This general truth is, that life, as disco- verable in the phenomena of animals, is action ; this action is the effect of what he denominates the excitability, which is a general susceptibility over the whole body to be excited by substances applied to it, and which may be, relatively to the func- tions of the animal, proper, excessive or defective. 94 He observed further, that the powers which excited the body, or, in his lan- guage, caused excitement, lost their effect by continued operation, proving the diminish- ed excitability of the system ; that these powers being withdrawn, the system be- came more excitable, proving the renewal of the excitability ; and he applies these facts to the explanation of health and of disease in his works, to w^hich I beg leave to refer. I have said, that this general truth has . been long perceived by philosophers, and indeed the latter observation also is recog- nisable not only in writings physical and moral, but even in common language, that such a thing has lost its efficacy, that we neglect, loathe and hate what we admired, desired and loved, are expressions univer- sally familiar. But the opinion, that the excitability is one undivided property equally diffused throughout the animal body and insepa- rable from it, which Brown esteems his particular discovery, or a tenet at least very similar, is attributed by Cicero to Dicsearchus in the following sentence : Vimque omnem ea?n^ qua vel agamus quid^ 95 njel sentiamus^ in omnibus corporibus vivis cequaUter esse fusam^ nee separahilem a cor- pore esse, qidppe qucs nulla sit ; nee sit quic- quam^ nisi corpus unum et simplex^ ita figu- ratum ut temperatione natiirce vigeat et sen- tiat.^ To vindicate the pre-eminence of intel- lect, and to adorn human nature, there have, during the long series of past ages, arisen superior minds, whose penetration reached the recesses of nature, and whose powerful comprehension greatly embraced and anticipated the range of invention and discovery ^ there is abundant proof of this even in the mutilated literature that has survived the convulsion of nations and the wreck of empires. But the enlightened notions of the ancients necessarily remain unnoticed or not understood, until some of the moderns, who view the phenomena of nature in a similar manner, describe the ideas in modern language, and then the identity of conception is evident even through the veil of ancient expression. In modern times, however, from the wider diffusion of knowledge, the students * Cic- Tuscul. qu^st. lib. i. 96 of nature are numerous in every civilized country, and by the improved method of experimenting, all the sciences advance ra- pidly toward perfection : instead of one or two philosophers in a fortunate age, con- fined to a favoured spot of country, there is now distributed over the inhabited world a great and noble fraternity of immortal names, who by united efforts are establish- ing, on the solid basis of a minute know- ledge of the operations of nature, princi- ples which were in the earlier times but dimly perceived by the intellectual eye of isolated genius. I have mentioned above, that some ge- neral principle is a desideratum in nosolo- gy, that Brown devoted himself to the study of the animal economy in order to dis- cover one, and that he seemed to have ap- proached the simplicity of truth more near- ly than any philosopher who had ever- turned his attention to the subject. Some, however, have of late ascribed to Professor Reil of Germany the merit of first conceiving and maintaining, that the living body is a united system, and that the laws of life are to be ascertained only by a strict 97 investigation and comparison of the actions of the animate being. The principle indeed was maintained by the illustrious father of medicine,* and must be avowed by every physiologist and physician, for unless the body is a system the laws of which are discoverable by hu- man industry, the study of the animal eco- nomy must be uninstructive, the practice of physic, imposture. Thus, while I admire the principle, I can- not allow Pveil the honour of originality in conceiving it, nor can I allow him this honour, either in the mode of investiga- tion or in its particular application. The mode of investigation is coeval with philosophy ; it was enforced and exempli- fied by Lord Bacon, and, since his time, has been strictly followed by all accurate in- quirers, both experimental and moral. Brown was the first who strictly followed it in exploring and explaining the laws of animate nature : deeply impressed with a full conception of the principle on which it was founded, he uniformly considers the body to consist of mind and matter, mutu- ally dependent on each other, and both on * Hippoc. lib. de locis In homine, sec. 4. G P8 external agents. The words in which he expresses his notion of the ijitimate and toutual dependence of the mind and body as constituted and existing in this world, evince both how decided his judgment was, and his critical skill in the language which he employed. There are three terms in the Latin language denoting the phenomena of vitality and of mind ; anima^ life simply; animus^ life as connected with the mind and influenced by the passions ; mensy the rational faculties ; that there may be no ambiguity he uses all these three to imply properties distinctive of animate from dead matter : his own words are, " vocabulo cor- pusj tam corpus simpliciter dictum, quam etiam mente, animo vel anima praeditum significatur, systema vulgo dictum." The manner of studying the living sys- tem and of reasoning concerning it, which this principle would dictate, has been of too rare use in medical inquiry. It is a la- mentable truth, that the science as gener- ally received, consists of a number of seem- ingly incongruous facts, often explained by absurd, most frequently by fallacious, and fortunate would it have been for humanity, if never by pernicious hypotheses.. Physi- 99 cians have endeavoured to support life, and yet have neglected to examine on what hfe depends. But now that the principle shines with the splendor of truth, ever propitious to the advancement of knowledge, under its influence the ingenious will explore the secrets of the animal economy, and we shall have a science built on an accurate acquain- tance with the internal operations of the living body ; thus physicians will not mere- ly be the willing, but the able benefactors of mankind. Have the philosophers, by simple expe- riments and attentive observations, unveil- ed the laws which regulate those luminous orbs decorating the vault of heaven, and station them at their relative distances, from each other inconceivably remote ? have they calculated the retrocession of the signs, the polar nutation, the aberration of the fixed stars, the velocity of light darting- through the immeasurable regions of space ? and shall we despair of some grand princi- ple being established, directing how to re- pair the waste of that frail machine of su- perlative beauty, the human body, which little fabric in importance to us far exceeds the boundless universe ! 100 CHAPTER VL VIEW OF THE NATURE AND TREATMENT PRINCIPALLY OF PHTHISICAL AFFEC- TIONS NOT TO BE CONSIDERED AS INFLAMMATORY. SECTION I. Phthisical Affections independent of Inflamma- tion, with the different Species of Phthisis Pulmonalis. SYMPTOMS of inflammatory action, general or local, most frequently precede spontaneous morbid changes, either in the whole system or in any of its parts, and it seems almost universally supposed, that all morbid changes are the consequences of such action ; but this notion is untenable, since morbid changes, both general and local, often commence and proceed imper- ceptibly. The gradual failure of the capability and general functions of life are evident in the progress of old age, Which itself, with fan- 101 ciful propriety, has been deemed a disease by the most profound moralists. At any period of Hfe also, though no in- flammatory action has preceded, the vital energies of the body are observed to fail, the pulse becomes feeble and intermits, dark petechiae and marks of general pu- trescence soon appear, and the patient ra- pidly sinks if not supported by the most powerhil means. The local morbid changes which take place, neither preceded nor accompanied by any symptom of local or general inflam- mation, are numerous and various. Such affections are of the most obstinate and dangerous nature ; in them, the local evil indicates a general tendency or depraved habit ; of which kind are ossifications, aneu- risms, scrofulous, scirrhpus and cancerous tumors. Besides these local changes, others of a more immediately dangerous nature occur j any part of the living body may be seized by mortification from the deficiency of vital action or of the susceptibility of that ac- tion ; as in the gangrene which often seizes the extremities of persons advanced in life and in putrid fevers. 102 It is a most interesting fact, never yet duly attended to nor appreciated, that por- tions of a nerve or its terminations, lose the power of supplying the prime agent of vital motion to a part and of conveying sensation thence to the sensorium ; but, in this manner alone, can be explained the gradual waste of such organs as the lungs, unaccompanied with the sensations of heat and pain ; and that, on some occasions, vi- tality abandons a part, while the general health and functions of mind and body are otherwise undisturbed, as has happened in hernia, but more frequently in the putrid throat, affected with which the person has not apprehended danger even within an hour of death. The state of a part, however, when at- tacked by mortification is the same, by whatever means induced, whether by the action of inflammation or some other less alarming, though more insidious and des- tructive power. Whatever i^ true with regard to the morbid affections of external parts, may also be afHrmed of the internal. They are both subject to diseases of the same nature, variously modified, according to the struc- 103 ture and office of each : consequently, the general treatment and, as much as possible, the local also, are to be regulated on the same principle for the cure of the lungs, as for that of external parts similarly affected. We may on many occasions judge pretty correctly of the internal disease of the lungs from the habit and marks of disease on the exterior of the body. Since now it appears, that such morbid action often commences in the substance of the lungs, as independently of inflamma- tory action entirely destroys them, it is con- sonant with truth to infer, that there is such a disease as phthisis pulnionalis indepen- dent of inflammation. We have already taken notice of those species of consumption which Dr Cullen has described. To the remarks then made may here be added, that what he terms species are only different stages of the same affection, while a species should indicate some difference in the general features ra- ther than in the degree or progress of mor- bid action. Accordingly we are, by the facts which have been and shall immediately be detail- ed, perhaps authorized to say, that con- 104 sumption of the lungs or those morbid ac- tions whjch destroy their structure or sub- stance, are of three species, llie hist, which has been above fully pointed out, commences in active inflam- mation, and proceeds through that series of change which such action induces. The treatment of which is to be fully consider- ed afterward. The second is independent of inflamma- tion, and the consequence of diminished vitality. The third, in which the two former are combined, begins in a state of torpor and becomes mflammatory. SECTION 11. In which are chiefly considered the Symptoms and Treatment of the Second Species or that which is independent of Inflammation. OF the first species we may just here observe, that the pneumoniae as generally understood, and the formation of phleg- monous tumors and abscesses, are exam- 105 pies : in the first stage they must be treated by the most active antiphlogistic means. Astonishingly good effects, as was well known by the ancients,* are experienced from the most copious vensesection. But afterward the treatment must be guided according to the manner, whether resolu- tion, effusion or suppuration, in which this stage has terminated. The second species, which is the conse- quence of diminished vitality independent of inflammation, is exemplified in those in whom the disease was not Well marked by any symptom, though after death the lungs were found to be almost quite destroyed. Whenever there is progressive emacia- tion, a sense of weakness in the breast, inability to respire, frequent dyspnoea, sick- ness at stomach or vomiting and irregular bowels, though there is no v^ry acute pain nor even any seemingly formidable symp- tom, we ought always to suspect the pre- sence of an affection of this nature. In such a state must be given nourish- ing diet, wine, bark and every thing that can maintain the frail movements of life. * Hippoc. Epidem. Aret. de Morb. Acut. Curatione, X06 Any other treatment would be speedily de- structive. To this species may perhaps be referred the following affections, though they are ra- ther anomalous. The conversion of the substance of the lungs into an adipose inorganical substance as is recorded by Morgagni, resembling that of the lungs neither in consistence, co- lour nor structure : * this appearance may have depended on a secretion of fat in the cellular substance of the lungs, as sometimes happens in that of the scrotum. Aneurisms, ossification which happens in the extreme vessels, in the parenchyma and in the bronchial rings : the presence of such a state of the lungs may perhaps be indicated by the rigidity of the thorax and laborious respiration which often infest old age. Calculous concretions, which are formed not only in the bronchia, but in the cells where they terminate. Their existence in the lungs was known to Aristotle. f We may sometimes learn, that they are present by their being brought up by cough- * Epist. X. Art. 19. - f De Part. Animal. 1. iii. c. 4i 107 ing. Persons, in whose lungs they are, have for the most part a sense of weight with pain in the breast and a hard dry cough, not reheved by any change of pos- ture and aggravated while sitting. When we know that such concretions are present, it would perhaps be useful to give such remedies as promote the increase of mucus in the bronchia, both to ob- viate and prevent irritation, and facilitate expectoration : for some persons have lived many years after expectorating very large and very hard calculi.* In all these complaints there occur severe fits of asthma, palpitations, deliquia animi or faintings, and often the lipothymiae or sudden deficiency of the powers of sensa- tion and motion, while the judgment con- tinues entire and the blood vessels perfornx their office. Of such affections palliation is all that art can accomplish, and caution, both on the part of physician and patient, can neveif' be more requisite. Motion by the exertion of ones own muscles, for reasons which will suggest themselves when we examine the * Morg. Ep. XV. Art. 16. 17. 2^. 108 effects of exercise, and every thing that may tend to excite powerfully or induce inflam- mation, must be very carefully guarded against. The patient must nevertheless have nutritious diet, nor can the food be digested without the assistance of stimulating cordial medicines. Vomiting cannot be induced but at the immediate risk of life from the rupture of blood vessels, and purging is not much less hazardous from the extreme ex- haustion which may ensue, nor can we promise, that it will riot be the commence- ment of unconquerable diarrhoea. In order that the body may be nourished and not much excited, let the food consist- ing of mild animal soups and jellies, be given in small quantities almost every half hour ; let the symptoms of disorder of the stomach be corrected by small doses of cam- phor ; if diarrhoea is threatened, let small doses of opium be preferred to all other astringents ; if constipation, let the powder of the rheum palmatum or rhubarb be taken in small doses along with the cinchona or Peruvian bark ; if the stools are dark and fetid, injections of beef-tea will be found of the greatest utility, whether the bowels are constipated or not ; if the contents of 109 the intestinal canal are very bad, injections of the infusion of bark with kino are on no account to be omitted, to which, when the bowels are too easy, the tincture of opium must be added. In instances of the great- est debility, bathing with warm water hold- ing some carbonat of ammonia in solution, produces the very best effects. The quan- tity of wine and nourishment given in the course of the day must always be in pro- portion to the evacuations, and the quan- tity of exhilarating medicines, in proportion to the debiHty, the languor, and the dis- turbance in the function of digestion. SECTION III. Phthisical Affections commencing without Injiammation. THE third species, which commences in a certain morbid change, independently of inflammation, but in which inflamma- tion is at length superadded, is most fre- quently the scrofulous. The presence of which may be known at the coQimence- 110 ment of pulmonary complaints, from the general habit of the individual or from that of his parents, and from glandular indura- tions in the neck, axillae and inguina ; but though this mark has long been thought * an important one, and is not to be neglec- ted, yet it is not alone sufficient to deterinine the nature of the disease. We daily see per- sons covered with scrofulous sores external- ly, whose lungs are good; and glandular swellings are found after death in the lungs of many who had no exterior sign of scro- fula ; nor is it rare for scrufulous persons to die of pulmonary consumption, whose pulmonary lymphatics do not appear to have been chiefly in fault. But if even without external proofs of scrofula, the person^ when otherwise in good health, has long been affected with a teazing cough, dry or followed by slight mucous expectoration ; if climbing or run- ning readily induce dyspnoea ; if these symptoms are aggravated in autumn, win- ter, spring, at which times scrofulous tumors swell, but are mitigated in summer when these tumors are known to diminish ; if the * Morton Physlolog, 1. iii. c. 1. Ill symptoms are relieved by remaining in a warm apartment and suddenly induced by exposure to cold air ; if they are made worse by low diet or much aggravated by the use of strong drink ; we shall seldom err in supposing the affection to be of a scrofulous nature. When we have reason to believe, that the complaint originates in tubercles of a scro- fulous nature, it is necessary to have in re- niembrance the changes which scrofulous tumors undergo, and how they may be in- fluenced by the state of the system. They do not commence when the System is in a vigorous state, but, on the contrary, when it is ill nourished and exposed to moisture or vicissitude of temperature. Under these circumstances the vessels of the glands hav- ing lost their necessary contractile power, are distended, indurated, obstructed, and form indolent, white, moveable tumors, from which the characteristics of inflam- mation, redness, heat, pain, are all absent. These tumors originate and continue du- ring a state of general debility ; consequent- ly, the symptoms, which they excite, must be exasperated by the debilitating plan of treatment- In this state it wa^, I imagine, 112 that Beddoes found nourisliing diet and tonic remedies successful, but we should err grievously indeed, if we inferred, that every incipient phthisis should be similarly treated. Tumors of a scrofulous nature in the lungs are often very numerous and minute, not larger than small seeds, and hence have been called tubercles, and these are most frequently implied in the phrase tubercu- lar consumption, though tubercles of a very different kind are frequently found.* It must be obvious, that in such circumstances those means should be employed, which have been ascertained to be efficacious in the diminution of scrofulous tumors on any other part of the body. I think, that I have ascertained, that the muriat of lime has a more powerful effect in removing indolent scrofulous tumors than any other substance used as a remedy ; but that, when they become open sores, it is almost useless. Tl;iis is a very manage- able substance ; the dose of it may be gra- * Vide Baillle's Morb. Anat. In the Lond. Med. Com- munications there are some very ingenious and interesting observations on the state of tubercles in the lungs, as ascer- tained from dissection by Dr William Stark. 113 I dually increased from five or six grains, three or four times a-day, to two drachms ; during its administration no particular change of regimen is necessary, and I have never observed it produce any disagreeable effects, except of the slightest kind, after its use had been long continued, and the quantity of the dose had become very great. Six years ago, I observed with ad- miration its effects in a young lady, who was so disfigured by these swellings that the apex of her head was that of a cone resting on the whole superior or atlantal as- pect of the trunk.* . During its use for six months the neck resumed its proper shape, and there scarce- ly remained an unusual enlargement of any gland, and since that time, I have never seen it administered in similar circumstan- ces without producing the most beneficial effects. This remedy, therefore, seems to offer it- self with great propriety in the state of the lungs now under consideration. * Dr Barclay's Nomenclature, — I do not think that the human body or even that of any other animal can be intelli- gibly described until this nomenclature be adopted ; and had it been generally understood, I would not in this work have used any of the old terms. H / 114 I have tried it frequently, and think, that it has always proved eminently useful ; but in none so conspicuously as in a gentleman about nineteen and in a girl of nine years of age. With respect to the former, the glands, in the situations above mentioned, were very much enlarged from his infancy. The skin of his extremities was rough and divided by numberless fissures, whence a thin watery fluid was constantly discharg- ed, and, to the symptoms of pulmonary affection above detailed, were added fre- quent attacks of haemoptysis. During the use of this muriat for several months, the skin healed, the glands dimi- nished in size, the pectoral complaints were removed, and the strength of his body was at least apparently improved by it. The young lady is of fair complexion and delicate skin ; her countenance is un- commonly lively and mind acute ; she had the glands of her neck in general some- what, but the parotid and tonsillary enor- mously enlarged, the latter seemed almost entirely to fill the fauces. She had occa- sional attacks of dyspnoea, teazing cough and copious expectoration of transparent 115 clammy or frothy matter. She began to take about five grains of the muriat of hme in solution twice a-day, and gradually in- creased the dose. The swellings soon di- minished, and the pectoral complaint was at the same time much mitigated. At the end of six months, when she was taking nearly two drachms of the medicine a-day and seemed nearly well, from cold or some such cause all the pectoral symptoms re- curred with greater violence then ever. Her appetite was much impaired, she coughed tremendously, suffered severe at- tacks of asthma, expectorated very copious- ly the same sort of matter that is above described, often vomited, and complained of headach and pain of chest ; was some- times hot, and sometimes shivered. By the antiphlogistic treatment the vio- lence of the symptoms was subdued ; in about a fortnight after which the quan- tity of the muriat taken a-day was about three drachms, the pectoral symptoms were now quite removed, when the doses of the -medicine seemed to cause squeamishness at stomach, and their quantity was therefore lessened. 116 She continues still, that is about one year from her commencing the use of the re- medy, to take small doses of it ; the visible tumors have signally decreased, and the signs of internal affection have quite dis- appeared. It would give me infinite pleasure, if the utility of this remedy in such complaints were completely established. It is of importance to remark, that reco- very is much promoted during the cold months by confinement in an apartment the temperature of which is kept at about the 70° of Fahrenheit's thermometer. The scrofulous tumors however, though they have not arisen from inflammation, become the seats, and, with regard to the neighbouring parts, the causes of the most dangerous inflammations. After being in- dolent and inert for many years, they be- come painful internally, inflame, suppurate and form sores of the most obstinate na- ture ; at the same time they irritate not only the parts immediately surrounding them, but produce inflammatory action of the whole system. The treatment in such event is extremely perplexing. If we use antiphlogistic means to allay the inflam- ' 117 mation, we increase in the system the dis- position to the disease which we wish to remove, and if we neglect them, we incur the risk of the hfe of the patient. But as the immediate risk of hfe is chiefly to be dreaded, we must first employ antiphlogistic means to allay the inflamma- tion, and afterward endeavour to obviate the debility thence induced, and prevent any bad consequences of it by nourishing diet and such regimen as will promote and maintain the activity, energy and strength of the system, which method has often suc- ceeded to a degree that astonished me. In instances of general debility the lungs become oedematous, and the water thus col- lected produces inflammation and ulcera- tion of their substance, and this is another change not uncommon at certain periods of life, which precedes the inflammatory symptoms of phthisis, but which has been almost entirely overlooked, or not perceiv- ed by physicians. This form of the complaint is to be ful- ly examined in a separate work, wherefore I shall just mention here, that it is most suc- cessfully treated by diuretics and nourishing diet. 118 Both men and women about the age of puberty, or during the first two or three years which succeed, are very hable to pulmonary complaints, accompanied with the utmost languor and most alarming de- bility ; the males most frequently from excess of indulgence : in each, the affection of the lungs and the general debility will be best treated by nourishing diet and tonic remedies, none of which are to be preferred to the digitalis properly admi- nistered. When one considers how complex, how variotis the pulmonary affections are, how different in nature from one another, and the great danger incurred, if the treatment is not scrupulously adapted to the peculia- rity of the complaint, one does not know, whether most to admire the courage, or wonder at the folly of those who commit their lives to the hazard of an empirical prescription, to which Alexander the Great would have preferred even the suspected cup of his physician.* Is there any thing more absurd, than that life, incomparably the most valuable * Vide Quinti Curtii lib, iii. c. 6. 119 of all possessions, indeed that without which there is no possession, should be treated with less care and skill than any common article of furniture ? we will not allow a foot-stool to be repaired but by the most expert joiner, while we entrust our lives to the rashness of empiricism. 120 CHAPTER VIL TREATMENT OF THE FIRST STAGE. SECTION I. Gener^al Obser>vatio?is concerning the Treatment of Injimmnatory Consumptions of the Lungs, from their commencement to their termination. HAVING endeavoured to distinguish those morbid changes in the structure of the lungs, which are not to be reckoned of an inflammatory nature, nor treated as such ; having found, that phthisis pulmo- nahs consists properly of three species, the inflammatory from the commencement, that which is independent of inflammation, and that in which inflammatory violence succeeds torpor, and having considered on what principle and in what manner the non-inflammatory phthisical affections are to be treated, some of which indeed seem to hold both science and art in derision,* we * Ch. vi. 121 are, I trust, well prepared to investigate now precisely and distinctly the treatment of the inflammatory phthisis pulmonalis, which comprehends all the first species and the latter part of the third. It has been already concluded* that this is a disease which, for the most part, will spontaneously go through all the stages of active inflammation, viz. active inflamma- tion, suppuration, gangrene, which last, by the bye, is not a part but the sequel of ac- tive inflammation ; that, as these stages are pretty distinctly marked by their symptoms and require very different treatment from one another, it seemed of practical utility to divide the disease into three stages. Induced by these reasons, I ventured to divide inflammatory phthisis pulmonalis into three stages, thus individually charac- terized : the first stage, when the incipient symptoms of progressive inflammation are present ; the second, when the symptoms of the formation or existence of pus are present ; the third, when those of gan- grene or sphacelation are present ; and these constitute the basis on which we here * Ch. V. ?.ect. 1. 