TREATISE ON THE PRINCIPAL DISEASES OF <5ntmti at ©tationer# JJ)aU. TREATISE ON THE PRINCIPAL DISEASES OF DUBLIN. \ B I MARTIN TUOMY, M.D. T.C.D. AND FELLOW OF THE KING AND QUEEN'S COLLEGE OF PHYSICIANS IN IRELAND. DUBLIN *. PRINTED BY WILLIAM FOLDS, .°»8, GREAT STRAND-STREET. Digitized by the Internet Archive , in 2016 https://archive.org/details/treatiseonprinciOOtuom L i 4t 0^ 4 T?3f PREFACE, THE Materials of the following pages have been collected from observations made in a course of several years private practice, and in a very extensive range of dispensary practice during those eight years past. In the Dublin General Dispensary I had many opportunities of appreciating the value of different remedies in the diseases which occurred at that institution, of marking the variety of those diseases, of comparing their symptoms, and of classing them according to the resemblance discovered between them, and to the nature of the remedies, which after a fair but cautious trial, proved most effectual in accomplishing a cure. The inferences which I had been enabled to draw from those bbservations in dispensary practice, were analagous to those which followed under . similar circumstances in private practice, with only such variety as arose from diversity of habits and of delicacy, and which principally related to the doses of medicines : I have taken pains to point out this variety in the course of the work. I found that in many disorders, whatever might have been the original exciting cause, a morbid or diseased secretion 435446 VI PREFACE. secretion in the alimentary canal, and in the abdominal viscera, particularly the liver, occasioned the greatest part or the whole of the patient's suffering ; though that injured secretion could only be considered as the effect of the primary causes ; and that the remedies which restored the healthy secretions of these organs were the best for curing the disease. A great number of particular instances, irresistibly leading to this general induction, impelled me to adopt the classification of hepatic and bilious diseases, which will be found in the following pages. Some diseases, of an acknowledged inflammatory nature, are classed together without much regard to sys- tematic order ; their inflammatory appearance, and ordi- nary danger, being the only particulars that led to this arrangement. Some epidemics, which appeared in great numbers, returned at different periods, and afforded a very extent sive range of observation and practice, are also taken notice of, and that mode of treatment recommended which ex- perience and repeated trials proved to be most effectual. A number of cutaneous disorders, unattended with fever, are described according to their leading symptoms, without any attempt whatever at system ; because, as far as I have been able to ascertain, there has not yet been any classification of them which could tend to introduce sounder PREFACE. VII sounder practice, though it might assist to facilitate the description of their symptoms : most of those disorders are found principally to affect the ,poor, but some of them are met with in all ranks of society. A few spasmodic diseases which have frequently oc- curred in practice, especially in dispensary practice, are also treated of; the frequency of their occurrence being the only cause of the preference given to them more than to other complaints of the same class, And for a similar reason some sexual diseases are mentioned, which are often a source of deep affliction, especially amongst the poor. I have dwelt on dropsy at some length, in consequence of its frequency and danger. Instances of it presented themselves almost daily at the Dublin General Dispensary. Prom the acknowledged fatality of this disease, I exerted myself to ascertain which of the many remedies recom- mended for its cure will prove successful in most cases ; and I had the satisfaction at length of adopting a method which is effectual in several instances, indeed in a majority of instances, unless there had been some primary incurable disease as the foundation of the dropsy ; thus dropsy aris- ing from suppressed perspiration, from fatigue, or con- nected with slight and curable obstructions in the liver, will be removed in a majority of cases ; but dropsy caused by ossified and aneurismal arteries, by ossification of the valves VIII PREFACE. valves at the mouths of the great blood-vessels, or by a diseased heart, cannot be cured, even though the collected fluid may pro tempore be carried away by means of medicines. Typhus, or contagious, or spotted fever, is another disease which I have treated pretty largely, in consequence of its very serious nature, and of the ravages which it has been known to commit in Dublin, until the institution of the fever hospital in Cork-street has almost banished it from the higher ranks, and greatly reduced its frequency and malignity amongst the poor. The blessings of that great monument of philanthropy are incalculable ; and this is less to be wondered at when we consider that it is in a great degree directed by the characteristic industry, the rigid honesty, and the unlimited benevolence of the Quakers. It was impossible to strike out exact limits, which hi all cases might distinguish typhus from bilious fever, as some of their symptoms are frequently intermixed to a certain extent ; I think, however, there cannot be much doubt about their being different diseases, and in many essential circumstances very distinct from each other. It was my original intention to treat separately of the principal diseases of children but from considering that most of the diseases which afflict infancy and childhood are PREFACE. IX are frequently met with amongst grown persons also, I preferred the plan of introducing them into the body of the work : I likewise abandoned my first intention of pub- lishing one or more cases of clinical patients after each disease for the purpose of illustration, because such a plan would swell the book to a very large bulk, without adding materially to its value. As to the remedies detailed in the appendix, it will perhaps be objected that they are often unchemically combined ; thus, for instance, calomel is sometimes tri- turated with other substances which have the quality of taking up some of the acid of the calomel, and thereby bringing it nearer to a metallic state. I am perfectly aware of the truth of the remark in this and some other instances, which might be pointed out ; but my answer is, that the medicine has, notwithstanding, the effect which I wish, and that the slight decomposition produced in those cases is an event which accords with the indica- tion of giving the medicine. In the instance specified for example, the medicine is not intended to act solely: as a purgative, but gradually to affect the biliary secretions, a quality which it possesses in a higher degree when its purgative powers are somewhat repressed, and when the medicine is in a less saline state. In the minds of some persons there is a prejudice against the use of mercurial medicines altogether, because they conceive X PREFACE. conceive them injurious to certain delicate constitutions, especially where there is a scrophulous taint. Mercury, it may be observed, is given with three different views ; lirst, with the intent of being largely conveyed into the system, and there producing the sensible effects of sali- vation, &c. ; the 2nd intent is that of exhibiting it in such a cautious manner as that it shall act slightly upon the se- cretary organs, particularly the liver, and perhaps preserve a regular . state of the bowels at the same time ; and the 3d is, that of giving it in some of its saline preparations, so that it shall affect the alimentary canal as a purgative, and dislodge the morbid and not unfrequently putrid contents of the bowels without being absorbed into the system. The 2d and 3d indications of mercury are perfectly consistent even with scrophulous delicacy ; and with those indications it is often exhibited not only without injury but with decided benefit. As to the 1st, in which the medicine is conveyed copiously into the sys- tem, it must frequently take place even in scrophula, namely, in venereal complaints : but with a view to scro- phula only, there are good grounds for questioning the propriety of liberal exhibitions of mercury ; it does not appear to exert any salutary influence upon the lacteal or lymphatic glands, the ordinary seat of scrophula, except when there is venereal infection. To quarrel then with this excellent remedy as being dangerous in rousing the latent morbidity of scrophula in all cases is neither just nor philosophical ; the distinctions pointed out above are necessary PREFACE. XI necessary to be observed in speaking with fair and correct accuracy on the subject. I have studiously avoided a display of great variety in the medicines which I recommended, and confined myself to those alone which I have been decided by experience in preferring. It has been my earnest exertion to dwell principally upon points of practical utility, and to make the whole as simple, as intelligible, and as interesting as possible. M. T. . • ' % CONTENTS. Bilious and Hepatic Diseases . Reasons fox such rangement ------ Symptoms of Bilious and Hepatic Diseases - Bilious Fever - Symptoms of Bilious Fever - Causes of Bilious Fever - - CWe o/' Bilious Fever - Bilious Fever of Children - Cure of Bilious Fever of Children Infammation of the Liver , acute ; its symptoms - Cwre of acute Infammation of the Liver Infammation of the Liver , chonic - Cwre o/* chronic infammation of the Liver - Jaundice ; its symptoms - Causes of Jaundice - Cure of Jaundice - Jaundice of Infants . CWe - Cholera ------- Symptoms of Cholera - - - - Cwre f Cholera ------ Dysentery or Bloody Flux - Symptoms of Dysentery - Cwre 0/ Dysentery - Dyspepsia , or Indigestion Causes of Indigestion - Prognosis , or judgment to he formed of its termi nation ------ Cwre Ojf Indigestion - - - - Dyspepsia of Children - - - * - Cwre 0/’ Indigestion of Children Intermittent Fever , or Agues - - - - Imperfect Intermittents - Diagnosis , or ^oro to distinguish imperfect Inter mittents ...... Perfect Intermittents - Cure f Intermittents - Dropsy ------- arieties f Dropsy - I 2 4 ? 5 6 22 23 28 31 37 38 42 44 45 49 i£. 50 51 59 60 64 71 74 77 & 84 85 ib* 86 87 88 90 95 96 XIV CONTENTS. Anasarca , or Dropsy of the surface of the Body ; symptoms - - . - - - 97 A sites, or Dropsy of the Belly ; symptoms - 99 Hydrothorax , or Dropsy of the Chest ; symptoms ib. Causes of Dropsy - - - - - -102 Judgment to be formed of its termination - - 107 Cure of Dropsy ------ 109 Fever , common , or Typhus - - - - -116 Symptoms of Fever - - - - -117 Favour ale termination of Fever; when it happens 131 Judgment to be formed of the termination of Fever; bad symptoms - * - - - 132 Good symptoms in Fever - - - - 1 34 > Causes of Fever - - - - - 137 Cure of Fever - - - - - -138 Worms; symptoms - - - - - -153 Varieties of Worms - - - - 1 55 Causes of Worms • - - - - 158 Distinction between Worm Complaints and others 159 Cure of Worms ------ 162 Catarrh , or common Cold ; symptoms - - 168 Influenza - - - - - - - -170 Danger of Cold in delicate Lungs - ib. Causes of Cold - - - - - -171 Parts affected in Colds - - - - -172 Terminations of Colds - - - - 174 * Diagnosis , or how to distinguish Cold f om other Complaints ib. Cure of common Cold - - - - 175 Cure of Influenza - - - - - -179 Inflammation of the Lungs ; symptoms - - - 180 Causes of Inflammation of the Lungs - - 185 Diagnosis , or hovo to distinguish it from other Complaints - - - - - -187 Cure of Inflammation of the Lungs - - - 188 Consumption of the Lungs , or Phthisis - - - 197 Causes of Consumption ----- 204 * Cure of Consumption ----- 207 Inflammatory sore Throat - - - - - 212 Causes of sore Throat - - - - - 214 * Cure of sore Throat - - - - - 235 Rheumatism - - - - - - - 218 Acute Rheumatism - - - - - - 219 Causes of acute Rheumatism - - - - 221 Cure of acute Rheumatism - 222 Chronic Rheumatism 226 CONTENTS. XV Causes of Chronic Rheumatism - 227 How to be distinguished from other Diseases - 228 Cure of Chronic Rheumatism - 230 Inflammation of the Stomach ; symptoms - 233 Causes of Inflammation of the Stomach - - 234 Cure of Inflammation of the Stomach - - 235 Inflammation of the Bowels - . - - . 237 Causes of Inflammation of the Bowels - - 239 Cure of Inflammation of the Bowels - 240 Measles -------- 242 Symptoms of Measles - - , - - 243 Hovo to be distinguished from other Diseases - 247 Judgment to be formed of the termination of Mea- sles -------- 248 Cure of Measles ------ 249 Sc arlet Fever ; its varieties ----- 252 Symptoms ---•*■ 253 Cause - - - - - - - -261 Hovo to be distinguished ib. Judgment to be formed of its termination - - 263 Cure of Scarlet Fever ----- 264 Sequelce, or dregs of Scarlet Fever - - - 269 Cure of the Sequelce of Scarlet Fever - - 271 Griping and irregular Bowels of Infancy .- - - 273 Symptoms - -- -- -- ib. Causes ------- - 274 Cure of Griping and irregular Bowels of Infancy 27 5 Purging of h fancy - - - - - 279* Cure of the Purging of Infancy - ib. Convulsions , or Fits of Infancy - 280 Symptoms ------- 281 Cure of the Convulsions of Irfancy - 282 Apoplexy - -- -- -- - 285 Symptoms of Apoplexy , premonitory - Symptoms of Apoplexy , proper - 286 Predisposition to Apoplexy - 288 Causes of Apoplexy - - - - Cure of Apoplexy - - - - - -291 Palsy ; its symptoms ------ 295 Causes ------- - 297 CWe - Asthma ; its symptoms - - - - - -299 Cwre* of Asthma ------ 302 Gouty Asthma ------ S06 Chincough ; its symptoms ----- 308 Cure of Chincough - - - - - -310 Leusorrhcea, or Whites - - - - - *314 XVI CONTENTS Causes - - - - _ - . qis Cure -------- 316 Profuse Menstruation - - - _ . - 318 Cure Irregular Menstruation of advanced life - - - ib. Cure - . 319 Chorea , or St. Vitus* s Dance - 320 Cure - 321 CUTANEOUS DISEASES. symptoms - Czzre ------ Scabby Sores of Adults , distinct Cure ------ Pustular Eruptions of Children Cure ------ Lepra , or Scaly Eruptions - C«re ------ Tinea i or Scald Head - CWe ------ Ulcerated and Sore Legs - Symptoms - 6 are ------ Ringworm; Symptoms - Czzrt* ------- Ztor£ coloured scaly Blotch - Cz/re ------ Venereal Eruption ; varieties How to distinguish Venereal Pains Cure of Venereal Eruptions and Pains White Blisters , or Burnt Holes Symptoms - Persons most subject to this Complaint Cure ------ Appendix ------ 324 326 328 329 331 332 334 335 336 337 339 341 343 ib. 344 345 ft. 348 349 350 351 353 355 259 Bilious and Hepatic Diseases OF JDUMhlJV, U NDER this general character, I have included a number of diseases, which in systematic works are far differently arranged ; and however objec- tionable this classification might appear at first sight, I trust, that, upon examination, it will be found at least as consistent with practical obser- vation, and as useful in regulating the mode of treatment, as any of the arrangements commonly adopted. In this class of diseases, it is true, there are some features in which they differ from one another ; and consequently there is some variety in the quality of the medicines to be employed but, throughout the whole class there appears a morbid secretion of the fluids of the abdominal viscera, particularly of the bile : there is a great resemblance between them in their leading symp- toms ; and the same method of cure in its most prominent outlines is adapted to them all. B The 2 BILIOUS DISEASES. The diseases ranked under this class are: Bilious Fever, Inflammation of the Liver, Jaundice, Cho- lera, Dyspepsia or Indigestion, and Dysentery or Fluxes. COMMON SYMPTOMS OF THE BILIOUS AND HEPATIC DISEASES OF DUBLIN. 1 . Pain and fulness of the Hypochondria and Pit of the Stomach , and sometimes oj oilier parts of the Abdomen. This pain is most sensibly felt upon the parts being pressed with the hand, especially at the pit of the stomach, and towards the right side ; some- times the pain descends towards the lower part of the belly, and is most sensible there ; sometimes it is most severe towards one of the loins ; and sometimes there is a general soreness of the whole belly, most painful at the navel. 2. Flatulence . This is often a very distressing symptom, and may be confined to the stomach or any part of the intestines, but it appears most commonly fixed in the arch of the colon. 3 . Bitterness of the Mouth. This is a common symptom, and sometimes changes to a putrid offensive taste. 4 . Loaded BILIOUS DISEASES. 3 4. Loaded Tongue . The tongue is covered with a dirty load, of a colour varying through all shades from a light yellow to a dark brown or black. 5. Nausea or loathing . This sometimes becomes so great as to end in vomiting, generally of a greenish or yellowish viscid fluid, very bitter and disagreeable. 6. A sallow or yellowish colour of the Face and whites of the Eyes . This is a very common occurrence, and mostly attended with an expression of dulness and lan- guor of the countenance. 7. Want of Appetite . This is more or less constant in bilious diseases. 8. Irregularity of the Bowels . The most common state of the bowels is cos- tiveness ; but it sometimes happens that there is a scanty purging, accompanied by straining, and which yet procures little relief for the patient. 9. Sighing . The occurrence of this symptom is most usual where any critical eruption upon the surface is likely to appear, particularly of the miliary kind. B 2 10 . Vertigo • 4 BILIOUS FEVER. 10. Vertigo. Vertigo or swimming of the head occurs in this class of diseases, and in many amounts to head-ache, often very violent and excruciating. BILIOUS FEVER. This complaint is known in Dublin throughout the year, but it is most frequent in autumn and winter. There are considerable varieties in its severity and duration. It often attacks with sick- ness at stomach, and lasts but a day or two, es- pecially if managed judiciously at the commence- ment. Sometimes it lingers on for several days scarcely attended to by the patient, and then be- comes troublesome, and perhaps continues for a fortnight or a longer time, notwithstanding the most skilful treatment. It is however a disease which, unless grossly neglected, never proves fatal, except it be combined with visceral obstruc- tions ; and then the termination of the complaint will depend upon the quality and severity of the other disease. There are intermediate degrees both as to duration and danger, in which, though the patient cannot instantly shake off the com- plaint, yet its progress is so mild that a few pur- gatives, well chosen, and properly administered, will banish it in the course of six or seven days ; the patient during the treatment being enabled to sit up and walk about his room. SYMPTOMS. BILIOUS FEVER. SYMPTOMS. Bilious Fever begins with impaired appetite *, loathing of food ; bitter or foul taste of mouth ; confined bowels ; and frequently cough. 1 hese symptoms gradually increase in severity, and are often attended with tension, pain, and heat about the pit of the stomach, which, in different persons extend to different parts of the belly. The tongue is foul and yellow; the head generally giddy or heavy ; the patient is distressed by light and noise ; the countenance is dull ; the face and eyes unusually yellow ; sleep interrupted and un- refreshing ; the pulse often but little quickened, and never so quick as in common typhus fever, unless in persons of great irritability, whose pulse is apt to encrease in frequency from the most trilling causes : the heat of the skin is generally moderate, but always above the healthy standard, and sometimes pungent ; the urine high coloured, scanty, and attended in its passage with a sense of increased heat, and in some cases with a scald- ing : there are often wheals or vibices on the skin, resembling the marks left by the stripes of a whip, which are sometimes of a pale, and sometimes of a red colour. I have sometimes observed small par- tial dropsical swellings on the thighs, or legs, or face. Several cases have lately occurred in this town of miliary points appearing on the skin, sometimes accompanied by sweats, but mostly without any sweats whatever ; these were the red miliary erup- tion in most instances: but I met with the white miliary 6 BILIOUS FEVER. miliary points in a young delicate female, who had been lingering for more than a fortnight in the complaint before I saw her. The continuance of these eruptions was uncertain, but commonly they disappeared before the termination of the disease ; and they always marked a more troublesome and tedious complaint. Delirium of the low and muttering kind is common in long protracted cases, especially after sleep. Sometimes there is a remarkable stupor or dulness, in which the pati- ent does not appear sensible of head-ache : this symptom marks a morbid state of the brain, for which I found a large and sharp blister, applied from the forehead backwards as far as the neck, the best remedy. Deafness is sometimes met with ; and here, as well as in typhus fever, I con- sider it a favourable appearance. CAUSES. There are some constitutions very much, and others very little subject to bilious fever. The causes which commonly bring it on, are habitual constipation ; exposure to cold, wet, or damp weather ; sudden changes of temperature, parti- cularly accompanied by wet weather ; sedentary habits ; depressing passions of the mind ; food difficult of digestion. CURE. The method of cure in this disease is very sim- ple, and consists in removing the acrid contents of the BILIOUS FEVER. the bowels by means of those purgatives which are best calculated to dislodge bilious sordes ; in correcting morbid and restoring healthy secretion; in relieving topical distress by appropriate appli- cations ; and in supplying the patient with light digestible food, mild diluting drink, cleanliness, and pure air. The purgatives must be steadily persevered in throughout the complaint ; for it is upon them we must principally rely for success : and as the accumulation of foul matter in the alimentary canal is constantly and copiously produced ; so there is no disease in which the free and regular use of purgatives causes less distress, or gives more uniform relief. It frequently happens, that from the operation of a purgative, a large quantity of foul excrements comes away ; and yet in ten or twelve hours after, there is another large evacua- tion, so as often to cause great surprise, how so much could be generated in so short a time ; and these copious and foul evacuations continue for several successive days without inducing propor- tionable weakness ; but on the contrary they procure great mitigation of the symptoms ; even delicate and young females are relieved, without being exhausted, by these evacuations. In the ex- hibition of medicine to produce those desirable changes, it is proper to observe, that some purga- tives will pass through the bowels with the effect of 8 BILIOUS FEVER. of causing repeated and liquid stools ; but Mill leave the greatest part of the sordes behind them ; (of this I have seen several instances) so that an appropriate cathartic exhibited immediately after this liquid purging, shall bring away copious stools of faetid, dark, and solid excrements. The ad- vantage of selecting the effectual purgatives, and of avoiding that injudicious use of any medicine, because it has the name of a purge, I conceive it necessary to enforce ; because I believe the practice of resorting to purgatives indiscriminately has often converted into a lingering disease, that, which might have been cured in three or four days ; and has, not unfrequently, been the means of sapping away a large portion of valuable health. A dose of the medicines, No. 1, 2, or 3, which contain calomel, a purgative of another kind, and an aromatic, is the best for completely dislodging and bringing away the sordes of the intestines ; but as these are commonly slow in their operation, the purgative mixture, No. 4, may be taken to co-operate with the others, and to clear the bowels more speedily. In five or six hours after the bolus or pills, two large spoonfuls of the mixture might be taken by a grown person, and repeated every two hours until the stools come away; these stools consist commonly of dark coloured excrements in a solid form, but some- times BILIOUS FEVER . 9 times of small lumps intermixed with a liquid slime, all dark, and of a faetor not unlike to that of a slaughter-house : sometimes the first stools have a more natural appearance, and a lighter co- lour ; and it is not until after a few evacuations of this sort, that the dark coloured excrements begin to come away ; and it is remarkable that we are disappointed of any substantial improve- ment in the state of our patient, whilst the dark faeces remain behind, notwithstanding the quan- tity of the evacuations procured. During the remainder of the day after the effect of the pur- gatives, the saline mixture, No. 19 or 20, may be used ; it settles the stomach, removes loathing, and gently co-operates with the indication of the purgative. The best time for the exhibition of the purgative is the morning early, for then the business of evacuating the bowels and quiet- ing the sickness of the stomach may generally be finished before bed-time, in such a manner that the patient may have the best possible chance for sleep. This observation as to the time of giving purgatives applies generally to all acute diseases ; and when we have a complete command of time, and circumstances, it ought to be attend- ed to ; but when we are called in at a late hour, and that evacuating medicines of this class cannot be delayed consistently with the comfort and safety of our patient, the purgative must be immediately ordered ; all other considerations yielding 10 BILIOUS FEVER. yielding to that of speedily and effectually re- lieving the patient. If there is pain or uneasi- ness felt at the pit of the stomach, or in any part of the belly, it may be rubbed with the liniment, No. 1 6 , for a few minutes from time to time, and afterwards covered with dry flannel heated before the fire. Should the pain become very severe, attended with vomiting and threatening inflammation of the bowels, we should without delay bleed freely from the arm, and apply a sharp and large blister to the belly, so as com- pletely to cover the whole of the pain ; and occasionally, throw up laxative oily glysters, as in No. 103 , every two hours until the bowels are evacuated, and the pain is removed. As the pain of the bowels generally proceeds from the acrimony of the confined faeces aided perhaps by flatus ; upon removing the fasces, the pain gradually subsides ; the purging plan must therefore be our main resource in our efforts finally to subdue the pain. It will be proper thus to repeat the purgative treatment, so as to procure at least one free passage every day ; and in cases where the belly is swelled abounding with excrementitious sordes and wind, a greater number of stools will be borne by the patient without distress. There BILIOUS FEVER. 11 There is sometimes an appearance of loose eva- cuations, caused by frequent and scanty motions, and accompanied by straining and irritation to go to stool ; here it will be necessary to have recourse to the double plan of mitigating this irritation, and of freely evacuating the contents of the bowels : for this purpose a dose of the pills No. 7, consisting of calomel opium, and an aromatic, will be an excellent remedy ; in this medicine the opium allays the straining and irritation, without destroying the purgative qua- lities of the calomel, which in some time passes on through the intestines (though somewhat more slowly in consequence of the opium) and carries off the sordes, upon the presence of which the irritation and straining depended : but as it will be desirable in many cases to remove the foulness of the belly somewhat sooner, the glys- ter No. 6, might be administered five or six hours after the pills, and repeated every three hours until the effect is attained. Should instances occur where the medicines already recommended fail to relieve the consti- pation, we may rely with considerable certainty upon the electuary No. 5, of which a tea-spoon- ful might be taken five hours after a dose of the medicines No. 1, 2, or 3, and repeated every three hours until a discharge is procured. In cases too where the purgative mixture and pills fail 12 BILIOUS FEVER. fail to produce a sufficient effect ; or where from the great fulness of the belly, or any other cir- cumstances we have reason to conclude that a powerful cathartic may be necessary to aid the medicines No. 1, 2, or 3, the electuary i o. 5, might be ordered as above directed, with a pretty strong certainty that it shall answer our expecta- tions. The calomel purgatives had better be repeated for the first four or five days, according to cir- cumstances, and followed up with the medi- cines already mentioned ; afterwards other cathar- tics will bring away those morbid excretions which might still remain in the intestines, with much greater certainty, than the same cathartics could have dislodged them, if administered without the previous exhibition of the calomel : hence it is manifest that calomel has a more powerful effect in expelling morbid faeces, than any other medicine in ordinary use. Should there be loathing and foulness of sto- mach, the calomel purgatives so much relied on will frequently cause vomiting in a short time after being taken, perhaps in less than an hour, and almost to a certainty before they operate by stool ; but this is a circumstance at least innocent, for the medicine will, notwithstanding the vomit- ing, pass off by the bowels in due time (unless the BILIOUS FEVER. 13 the vomiting occurs immediately upon taking the purgative) and sometimes the effort of vomiting will give temporary relief by unloading the stomach. In delicate stomachs the saline mixture sometimes gives little relief, then a little burnt brandy will prove a grateful cordial ; but the most effectual of all cordials is generally a little ice-cream. A thinly sliced lemon with some white sugar powdered on it, is a vulgar and yet a grateful remedy for cleaning the tongue and inside of the mouth. The above treatment, in most instances, com- pletely removes the disease without the necessity of resorting to other medicines. The com- plexion becomes gradually more clear ; the pulse more soft and slow ; the tongue cleaner towards the edges, softer, and of a natural colour ; the stools lose their dark colour and unnatural morbid fretor ; the tension, and pain, and fulness of the belly subside ; appetite begins to return ; the urine, before scanty and high-coloured, now encreases in quantity and deposits a sediment ; the eye and countenance assume a natural expres- sion ; sleep gradually gains upon the harrassed patient and becomes profound and refreshing; the breathing, before somewhat hurried, now is slow and regular ; the speech more firm and ar- ticulate. 14 BILIOUS FEVER. ticulate ; and the train of thoughts more orderly and collected. v After convalesence begins, the cordial mixture No. 18, may be taken twice a day, for at least a week, to strengthen the stomach and to assist in improving appetite. The pills No. 8, will oc- casionally be useful, and may be taken at bed-time for several days after the disease disappears, in order to guard against the danger of confined bowels. Some instances occur where untoward symp- toms call for more attention and require a greater variety of remedies. The distress of the head will prove obstinate and continue after the treat- ment abovemention ed has been fairly tried ; the complaint of the head is sometimes a low mutter- ing delirium, teazing the patient with irregular fancies, and greatly interrupting or entirely banish- ing sleep : this may be called the low delirium. Sometimes the distress is a stupor, whence the patient continues in a state of drowsiness with- out getting any refreshing sleep, and if asked about the state of the head, does not appear sen- sible of pain ; but it commonly happens, that if strong light be admitted, there is an aversion expressed sufficiently strong to prove that light is disagreeable. Most of the cases of this sort which I met with, were in young persons under the BILIOUS FEVER. 15 the age of puberty. In some instances there is a violent outrageous permanent delirium, accom- panied by a shining prominence of the eyes, a throbbing of the temporal arteries, and com- monly a turgid fulness of the face, with a pulse full and strong. This may be properly called the phrenitic or violent delirium ; all the instances of this sort which I met with, were in persons who were strongly addicted to the immoderate use of spirituous liquors ; and most of them were no- torious drunkards. In those cases there is some- times a bleeding from the nose, and sometimes an hsematemesis or bleeding from the stomach. Those discharges of blood are somewhat critical. In those three different varieties of disordered brain, the head should be immediately shaved, and occasionally wetted with strong spirits or spirituous embrocations. In the first sort or mut- tering delirium, if the uneasiness of the head ban- ishes sleep entirely, after clearing the bowels suf- ficiently, we may try the opiate pill, No. 13 , at bed time, and if necessary repeat it in three hours after ; it often has the effect of procuring a sound sleep of some hours, and of leaving the patient upon awaking refreshed and free from delirium, or at least with a slighter portion of it than before the opiate was given : blistering and perhaps leeches may be useful too, particularly should there be a throbbing of the temporal arteries, or other indi- cations 16 BILIOUS FEVER. cations of encreased vigour of circulation in the vessels of the head. In the drowsy or torpid state, along with the usual evacuations mentioned already, a large blister should be applied without delay to the whole of the upper part of the head, from the forehead to the nape of the neck ; this seldom fails to procure decided relief in the course of twenty four hours ; but as the hairy scalp of the head is not easily vesic- ated, it will always be proper after the blister is spread, to lay over it a thin covering of powdered flies. The discharge from the head may be kept up afterwards if necessary by means of vesic- ating ointments. In the phrenitic or violent delirium, accompanied by a strong full pulse, we must without delay bleed freely from the arm. From fourteen to sixteen ounces may be taken away at once and from a large orifice, and repeated if necessary in the course of twenty four hours ; and as often as the strength and hardness of the pulse returns, blood must be taken away : here too the blisters with the circum- stances of their sharpness &c. and the careful ex- hibition of purgatives, already pointed out, will be proper. The various modifications of head-ache, torpor, and delirium, are often accompanied by encreased action BILIOUS FEVER. 17 action in the vessels of the head, as the noise in the head, the throbbing of the temporal arteries, and the flushed complexion sufficiently denote ; and are frequently accompanied by a quick and feeble pulse : blisters therefore to the head, with topical bleeding, by means of leeches, or by means of cupping and scarifying, must be relied on, without general bleeding from the arm : it is only when the pulse is strong and full that blood-letting from the arm is admissible ; but it is in the phrenitic delirium only, that this state of the pulse occurs. Sometimes we meet with cases of obstinate con- stipation, incessant vomiting, and severe pain and tension of the belly. Such cases are peculiarly dis- tressing ; because the purgatives, which are indis- pensible to remove the constipation and distress of the belly, cannot be retained by the stomach, but are immediately rejected by vomiting ; and enemata are but a very inert substitute on those occasions ; such a state is apt to terminate in inflammation and gangrene of the intestines ; and even if it be at length relieved before inflammation commences, the long continued tension of the belly induces a state of atony which soon ends in dropsy of the belly : sometimes a dropsy of the belly with general anasarca supervenes ; the treat- ment of which is to be conducted according to the directions pointed out in the cure of dropsy. Where the pain and writhing about the naval c mark 18 BILIOUS FEVER. mark the existence or the approach of inflammation of the intestines, we must bleed freely from the arm, and then perhaps cover the part in pain with a sharp blister. Bleeding he^*e is a melancholy ne- cessity, because the weakness likely to ensue is thereby increased ; but if the bleeding is omitted the event is fatal. The following is the method I had recourse to in those instances, and with flattering success. The opiate draught, "No. 14, is exhibited with a view to allay the irritability and straining of the sto- mach, and repeated every ten minutes until this object is attained ; then the pills. No. 1 1 , are taken, and in three or four hours afterwards the electuary No. 10, of which a tea-spoonful is to be taken for a dose, and repeated every two hours after- wards until a stool is procured. As soon as a co- pious evacuation takes place, the general distress of vomiting, pain, restlessless, and tension begin to subside ; then the subsequent treatment is to be regulated according to the method already des- cribed. The general blood-letting is not to be employed in ail cases of this kind ; it is only where inflammation of the bowels is apprehended, that it mus^ be practised. It will be of great benefit to swathe the belly with a very long flannel roller as soon as convenient, the coiling of which must be continued from the bottom of the abdomen up- wards towards the pit of the stomach $ the roller seldom BILIOUS FEVER* 19 seldom falls to give immediate relief, by its sup- port and warmth. * In bilious cases it sometimes happens, that after evacuating the contents of the bowels freely, and taking such other steps as the nature of the com- plaint seems to require, a degree of listlessness remains ; the patient recovering but very slowly, and yet having no particular pain or distress : here it will be proper to examine the state of the hypochondria, because in such instances some derangement of the liver is commonly the source of the malady : accordingly we shall find indica- c 2 cations * I met some time ago with a remarkable instance of the comfort experienced from the roller, in a gentleman who had this complaint to an alarming degree. He had been very judiciously bled, before I saw him, and treated with purgative pills and glysters, but without effect ; the incessant vomiting entirely frustrated the benefit of the pills, and the glysters procured but • slight relief. His belly was greatly enlarged, and his strength much exhausted when I was called in ; the opiates, above mentioned, were directed and followed by the purgative pills and electuary, in consequence of which large and faetid evacuations were procured ; a roller was then applied with such immediate and marked relief, that he exclaimed, why was not this done at first ! — upon his convalescence from the bowel complaint, he filled with water in the legs and in the belly, for which he was treated according to the principles detailed in the account of dropsy ; to which I beg leave to refer. He soon recovered, and is now in good health. 20 BILIOUS FEVER. cations of some degree of chronic hepatitis, of which encreased fulness in the right hypochon- drium is a very common symptom. In those in- stances we must recommend the gradual and gentle use of mercurial medicines. I have treated such cases successfully by means of the pills, No. 9, persevered in until the mouth became sore, and the system sensibly charged with the medicine. Along with these I recommend a few trials of the warm sea-bath. The various marks and eruptions on the skin, which sometimes accompany bilious fever, most commonly disappear along with the fever, and re- quire no specific treatment : this remark applies to the miliary eruptions themselves : but in tedious cases, where there is great delicacy and relaxation, and particularly where the eruption consists of the white miliary points, accompanied by a pungent feverish heat of skin, I have given the bitter cordial. No. 17, with considerable benefit: it strengthens the tone of the stomach and bowels ; corrects the acrimony and fetor of the excrements ; mode- rates the heat of the skin ; and is sometimes gently laxative. Cough is a common symptom ; but it generally disappears along with the others, without the aid of expectorating medicines : even in cases of se- vere cough in bilious fever, upon removing the sordes : BILIOUS FEVER. 21 sordes of the alimentary canal, the cough becomes so mild as to need no particular treatment : of this I met with repeated instances. But if the cough should still continue distressing, in con- sequence of any peculiar delicacy of the lungs ; or of the combination of catarrh with the com- plaint ; the expectorating mixture. No. 1 5 , is commonly sufficient to remove it. In some of the cases in which miliary eruptions appeared, there were severe catarrhal symptoms } and after the bilious symptoms vanished, the complaint required to be treated like a serious catarrhal af- fection. The diet throughout should be light, and easy of digestion 5 the drink light, mild, and dilut- ing- Roasted apple ; flummery ; gruel ; ripe fruit ; sago ; tapiocco ; arrow root ; light broth ; a bit of dry toast, and such like, will answer for food : but in long protracted cases, where the strength is much worn down, nourishing broth ; an egg ; a small bit of chicken, and a little wine, will be proper ; and in cases where these can be easily digested, it is usual for the patient to feel a long- ing for them, which, in convalescence from acute disease, it is always safe to indulge in a cautious manner. The drink might be whey 5 barley water *, buttermilk 5 milk and water ; syrup of raspberry 22 BILIOUS FEVER. raspberry vinegar and water ; and such like ; and occasionally wine and water. The patient will sometimes express a liking for a glass of toast- water, or cold water, which it is perfectly safe to indulge. Where there is such a mass of foul and foetid excrements coming away, it is particularly neces- sary to keep the apartment clean, well ventilated, and of moderate warmth, without being hot : the cloaths and bed-cloaths must be kept very clean and fresh ; and the vessels for the patient’s use, and the furniture of the room, (which should consist of a very few articles) kept very neat and clean also : crowds of visitors should be strictly prohibited, and the patient kept as free as possible from noise, light, and disturbance of every kind. The patient, when able to walk about a little, should be indulged in an airing in a coach every day, and, if the weather permit, very soon after- wards in an open carriage. BILIOUS FEVER OF CHILDREN. Bilious fever often occurs completely formed in children and young persons, with this differ- ence, however, that those symptoms which mark the morbid secretions of the stomach, liver, and intestines, are more strictly and uniformly the pre- BILIOUS FEVER. 23 prevailing characters of the disease in young per- sons : it is in these too that we most commonly meet with that modification of head-ache which may be called stupor, or drowsiness ; the appear- ance of which often causes well founded appre- hensions of dropsy of the brain. This is a pow- erful reason for immediately adopting the treat- ment of mercurial purgatives ; for blistering the head, and keeping up the discharge from the blistered parts by means of Savin ointment, or blistering ointment ; and if the blistered parts should heal, for blistering again about the neck, or the ears, or the temples ; and thus keeping up a perpetual drain from the head, or from some part in its neighbourhood, until we perceive une- quivocal marks of returning health. Children will linger on in this complaint some- times for two, and not unfrequently for three weeks, particularly if injudiciously managed at first, in a state of alarming danger and uncertainty $ and yet recover almost contrary to all hopes. CURE OF BILIOUS DISEASES IN CHILDREN. The treatment already detailed in the cases of adults, will apply also in the bilious complaints of children; but as in these the symptoms are more regular and simple, so the variety of medicines does not require to be equally great. The calo- mel i 24 BILIOUS FEVER. mel medicines No. 1, 2, and 3, are applicable to children, with the following limitations. The quantity of the dose must be proportioned to the age and strength of the child. Instead of pills, which children cannot be made easily to swallow, the medicine must be taken in a pow- der, the unpalatable ingredients being left out ; and the calomel, which is a heavy metallic powder, should never be mixed up with any thin liquid, such as milk, tea, whey, &c. for it then generally falls to the bottom of the vessel, and is lost ; but it ought to be blended with some viscid and adhesive substance, as honey, currant- jelly, currant-jam, syrup or brown sugar. It is peculiarly fortunate too, that as in children this is more purely a complaint of the bowels, than in grown persons ; so likewise in children, repeated and active purgatives will have comparatively a less distressing effect than in adults. The powder No. 12, composed of calomel, sugar, and ginger, will be a moderate dose for a child six or seven years of age ; the dose to be regulated as the child is younger or older ; one grain of calomel is a moderate dose for a child one year old ; females and delicate frames will not require as large doses as will be necessary for males and robust constitutions. The safest method at first is always to exhibit moderate doses of the calomel purgative, because in a few hours after, we have BILIOUS FEVER. 25 have it in our power to give other medicines which quicken its operation; thus after ordering the medi- cine No. 1 2, it will be proper to direct a desert spoon- ful of castor oil to be taken in four hours after, and to be repeated every three or four hours as long as it may be necessary. By these means we shall evacuate the bowels as satisfactorily as by ordering a larger dose of the calomel in the beginning ; and by this cautious method we avoid entirely the danger of severe purging and griping. Children are remarkable for being able to take calomel for many successive days, without causing a soreness of the mouth. The saline mixture, No. 19, is a medicine very grateful to children, and may be freely exhibited in the intervals between the purgatives. For a child six years old, a desert spoonful of lemon- juice, with a proper quantity of the saline solution, is a sufficient dose, and may be repeated every four hours until it be taken three or four times. Where opiates are indicated for children in bilious fevers or any other complaint, they must be administered cautiously and sparingly : in combining opium therefore in pills, or laudanum in mixtures, the proportion of the opiate must be considerably below the standard for grown persons ; ‘26 BILIOUS FEVER. persons ; the reverse is the case in the exhibition of mercurial purgatives ; the doses of which, necessary for a child, must be greatly above the ratio of their age. In bilious fever it will be adviseable to bathe the feet every night in hot water, or to stupe them with cloths wrung out of hot water, or chamomile water, &c. this discipline is useful to adults also. Though mercury is much more slow in produ- cing a soreness of the mouth in young persons than in adults, yet cases will occur, in which, from severely affected liver, the mercurial me- dicines must be persevered in until a soreness of the gums and mouth takes place, but this is a trifling inconvenience in itself, and, as far as it is a symptom of mercurial action, it is favourable. Medical writers remark, that when mercurial medicines, exhibited for the cure of febrile diseases, produce a soreness of the mouth, that soreness might be considered as a sign that the disease has given way, and convalescence begun. I think this observation is generally well founded, at least in bilious diseases. I have frequently known instances of such affections, and I have always obser- ved that the febrile appearances had then begun to BILIOUS FEVER. 27 to vanish. Of this fact I would offer the fol- lowing explanation. Copious discharges of putrid sordes commonly take place from the intestinal canal, for several successive days, in these complaints, though the patients all the time take no other nourishment but mild drink, and a small portion of food, in a diluted and liquid state. It is obvious that these large masses of faetid excrements cannot be formed of such food and drink ; but must be the result of morbid secretion in the stomach, liver, intes- tines, and perhaps in the pancreas. It is pretty clear that this morbid secretion becomes, at least, a considerable part of the disease, and that the remedies which correct morbid, and restore heal- thy secretion, are most effectual in removing that disease ; but mercury is the remedy whose prepa- rations have the most valuable effects in this way, and those effects are manifest when the system is decidedly under its influence, an event which the soreness of the gums and mouth clearly proves ; the occurrence therefore of that soreness is a sign that morbid action has given way to healthy secretion, and that convalescence has begun. HEPATITIS 28 INFLAMMATION OF HEPATITIS, OR INFLAMMATION OF THE LIVER. The most common symptoms of this disease are a sensation of weight and fulness at the pit of the sto- mach, stretching across to both sides, but particu- larly the right side, attended with a constant unea- siness and pain. The pain is sometimes very severe and accompanied by a pain also at the top of the shoulder, but in many instances it is a dull heavy unpleasant sensation rather than a pain; # a bilious colour of the skin ; a teazing constant cough ; sickness at stomach ; often flatulence ; im- paired appetite ; hurried or quick breathing ; confined bowels ; short and interrupted sleep ; the patient generally lyes with most- ease on the right side ; f the pulse is commonly quick and small, * The pain is most acute when the inflammation is seated in the upper or convex surface of the liver, and in the membrane which envelops it ; but the dull pain is felt when the concave Or lower surface of the liver is the seat of the inflammation. The pain of the shoulder is most constant when the inflamma- tion affects the convex surface of the liver, close to the part attached to the diaphragm, and it fixes sometimes in the right, and sometimes in the left shoulder. -j* To this however there are exceptions, as in some in- stances the patients can lye easiest on the left side, or on the back, inclining to the left side ; but by much the most usual occurrence is that of lying best on the right side. THE LIVER. 29 small, but in the acute pain it is hard ; the urine is high coloured; there is commonly encreased heat and dryness of the skin ; thirst ; lassitude ; and low spirits. Such is the assemblage of symptoms which generally characterize the complaint in this coun- try ; and unless other appearances of a severer nature occur, the patients, if judiciously treated, will in most instances recover. But in the confirmed and dangerous degrees of the disease, there are other symptoms of a more alarming nature to be met with ; such as great emaciation ; pulse very feeble and irregular ; sleep entirely banished, or constantly interrupted by frightful dreams ; the trunk of the body bent backwards so that the spine forms an arch ; the gums hard and firm ; the belly tense and inflated ; and often an enlargement and hardness felt at the pit of the stomach ; a putrid spontaneous purg- ing ; fits of cold shivering, and oppression in breathing, succeeded by encreased heat and profuse perspiration, so as to resemble very exactly the fits of an ague ; cough attended by large and purulent expectoration ; a leaden colour of the face. The edge or border of the liver is often felt projecting below the ribs, and some- times stretching downwards large and prominent towards the lower part of the belly, as far as the spine of the ilium. Hepatitis 30 INFLAMMATION OF Hepatitis most commonly attacks old persons, those of irritable and relaxed constitutions, those who are much addicted to the use of spirituous and fermented lipuors, persons of indolent and sedentary habits, and who indulge freely in the use of tea and coffee ; hence, women frequently suffer from liver diseases in consequence of their sedentary habits, and of their excessive indul- gence in the use of these slow poisons, tea and coffee. They whose constitutions have been much shattered by former diseases, and Europe- ans who have been long resident in hot climates, are often victims to this complaint. Hepatitis is best known in these countries since we have had a free and extensive inter- course with tropical climates ; it is not confined however entirely to such climates ; instances of it are met with frequently in cold and temperate la- titudes, and in persons who never visited tropi- cal countries ; but even they who most usually suffer from it in temperate and cold climates, are persons who have spent some time in hot coun- tries. Thus it often happens, that Europeans, who visit our remote settlements to acquire large fortunes, return to their native land, enriched ’tis true, but with constitutions so shattered as to be incapable of enjoying the fruits of their industry.* In * It is remarkable that Europeans in hot climates seldom escape the effects of a diseased liver, and it is mentioned that European THE LIVER, 81 In incorrigible drunkards, it is not unusual to find a combination of schirrhous and partly ossified liver, of tubercles and abscesses of the lungs causing pulmonary consumption, and of general dropsy of the belly and of the cellular membrane all at the same time CURE. There are few instances of hepatitis, if timely attended to, that may not yield to the judicious use of medicine ; * and yet it is a melancholy fact that it is often suffered to proceed to that extre- mity, in which the most able treatment can avail but little. If there are symptoms of acute inflammation, such as quick and hard pulse, sharp and distressing pain of the side preventing full inspiration, encreased heat of skin, thirst and anxiety, it will be necessary to bleed freely from the arm ; but in order to regulate our judgment as to the propriety of bleeding, we are not to delay it, until all the symptoms here enumerated are met wi h ; it is true they commonly exist together European dogs get enlarged livers in hot climates. The plague, which is principally confined to hot countries, very constantly produces enlargements of the liver, and frequently of the heart. Intermittent and remittent fevers in hot coun- tries often leave chronic diseases of the liver, and an enlarged spleen, called ague cake. INFLAMMATION OF $2 together in acute inflammation of the liver, but the pain alone is decisive of the necessity of bleeding. After the blood is taken away, we should endeavour to procure a speedy and co- pious evacuation by stool ; this object is com- monly attained by means of the medicines No. 1,2, or 3, which, if necessary, may be followed up in five or six hours by a dose of castor oil, by repeated spoonfuls of the mixture No. 4, or by the electuary No. 5, two table spoonfuls of the mixture, or a tea-spoonful of the electuary may be exhibited in six hours after the pills, and repeated every two hours after until an evacuation is procured. By these means the pain and other distressing symptoms are mitigated ; but should there be little improvement still in the state of these symptoms, the venesection should be re- peated, and a large sharp blister applied to the side, so as completely to cover the part through which the pain is sensibly felt. The feet should be immersed in baths of hot sea or salt water, or kept for some time wrapped up in hot stupes or hot flannels, &c. The food in the mean time must be light, easy of digestion, and contain but little nourishment in a given bulk ; as gruel, flummery, sago, arrow root, roasted apple, and such like : the drink light, subacid, mild, and agreeable, such as two milk whey, vinegar whey, runnet whey, barley water, fresh butter milk, syrup of raspberry vinegar and water, oranges, &c e This THE LIVER, 33 This bold and decisive treatment, consisting of blood-letting, purging, and blistering, should be actively persevered in, and repeated until the pain be subdued ; because, if the inflammation be permitted to proceed until suppuration forms, all the exertions of the physician are ineffectual in saving the life of the patient ; the marks of suppuration are an encreased sense of weight in the affected part ; a return from time to time of shivering fits, succeeded by encreased heat, an- guish, and profuse perspiration ; the oppression in breathing rendered more distressing ; the cough more laborious ; and sometimes (though not always) a copious discharge of a faetid purulent expectoration. Cases of this sort are often met with, and we not unfrequently have the mortification to be called to patients with those suppurative symp- toms completely formed, which point out an abscess of the liver, and yet where the alarm of the patient did not extend beyond the appre- hensions of a feverish cold. It is still perhaps a more melancholy reflection, that instances of this kind occur, where, from want of strict and cautious examination, the physician has fixed his attention principally on the pectoral symptoms, has consequently treated it as a pulmonary com- plaint, and has thus been the cause of allowing ft the 34 Inflammation of the disease to proceed to the fatal suppurative process.* After the symptoms of acute inflammation are subdued by those means, we must have recourse to mercurial medicines, of which perhaps the mercurial ointment is the best ; a drachm of the. strong ointment might be rubbed to the hypochondria every night, until the mouth is sore, and then intermitted for some time until the soreness begins to heal ; it should be then resumed, and thus from time to time resorted to, until the practitioner is satisfied that the com- plaint is removed, and the sound secretion of the liver restored. It sometimes happens that the delicacy of the patient’s constitution cannot bear with safety, at one time, as much mercu- rial * I had some time ago an opportunity of seeing a case of this description, in a respectable female in this town, the mother of a large family. She had been visited in the spring by a physician, not now in this country, who, from a hasty examination of her symptoms, decided that her complaint was entirely on her lungs, because she had cough and breath- ing somewhat hurried : he accordingly sent her some miles out of town, to an inland situation in the country, where she spent six or seven months ; her complaint all the time growing worse ; I saw her in the course of the ensuing winter with a diseased and enlarged liver, and suppuration formed. I could have no hesitation as to the probable termination of the complaint, and my prognoses was but too soon con- firmed by *th« event. , THE LIVER. 