!,mu1l. >
REMNANT
EDMONDS )
Ex Libris
C. K. OGDEN
THE
VILLAGE PASTOR'S
SURGICAL AND MEDICAL GUIDE ;
IN LETTERS FROM AN OLD PHYSICIAN TO A
YOUNG CLERGYMAN, HIS SON,
ON HIS ENTERING UPON THE DUTIES OF A PARISH PRIEST.
BY FENWICK SKRIMSHIRE, M.D.
PHYSICIAN TO THE PETERBOROUGH PUBLIC DISPENSARY AND INFIRMARY,
EDINB. TAT. HIST. SOC. OLIM PRESKS ;
EDINB. REU. MEI). SOCLBT. SOCIU8 EXTRAORD.
LONDON :
JOHN CHURCHILL, PRINCES STREET, SOHO .
AND ITATCHARD AND SON, 187, PICCADILLY.
MDCCCXXXVIII.
LONDON:
IBOTSON AND PALMER, PRINTERS,
SAVOY STREET. STRAND.
PREFACE.
IT was long a matter of doubt with me, as it still
is, I believe, with many of my professional bre-
thren, whether medical works, written for unpro-
fessional readers, were not calculated to do as much
mischief as good. Now, however, with the expe-
rience of what the general improvement in educa-
tion and diffusion of knowledge has effected in the
dispersion of error, and the introduction of useful
truths, on this, as well as on every other subject,
either of art or science, I am decidedly of opinion,
that the mind of that class, for whom such produc-
tions are intended, is prepared to seek, and enabled
to receive, instruction on a subject so peculiarly
interesting to every one as the preservation and
recovery of health.
Every practitioner of my own standing must well
remember the time when old nurses were the autho-
rity that regulated the treatment, not only of trivial
1104500
IV PREFACE.
ailments, but of almost all the most serious disor-
ders of infancy and childhood. Most mothers sur-
rendered their judgment in these matters to the old
nurse of the family, and every village had an old
crone for its oracle in all matters of surgery and
medicine. The farrago of absurdities, which was
then generally practised, is now utterly discarded
by all but the grossly ignorant ; and to what, let me
ask, is this improvement to be ascribed, but to a
more free and candid intercourse between intelli-
gent practitioners and their patients, and to the
general perusal of popular treatises on medical
subjects ?
I am confident too, that, with growing intelli-
gence on these matters, there is an increasing de-
pendence on well-educated practitioners. Fathers as
well as mothers of families, who have acquired
rational views on this subject, now manage dis-
creetly the minor accidents and ailments, which
ignorant nurses formerly mismanaged; but they
know too well the profound judgment and practical
skill that is required for the treatment of more
serious cases, to hesitate or procrastinate in calling
for the aid of highly-educated practitioners, when-
ever such cases occur. Neither is it amongst the
readers of popular medical treatises that we meet
with advocates for advertised nostrums, pretending
quacks, or illiterate bone-setters.
PREFACE.
The public being now accustomed to professional
works written by surgeons and physicians of emi-
nence, a sufficiency of general readers will, no
doubt, continue to be found, to create a demand
for further publications of the kind. The ques-
tion therefore is not, whether such works do good
or harm, but what style and character of writing
will best instruct the reading public on a subject, so
interesting to all, as the preservation and restora-
tion of health.
The object of such a work, I apprehend, should
be to prepare the reader to meet sudden emer-
gencies, and to treat minor accidents and ailments ;
to teach him to discern danger, and to impress
upon him the necessity of calling early to his aid
the superior judgment, and acquired knowledge of
the experienced practitioner in all cases of im-
portance.
With these views I venture to add to the number
of professional works for non-professional readers.
I have selected the epistolary style as most free and
familiar, and therefore best adapted for the com-
munication of useful knowledge, when the pedantry
of the schools and the jargon of technicalities are
purposely avoided; and I have addressed myself
more particularly to the Clergy, because from edu-
cation they are better prepared to receive instruc-
tion, and to comprehend the limits, within which it
6 3
VI PREFACE.
is intended to be applied in practice ; and because,
from their position in society, they must neces-
sarily be most frequently called' upon to exercise
their judgment, and bestow their advice on those,
for whose ultimate benefit the work is designed.
Of all classes of society in all Christian countries
the ministers of religion hold pre-eminently the
most important place. The possession and proper
exercise of political power, it must be allowed, has
a vast influence over the temporal happiness of
nations, but the efficiency of the ministry of the
gospel affects both our moral condition here, and
our destiny hereafter. A national establishment
affords the surest means of extending such a mi-
nistry over the whole population of a country, and
this surely is one powerful argument in favour of
its propriety. Every man of reflection, who can
look back, as I can, upon the transactions of half a
century, must rejoice at the vast improvement in
the condition of our own established church. Merit
is now the passport to the highest dignities, and
the highest dignitaries are working safe and im-
portant improvements in the whole clerical com-
munity. The number of our resident village pas-
tors has, within the last fifty years, been nearly
doubled ; their education is of a higher order, and
the zeal of a great proportion of them is more pure
and more ardent; and the time is fast approaching,
PREFACE. Vll
I trust, when every village in England will be
blessed, and the eternal interests of its inhabitants
be watched over, by such a resident clergyman of
the established church.
That every such resident should hold a strong
place in the affections of his flock is greatly to be
desired : an interchange of kindly offices will surely
both generate, and be generated by, such affection.
And if the humble efforts of the author of this
volume should in the slightest degree facilitate
such interchange, one object of its publication will
be attained : and should the less educated portion
of such pastor's flock, only in a few instances, ex-
perience, through its means, restoration of health,
or mitigation of bodily pain, the author's best feel-
ings will be gratified, and his object will be then
fully effected.
CONTENTS.
LETTER I.
INTRODUCTORY. Page 1.
Usefulness of medical knowledge to clergymen, 2. Cour-
tesy to medical practitioners, 3. Object of the work to
prepare the village pastor to act upon emergency, 4.
Subject not treated scientifically, 6.
LETTER II.
ON WOUNDS. Page 6.
Flesh-wounds, 8. Union of cut surfaces, 9. After-dress-
ings, 12. Bruised wounds, 14. Punctured wounds,
15. Extraction of thorns, needles, &c., 16. Bites, 18.
Sting from poisonous animals, 19. Hydrophobia, 21.
Gun-shot wounds, 22. Suicide by cutting the throat,
.23.
X CONTENTS.
LETTER III.
ON HEMORRHAGE OR BLEEDING. Page 23.
Circulation of the blood, 24. Bleeding, whether venous
or arterial, 26. Fainting from loss of blood, 27. Bleed-
ing from the nose, 29. Bleeding from the lungs, 32.
Bleeding from the stomach, 33. Piles, 34. Bleeding
from wounds, 36. Tourniquet, 37. Bleeding from ex-
traction of a tooth, 45.
LETTER IV.
ON SCALDS AND BURNS. Page 51.
Scalds and burns defined, 51. Scalds, 52. Application
of cold, 55. Lime liniment, 58. Turpentine, 59. Scald
in the mouth, 60. Burns, 63. Treatment, 65. Re-
capitulation, 73.
LETTER V.
ON BRUISES, SPRAINS, &c. Page 77.
Bruises, 78. Whitlow, 81. Bed-sores, 83. Sprains, 85.
Surreptitious credit of bone-setters, 91. Concussions,
94. Fractures, 100. Dislocations, 105.
LETTER VI.
ON ABSCESS, ULCER, &c. Page 107.
Abscess, 107. Boils, 111. Carbuncle, 113. Ulcer. 114.
Chilblain, 123. Warts, 125. Corns, 127.
LETTER VII.
ON SUSPENDED ANIMATION AND POISONING. Page 131.
Object of the work in the medical department, 131. Re-
spiration, 133. Signs of death, 135. Drowning, 137.
CONTENTS. XI
Hanging, 140. Suffocation, ib. Choking, 142. Poisons,
146. Recapitulation, 160. Table of antidotes, 162.
LETTER VIII.