122 proceed to consider and point out the treat- ment of the inflammatory phthisis pulmo- nalis. If the disease is not arrested in its pro- gress, the first or inflammatory stage runs into the second or suppurative, and this in- to the third or that of gangrene and spha- celus. The object of the physician is to prevent the first stage from running into the se- cond, and this into the third. The par- ticular phenomena of these stages are to be found in the history of the disease. To detail minutely every thing that may be done to remove those symptoms pre- ceding distinct inflammatory action which characterize incipient phthisis, is unneces- sary, as the treatment only differs in degree from that in which distinct inflammatory action is present, it seems requisite how- ever, to be aware of several circumstances besides those already stated, which must greatly influence our judgment, not only at the commencement, but during the whole course of the disease. Of these none deserve greater attention than age, sex, hereditary disposition, im- ■ 123 mediate habit of body, previous manner of life and duration of the complaint. In those from birth to puberty, we must be anxiously attentive to discern how far the pulmonary complaint may depend on or be complicated with the usual diseases of infancy and childhood ; from puberty to about forty years of age, powerful evacua- tions are most useful, and from the latter period every year increases the danger of them ; persons who have passed their six- tieth year are in general most successfully treated by strengthening remedies, and in the most advanced stages of life, any other are seldom admissible. Women neglect their bowels ; for the greater number of whose complaints in. their commencement the purgative plan, as proposed by Dr James Hamilton of the Royal Infirmary,* affords the most effec- tual cure ; the pregnant bear the abstraction of blood to a much greater quantity, and are much more benefited by it than even men are ; at the time of the final cessation of the menstrual discharges, copious and * Observ. on the Utility and Administration of Purgative Medicines in several Diseases. 124 continued evacuation of any kind is hurt- ful, and a great ioss of blood is "certain de- struction. The knowledge of that particular form under which the disease has existed in the progenitors enables the judgment iTiore early to decide of what species it is. If the constitution is tainted with any other disease as scurvy or lues venerea, the i'emedies of approved utility in these affec- tions are the fittest to remove the concomi- tant pulmonary. When the pulmonary symptoms have succeeded the use of low diet, both the powerfully evacuating and highly stimu- lating plans of treatment are dangerous, each must be used sparingly and witli great caution ; to prohibit entirely also the use of strong liquor after the constitution has become accustomed to it, not only often aggravates the disease, but produces a state of the sensations that is almost insufferable, and a state of mind more to be dreaded than consumption with all its horrors ; in persons of this description, vensesection is to be avoided if possible ; to them, unusu- ally great doses of cathartics are very use- ful, and their diet must be of the nutritious 125 kind ; the robust, who are neither too ab- stemious nor intemperate,- are the proper subjects for the most rigid antiphlogistic treatment. We may suppose the disease to approach the nature of our third species or that which commences in a state of torpor, in propor- tion to its duration, and it is to be treated accordingly. Flannel shirts are very useful during the incipient symptoms and the milder part of the first stage, but, during the activity of the fever, they are intolerable. Emetics are to be administered with great caution, and unless during the incipient symptoms their use is scarcely to be per- mitted. Meloe vesicatorius, sulphuric acid, laxa- tives, mucilages, &c. are to be employed occasionally during the disease. There is an incalculably pernicious cus- tom now prevalent, that of the administer- ing of opium in some form or other, at every period of the disease ; though in the commencement it may alleviate the cough, it certainly increases inflammatory action ; and though it may occasionally, at an ad- vanced period, dispose to sleep and arrest laS the expectoration, yet it eventually pro- duces the restlessness of aggravated fever, and increases the danger of suffocation from the accumulated sordes in the lun^s. o In short, nothing is more injudicious than the use of opium where inflammation is to be prevented or its activity to be diminished. It is obvious indeed, that nothing is more absurd and dangerous than the indiscrimi- nate use of any substance as a remedy, since the nature of every disease and the suscep- tibilities of constitution, are not only differ- ent in different individuals, but constantly vary in the same person. However fami- liar this truth may seem, it has too little influence in medical practice : a disease is distinguished by the general epithet pul- monary, and medicines of equally vague description are administered. If physicians not only knew the names of the remedies in common use, but were able to explain for what reasons and on what occasions certain means are to be selected as salutary or rejected as pernicious, it would contri- bute more to the extermination of quack- ery than the anathemata and denuncia- tions or the authority of all the colleges of the world combined. 127 SECTION II. Treatment durbig the Inflammatory Symptoms which terminate in and accompany Suppuration. THIS part of the first or inflammatory stage requires every part of the antiphlo- gistic treatment, regulated according to the severity of the symptoms ; here venaesec- tion is often indispensably necessary, in whatever condition of the parts it origi- nates, except that of cfidema. I am convinced, that even when the symptoms of the formation of pus have commenced, venaesection is often beneficial, and unquestionably when the fury of in- flammatory action is not abated, for those means which diminish inflammatory action check the formation of pus ; which is most carefully to be attended to in the affections of the lungs, where by diffusion in the cel- lular substance or obstructing the ingress of the air, any fluid may cause destruction of most important parts or even sudden death. I first witnessed the decidedly good ef- fects of this practice some years ago in a 128 - man aged twenty-two, a mechanic. He was about six feet high, of florid complex- ion, athletic form, and a mind intelligent above those of his station. At the time when he called medical assistance, he com- plained of pain of chest and slight teazing cough ; he could only lie on one side and was frequently squeamish. He had frequently for some years felt slight pains in his breast, and had been troubled, though not severe- ly, with coughing ; but these symptoms had been very severe for a few weeks. He had no oppression of breathing, but he was interrupted by a pain when he made a full inspiration ; there was no expectoration ; his bowels were rather costive. The bowels freely opened did not mitigate the symp- toms. He was now attacked by slight shi- verings; his countenance began to be pale, particularly round the mouth. His pulse was full and about ninety. Now v^ere abstracted by vensesection sixteen ounces of blood, on which was form- ed a thin buffy coat. Rest, qui^t and mo- derate food were enjoined. In a few days after which he went to the country, where he lived sparingly, took moderate exercise, and in a few weeks completely recovered. 129 In this stage digitalis is very hurtful ; it heightens inflammatory action, accelerates the formation of abscesses, and if it is exhi- bited with the usual intention of allaying inflammation, the consequences not only disappoint the practitioner but are signally disastrous to the patient. Critically examining the writings on this subject, we shall discover the most sa- tisfactory proofs of what I have affirmed ; and referring to the observations and cases which are given in the second part of this work, for the complete demonstration of the same truth, it seems not improper to relate here the following case. I was called to Mr - — - June 23. I8O6 ; his face was pale and extremely ghastly, his eyes sunk and of a beautiful pearly colour tvith the cornea lucid and pupils of a fine chesnut colour ; his temples were collapsed, eye-lids and lips pale, teeth of a yellowish white, tongue foul and moist ; the sweat run down his face ; he vomited in my pre- sence several quantities of rnixed matter, dark and variegated with yellow and red. He was emaciated to the last degree, the bones of the trunk and extremities were not only wasted, but felt as if nothing soft .130 intervened. All the body was wet with copious sweat ; his heart was felt beating forcibly and interruptedly through the chest ; his pulse at the wrists, ankles and temples, was about seventy, feeble, easily compressible and intermittent. He thought himself dying, and his looks and words expressed resignation without any hope of life or dread of death. He had no appetite, though what he swallowed remained on his stomach; he was rather costive ; his stools were of natural colour ; his urine limpid after depositing a white copious sediment. He slept little, and when he did, he was awakened by the cough and emission of the sputa. He says, that he has cold shiverings, sick- ness and sweatings, every half hour, and very frequent alternations of heat and cold, which in their attack do not observe any particular time of the day. The attendants say, that he, in particular when sleeping, breathes loudly and laboriously, and has great flushing in the cheeks ; at other times he breathes so mildly and is so ghastly, that they think, that he has imperceptibly ex- pired. He cannot make a full inspiration, has a constant sense of weight, chiefly 131 in the middle of the breast, and often dreads suffocation from the defluxion. He can lie on either side with equal ease. He sometimes thinks himself oppressed when lying on his back ; he seldom has headach ; his senses are entire. Often the, purulent sputa stop for some time, and then he be- comes intolerably sick and faintish, cold shiverings succeeded by slight heat and co- pious renewal of the sputa, relieve him. He has during his illness been attended by two eminent medical gentlemen of this city, but during i these last eight days they have not thought it requisite to visit him daily ; they just ordered him to use a little wine, or any thing that he would, or thought that he could take. I was informed, that he had never been remarkably subject to catarrhal affections, that he was in general healthy, not robust, a diligent, sober, quiet man ; he was natu- rally somewhat ruddy of complexion, about six feet high, rather narrow chested perhaps, but not particularly so ; by trade a cabinet- maker ; his parents are far advanced in life, and healthy. He knows no cause for his complaint, unless it were a stress from attempting, 132 about nine months ago, to lift something that was very heavy ; at least he does not re- collect, that any thing was the matter with him previously ; and he has never been well since. He has been confined to bed for six months, during which time he had severe continued pain in the middle of the chest, hard, dry, painful cough, no cold shiverings but continual heat; felt severe beatings or throbbings in his chest, head and temples, and often in the arms and legs ; often thought, that his heart would force it- self through his sides. He loathed all food ; frequently vomited ; his belly was in general bound ; he had frequent headachs, which were sometimes attended with delirium ; he slept little, or believed so, and was never refreshed by it; he could hardly inspire on account of the pain, which gradually increased, and was attended with great, and sometimes, particularly of late, with, as it were, a burning heat and throbbing in the seat of the pain. His urine was high co- loured, and deposited a red sediment. This pain, heat and throbbing became about a fortnight ago excruciating, when for the first time he was seized with the most dis- tressing sickness accompanied with severe 133 cold sliiverin!^, followed by a very copious discharge by tne mouth of variously colour- ed, ill-smelled and horribly disgusting stuff as he said, and since that time he has conti- nued as above described. 134 CHAPTER VIII. TREATMENT OF THE SECOND OR SUP- PURATIVE STAGE. SECTION I. Treatment according to the Different Appear- ances of the Sputa. THE second or suppurative stage, as is implied in the name, commences with the generation of pus, which occurrence is in- dicated by the symptoms detailed in the history of the disease, even though, as fre- quently happens, they are succeeded by no purulent sputa. The management of this stage requires more skill, caution, prudence and scientific discrimination, than that of any period of this, or perhaps of any other disease. The sores of the lungs, as has been anti- cipated, may have all the different charac- ters of sores on the external parts of the body ; the scrofulous, the scorbutic, the 135 scyphilitic, the erythematic, the phlegmo- nous, encysted, cancerous ; they may be superficial or deep seated ; small or exten- sive ; they may be slow or rapid in their morbid changes ; they may be of the ac- tive inflammatory, or of the putrid kind. It is of the utmost consequence, that these varieties be accurately distinguished, as they must regulate our treatment and our hopes of cure. To judge concerning the nature of the sores, it is particularly necessary to know the state of the constitution, the affections under which the patient has laboured, and those to which he is liable. The violence or mildness of the symptoms, their progress and changes, will often enable us to form a pretty accurate opinion with regard to most of the other circumstances. There is another index, most frequently present, which points out with much pre- cision the condition and tendency of the sores, and therefore has always claimed at- tention. Aretaeus thus judiciously appre- ciates it : * " The white, inodorous, globular, smooth and easily expectorated sputa, are salutary ; * L. i. c. 9. De Causis et Signis Morb. Diutum, 136 the pale, bilious and mixed, are bad, but the worst of all are the livid and black, which indicate phagedaenic ulceration and gan- grene." We have formerly given our reasons for not deeming the matter expectorated so va- luable a diagnostic mark as it had general- ly been believed to be ; but as merit has the only just claim to preferment, we shall now invest it with a much higher office, that of assisting our prognosis and direct- ing our treatment. When sores are in that state of action during which they heal, the matter dis- charged from them assumes the form of laudable pus, the formation of which re-^ quires an action of the system a very little stronger than that of usual health, to main- tain which, generous diet with wine, bark, &c. and gentle exercise are necessary, which are to be diminished if inflammatory symp-r toms tend to violence, and all but the exer- cise to be augmented if the actions of the system languish. When the suppurative process begins to degenerate, and instead of resembling laud- able pus, the sputa are thin, viscid and transparent ; our remedies must* be of the 137 more active kind, and their use must be persevered in, and their doses increased in proportion to the difficulty which we experience in rousing the vital functions to the requisite .activity, and even though a considerable degree of fever should be excited, we must persevere until the sputa assume the proper form. We are not to be deterred, by the no- tions, that the access of air to the wounded surfaces, or the continual motion of the lungs, frustrate all attempts to induce a cure, for ulcers often form in the lungs and heal spontaneously ; in fine, what is chiefly to be dreaded, is the spreading and degen- eracy of the ulceration. When the spu- ta become sanious, ill coloured, fetid and putrid, the most powerful remedies are to be employed with the utmost activity ; wine, cinchona, camphor, &c. in profu- sion ; digitalis with circumspection ; and all of them to be alternated with substances of similar quality ; and if any substances are found which can be inhaled with safety, to promote the activity and healthy granula- tion in the diseased surfaces, they certainly ought to be prescribed. 138 *rhe first time that I treated any one strictly according to the method here de- scribed, was in the following case : M — ~ set. 19. August 1804- This gentleman was of slender shape and tall ; of very acute mind, and very irasci- ble. Naturally indolent, but capable of very great activity and exertion. One of his testes never descended into the scrotum, but remained in the groin, and latterly gave him much uneasiness. He had from in- fancy a slight cough, aggravated by bodily exercise ; he was fair haired, light eyed and well complexioned. He went to London and was engaged in a counting-house, where, from fatigue, ex- posure to cold, and the irritation of the tes- ticle, he became very unwell, and returned to Scotland, labouring under phthisis pul- monalis in the puriform stage ; he was in- expressibly feeble and emaciated, and evin- ced all the ordinary symptoms of ulcerative fever ; his pulse about 130 ; in which state he was when I visited him in the country at his father's house. The father was one of my best friends; the son and myself were on terms of the strictest intimacy. I esteemed him highly for his superior ge- 139 nius, and was very much grieved to see him rapidly approaching to that awful change, that cessation of intercourse with this world, which none of mortal race can view with indifference. Some time before this, I had turned ray mind seriously to pulmonary affections, and was satisfied as to the principles, that should regulate the me- dical treatment of phthisis in the different forms which it assumes during its progress. I thought my time on this occasion could not be spent more usefully than by attend- ing to the health of my friend. To the circumstances above mentioned, we may add, that he took food in small quantity and seldom, and shortly after eating he was harassed by cardialgia, flatulence, vomit- ing, or severe tormina ; so that the taking of food was a terror to him. His sputa were copious and ill coloured ; his cough very distressing during sleep, which was always short and not sound ; his breathing was very noisy, and he frequently moaned. In this state, nourishing diet, gentle exer- cise, agreeable conversation, seemed the best means that could be employed. It was necessary at the same time to raise and maintain such a state of actipn in the sys- 140 \ ) tern as would induce a healthy state of the'^ sores of the lungs. I made him take a i little white wine at mid-day and a short ! walk ; at dinner a little animal food, and | after it a little ardent spirits, which com- ; pletely prevented the cardialgia, tormina, \ &c. I walked with him, commenced, and i carried on such conversation as seemed i most agreeable to him, and watched him i carefully while he took food, examining on ' all these occasions the pulse and other in- i dications, and was also very attentive to the ; sputa and other evacuations. I was ex- ; tremely happy to observe him speedily ac- \ quire cheerfulness, and improve in health I and vigor. The pulse became slower and ; more regular ; the affections of his bowels | scarcely gave him any uneasiness ; the spu- ; ta began to assume the form of laudable I pus, and to diminish in quantity ; the j morning sweats were far less copious and I debilitating. At the end of eight days, he j walked with me three miles to. the house of i a relation, was indeed somewhat fatigued, \ but this wetit off in a short time, and he 1 took food heartily. Next morning we ; walked two miles and a half to the house j of an acquaintance ; he was considerably j 141 «fatigued, was paler, and to his sensations feebler than he had been for three or four days. A glass of wine how:ever, renewed his strength. I here continued my plan of regimen. I lay in the same bed, and observed him carefully during the night; he slept now tolerably well without the assistance of the anodyne draughts, which he had formerly been in the habit of taking ; his breathing- became less noisy, and his involuntary plain- tive expressions very rare. We remained here together about four weeks, and during the last week the cough gave him no un- easiness ; the pulse was about 90 ; and from food, change of posture, or exercise, ob- served nearly the same changes as that of a person in health ; and he walked, run, rode, or went a-shooting, from morning to night, without inconvenience. But as he exercised and exposed himself now with too little caution, I admonished him to be more cautious ; and on quitting him to rC" turn to my studies in town, I was highly gratified with the thought, that means had been found to rescue from death this most valuable youth : but the event was far otherwise ; the regimen was discontinued, 142 and all the train of symptoms above de- cribed returned with accumulated severity. I would not conclude however, that the discontinuance of the treatment which I had employed, was the occasion of the fa- tal event in the month of January follow- ing; it must be obvious with how little certainty we can predict, that the event will be favourable or unfavourable in any case of pulmonary complaint, however mild or desperate it may appear.* SECTION IL i Treatment as regulated hij the various Phenomena \ of the Fever whicli atteiids Ulceration. ' WE have given the general plan of treat- I ment, as indicated by the state of the sores ; \ but the administration and regimen must be \ regulated by many occurrences, and none | are to be more regarded than the varieties | in the state of the body and mind, which j are observed to happen during the fever I which accompanies this stage of the disease, i * Ch. i, sect. V. ■ 143 Many persons, particularly at the begin- ning of this stage, are pretty strong, and the fever has very little either of exacerba- tion or remission. It is best for them to use generous diet in moderation, gentle exercise, riding on horseback, a voyage, swinging in the open air in a seat so con- structed as to support the body without much muscular exertion ; change of cli- mate, agreeable conversation, &c. The use of food in a liquid form alone is improper, because thus the muscles of ver- micular motion are deprived of the only power that can resist their contraction and regulate their movements, consequently the function of digestion must thus be but very imperfectly performed, though no other de- ficiency co-operated. Nay, from the dis- use of solid food, the portions of the canal which ought to be largest, have been found pf the size of the ilia. When the mind of the patient is hypo- chondriacal, is too easily or unreasonably impressed with either joy or despair, we must not believe, that he is nervous, or, in other words, that his troubles are ideal, and require no medical attention. If we recol- lect, that the mind and body mutually m- 144 fluence each other, and that those muscles, which by their action, those eyes, which by the variety of their appearance, so truly declare the internal operation of the mind, are like all the parts of the body, moved by the nervous influence ; there is as much reason for assistance when their actions are irregular, as there is when an arm or a leg is convulsed or paralysed ; both equally indicate the irregular distribution of sen- sorial power. For those in whom the exacerbations are distinct but mild, the treatment will as much as possible resemble that above de- scribed ; in short, the similarity of treat- ment must be guided by the similarity of symptoms. But in those whose exacerbations are severe, the varying state of the body and mind ought to be most carefully watched, and medicines and food to be administered accordingly. If the pulse is feeble and the mind de- pressed, he should be encouraged by words, and receive wine and exhilarating medi- cines. When he becomes complacent^ animal food should be given ; if the eating is followed by cardialgia, nausea, gripes of 145 the bowels, or other symptoms of depraved digestion, a little brandy and water will of- ten give immediate relief, and is always iiseful. When the feet become oedematous, they are to be rubbed with camphorated oil and bandaged pretty tight with a roller of linen, morning and evening, which is indeed in- dispensably necessary, if the patient is able to walk or even sit* When aphthous sores invade the mouth and fauces, port wine containing the tincture of opium, or an in- fusion of bark containing a quantity of the same tincture, is a very useful local appli- cation : we have formerly considered what the treatment must be when the bowels are troubled and their contents vitiated.* Circular cushions, hollow in the middle, should defend those parts of the body which must sustain its weight in bed, and when gangrenous sores form, the appropriate sur- gical means must not be neglected. It is extremely cruel, if not criminal, to over- look such sores because the patient may be thought irrecoverable ; I am satisfied, that lives might have been preserved, had it not * Ch. vi. sect. 2. 146 been for the neglect or mismanagement of these external evils. If the pulse is irregular, languid and scarcely perceptible to the touch at the temples, wrists and ankles ; if there are ri- gors, cold sweats, diarrhoea, sickness, vomit- ing with ghastly paleness of countenance, disgust of life and low delirium ; if livid spots or petechiae appear all over the sur- face of the body, then we must endea- vour, by all the means which the medical science or art can suggest or employ, to intercept mortification and induce some degree of regularity in the functions of life. Here opium, wine, ether, camphor, musk, &c. are to be administered ; and the repe- tition of the doses, and their quantity, to be regulated by the effects produced on the arterial system, and the sensations of the wretched sufferer. It seems to have been the opinion of the ancients, * that when the symptoms, of what is now called hectic fever, were pre- sent, that certain parts were affected in some degree with sphacelation ; and this opinion of theirs is founded in truth, and * Aretsei 1. i. c. 8. De Morbis Dluturnis. 147 is the result of accurate observation ; it de- rives confirmation both from the symp- toms and the method of cure. It is very fortunate, that diminishing the severity of the cold stage, and supporting the strength in the manner just described, greatly prevents the danger and severity of the febrile exacerbation. The fever which attends ulceration of the lungs, is not of one uniform kind ; it is in one remittent, in another intermittent, in a third typhoid ; it is various, in short, according to the different conditions of the system. In proportion as the person becomes cheerful and lively, and his pulse regular, this treatment must be relaxed ; if he con- tinue in this state, weak beef-tea, wine di- luted with water, &c. are to be given. If the face become flushed, the lips dry, and their cuticle like oiled silk, and the skin dry and hot, acidulous drinks are to be admini- stered ; cold vinegar and water mixed re- move that most disagreeable heat which so often invades the extremities ; the acute pain which often accompanies their spasmodic affections is greatly alleviated by bathing them with brandy ; if the skin becomt 148 Very hot, cheeks florid, mind morbidly ac- tive, or if it indicate a degree of dehrium with much inquietude, the tepid bath or even gently wetting the shaved head and surface of the trunk with a spunge dipped in vinegar and water, are very beneficial. I have even seen the action of the cold bath administered in such circumstances, followed by much relief and sound sleep. If phrenitis seem to be threatened, vesica- tories must be applied to the head. The sweat must be wiped off assiduously by which the vessels of the skin partly re- cover their tone, and thus we prevent the very bad effects of the cooHng perspiration, and in a great degree, the alarming effects of exhaustion, which are so apt to appear in the remission. 149 SECTION III. Account and Explatiation of the Effects of Pos- ture on the Heart and Arteries, in Health and Disease, and the Reason assigned why a certain Position is easiest for the Body of an enfeebled Person. EVERY man or animal conscious of sensation, that ever existed, must have ex- perienced, that, when debiHtated or labour- ing under disease, one posture of body was more agreeable or tolerable than another. I do not know however, that the effects of posture alone on the vital actions in health and disease have ever been duly investiga- ted, but it is indubitable, that if a certain position of body is more conducive than another to our comfort when we-^re suf- fering from disease, that it is worthy of our attention ; and that such a position may be ascertained, the following considerations induce me to believe. Some years ago I happened to count my pulse when I was standing erect, and while I still held my finger above the pulsating 150 vessel I stooped to look at something lying on a table Deiore me, and immediately observed the pulsations to become slower. 