35 rial medicines as may be proper for curing the disease. In such instances it will be proper to drop the medicine for the time, if we conclude that a longer perseverance might sink the strength too much, and to defer the prosecution of the mercurial course until the strength be so far re- cruited as to be fit to bear the farther use of the mercury. In general, we can wait until the fol- lowing summer, without inconvenience to the patient ; and should it be necessary again to intermit the continuance of the cure, it may be put off to the next summer ; and thus, the treatment managed in the most delicate constitu- tions, with caution and perseverance, until the disease disappears. In the intervals the pills No. 9, might be exhibited from time to time ; they help to preserve a regular and free state of the bowels, and they often affect the liver, though very gradually and slowly, in such a manner as to answer the end of completing the cure, without any farther use of the ointment. It is only in delicate habits, that it will be prudent to intermit the mercurial treatment, before the symptoms disappear ; and even in such habits the disease will frequently be cured by an un- interrupted continuance of the appropriate remedies. The warm salt bath may be used occasionally with a view to soften the skin, to determine r>2 to 36 INFLAMMATION OF to the surface, and to mitigate internal pain it is also useful in moderating the severity of distressing and profuse ptyalism. The pills No. 35, composed of soda, ginger, and a chaly- beate, or some such medicine, may be taken every morning, after the inflammation is sub- dued, for the double purpose of restoring the healthful secretion of the liver, and of improving strength and appetite, by their action on the ■stomach and bowels ; they may be washed down with soda water, or with a light infusion of an agreeable bitter, such as an infusion of chamo- mile, cinchona, quassia, or columbo : a little ginger added to the infusion will improve its flavour. Soda is a medicine of such ac- knowledged utility in hepatic complaints, that we sometimes hear of boasted cures in liver diseases from soap pills, the efficacy of which depends upon the soda they contain. If symptoms of incipient suppuration commence, we must drop the plan of bleeding and blister- ing, and direct all our efforts to cause the abscess to point outwards, as this is the most desirable termination of the disease when abscess forms ; for this purpose a large cataplasm should be ap- plied warm to the side, and repeated three times a day ; and the patient remain very quiet and take such nourishing food as the appetite can bear, with a little wine. The cataplasm may consist THE LIVER. 3 ? of the ordinary materials, that is, bread and milk, stirrabout, carrot poultice, &c. and if the abscess points outwards it should be opened with a large orifice. When the patient is harass- ed by want of sleep, opiates must be occasionally allowed; 'the opiate draught, No. 14, will gene- rally be sufficient ; but the laudanum may be encreased if necessary, or the draught repeated. There have been instances of a recovery from abscess of the liver, when the matter was dis- charged externally ; though even in such cases the patient will most commonly sink under an hectic fever; but when the abscess bursts in any other direction, it commonly proves fatal. Sometimes a communication is formed by means of inflammation, between the liver, diaphragm, and lungs, and the matter of the abscess from time to time discharged by coughing, and ex- pectoration, attended by a fatal hectic. Some- times the connection is between the liver and the stomach, and the contents of the abscess discharged by vomiting : in a few such cases the patient recovers, but the most frequent event here also is a fatal hectic. Should the symptoms of acute inflammation be absent, such as pain, heat, and fever ; and only the others constituting chronic inflammation, be present ; the treatment in many respects must differ 38 INFLAMMATION OF differ from that of acute hepatitis. In the chronic hepatitis, we must immediately proceed to the use of mercurial ointment ; the medicines, No. 1, 2, or 3, will be proper to co-operate with the indication of the ointment, but particularly to preserve a regular state of the bowels ; here too the warm sea bath will be very useful. Should N\ ' the use of the ointment be resisted by the patient, we might order the pills, No. 36, which must be persevered in for a long time ; and during the convalescence, one of the draughts. No. 45, may be taken every morning. The diet must bemiore generous in the chronic complaint, than in the acute or inflammatory hepatitis ; and may consist of broths, jellies, a moderate allowance of fresh lfieat, and a little wine y the indulgence in those articles to be regu- lated by the severity of the disease, by the habits and constitution of the patient, and by the state of the appetite. In general it is proper to re- member, that, wherever mercurial medicines are necessary, a more liberal indulgence in diet will be required, because, mercury is known to pro- duce its salutary effects most decisively, where the strength is somewhat supported ; because a wasting drain of saliva commonly attends its exhibition ; and because in hepatic diseases, mercury, by removing, in a short time, much of the dyspeptic distress of the patient, and restoring the THE LIVER. 39 the healthful secretion of the stomach, liver, and intestines, improves the appetite, whence arises a more keen craving for nourishment ; nature point- ing out the resources for recruiting the frhme, now greatly exhausted, and at the same time mani- festing an improvement in the state of the organs destined to digest that nourishment. Diseases of the liver have sometimes lasted for many years without suspicion ; and in some instances, it was only after death that the exist- ence of the disease was discovered: even abscesses and schirrhous enlargements of this organ, have been sometimes found after death, in persons in whom no liver disease was suspected during life. But though in such cases the patients might not have been impelled by any pressing distress through life to resort to medicine, it is not pos- sible they could have enjoyed the comforts of sound and vigorous health. It is more than pro- bable also that the state of the liver was not as carefully examined formerly, as within those late years, nor its diseases so often suspected, and consequently not so much the subject of medical enquiry. The liver in some persons swells to a great size, unaccompanied by pain, and occassoning no other sensible inconvenience except that of hindering, by it pressure, a sufficient quantity of food from being 40 INFLAMMATION OF being conveyed into the stomachy which cannot now be properly expanded to receive it. The obvious consequences are, impaired appetite, emaciation and weakness ; and yet persons in this state will linger on for many years ; but as livers greatly enlarged are seldom or never cured, so soon as the encreased size begins to appear, even though unattended by any other distress, we should, without delay, have resource to that method of cure, which experience recommends as the most effectual in removing hepatic disease. In chronic hepatitis we often find, that after the mercurial ointment has produced sensible effects in the system, manifested by soreness of mouth and ptyalism, a sharp pain shoots through the seat of the liver, though there had been no pain pre- vious to the exhibition of the mercury : in such cases a blister laid over the part affected soon dis- sipates the pain. In hepatitis, erysipelas will seize upon dif- ferent parts of the surface ; sometimes it fixes on the leg or arm ; sometimes it imperfectly encircles the trunk below the hypochondria, in the form called zona ignea, and it is then of the papulary kind ; and sometimes it appears in the form of a spreading vesicular inflammation on or about the face, neck, and head, attended with drowsiness and delirium, and threatening the substance of the THE LIVER. 41 the brain itself. This species is highly dangerous, and not at all unusual $ it requires immediate and brisk purging, and a sharp and large blisser to be applied to the head, with the exception of the sur- face immediately inflamed. I met with a few in- stances of the latter and with two of the former kind of erysipelas in liver disease : should the pulse be hard and the inflammatory symptoms severe, we should bleed freely from the arm without delay, then purge very briskly with ca- lomel and aloetic medicines, assisted, if necessary, with enemata or with strong purgative mixtures which operate speedily. Some inconvenience, it is true, might arise from bleeding under circum- stances of weakness and relaxation ; and particu- larly in chronic disease of the liver, which com- monly has a tendency to terminate in dropsy : but it deserves to be remembered, that an ery- sipelas of the face or head is strongly disposed to spread internally, and to end in inflammation and suppuration of the brain, which must inevitably prove fatal, and which therefore must be the worst of all possible alternatives. The schirrhous liver is always firmer than the liver in its healthy state, often abounds with hardened lumps or tubercles, and is generally much enlarged in size; but in some cases its healthy structure is altered without any morbidly encreased bulk ; and there are instances even of 42 JAUNDICE. its size being found under the natural standard : sometimes there are ossified spots scattered over its surface, and there are cases of combined disease of the liver and lungs, in which the structure of the two organs is greatly altered together, and throughout full of tubercular concretions : ab- scesses of the lungs and liver likewise are met with in the same person ; and it may not be im- proper to observe, that it is in incorrigible drunk- ards those masses of disease in liver and lungs are mostly found to exist together. ICTERUS or JAUNDICE. The presence of jaundice is marked by the fol- lowing symptoms : a deep yellow colour of the skin, of the nails, and of the whites of the eyes ; urine of a deep saffron colour, which it commu- nicates to white paper, or white linen immersed in it ; clay coloured stools ; costiveness ; lassitude ; bad appetite ; a sensation of weight at the pit of the stomach, stretching along the sides, particularly the right side. These are accompanied by marks of dyspepsia or indigestion, such as flatulence ; rumbling noise in the belly ; sometimes griping pains ; bad taste of mouth ; sickness at stomach ; and frequently the patient is distressed by a trou- blesome incessant itchiness of the skin. There is sometimes pain felt in the right side, but most frequently the pain is absent altogether, and some- times JAUNDICE. 43 times it remits and returns again. The pulse is generally more feeble than the natural pulse, and somewhat quicker. In the advanced stages of the disease, the colour of the skin and of the whites of the eyes become more dark, and in some instan- ces the skin acquires a livid hue ; the disease is then vulgarly called a black jaundice. In the ad- vanced severity of the disease, the breathing be- comes hurried ; there is often a troublesome pal- pitation of the heart, and a tightness felt at the pit of the stomach ; sleep is greatly interrupted or entirely banished ; and the patient sinks under the complaint, worn down by a wasting hectic fever, or by a fatal dropsy, a complaint in which Jaundice, especially when neglected or maltreated, is apt to terminate. This is the progress of jaun- dice when it proceeds through its stages, without any favourable change either induced by an effort of nature, or occasioned by the interposition of medicine. Instances however frequently occur, where jaun- dice will disappear even without the assistance of medicine, and return again, and thus proceed returning and spontaneously disappearing through a long course of years. Sometimes too, after being removed by the exhibition of medicines, it will again visit the patient. CAUSES. 44 JAUNDICE. CAUSES. The causes of jaundice are such obstructions as prevent the passage of the bile into the intes- tines through the biliary ducts. Those diseases of the liver which interrupt or destroy the secre- tion of the liver, although accompanied by a bi- lious or sallow colour of the skin and complexion, yet do not occasion jaundice : it is necessary that the bile be actually secreted, and then taken up by the absorbents and conveyed into the circu- lating mass of fluids, in order to produce this com- plaint. The most frequent causes of jaundice are biliary calculi impacted in the ducts and thereby preventing the passage of the bile : schirrhous en- largement of the extremity of the pancreas press- ing upon the common choledic duct is also some- times a cause, as I have had an opportunity of observing in a patient who died of a combina- tion of dropsy, jaundice, and schirrhous liver. There are other causes of jaundice enumerated, as spasms of the ducts causing temporary jaundice, and adhesions of the sides of the ducts, the sequela of preceding inflammation. It is extremely probable that whilst the liver is in a sound state and its secretions healthy, biliary calculi are not formed; perhaps it may be afKrmed with confidence, that the formation of biliary cal- culi is inconsistent with an healthy secretion in the JAUNDICE. 45 the liver ; that bile in a natural and pure state is always fluid in the gall-bladder ; and that it is only when its secretion departs from its healthy qualities that biliary calculi or gall-stones are deposited: and as those gall-stones, by stopping the current of the bile through the ducts, are most frequently the cause of jaundice, it is pretty evident that we should endeavour to restore the healthy action of the liver, and secretion of the bile, as an important step towards the removal of the complaint. CURE. We are not acquainted with any remedy which has the power of restoring natural secretion, and particularly the secretion of the liver, as effec- tually as mercury ; it is therefore the remedy chiefly to be relied on in jaundice. The best method of exhibiting mercury is in the form of ointment, of which a drachm may be rubbed every night to the hypochondria, until the mouth becomes affected : it is afterwards to be regulated as in cases of hepatitis or inflammation of the liver: but the same quantity of ointment which an inflammation of the liver requires, is seldom necessary in cases of jaundice. In consequence of the deficiency of bile in the alimentary canal, which might assist in stimulating the in- testines to propel their contents, costiveness is a distressing 46 JAUNDICE. distressing occurrence, and therefore purgative medicines will be frequently required. The pills No. 3, consisting of calomel and aloe, are well suited to this state : should the pills operate slowly or imperfectly, the purgative mixture No. 4, or the electuary No. 5, may be taken in four or five hours after the exhibition of the pills, and re- peated every two or three hours until they ope- rate ; two table-spoonfuls of the mixture, and a tea-spoonful of the electuary, are the doses to be taken at a time. \ The deposition of calculous concretions in the gall bladder, as it forms the most common cause of jaundice, so it points cut the necessity and advantage of using medicines possessed of resol- vent qualities, which might be gradually com- municated to the circulating mass of fluids, and thereby at length, to the secretions themselves. The alkalis are the remedies which have these properties in the highest degree, and which ought therefore constantly and regularly to be exhibited for a long time : such as the pills No. 35 and 37, particularly the former, and the alkaline solution No. 31. Though it cannot be maintained that an alkali passes unchanged from the stomach to the liver, yet we must admit that it neutralizes the redun- dant acid of the alimentary canal, and thus de- stroys, JAUNDICE. 47 % stroys, probably, one of the most prevalent causes of calculous concretion : with this view alone alkali is valuable in preventing the apposition of new matter to the calculus, or, in other words, in checking its growth : alkaline preparations also have the effect of acting as a cordial, and of improving appetite. 'It is a serious question how far the above method can dissolve the biliary con- cretions already formed, and thereby facilitate the removal of the obstructions, on the presence of which the disease depends. There cannot be a doubt that one of the most valuable steps is to restore the healthy secretion of the liver, which will prevent the generation and deposition of more gall-stones : the secreted bile will like- wise by degrees acquire more alkalescent and resolvent qualities, and thus probably soften and melt down those gall-stones, so as to make them subject to the action of the absorbents, whereby their bulk is reduced so far, as to facilitate their passage through the biliary ducts into the intes- tines. Mercurial and alkaline medicines are the most powerful also in resolving those schirrhous en- largements, which, by their pressure, are some- times the cause of jaundice. Where the patient suffers from severe pain of the hypochondria, and from , want of sleep, opiates are 48 Jaundice. are necessary, And must be given in doses propor- tioned to the severity of the pain. The draught. No. 14, is an agreeable form of N an opiate; it might be given at bed-time, and repeated, if ne- cessary, in an hour after ; and even once again through the night if the pain still continues. If there is great sickness at stomach, the pills, No. 13, might be given in place of the draught, and re- peated every hour until a mitigation of the symp- toms is procured. With a view to relieve the pain, warm fomentations, and the warm sea-bath, may be resorted to ; and if it should still continue, a blister to the part affected will be useful here, as well as in the internal pains of other hepatic diseases. When the icterical symptoms are removed, and relaxation and weakness only remain, it will be proper to adopt those general methods of diet, air, and exercise, which are found proper in the convalescense from other hepatic disorders, viz. pure, dry country air ; exercise in an open carri- age, on foot, but most especially on horseback ; digestible food, consisting of broths, jellies, milk, and when the stomach can bear it more generous diet, such as a moderate use of fresh meat, with a little wine. A course of light bitter infusions, and of chaly- beates, will assist to promote convalescence, and to CHOLERA. 49 to restore health. Should irregularities in diet, or in the mode of living, have contributed to bring on the complaint, it will be particularly necessary to guard against those irregularities in future. JAUNDICE OF INFANTS. ( Jaundice sometimes occurs in infants, in conse- quence of the viscid meconium and bilious sordes retained in the bowels, parts of which are resorbed and mixed with the circulating mass of fluids. Here the obstruction is removed by exhibiting a purga- tive, to carry off the morbid contents : half a grain of calomel, with a tea-spoonful of castor-oil given in an hour after, will commonly produce this effect. CHOLERA. During the summer of last year, 1 808 , Cholera became epidemic in Dublin and its vicinity ; con- tinued to spread until the beginning of autumn ; and did not disappear until after the cold weather had set in : but towards the end of autumn it became less frequent ; its symptoms assumed a milder character, and approached nearer to the type of other diseases ; not unfrequently to that of colic ; sometimes to that of dysentery ; and in some instances it resembled a bilious purging. In many cases it was very sudden and severe £ and where proper medical attendance could not e be 50 CHOLERA. be procured in the beginning, its progress was so rapid as to prove fatal in some persons before the end of the second day. When most regularly formed, it began with thirst ; severe griping pains of the belly ; a vomiting of a yellow or green bitter fluid ; accompanied by a purging, most commonly of bilious slime, which irritated the intestines in its passage : any food or drink soon after being swallowed, was discharged by vomiting: pains similar to those of colic fre- quently attacked the patient, with the sensation of a ball in some part of the belly, but mostly about the navel : this sensation was exquisitely painful, and, upon subsiding, left the patient much ex- hausted and very feeble : the muscles of the legs were commonly seized with painful cramps ; and in some cases, the muscles of the arms and of the thighs were affected with spasmodic twitches, and in a few instances the muscles of the jaws, causing temporary lockjaw ; and in cases of uncommon se- verity, there were spasmodic pains or cramps of the stomach. This was the most dangerous and the most re- gular shape under which the complaint appeared, but it often occurred in a more irregular form : sometimes the purging was absent and all the other symptoms present ; sometimes the charac- teristic severity of the vomiting was wanting ^ and CHOLERA. 51 and in several instances the cramps did not appear. The most regular and constant symptom was the pain and griping of the bowels ^ the tongue was always loaded, yellow or brown ; a great and often sudden prostration of strength supervened ; sleep and appetite were banished ; and the countenance acquired a particular expression of anguish ; the pulse was quick, feeble, and in several instances ir- regular and intermittent. CURE. In cholera the principal exertions of the phy- sician must be directed to the object of allaying the spasms, and irritability of the stomach and primse vise, and then of carrying off the foul con- tents of the alimentary canal, which are in this complaint possessed of an high degree of acrimo- ny, particularly the bile. If the pain of the belly be alarnting, we must without delay resort to general venesection, not- withstanding the weakness and quickness of the pulse ; this is a step, however, which is seldom required ; and the necessity of it must be judged of by the intensity of the alarming symptoms, such as violent pain and twisting of the belly ; the expression of the countenance ; the severity of the cramps ; the duration of the complaint $ and the habits and constitution of the patient. e 2 The 52 CHOLERA. The skill and experience of the physician must decide upon those important circumstances. In general, where the pain is very violent, and the cramps severe with little intermission ; the anguish of the countenance distressing ; the constitution of the patient inflammatory and bilious ; and the ordinary state of the bowels slow or constipated ; the propriety of bleeding is less questionable : but where most of these symptoms are absent, or, if present, where they are mild, bleeding may for the most part be omitted : we may observe that in the epidemic of this town, bleeding was seldom necessary ; and that there was scarcely an in- stance of a fatal termination, where a judicious method of cure was timely resorted to. With a view to allay the distressing irritability of the system, and particularly of the alimentary canal, we may order the opiate draught No. 14, and repeat it every twenty minutes, until the pain and vomiting subside ; should the irritability be so violent, that any medicines, even the opiates, cannot be taken without being rejected by vomi- ting, we must have recourse to the use of opiate glysters : the enema No. 41, containing sixty drops of laudanum, may be administered, and if necessary, repeated in the course of an hour after. Opiates given in glysters are peculiarly indicated in cholera ; they have the effect of allaying with considerable certainty the pain of the stomach and bowels, CHOLERA. 53 bowels, and of relaxing the spasms, as they unite the doable benefit of an opiate and of an internal warm-bath : as Saon as we have accomplished the purpose of mitigating the pains and cramps, the pills No. 7, will be proper to carry off the foul contents of the intestines ; and in four hours after the exhibition of the pills, unless a free stool has been procured, the enema No. 23, may be administered, and repeated again in the course of two or three 'hours, unless the bowels have been in the mean time relieved. During this process the warm salt-bath, either natural or artificial, will be found a valuable auxiliary ; the patient may remain for five or six minutes in the bath, heated up to 98 degrees ; or in place of the bath the feet may be kept wrapped up in warm stupes, and the belly rubbed with strong spirits and then kept covered with repeated applications of hot flannels : instead of the stupes, hot bricks, or bottles filled with hot water and wrapped in flannels, may be kept applied to the soles of the feet : when the bowels are freely evacuated, we may consider the principal danger removed, for the subsequent ex- hibition of purgative medicines is attended with little difficulty ; we ought, however, to take care to give but moderate doses of purgatives, and so to regulate them, as to leave no danger of their pro- ducing violent irritation : the pills No. 27, will commonly have a valuable effect on those occa- sions ; and should they prove too inert, half an ounce 54 CHOLERA. ounce of castor oil, mixed with half an ounce of tincture of senna or Daily’s elixir, and given in three or four hours after the pills, will in most instances answer completely. In place of the opiate given separately in a draught, or pill, or combined with purgatives, according to the directions here pointed out ; some practitioners prefer the external applications of opiate liniments to the pit of the stomach, and belly ; and with the same indication. I prefer the internal use of the opiate, because its effects are then more quickly produced, a circumstance of importance in a disease, the progress of which is so rapid and alarming. This, or some analogous treatment, should be persevered in until appetite begins to return ; until the cramps entirely disappear ; and until there remain no longer any hardness or pain of the bowels, even on pressure. But as inflammation of the peritonaeum or membrane, which lines the in- side of the abdomen, sometimes occurs; we should keep steadily in view the use of a sharp blister, which must be made so large as to cover the whole of the part in pain. The blister must be applied, when we perceive, that notwithstanding the compleat evacuation of the bowels, and the natural appearance of the stools, the pain of the belly still continues. This CHOLERA. 55 This pain ? arising from peritonaea! inflammation, is generally found to spread more to one side than to the other : thus it attacks the right loin more than the left, or the left more than the right, or one of the hypochondria, with little uneasiness of the other. I have not met with any in- stance of its being equally severe in both sides : but whatever part be the seat of the pain, the blister ought to be applied to that part, and made so large as to cover it entirely. Where, in consequence of incessant vomiting, we have reason to conclude, that draughts might prove too bulky to remain on the stomach, we may very freely substitute the plan of giving opium and calomel combined, as in cases of dysentery ; but as the indication of cure depends upon relax- ing spasm, and subduing morbidly encreased irrita- bility in cholera, more than in dysentery ; so it will be necessary to insist upon a more liberal ex- hibition of the opium in cholera. The pills, No. 22, will generally answer the desired indication ; two may be taken as a dose, and repeated every four hours until they affect the bowels ; and un- less the six pills of that formula open the bowels, the enema, No. 21, may be given, and repeated every three hours, until a free stool is procured. If we wish to make the enema less irritating, the sulphat of magnesia, ordered in the formula, No. 21, may be lessened, or left out entirely, as in the enema No. 42. Light 36 CHOLERA. Light chicken broth, or beef-tea, will form a proper drink to be taken, as soon as the stomach can bear it, and should be repeatedly used in the intervals between the doses of the medicines, and after their operation. Light broths and mild drinks, as barley water, runnet whey, &c. are a valuable remedy in this complaint. By diluting the acrimony of the morbid contents of the sto- mach and bowels, they lessen their irritating qua- lities, and thus they have a tendency to mitigate the severity of the vomiting : for the same reason they diminish the pain of the bowels, and facili- tate the passage of the intestinal sordes, by en- creasing their bulk, and rendering them more liquid : and thereby they also correct that distres- sing heat and pain which those acrid excrements, when undiluted, are generally found to produce in their passage through the intestines. As large quantities of opium must commonly be taken in the beginning, it becomes necessary to give frequent laxatives for the purpose of coun- teracting the costive effects of the opiates. The castor-oil, as prepared in any of the three formulae. No. 23, is well adapted to this purpose : this me- dicine opens the bowels speedily, and has the agreeable effect of mitigating the soreness of the belly. But if the feces continue still dark colour- ed, or clay coloured, and of a fetid odour, ac- companied with pain, or tension of the belly, some CHOLERA* 57 some calomel will be occasionally necessary to clear away those foul excrements : the enema, No. 21, will be useful in quickening the operation of the calomel purgative. Should the castor-oil be nauseated, in the forms recommended, we might occasionally use the lax- atives, No. 25 or 26, always, however, keeping in view the necessity of interposing the mercurial purgative, as long as the excrements continue to have an unnatural faetor or colour. After the characteristic symptoms give way, we should still attend to the state of the bowels, and to the regularity of the patient’s habits. During the convalescence, the medicine, No. 24, will preserve an uniform regularity of the intestines, without creating distress. Throughout the course of the disease, the pa- tient must be kept agreeably warm ; the apart- ment clean, well-aired, and dry ; and foulness of any sort immediately removed. This disease is so rapid and treacherous, that the mildest forms of it require to be treated with vigilance and attention ; and after all symptoms disappear, we must still v/atch the progress of the convalescence, as the complaint is apt to return. During 38 CHOLERA. Duririg the recovery, the diet might consist of broths, jellies, bread, mild drink ; and occasionally an egg, imperfectly boiled, may be allowed This cautious treatment, in food and drink, is to be con- tinued for a longer or shorter time, according as the preceding disease had been more or less severe. Throughout the last winter and spring, several instances of bilious attacks, (many of them of a mild form,) were attended with cramps in the muscles of the legs ; from which, however, they did not appear to acquire any encreased severity ; the complaint yielding to the ordinary method of cure, practised in bilious fever, and the cramps disappearing without the necessity of any par- ticular treatment. Cholera has made its appearance again this summer, 1809, but in a milder form: how far its severity may encrease or subside during the subsequent part of the season, remains yet to be ascertained. In some of the instances which I have seen, the operation of the first purgatives was attended with griping pains, which were evidently caused by the irritation of the foul and bilious excre- ments, as they passed along through the intes- tines ; for the same purgatives, when repeated, occasioned considerably less distress than at first, and DYSENTERY. 59 and after being exhibited three or four times* they were generally unaccompanied by any pain whatever. From the comparative mildness of the complaint* it might be considered a bilious fever, but that it was uniformly marked by symptoms of slight vomiting and cramps, principally in the muscles of the legs. The use of opium, either alone or combined with other medicines, was not as necessary here as in the cholera of last year, because the spasmodic affections were very trifling. The powder No. 105, given at bed-time, caused little pain or uneasiness, and, aided the following morning by one or two of the powders No. 24, it had an excellent operation, so as to be called for by the patient, in some instances, in prefe- rence to any other purgatives. Upon this, and several other occasions, I have found that calomel, without being joined with any other opening medicine, especially where there are indications of morbid secretion of bile, is a safe, a mild, and an effectual purgative. This observation applies still more strikingly to the diseases of children. DYSENTERY, OR FLUX. Cases of dysentery are met with in Dublin, at all seasons ; but from the middle of summer to the end of autumn they are most frequent. Such 60 DYSENTERY. Such cases as occur during the winter and spring are often combined with cough, and other catar- rhal symptoms, and sometimes with rheumatic pains : those which occur at other seasons, are more purely dysenteric. Dysentery, in its most regular form, begins very much like a troublesome purging, accom- panied by slight febrile symptoms ; but in a short time the purging changes its character, and other symptoms set in, such as impaired appetite ; some sickness at stomach ; thirst ; tension ; flatu- lence ; and griping pains of the belly : the pains which at first are general over the whole abdo- men, and most severe at the pit of the stomach, by degrees fix at the bottom of t-he belly. The patients have an urgency to go to stool, and expect they shall have copious evacuations, with immediate relief ; but the discharge is scanty, consisting mostly of a slimy fluid, often without any admixture of blood ; more frequently, how- ever, there are bloody appearances in the stools ; this blood is sometimes in streaks, or lines ; at other times, it is more intimately blended with the slime, so as to give it an uniform red colour ; and sometimes the discharge appears to be little else but blood, especially in the advanced period of the complaint. In some instances the bloody and the mucous evacuations alternate with each other, DYSENTERY. 61 other, but not in regular succession ; and some- times it happens that the discharge appears like a mixture of mucus, blood, and corruption. At stool, there is great and long continued straining, to relieve the bowels, but with trifling effect ; the natural excrements are not voided at all, or only in very small quantity, and in the form of lumps, floating in slime ; and the patients are at length obliged to desist, with the painful feeling that their efforts have not been attended with the expected relief : the urgency to go to stool soon returns, accompanied wdth the same train of symptoms. As the complaint becomes more tedious, those paroxysms return at shorter inter- vals, sometimes every half hour, and sometimes even more frequently : and we often observe, towards the end of the disease, that the trunk of the body cannot be raised erect, but must be con- stantly bent forward in consequence of the inces- sant painful griping of the belly 5 membranous filaments and corruption appear in the stools ; and worms, in some instances, are discharged. The stools have always an offensive and unnatural smell, and even from the body of the patient there issues a disagreeable odour, which the strictest attention to cleanliness can scarcely remove entirely. Fre- quently the tension and griping become so severe, and the calls to stool so incessant, that sleep is ba- nished altogether ; the tongue is always somewhat foul 62 DYSENTERY. foul ; eruptions in some instances appear about the lips, which are considered a dangerous symp- tom. At length the strength and flesh decay ; the spirits sink ; the pulse is quick and feeble ; and the countenance sunk and relaxed. When dysentery terminates fatally, a putrid sa- nk) us discharge, which announces a gangrenous state of the bowels, is commonly the forerunner of death. In hot climates, and in countries where it is epidemic, the symptoms are more severe, and more rapid in their progress, in consequence of which the malignity and danger of the complaint are greatly encreased : and in this country, in per- sons who have suffered from it a long time, with- out employing a proper method of cure, it becomes more tedious and difficult to remove ; and more ready from slight causes to return. Its severity is principally confined to the tract of the larger intestines, which have been always found after death more or less ulcerated on the internal surface, or schirrhous, or gangrenous; andfrequent- ly these several diseased appearances in different parts of them, have existed all at the same time. It is obvious, that where dysentery has continued so long as to produce a morbid change in the structure DYSENTERY. 63 structure of the intestines, a perfect recovery is seldom to be expected, and that early attention should be employed ; for in the beginning the cure, if judiciously conducted, is, for the most part, easy and expeditious : this caution is particularly necessary in fleets, and in armies in the field, where it spreads by contagion, and where its ravages are most destructive. In long continued cases of bad dysentery, the morbid affection sometimes creeps along from the large into the small intestines, causing ulceration and schirrhus, similar to those of the larger intestines, but never in the same violent degree. o I suspect that the doctrine of treating diarrhea, or simple purging, with astringents, has some- times led to dangerous practice in dysentery $ as it begins, in most instances, like a diarrhaea. I met with appearances of this sort during the pre- valence of an epidemic dysentery in Dublin, which I treated as dysentery, without waiting for the tenesmus, and ether characteristic symptoms of the complaint to set in ; and with the happiest success. In the course of two or three days the patient generally recovered.* CURE. * It may not be improper here to observe, that very little injury can arise from the mistake of considering, and treating as dysenteric, a diarrhaea which might not be con- nected with dysentery ; for diarrhaea, except when it is a symp- tom of relaxation, of atrophy, or hectic, is always occasioned by 64 DYSENTERY. CURE. The medicines commonly employed for the cure of dysentery, are purgatives, to carry off the con- fined faeces and other sordes of the alimentary canal ; diaphoretics, to relieve internal parts by creating a determination to the surface ; opiates, to allay the irritation of the bowels, and of the whole system, and to procure sleep ; and after the evacuating plan has been completed, and convales- cence has commenced, astringents and tonics to strengthen the relaxed parts. The purgatives are, sulphat of soda ; rochelle salt ; phosphorated soda ; sulphat of magnesia ; rheubarb ; jalap; scammony ; small doses of pow- dered ipecacuanha ; senna ; calomel ; and castor- oil. * ' The diaphoretics are, antimonial powder ; James’s powder ; Dover’s powder ; tartar emetic, in small and repeated doses ; a combination of opium and emetics ; the warm salt -bath ; and flannels worn close to the body and covering it all over. The vitrum antimonii ceratum is now little relied on, as it is very irregular in its effects, sometimes proving altogether inert, and sometimes inducing violent vomiting. The by acrid ingesta or by morbid secretions or excretions contained in the tract of the intestines, and must therefore be relieved by dysenteric remedies, that is, by those remedies which are most effectual in carrying off this acrimony. DYSENTERY. 65 The opiates are laudanum, opium in substance, and the watery extract of opium. Sulphat of zinc given in doses, from eight to twelve grains, and repeated three or four times a day, in some agreeable form, often proves a valua- ble remedy, in the advanced stages of dysentery, after the acrimony of the - primae vise has been entirely removed, and only relaxation remains. The common method of exhibiting the purga- tive and opiate remedies is the following: the purgative is given in the morning, and its opera- tion assisted by mucilaginous drinks, or by weak broths, taken in small quantities, but frequently repeated during the day : after the effects of the purgative, the opiate is given at night : this plan is persevered in, day after day, with such modi- fications as circumstances might require. If antimonials are employed, 'they may be given the day after the operation of the purgative, or they might be exhibited at first, as in small and repeated doses, they frequently act as purgatives and diaphoretics. Calomel has been much used of late years, in consequence of its superior efficacy in expelling acrid bile, and other sordes from the primae viae, and with decided advantage : it carries off those f acrid 66 DYSENTERY. acrid lumps of excrements upon which the action of other purgatives is exerted, comparatively with little effect, and the removal of which is the first step to a cure. The following is the treatment on which, from experience, I have the greatest reliance, and which I have reason to believe will prove uni- formly successful, unless it be delayed until schirrhus or ulcers have taken place in the intes- tines. # The two pills, No. 7 1 , consisting of calomel, ginger and opium, are given at bed-time : the effect of this medicine is, very soon to quiet the irritation, gripes, and tenesmus or fruitless strain- ing ; and to procure some hours comfortable sleep, after the patient had spent perhaps several days and nights in a state of painful restlessness. Towards morning a stool, consisting principally of morbid slime, but often intermixed with lumps of solid excrements, is discharged, with great relief to the patient. In the course of the day afterwards the irritation to go to stool, along with the griping and scanty mucous evacuations, com- monly returns, but in a slighter degree ; and then the absorbent and anodyne mixture, No. 28 or 29, * The doses recommended are for adults, except where children are particularly specified. DYSENTERY. 67 29, may be given with advantage ; a table-spoon- ful may be taken after every stool ; a little syrup may be added, if necessary, to render it more palatable. At night the pills are again ordered, with such alterations in the quantity of the ca- lomel and opium as the circumstances of the case require. In general, as the stools become less frequent, and more natural, the quantity of the calomel is diminished, and the opium is by de- grees omitted altogether : but where the tenesmus and pains continue but little diminished, the quan- tity of the opium must be encreased. If there have been any bloody appearances, they become less after the first day, and in four or five days they generally disappear entirely. When we find the tenesmus greatly mitigated, and the stools less frequent, the pills. No. 71, alone will often be sufficient to complete a cure, of which one may be taken every night at bed-time. When a soreness of the belly remains, very distressing to the patient, one of the doses of castor-oil, No. 23, will often be found to have excellent effects : it gently opens the bowels in a short time, and mitigates the soreness better than any other purgative. But as long as tenes- mus continues, accompanied by fsetid stools, it will be proper occasionally to have recourse to the calomel and opium. In some cases in which the mixtures, No. 28, 29, did not appear to give any decided relief, I tried the mixture, No. 30, with F 2 great 68 DYSENTERY. great benefit ; it was, like the other mixtures, ex- hibited by table-spoonfuls after the stools. The patient’s food and drink should be given warm, and may consist of light broth, beef-tea* and any mild mucilaginous drink. Flannels should be worn all over the body ; the warm salt bath, is a valuable auxiliary, and in tedious cases ought to be resorted to. From this method, in a little time, the stools become more natural, and less frequent ; the ten- sion and griping pains of the belly subside; the slime and blood disappear; and sleep and appetite return. After the bowels have been relieved from the morbid lumps and slime, a few liberal doses of rheubarb have been sometimes found to arrest the encreased irritation of the bowels, and to improve the tone of the stomach and intestines. In long protracted cases of dysentery, a schirr- hus of the rectum sometimes takes place, which contracts the passage through the intestine very considerably. This local disease is accompanied by all the painful symptoms of dysentery. In this case, after relieving the bowels from confined sordes, mild oily laxatives and glysters, and a proper bougie introduced per anum, are the best remedies. If the structure of the gut be greatly . altered DYSENTERY. 69 altered by disease, a perfect cure is not to be ex- pected : but even in such cases the treatment here recommended, along with attention to warmth, and a temperate life, will afford the best, and most permanent relief. * In some instances of lingering diarrhaea after dysentery, Dovers’s powder, exhibited in doses of ten grains, every five or six hours, has put an end to the purging. In some, about ten grains of the sul- phat of zinc, taken in an agreeable mixture, three or four times a day, have had the same effect. There are unfortunate cases of dysentery, of long standing, in which the structure of the internal membrane of the intestines becomes so far diseased, and its excretions so morbid, that it keeps up an ir- ritation for a long time, notwithstanding the mode of treatment already recommended : in such cases, the free exhibition of mercury, until it affects the whole system, is our most valuable remedy. The following case is a striking illustration of this opi- nion : A woman * As the disease of the rectum is often met with where there had not been previous dysentery, it is evident that it cannot always be considered the effect of dysentery. But in all cases of its existence in dysentery, there is little doubt that it aggravates the severity of, and is, in its turn, rendered worse by the straining inseparable from this complaint. 10 DYSENTERY. A woman about fifty years old laboured under dysentery two months, and had medical attend- ance only four days before I saw her. Her symp- toms then were thirst ; great emaciation ; quick and feeble pulse ; severe vomiting ; a drum-like tension of the belly, excessively painful to the touch, particularly at the pit of the stomach ; in- cessant tenesmus ; and a discharge of dark co- loured slimy stools, extremely faetid. The state of the pulse ; the severity of the pain ; the ten- sion of the belly ; and the faetor and colour of the excrements, caused apprehensions of approach- ing gangrene ; and left very little hopes of reco- very. A large blister was immediately laid on the belly, where the pain, on pressure, was most severe ; the pills and absorbent mixture already noticed, were ordered : by this treatment the symptoms were considerably relieved, yet the dis- ease became obstinate : this method was still perse- vered in ; warm baths ; glysters of starch and opium ; absorbents and agreeable cordial mixtures were given ; and the body of the patient cased in flannels : and though the severity of the complaint was greatly mitigated by this method, still there remained, at the end of three weeks after I had first seen her, frequent stools ; flatulence ; loss of appetite ; and interrupted sleep. The fsetor of the alvine evacuations, the tension, the griping, and the tenesmus were the appearances most com- pletely subdued. A drachm of mercurial oint- ment DYSPEPSIA. 71 merit was then ordered to be rubbed every night to her abdomen ; and when she had used one ounce of ointment a salivation came on, upon which the remaining symptoms began to disap- pear ; and in a little time after, the patient com- pletely recovered. DYSPEPSIA, OR INDIGESTION. This is one of the most common diseases which we meet with ; and perhaps there is none, whose symptoms are more numerous, or more various. - It may be distinguished into primary and sympto- matic. When primary, it seldom proves fatal ; but when symptomatic, it is dangerous, in a greater or less degree, according to the duration, the nature,* and the severity of the disease, from which it springs ; and the constitution, age, sex, and habits of the patient. Its most usual and constant symptoms are the following : impaired appetite ; sickness at stomach, and sometimes vomiting, especially after food ; flatulence in the stomach and bowels ; eructation, or a rushing of wind from the stomach through the mouth, which often brings along with it a sour liquor, an insipid water, or a roapy phlegm, and some- times a putrid ill-tasted fluid, so disagreeable as to sicken, even to vomiting : the sharpness of the sour discharge is oftentimes so great as to fret and irritate the parts over which it passes. The 72 DYSPEPSIA. The matter vomited is often a bitter, green or yellow slime, compared in colour and consistence to the yoke of an egg ; the eructation is attended with temporary relief ; there is a disagreeable taste of the mouth, mostly bitter ; and the tongue is foul and loaded ; there is generally pain felt, on pressure, at the pit of the stomach, and a burn- ing sensation often in the stomach, called heart- burn ; the bowels are commonly slow. These are the combination of symptoms, which, with very little alteration or addition, are found to distress many patients for years : but in several instances, they are accompanied by a pain in the stomach ; an encreased secretion of saliva ; tension and fulness about the pit of the stomach ; an irregular state of the bowels, but most com- monly costiveness, which, after having continued for some time, often terminates in a purging :* a sallow complexion ; a lightness or reeling of the head ; coldness of the feet ; pulse small, but seldom quick, unless combined with visceral obstructions ; and then it becomes quick, small, and sometimes irregular : breathing hurried from slight * It is probable that the faeces acquire, from heat, delay, and in consequence of being mixed with morbid secretions, an acrimony, which stimulates to encreased action, producing diarrhoea, or purging. Certain it is, that when secreting and excreting organs are diseased, those secretions and excretions become irregular : sometimes they are morbidly increased ; sometimts morbidly diminished. DYSPEPSIA. 73 slight causes, especially from motion and exer- cise : cough is very common, and often very severe. The following symptoms are more unusual, but their existence generally marks a greater degree of severity : weight and fulness of the hypo- chondria, stretching along the sides ; it is some- times more sensible in the left side, but when the liver is diseased, it is more sensible in the right ; head-ache, and in different parts of the head ; pains in the balls of the eyes ; sometimes a shower of spangles before the eyes ; flying pains in the sides and breast, with partial sweats, are met with in dyspepsia, in consequence of which phthisis is often suspected. Many dis- tressing affections of the bowels frequently belong to dyspepsia, such as tension, pain, gri- ping, borborygmi or a rumbling noise, and a sensation of a lump or ball, rising through the bowels up to the throat : in some instances there is a difficulty or pain in making water ; and in some, a discharge of blood by stool ; in others, a vomiting of blood : dyspepsia, in particular constitutions, is connected with great despon- dency or dejection of spirits, which is often extremely distressing and obstinate : when this occurrence takes place, it is called hypochon- driasis. Such a state of mind is variously united with a greater or less degree of severity in the complaint. 74 DYSPEPSIA. complaint. Sometimes there is distressing dys- pepsia with little despondency, sometimes great despondency with little dyspepsia ; and thus, in different instances, they are found in every possible variety of combination. In hypochondriacs, a ve- nereal complaint generally becomes a serious cala- mity; because such persons perpetually suffer from the apprehension that the venereal poison can never be eradicated from their system. Dyspepsia is -common in women, during the first months of pregnancy, but then it can scarcely be considered a disease. It is often symptomatic in other dis- eases ; in worms ; dentition ; in gout ; gravel ; asthma ; hysteria ; in schirrhus of the viscera, as of the pylorus, omentum, pancreas, spleen or intestines: but its most common connexion is with complaints of the liver ; this connection, indeed, is so general, that in most instances of severe dyspepsia, the secretkms of the liver are morbid, and not unfrequently, its structure diseased. Dyspepsia, long continued and neglect- ed, has a tendency to terminate in incurable dropsy. CAUSES OF DYSPEPSIA. The following may be considered the most ordinary causes of dyspepsia ; viz. suppressed perspiration ; habits of drunkenness ; a moist state of the atmosphere, (hence we frequently meet with persons who are mere barometers, from the painful DYSPEPSIA. 75 painful distress in their head and stomach in damp weather, or at the approach of rain) ; a sedentary life, exposure to damp and cold, therefore weavers, tailors, shoemakers, porters, &c. are often dyspeptic : depressing passions of the mind ; close and long continued study and application of the mind, therefore reading and studious persons are often troubled with dyspepsia, in consequence of their sedentary life, their contracted attitude of body, and the intensity of their application. Females between the age of forty four and fifty years are very subject to dyspepsia, this being the period at which the Catamenia generally cease, and the female system undergoes an important change. The causes already enumerated have a general effect on the whole body, and on the stomach, from its great sympathy with every part of the body. There are other causes which act more on the stomach itself, as poisons of various kinds taken into the stomach, such as tea, coffee, fermented liquors, and distilled spirits. Such things as dis- tend and relax the stomach, as large quantities of warm fluids ; thus tea and coffee are injurious in a double way, first, from being actually poisons, and secondly, from being commonly taken along with DYSPEPSIA* 76 with a large quantity of warm water. Tobacco, in all the forms in which fashion or drunken habits recommend it, is often a cause of dyspep- sia. The stomach is weakened, and consequently dyspepsia brought on by the frequent use of erne- ticks, and by food of difficult digestion, as rancid oils, unripe fruits, unripe vegetables, smoked and seasoned meats ; to these may be added, much variety of dishes at table, and savoury luxurious diet, which encourage too much eating, overload and weaken the stomach, and thereby often induce dyspepsia and gout.* PROGNOSIS. * The gastric juice, in dyspepsia, is often secreted in too small quantity, but sometimes the secretion is encreased beyond the natural standard, in both cases however its quali- ties are impaired : instead of being healthy juice, it is an insi- pid glary liquid, incapable of dissolving the food, and of re- pressing its fermentation ; effects, which in a healthy state, it is competent to produce, as the experiments of Stephens and Spalinzani clearly demonstrate. The food, under these cir- cumstances, proceeds through the acid and sometimes through the putrid fermentation, with a copious extrication of air j the bile too is morbidly secreted, and incapable of retarding the fermentative process in the food as it passes through the intestines. The foulness of the mouth and tongue arises from that of the stomach ; hence foul mouth and breath are common in dyspepsia. The biliary ducts are emulged by the efforts of nausea and vomiting, and bile forced into the stomach, whence sometimes arises a vomiting of bile. All the dis- tressing affections of the head are the effect of sympathy be- tween the head and stomach. The sympathy or consent be- tween the stomach and surface explains the appearances on the DYSPEPSIA. i / PROGNOSIS. Dyspepsia never kills suddenly ; but by under- mining the constitution, it may bring on dange- rous diseases, and thus at length prove fatal. When it is symptomatic of other complaints, its danger is considerably greater than when it is a primary disease. Should there be schirrhus of the pilorus, of the omentum, of t e spleen, pan- creas, or intestines, our efforts must only be di- rected to palliate or mitigate symptoms : in such cases, though the patient may linger on for years, yet a cure is not to be expected. In all cases, the duration of the disease ; the time of life ; the violence of the symptoms ; the nature of the cause ; and concomitant circumstances, must greatly modify the prospect of recovery. CURE. As the stomach and primse vise are the more immediate , seat of dyspepsia, so there are two ob- jCC'ti the skin, such as coldness, and often sweats ; and in conse- quence of the same consent, causes which act on the skin and check perspiration particularly in the feet, disorder the sto- mach and intestines, and bring on sickness, griping purging, inflammation, and tenesmus. The sensation of a ball or lump in the intestines, attended with pain, arises from spasms af- fecting two different parts of the intestines at the same time, and confining the air between them : the pain occasioned by these spasms is greatly exasperated by the irritation of the morbid and acrid ingesta, passing through the intestines at the same time. 78 DYSPEPSIA, jects to be kept regularly and constantly in view, for the purpose of effecting a cure, namely, to preserve a regular state of the bowels, and to strengthen the tone of the stomach. In most in- stances there is also a necessity to correct morbid secretion in the stomach and liver. A dose of the medicines, No. 1, 2, or 3, is generally well adapted to the end of relieving the bowels from their foul contents, and may be taken twice a week , until the complaint begins to disappear ; should these medicines fail to keep the bowels re- gular, they may be assisted by some gentle laxa- tive, taken on any of the intermediate days, such as the formula, No. 24, consisting principally of Epsom salt, and dissolved in an agreeable water. A table-spoonful of the cordial mixture, No. 18, may be taken in the morning and afternoon of those days on which the laxative medicines are not exhibited. If we have reason to apprehend that the liver is engaged, (an event which is not un- common) the calomel purgatives may be ordered more frequently, unless they are found to purge or sicken too much, the cordial mixture being persevered in, as above directed : when the seve- rity of the disease is subdued by these means, the alterative pills, No. 9, might be taken with ad- vantage at bed-time, and persevered in until the mouth becomes sore. These alteratives are more particularly indicated when the disease is con- nected with a morbid state of the liver. This DYSPEPSIA. 