ON FITS. Page 164.
Fainting-fits, 164. Convulsions, 166. Hysterics, 172.
St. Vitus's dance, 176. Epilepsy, 179. Apoplexy, 187.
Paralysis, 189. Insanity, 197. Delirium tremens, 202.
Angina pectoris, 206. Asthma, 209.
LETTER IX.
ON FEVERS. Page 214.
Division, 217. General treatment, 221. Treatment of
symptoms, 222. Congestion, 233. Diet, 234. Pecu-
liarities of remittent, 237. Agues, 244. Consequences
of ague, 250. Neuralgia, 254. Chronic remittent, 257.
LETTER X.
EBUPTIVE FEVERS AND CHRONIC ERUPTIONS. Page 260.
Scarlet fever, 260. Measles, 269. Small-pox and cow-
pox, 273. Symptoms of small. pox, 282. Vaccination,
284. Modified small-pox, 288. Erysipelas, 291. Mi-
liaria, 294. Nettle-rash, 294. Herpes, 296. Tooth-
rash, 297. Humid tetters, 298. Ringworm, 299. Itch,
303. Lepra, 306. Dry tetter, 307.
LETTER XI.
ON EPIDEMIC DISEASES NOT TREATED OF AS FKVKUS
Page 309.
Catarrh or cold, 310. Cough, 313. Influenza, 315. Cho-
lera, 319, Hooping-cough, 327. Croup, 331. Crow-
ing, 337. Sore-throat, 339.
Xll CONTENTS.
LETTER XII.
ON VISCERAL OR INTERNAL INFLAMMATIONS. Page 346.
Inflammation of the brain, 347. Hydrocephalus, 349.
Inflammation of the heart, 353. Bronchitis, 357. In-
flammation of the lungs, 360. Consumption, 363. Ab-
dominal inflammations, 370. Inflammation of the eye
and ear, 376.
LETTER XIII.
ON VARIOUS CHRONIC AILMENTS. Page 378.
Rheumatism, 378. Sciatica, 384. Gout, 384. Indiges .
tion, 389. Dietetics, 392. Sick headache, 395.
Worms, 399. Gravel, 402. Dropsy, 404. Hydatids,
406. Water in the chest, 408. Water in the abdomen,
409. Ovarian dropsy, 411. Anasarca or general
dropsy, 413. Concluding Remarks, 415.
Xlll
SUBSCRIBERS.
ABINGER, Right Hon. Lord, t copies.
Anderson, Rev. Sir Charles, Bart., Lea, Gainsborough.
Anderson, Miss Emily.
Addison, Colonel, Chilton Lodge, Sudbury. 2 copiet.
Allen, John, esq.. Master of Dulwich College.
Arnold, T. G. esq., M. D., Stanford.
Ansells, Miss, Loath.
Addison, J. C., esq., Chilton Hall, Sudbury.
Arnold, Rev. T. K., Linton.
Atkinson, T., esq., Peterborough. 2 copies.
Atkinson, Rev. Richard, Laughton.
Atkinson, J., esq., Leeds.
Allay, Rev. H., Stamford.
Atlay, Rev. C., Stamford.
Bedford, His Grace the Duke of. 5 copies.
Burlington, Right Hon. Earl of.
Bateman, Right Hon. Lord, Kelmarsh.
Bateman, Lady.
Bedford, the Ven. Archdeacon of, Cliffe.
Bouverie, Col., Delapre Hall.
Brereton, Rev. Dr., Bedford.
Bacon, Rev. Hugh Ford, Fen Drayton.
Babington, Mrs., Cossington.
Ball, Mr. T., Peterborough.
Banks, John, esq., Holt.
Barclay, Mrs., East wick Park. 3 copies.
Barke, Mr., Alwalton. 2 copies.
Barker, G., esq., Surgeon, Peterborough.
Barber, Rev. B., Shipdham.
Barker, James, esq., and Mrs., Camberwell. 2 capin.
Barker, Miss, Camberwell.
XIV SUBSCRIBERS.
Barrett, Mr. E., Stamford.
Bate, W., esq., Werrington. 2 copies.
Beard, Rev. J., Cranfield.
Bell, Thomas, esq., Surgeon, Deeping.
Benets, Mr. R., Stamford. .
Bennet, Rev. Tancred, Cheveley.
Benton, Miss, Wick House, Bristol.
Berkeley, Rev. Miles John, Cliffe.
Bicknell, F. B. esq., Leamington.
Birch, Rev. C., Sawtry.
Bircham, R., Esq., Dunton.
Birkbeck, George, M.D., London.
Birley, Rev. G., Wisbeach.
Birrell, Rev. A. P., Welney.
Blencowe, J. P., esq., Lynn. 2 copies.
Bloom, Matthew, esq., Leeds.
Boake, Rev. J., Paston.
Bodman, G. B, esq., Surgeon, Castor.
Bolland, Miss, Paston Hall.
Bolland, H., esq., Trinity College, Cambridge.
Bompass, M. C.,esq., Edinburgh.
Boultbee, C., esq., Surgeon, Whittlesea.
Bowker, T., esq., Whittlesea.
Broughton, J., esq., Peterborough.
Brown, T., esq., Lanfine. 3 copies.
Brown, Rev. T., Stamford.
Buckworth, Mrs. G., Clinton.
Bullen, Mr., Peterborough.
Burdett, W., esq., Surgeon, Stamford.
Burnaby, Rev. G. A., Bedford.
Burnbam, Mrs., Whittlesea.
Burr, F., esq., Luton.
Butcher, Mr. W ., sen., Shipdham.
Butcher, Mr. J., Shipdham.
Compton, Right Hon. Earl.
Clarke, Sir Charles Mansfield, Bart., M. D.
Cave, Otway, esq., M. P., Stamford Hall.
Chatfield, Rev. Dr., Chatteris.
SUBSCRIBERS. XV
Cook, F., esq., M. J)., Loutb.
Cookson, W., esq., M. D., Lincoln.
Calthorpe, Rev. H., Corpus Christi, Cambridge.
Cape, Rev. W., Peterborough.
Cape, Miss, Peterborough.
Cape, Rev. Joseph, Clare Hall, Cambridge.
Carr, Rev. C., Newborough.
Castor, Mr., Peterborough.
Cattle, Mr., Peterborough.
Chalk, Rev. W. J., Wildin.
Christopherson, Rev. J. R., Leverington.
Clapham, Rev. C., Leeds.
Cobb, G., esq., Tuinp, Monmouth. 5 copies.
Cobb, Miss, Tump, Monmouth. 2 copies.
Cobb, Miss M. ., Malvern. 2 copies.
Cobb, Miss C., Malvern. 2 copies.
Cobb, Rhodes, esq., Banbury. 2 copies.
Cobb, Edward, esq., Banbury. 2 copies.
Cole, Charles, esq., Paston Hall. 2 copies.
Cole, Martin, esq., Putney.
Cole, P. S., esq., Sculthorpe.
Cook, John, esq., Hothorpe, Harborougb.
Cooke, Mrs., Peterborough.
Cooke, Rev. J. P., Tborney.
Cookson, Mrs., sen., Lincoln.
Cookson, Miss, Lincoln.
Cookson, Rev. Christopher, Stamford.
Cookson, Rev. Francis, Leeds.
CooksoD, Rev. Charles, Peterborough.
Cookson, Rev. Edward, Leeds.
Cookson, T. H., esq., Thorparch.
Cookson, Rev. Frederick, Great Easton.
Cooper, B., esq., Surgeon, Stamford.
Core, Mr. J., Peterborough.
Conic, Rev. H., Kettering.
Cory, Mrs., Peterborough.
Cory, Rev. E., Peterborough.
Corv, Rev. J., Kettlestone.
XVI SUBSCRIBERS.
Cox, Miss, Peterborough.
Crisp, Mr., Peterborough.
Cullege, C., esq., Surgeon, March.
Durham, Right Rev. Lord Bishop of. 3 copies.