1 repeated this experiment often, and al- ways with the same result ; 1 found, that the pulse was in general about ten beats more, when I stood, than when I lay, and that when I sat, it maintained a medium number. An immense number of observations made on this subject in various circumstan- ces, proves, that the rule is invariable ; and further, when the pulsations are increased by any means to an unusual number, that then the diminution on change of pos- ture, is most conspicuous. When the pulse is raised by food and strong drink, it will, on our lying down, diminish in number by twenty or thirty beat^ per minute ; the pulse at the same time becomes much stronger ; we feel, or even think we hear the carotid arteries pulsating ; we feel also the move- ments of the heart and of the abdominal aorta ; we are sensible of fulness in the head ; and, if the head is as low as the rest of the body, vertigo and a degree of stupor are very common occurrences. It does not seem improbable, that the more free supply 151 of blood to the brain in the horizontal pos- ture is a chief cause of this position being more favourable to sleep than any other. The pulsations of persons much debili- tated, and in a febrile state, are remarkably increased by change of posture ; the heart flutters, the pulse becomes of extraordinary frequency, even on assuming or attempting to assume the sitting posture. A remark of this kind is given by Dr Beddoes on the authority of another, who observed, that in a patient taking digitahs, there was a wonderful increase of pulsations when he sat up, but such is a common occurrence in cases of debility, and if it were consistent with my present design, to take notice of such effects in diseases, I could recount many instances where not only such in- crease of pulsations evinced itself, but where fainting, apoplexy, convulsions, were the consequence of the smallest attempt to raise the body. On close comparison, the effects of pos- ture should be reckoned of the same nature with those of the exertion of our voluntary muscles in moving the body, as in walking, &c. for the increase in the number of the pulsations by change of posture, is in pro- . 152 portion to the number and force of the muscles by the action of which the change is made, or the new position maintained ; consequently the pulsations are fewest when the action of fewest muscles is required, viz. when a man is in the horizontal pos- ture ; from this posture, if we proceed to those of sitting and standing, and thence to walking, running, or any other variety of exercise in which the action of ones own muscles is required, we shall find the rule completely established, and the number of the pulsations and respirations increase to- gether. The weaker any one is, the greater is the acceleration or retardation of pulse by change of posture 5 thus change of posture may be a measure of debility. Since there is in the standing and sitting postures a number of muscles in a state of action from which alone some degree of fa- tigue may ensue, it appears, that the easiest position, as being that in which the system is least excited, is the horizontal ; but even this position must be under certain limita- tions, for it has been found, that, if the head is no more elevated than the rest of the body, giddiness and vertigo very soon super- 153 vene, particularly after taking food. This^ I think, may be easily explained, for the ca- rotid arteries proceed upward nearly in a straight direction, and accordingly the blood moves in them with an impetus less coun- teracted by the flexion of vessels than in most of the branches sent off from the aorta ; but when the head is a little elevated, gra- vity in some measure impedes this flow ; so it should seem, and if I mistake not, expe- rience has confirmed, that the patient lies most easily and safely as it were on a gently inclined plane, the head being the most ele- vated part of the body.* From knowing the great power of mus- cular motion in accelerating the movements of the heart, and those of the vessels de- pendent on it, we shall likewise be enabled to account for that dyspnoea and redness of the face w^hich running and climbing al- ways induce. The action of the loco-mo- tive muscles while it increases the velocity, impedes the efllux of the blood from the interior of the body ; during running and climbing therefore the blood vessels of the * Celsi 1. Iv. c. 4. Caput hujui quoque cuba.ntis subliinc /;sse debet. 154 lungs become turgid, and by a natural con^ sequence those of the head, but the lungs must be more forcibly affected by climbing than running, for this reason, that, when •We ascend an eminence, the body is incur- vated forward, the abdominal parietes press the viscera in such a manner as almost entirely to resist the descent of the dia- phragm ; and the contraction of the exte- rior thoracic muscles while the pelvis is the fixed point, opposes the elevation of the ribs;, thus the motions of respiration are almost completely arrested, the circulating fluids accumulate in the lungs, and the difficulty of breathing becomes very distressing. Not aware of this necessary physiological event, philosophers have erroneously ima- gined, that animals could scarcely breathe on the tops of high mountains because af the rarity of the atmosphere. In fine, that the increase in the number of pulsations is in proportion to the num- ber and force of the acting muscles, affords the link which unites change of posture with every variety of bodily exercise, in as far as regards the effects of muscular ac- tion on the circulating systems ; a thing, as often happens to the more obvious oc- currences, the simplicity, plainness and vulgarity of which have concealed from the serious attention of the wise. It should ever be remembered however, that the most common events, which obtrude themselves on us, are the only guides to the innermost recesses and occult operations of nature : the motion of a stone thrown from the hand explains how the heavenly bodies are arranged throughout the universe. SECTION IV. JVhat Kinds of Exercise, and zvhen Sea Air and Change of Climate are to be advised. FURTFIER experiments on every kind of exercise by land and sea have demon- strated to me, that exercise by the action of ones own muscles raises ones pulse speedily and to a greater frequency than any power that acts on the body ; that riding on horse- back raises the pulse in proportion to the exertion of the rider ; that being drawn in a curricle or wheeled carriage even very briskly has but a very moderate influence ; 156 that swinging raises the pulse in proportion to the exertion which the person is under the necessity of making to maintain his seat ; and I have found the pulsations to be increased bj thirty in the minute, by the motion of a swing of the best construction ; besides, the sickness which such motion in- duces in those unaccustomed to it^ is a great objection. It is evident however, that the least fa- tiguing mode of exercise must be prescrib- ed to the feeblest. The first time that I observed the decid- ed utility of sailing as a remedy in this stage of phthisis, was about twelve years ago,, in the case of a young gentleman, who by intemperance and dissipation brought pulmonary consumption on himself. He had the first medical advice in Britain, particularly that of Dr Monro, senior, and Mr Benjamin Bell. After purulent expectoration came on he procured a sloop, and having sailed along the coast a few months, he seemed to have entirely recovered. Self subjugation is the most difficult of all enterprises : this gentleman, even under the dread of death, could not abstain from 157 his former habits; the disease returned with greater violence, and the consequences were fatal- It has been found, that, if one is not seiz- ed with sea sickness, to which the phthisi- cal are less liable than others, sailing expos- ed to the sea air does not perceptibly dimi- nish nor increase the number of pulsations. Sailing then is useful by some other effects than those on the heart and arteries : the temperature at sea is equable ; the body in the vessel is kept perpetually in some de- gree of motion without fatigue ; the air being cool checks febrile heat, and being impregnated with saline particles, reaches the lungs, and acts as a gentle stimulus to the wounded surfaces of the bronchos and its ramifications, and thus promotes the healing process. Now as for the healing of suppurating sores an action of the system is required not much stronger than the healthy, and as equability of temperature also and slight stimulation are necessary to keep up a steady degree of action in the wounded surface, and coolness is at the same time required to check febrile heat, are not these ends well accomplished by an excursion on sea ? and would they not 158 be equally so, by riding in a curricle on the shore ? Sydenham highly extols gestation on horseback ; Dr Carmichael Smyth, swing- ing ; but these modes of exercise are not different in principle from each other. I shall not minutely inquire why it has been supposed, that sailing and swinging diminish the velocity of the circulation of the blood ; but this I know, that sitting in a swing does not diminish the number of pulsations more than sitting on a chair, nor does sitting in a vessel at sea diminish them more than sitting on a stone on the beach > or, cceteris paribus^ on a seat in any other place. Of this I have repeatedly satisfied myself by comparative observation, but if a person is walking or standing on the shore when his pulse is counted, and then go on board and sit down, and have it count- ed again, the pulse will diminish in number of beats proportionally to the debility of the constitution ; and the event will be pre- cisely similar, if the pulse be counted when the person is walking in a garden, and next when seated on a sling ; and in neither case different from what might have been ob- served, when he walked in his room and sat 159 down on a chair. If a person labouring under ulcerative fever be exposed to the sea air, the pulsations will be aflfected precisely as they would be by air equally cold in any other place ; but, as Galen remarked, who seems to have known the effects of cold affusion as accurately as the late inge- nious Dr Currie of Liverpool, the velocity of pulse in this fever is not diminished by the surface of the body being cooled as in other fevers ;* if a vomica burst in the lungs, the matter escape, and the sore heal, the pulse will resume its healthy number, whether a ship, a swing, or his usual abode have contained the patient From time immemorial the utility in pulmonary complaints, of change of cli- mate, travelling by sea and land, sea air, and bathing, have all been well known from innumerable instances, yet unfortu- nately these means were adopted improper- ly, because they were advised indiscrimi- nately,f and for the same reason have been praised or condemned by physicians, just . * De DlflFerent. Pebrium, 1. i. c. 13. f Utllis etiara in omni tussi est peregrinatio, navigatio Jonga, loca maritima, natationes., Celsi 1. iv. c. 4. 160 as they chanced to be used in advantageous circumstances, or the contrary. Unifor- mity of temperature, steadiness of weather and pure air are always to be preferred. For scrofulous habits, of which we have already considered the nature and treat- ment,* the warmer climates are salutary, the sea air sometimes hurtful ; but, dur- ing incipient inflammatory affection of the lungs, both the stimulating atmosphere of the sea and its coolness are bad, now a moderate temperature is chiefly desirable : in the inflammatory stage, bodily exercise, the stimulating atmosphere of the sea, tro- pical heat, are all to be avoided, the treat- ment must resemble that of the inflamma- tory stage, above described : f in the suppu- rative stage accompanied with the ulcerative fever, nothing is preferable to sailing and sea air, hot climates and hot seasons are pernicious ; but though there are puriform sputa, acceleration of pulse, and other evi- dent symptoms of ulceration, yet if the countenance is uniformly pale, the mind depressed, the extremities rather in general cold ; if the patient complains not of pain, * Ch.vi. sect. 2/ f Ch. vii. 161 but of oppression in the breast and fre- quent attacks of dyspnoea ; if, in fine, there are no exacerbations of fever, the sea air is only useful in the hot seasons, and a warm climate will be of almost certain advan- tage : cold bathing is in every stage, for the most part a precarious remedy ; the warm bath is most generally useful. Let it be impressed on our minds then, with how much circumspection voyages and changes of climate ought to be advised. An abode in the islandr-of Madeira may be no more useful in some instances of phthi- sis, than an abode in Iceland would be for an old man with mortified limbs. SECTION V. Utility of inhaling certain Substances to^ promote the healing oj Ulceration in the Lungs. WHEN chemistry, improved by the ever memorable discovery of the different gases, began to elucidate the nature of those changes essential to life, which the common air and blood undergo by their mutual and L 162 reciprocal influence in the lungs, some men of enterprising minds conceived, that the breathing of the constituents of the air, in proportions different from those in which it was contained in the atmosphere, might be a mean of preventing or curing disease, but further investigation seems to have shown, that wise and provident nature has mingled the ingredients of the atmosphere with that admirable precision of relative quantity, which renders it the unique, the only com- pound adapted to preserve and to maintain animal existence. I atn inclined to suppose, that if the in- halation of stimulating gases has promoted convalescence, its effect is rather to be at- tributed to their local agency on the sur- faces of the bronchia, than to any modifi- cation occasioned by them in the changes of the blood. Impressed with the idea above mention- ed, of the operation of the air containing some of the saline particles of the ocean, and this idea being confirmed in my mind by what we daily observe in the application of stimulating substances to sores on the exterior of the body, it appeared to me, that the common inhalation of the steams 163 of vinegar and v/ater, or of air impregna- ted with ether, which affords such imme- diate relief, and seems in the event so use- ful in many instances of dyspnoea from a phthisical state of the lungs, acted in a si- milar manner ; and that hence we had every reason to conjecture, that the disse- mination of stimulating effluvia in the ap- partments of the phthisical, when the sputa indicated the sores to be in a degenerating or depraved condition, would be highly ser- viceable not only to clean the sores, pro- mote the healing action of their surfaces, and prevent or diminish the acrimony and putrescence of morbid matters there collect- ed or secreted, but to invigorate the expec- toration of such matters, as lodging in the bronchia, obstruct the ingress of the air and spread the devastation. It has indeed been observed long ago, that an atmosphere impregnated with sti- mulating fumes was serviceable to the phthi- sical ; nay, the fames of arsenic and sulphur were deemed a remedy of very great effi- cacy in the most desperate cases of pulmo- nary ulceration.* This fact would have * Thomse Willis Pharmaceut. Rationalis, c. vi. sect. 1. 164 been of great practical utility, had those circumstances of constitution or of disease been pointed out, in which alone such means ought to be employed. The inhalation of air containing muriatic acid gas or ether has at my suggestion been for some years prescribed by others as well as myself with manifest advantage. The patient is conscious of much relief from it, and the salutary changes in the appearance of the sputa, which soon succeed, fully tes- tify the utility of the practice. I pursued this plan with steady attention in the case which I have partly related, to shew the effects of digitalis in the inflam- matory or first stage of phthisis. The symptoms of that case, the relation of which is now to be continued, clearly indicated, that a species of abscess had formed and burst in the lungs, the contents of which were now discharged by expecto- ration, and that the system was exhausted to the last degree. The matter shewed, that the wounds were in a very bad condition. In order to pro- mote the activity and energy of the sys- tem, I ordered one glass of port wine to be taken every second hour, and beef-tea to 165 be drank in the intervals. To open the bowels and procure sleep, I prescribed, 5t Extract! hyosciami nigri, Aloes Socot. a. 3i« Pul. Cinnam. q. s. ut simul in massam probe subigantur in partes xxiv. aequales dividendam. Signetur — 24 pills, two to be taken to-night, and one every night unless there shall have been two loose stools. In order to stimulate the wounds in the lungs to co-operate with the internal re- medies in promoting the healthy action of their surfaces, and the formation of healthy pus, I taught the woman attending how to disengage the fumes of muriatic acid gas in his apartment ; and the smell of the acid was always to be kept up in the air of the room. I ordered the sputa, the stools and urine to be kept till I saw them. January 24. The patient looks better, sputa not quite so black, two pretty consis- tent dark coloured stools, much white se- diment in the urine ; he slept pretty well during the night ; pulse 70, stronger and more regular ; the muriatic acid fumes excited severe coughing at first ; I found, that they had been disengaged at the pa- tient's bed side ; I now ordered them to 166 be disengaged so as to be disseminated throughout the appartment, but not imme- diately to reach the patient in great quan- tity ; the cold shiverings were much less frequent than for some time past. I was informed, that the former medical atten- dants had for some weeks given a certain medicine, and was asked whether it should be continued ; on examining it I was certain that it contained tinct. digitalis ; I gave it as ordered by the label, and perceived the pulse immediately strengthened and acce- lerated by it ; to be taken again in the eve- ning ; only one pill to be taken, csetera as yesterday. 25th, 26th, 27th. He continued as on the 24th, except that the cold shiver- ings were much less frequent, the sputa better coloured ; pulse about 60 : I gave him the mixture and it rose immediately to 65. 28. He does not think himself so well^ had much cold shivering and sweating du- ring the night ; his urine contains much white sediment ; sputa increased in quan- tity but white, except some streaks of a florid red colour ; pulse about 50. I called again in the evening, he had been much worse : his pulse was 48. I gave another 167 dose of the mixture, which immediately strengthened and accelerated his pulse by about five beats a minute. 29. He had not been so sick nor brought up so much sputa which still were variegated with the red streaks ; pulse still 48. Think- ing that the diminution of the pulse might be influenced by the sickness and collec- tion of pus, I gave him another dose which as formerly immediately strengthened and accelerated the pulse. 30. Sickness not so troublesome, sputa not nearly so copious, red streaks gone. He feels himself very weak, his urine does not contain so much sediment ; stools pretty natural ; he sweat much last night ; pulse 48 ; mixture to be discontinued. 31. He had not much sickness since yes- terday ; his sputa now mixed with some- thing green, were diminished much in quantity ; he had a pretty easy night ; his cough gave him more pain ; pulse about 60. I called again in the evening, at which time he was very sick and had been so a great part of the afternoon ; his sputa were very copious of mixed colours ; pulse about 110, feeble and intermittent. I gave him two glfisses of port-wine, and ordered the same to be repeated at any time when he was seized with sickness. February i. Sickness had not troubled him much during the night, he had slept pretty well, his sputa were copious and better coloured, his urine contained much white sediment, he had not sweated much, he thought himself rather better, his face was somewhat flushed, his tongue was foul and moist ; his pulse about 100. 2. He is continuing better without any cold shivering, sputa less in quantity and resembling laudable pus, his pulse is 100, strong and regular, he has some appetite for food, he took some tea with bread and butter this morning. As the matter indicated a healthy state of the sores, and the circulation had as- sumed an inflammatory action, I ordered only half a glass of wine to be taken every two hours, but if cold shivermg should come on to give two or even three glass- fuls ; his bowels were kept regular by one pill each night. 3 & 4. The same as the second. 5. In the afternoon of the 4th he had a sense of heat in the chest, followed at night by cold shivering, but not so severe as on 169 former occasions, followed also by an in- crease of the sputa which were white ; he took at this time two glassfuls of wine which relieved him much, he slept pretty well, his pulse 120, irregular and not strong. Regimen to be continued. 6. He is much better, his sputa are dimi- nished in quantity and of good colour, ap- petite better, pulse 100, regular and strong. As it now appeared, that there was a disposition in the lungs to form new sores, and as the action of the system was such as favoured their proceeding through in- flammation to suppuration, I now limited the wine to two glassfuls per diem, and kept the bowels regular by the suppertart. potassas. 7, 8, 9, 10, 11. He had continued im- proving in appearance ; his emaciation was diminishing, and he had got some appe- tite for food ; pulse 90, pretty strong ; spu- ta in small quantity ; he had a sense of stiff- ness and tickling in the lungs. He sat up in bed to day the llth, to let me feel his pulse. 12. He felt himself a little hot, thirsty and uneasy, he felt a darting pain in the 170 cliest and had very little appetite this morn- ing ; sputa in very small quantity. 5* accidi sulph. dilut. 3ii- Syrup, ros. rub. aq. a 51. m. two tea spoonfuls to be taken in a wine glass full of cold water every four hours while the sense of heat and restlessness continue, wine to be omitted to-day unless cold shivering come on. It may with great propriety, I think, be doubted, whether the sulphuric or any other acid diluted, or taken in any admis- sible form, has the power of diminishing febrile heat. 13. He had a pretty severe attack of cold shivering last night ; sputa much increased in quantity, but white; pulse 120, and other febrile symptoms are present. To take Supertart. Potassae, gi. this afternoon. 14, 15, 16, 17. He continued to get bet- ter every day, the sputa daily diminished in quantity, he slept well, his urine was without sediment, he now took, though in small quantity, of his usual food, and sat up an hour in the afternoon. 19. No puriform sputa, what was spit up resembled frothing saliva and was in 171 no great quantity ; breathing pretty easy ; slight cough ; bowels natural, urine natu- ral ; he enjoyed quiet nights, and pretty good appetite ; he sat out of bed several hours of the day without inconvenience ; pulse 70, and regular ; he had eaten a little steak with relish. It did not seem any longer necessary to continue the inhalation of the muriatic acid, as there was reason to believe, that the sores of the lungs had closed ; and it occurred to me, that the same stimulus which would promote the healthy action of a diseased surface;, could injure a sound one, and much more rCvT-diiy one in a recent state of cicatrization. I have no doubt that muriatic acid gas diluted as in this case, in- haled into sound lungs, would soon pro- duce inflammation of the bronchia. Accordingly I ordered the fumigation to be discontinued. The patient continued thus gradually improving for eight days more, when his cough became sharp and painful, and his breathing somewhat stiff; he felt some heat in the middle of the chest, and his sleep was not so sound ; he was now able to walk in his room ; his appetite was a little 172 impaired, and he felt a slight heat over the body ; his urine was high coloured, and bowels rather costive. I ordered him to desist from taking ani- mal food. Bi Pulv. jalap, comp, 3iss. to be taken in warm gruel immediately. His appetite returned ; in three days the puriform sputa, which had recurred in small quantity, had quite disappeared again ; the fumigation was again desisted from ; the patient could walk pretty easily for some considerable time in his room, and had the highest hopes of recovery. Fie continued improving in health to the 19th March, when I left town, and requested another medical gentleman to visit him in my ab- sence. During this time he was seized with a sort of asthmatic affection, which yielded to the pill, scilliticae and the inha- lation of the steam of water. On my return in May I found him won- derfully improved in health and stout ; we now sent him to the country. The inhalation of gently stimulating sub- stances in the manner just described, is of 173 very great utility in chronic affections of the lungs, and those accompanying general debility from whatever cause. In the Jour- nal de Medecine there is an essay in which the propriety of administering stimulant in- halation to operate on the lungs immediate- ly and locally, is strenuously and judiciously maintained, and the author affirms, that he often succeeded by this remedy in curing very dangerous chronic affections of the breast.* May not a great, if not the greater part of the beneficial effects, which have been derived from the fumigating with acids where contagious fevers were raging, be ascribed to the immediate agency of the vapours on the exterior surface of the body, and of those inhaled on the interior sur- faces of the lungs ? * Reflexions et Observations, sur la Medecine Pneumatique, ct sur les Principaux Moyens de Trailer les Affections Chro- niques de la Poitrine, par J. B. Burdin. tome x. p. 144. 174 SECTION VL Utility qf administering Digitalis in the Suppiirati've Stage. IN this stage it is, that digitaHs is une- quivocally and certainly useful ; some how- ever, have supposed, that there are at least two species of consumption, in one of which the use of digitalis is attended with advantage, in the other not ; though this is correct, according to the distinction suggested in the sixth chapter, it appears to me, that they would have discovered a more satisfactory solution for by far the greatest number of their difhculties, if they had supposed, that there were two stages, in one of which it was highly salutary, in the other dangerous, if not decidedly perni- cious : In this manner, I can account for the disappointments of which Ferriar so often, and I believe very justly, complains. To establish the truth of this assertion, I not only appeal to the experiments and cases which I have detailed in the second 175 part of this work, but to every case on re- cord : and in what manner the administra- tion of it ought to be conducted, cannot perhaps be more clearly pointed out than by the following anecdote. Last winter a gentleman of my acquaintance informed me, that there was a patient in the Royal Infirmary affected with phthisis pulmona- iis in the suppurative stage, to whom digi- talis was prescribed, and asked me what I . expected would be the consequence of its administration in this case. I answered, that digitalis was one of the best remedies that could be employed, but that, if care were not taken to intermit its use when inflammatory symptoms began to increase, that the consequences would be very bad. This gentleman watched daily the progress of the case ; the febrile symptoms in a few days were aggravated, the pulse became strong, the patient restless, hot and un- easy ; she became sensible, that every dose of the medicine made her worse, and refused to receive any more of it, when Dr Dun- can, senior, with his usual prudence and good sense, discontinued the prescription. 176 SECTION VII. Neti) Modes of Treatment proposed for the re- mo'val of Air or of Pur form Matter from the Cavities of' the Chest. THERE are, not unfrequently, two con- sequences of phthisis which require distinct consideration, viz. either the effusion of pu- riform matter, or that of air into the cavi- ty of the pleura investing the thorax. I am persuaded, that the operation of paracentesis thoracis, which has been very rarely performed for the evacuation of pu- riform matter from that cavity, would very often be of great service. The objections to this operation seem to be derived from an opinion of the delicacy of the lungs and the danger of either irritation or collapse of them, when air is admitted into the cavity of the pleura. We have already seen some astonishing morbid changes to which the lungs are liable ; and it may be affirmed, that no vis- cus, the spleen perhaps excepted, can suffer to a greater extent than they. 177 Extraneous bodies, such as bullets, have long remained in the lungs almost without exciting uneasiness or pain ; and wounded with sharp instruments, they have healed by the first intention. Those of one side have even been almost entirely converted into pus and sloughs 5 or even, with part of the bronchos, have seemed to be one gelatinous mass ; some- times the denuded vessels appear to have been cut across as it were, showing their mouths open, or obstructed with a species of callus ; in fine, so complete has the des- truction been, that those of one side were declared to be totally wanting. What other internal or external part ever exhi- bited a worse state while life remained ? By a series of experiments made during the last four years, on the effects of air ad- mitted into the cavities of the pleura through apertures made in each side of the thorax of dogs, it has been ascertained, that incised wounds of the lungs, not affecting any of the larger blood vessels, heal by the first intention. It has been long well known, that a por- tion of the lungs may be cut out without M - ITS producing death ;* I have further ascertam- ed, that when a large portion of them is cut off, the air, in the mean time, having free access, and the puriform matter free outlet, the wound heals, like any common external sore, and the lungs afterward per- form their function without any perceptible impediment ; that air admitted into the cavities of the thorax, even for any length of time, does not induce inflammation of the pleura pulmonalis ; and that, contrary to the opinions of Vesalius^ Mayow, Houston, Van Swieten, Haller, Whytt, Monro and others, the lungs do not instantly collapse, even though air is admitted through two apertures in opposite sides of the thorax, each at least thrice the diameter of the rijna giotidis. Mayow ascertained f that the common air inspired, diminished in volume. Dr Hales J endeavours to explain this fact by supposing, that the vapours arising from animal bodies partly destroy the elasticity of the air, and in this way accounts for the diminution of any redundant quan- * Halleri Physiolog, Prim. Lin. de Pancreate. f Experj de Sp. Nitro Aereo. X Statical Essays, Analysis of Air, vol. i. 179 tity which may have escaped through the wounded or imperfect lungs into the cavity of the thorax. It would be tedious to inquire here whe- ther this explanation is well founded ; I feel myself happy however, in being able to state two facts which seem to be of infi- nite practical importance : first, That air, not passing from the interior of the Uings, as in the occurrences alleged by Hales, but admitted through orifices made in the parietes of the thorax where the lungs are sound, rapidly disappears from the cavities of the pleura ; second, That the gravity of the lungs may be used so as completely to obviate the pressure of air entering through such wounds or orifices. In consequence of the former fact being communicated to Mr James Wardrope, a surgeon of this city, he successfully treated an effusion of air through the wounded lungs, by merely putting a linen roller round the thorax to keep the fractured ribs steady, and trusting to the power of absorp- tion for the removal of the air.