79 This is the treatment on which I principally rely, and which, even in very old and deplorable cases, I have found most successful. In persons in whom an active purgative was indicated, by the constipation of the bowels, other purgatives which I sometimes tried, and with the effect of procuring free evacuations, yet were not at- tended with that immediate relief from pressing uneasiness, which the calomel purgative pro- duced ; and in several instances, where I had tried the calomel at first, and, at a subsequent period, the other purgative, the patients regu- larly declared in favor of the calomel purgative, as the medicine most decisively productive even of temporary relief. I have treated cases of some years standing according to this method, and uniformly had the satisfaction of seeing my patients restored to health, from a state of deep suffering, occasioned by the sickness of the body ; and sometimes from a degree of suffering, very painful too, arising from a gloomy despondency. I have tried a large catalogue of absorbents ; bitters ; aromatics ; and chalybeates, generally ordered in cases of this sort ; and I am inclined to believe, that a steady adherence to this method will cure more cases of dyspepsia, than all those medicines together, without mercury;* No. 31 , is * The remedies commonly recommended are such as are calculated to open the bowels, and strengthen the tone of the alimentary so DYSPEPSIA. is another medicine which I have frequently re- commended in dispensary practice, with benefit. Cases sometimes occur, in which, from long and indispensible exposure to the weather, in cold seasons ; and others, in which, from the obstinate prejudices of the patient, mercurial purgatives are impracticable. In those cases, the bolus, No. S3, is a mild and useful laxative ; the alkaline solu- tion, No. 31, as a valuable absorbent and tonic, may be taken every morning of the interme- diate days. After the distressing symptoms of the com- plaint are removed, the pills. No. 34, are an ex- cellent tonic, and might be persevered in. for some weeks, with a view to restore the health and vigour of the stomach, to improve appetite, and to brace the whole system. During the first days, we sometimes find that little material benefit is experienced from any treatment in chronic dyspepsia ; but before the alimentary canal ; as, aloe ; asafaetida ; rheubarb ; calcined magnesia ; calcined magnesia and rheubarb combined ; to these medicines, there is commonly added an aromatic, or such remedies as are qualified to repress flatus, and correct acidity 5 as ammonia; kali; soda; prepared egg-shells ; 8 cc.: or such as have the effect of warming the stomach, relaxing •pasm, and improving appetite, as bitter tincture 5 tincture of Colombo ; tincture of serpentaria, and of valerian. DYSPEPSIA* 81 the end of a fortnight, the treatment here recom- mended, is generally productive of considerable amendment : we should not, therefore, be d tpr- red, by the gloomy bodings of the patient, a ter three or four days attendance, but rather prose- cute this plan, until we give it a fair trial, in the well founded hope, that our exertions will even- tually prove successful. As in this disease the stomach is the organ most directly and immediately affected, attention to the diet of the patient is most particularly neces- sary; in general, food most easy of digestion, and least fermentable, should be recommended, and animal food in preference to vegetables ; plain meat, or meat a little corned, is better than salt, seasoned, or smoaked meat. In enumerating the causes of dyspepsia, tea . and coffee were pointed out as some of the fashionable sources of the complaint ; coupling this observation with what has been just mentioned respecting animal food, it will be easily conceived, that for two powerful reasons a bit of meat will often prove an excellent breakfast in dyspeptic patients. This breakfast is often suited even to delicate females, and is well entitled to a trial, notwithstanding the apparent courseness of the prescription. There are some stomachs with which fish of a particular kind agrees very well, especially shell- g fish. 82 DYSPEPSIA, fish, and to such it ought to be allowed. Of ve- getables, the most nutritious and least flatulent should be preferred. Whatever food be allowed, the patients must be strictly commanded to eat but little at a time : at first they should, in most cases, be confined to the use of light broths ; jellies ; eggs but mode- rately boiled ; well baked light bread, and such like : and when the disease is chronic, and the strength of the constitution is much wasted, a little plain fresh or corned meat is the best diet of all others : whatever drink be used, it had best be taken cold, unless the cold induces spasms or cramps of the stomach ; in such cases it ought to be given warm, and by degrees its temperature diminished, until it be reduced to that of cold water : as to its quality, it might consist of plain water ; or water with a little wine ; or of a small quantity of some pure spirit in water : porter, if sound and aged, often agrees well with dyspeptics ; it is gently laxative, and less disposed to ferment than other kinds of malt liquor. When the patients are convalescent, mineral waters agree very well, such as Pyrmont or Seltzer water, and chalybeate water ; and if the cold of these prove distressing or painful to the stomach, a small portion of brandy, or of some agreeable tincture, will make them more palatable. It is proper dyspepsia. 83 proper to caution the patients against the danger- ous consequences which often follow from spirits mixed with the drink in order to render it grate- ful to the stomach, and which arise from this cir- cumstance, that the proportion of the spirit may be gradually encreased, until a direct and palpa- ble habit of dram drinking be induced. There should be a strict injunction therefore to mea- sure the proportion of the spirit which is to be mixed with a given quantity of the drink ; and by slow degrees to withdraw this allowance of spirits, until the stomach can bear the drink without it. It is proper, throughout the whole of this com- plaint, to keep the body, and particularly the feet, comfortably warm ; therefore, flannels should be worn close to the body, especially in cold and damp weather. Friction applied to the feet and stomach, by means of a flesh brush, or flannel, is often useful. After the patients are so far re- covered as to complain of nothing but weakness, if the season of the year permits, the cold bath, cautiously and judiciously employed, is one of our best remedies to restore strength and health : country air, and regular exercise on horseback, should be, if practicable, enjoined, or, if riding be too severe, exercise in an open carriage. It should be the physician’s care to promote serenity and cheerfulness of mind, especially as the pati- o 2 ent 84 DYSPEPSIA. ent is too often under the influence of low spirits, and unfounded melancholyc INDIGESTION IN CHILDREN. The common symptoms of dyspepsia are often met with in children in Dublin, occasioned by want of exercise ; impure air ; sedentary life ; and frequently by poverty and bad clothing. Poverty and nakedness are not so much the cause of this disease in country children as they are in those of the town ; because in the country their baneful effects are greatly counteracted by the purity of the air, and the free opportunities of exercise : in the country too the children in- herit sounder constitutions; their parents being oc- cupied in those employments, which, though they often fatigue, yet are always attended with constant exercise in the pure and open air ; and having less opportunities of indulging in those or- gies of intoxication, which are periodically cele- brated every week by the poor tradesmen of Dublin, whereby they uniformly entail poverty and want upon their little families ; sickly and consumptive constitutions upon their offspring ; and a miserable existence, and premature old age upon themselves. CURE. INTERMITTENT FEVER. 85 CURE. In the dyspepsia of children, the powder, No. 1 2, repeated twice a week, seldom fails to remove the distress in a short time. Afterwards the cha- lybeate, No. 34, may be persevered in with ad- vantage until the health is re-established. The attention to warm clothing, particularly for the feet, which has been recommended for adults, will be essentially necessary in the cases of children. INTERMITTENT FEVER, OR AGUE. During the autumn, winter, and spring, some sporadic cases of ague are corpmonly observed every year in Dublin, especially those of the irre- gular or imperfect kind ; and generally under the quotidian form. But in the end of the year 1 805, agues became very common in Dublin, and throughout the whole kingdom, so as to appear the prevailing epidemic ; continued to spread until the ensuing summer of 1806 was far ad- vanced ; and did not disappear entirely during that year : in the succeeding autumn and winter, they again encreased in frequency and severity, and became epidemic, but they were not as uni- versal as in the two preceding years. In the be- ginning of this year, 1 809, they broke out again, but their frequency and severity were less than during 86 INTERMITTENT FEVER. during those former years. Since the epidemic of 1805, some cases of ague have been always met with in Dublin and its neighbourhood. It was remarkable, that when the intermittents spread epidemically, they proceeded more uni- formly through their regular stages, than when they were less frequent : there was also a greater proportion of tertians amongst those epidemics, than amongst the imperfect agues of former years. IMPERFECT INTERMITTENTS. Those generally appeared like severe head-ache. Sometimes the pain was in one side of the fore- head, over the eye and temple ; sometimes it shot along the side, to the back part of the head ; in some instances it penetrated into the ball of the eye; in others it spread from the nose along the jaws, the cheek, and the teeth, to the ear on the same side, without rising to the upper part of the head : and thus one side of the head was commonly altogether free from pain, the other side being severely attacked in some part or other : a few instances, however, occurred of general pain, occupying the whole head, from the eyes back- wards, to the nape of the neck. There was commonly a slight swelling, and sometimes in- flammation in the part attacked by the pain, and a great tenderness of the eye, accompanied by a flow of tears, when that organ was affected : the fit usually began with slight rigor, soon suc- ceeded INTERMITTENT FEVER. 87 ceeded by encreased heat and quick pulse* and lasted some hours ; in some instances its dura- tion did not exceed two hours, in others it con- tinued six, and in some even eight hours ; and in different persons came on at various times of the day, but most commonly in the morning: in some instances the pain attacked suddenly, without any previous affection whatever : in the intervals between the fits, the patients were free from distress* Persons of sedentary lives, and of delicate constitutions, and most particularly they whose employments oblige them to be long exposed to the weather, such as bricklayers, labourers, basket-women, were most subject to this com- plaint, DIAGNOSIS. Those imperfect intermittents were distin- guished from other local affections of inflamma- tion and pain, by being generally confined to one side ; by their receiving but comparatively little benefit from the use of active remedies, such as leeches, blistering, &c, which give relief in other local affections; but they were particularly dis- tinguished by the intermission from pain, during a great part of the day, and by the periodical return of the fit, at stated times. CURE* 88 INTERMITTENT FEVER* CURE. , The method of cure differs little from that of PERFECT INTERMITTENTS. The perfect intermittents formed the majority of those epidemics already mentioned, and con- sisted of three stages, the cold, the hot, and the sweating stage. The cold stage began with lassitude ; heaviness ; yawning ; weakness ; quick and anxious breathing ; a livid paleness of the surface, particularly of the nose, of the lips, and of the nails of the fingers ; pain of the back, and sometimes of the limbs ; a distres- sing sense of cold and shivering of the lower jaw, and then of the whole body ; sickness of stomach ; bilious vomiting ; small quick pulse ; pa* e urine ; thirst ; bitter taste of the mouth ; foui and loaded tongue ; and sometimes an ir- ritating dry cough. After continuing for some time, in many instances, for one hour, in some a longer time, but seldom more than two hours, the cold and shivering gradually subsided ; and heat began to return, and soon encreased to a burning degree, accompanied by the following train of symptoms : encreased strength of pulse ; head-ache ; and sometimes delirium ; pain often at the pit of the' stomach ; flushed and turgid face ; a shining and prominent brilliancy of the eyes \ encreased thirst ; confined bowels * and high INTERMITTENT FEVER, 89 high coloured urine: after lasting some time longer than the cold stage, these symptoms gave way to the sweating stage : here the burning heat became milder, a softness of the skin took place, and soon a profuse sweat spread over the whole body, with the effect of mitigating all the distressing symptoms of the preceding stage, and sometimes accompanied by a looseness of the bowels. The sweat lasted for several hours, during which, the patients, in some instances, fell asleep, and upon awaking, found them- selves relieved from all the symptoms of the complaint : during the intermissions, the pa- tients experience little uneasiness, except perhaps a slight thirst ; some trifling lassitude, or heavi- ness of the head. In all agues, whether of the irregular or per- fect kind, the biliary organs were considerably deranged, as appeared from the loaded tongue ; the sickness at stomach ; the vomiting ; the colour and fsetor of the excrements \ and the pain of the prcecordia. The regular succession of the three stages oc- curred in most instances of the late epidemics ; and particularly on the first days, before medical treatment was resorted to ; but many cases also were observed, in which this regularity did not exist, especially as to the cold fit, which was frequently wanting altogether, and which in others amounted only to an encreased sense of cold 90 INTERMITTENT FFVER. cold without shivering : and even where the cold stage was complete in the first fits, it often happened, that in the progress of the complaint, the cold became less marked, and was even wholly absent. Sometimes the fits consisted only of a slight degree of cold, succeeded by a complete hot stage, but without any subsequent sweating. Of all the stages, the encreased heat was the most constant, and often appeared with- out the combination of either of the other stages ; but along with the heat, some head-ache and sickness at stomach were commonly present. Several cases of intermit tents occurred, which at the commencement resembled common fever, and continued under that form for a few days ; but when the bowels were thoroughly freed by means of appropriate purgatives, the intermissi- ons began to appear. CURE. In agues, the state of the stomach and bowels claims the first attention : it is necessary to relieve them from the foulness and accumulation in the alimentary canal, which constantly accompany the disease : with this view, a full dose of calo- mel, combined with some vegetable cathartic, such as rhubarb, scammony, jalap, aloe, and in great constipation with gamboge, may be exhibited. The medicines, No. 1, or 2, may answer ; but where a more active purgative is called for, by a great degree of constipation, and INTERMITTENT FEVER. 91 and obstinate bowels, the pills, No. 3 , or 38, wiU be more effectual. The best time for giving the purgative, is the beginning of the intermis- sion : if it fails to operate in three hours, the purging mixture, No. 4, or one of the opening draughts, No. 23, wiU quicken the operation of the pills. Where weakness or delicacy of con- stitution recommend a more gentle treatment, the glyster. No. 6, may be administered in place of the mixtures. The system is thus freed from ir- ritating excrements, and prepared for those me- dicines which have more immediately the power of removing the fever. These are usually the first steps necessary to be taken by the physician, upon being called to an aguish patient ; and for the most part, the only medical treatment that could be employed, during „ one intermission in quotidians : after the inter- mission, the sickness and nausea of the subsequent fit leave little room for medicine, until the next intermission commences : but at the beginning of the cold fit, a liberal dose of an opiate, given in a warm and agreeable cordial, such as the for- mula, No. 64, or in mulled wine, with a free allowance of cloves, or nutmeg, or any other grateful spice, breaks the force of the cold fit, shortens the duration of the paroxysm, and soon brings on the sweating stage, which may be considered the critical solution of every fit ; and which gradually becomes milder in proportion as the violence and continuance of the preceding stages are diminished. During the hot fit, there 92 INTERMITTENT FEVER. is nothing more grateful than a glass of ice-cream ; where ice cannot be procured, acids are cooling and pleasant, such as lemonade, effervescing draught somewhat supersaturated with acid, syrup of cappillaire and water, syrup of rasp- berry vinegar and water, oranges, &c. During the sweat, little attention is required except to admit fresh and pure air ; and to take care, that the sweat is neither forced., nor imprudently checked. / After the sweat is over, and when the stomach is settled and most likely to bear medicines, the Peruvian bark is to be administered. A drachm of the powdered bark is a very moderate dose, and may be given, in new milk, mixed with four or five grains of Cayenne pepper, and repeated every half hour, until half an ounce be taken. In obstinate cases, the half ounce of powdered bark, with a proportionable' quantity of Cayenne pepper, had best be taken in two equal doses, at the interval of an hour from each other, as it is found to have more powerful effects when a given quantity is taken in large doses, than when it is divided into a number of smaller ones. This is one of the most agreeable forms for taking the bark. It may be also given with the saline mix- ture, or with vane, or with a mixture consisting of an infusion of bark, with tincture of bark, or INTERMITTENT FEVER. 93 or of some other good bitter, as columbo, serpen- taria, &c. as in No. 39. * The effect of this treatment is to break the force of the ensuing fits, by diminishing their severity, shortening their duration, and generally by delaying the period of their return. This treatment, of emptying the bowels with calomel purgatives y of mitigating the severity of the various stages of the fit ; and of exhibiting the bitters during the intermissions, should be persevered in until the fits entirely disappear ; and afterwards, one dose of the bitters ought to be taken every day, for a fortnight at least, as a pre- ventive. As the time for taking food must be the intermission ; and as the bark answers best upon an empty stomach, the medicine had best be taken first, and the food in three or four hours after, or as soon as it can be retained on the sto- ijiach • but where the appetite for food is injured for * In dispensary practice, from the great expense of Peru- vian bark, I tried a combination of powdered Angustura bark, of Kino, and of Cayenne pepper, directed in No. 40 as a substitute for the Peruvian bark, and had the satisfaction to find, that it was not inferior to the Peruvian bark in effi- cacy ; and in some cases it removed the symptoms after the Peruvian bark had failed. I was encouraged by this success to recommend it in private practice, where it proved equally effectual. 94 INTERMITTENT FEVER. for any length of time, by having first taken the bitters, in such cases the food had best be taken first, and the bitters in three or four hours after : but in tertians, where the length of the intermis- sions will admit of it, the best plan is to delay the exhibition of the bitters for a longer inter- val after taking food. In the intermittents of this year, I tried the powdered root of the acorus calamus, or sweet flag, mixed with Peruvian bark and Cayenne pep- per, and with the best success. In a few cases, I gave Cayenne pepper and the sweet flag, without any other addition ; and from their effects I have reason to entertain a very favourable opinion of their virtues. When the paroxysms are giving way, it gene- rally happens that the cold stage does not return, or returns in a slighter degree ; the heat is shorter and milder ; the sickness less ; and the sweat either does not follow, or it is a gentle moisture of short duration : sometimes the paroxysm is reduced to a slight degree of encreased heat ; and sometimes there is no more than a hea- viness, with a trifling head-ache. In tertians, if the purgative is given in the be- ginning of the intermission, there is commonly time DROPSY. 95 time sufficient also to exhibit the bitters before the approach of the subsequent fit. The bile was morbidly secreted in all the cases of intermittents which came under my observa- tion : in many instances there was a chronic dis- ease of the liver ; and I heard of some instances where jaundice supervened. All those cases therefore, required a liberal use of calomel pur- gatives, or of mercury exhibited in some other shape : and so strongly was this medicine indi- cated, that, as I am well informed, many cases of ague were cured in hospital practice, by the use of mercury alone, or combined with medicines which could have scarcely contributed to the re- moval of the complaint. DROPSY. Is one of the best known and most fatal of all chronic diseases. There are different names given to it, according as the dropsical collection happens to be contained in various parts of the the body ; as in the ventricles of the brain ; the cavity of the chest ; within the pericordium, or sack which encloses the heart ; within the cavity of the belly ; in the loose cellular texture diffused between the muscles, on the surface of the body and under the skin ; in the tunica vaginalis testis ; or in cysts or hydatids, attached to some of the viscera : 96 DROPSY* viscera : in women the viscera to which hydatids generally attach themselves, are the ovaria ; and in men most commonly the liver. The three great varieties to be considered here* are the dropsy of the chest, or hydrothorax : the dropsy of the belly, or ascites ; and the general dropsy of the cellular membrane, or anasarca. As the nature of the complaint is the same in those varieties, and only modified by the different seats of the disease ; the peculiarities of the parts where the watery fluid is collected ; and their greater or less delicacy and importance to life ; the mode of treatment must in all be founded on the same general principles : and the most successful remedies in one kind are likely to be the most successful in the others. It will be ne- cessary, however, in the progress of the cure, to keep constantly in view the peculiarities and func- tions of the parts affected, and to adapt our treat- ment to those varieties. Anasarca, hydrothorax, and ascites are seldom found perfectly distinct from each other : for though in most of the dropsical patients we meet with, one of the three predominates, yet that one is commonly combined with one, and frequently with both of the others. ANASARCA. DROPSY. 97 ANASARCA. SYMPTOMS OF ANASARCA. In anasarca there is a soft, pale swelling of some part, or of the whole of the surface of the body and limbs, which pits on being pressed. * The swelling is at first partial, and most commonly begins about the ankles and feet ; it then ascends, and spreads until it occupies a large portion, or perhaps the whole of the surface of the limbs and trunk of the body, and sometimes penetrates even into the cellular membrane of the lungs : there are however instances where the swelling is from the commencement universal ; and there are a few instances alsa where the upper parts of the body have been first attacked : the cellular membrane, under the eyes, is commonly swelled, whence the general complaint has been called hydrops : the scrotum and prepuce in men, and the pudenda in * women, often swell to an enormous size ; the fluid being copiously collected in the loose cellular mem- brane : the fat is absorbed, whence there is great emaciation, * Sometimes an erysipelatous inflammation spreads over the dropsical surface, especially in the legs, whence the skin be- comes hot, inflamed, and hard ; this appearance is most com- monly combined with diseased liver, and is not uncommon in habitual drunkards ; it happens too in those poor people whose naked legs are much exposed to the weather, such as washer- women. H 98 DROPSY. emaciation, but it is prevented by the dropsical enlargement from being perceived : * the counte- nance looks dull and languid ; the urine is scanty, and of a dark brown colour, and in its passage attended commonly by an unusual heat ; the skin is dry and cold ; breathing quick and hurried, particularly on exertion or motion ; there is often a cough ; the patient feels unusual lassitude and weak, ess, and generally suffers from thirst ; the pulse is small, and sometimes irregular ; the ap- petite is uniformly impaired ; the sleep is inter- rupted and unrefreshing ; costiveness mostly at- tends dropsy, but some cases are met with in which the urine and stools are passed in natural quantity, and there are instances even of purging. Anasarca occurs frequently without any admix- ture of hydrothorax or ascites ; but it commonly accompanies, in a greater or less degree, both of the others ; especially hydrothorax, in which it is so constant, that it is enumerated as one of its symptoms. ASCITES* * The swelling of the lower extremities, the most common appearance of the disease at its commencement, arises from the watery exhalations, by their gravity, descending into the lowest parts of the body, in consequence of the body being very much in an erect posture : another cause is the more lan- guid circulation of the blood «n the lower extremities, whence arises aij encreased exhalation into the cellular membrane. DROPSY. 99 ASCITES, OR DROPSY OF THE BELLY. SYMPTOMS OF ASCITES. The symptoms are, a swelling of the belly, which, in the progress of the complaint, becomes very large and tense ; a fluctuation felt about the loins and lower part of the belly ; # flatulence, or wind, in the stomach and bowels ; encreased weight of the belly ; and (as in anasarca) languid counte- nance ; hurried and laborious breathing ; cough ; scanty and deep coloured urine ; weakness and relaxation ; thirst ; impaired appetite ; small, and sometimes irregular pulse ; bad sleep ; costiveness ; cold skin, and sometimes livid complexion. HYDROTHORAX, OR DROPSY OF THE CHEST. SYMPTOMS OF HYDROTHORAX. In dropsy of the chest there is an encreased difficulty of reclining in an horizontal posture ; sleep much interrupted, and attended by fright- ful dreams ; great difficulty of breathing, amount- ing, in many instances, to orthopnea, and threat- h 2 ening * The enlargement oftentimes is first perceived in the upper part of the belly, from the fluid in the bottom of it pressing up the floating viscera of the abdomen, towards the arch of the ribs, and pit of the stomach. This enlargement becomes more sensible where there is chronic disease of the liver, „ the encreased size of which adds to the bulk at the upper part. DROPS?. 100 ening suffocation ; the patient can best remain in an erect attitude, and, in some instances, inclined rather forward, with the chest supported against some firm substance, as a table : there is a sense of tightness about the chest, arising from an ac- cumulation of water which impedes the free motion of the lungs : in the progress of the dis- ease the countenance and the lips become livid and bloated ; the patient is often suddenly roused from his sleep as if startled $ there is sometimes a spitting of blood. Along with those peculiar marks of hydrotho- rax, the common symptoms of anasarca and ascites also occur, such as languid countenance \ cough ; scanty and deep coloured urine ; lassi- tude ; thirst ; impaired appetite ; costiveness ; coldness of the extremities ; great irregularity of the pulse : * anasarca is very common in cases of hydrothorax ; and it is not uncommon to meet with instances in which all three are combined. In hydrothorax there is said to be a fluctuation sometimes perceived in the chest, upon applying the * All the possible varieties of irregularity in the pulse are to be met with in dropsy, particularly in hydrothorax : if the watery fluid is collected in the pericardium, or if the heart or large arteries are ossified or diseased, the irregularity of the pulse is the greater. DROPSY* 101 the hand to the forepart of the chest, moving back the upper part of the body, and then bring- ing it suddenly forward. Such a fluctuation however is not always perceived ; and though it were constant, yet the steps necessary to ascertain it, are attended with such danger, that they should not be hastily resorted to, as the trial has been known to induce palpitation, and fainting ; and sometimes nearly to have killed the patient sud- denly : it is an experiment too which is not ne- cessary ; for the great dyspnaea ; the lividity of complexion; the distress in breathing, which makes the patient remain in an erect or prone posture; and the severe cough, accompanied by the general symptoms of dropsy, sufficiently characterize this species of the complaint. The brain is sometimes affected in the progress of dropsy with symptoms of apoplexy, such as stertorous breathing and stupor, * and sometimes the sight is lost pro tempore :f a jaundiced tinge of * The apoplectic and comatose symptoms seem to arise from effusion on the brain ; and are produced by the same cause on which the lividity of the cheeks and lips, and the bloated fulness of the eyes and face depend, viz. obstructions to the passage of the blood through the lungs, and consequent accumulation in the head. f About eight years ago I met with a case of general anasarca and ascites in a man between fifty and sixty years old, who got a relapse of his dropsy every winter, for four successive winters ; 102 DROPSY. of the whole surface has been seen where the liver was primarily diseased ; and in hydrothorax all the symptoms of a feverish paroxysm have been sometimes observed. Slight effusions of blood under the cuticle, causing ecchymosis and petechial marks, have likewise been seen in this disease. CAUSES OF DROPSY. The causes of dropsy are such as give rise to encreased exhalations into the cellular membrane and cavities of the body, without a proportion- ably encreased absorption: the circumstances which encrease those exhalations are ; suppressed per- spiration ; # a sedentary life ; tumors, or ligatures ; enlargements winters ; from a course of medicines continued for four or five weeks, his dropsy commonly disappeared; after which he returned to his ordinary occupation of a labourer : at this he worked until the relapse of the following winter brought him again to the dispensary : after the expiration of the 4th year, he continued during three seasons free from the complaint ; but last winter I visited him again, labouring under dropsy, in the usual form. During the three last attacks he got a dimness of sight nearly amounting to blindness, which disappeared al- most entirely from the use of the medicines exhibited with a view to the cure of his dropsy only. * Suppressed perspiration produces dropsy, by determining a greater quantity of fluids to other parts, and thereby encreas- ing the exhalations in those parts. DROPSY. 103 enlargements of the heart, and adhesions to the surrounding parts ; organic lesions in the heart, and neighbouring parts, such as polypus or ossifica- tions in the heart, or in the large arteries, or ossifi- cations of the valves at the mouths of these arteries. These causes operate by impeding the free circula- tion of the blood through the heart, and by thus producing increased exhalation, chiefly in the course of the vessels which are nearest to, and which most immediately return the blood to the heart ; hence hydrothorax is most commonly the dropsy, produced by these causes : but the causes first enumerated, such as suppressed per- spiration, sedentary life, tumours and ligatures, will cause any species of the disease. Ascites and hydrothorax, by their pressure, will bring on anasarca, hence, they seldom occur without anasarca existing at the same time. Long standing will cause partial anasarca, though walking a great deal without fatiguing will not, but will rather remove the dropsical swelling of the feet, caused by standing ; walk- ing, in this case, encreases muscular action, promotes the circulation, and absorption at the same time, and thus removes the complaint : asthma and pneumonia, by causing the blood to be obstructed in its circulation through the lungs, will encrease the watery exhalation, and will often produce dropsy, principally of the chest 5 some 104 DROPSY. some eruptive diseases are often attended with dropsy, such as erysipelas and scarlatina ; ob- structions of the different viscera of the belly are some of the most common causes of dropsy, such as schirrhous enlargements of the spleen, of the omentum, of the pancreas, of the kid- neys, but especially obstructions of the liver :* dropsies are often the consequence of acute dis- eases in hot climates, and sometimes even in temperate and cold countries : debilitating causes of all sorts may lay a foundation for dropsy, such as repeated attacks of venereal com- plaints ; large discharges of blood ;t great eva- cuations of any sort, such as diarrhaea, dysentery, and even diabetes, and nursing in very delicate persons : * In obstructions of the liver, the blood of the floating viscera of the abdomen is retarded in its progress to the heart, in consequence of which, there is an increased determination to the exhalants connected with that circulation, that is to the numberless exhalants on the very extensive surface of the me- sentery, whence sometimes arise great and sudden collections of watery fluids in the cavity of the belly, producing ascites. It is likewise probable, that the relaxed state of health, which uniformly occurs in persons of obstructed viscera, by allowing a greater quantity of watery fluids to escape through the exhalants, and by weakening the tone of the ab- sorbents, encreases the general tendency to dropsy. •j- This points out a necessary caution not to carry blood= letting too far in acute diseases. DROPSY. 105 persons : amongst the causes of dropsy is plethora, particularly if attended with weakness ; thus, re^ peated blood-letting will cause fulness and dropsy ; its effects, with respect to the circulating mass of fluids, consist in renewing the quantity of those fluids soon, but with less proportion of crassa- mentum ; the watery parts therefore of those fluids are encreased, and a disposition to a more copious exhalation is produced: repelled erup- ruptions are by some considered as causes of dropsy, and also the drying up of old sores ; the stopping of habitual discharges, such as issues and setons 3 likewise bad or poor diet ; want of sufficient nourishment 3 and such a weakness of the digestive organs as cannot extract sufficient nourishment from the food, will dispose to the complaint : a suppression of urine has been con- sidered capable of causing dropsy, but though it may produce a translation of that fluid to un- usual cavities, it is probable that it never has been the cause of dropsy ; the opinion seems to have been formed in consequence of this circum- stance, that in dropsical complaints, the urine is diminished.* Dropsy * The difficult breathing, the anguish, and the disturbed •sleep, which are common symptoms of dropsy, are caused by weakness and by pressure on the lungs ; in dropsy of the chest, the cause of this pressure is obvious j in general anasarca, the watery 06 DROPSY. \ Dropsy is most apt to attack the old; the infirm ; the dissipated ; and most particularly those whose constitutions have been broken down by former disorders ; the poor who suffer from fatigue, bad diet, and the severity of the weather ; and persons who have long resided in tropical climates. PROGNOSIS. watery fluid insinuates . itself into the cellular texture of the lungs and occasions similar distress, except that in anasarca it is more uniform and less sudden : in ascites, the diaphragm is by the collection of water in the belly pushed upwards, and thus by its pressure, it prevents the lungs from being dilated, and causes the distress of cough, shortness of breath, and disturbed sleep : the paleness of the face and of the lips,’ de- pends on the watery nature of the blood, and on its languid circulation : the livid colour, and bloated appearance of the face, and the blackness of the lips, which occur in the last stage of dangerous dropsy, especially hydrothorax, are caused by the venous blood, accumulated in the vessels of those parts, in consequence of its difficult passage through the lungs ; the encreased watery exhalation into the cavities of the body, and into the cellular texture is' attended by a diminished propor- tion of fluids in other parts ; hence arises scanty and high coloured urine, and thirst : the confinement of the bowels is occasioned partly by the general weakness of the system, of which the intestines partake ; partly by- the want of the na- tural stimulus of bile, when the liver is engaged ; and partly by external pressure. An impediment to the free and natural action of the heart, and a disturbance of the functions of tha brain, in conseqnence of encreased pressure, will cause palpi- tation, with an irregular and intermittent pulse, so usual in bad cases of dropsy. DROPSY. 107 PROGNOSIS. It is obvious, from the account already given of dropsy, that it is sometimes the primary com- plaint, and sometimes the sequela, or conse- quence of other complaints ; but the latter is the more frequent occurrence : when it is the primary complaint, unconnected with any pre- vious derangement of the system, the prospect of recovery is greatest : when it is the conse- quence of other complaints, the danger is pro- portionably greater, and always most alarming when the primary complaint on which it depends is itself incurable : such are the ossifications of the great arteries, of their valves, of the heart itself ; aneurisms of the arteries ; incurable schirrhus or ossification of the liver, or other viscera of the belly ; or so great an enlargement of the liver, as to leave no chance of being cured. It happens, however, that most frequently, the disease of the liver will yield to medicines ; and a dropsy, in such cases, though combined with liver disease, will often be permanently cured also. The anasarca, or dropsy of the cellular mem- brane, is the sort most commonly and easily cured ; indeed, where it is unconnected with any of the other two sorts, it will be removed in a great majority of cases. Whether '108 DROPSY. Whether dropsy of the chest, or of the belly is most easily cured, seems very doubtful. When there is no incurable disease of the heart, of the arteries, or their valves, or of the viscera of the belly, as the foundation of the disease, perhaps dropsy of the chest will be cured in a greater number of instances, than a dropsy of the belly : but where such injuries of any im- portant viscus, or of the arteries and heart exist, the termination is fatal ; and even in such cases, the dropsical collections shall often be re- moved, and yet the patient, in a short time after, fall a victim to the primary disease. In hydro- thorax, the patient sometimes falls dead as sud- denly as if killed by apoplexy. The dropsy of the chest and belly are in all instances, much more difficult to cure than ana- sarca, because they are commonly connected with diseased viscera, and because we can apply general and topical remedies to the surface, which is the seat of anasarca, but in dropsy of the chest and belly, the water is in cavities which we cannot reach, and immediate applications to which are utterly impracticable. Though the cure is commonly conducted on the principle of procuring encreased watery evacuations especially by stool and urine ; yet it sometimes happens that purging will set in, and become an alarming symptom, and by wasting the strength of the patient DROPSY. 109 patient often prove fatal, notwithstanding all the attention and skill of the physician. A bloated face ; livid cheeks and lips ; great an- guish in breathing ; and cold extremities leave very little hopes of recovery. An irregular pulse is always a very bad sign, and alarming in pro- portion to the greatness of the irregularity. When in the course of the treatment, the symp- toms continue day after day to grow worse, it is a bad symptom, for then the progress to a fatal termination is commonly rapid. The prognosis, however, should be always guarded ; because instances occur, in which the young and vigorous will fall victims to the mildest form of dropsy, viz. anasarca ; and on the contrary, where the aged, the enfee- bled, and the intemperate, will sometimes re- cover from the worst kinds of it, viz. dropsy of the chest or belly. CURE OF DROPSY. In attempting the cure of dropsy, our first object should be to carry off the collected fluids ; then to cure those causes which have produced the accum ulation ; and lastly, to restore the health and vigour of the system, so as to enable it to support itself against any future return of the complaint. The first and second indication are 110 DROPSY. are generally, though not always, attained by the same treatment ; and it sometimes happens that where those two purposes are accomplished, nature will effect the third. After having given a free and extensive trial to the diuretics, purgatives and strengthened gene- rally employed for the cure of dropsy, in the course of an extensive practice at the Dublin general dispensary ; I fixed upon the following plan, as being that which I found most com- monly, and most permanently successful.* I order * It is a great misfortune, that in a complaint of distressing weakness, the remedies on which we must rely for ultimate success are evacuants, that is, medicines whose property it is to weaken : this, however, must be the case, because it will be vain to attempt a cure without removing the collected fluids. The evacuants employed must be either emetics ; sudorifics ; diuretics ; cathartics ; or mechanical means to dis- charge the water by puncture : this method of carrying off the water by an operation is seldom practised in dropsy of the chest, or cellular membrane ; but frequently in dropsy of the belly, and in a few instances with success, where’ a conside- rable portion of vigour still remains, and where the tone and elasticity of the parts are not greatly injured by the duration and severity of the complaint. Tapping generally gives great relief, at least for a time, and even encreases the flow of urine. There are some instances of permanent benefit from this operation, but they are extremely rare. The most usual occurrence is, that in a few days the dropsical swelling returns, and must be again carried off by a new opening ; and thus the DROPSY. Ill order two of the pills, No. 43, to be given every night ; but if there are appearances of dropsy of the chest, two of the pills, No. 44, which differ from the others, only in containing a grain of digitalis in every dose. A tea-spoonfull of the electuary, No. 5, is to be taken every mor- ning, and to be repeated twice or three times in the course of the day : the directions are to take a tea-spoonful the operation must be repeated frequently, and at short inter- vals. The impediment which the functions of the body suffer from the pressure of the water, often frustrates the effect of medicines ; the operation removes this impediment, and sud- denly encreases the flow of urine, the pressure haying injured or prevented the secretion in the u inary organs : and though the body fills rapidly after the tupping, 'yet from the intole- rable distress and weakness caused by the pressure of the water, when medicines lose their* effect, the operation must be practised, even with a view to procure temporary relief. Other mechanical remedies used in dropsy are, punctures and scarifications. Whether the punctures or scarifications be the plan decided upon, they ought always to be superficial, and at some distance from one another, perhaps at the distance of an inch or more. The danger from those methods is, that gangrene may supervene, and especially in the legs, where the circulation is most languid ; but this danger is lessened by making them at some distance from one another, and as near to the trunk as the nature of the complaint will admit. Some- times one puncture will run into gangrene, though the others heal ; and sometimes one set of punctures or scarifications will heal, but upon the water collecting again, the new punctures or scarifications, or some of them, will run into a fatal gan- grene. 112 DROPSY. a tea-spoonful of the electuary in the morning, and to repeat it every three hours until two or three doses of it be taken in the day. This treatment keeps the bowels regular, and in the course of a week, generally encreases the discharge by urine ; the pills along with their lax- ative effects are in some degree diuretic, and contain a preparation of mercury, which slowly and gradually affects the system in such a man- ner, as to make it more easily acted upon by lax- ative and diuretic medicines of another kind, such as the electuary contains. The watery eva- cuations by urine and by stool are thus encreased ; and it commonly happens, (at least in a great number of cases,) that without any other me- dicine, the patient is entirely freed from dropsical swellings by this treatment only:* the watery stools and the large quantitity of urine diminish the exhalations * The most useful cathartics are those which cause very liquid discharges by stool. The following are the class most commonly recommended : elaterium, or winter apple ; aloe ; scammony : gamboge : jalap, and calomel. All these are occasionally employed by different practitioners ; but the ela- lerium 19 at present least in use. These medicines frequently act upon the kidneys likewise, encrease their secretion, and bring away large quantities of urine : they arc sometimes ex- hibited separately, and sometimes combined, more or less, with one another ; I think their effects are most valuable when they are combined. DROPSY. 113 exhalations into other parts, which were the cause of the dropsy, on the common principle, that an encreased action in one part causes di- minished action in another : it is obvious, that there is an encreased absorption of the dropsical collection also ; this is proved by the sudden de- pletion which often takes place from the use of those medicines. Their doses must in many instances be encreased to produce the desired effect, because there is in dropsy a great degree of torpor, whence the system is not easily stimulated as in other diseases ; it is safest, however, always to begin with the moderate doses here pointed out, which, in cases of emergency, might be en- larged to the extent desired. It is when the quantity of the urine is greatly encreased, that the dropsical symptoms are found to subside most sensibly, and with the greatest relief to the patients, the watery discharge which passes off in this manner giving very little distress s purgatives, though they reduce the swellings, yet weaken very much ; therefore they are most useful when their diuretic effects are produced : when the urine encreases, it will be proper to persevere in the use of the electuary, oy of some other diuretic, (always taking care, that the bowels are kept tolerably free,) until the symptoms disappear.* i The * The diuretics commonly in use, are squills, crystals of tartar, digitalis, and kali acetatum ; colchi^um is now seldom employed. 114 DROPSY. The purgatives frequently cause a griping and pain of the belly : when this occurs, these me- dicines must be omitted, and small doses of castor oil and tincture of senna exhibited as in No. 23, this in most cases of griping is a soothing, agree- able medicine. Nourishing broths ; jellies ; and a glass of good wine should be allowed. In dropsy of the chest, digitalis is added to the pills, as in No. 44 ; sometimes the digitalis may be given with advantage in tincture, of which from ten to twenty drops may be taken in an agreeable draught three or four times a day ; it relieves the breathing, and often encreases the flow of urine. Blisters to the breast, or between the shoulders, are very useful in this land of dropsy ; but with a view to a permanent effect from a drain about the chest, issues between the shoulders, or a seton are to be preferred : the issues should be made large, so as to hold two or three peas. In anasarca, flannel rollers coiled round the feet and legs, from the toes upwards to the knees, greatly assist in carrying off the swellings : simi- lar rollers round the belly are of great use in dropsy ■employed. I have found great benefit from the use of squills and crystals of tartar, as they are combined with the pills and electuary which I recommend. Digitalis is greatly com- mended in dropsy of the chest j it is sometimes given in powder, and sometimes in tincture. DROPSY. 115 dropsy of the belly : these rollers, by their pres- sure and warmth, support the muscles of the parts and promote absorption. In all kinds of dropsy, the body should be kept comfortably warm, and in as pure dry air as possible. The diet should be nourishing and easily digested, such as gruel, jellies, broths, eggs, dry toast, or toast with a little fresh butter, and, where the stomach can bear it, a bit of meat. The patient ought to be allowed to take a mode- rate drink of some subacid light liquor, from time to time, such as imperial, small beer, le- monade, butter-milk, orange juice, whey, &c. a lit- tle old wine must be allowed, particularly at meals; and if there is great weakness, a glass of wine will be proper three or four times a day : it may be taken pure, or mixed with water, or with whey, according to the patient’s liking. After the dropsical collections are removed, a course of light bitters, aromatics, and chaly- beates will be useful, as in No. 45: exercise in the open air, flannels worn close to the body, and the continued use of the rollers, and of the issues, where such are necessary, must be adopted for a long time after the convalescence. If the wea- ther permits, the exercise should be on horseback, or in an open carriage. Inland pure country air is to be preferred to any other. i 2 Where 11 6 DROPSY. Where iiver disease has induced the dropsy/ it is obvious that the removal of the swellings alone will not restore health ; in such cases it will be necessary to proceed to the cure of the liver, according to the plan recommended in treating of diseased iiver. COMMON or TYPHUS FEVER. This fever has been called by various names ; such as, nervous fever, low fever, spotted fever, fourteen day fever, sometimes hospital or jail fever, and sometimes putrid or malignant fever. Fever * Emetics and sudorifics have been tried in dropsy, but the danger of the one, and the difficulty of forcing a sweat with the other, added' to their small benefit when compared with the purgative and diuretic plan, prevent them from being now much relied on. There is a quack poultice, consisting of pounded snails, powdered liver- wort, barley meal, and as much water or beer as will be necessary to give' them a consistence in boiling, much extolled in the cure of dropsy of the belly ; it is directed to be applied to the umbilicus, and it is said to have caused profuse per- spiration, and thus to have cured dangerous instances of dropsy. It is probable, that the application of a warm emolberit poultice to the belly, might have produced a copious •weat, and thereby caused a depletion ; there is little reason to expect much benefit in any other way from the ingredient* in this poultice* FEVER. 117 Fever is entitled to particular attention, as being a disease perhaps the most universal and com stant with which this country is afflicted. In consequence of its prevalence at all seasons of the year, it has been a question at what season it is most universal. The symptoms of fever are greatly modified by the difference of climate and season : thus in warm climates, and in the warm seasons of tem- perate climates, the bile is morbidly secreted and gives a character to the fever ; whilst in cold countries and seasons, it is accompanied by a cough and other pectoral symptoms : hence in its first attack, it is supposed to be no more than a cold, a mistake frequently pregnant with mischief. The symptoms which belong to fever at different times and in different persons, are very numerous : the most proper and useful method of arranging them therefore is, according to their most ordi- nary appearance. SYMPTOMS. The first symptoms are, an uneasy sensation of cold or shivering; lassitude, as if from great fatiguej an unwillingness to make an effort either of mind or body ; depression of spirits ; loss of appetite, with a loathing of food, especially of animal food ; sickness 118 FEVER* sickness of stomach and vomiting ; head-ache, and in different instances, it is in various parts of the head, but most commonly in the forehead, and not unfrequently in the back part of the head, extending to the neck ; pain of the back ; sore- ness of the whole body, as if the patient had been bruised or beaten ; clamminess of the tongue and mouth ; tongue at first whitish, but it soon becomes foul and yellow, and gradually advances to a dark brown colour ; bad taste of mouth ; thirst; bowels commonly slow ; sometimes a sense of creeping over the whole body, called horripi- latio ; oppression and uneasiness about the pit of the stomach ; the skin is dry and hot ; the eyes look dull and heavy. The face is different from its natural appearance; for it is either pale and shrunk, or red and turgid; sleep either is banished entirely, or it is inter- rupted and not refreshing ; light and noise create much distress, even when the patients tell you that they are not sensible of much uneasiness in their head. The urine is commonly in small quantity, and high coloured ; deafness is a common symptom ; from the contracted state of the surface, sores and eruptions dry up and shrink ; and in some cases, the skin of the patient communicates to the hand, a feeling of a prickly pungent heat : this FEVER. 119 this happens most usually in that modification of fever, called malignant, or putrid ; the patient generally longs for cold and acid drink; the breathing is quick and hurried. In this and other cold countries, catarrhal symptoms, such as cough, hoarseness, and pain in some part of the chest, often occur in the beginning of fever ; but these symptoms are merely accidental ; the pulse is small, somewhat quicker than in health, and its quickness is en- creased by the smallest exertion, even by that of sitting erect in bed. Such are the symptoms which generally cha- racterize fever, during the first week, in its or- dinary state of severity. When the disease is very slight, even those symptoms are milder in degree, and fewer in number ; but when it at- tacks with great violence, those symptoms are more severe, and accompanied with others which have not yet been enumerated. Unless the complaint is cut short during the first week, the symptoms grow worse about the second. The strength sinks apace ; along with the vertigo or head-ache which existed before, delirium comes on, principally at night, and when the patient is dozing ; but in a little time the delirium continues during the day, and whilst the 120 FEVER. the patient is awake ; it is sometimes violent, exciting the patient to vehement rage and great exertions of strength, so as frequently to rush out of his bed and room, if permitted; but more commonly it is of the low muttering kind, unattended with any violent efforts. The deli- rium ferox is accompanied with a turgid redness of the face ; inflamed appearance of the eyes ; great pain of head ; pulsation of the carotid and temporal arteries : in the mild or low delirium the face appears of a dirty pale colour ; the eyes hollow, watery, of a dirty red tinge, and slow and heavy in their motion. Instead of lying on either side, the patient now feels inclined to remain mostly on the back, and in the still more advanced stages of the fever, always on the back. In the moments of recollection, the depression of spirits will sometimes amount to despondency : the memory now becomes slow and somewhat difficult ; the flesh is wasted ; the whole body is more shrunk than natural ; the skin acquires a dirty colour, more or less inclined to yellow ; and in bilious seasons, the skin from the beginning has, in many instances, a yellow' tinge. Spots, cal- led petechise, often appear, first and principally over the upper part of the body, such as the breast, neck, and shoulders ; and in a short time, over the whole of the trunk and extremities also : these spots are various in shape, extent and colour ; but the deeper or more livid is their colour FEVER. 121 colour, the greater is their danger ;* they some- times resemble the small punctures of flea-bites ; sometimes they are large and irregularly circular ; in some instances, they are thinly scattered over the skin, so that large portions of it appear fair between them ; but often they are so crowded and thick, as to give the skin a dark colour ; and in some in- stances the skin appears marbled : the petechias are observed to be most crowded and dusky, where poverty, foul air, and want of cleanliness exist. The foulness of the tongue turns into a dark thick crust, chopped and scarred in various places : in several instances the tongue clears off and becomes clean, but its colour then is a deep red, much darker than its natural flesh-colour ; in these cases, it soon becomes dry and parched again, and a dark brown crust forms upon it extending to and lapping over its point :f the lips and teeth become incrusted ; these crusts require to be gradually and gently cleared away from * To this observation there is an exception, namely, when some time before death, the whole skin acquires a deadly pale cast ; then the petechiae partake of this paleness, and acquire a lighter colour. f I have seen two instances of an inflamed oval blotch on the middle of the tongue, circumscribed and deepest in its colour than the rest of the tongue, and not unlike venereal blotches, which arise from an infected system. FEVER* from time to time ; because during their existence there is a sickening taste in the mouth, commu- nicating its effects to the stomach ; and then the most grateful drink has not its proper flavour, but partakes of the foul taste of the incrustations ; or more properly, it is the foulness of the tongue, of the teeth, and of the lips, and not the flavour of the drink or aliments, that is tasted by the patient. Sometimes, when the tongue and lips are parched, and covered with those crusts, the patient has no desire for drink, and this is an alarming symptom, as Huxham properly observes: it shews great insensibility in the nervous sys- tem, and points out the necessity of a strict at- tention to the state of the brain. A tinnitus aurium, or noise in the ears, often gives great distress ; the patients frequently fancy themselves in company with absent persons, which occasions much low muttering conversa-" tion : with this is often connected another symp- tom, called floccos cofligere, here the patients put out their hands and feel for something which they fancy before them : under this impression they seize the bed-cloths, pull them up and ex- amine them with attention: sometimes they con- ceive themselves annoyed by the presence of disa- greeable persons or objects, which, with an expres- sion of disgust, they request to be removed ; some- times they neither know their intimate acquain- tance, FEVER. 123 tance, nor hear the noise of conversation, nor even very loud sounds, (these last are alarming symptoms,) : the tongue trembles in the effort to thrust it out, and cannot be pushed far out- side the lips ; the speech is tremulous, thick and indistinct ; the tendons of the muscles are agitated with irregular contractions, particu- larly in the fore arm, which often makes it difficult to examine the pulse ; the hands and the upper eyelids are disturbed with similar tre- mors ; and, frequently, during sleep the lids are not closed completely, so that the whites of the eyes can be seen between them : the bowels are confined with a sense of weight, attended by a painful swelling, especially about the hypochondria and pit of the stomach, which cannot bear to be pressed ; and it often happens that a scanty purging of foul slimy stools occurs, and yet neither removes nor diminishes this swelling: jpjmetimes the pain stretches downwards to the bottom of the belly, and laterally to the loins ; this pain commonly remains fixed, particularly towards one side of the belly, notwithstanding any purgatives which might be given for the pur- pose of clearing the bowels ; and then we have reason to apprehend peritonaeal inflammation, a complaint which, if unattended, to certainly proves fatal. The urine is of various colours, from a light whey to a deep porter colour, with a light cloud floating in it: in making water there 124 FEVER. there is often heat and pain, it is passed in small quantity, and in some few instances there is a distressing strangury, which requires the use of the catheter. There is a remarkable smell in fever, compared to that of earth newly turned up (this smell is more striking in small pox) but in the progress of the disease, the smell, without great attention to ventilation and clean- liness, becomes extremely offensive and sickening. Restlesness and want of sleep encrease and ex- asperate all the other symptoms ; but in some few instances the patients remain in a continued state of torpor, unwilling to be roused, and in- sensible to those excitements which operate briskly and sensibly in health. : ( The breathing becomes more hurried, the pulse quicker and more feeble, and often irregular.