Dunclas, Hon. Thomas, esq., M. P., Upleatham.
Dundas, Hon. and Rev. Dr., Harpole 2 copies.
Danford, Mr., Oundle.
Dalzel, Robert, esq., Lincoln's Inn.
Dawson, Rev. E., Clapham.
Dennis, Mr., Peterborough.
Dew, W., esq., Swan ton.
Dimock, Rev. J. G., Uppingham.
Dodson, Mr., Peterborough.
Dolben, William Mackworth, esq., Finedori.
Dolben, The Misses, Finedon.
Donne, Rev. J., Bedford.
Douglass, Miss, Harrowgate.
Duthy, Rev. W., Sudborough.
Exeter, The Most Noble Marquis of. 2 copies.
Ely, Right Rev. Lord Bishop of.
England, W., esq., M. D., Wisbeach.
Elger, Isaac, esq., Surgeon, Bedford.
Ely, Mr., Sudbury.
Emly, Rev. F. S., Deeping.
Fitzwilliam, Right Hon. Earl. 5 copies.
Fitzwilliam, Lady Charlotte Wentworth.
Fitzwilliam, Lady Anne Wentworth.
Fitzwilliam, Hon. George Wentworth. 2 copies.
Fazakerley, J. N., esq., M. P., Stoodley. 2 copies.
Fardel, Mr., March.
Fardell, Rev. H., Wisbeach. 3 copies.
Field, Rev. J., Braybrooke.
Foord, J., esq., Hull.
Fox, R., esq., Surgeon, Godmanchester.
Fryer, J., esq., Chatteris.
SUBSCRIBERS. XV11
Fuller, Rev. H., Wellington.
Grey, Right Hon. Earl.
Gloucester and Bristol, Right Rev. Lord Bishop of. 5 copies.
Gordon, Hon. and Rev. Lord George, Chesterton.
Grantham, Captain Charles, Ketton.
Gates, J., esq., Peterborough.
Grey, Rev. R., Colmworth.
Gibbon, W., esq., Surgeon, Kettering.
Gibbons, Edward, esq., Castor.
Gibbons, Mrs., .
Giraud, Rev. E. A., Dulwich College.
Girdlestone, Steed, esq., Stibbington Hall.
Gleadowe, Rev. R. W., Stamford.
Golby, James, esq., Banbury.
Golding, Rev. J. E., Walton.
Good, Rev. F., Maxey.
Goodall, Rev. J. J., Bromham.
Goodman, Mrs., Peterborough.
Goodman, Thomas, esq., Edgbaston.
Goodman, B. B., esq., Peterborough.
Goodwin, F. C., esq., Edinburgh.
Gotch, J. C., esq., Kettering. 2 copies.
Gough, Miss, Camberwell.
Green, J., esq., Bury. 2 copies.
Green, Rev. H., Cople.
Griffin, Mr. Robert, Werrington.
Grimshawe, Rev. T. S., Briddenbam.
Heron, Sir Robert, Bart., M. P. 3 copies.
Heron, Lady. 2 copies.
Hanbury, Major-General Sir John.
Hardy, Lieut.-Colonel, Fletton.
Hughes, Rev. T. S., Prebendary of Peterborough.
Hall, Rev. T. G., Professor King's College, L. U,
Henry, W. E., esq., M. D. Manchester. 5> copies.
Hopkinson, W. L., esq., M. D., Stamford. * copies.
Hill, Captain, Sunderland.
Hall, W., esq., Thorpland.
r 3
XV111 SUBSCRIBERS.
Hanbury, Rev. George, Swaffbam.
Hanman, Rev. G. E., Loddington.
Harber, M. A., Wisbeach.
Harman, Rev. J. W., Peterborough.
Harrison, Rev. T., Peterborough.
Haynes, H., esq., Whittlesea.
Haynes, Miss, Whittlesea.
Head, Mr. J. K., Peterborough.
Heathcote, Rev. George, Sawtry.
Henderson, J. P., esq., London.
Henery, Mrs., Whittlesea.
Henry, Alexander, esq., Lincoln's Inn.
Henson, Cheselden, esq., Bainton. 2 copies.
Hicks, J., esq., Dancers Hill, Barnet.
Higgins, J. C., esq., Turvey House, Bedford.
Hildyard, Rev. W., Deeping.
Hill, Hepworth, esq., Leeds.
Hill, Mr. J., Peterborough.
Hind, Mrs., Newton Green, Leeds.
Hodgson, Rev. Christopher, Castor.
Holland, W., esq., Surgeon, Deeping.
Holmes, Rev. T. P., Wisbeach.
Hopkins, E. J., Esq., Yaxley.
Hopkins, Mr. H., Birmingham.
Hopkinson, W., esq., Stamford.
Hopkinson, Rev. John, Alwalton. 2 copies.
Hopkinson, Francis, esq., Peterborough.
Hopper, Mrs. William, Bailey, Durham.
Horn, Rev. Thomas, Mursley.
Horsfall, Abraham, esq., Leeds.
Howarth, Edward, esq., Fakenham.
Hudson, J., esq., Surgeon, Sunderland.
Hurstwaite, Mr., Doddington.
Hustler, Rev. J. D., Euston. 3 copies.
. Jenkinson, Lady Louisa.
Johnson, Major-General, M. P. 2 copies.
James, Rev. Dr., Prebendary of Peterborough.
SUBSCRIBERS. XIX
Jackson, William Goddard, esq. Wisbeach.
Jackson, Rev. Marshall, Sutton.
Jackson, Edward, esq., Wisbeach.
Jeffery, Christopher, esq., Peterborough.
Jellings, W., esq., Mepal.
Jenkins, Edward, esq., Peterborough.
Jenkins, Rev. Edward, Billingay.
Jenkins, H., esq., Surgeon, Peterborough.
Image, Rev. J., Dulwich College.
Johnson, Rev. F., Great Gidding.
Johnson, Mr. B., Dogsthorpe.
Johnson, Hardy, esq., March.
Jones, Rev. F., Kettering.
Jones, Rev. B. ., Stamford.
Isaacson, Rev. J. F., St. John's College, Cambridge.
Isham, Rev. C. E., Polebrook.
Ivory, J., esq., Fakenham.
Keppell, Hon. and Rev. T., Warham.
Kennedy, John, esq., Lincoln's Inn.
Kershaw, , Jun., Boston.
Knight, Mrs., Mursley.
Knipe, Mrs., Waternewton.
Knipe, E. S., esq. Chenies.
Liverpool, Right Hon. Earl of. 5 copies.
Lilford, Right Hon. Lord. '2 copies.
Lilford, Lady. 2 copies.
Lincoln, Right Rev. Lord Bishop of.
Lamb, H., esq., Kettering.
Langham, Herbert, esq., Cottesbrook.
Langham, Burdett, esq.
Lawrance, W., esq., Peterborough.
Layng, Rev. W. W., Harrowden. t copies.
Leete, H., esq., Surgeon, Thrapston.
Leete, E. S., esq., Liverpool.
Levett, H., esq., Hull.
Lewin, Mrs., March.
XX SUBSCRIBERS.
Linton, Rev. Thomas, Fotheringay. 2 copies.
Linton, Rev. Hewitt, Nassington. 2 copies.
Linton, Charles, esq., Surgeon, Oundle.
Lockwood, Rev. E. I., Bedford.
Lucas, Rev. R., Stamford.
Lucas, Rev. St. John Wells, Downing College, Cambridge.
Milton, Right Hon. Lord Viscount. 2 copies.
Milton, Viscountess. 2 copies.
Madan, Rev. Spencer, Prebendary of Lichiield.
M'Dowall, Rev. W., Prebendary of Peterborough.
Marsh, Rev. Herbart, Prebendary of Peterborough.
Maclear, Rev. G,, Bedford.
Madan, the Misses, Northwich Terrace. 3 copies.
Madan, Frederick, esq., Northwick Terrace.
Madan, Rev. George, Cam, Gloucestershire.