* But when * Vide Disput. Med. Inaug. De Pneumatosl Andrese Ilal- liday, M. D. viii, Cal. Jul. edit. 180G, appendicem. 180 the air is effused in greater quantity than the absorbents can remove, all that is ne- cessary, conformably to the latter fact, is to order the patient to lie prone, in which position of body the gravity of the lungs will entirely prevent the accumulation of air in the cavity of the pleura. How use- ful it is to be aware of this, will appear from the relation of the following unfortu- nate occurrence, of which I was informed immediately after it happened, and was present at the examination of the body. An apparently stout young man, who had some time laboured under pulmonary complaints, was suddenly seized with a sense of suffocation and other symptoms of effu- sed air oppressing the lungs. After con- sultation it was agreed to perforate the tho- rax ; but instead of air escaping, the atmos- pherical air rushed in, and the man died of the operation. If this man had been or- dered to lie prone, no operation would have been necessary, and he might have been still alive. When therefore it is judged proper to perforate the thorax to allow puriform mat- ter to escape from the cavity, the patient should lie in that position in which there 181 is no danger of collapse of the lungs from the pressure of the atmosphere, and the fluid matters will escape by their own gra- vity, assisted by the distending lungs. In conducting these experiments, I had the assistance of my learned friend Dr John Barclay, Lecturer on Anatomy in this city, which is sufficient proof, that I wished them to be made with as much anatomical accuracy as possible. If these facts satisfy us, that the thorax may be perforated without much danger from the operation ; that the lungs can bear the ravages of disease, and will heal as well as any part of the body, when the purulent and acrid matters are evacuated — we cannot hesitate to affirm, that such mat- ters should be discharged from the cavity of the thorax as speedily as possible, where such an organ as the lungs, and such a function as respiration, are concerned. " From having opened," says Dr Wil-^ liam Hunter,* " a great variety of dead bodies, I cannot help thinking that many lives might be saved, if it was the custom to try the operation for the empyema^ in * Med. Obs. et Inq. 182 most cases, where there is supposed to be suppuration in the chest, especially where there is reason to believe that the disease is merely local ; as after pleurisies, in people that are not strumous, or otherwise unsound in their whole habit : and more especially still, wherever we can, from the symptoms, ascertain the seat of the abscess with some degree of probability. In such cases, if ever we are fortunate enough to discharge the matter, we give the patient a very good chance for life, who had almost none with- out such an attempt ; and, if we fail, we shall have done no great mischief." If the operation were performed, should not such substances be injected as are found useful in promoting the healthy action of sores ? There is a case related in Bone- tus,* in which a prodigious quantity of ;^uriform matter was evacuated by paracen- tesis thoracis, and decoctions of myrrh and aloes were injected to promote the healing of the wounds with the very best effects. I am of opinion, that physicians have too frequently abandoned their patients under such circumstances, nor can I better ex- * Sect. vi. obs. iv. p. 674. 183 press my disapprobation of such conduct than in the words of Lord Bacon : " Therefore I will not doubt to note as a deficience, that they inquire not the per- fect cures of many diseases, or extremities of diseases, but, pronouncing them incu- rable, do enact a law of neglect^ and exempt ignorance from discredit.'' 184 CHAPTER IX. TREATMENT OF THE THIRD STAGE. IN the third stage, or when the symp- toms of gangrefie and sphacelation are pre- sent, the strength of the patient must be supported by all possible means ; here the person often faints on attempting to rise, or even on being raised, therefore bodily motion is to be prohibited. Though life never remains long after the influence of mortification has tainted the general powers of vitality, yet it has been long protracted, when, as has just been proved, the lungs have been wasted to an astonishing degree, and it is impossible to say, when to afford relief cannot, or ought not to be attempted. We ought not to abandon the patient, even when the dismal image of death is pourtrayed in the coun- tenance, and the longing, lingering looks of the departing victim, show all the anxious misery of calm despair. 185 Means and substances of the most dissi- milar nature, the most active and the most inert, the mithridate and hchen Icelandi- cus, have all been successful and have all failed in removing this disease. Which discordant accounts may, per- haps, be reconciled with the truth, when we know that, on some occasions, the af- fection is so gentle, that it would be ob- viated without the interference of art ; that, on other occasions, it is beyond the reach of human ingenuity ; that it undergoes changes in the same individual, requiring corresponding changes of treatment ; that, in fine, it is the most precarious, insidious and delusive of all the destroyers of man- kind. Human milk, and that of the ass, mare, cow, goat, ewe, have all been prescribed, and that, too, in this last stage, when no- thing but the most stimulant and nutritious substances can support the nearly exhaust- ed vital powers ! Human and ass milk ar^ preferred, because they are most serous, that is, merely because they are weakest I Who would prescribe ass milk to a person reduced to extreme debility from a gangre- nous limb ? what is there in suqh milk r / 186 what in serum, to remove depraved pus, to obviate putrefaction, to promote healthy granulation, to restore and sustain the pro- per action of the vascular systems, of all the vital and all the animal functions ? O rea- son, first of human faculties, whither hast thou fled ! I am inclined to believe, that it was the treatment of phthisis pulmonalis, which suggested to Bacon this observation, " that, though from daily practice it might be ex- pected, that physicians had formed correct rules of treatment, nothing was discovered on examining their prescriptions but tem- porary expedients and perplexity, of judg- ment." * * JJh. u De Augmentis Scient. PART II. AK INQUIRY CONCERNING DIGITALIS, INQUIRY, &c. CHAPTER I. EXPEPtlMExNTAL PART OF THE INQUIRY SECTION I. Preliminary Obser'cations. Before I commenced the study of the administration and operation of the articles of the materia medica, as a particular branch of my medical education, curiosity had made me pay some attention to the imme- diate effects that the tincture of the purple digitalis produced, when received into the human body. I observed, that it uniform- ly strengthened the arterial pulsations, and made them succeed one another more ra- pidly. So little was I acc^uainted with the views of medical men, that I believed it to be their intention to produce these effects 190 by the medicine : afterward I was not a little surprised to learn, that this substance was deemed by authors, teachers, and prac- titioners of medicine, to be a direct sedative, Endowed with the most remarkable proper- ty of diminishing the momentum of the blood and the number of pulsations in a given time. The authority of those who maintained the above opinion induced me to conclude, that my observation had been incorrect, and I resolved to lose no occasion of discovering the reason of this mistake. Instances but too soon occurred of this substance being prescribed to persons in whose fate I felt the most lively concern. I administered care- fully the prescribed dose, and always found the reverse of immediate diminution either in the force or the frequency of the pulse. I watched the immediate effects of it on the patients to whom it was prescribed in the Royal Infirmary of this city, and had the pleasure to witness some very remarkable cures accomplished by means of it, in phthisical and dropsical persons under the care of Dr Duncan, senior, and Dr Home, junior, but its immediate effects invariably 191 corresponded with those which I had first observed. Two years ago, Dr Gloster, one of the Presidents of the Royal Physical Society, watched its administration in this hospital, and the results of his experience confirmed my observations in every particular ; and last year, Mr De Courci LafFan, student of medicine, not only attended to its effects in the patients to whom it was prescribed in the hospital, but also in private cases, and in no instance did he find the results diffe- rent from those which I have stated. 192 SECTION IL Concerning the Effects of Digitalis on the Pulse of Healthy Persons. AT length I began to believe, that those who had written on the subject of digitalis might have been led into mistake, and pro- posed to some gentlemen of my acquain- tance, that we should institu^te experiments to ascertain the medicinal qualities of this substance. We agreed to take it ourselves in order to ascertain its effects during health, and some of us devoted much time and at- tention to observe how it operated in those labouring under disease.* Many gentlemen have occasionally taken it with me, whose names I have forgotten, but r acknowledge myself much indebted to the following, whose names are arranged in the order of time in which they made their experiments. Mr Richard Arrindel, student of medicine ; Dr Benjamin Hardt- * The tincture of digitalis, whicli I eitiployed in all those experiments, was accurately prepared according to the Edin- burgh Pharmacopoeia by Mr Benjamin Brown, surgeon and apothecary. 193 man ; Mr Theodore Gilbert, surgeon ; Drs Charles Farquharson, CD. Johnston, Hen- ry Davies, J. H. Walker, William Win- Stanley, lecturer on botany in Manchester ; Dr David M'Laggan, one of the presidents of the Royal Physical Society ; Mr Murray, lecturer on chemistry ; Mr G. R. Nuttle, f student of medicine ; Mr George t^ordon, one of the presidents of the Royal Medical Society of Edinburgh ; Mr R. H. Dyett, surgeon ; Mr J. W. Turner, student of medicine ; Mr Hall Veitch, surgeon ; Dr James Low, president of the Royal Physi- cal Society ; Dr William Stott ; Mr J. T. Gaines, and Mr William Back, students of medicine ; Dr John Gordon, one of the presidents of the Royal Medical Society; Mr Alexander Walker, lecturer on the laws of organic existence ; Drs Hinton Spalding, and H. H. Tyler ; Mr De Courci LafFan, student of medicine ; Dr Thomas Lee ; Mr Allan Burns, lecturer on anatomy and sur-^ gery in Glasgow ; Mr Henry Hardie, Mr Michael M^Creery, and Mr George Sanders, students of medicine. Two or more of us met at a time, count- ed each others pulses, administered to each other from 10 to 30 gtt. of the tincture of 194 digitalis in a wine glassful of cold water, and the general result was, that these small doses increased the force and fre- quency of the pulse. We previously satis- fied ourselves, that the swallowing of the same quantity of water, produced no sen- sible effect on the circulation, nor was the effect different when we put into the water a quantity of alcohol equal to the dose of the tincture of digitalis ; thus it was evi- dent, that the effects were to be ascribed peculiarly to the digitalis contained in the draught. The human mind is wonderfully fertile in objections to facts, which are repugnant to opinions sanctioned by general consent ; and this faculty of the ixiind has contri- buted much to the advancement of accu- rate science, though it has also retarded her progress when exerted in defence of prejudice, or from motives ungenerous and culpable. Those gentlemen, who object- ed to the experiments which I had made, were actuated by the purest motives, and as I wished to ascertain and establish the truth, I entreated them to repeat the expe- riments along with nie ; and no one has done so, who has not assured me, that he 195 was convinced of the stimulant powers of this remedy, and it was in this way that all those whose names are mentioned, were induced to repeat the experiments. One gentleman in particular was of opi- nion, that the mind, in expectation, might have some influence in increasing the strength and frequency of the pulse. I, re- plied, that as he expected, that the pulse would be diminished both in number and strength, I advised him to take a dose of it, to satisfy himself whether the event would correspond with his expectation ; accord- ingly he, other three gentlemen and myself met, and the event in all was an increase of the pulse in frequency and force. That the mind indeed had very little influence in modifying the effects of the digitalis, is established by this fact : water, coloured with inert substances, given to persons who think they are receiving digi- talis, is followed by no change in the state of the pulsations, after which if the digi- talis be taken, the arterial system never fails to evince the phenomena which I am now detailing. I taught some persons, who had no in- terest in medical theories, to count the pulse 196 of their relations, to whom this medicine was prescribed, and they all assured me, that they perceived the beats become stronger and quicker after taking the dose. The dose of digitalis is no sooner swal- lowed, than changes are perceptible in the arterial contractions. Sometimes the pulse flutters for the first three or four seconds, and then becomes regular, firmer and more frequent than before the dose was taken ; occasionally it will evince a degree of irre- gularity in the strength and succession of its beats even for an hour ; there is often an increase of impetus and none of, velo- city, or the contrary ; often also, the one precedes the other, though in general, they accompany each other. I have once or twice observed, after a large dose, that the pulse seemed to stop for a moment, and then proceeded with increased activity ; in some persons I have observed the pulse diminish in number, and at the same time, becomiC much stronger ; this however never happened, but when the pulse was irregu- lar both before and after the taking of the medicine, and when it was taken by the same person at another time, the pulse fol- lowed the general rule. 197 The stimulant effects of digitalis are not transitory, but of different duration ac- cording to peculiarity of constitution. Of these experiments I made and witnessed at least two thousand, with this uniform re- sult, — augmentation of the velocity and impetus of the circulation in healthy per- sons. I now resolved to observe what might be the effects of digitalis on the healthy sys- tem, if it were taken daily for some length , of time. To know what my pulse was in my usual state of health and manner of living, I kept a table of the number of pulsations counted daily for many weeks before break- fast, and before supper. In the morning before I took any exercise, my pulse was uniformly 60, feeble ; and at night after sitting about two hours, it was 56, feeble. This being ascertained, I began, 24th May 1805, to take fifteen drops of the tincture of digitalis in a wine glassful of cold water, night and morning. The first three days, my pulse was about 70 in the morning and 66 in the evening, during which time I felt myself uncommonly well, except, I thought .198 that I sometimes felt slight shifting pains in the breast. My daily reports after the 27th, on which I took 25 gtt. are : May 28. I passed a restless night, being hot and feverish, and the pain of breast^ which I had been troubled with, was more severe than ever this morning, and from the ensiform cartilage upward, my breast was sore to the touch , pulse before break- fast 76, and strong, and in the evening about 70. 26. I was harassed with tormina the preceding night after going to bed, which did not abate before three o'clock in the morning. I had a sense of weight in the head and of uneasiness in the breast all day ; pulse as yesterday. 30. I slept but little during the night, and my mind had somewhat of that restless activity which I have experienced after taking too much wine, but particularly after taking tinct. opii ; pulse about 80 in the morning, and 90 in the evening : du- ring this day I took 50 gtt. of the tinct.~ digitalis. 31. I was very drowsy when I went to bed, but did not sleep soundly. I had a 199 troublesome sense of weight in the head, which was reUeved in the forenoon by an attack of epistaxis. I continued drowsy and incapable of study till the evening. Appetite still impaired ; pulse nearly as that of last night. My taking of the digitalis was now given up. June 1 . My headach still continued ; I slept better during the night ; appetite still impaired and mind incapable of study ; pulse nearly as yesterday. I took a laxative composed of aloes and hyosciamus, and adopted an antiphlogistic regimen. June 2. I slept well during the night; appetite impaired ; pill operated gently du- ring the day ; on the 3d some degree of headach and unsteadiness of mind were still present ; my pulse about 78 and pretty full. In eight days from the first of June, the pulse returned to its usual standard. These facts afford this inference, that di- gitalis possesses the property of increasing the frequency and force of the pulsations in healthy persons, and that, if its use is persevered in, it will induce the symptoms of inflamniatorv disease. 200 Section iil \ '\ ileasonsfor beliexmg that the Digitalis is admi- i nistered on False Principles. \ THE effects of the digitalis on the heal- i thy constitution precede in this detail those I on the constitution disturbed by disease, i but it is an inversion of the order in which i the facts occurred to my observation ; be- \ sides attending, as I have already said, to i what happened in the patients in the Infir- | mary, I had carefully marked the parti- ; Gulars of the following cases, before the ex- \ periments were made on persons in health. ; It seems not improper to mention here, j that the first cases, which I watched, were J those of persons under the care of the first i medical men of this city ; I prescribed no medicines, nor did I interfere in the ma- | nagement ; I only, for my own instruction, \ noted the symptoms, attended when the ■ medicines were taken, and carefully marked i whatever changes supervened in the pulse, ; ^s well as in the general state of the consti- i tution of the patient. ] aoi CxiSE I. P*1rs , aged 46, of ordinary sta- ture, florid complexion, dark eyes and hair, haughty and irascible mind ; was some- times extraordinarily animated and lively, but more frequently peevish, melancholy and dispirited. In September 1802 she took a very distressing catarrh, which yield- ed, in a short time, to the antiphlogistic treatment, but there remained slight pains of the chest, with a tickling sensation in the fauces, and a short dry cough, aggra- vated on taking exercise. These symptoms became ' imperceptibly worse ; in the be- ginning of December she could only lie on the left side ; her pulse, which had risen gradually in the course of three months from between 60 and 70, was now about 90, and feeble. Her nights were restless, her days gloomy ; and desire of death, which she had often expressed after the loss of her husbanilj^s^ho had died some years before of phthisis pulmonalis, was now more frequently repeated an 'I with greater earnestness than ever. Since that misfor- tune, opium had been her only solace ; she began by taking small doses of the tincture, and had imperceptibly augmented them till the quantity that she took daily, for some months, was enormous, frequently five tea- spoonfuls in" twenty-four hours, and the spoon contained easily 100 gtt. She was very languid in the mornings, had no ap- petite, 'tea made her sick, and she vomited whatever she took to breakfast. Her stools were pretty natural, urine high coloured. She was ordered, in the beginning of Ja- nuary 1803, to limit the quantity of tinct. opii to 30 gtt. twice a-day, and to take 10 gtt. tinct. digitalis three times a-day, and to increase the dose to 20 gtt. gradually. I examined the pulse before and after every dose, and found it increased in strength and in number of beats. It v/as raised to about 100, and continued so for an hour or two after every dose. She became cheerful, thought herself improving in health for five weeks, during which time she had obeyed the prescription with a few intermissions of a day or two, and, at the end of it, she thought herself so much better, that medi- cine was unnecessary ; but she was per- suaded not to desist from its use, by being told, as is too ofter^ done, that she ought not 203 to give up the use of a substance which had done her such evident service. The pulse had been gradually rising, and was now about 120. She began to be affected with cold shiverings, and in five weeks more she laboured under a most violent hectic fever ; the pulse in the hot stage about 150, and strong ; in the cold, so irregular and feeble that it could not be counted ; the purulent sputa were very copious. The digitalis had, all this time been taken, but not daily, for she sometimes imagined that it was hurtful to her, and let it alone for two or three days ; again, imagining it salutary, she resumed its use* After every dose taken in my pre- sence the pulse became more regular and firm, and, during the last five weeks, :had arrived at the alarming number already stated. The event of this complaint I need scarcely mention. CASE IT. Mrs , widow, and mother of nine children, aged 39 years, was admitted into the Lying-in Hospital of this city to- ward the end of May 1803- Her shape 204 was such as is deemed characteristic of pre- disposition to phthisis, and, from her ap- pearance, it could not be doubted, that such an affection had aheady made considerable ravages on her constitution. It occurred to me, that I should embrace this opportu- nity of observing the effects of pregnancy and parturition in such a state of body. Her ankles swelled toward evening, but this is a very cominon occurrence in the last stage of pregnancyj and several of her other complaints might have been attri- buted to the same source, were it not that she had been affected for more than three years with a dry cough, difficulty of respi- ration resembling asthma on taking exer- cise, slight obtuse pain of the left side, &c. Her pulse was now pretty quick and ir- regular ; but the pulse exhibits very great varieties in all pregnant women, and is, during pregnancy, more quick and variable than during health, at other times, in the same person. On 3d April, after an easy and short la- bour, she was delivered of a male child by one of Dr Hamilton's pupils. Immediate- ly after delivery she was remarkably feeble and exhausted, but speedily regained her strength, and, in a fortnight, took leave of the house. I was surprised to find, that all this time, her pulse never gave fewer than 120 beats per minute, and the swelling of the lower extremities continued. Not long after her dismissal she entreated my assistance. I found her in a truly piti- able condition. Her breasts enormously swelled, hard and knotty ; pulse 120, and strong ; tongue foul ; face flushed ; breath- ing uncommonly drfficult ; abdomen and inferior extremities dropsical ; an odd com- bination of the symptoms of inflammatory fever and extreme debility. By the free use of saline purgatives, the distension and tu- mors of the mammae were subdued ; respi- ration was very much relieved by a large vesication, which was always re-produced, for when it was allowed to heal, she felt as if threatened with instant suffocation. The pulse became again 120, and feeble; the symptoms of phthisis pulmonalis, hydro- thorax, anasarca, ascites, made alarming progress. In this case I thought it proper to try what digitalis could effect, along with as good diet as she could procure. The bowels were kept regular. Half a grain of foil, digitalis 206 was administered night and morning, and half an ounce of the pulv. cinchonae was taken during the day. Her pulse continued three weeks undiminished in number, of in- creased strength and regular. In the mean time, the quantity of urine discharged be- came greater, the swellings decreased, the pectoral symptoms were much relieved, so that the patient conceived fond hopes of recovery ; strange tenacity of life, gratified with the prospect of existence amidst dis- grace and poverty ! At the end of this time, the pulse be- came feeble, intermittent, slow, of not more than fifty-five or sixty beats per mi- nute ; thirty drops of tinct. opii were now given twice a-day instead of the digitalis ; the regimen, in other respects, remaining the same ; in three days the pulse became very good, of seventy beats per minute, but the other symptoms worse. The digitalis was now repeated in greater doses with a repetition of the same phenomena, except that the pulse was elevated to a much greater degree, and, in a much shorter time, the intermission and paucity of its beats recurred ; it was asain restored by the 207 ^ laudanum. This was repeated with the same result several times. To ascertain how far other stimulants would promote the restoration of vigor in the sanguiferous system, wine, gin-punch, porter, &c. were used in very considerable quantity ; but, what astonished me, with- out altering the pulse in the least ; the lau- danum being added, recruited the pulse in about three days. The treatment of this case partly resem- bles that of a man named Cunningham^ who was under the care of Dr Duncan, se- nior, in the Royal Infirmary.* Finding, that the beneficial influence of the digitalis was but of short duration, and by no means adequate to compensate the bad effects which ensued, I endeavoured to give relief by other remedies. Squills and calomel were Used in very great doses in- ternally, and a drachm of the mercurial ointment was rubbed on the limbs daily. An immense quantity of mercury thus in- troduced into the system never excited sali- vation, nor did she complain of uneasiness in her teeth or gums ; and such was the * Annals of Medicine. 