* Hoemorrhages, or discharges of blood, though rare, yet are met with in some cases : in the early part of the disease, when preceded by an encreased im- petus of the circulation, in any part of the body, these discharges are favourable: thus, in great head- ache, flushed face, and pulsation of the tem- poral arteries ; epistaxis, or a discharge of blood from the nose, will greatly relieve those distres- sing * The pulse is commonly from 110 to 120 strokes in a Triinute, this frequency is not alarming : it often rises to 1 30 and in many cases to 140, and even more : this last is an alarming frequency in adults, and mostly fatal ; but even from this, recoveries will happen. FEVER. 125 sing symptoms, (this encreased action, however, often takes place in the vessels of the head, when the circulation in the rest of the system Is feeble, as is manifest from the pulsation at the wrists,) but when the powers of life are much exhausted, and the leading symptoms are those of weakness and langour, discharges of blood are bad, as as they indicate great relaxation : in excessive weakness too, large evacuations of any sort are dangerous ; but of all evacuations, loss of blood is the most wasteful and alarming : when hoemorr- hagy comes on, it commonly issues from the nose, but it has been known to come from the anus, through the vessels of the skin, and even from the tops of the fingers, and its danger is greatest when it comes from the skin and fingers. The urine and stools are frequently passed in bed, without the controul, and often . without the knowledge of the patient. Such are the symptoms which generally attend the common fever of this country, during the second week. All of them may justly be called dangerous, but not desperate symptoms, or such symptoms as leave no hopes of recovery. It may be properly observed, that the earlier this second class of symptoms appears, the dan- ger is the greater : thus, if many of them set in before the end of the first week, so much worse is the 126 FEVER. the disease, and the more numerous is the assemb- lage of them, the worse the disease also : on the other hand, the later they appear and the smaller their number, the greater the chance of recovery: this may be considered a very general rule; but there are exceptions ; for, fevers are sometimes met with, which begin violently and severely, and which in a few days yield to medicines : in those instances however, in consequence of the alarming seve- rity of the symptoms, medical aid is early re- sorted to, and by these means the disease is either cut short, before it is radically fixed m the sys- tem ; or at least the force of it is broken, so that it entirely yields in a few days. On the other hand, there are many instances in which the patient is just not well for some days, be- comes worse in the course of the second week, and towards the end of that, and in the progress of the third week, is attacked with the worst symptoms of fever ; and thus, perhaps, falls a victim to a complaint, in the beginning of which there was hardly supposed to be danger. Here too it is material to observe, that in consequence of the great mildness of the symptoms at the begin- ing, little danger is apprehended for some days, and there are no remedies given until the malady takes root, and becomes so intimately incorporated with the system, as to baffle the most able and judicious efforts of the physician, efforts, of which a moderate part early exerted, might have soon restored the patient to perfect health. From FEVER, 127 From what I have already mentioned, it is obvious, that it is not intended to point out one class of symptoms as occurring only on the first, and then another class as occuring only on the second week ; for in mild cases, some of those which are enumerated as symptoms of the first shall not appear until the second week ; and in severe cases, some of those which are called symptoms of the second week, set in on the first: but their occur- rence on tliefirt and second week is such, in general, as is here pointed out : and it is hoped that this dis- tinction may be useful, as it helps to shew the probable danger of the complaint, by enabling the practitioner to compare the severity of the symptoms with the period of the fever. There is in a slight degree an encreased seve- rity of the symptoms, or an exacerbation towards evening, and a slight mitigation or remission in the morning, throughout the disease, unless interrupted by remedies. The remission begins early in the morning, and the exacerbation about four or five in the afternoon. There are some symptoms more commonly met with in hot climates, but of which there have been instances also in this country : such are early and profuse sweats, without being criti- cal : they are dangerous from the weakness which they 128 FEVER* they induce.* In fever, the occurrence of jaum dice is a dangerous symptom, especially when it sets in early, but in this country it very rarely occurs ; it is more commonly a symptom of fever In hot climates. A painful spasm of the neck is considered unfavourable ; it is a symptom not unusual in hot, but seldom met with in cold climates : dif- ference of colour in the skin in different parts of the body is an unfavourable symptom, and some- times to be met with in this country : thus the complexion of the face, consists of red and pale patches, variously tinged ; some spots appear of a deep red, others pale, and others bilious j all irregularly circumscribed, and exhibiting a mar- bled appearance of the face : aphthae about the mouth and fauces occuring in the advanced period of the fever are bad ; they are apt to spread through the whole tract of the intestines*! There * Those destructive sweats were frequently caused by the ^>ld fatal custom of confining the unhappy patient within close curtains ; of loading him with bed-cloths ; of con- demning him to the same foul linen, sheets, and cloths, throughout the whole course of the disease, charged as they were with feverish and putrid exhalations $ of excluding every breath of fresh and reviving air, and of giving neither food nor drink but very hot. This fatal and preposterous fashion is not yet entirely exploded. f Pustular eruptions about the lips, mouth, and cheeks have sometimes been observed in the commencement of fever in FEVER* 129 There are other symptoms met with in the pro- gress of typhus, which in point of time, may be considered the third and last set of symptoms, such as the following : Face shrunk and collapsed, so that the features, particularly the nose, become sharp ; eyes hollow, torpid, sunk, and of a dirty colour, sometimes they are palsied so as to acquire an unusual squint ; objects appear in some instances different from their real figure ; the eyes get a glassy fixed look, and sometimes they lose the sight altogether ; per- petual low delirium without remissions ; patients lying constantly on their back, and sliding down towards the feet of the bed ; the knees becoming bent and turned up towards the belly ; the lower jaw falling down towards the breast ; countenance so altered as to appear lengthened ; tongue so pal- sied, as to make it impossible for the patient to thrust it out or to articulate distinctly ; # speech totally lost ; impossibility of swallowing ; colli- quative, black, faetid purging ; (this often super- venes this town, without being attended with danger, and in a fever which was comparatively mild ; but those were different from aphthae. * This must be distinguished from that difficulty of arti- culating, which arises from a black foul crust formed upon the tongue and lips, and which is relieved by the removal of this crust. K ISO £ever. venes where there has been long neglected cos- tiveness), painful elastic swelling of the belly; urine of a dark porter colour, depositing a brown sediment, offensive in its smell ; clammy, cold, and strong smelling sweats ; respiration quick, noisy, laborious and performed by fits and starts, so that the expiration is rapid and succeeded by a pause, and attended by an heaving of the should- ers ; respiration quick, in proportion to the pulse, viz. one respiration to every two pulsations ; pa- tient being felt uncommonly heavy by another person ; dropsical swellings of the limbs ; singultus or hiccup ; a cadaverous or slaughter-house smell from the excretions ; convulsive tremors ; fainting ; pulse compressible, indistinct, or irre- gular, and intermittent :* the extremities feeling cold ; nails becoming livid and more curved or bent than natural ; breathing performed with a disagreeable rattling noise, in consequence of mucus accumulated in the cells of the bronchise, which the patient cannot expectorate, and which, if * An intermittent pulse, however, is sometimes habitual and exists in sound health ; and we meet frequently with persons whose pulse in health, is regular, but always in sickness in- termittent ; of this, I met with a striking instance in a boy about fifteen years old, in a slight fever ; his pulse was very intermittent, but upon enquiring of his father, who was an uncommonly intelligent man, I was informed that in the slightest complaints his pulse intermitted, but that there was no intermission of it when in health.. FEVER. 1S1 if not discharged by expectoration, soon suffo- cates : this is commonly called the rattles, and may exist in a moderate degree, without being fatal, viz. whilst the patient has still strength enough to throw up the mucus ; large doses of very active purgatives retained, without having any effect on the bowels. All the symptoms of the third class which I enumerated are dangerous in a high degree, and many of them mortal. In very bad cases of fever, they come on before the end of the second week. FAVOURABLE TERMINATION AND PERIOD OF ITS OCCURRENCE. The favourable terminations of typhus fever in this country sometimes take place on the seventh, but most commonly on the morning of the four- teenth day. There are some instances of recovery on the eleventh, and other intermediate days, between the seventh and fourteenth ; and some- times the fever is protracted to the end of the third week ; and there are instances, though rare, of its passing into the fourth v/eek. The critical termination on the fourteenth is the most complete and permanent of those which happen the first fortnight. Relapses more frequently occur in fevers which terminate more early, especially on the seventh day. K 2 Some 3 32 FEVER. Some hours before the favourable termination, an high degree of exacerbation, or a great seve- rity of the symptoms sets in, so as often to alarm the friends with the terrors of approaching death : after continuing for some time it is succeeded by a warm sweat, which begins about the chest and arms, and gradually spreads downwards, and soon covers the whole body. During the pro- gress of this sweat, the pulse becomes slower, larger, and softer ; the surface of the tongue be- comes soft, and the point and edges moist and clean ; the urine in a short time is yellow or whey-coloured, and very turbid, and in a few hours it deposits a sediment of a light branny con- sistence, after which it is somewhat transparent ; the sleep becomes sound and uninterrupted : all the symptoms which existed before begin to dis- appear, except weakness, which is now more sensibly felt by the patient, than it had been during the excitement of the fever. PROGNOSIS. The following are severe symptoms and always attended with danger : great despondency of mind and anxiety ; want of power to apply the mind ; a change in the countenance to a pale, languid, or to a red bloated appearance ; delirium per- manent and uninterrupted ; great restlessness, and total want of sleep ; a thick black crust on the FEVER. 133 the tongue and teeth, without thirst ; great noise in the ears; subsultus tendinum, or irregular tremors of the tendons and muscles ; crowded and dark coloured petechiae; an elastic tense enlargement of the belly; picking at the bed- cloths ; early and profuse sweats, without being attended with relief; pain of the internal ear, as indicating internal inflammation ; whites of the eyes appearing between the eye-lids, during sleep ; abscesses, or sores difficult to heal, and consequently shewing great acrimony of the system ; a dirty squalid appearance of the skin ; singultus or hiccup, especially if connected with great debility; stools or urine passed without the knowledge or controul of the patient ; breath- ing very quick ; drowsiness occurring late in the fever : those are bad symptoms, but not desperate. The following are still more alarming : spasms of the muscles of the neck, causing it be turned to one side ; a dull, uneasy, oppressive pain about the pit of the stomach ; swallowing becoming impossible ; the parts on which the patient presses most becoming gangrenous blis- tered parts producing no discharge ; putrid diar- rhoea; discharges of blood, in great debility; total loss of voice ; a fsetor of the breath ; blind- ness ; squinting ; a glassy fixed look ; the patient sliding down in the bed, with the knees con- tracted, * I h av e met with some cases of fever, in which the parts most pressed upon, about the hips and haunches, sloughed away, and the patients recovered. 134 fEVER. tracted ; ulcers becoming livid and gangrenous ; total prostration of strength ; countenance length- ened, with the lower jaw falling down towards the breast ; fingers and nails acquiring a livid hue ; large and repeated doses of active purga- tives retained, without producing any effect ; rattles, without any power to expectorate. Most of those symptoms are fatal. It cannot be too strongly impressed, that the greater the combination of bad symptoms, the more dangerous is the fever ; that the earlier they set in, the more dangerous is the fever ; and that the more they are pure and unmixed with favourable symptoms, the danger is greater also. It will often require much discrimination in the physician, to be able to form a judgment of the probable termination of the fever, because a bad symptom is sometimes so tempered with others of a favourable nature, as to create much uncertainty : in such cases, it will be necessary to be circumspect and guarded in giving an opinion. FAVOURABLE SYMPTOMS. Delirium rot coming on until after the first week, and the laL r, the more favourable; deliri- um interrupted by long intervals of reason, or oc- curring FEVER. 135 curring only whilst the patient doses ; sleep re- turning, even though accompanied by transient fits of delirium ; deafness is favourable, perhaps because it shews the absence of that morbidly encreased sensibility, which is a bad sypmtom ; where there is encreased determination of blood to the head, in the beginning of fever, early bleeding from the nose is a good sign ; a sponta- neous bilious purging often allays the distressing symptoms, even delirium and head-ache, and is favourable ; urine becoming turbid, and then depositing a light coloured sediment ; a thin warm sweat, which neither distresses nor fatigues, but rather refreshes the patient ; these two symp- toms are often critical, and are most desirable after the eleventh day, because a crisis beginning at that period is more permanent, than if it had commenced on an earlier day ; the pulse becom- ing more slow is an excellent sign, indeed the best and surest of all favourable symptoms ; prae- cordia not painful on pressure, nor tense ; or, after being tense and painful, becoming soft, de- pressed and free from pain ; the patient lying much on the side, and particularly during sleep ; breathing becoming more slow, and less noisy ; tongue softening and beginning to clean away about the point and sides, this symptom is con- nected with the state of the stomach, and is very favourable , where there are other favourable symptoms, it is desirable that the patient should have 136 FEVER. have a sense of his own weakness, which, du- ring the excitement of the fever, he had not ; a desire for warm drink, or for more bed-cloths ; the eye getting a more brilliant lively look ; face looking more clean and natural, though still very pale y petechiae becoming paler, or disappearing ; return of venereal appetite ; return of appetite for food ;* the patient calling for, and relishing wine, is favourable, and points out the pro- priety of allowing it ; pulse becoming slower than in health, is sometimes known in con- valescence, and is a good sign. It is favou- rable, that the bad symptoms of every kind disappear. The dangerous symptoms, are those of topical affection, such as of the brain, sto- mach, intestines, lungs ; those of great debility and relaxation ; and those of putrescency. As the departure of any of them is favourable, in enumerating * Hence, it has sometimes happened, that the restoration of health has been ascribed to some particular food with which the patient has been indulged, at the time of returning ap- petite, even though that food might have been of an impro- per or dangerous kind. Thus, salt herring has got the re- putation of curing fever ; bacon, and salt beef have been equally successful ; and a cunning nurse has more than once stepped aside from the doctor’s orders, and clandestinely cured the patient with a bit of some salt food, where the physician would not have allowed any thing more nourishing than flum- mery, gruel, a roasted apple, or at most* but a little light broth. FEVER. 137 enumerating them, we will easily discover the negative circumstances which are good symptoms. Grown persons, between childhood and old age, are most subject to fever. It is, however, some- times found before the age of puberty, and in advanced life. The persons least of all attacked^, by it, are very young children, and pregnant women ; in pregnancy, when seldom it occurs,^^ it is extremely dangerous, as in many instances they either miscarry or die of the fever ; but sometimes they will recover without miscarriage. CAUSES OF FEVER. Great inanition ; large evacuations ; raw, spoil- ed, indigestible food : thus fever is more usual and severe in seasons when there is a scarcity of corn, and other food, and consequently when corn and other provisions are much damaged : foul, stag- nant, corrupted air, as of dirty cellars and garrets ; intense application of the mind ; great distress of mind ; despondency ; want of sleep for a long time; sedentary life; great fatigue; cold and moisture ; human effluvia ; contagion. Two or more of these combined will cause fever with more certainty and danger than a smaller number. Thus, a goal fever is a bad fever, and spreads with great virulence; to produce this fever are united, confined foul air, an inactive sedentary life, and frequently great distress of mind'; 138 FEVER. mind ; and such a fever spreading its contagion abroad will cause fevers of a very bad kind. It might, perhaps, be • ' • - ' ' „ CATARRH OR COMMON COLD, This is a very common complaint, and gene- rally so slight that it does not require the aid of medicine \ sometimes however it is more severe, and, from the fatal consequences which may follow it, demands serious attention. SYMPTOMS. The most ordinary symptoms, are an unusually encreased sensibility to the impression of cold ; a difficulty of breathing through, or a stuffing of the nose ; a weight or heaviness of the head ; there is commonly a running from the nose, and the sense of smelling is greatly impaired, or en- tirely CATARRH. 169 tirely lost ; the discharge from the nose is in the beginning thin and acrid, but in the progress of the complaint it becomes a thick and viscid mucus, which towards the end assumes a more purulent consistence and colour. Generally, but not al- ways, there is a cough, at first irritating and dry, with a hoarseness of the voice, but it afterwards changes to a moist or humid cough, with an ex- pectoration, which undergoes changes similar to those already mentioned, that is, at first it is scan- ty, thin, and acrid, then it becomes viscid, opake, and encreased in quantity, and last of all, of a purulent appearance ; there is a rawmess and sore- ness felt along the course of the trachea or wind- pipe and into the bronchise ; the eyes become somewhat sore, and their motion painful ; a sense of stuffing or fulness is complained of in the chest. Some lassitude or listlesness attends even very mild attacks of this complaint ; the breathing is somewhat quickened ; often small pustules break out about the lower lip, and sometimes on the upper ; slight pains are felt in different parts of the chest ; and in the decline of the complaint, sneezing is not uncommon. Such are the general appearances of this disease, and when no others occur, it is seldom of im- portance, particularly in constitutions in which the lungs are not delicate or diseased. INFLUENZA 170 CATARRH. ' jL '> . tj/UB INFLUENZA OR EPIDEMIC CATARRH. There is another sort, the influenza or conta- geous catarrh, which is more severe, and not unfrequently attended with danger. It returns commonly at the interval of a few years, and spreads over a large portion of the globe. It sets in with fever, and with great and sudden debility ; so that in some instances, soldiers exercising have been known to drop their arms suddenly, and mowers in the field their scythes.* COMMON CATARRH RESUMED l ITS DANGER IN DELICATE AND DISEASED LUNGS. In the common catarrh or cold too, the danger is often great ; indeed in particular constitutions, much greater, than it is in the ordinary state of influenza in persons of sound lungs. The cough becomes sometimes extremely distressing, espe- cially towards night, attended with great difficulty of breathing ; sometimes the breathing is so op- pressed as to resemble asthmatic breathing, and that in patients who never had an attack of asth- ma before ; the expectoration is in some cases bloody; * There is an instance recorded of the crew of a 64* gun- ship, amounting to upwards of 500 men, so suddenly and vio- lently attacked, that in the course of 24; hours, only 26 could stand on the deck. Such was the severity of the influenza in 1775, but it has returned since, and commonly with less severity than at that period. CATARRH* 171 bloody ; there is a turgid and red appearance of the face with head-ach encreased on coughing; the cough is dry, irritating, and frequently repeated, with little or no expectoration, and accom- panied by a severe deep-seated pain in the chest, which in some shifts its place, but in others is fixed ; this pain often makes the effort of cough- ing nearly intolerable, and is an occurrence which attends the transition of catarrh into pneumonia or inflammation of the lungs ; the tongue is com- monly loaded, and the pulse quicker than natural; but this state of the pulse and tongue also belong to mild species of catarrh. Repeated attacks of this disease will lay a foun- dation for its returning frequently, and will destroy the most vigorous constitution. Exposure to fresh cold during the cure will render it more violent. In old persons from frequent attacks of it in the course of life it becomes habitual and incurable ; it is then called tussis senilis, of which we meet with daily instances. CAUSES OF CATARRH. In cold and damp countries, cold applied to the body brings on many complaints by obstructing perspiration, but most particularly catarrh ; it is also produced by sudden changes of the temperature of the atmosphere, espe- cially where the change is attended with an encreased 112 CATARRfi. encreased degree of moisture; by passing suddenly from a warm into a cold air ; and by contagion. The last is the cause of the influenza ; the others* the exciting causes of inflammatory or common catarrh. Those causes will bring it on with more certainty and danger, in persons who have a great sensibility to the impressions of heat and cold ; and in those who are addicted to habits of intoxication, which create an encreased irritability of the Whole system, and particularly of the lungs : drunkards are generally remarkable for sore eyes and a husky dry cough ; it sometimes happens also in such persons that the liver is diseased, which, for an obvious reason, affects the lungs. A scrophulous or tubercular statk of the lungs, adhesions in the lungs arising from former attacks, and an irritable state of the lungs occasioned by former complaints, or by mal* conformation, as in cases of narrow chests, or broken ribs, will like- wise dispose to catarrh. SEAT OF THE DISEASE. The parts on which this disease most imme- diately fixes, are the lining membrane of the nose, of the trachea, and of the bronchlae throughout their elongations. A slight inflammation of this membrane causes the symptoms which charac- terize the complaint ; first the secretion from this membrane seems to be almost checked ; then, as the CATARRH. 1 13 the inflammation subsides, it becomes morbidly encreased, and mucous, and last of all more vis- cid, and of a purulent appearance. Catarrh, when mild, ends in the course of a few days, perhaps in less than a week, and in such cases the best treatment is to leave it to nature, enjoining moderate exercise in the open air, but guarding against all exciting causes, as intempe- rance in food and drink, and exposure to cold or damp air. Confinement to a warm room, and the use of laxatives and diaphoretics will, it is true, banish the complaint sooner ; but by this treatment, the patient will be more relaxed, and more susceptible of fresh attacks. Catarrh how- ever is often very alarming and demands all the skill and exertions of the physician, in con- sequence of its tendency to end in inflammation of the lungs, or in phthisis, by the inflammation spreading from the mucous membrane of the bronchise into the substance of the lungs : in cases g£ tubercles of the lungs a moderate degree of catarrh may produce phthisis, by causing an inflammation of those t ubercles 5 such a termination is unfortunately too frequent. This disease some- times ends in asthma, and in some rare instances in dropsy. Repeated attacks of it occasion a delicacy of the lungs, attended by an obstinate and habitual cough, in old persons called tussis senilis, a complaint which medical aid in this climate can only 174 CATARRH. only relieve or mitigate, and which in a few instances has been known to bring on peri- pneumonia notha, a fatal and treacherous disease. TERMINATION OF CATARRH. Catarrh terminates often without any obvious critical solution ; sometimes the only change is the expectorated matter becoming free and of a yellowish appearance : a bleeding from the nose is not unusual, and when it occurs it brings relief : sometimes an encreased discharge of urine, but more frequently a copious and general moisture on the surface carries off the complaint. DIAGNOSIS. Catarrh is easily distinguished from all others ; an inflammation of the lungs is that with which severe catarrh is most likely to be confounded ; little mischief however can arise from a mistake of this sort ; as severe catarrh and pneumonia require the same treatment. It may be more necessary to distinguish it from fever, as the bleeding which the severe catarrh requires is Very seldom safe in fever : from fever it can for the most part be known by comparing the pulmonary symptoms with those which shew a disordered stomach. Where we are told that the attack began with a loathing of food, sudden loss CATARRH. 175 loss of appetite, and some head-ache, or, that upon approaching food, the patient took a disgust against some particular dish, and that he could not afterwards take any food ; in short when the stomach, tongue, and head are more disordered than the lungs, that is, when sickness at stomach, foulness of tongue, inclination to vomit, ge- neral lassitude and head-ache are the prevailing symptoms, then we are justified in considering and treating it as fever, even though there should be a cough with other catarrhal symptoms : but if the distressing appearances are a severe and oppressive cough, stuffing of the chest, and encreased difficulty of breathing, without the stomach raid head being much affected, or without being affected, much in proportion to the cough, oppression, and short breathing ; we may then safely pronounce it a complaint of the lungs. CURE OF CATARRH. When the pectoral symptoms are severe, and accompanied by a hard and quick pulse, particu- larly in habi cs predisposed to inflammation of the lungs, or phthisis, bloodletting from the arm is necessary and may in case of emergency be repeated : but unless such an alarming combina- tion of circumstances exist, our principal object should be to cause a determination to the surface, and encrease the action of the cutaneous exha- lants : 176 CATARRH. Jants : for this purpose the patient should wear warm clothing ; remain in pure, dry, and warm air ; bathe the feet in warm water at bed time, and repeat the bathing every night or every second night, especially when the complaint is recent : the food should be easy of digestion, rather in a liquid form, and contain comparatively but slight nourishment ; the drink diluent, light, and taken warm ; the drink may be occasionally impregnated with medicines of a diaphoretic quality, such as nitre whey, whey with some ' drops of spirit of ammonia, &c. If there is much irritability of the trachea with soreness and a teasing cough, mild mucilaginous and oily -mixtures in small quantity will be useful, com- bined with camphor, or with opium ; thus almond milk, oily emulsions, spermaceti emulsions, will be useful as in the formulae, in the appendix marked No. 66. 67. Honey variously prepared, and liquorice, are sometimes used with the same indication : if the branchiae are loaded with tough mucus dilScult to be brought up by expectoration, a liquid preparation of squills, of laudanum, and of gum ammoniac, as in No. 69, is a good expec- torant : but where there is a sense of suffocation and oppression, an emetic of ipecacuanha in powder or its vinous preparation as in tire formulae, No. 46, 102, will relieve, where demul- cents and expectorants fail. In such cases a blister applied to the sternum or between the shoulders is CATARRH. 177 is also useful ; a pitch or warm plaister operates on the same principle with a blister, but is more slow and less effectual. These applications are particularly indicated when the morbid secretion of mucus into the bronchise is considerably encreased and will only receive a temporary check from other medicines* and where there are apprehensions that the disease may pass into the substance of the lungs. In cases in which asthmatic symptoms, such as laborious and difficult breathing, &c. are induced by the complaint, or when it occurs in asthmatic constitutions, a solution of asafcetida, some vinegar of squills, and some paregoric elixir or laudanum, as in No. 68, is a valuable remedy : pills of asafcetida squill and opium are also useful in this modification of the disease : in chronic catarrh these pills taken at night are found excel- lent in mitigating the severity of the cough, in relieving respiration, and in procuring sleep. Small doses of powdered ipecacuanha, as in No. 106, taken gt bed time, have also frequently the effect of relieving this catarrhal- and asthmatic breathing. Ihroughout the course of the disease the bowels must be kept regular ; half a drachm of the compound powder of jalap is a moderate dose n for 175 CATARRH, for an adult, and generally answers this purpose : moderate doses of any of the saline purgatives likewise will keep the bowels free ; the same object will be attained by means of the purgative mixture No. 4. But when the tongue is loaded, and the pit of the stomach tense and painful on pressure, the bolus No. 2, or a dose of the pills No. 1 or No. 3, will be most effectual in dislodging the foulness of the alimentary canal and carrying off this pain : in such cases too the combination of antimonial powder and of calomel in No. 65 is excellent, as having the effect of softening the skin and opening the bowels at the same time. In tussis senilis, issues or a seaton between the shoulders are found to give great relief. In all cases of chronic or habit ual catarrh, flan- ' nels should be worn close to the body, the feet and legs kept warm with woollen stockings, and, where it can be done, exercise taken every day on horseback: temperance in living and regular hours are indispensable. When the disease sets in with a febrile paroxysm and is recent, it is good practice to give an emetic at night, and the purgative bolus or pills the fol- lowing day ; this breaks the violence of the com- plaint : afterwards the patient may continue to use an appropriate expectorating mixture* CURE CATARRH* 179 CURE OF INFLUENZA. Influenza is best treated in general like typhus fever : instances have occured in this disease where wine became more necessary than in typhus fever itself : but along with the remedies adapted to typhus, some expectorating medicines will occasionally be useful to relieve and carry away the cough: the formulae recommended for the inflammatory or common cold will be proper for this purpose. Epidemic colds have of late years been known in Dublin to commence with feverish paroxysms, but soon to assume the character of inflammatory catarrh, without those symptoms of great and sudden prostration of strength, remarkable in former influenzas ; in such cases the cure differs very little from that of the inflammatory disease ; an emetic in the commencement will be proper, and the following day a calomel purgative, the dose to be suited to the state of the patient : afterwards the expectorating medicines already pointed out in treating of the inflammatory cold are to be employed, the purgatives being occasionally repeated. It will be a good plan in general in those cases to consider whether the complaint most resembles n 2 fever ISO PNEUMONIA. fever or inflammatory cold : if its character approaches nearer to that of fever, it will require more of the treatment necessary in fever ; but, if to that of inflammatory cold, the medicines adapted to the cold will be most proper. PNEUMONIA OR INFLAMMATION OF THE LUNGS. Inflammation of the lungs begins with shiv ring followed by cncreased heat, thirst, a remarkable sense of weight and tightness of the chest : earlv in the complaint, perhaps on the first but some- times not until the 2d day, there is a severe pain felt in some part of the chest, either under the sternum, under one of the scapulae, or under one of the mammae, but most commonly under the arch of the ribs: this pain is sometimes confined to one spot, but at other times it shoots from the part affected in various directions through the chest ; in some instances the pain is extremely severe, and aggravated even by the effort of respiration, in consequence of the motion of the ribs and diaphragm which that process requires : this pain greatly encr eases the severity of another symptom common in pneumonia, viz. dyspnoea or a diffi- cult and laborious breathing, which often amounts to orthopnoea or a necessity of breathing in an erect posture. Sometimes it is not an acute pr pungent pain, but rather a sense of weight and oppression PNEUMONIA. 181 oppression which the patient suffers ; but in either case the breathing is laborious : cough is constant, and is a very distressing symptom ; it is teasing and dry, or accompanied by a viscid, frothy and scanty expectoration, which is frequently tinged with blood. When the pain of the chest is pungent and acute, the pulse is quick and hard ; but when it is not so much an acute pain as a sense of weight and oppression, the pulse is small and feeble. The patient lies with most ease commonly on the side in pain, but there are instances of the reverse : the skin is mostly hot and dry, but not unfrequently a burning sweat breaks out over the whole surface without any relief to the patient, but rather with the effect of encreasing the gene- ral distress. Some cases occur, in which the patient breathes most easily, not in an erect, but rather in a prone attitude or posture. In the progress of the complaint, the strength sinks apace ; the eyes get an expression of extreme distress ; the lips become livid ; the face deadly pale or livid ; the chest heaves very much in breathing; the patient, incapable of reclining, must sit erect, or with the body inclined forward. The tongue is never as foul as in typhus fever, and very frequently it is not foul at all, but rather of 182 PNEUMONIA. of a dark red colour. Head-ache and deliriunj are unusual, but when they occur they are very dan- gerous. In the last stages of pneumonia the patient breathes as if half strangled. Remissions sometimes come on which might impose upon an incautious observer ; but the symptoms of deep distress soon return with aggravated severity. Instances have been known where the patients walked about their room a few hours before death in this disease : death is often sudden and caused by suffocation, the consequence of blood effused into the bronchiac : the lungs from this effusion have in the diseased part an appearance not unlike the liver, but darker from the badly oxygenated state of the effused blood. The fatal termination is in some instances more slow when a watery fluid is exhaled into any of the sacs of the pleura, or within the cavity of the chest, causing hydrothorax : this termination suffocates by pressure on the lungs, and perhaps on the heart. Adhesions are often found in various parts between the pleura costalis and pleura pulmonalis, and sometimes exudations, whence clots of gluten are deposited on the surface of the lungs. Suppuration in some instances takes place, which forms an abscess within the substance of the lungs. PNEUMONIA, 183 lungs, and this by bursting into the bronchiae suffocates suddenly, or causes the complaint called empyema by opening into the cavity of the chest, and brings on a fatal hectic, or by being discharged into the cavity of the abdomen, through adhesions formed at the diaphragm, ends likewise in hectic. A few instances are mentioned by medical writers in which the abscess pointed outwards and was discharged by an operation ; and in some of these the patient recovered. The only termination of this complaiut which can be regarded as favourable, is resolution : it should therefore be the object of the physician to procure it by all the means in his power. When pneumonia takes a favourable turn, the cough becomes more loose ; the expectoration more copious, more opake, and more friable ; the distress of breathing gradually abates ; a thin warm sweat breaks out over the surface ; the urine is rendered in encreased quantity, upon standing for some time it becomes turbid, and then deposits a thick sediment ; the pulse be- comes softer and slower ; the tongue moister and of a natural colour ; appetite and sleep begin to return : in some instances a discharge of blood from the nose, and sometimes from the anus, gives relief in the beginning of the disease. The 184 PNEUMONIA. The unfavourable symptoms are, great difficulty of breathing, particularly orthopnoea ; great op- pression ; pain excessively severe, and seeming to shift its place, or shooting in various directions through the chest cough continuing dry and teasing ; pulse low and contracted ; difficult, scanty and viscid expectoration ; expectoration very bloody, or entirely checked ; cough fre- quent, and incessant, or entirely repressed ; pulse becoming irregular ; severe head-ache, and de- lirium ; livid countenance and lips ; or pale countenance with livid lips ; a cold clammy sweat ; great and sudden prostration of strength ; ail these are generally fatal. This disease most commonly attacks in winter or spring ; it is often met with also in autumn ; but its occurrence is least frequent in summer. The circumstances which favour its return at any season, are great and sudden vicissitudes of heat and cold. Pneumonia is the sequela sometimes of small- pox, but much more commonly of catarrh, of chin-cough, and of measles, particularly in scrophulous * The shifting of the pain, and the sensation of Its shoot- ing in various directions, are signs of general inflammation j this general inflammation has been found in' several of the lobes of the lungs after death, in persons in whom the above sensations had been felt during the existence of the complaint. PNEUMONIA. 185 scrophulous habits : we often hear the dregs of measles more feared, even amongst the poor, than the measles themselves ; and they certainly are in several instances more fatal : catarrh also passes sometimes into pneumonia, and therefore every kind of catarrh should, in persons of de- licate lungs, be carefully attended to ; the same observation applies in a stronger degree to per- tussis or chin-cough. Pneumonia is most usual between the age of fifteen and thirty five ; but many instances of it occur in children, and it is sometimes met with In old persons. CAUSES OF INFLAMMATION OF THE LUNGS. The causes which predispose to this complaint, are an ill-shaped, narrow or contracted chest, as in persons of broken backs : this deformity produ- ces an increased irritability of the lungs, an im- pediment to a free circulation through them, and an accumulation of blood in their vessels, as they want sufficient room now to be expanded within the contracted thorax, all concurring to bring on this disease : an habitual delicacy of lungs will lay a foundation for it, as in asthma and dys- pnaea; repeated attacks of catarrh, and of in- flammation of the lungs, cause an increased ir- ritability of them, and leave adhesions which dispose 18C PNEUMONIA. dispose to a new attack of inflammation from the application of cold ; intemperance in drink- ing vinous and spirituous liquors has the same effect : indeed, hard drinkers are seldom free from cough, and temperate persons, if at any time they indulge too freely in drinking, generally have a cough the following morning ; violent ex- ercise ; and a scrophulous constitution. Such may be considered the predisposing causes of pneumonia. The most common cause which excites it, is cold applied to the surface when the body is heated or otherwise predisposed ; hence, it is often the reward of dancing, the performers rushing into the cold air from a heated room, and not unfrequently covered with sweat, soon get an inflammation of the lungs ; violent inju- ries to the chest will excite the disease, such as strokes, bruises, falls, fractured ribs ; sometimes too great exertion of the voice and of the lungs, as singing long and loud, loud and long conti- nued talking; blowing trumpets and wind in- struments ; a metastasis or translation of other diseases, as of angina tonsillaris, erysipelas, but more particularly gout, will sometimes bring it on ; and in those instances, even when it is the effect of gout, it must be treated as if it were produced by cold. DIAGNOSIS. PNEUMONIA. 187 DIAGNOSIS. Pneumonia is distinguished from other inflam- mations, by the seat of the disease : hepatitis, or inflammation of the liver, has many symp- toms in common with pneumonia, such as severe acute pain in some instances, but in others, dull pain, both encreased by cough and full inspira- tion, cough and dyspnoea ; but in hepatitis, the pain is referred to the seat of the liver, here too the pain is much encreased on pressure, but not so in pneumonia, nor are the pectoral symp- toms of cough and difficulty of breathing, at any time, as severe in hepatitis, as they are in pneu- monia : a pain in the stomach is distinguished from inflammation of the lungs, not only by the seat of the pain, but likewise by the sickness, loss of appetite, and by the vomiting which be- longs to the pain of the stomach : catarrh or common cold is sometimes so severe as to be taken for inflammation of the lungs, but from a mistake of this sort there is little danger that any serious evil can arise, as severe catarrh and pneumonia require nearly the same treatment ; and because, what was in the beginning catarrh, sometimes terminates in pneumonia, the inflam- mation of the mucous membrane of the bronchiae, which is the immediate cause of catarrh, passing into the substance of the lungs, and tense membrane of the ISS PNEUMONIA. the pleura, and bringing on pneumonia : except where the catarrh actually passes into pneumonia, they will be distinguished by the degree of seve- rity in the symptoms : thus, the dry, severe and incessant cough, the difficult respiration, and above all, the severe pain in the chest, mark the inflammation of the lungs. The symptoms of pneumonia far advanced, such as livid coun- tenance and lips ; orthopnoea ; excessive anguish and restlessness, . are not met with in the other complaint : it is in incipient pneumonia only that there is danger of confusion. Typhus, or common fever is the disease from which it is most important to distinguish this complaint, because the bleeding necessry in pneumonia, might prove fatal in fever ; and the treatment most judicious in fever would prove inadequate and inert in pneumonia : but the distinction already pointed out, between fever and catarrh, in treating of the latter complaint, will be more decidedly marked between fever and pneu- monia, — vide catarrh. Pneumonia seldom proves fatal before the ninth or tenth day, and often not before the fourteenth, and sometimes not before the sixteenth day. CURE. The principal remedy to be relied on, is bleeding largely; ir called in early, from eighteen to twenty PNEUMONIA. 189 twenty ounces might be taken at once, from an adult, and even more from robust persons : the bleeding is always most useful if it be taken from a large orifice, and in a full stream, and perhaps.* from the arm of the side affected, rather than from the other ; but if there is any awkward- ness in taking it from that side, we should not hesitate to take it immediately from the other, as the difference of the benefit, if any, is tri- fling, compared with the importance of bleeding without loss of time : a remission of pain pro- cured by the first bleeding must net deter us from repeating the venesection perhaps on the same day, if the “pain should apear to return, but certainly on the following day ; and if the first bleeding procures little or no mitigation of the pain and other symptoms, we must repeat the blood-letting copiously, in five or six hours after. The orifice ought to be large, in order to admit of a full stream, whereby in a given time a greater quantity of blood is taken away, because the suddeness of the depletion is of material importance in contributing to its utility, perhaps of more importance than the actual quantity of blood lost : this treatment must be resolutely persevered in, until a decided mitigation of symp- toms takes place, such as a relaxation of the tight- ness felt round the chest, a marked alleviation of the pain, but above all, a more humid cough, and a • more copious expectoration $ the pulse also becomes 190 PNEUMONIA. becomes softer and slower, when the inflamma* tion begins to give way : it has frequently hap- pened that from sixty to ninety ounces of blood have been lost in the course of four days, and instances have occured, where one hundred and twenty ounces were taken away in the course of the disease. Blisters applied before blood is drawn only add to the general irritation and distress, but after relief from pain is procured by bleeding, and the expectoration begins to grow more loose and copious, blistering is a good remedy ; the blister should be made very sharp ; a good method of preparing the blister is to sprinkle a thin layer of powdered flies over the blistering plaister now laid on the leather : if the blister does not discharge well we should blister again, and perhaps remove as much of the cuticle as has been raised by the former blister : any inconvenience caused by the blistering is trifling indeed when compared with the mischief we endeavour to avert : whenever blisters or sinapisms are applied in order to remove, or to prevent alarming internal pain or inflammation, it may be prudent in general to form a freely suppurating sore : it is not the slight discharge of serum caused by a blister in the ordinary way that we are to be satisfied with in cases of great danger from internal inflamation, or from morbidly encreased action : an inflammation and PNEUMONIA. 191 and sore should be made externally by these irritants ; and, in cases of such danger, when they are pushed to this extent, the physician will in general have reason to be proud of his boldness : warm stupes applied to the bottom of the belly ; diluent warm drink ; and camphorated mixtures, will relieve the urinary pains and ischuria caused by the flies. The best time for blood-letting is the first week, particularly the three first days ; but it will be sometimes useful in the second week ; when the pain is severe and the cough distressing with little or no expectoration ; or when there is much oppression and seemingly threatened suffocation, without acute pain, but* rather with a dull heavy pain, we must bleed likewise, even though the pulse be small and feeble : the puise is sometimes oppressed by the extent and severity of the inflammation, and in consequence of venesection it will be relieved from the oppression and grow larger and fuller : it is proper to observe, that when the pulse improves from bleeding it is a favourable sign. If, after the remission of pain obtained by the loss of blood, the distress returns again, we must again bleed ; or if the bleeding gives no relief, we must bleed very soon again, and keep this treatment steadily in view until the expectoration begins to be more free and the cough more loose. Where inflammation of the lungs is clearly marked, we must not be deterred from venesection by appre- hensions 192 PNEUMONIA. hensions of weakening the patient too much ; for unless the inflammation is removed by resolution, there is no prospect of the patient’s recovery : but when expectoration begins to be loose, it is neces- sary to be more guarded in the use of the lancet ; because then there is evidence of the inflammation subsiding, and because blood-letting pushed too far then might weaken so as to check expectora- tion, the free continuance of which is here the best symptom ; or, though the sputum might be free, it might weaken so as to produce hydrothorax or dropsy of the chest : the application of a blister will afterwards maintain the advantage gained by the bleeding. Cases sometimes occur in which the propriety of bleeding is doubtful ; blisters are then to be tried, and if they add to the distress of the patient, it will help to remove the doubt and to points out more decisively the necessity of blood- letting : the irritation caused by the blister, without any relief obtained from it, removes the doubt which might have been entertained about the safety of bleeding before the blister was applied, and points out pretty dearly the propriety of instantly resorting to venesection. When a thick bufiy coat forms upon the blood without a large proportion of serum, it is safe to bleed again, but the physician must not be deter- red PNEUMONIA. 193 red from recommending blood-letting again, because there is not a buffy coat upon the blood already taken away ; for sometimes the blood trickles slowly from the arm, and then the buffy coat will not form upon it, and then too venesec- tion will give little relief in general, it will therefore be proper always to recommend bleeding from a large orifice in order to make the blood flow freely ; it will be of service also to put the patient into a recumbent posture : thus two advantages are gained, there is more blood taken away in a given time, the suddenness of the de- pletion being important ; and a chance is given of having that buffy coat formed, which may help to direct our judgment as to the necessity of recommending or forbidding further venesection. It often happens that in the beginning the blood first drawn has no buffy coat, the pulse being oppressed by the inflammation, but that the blood next taken away, when the pulse is relieved by the first bleeding, will have the buffy coat, though it flows under the same circumstances at both times. When the case is very pressing, and doubts arise about the propriety of bleeding, it will be of use to open an orifice, and to examine the pulse whilst the blood is flowing ; if the pulse begins to sink as the blood comes away it will be proper immediately to desist ; but if the pulse swells as o the 194 PNEUMONIA the blood flows, we should boldly persevere, for then the bleeding will relieve : this trial, even where the pulse is found to sink, cannot be attended with any serious injury, because when that change begins to appear the bleeding can be instantly stopped. When the crassamentum, or firm part of the blood, even with a buffy coat upon it, floats in a large proportion of serum, we must be cautious in pushing venesection far, as the blood is of a watery and poor quality, and the complaint might by mismanagement rapidly pass into dropsy ; we had better in those cases rely on sharp blisters instead of blood-letting : few instances will occur where bleeding will be necessary when the serum abounds in this krge proportion,* The * If the vessel in which the blood is received be shallow and wide, no buffy coat will form upon the most inflammatory blood; but the reverse happens where the vessel is deep and narrow : therefore vessels of a proper _shape are commonly kept in. hospitals for this purpose. The blood in inflammatory diseases is more fluid than under other circumstances : the formation of a buffy coat depends on this encreased fluidity, which prevents the blood from coagulating as soon as it otherwise would, and allows time for the red particles, which are the heaviest part of the blood, to descend below the surface before the coagulum is formed : this coagulum is of a whitish colour and called the buffy coat : but if the blood even though very fluid coagulates soon, the red PNEUMONIA. 195 The immediate benefit resulting from bleeding is, the expectoration, which was stopped before, becoming free, opake, and at length friable ; the pulse more soft and more slow, and the pain abating. The remedies on which, next to bleeding, we must rely are blisters : I have already mentioned the manner and circumstances of their application. In pneumonia it will be necessary to keep the bow- els regular. When the state of the tongue shews the stomach and bowels to be loaded with bilious foulness, the pills No. 1 or 3, or the bolus No. 2, will be proper, the principal ingredient in these medicines is calomel, which is indisputably the most efficacious in dislodging bilious and morbid excrements from the alimentary canal, and in resT toring the healthful state of the vitiated secretions in the liver and intestines : where it is desirable to procure a speedy evacution by stool, a dose of castor oil may be given in four or five hours after the calomel j the castor oil may be taken in some o 2 agreeable red particles are prevented from falling down through the coagulum, and therefore a buff is not formed ; hence when it flows slowly, or is received in a shallow vessel, it will cool too soon to allow the red particles to descend through it, that is, to have a buffy coat formed ; but if it comes away in a full stream, or is received in a deep vessel, its fluidity is longer preserved, and the red particles descend below the surface, that is, there will be a buffy coat. 196 PNEUMONIA. agreeable water, or in white wine, or in tincture of senna, as in No. 23 ; by this management the calomel is made to pass through the bowels with effect and in the course of a few hours. Where the above purgative is not immediately indicated, a saline purgative with infusion of tamarinds and senna, as in No. 25 and 48, will generally answer. .Antimonial powder, . and James’s powder, are also useful medicines : they soften the skin, gently determine to the surface, and also keep the bowels free ; but they are most proper after bleeding has been premised, and the sordes of the alimentary canal first carried away : divided and small doses of emetics are also useful in the same way, such as ipecacuan wine ; antimonial wine ; preparations of squills ; spiritus mendereri : these may be com- bined with some agreeable water and mixed with a small quantity of some pleasant syrup : expec- torating emulsions made with mucilage, gum ammoniac, spermaceti, or asafcetida, as in the formulae No. 66, 67, 68 and 69, are useful in promoting expectoration and softening the cough : No. 68 is best adapted to those cases where asthmatic breathing and dyspnsea are distressing ; camphor is useful to allay irritation and to relieve from the urinary distress which blisters occasion ; the inhaler is a useful instrument in diseases of the fauces and lungs, it enables the patient to inhale the vapour of warm water or of any other liquid into the lungs : these vapours act as an emollient PNEUMONIA. 197 emollient, and probably have the same effect inter- nally where they are applied, which fomentations have at the surface, but they are of little use except where the inflammatory stricture has been already removed. The food should be very light, easy of digestion, and contain but moderate nourishment, such as gruel, sago, flummery, arrow- root, roasted apples and such like : the drink, any mild, palatable liquid, such as whey, barley-water ptysans, &c. The air of the patient’s room should be pure and dry, but not cold ; therefore a clear but moderate fire should be kept up, and a small but continued stream of fresh air admitted : pre- cautions should be taken however to prevent the air from passing in a direct stream over the patient’s bed. Opium is cautiously to be ventured on, and not at all until the necessary bleedings have been premised; it may afterwards be combined in small doses with emetics and other medicines, to promote their diaphoretic and expectorant effects. Pneumonia is sometimes epidemic, and then, like epidemic catarrh, requires blood-letting more sparingly ; but the caution against bleeding is more to be insisted on in the influenza than in the epidemic pneumonia. FHTHISSIS 198 PHTHISIS. PHTHISIS PULMONALIS, OR CONSUMPTION OF THE LUNGS. Consumption of the lungs is very common, particularly in cold and damp countries. It generally begins with a slight cough, at first short and dry, which sometimes continues for months without any other considerable distress. But often the progress of the complaint is more rapid, so that it proves fatal in a few weeks, especially if it takes place in the latter end of autumn or begin- ning of winter : the cough is attended commonly with a sense of heat and stuffing in the chest, encreased on motion: sometimes blood is hawked up, attended with a tickling sensation in the fauces, which makes the patient suppose that the blood does not come from the lungs but from the throat ; the pulse is always quicker than natural, seldom below 100 vibrations in a minute, and often above 120. In most instances the spirits are good and the appetite moderate, even in the advanced stages of the complaint ; there are instances how- ever of great dejection of mind and loss of appe- tite ; there is a sensible wasting of the flesh, and a burning heat felt in the palms of the hands. Such are the first appearances of consumption of the lungs; but all the symptoms very soon become more alarming ; the cough, which was at first slight and dry, is soon distressing and severe, attended by an expectoration white or greenish, or PHTHISIS. 