Marishall, Miss, Peterborough.
Marsh, George, esq., the Temple.
Marshall, Mrs. Joseph, Elm.
Marshall, Thomas H., esq., Leeds.
Martin, Edward, esq., Edgbaston.
Mathews, R. esq., March.
Maude, F., esq., Hatfield Hall, Wakefield. 3 copies.
Maude, Rev. F., Hoyland.
Mayor, Rev. J., Collingham.
Metcalfe, Charles, esq., Wisbeacb.
Metcalfe, Mrs., Wisbeach.
Metcalfe, Charles, Jun., esq. Wisbeach.
Metcalfe, W., esq., Lincoln's Inn.
Mewburn, J. W., esq., Peterborough.
Micklethwaite, J. B., esq. Place, Hurst Green.
Micklethwaite, Mrs.
Miller, I., esq., Peterborough.
Miller, H., esq., Surgeon, Scham.
Mills, Rev. Thomas, Wittering.
Mills, Rev. Thomas, Peterborough.
Mills, Rev. John, Orton Waterville.
Moore, Thomas Sewel, esq., Warham.
SUBSCRIBERS. XXI
Moore, Rev. Robert, Hunton. 3 copies.
Mortlock, Miss, Peterborough.
Mortlock, Rev. Edmund, Christ College, Cambridge.
Morton, H., esq., Wisbeach.
Muff, Mr. Joshua, Leeds. 2 copies.
Murray, J., Esq., Sunderland.
Nelthorpe, Lady, Scawby.
Northampton, the Venerable Archdeacon of, Peterborough.
Nelson, Rev. John, Lincoln.
Nelson, Mrs.
Nevrnham, W. H., esq.
Newcombe, Mr., Yaxley Hill.
Nicoll, Rev. Charles, Great Coraard.
Norgate, B., esq., Norwich.
Oates, Mrs., Barlings, Lincoln.
O'Brien, Stafford, esq., Blatherwicke. 5 copies,
Oliver, H., Jun., esq., Surgeon, Stilton.
Orton, Thomas, esq., March.
Orton, Mrs. Richard, March.
Orton, Richard, Jun., esq., Peterborough.
Overton, I., esq., Fakenham.
Peterborough, Right Rev. Lord Bishop of. 5 copies.
Pell, Sir Watkyn, Sywell Hall.
Ponsonby, Hon. Frederick, Bishop's Court, Ireland, t copies.
Powys, Hon. and Rev. Lyttleton, Tichmarsb.
Powys, Hon. and Rev. Frederick, Achurcb.
Pratt, Rev. J. S., Prebendary of Peterborough. 2 copies.
Paley, W., esq., Surgeon, Peterborough.
Palmer, Rev. C., Lightborn.
Parsons, Mrs., Peterborough.
Parsons, Rev. Henry, St. Leonard's Court, Gloucester. 2 copies.
Pate, R. F., esq., Wisbeach.
Paul, Rev. S. W., Finedon.
Paul, Mrs.
Pearson, Rev. R., Bedford.
XX11 SUBSCRIBERS.
Peck, Rev. E. M., Wyton. 2 copies.
Peck, Rev. W., Boxworth.
Peckover, W., esq., Wisbeach.
Peckover, Algernon, esq., Wisbeacb.
Peill, Rev. J. N., Stamford.
Pell, Edwin, Esq., Sywell Hall.
Peyton, Rev. Algernon, Doddington. 3 copies-
Peyton, Abel, esq., Edgbaston.
Pickworth, Thomas, esq., Tydd St. Mary's.
Pidcock, Mrs., Whittlesea.
Pidcock, J. H., esq., Surgeon.
Pooley, Rev. , Scottor.
Porter, G. W., esq., Surgeon, Peterborough. 2 copies.
Porter, Rev. Charles, Stamford.
Powys, Rev. F., Yelverton, Mepal.
Powys, Rev. Spencer Perceval, Achurcb.
Pratt, Rev. Joseph, Paston.
Pratt, Rev. Charles, Packington.
Russel, Hon. and Rev. Lord Wriothesley, Chenies.
Reynardson, Lieutenant-General Birch, Holywell. 2 copies.
Rastall, Rev. Richard, Winthorpe.
Raymond, Mrs., Bedford.
Reid, John, esq., Cambridge.
Richards, T., esq., Doddington.
Robinson, Mrs., Sunderland.
Rogers, Rev. S., Orton Longville.
Rooper, J. B., esq., Abbot's Ripton.
Rooper, Mrs.
Roughton, W., esq., Surgeon, Kettering.
Rudge, Edward, esq., Surgeon, Fakenham.
Spencer, Right Hon. Earl. 2 copies.
Simpson, Lady Frances Bridgman.
Smith, Sir Culling Eardley, Bart., Bedwell Park.
Smith, Lady Culling.
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DAY, (J. S. Ks?/, inflict a severer injury than water heated only
to 200, and boiling oil, which is hotter by several
degrees than boiling water, will produce mpre mis-
chief still. Again, boiling water poured over a
person's naked leg or foot will not inflict so severe
a scald, as if the same part were immersed in the
boiling water, or as if the water were retained some
time in contact with the skin through the interven-
tion of the stocking ; the contact in the former case
being momentary. In the case of immersion too
the mischief will be the greater the longer the
limb remains in the scalding liquor. Ifc also stands to
reason that the whole or greater portion of the body
being immersed in scalding water, as when a person
falls into a copper, which is not an unfrequent
accident, the shock to the constitution and conse-
quent danger is greatly increased by the vast ex-
tent of surface necessarily exposed and injured.
Again, the application of a boiling fluid to the
54 ON SCALDS AND BURNS.
trunk of the body is more injurious than to the hand ;
to the lips mouth and throat, than to the external
surface of the body, in consequence of the greater
sensibility of those parts ; which circumstance will
account for the severe mischief and sometimes
speedy death, when a child incautiously drinks
scalding tea or water from the spout of a teapot.
And further, with regard to the influence of the
sensibility of the part in determining the magnitude
of the mischief, it has been pointed out by Sir
James Earle that some persons, from peculiarity of
constitution, or from a local morbid state of nerve,
may be less able to resist the effects of high tem-
perature, and consequently may suffer greatly more
than others from scalds or burns.
A scald may be so slight as to occasion only a
little pain and redness, and these effects may
speedily pass away. In such, and even severer
cases, where the cuticle or scarf-skin is not raised
into a blister, or the true skin injured, the applica-
tion of cold relieves the smarting, and the immer-
sion of the part in cold water, or its free applica-
tion by sponge or wet cloths, is all that will be re-
quired.