208 inveteracy of the disease, that these power- ful substances never so much as alleviated the symptoms ; but the digitalis was never taken without exhibiting, in a greater or less degree, the effects already enumerated. This complication of maladies at last reached the highest pitch of malignity. .The head and trunk, with extremities su- perior and inferior, were one mass of tume- faction. Excruciating pains were felt in the feet, on which rose la,rge blisters, re- sembling those from boiling water ; the toes became black ; mortification seized various parts of her body, and was spreading with rapid havoc, when one night in September terminated her sufferings. The case of this patient was to me very instructive. The events were in perfect conformity with what is affirmed by Dr Hamilton in his invaluable Lectures on Midwifery ; " that if the pulse remain se- veral days after delivery to beat above 100 per minute, we may be assured, that there is some latent evil preying on the consti- tution, which will soon manifest itself in the form of some dreadful distemper," — a remark highly honourable to his genius and 209 talent for observation ; and, " that death is the inevitable consequence of parturition to a woman labouring under an advanced phthisis pulmonalis . ' ' CASE in. Mr- , aged 15. This patient had scrofulous swellings of the bones, muscles and glands ; besides symptoms of pulmo- nary consumption. He was of great, or ' rather premature, judgment. His com- plaints began to show themselves after a severe cold which he caught in the north of Scotland. He had soft tumors on the angles of the inferior maxilla, on the right side of the dorsal and lumbar vertebrae, on the middle and at the joints of the superior and inferior extremities ; the tops of those on the joints were brown, with open sores discharging a thin, transparent, viscid mat- ter, sometimes fetid and containing spi- culae of carious bone ; these tumors and sores were particularly conspicuous on the second joints of his thumbs ; he had in ge- neral an uncommonly keen appetite, was pe- culiarly fond of highly seasoned food and ar~ 210 dent spirits ; his. sputa resembled much the matter discharged from the exterior of his body ; his urine sometimes deposited a red, at others a white sediment ; his bowels were rather costive; pulse no, sometimes even 120. He took, according to prescription, half a grain of foil, digitalis with one grain of the submuriat of mercury, night and morn- ing, for six weeks, during which time, the pectoral complaints were removed, and the sores discharged a much smaller quantity ; the pulse was rendered full and regular, but never evinced any peculiar alteration either in the diminution or increase of the lium- ber of its beats. The use of the digitalis was now discontinued^ a day or two after which he was seized with sickness and vo- miting. I am not certain whether this oc- currence should be attributed to the digita- lis, for there was no remarkable diminution in the number of pulsations, and he had often been similarly affected previously to its use, but not during it. After this, I gave him the muriat of lime to the amount of half a drachm a-day in solution, which seemed to be of very great service to him, not only in diminishing 211 some of the tumors, but more conspicuously in invigorating his body ; for at the end of a month, he was able to walk out and amuse himself; his progress however, in convalescence, did not long continue, al- though he persevered in the use of the sam.e preparation. There was no distinct return of his pul- monary complaint for some time, but that hectic fever of the continued kind, which is described by Galen, and seems to have been well known in his time,* with general wasting, destroyed his body ; the bones, muscles, tendons, cellular substance and membranes, all wasted. He did not yet suffer much from pain, and he saw his dis- solution near with much complacency. At length however, he was much pained, he had a severe cough and expectorated co- piously the most horrid stuff. Nothing af- forded him alleviation and repose but opium. Some short time before his death the fifth, sixth, and seventh ribs were frac- tured at their salient curvatures by his weight on them in bed. His senses re- mained entire to his last moments, when * De Different. Fcbrium, a cap. x. ad xili. 212 he was a singular spectacle of decay ; liis head, like that of a foetus, seemed the largest and most weighty part of his body. In these three cases, increased impetus of arterial action continued for several weeks during the administration of digitalis. Comparing this fact with the other, that digitalis accelerates and strengthens the pulse in healthy persons, and, by its con- tinued use, induces symptoms of inflam- matory fever, I believed, that the powers of digitalis were misunderstood, and that it was administered on false principles by those who prescribed it for the purpose of im- mediately diminishing the vigour and fre- quency of the contractions of the heart and arteries. 213 SECTION IV. Demonstrates, thai the Digitalis is administered on False Principles, and that its Primary Operation is powerfully Stimulant, IN February 1805, Mr Arrindeil and myself agreed, that we would observe the effects of the digitalis more strictly than had yet been done in disease ; that we would stay by the patients a much longer time at each visit, and, for the sake of ac- curate comparison, mark the state of the pulse for some days before the administra- tion of the digitalis, and, afterward, mark the immediate effects of it when each dose was taken, and also make daily reports of the pulse counted some hours after one 'dose and before the taking of another. CASE I. ■ March 2. 1805. Mr William Shirreff, aged 18, was stout, plump and ruddy, with brilliant dark eyes and dark hair ; of a most 214 acute mind and exalted genius. He was fond of bodily exercises, bold, active and enterprising. Wken he wasv keenly ani- mated by any passion, his eyes expressed astonishing vivacity and energy of soul. But nature, as if to render her favours abor- tive, had sowed deeply in his constitution the seeds of disease. He had occasionally, for several years, felt pains of the thorax extending particularly toward the left shoul- der, both with and without spitting of blood, which had always, before the 4th of Febru- ary last, yielded to vensesection and a strict antiphlogistic regimen. On the evening be- fore this last attack, when walking with an acquaintance, his foot slipped, he fell and threw his arms backward to save himself; on rising, he complained of pain in his breast, and, being uneasy, went home : next day, while earnestly occupied in paint- ing,* a sudden sense of heat in the breast and sickness at stomach overwhelmed him, * He was at this moment nnisliing an original design, which he had conceived the year before, representing the escape of Mary, Queen of Scots, from Lochleven Castle. This piece, considering the age of Mr Shirreff, is worthy of great admiration. It has since been engraved by Mr W. H. Lizars, his acquaintance, of the same age -svith himself, in a very masterly style. 215 and he instantly vomited an immense quan- tity of florid red blood. The first medical assistance of this city was procured; he was freely bled at the arm the first afternoon and the succeeding day ; on the third evening, I saw him for the first time after that misfortune ; his looks were the most ghastly and pale im.a- ginable ; he vomited mouthfuls of blood every few minutes, and death was expected every moment. Though I had no right to interfere in the treatment, yet, in this awful state of despair, I advised his father to apply flannel soaked in cold vinegar and water to the breast, which, after some hesitation, the vomiting of blood becoming still more urgent, he did, and from that instant the haemoptysis stopped. Next morning, the medical at- tendants approved of what had been done, and ordered the application to be repeated, if necessary. He seemed, for some days, convalescent, but there remained a teazing cough and pain under the sternum ; he did not sleep well, and was sometimes very fe- verish, but had no cold shiverings. About ten days ago, these however came on in a 216, slight degree, succeeded by pretty copious expectoration, and still continued. This day, the tincture of digitalis was prescribed by the physician, and Mr Ro- berton and myself agreed to watch its ef- fects. His pulse had, in general, been about 96 per minute and not strong, but at four o'clock p. m. the pulse was varying from 94 to 96, and immediately aftec taking 11 gtt. of the tinct. digitalis, it beat 100 per minute and was much stronger. 3. Ten o'clock a. m. He has passed an easier night; has taken some food this morning; pulse about 100, immediately raised to 106 by 11 gtt. of the tinct. di- gitalis. Four o'clock p. m. he had been somewhat restless in the former part of the day; his pulse was now about 100, and pretty full ; instantly much increased by 11 gtt. of digitalis. 4. Reports of this day nearly as those of the preceding. 5. Ten o'clock a. m. pulse 104, pretty regular, by 1 1 gtt. instantly rendered more frequent, and, in a few minutes, much stronger. Both yesterday and to-day the digitalis seemed to excite coughing. The patient complained, that the difficulty of 217 respiration had been much more distressing to-day. Sputa less in quantity and less fluid than I had observed them to be on any former day. He complained also, that the force and frequency of his pulse beating in his head and neck disturbed and alarmed him during the night. He has been very restless in the night and is so still. Took an opiate draught last night which he has done every night since he was last seized ; it uniform- ly quieted and gave him relief. This young gentleman having paid some attention to anatomy, observed his pulse with peculiar care, and was much alarmed at any change which he thought that he perceived in it ; he sent for Mr Roberton a few nights ago, because he dreaded, that his pulse would immediately cease to beat. Four o'clock, p. M. he has been very feverish, thirsty, restless and drowsy all day ; pulse 105, and strong ; 1 1 gtt. instantly raised it to 11 2, and in about three minutes it was much strong- er. Half an hour past eleven p. m. all the symptoms were much aggravated, and the pulse beat 120. A short time before I ar- rived, the patient finding himself very un- easy had taken an opiate with some relief. 6. Ten o'clock a. m. his face is flush- ed and anxious ; breathing more difficult than ever, he feels severe pain in the right side, and evinces some degree of deafness. He had been alarmingly distressed to three o'clock in the morning, after which he slept some, and continued easier ; pulse 128, as counted by Mr Roberton and myself. He had inhaled the steam of vinegar and v/ater in the night with relief. The state of the pulse and other symptoms had become so much worse since the employment of the digitalis, that we doubted whether it should be continued ; but, as the state of the patient was desperate, and as the digitalis had been found, according to authors, be- neficial in such cases, it was resolved to increase the dose to 1 5 gtt. twice a-day, and in the mean time to watch the symptoms with the utmost care, and, if they were still aggravated, to intermit its use. On return- ing to the patient's bed-room, we found the pulse much milder, and beating 120. This occurrence suggested to me, what I deem an important lesson in conducting such observations. If we had given the di- gitalis during the hot exacerbation which the patient suffered when we first examined. 219 the remission mioht in the same manner have ensued, and we would have been per- haps incHned to attribute to the medicine, what would have happened independently of it. 15 gtt. of the digitalis were nov/ given him, which had no other immediate effect on the pulse, than that of making it stronger. A¥hen the medicine was offered him, he said he wished to have no more of it, for it made his pulse very strong. Half an hour past four o'clock r. m. he was very restless and dreaded instant suffocation from a species of asthmatic paroxysm. His pulse v/as exceedingly irregular, and his counte- nance livid. I gave him about 51. of sul- phuric ether in a wine glassful of cold water, which instantly produced a discharge of flatus upwards, and was succeeded by relief and composure. The pulse was now 120, and continued so for 1 5 minutes, when I gave him other 15 gtt. of the digitalis, immediately after taking which, the pulse became variable, and in three minutes was 126, regular and stronger. 7. I visited him this imorning along with Mr Roberton. He suffered many severe paroxysms of dyspnoea during the night ; he enjoyed some rest before live in the 220 morning ; had a severe febrile exacerba- tion between seven and eight o'clock, since which he has been somewhat calm ; pulse about 116, and skin cool ; 15 gtt. of digita- lis immediately made it much stronger, and increased the beats to one hundred and twenty-three ; he became immediately very restless, and complained much of his diffi- ^culty of breathing. Half an hour past four o'clock p. M. a vesicatory was now on his breast on account of the dyspnoea ; he was very drowsy and restless ; pulse 114, some- what irregular, and not very strong ; 1 5 gtt. made it immediately very irregular, but in three minutes it was distinctly about 120 ; slight cough was excited, but he coughed a little just before he took the draught. The sputa were much diminished in quantity and resembled small inspissated globules. 8. Ten o'clock a.m. the dose of the digitalis had been given fifteen minutes before I arrived ; the pulse previously beat one hundred and twelve, immediately after taking the dose, it increased in velocity, and now it was one hundred and twenty- six, and very strong ; the patient was very restless. Four o'clock p. m. the patient was exceedingly uneasy, every symptom re- 221 markably aggravated. He had been alarm- ingly ill from the time of our morning visij, and wildly delirious ; pulse varying from 150 to 158. He often asked, why his breast was tearing open, and why portions were cutting from his lungs ? This young gentleman's father, a man of literature and observation, would not allow any more of the digitalis to be given. The vesication had afforded no relief. g. He had rested a little during the night after the opiate draught ; the symp- toms were in general mitigated; pulse 120; sputa as yesterday. Four o'clock p. m, he had been much easier than on the three preceding days ; the breathless exacerbjl- tions were neither so frequent nor so severe ; sputa as last described; pulse about 1.30; delirium somewhat abated. 10. Four o'clock p. m. the report of this day the same as that of the 9th, except that the sputa were fluid and more copious, 11. Ten o'clock a. m. he has been very restless all night ; sputa as yesterday in quantity but much more fluid ; he is now labouring under a hot exacerbation, with the pulse about 140, and strong. 222 12. Ten o'clock a. m. he had passed a very bad night ; he took an opiate at midnight, which only increased the deli- rium ; he was now torpid ; eyes very heavy ; nostrils expanded ; mouth open ; breathing laborious; features collapsed; countenance livid; pulse 138, not very weak ; a slight decree of subsultus tendinum ; he still takes food, and has had pretty good appetite all the time ; he never has had any tendency to diarrhoea ; his bowels have been kept regular by laxatives ; his tongue has in ge- neral been moist, and not very sordid. Next morning after some moments of fury and convulsion, he bade this world ^dieu forever. The administration of digitalis was, in this case, sanctioned by that unanimous consent of medical authors, and universal practice of physicians to which the whole of this part of my work has an allusion. But this unfortunate youth had so long la- boured under the disease, and the havock made in the lungs was evidently so exten- sive, that no human power could have saved him. 9 y Q CASE II. March 3. 1805- Mr , aged 45, a handsome little man, had all his life enjoy- ed pretij good health, as he thought. Pains of the breast however, of various severity, seized him occasionally ever since his 1 7th year. He was very Hable to catarrh in autumn and spring, and the two last years the cough has often been so severe as to excite vomiting. He has never been able to run or clim.b much on account of dysp- noea.- During the last v/inter, emaciation had made very great progress in his body. The cough was terribly distressing, and ter- minated in a discharge of transparent viscid sputa. Cold air, or cold any how applied, produced intolerable chilliness. About the beginning of last autumn, he was frequent- ly sick in the mornings, and often vomit- ed particularly ^on taking tea ; but of late whatever he eats or drinks induces sickness and vomiting. He loathes all food; he does not suffer from any acute pain, but keeps himself in bed from a consciousness of great debility. He is fretful, peevish, pnd apprehensive of danger. He is, at 224 times, hypochondriacal, and during the last six months has often been outrageous, and shown many signs of a tendency to mental derangement, which was formerly in him not an uncommon temporary con- sequence of intoxication. For about three years past, he has been pretty sober^ and has refrained from the worst kinds of dissi- pation.* When in his usual health, his pulse beat about fifty times per minute. March 6. Five o'clock p.m. pulse about 60 and weak, which was not altered by 1 5 gtt. of tinct. digitalis. 10. Four o'clock p. m. pulse 66, made immediately stronger by 1 5 gtt. of digitalis, which dose was given twice a-day since the 6th. -11. The cough had been more trouble- some during the night ; he is somewhat cheerful ; he took 15 gtt. of his own ac- cord this morning. Five o'clock p. m. pulse 65, pretty strong; increased immediately in strength and velocity by 15 gtt. ; in five minutes after taking the dose, it beat regu- larly 71. In a short time considerable coughing came on. * He had long been devoted to the detestable practice of self-pollution. ^25 12. The cough has been more trouble-^ some at intervals during the night, than for some nights past, he slept however pret- ty soundly and was refreshed by it ; pain of chest almost gone ; sputa and urine as usual ; mind pretty cheerful, and sensations more agreeable than he thinks they have been for six months ; appetite improved ; he took 1 5 gtt. this morning. Five o'clock p. M. pulse about 63, of natural strength ; functions natural ; 1 5 gtt. instantly increas- ed the strength of the pulse, which I conti- nued to feel for five minutes ; in fifteen minutes more it was not quite so strong. Slight cough came on. 13. He enjoyed good rest in the night ; cough easier ; expectoration easier ; pain of chest not troublesome ; he took about 20 gtt. this morning ; appetite not so good as yesterday ; mind depressed ; he felt some sickness this forenoon, which can scarcely be attributed to the medicine, as the patient had been but very few days free from sick- ness and vomiting for some months till within these three weeks, and had never been one day wit-hout sickness for a long time till he took the digitalis j evacuations p ^26 natural ; pulse about 56, and feeble ; which 20 gtt. of digitalis immediately invigorated, and increased to 58. 25. He has been very feeble since the former report ; 20 gtt. digitalis have been taken twice a-day ; pulse for three or four days has been 48, and strong ; to-day the pulse is 48, and strong, except that a very feeble beat frequently intervenes ; 30 gtt. instantly raised the number of its beats to 54, weaker and more regular ; he has been much distressed with coughing and vomiting, and was very restless during the night ; he has, for some days, refused his proper nourishment This lowness of the pulse did not alarm me, for three years ago, •when making observations to ascertain, whether there v/as any difference between the pulsations of night and morning, I counted this gentleman's pulse for some weeks, as well as that of several other per- sons, and found it, when to all appearance he enjoyed good health, to beat 50 in the morning and 48 in the evening. Its beats were uncommonly strong, a feeble one often intervening ; so that in him the ar- terial system seemed to have resumed the number of its healthy action. 227 26. He had no vomiting last night ; he was very sick, and much troubled with tenesmus ; he had a sound and refreshing sleep this forenoon ; countenance very pale; lips livid ; gums of a pale red ; teeth very clean and white, which they were not when he was in health ; eyes of a pearly hue, and, though brilliant, expressive of languor ; he complains of great debility. Half past four o'clock p. m. pulse 48, not very strong, with some indistinct beats ; after 1 1 gtt. digitalis the pulse immediately became very irregular both in strength and number of beats ; this state of the pulse continued about half an ''hour, when the pulsations became regular and of equal and moderate strength, and two more per mi- nute. 28. Half past four o'clock p. m. a ca- thartic, given on the 26th, produced sick- ness and vomiting instead of the intended effect, since which he has continued very poorly. Last night, ghastliness and des- pair were depicted in his countenance ; pulse about 42, and irregular. He now got a dose of a mass composed of aloes and the extract of hyosciamus ; to take a glass of port wine almost every hour. 228 29' Half past four o'clock p. m. the pills above mentioned operated well during the night ; they have relieved him much, and he has since had a comfortable sleep, and is much better ; pulse 44, and pretty strong ; 30 gtt. now excited slight cough, made the pulse first irregular, next vigorous and quicker, but, in half an hour, it was the same as before, and he says, that there is a certain uneasy sensation at the pit of his stomach which the drops always relieve. 30. Half past four o'clock, p. m. he slept well during the night, and had consi- derable pain in his breast this morning, which is much easier. Sputa, for some days, have been much thicker than before. He took 20 gtt- about eleven o'clock, a. m. and thought himself very comfortable till a little after one o'clock, but has been rather worse since ; he has taken almost no food ; he attributes this change to a mixture of beer and bread, sweetened with sugar, which he took ; his looks are improved ; pulse 44, with beats of unequal strength ; he now took a small bit of beef-steak, and about half a pint of London porter, to which about 3i. of alcohol was added ; he w^ould not have wine. Immediately after 229 taking these, his pulse was of equal strength, but not altered in number. In half an hour, he became drowsy, and his pulse was now less strong and about 42 ; in another half hour, it was firm and strong again and still 42, and the drowsiness left him ; 20 gtt. made the pulse immediately irregular, and excited coughing, but the beats were, in a short time, 44 and strong. To take one of the laxative pills. 31. Half past four o'clock, p.m. he, having neglected to take the pill, has had no stool. He thought himself tolerably well, and enjoyed some sleep the latter part of yesterday, but has been very uneasy since midnight, and frequently attacked with very oppressive sickness. He took 20 gtt. about nine o'clock this morning, which very much relieved him ; but, soon after mid- day, sickness attacked him with vomiting ; pulse 42, regular and rather feeble ; some beef, and porter ^containing alcohol, made it immediately 48, and strong ; in ten mi- nutes, it returned to 42, but continued strong. To take two pills. April 1 . The pills produced several fetid and dark brov/n stools since eleven o'clock last night ; he has been frequently sick ^ 230 he has taken some food. Half past four o'clock p. M. pulse about 44 and not strong; in a few minutes it seemed to increase in strength ; he now took some porter and alcohol, which had no effect on the pulse ; in half an hour more, the pulse continuing as above, he took two glasses of port wine, which had no effect on the pulse ; he does not appear so much debilitated as he has done for some days past. April 2. Four o'clock p. m. he slept well during the night, and felt very agree- ably all the last evening ; he took break- fast with appetite, but felt squeamish to- day several times ; this sensation was always removed by taking a little wine, porter, or porter with alcohol. His countenance is pretty cheerful ; he complains of pain in the breast, and also in the abdomen about the umbihcus ; pulse 44, with frequent feeble beats or rather vibrations ; 20 gtt. digitalis increased the strength, but not the frequen- cy of the pulse, and the vibrations were nearly removed ; the pains were immediate- ly relieved ; to take a pill to-night ; in twenty minutes after he took the digitalis, he eat a bit of beef-steak, which seemed to have accelerated the pulse, but, in twenty 231 minutes more, the pulse was 44? strong and firm, without the vibrations ; he now be- came drowsy. 4. He had an uneasy night between the 2d and 3d, with vomiting ; the pill operated well ; he has taken some food ; he slept well last night ; appetite much improved ; he took the digitalis twice yesterday and once to-day, with beef-tea, wine, and por- ter containing alcohol ; pulse 44 ; I now gave him 30 gtt. of digitalis, which did not immediately affect the pulsations. 5. He slept well, and was very comfort- able last night ; this morning he took the digitalis, and a little port wine, after which he enjoyed an agreeable and refreshing- sleep. Four o'clock p. m. he is somewhat sick, which he attributes to some potatoe- pudding which he eat ; pulse 46, very va- riable in strength ; his countenance vety pale ; he took a little beef-steak, with por- ter containing alcohol, on which the sick- ness went off, and the countenance became cheerful ; pulse still of the same number, with its beats almost all of equal strength, and continued so till six o'clock, when they became very strong, and still of the same number ; 30 gtt. now given had no per- 232 ccptible effect on th'e pulsations j belly re^ gular. 6. He slept well last night ; he took 20 gtt. this morning, and felt himself very- comfortable till dinner-time, when he took some soup with a little bit of beef, after which he became sick, and, notwithstand- ing some wine, &c. which he took, has vomited twice some of the fluid, but none of the solid. Nine o'clock p. m. pulse 44, weak, and pretty regular ; I gave him 30 gtt. digitalis ; the pulse immediately became very strong, beating 44, besides six weak beats per minute ; in ten minutes, the beats began to diminish in strength, unaltered in number, and still with the intervening weak beats ; belly regular ; his health upon the whole seems to improve. After this time, it was not in my power to watch the effects of every dose on this gentleman's pulse. He continued to take the medicine with apparent advantage for about a week more, when all the symptoms became worse than ,ever. His pulse was now 36, feeble and intermitting ; and his body, instead of its athletic form, now re- sembled that of a delicate stripling. The use of the medicine was no longer persisted 233 in, but after this, he took nourishing diet and port wine without inconvenience ; the cough had lost its severity ; his bowels were pretty regular ; his urine deposited a whitish sediment ; his pulse rose to about 50 and feeble, and in this way, for some time, he seemed convalescent ; but emaciation pro- ceeded with uninterrupted pace ; he after- ward became frequently delirious and child- ish ; his pulse was about 65, and feeble, and so continued till near the end of May, when one morning he felt himself free from all pain, his senses were sound, his countenance was pale, but the rays of hope imparted un- usual animation to his eyes ; he took wine freely, and even some animal food with ap- parent satisfaction, but his lips touched each other, and his tongue moved, not with the elasticity of life, but as if they were inani- mate instruments of lead. The fascinating dream of recovery deluded him only till next forenoon. He was raising a glassful of wine to his mouth with complacency, when it fell from his hand ; he seemed astonished and alarmed ; he tried to lift a spoon that was near him, and found, that his fingers fell from the spoon before it reached his mouth. The charm was now 234 dispelled ; despair appeared in his face ; weeping like a child, he sunk in his couch ; he became now regardless of the world and of life ; his feeble pulse now varied from 90 to 120 ; colliquative diarrhoea came on, and he died without a struggle in a few days. CASE III. Mrs ^ aged 33, mother of one child, was tapped by Mr Arrindell, Feb, 7, 1805, and two gallons of a thick viscid fluid were evacuated. Her complaint began about two years before with excruciating pain in the right side, sickness and bilious vomiting in the mornings, &c. She had suffered all the routine of remedies for in- flammatory affections of the liver, and sub- sequent dropsy ; she had been vomited, purged, blistered, tapped, sahvated. Mercurial preparations in particular had been employed internally and externally, in great quantity and for a long time, but never were of any permanent advantage. About the end of the year 1803, the above enumerated symptoms had almost all left 235 her, but she had become very feeble, and con- tinued so, and ascites seemed to be making- rapid progress. She was first tapped in the beginning of May 1804, and has been four times tapped since. The catamenia had been suspended, but were now pretty re- gular. She lay with ease on either side. 20. She was tapped again, and about three gallons were evacuated. That internal disease extensively infested the abdomen was evident, for, through its parietes, irregular indurations were percep- tible to the touch in many parts from the scrobiculus cordis to below the umbilicus, and spreading latterly to the anterior and superior spines of the ilium ; the largest of them commencing at the middle of the epigastric region seemed to occupy all the right hypochondrium and cover the kid- ney. 28. For some days the pulse had been varying from 70 to 90 per minute. This day, Mr Arrindell began the use of the tinct. digitalis. He gave her 15 gtt. in a wine glassful of cold water ; the pulse was previously 88, but immediately after swal- lowing this dose, it became irregular, and, during the first three minutes, varied from 236 eighty to ninety-two beats, weak and strong alternately, but, at the end of three minutes, the pulse was 96 and stronger. Five o'clock p. M. pulse 92, full and hard. She com- plained of nausea and pain of back. Seven o'clock p. M. pain and uneasiness gone ; pulse irregular, which it continued to be after she took other 15 gtt. March 1. noon. Pulse varying from 76 to 80 ; in five minutes after taking 20 gtt. it varied from 82 to 86, and was stronger. Four o'clock p. m. it was still irregular, much more frequent and strong. Half past eight o'clock p. m. the pulse was 92, and regular ; three minutes after taking 20 gtt. it was irregular and stronger, varying from 84 to 98 ; in fifteen minutes more it was 100 ; she now felt shooting pains in the abdomen. 