199 or purulent, and foetid : the expectorated matter has various tastes in different persons ; for it is salt, or sweet, or nauseous and putrid: respiration becomes hurried, laborious, and anxious, with a sense of streightness or tightness round the chest : the tongue is clean, red, in the progress of the disease slightly inflamed, and covered with aphthoe, which at its root about the tonsils, and in the fauces, at length sink into ulcers, in several cases exhibiting the appearance of ulcerated sore throat ; the ulcers in numerous instances spread down along the trachea, and there is then com- monly a weakness and hoarseness of the voice, en creasing to such a degree, that the patient can scarcely be heard, and can speak only in whispers : there is a morbidly encreased sensibility to cold, and exposure to cold very much exasperates all the symptoms. The eyes generally acquire a high degree of brilliancy, the albuginea being of a pearly whiteness ; and the cheeks get a limited or circumscribed redness, the redness however is in many instances not circumscribed, but, towards the circumference, gently blended with the rest of the complexion, so as to give along with the brilliancy of the eyes a great improvement to the charms of the face but these symptoms are not constant, for the face is sometimes pale and languid : the thirst is always distressing ; the breath offensive ; and the debility very great, in consequence of which motion is very painful. The 200 PHTHISIS. The emaciation becomes in the advanced stages of the disease excessive, so that there is scarcely a , vestige of fat remaining, and the bones literally pierce through the skin, and cause bad sores on those parts on which the pressure of the patient is greatest : there is an exacerbation towards evening with an encreased sensibility to cold, the patient almost insensibly approaching towards the fire ; this shivering or cold fit ends in the course of the night in a perspiration which continues until morning with temporary relief; the smell of the fceces is now very sickening ; a purging sets in which alternates with the sweats, . that is, whilst the sweats continue the purging is less severe, but upon the sweats subiding, the purging returns : even if we succeed in restraining the diarrhoea with medicines, we thereby in general encrease the perspirations : the eyes at length become hollow and sunk ; the voice can scarcely be heard ; there are now no intermissions as in the beginning, but only slight remissions. In women, from the commencement of the disease the catamenia are suppressed; and to this suppression they are inclined to ascribe all their sufferings, substituting the effect for the cause.* The nails are * It commonly happens that women whose catamenia are suppressed ascribe to this suppression all their ailments. It is true that sound health in women during the menstrual age is incompatible with suppressed catamenia; but the suppression is very frequently the consequence not the cause of other complaints. PHTHISIS. 201 are incurvated ; the lower extremities become dropsical, especially about the feet and legs ; the hair of the head falls off : the patient has an inclination to cough, but from extreme weakness cannot expectorate. The sight is sometimes entirely lost, in consequence of which the patients, not aware of the real nature of the sight, will call for light : the breathing is interrupted and difficult : a coldness of the extremities spreading gradually, until it seizes upon the more vital parts, soon closes the scene. In no complaint does it happen perhaps so much as in this, that a sudden and extraordinarjifcelief from all kinds of distress flatters the patient with hopes of a speedy recovery ; but the delusion too soon vanishes, and the malady never fails to resume its former malignity ; even a few hours before death the patients will sometimes give us to understand that they are not sensible of any particular distress except weakness, and that they expect to be well in a short time. The understanding commonly remains dear until a few days before death, when the patients occasionally labour unde.r slight delirium. Where this occurs it announces the fatal period to be fast approaching. Phthisis when completely formed is perhaps never radically cured. When treated early, and before 202 PHTHISIS. before tubercles are inflamed and ulcerated, much may be done, and life in many instances protracted for years : pregnancy in many cases retards the progress of the complaint, and phthisical women will sometimes live consumptive for a long time in consequence of quickly succeeding pregnancies. The more usual progress of the complaint in such persons however is the following. During the first months of pregnancy the hectic and phthisical symptoms disappear ; miscarriage takes place about the fifth, sixth or seventh month ; the hectic then returns with encreased severity and soon carries them off: nursing also sometimes cheqj|(5 the course of hectic ; the encreased determi- nation of blood to the uterus in one case, and to the mammae in the other, relieving the lungs for the time : but if the nurse be delicate, nursing has the opposite effect, namely, that of making the complaint set in sooner and with more fatal cer- tainty. Mania supervening in phthisis destroys it and restores health and vigour, but when the mania disappears the hectic returns : typhus fever supervening on this disease likewise suspends for the time the progress of the hectic symptoms ; but when convalescent from the fever the patient will generally get a relapse of % the phthisis which will rapidly prove fatal. Of these occurrences we meet with melancholy instances in this city. The age most subject to phthisis is from fifteen to forty years : the persons most liable to it are those PHTHISIS. 203 those of delicate lungs, such are persons of narrow chests ; of broken backs and ribs, in whom the lungs cannot be properly expanded, and in whom the circulation is impeded in a high degree, whence arise a sense of oppression, weakness, and a disposition to suffer from hoemoptysis, catarrh, pneumonia, and phthisis : likewise those who from neglect or otherwise have had repeated attacks of pulmonary complaints, especially if their habits are sedentary ; those whose constitu- tions are broken by early habits of dissipation ; but most of all the offspring of phthisical and scrophulous parents, for it is in such that tubercles of the lungs are principally found. In one indi- vidual of the family the scrophula will appear to waste itself on the surface, producing disagreeable marks on different parts of it, particularly on the cervical and maxillary glands : * others again of the same family will grow up fair and beautiful without a blemish on the surface, but will fall victims to phthisis at an adult age. The * Such marks are commonly the consequence of inflammation' and suppuration of those glands difficult to heal : but I have seen a very scrophulous family, in two of whom, a brother and sister, there were such marks shining and smooth spread over the greatest part of the face, and neck ; and yet in whom those unseemly impressions had not been preceded by any tumours or sores whatever : but in those instances there were sores on different parts of the arms, producing an oozy, foetid discharge ; the state of those sores however I had not an opportunity of examining. 204 PHTHISIS. - The analogy between phthisis and scrophula is also demonstrated by the following facts : scrophulous tumours and sores will begin to appear in winter and spring and heal in summer : phthisi- cal patients also in the beginning of the complaint will suffer much during the cold of winter and spring ; and will be greatly relieved during the summer season. From this circumstance arises an useful indication in practice, namely to recom- mend warm and equable climates to phthisical con- stitutions ; and where this plan is impracticable, flannels should be worn next the body, because, in consequence of being bad conductors of heat, they preserve the natural warmth of the body little altered, and guard against the severity of encreased heat and cold. Another striking resemblance between scrophula and phthisis is, that both are most prevalent in cold climates. I have heard it asserted that scrophulous complaints are more frequent in Scotland than in Ireland, but I have not heard any data from which I could rely on the truth or accuracy of this observation. CAUSES OF PHTHISIS. The causes which act more immediately in exciting phthisis are foul, poisonous, and impure air, and particularly if it be cold and damp ; de- pressing PHTHISIS. 205 pressing passions and affections of the mind, which, by repressing perspiration, encrease the determi- nation to the lungs ; small pox in predisposed constitutions is supposed to bring on this com- plaint sometimes, though in many instances, when scrophula does not exist, small pox is known to improve the strength and vigour of the system. There is no doubt that chin-cough and measles will act upon a diseased delicacy of the lungs and pro- duce phthisis in predisposed habits, indeed this sequela seems to be the most alarming part of these diseases. Dyspnea and asthma may end in phthisis, hence arises a necessary and useful warning to persons labouring under these complaints, to keep the surface equably warm ; and to guard most scrupu- lously against intemperance and dissipation : the common termination of asthma, however, is a fatal dropsy. Repeated attacks of syphilis, and the frequency of mercurial courses necessary for its cure, relax and weaken the system, and dispose to phthisis : cold applied to the skin and to the lungs, will induce catarrh, and in delicate habits cause inflammation of the tubercles, and perhaps pro- duce scrophulous concretions. Cold has the effect of exciting a scrophulous inflammation and sup- puration on the surface of the body ; from ana- logy it is fair to conclude that it may act in a similar manner in the lungs, even without previous catarrh. 206 PHTHISIS. catarrh. Pneumonia in scrophulous subjects, is sometimes known to terminate in tubercular ab- scesses and to bring on phthisis. Those are the causes which commonly produce this deplorable malady. There are others which in constitutions greatly predisposed may sometimes cause it ; such as suppressed haemorrhoids or piles ; sup- pressed periodical bleeding from any part of the system ; issues, setons, or sores, and ulcers of long standing dried up ; old cutaneous erup- tions repelled. There a difference of opinion about the contagious nature of this disease ; but the probability is, that in this country at least it is not contageous. The opinion that it is contagious seems to have been formed from the fact, that several of the same family have been often known to have suffered from it : but this fatality can be explained, from considering the family predisposition, or pulmonary delicacy. In other countries, however, there is a strong belief of its being contagious. I have been as- sured by enlightened men, who have lived many years in Italy, that phthisis is a very contagious disease in that country. Flax-dressers ; hair- dressers ; stone-cutters ; and lime-burners, are supposed to be liable to phthisis, from their res- pective occupations : it is highly probable, that in cases of great predisposition, the particles of dust, with which they are constantly surrounded, might, by their irritation in the bronchia, excite a cough. PHTHISIS. %0 7 a cough, and thereby tubercular Inflammation, ending in phthisis. CURE. By early attention to this complaint much may be done, at least to protract life. Pure, dry and temperate air, with uniform warmth, particularly the warmth of flannels worn next the body, are of essential service : where it is practicable, the pa- tients ought be sent to climates of equal and regular warmth : by this, two advantages are gained, name- ly, the improvement of the temperature of the cli- mate, and the mild exercise of sailing, an exercise peculiarly fitted for delicate lungs ; the benefit to be expected from such climates, is strongly illustrated by the analogy of external scrophula, appearing in cold, and disappearing in warm weather.* Phthisical patients too, are much relieved during the warm summer months when the complaint is recent, and nearly free altogether from distress ; but * We often see the maxillary and cervical glands swell, inflame, and suppurate in the winter, and the swellings sub- side, and the sores heal in the progress of summer. It seems that in the lungs, slightly inflamed and ulcerated, tubercles might heal likewse during the summer, and that the inflam- mation and suppuration may return during the cold of winter and spring. 208 PHTHISIS. but when .the disease is far advanced, the progress of it is scarcely arrested even by the mildness of summer : this circumstance has led to the obser- vation, that a summer cough is worse than a win- ter cough, because there is not any cough which continues obstinate and unmitigated during the summer, except the cough of phthisis. If there be a spitting of blood, attended with febrile exacerbations, some blood should be taken from the arm or foot ; but not otherwise $ a spitting of blood, unless severe, will not of itself justify blood-letting ; and in a complaint where the strength sinks so rapidly, blood-letting must be carefully avoided, except perhaps in the above instance, viz. where there is an exacerbation of fever. Small doses of emetics, frequently re- peated, are useful in the feverish fits of this complaint : James’s powder is also a good medi- cine on those occasions : it softens the skin, diminishes the febrile heat, and keeps the bowels regular. Antimonial powder cautiously mana- ged has the same effect. The diet should be light and easy of digestion, such as milk, particularly the milk of asses, mares, or of women : such milk is slightly laxative, easy of digestion, and gently diaphoretic, goats- whey is in a small degree possessed of the same qualities. Raw oisters are in many instances well PHTHISIS. 209 well relished and good food ; but they should be used sparingly. All very nourishing diet must be avoided, even large quantities of milk, and particularly of cow’s milk, must not be allowed. The bed should be firm and even ; a hair matrass is in most cases a proper bed. The bed-room must be large, with a fire occasionally light in it, to prevent the cold and damp of the air. Unless the patients be very feeble, they should rise early ; this is in general a healthful habit, and in phthisis shortens the duration of the sweats. The best medicines are those which are calcula- ted to discuss tubercles, but it is doubtful if v/e possess any medicine adequate to such, a purpose. Barytes muriata is much applauded in internal and external scrophula ; from 10 to 20 drops of it largely diluted, may be given three or four times a day, and it has been found to have made the disease milder in some instances. Digitalis, or the leaves of fox-glove, are of late much used, and with great benefit in phthisis, pills consisting of digitalis and squill, as in No. 70, are frequent- ly of considerable benefit in phthisis, draughts, each containg from ten to fifteen drops of tincture of digitalis, and taken three times a day, are also valuable in checking the fever, and relieving the breathing. Cicuta has often been given with great relief; it produces sedative effects like opium, without occasioning costiveness : cicuta p certainly 210 PHTHISIS. certainly improves the discharge from foul sores, and often is of use in discussing scrophulous tu- mors. Myrrh is a valuable medicine ; it keeps the body gently open, mitigates the pectoral symptoms, and seems to dispose the tubercles to heal. Ac'dulous mixtures and fruits are valuable, partly to allay the cough, partly with a view to their refrigerant effects in checking perspiration, and partly from their quality in keeping the bowels regular : as the cough is often very troublesome and incessant, it is desirable to command the means of subduing its irritation and severity ; this pur- pose will be generally attained by the use of the demulcent expectorants, No. 66 and 67. The pati- ents must be particularly cautioned against any exertion of the voice, as singing, talking much, playing on wind instruments, and against heating themselves with exercise or otherwise. Riding on horseback whilst the patient has strength is one of the most effectual remedies that can be employed : sailing is also excellent, but here there is great necessity to make the first voyage short and in mild weather if possible, in order by degrees to accustom the patients to bear the mo- tion of the vessel ; in a little time, longer voyages shall be endured without distress, by proceeding- in this gradual manner ; whereas if the patients were at first to risk a long voyage they might be killed by the experiment. When PHTHISIS. 211 When the bowels are slow, laxatives must be used, but we must beware of active purgatives, and especially in the advanced stages of the dis- ease. Even a dose of magnesia or sulphur might injure, by causing a severe purging : oftentimes glysters of warm water only will be sufficient : but in the beginning whilst there is still a consi- derable portion of strength, pills of aloe and myrrh, commonly called Rufus’s pills, will be use- ful. It will be proper, particularly in spitting of blood, to examine the state of the hepatic system, and, if there be any morbid affection of the liver, marked by foul tongue, fulness of the hypochon- dria, bitter taste of mouth, and uneasy feel of the head, we ought to give occasionally moderate doses of calomel purgatives, as in No. 1, and a tea-spoonful of the laxative electuary No, 5, the following morning if necessary; and this treatment should be from time to time repeated at the inter- val of three or four days, until the tongue begins to clear off, and the other symptoms to subside. The medicine No. 72 should be freely taken whenever there is a spitting of blood, or a profuse sweat, and repeated according to circumstances occasionally during the day, as long as these symp- toms continue: mild mucilaginous drinks give great relief, and might be taken freely every day, such as barley water ; linseed tea ; almond milk : decoctions of Iceland moss, which prove often . p 2 purgative, 212 ANGINA TONSILLARIS. purgative, and should therefore at first be taken sparingly, and mixed perhaps with milk and some agreeable syrup. ANGINA TONSILLARIS OR INFLAMMATORY SORE THROAT. This complaint, though often troublesome and painful, is seldom dangerous. The appearances are *d swelling and inflammation of the throat, which are most commonly seated in those glands at both sides of the throat called tonsils, and in many instances confined to one or both of these without extending farther : often however the inflamma- tion rises along the velum pendulum to the uvula, and the whole of that curtain becomes inflamed, swelled, and painful : the swelling of the uvula causes an apparent elongation of it, whence in many cases its apex reaches downwards and lodges upon the back part of the tongue ; the roof of the mouth is then in vulgar language said to be down ;* sometimes the inflammation runs backwards to * Amongst the lower orders this occurrence is called the roof or palate of the mouth being down j and various and sometimes extremely painful are the remedies employed for lifting it up. One in particular is so singular that I will beg leave to mention it. The patient is seated between the legs of an athletic and muscular operator, who seizes a lock of hair as nearly as he can guess on the crown of the head and pulls it with all his force until he hears a crack ; then the cure is pronounced to be accomplished, and the patient is dismissed. ANGINA TONSILLARIS. 213 to the muscles called constrictores isthmi faucium and spreads over the membrane which covers them. Deglutition becomes painful and often very difficult ; and, when the inflammation is very high, solids in small bulk are more easily swallowed than liquids : there is an encreased secretion of saliva, which cannot be swallowed, but must be spit out, and during sleep it runs out along the angles of the mouth : the breathing is laborious and noisy, and performed with the mouth open, the passage through the throat being now con- tracted by the inflammation. The swelled tonsils become externally enlarged, particularly in chil- dren ; and it often happens, especially in young per- sons, that yellow purulent ulcers suddenly spread over their upper surface, surrounded by a vivid fiery inflammation : the tongue is bilious and loaded ; sometimes the inflammation and pain begin in one tonsil and are soon transferred to the other. The pain is often so severe and lancinating as completely to destroy sleep : in violent cases the liquids which the patient would swallow come out of the nostrils: the tongue is sometimes thrust somewhat out of the mouth, and the pain shoots along the eustachian tube to the ear. When suppuration is formed, the abscess will often burst, and then the complaint with all its distressing 214 ANGINA TONSILLARIS. distressing symptoms will disappear almost instan- taneously : but in some cases the abscess will not burst spontaneously, the contents of it remain confined, and the pain is exquisitely severe as it is in most instances of confined corruption : the matter discharged is extremely nauseous, bitter, and mixed with blood. The pulse is generally quick, but without any proportionable danger. Inflammatory sore throat is commonly a disease of youth, and of the vigorous period of manhood: it is sometimes, but seldom, met with after the age of forty. The spring and winter are the seasons when it is most frequent and severe, but it might attack at any season of the year when the patient is exposed to its exciting causes. CAUSES. There are many who have a greater predisposi- tion than others to this complaint, and in whom from slight causes it has a greater tendency to return. The exciting causes are cold applied to the body, especially in a state of predisposition and encreased irritability : thus after violent exercise ; after a debauch in drinking, and late hours ; and after being greatly heated by dancing in a warm and crowded room at a party, and suddenly plung- ing ANGINA TONSILLARIS. 215 ing into damp and night air, a variety of dan- gerous complaints are produced, and amongst them angina tonsillaris is often known suddenly to appear. It is frequently caused by a stream of air passing over the body seated at an open win- dow : and cold alone will often produce it in persons, in whom there had not been any evidence of a marked predisposition. Angina tonsillaris terminates by resolution or suppuration. A schirrhous hardness of the tonsils has been observed in a few instances, but so rarely, that it cannot fairly be considered amongst the regular terminations of this complaint. CURE. It ought to be the study of the physician to remove the inflammation by resolution, because that is the least tedious, the least painful, and the least dangerous termination. In the beginning an emetic should be given, with the intent of deter- mining to the surface, and discussing the inflamma- tion, the patient being confined to his room. The morning after the emetic is given, an active purga- tive will be useful, such as the pills No. 3, after which the mixture No. 4, or castor oil may be directed, if necessary, to quicken the passage of the pills and to procure a more complete evacuation : the purgative glyster No. 6 is an auxiliary of the same 216 ANGINA TONSILLARIS. same sort, but milder, and answers very well where there is any loathing or sickness at stomach, which might cause the purgative mixture, or castor oil to be rejected by vomiting. The feet at bed-time should be uniformly bathed in warm water ; and the neck covered with a thick collar of warm flannel. The drink and food must be always taken warm : these means alone will commonly remove the disease when mild : if however the symptoms are severe and have continued for some days, or if recent, but will not yield to this treatment, we should not hesitate to apply leeches externally to the tonsils; they are an incomparable remedy, and, if used before suppuration has com- menced, they reduce the inflammation almost in- stantaneously. Where leeches cannot be procured, or, where their application will not be submitted to, a sharp and large blister should be laid across v the throat ; the purging medicines above mentioned being occasionally employed. When the pain and inflammation, though some- what mitigated, still continue after this treatment ; or, when, though they remit considerably, they soon return ; there is strong reason to suspect that suppuration has commenced ; and if there be a throbbing shooting pain, the existence of suppu- ration is less doubtful. We must then lay aside all ANGINA TONSILLARIS. 217 all hopes of a termination by resolution, drop all external applications except the warm flannels; trust to the use of mild detergent gargles, and the inhalation of the steams of warm water, and wait for the bursting of the abscess, an event now most anxiously to be promoted, and which puts a sudden and complete termination to all the suf- ferings of the patient. Mild subacid gargles are very grateful, and might be used throughout the whole course of the complaint : for the gargles there is a great variety of formulae. The gargle No. 54 will answer very well. A mixture of honey, vinegar, and water ; or of honey, lemon- juice and water, will likewise form an agreeable gargle : port wine, water, and sugar or syrup, is also a good gargle. The pain of the confined matter is most agon- izing in this disease, and therefore, if there is evi- dence of matter being formed, without a proba- bility of its being discharged by the spontaneous bursting of the abscess, an inscision should be made by a convenient instrument in the part which is most pointed. When the matter is discharged, all distress is completely at an end; and it is very remarkable, that in many instances there is but a small quantity of pus discharged, where therehad been most excruciating pain. It has been already mentioned that children are attacked with inflam- matory sore throat, and that then ulcers sometimes appear 218 RHEUMATISM. appear upon the tonsils surrounded by a fiery in- flamed base : in those cases, as far as I have been enabled to observe, the inflammation terminates by resolution, and is connected with strongly marked indications of morbid secretion in the liver and alimentary canal : two or three grains of calomel, according to the age and constitution of the patient, removes the bilious distress of the stomach and bowels, and with only the addition of warm flannels worn round the neck, the ulcers become smaller and cleaner ; the fever and inflam- mation abate ; the glandular enlargements about ' the throat and jaws gradually subside; deglutition becomes easier ; and very soon appetite and health return : a second dose of the calomel may some- times be exhibited in two or three days after the first, where there still appears to be a morbid col- luvies of the intestines ; but a third dose is sel- dom required, unless there be some other morbid affection of the system existing at the same time. RHEUMATISM. This is one of the most common complaints to which the poor, and especially the labouring poor of Dublin are subject. It is properly a disease of cold countries, in which it is endemical, and but rarely known in warm climates. Its attacks are most frequent in winter and spring, but it is sometimes observed in summer and autumn in cold countries. There RHEUMATISM. 219 There are two sorts of rheumatism, the acute and chronic. The acute is an inflammatory dis- ease, and commonly begins with strongly marked symptoms of fever, as chilliness succeeded by en- creased heat ; impaired appetite ; thirst ; quick pulse ; and a severe pain of some of the larger joints ; such as the shoulders, hip-joints, knees, ankles : the smaller joints are not affected at first ; but after the disease has often returned and con- tinued long, it attacks the small joints also, such as the wrists, and the joints of the fingers, which frequently become stiff, contracted, distorted, and motionless. The pain at first generally visits one joint, and shifts rapidly to one or more joints, from that first attacked ; and it sometimes conti- nues shifting in this manner for several days, whilst under the form of acute rheumatism : but in chronic rheumatism the pain is fixed : inflam- mation and swelling of the part affected supervene, upon the appearance of which the pain is consi- derably mitigated. The pain in many instances is confined to the joint, without running along the muscles ; but sometimes it attacks the middle part of the limb, between the joints, and courses along the muscles of the limb, and often along one muscle, to the extent of which it is confined without being com- municated to the other muscles in its neighbour- hood. The general disorder of the functions which 220 RHEUMATISM. which accompanies other pyrexiae or fevers, never occurs in rheumatism. The pains of acute rheu- matism will sometimes affect any part of the sur- face of the body and will be increased on pressure : sometimes the hairy scalp and the neck are the seat of this pain, whence there arises great head- ache encr eased on pressure. The pains often at- tack the lower part of the back, and shoot through the loins to either side, producing that modifica- tion of the disease, called lumbago. Sometimes they are fixed lower down in the muscles and li- gaments of the os sacrum, and spread to either side about the origin of the glutaei muscles : in such cases the distress is principally felt at one side. The pains in many cases are seated in the hip-joint, and shoot along from thence in the direction of the great sciatic nerve to the knee, and frequently as far as the ankle ; and the knee and ankle joint suffer often severely from pain, weakness, swelling and rigidity. In many cases a fluctuation is evi- dent in the knee ; this symptom however does not occur until some time after the inflammation has begun ; and perhaps should more properly be referred to chronic rheumatism : but the exact limits betv/een acute and chronic rheumatism are not easily fixed or ascertained. During the in- flammatory stage of acute rheumatism, the appli- cation of external heat generally causes distress and pain, hence encreased pain from the heat of the bed ; but sweat breaking out on the affected part RHEUMATISM. 221 part gives considerable relief. In chronic rheu- matism, external warmth is uniformly a source of comfort. Though acute rheumatism be a very inflammatory* disease, it never terminates in sup- puration or gangrene ; in some instances there is an exudation of a gelatinous fluid into the sheaths or capsules of the affected joints ; the bursae mu- cosae appear to be generally the seat of this depo- sition. This disease terminates by resolution, without leaving any marked sequela ; and very frequently it passes into chronic rheumatism. Rheumatic limbs sometimes become wasted and paralysed ; and in predisposed an,d scrophulous habits, a rheumatic pain of the knee frequently ends in a white swelling 5 but it is probable that it is only in scrophulous constitutions such un- toward terminations take place. Pleurodyne is a rheumatic affection of the intercostal muscles. In rheumatism there is commonly an exacerbation towards evening. The persons most subject to rheumatism are the plethoric and those about the prime of life : after having once attacked with severity, it is very much disposed to return. CAUSES. Acute rheumatism is caused by cold and mois- ture, which constringe the exhalants of the sur- face and repress perspiration. Thus a damp shirt 5 damp 222 RHEUMATISM. damp sheets ; clothes which have got rain or wet still kept on the body, will bring on acute rheuma- tism ; and also any part of the body being exposed to a stream or current of air, particularly of damp air: the application of those causes will more certainly produce the complaint, if the body be in a state of great irritability at the time, as after a fit of drinking ; after violent exercise, such as dancing; or after great perspiration. CURE OF ACUTE RHEUMATISM. In acute rheumatism the cure must be conduct- ed strictly on the plan of allaying acute inflamma- tion ; our principal view being directed to pro- mote an encreased discharge by the skin. Blood- letting is a powerful and quick remedy, it relieves the pains immediately ; and prepares the way for exhibiting the other medicines, indicated for re-' moving the complaint. Thus diluents, laxatives, and diaphoretics will be most successful in reliev- ing the pains where blood-letting has been pre- mised : but it must be carefully marked, that it is only in youthful and strong constitutions that blood-letting is admissible even in acute rheuma- tism ; in such persons venesection, if necessary, might be repeated three or four times, according to the urgency of the symptoms ; but we must be very careful not to carry this evacuation too far ; as it might convert acute into chronic rheu* matism ; or lay a predisposition favourable to the return of the complaint. Where RHEUMATISM. 223 Where the propriety of general blood-letting is doubtful, leeches might be applied to the part in pain, with perfect safety, even in delicate persons. They are of essential service in that modification of the complaint called lumbago. The bowels ought be kept open, particularly at the commencement : there is no treatment which has such decided advantage in removing rheuma- tism as purgatives judiciously and regularly em- ployed : their efficacy is so decisive that they will often cure acute rheumatism without the aid of any other medicine. A dose of the purgatives No. 1,2, or 3, is well adapted to this end, follow- ed up, if they prove too slow, with the enema No. 6 , or a dose of castor oil, or with a purga- tive mixture, such as that in No. 4. This purgative process in persons of moderate strength might be repeated so as to procure one or two free stools every day. If the pains still con- tinue after the blood-letting and evacuations by stool, or after free evacuations by stool alone, where blood-letting is deemed inadmissable, it will be proper to encourage a copious and long continued sweat: its duration should not fall short of forty-eight hours, and oftentimes it ought be longer. Dovers powders are commonly employed for this purpose : the dose is about ten grains, to be repeated every six hours until a sweat breaks out : 224 RHEUMATISM. out : the sweat is to be kept up by warm diluent drink taken at short intervals, and in small quan- tities at a time, as long as it is conceived proper : during the sweating process, the sheets should be taken away, and the patients lye in blankets, taking care to be properly supplied with dry well aired linen occasionally. No drink should be taken for an hour after the powder, least vomiting might ensue, which sometimes happens when a draught of any liquid is immediately used after a medicine containing emetic or purgative qualities. Some prefer preparations of antimony to dovers powders as diaphoretics, because their effects are more durable, and because they open the bowels as well as relax the surface : thus antimonial pow- der in small doses might be added to nitrate of kali, as in the formula No. 59, and repeatede very four or five hours until the sweat breaks out. Other practitioners order antimonial wine and laudanum, or a solution of tartar emetic and laudanum, with the same intent ; these substitutes are unquestionably very valuable. Whatever sudorific be employed, warm fomentations to the lower extremities will be useful in a high degree. After the pains disappear, the patients should be particularly careful not to expose themselves to the risk of catching fresh cold, but confine themselves to a warm apartment, and wear flannels close to their body. The RHEUMATISM. 225 The blood drawn in rheumatism is always buffy, and the urine high coloured ; but when the pains begin to subside, the urine deposits a brick coloured sediment. The sweats will be most effectual in curing this disease, if the in- flammatory force of it has been already reduced. The pain of rheumatism is always more violent than the pain of phlegmon, both because it is seated amongst parts frequently in motion, viz. muscles and joints ; and also because those parts are less yielding and possessed of more sensibility than the seat of phlegmon. Peruvian bark has of late years been commended, as a cure of acute rheumatism : but its benefits are more sensibly felt as a roborant after the severity of the complaint has already yielded to other treat- ment. The acute will sometimes last two or three weeks and insensibly pass into the chronic rheu- matism ; but in many instances a smart purging and sweat will soon put a stop to it. The diet throughout the inflammatory stage must be low. After the removal of the complaint, a strength- ening plan must be adopted, with a view to guard against its return, such as temperance $ exercise, particularly on horseback ; friction with the flesh- brush to the parts which suffered ; and the cold sea bath, or shower bath. q chronic 226 RHEUMATISM. CHRONIC RHEUMATISM, Is disposed to attack those parts which are the seats of acute rheumatism. It is attended with considerable pain, encreased on motion. Some- times the affected limb becomes stiff, cold, di- minished in its sensibility, and considerably wasted in its size ; and a real palsy of the limb will sometimes ensue from chronic rheumatism. It is known to fix in the muscles ; the ligaments and membranes of the joints ; and in the sheath, or involucrum of the nerves : this is remarkable in sciatica, which follows the course of the great sciatic nerve : and instances have been ob- served, where the chronic pain ran along the anterior crural nerve. Into these seats of rheu- matic pain, a gelatinous fluid has been sometimes^ effused, but by proper treatment again taken up by the absorbents : should an opening be made into this fluid, it leaves very bad sores, dangerous and difficult to heal. The pains of chronic rheu- matism often run their course without any feverish exacerbation : sometimes sweats will come on spontaneously over the whole body, except the part affected, without any relief : but its pains are generally relieved by the warmth of the bed, and by those sweats which occupy the rheumatic limb. Chronic rheumatism is most commonly known to visit the infirm and old, and particularly those who, RHEUMATISM. 227 who, at an earlier period, were subject to acute rheumatism ; and frequently a- fit of the acute will terminate in the chronic rheumatism. CAUSES. The causes which in younger persons produce acute, will in the old and predisposed occasion chronic rhematism : it is likewise often caused by external injuries, as bruises, luxations ; by deposi- tions of morbid matter in the hip joint, as in scrophula ; and those depositions which are some- times the sequela of acute diseases, have been observed to occasion sciatica ; but the most com- mon cause is the same which brings on acute rheumatism, viz. cold or damp applied to the body, in a state of encreased sensibility. DIAGNOSIS. Rheumatism may be distinguished from gout, syphilis, and scurvy, the diseases to which it bears the strongest resemblance, by the following cha- racters. From gout it is distinguished by the habit of the patient ; the acidity and indigestion which generally precede a fit of the gout ; by the hereditary claim and rank of the patient, the gout belonging to the rich, the rheumatism to the poor ; and by the seat of the disease, the gout attacking the ball of the toe and the smaller joints of the extremities; but rheumatism the larger joints, at least in the beginning. It fre- q 2 quently 228 RHEUMATISM. quently happens, however, that gout and rheu- matism go together, and that we shall find our patient suffering from their united force. From syphilis rheumatism is for the most part easily distinguished by those marks which characterize syphilis ; such as pains fixed and re- ferred to the bones ; by dark copper coloured blotches on the skin ; by an ulcerated inflamed soreness of the tonsils ; by nodes or swellings on bones which have little covering, as the shin bones, the forehead, the upper and lateral bones of the cra- nium, the radius near the wrist, and the clavicles : by the venereal eruption, called corona veneris : but notwithstanding the clear distinction where these occurrences take place ; it wall often be found that venereal pains attack like those of rheumatism, even like lumbago, and very fre- quently like sciatica accurately marked ; and can only be distinguished by their receiving no relief from profuse perspirations, but being rather exasperated thereby ; by their continuing un- mitigated by such medicines as are efficacious in curing rheumatism ; and by their yielding easily to the liberal use of mercury. Rheumatism is easily distinguished from scurvy, by the patients having used such diet, and being exposed to the other causes and circumstances which ordinarily produce scurvy ; by the faetid breath, spungy gums, and ill-conditioned ulcers of RHEUMATISM. 229 of scurvy. Rheumatism and scurvy will some- times attack together persons exposed to their united causes, erg: seamen in long voyages. CURE. Chronic rheumatism is often a very afflicting complaint, and in some instances incurable. The remedies mostly relied on, are those which quicken the circulation through the diseased limb ; restore the healthful action of the exhalants ; promote the absorption of any fluid which might have been ef- fused, and remove any obstruction which might have taken place. Venesection is inadmissible in chronic rheumatism, but topical bleeding by cup- ping or leeches will be useful. Blisters applied to the seat of the pain will often entirely remove it for the time ; even sciatica has frequently yielded to a blister applied over the hip joint ; blisters suc- cessively applied round the knee have been found to promote the absorption of the effused fluid, and to remove the disease when seated there : in this modification of rheumatism, diaphoretics are a good remedy ; the warm salt bath is likewise valuable : the diaphoretics most usually employed, are combinations of opium and antimony ; spirits of turpentine ; and the various preparations of guaiacum ; guaiacum in every shape in which it is given, is unquestionably a valuable medicine in chronic rheumatism ; the ammoniated tincture is the preparation most generally used. In many instances of chronic rheumatism I gave the pills No. 230 RHEUMATISM. No. 62, consisting of guaiacum, calomel, antimo- nial powder, opium and cayenne pepper, with con- siderable benefit ; along with the use of the pills I recommended that the limb should be well rubbed twice a day with the liniment No. 63, and afterwards rolled in flannel ; this liniment rubbed to the rheumatic limb, e: g : to the knee in swelling and effusion will sometimes answer as a substitute for blisters ; the part, after the friction, being always wrapped up in flannel rollers, which will improve the progress of cure very considerably. Spirit of turpentine is sometimes given with great effect in inveterate rheumatism, and has been found to remove it after the ordinary dia- phoretics, and even mercury had failed. It may be given dropped on a lump of sugar, in doses from ten to thirty drops every night at bed time ; and some mild drink, such as whey, taken imme- / diately after : thirty drops are too large a dose in general to be continued for many successive nights : the best method is to begin with ten drops, and gradually to encrease the dose by the addition of one or two drops every successive night, until it amount to the largest dose, which the patient can bear without griping or sickness.* This is a treatment * I met with two inveterate and obstinate cases of rheuma- tism, in which I exhibited the turpentine with gratifying success. In one the pain had been fixed for years in the mus- cles of the leg, particularly the tibialis anticus, along the course of the shin-bone ; from suspicions of a venerial taint, I recom- RHEUMATISM. 231 treatment that I am inclined earnestly to recom- mend in all refractory cases of chronic rheumatism. Sometimes a combination of symptoms similar to those of rheumatism will set in and obstinately persevere, notwithstanding the liberal exhibition of those medicines already recommended. We have then reason to suspect a venereal taint, and to order mercurial unction, which will generally cure the complaint. The confident assertions of our I recommended mercurial ointment, until a profuse ptyalism came on ; and then some of the most active saline prepa- rations of mercury, but all without any benefit ; I then blistered the part and kept up the discharge for several days by means of savin ointment, but without much relief : the patient then requested permission to use spirits of turpentine, which I readily and chearfully granted : he began by taking five drops at night on a lump of sugar, and encreased the dose every night until it arrived at thirty : he then took a retrograde course in diminishing them in the same gradual way until he came back to five ; he then advanced again as before, and by these means he soon got 'entirely and perma- nently free from pain. Soon after this I had the care of another, who had been nearly paralysed in one of his legs by chronic rheumatism of many years standing, the pain of which was most severe at the ankle and instep. He had used several courses of mercury under different persons, so freely exhibited, as to cause profuse salivation, but without relief. I recommended the spirits of turpentine as in the other case, but of which the patient took very large quantities without my directions, along with the liniment and flannel roller already mentioned : he recovered in less than a month in a great degree the thorough use of a limb, which before had been nearly palsied. 232 GASTRITIS. our patients that venereal disease is impossible might stagger us at first ; but a little experience will soon direct our attention to the state of the symptoms, and to that alone ; and here it is but candid to observe, that the patients frequently treasure up a system of causes and effects which they conceive to be conclusive with respect to the existence of venereal poison ; and that the hard- iness of their assertion is often founded upon the supposed infallibility of that system. GASTRITIS, or INFLAMMATION OF THE STOMACH. This is fortunately a very rare disease. Its most striking symptoms are violent and incessant straining and vomiting, so that any thing swal- lowed is instantly thrown up ; a very severe pain at the pit of the stomach, stretching towards the left side ; a burning heat in the stomach ; singul- tus or hiccup ; great anguish ; thirst ; quick breath- ing ; there are aphthae or slight sores on the lips and inside of the mouth ; the pulse is quick, low, and hard ; (this low, quick and wiry pulse is re- markable in inflammation of the stomach and of the intestines) in the last stage of the complaint, when a fatal termination is approaching, the patient is apt to have cold clammy sweats ; faint- ing ; coldness of the feet ; a lightness or reeling of the head ; loss of sight ; suppression of urine ; and convulsions ; and sometimes the fatal termi- nation GASTRITIS. 233 nation of the complaint is so rapid, as to leave no room for the exhibition of remedies. CAUSES. The causes are cold drink taken when the body is heated, even a drink of cold water will some- times produce it under these circumstances, of which many instances occur in soldiers after long marches ; but the drink will cause gastritis with more certainty, if it be of a sour, or acrid, or poisonous nature, such as laurel water and distilled spirits, which will suddenly induce in- flammation of the stomach, gangrene, and death ; all stimulating and strong liquor taken to excess. The milk of a nurse in a fit of violent rage or anger, will sometimes cause an inflammation in the sto- mach of the child, accompanied with convulsions and all the bad symptoms of the complaint (hence a strict caution to avoid drunken and passionate nurses) ; strokes on the pit of the stomach, and the passage of a cannon bail close to the pit of the stomach, will suddenly kill ; inflammation of the liver will sometimes spread to, and cause in- flammation of the stomach. The stomach how- ever is covered with a mucus which most com- monly protects it from the baneful consequences of those causes. When inflammation of the stomach has taken place, it has generally a very rapid, and most commonly a fatal termination. Sometimes it will run 234 GASTRITIS. run its course of inflammation and gangrene* and kill in the course of twelve hours ; and the pa- tients who have once escaped from it, are liable to attacks of it from very slight causes ; if costiw ness exists, it is sure to exasperate the symptoms and to encrease the danger. When gangrene sets in there is a mitigation of the pain ; but with coldness, loss of strength, and a sinking of the pulse, which sufficiently point out the approaching event. Acrid food and hard of digestion, as smoked meat, may cause gastritis, in persons sub- ject to it ; too great or too frequently repeated doses of emetics, especially antimonials, and acrid purgatives in large doses, or in doses badly or injudiciously prepared, may also cause it. Erysi- pelas repelled or spreading from the surface to the stomach, may induce dangerous gastritis. CURE. The prospect of saving the patient depends almost entirely upon blood-letting, from which we must not be deterred by the state of the pulse; and it will be necessary to repeat it from time to time, until the danger be subdued. It is obvious that medicines taken by the mouth must rather exasperate than mitigate the symptoms, whilst the stomach is so extremely irritable, that it in- stantly throws off by vomiting every thing swal- lowed ; even opiates are hurtful in the beginning until this irritability is allayed, but as it is of material GASTRITIS. 235 material advantage that the bowels should be opened and preserved in a regular state, purgative glysters in small bulk, as in No. 95, ought be ad- ministered, and repeated at short intervals until the bowels are relieved. The feet ought to be bathed frequently, and a large sharp blister laid over the pit of the stomach. If it be produced by poisons ; along with the blood-letting, and the evacuations by stool already mentioned, correctors should be employed if possible, adapted to the qualities of the acrid or poisonous cause ; but when inflam- mation of the stomach is the effect of poisons, it is but candid to observe that the case is com- monly hopeless. After the inflammation has subsided, and the acrimony of the primse vise has been removed by means of the glysters, opiates injected per anum, as in No. 41, will be useful to allay irritation. The diet in gastritis, or more properly, after the vomiting and inflammation have stopped, must consist of liquid aliment, bland, and easy of digestion, such as light broths, gruel, panada, arrow root, and such like ; the drink might be barley water, runnet whey, fresh buttermilk. See. There must be particular attention to keep the patient warm and protected from every exci- ting cause. When the pain, inflammation, and vomiting have disappeared, a little castor oil might 256 ENTERITIS. might be taken occasionally to preserve a regular- ity of the bowels, and repeated as often as may be necessary, until the health is restored ; after- wards the patient might resort to such other purgatives as the nature and urgency of the symptoms might require. From the tendency of gastritis to return in persons in whom it has once occurred, the means recommended for the purpose of securing the patient against a relapse, must be persevered in for several weeks after convalescence has begun. ENTERITIS, OR INFLAMMATION OF THE IN- TESTINES, COMMONLY CALLED INFLAM- MATION OF THE BOWELS. This resembles the inflammation of the sto- mach in many respects, as in the low typhoid state of the pulse, in the agonizing severity of its pain, in its disposition to return, and in the rapidity of its progress often to a fatal termina- tion. Inflammation of the intestines is a more fre- quent disease than gastritis. As the pain and distress in gastritis are referred to the seat of the stomach ; so in enteritis there is a violent twisting pain of the belly, most severely felt about the navel, accompanied by the following symptoms ; tension and hardness of the belly, and frequently an ENTERITIS. 237 an irregularity of its surface as if from a number of balls or lumps ; flatulence ; great anguish ex- pressed by the countenance ; thirst ; difficulty of making water; bowels confined, and sometimes a scanty purging accompanied however with a re- tention of the solid excrements ; a burning fever ; vomiting, but not so violent and incessant as in inflammation of the stomach ; the pulse is small, quick and wiry. When a fatal termination is ap- proaching, the extremities become cold, the face and lips of a livid paleness ; and a cold clammy sweat breaks out upon the face, head, and upper prrts of the trunk of the body. When this com- plaint has once happened, it is very apt to return from slight causes. In those cases which termi- nate favourably, adhesions are generally formed in consequence of the preceding inflammation, between different parts of the intestines, and also between their enveloping membranes, which in a state of health are not attached to each other ; hence there is a greater degree of soreness ex- perienced where the inflammation existed, and a stronger predisposition to the renewal of the com- plaint. When gangrene sets in, the pains entirely sub- side, and often leave hopes of a recovery ; but the sinking of the pulse, the expression of the countenance, and the coldness and livor of the body, are always sufficient to correct this mistake. Death 238 ENTERITIS. \ , Death supervenes sometimes very rapidly in enteritis, not unfrequently in twenty four hours. The symptoms of colic are very like to those of inflammation of the intestines, but in the latter the pains are more constant than in colic ; should a mistake however arise concerning the nature of the disease, it cannot be productive of any material injury, because the same treatment is suited to them both. The pain in this disease is excessively severe, because the parts inflamed are naturally very tender, because it is exasperated by the in- cessant peristaltic motion, to which the intestines are subject, and because the food and excrements must pass constantly through, and therefore irri- tate them. The distension likewise of the in- testines occasioned by the extricated air, and by the bulk of the alimentary mass, must greatly aggravate the suffering and encrease the pain. causes. The causes are similar to those of gastritis, as poisons ; acrid food ; large doses of acrid medi- cine ; long confinement of acrid excrements in the alimentary canal. Ruptures will also cause it ; erysipelas translated from external parts is said sometimes to cause it ; colic often ends in inflam- mation of the bowels : but the most common cause of all, is cold applied to the surface, particu- larly the feet, if the body is at the same time in a delicate ENTERITIS. 239 delicate or irritable state ; excessive eating, intem- perate habits, and drinking largely of spirituous liquors may likewise bring it on. Irregular gout is sometimes inclined to attack the intestines, and then it will occasion all the distressing symptoms of enteritis, with their melancholy consequences. Instances of enteritis are met with at all periods of life, but it is more frequently a complaint of advanced years than of youth or manhood, perhaps because the bowels are more slow in persons who have passed the meridian of life, than at earlier periods ; it is probable too, that the proportion of the mucus, which protects the internal coat of the intestines, and which is very copious in infancy, becomes gradually diminished as we advance in life, and thus at length exposes the intestines to be more easily inflamed by those irritants which cause the complaint. CURE. In inflammation of the bowels the method of cure is very similar to that of inflammation of the stomach. Bleeding freely from the arm and repeating that bleeding at short intervals is our principal resource ; the pulse which was small and wiry before, becomes full and soft after the bleed- ing ; warm fomentations, particularly spirituous fomentations, should be applied to the belly, and frequently repeated after the symptoms are miti- gated 240 ENTERITIS. gated by the bleeding, and continued for a long time, perhaps for an hour or two : these fomenta- tions have a powerful effect in relieving the in- flammation and spasm of internal parts, but if applied before the internal inflammation be already mitigated by blood-letting, they only encrease the feverish heat, without reducing the severity of the pains. The effect of warm fomentations might also be produced internally, by means of enemata or glysters, composed of linseed decoction, with the addition of some sweet oil ; these enemata might be frequently repeated. There are but few hours in which we can have any chance to save the life of our patient ; there- fore our practice should be vigorous and decisive. After bleeding to the extent which appears neces- sary, in cases of alarming danger, instead of the spirituous fomentations just recommended, a large and sharp blister ought be laid over the whole belly as far as the pain extends : this is an ex- cellent auxiliary to bleeding, and frequently sub- dues the remains of the pains and irritation. After the severity of the disease has been greatly mitigated by those means, mild laxative glysters might be used, and repeated at the interval of six or seven hours until a stool is procured. De- coction of senna, with manna dissolved in it, will commonly answer this purpose ; afterwards mild purgatives taken by the mouth, such as phospho- rated ENTERITIS. 241 rated soda dissolved in broth, and given in small repeated doses, will be very useful. After the re- gularity of the intestines is pretty well established, two or three grains of calomel given without any addition, and soon followed up by a moderate dose of castor oil, is an excellent laxative, and leaves the alimentary tract more free from acri- mony than any other aperient in common use ; afterwards rochelle or epsom salt in small doses, and dissolved in any agreeable water, will help to preserve a regular habit of bowels, and to secure from a return of the complaint. Warm clothing, light food in a liquid form, and taken in mode- rate quantity, ought be used as in gastritis ; and all the exciting causes carefully avoided. The bowels are to be preserved in a state of uniform regularity ; and whenever any tendency to bilious acrimony is manifested by the state of the tongue and prcecordia, a small portion of a mercurial purgative should form a part of the medicine re- commended for the relief of the bowels. After the immediate danger is subdued, we must for a long time persevere in the precaution- ary plan of guarding the patient from a relapse ; because this is a disease which is known most commonly and severely to make its appearance again from the slightest causes. MEASLES. 242 MEASLES* MEASLES. Measles, according to Sydenham, commonly begin in December or January, continue to spread and encrease until the vernal equinox, and though they still continue in many instances, yet- from that period their severity gradually abates, and the numbers attacked by them become less until the month of July, when they for the most part disappear : sometimes however a few scattered cases of them are found at all seasons of the year ; but this account of their occurrence and frequency is not always exact. Measles, like all diseases which seldom occur but once through life, chiefly attack children ; but all those who have not had the disease before, are liable to be attacked by them at any period of life : though they very seldom visit the same person twice, yet there are undoubted instances of their having occurred a second time.* Measles * I attended a gentleman about twenty three years of age, in this complaint, who from a nrm conviction of his having had measles when a boy, could not be persuaded that the complaint he then had was measles ; he admitted that he had been for several days before visiting a friend in measles, that the appearance of the symptoms in him and in his friend was the same, and in all respects, as well as he could remember, similar to the symptoms of the measles which he had when a boy MEASLES. 