The effects of a scald somewhat more severe,
but still moderate, are greater pain, more lasting
redness, and the rising in a few minutes of a bleb
or blister. Such often arises from hot water, per-
haps below the boiling point, being accidentally
ON SCALDS AXD BURNS. 55
poured over a foot, or leg, or some other part. In
these cases cold again is the chief remedy. Im-
merse the limb in cold water, apply ice to the part if
at hand, or cloths constantly kept wet with cold water,
to which, if the skin be not abraded, some neutral
salt may be added to increase the degree of cold,
as common salt, or saltpetre, or sal ammoniac ; or
with a view of producing a far colder fluid, add to
the water, from time to time, a small quantity
of the combination of salts, called the freezing
powder. Some persons prefer wetting the scalded
part with spirits of wine, and this, evaporating more
speedily than water, produces more cold, and is
therefore an excellent remedy, when the skin is not
already denuded, and where expense is not an object
I may here describe a very simple mode of
applying the property of the syphon, and our
knowledge of capillary attraction, to the comfort
and advantage of a patient, who, from an accident,
such as we are now describing, or from ordinary in-
flammation of a part, or other malady, requires the
continued free application of lotions or embroca-
tions. It consists in introducing threads, few or
many, from a single thread to a skein of worsted,
into a bottle filled with cold water or the required
lotion, with one end of the thread or skein hanging
from the mouth of the bottle, and then properly
suspending the bottle over the affected limb, or
other part requiring the application. For general
purposes, the quantity of worsted should be about
56 ON SCALDS AND BURNS.
the thickness of the little finger. A little inge-
nuity will devise the most commodious method of
suspending the bottle according to the position and
situation of the patient, and of the part upon which
the fluid is required to be dropping. If the patient
be in bed, the bottle may be suspended from one
of the curtain-rods, or from a cord, or lath of wood,
or a long stick laid across the bed from one curtain-
rod to another. If the patient be on a sofa, or in
his chair, the bottle may easily be contrived to be
suspended by a stick laid across and fastened to
the back of two chairs, or the back of one chair and
the sofa. These are schemes to be adopted on
the spur of the moment; but the most conve-
nient contrivance of all is a stand, made for the
purpose, with a projecting arm, to any part of
which the bottle may be suspended, and this arm
may be made to rise and fall, and be fastened with
a screw, as in the construction of ordinary pole-
fire-screens. To make use of this contrivance, all
that is required is to suspend the bottle directly
over the part which is to be subjected to the appli-
cation of cold, and to draw the end of the worsted
sufficiently out of the mouth of the bottle, so that
it be somewhat lower than the surface of the fluid
in the bottle. Or the general direction may be
that the worsted touch the bottom on the inside,
and be drawn below the bottom on the outside.
This latter portion of the worsted represents the
longer leg of a syphon, and the fine threads, of
ON SCALDS AND BURNS. 57
\vhich the skein consists, raising the fluid by capil-
lary attraction, there will be a constant dropping from
the end of the worsted upon the affected part, as
long as any fluid remains in the bottle. To cause
an uniform distribution of the lotion over the part
to be cooled, and a more extensive surface for eva-
poration, the scalded or inflamed part should be
lightly covered with a single fold of fine cloth.
In some cases the application of cold is more
conveniently effected by means of poultices, or
cataplasms, in which case nothing answers better
than scraped potatoe, or carrot. Such poultices
must be renewed as often as the burning pain,
which the application of them instantly relieves,
shall have returned ; of this, therefore, the patient
will be the best judge, and his feelings must direct
you ; or if the removal of the poultice and conse-
quent exposure to the air, aggravate the smarting,
it may be kept cold by frequent application of cold
water without removal. The same observation, as
to the feelings of the patient, applies also to the
renewal of cold water, or wet cloths used in the
ordinary way.
We have hitherto been considering only cases of
trifling severity ; but the scald may of course be
of every grade from these to the appalling cases,
which we are sometimes called to witness, of a per-
son's falling into a copper of boiling water, beer,
or tallow, where, from the extent of surface injured,
and consequent shock to the whole nervous system,
DO
58 ON SCALDS AND BURNS.
the patient dies after a few hours, sometimes of
indescribable suffering, at other times of stupor
approaching to insensibility.
In cases of moderate severity, where blisters soon
arise, my advice to you is this, that if the blisters
be small, you leave them to their natural progress ;
and that if so large, as by their bulk or situation to
be liable to friction, and thus or by distension to be
the source of additional pain, then you are to prick
them with a needle, so as to empty them without
exposing the inflamed and tender subjacent skin
to the contact of the air, or of the medicated appli-
cations. In accidents of the degree of severity we
are now contemplating, after the continued appli-
cation of cold, as long as the sensation of burning,
such as it was at the commencement of the accident,
shall continue, which will vary from two or three
to twenty-four hours, you may substitute the lime
liniment, or lime-water and milk, gently applied,
first by means of a feather, and then by covering
the parts with rags well soaked in the same. When
the injury sustained is on a part of the body co-
vered by the dress, it is a common but mistaken
practice to proceed immediately to strip off the
clothes, in doing which it is not unusual to strip off
also the cuticle, which, by exposing the tender true
skin to the air, greatly aggravates the sufferings of
the patient. But in such cases the parts should
be instantly submitted to the cooling process ; and
this, even if it extend to the whole surface of the
ON SCALDS AND BURNS. 59
body, as when a person falls into a copper of boil-
ing fluid. In this latter case, however, as well as
in scalds occupying any considerable portion of the
trunk, the immersion in cold water must be con-
tinued but for a few minutes, lest its effect upon
the general constitution should induce internal in-
flammation, particularly of the lungs; to which
persons are greatly more liable after accidents im-
plicating so much of the cuticular surface. When,
however, a limb is the seat of the scald, the im-
mersion, or other application of cold, may be per-
sisted in for some hours, and then the clothes
should be taken off, or cut away, with the greatest
tenderness, and with all due care to avoid exposure
to the air. Indeed through the whole treatment
such exposure must be avoided as much as pos-
sible ; when, therefore, the lime-liniment, or other
dressing, in the severer cases, is substituted for the
cold applications, apply the rags imbued with these
matters smoothly and closely to the injured sur-
face, and renew them but seldom.
In very severe cases, after the application of
cold as above described, you will do v. ell to apply,
first, rags dipped in oil of turpentine, and over
these, in the most injured parts, pledgets of lint
covered with oil of turpentine and yellow basilicon,
mixed in equal proportions, and, where it can be
effected, bandages over these, to keep all firmly
in their places; and if upon the subsidence of
the inflammation, and the separation of the cu-
60 ON SCALDS AND BURNS.
tides, the parts are deeply ulcerated, common
poultices will be serviceable to promote the se-
paration of the slough, and the surgeon will find
stimulating applications called for in the progress
of the cure, as blue vitriol or the solution of lunar
caustic ; but, as in such severe cases your judgment
will only be required to direct the early treatment,
I need not discuss these points.
We will now suppose, that you are called to a
child, who has inadvertently sucked the steam, or
some of the fluid, from the spout of a tea-kettle or
tea-pot, which, as I formerly stated, is not a very
rare occurrence. The child i?, in all probability,
about two or three years old ; and, when you ar-
rive, you find it screaming and crying violently,
and as you can obtain but a slight view, if any, of
the back part of the mouth and throat, the only
injury you can discover is a dull white and wrinkled
appearance of the delicate cuticle covering the out-
side, and lining the inside of the lips. If, however,
the screams have continued long, and particularly
if any witness of the accident assures you that the
water was nearly boiling hot, you may feel assured
that the mischief is considerable ; and you may
proceed immediately to assuage its sufferings by a
dose of laudanum, proportioned to its age. If it
be an infant under a year old, give two drops, and
if older, give an additional drop for every half year
of the child's age. Give the laudanum in a tea-
spoonful or two of cold water, putting the spoon as
ON SCALDS AND BURNS. 61
far back into the child's mouth as possible. The
only local treatment that can be resorted to in
such cases, is to smear the lips and inside of the
mouth with sweet oil, or cream, by means of a soft
feather, or camel-hair brush ; to drop a little cold
water frequently into the mouth from a sponge or
wet rag, or, if the child seems to prefer it, you may
allow it to suck a piece of ice, or a camel-hair-
brush repeatedly dipped in cold water. If in a
few hours the crying becomes hoarse, and the
child's sufferings do not much abate, you may sus-
pect incipient inflammation in the gullet, and per-
haps in the windpipe from the heated steam that
entered the air passages, and you will do well to
apply two or three or more leeches to the external
throat, according to the age and strength of the
little patient. The dose of laudanum may be re-
peated about the same time, and the after treatment
will be best directed by a medical practitioner.
The severity of the injury in other cases may in
a great degree be judged of by the effects of it
upon the general system. If immediately after the
accident, and previously to the application of cold
to the injured part, the patient is seized with shi-
vering, you may consider the case as one fraught
with danger, and to obviate as much as possible
the evil consequences of this constitutional dis-
turbance, you may instantly, in the absence of
professional aid, administer a full dose of lauda-
num in hot brandy and water; if the patient be an
62 ON SCALDS AND BURNS.
adult you may give sixty drops of laudanum with
half a wine-glassful of brandy in about a quarter
of a pint of hot water ; you will also be careful not
to expose the patient to the cold unnecessarily,
and instead of the continued immersion of the in-
jured parts in cold water, or the free application of
cold in any other way, consider this, if left to your
own judgment, as one of those severe cases which
require the early application of oil of turpentine.