2 . noon. She had passed a restless night ; pulse 80 ; 20 gtt. made it very irregular, but in twenty minutes the pulse was 88, and regular. Half past six o'clock p. m. the pulse was 96 ; she had been exerting herself a little, and complained of slight pain of back ; 20 gtt. produced an imme- diate fluttering of the pulsations, which, in four minutes, varied from 96 to 108. 237 March 3- Previously to taking the drops, the pulse was varying from 80 to 88 ; immediately after, from 88 to 96, and stronger, without any fluttering. She is cheerful and much improved in her looks. Half past eight o'clock p. m. she slept this afternoon, and, on awakening, was affect- ed with nausea ; her pulse strong, vary- ing from 92 to 104; drops not repeated. Eleven o'clock p. m. sickness gone ; pulse much stronger than formerly, and 88 in the horizontal posture. 4. noon. Pulse previously 88 ; in se- ven minutes after, it varied from 88 to 96. Seven o'clock p. m. the pulse before tak- ing the medicine varying from 96 to lOO ; in five minutes after, it was 104 in the ho- rizontal posture. 5. noon. She had passed a restless night, had severe pain in her right side, and great thirst ; such distressing symptoms continu- ed for four days, and, in the interim, the quantity was increased to about 5i. per* diem. 9. One o'clock p. m. her pulse before taking the medicine 60 ; after it, from 52 to 60, and much stronger. 238 10. One o'clock p. m. the pulse was 54, and feeble ; he gave her an increased dose, and, in eight minutes, her pulse was from 64 to 72, and full. The digitalis was still continued for a week ; the pulse never fell below 52, and was, for the most part, increased imme- diately by every dose. Though after this time, the digitalis was occasionally administered to this pa- tient, and uniformly with results similar to those above detailed, it would be unneces- sary to relate the daily reports, as the in- tervention of many symptoms caused other remedies to be employed as palliatives, and rendered it difficult to judge what share each of them had in the changes that fol- lowed their administration. The patient declared, that she derived more benefit from this medicine than from any other she had ever received since she was affected with the dropsy . This in- deed appeared evident, for before Mr Ar- rindell attended her, she was not able to move from her seat, or bed ; she was ema- ciated and feeble to the last degree ; but a short time after, she acquired strength, and was able to go about her usual employ- 239 ment. Having had various health, she hngered to May 6. 1806. That her case was both extraordinary and incurable, the following examination of her body after death will demonstrate. An incision being made through the parietes of the abdomen, we saw, as it were, a vessel full of v/ater, but no intes- tines ; we found, that we had entered a cyst firmly and closely adhering to the pe- ritonaeum which invests that cavity, as far up as opposite the junction of the seventh rib with its cartilage, where passing trans- versely, it imitated in some measure the dia- phragm ; from within an inch of the left side of the linea alba to the top of the os ilium of the same side, and from the um- bilicus to within an inch of the pubes, oc- cupying a space of about a foot in diameter, large irregular protuberances hung into the cyst ; the internal surface of the cyst was va- riegated with appearances of a red and white colour, the red evidently from blood effus- ed, the white appearing to be the natural colour of the cyst, as it exhibited the same appearance in the parts separated by sec- tion, and on its external surface, where it 240 adhered to the parietes of the abdomen : there were many layers of coagulable lymph upon its internal surface, which coagu- lable lymph was also in great quantity in the fluid with which the cyst was filled. This fluid was of a dark yellowish colour, about the consistence of the white of an egg. There were small protuberances into the cyst on the left of the epigastric region, and large ones in the right. Other tumors extended from the linea alba to the termi- nation of the twelfth rib, and occupied a considerable portion of the umbilical and lumbar regions. The cyst posteriorly ex- hibited an equal, smooth surface, as well as at the other parts not otherwise describ- ed ; the cyst seemed even to fill the pelvis and line the cavity as completely below the ribs mentioned, as the peritoneum usu- ally does. A cluster of tubercles on the left side of the uterus were evidently con- tained within the cyst, although the uterus itself, of its natural size and in situ, was ex- cluded. The broad ligaments were ob- literated. The cyst was a dense ligamen- tous substance about two lines in thickness, exterior to which were all the abdominal viscera. 341 The viscera in the space between the atlantal end of the cyst and the diaphragm were inundated with a fluid hke serum, the omentum was puckered upward, and much increased with large abscesses, from which when cut, a quantity of matter issued very hke that which was contained in the cyst.* Present along with me, Mr William Back and Mr James Thomas Caines, stu- dents of medicine, and Mr Brown, surgeon and apothecary, Edinburgh. CASE IV. March 4- 1805^ Mr ^ , aged 36, a very tall man, by trade a mason, is greatly emaciated ; his eyes are pearly white, his features sharp, face pale ; he has high broad shoulders, short neck, and stoops much ; his mind is remarkably despondent ; he is much distressed by a cough, his sputa are com- pletely puriform ; he complains of some pain in the right side, though he lies with ease on either, and he has a sense of tight- ness across the breast ; his inferior extrerni- * There Is a case similar to this related in the Med. Obs. and Inq. 242 ties are oedematous. There is now beside him his son, aged 9 years, dying of phthisis pulmonalis, which had aheady been fatal to his other children. This man has labour- ed under various forms of this disease, for above three years. The means employed have afforded him transient relief, but never the hopes of recovery ; his pulse is about 75, and feeble. Mr Arrindell prescribed for him the digitalis. He began by giving 15 gtt. thrice a-day, and wrote down whatever occurred. His cough speedily became more distressing, his breast more pained, his nights more restless. His pulse was imme- diately stronger, and daily, with little varia- ation, became more frequent. Sometimes the dose quickened and strengthened the pulse immediately ; at others, particularly after the medicine had been taken for some days, it produced no alteration. At one time it rendered the pulse more irregular ; but, in general, this irregularity subsided and left the pulse more full and frequent* In the mean time, his appetite was much improved, and vomiting, which formerly annoyed him much, had not attacked him. Febrile symptoms however, became more violent, and, about the end of a fortnight. 243 his pulse varied from 100 to 120, full and strong ; for some days he complained of a headach, which was at length so severe, that we were under the necessity of em- ploying the antiphlogistic treatment, by which it was removed in a few days ; but, on renewing the administration of the di- gitalis, these inflammatory symptoms were reproduced with aggravation, and, accord- ingly, we no longer persevered in the pres- cription. It now appeared certain, that the digita- lis, taken in small doses, was a very power-' ful stimulant to the arterial system, and to the body in general, both in health and in disease ; that it gradually induced febrile activity, on which, if the remedy was in- creased in the dose or even continued, an astonishing lowness of pulse and alarming debility ensued, and that its salutary effects were all produced during this state of acti- vity, but that the consequent debility was fraught with danger. ^44 SECTION V. Shows, that the Digitalis may he successfully aci-^ ministered, and in such a manner as to avoid that Debility which has been reckoned its Pro- per Effect. FROM these facts it was obvious, that, contrary to the general practice, the me- dicine should be administered in such a manner as to avoid the debility, which, I presumed, could be very easily accomplish- ed ; for, as its primary and salutary effects were febrile symptoms, , it would only be necessary to intermit the use of the reme- dy, when these approached to violence. On this principle the following cases were treated. CASE L May 29. 1805. Miss , aged 17 years, had scarlatina about five years ago, from which, she says, that she then per- fectly recovered ; about a year after, she was affected with sickness, coffee-coloured Vo- 245 miting, pains in every part of the body, and difficult respiration ; after these symptoms abated, the affection assumed the form of hysteria, and, for three successive months, she was affected by alternate paroxysms of excessive grief and immoderate laughter ; she got bitters and other tonics ; but has never since been entirely free from several symptoms of the above affections ; she has been much harassed with sickness and vo- miting, particularly after taking food, and, of late, has felt herself becoming daily worse; no food stays on her stomach ; vertigo frequently seizes her to such a degree as to terminate in syncope ; she has a sense of extreme debility ; her mind is very depres- sed and anxious ; her countenance and lips pale ; eyes dull, and her appetite very de- praved ; she has no fixed pain in the breast or any other part, but occasional pain be- low the upper part of the sternum, and also occasional headach ; she is sometimes at- tacked with a sort of spasmodic affection in respiration, which is always brought on by exercise, climbing or even walking up stairs ; she has no difficulty in making a forced inspiration, but says, " that she feels as if she had no lungs to breath into ;" ^u 246 obtuse pain and difficult respiration trouble her when lying on the right side ; she has frequent cough with difficult expectoration of a thickish sputa, but was much more troubled with this two years ago, at which time also she often fainted ; she has often, for these four years, had pains in the mam- mae, particularly on pressure, which have become much more troublesome of late ; she complains of frequent cramp and numbness of the lower extremities, and fee- bleness of their joints ; catamenia have never yet appeared ; the palms of her hands and soles of her feet are often very hot ; she often has a disagreeable sense of heat over the whole body ; her skin is in general dry, and she scarcely ever sweats, even on taking exercise to fatigue ; her inferior extremi- ties do not swell, though they did so to- ward night some time ago ; her belly is re- gular, and urinary discharge natural ; pulse 90, and feeble, _ Ten o'clock p. m. 15 gtt, tinct. digitalis imnciediately strengthened the pulse. At half an hour past eleven o'clock p, m. pulse full, and 92. May 30. Ten o'clock a. m. her looks are improved ; she slept well toward morn- 247 ing, and on awaking neither coughed nor expectorated ; she feels somewhat reHeved and more hvely ; pulse about 90, and un- equal ; after taking 15 gtt. it was for the first sixth of a minute at the rate of 108 ; during the first two minutes 99 each, regu- lar and equal ; in forty-five minutes, pulse down to 9O5 and full ; in the interval, she had taken some tea without bread. At half past twelve noon, after taking a walk and resting half an hour, her pulse was 108, regular and of natural strength ; transitory headachs have troubled her this forenoon, but she thinks herself much better than yesterday. Ten o'clock p. m. pulse 90, re- gular and of natural strength. The pulse being sufficiently good, I did not think it proper to give her any more digitalis this night. She took dinner to-day with some appetite, and thinks, that she continues much better. I ordered, that she should go out in the morning and take some new milk in the fields. 31. Ten o'clock a. m. her looks are much improved; she has taken a walk this morning and milk ; pulse about 80, and of natural strength ; she must never, as she was wont to do, take tea without bread, 24§ and, if the weather permit, she niust walk every morning as to-day, and pay attention to her bowels. June 2. Ten o'clock a. m. she fainted yesterday in the street ; she eat a bit of veal to dinner, which, in half an hour after- ward, was vomited ; she was very sick, had severe pain at the stomach, headach and ringing in the ears ; she did not walk yes- terday morning, she slept well last night ; walked, and took milk this morning ; she complains of headach, pains of stomach and slight vertigo ; pulse 96, and irregular. Two o'clock p. M. the pulsations were 120 ; they had been accelerated by walking, but sitting fifteen minutes reduced them to 96, feeble and irregular, and 7 gtt, imtne- diately rendered them regular and strongs er. Ten o'clock p, m. she took a bit of beef to dinner, and has not vomited after it to-day ; has felt no sickness, and has been much better ever since she took the last mentioned dose of the digitalis ; pulse 90, regular and of natural strength ; she took to supper a small bit of beef-steak, and after it, a glass of wine, soon after which her pulse was 84, and of proper strength. 249 3. Ten o'clock a. m. she had no head- ach nor vomiting after supper, and slept well during the night ; pulse from 96 to 102 ; she has taken tea and bread to break- fast, and is now affected with slight cough. About two o'clock p. m. her pulse being 78 and regular, 7 gtt. made it, in the first sixth of a minute, beat 20 ; in the first half minute, 47 ; in the whole minute, 90 ; in the fifth minute, 84 and variable ; in the twenty -second minute, 86 and irregular ; she has had no headach this forenoon nor ringing in the ears ; has had slight vertigo, but by no means either so constant or severe as formerly ; she has had no pain at stomach. Nine o'clock p. m. to-day she took some dinner of mild soup, a small bit of beef, and a wine glassful of brandy diluted with water ; she felt very uneasy at stomach for sonie time after dinner, but did not vomit, and, in half an hour, be- came quite easy ; she has been teazed with a tickling cough all the afternoon ; pulse 79, pretty regular and distinct. 4. She was frightened in the morning, and has been unwell all day ; she walked and took milk as directed, which was soon followed by sickness, pain of stomach and 250 , 1 I vomiting ; she took some tea and bread about ten o'clock a: m. felt very uneasy and asthmatical all the forenoon ; about noon, of her own accord, she took 7 gtt. of digitalis which relieved her much. Four o'clock, she took some roasted lamb, po- tatoes and gooseberry tart with cream ; after which she became very sick, was af- fected with swelling and pain at stomach, and vomited ; since dinner, she has^ had several fits of dyspnoea with a sense of stric- ture in the breast, which was instantly re- lieved by a small quantity of nitrous ether. At nine o'clock p. m, she was labouring un- der a severe fit of this kind, sighing pro- foundly, and alarmingly oppressed. I gave her first about 3i. of nit. ether in cold water, which immediately raised the pulse to 120, but it sopn fell to 90, which it previously was ; this relieved her but very little.. I now gave her about double the quantity, which relieved her greatly, and the pulse instantly fell to below 90. It was about an hour be- fore the attack entirely ceased, and it went off with sighing and yawning, leaving her pulse 90, and regular ; her countenance and pulsations were the whole time pretty 251 natural ; her face slightly flushed, and, at no time, asthmatic ally livid. 5. She slept ill during the night, but got some sleep in the latter part of the morning ; she did not walk this morning ; took breakfast of tea and bread about ten o'clock, and has been pretty well this fore- noon; her looks are improved. Ten o'clock p. M. pulse 106, feeble and irregular; she took 10 gtt. ; in ten minutes after, her pulse was of the same number and regular ; se- cond minute, lOO ; third minute, 102 ; fourth minute, 100, and stronger ; sixth minute, 106, and still strong ; seventh mi- nute, 100 ; eighth minute, 104, and still strong ; thirteenth, fourteenth, and fifteenth minutes, it varied from 98 to 104? and was as feeble as before' she took the medicine. Eleven, p. m. she took some dinner of boiled beef, and, after it, a small quantity of brandy and water, she felt sickish and had a slight headach which went off in about half an hour ; she took tea, bread and butter about six o'clock p.m.; pulse now 66, and regular ; her looks cheerful. 6. She felt very well during the night ; rain prevented her from walking this morn- ing; she took breakfast with some appetite, 252 and has no complaint. Eleven o'clock A. M. pulse about 87, and irregular, but not feeble ; she had been walking a good deal. Two o'clock p. M. pulse 78, regular and of natural strength. Eleven o'clock p. m. she continued well ; took some soup and beef to dinner, which made her a little uneasy, but this soon went off, and she has taken food since without inconvenience. June 7. Ten o'clock a. m. she took an airing and new milk this morning ; feels herself active and without complaint ; pulse go, regular and of natural strength. She slept very well last night. Ten o'clock p. M. she took some fish and roasted lamb to dinner, and a small quantity of brandy and water after it, which was followed by no inconvenience ; she has taken other food in the afternoon, and thinks herself in per- fect health ; pulse 80, regular and of natural strength. February 3. 1807. Remains well. CASE II. Mrs — , aged 30, became ill on 2d February I806. She has fair hair, light 253 blue eyes, delicate countenance, slender form. I visited her first on the sixth day of the fever, which, in that time, had reduced her very much. Her pulse was feeble and quick ; petechise were over all the body ; her mouth was sore and lined with sloughs; next day she seemed better, but a slight insidious cough, which had not yielded to vesication, began to be more severe and frequent; in two days more, dyspnoea and smart febrile symptoms were superadded. On inquiry, 1 found that she was very subject to catarrhal affections in winter, frequently complained of pains in her sides, particularly after fatigue from bodily exer- cise, and had always- been troubled with a slight cough. Vesication was again resorted to, but without affording more than a momentary relief. Her bowels were regulated by gen- tle laxatives, as pulv. rhei paimati ; she took beef-tea containing supertart. potassae in- stead of common salt. The disease became rapidly more formidable ; her stomach re- fused wine ; stools were of the colour of venous blood ; urine scanty ; she was sud- denly raised from sleep by starting and dread of instant suffocation ; she could not 254 He, but persons supported her in the sitting posture ; her eyes were dull, her face hvid, her looks anxious, and the cough attacked her frequently in very rending fits, and was followed by a copious viscid expectoration. The heart pulsated as if it would burst the thorax ; the pulsations at the wrists, tem- ples and ankles, , were about 130 per mi- nute, and irregular ; the whole under ex- tremities were spasmodically affected, kept in a state of extension, and occasionally were excruciatingly pained about the an- kles, but the pain was always removed by applying alcohol to them. She was so ill one morning about one o'clock that it was thought, she could not live many hours. The accession of the symptoms was in the space of five days, and nearly in the order of their detail. I was under the disa- greeable necessity of answering to the anxious interrogatories of an attentive hus- band, that this lady's situation presented but few hopes of recovery. Large blisters had all this time been kept open on her breast, and had discharged freely. I now prescribed a mixture of the tinct. digitalis purpurea, to be given every three hours in portions containing about 12 gtt. each. 255 I informed the husband, that this was a very active remedy ; instructed him how to feel the pulse, and told him that if sickness, vomiting, languor, or diminution in the number of the pulse came on, to discon- tinue the remedy. Next morning, her breathing was much easier ; she liked the mixture well, and sought it ; she had taken some food ; had made water pretty freely during the night; had enjoyed some sleep, but could not deviate from the sitting pos- ture; pulse 130, full, strong and regular ; the beating at the chest was not now so forcible. The husband told me, that he found the pulse quicker and stronger every time that he gave her the medicine. I now gave her one dose which first pro- duced a certain irregularity in the pulse, but, in the space of one minute, it was re- gular and 135. This medicine was con- tinued, in the same manner, for three days more, during which time the pulse increased in force and frequency, and at the end of it, she could lie with three pil- lows under her head ; all the symptoms were much relieved, but the pulse now iDcat 150, and strong ; I hesitated whether I should continue the exhibition of the di- 256 gitalis, but reflecting that its power of pro- moting absorption was always in propor- tion to the activity which it caused in the sanguiferous system, I ordered it to be con- tinued as formerly. Next day, the breath- ing was easy, the mind cheerful from dawn- ing hopes of returning health, the pulse was diminished in number and somewhat irre- gular ; she desired some food and eat a bit of fowl with some rehsh ; her limbs were still in the spasmodic state ; her stools coffee- coloured ; bhsters still open ; cough hard, dry, frequent and severe. I ordered the digitahs to be taken during the day, but not in the night. On the following morning, she had suffered a little from sickness, and, when I saw her, the pulse was irregular, in- termitting and not exceeding no ; the cough nothing reUeved. I ordered her to inhale the steams of vinegar and water, to take hght nourishment, &c. but no more of the mixture. Her stools had not assumed a natural colour, nor had the spasmodic af- fection subsided ; her urine was of natural quantity, but red coloured, containing se- diment of the same colour. She remained in this state for about two days when the febrile symptoms returned, with aggrava- 257 tion of the cough ; pulse about 14O, quick, sharp and irregular ; the movement of the heart was so forcible, that it was not only- felt by herself, but was perceptible to per- sons in the same room ; she could lie on her back, or on either side ; felt burning pain under the sternum ; her face was of a florid red ; her mind incoherent and some- times delirious. One easily saw the im- pulses of the arterial blood in the wasted and collapsed temples, and in the caro- tids of the long and emaciated neck ; the pains of the stretched limbs were renewed. I put a large vesicatory on the sound part of the thorax, and pushed the antiphlogis- tic plan as far as I could venture to do in a wasting skeleton covered with skin and pos- sessing animation. On the second day, the violence of the symptoms relaxed, and the countenance exhibited the most awful re- semblance of death that I ever beheld in a living being ; the pulse at her wrists, &c. was feeble and irregular ; I could not ascer- tain its number ; the heart still beat for- cibly ; the pain of the chest was almost gone ; she had been often seized with hea- ving of the chest, and faintings during the night. Though I did not expect, that R 258 she could possibly live more than a day, I directed, that she should have sorae beef tea, and a glass of port wine containing about 31 of alcohol, alternately during the day, so that she got the wine and alcohol every two hours. The following day, I was surprised to find her much better, and to be informed, that her senses were pretty sound after I left her ; her urine deposited a white sediment ; the stools were still dark ; the cough was now much less severe, and brought up a great quantity of purulent ill-coloured sputa; pulse about 120, and feeble ; wine, &c. to be continued as above directed. In the course of this day she relapsed, the delirium returned, the breathing again became very difficult and noisy, which it had not been before ; the lips were very pale ; the pulse scarcely could be counted on account of its irregularity, though it was perceptible to the touch at the ankles, wrists and temples; the mo- tions of the heart had again become worse, and were between 120 and 130 per minute ; some parts of the chest, which had healed, were to be blistered again, and wine, &c. to be given at any time. On the next day I found, that the blister had risen well, but 259 had not afforded much relief; pulse as yes- terday. I resumed the mixture containing the digitalis, and ordered a dose containing 20 gtt. to be given every two hours. I vi- sited her after this thrice a-day ; at nine o'clock A. M. two o'clock, p. M. and at mid- night. On the evening of the first day, the pulse became distinct at the ankles, wrists and temples, beating irregularly about 130, but synchronous with the heart ; already also the breathing was relieved, and the sputa came up with greater ease. The fol- lowing morning she was very feverish, skin hot, tongue somewhat dry on its upper sur- face ; motions of the heart not diminished in force ; pulse about 140, and strong ; she was delirious and incoherent when drowsy, but, when roused, her judgment was sound. The medicines were exhibited in the same way for three days ; the pulse continued strong as above, but, in other respects, she became rapidly better ; the heart beat with less force ; she called for food, and took some beef-tea and wine with pleasure ; the sputa became gradually less copious and thicker, resembling healthy pus mixed with mucus ; stools began to be lighter in their colour ; urine nearly natural with scarcely i6o any sediment ; the spasmodic affection of the extremities began now, for the first time, to relax. On the morning of the fourth day, after the resumption of the digitaHs, the pulse was intermittent, and not above 120, sometimes beating even below 100. I or- dered the digitalis to be discontinued, and by following this with wine, tinct. cinchonae, scilla maritima, myrrh, &c. as circumstan- ces required, she had a complete recovery in the space of three months from the first attack of the above described succession of diseases. CASE III. Mr , I was called to this gentle- man 2 2d March 1806. He had an cede- matous swelling from the knee downward, caused by a sprain and bruise which the limb had sustained four months before. At this time it was enormously swelled and pitted on pressure ; the skin of the limb was like dried parchment, and scaly ; a crowd, of red spots covered it, from which a serous fluid issued ; he was pale and much dispirited. This was a man of superior judg- 261 ment, who had, during his whole life, en- joyed a good constitution, and was a pattern of temperance, moderation and diligence. Some years before this, he had a cuticular affection, which was completely removed during a visit to one of the watering-places in England. Friction with various oint- ments had been employed for the present affection, but discontinued because it al- ways produced excoriations and ulceration. An open sore, however extensive, is much less dangerous than such a swelling ; it therefore appeared to me of the first moment to remove the oedema, and to restore.the tone of the limb, as local mor- tification or general dropsy might super- vene and prove fatal. The limb was in eiglt days reduced nearly to its proper size by bandaging ; through the cuticle a great quantity of fluid was discharged daily, and a great part of the limb was denuded and gave great uneasiness. I dressed the sores with a liniment containing tinct. opii and sp. ammoniae, which I had often found powerfully to promote the healing of watery sores ; the serous discharge v/as merely mo- derated by it on this occasion. He took very nourishing diet, and, according to pre^- 262 scription, nearly two pints of claret per diem. In order to obviate this dropsical tendency, I gave lo gtt. of tinct. digitalis in a glassful of claret thrice a-day. His pulse, since I attended him, had been about 70, and feeble ; the digitalis raised it to 90, and strong, and, in four days, arrested the serous exudation ; at this time the exhi- bition of the digitalis was stopped, because many inflammatory symptoms were evin- ced ; his face was flushed ; he was restless during the night, and affected with slight headach ; pulse 100, and strong. He was now allowed very little claret, no animal food, and was freely opened by laxatives, notwithstanding which, the inflammatory action continued nearly a week ; gradu- ally, in the mean time, the limb received a new healthy cuticle, and had nearly resum- ed its proper size. The pulse, in about eight days, came down again to about 70 ; the limb continued to acquire strength, and we entertained hopes of a speedy cure. The regimen was now continued the same as before the administration of the digitalis. In the course of a fortnight the pulse began to rise again, and this was accompanied with other slightly febrile symptoms, which 26^ were not subdued by a pretty strict anti- phlogistic treatment. This was one of the innumerable proof , that an education, at once medical and surgical, is indispensably necessary to him who practises the healing art. In a few days, a very distressing pa- pulous eruption broke out over all the body, but particularly the back, on which not half an inch of sound cuticle was perceptible. This rush becoming watery was anointed in the same way and with the same sub- stance that had been applied to the limb, and with no greater efficacy. I proposed to the very intelligent and ingenious Dr Cleg- horn, who was called into consultation, to try the digitalis. He objected