243 Measles set in with a chilliness, shivering, and sense of encreased heat and cold, which alternately succeed each other ; these are the symptoms of the first day : on the second the fever becomes more completely formed ; vehement sickness, thirst, and loss of appetite come on ; the tongue is loaded, white and moist, but often foul and bilious ; this is the state of the tongue at the commencement of most febrile diseases ; there is a dry and husky cough, hoarseness, sore throat, heaviness of the head and eyes, drowsiness, particularly in children, sneezing as if from having caught cold, a running from the nose and eyes, and an into- lerance of light ; these symptoms encrease in vehemence until towards the fourth day, when the eye-lids swell a little, and sometimes a vomiting comes on ; in children there is also frequently a purging, and that more certainly during the period of dentition ; then too the stools are green, and the little patients very fretful. About the fourth day, when the symptoms have all arrived at their greatest severity, little red spots like flea-bites begin to appear on the forehead and other parts of the face, which, encreasing in number, run to- ri 2 gether boy, and yet from a rooted conviction that measles never vi- sited a second time, he could not be brought to acknowledge that his complaint then was measles. I could not ascertain whether the former complaint had been the mild measles with little fever or catarrh, but the complaint which I saw was in® flammatory, with a sharp fever and severe catarrhal affections. 244 MEASLES. gether in clustres, forming spots of different size and shape over the face ; they also appear on the palate, velum, tonsils, and internal fauces, in deep- coloured irregular streaks, and encrease the sore- ness of the throat, the hoarseness of the voice, and the huskiness of the cough ; the eruption sometimes begins on the third, and sometimes not until the fifth day, but most commonly on the fourth ; these spots or blotches often cover almost the whole of the face, and are composed of small red pimples seated close to one another, and rising a little above the surface of the skin, so that they may be felt with the finger in cases where their elevation cannot be perceived by the eye. Those spots spread from the face, where they first begin, over the breast, trunk, arms, legs and thighs ; but on the trunk and extremi- ties they are merely red spots in general, without being perceived even by the touch elevated above the skin ; there are some cases however of high fever and vivid eruption, in which the elevation of the clustered papulae can be perceived also on the breast and trunk by the finger : sometimes, though seldom, the eruption appears first on the breast and upper part of the trunk, and not on the face. The fever and eruption in some instances begin together : there is often a considerable stupor from the beginning of this complaint, which produces retention of urine, and sometimes ends in a spasm of the sphincter of the bladder, causing MEASLES. 245 causing strangury ; and in some instances the stu- por rises to apoplexy. The pulse is generally full and quick, but during the torpor it is often uncommonly slow. In the beginning of measles, there is often an epistaxis or bleeding from the nose, and some- times a spitting of blood. The eruption is often delayed for some days by accidental causes. Cold applied to the surface, severe diarrhoea or purging occurring in the begin- ning of the eruption, and a copious hoemorrhage, such as a large bleeding from the nose, will retard the eruption ; and in those cases the eruption is paler than when such causes do not occur to delay it ;* the breathing is somewhat laborious, and there is often a pain the chest. In three, four, or five days after the eruption has begun, the skin becomes paler and is covered with small branny scales, but these scales are not so constant nor so copious in this as in scarlatina. In most * Instances have been known where the patients having been exposed to the contagion of small -pox, after being attacked by measles, first went through the regular progress of the small pox, and then had the measles. -Jfun fir oa , .fa 246 MEASLES. In most cases measles are a very trifling disease ; the symptoms then are those of slight ophthalmia and of catarrh united, the most prominent of which are soreness of the eyes, sneezing, hoarse- ness, and cough ; and upon the eruption appearing all the symptoms are considerably mitigated, so that the patient feels little uneasiness, except per- haps a slight soreness of the eyes, and some re- mains of cough. There are however some alarm- ing instances in which the eruption proves slightly critical, and even in which the symptoms are worse after the eruption ; in those cases the cough be- comes more distressing and more frequent, the oppression of the chest encreases, the breathing is more laborious, and all the other symptoms of inflammation of the lungs come on. In the milder measles, the eruption is always critical more or less ; and soon after its fading, the disease is entirely carried off by a slight diar- rhea, or purging, which is the natural solution of the complaint. Children are more subject to this disease than grown persons, but it spares neither age nor sex in persons who have not had it already. The danger of it is greatest in scrophulous constitu- tions. As it affects the mucous membrane of the throat and lungs, throughout its elongations, with an inflammation of a peculiar kind, it has a strong resemblance MEASLES. 247 resemblance to catarrh ; like that complaint too, it will sometimes pass from the mucous mem- brane into the substance of lungs, and cause pneumonia in some, and tubercular inflammation ending in phthisis, in others. These are its fatal terminations. DIAGNOSIS. The eruption is sometimes so slight and pale, and disappears so soon, that it is altogether over- looked, and the complaint passes for catarrh ; but from this mistake little injury can arise, as mild measles and slight catarrh require pretty nearly the same treatment ; and as the pectoral symptoms in measles are those for which it be- comes most necessary to provide remedies : but even before the eruption, a distinction can be marked between measles and pectoral or pulmona- ry complaints properly so called, by the sneezing ; running from the eyes ; and husky cough, which belong to measles : the great drowsiness which commonly belongs to this and to most other erup- tive disorders, does not occur in catarrh. From scarlet fever measles may in general be distinguished by the following characters. In scarlet fever, the eruption is more uni- formly spread over the surface than in mea- sles, in which the eruption is in irregular blotches or 248 MEASLES. or clusters, leaving interstices of the skin of a natural colour ; but the scarlet eruption either forms an universal redness of the whole skin, or it is in wider and more equal patches, without such pale interstices. In scarlatina, the eruption is commonly complete on the second day of the fever ; in measles it seldom begins before the fourth. The pectoral and catarrhal symptoms of husky cough, sneezing, running from the nose, and eyes, are more peculiar to measles ; the in- tolerance of light is not so severe in scarlatina as in measles : the colour of the skin is a deeper crimson in measles than in scarlatina : the sore- ness of the throat is more superficial and slight in measles, without the enlargement of the tonsils, and maxillary glands, and the ptyalism and diffi- cult deglutition which are often met with in scar- latina. PROGNOSIS. A slight fever, which goes off when the erup- tion appears, is favourable : a florid eruption on the face elevated above the skin ; the skin becoming tense and somewhat inflamed; upon the fading of the eruption, the skin becoming soft with a gentle diffused sweat breaking out upon it ; the drowsiness and pectoral symptoms of cough and quick respiration being mitigated by the appearance of the eruption ; and a gen- tle MEASLES. 249 tie purging coming on, when the cuticle begins to scale off ; all these are favourable symptoms. An enumeration of the symptoms which mark a mild disease, clearly points out those of the op- posite kind, which are dangerous: such are a violent fever, attended with stupor and oppres- sion about the chest ; the eruption not coming forward vigorously, when the pectoral symptoms are severe ; where the febrile symptoms are not mitigated by the appearance of the efflorescence ; and when the pectoral distress encreases after the eruption fades ; it is also a bad sign when the eruption does not advance, or is checked, or repelled in consequence of imprudent exposure to cold, or of a severe discharge of blood, or of a violent purging caused by accident or design. cure. The cure of measles i,s conducted on very sim- ple principles. For the purpose of guarding against the danger of catching cold, the patients should be confined to their apartment, the air of which ought to be kept pure, dry, and rather warm ; by these means too the skin is kept soft, and the progress of the eruption is encouraged. Light and noise, and particularly conversation with the patient must be avoided in all febrile diseases, but especially in measles, where the chest 250 MEASLES. chest is so much affected, and consequently where an exertion of the lungs must be hurt- ful. In mild measles, the principal remedies to be employed are from the class called demulcents and expectorants. In consequence of the torpor peculiar to this complaint, emetics which have a tendency to determine to the brain, are to be cautiously employed where this symptom exists ; but where it does not, a gentle emetic is a safe re- medy, and may assist in promoting the eruption : with the same view the lower extremities might be bathed in warm water at bed time every night until the eruption begins to fade. Expectorat- ing 'emulsions are useful to soften the cough and allay its irritation, such as spermaceti beat up with yolk of eggs, and given with some agree- able water ; oil of almonds and gums properly prepared have the same effect, as in No. 79> 80, these formulae are fit for children : a small quan- tity of ipecacuan or antimonial wine, may be added, where it is an object to determine to the skin : but the antimonial wine must be sparingly used for children. Measles, however mild, should never be ne- glected, as the mildest case of it might end in phthisis. Gargles in adults will be useful to keep the mouth and fauces clean, and to improve de- glutition MEASLES. 251 glutition : they might be made with a decoction of figs or raisins, or with mucilage, a small quan- tity of acid, some pleasant water, and honey ; the vapour of warm water, or of any mild warm li- quor, is also useful in relaxing inflammation: where the bowels have a tendency to be confined, they must from time to time be kept open with mild laxatives, such as manna, castor-oil, tamarinds, cream of tartar, or small doses of salpolychrest and rheubarb, or some agreeable neutral salt, as rochelle salt, or phosphat of soda, &c. but wiiere the tongue is loaded and bilious, the purgatives, No. 1, 2, or 3, are best for adults ; and for chil- dren, the powders, No. 12, 73, or 76. These will remove the sordes most effectually, and thereby mitigate the inflammatory and pectoral symptoms also, as I have often observed : if these medicines do not open the bowels in five or six hours, castor-oil given in doses proportioned to the age of the patient, will quicken their operation; for adults the purgative mixture. No. 4, may be employed, in place of the castor oil. When the powers of the system appear languid or exhausted, which can be ascertained by the cold skin, pale eruption, great dejection, and quick breathing ; as this sort rapidly sinks the patient, stimuli and cor- dials must be allowed, and of all cordials, wine is perhaps the best ; it may be conveniently given in the whey or drink of the patient : fomenta- tions in these cases are also useful by helping to encourage 252 MEASLES. encourage a more vivid eruption, and to relieve the head and lungs : blisters then are indicated likewise for the double purpose of stimulating, and relieving the lungs ; they should therefore be applied to some part of the chest, and in cases of torpor, to the head also. Where a sudden ef- fect is desired, sinapisms may be used, as they are quicker in their operation. A purging some- times occurs, which should not be hastily checked, as it is the most critical termination in this com- plaint. Where the pulmonary symptoms of cough, pain of breast, dyspnea, and oppression are alarming, we must bleed very freely, and even more than once, if necessary : children them- selves, who in general cannot bear bleeding well, must be bled under these circumstances ; there is no other remedy to be relied on : even bleeding with leeches is too inert practice : blood must be taken from the arm, and from a large orifice ; and when relief is thus procured, a blister will help to maintain the advantage gained by the bleeding. If severe pulmonic symptoms set in after the eruption fades, the case is still more alarming, and requires blood-letting more decisively, and is to be treated in all respects like an inflammation of the lungs. The MEASLES. The torpor is sometimes so great as to make the patients insensible to the natural stimuli ; it will then be necessary to call their attention from time to time to the state of the excretions, to urge them to make water, and to remind them of taking their drink, and whatever light food be allowed. In case of urinary retention, warm fomentations to the bottom of the belly will relieve, and if these fail, turpentine glysters will generally succeed. In measles there is always danger, as long as any cough continues, therefore the physician’s attention to the patient must be continued until the cough is entirely removed. In those who are disposed to phthisis, and in scrophulous habits, all danger is not over, even when the cough disappears ; to persons in whom this delicacy of constitution decidedly appears, it will be proper to recommend pure country air, milk diet, and exercise on horseback, or in an open carriage where there is not strength enough to ride ; but when strength enough is gained to remain on horseback, that is decidedly the most valuable kind of exercise. The food must be light, &c. as in inflammation of the lungs. Vide Pneumonia. SCARLATINA 254 SCARLATINA. SCARLATINA, OR SCARLET FEVER, Scarlet fever has appeared frequently in Dublin during those twelve years past, and with con- siderable variety in its symptoms, at different times. In some instances, the mildness of the disease is such as to require very little medical assistance ; in others its malignity is so great as to baffle all medical aid. It is observed too, that the mildest attack of it is in a few instances followed by consequences the most insidious and fatal ; and that those who recover from the most alarming form of it, sometimes escape the danger of its sequelae. It commonly happens in scarlatina, as in other epidemics, that its severity is greatest in those whom it attacks at its commencement ; and that its virulence abates considerably when it has continued for some time : at all periods however during its continuance, some instances are ob- served, in which its severity is attended with alarming danger. There were three varieties observed in the epidemic, which at different times appeared in Dublin of late years. The angina maligna, or scar- latina with aphthous and gangrenous sore throat ; the mild scarlatina, in which the florid efflores- cence upon the skin formed the whole or the principal part of the complaint ; and the inflam- matory scarlatina, in which a deep efflorescence. SCARLATINA, 255 an inflammatory sore throat, commonly with purulent ulcers on the tonsils, and a high fever, were the characteristic symptoms. The season of the year in which scarlatina most commonly begins to spread is the month of Au- gust and September, but it is found to exist at all seasons. It sets in with the ordinary symptoms of fever, such as lassitude, languor, head-ache, pain of back, a sense of coldness or shivering, succeeded by encr eased heat, anxiety, pain and oppression about the pit of the stomach, and sometimes nausea and vomiting : instead of head-ache, there is in some instances vertigo, in some delirium, and not unfrequenty fainting has been observed. The neck soon becomes swelled and stiff, and ac- companied by a soreness of the throat, which is most distressing towards evening ; and in scarla- tina, it is remarkable that there is a considerable exacerbation towards evening, throughout the whole progress of the complaint ; and the remis- sions of the morning are more considerable than in most other fevers, except the hectic of pulmonary consumption, and fevers of an aguish character. The fauces and velum pendulum appear inflamed, but the inflammation is different in different per- sons ; sometimes the inflammation is slight and sur- rounded by a paleness of the neighbouring parts, and as the complaint advances, light coloured spots form 256 SCARLATINA. form on the inflamed surface, which conceal ulcer# of a livid colour that discharge a corroding ichor ; this fluid excoriates the lips over which it runs from the nose ; and where it is swallowed it causes a faetid watery purging by its irritation in passing through the alimentary canal ; in many instances however of the worst appearances of this complaint, the bowels are slow and sometimes obstinately costive; the patient com- monly breathes through the nose with a disagree- able snuffling noise, and the smell of the breath is extremely offensive ; the maxillary and parotid glands become enlarged, whence arises pressure on the trachea and fauces or throat causing; diffi- cult respiration, and making it extremely painful to swallow. The tongue is covered with a white viscid mucus, which soon becomes of a dirty yellow, and then of a dark brown colour, particularly towards the root ; the pulse is quick and feeble. The febrile symptoms in short, are very like those of bad typhus or nervous fever. The affections of the threat are the most alarming part of the complaint and often run into gangrene. It sometimes happens, especially in this modifi- cation of the complaint, that the eruption is not a spreading florid efflorescence, but consists rather of a number of red points scarcely visible, and sometimes not to be distinguished but by an ac- curate examination of the skin ; they are most ob- vious on the upper part of the chest, on the neck SCARLATINA. 257 neck and on the shoulders. In such cases, which are commonly the most alarming, the skin is paler than in the others. Such are the ordinary symptoms of scarlatina with putrid sore throat. More frequently however the symptoms of sore throat are different, and more like those of angina tonsillaris or inflammatory sore throat ; the tonsils are then very much inflamed, attended by a trouble- some salivation, and ulcerated on their tops so as greatly to resemble inflamed tonsils covered with venereal ulcers; these appearances are accompanied with head-ache ; throbbing of the temples ; often delirium, and sometimes stupor. The skin is hot and dry ; the pulse quick, but not as feeble as in angina maligna; the tongue is very foul and loaded ; the praecordia painful and often hard ; the breath- ing quick and anxious ; and the sleep interrupted. Commonly on the second, but sometimes not un- til the third day, the whole body becomes covered with a florid efflorescence, of a brighter colour generally in persons of fair skins, than in those of darker complexions : Huxham observes that it is not unlike the colour of the juice of raspberries rubbed to the skin ; the skin appears slightly in- flamed ; the swallowing is very painful ; the max- illary and parotid glands swell, and sometimes in delicate subjects, where due attention has not been s paid 258 SCARLATINA. paid to the state of the fever and of the bowels, these glands are known to inflame and suppurate. In some cases the whole skin swells and inflames with a considerable sense of pain, and this inflam- mation is so severe that the fingers literally stand an end. It is obvious that the affections of the fauces and of the surface in this species, are of the in- flammatory kind. My own experience leads me to conclude that the angina maligna is more in- clined to appear in autumn ; and that as the winter advances the disease assumes more of the character of the inflammatory scarlatina ; but to this general tendency of the complaint there are exceptions. In the angina maligna it is not in the throat only that ukers are observed, but on the inside of the mouth, on the edges of the tongue, on the lips, and on the cheeks near the mouth ; the more purulent the discharge is from these ulcers, the more favourable is the prognosis, and the reverse when the discharge is thin and acrid. The eruption of scarlatina is sometimes retarded by particular modes of treatment, especially by the application of cold, and promoted by the op- posite mode ; the same result will sometimes arise from the same causes in small-pox and in measles. The SCARLATINA. 259 The eruption is not so critical as in small-pox, nor its repulsion so dangerous as in measles : when it appears it generally causes some slight remission of the febrile symptoms, but often there is little alteration perceived in the fever, in consequence of the eruption ; pectoral symptoms of cough and oppressed breathing, are often observed throughout the whole progress of the disease. In some instances the patient for six or seven days will be not quite well in health, and then the anginal and typhus symptoms will set in ac- companied by all their peculiar severity ; and that patient, who at first was hardly supposed to be in danger, in two or three days after the malignity sets in falls a victim to the complaint. The symptoms of recovery, when the disease terminates favourably, will appear on the fourth or fifth day ; but in some instances not so soon, especially in the inflammatory scarlatina, in which decisive marks of improvement will often not be discovered before the beginning of the second week. The favourable change begins with the following appearances ; the ulcers of the fauces and mouth become smaller and cleaner ; the swallowing easier and less painful ; the heat of the body diminishes ; the efflorescence begins to turn paler and to scale s 2 off ; 260 SCARLATINA. ofF ; and the distress of the head to subside ; the pulse becomes more full and slow ; and sleep and appetite return. Wherever the symptoms of angina maligna and typhus predominate, the danger is greatest, and always the danger is proportioned to the preva- lence of those symptoms, especially of the gangre- nous sores. Where vivid efflorescence and swelling of the skin alone exist, or exist with a slight combination of the anginal symptoms, the danger is trifling. In the inflammatory scarlatina with vivid efflo- rescence, swelling and pain of the skin, head-ach, and inflammatory sore throat, the danger is not as great as in the putrid sore throat ; but it is greater than in the mild scarlatina consisting al- most entirely of efflorescence ; and in general the colour of the skin is palest, and its swelling slightest, where the throat is most dangerously affected. It is remarkable that from the same contagion, and amongst individuals of the same family, the symptoms of gangrenous angina, and inflamma- tory scarlet fever are blended in every degree and variety *, and in some individuals one is found to exist pure and complete, without any combina- tion of the other. CAUSE. SCARLATINA. 261 CAUSE. The cause of scarlatina is a specific contagion, and all persons are liable to its attacks, of what- ever age, or temperament, or constitution, or sex ; and though it does not often visit the same person a second time, yet there are several in- stances of those being attacked again who have had it already. The persons most liable to it are the young and delicate ; and children, of all others, are most frequently attacked by it ; as indeed they are by all kinds of eruptive fevers. DIAGNOSIS. Scarlatina, by attending to its symptoms and to the prevailing epidemic, can generally be distin- guished from all other disorders. From angina tonsillaris, or common inflammatory sore throat, the malignant scarlatina is distinguished by low fever, sickness, prostration of strength, loss of appetite, by the sanious and acrid discharge, and by the ash coloured and gangrenous appearance of the ulcers. The inflammatory scarlatina dif- fers from the common inflammatory sore throat, by the high fever, the head-ache, the delirium, and throbbing of the temporal arteries. And all the varieties of scarlatina are distinguished from the 262 SCARLATINA. the inflammany sore throat, by the efflorescence. In angina tonsillaris too, the pain of the fauces and the difficult deglutition are the urgent distress ; but in scarlatina the whole system is affected. From measles it can be distinguished with- out much difficulty, by the catarrhal symp- toms, and intolerance of light, which are found uniformly in measles, and by the appearance of the eruption. In measles the eruption appears slightly marked, first on the face, and by degrees it spreads over the whole body : but in scarlatina it forms suddenly over the whole of the body, and most commonly is less florid on the face. In scarlatina the eruption spreads over the skin, so as to give it an uniform colour ; but in measles the eruption consists of a number of clusters ir- regularly shaped, but commonly composed of segments more or less circular or curved, and these clusters are formed of points closely corn nected, whose elevation above the skin on the face, and often on the neck and breast, is dis- covered by the touch, and in many instances by the naked eye : these clusters are sometimes con- siderably inflamed, and sometimes but obscurely ; and the interstices between them retain the natural colour of the skin. Sore and watery eyes ; sneezing ; a running from the nose ; soreness along the chest, and a husky cough, occur in measles, and form its most striking and most dangerous SCARLATINA. 263 dangerous character : but in scarlatina, though a slight inflammation of the eyes and catarrhal symptoms may occur, they are in general trifling, and by no means the leading appearances which fix the attention of the observer. PROGNOSIS. Scarlatina, in general, is not fatal before the third day, and the prospect of recovery is the greater, as the disease is protracted beyond that day, and if it passes the eighth or ninth day, the patient will most commonly recover. The dan- gerous symptoms (as already noticed) are those of typhus, and angina maligna ; that is, great heat and prostration of strength ; low, quick, fluttering or compressible pulse ; head-ache ; tre- mors ; early and great delirium ; flushing of the face ; and vomiting. The worst of all are dark or brown ulcers on the tonsils and internal fauces : dyspnoea ; swallowing difficult or nearly impossible, and causing the liquids to run out by the angles of the mouth ; stupor ; and offensive watery pur- ging : this latter class may be considered most commonly fatal. Favourable symptoms — When the fauces are but slightly affected, and the head free from uneasiness, there is little danger : an early, copious, and florid eruption is a favourable sign, and the repulsion of it is dangerous ; gen- tle sweats breaking out in the progress of the complaint ; little or no general fever ; the breath- ing 264 SCARLATINA. ing and swallowing remaining free or but little affected ; the sloughs falling off and leaving the parts underneath clean and of an healthy red colour : the swelling of the neck subsiding : all these are favourable symptoms. When it is announced that the swallowing is very difficult, and that there is a foul watery purging, the prognosis is unfavourable : and in all cases of scarlatina, the prognosis should be guarded until decisive symptoms of improvement occur; because instances are often met with* where the disease goes on mildly for several days, and where suddenly violent affections of the head, such as coma and delirium come on, and kill in the space of a few hours. Persons of delicate habits ; of shattered con- stitutions ; and scrophulous children, perhaps, most of all are those whom scarlatina attacks with greatest severity. CURE. The cure in scarlatina is to be directed by the state of the fever, and of the inflammation of the throat. General blood-letting in this town is seldom admissible ; and in some cases where it was tried it proved hurtful.* * During the epidemic scarlatina of 1798 I was called to see a boy about ten years old labouring under the angina maligna : SCARLATINA. 265 If called in early in the complaint, an emetic is our best remedy. Ipecacuan in wine or pow- der is one of our best emetics ; when a rough effect is not to be feared, a small quantity of tar- tar emetic might be added to the powder, or dis- solved in the wine. Emetics timely administered are sometimes known to cut short the complaint : they discuss incipient inflammation ; cause a de- termination to the surface and soften the skin ; carry away the slime of the fauces and the foul contents of the stomach ; and in these several ways contribute to remove the disease. The morning after the exhibition of the emetic, or immediately, when an emetic is conceived to be improper, the bowels must be freed from their morbid contents ; with this view, the medicines. No. 1, 2, or 3, in adults, and in children, the cathartic powder, No. 52, may be given, (this powder will generally prove a moderate dose from the age of ten to fourteen years, and may be modified for those who are younger or older in maligna : he had been just bled before I saw him, and was much weaker after the bleeding ; and the anginal symptoms were not in the least relieved. I ordered him cordials, such as wine, Peruvian bark with sulphuric acid, gargles with muriatic acid, and fruit jellies : I paid strict and regular attention to the state of his bowels, and though his improve- ment was very slow, he recovered. Had he not been bled, I am convinced his recovery would have been less difficult and more rapid. 266 SCARLATINA. in proportion to their age and the vigour of their constitution.) These medicines should be fol- lowed up within four or five hours with an enema ; or with the purgative mixture, No. 25, or with a dose of castor oil in some pleasing water, or combined with some purgative tincture, as tinc- ture of senna, or jalap, according to circum- stances : this plan being persevered in until the bowels are freely opened. If the complaint be the angina maligna, the greater delicacy of the patient requires that some caution should be used in the dose and quality of the purgatives ; but even in this modification of the disease, the bowels must be kept regular, and the foul collu- vies daily removed: but in the inflammatory scarlatina, the use of active and frequently re- peated purgatives is necessary ; in the latter too, the head had better be kept shaved and washed daily with spirits, or with camphorated spirits of wine : but where there is violent head-ache, de- lirium, or great drowsiness, the head should be covered with a large blister, and the discharge from the blistered part kept up with savin or blistering ointment, until those symptoms sub- side. In cases of violent inflammation of the throat, leeches ought be applied to the throat, and if the inflammation still continue distressing, a blister should be laid across the throat, after the leeches have been applied. The leeching and blistering of the throat not only carry off the distressing SCARLATINA. 267 distressing pain and soreness of the throat, and relieve the swallowing, but they also help to remove the pain of the head, and thus cooperate powerfully with the blisters and embrocations ap- plied to the head itself. In some instances, the severity of the complaint is so great, that a re- petition of the leeches and blistering will be required, and in cases of such alarming danger, we ought not to hesitate to repeat those remedies which are best calculated to remove the distress. The purgatives should be given regularly, so that a free passage of the bowels be produced at least once a day ; and in scarlatina, the contents of the bowels are commonly so foul, that from their ap- pearance we may be enabled to form a judgment of the propriety of altering, or omitting, or persever- ing in the purgative plan. Throughout the whole of the disease gargles are useful : they serve to cleanse the internal parts of the mouth and fauces, to enable the patient to relish the flavour of food and drink, and also to remove the sickness at stomach. Of gargles there are great varieties, of which some specimens are to be seen in No. 53, 54, 55, and 56, the two first are best adapted to the inflammatory scarlatina : the other two, viz. 55 and 56, to the putrid sore throat, in which these gargles are attended with the additional advantage of correcting the putrid foulness of the throat, and of disposing the parts to more healthy action : the gargles must be freely used and inject- ed 268 SCARLATINA. ed with a syringe gently and carefully, lest they pass into the wind pipe ; the safest of all methods perhaps consists in dipping some spungy substance in the gargle, and touching with this the diseased parts , these expedients are principally indicated in young subjects who cannot use the gargles themselves. For children honey of roses and borax make a good gargle in ordinary cases ; currant jellies are very useful, they act as a mild gargle, and they are slightly nutritious, cooling, and antiseptic. In the putrid sore throat, along with attention to the regularity of the bowels and the use of gargles, wine must be freely allowed, and likewise the Peru- vian bark, which might be combined with some bitter tincture and acid, as in No. 17, and if the irritation, pain, and difficulty of swallowing be severe, along with the bark preparation, the opiate liniment No. 57 will be proper ; it may be fre- quently and freely rubbed to the throat and jaw^s externally. In children sometimes the bark pre- parations cannot be taken by the mouth, then they may be given in glysters and in small bulk. Tincture of myrrh, honey, vinegar, and sulphu- ric acid may be variously combined to form agree- able and antiseptic gargles and cordials. In putrid purging, along with the above method, opium, barm and starch in glysters should be administered. SCARLATINA. 269 Bathing the feet with warm water at bed time, or fomenting them with warm stupes is a very useful practice, because it tends to relieve the head and soften the skin ; it might therefore be freely used from time to time. Should there be oppression of the chest and cough, a blister between the shoulders will be useful ; and the expectorating mixture No. 15 taken by spoonfuls will relieve the cough ; but when intended for children, the proportion of the opiate must be greatly reduced. The food ought to consist principally of ripe fruits, of roasted apples, of sago, flummery, gruel, &c. but where the patient is much exhausted and the stomach can bear it, broths, jellies, eggs and bread might be allowed. The drink might consist of any mild slightly nourishing liquor, as whey, barley water, milk, buttermilk, lemonade, oranges, &c. SEQUELAE, or CONSEQUENCES OF SCARLA- TINA. Scarlatina is disposed to leave dregs behind it which are often more alarming than the primary complaint. These are dropsical collections in some part of the body; these collections are sometimes formed in the cellular membrane, pro- ducing general anasarca or dropsy of the surface, and this is the most usual; but those collections may 270 SCARLATINA. may form in the chest, in the belly, or iivthe brain. For those dropsical sequelae the following medi- cines answer in general, viz. calomel and squills taken at bed time, and a diuretic and laxative electuary the following morning. Thus twT> of the pills No. 43 may be taken by a grown person every night, and a tea spoonful of the electuary No. 5 every foilwing morning. According to the purgative effects of these medicines, they may be modified so as not to purge too severely, but at the same time to keep up a regular state of the bowels ; thus should the patient be purged smartly after the pills and electuary, the dose of the pills should be omitted the following mght, and per- ha ps the electuary the morning after ; but if from a dose of the pills and of the electuary, the bowels are not sufficiently moved, the dose of the elec- tuary should be repeated every two or three hours until a stool be procured. To children the powder No. 12 may be given at bed time, with a little castor oil the following morning if neces- sary ; the dose of both being adapted to the age and circumstances of the patient. Sometimes it happens , that the patients have had little suffering during the primary complaint, that they had neither pain nor distress of any sort, and that the only appearance of disease was SCARLATINA. 271 was the general efflorescence, but that in a few days after the eruption scales off, a restlessness and heaviness come on, sometimes attended with a slight swelling of the face ; that they will loathe their food, and feel an uneasiness to move or ex- ert themselves : a brisk purgative will relieve for the time ; and they will appear well ; but soon again they feel a return of the same combination of unpleasant symptoms : and these successions of sickness and convalescence , will take place, until great distress and pain of head set in, encrea- sed in severity at each succeeding relapse : and the little patients at length die convulsed. In cases of tins sort, before the head be engaged, we ought to have recourse to those remedies which we believe most effectual in the insipient dropsy of the brain. The whole head ought to be shaved, and then covered with a sharp blister, which might be left on for forty-eight hours, and the blistered parts afterwards dressed with savin oint- ment, or ointment of powdered cantharides, so as to keep up the discharge until the threatened danger be removed. Doses of calomel, or of ca- lomel and James’s powder, or of calomel and antirnonial powder, suited to the age and strength of the patient, should be exhibited frequently, so as to keep up the free state of the bowels : and if the symptoms of affected brain be alarming, we should rub mercurial ointment every night, until 272 SCARLATINA. until a salivation come on ; and thus proceed until all appearances of danger subside. It will appear manifest, from a consideration of the dregs which this complaint is apt to leave behind it, that in our treatment of the primary disease, we should not only attend to the symp- toms under which the patient at any time labours ; but that we should have in our contemplation also the consequences which may follow, and regulate our practice with a view to prevent their occurrence. There is serious reason to apprehend water on the brain may follow, where, in the progress of the disease, high fever, and symp- toms of violently attacked brain exist, as severe head-ache ; delirium ; great drowsiness ; and restlessness. In such cases, therefore, the treat- ment recommended for the removal of those symptoms, such as leeches, blisters, and smart purging with mercurial medicines, will be ex- tremely proper, as they not only have the effect of banishing those alarming symptoms ; but also as they are the most powerful means of averting the treacherous and fatal consequences which might ensue. OF IRREGULAR BOWELS OF INFANCY. 2 73 OF THE GRIPING AND IRREGULAR BOWELS OF INFANCY. Children are very subject to bowel complaints, especially those who are nursed in large towns, where they generally want pure air, healthful ex- ercise, and often nourishing and wholesome food. This disease I have denominated griping and ir- regular bowels, in consequence of the leading symptoms by which it is marked, such as the following : SYMPTOMS OF GRIPING AND IRREGULAR BOWELS OF INFANCY* Loss of appetite ; loaded tongue ; often a swelling and pain of the belly, pointed out by the children pulling up their knees to their belly ; they become fretful and restless ; the flesh is soft ; the hands hot ; the lips dry ; the complexion mostly pale, but sometimes flushed, and that on one cheek more than the other ; the breathing is quick ; the sleep interrupted and unrefreshing ; the bowels slow, and the stools mostly bilious, of a green, brown, or black colour, and consisting only of lumps, or of lumps mixed with slimej and of a very fetid and unnatural odour ; but in many instances they are of a whitish or clay colour, without any apparent admixture of bile, and of a smell equally foul with the others : the breath, which is very sweet in children, in this complaint becomes offensive : a cough in a t preat c 274 IRREGULAR BOWELS OF INFANCV. great many cases accompanies the above train of symptoms, and indeed the attack is often caused by exposure to cold or damp weather. In severe attacks, vomiting and sometimes hiccup add to the suffering of the little patient. If this com- plaint occurs during dentition, it is uniformly rendered worse by the general delicacy of that period. CAUSES. The causes are hereditary delicacy ; want of proper exercise ; foul air of large towns ; indi- gestible and improper food ; bad nursing ; damp and cold weather, particularly when the child is too slightly clothed. Whether one or more of these operate to produce the complaint, the effects are evidently a morbid secretion of the bile, and of the fluids of the alimentary canal: in conse- quence of this, the bowels are loaded with a col- lection of sordes, the irritation of which raises a general fever through the system, attended by the symptoms already enumerated. I think it of importance to fix the attention of the practitioner upon the immediate source of the patient’s suffer- ing, viz. the diseased secretions of the intestines and liver j because there cannot then be much hesitation about the quality of the remedies which are suited to the complaint. CURE* IRREGULAR BOWELS OF INFANCY. 2*75 CURE. Whether the bowels are constipated without any evacuation by stool ; whether the stools are whitish, or dark coloured and hard ; or whether there be an appearance of faetid slimy purging ; the indication of cure is the same, namely, to relieve the system from the acrid contents of the bowels ; afterwards to correct the diseased secre- tions on which this acrimony depended ; and lastly, by the use of strengthening remedies, pro- per food, and attention to exercise and clothing, to guard against a return of the complaint. In treating of the diseases of children, some difficulty arises respecting the doses of medicines, which does not belong to adult age ; because the quantity of the dose must be regulated by the age of the child, and by the nature of the com- plaint. During the first quarter after birth, half a grain of calomel, triturated with two or three grains of lump sugar, will be a medium dose.* This * The following will answer pretty well as a scale to regulate the quantity of calomel, which may be proper for bowel complaints during the two first years after birth ; sometimes however we meet with children who will require much larger doses. For the first quarter after birth, half a grain of calomel beat up with three grains of lump sugar. For the 2nd quarter, \ of a grain of calomel and 3 grains sugar. T 2 For 276 IRREGULAR BOWELS OF INFANCY. This should be given as early in the day as pos- sible, and in four hours after, a small tea-spoonful of castor oil, if the calomel powder has not yet operated; and in three hours afterwards, a purg- ing glyster proportioned to the age of the child, and made up with brown sugar, or a little com- mon salt and sweet oil, ought be thrown up, if the bowels have not been relieved within that time by the purgatives already exhibited. In one or two days ^fter, the powder, castor oil, and glyster, if necessary, might be repeated in the same manner if the complaint still continue ; and thus we may proceed at the interval of one or two days, to exhibit these medicines until the complaint is removed. In cases where the above doses will have little effect, it will be necessary to encrease the quantity of the calomel, perhaps by a quarter of a grain at every dose, until the proper operation takes place. In severe cases the exhi- bition of the above medicine will be necessary every day ; and in mild cases it will be safe to allow an interval of two entire days. There are instances too where one dose of the medicine will remove all the symptoms and restore the patient to perfect health. Should the castor oil be nause- ated, senna infusion or tea with some syrup of gin- ger will answer, and this infusion will also keep the For the 2nd half year, 1 grain of calomel and 3 grains sugar. For the 3d half year., I £ grain of calomel and 4 grains sugar. For the 4th half year, 1^ grain of calomel, and 4 grains sugar. IRREGULAR BOWELS OF INFANCY. 277 the bowels regular on the intermediate days when the calomel powder is not given. The above treatment not only carries off the acrimony of the bowels, but also by degrees corrects the dis- eased secretions which produced it. Hot spirituous fomentations' and flannels applied to the belly and stomach will occasionally assist in relieving the pain and griping of the bowels, until the morbid excrements are carried off. It will be necessary to keep the child comfortably warm during the whole of the treatment ; and where too much exposure to cold has contributed to bring on the complaint, it will be highly proper to allow” more clothing, and of a warmer kind after its removal. From perceiving that robust children, under the favourable circumstances of regular exercise, clean* liness and good air, grow up healthy and strong, though lightly clothed ; there is an impression very generally received that light clothing and considerable exposure to the air will in all cases make children hardy and strong. Very delicate infants have therefore been too frequently allowed to go almost naked, and that, in many instances, where they were exposed to impure and stagnant air, and deprived of the benefit of exercise. There cannot be a doubt that exercise in the open air is salutary to the delicate as well as to the robust ; but to delicate children comfortable ■warmth in their clothing will be indispensible, though 278 IRREGULAR BOWELS OF INFANCY. though strong children may be lightly clothed not only wiith impunity, but with advantage. I have met with instances of delicate children, who from being trained according to this hardy discip- line continued feeble and sickly, and frequently afflicted with bowel complaints ; but who upon wearing shoes and stockings, and being in other respects comfortably clothed, immediately mended in their health ; and afterwards from persevering in this habit uniformly and permanently improved in constitution and strength. The patients upon recovering should have country residence if practicable, and exercise in the open air when the weather is favourable. As to food, the quality and variety of it must be suited to the age of the patients. In early infancy, the milk of a healthy nurse, who has been bred in the country in habits of constant industry and exer- cise, is the best food ; afterwards, as they grow older, sound well baked bread and milk will be proper, and occasionally broth and a small bit of meat. The fashionable but pernicious indulgence of children generally Consists in a glass of wine or punch, in sweetmeats, and in tea and coffee : these articles are all bad, and had best be entirely withheld, but if they must be given, like all poisons, the weaker they are, and the less of them that is allowed, the better for the child. If the delicate child be treated according to this plan viz. fed with sound and appropriate food PURGING. 27§ food only ; exercised and kept for a long time daily in the open air when the weather is season- able ; and protected by warm comfortable cloth- ing from the impressions of cold and damp ; he may by degrees acquire a portion of health and strength which will enable him to resist the con- sequences of\that light clothing to which at first he was unequal. After the complaint is removed the chalybeate powders No. 77 will be useful in improving appetite and strengthening the system* PURGING OF INFANCY. Purging is very frequent in infancy, and is ge- nerally accompanied with foul bowels ; in such cases the treatment recommended for the preced- ing disease, viz. griping and irregular bowels of infancy, will be most proper. Sometimes a purg- ing attends dentition ; warm clothing and proper food will in those instances be commonly sufficient to correct it ; but if the stools are foul, a small dose of calomel will carry off the acrimony, and if the looseness still continues in such a manner as evidently to weaken the child, a tea spoonful of the absorbent mixture No. 82, taken three or four times a day, will help to check its severity and to improve the tone of the bowels. Some- times a purging in infants is the consequence of cold acting upon the surface, and producing an encreased and morbid determination to the intes- tines 9$ O CONVULSIONS. tines , the method of cure is similar to that recommended for the looseness of dentition, viz. warm clothing, one or two calomel powders to expel the acrimony ; and, if there appears to be still a purging which continues to relax and weaken the child, the mixture No. 82 will gene- rally remove it. There is a laxity of bowels peculiar to some infants attended by a few loose stools in the day ; this state unless it appears to weaken the child should not be hastily tampered with, as it is often consistent with perfect health ; but where the evacuations by their copiousness and frequency manifestly injure the health and strength, the occasional use of the mixture No. 82 , along with proper attention to clothing and exercise will mostly effect a cure. OF THE FITS OR CONVULSIONS OF CHILDREN. Children in consequence of the great delicacy of their nerves are subject to convulsions from various causes, such as worms, dentition, small- pox, indigestion, and watery effusions on, or dropsy of the brain. The convulsions attending the eruptive fever of small pox commonly disap- pear when the eruption breaks out, an event which the warm bath is found to accelerate. The convulsions of dentition subside when the tooth appears ; but we should not wait for the spontaneous cutting of the tooth, because in many instances that process is slow and the fever and pain CONVULSIONS. 281 pain accompanying it might at length prove fatal ; there is an additional motive too for exerting our- selves to put a stop to the convulsions, because in my opinion the convulsions of infancy, from what- ever cause, if frequently repeated or long neglected, have a tendency to bring on dropsy of the brain, and that in persons in whom there had not been a vestige of this complaint previous to the convul- sions. In cases of dentition therefore the gums should be freely cut down to the tooth, an ope- ration often attended with sudden and extraordi- nary relief. In the convulsions produced by the irritation of worms, it is manifest that the expul- sion of the worms and of the slime in which they nestle must be the most useful practice, vide worms, page 153. Convulsions are likewise caused during in- fancy by indigestion, costiveness, and a collec- tion of acrid excrements in the intestines ; and if neglected they will at length return at very short intervals and infallibly kill. In a few of those cases of early fits, the cause is dropsy of the brain, but in the greatest number there is no dropsy, at least in the beginning of the complaint. Of this disease the following are the symptoms : SYMPTOMS. All the bad symptoms of griping and irregular bowels in children occur in this complaint, such as loss of appetite ; loaded tongue ; disturbed sleep; fretfulness ; 282 CONVULSIONS. fretfulness; foul breath; great heat of skin; costive- ness ; hard dark-coloured or whitish stools, very fsetid and offensive, and sometimes a scanty and putrid purging; along with these, convulsions appear and return at uncertain intervals; but the more frequent they are, and the longer they continue, the danger is the more alarming. CURE. In cases of convulsions the doses of purgatives require to be encreased considerably above the Ordinary doses for other complaints; we must not hesitate therefore about the liberal exhibition of these medicines, because the danger is not sub- dued until the torpor of the bowels is overcome, and a free discharge by stool is procured ; and upon copious evacuations taking place all the symptoms begin to vanish. Two grains of calomel, beat up with four grains of lump sugar and one grain of powdered cinnamon, will be a proper dose for an infant in this disease ; this is a very agreeable powder, and may be given in a little syrup or honey, or fruit jelly, &c. In the course of two hours after taking the powder, a tea-spoonful of castor oil will be proper to quicken and assist its operation, and unless a free CONVULSIONS. 283 free motion be procured in two hours after taking the castor oil, a smart glyster will generally succeed in bringing away the medicines already exhibited and a large excrementitious stool with decided relief to the patient. The child in the mean time should be occasionally immersed in the warm bath ; or spirits should be applied along with hot flannels to the stomach and belly ; these steps procure temporary relief, until a more decisive and permanent advantage is obtained by the ope- ration of the purgatives. If the treatment just mentioned fails to evacuate the bowels and to mitigate the convulsions, it will be necessary to go over the process again without delay, and to encrease the dose of the calomel as the practitioner may think necessary ; perhaps half a grain or one entire grain more of calomel may be added. Should the castor oil be nauseated, some infusion of senna warmed with syrup of ginger and some tincture of senna may be substituted, and will answer pretty well , but where the castor oil is borne by the stomach, it is a more suitable medi- cine. This practice must be repeated the follow- ing day, and continued day after day until the bowels are brought to a natural state, and the fits disappear \ but in proportion as the symptoms become milder, and the health returns, the doses of the calomel must be lessened, and the enema, and by degrees the castor oil omitted. In cases where the fits return at short intervals, we must begin 284 CONVULSIONS. begin immediately with large doses of the calomel powders, &c. and repeat them on the same day according to circumstances ; but where they re- turn at longer intervals, more moderate doses may be given at first, and if necessary encreased at the subsequent repetitions. After the purg- atives have operated, the anodyne and absorbent mixture No. 107 will help to calm the irritability of the nerves, and to correct the acrimony of the bowels, and is therefore useful in the intervals between the exhibition of the purgatives. Where in consequence of the long continuance of the complaint, and of the violence and frequency of the convulsions, we have reason to fear effusion on the brain might ensue, it will be proper to shave the whole of the head, to cover it with a large blister, which must be left on perhaps for sixteen hours, certainly until a vesication takes place, and to keep up a discharge from it with savin ointment or vesicating ointment until all danger disappears. After the fits have entirely subsided, the regularity of the bowels must be attended to for a few weeks longer. It will be good practice to give a moderate dose of calomel suited to the age of the patient once or twice a week for a whole month after. The child upon recovering is to be clothed in such a manner as to leave no danger of catching cold ; APOPLEXY. 285 cold; and instead of using .water, the head, if washed at all, must be washed with strong spirits : in short, whatever maintains an equable action on the surface, prevents the perspiration from being repressed, and thereby guards against a morbid determination to the internal parts, such as the brain and the bowels, must be carefully observed. APOPLEXY. This disease like gout most commonly visits the rich and luxurious, yet instances of it are met with amongst the laborious and the poor. SYMPTOMS. The symptoms may be divided into premoni- tory and proper. The premonitory symptoms, or those which precede the apoplectic fit, are head-ache ; vertigo or a swimming or reeling of the head ; nausea ; vomiting ; bad memory ; imperfect articulation; impaired vision; weakness or numbness of some part of one of the sides, as of the arm, of the leg, of the face ; the tongue, if thrust out, commonly turns to the side not af- fected. The degrees and modifications of impaired vision are very various, such as squinting, objects seen double, moates or spangles floating before the eyes. The degrees of impaired memory are likewise various, in some cases words are re- membered 286 APOPLEXY. membered, but ideas forgotten, and in some it is the reverse. Sometimes blood comes from the nose, and there is generally a turgescence or fulness in the face and eyes ; often an unusual drowsiness comes on, and, in some instances, fits of incubus or night-mare. It ought in general to be considered a fortunate event, that some of these premonitory symptoms occur, to announce the approach of the threatened danger ; because they suggest the imperious neces- sity of instantly flying to the most vigorous means for averting the attack. Whichsoever of those appearances takes place, we must be uniform in referring the mischief to the head, as the seat of the disease ; and accordingly direct our method of cure to the relief of the brain. The premon- itory symptoms demand the same remedies to which we would resort, if the fit had actually come on ; at this period they will often save the life of the patient, but when once the paroxysm has set in, it will in most cases baffle all the power of medicine, and prove speedily fatal. We fre- quently meet with melancholy instances of the truth of this observation. THE PROPER SYMPTOMS OF APOPLEXY. The symptoms which are found to occur upon the attack of the paroxysm, and during its conti- nuance APOPLEXY. 287 nuance are, the patient suddenly falling down ; a stertorous, slow, and noisy breathing ; a total loss of power in the muscles of voluntary motion ; pulse for the most part very slow and strong ; a throbbing of the carotid and temporal arteries ; face either pale, or bloated and livid ; a discharge of blood, sometimes from the nose, sometimes from the anus, and sometimes from the ears ; in some fatal cases the pulse is quick and weak a little before death. The fits of apoplexy are not always fatal, namely, when they are but slight ; and the patient will escape for that time, with a pretty strong certainty that, without particular care, they will visit soon again, and in a severer degree. Sometimes the use of appropriate remedies will break the force of the attack so as to avert the fatality with which it might otherwise have been attended ; in most cases however, in which a severe attack has once taken place, it generally happens, that though the patient survives, yet a paralytic weakness remains, either a weakness of the muscles of one side of the body, or of the lower extremities, (but this is rare) or a loss of speech either partial or total, or impaired vision, or imperfect and weak memory, or a palsy of the bladder causing a perpetual and troublesome dripping of urine. And even in those melancholy cases an apoplectic fit one time or other finally doses the scene. Apoplexy 288 APOPLEXY. Apoplexy when it proves fatal sometimes kills instantaneously, and sometimes not for hours, or perhaps one or two days, and when the attack has once commenced it will be extremely difficult to accomplish a perfect cure ; but proper atten- tion and skill will cure in many instances, if em- ployed upon the appearance of the premonitory symptoms, and before the apoplectic stroke has taken place. In young persons the chance of recovery is much greater than in the old. PREDISPOSITION. The persons most subject to apoplexy are those who have passed beyond the meridian of life ; per- sons of large heads and short necks ; the corpulent, the indolent, and sedentary; epicures; drunkards; such as are in the early part of life accustomed to activity and labour, and who afterwards become indolent ; of this description are those who are raised to unexpected or sudden affluence from a state of poverty ; gouty habits ; they in whom the piles entirely disappear, after having continued for years ; and persons of constipated bowels. CAUSES. The predisposition alone without the concur- rence of any unusual excitement, will cause apo- plexy ; but the disease is more certainly and fatally produced APOPLEXY. 