The dose of laudanum, and also the quantity of
brandy, in such a case, must of course vary with the
age, and constitution, arid previous habits of the
patient. To a youth of about fifteen, or to a deli-
cate female, half the above dose would be ample,
and to a child of five years you should give only
ten drops of laudanum and about two tea-spoonfuls
of brandy. Should the shivering or sensation of
chilliness and the depressed state of pulse not
abate in a very few minutes, more brandy may be
given by only a single tea-spoonful at a time even
to an adult, with a desire that he hold it as long
as he can in his mouth before swallowing it ; as,
when thus given, I believe its effect to be more
speedily and universally diffused. If the sufferings
of the patient be not materially mitigated after a
few hours, it may be advisable to repeat the lau-
danum ; but by this time it is to be hoped that you
will have resigned so formidable a case into the
surgeon's hands.
In cases of less danger, which may be supposed
ON SCALDS AND BURNS. 63
to be left to your own superintendence, I may here
observe, that a moderate dose of salts should be
early administered, and occasionally repeated during
the progress of the cure ; that the diet should be
light; and that as little confinement to the bed or
to the house be insisted upon as the situation and
extent of the injury will allow, because so material
an alteration in the habits of your patient would be
likely to induce disease.
BURNS, which will now become the subject of
consideration, I have above defined to be injuries
inflicted on the living body by ignited or burning
bodies, by solids heated to a high temperature, or
by such substances in a state of fusion as are ordi-
narily solid at the common temperature of the air.
These injuries so much resemble in their effects the
scalds of which we have just been treating, that
much of the same reasoning will apply, and much
the same treatment will be applicable; but still
as there are some peculiarities in burns, and as the
nature of the accidents, by which the injuries are
inflicted, are so different, I have preferred con-
sidering the subject separately, as affording a more
easy and natural introduction of the various acci-
dents, in which you are more peculiarly liable to
be called upon to act, and to give your advice.
I shall begin with an accident of very frequent
occurrence, particularly amongst the children of
the poor, who are so often, either from negligence
or from necessity, left to themselves in apartments
64 ON SCALDS AND BURNS.
where there are fires or lighted candles, but parti-
cularly the former. I here allude, of course, to the
burns occasioned by the clothes catching fire. The
instructions which I would inculcate upon the first
witnesses of such accidents, and upon the sufferers
themselves when old enough to comprehend them,
are to exclude the access of air, and particularly
of draughts of air, as much as possible ; to apply
water or damp coverings for the purpose of ex-
tinguishing the fire; and thirdly, to remove, as
expeditiously as can be done without encouraging
the flame, all the ignited articles of dress. Thus,
instead of running to the door or out of doors,
which fans the flame and extends the injury ten-
fold, keep the doors and windows shut, and let
your first efforts be to wrap up the sufferer in
something sufficiently large and thick, to cover and
exclude from the air all the ignited portions of the
dress, as a great coat, a blanket, or a carpet ; un-
less, as is sometimes the case, the article of dress
which is in flames can be instantly torn off, which
may be done if it be a cap, a handkerchief, or a
child's pinafore ; but do not run the risk of pro-
longing the mischief by attempting in the first
place to undress the sufferer. I have seen an in-
stance of very serious aggravation of the injury
from fruitless attempts to strip off the trousers
from a youth, who had the misfortune to have fire-
works set fire to, which he carried in his trouser
pockets. Had he courageously introduced his
hand and thrown out the fire-works, ignited or not
ON SCALDS AND BURNS. 65
ignited, and had one of the numerous witnesses
wrapped a great coat closely round the burning
clothes, whilst another with water, which was nigh
at hand, had presently soaked it well, the young
gentleman's life would not have been endangered,
and he would have been saved many weeks of acute
pain and suffering.
When the air has been by these means excluded
sufficiently long to satisfy you that the fire is extin-
guished, proceed to cut and strip off carefully all
the clothes, and adopt the curative means which I
shall now describe generally, as applicable to all
burns, whether inflicted by the dress catching fire,
or by the immediate application to the skin of
flame, burning coals, melted metals, or other highly
heated substances.
The mischief produced by burns, generally
speaking, penetrates deeper, and more frequently
destroys the skin, and seriously injures the subja-
cent parts, than that produced by scalds. These
accidents consequently require more frequently the
stimulating applications after the first few hours,
as rags dipped in warm oil of turpentine, or the
liniment made of turpentine and basilicon ; and in
cases only moderately severe these dressings may
be substituted for the cold applications more early
than in scalds. Still, however, in very mild cases,
as the momentary handling of hot metals, the
dropping of melted wax upon the fingers, a com-
mon accident in the sealing of letters, and the fall-
66 ON SCALDS AND BURNS.
ing of other melted or burning bodies on the sur-
face, and which remain there but for a moment,
cold water and cold poultices will be the most
agreeable and efficacious applications, and nothing
more will be required.
In severer cases, there is much discrepancy in
the directions given by different surgeons; some,
as Kentish, advising the immediate adoption of
warm oil of turpentine, others preferring in all
cases the application of cold, and others, falling in
with the intermediate plan recommended by Cleg-
horn, using warm vinegar as a first application.
From experiments that have been frequently
made with a view to decide the controversy, it is
evident that each mode has in many cases proved
equally successful, but that in some one plan has
had its advantages, and in other cases a different
treatment has succeeded best. Unfortunately for
our patients surgeons have not yet been able to ap-
preciate the causes of these different results, and
therefore cannot say a priori what remedy is to be
preferred in any particular case. In this dilemma
my advice is, that in every case you commence the
treatment with cold applications, as being always
most easy of access, and as they may indeed be in-
stantly had recourse to, by immersing the limb in
cold water, or by the free application of wet cloths.
This may be done, as was recommended in scalds,
even before the injured part be stripped of its
clothing, and when, after an hour or more, you
ON SCALDS AND BURNS. 67
proceed to remove the clothes, which must be done
carefully, with a view to ascertain the extent of the
injury, and for the application of other dressings,
it may by proper management be done without de-
sisting for a moment from the cold applications.
In very mild cases you cannot do better than
persist in the use of cold water or ice, and then
cold cataplasms of potatoe or carrot very frequently
wetted or renewed, but in the latter case without
removing the single fold of linen which should
always be interposed between the poultice and the
skin, and retained there, to prevent the immediate
contact of the air with the denuded skin.
In severer cases, as from the clothes catching
fire, the explosion of gunpowder or fire-damp, or
the continued contact of ignited or melted bodies,
after the immediate application of cold, the convey-
ance of the patient to his home, the removal of his
clothes, and the comfortable arrangement of his
bed, his couch, or chair, as the case may be, you
may proceed to try by actual experiment in the
particular case in hand, what kind of treatment
should be permanently persisted in, at least until
the arrival of a surgeon. 1 shall suppose that you
have by this time procured oil of turpentine and
the lime-water liniment Where the extent of sur-
face injured is but small, you may now substitute
either of these for the cold applications hitherto
employed; a very short time will suffice for the
experiment, and the sensations of the patient alone
68 ON SCALDS AND BURNS.
must decide ; for no doubt seems to be entertained
by professional men, that in the early treatment of
burns and scalds, that application is to be preferred,
which most effectually allays the acute burning
sensation in the injured part. Should the patient
express no preference after the first change, substi-
tute the other, and after about an hour's trial, ul-
timately persist in that which he prefers. Should
the injury extend over many parts or a large extent
of surface, the cold poultice, the lime liniment, and
the warm turpentine may be applied each to a dif-
ferent part at one and the same time, and after an
hour or two's trial, that most approved by the pa-
tient may be substituted for the rest.