to it on ac- count of the very feeble state of the patient, and the remarkably debilitating properties of this medicine. I took the liberty to in- form him, that the common opinions with regard to the powers of this substance, as I had satisfied myself by observation, were erroneous. The remedy was accordingly exhibited. I gave him 15 gtt. thrice a-day. The pulse had for some days been from 90 to 100, feeble and irregular, but, after tak- ing the third dose, it was about 120, and full. In three days, this watery exudation wa§ 264 completely removed. The eruption con- tinued to be anointed chiefly with the same liniment as before ; the citrine ointment, and a liniment containing the nitric acid, were also tried, but they were more severe and less useful than the former. This eruption being inexpressibly distres- sing, I was happy to observe that it began to disappear and the skin to heal. Shortly after this, I was c^alled from Glasgow on an urgent occasion, the same treatment how- ever, was continued, and the gentleman got well. If I had been then as well acquainted as I now am with the effects of the tinct. can- tharidum, used internally, for the cure of watery cuticular eruptions, these complaints would have been removed speedily, and with very little or no pain to the indivi- dual. CASE IV. Mr , aged 28 years, a man of a spare figure, irritable temperament and acute mind, one of those printers called com- positors, was, in the end of October 1806, 2di affected with pain in the wrists, seated seem- ingly in the first row, or, as Dr Barclay would more correctly say, in the proximal row of the carpal bones, whence the pain darted upward as far as the shoulder, and, on account of it, the hands and fingers could not be moved. The left hand was, at first, most severely affected, it swelled much and became oedematous. A slight degree of fe- ver and very great irritability were present. The pulse was, in general, about 80, sharp and irregular. Pressure on the diseased parts produced extreme torture, which was terminated by fainting. During a mild antiphlogistic regimen, and vesication of the back of his hand and wrists by the melo'es vesicatorius, the pain gradually abated, and the limb returned to its healthy state. Next, the other wrist and hand, which had been but slightly uneasy for about three weeks from the commencement, began to take the same troublesome course ; this Umb was treated in the same way, and the pain of the wrist was, in three or four days, very much alleviated ; an enormous oede- ma supervened, and it was thought, that puncturing would be necessary to prevent 266 the bursting and sphacelation of the inte- guments ; pulse about 80, and feeble. In the mean time, to the more formi- dable external operation, I preferred the internal use of tinct. digitahs, of which, conveyed in water and simple syrup, he took 15 gtt. night and morning ; this raised the pulse to above 90, and strong, and, in the space of five days, completely removed the oedema ; the integuments became shri- velled like a dry and emptied bladder. A cure however, was not thus effected, for the pain in 'the same wrist now return- ed with as much violence as ever ; the use of the digitalis was discontinued, and ve- sicatories again employed, with cathartics and low diet. On the evening of the second day after this, I was called to him, because he thought himself in the greatest danger. His pulse was uncommonly strong and beating 114 per minute ; his looks were anxious ; face flushed ; respiration interrupted, short and painful. This afternoon he was seized with an inexpressibly acute pain of the left side, which preceded the symptoms just men- tioned. He was, he said, somewhat subject to pains of the side, and, some years be- 267 fore, a pain, which distressed him, had been removed by venaesection. Since last visit, he had taken four powders, each contain- ing oiss. of the compound powder of jalap, which had not moved his bowels in the least. The pain of the wrist still conti- nued, though the blister discharged copi- ously. Sxvi. of blood, which exhibited the buffy coat, were now abstracted from the arm ; this gave him instant relief. He was ordered to repeat the powders, one every six hours, till his bowels were freely opened. Next day he continued easier, but still felt the pain of the side, and was sick at stomach ; he had taken other three powders, which had only produced one scanty stool. He was now ordered two powders containing each one scruple of jalap and five grains of the submuriat of mercury ; the one to be swallowed six hours after the other if ne- cessary, which two, and the same quantity on the second day after, were taken, before his bowels were freely opened. This free purgation at length removed the pain of the side, and the CEdema of the affected limb, but not its pain. This pain however, daily diminished, while the oedema returned, and, in the be- 268 ginning of December, was very great. As the pulse was now reduced to about 70, and every symptom of inflammation absent, he resumed the digitalis in smaller doses than formerly, which, in a few days, * rendered the pulse full and about 90, and removed the oedema. From this time, he began to use his right hand again, he rapidly reco- vered his general health and the use of his hands, and is now (June 4. 18 07-) almost as well as ever he was. CASE V. January 20. 1807- Mrs , aged 51, a slender active lady, the mother of many children, of pale con^plexion, in ge- neral very healthy, has suffered much from distress, grief, fatigue and family misfor- tunes. Her menstruation had ceased some years ago, on which occasion she was long very delicate and ailing. Of late, though she could scarcely complain of bad health, she was very feeble, and was, for some days, surprised, that her feet were very tight in her shoes, and her legs in her stockings. I found them much tumified with an cede- 269 ma; pulse about no, feeble and irregular. I ordered her to keep her bowels regular, use nourishing diet, take 12 gtt. tinct. digi- talis in a wine glassful of cold water thrice a-day, bandage the limbs from the knees to the toes, and bathe them with brandy. 22. CEdema nearly gone, appetite good, pulse 120, pretty full and regular. Same regimen continued ; to take 1 5 gtt. thrice a-day. 26. She complains of some headach and squeamishness ; oedema gone ; face flush- ed ; pulse 120, and, in strength, resembling the pulse of inflammatory fever. To con- tinue the same regimen, but discontinue the digitalis ; the urinary discharge was now much increased in quantity. Feb. 8. She has been much troubled with pains in her bowels, and a sense of weakness to-day ; no return of the oedema. To take a laxative, and wine diluted with water and sweetened. 10. She was relieved by the operation of the medicine yesterday, and is pretty well. June. She continues well. 270 SECTION VI. Communication on the Pozvers of the Digitalis, from Mr J. De Coiircy Laffan, one of the Presidents of the Royal Physical Society of Edinburgh. Dear Sir, The elaborate and circumstantial view (with which you have favoured the Koyal Physical Society) of the modus ope- randi and effects of digitalis in the cure of disease, was sufficient, I own, to rouse the attention of every member, and call forth such a spirit of inquiry as the evident importance of the subject demands ; and would probably have led to the full esta- blishment of your opinions in the minds of many in the society, had not the effects of this drug been confidently stated by men of known experience and of considerable fame, who, viewing its medicinal properties in a different light, held an opinion directly contrary to that which you would have us adopt. You could not therefore, wonder to find me in the number of those who re- ceived your doctrine, if not with incredu- 271 iity, at least with particular caution and some deductions. As digitalis however, had been announced to the world as pos- sessing powers nearly specific in curbing the ravages of phthisis, I resolved to examine the data on which the prevalent opinion of its virtues was founded. On consulting every work which I could procure, from that of Fuchsius * down to those of the present day, I perceived, that the opinions, which medical men had form- ed, of the properties of this plant, were so various, so opposite and so contradictory, that the question remained to be decided by new observations ; of which I was the more satisfied, when I found a Hamilton, a •Beddoes, and a Kinglake, opposed by a Currie, a Ferriar, and a Drake. Accordingly, in conjunction with Dr Lee, and several other gentlemen, who, uninfluenced by any theory or preconcei- ved opinion, were desirous to satisfy them- selves with regard to the medicinal pro- perties of digitalis, I conducted a number of experiments too tedious for detail, of which the following were the results. * Hist. Plant. 272 First, That digitalis, taken by a person in health, raises and maintains, yb;* a certain time, an increased force i.nd trequency of pulse. Secondly, That this action increases but not in the direct ratio of the quantity of the medicine taken. And, /ajt/i/, That it, in many instances, produced a sedative effect apparently greater than what we could expect from the preceding excite- ment. Shortly after this, several opportu- nities occurred to me of proving its effects in disease, and I found, that small doses generally raised and maintained an increas- ed action, under wliich morbid etfusions were removed from marii/ cavities of the body, and sores assumed a healthy appear- ance ; the evacuations by the skin and uri- nary organs were increased, wlnle the pulse acquired a greater fulness. I have thus endeavoured to lay before you the result of my limited observa- tions, without attempting to account for the various and contradictory opinions which, ^vith respect to the effects of this medicine, have progressively swayed the minds and directed the practice of physi- cians for a number of years. I • i 273 ' i This subject has excited the public at- tention, and it is with no small degree of anxiety, that the determination of the ques- tion is expected ; for who can be indifferent on a point that involves the safety or destruction of thousands of his fellow-crea- tures ? I am yours, &c. J. De Courcy Laffan. Edinburgh^ Nov. 3- 1807- 274 CHAPTER, 11. int FACTS ASCERTAINED CO^XERNING THE OPERATION OF THE DIGITALIS APPLIED TO THE EXPLANATION OF THOSE CIRCUMSTANCES WHICH HAVE LED TO THE MIS- TAKEN OPINIONS PREVALENT ON THIS SUBJECT ; AND THE NEV/ PRINCIPLE FOR THE ADMINISTRATION OF THE REMEDY FURTHER ILLUSTRATED. SECTION I. Operation of Digitalis, zvith some Obsei'vations on the Nature and the Manner of Action of those Pozvers which maintain the Vital Pheno- mena. IT has been demonstrated, that each small dose of the digitalis taken by a per- son in health, increases the force and fre- quency of the pulse ; and if the doses are repeated, that they will induce an inflam- matory action of the system ; that also in disease, the first effects of digitalis exhibited in small doses, are to increase the force and frequency of the pulse ; to excite and main- tain that degree of action during which 275 sores assume the action of healing ; to pro- mote the process by which effiisions are re- moved from any of the cavities or parts of the body ; to enhven the mind and improve the powers of voluntary motion ; to invi- gorate digestion and increase the evacua- tions by the skin and by the urinary or- gans; in the mean time, the pulse is gradual- ly attaining a febrile activity, so that from 70 or go, if the use of the medicine is in- cautiously persevered in, the pulse shall be raised in a short time to 120, 130, or any number between these and 150. The stomach begins to be disordered, giddiness, beating of the vessels of the head, restlessness, general uneasiness, heat, and pains in different parts of the body, are superadded. Though the use of the medicine is now discontinued, these febrile symptoms may continue undiminished for four or five days ; generally however, in the space of twenty-four hours, and often much less, after their accession, the pulse sinks to 120, 110, 100, very irregular in the repetition and strength of its beats ; the pulse sinks still more ; the mind droops ; oppression about the prsecordia and nausea are very 276 severe ; vomiting is added, but gives no re- lief ; at this time there are often an increased flow of sahva, diarrhoea, a very copious dis* charge of hmpid urine, and considerable clammy moisture of skin, or even profuse sweating ; the countenance is pale and cha- racteristic of despair. The patient may con- tinue in this state for one, two, or even four hours, when all the distressing symptoms abate ; but the pulse does not rise immedi- ately again, but will continue to sink, and in a few days will be down to 50, 40, or even 30, and perhaps lower : this series of events I myself have witnessed ; but much worse than those are recorded by Withering, whose treatise on the fox-glove is a valuable specimen of truth and candour. With regard to the pulse alone, during the use of the digitalis, we may observe, that its beats are gradually increased in force and frequency for some time, after which they speedily sink below the usual medium of health, and this increase and diminution follow sooner or later in pro- portion to the quantity of the medicine and the excitability of the system. The increase of force and frequency in the pulsations is greatest and most rapid 277^ during the use of digitalis in persons pre- disposed to, or affected with active local in- flammation, and most speedily when either parts, previously sound, or those ulcerated, are proceeding, or are brought back to healthy suppuration, in which instances the digitalis and disease act with united vio^ lence. In persons, on the contrary, affected with dropsy or collections of matter from dege- nerating ulcers, the pulse is invigorated^ rendered steady, and, diminishing in num- ber, returns toward the standard of health in proportion as the effused fluid or puri- form matter is removed ; but this diminu- tion is very different in its nature from that which succeeds the too liberal or too long continued use of the medicine, the former is the effect of the irritating cause being re- moved, the latter of the powers of life be- ing exhausted by its action ; the one salu- tary, the other pernicious. When the system is in a complete state of asthenia, or when the phlogistic diathesis has been entirely subdued by the abstrac- . tion of blood, the digitalis does not, pre- viously to the diminution of the number of the pulse, produce that great accelera- 278 tion of beats with the inflammatory violence which is above pointed out : a person in such a state, and dropsical, with his pulse from 120 to 130, feeble and irregular, may be ordered to take from l o to 15 gtt. thrice a-day, with this precaution, to discontinue their use if headach or sickness supervene ; at the end of eight days, the health will be improved, the swelling diminishing, and the pulse 120, 130, or even more, strong and regular ; at the end of a fortnight, we shall find the dropsical swelling of the abdomen and limbs removed, all the vital and animal functions invigorated, and, though none of the symptoms of debility or exhaustion have intervened, the pulse reduced to about 72, and full ; in pneumonia likewise, after the pulse has been reduced to between 80 and 90, and the phlogistic diathesis com- pletely subdued by vensesection, great breathlessness and debility are experienced ; during the use now of a few drops of the tincture of digitalis given twice or thrice a-day, the vigour both of the respiration and of the general system will return, and in the course of six or ten days the number of pulsations will be increased to between 100 and 110 ; when neither preceded nor 279 accompanied by any disagreeable symp- toms, they may speedily diminish to bcr tween 50 and 6o, strong and irregular.* Concerning the operation of substances in general on animate bodies, it is not per- haps improper here to observe, that certaiii substances or powers which influence the animal body, act naore conspicuously on one organ or particular set of organs than the rest, and this fact suggested the princi- ple on which the articles of the materia medica have been systematically arranged : hence emetics, cathartics, diuretics, &c, hence also the notion of specifics. This fact however, though it must have always been partly perceived and recognis- ed, has never been considered in its full ex- tent ; for, on a more close view of the phe- nomena of animal life, it will be found, that there is scarcely any one substance or power which influences the body, but acts more conspicuously on one organ or particular * There are many very useful observations on the powers of digitalis, in a very ingenious Treatise on the Origin, &c. of Consumption, lately published by Dr John Reid of the Finsbury Dispensary, London. I would have fre- f\ntnl\y availed myself of this author's remarks, had I seen his Treatise while I was composing tliis Work. 280 set of organs than on the rest, or, in short, produces effects pecuhar to itself : thus, light, on the eye ; odoriferous and sapid bo- dies, on the nose and palate ; the will, on the voluntary muscles ; shame, on the ca- pillaries of the face ; fear and grief, on the heart and respiratory organs ; all the fluids of the body, on the vessels which contain them. Partial views of this fact, have served as a basis to many ingenious, though absurd hypotheses, as the spasms of Hoffinan and CuUen ; the reverse sympathies of Dar- win ; and the animal, organic and proper lives of Bichat, which is nothing more than a revival of the opinions of Paracel- sus. From another view of this fact, certain substances have been denominated stimu- lant, and these have been divided into per- manent and diffiisible. The opinions, however wild or fanciful they may occasionally seem, which have prevailed from the most remote antiquity, concerning the immediate agent of vitality, are astonishingly similar to each other ; we can scarcely discover any more than diver- sified repetitions of the same idea. 281 That the opinions of the moderns should resemble those of the ancients, is not sur- prising, when we consider the enthusiastic veneration for the works of Cicero, which animated the restorers of literature in the western world ; but that the sentiments of all men in every age should not differ from one another on a particular subject, seems to be solely attributable to this, that they are fundamentally warranted by the truth of nature. I have long believed, that, divested of the varieties of expression, these opinions might be thus reconciled with one another, and with the peculiar events to which they are referred ; that the phenomena of life are immediately produced by a certain unique power, somehow immediately connected with the brain, supplied by the nerves to all the parts of the body conjointly and in- dividually ; that this power is generated in the body itself; varies in its properties; is modified in its effects according to the struc- ture and changes in the structure of each part or organ ; and is directed to all, but more forcibly to any one part of the body, according to circumstances ; that any other substance or power acts solely through the 282 mediura of this one, which is the only di- rect cause of the phenomena of hfe. That this power, in a certain state, is partly or wholly contained in, or conduct- ed by every substance which is said to act on animal bodies so as to cause the pheno- mena of life, and is communicated from them, and conveyed by appropriate organs to the brain, where it receives its proper formation, and is thence distributed by a distinct set of organs to the different parts of the body. Thus, we know, that the power which causes sensation or the opera- tion of intellect proceeds toward the brain, while that which causes muscular motions proceeds from that organ. This notion, which, if verified, would not only change many generally received opinions, both in physiology and patholo- gy, particularly concerning sympathy, and the operation of substances on the system either externally or internally, but would destroy the doctrine, that poisons must be absorbed before they produce their peculiar effects on the living body, I shall endeavour to elucidate hereafter ; in the mean time, I affirm it to be, so far as I now remember, a law of the animal economy, that every 283 power which induces vital phenomena, while it influences the whole body, affects some function or functions more than others. Thus, lead affects the nerves ; mercury, the secretion of' saliva ; cantha- rides, the urinary organs ; opium, the ima- gination ; digitalis, the blood-vessels, 284i SECTION 11. Opinions of Authors esamified, and their Incon- sistencies pointed out. THAT, during the use of digitalis, the pulse is first increased in force and frequen- cy, and next sinks suddenly to a very low degree, is in direct opposition to what is generally believed and taught. It is maintained, that digitalis is a direct sedative, or, in other words, that, when re- ceived into the system, its proper effect is to diminish the force and frequency of the motion of the circulating blood. We shall here consider some of the facts detailed by the best of those authors who have written most fully on the powers of digitalis, to see whether their accounts will warrant this conclusion, which seems to have been universally adopted. To warrant this conclusion, it would be necessary to show, by cautious ob^rvation, that the pulse diminished both in the force and frequency of its beats immediately when the dose of the digitalis was taken, 285 and continued to fall during its use ; that it is most useful in persons of the phlogistic diathesis, labouring under diseases of the most inflammatory nature, and during the rage of inflammatory violence ; that it should not be administered along with sub- stances decidedly of a stimulant nature. That the doses of digitalis do not imme- diately and successively from the commence- ment of its use, diminish the force and fre- quency of the pulsations, is evident from the rules that are given by authors for its admi- nistration ; as, " let the use of the substance be continued till it produce its peculiar ef- fects ;" "it was used such a length of time before its effects on the pulse appeared.'* That it has no such effect is also proved by the cases which they relate : " The remedy,'* (/. e, the digitalis) says Ferriar,* " seemed in many instances for a while to retard the progress of the disease, but the symptoms at length burst out, and seemed only to proceed with more rapidity in consequence of the transient delay," why not in conse- quence of the digitalis ? and, " the remedy was given in small doses, but for some time • On Digitalis, p. 20. and 23. 286 without any sensible effect. The pulse continued rapid, night-sweats came on, the cough increased in violence, pains in the hypogastric region were felt." After this he increased the dose to two grains and a half every day. " The effect on the pulse," says he, " now took place ; it was reduced to 86." What was the cause of the pre- vious aggravation of symptoms ? Are not the phenomena of this case ill perfect conformity with the previous in- crease, and consequent diminution of in- flammatory action ? He says, (page 36.) " The vigour and steadiness of the pulse increased exactly in proportion as the water was withdrawn from the cellular mem- brane." In the cases of Dr Kinglake, we find, that the digitalis was administered for a consi- derable length of time, even for weeks, without diminishing the frequency of the pulse ; and the invigorating powers of it are variously expressed by every author who has written on the subject. This phy- sician, speaking of a patient who had been taking digitalis from the 2 1st of August to the 13th of October, says, " The pulse held uniformly at 90, and was affected only in 287 being changed from hard, small and weak, to soft, full and firm, an alteration which appears to me to be a condition sine qua non of the beneficial effects of the medicine'' I fear, indeed, we shall no where find much consistency between what has been asserted and related in the works of authors concerning the operation of digitalis. Ferriar asserts, (p. 5.) " That the pulse may be reduced from 120 to 75 or 80, without danger, at the will of the practi- tioner ;" while in his cases we have found that, during its use, the inflammatory symp- toms proceeded with incontrolable fury ! " Under the administration of digitalis,'* says Dr Beddoes, * " the frequency of the pulse was always diminished, but still the dilatations of the artery in a given time would have communicated much more motion." But in p. 207, he says, " I have known digitalis occasion an increase of the pulse from 76 to 120, with heat of skin and headach." And, (p. 219.) we find, that " digitalis increases the action of the arterial system, is a stomachic, soporific poison, like opium, and powerful stimulant j" but * On Consumption, Digitalis, &c. 288 (p. 220.) that " certain properties are so combined in the digitalis as to give it its common^ but by no means constant^ power of re- ducing the frequency of the pulse." Who from such data could conclude any thing certain, except that the authors had no cor- rect knowledge of the subject on which they wrote ? In fine, we are informed, that " digitalis shall be taken daily for a considerable time without producing any effect^ till, all at once, the most dreadful exhaustion ensue, accom- panied with enormous diminution of the pulse, nausea, vomiting, and a most oppres- sive sensation about the prsecordia.'* Is it not repugnant to every thing that our mind is capable of conceiving, that a most powerfully deleterious substance, one half grain of which is said to have produced the most direful effects, should be so capri- cious in its operation as to be received into the system daily for a considerable time, and then, by one assault, like a lion dart- ing from his concealment, fiercely attack the unwary victim ? The habit of body fitted for the recep- tion of digitalis, is not the robust or the phlogistic, as Dr Beddoes hypothetically 289 supposed ; this we may learn fron> the ob- servations of Dr Withering, which are de- duced from long experience independently of hypothesis. " It seldom succeeds in men of great na- tural strength, of tense fibre, of warm skin, of florid complexion, or in those with a tight and cordy pulse. On the contrary, if the pulse be feeble or intermitting, the countenance pale, the lips livid, the skin cold, the swollen belly soft and fluctuating^ or the anasarcous limbs readily pitting un- der the pressure of the finger, we may ex- pect the diuretic effects to follow in a kindly manner." Hence we learn also, that the diseases in which it is most conspicuously useful are not of the active inflammatory kind, but those of extreme debility, as in dropsies, chlorosis, &c. Nor is it useful during the violence of inflammatory action, as the pas^ sages which we have quoted warn us ; apd authors order its exhibition in haemoptysis to be preceded by the copious abstraction of blood. These subjects, however, I shall afterward resume in a work on dropsies, hccmoptysis, &c. 290 We find in authors, that it is adixiinister- ed beneficially along with preparations of the most active nature, as of opium, cam- phor, assafoetida, iron, mercury, &c. — Are these also sedatives ? Of what value then is an opinion con- cerning the powers of a substance, not war- ranted by experiment, nor by the facts re- lated by those who have promulgated it ; not corroborated by the state of the body which receives the substance, by the nature of the affections which it removes, nor by the acknowledged properties of the medi- cines along with which it is administered ? No wonder, that physicians are often so grievously disappointed in the effects for which they prescribed the digitalis, and that it is deemed a precarious and desperate remedy : who would be surprised, that a traveller, unguided by the magnet, was bewildered in the trackless regions of Si- beria ? 291 SECTION III. Endeat'Giirs to show those Occurrences which mis- led Physicians in Jorming their Opinion con- cerning the Forcers of Digitalis. IT is however, far from my intention to impeach the veracity of those most respect- able authors ; on the contrary, I affirm, that their cases, though not circumstantially, are, in my opinion, very fairly related ; I only contend, that their inferences are inadver- tently formed, and I think, that I can point out the chief circumstance which led them into the notion of the peculiar direct seda- tive properties of digitalis. Physicians had not been accustomed to conceive, that any substance whatever could excite the symptoms of inflammatory fever, and that a diminution of the force and fre- quency of tlie pulse would ensue as a con- sequence ; therefore, during the use of di- gitalis, when inflammatory symptoms oc- curred, they attributed these symptoms to the disease ; but the depression of the vital phenomena which supervened, they deem^ 292 ed the peculiar effect of the operation of the remedy. They may have been deceived also by observations on the pulsations of persons extremely debilitated : for when, from mere depletion, as from the loss of blood, &c. the body is very much debilitated, and the pulsations are exceedingly rapid and feeble, all stimuli diminish their number, by in- creasing the force and duration of arterial contraction. What physician has not ob- served in typhus, that a few glassfuls of wine have diminished, the number of pul- sations by 20 or 30 per minute ? nay, I would ask, what man is there, who watches the phenomena of disease, or is acquainted with the effects of those accidents to which our bodies are daily exposed, but has, in al- most numberless instances, witnessed simi- lar effects on the pulsations from the admi- nistration of strengthening remedies ? In similar circumstances the digitalis will, more conspicuously than any other sub- stance, diminish the number of arterial contractions, and invigorate all the func- tions. I may here however, add, that very rarely, in any state of constitution, does the digitalis not instantly w^hen taken accele- 293 rate the pulse ; we shall find, that a few drops in the morning will instantly raise a weak pulse from no to 120 ; ?