289 produced, if an exciting cause be added to the predisposition. The cause might be whatever occasions pressure on, or congestion within the brain ; as external injuries to the head; tumorsor morbid enlargements within the cranium, an occurrence not unfrequently arising from old venereal complaints ; an accumulation of blood in the vessels of the head ; blood effused from rup- tured vessels within the head ; serous effusions into the ventricles of the brain, and therefore, suffo- cating, metallic and poisonous vapours, which obstruct the circulation through the lungs, and thereby create congestion in the head, will cause palsy and apoplexy ; also a fit of rage and violent passions may bring it on. A morbid state of the great arteries near the heart, and of the heart itself may cause apoplexy by obstructing the circu- ‘ lation and creating fulness in the head, such are ossifications, aneurisms, polypus : sometimes asthma, and dropsy, particularly of the chest, ter- minate in a fatal apoplexy. Full eating, especially of animal food ; heavy suppers ; indulgence in fer- mented liquors, such as ardent spirits, wine, strong malt liquors ; a sudden change from an active to a sedentary life; the drying up of habitual discharges, as of issues, setons, haemorrhoids or piles ; consti- pation and sudden stooping in predisposed habits, may cause a fit of apoplexy, and also exposure to a hot sun ; tight ligatures round the neck kill by inducing apoplexy. tj The 290 APOPLEXY. The most usual of those causes are indolence, intoxication, gluttony and over eating, external injuries, costiveness, and vehement passions. The exciting causes sometimes bring on a fit of apoplexy in persons of long necks and slender bodies. The symptoms of drunkenness are very like those of apoplexy : and such persons as are inclined to stutter and speak imperfectly from having taken strong liquor, have greater reason to apprehend apoplexy, as a consequence of intoxica- tion, than they whose tongues do not faulter somucli from the same cause. Hence an useful warning to drunkards, to beware at least of that excess which disturbs the articulation, and which in the midst of their festivity might prove suddenly fatal : eating to excess is oftener a cause of a fatal fit of apoplexy than even drinking to excess ; crowded and hot rooms will bring on a fit of apoplexy in predisposed habits; hence it sometimes happens, that at large parties, the noxious suffoca- tion of the air, the heat of the room, and the indulgence of eating and drinking to excess, are productive of sudden death.* cure. * Upon such occasions the melancholy event is announced in the public prints with an observation that the gentleman was in excellent health before dinner, never better in his life, that he eat and drank with good appetite and good spirits, and that he suddenly dropped down never to rise again, after making APOPLEXY. 291 CURE. From a view of the exciting and predisposing causes of apoplexy, it is manifest that the most valuable part of the cure must depend upon the conduct of the patients themselves. Sobriety, moderate eating, and that rather of vegetable than animal food, abstaining from suppers altogether, an active course of life, early hours, regular exercise, tranquillity and composure of mind, sleeping with the head raised high, attention to regularity of bowels, so as to have at the least one stool every 24 hours : all these circumstances should be attended to very strictly by those who have a tendency to paralytic and apoplectic com- plaints. The regimen here pointed out will contribute to form a loose habit of body, but if costiveness should still remain, purgatives must be occasionally employed, the medicine No. 3, is useful for such a purpose, and as apoplexy some- times requires larger doses than other diseases, the quantity of the purgative materials in the medicine might be encreased if necessary, and in a few u 2 hours making an hearty meal. It is scarcely necessary to observe that in those cases, the goodness of the appetite, the largeness of the meal, the excitement of the spirits, the seducing ex- cellence of the wine, and perhaps the heat of the apartment, were the causes of the sudden death. Hogarth gives a sketch of an election dinner, in which he represents a man dead of apoplexy with an oister on his knife. 292 APOPLEXY. hours after the pills, the purgative mixture No. 4, or a dose of castor oil, might be taken to improve and quicken their operation. It is before the visit of the apoplectic lit, as I have already urged, that remedies are most useful ; . therefore it is at this period all our resources should be employed : the head should be shaved, and the shaving repeated at least every week; spirits or a spirituous mixture should be rubbed to the head every morning. Tire bowels ought to be freely purged with a medicine containing a large portion of calomel, because from such a purgative we have the strongest grounds to rely on a complete removal of irritating and putrid excrements ; any purgative which passes quickly through the bowels may be given soon after, such is the mixture No. 4, the electuary No. 10, or castor oil ; low diet should be enforced : if from the appearances there is a strong probability that a fit is to be apprehended, we might recommend a large issue to be made in the back part of the neck, close to the head, so as to hold two or three orange peas. If a slow and strong pulse, with a turgid fulness of the face and eyes, announce alarming and immediate danger, blood should be taken instantly from the temporal artery, or from the arm ; in cases of less alarm, leeches might be applied to the temples. It APOPLEXY. 293 it may be very proper to observe, that in the situations here mentioned, namely, when the pre- monitory symptoms warn us of the approach of a serious fit, hesitation is fatal, a middling or timid practice is equally fatal ; upon those important oc- casions decision and vigour are imperiously de- manded. Strong irritating warm baths, with mus- tard and horse-radish, maybe used for the lower ex- tremities, and sinapisms may be afterwards applied to the legs or soles of the feet. In sudden danger, a large blister should be laid over the head, from the forehead backwards, and stretching down over the nape of the neck ; a layer of powdered flies having been spread over the plaister when made ; this blister may be left on for two days, and the discharge afterwards kept up with strong issue or savin ointment. The blister is best calculated for pressing and immediate danger ; the issue for the more slow and permanent purpose of securing the patient from future attacks. The vigorous treat- ment recommended here is more indispensible if the patient has been gouty, as the apoplectic attack of gout, or gout in the head, is one of the most alarming appearances of the complaint. ' When called to see a patient in the fit, all the practicable part of the above treatment should be adopted, such as bleeding from the arm and temples, shaving the head, strong stimulating baths to the feet, purging, if the patient can swallow, with 294 APOPLEXY. with very active pills, assisted by a purgative mixture or castor oil, and where swallowing is difficult or impossible, enemata should be thrown up, and repeated every one or two hours until the bowels are relieved ; the formula 83 is a good purgative enema in desperate cases. I have lately seen a striking instance of gout in the head, where this bold treatment restored the patient, although a palsy of one side had existed for some time before the fit of the apoplectic gout had attacked him. As in apoplexy the brain, which is the origin of all the nerves and of the spinal marrow, is the seat of the disease, it is not matter of surprise that a great variety of nervous complaints are apt to follow. Indeed in apoplectic patients, there is often observed a general mobility and delicacy pf the whole nervous system ; this state is marked by a tremulous agitation of the muscles of volun- tary motion. When the danger of the apoplectic paroxysm is removed, and this delicacy remains; it \yill be proper to recommend a plan in some degree different from that which was adapted to the apoplexy itself ; because in the apoplexy our objeci is to rescue from instant death, even at the hazard of debilitating the system ; in the other, that imminent danger being subdued, we ought to strengthen the frame, restore its functions, and endeavour to make it proof against future attacks. The PALSY. 295 The state of the bowels is to be closely watched, and if slow to be immediately relieved. Pills containing a large portion of aloe, as in No. 84, are well suited to this purpose. They preserve in general a regular state of bowels, without leaving a disposition to costiveness, as other purg- atives are commonly observed to do ; and when stronger purgatives are necessary, the pills No 3 might be employed with advantage. In delicate and old persons the draught No. 85 or 86 might be used with benefit, and repeated as often as the confined state of the bowels requires it. Regular exercise in the open air is indispensible when the weather permits, and had best be taken on horseback, or in an open carriage. With a view to quiet the agitation of the nerves, one of the cordial draughts No. 87, might be taken every morning. It sometimes happens that the patients will get a sudden fit of great nervous distress ; in such cases an aether draught as in No. 88 is our best remedy for procuring immediate relief ; but this is only adapted to a sudden emergency, and by no means to be used for a continuance. White mus- tard seed, swallowed whole, is sometimes of advantage to preserve a regular state of bowels, to stimulate the stomach, and to improve appetite. PALSY. Palsy is most frequently of the same kind as apoplexy, differing from it only in degree : it is 296 PALSY. is often the forerunner of apoplexy; and an apolectic fit if not fatal generally terminates in palsy. The symptoms of palsy are very various. There is often loss of memory, in which things are forgotten and words remembered, and vice versa ; in some cases, one language alone Out of many remains ; in some, the transactions of one period of life are recollected, and of other periods forgotten : the speech is imperfect ; the patient often endeavours to pronounce dif- ferent sentences, but the effort always termi- nates in the repeated pronunciation of the same sentence ; there is commonly an hesitation or stammering in the speech : there is a morbid diminution of the sensations, and of the powers of the muscles of voluntary motion, so that the patient is totally or partially deprived of feeling in the former case, and incapable of moving the affected limbs in the latter. There is sometimes a palsy of one, of a few, or of all the muscles of one side, though the feeling be natural ; and sometimes the feeling is lost, but the motion of the muscles remains, and there have been instances where the feeling was lost on one side and the power of motion on the other. A creeping is often felt over the whole surface, called formicatio : the limbs of the palsied side are frequently cold r and heavier than those of the other ; and sometimes, but rarely, the pulsation PALSY. 297 of the arteries is weaker in the palsied than in the sound side. The palsied limbs often become stiff and wasted, more especially where poison- ous gases or vapours, or poisons absorbed by the surface, or swallowed into the stomach, have been the cause of the palsy. CAUSES. The causes of palsy are generally the same as of apoplexy: rheumatism is also sometimes a cause of palsy. CURE. The cure is commonly similar to that of apo- plexy ; but the blood-letting, so indispensible in the apoplectic fit, is seldom or never necessary in palsy. In general, the exciting and noxious causes should be avoided ; these are already enu- merated in the description given of apoplexy, as intemperance in eating and drinking ; sedentary habits ; exposure to poisonous causes, however modified. The relation between the two diseases is analogous to that between acute and chronic diseases of the same sort, as between acute and chronic rheumatism. The variety of treatment is analogous also : the bleeding, for instance, so material, and often so indispensible in apoplexy, is seldom, if ever, required in palsy : but in palsy the necessity of a regular habit of body is the same : issues or a seaton in the back part of the neck. 298 PALSY. neck, close to the head, are particularly indicated in palsy : friction to the palsied limb, and often a blister to the origin of the nerves supplying that limb, and a long continued discharge from the blistered part, are of great use in palsy : the shaving of the head, and the regular and daily application of spirituous embrocations, as already recommended in apoplexy, are very useful in palsy. The limbs are often wasted down to a small size in palsy, so that the muscles become mere membranes. This is an occurrence more usual in palsy occasioned by poisons, as in colica pic- tonum, when that causes palsy. Where there has been undoubted evidence of affected brain, as the foundation of palsy, the use of electric shocks is dangerous ; and the cold bath is at least doubtful, if not dangerous likewise : sparks, however, may be taken from the affected limbs with safety and advantage. But where the dis- ease is the offspring of rheumatisms, or of poisons ; the bracing system of cold bath, electricity, chalybeate and light bitter medicines, is most effectual ; the bowels being kept in a regular state all the time. The palsied limbs should be uni- formly and constantly exercised, as much as they can conveniently bear ; this practice, in many cases, helps to restore a considerable portion of strength j and in a few instances it has been known ASTHMA. 299 known to renovate the health of the limbs alto- gether : friction produces the same effect, in a milder degree ; it may be applied with the flesh- brush or flannel, or with the naked hand, but it is more convenient to uge a little sweet oil, when the hand alone is employed ; and when we wish to combine with it the advantage of a strong stimulus, as will be proper in cases of great stiff- ness and diminished sensation, the stimulating liniment. No. 16, will be found very useful. The linimeni;. No. 89, is also excellent, particu- larly in the stiffness and palsy caused by rheu- matism. ASTHMA. This disease is often met with in Dublin at all seasons, but in the cold weather its attacks are most frequent and severe. A fit of asthma is marked by laborious breathing, accompanied by great and suffocating anguish ; there is a sense of tightness across the chest ; expiration and inspiration are difficult, and performed with a wheezing sound, as if the passage through the windpipe and lungs were greatly contracted ; during the fit speaking is very difficult, and in some instances nearly impossible; the patients gasp for breath and are obliged to sit erect : the cough in the beginning is difficult, interrupted and dry, but by degrees it becomes easier, and at 300 ASTHMA. at length a mucous expectoration is thrown up, which causes a remission of all the symptoms. The fits usually come on suddenly, more fre- quently in the night than at any other time, and continue for some hours, but remit towards morn- ing, when the patients generally fall asleep, and after some hours repose awake greatly relieved, but still with a slight affection of their breathing. The pulse is sometimes natural, but more com- monly quick ; the heat of the body is encreased ; the paroxysm is accompanied by sickness at sto- mach, by flatulence, and sometimes by head-ache. During the intermissions, the patients cannot bear fatigue, or great motion. After the parox- ysms remit, the urine, which was before pale and copious, is deep coloured, and often deposits a sediment. Towards night, the breathing becomes again laborious ; the fit is completely formed as before, aud runs its usual course ; and thus the complaint proceeds, the fits returning towards morning, until they gradually become less severe, and of shorter duration ; the intermissions longer and more free from laborious breathing : and after some days the attacks entirely subside. After- wards, it often happens that the patients enjoy a comfortable portion of health for a long time, without any annoyance from the complaint : but when once a fit of asthma has attacked, it is sure to return again ; and the patient cannot entertain ASTHMA. 301 entertain any well grounded hope that it has at any time taken its final leave : on the contrary, after having suffered from the repetition of some distressing attacks, the breathing even in the intervals continues hurried and laborious ; and if the patient gets a common cold or catarrh, it is sure to cause a very severe return of the com- plaint ; and in its advanced stages, a fit of it will occur in the day time as well as at night. Asthma is mostly a disease of advanced life, and frequently hereditary ; but there are many instances of its attacking very young persons, and even children are martyrs to it. Asthma will continue through the whole of life, and often of a long life ; but it more commonly proves fatjal before the period of old age, by breaking down the constitution by repeated attacks ; by ending in hamoptoe and pulmonary consumption ; by inducing dropsy of the chest ; or by a severe convulsive attack of it, terminating in apoplexy. Asthmatic persons are remarkable for high shoulders, narrow chests, and commonly a slight habitual stoop, or a slight inclination of the upper part of the body forward. When the system is predisposed to asthma, the slightest causes will provoke it : a paroxysm may be brought on by drinking a glass of water ; by flatulence or wind in the stomach and bowels ; by a full meal ; by perspiration 302 ASTHMA. perspiration being even momentarily checked, from exposure to cold. Catarrh or catching cold will cause it with great severity ; strong and violent passions, as rage, &c. and severe or fatiguing exercise will also bring on a distressing attack. As asthma often terminates in dropsy of the chest, so likewise is dropsy of the chest often accompanied by an asthmatic breathing. CURE. Riding on horseback is the best remedy for asthma, and for all cases of delicate lungs : the food ought to be light, easy of digestion, and taken in moderation : animal food should be taken very sparingly, especially in a solid state, because the distension of the stomach even with a large or full meal of vegetables, and still more of animal food, is apt to bring on a fit of asthma in predisposed persons. The strictest attention is required to the state of the bowels, and there- fore costiveness should not be permitted to exist for a moment ; for this reason the patient should be furnished with some mild purgative, which has the property of leaving a regular state- of the body, after its immediate operation is over ; such are the pills, 84 . The clothing should be com- fortably warm, in order to guard against the consequences of repressed perspiration ; and the composure and ehearfulness of the mind should be ASTHMA* 303 be supported by all possible means. As a bilious colluvies of the alimentary canal is frequently found in asthmatics, as is evinced by the foul and loaded appearance of the tongue, we should in such occurrences recommence some purgative analogous to the medicines No. 1 or 2, because they have the effect of carrying off this acrimony more completely than other purgatives. With respect to air, one rule will not hold in all cases. Some asthmatics will find the mild air of inland situations agree best with them, and this is most frequently the case ; others, the sharp and bracing air of the sea coast 5 and others, the loaded and im- pure air of large towns. The warm and mild air of inland and southern situations, how'ever, agrees best in the greatest number of instances, as has been already stated. Where the cold bra- cing air of the sea answers best, the prospect is most favourable, because it is manifest that the delicacy of the lungs is not then so great ; and because in those instances, the bracing plan of cold bath ; cool air ; and vigorous exercise is likely to be successful : but where this invigorating method cannot be resorted to, in consequence of its inducing a violent attack of the com- plaint, it is evident that the lungs are more deli- cate, and that the palliative treatment of guarding the patient from the exciting causes is the most that can be effected. Here however it will be proper to remark, that even under those circum- stances 304 ASTHMA. stances of morbid delicacy of the lungs, the plan of riding on horseback, or of exercising in an open carriage, may be sometimes so managed in young persons, as to cause that change in the habit of the patients which shall ultimately enable them to adopt the strengthening regimen : thus the duration of the exercise may be encreased day after day, so that in some time they can bear to be in the open air a great part of the day, and to begin at an early hour in the morning. The difference produced in the strength of the constitution, and in the firmness of the patient’s habits by such means, is sometimes very great : after sufficient strength is acquired by these means to enable the patients to v/alk without fatigue or danger of bringing on a fit ; they ought to unite both kinds of exercise, so as to walk and ride alternately ; and by degrees accustom themselves to spend the greatest part of the day in the open air, when the weather is favourable. By following this method, they will in several instances be enabled to approach that sharp air, which at first was intolerable ; and acquire firmness enough at length to exercise in that air also. Habits of sobriety must be strictly enforced ; and the patients ordered to sleep in a large room and on a firm bed with- out curtains. I have here dwelt on regimen and discipline more than I have on any medical treatment strictly so ASTHMA. 305 «o called, because the complaint is to be subdued more by attention to regimen than by the use of medicines ; but sometimes a severe fit of asthma requires the aid of medicine to break the force of the attack and to shorten its duration. When the patient labours under the symptoms of catarrh along with asthma, an emetic will be proper. One ounce of ipecacuan wine, with half a grain or a grain of tartar emetic dissolved in it, is a good and safe dose for an adult. On the following day a dose of the purgatives No. 1 , 2 or 3 might be prescribed according to the circumstances of the case ; or if there is no evidence of the bowels being oppressed with much acrimony, the mixture No. 4, may be recommended, or some other mild purg- ative, but in small bulk. The patient should be strictly restrained to low r diet, and to the use of emollient and subacid drink taken tepid, such as whey, fresh buttermilk and such like. In cases of asthmatic and of quick breathing, I have found great benefit from an expectorating mixture, con- sisting principally of a solution of asafaetida as in No. 68, the mixture No. 69 is less nauseous and fre- quently very useful in such cases, but in delicate persons these mixtures will sometimes sicken ; we may then try the expectorants No. 66 or 67. It is during the existence of catarrhal symptoms that these formulae are most proper ; but when the fit is purely asthmatic, or when the catarrhal symp- toms are mitigated, so that the asthmatic are now x the 306 ASTHMA. the predominant symptoms, the draughts No. 90, or 9 1 may be taken to allay the difficult breathing, and repeated as often as the oppressive breathing may return. Very small doses of ipecacuanha in powder taken at night, are also frequently found to mitigate the distress of asthmatic breathing, and their efficacy is sometimes encreased by adding to them a small particle of opium. In some cases of catarrh combined with asthma, the sense of op- pression and the irritating cough derive great benefit from a blister between the shoulders. Bleeding in severe cases of the same combination will be necessary, and will give immediate relief ; but in a purely asthmatic fit, unaccompanied by catarrh, bleeding is not only a doubtful but a dangerous remedy. Gout frequently assumes all the distressing form of asthma, and that sometimes in robust persons. The delicacy of health during the exist- ence of this treacherous complaint is marked by a sallow complexion ; impaired appetite ; inapt- itude for the ordinary exertions and habits of in- dustry or employment ; a bilious loaded tongue ; flatulence and uneasy tension of the belly ; irre- gular secretion of urine, sometimes copious but more commonly scanty ; and an imperfect evac- uation by stool, accompanied by straining similar to that of dysentery. At night the patient is suddenly seized with quick breathing, oppression about ASTHMA. 307 about the chest, and feverish hurried pulse ; he is obliged to start up, sit erect in bed, and some- times to throw open the window to relieve his breathing. This modification of gout is not unusual, though in many instances where it exists gout is not suspected. Here the purgative pills already re- commended are decidedly valuable, as the removal of the acrid alimentary mass by means of appro- priate evacuants gives instant and completere lief. Exercise on horseback, attention to the state of the bowels, and a rigorous injunction to avoid all excess in eating and drinking, should be strongly enforced. Country air and exercise agree much better with those gouty asthmatics than the habits and air of the town ; even the severe exercise of hunting and shooting will rather brace than fatigue them in many instances. Along with the directions of attention to sobriety, regularity of bowels, and moderation in eating already recom- mended, the strengthening and chalybeate pills No. 35 might be taken during the intermissions with advantage, and washed down with one of the draughts No. 87. These medicines are well adapted to gouty infirmity, as they are calculated to strengthen the stomach and the whole system, and thereby to correct the wanderings of its at- tacks, and to give them a fixed and regular form. x 2 CHINCOUGH. 308 CHINCOUGH. CHINCOUGH. This is a common disease in Dublin, and gene- rally to be found in those seasons in which catarrh and measles are prevalent : indeed there is seldom a season in which some cases of it might not be met with, but its greatest frequency and severity are known during the winter and spring. It is a convulsive disease and propagated by contagion, and like most contagious diseases it is often epi- demic. Its attacks are principally confined to children and young persons, like all those diseases which seldom occur but once through life : grown persons however, and even the aged, who had it not in the preceding course of their lives, may be attacked by it. In the beginning it appears like a common feverish cold ; but by degrees its real character is evolved. It is not until the end of the second and sometimes of the third week that the whoop or kink sets in, and points out the genuine nature of the complaint ; it is often met with in dispensary practise. The patients appear in the beginning to have got cold, but when the marks of the disease commence, the cough is found materially different from that of a common cold : it consists of a violent convulsive expiration frequently repeated by successive efforts, without the intervention of an alternate or reciprocal inspiration, This suc- cession CHINCOUGI-I. 309 cession of short expirations is called a kink, after which the patients, who are now ready to perish from want of breath, when the lungs appear entirely exhausted of air, have a rapid noisy inspi- ration, as if through a streightened passage, until a sufficiency of air is again received into the lungs to enable them to repeat the former process of short, quick, and rapidly succeeding expirations ; and thus this convulsive cough, succeeded by a noisy and violent inspiration, is frequently repeat- ed, until some viscid mucus is expectorated, which is commonly followed by an effort to vomit ; and this puts an end to the paroxysm or fit for the time. During the continuance of the fit, the face grows turgid and red, the eyes are swelled and suffused, and the pulse becomes quick and feverish. After the fit however it often happens that the little patient, although for a moment exhausted and weary, soon resumes his usual amusements and chearfulness, and does not seem to have suf- fered any serious mischief ; even the appetite is not impaired ; and there are instances of cases so very mild, that the patient is attacked during sleep, and passes through the fit without awaking. Frequently too the complaint has an evident effect upon the health and strength of the patient, who continues for some time after the fit exhausted, tottering, and stupid. Sometimes the force of coughing causes hoemorrhages or discharges of blood from the nose and from the lungs ; some- times 310 CHINCOUGfi. times hernise or ruptures, and sometimes a pro-* trusion of the anus are the consequence ; and in many instances the accumulation of blood in the head becomes so great as to bring on an apoplectic paroxysm. In the progress of the disease, the approach of the fit is perceived by the patients who will catch at any person or thing within their grasp, in order to support themselves during the distress of the approaching attack, and sometimes they will seize upon their own throat, in order to check or to stop it altogether. CURE. In the beginning when the disease has the ap- pearance of common cold, it may at least in most instances be treated like catarrh, that is with the exhibition of an emetic ; and this practice either with a view to the catarrhal appearances, or to the probability of incipient chincough is judicious and proper ; the emetic may be repeated once and again during the symptoms of catarrh. But when it assumes its genuine character, emetics must be given with considerable caution, because they weaken the constitution, and have a tenden- cy to make the disease more obstinate. Bleeding also is to be avoided, unless the violence of the fit threaten apoplexy or the rupture of a blood-vessel. Expectorants are the remedies principally to be relied on. The mixtures No. 92 or 93, taken by spoonfuls. CHINCOUGH. 311 spoonfuls, and repeated at short intervals three or four times before the fit begins, will often break its force and shorten its duration. In cases where these mixtures may prove too inert or mild, the formula No. 94 may be taken. If the patients are under six years of age, the quantity of the opiate in these medicines ought be diminished. Warm clothing, exercise in an open carriage, and change of air are of great service, but the change should not be from a warmer to a cooler air ; but rather to a warmer air, from air not so warm. I have known instan- ces of bad consequences having followed the re- moval from Dublin to the seaside in this com- plaint. This is a circumstance that should be carefully attended to, and which I have reason to believe has been too frequently neglected. I tried the expedient of filling the bed-room of the patients with nitrous vapour in two instances of delicate children, and with decided advantage. This is a practise which appears to me entitled to serious trial in dangerous cases of chincough. There is no disease on which more quackery has been expended than chincough. Liniments rubbed to the surface have been greatly applauded and are daily employed ; there is one particularly, in high estimation, of which oil of amber forms the basis. The 312 CHINCOUGH. The most plausible applications of this sort, are those which contain anodyne qualities. I have uniformly found in convulsive cough, as well as in all other modifications of cough, that where the bowels are slow, and the tongue bilious and loaded, an appropriate purgative, such as the powder, No. 52, will not only relieve the first passages from the foul contents, but also greatly mitigate the severity of the cough ; this powder is a proper dose for ordinary constitutions, about twelve years old, and should be modified according to the age and the delicacy of the patient. This purgative ought be repeated whenever a new accumulation of sordes takes place, an event which the loaded tongue, the slow bowels, and the uneasy feel about the prae- cordia will announce : if this does not operate in the course of five or six hours, a spoonful of castor oil, proportioned to the circumstances of the patient’s age and constitution, will be useful in rendering the operation of the powder more speedily efficacious. I met with two alarming instances of chincough in the month of February, in two very young, and delicate children, who had neither the vaccine nor small pock. From the period of the year, the delicacy of their constitution, and the ten- derness of their age, one being only two months, and CHINCOUGH. 313 and the other fourteen months old ; I entertained but slender hopes indeed of their recovery. I determined to try how far the habit and severity of the disease might be shattered and subdued, by subjecting the system to the action of a strong fever ; and accordingly inoculated both with the infection of small pock, (I preferred small pock to the vaccine pock on this occasion, because its fever is more violent, causes a greater shock to the body, and therefore holds out a better pros- pect of overcoming a powerful morbid action, under the influence of which the system al- ready laboured,) My views were happily gratified. The severity of the disease was so dissipated by the fever of the small pock, that after its departure, the convulsive symptoms of chincough had disap- peared, and only a slight cough remained, which in a little time was removed likewise ; and left the little patients in a state of convalescence which soon improved into perfect health. In alarming cases, preparations of the leaves of cicuta or hemlock, and of hyoscyamus or henbane, should be tried, particularly the latter, a few drops of the tincture of which are found to produce anodyne effects, in convulsive com- plaints, sometimes better than opium ; without being attended with the inconvenience of causing a constipation of the bowels. LEUCORRHjEA. 314 LEUCORRH^EA. LEUCORRHjEA, FLUOR ALBUS, OR WHITES. This complaint is often met with in Dublin, particularly among the poor. It is accompanied by pain of the back and loins ; paleness of face, and of the whole surface : the stomach and bow- els are injured in their functions, hence proceed loss of appetite, and irregularity of the bowels, but mostly costiveness ; the tongue is foul and yellow ; and there is a feeling of oppression at the pit of the stomach ; the spirits are generally depressed ; the patients are unwilliug to make any exertion ; and in several instances there is a light- ness or reeling of the head : a white or yellowish mucous fluid is discharged by the vagina, some- times in small quantity, and at the usual interval of the catamenia; but the discharge is often copious and returns at much shorter periods ; and in some cases the relaxation becomes so great, that there is almost a perpetual discharge with very short intermissions. The train of symptoms which characterise this disease will commonly disappear with the discharge, and return perio- dically along with it : in many instances, parti- cularly in the higher ranks, the matter is some- times a mucous fluid, and sometimes blood ; and at the monthly periods, there is frequently a pro- fuse evacuation of the ordinary appearance, which, as it diminishes and is about to cease, loses its colour LEUCORRHiEA. 315 colour, and becomes similar to the mucous dis- charge of flour albus. In irritable habits it is often accompanied by hysteria, and when it has long continued without any relief, it has a ten- dency to terminate in dropsy. CAUSES. The habits of fashionable life, such as late hours ; want of exercise ; warm liquids, such as tea and coffee freely used ; the custom of being restrained from the use and exercise of the limbs in the open air, and of being carried about only in a carriage, greatly dispose to this complaint : dress likewise often leads to it, especially such as by "squeezing or pinching the soft parts of the body confines the circulation, and restrains the easy and healthful motions of the limbs and trunk of the body. In humble life, the complaint is occasionad by labour ; fatigue ; want of comfortable clothing ; exposure to cold ; and sometimes by habits of intoxication : frequent abortions will cause it ; and in females who suffer long from its attacks irremediable barrenness is often the consequence ; or though pregnancy take place, there is neither vigour nor health of constitution sufficient to enable the infant to arrive at maturity, and mis- carriage commonly ensues. Sometimes 316 LEUCORRH^EA. Sometimes a cancer of the womb is attended with all the painful symptoms of profuse mens- truation, and of flour albus ; and though the cause be permanent, yet the complaint will observe periodical returns. Venereal intercourse during the existence of leucorrhaea will greatly exasperate the symptoms. CURE. The first and most important step in effecting a cure, is to correct the habit, if possible, which predisposed to the complaint ; but it is often extremely difficult to correct inveterate habits, nowithstanding the pernicious consequences which manifestly result from their indulgence. If there be evidence of foulness of stomach and bowels, marked by pain and fulness of the pit of the stomach and hypochondria, by costiveness, and most particularly by a loaded tongue ; an appro- priate purgative is to be administered, to carry off this foulness, such as the medicines, No, 1 or 2, and they might be repeated twice a week, or oftener, according to circumstances, until the healthy secretion of the stomach and bowels be restored : afterwards the piluhe rhei composite of the Edinburgh dispensatory may be occasionally used, whenever LEUCORRH^EA. 317 whenever the bowels are confined : such a treat- ment alone will in many instances cure this complaint, as I have sometimes experienced : and in all cases of leucorrhaea, it will be found an useful auxiliary, because in all cases it will be an indis- pensible step to free the alimentary canal from its irritating and morbid contents, and to restore the sound secretions of this important part of the system. After this evacuating method has been properly premised, the most valuable remedies are those which have the general effects of bracing the sys- tem; and such as are peculiarly fitted to strengthen the uterine organs ; of this class are the astringent mixtures. No. 81 or 82 ,* cold water topically applied by means of a linen cloth or napkin, is useful in this way, and in slight cases of the complaint, will sometimes effect a cure; exercise is also proper either on horseback, in an open carriage, or on foot, according to the constitution and vigour of the patient ; but it should be always moderate, and within the limits of the patient’s strength : the cold sea bath or shower bath is an excellent remedy, and ought be persevered in for a long * The rubia tinctorum or madder root, has been in high estimation in this complaint ; and from its astringency seems intitied to more respect than is now paid to it ; as it is at present almost omitted in medical practice. 318 MENORRHAGIA. a long time ; lime water, both simple and com- pound, has been sometimes found useful. The cordial mixture. No. 78 , is a good roborant, after the medicines adapted to the evacuation of the bowels, and to the constringency of the parts affected, have had a proper trial, and might be exhibited for a long time with decisive advantage. MENORRHAGIA, OR PROFUSE MENSTRUATION. Too copious a flow of the catamenia is ana- lagous in most of its symptoms and causes to leucorrhaea. The quantity of the discharge is not only excessive, but it returns at shorter inter- vals, continues at each period for a longer time than the natural evacuation, and is accompanied by the weakness of leucorrhxa. The melancholy consequence also of barrenness and of miscarriage, enumerated in treating of Jeucorrhcea, will follow with equal certainty in this complaint. The method of cure is the same as that of leu- corrhsea. At the period when the catamenia' are about to cease, an irregular kind of menorrhagia occurs. Sometimes the discharge is profuse and returns at short intervals; sometimes the intermissions are longer than natural ; and sometimes the quan- MENORRHAGIA. 319 tity of the discharge is very scanty j and those varieties in its appearance as to quantity and period succeed one another, with considerable ir- regularity. CURE. The complaint in those instances must be treated with such remedies as are calculated to preserve a regular state of the bowels, and to al- leviate present distress. The purgative medicines No. 1 and No. 2 are properly qualified for this purpose, and they may if necessary be assisted by the purgative mixture No. 4, or by a dose of castor oil and tincture of senna taken in a few hours after. These medicines might be resorted to from time to time, as often as there is a con- stipation of the bowels accompanied by a fulness of the prsecordia, or a bilious foulness of the tongue ; but with a view merely to preserve a regular state of bowels, when there is no evidence of morbid coiluvies of the alimentary canal, a moderate dose of sulphat of magnesia and two grains of powdered ginger may be taken at bed time in some agreeable water, such as peppermint or cinnamon water, or with an infusion of roses, as in No. 49, and frequently repeated. The treatment here recommended will in most instan- ces be fully sufficient to remove any pressing dis- tress and to preserve a comfortable portion of health throughout this delicate period. But if the quantity 320 CHOREA. quantity of the menstrual discharge become so great, or return at such short intervals as to weaken the system considerably, and to threaten dropsi- cal consequences by a pale swelling and stiffness about the ankles, legs, and feet ; the medicines, No. 34, 35, or 37, may be taken for a constancy, until appearances of decisive improvement take place ; with these may be combined with much advantage the cold salt bath or shower bath, when the season of the year is favourable ; the bath is a strengthener of superior efficacy, particularly in cases of relaxation, like those of the present complaint. In two or three years the constitution generally becomes adapted to the change ; the strength is re-established, and in many instances the patients enjoy for many years after a more comfort- able portion of health than they were ever blessed with in the preceding course of their lives. CHOREA, OR ST. VITUS’S DANCE. This is a complaint of youth, from the age of eight or nine, to that of puberty about the fifteenth year. Its attacks are confined to the delicate and relaxed of both sexes ; but more commonly to females than to males : it is however a very rare disease, and so seldom met with in males, that it is CKO REA. 321 is most commonly considered a sexual disease. I have seen a few cases of it in dyspensary practice, and but a very few in private practice. The symptoms of it are an hobbling or unsteady motion of one of the lower extremities, which in walking is more or less dragged along with a starting or jumping of the limb, that cannot now be lifted firmly as in its healthful motion in walk- ing ; the complaint in many instances is confined to this symptom ; but when it becomes more severe, one of the arms is convulsed in a similar way ; and when the convulsed limb is held steady by force, the corresponding limb, which was steady before, is now agitated like the affected limb ; in more severe cases the muscles of the head and jaw are also disturbed by irregular con- tractions ; there is an evident alteration in the general appearance of the health, particularly when the disease has continued for a long time ; the spirits and usual playfulness are lost ; the belly becomes uncommonly hard and swelled ; the bowels confined ; and the tongue foul and loaded. Those however are the symptoms of chorea com- pletely formed, and after it has continued a long time. CURE. I treated the few mild cases which occurred to me on the principle of the disease being connected with Y 322 CHOREA. with a morbid secretion of the stomach and bowels; and with success.* I recommended the powder No. 52 to be taken in the morning, and in four or five hours, a dose of the purgative mixture No. 50 to be used if necessary, and repeated every two hours until the bowels were relieved ; this method to be resumed as often as the bowels were slow, in such a manner that there should be an evacuation at least once a day ; and to be persevered in until the stools, which at first were generally dark coloured and faetid, began to assume a natural appearance ; the bov/els afterwards to be kept regular by means of gentle laxatives or glysters. It is not necessary that the calomel purgative should be persisted in throughout the continuance of the complaint ; after being exhi- bited three or four times, other purgatives wall generally answer, such as the mixture No. 4, of which a dose may be taken every two hours until the * For the simplicity, the propriety, and success of this treatment, I profess myself indebted to the valuable pubn lication of Doctor James Hamilton of Edinburgh on the effects of purgative medicines, a work which I hold to be one of the greatest treasures that has been published on the practice of medicine. At the same time I must candidly own that I conceive its value would have been much greater, if he had made a distinction between the qualities and effects of jthe different purgatives he recommends, and pointed out those varieties of symptoms and of disease, which required particular purgatives, in preference to others ; with an explanation of the reasons for such a preference. CHOREA. 323 the bowels are relieved ; but I conceive the calomel purgatives decidedly the best in the beginning, because they are the most powerful in dislodging morbid excrements, and in correcting depraved secretions ; other purgatives will afterwards keep up the action of the alimentary canal. By degrees, in consequence of this treatment, the irregular motions of the muscles subside, and health returns. On the intermediate days, some agreeable tonic medicine might be ordered, such as the mixture No. 18, and of this a table spoonful taken in the morning and middle of the day. After the natural action of the bowels is restored, and the tremors begin to subside, it will be proper to recommend chalybeate and strengthening reme- dies, with a view to the state of the stomach, and to brace the system ; such as the pills No. 34, 35, or the draughts No. 45 : when the pills are taken, they might be washed down with a table spoonful of the mixture No. 18. In most cases however, particularly when recent, I am strongly disposed to believe, that the purgative plan alone will be competent to banish the complaint. The cold shower-bath or sea-bath, where the constitution ean bear it, may be used two or three times a week after convalescence has begun, if the season of the year permits ; and is an excellent remedy both to restore the health of the system, and to guard against a return of the complaint. y 2 OF 324 CUTANEOUS DISEASES. OF CUTANEOUS DISEASES. In Dublin we meet with considerable variety of those cutaneous diseases, which though some- times connected with a vitiated secretion in the stomach and other viscera, yet are not attended by any specific fever ; which are of uncertain duration ; and which, if cured, may again return as often as the system is exposed to the operation of the same cause which produced them at first. Of this description the most common and general are the following. PSORA, OR ITCH. This complaint is purely cutaneous, and has little effect upon the constitution, except where, by becoming neglected and inveterate, it produces such a general irritation, as is inconsistent with sound health. The appearances of psora are well known : they consist of' distinct vesiculae filled with a slightly opake fluid, and caused by animalcule that creep along under the cuticle. The eruption is attended with intolerable itching, which is always most distressing when the warmth of the affected parts is e creased by being close to the fire, or by be mg heated in bed. As the animalculae creep on, new vesicles are formed, the fluid of the old ones CUTANEOUS DISEASES. 325 ones concreting into small crusts or scabs ; and thus in a short time each distinct eruption consists of a line, at one end of which is the most recent vesicle, and at the other the driest and darkest part of the crust : and in several of these erup- tions the crust at one end becomes detached from the skin, a new cuticle being formed underneath, whilst , there is a vesicle at the other end still filled with a fluid serum. These eruptions are principally seated between the fingers, upon the inside of the wrists, about the axillae, and the knees ; but by degrees they spread over the thighs, legs, arms, loins, and the fore part of the belly. The old marks dry up and new eruptions appear in encreased numbers ; and thus the complaint gains ground until it dis- figures the greater part of the body. In process of time the crusts become larger ; and a quantity of purulent fluid is discharged from beneath them. If the crust be removed, the fluid soon concretes into another crust, under which new matter is produced. The severity of the itching is now very trou- blesome ; the whole skin acquires a disgusting and dirty look ; at length the eruption spreads over the chest and back, and last of all over the jaws and cheeks ; and the patient begins to decline in health and flesh very sensibly. The 326 CUTANEOUS DISEASES. The regularity of the pustular lines already mentioned is not to be found in every place where the eruptions appear ; because the itchiness is so troublesome that the nails in scratching lacerate and destroy the cuticle, and frequently cause a severer degree of inflammation and a more ex- tensive sore than would otherwise have existed : and this is, at least in part, a reason why in cases of inveterate itch the inflammation is greater, and the crusts larger than when the complaint is recent. CURE. Sulphur is the safest and most certain cure for psora. In infants the sulphur may be given inter- nally, and thus it will effect a cure, though slowly, if the nurse uses sulphur ointment at the same time : but it is evident that it w ill be useless to give medicines to the infants, unless the nurse also has recourse to them. Brimstone will com- municate to boiling w T ater a sufficient impregna- tion to cure infants ; the affected parts being bathed with the water when tepid : indeed w r hen the nurse rubs sulphur ointment for her own cure, the sulphur vapour issuing from her w ill of itself commonly cure an infant who lies with her. The speediest method of completing the cure is to rub strong sulphur ointment to the affected parts every night until the complaint disappears : and it is adapted to every age after the first two or three years. During CUTANEOUS DISEASES. 327 During the use of this remedy the patients ought be careful to avoid all danger of catching cold. For the greater convenience of banishing the complaint in the most satisfactory manner, they should be directed to wear the same clothes, as much as it could be done, throughout the whole progress of the cure ; because the impregnation of the clothes becomes so strong, as to assist greatly in effecting a cure ; and the sulphur taints them to such a degree that it becomes nearly impossible to use them afterwards. When the sulphur has completely penetrated the system, the eyes generally become slightly sore ; this, how- ever, is but a trifling and temporary inconve- nience ; as they get rapidly well when the use of the medicine is laid aside. In most cases of recent itch about a fortnight’s rubbing will be sufficient to remove it. When the itch becomes inveterate, and puts on those appearances of superficial sores, covered with large crusts, already mentioned ; the sulphur alone will prove ineffectual. We must then have recourse to mercurial alteratives. I have found the pills. No. 96, and the warm bath used once a week, completely answer in the cases of this sort that I met with ; and I suspect that this treat- ment will remove the worst kinds of itch which offer themselves to our notice. Itch 328 CUTANEOUS DISEASES. Itch is contracted by poor, crude, and unwhole- some diet *, by foul and dirty clothes and habits ; and by contagion : it will therefore be necessary to avoid those occasional causes in order to guard against a return of the disease. DISTINCT SCABBY SORES OF ADULTS. There are other forms of eruptive complaints, in which the striking features are an inflamed margin, most commonly of a circular form sur* rounding a superficial abscess, which is covered over with a dark coloured crust or scab ; upon pressure there issues from under the crust a red- dish coloured thick pus. These sores begin like inflamed red papuke, which soon enlarge into pustules of the same colour, and commonly of a conical shape ; these are filled with an opaque purulent fluid, and surrounded by a slightly in- flamed border, which enlarges as the pustule en- creases in size. The pustule, if broke or abraded, leaves underneath a raw surface, which becomes covered with a scab, and under this matter is soon collected ; and so on, as often as the contents are discharged, or the incrustation removed, there is more matter formed and covered again with a crust similar to toe foimer. These eruptions are most conn .only seated upon the thighs, and but- tocks, over the glutaei muscles, and upon the legs and CUTANEOUS DISEASES. 329 and feet; and after some months, continuance they will spread over different parts of the arms and trunk of the body. They are not crowded together or confluent like the crusts of inveterate itch, but continue scattered and detached from each other, with large intervals of sound skin between them ; they have each a larger base than any of the incrusta- tions of the itch ; and they are seldom attended by itching, at least to any considerable degree. The itch is rarely found except amongst the lower orders, who live in poverty and dirt, and are much exposed to its contagion ; but these distinct circular eruptions are found amongst per- sons of the cleanliest habits, and in the most comfortable ranks of life ; they do not seem to affect the general state of the health ; but it ap- pears that like itch they may be propagated by contagion. These eruptions, as well as many others, have a great connection with the state of the alimentary canal, and therefore a principal part of the treat- ment must consist in a proper attention to the regularity of the bowels. CURE. The cure in those eruptions is effected by mer- curial alteratives ; by purgatives calculated to re- move 330 CUTANEOUS DISEASES. move bilious acrimony and morbid secretions ; and by the warm bath. The pills No. 96 will in most instances prove excellent alteratives and open the bo^vels ; but should they fail to operate as purgatives, then we may employ the medicines No. 1 , 2 or 3, assisted if necessary by liquid cathartics. The medicine 96 should be regularly exhibited until the erup- tions entirely disappear. The warm bath used twice a week will greatly assist in forwarding the cure. I have found this treatment uniformly suc- cessful, except in two cases, in which the eruptions had spread to the legs and feet ; in those cases too, in consequence of the method here recom- mended, the eruptions had entirely disappeared on all other parts, but still continued obstinate on the upper part of the legs ; here I had the sores dressed daily with the ointment No. 97, and then applied a flannel roller about the feet and legs, beginning at the toes and coiling it upwards to the knees. This method, along with the alteratives and warm bath, soon effected a complete cure. Here it may not be improper to observe that one of those obstinate cases occurred in a married young lady, who had been treated with mercurial unction in the country, until she had been plunged into a profuse salivation, which had no other effect but that of injuring her teeth and weaken- ing her constitution for the time. PUSTULAR CUTANEOUS DISEASES. S3 1 PUSTULAR ERUPTIONS OF CHILDREN. This is a cutaneous foulness of a peculiar and distressing kind. At its commencement it consists of a crop of papillary eruptions which soon fill with a serous fluid ; the cuticle being elevated into a conical vesicle in which the fluid is con- tained. Here the vesicles are distinct, though spread pretty thick over the skin, without that line or continued mark which is peculiar to the itch. When the cuticle is abraded, a tender sur- face is exposed, which becomes soon covered with a crust formed of the oozing matter of the pus- tule ; these crusts are in a little time renewed after being rubbed off, and spread thick over the surface of the body ; on the face ; behind the ears ; and at length over the hairy scalp ; and as the disease becomes inveterate, they encrease in size, so that in many places from approaching close together they become confluent ; and the scabs covering them unite into a large convex in- crustation in many places, which when lifted up discharges a great quantity of a yellowish fluid, and leaves an extensive surface raw and sore: these eruptions are but slightly itchy. On many parts of the body, the bases of the sores are so much inflamed as to exhibit the form of running ulcers, very painful, and of a dirty aspect. This disease in many instances leaves no part of the surface free $ even the soles of the feet and the hairy 332 CUTANEOUS DISEASES. hairy scalp become covered with pustules ; and on the feet it causes the appearance and all the distress of chilblains, completely crippling the little patient. This is the most universal eruptive disease un- connected with fever, that is perhaps to be met with. When it becomes inveterate the sores are surrounded in several places with a troublesome inflammation ; and the health is sensibly under- mined. Most of the instances of this kind which oc- curred to me, were in the comfortable ranks of life, where good air, cleanliness, sound food, and proper clothing were used : they have also occurred in large and otherwise healthy children ; so that the complaint could not be fairly ascribed to those circumstances which are generally sup- posed to produce the itch. In some of those too, the sulphur ointment had been used very liberally without any benefit. CURE. In this eruption the cure is effected without the aid of sulphur ; indeed that remedy appears to have no power whatever in assisting to remove the complaint. The CUTANEOUS DISEASES. 333 The following is the method which I have ex- perienced to be uniformly successful. The body is to be kept clean and comfortably warm* with a view to promote the healthy and natural action by the surface. The head to be shaved two or three times a week ; to be afterwards bathed with spirits, and dressed every morning with pepper ointment, and then to be kept covered with a warm cap. The medicine, No. 101, # along with this discipline, is the only mode of treatment necessary for the removal of this disease : by persevering in this mode, the sores soon manifest a disposition to heal and dry up, and the crusts to fall off, leaving underneath a sound but at first a tender cuticle, which by degrees recovers its natural qualities and colour. The sores on the feet have a disposition to heal more slowly than on other parts of the body : they may be then dressed daily with the ointment, No. 97, spread on soft linen ; and the limb should afterwards be covered with flannel rollers, coiled from the toes to the knees. Immersion in the tepid salt bath once a week is a pleasant and useful auxiliary. By * The dose ordered in this formula is fit for children from two to four or five years old, and may be repeated every third morning ; or, in cases where they do not affect the bowels st erely, every second morning. In robust children too, it will b necessary to augment the dose; but these particulars can only be regulated by seeing the patient, and ascertaining from experience the nature of his constitution. 