The only observations I can offer to guide you
in these experiments are these. First, that the ap-
plication which relieves most at the first instant of
its use sometimes loses its cooling or soothing effect
so speedily, that the frequent renewal counterba-
lances this advantage ; thus, rags soaked in the
warm oil of turpentine soothe often for an hour or
two, whereas the cold water or lime liniment may
afford somewhat more relief, but only for the first
few minutes, and must therefore be continually re-
newed. A second observation to guide you is this,
that the turpentine has been found to be more fre-
quently soothing in burns than in scalds, and the
cold water more so in scalds than in burns ; and,
thirdly, I may observe that as the frequent renewal
of the dressings, by some exposure to the air, which
ON SCALDS AND BURNS. 69
can scarcely be avoided, and by other circum-
stances, gives more pain where the cuticle is re-
moved, it follows that in these cases the turpentine
or the liniment, as evaporating more slowly and
consequently not becoming so soon dry, are pre-
ferable to the water or cold lotion.
With a view of obviating as much as possible the
pain thus occasioned by exposure of the sores to
the air, it is desirable, not only in the early part of
the treatment, but still more so after the separation
of the cuticle and of the skin, if the injury has ex-
tended thus deep, that the rags, whether soaked in
water, or lime liniment, or turpentine, and the
pledgets of turpentine and basilicon, if these be
used, should be in narrow slips ; so that by taking
off and renewing them separately, a small surface
only need be exposed at once, and the part may be
more expeditiously re-covered. When the cold ap-
plications are preferred, the surface need not be
frequently exposed, whatever be their form ; as the
w ater, the snow, the ice, or the scraped potatoe may,
and always ought, to be employed with an intervening
fold of linen rag, which need never be removed
from the injured surface, though the renewal of the
cold application itself cannot well be too frequent,
as the burning sensation, which it is intended to
allay, usually returns the moment the cloths have
acquired but a small increase of temperature. On
this account the use of snow or ice in a half-filled
70 ON SCALDS AND BURNS.
bladder, should always be preferred where prac-
ticable.
When the preference is given to the lime lini-
ment, it is to be used as described in the treatment
of mild cases of scald. When oil of turpentine is
preferred, pour the oil into a basin, and place this
basin in a larger one of boiling-hot water ; and then
soak narrow slips of rag in the oil thus heated, and
apply them separately and smoothly over the burnt
surface, so as to cover every part. And where
pledgets of the turpentine liniment are used, they
need not be removed for two or three days.
Injuries from the accidental explosion of gun-
powder also afford pretty frequent examples of
burn, particularly with schoolboys. These may be
of every degree of severity, and the mischief is often
aggravated by suffering the burning clothes to re-
main longer than need be in contact with the skin,
and without an attempt at extinguishing the fire
by wrapping the parts in some damp covering, as
directed above. There is nothing peculiar in the
treatment of this species of burn ; I have therefore
only to refer you to my former instructions, and to
leave you to apply them according to the severity
of the case. I may, however, observe that so vio-
lent is the force of exploding gunpowder, that
burns from this cause are frequently combined with
other serious mischief, as a fracture of a bone, the
loss of an eye, or a concussion of the brain, in all
ON SCALDS AND BURNS. 71
which cases, you will of course be speedily super-
seded by the practised surgeon.
We have hitherto been considering principally
the treatment applicable only upon the first occur-
rence of the accidents, or at most such as may be
persevered in for the first few hours, or for the first
day or two, or until surgical assistance shall have
arrived. But should the case, from its being deem-
ed unimportant or for any other good reason, be
continued under your unassisted care, I must cau-
tion you against persevering too long in the use of
-old applications ; for, as I formerly observed, when
treating of wounds, nature cannot repair the inju-
ries sustained in these cases without setting up the
process of inflammation in the sound parts imme-
diately in contact with the parts destroyed, and
this will certainly be retarded, or altogether pre-
vented, by too free and too long an application of
cold.
In deciding upon the proper point of time for
substituting warmer and more stimulating dressings,
the feelings of the patient will greatly aid us. The
pain occasioned by a burn or a scald, whether mild
or severe, is of a peculiar kind, as every one's ex-
perience must have taught him. It is described
as a burning pain, and as long as this remains, it
is a very common expression to say that the fire is
not yet out As long as this peculiar pain is com-
plained of by the patient, the cold applications, if
they have in the first instance been preferred, may
72 ON SCALDS AND BURNS.
be persevered in. It may also be here observed,
that in feeble and delicate constitutions the free
and long-continued application of cold is more ob-
jectionable than in the robust.
In the after-treatment of burns of moderate se-
verity, slips of rag well moistened with the lime
liniment, or with a mixture of lime-water and milk,
will perhaps have proved the most serviceable
dressing ; if so, let them be renewed with as little
exposure to the air as possible once a day, or of-
tener if the comfort it affords to the patient makes
him wish for it.
When the blebs or blisters are numerous, and
the surface of the injured part is consequently
moist, fine flour or very finely powdered chalk
sprinkled freely over the surface is a mode of treat-
ment recommended by some authors, and if the
lime liniment produces smarting, this may be tried
in such cases, and should be washed off with warm
water, and renewed once only in the day.
In all severer cases where the true skin is de-
stroyed, and perhaps the flesh or even the bones,
as I have seen them in cases of epileptic patients
who have fallen into the fire, the best applications
will be rags dipped in the warm oil of turpentine,
and over these pledgets of lint spread with a mix-
ture of the oil of turpentine and yellow basilicon
or yellow wax in equal proportions. I mean to
say that these will be the best dressings after the
first few hours; for even in these cases, as I have
ON SCALDS AND BURNS. 73
before observed, the cold applications will generally
afford the most relief at first ; though they should
not, in my apprehension, be so long persevered in
here as in milder cases.
During the further progress of the cure in all
cases of severe burn, whatever be the nature of the
accident, some variety of treatment will be required
according to the established rules of surgery. If
the granulations are too high, or appear soft and
spongy, or if, as it is commonly expressed, there is
proud flesh, its surface must be touched with lunar
caustic or blue vitriol ; if abscesses are formed they
must be opened, and sinuses must be dilated, and
when the sloughs or dead parts have separated, and
the healing has commenced, straps of adhesive
plaster, wherever applicable, will expedite the
cure.
With one or two more observations of general
application I shall conclude the subject of local
treatment It was observed in treating of wounds,
that whenever two cut surfaces are brought into
apposition, they will unite, and grow together, a
law of the animal economy that is frequently taken
advantage of in surgical operations. The same law
holds good of any two surfaces denuded of their
skin by such accidents as we have been now treat-
ing of; and when the healing process commences
after a scald or a burn, the greatest care is often
necessary to prevent the adhesion of parts together,
which would occasion much future inconvenience.
74 ON SCALDS AND BURNS.
This is of course most apt to occur between the
fingers or the toes, or where there are folds or du-
plicatures of the skin, as in the groins, the arm-pit,
under the chin, or about the eyelids ; and many such
cases (occurring, be it remembered always, from in-
attention) have occasioned considerable deformities,
and have required serious operations afterwards for
their removal, and not always attended with success.
The certain means of obviating such accidents are
the careful interposition of your plasters, or other
dressings, between the healing surfaces, and this of
course ought never to be neglected.
Another species of deformity arises from the con-
traction of neighbouring parts during the healing of
such wounds, or sometimes even after the cicatrix
is formed by the entire healing of the sore. The
force with which this gradual contraction takes
place, is sometimes so great, that the forearm has
been drawn up close to the arm, and the elbow joint
rendered stiff; or the chin has been drawn down
upon the breast. To obviate such serious evils,
whenever extensive and deep burns occur in these
or similar situations, splints or such other me-
chanical contrivances, as the experienced surgeon
shall recommend, must be worn during the whole
progress of the cure, and for some time after-
wards.
The general or constitutional treatment is so
precisely the same after a burn as after a scald,
that I shall refer you to what 1 have said in the
ON SCALDS AND BURNS. 75
former part of this letter upon that subject; only
observing here, that as deep-seated burns are of
more common occurrence than deep-seated scalds,
and therefore profuse and long-continued discharge
of matter a more frequent result, so you will
oftener be called upon to support the strength of
your patient by nutritious invigorating diet, aided
by the use of bark and other tonics.