-nd that the same pulse will in the evening be as low as 70 ; this event occurred to my notice in asthmatical affections which I supposed to arise from oedema of the lungs. The phenomena of the pulsations during the administration of digitalis in dropsical affections, may have also contributed to the belief of the sedative virtues of this sub- stance. When a watery effusion is collected in any of the cavities or parts of the body, it becomes, in some degree, an irritating cause, but when in the thorax, it most remark- ably accelerates the pulsations ; after this effusion is removed by any means, the pul- sations will diminish in number ; this I have often observed, but it is not the ef- fect of the digitalis in diminishing the num- ber of the contractions of the heart and ar- teries, but it happens because the irritating- cause, the water, is removed, and the effect on the pulse is different from that which might have been observed, if the water had been removed by the art of the surgeon. In order to elucidate my meaning, let us 294 suppose, that a person's pulse is, in a given state of body, 80 and feeble, but that water being collected in the thorax, has raised it, and keeps the number about 120 ; if the water were drawn off by means of the ap- propriate instruments, a trocar and canula, the pulse, after the immediate effects of the operation had subsided, would be 80 and feeble ; but if the water were removed by the digitalis, the pulse would be about 95 and pretty strong, so that the digitalis would virtute sua have augmented the force and frequency of the pulse ; and this fact it was, I imagine, which made Kinglake declare, " that a pulse at 90, soft, full and firm, is the sine qua ?ion of the beneficial effects of the medicine." It is however, necessary to remark, that, if the dropsical effusion is combined with local inflammation, or, if the effect of re- moving the effusion is not produced during the administration of the digitalis, the pulse is increased, both in force and frequency, as on other occasions. It seems to have been neglected, that there is an important difference between the reduction of the number of the pulse by the removing of an immediate irrita- 295 tion, and that, by exhausting the powers of life while the irritating cause remains. Some physicians dread the substance now under consideration, because it has of- ten produced the most alarming symptoms, without having been of any service to the patient ; but if they had been aware of such circumstances as those just pointed out, their disappointment would probably not have occurred. It has appeared, I trust, that the speedy diminution of the number of the pulse, after the use of the digitalis is begun, either in debilitated constitutions, or in cases of dropsy, is not to be ascribed to any seda- tive power ; and with regard to any im- mediately irritating cause, I would further add, that, whenever such a cause is remov- ed, the arterial system will gradually re- sume its healthy action. If the irritating cause is pus, anywhere collected, when the pus is removed, the morbid increase of action dependent on it will cease in the sanguiferous system ; but this effect is not to be attributed to a seda- tive power, any more than the removing of febrile symptoms by opening an abscess. 29§ is to be attributed to the sedative power of the lancet. If digitahs promotes the heaHng of a sore, or the absorption of pus in the lungs, the consequent diminution in the frequency of the pulse is to be ascribed to the removal of the cause, not to a sedative power. In like manner, in convalescence from all dis- eases, in which the pulse has been mor- bidly accelerated, it gradually resumes its healthy number ; but is this to be ascribed to a sedative power ? "When febrile exacerbations abate, the pulse diminishes in force and frequency ; but tliis is no more to be ascribed to the sedative power of any medicine previously taken, than the increase of force and fre- quency during the exacerbation, to the ope- ration of a stimulant medicine. In short, when the pulse is lowered in consequence of the digitalis, independently of any other circumstance, this effect indi- cates a diminution of the contractibility of the heart and arteries, as well as great ex- haustion of the powers of life ; but when it is diminished by the removal of irritation, this indicates the restoration of those powers to the equilibrium of health. 297 The contradictory accounts and strange- ly hypothetical notions in which every author has involved himself, might alone have induced us to suspect the soundness of the doctrines on this subject ; but I feel peculiar satisfaction, that the result of ex- periments will enable us to reconcile all those contradictory accounts, and show, therefore, that the cases recorded by au- thors differ in no essential particular from those which I have detailed ; nay, so pal- pable does this appear, that if these gentle- men had but read their own cases attentive- ly after they wrote them, their conclusions would have exactly coincided with mine. In short, this is the best example which I know of erroneous reasoning from sound data, and proves, that the Aristotelian mode of reasoning is as necessary to enable us to form sound conclusions, as that of Bacon, to enable us to procure sound principles. For the sake of illustration, I shall give a syllogistic arrangement to the facts which these authors have related. The pulse diminishes in number during the administration of digitalis, but this sub- stance is taken for a length of time before this diminution occurs, therefore the dimi- 298 nution is not the immediate effect of the digitahs. If they had next recollected, that all the symptoms of inflammatory disease were often aggravated during its administration before any diminution supervened, they would have been led to imagine, that the digitalis might have some other power than that of dimhiishing the number of the pulsa- tions^ and consequently would have perceiv- ed, that its first effect is that of increasing the pulse in force and frequency \ having proceed- ed so far, they would have observed, that after the digitalis was taken for some time, the pulse then, and not till then, diminish- ed greatly in the number of its beats ; ergo^ the immediate and proper effect of the digitalis is directly stimulant^ and the diminution in the number of pulsations is the consequence of the previous increase ; thus, it appears incon- trovertibly, that the facts, which authors have related, rigorously considered, would have afforded no general conclusions differ- ent from those which I have judged myself warranted to form, and thus also would have vanished all their difficulties in ex- plaining the operation of the substance. In fine, that the first effect of the digitalis is 299 stimulant^ and that the lowering of the pulse is a secondary effect^ will explain all the cases, and reconcile all the contradictions in the writings of medical men on this subject. I suppose, that besides recollecting this general fact concerning the operation of digitalis, that the observer is at the same time on his guard against any circumstan- ces which might mislead him. I have pointed out the most important of them, but there are others of which it is very use- ful to be aware. Age and sex ; the particular condition of the body with regard to health and dis- ease ; the previous habits, whether of tem- perance or dissipation ; the particular dis- position of the mind, and the passions which actuate it ; the substances taken into the stomach either for food or for pleasure ; the length of time after taking food, and the kind of food that has been taken ; the particular time of the day, whether morn- ing, middle part of the day, evening or night ; whether the person has been lately exercising, and how ; the posture of body, and the change of posture from lying to sitting, and from this to standing — are all circumstances which, in a special, and per- 300 haps I might say, in a specific manner^ in- fluence the sanguiferous system ; the ne- glect of which will greatly diminish the value of any observations on the pulse. What I now mention has been partly anti- cipated in the treatment of the suppurative stage of consumption, and I think it only necessary here to suggest these things to any one who may incline to make obser- vations on the pulse, as I shall endeavour to examine these topics afterward ; my rea- son indeed for introducing them here is, that many gentlemen, who repeated the experiments on the effects of digitalis, have informed me, that their results were differ- ent from mine, who afterward found, that they had been misled by not attending to some of the circumstances now pointed out. In a discussion which took place in the Medical Society last winter, on the powers of digitalis, one gentleman stated, that he had made five experiments on himself, and in every one of them the result was contrary to the results of mine ; another stated, that he had taken it repeatedly during these three years, and always found, that the digitalis di- minished the force and frequency of his pulse ; 301 I replied, that many mistakes might occur, but I had only one answer, that v/e should meet together and take a dose of the sub- o stance. Five of us retired to another apart- ment in the Society; Dr John Gordon, Pre- sident of the Society, counted the pulses and administered the dose to each ; the event was, that the pulses in four persons were immediately increased in force and frequen- cy. The pulse of the gentleman, who said, that he had repeatedly taken it during these three years, was increased in number by 13 beats per minute. The pulse which was not increased, is also easily explained, and is a proof of the necessity of atten- ding to every particular : the gentleman had been keenly engaged in the debate ; on retiring from the Hall of the Society, his pulse beat Ii6, and was rapidly dimi- nishing in number ; in five minutes it beat only 100 and was still diminishing in num- ber, but a few drops of the tincture of di- gitalis now given arrested instantly the di- minution, and it continued 100. The gentleman who had made the five expe- riments, and I, met next morning ; he took 20 gtt. of the tincture of digitalis, which accelerated his pulse instantly, and 302 at the end of an hour it was i o beats more than it was immediately before he swallow- ed the substance. Walking at an ordinary pace raises the pulse by about 30 beats, but on sitting- down it resumes its usual number in a few minutes. Suppose, that the usual number of a person's pulse is 60, that by walking it is encreased to 90, if now on sitting down he take twenty drops of the tincture of digitalis, his pulse instead of being reduced in a few minutes to 60 will beat about 75, and at the end of an hour will be 70, the number which it would have been if he had taken the quantity of digitalis when his pulse was 60 ; so in the one instance it prevents the diminution in the number of beats by 10, in the other it accelerates it by 10. This I have ascertained in my own pulse very often. 303 SECTION IV. Comparaike Effects of the Digitalis. THE powers of this substance indeed are so extraordinary, that it is not surpris- ing, that its effects were, at first, misunder- stood ; for on comparing and examining critically the different cases which are pub- lished, it will be evident, that, though all active substances sooner or later exhaust the powers of life, none have been so remark- able for speedily exciting inflammatory action, and terminating so soon in dimi- nution of arterial action with the most alarming debility. In short, if we wished to know, what would be the effect of a sub- stance applied to the animal body, which had the power of speedily raising its func- tions to the highest activity of which they were capable, we may acquire this infor- mation from the cases in which the digita- lis has been employed. When we review the various powers which act on the body, and by their ex- cessive operation exhaust the powers of life, 304 we shall find them very different in their effects from those of the digitalis. Common food and exercise which sup- port those inevitable changes terminating in old age, are not found, toward the end of the longest life, to have diminished the pulsations in any other respect than in their vigour and regularity. The effect of fatigue of body is great de- bility with a quick and feeble pulse. Some indulge in the use of the richest viands to excess ; others, in that of various liquors containing alcohol, and persist in such prac- tices, or even in every variety of dissipation for years, before they accomplish their own destruction. I have frequently observed, that persons who had been accustomed to the use of ardent spirits, had, when they thought themselves in health, a pulse of not above 50 per minute. Of two persons, I recollect well, that in one the paroxysm of hectic fever scarcely ever raised the pulse above 70, and the other, some eminent physicians pronounced free from fever, be- cause his pulse was not above 90 ; but, instructed by my previous observations on the pulses of different persons, I suspected, that this was a very quick pulse for this 305 man, because a considerable quantity of beef-steak, and nearly two pints of port wine, which he one day thought proper to take, did not accelerate his pulse by above two beats per minute. This person died of a cancerous affection a few weeks after the above observation was made, but his pulse never beat above 100 per mi- nute. The mode of comparing the present state of the pulse with its previous habit, has, I believe, been too much neglected, and I have sometimes imagined, that the accounts, which we have of fevers without accelera- tion of pulse, have originated in this ne- glect. If a physician is called to a person whom he has not seen, and whose pulse is not above 70, though he has the other symp- toms of fever, he may, from this circum- stance alone, judge what has been the pre- vious state of the pulse ; and, if the patient is in a debilitated condition, and such as requires wine, or the more active medicines, and if a pint of port wine, or any active substance, when taken, do not instantly make some alteration in the pulsations, it may be deemed an infallible proof, that the u 306 contractibility of the heart and arteries has been exhausted by the previous manner of Hfe : both the men above ahuded to had for many years led hves of unparalleled inebriation. On the contrary, however old a man is, if his pulsations are readily influenced by common food, by a little wine, or by a small quantity of any of the more active substances, v/e may thence judge, that this has been a temperate man, and may pro- mise recovery in circumstances in which, without the knowledge of this fact, we could scarcely expect, that even the best treatment would succeed. The common causes of disease can ex- cite the highest degree of inflammatory ac- tion of which the body is susceptible, but, except in hydrocephalus, the diminution of the pulse is in its strength chiefly, while the pulsations remain very quick and very irregular. I at one time thought, that the extreme debility and sickness which often super- vene to the febrile hectic exacerbation, with vomiting and expectoration of puru- lent matter, would, from the similarity of the general symptoms to the effects of the 307 digitalis, be accompanied with a slow pulse. In such circumstances I have observed the pulse to beat below go, weak and flutter- ing, but most frequently about 120, irregu- lar and feeble, and never to be compared with the pulse which acconipanies similar symptoms induced by the digitalis. In comparing the digitahs with other substances used as remedies, we shall find, as has been already said, that it exhausts the contractibility of the heart and arteries more speedily than any other with which we are acquainted. Like other substances, digitalis loses its efficacy by repetition ; but when this ceases to~ raise the pulse immediately, other stimu- lants of the strongest kind have no imme- diate effect ; on the contrary, though the other stimulants produce no immediately perceptible effect, the digitalis will directly increase the force and velocity of the cir- culation. Even after the digitalis has re- duced the number of pulsations to below 50, the effect of 20 drops of it will instant- ly be evinced by an increase of their force, their frequency, or both. According to the experiments of Crumpe, opium also immediately increases the num- 308 ber of pulsations, but its power in this re- spect is much less than that of the digitalis. Substances, cceteris paribus^ can only dif- fer in their effects by their quality or their quantity ; we have observed, in the cases detailed, that digitalis, considered in both points of view, is more active than alcohol, ether, opium, scilla maritima, and several of the preparations of the different metals. Even the muriat of mercury, and the white oxide of arsenic taken in an admissible form and safe dose, have never yet been known by their repetition to produce the diminution of pulse, except in fainting. As to the muriat of mercury, I know well, that it, like most of the others, produces emacia- tion, extreme debility, headach, vomiting, diarrhoea, tormina, and other very distress- ing consequences, and not a slow, but a very rapid and feeble pulse, easily influ- enced by change of posture, and the least mental agitation. I have watched the effects of the extract of hyosciamus, taken in pretty large doses for a long time, but they never in their remote consequences resembled the digi- talis. ■ 309 For many months I have watched the effects of phosphoric acid and of phosphorus dissolved in ether, exhibited in paralytic cases, and in those of molities ossium. This medicine produced a quick, full and mild pulse, with diaphoresis and an increase of the urinary discharge ; it at the same time invigorated the muscular energy of the pa- ralytic limbs, but the pulse did not, in that time, evince any consequent diminution in its activity. I have observed, that the tincture of can- tharides could be gradually increased, till the dose amounted to Sss. per diem. Pains were excited in the urinary organs, in the bowels, in the thorax, and in the head ; the pulse was kept much quicker and stronger than it had been before the administration of the medicine ; but at the end of two months 3i. for a dose did not accelerate the pulse by one beat. In other cases, I have found the pulse become feeble under their use, and the doses now seemed to have lost the power of strengthening it ; in one in- stance, after cantharides had been exhibited three months successively, with the view of promoting healthy action in a very despe- rate phagedenic affection of the face, and 310 their use carried as far as boldness directed by prudence would warrant, the system seemed very much enfeebled, or rather ex- hausted ; the pulse was now about 120, and only evinced feebleness and irregularity ; so different are their effects from that tardiness of contraction which the digitalis will not fail to induce in a much shorter time. From what has happened however, in certain persons who had accustomed themselves to the use of ardent spirits, we have reason to believe, that in a greater length of time, the continued use of all these more active sub- stances would destroy the contractibility of the heart and arteries in the same manner as the digitalis ; and in so far, we have some data to decide the long agitated ques- tion, whether the action of substances, which influence the general powers of vi- tality, differs in kind or degree ? 311 SECTION V. Administration of the Digitalis. HAVING ascertained, by experiment, that the medicinal properties of the digita- Hs are of a nature directly opposite to that of which they are generally believed to be ; and having shown, that on this principle, and on this principle alone, the contradic- tions of authors on this subject can be re- conciled, the operation of the medicine in the cases reckoned anomalous, explained, and the circumstances, which led physi- cians into the mistake, pointed out ; I shall now proceed to consider the mode of ad- ministering the remedy which the change in our knowledge of its operation suggests. We have seen, that the increase of the pulse, and the accession of inflammatory symptoms, guide us with certainty to se* cure the good, and with safety to avoid the bad effects of this substance. The rule, accordingly, of its administra- tion, is to commence it in small doses, which must be gradually increased in pro- 312 portion to the difficulty of exciting inflam- matory symptoms, and when the pulsations become too strong and rapid, along with other signs of inflammatory action, the dose is to be diminished, or the use of the substance to be intermitted. From the great activity of the digitalis it is obvious, that it must be prescribed for the invigorating of the debilitated. The tincture, I have found to be the best form in which to prescribe it, as the quantity of the medicine is more accurately known, and the dose is more easily taken by the patient. The dose, at first, is from 5 to 20 gtt. in a little cold water, or wine diluted with water, two or three times a-^day. The smallest doses must be prescribed to the youngest and most excitable persons. Those, whose constitutions are exhausted by chronic diseases, are more benefited by the remedy, and take it in greater doses and for a longer time than others. Those, whose diseases originate in sudden depletion or loss of blood, are most liable to inflammatory action from the continued use of the digitalis, which seems- to corro- borate the opinion, that the susceptibifity 313 of action in the animal body is much greater in that state of debiUty which arises from the abstraction of those powers which act on the system, than in that which succeeds excessive action.* The rule, to stop the exhibition of the digitalis when the symptoms approach to violence, must be strictly observed in cases of local inflammation, where some degree remains of the inflammatory diathesis, as often happens in the puriform stage of phthisis pulmonalis, f or in the milder dis- eases of any kind, in which it is administer- ed ; but when the system is very much de- bilitated in consequence of excessive action or chronic disease, as is most frequently its state in dropsies, the doses must be gradual- ly increased, and their use persevered in, until the pulse begin to diminish in num- ber, when some of the other powerful tonics are to be substituted, none of which are in general preferable to cinchona and the submuriat of mercury conjoined with opium. The pulse will, in cases of the latter description, diminish by 20 or 30 * Vide Joan. Brunonis, Princip. Medicinae. f Treatment of the Second Stage of Phthisis, 314 beats, and even continue to diminish a few beats daily for three or four days, without any sickness, vomiting, or any sign of in- creased exhaustion, but often the contrary. We must always however, warn those who have the charge of the patient, to give no more of the medicine after sickness or vo- miting has attacked him. This remedy is most conspicuously use- ful in every serous effusion, whether the fluid is contained in the cellular mem- brane near the external surface of the body, or in any of its interior cavities. To those, in whom such varieties occur, the dose should not be given during febrile exacerbation, but when it abates ; not when the mind is cheerful, or countenance ani- mated, but when it is despondent. When the digestive organs are unable to perform their functions easily, that is, with- out cardialgia, flatulent discharges, tormina, &c. immediately after taking food, the dose of the digitalis should be given in a little wine, or along with some agreeable aroma- tic or cordial, a few minutes before the pa- tient takes his food. It has been affirmed of late, that there is a species of pneumonia, which is cured by 315 the digitalis, and in which venaesection must not be employed ; but the complaints, which are said to be of this nature, appear to me to have chiefly depended on anasarca of the lungs. The digitalis must not be exhibited in any other than passive inflammations. When the patient is affected with diar- rhoea, let opiates be given along with the digitalis. I cannot refrain from reprobating the proposal of blood-letting, purging, &c. to make such a change in the constitution of the patient as might give a chance of suc- cess to the digitalis,* which would certainly be speculating in the treatment of disease beyond the boundaries of reason, prudence and humanity. Since by an evident deduction from nu- merous facts carefully ascertained, I have established a principle for the administra- tion of digitalis, the opposite of that which guides the practice of physicians, it might be expected, that I should advise it to be prescribed in morbid affections opposite in nature to those in which they employed it, * Withering on the Fox-Glove, p. 190. 316 but in this we have an instance of that struggle which must ever subsist between the influence of fact, and of opinion found- ed only in prejudice ; for it has been em- ployed both in sthenic and asthentic dis- ease, and even in combination with the most powerful stimulants to assist, accord- ing to them, its sedative effects. To illustrate what we have said, we shall quote from a work in common use, the Edinburgh Dispensatory, in which the sup- posed effects of the remedy, and the diseases which authors have advised to be treated by it, are enumerated. *' Its effects, when swallowed, are, '1. "To diminish the frequency of the pulse. 2. "To diminish the irritability of the system. 3- " To increase the action of the absor- bents. 4. " To increase the discharge of urine." Internally, digitaUs has been recom- mended, 1. "In inflammatory diseases, from its very remarkable power of diminishing the velocity of the circulation. 2. "In active hsemorrhagies, in phthisis. 317 3. "In some spasmodic affections, as in spasmodic asthma, palpitation, &c. 4. " In mania, from effusion on the brain, 5. "In anasarcous and dropsical effu- sions. 6. " In scrofulous tumors. 7. " In aneurism of the aorta, we have seen it alleviate the most distressing symp- toms." Here we have an epitome of all the ab- surdities of writers on the effects of digita- lis : here are ludicrously attributed to it the contradictory effects of diminishing the fre- quency of the pulse with the irritability of the system, and of, at the same time, in- creasing the action of the absorbents. In like manner it is recommended in the violence of inflammation, in active hae- morrhagies, as well as in the extreme de- bility of general dropsy ; in scrofula where inveterate torpor reigns ; in spasmodic asth- ma and palpitation which require the most powerful remedies, as assafoetida, camphor, musk, opium, ether, and in aneurism of the aorta where such substances are justly deemed most dangerous. 318 The same contradictory influence of truth and hypothesis, made Beddoes, as has been aheady noticed, declare, that the ro- bust, and Withering, that the feeble, were best fitted for the reception of the digitalis. What are we to think of an immediate sedative, the efficacy of which is often pro- moted by the addition of the most power- ful stimulants, equally useful in active in- flammation and its consequences ; a sub^ stance, which at the same moment most powerfully subdues the energies of life, and renovates with admirable virtue the almost exhausted body ? It must appear fortunate, that experience has improved our knowledge of the proper- ties of the digitalis, and taught us to substi- tute the above simple rule for the one now commonly received ; viz. " to continue the use of the substance till nausea, sickness, vomiting, and diminution in the number and strength of the pulsations supervene ;" which seems to me just as rational as to say. Continue devouring rich viands, till surfeit ; drinking ardent liquors, till intoxi- cation ; or rather continue the intoxication itself, by their use, till sickness, vomiting, and great exhaustion supervene ; for accu- 319 mulated disease with exhaustion, and, I fear, not rarely death itself, have been the con- sequences of the unguarded or indiscrimi- nate administration of the digitalis. It is fortunate, I repeat, that a substance, which is the terror both of physicians and patients, but which, on account of its infinitely supe- rior efficacy, should be employed in diffe- rent periods of every consumption, in al- almost every dropsy and other diseases of general debility, can be managed in the mild, as well as the alarming degrees of such morbid affections, with as much ease as the mildest, and least effectual substances. Let no man think such inquiries the in- signia of abortive labour, for in them are involved the lives of individuals, the hap- piness of families, the prosperity of nations. FINIS. Printed by Walker &c Greig, foulis Close, Edinburgh. 'A COLUMBIA UNIVERSITY This bQQ.k is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE I \ C2a(63e)MS0 J