334 CUTANEOUS DISEASES. By persevering for some time in the treatment above recommended, the worst species of the complaint disappears. r LEPRA, OR DRY SCALY ERUPTIONS. Lepra is a disease sometimes met with in Dublin : the severest instances I have seen were in dispensary patients, and consequently among the poor ; but it occurs also in the better ranks of society. It consists of circular or oval patches, from the size of a silver shilling to that of half a crown piece, and sometimes they are larger ; I have seen some larger than a crown piece, but they are rarely of this size*. The affected part is cover- ed with whitish thick scaly crusts, and circum- scribed by an inflamed margin, slightly elevated above the surrounding skin: when any part of the scales is forcibly removed, it exposes to view a purple coloured sore and inflamed surface. They fix at first commonly upon the arms and legs ; and advance nearly in the same manner along the corresponding limbs of both sides ; thus if the arms are the seat of the disease, the eruptions appear equally situated, and equal in number on both arms ; but this resemblance does not exist in every instance, though it is the most usual occurrence : they afterwards break out on the thighs and on the trunk of the body ; and if neglected, they spread to the hairy scalp ; indeed CUTANEOUS DISEASES. 335 indeed when they attack this part, they are more crowded and the crusts more thick and more elevated upon it, than upon any other part of the body. I could not ascertain that this complaint was contagious, or necessarily con- nected with any derangement of the system. The severest instance of it which fell under my observation was in a young woman, about twenty years of age, in whom the catamenia had been suppressed for many months before I saw her, but the lepra had been of long standing ; and in others the general health was perfectly good. Most of those in whom I met with th : s com- plaint were females, occupied in sedentary pur- suits, exposed considerably to impure and damp air, and to want of cleanliness. i CURE. The method of cure which 1 found successful was the following. The head, when that was affected, was shaved and regularly dressed with strong pepper ointment : the sores on the body were dressed with citrine ointment ; or in cases where the soreness was severe, with equal parts of citrine and spermaceti ointment. The alterative pills, No. 96, were regularly exhibited at bed-time, and the alkaline infusion, No. 100, taken every morning. The regularity of the bowels was preserved. 336 CUTANEOUS DISEASES. preserved, if necessary, by the use of sulphat of magnesia, phosphat of soda, rochelle salt, or some other purgative of quick operation ; and if there was any uneasiness experienced from griping or tormina, a dose of castor oil soon procured relief. The warm salt bath was- used when prac- ticable, at least once a week. TINEA, OR SCALD HEAD. This bears a very striking resemblance to the preceding disease ; the hard and thick crusts of both are very like one another : but in the lepra the head becomes seldom affected, and the tinea is commonly unattended by an eruption upon any part of the surface except the head. Tinea is a well known complaint, and consists of whitish hard thick crusts, clinging firmly to some part of the hairy scalp, extremely difficult to remove, and strongly attached to the bulbs or roots of the hair, which is but thinly scattered over the diseased surface. The whole part affected is hard and stiff. This complaint does not appear to have any sensible effect in injuring the general health. It is seldom met with but in young per- sons. CURE. The most effectual method of cure perhaps yet discovered, is to shave the head regularly* at least CUTANEOUS DISEASES. 337 least every second day, and to dress the diseased surface every morning with strong pepper oint- ment ; the ointment is made by mixing finely powdered round black pepper with spermaceti ointment : it will be proper to keep the whole of the hairy scalp very clean, and therefore it might be washed previous to the dressing with soap and spirits. To this simple treatment the severity of the complaint soon gives way ; but in order to eradicate it completely, the shaving and dressing ought to be persevered in for some months after the last particle of crust is removed ; because if any particle of the crust remains the complaint will be speedily renewed. In the mean time we must attend to the state of the bowels, and have recourse occasionally to such laxatives as are indicated by the present symptoms : if the tongue is foul, calomel pur- gatives are best ; but if not, and there is simply a slow state of the bowels, cooling saline laxa- tives, as Epsom salt, &c. or sal poivchrest and rhubarb, will be sufficient. ULCERATED AND SORE LEGS. This complaint is so common, and in several instances attended with such little injury to the health, that it is scarcely considered a disease : we frequently find persons who labour under its most z troublesome 33 8 CUTANEOUS DISEASES. troublesome shape still persevering in those ir- regular habits which gave it birth, notwithstand- ing their own irresistible experience of the mischievous consequences, which follow from those irregularities. There are many like- wise who will not admit of a cure, from a rooted notion, that the drains from the legs are a kind effort of nature, to relieve the system from an acrid or morbific humor, which if retained might fall upon more vital parts, and occasion some dangerous or fatal disease. It is true that where the system has been long accustomed to any particular evacuation or drain, it may be dange- rous to put a stop to it without substituting some other discharge especially in full habits : but it is also certain, that independent of the pain and lameness with which this complaint is attended ; it has a tendency gradually to break down the strength of the constitution ; to lay a foundation for chronic complaints ; and thus to shorten life. It is likewise proper to observe that those sores are often but symptoms of obstructed and diseased viscera, but most commonly of diseased liver ; and that a determination to resist tne use of me- dicines has the effect of allowing the primary complaint to prey upon the system without in- terruption. I thought it necessary to premise thus far, in order to dissipate a delusive and dangerous notion. SYMPTOMS. CUTANEOUS DISEASES. 339 SYMPTOMS. There are some varieties in these sores. Some- times they have the appearance of small pustular points crowded upon the diseased surface, the skin of the affected part being considerably thick- ened, so that the limb is large beyond its natural size, and its colour darker than that of the sound skin. If the tops of these pustules be abraded, they exhibit a number of small oozing and shining spots, from which drops arise in the form of serous or watery globules. This appearance of the complaint is attended by a troublesome itch- ing. In other instances the skin is sound, except in a few places where slight inflamed pustules, not unlike small boils, break out, but without suppurating kindly like those little phlegmons $ the tops come off, and leave an abscess which spreads . wider and' sinks deeper into the skin, until in some instances it penetrates quite through its substance ; the inflamed edges be- come more livid, and these morbid changes gradually spread wider and wider, until some- times a very large portion of the integuments of the leg becomes thick, hard and dark coloured. In some cases there is but one large and deep ulcer seated on one of the legs surrounded by this diseased skin ; but in others there are more than one, distinct from each other. z 2 In 340 CUTANEOUS DISEASES. In other cases of sore legs, the natural colour 3nd softness of the skin, on one spot, are changed, so that it becomes a thick hard substance, over- spread by thin branny laminae which are easily rubbed off, and soon succeeded by a new crop : upon the removal of these laminae, the skin ap- pears occupied by a vivid erysipelatous inflam- mation. The diseased spots enlarge, in some persons rapidly, in others more slowly ; new spots break out at a distance from that first affected, but by degrees the old and new, by spreading, become continuous. From different points of this diseased surface arise globules of thin serum, attended with intolerable itching. All the varieties of sores upon the legs are often accompanied by partial dropsical swellings of the limb in the neighbourhood of and below the affected part ; but this dropsical appearance is peculiarly connected with the species of eruption last mentioned. In most instances there is but one leg diseased at a time ; but it sometimes happens that both are affected together. These sores are most commonly seated upon the small of the leg above the ankles ; but they sometimes appear upon the upper part of the foot about the instep : I have met with only one instance where they broke out upon the upper CUTANEOUS DISEASES. 341 upper fleshy part of the leg ; but in this instance there were ulcers also upon the small of the leg, which was the part first attacked, and from which they spread after long standing to the part above. This complaint mostly attacks those who are most subject to liver diseases, as persons of seden- tary habits ; hard livers who drink largely of spiri- tuous liquors and who keep late hours ; those who are subject to depressing passions and great anxiety of mind ; and persons of corpulent and apoplectic figures, and of habitual costiveness. It is likewise sometimes met with in temperate persons; but then there are commonly marks of a scrophulous con- stitution. CURE. It is manifest that in order to establish a sound method of cure, our first object should be to as- certain whether the complaint be connected with diseased viscera. Should there be decisive marks of such disease, the best cure must be that which has in view the removal of the primary complaint. It certainly occurs in many instances without any evidence of a primary disease for its origin or foundation, particularly in plethoric persons and in scrophulous constitutions. In all cases the best method of cure is founded upon the principle of correcting morbid secretion, of restoring the heal- thy action of the viscera, of improving the state of the discharge, and of disposing the ulcers or sores to 342 CUTANEOUS DISEASES. to heal at the same time. These effects are pro- duced by the pills No. 96, which should be ex- hibited in such a manner as to preserve a regular state of the bowels ; one of the draughts No. 87, might be taken every morning ; and the sores dressed with the ointment No. 97, and after the dressing, a flannel roller coiled round the foot and leg, from the toe upwards, and continued after arriving at the knee down again until the limb be cased in a double covering of the roller. In old and in plethoric persons, and in those who had the complaint a long time, an issue to hold a number of peas proportioned to the cir- cumstances of the case ought be made in some convenient place above the seat of the sore. In apoplectic habits the issue had best be made in the neck close to the head. Where there are evident marks of scrophula, unconnected with any other cause which might appear to have brought on the complaint, the whole of the above treatment may be employed with the exception of the mercurial alteratives, but here too the bowels must be preserved in a regular state, by means of appropriate purgatives ; and if the state of the tongue points out a foulness of the stomach and intestines, calomel purgatives will be highly proper. I have met with several instances of this com- plaint, which uniformly yielded to the above treatment, CUTANEOUS DISEASES. 343 treatment, where it was allowed to be fully carried into effect. If bad habits have laid a found- ation for the complaint, it is evident that they must be abandoned. RING WORM. This eruption at first appears in the shape of a red itchy vesicle, which, spreading in a manner more or less circular, soon after its commence- ment consists of an enclosed space with a few of these vesicles thinly scattered over it, and sur- rounded by a red margin elevated above the .kin and composed of these vesicles crowded together. This circular blotch encreases by the margin re- ceding farther and farther from the centre, and in many instances acquires a very considerable size ; in some instances the vesicles of me inclosed space become more crowded, and give to the whole part affected a more uniform redness. From all the vesicles of the eruption there proceeds an oozing of a serous fluid accompanied by a slight itching. This complaint seems to be very much connected with the state of the stomach and in- testines, and occurs most frequently in children and young persons ; it appears upon different parts of the body, but most commonly upon the face. CURE. The general health is so little injured by this eruption that in most cases it iray be left to nature, the 344 CUTANEOUS DISEASES. the affected person only attending to cleanly habits, and taking care to keep the bowels regu- lar with some mild laxative and absorbent, such as a moderate dose of calcined magnesia and rhubarb taken in the morning and repeated every second or third day ; but when it is inveterate, and accompanied by a foul state of the alimentary canal, the powder No. 104 is a proper medicine, and may be taken once or twice a week, the dose being encreased or diminished according to the age, &c. of the patient, and the tepid sea-bath oc- casionally employed. By means of this treatment the complaint will in most instances be soon ba- nished. DARK COLOURED SCALY BLOTCH. In this eruption a small spot of the cuticle loses its natural softness, and is changed into a brown, dry, and somewhat thickened lamina, which gra- dually spreads wider, and cracks or splits into Fragments accompanied by a mixed sensation of slight itchiness and pain ; from those cracks there oozes a scanty serous discharge, which concretes into brown scales similar to those first formed. The first laminae By degrees entirely separate from the skin underneath and fall off, and the laminae which form next after them proceed through the same course and drop off in their turn ; and thus, in some troublesome cases, the complaint goes on for a long time ; but in many cases the skin after the VENEREAL ERUPTION. 345 the first crop disappears is left smooth, red and tender, and it soon acquires its natural healthy- colour and appearance. These eruptions are most frequent in cold weather, are most commonly met with in persons of fair and delicate skins, and are principally seated on the hands, the fore arms, and the face. They disappear in many instances in mild and warm weather, even without the aid of medicines; but in obstinate cases it may be proper to have recourse to laxative and absorbent medicines, such as are recommended for the preceding eruption, called ring worm. VENEREAL ERUPTION. There are some appearances of venereal erup- tion, which are more frequently than any other the subject of dispensary and of private practice. This consists in purple coloured spots nearly cir- cular, somewhat elevated above the skin, and slightly painful on pressure. The cuticle over these spots is for the most part perfectly sound ; they spread thick and crowded over the limbs and trunk of the body, and are sometimes found upon the glans penis ; their diameter is nearly that of a common garden pea. In some instances the venereal eruptions are large blotches of a light rose colour, with which the 346 VENEREAL ERUPTION. the face and trunk of the body principally are marbled ; the coloured parts are slightly elevated and in a small degree painful to the touch ; when either of these kinds of eruption spreads to the jaws, the effort to shave the beard causes intole- rable pain. If this marbled eruption or discolou- ration be long neglected, it becomes darker, ex- tends over the extremities, and is soon followed by distressing pains of the joints and muscles, very like rheumatic pains. As far as I have been ena- bled to judge, the deep seated pains are more commonly connected with the light coloured marbled eruption, than with the deep coloured crowded spots first mentioned. When the pains commence, they are accompanied by a sallow complexion, loss of appetite, and wasteful general hectic ; and these symptoms of general health impaired are frequently found also, previous to the commencement of the pains, and when the cuticular discolouration is the only symptom of the disease. The pains of inveterate lues are com- moply confined to the bones which are super- ficially covered, and often accompanied with nodes or swellings upon the bones ; but they sometimes put on the resemblance of every sort of rheumatic pain, even that of sciatica ; and this assemblage of venereal pains, hectic, and loss of appetite, are met with too in many instances without any concomitant eruption. The VENEREAL ERUPTION. 347 The bones on which syphilitic nodes most com- monly appear are the tibia, the outside of the fibula near the ankle, the lower part of the ra- dius near the wrist, the middle of the upper bone of the arm, the clavicles, the sternum or breast bone, and the upper bones of the scull ; in some in- stances too they fix in and destroy the alveolar process of the jaws, or those bony sockets in which the teeth are lodged. The eruption on the face, if neglected, en- creases, and at length assumes the form of fiery and sore boils ; the nose likewise swells and in- flames, and by degrees its cartilages and lastly its Tones are destroyed. Sometimes the first appearance of venereal erup- tion on the face is a number of small purple phlegmons or boils, so crowded as to give it an uniform complexion. Along with those eruptions the maxillary and cervical glands are often affected ; they swell, inflame, and suppurate, with a discharge of an offensive ill conditioned matter. If those symp- toms are long neglected, the suppuration extends to other parts of the body, particularly where lymphatic glands are seated ; and, having once commenced, it rapidly spreads, sinks deeper, and is surrounded by a hard, purple, highly inflamed, and 348 VENEREAL ERUPTION. and unequal margin ; the whole of the internal surface of the sore within the border of this in- flamed margin is foul, yellowish, and uneven : this purulent foulness is peculiar to sores of this des- cription, and cannot be wiped off or cleansed by any mechanical means which can be devised ; and indeed one of the most favourable appearances in the progress of the cure is its giving way and leaving a clean, smooth, and red surface. We frequently meet with persons labouring under those eruptions and pains, who obstinately maintain that they cannot have a venereal taint ; but when we are acquainted with the hardy assertions which many are inclined to make in defending themselves from the imputation of ever having been visited by this disease, we will fix our attention on the symptoms before us, regard- less of those assertions, and treat the case with a liberal use of mercury. Notwithstanding the resemblance between the pains of syphilis and bad chronic rheumatism ; in distinguishing one from the other, our judgment may in general be guided by the eruption, when that occurs ; by the venereal pains continuing undiminished or rather encreased from the heat of the bed ; by the appearance often of a profuse and general sweat without any mitigation of the pains ; and sometimes by a circumstance which occurs VENEREAL ERUPTION. 349 occurs and is then decisive, namely the torturing pain that attends the effort to shave, where there is neither ulcer nor sore to account for that pain. CURE. It is obvious that all those symptoms must be treated as venereal symptoms of the secondary kind, or such as arise from an infected system. In the choice of medicines we have a great range to select from. In most cases, the strong mercurial ointment alone will effect a complete cure. Some- times the symptoms disappear more speedily by combining with the ointment the saline prepara- tions of mercury internally, as in No. 98, 99. In obstinate cases sarsaparilla broth is very valuable, and contributes to support the vigour of the con- stitution, and to cure symptoms, which resisted the use of mercury alone in its various preparati- ons. There are instances sometimes met with in which the system is charged with mercury, and yet the venereal sores will not assume a healing- appearance, but rather spread, and become more painful, the constitution in the mean time sinking under a wasteful hectic. Here we must drop the mercurial medicines, recommend the continuance of the sarsaparilla broth, give some good cordial mixture to improve appetite, remove our patient to some healthful situation in the country, and employ the warm bath now and again. The mer- cury 350 WHITE BLISTERS, OR BURNT HOLES. cury then resumed will rapidly cure those sores which proved refractory whilst the patient re- mained in town. This fact is well entitled to attention, as it freqnently happens that venereal sores, both recent and secondary, which are in- curable in this town, shall, upon the patient being removed to the country, easily yield to judicious treatment. ' WHITE BLISTERS, OR BURNT HOLES. This disease, though not often met with, yet in consequence of i£s severity and danger deserves serious attention. T he abilities and industry of Dr. Stokes, professor of the practice of medicine yi our university, have been so successful in ascertaining its history, and proposing the best method of cure, that I shall merely extract from his account those passages which more immediately relate to its symptoms and treatment. A very severe disease is to be met with occasi- onally, among children, in various parts of Ireland; and, if I can depend on the information of un- professional persons, in England also. This is, an eruption of vesicles often behind the ears, follow- ed by ulcers with copious discharge, loss of sub- stance, and rapid tendency to mortification. This WHITE BLISTERS, OR BURNT HOLES. 35 1 This disease is known by various denominations in different parts of Ireland, as might be expected. In the counties of Dublin and Wicklow it is called, the white blisters ; in the counties of Down, Antrim, Derry and Monaghan, the eating hive ; in the counties of Waterford and Tipperary, the burnt holes : I would propose to call it Pemphi- gus gangraenosus. t The approach of this disorder is sometimes, though rarely, denoted by a livid suffusion like that of erysipelas slightly elevated. It more fre- quently happens, however, that the complaint comes on in perfect health. One or more vesicles appear, mostly larger than the best distinct small pox ; these increase for two or three days, burst, and discharge a thin fluid, having a disagreeable smell, limpid in most cases, sometimes whitish and sometimes yellowish, the latter less dangerous ; usually the weaker the child’s constitution is, the thinner is the matter. Before or after breaking, the vesicles run together, the sore becomes painful, with loss of substance and a thin foetid ichorous discharge, the edges of the ulcer are undermined, and it spreads quickly. The more usual seats of the disease are, behind the ears, sometimes on the hands or feet, on the private parts, (seldom on the arm-pit,) the breast, folds of the thighs, lower belly, on the inside 352 WHITE BLISTERS, OR BURNT HOLES. inside of the mouth or lips. The disease, how- ever, it is said, seldom passes from the inside to the outside of the mouth. In the progress of the disorder, the ulcers enlarge rapidly, with remarkble fcetor, very great dis- charge, and livid edges. $ If the sores are behind the ears, they destroy the connection of the posterior cartilage with the Cranium ; they spread to the meatus auditorius ; to the eyes, the sight of which seemed, in a few cases, to have bsen destroyed one or two days before death ; and they sometimes extend to the crown of the head. The constitutional disturbance that accompanies this disease, seems principally the effect of irri- tation. When the vesicles burst, the child begins to grow peevish and fretful, pale, loses its appe- tite, and the flesh becomes remarkably flabby. The periods of the disorder are not very regu- lar ; but it often happens, about the eighth day, that the pulse sinks, the lividity spreads over the whole sore, the foetor and discharge increase greatly. The smell is so strong, as often to be perceivable at a distance from the bed. The discharge, in one case, where the ulcers affected the armpits and breasts, was such, that the linen Was completely loaded several times a day. Death WHITE BLISTERS, OR BURNT HOLES. &5$ Death takes place about the tenth or twelfth day, often preceded by convulsions, sometimes by extreme debility. Patients are apt to relapse soon after the sores are skinned over. The causes of this malady are rather obscure. It seems exclusively confined to children. Dr. MT)onnel saw twenty cases before the year 1795; all the patients were under four years old. Dr. Spear observed, that it was confined to children from the age of three months to that of five years; but it has been observed, near Dublin, in children of nine years old. It attacks the finest children in preference ; the children of the poor more frequently than those of the affluent ; and those who live in damp situations seem more peculiarly subject to it than others. The disease is more prevalent in summer than in winter. It appears to be infectious, though obscurely so, in general ; but, in the year 1 800, Dr. Spear observed it to spread epidemically. It has been said, that the disease oftener affects the younger from the older than the reverse. It would be interesting to de- termine, whether it attacks the same person twice; it certainly is apt to return after apparent reco- very. Children, as is well known, are very subject to excoriations behind the ears, which sometimes produce formidable sores ; these may, possibly, in a few cases, resemble the disease we speak of in its advanced stages ; but in a great a a majority 354 WHITE BLISTERS, OR BURNT HOLES. majority of cases, these excoriations are far less rapid and dangerous than the complaint in ques- tion. On the other hand, the swine pock (varicella) resembles this disease in its first stage ; but the fever rarely precedes the eruption in white blisters, and pustules of varicella dry readily. This is a disorder of great danger, but of various progress in different individuals. It often happens that a fatal change takes place about the eleventh day. The unfavourable signs are, the rapidity with which the sores spread ; the blackness, first at the edges, after some time spreading over the whole sore ; the quantity and fetor of the dis- charge ; its colour, the paler being the most dan- gerous. It has been alleged, by empirical practitioners in this disease, that, after the blackness had covered the whole sore, death was certain ; but I have observed the blackness to go off, although it had spread over the whole surface of the sores. When this appearance abates, livid streaks generally remain for a day or two. When a favourable change is effected, in bad cases, the diminution of the fetor and discharge were the first signs of the abatement of the malady appetite was after- wards restored. As WHITE BLISTERS, OR BURNT HOLES. 355 As I had many recipes for making a green vegetable ointment, and had good grounds to suppose, that several different compositions of this kind were used with success, I determined to make an ointment of a single vegetable ; and, in selecting that vegetable, I was directed by its oc- curring in many recipes of this kind, and having itself a character among the common people, as a useful application to obstinate ulcers. Upon this ground, I fixed on the scrophularia nodosa, called in the North of Ireland, rose noble ; in the south, phoghram, pronounced phoram ; in England, great figwort. This simple ointment, I hope, is as powerful as the compound, although my success with it has not been uniform ; but the failures, which have been very few in comparison of the successful cases, have been those not under my own eye, or very far advanced ; and I have reason to know, that no person is so successful as to be sure of rescuing the patient in all stages. The following method is nearly what I have pursued for several years past, and 4 what I advise. When the parts adjoining the sores are swelled, and strongly suffused with a dusky redness, or if the sores have been previously dressed by any dry powder, I apply a poultice of porter and oatmeal. The carrot poultice, in fermentation, if it can be procured without any delay, would perhaps be useful. After about eight hours, the poultice a a 2 should 356 WHITE BLISTERS, OR BURNT HOLES. should be removed, and the parts affected very gently wiped with a roll of lint or soft rag ; then the scrophularia ointment should be applied. It should be as highly saturated with green vegetable matter as possible. For this purpose, the plant should be taken fresh, the smaller leaves selected, and stewed a considerable time with as small a quantity of unsalted butter as will be sufficient to prevent the leaves from being scorched. If well prepared, it is of a full grass green colour ; but after keeping, it becomes the colour of box leaves, especially at the surface ; yet I apprehend it pre- serves its efficacy, in a great degree, for many months. When applied, it should be melted, and suffered to cool to the consistence of honey ; it should be applied, by a soft feather, with the utmost gentleness, to the whole surface of the sore. Through the whole of the treatment, the greatest gentleness should be used. If the ear is strongly drawn open, the parts affected are made to bleed, which produces many inconveniencies, and re- tards the progress of the cure. After smearing the ulcer with ointment, it should be dressed with the same ointment, with the addition of one-eighth part of wax. This last ointment should be spread on lint folded to the dry side, and cut so as to fit behind the ear ; the whole should be secured by a broad bandage, drawn under the chin, and fastened over the top of the head. This dressing, in very severe cases, should be repeated WHITS BLISTERS, OR BURNT HOLES. 357 repeated every fourth or sixth hour ; but as the foetor abates, larger intervals may be allowed. Hairs should be completely removed from the neighbourhood of the sore. I believe it to be necessary that the child’s bowels should be kept open. 1 also direct the internal use of yeast, which I am of opinion is of service, but cannot decidedly prove it to be so. Such is the treatment I propose for this disease, selected from such parts of the traditional method of cure as seem to have been most successful, with a very little addition. I do not pretend that this treatment will always succeed ; but perhaps of four such cases as may occur to any practitioner, not excluding the most hopeless, it will succeed in three on an average : and if we could accu- rately ascertain the mortality which takes place when other methods are used, we should consider this proportion of success as very satisfactory. I have had a variety of opportunities of concluding with a high probability, that the treatment I re- commend is superior to any of the followiug ap- plications. The carrot poultice, although this, I doubt not, has been of use in a few cases ; pre- parations of mercury, of lead, of zinc ; powder of bark, of starch ; washing with brine, with soap and water. I have named these in the order in which they are more and more objectionable. The first I believe to have been useful \ although I have S58 WHITE BLISTERS, OR BURNT HOLES. I have pretty well ascertained not so useful as the green vegetable ointment : the last I have some reason to believe to have been perni- cious. The utility of the scrophularia ointment does not stand on my testimony alone. I have annually mentioned, at lecture, the state of my observa- tions on this disease, and I have received favourable accounts of the use of it from several friends ; some engaged in the profession, and some not. I do not pretend to have proved, that the scro- phularia has a specific effect on this disease ; possibly it is only useful, by supplying the green vegetable matter ; but as I and some of my friends have hacka success more uniform, by means of this ointment, in a disease in which our failure was almost uniform before, I shall continue to prefer it to other vegetable matters until the subject is better understood. In addition to this clear and satisfactory account extracted from Dr. Stokes’s publication, I will observe from some circumstances within my own experience, that the cure is facilitated by keeping the bowels free from sordes with moderate doses of purgatives, of which calomel forms a part. APPENDIX. 359 H gi & ^ & o ^ ^ s § ^ .b ;s s § ° k w< s a eu.g -5 § S’Oa “SSU 4 fe'S M " u 5 2 I'S ~ - n r— H O •i.g’g c £ 2 * •- G 2 O 5 JP > H S 7 J fe rH* ^ (h O S . O % q o & G .O o> -a *c -g G *-* «S «*;=, B - g G £< £ 2 . 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The quantity of the jalap may be diminished when diuretic effects principally are looked for ; and where the case requires a powerful cathartic, the jalap may be encreased. The dose is about a tea-spoonful taken every two or three hours until it operates. 362 APPENDIX c C 2 >» E S 8 2 4) ’"G G G T3 o k "G ~ 8 S S M-j 4) 4? ’g G "G -COG -"g s O CN 4) G 'o G -S G 4-J 4) g £ pG-S oX) G QJ <-4H c 0) c| o go G CD o y CO CD G G CT2 G $-1 CD q to ^ bo co bQ P* G - CO £ CO O & APPENDIX, 363 2 i s o § ° CCJ o' I ° g cl £ rJd <1> Cu 5 C2 O ~ a T* •— i Q* 364 APPENDIX. •ag°f?g > "G gH Oh 75 13 *£ o g § g " * c XT' G P v o ^ ^ G g Oh C .O OJ pu .3 < 8 ^ o 2 O i~i r* <*G o iS g G. Cl C/3 rj , * 5-i .S3 b o3 G & +-» bp Sh bdO G O CO a W '-M ^ Q O ***H ^ a £ ^ *h flj 2 a a g ^.2 cr § "5 S' C2 hSG .55 hO-T3 g •• \J » . G <+H ii u o G O uj d'+i ^ ^ £5 G C/3 c . ‘g bX) o £ bXincj o 13 G G O Oh £ 13 *- G 'G ^ bA.G o g U 3 ? C o G *G ^ ^ O > 0 ) o Oh o U Gh G ^ G (D ° 'S ^ '5 7^ G C/3 U .. 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CD-I-) IZ Qh 3? ca ■ H 13 !D Li S3 cd ir .13 Li a ^ CD • • c/3 CD Li p L p Li +-' £j 4-» .. CD g.S is *■■ O CD ca td ■S’S Lh x; - « St; T3 ^ CD 8.3 g w‘g 3 •- 53 ^ 53 ca . Li cd ja c3 ca ca c o 42 d w P g w -5 35 cr •• C4CO p 3 .S CD P CD ca ►a *Lh CD 3S MH 53 CD S3 O o O 7 ? p C CD 3$ CU si £ ca T3 [> ca o 6 Li ^3 e ,CD 5 ca o ca • CD 53 S3 ca # . E *2 ft o S ^3 s I No. 20. R. Oarbonatis sodse ppt: drachm: tres. No. 20. Dissolve three drachms of prepared Solve in aquas unciis sex & adde carbonate of soda in six ounces of water, syrup: zingiber: drachmas duas m: sumat unci- and add to the solution two drachms of am cum semuncia sued limon: pro dosi. syrup of ginger; let two table-spoonfuls of APPENDIX. 367 o a o o Cl* n a 0) *-> on £-§ CD c n S-« CS 4-1 ay bC.2 Cm o -fJ . C fe bC ^ a Jj •p O a! G 4 -J 1 O 03 5 ^’o o CO 0 'MM qn > o o £ Q ° O £ <-H § O % o CD on o £G S 2 O c ~G "d ? T3 G O rt a; C/3 I i c o ^ G •p o § 2 <3 £ « *®.S CD p w £ fefa.S> mC tH ~ O % r\ J> ■-£< « - M Tl G.sl O CD d ° £ > 6 . . "o -G* E3 cS 3 g on C/3 as 3 C/3 • .2 *d c , cj cd ■rl G G g ^ " £ & <4-1 • • *n • • -73 CD C £ C « B gjOfl SD rt h g g .2 S cj S Cj C/3 £ sp’S'i 3 t-! ^ C3 2 cr CL| .. is B O on G3 O .2 ^ ^ +3 «J > C 5-t CvJ cs c3 fcoC 1-4 bO •• c' • pH CL, K Sr rrs * *■ 8 ”-g £ (D CD O s "Td T3 ..h S.s b,0 *Z3 QJ mt-j Sg.-a? £ SG ^ ^-4 .mi cn £ GJ N S ^ *C ° *GJ > £ S jd fi-5 • r-H 0) H3 pi ll O r-H > • rs ■ ,s ci CM CO rQ d ’a 6 c rt S5 CJ ^3 o O £ S C3 nj 4 -» r 5 C 3 S'E. c .•• 368 APPENDIX. d G ^ G a O G o> c ^ to O G « a Uh G ° ts C/3 G S - •s 4* G O u T 3 a) < X* 03 tbx> G — i So T3 n W)0 ,S $ G bX)S- G vm a, o C3 g £ § m M ,c O O 2 ■m G c/3 o G 03 r! O 03 T G CO t frH G HH d m Cu a> SS'g I £ ••'CO J} 3 £ -2. £ c3 "bb cm o o o G G O "d d 68 a> S-? ,rH § £ ^ _• *■« G C d G G « O d x ^ r *o aJ f * rG t> e/3 4^ -a 0 .£ S £ ° 3 g I o £.a O C/3 a> g o G 3 CO J CM .2 o 2 Q %■* & •* So 8 CM G 03 g E*S , ^ s ,G G G C S-i «« ’d Cm 0) O a> 2 52 pG S pG d o ^ 2 (U O -G £ .52 £ G «G "d G bO « G ^ > *0 a § ” d g •— ,2 ’o u G 3 Jh G M» . ,^_ G C/3 CD ^l s CU^ cn • M CO x: cm 1* •G ^ Jh * G cj .y ,P-rV 2 O- cs "P’S M o 4-» 3 ~ fe - ^ p 2 _s C ^OcM^S S . S . e 2, « G • Cl, • Cd .g - ^ U G ^ s '* S ? g g G *rJ » « Sw’Pg ^.d*a <5 '-3 3 O 25 S' G 8 § cr 1 c/3 m 2. O +- 1 d ° m ^ ® g S -a 2 •2.S H-| g-g gcj 3 S » .. 3a5 rp .1 r 5 8 G .2 ^ | S fe 3 Cm O) O G ^ ^T)d c/3 £ 'd .. g 2 G m G g G Gh _*■« 2, C G ^ 0.52 ^ o -G O G . G rj u in ^ G G e» S a b d MS _J CnJ K 2 ri adde tincturae Jalappae dr : duas m : & tartar, and afterwards strain it ; to the strain- divide in haustus tres. St. unum 4ta qq. ed liquor add two drachms of tincture of bora ad effectum. jalap, and then divide the whole into three draughts. Let one be taken every four hours until the desired effect be attained. APPENDIX, 269 % *0 G 5 cd ~ bJO P C £ G £ ° c § gJ= g G -4-1 ri *“• Ph (D O CD H-J oi .3 o .**73 Li-, CD o G G ^ O H-J O G O £ OS G .£ *o Gh O 03 CD O G G O „ o xi g . £ f-G ^G ti J _r ^ O tr « O G 4-» .2 g-Soc 2 o c o •" „ OS o o '-G G p lr r j O O w" +2 03 S CD »-G 03 O 03 O § jg.S -a 'g co o 3 cr 1 4 -» G aj as 2 « 60 M fr o^ ■§ » G • • Gl, o-< W w -a o 03 03 03 C8 CD -G ^ § E Qh as 03 a -G cu .. o > G rS ~ O o flj " G t! O w G*G -- 5 01 •a S-g 2 U c o £ G G 4_l f-H § G CG bJO G *2 G G as ^ g b£ ^ . D o.-e § I* 03 s c ^ G K. G p ao 03 w g 8 G CO 01 CD as TJ fc £ « ^ p G 2^0 £ 5 •Q £ . jd G cr 1 T 3 CO G~* £ N £ .. j 2 > G ^ 01 G G CD „ oT 3 !5 Ph G 4 — » : H, § °o « hG ^ O Ph 2 G ^ S S 5 G O . £ :g g OJO G r£ .£ ^ G *6 *5n K U •• G bl cr' cr 1 g > B g 03 TO +-< “ 00 o & 01 s 2 6 .s •&& S b 370 APPENDIX. D tJ P £ o D D ;z$ D £ 0 ^ rs aj *73 C3 .a oj<5-s -g X5 ^ P f 3 P ^ O +-. ge - a.?"* 0) as P :|s . &> &>i Cm o D D 5-, .P D H-l & as Oi 6 £ CU o bio'-g aS O 73 O O D P 53 e G D o bEtf P ^ as s-, O bJD P • *-H > aS as D > g o wa -p ”0 4-» 4H D O bJD «J O C/3 ■s -ill 25 ci aj.2 P 5— < 5— < . O 73 73 P £ c D as D 1 StH ^ o £-2 w ^ s £ 73 g £ g ^ p „7d 2 CJ D ^ C U- ^ C P 73 ^ u-i .P P .P *7? CD <-. O £ o Oh fcfl g ^ ^ C P o °S 2 ^2g- § g o ° ° A c£i»'S3 C R<*G ^ ^ D - '^ D 3 C3 p Sh° g •• 1/3 D +-> bJD , <-M ,P D CO *r-l ^ O ^ /j D D O U D >““< D > f D feJO ♦ P ^ ^±J D C p4 p .79 P ^ „ o c^up P t3 ('■v . ’ O D n s $-o S « s<. D 03 .73 P fe.J' .&• s Ph O 03 g "8 G II 73 aS 'S' -o g n ST- §•' 173 P D OS 2 [g e’S* -C c3 o W 03 03 ’to P VJ ~ ' IP (up G « p 5 aj J-< ^ J 3 «S P . . | ‘I K H P P o" 1 cr 1 <5 <1 a p "O tn .&• 3 ; - "3 g “g -1 ^ bC . o « -3 S S '3 o b 3 C uSh o 5-i a, p p ^*3 Cu G P G £ P ^ s C/D w S-i D CU c/3 O P X5 C/3 O s’. I II 2 “ o J • P cu g i’fl g g •I s S W Sh g 5^ cr <1 <3^ O ^2 co co T3 .. *P pi p as CM s p CO 6 CO 6 . . 6 a s 55 -§ s<§ 3 5 § » O C/3 P P CU.^ P 73 'S^2 o u “ g ’-* ' S CUP cr-73 u P *o *D .S >> G u* G £ 3 cfi nd CD *2 .S H3 r» r— 1 0) 'Tl I" I ■Sis C co £§ biO 3 S CD o V s'S § © JS * 5 ? G j§ 3 S.s^ . G G ° ,G -G co £ 8 G O g cO co * G GJ ‘'ll •§ Vh

rG *r< 4-4 CD CD JO bJD G O O CD Gi £ O G ■03 e 1 nd ”gj I « §■8 § 5/3 -G .2 a £ g S 2| o G E CO CJ "3*8 g\S.J 3h^. cG G o<5 nd i: « § S ^G L*- s .S 3 CD J-* G ^ „ J] O rf JJ z k :■§ G ^3 «r; >H g bJO 3 ^ r: o-H 2 CD *dG ts g O"® fra-s-rf 43 “fe.ts co oS ^ G g a bJO G Q - o 8 2 CO 44 M o CO CO CO _ O o 5-i > .. 3 ^ CO *rt co o CD ~a a c g o G3 -3 G. s «50is CN CO d S5 B 2 4-4 ^ rr* O ^ 4-1 ©I P CO c*4 2 G^ and repeated every four hours until the desired effect be produced. 372 APPENDIX.,. | S sT-gl.iTS -1 £&§ d bX)^ Jl o-53 .gofi * “> S b/j O 'Q bX) C . M_, o-c: g 8 o a £ . _, a ,-c -a « Jg 3 -a « •§ * 3 ^ £ id o c .5 © o ^ bJO Ph . p* bO £ .O a _Q . f ^ | 2^*5 XJ O, 4_! ^ .J a ^ •g 8 d ?! * a co H co co .-U C'U ..3 S a &.. § s ®° .f « |[ fe o & •S 3 ^ *g dj *bX) .. oj ^ W a > % frs fe„g S a •• 2 . > bO > 5 cd 333 8 O' Oh^Ph a (X ? * C8 2 .2 bX) 4-1 {-I •r a +3 Oh co CO jo ^ a .a o • • a *h a s-* ca a 3 g ^ .. * 2 a a fe'S g, JS 8 o S u o 5 ^ o 8 a-d •• h ^ Jd z, > a .cd a c S 5 ,. E £ “ § a s &>§ ^3 •g.a « g.a 3 ft*" I S.g.a . _ fi N,t! P M O r-4 .a a ! ’ d y ^ > d g OJ Kja oa ^ o£ « 3 $ ° -3 > co o a a B fc. r ■ £"§ g P cu ^ U cf.S o'O y -a a ^ «s '5 ^ « 3 2 8 2 g 2a 2 S3 £ bjQ 0-t , r* bX) .. o/j O OX) r< .. °° o> a xx n c ^ a •*-* a ga^ a a a w bD« y a 2 a bo .. «S - S g-a W 'S «-;§§.. a. « £ U w -2 S 2 ^ a a co _; oca w o^ a 3 • a r? «o ^ -w .3 co a ^ g | s 'd(T; ? No. 36. R. Massx pilular: hydrargyri phar: No. 36. Let one drachm of the mass for ma* Dublin: drachmam f: pil: duodecim. Su- king the mercurial blue pill according to the mat unam mane nocteque. Dublin dispensatory, be made into twelve pills, one to be taken in the morning: and one APPENDIX. 373 3 -o G 53 73 g 2 £ 8 g a d O eG CL *-i rG 03 ,0 CD O £ S bJD<£j G to ’co G CO 3=3 "d •75 £ 03 a rG . u 4_| G bJO^ *G ^ G G O u V CD t—H G • CD CO CO * “ (5 ^ <« 8°. i-G G y G g G c rG a^^ bJO O O <*4-1 o O 2 « D « «* -o * O) ' ►> a> J "d <£ 13 cd 3 .* " * O 4-4 G cd C/2 1 § * fj §^~ ^°*j§ o °\2 0 ) T 3 S- g L ? O’g | § I f. § 3 0 £ cd cd 'S,E|jj‘ 8 S“o b-s s s'g ~ £ _ PhC^ g^.a c - o 2 a £ § v Jb a „ fc,o^ -•aSs-s" ^ 3 2 °=3 ? * 8 E i| w d op cj O cd co ■*—i G ^ 5 o cd S G V W=! -r! c JD £ , ft O £ -a Oh _ cu o CD •*->' cd g^ooE £ <•> 3 O « CQ 3 £ 8 cd § S *S « , G 8 ■« s ^ cd 2 O J-< c/d Oh . «*» O 3 d b £ Cd r> >^,.-4 o .52 do p o T 3 a; *c -g 4-J X G ,• cd CO o - Oh*C £ ^ £ ^ Cd_ > bJD. G o C8 00' CO £ &-§ .s’S o in ^ . 4-4 TJ <1^ JD O k a ^ O .. 2 £ G So.’S 8 &- § 73 .S S £ s 13 *3 V Ph * Lctl eu mentis, adae gelatin: sap: q: s: utf- pUulas duse. APPENDIX 375 ?-< G _G OJ CT 1 c« ^ 02 O OJ G QhXP ^ ^ X >> OJ 'oj *£ g e g £ 8 -d | /J cj . z; £ - OJ w c_jz O O G ^ O .G G ^ ? ^ o C -a 3 '4 P oj r£ *-*■ £P G ._ C & 2 a Cj CO . Oh — — r. j_) j_» 3 ^ ^ « r. .sp 1 ° g S • — ' CL) f _^ ' ’ -H g 8 "2 w CO; <4- c CTJ C cg - <3 u 73 OJ “3 .W OJ a/> • >-' G +-j H CJ g p q? O G c G *-G O CJ G 2 # a Sh X g £ - Gu 5-. oj o <-G Gh oj r-c 73 X3 0/ "r t; ’ ’ CJ o '""* *** n B^o^ P G G G G > ^jj'd o '£ -P ^73 &.« ^ p ^ — x .. oj 0-« g .. Ji4 > £ 2 £ r £ ^ & C 5 -h Q o G G O eo 73 73 G 0 ) C CU > £> r< o . 5 tj E? ' g ^ ^ q^a-G ^Gcjcmc c * bfi-a C .G % CD cj G G O e\ C J-j C G ' >> A J « £ ° *5 T) *■8.3 a a B .2-3 0 ’ o o -a O q 8.3 g ■a 0.2 8*** <4H. a> o C/2 OJ T/ C/2 a> ^bJD X. CC5 4~i —r W S G. u cr 1 g ^ q a; .G U ^ < 3 J '-J-H o l-l O O •“ rG _ . G C /2 QJ ^ o oG S ti a> ^ £ G bJO a w _§ G -j3 c £ . -s * ° tD T3 G G O C/2 G. 4- > C^ G G OJ bJD G G C /2 ’ O ^ 73 LG G g B G •* •• £ O- G s *y c 5 v p X o G «J *-< G |I O-. G £* O ’Z3 u u Gh oj 'g 1 .G 5 _Q '- Q W O w B.S CJ .. o ^ £ v G >G x. G -w G 73 G G C/2 O G 13 9^ cg u G CJ ‘- 1 w CD --H 73 •m:> g-T3 G G OJ 73 £ s ° G ,hG 8 £ G X3 a G G ’1° OJ VI 03 G 4-< 4-» G bJQ '£ >•£ ft «n r* vs- « i « G Oi G c^ £ - G £ o g 85-3 S o o OJ O • H CJ CJ OJ >pO s 7 2 ^ Xi . G r_H ll. a< . O G « I 2§ CJ . G ^ 376 APPENDIX* *■ CO G 03 • 2 o O o rG 8 ° TJ 0 > £ „ o CO *, *-i G-i 'Ss 3^ « C3 S I^l^l §| ^3 m T3 g ^ ^ °T3 §^-fl ° S ^ o .5 33 o co d & G g ®P £ »h o •G G .£ g 0) 43 £ 2 a, bo % -5 .G £ 530 ^ > 03 4, <73 — < ^ 8 (DTjTj h >-i 03 +~i CO . b* 43 C 2 ^ o OhS o o +j a> d i> a) ^ ^ T| ^ P* . 4 *■" r*~i QJ G +-» C C 1? ±3 S ^ G g g V C r-J 2 ^ ^ a, S ? M w 5) u > . 4 .S .S « — . 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G G ^ G 4-1 U .5 § .2 "8 *CD G CD T* Oh G G O rG O £ - Oh CD CD ID O o _ G , ^ 13 > > S’© 0) cL^cl 13 o S 4— 1 G "H CTi § O ^ co 6 & a- S g .g b o c I - G ccj • r-* r, \ CD Q CD 3 O CL) CD g, .. -d &s S G G >— -} r J-» G cd o • — > CD G * * J— l. ’ 1 ^ _T O CG 4-1 CD Q-< O G w G g g ’Z) ^g 13 o 4-4 CD o o G G u G CD CO •S E s J 8-;- S-oi' G G CO I§ adde tinctur cinnam dr: auas. tincture of cinnamon, and one ounce of the Syrup: limon: unciam; m: & divide syrup of lemons : let the whole be divided in haustus sex, Sumat unum • tertia qq. hora into six draughts, one is to be taken every ad effectum, three hours until the effect be produced, 4 APPENDIX 379 ~ jn o x O ^3 * — X ^ ^ *£ S a o ss ?« 2 g ^ x ^ \c * T 3 s 7 c 5 t X a> o ,! S o O W bO «* q 4) j® X) T 5 — « O X o « o g ” b/J o § ^^2 8 -g 'l .a o* S ■“ 8 "»<*<_§ ^ °~ 8 s .3 *- pL|~M o ■§ sa 55 '5 g ^ > X X O "g Jh q &g £T E o 03 q q * t_« f £ o ^ co O c O o X O o g X o o Qj *— < q a, •'-* k> ^T3 q a> 5-4 4) 73 o3 fcJ>q o c > q ; nj T3 >. u * £L' ”d e/5 r ..3 X CO r < & O Oh £>* X o q D q X C .0 4-1 eo ^ q o x q o 2 4-4 q Oh _ crJ _q X Qh « Jtj £ ' - ^ 0> , n , J-< ’ °,0 «* >»X * * C g s- Oh 0) a* • q C5 q q q rs a •a o pM _2 x t. .2 ft; « "3 X r3 ^ x P ^ feb g ° CD Bh 0^3 co Qhx a> - 0 X ^ x co q o s_i ^ x f a> O x Tj +j X q X O O q •- O P X CO ° ~ 6 CT; - r< x.q o ©H f .;. -V5 O a ^ Q ^ C S2 CO a> o $ S -^ 13 o - O bo O ^ o a> OhX CO 4-» s o' C4 4-f 1^ ^ ■w m to p .5 # «J O X 5 'SO 9 3 f 4 .9 | §.SES*S cS^S ^ S S ‘5L ^ o o .5 M § 0 .. § o =. p V> # ^ 03 .. O) o s-e -»-» o o X ^ a> X .. o +_» 03 g-a CO fH S 3 CU S £ 03 p q -*-' cr qj «^S x ai X w «« a X co 4_» q O -, c 5 *n 03 22 O q 0 o q c o q n q - 1 u 4 -h C 7 1 <3 »S o - 0 u 9 .. T5 n ^ Oh c 0 -- q x S « oS - 13 q q g g.§ a OJ p I 3 » J ^ •SdS o 0 > CVJ 172 0 / 1/5 o> § 2 oi! 3 «•§ " CP* o q *0 J3 o hS 1 ) T 3 qJ HH " « /g o ^ Sh 5-h o o JT3 ^ CD .O 4 > S~< . o O CD 03 Q* Oh d o 3 ° O fl H -3 ° « o bjQ d «T .2 2 o ? CD P-< p £ o P o d d .. T 3 £ 13 03 o d .. d fa c 3 4 -J rj d d d b 0 3 . _c d o dl 6 55 «• W 4 -» << tJ .> CD d ^ b/D O d 5 - 5- 1 CO d .,_, ^ a nd <4 h *u o 55 adgutt: vigintiquinque. acid, two drachms of compound tincture Tinctur: cardamom i comp: dr: duas. of cardamoms and three drachms of syrup Syrup: cort: aurant: dr: tres m: f: of orange peel, be mixed together to form gargarisma. a gargle. No. 55 . R. Decocti Cort: cinchona; uncias sex. No. 55 . To six ounces of the decoction of • ^ lnctur: ^ no drachmam m: & adde Peruvian bark, add one drachm of the tine- acid: munat : q: s: ad acorem, f: gargarisma. ture of kino, and as much marine acid as will give the whole a sour taste and form APPENDIX* & >> 3 G M 03 4 ^ £ *> U -S q ^ £ F-a O C C bJO S CLI J_T g °«s cy CD 3 q M o V4H o C/3 4-J &jq S' q c3 5 w R " 1 • • ^ £ q ^ S 2 "S Jjf.S *o pi CO *0 c3 c/2 c 3 cjii'diioc" £ CT) £ ^ o ‘sIsIjst! -s : •§ g ^ ^ .£°"3 UPi q *H g 2 ea S or! <» o H .G bo G3 G _ n ~ 03 G t {3 a >s3 g°o^ •q ^ « u .s o ^OS^CiSfirfl 4 -> p 3 (Jj *0 5 -« ? O ^ !-Dw ” "7j G ^ ^ « tJ 2 S pfl c rT, ’ ,c ^ ^ ^ u r- G as ,g nj CO C) - 1 CO o co jj fi to ^ ^ rt q _ Rj > Jh O s !>. w «s .2 ^ Si ?u. O. a ° >. S? n< +J qj — rg S « 5^ . cn bo ,,c “ 2 ^ 5 * {a £| » 2 - jr bofe ^ Ph 'So cd a, -C3 o §| «■£ S-5- B fc. 5 ^ 0^0 ^ ^ C ^ 4 ^ O O j= C o, 5°.^ bJO-^ £ S.«.^ I J s ! 5 X *' "" rs "u CD .« “ (U CD-d no O ■ a _, kU ~ O G flj ^ 5 bJO.ti aJ ^3 CD _ cn O a =q « H « c K o r §*c s*g bo a g S C .. C JJ g >4 — < *o ’O *- R c cj q Si ctf bp uj cx3 no ^ £'•§!.§ W>..| g. e dp aj G rG si O g o ■*-* ©0 b ^ q __ CJ ^’5^no • G 3oSc^«SS O +-* co O G E cj 5 S H - ^ is 1 1 s, st.S3 ^ |?« g-^-s-s •SHOftStfigg 381 0 . 5 /. R. Lmimenti saponis uncias t res. . No. 57. Let three ounces of soap liniment and lincturse opii unciam m: f: lira- one ounce of tincture of opium, be mixed mentura. together to form a liniment. 382 APPENDIX 5.2 !fl « . *"13 I~< t .EL too T 3 , P & d tu h b"“ S* 'S's » s j’H ^gMo x -fe.S o* *o o d 5 o £ i-i . 9 o S £ eS^O §*g a s £ r rt oi:) »-t *r* w S JC 3 ~ 13 1 1 JH bJD a to 03 CD g ^ *c3 fee ^ _. Qj OiC H m j r— -4 5-h 03 T5 £ c - 513 £ G 03 ,Q G -M o3 y CD - *S mQ o ^ o O O _ So^’g §*» 2 §.S S T 3 o $ - G TJ -O C3 • o c P Jx bJO *co 4 -J ’ CD g a Cl* 3 1 8 < !~i cfc a> co _3 r-t P o 03 c «•- g"d bbd T 3 • •-» CD 03 — . fli tr> u 3 U-t •« 0+2 0^0 *rH QJ . C .'2 £•■ > -‘-a o P o CO K* ’ CD CD^g & £ - *- ° &« g c^ Jj p 7 ! — o _q »-£ 03 c ,. m 4 -# . 4 -J # r T 3 i_j o t+i co cl. o g, P?,u c O C « fc£ 03 "tz V O u< +j .— 03 JP « U^t; - CCS ><; CD CO c3 C t? c^ fe-i CT 4 3 4 -* co a I CCS ^5 fe P w ■o >•> 3 h .5 • w L 2 6 JD *£•1 «I c o . > 5 c Cu CCS a-i« u co CO 03 _f i C'h j- r-^-J Q. S-< «w H “ o G -fa CD S CCS o d 4 co o 4 u 8 ^ Ph ^ CO 3§£S ^ G 2 Aq: Vin: Tine Lh CO Ctf 00 to 03 ^ |*i § & ^ *4 13 c ii.2 ’-’ +-> co c« 03 CU 03 cc No. 61. R. Tartar! antinr. gfanum terendo solve No. 61. Triturate and dissolve one grain of in aquae uncia, dein adde tincturae opii tartar emetic in one ounce of water, and gutt: decem. Sacchari grana sex m: f: then add ten drops of tincture of opium, haustus. St. & repetat 3tia. qq. hora ad and six grains of lump sugar : let the whole APPENDIX 383 P 52 ^ w 8 > .C O QJ ^ _■ | . , £ 'Tj P C/2 G bX) ^^•11 ^ o cj > . .-r c o g 55 G 2 .-m ^ Mh G P* p .P n C o3 _ O * rT G ^ ^ a j S'S.H c .b , r c3 f3 ~ G 03 d o p C1 “ ^bbp 2 g 4S1 t G 'in „ T3 g 2 .3*3 + - j s g £ G O 03 !> c/3 ^ 232 *rj D-i 4-> £ 0/ (1) < V -O £ # <4H G ■M O o * 4-> '-M — „ G © g a ^ G G a> ?g p G T3 p o3 P< § o * O § - 'o § o C^H O W pp p G g £ TJ 2 jh P ri 03 O "5 -d T; dTl ^ p g s p 03 b ,P a> T3 a) g g .3 ^ ® 1) p liil 2 l| 5 ^ fcJQ cn O G r a3 2 c IS 0 pi 01 co o V os G « ' > :s 30-G 8 O a> 5-i 03 w S G co 2 •l! § K S 8 3 2 2 2? S ^ e .5 o i:.2 g £ 2 $ g rs w.§ G "O cr 1 .^s-i O co esj CO ’p^s 384 appendix, 11 +J C-M G O s * T3 G G r\ £ G *CG O U G G <4H O O 4-> o> .50 On"g o ° ’’0 £ ^"5 £ g IS ^ G u -Gj gf J g te £ -G H3 rG £ G £ rG 8 *H n 3 cu BP G •M C/3 G G tG £ o 4J •c '5, CO GJ £5 3 O &. S o o o £ oj £ S w -C ~H 3 co o3 o3 - a £ G O “ o « G ttt ["n$ gj o ~G 3 CT I c« Mh U r* G O £ TJ '{Lg^ !°2 f ^-n ~ £ 0 O ,-T £ T3 S £ ° c £ £ G ^ js*§ ai G s G y • r-f **M rsly £ O U > T3 C/3 ^ § .£ T> £ S £ g in tj «« W) Q-» 0 G £ >H_ W)«» O G G .£ £ G <+H O C O 6 ° cx-5 <-> Vm O §iP ■H V / fl C« *H " I’g S J E S 11 /■ ? o V.t £ X> In .d ^h . 2 ^ £% g> -g-i ° §o2 &-M m « V 3 C/3 £" . Q ♦>-! G ^ ^ G .22 3^ £ .G « « o !l's a .s ^ SJ^s « 2 |>J ^ -G nj +h O C/5 ^ QJ CO APPENDIX. 385 a .o bJO O bjQ QU O a> Is g* CJ <+l <-*h O co O cu o _h c 03 O & a> ■*- J O b -0 . CO * .2 g S-£ ^ 03 ■ *G O 05 -h r-< ■o ~ s-s c * 03 *•* fa VM - § g-^ ^ Dh Oh (h O TS G >>J9 +-' Jh 4 h « c & °^-§3 n „°^ O a> -- > o 2 § O o 0) ^Tl fi s— I o a> J-J _r< .*£ +3 J> fa 5 73 .‘C s o '*-' a l-s O 73 C g 03 O'+H O I M XI Oj - M OJ^-Sj « st jd Sr 4? S o 2 « 2 o rn ° 4-1 *5 fa ^ o tj § — ^ « s I c § 03 *«w £ re £ G 4 _i O) ryT H Oh P . O . HE* ^ g g, g -O oo O a> .2 K 5 ~ » fa 03 .2 $ . • ^ S t! ^ ft ^ o^ ^ « o o £ £ a; 2 *co 03 co co o g 73 73 . 03 ^ co « S " ° £ -g^ g» C 3 o? §" a> bn co rr V o G co f|s-|l SjJ §<§. 03 £> H <1 co <0 $§ B G 3 CD +j Q) f-'i % O s u a S o 9 o 2 ^ 73 °° CO .. 03 2 --H Kl a,Tj o 1 CO K ’Si =« O p H 8 G a, S .2 g 00 .> T3 OG co o3 O 03 co pi s £P G .3 u G G s * c c spoonful be taken whenever the or shortness of breath come on. 80 APPENDIX. C ^ r' *JT . .r g> ■ — . cn rrf O S S « o ^ *B ^ ^ * 1 ^ ^ ’’G §•! %*% js B § «* i^'g So 2 ^ §^o 4 s „ o ° -5 73 -3 .Si ~ £ c ~ £ O 2 £ P t-> C, , ~ O <-W cn G ^ *H > G nd cd > ^ 6 M ; £• G O Rf l S**® bJQ P-< CD bJD C o Lh O G !i-H Cd -*-i CO cd u w CD L rO cri fe CO >> ' CD DCJ G bl •JG r 4 -> o CD » , _cd c cd L CD co O CD U G 'G o o four 73 5 ? +j c- t+H i CD •xJ G o o & - bfc.G p CD ^ ^ G O ^r* co ._ o . _ °P 9* A ^ £ CD CD > „G L_< * « -. CD rv> r ~^ £L "3 S" r* •dd bhi ^ CD £ ^ . r J •& QD . - 1 o £ K 0 O ^ '"°^ "O- G cd bC M PDSL'S g '"S a? o jg r 3 o c § Bo'S ^ £ g ODS ^ ^ C 2 o H S°sr| 0 § ' 5 1 s £ ^CG CD G l cp JD ^ 2 bio ►" *d O &>.S £ S ~ G 530 'tf’S vS g § ^ •L S 3 .2 rv »N CD -O cl g G2 )-h o £ rg r Sc § o 3 ? 1 U-* CD -* > O 3 cd £ ^ O 55 co L G 2 *3 G CD G S 0 ) 4 J A n G 2 O .. * H p, r/: cAJ 8 T3 O G T) O e e cd co *i-i a cd cd o 55 CO cd "5 j”. T3 B cd C/J • f-H O CD G G ShS G S s s M a.; '% | a-5 uj m B Hh B ^ .S fcL hco W T3 'G p. 5 cd CL Co* p Um ^ cd bJO 2 w>ts‘ r ° 2 ^ c . 2 u 2 S’ 3 S gG.g § CL S Gd cd .. co hi M CT 0) bD n$ 1> c bO £ -d -y^a’ o *H o LD 'Gn <» h Q co.^ ^ §•2 -• bJO^.G B 2*n 2 ^fficScS -.. * cn.s tl r^» o N Cd B •• o i> o G ’o R g S 73' |WfiO cGfG XJ Li X5 CD G^So^g QD CL G ^ +-J . . o os - o £ -d & as G a) s-< CD -*-> ,G C/2 ? « 8 5 G G O ^ CS +J «* £ G G cl> o .2 *bJQ bp 3 as G G* G 13 ^ r-^H ** CvS n, aS *a Jar to & a> G qh g Gh --3 3 ° " •q S 2 i ^ 3 >Ji 3 ^ «-n ,V G ^3 C/2 « S* G £ g a oG K G* a> tXV '-4H JP Jo2 In n s'S 6^ 2 s a-T bJO'G g * § ’S'H-a OS ® <-M Od O gT S 2 g ouf G 5 G cs O 2 G 2 3 bC-C I " 35 a> hJ a> T3 o ^ mh -S o 6 & •rN aT o 2 " P— »*h £ Td +-» CD k O u 3 .S ’ 3 G ^fiS °- ^3 G G G Ck •• G Gh.-2 g G-< bO- co J> 55 ■S ^ G ^ ti *- o JS G G 4 - > § o 0> •§ 5- t Ok c c 388 APPENDIX. Sfl i.” . II Si* ? 1 t° ^ .£ >> s=T ^53 ® CD g t § a 'S ^ O *a *a ^ i£p* j> 0 bJDg £ Uh _, c/5 c o ^3 ^=J /-< QD •th g o T3 ^ |i M 1^1! ■H \j3 O O ^ U-QT3 t-H CS a .a ft p R « &C 1 - c «+h .a a o O bJQ a O a jT od ^ ** ^ -S P* o Oh T3 rO O '"g ju o° o g W rg b.s £ w a « bi > 5/3 o o> a a o 3 s 1 3 £ o a ~ c £ £ CD CD .£-*3 *H 4 h fe-g.# £ i-O £ W) o a CD 'g ^D ^ U bp o C a G bJO a k°n3 ^ bjQ bJW o ^ SH-S * o * 1 a %°T$ § » «rag. 6.2 "■S e a a o T3 CD a o 8 "p ^ g -a ^ S Hio ^ S a:S - E E 3 a «e l> CD rj QD rO 0 c a vh o p ^ • ♦N 4-J 5£ v a J* £s p ^§.2 •aWfi a > Oh & a a P i »o i> c n O a *0 £ i$ 3 «5 C W s ^ 5 -h • a ?'3 S £ Oh Oh^O eg : a .. a,. a g S.S a l‘So|| a .S ° ^ a B 2 u - w>-S g J-t C/5 QD QD Oh « 6 i bX) a ^ a cin a ' T3 3 3 -i ps; i> si a a CD a 4-i &, No. 78 . R. Pulveris crassi cinchona? semunciam No. 78 . Infuse for one hour. Half an ounce of infunde per horam in aq: bullient: q: s: ut coarsely powdered Peruvian bark, in as colentur unciae sex. colaturae adde tincturae much boiling water as shall strain shcounces * APPENDIX. o o co co a a rSl o o c s 03 u Sh 0 W 1 g T3 ^ 33 33 3 3 n 03 § O la tjJ 0 ) o .a ° 03 '-t-i u, o 4-> CO q; cu> _c? ^ .2 w " js ^ 3 g J3 Trt 1-4 ° §31 ^ o . J . • XJ o-Wtj-i 2 33 3 43 ■nZ w > u 3 r _ o*^3^ 3 ° S.M g S3 £ o C G-> feJ0r3 3 £ a ^ o I p ^ -f3 rj^ 3 «3. » * 2 2 S .•°J JU s £ « « « J o A p &, Jh - ~ Q o H3 33 £ ^ 0(5 W *C *-M 3 £ Jm 3 2 *go *? 3 2 3 «* 5 •• 3.S 4-» O QJ c X) CO "O !•* 8 S a * ^ * 3 g CO 2 2 a 3 .a bjo ^ T5 C 3 £3 3 1 o a> fl "O 3 3 e 'l 3 3 a 3 ■d 2 „ a & a a 8 a # § & 3 3 3 -3 ^ 3 .2 cr* 3 S 3 4-J cO 3-S s §- 389 troublesome. No. 80. R. Spermatis ceti semidrachmam j No. 80. Let half a drachm of spermaceti be Tere cum vitello ovi recentis, & dein pounded well with the volk of a fresh 390 appendix, H fe -O > G ! o | c ^ § V-+H QJ 5-( , ' Oh G O t O ^ ! o § I *=} ^ ° > *2 g< S O % O Q. G G CD ~G m Gh Ci) f g s § .3 O SG G g g "o ^ 3"C -t-j o g G 13 .2 G C o cr - <3 ^ .g +J *'d g p 4 -j ^3 G G co a.3.2 G ’ * Oh G w P TO CD ' r §'-2 Q.-S > ^ cn w ^ § 18 3 «8 & No. 82. R. Crete precipitate drachmam. No. 82. Triturate in a mortar one drachm Tere in mucilag: gum: arab: semuncia, of precipitated chalk, with half an ounce dein adde tinctur : kino drachmam. Aque of mucilage of gum arabic, and then add to unciassex. Syrup: croci drachmas tres m: it one drachm of tincture of. kino, six APPENDIX. 391 o p D3 TO u #v . ° c/3 'O O CD P 4 ) P DP O > 05 O o OgPS a c-s-o p •O C Xj £ TO Ph Ph CD X oS£ 2.2 a o g.2 § (D P 3 M P ^ L> • M _T TO g ^Px3 G c/2 P c+h ^ oo > Jh TO P CJ 4 . H £ C/3 O 4 J X ZJ *£ TO 0) G ^ O “ g a •• s . ^ ll cti a K ^ ‘o Q CD o « o ^3 — J C73 <1 *< & 00 6 Pulv: capsici grana quinque. probe grains of powdered cayenne pepper, be well in mortareo contritis adde gel: sap: q: s: f: triturated together in a mortar, and made pilule decern. St. duas pro re nata. into ten pills with jelly of soap. " Two to be taken occasionally. 392 appendix o <0; o g G o CD G O u OD J-) CD bJO C CO o £ a § S e ” £ <-h Vm O C . CD u a p Co 4 -> 2 g 8~ t_4_ CD ° s -So a <-t-i * *73 o -G §? cd cd 9 g c/5 G ,£5 4-> O “ CD ? . c i ° * ‘ . **-H fe O- -■ 2 £ .-T> * 2^ 8 £ .5 G Oh -t-j cd cd • O , 4 h Jh ti s-t G3 nd rG p>> G 13 b£> G G G P G C G cd .CGOQG fa a Cl,* Or g g , , G Ju cl, c rr J — N ^ o,--h . G 13 fa fa T5 cd w *G c+h O fa G co bfio O C^t! S tgo; li 'I - C/9 J —' f ■ ■ G I 73 s oT b .d £ fa Cd <*> bi)§ C C ^ 5 S .s g C y ^ C o _ _ <2 S ° 6 5 ° S g-J 8.S-o«| 0/3 g .2 a . g 13 G fat o o c 9^13 C/9 ~ o G ° G cd >- a ’<-1 G CD P > O 0D r 2 G P CD « 5 O G > 4-J °c.s •-"2-a S § S «S rs.fa £ .a g G3 ■u Cj CD G 5-T O a 3T " . co fa <3 jw . a £<-£ * s g >1 Cd *fa G n C V CO CD G cd O £ s o v, y cd '"' r^H U _H W G3 CO O C_i_j ’ 1 ^ ^ Cfl O ^ A -U 2 . £ £ $ J£ \ ^^G 3 g jg s ^ ^ oc °" ScJcdca.tivg.^nassO - £ £ s§ C 3 - S-o l CD ’r* cm b/j fa c jd b CD G P h G G G G 55 G G . C '-M ^ • o O 4-| £ ^ § SS -,7 £h Cd C-M G ^ M ~ 2 S' 0 -G 13 co cd a a G ^ 3 G Sh.2 G G 5-h G ^ 3 fa o a cd cj G w G ’g *5 « G cr S fa cd G 13 13 G 5 CO • G a a s §D.S 3 G O c/3 G G G Oh G _9 C/9 G 3 *sb .. co OD , n a CJ G CD 4-J CD Oh CD td bJO u G Oh* CD „ - Gh.-G *Ph .. 8 rG a s § S 2 Gh g CO CD a rH a o a a p cd fa 4-> c! ! 4-J CO cd a G S 21 13 G G t # G co G2 O cd Oh G £ o St. 3 •• a .fa -5 CO u F 5 n *; -a 00 o o £ • • to G ^ fa 13 H fH M G to Is r- 4-> .. H V9 G G ed ** GJ 4-J ;g # o rrfa ^ C/D *> 13 ,£^ 13 G Oh O .. a ^ fa b bJO- 3 Oh .. G b/D o cd C/9 CD G • • cd a a Jr^p 5 oi "fa ^ CO 00 fa 00 fa G3 1 ^ APPENDIX, 393 G -M Lh Q o o S 2 2 J 0) . ^ bX) S-H S-H Q O +3 a> o -a C a -> I U ^ a> ' CD d) ° i-Bf f &s » c . S g '"d ° ' ^ -o O 0( ti TJ *X3 « c ^ § ° O g vs o Gh « «* ~ 5h «j_i 'rt 3^ C 03 C e»s s m cs g ^•5 co 5h 03 $ f-S « ° G 4-j d> G £ d/ 2 G [g G G o 3 03 §1 0) 8 * G * C/5 -o o ^.‘T’S ~ CD ^5 C/D CD G fcc-s G £ 5 o « G 2 o £ G C/5 03 bJO G G o £ H G Oh S <-2 O G> 03 _ >? G O bfl 4-> £ rx CD ^ £ t— | G *£ 4-1 <+_, 3 5 0-3 « o . ^ G 03 H 8|-IJ IIbIi g b w.: jf 8. * 'H = C + -' d> 2 wig >?.B 3 G u o G G G C/3 5-T £ ^ ‘’G G 03 M '3^*0 5-i ^ S-i 00 bo 72 G ‘I ^ § 2 Oh G es CJ co r* G G . S £ -g G o r3 G G *-• Oh.^ G c 5-i G cj a> co c/5 (V 4-1 .. G G £ 5h G (*H "d H 0) . r\ u G CD 5-i T3 o ....GO *G ^•5 5> B « ° 3 G ... &.S d 00 si s ^ I-* .—I * * • — h Oh G 05 ^‘bjQ G ^ .. ... o .. ■Ss 3 ^2 o .. o g a> o O) . H 3 -G G I s ' &8 41 . sps 3 8 I" tl G c Oh 0) ’ 5h CD si ^ G I o h£-g G .. £r cr 1 §,§ d> Oh . *' G CD G w G > — H T3 £ G 'C > -G T 3 -G 5-i a g CO rj G 7 d s s . CO G 5h T3 Gh G Oh 8 ■'“°"S8 L’.SS M & 1 G ^ ^ 4-1 GD HH OG J ^ 3 ■ G co S-« G G 4 -/ *rt CO ^ G co »G •=* I one scruple of sulphuric aether. Let the whole form one draught, to be taken and repeated every two hours, or oftener, whilst the difficulty of breathing continues. S94 APPENDIX. O P O P o a .a § _T 1> £ -a g ** •as °-3 <-M Cf O c/5 Ph £ o 2 o o p .a ^ T3 ° CD <«M s ° fe 8 rP P &. P o u-> r p .2 "u? "2 £ a> o P bO O 2 . a T3 ” 05 + J X « CO ”0 05 * d 13 E 1=3 Jja * p , 4-1 ° T3 ^ <-w P ° * ^ CD p* 05 bJD P o3 j-i O •tJ t5 . r 3 03 *** - 1 O O <15 *2 05 .P 8 i * P .2 *00 2 2 05 ° =1 O 03 ^ T3 O) O -5 .h o- H p M (l 1 •_, H Q-* l c C/5 o o p p o P of £ t> S ^ •3 & g Tj|*g 2 g s 2 g <+. c .p o rP Cu o3 o o w P< p »- fe* 0 IrJ.a r 5 c« o-g 0 O P P a a> C/5 w P 2 8 2 C/5 03 a ^3 o s 2 03 “O S 1 : r> ^ G O 2 g p p C3 U P O nr; P-< g o « c/5 Jh 'B P p +J s p W tS 05 ^ P^ ** •tr Ph .rH P P H HO . H > 00 CO 05 o S 5 e .2 *o . P « g 05 H M S C/5 C/5 03 O P P s u 03 P »h rri o 2 2 ■§ PhH p .. 2 8 . 3 ^ 'o- g o 0^5-1 ,. .p o 3 e • • 03 P-i P P •*-< P P P 5-. W kT* ^ H > C ^5 P< 05 o In cases where it may be wished that the two last prescriptions should have a nauseating effect on the stomach, the quantity of the emetic wine might be encreased, if necessary, viz. the ipecacuan wine in No. 93, and the antimonial wine in No. 94*. APPENDIX, 395 «» 4 > '05 k (U B X g e O b/D*-M *Q °Xj , . <-M ft -a ft o £ ^ o 0 )TJ M •fMS §| c" 3 ^ X <-4-4 4-J S-i , ft Sot ft E So 5 g P c 'Si> u e e § •a & f +_, <4H O c ~ ^ . o ft ° *£ 73 . s s JS « . jB ° s. 5 ^ ^ .ft ^ 0^2 o £ 5 B.-S g, 6 £ 1— ( C ^ t-H ■S. ^°-e-a cSg'S^'S® 2 - fS 8 o.s^ 05 b° o-§ fro *> 2 fee's a s "** § » ° S o I U -5 C^v S^® C S ? 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J 3 « G ^ « s s 1 « fc “8o • .C G O g 01 „ a g sl W W Q- CJ ^ -2 111 c£ T3 3 •S ^rt § S 5 o g B p *c § £.§ G d P-< G pi C9 o sl G CO "C 03 Oh co £ £ Q 5m O) > Oh 398 APPENDIX, p a n S ■g S o « c v tM o co CD o c p o G P *s T5 IS ■y ^ P 03 £ CD «£ is"- <-M o co M ^ (1) X P o ; O "-§ 5 CP a; O CP £ P bC 1—4 £ G G . CD •*-< *rj p X OJ f-i ^ T3 G o i-i 0) QJ > G CP O * ' « g co G .5 <44 ?4 o p jg a> P^ HD § co^. .2 *o ^ § : § K e § S 3 ° a & &' *o $0 8 cu O p'd T-, CTXJ P P £ 3 ,2 03 ; • £ O" 1 h£) L* i: s bJD bJQ P tt G O o 53 Jp "3 ^ 5.S - o >S^3 r! i§ 4- > P 5- i o *£ o P .. 4- u • CO o o mortareo in pulverem. a mortar into a powder. No. 106. R. Pulv: rad: ipecac: scrupulum No. 106. Let one scruple of powdered ipeca- divide in partes sex sequales. St. unam cuan be divided into six equal parts ; one to omni noctc. be taken every night. APPENDIX. $99 H.2 S 8 CD .§ ' u “ C ^ C ft G _, > ° o "G 2' 5 SP-s 's £ 5 * d 1 r — "~ > ~“ Q_ »\ c o G S 'u § j- § £ ^ « 2:» -O Hs -g £. 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