The observations, which I have been induced to
make on the treatment of scalds and burns, having
been desultory, and, from the discordance of sur-
geons, not always very precise, I shall now briefly
recapitulate those points of treatment, which may
serve best to direct you in actual practice.
In every case of burn, if present at the time of
the accident, damp the fire, if the clothes be burn-
ing, by wrapping the sufferer in a great-coat,
blanket, carpet, or anything else that is at hand ;
and then carefully strip off the clothes : but in
scalds do not strip off the clothes till after the
temporary application of cold, lest you should in
doing so strip off the skin also, but let your first
object be to immerse the part in cold water. In
all cases both of burns and scalds fly first to cold
applications cold water, ice, snow, scraped pota-
toes, or carrot. In mild cases nothing more may
be required. In severer cases, after a few hours,
the patient having been stripped, and put to bed,
apply slips of rag, soaked or well spread with lime
liniment, smoothly over every part, and renew the
E2
76 ON SCALDS AND BURNS.
dressing three or four times a day. But in still
severer cases, where for instance the skin is de-
stroyed, make use of the oil of turpentine, applying
first slips of rag soaked in the heated oil, and over
these pledgets spread with the turpentine liniment,
and do not remove the dressings for two or three
days. And here let me observe, that it will fre-
quently happen that you will have in the same
case burns of different degrees of severity in differ-
ent parts, and that therefore you will find it of
advantage, after the first general application of cold,
to use at the same time cold poultice or lotion to
a superficial burn upon the face, we will say, lime
liniment to a severe burn upon an arm, and the
turpentine to a deeper burn upon the trunk.
When blisters rise, it is better not to break them,
unless they are so large as by their bulk to be
sources of additional suffering. In applying your
various dressings, attend particularly to the inter-
position of your plasters between the fingers, or
toes, in the bendings of the forearm, or ham, and
in all natural foldings of the skin, with a view of
preventing preternatural adhesions and contrac-
tions.
The general or constitutional treatment con-
sists in moderate purging and moderately low living
in all mild cases ; and in the immediate administra-
tion of opiates and stimulants in severe cases at-
tended with rigors or shiverings, and opiates alone
where the pain is severe but unattended by shiver-
ON BRUISES, WHITLOWS, &C. 7?
ing. As these severer cases advance, fever may
arise, and require the usual treatment, and pro-
fuse discharge of matter may so exhaust the
strength, that bark and other tonics, and a strength-
ening diet, may become necessary to support or
restore his sinking powers.
LETTER V.
ON BRUISES, WHITLOWS, BED-SORES, SPRAINS, CON-
CUSSION, FRACTURES, AND DISLOCATIONS.
MY DEAR SON,
THE subject of the present letter is multifarious ;
but for reasons, which I shall now assign, the letter
itself need not be proportionally long. Having
already treated of most of those accidents which
are important, and at the same time within the scope
of that moderate amount of surgical lore which I
aim at inculcating, I may, in strict accordance with
the views which I have already stated, pass very
briefly over most of the remaining topics in sur-
gery. Very briefly, not on account of their want
of importance, but, on the contrary, because they
are too important to be allowed to be under other
management than that of skilful and talented sur-
geons, even in their earliest stage of treatment. Of
78 ON BRUISES, WHITLOWS, &C.
this description of accidents are all fractures of bones
and dislocations of joints, in which accidents my
instructions will only embrace certain attentions to
be paid to the present ease and comfort of the suffer-
ers. The effects of concussion of the brain are like-
wise so serious as to make it incumbent upon you
to send immediately in almost every case for pro-
fessional aid. Let me, however, proceed to make
such observations, as I may deem necessary and
useful, on each species of accident, in the order
which I have assumed as the title of this letter.
BRUISES are the consequence of a great variety
of accidents, such as falls, blows, or severe pressure.
Indeed they occur in some feeble constitutions from
the slightest possible degree of pressure. The well-
known external appearance that constitutes a bruise,
arises from the extravasation of blood ; that is, from
the rupture of very minute blood-vessels, and conse-
quent escape of blood into the cellular tissue in
and under the skin. The gradual disappearance
of a bruise takes place by the natural absorption of
this extravasated blood by certain vessels, freely
disposed throughout the animal frame, called, from
their office, absorbents; and during this process
of absorption the external appearance of the
bruised part assumes a variety of hues, changing
from its original purplish hue to a greenish, and
then a yellow tint. The severity of this, as of
most other accidents, may be of every grade ; some-
times so slight as to demand no attention ; at other
ON BRUISES, WHITLOWS, &C. 79
times, where the force occasioning it has been great,
the bruise is extensive, deep-seated, and intensely
painful; perhaps some important viscus is involved
in the mischief, and dangerous or even fatal in-
flammation may ensue.
In every bruise, besides the rupture of vessels
and extravasation of blood, which give it its cha-
racteristic appearance, the skin itself, and, if the
violence has been great, the subjacent cellular
substance, and muscular fibre, and nervous fila-
ments, which everywhere abound in all these struc-
tures, have suffered. In the progress of the cure
a certain degree of inflammation is set up in the
sound vessels immediately contiguous to the in-
jured parts, and according to the violence of the
cause and extent of mischief done, must be the
degree of inflammation and activity of the vessels
in the surrounding parts, first for the purpose of
removing by absorption the extravasated blood ; in
the next place, for separating and removing by the
process of suppuration and absorption all dead
parts; and lastly, for renovating them by new
growths, as in wounds and ulcers of every other
description.
When from a blow or fall there is an im-
mediate swelling of the part, which indeed is
often very considerable in a few minutes, particu-
larly if the eye be the part injured, nothing is so
successful, both in abating pain and reducing the
swelling, as the free application of cold ; and the
80 ON BRUISES, WHITLOWS, &C.
most efficacious mode of applying it is by means
of a handful of snow or pounded ice (when it can
be procured) wrapped up in a pocket handker-
chief, and kept constantly to the part. When from
neglect of the cold application in the first instance
the swollen part has become very sore and stiff, fo-
mentation of the part with warm water in the first
instance affords most relief; and, after the pain
has thus been in some measure subdued, cold vine-
gar, or some spirituous embrocation, frequently
renewed, is found most efficacious in promoting
the absorption of the extravasated fluids, and in
thus restoring the natural size and colour of the
part.
In severer cases much inflammation and con-
sequent swelling often come on after one or two
days in the parts immediately contiguous to the
bruise ; in such cases, after a few hours of cold ap-
plications, leeches, in number from two to twenty,
according to the extent of inflammation to be appre-
hended, or rather now setting in, and according to
the age and constitution of the patient, must be ap-
plied, and followed by the use of warm poultices for
the first few hours, and cold spirituous embrocations
afterwards.
In bruises of the finger by blows, or by squeezes,
or pinching, which is by far the more frequent oc-
currence, the pain is usually intense at first, par-
ticularly if the nail be implicated in the mischief,
and the most relief is experienced from immersion
ON BRUISES, WHITLOWS, &C. 81
of the part in warm water, and the application of
warm poultices. In somewhat severer cases the
nail ultimately falls off, and here poultices are the
proper application during the shedding of the nail,
and soap plaster spread on thick leather as a de-
fence to the part during the growth of the new
nail. In other cases, the periosteum, or fine mem-
branous covering of the bone, becomes inflamed,
and in the progress of the treatment deep incisions
become necessary ; such cases must be referred to
the surgeon ; and a fortiori all cases of bruise com-
bined with fracture of the bone.
In some of these cases of bruises on the fingers
the sheaths of the tendons become the seat of in-
flammation, and one species of whitlow is the con-
sequence, which, as well as other kinds of whitlow
arising spontaneously, requires leeching, fomen-
tation, and poultices, and, what cannot be too
strongly impressed upon the mind of both patient
and surgeon, an early free incision down to, and
through the inflamed sheath or membrane. This
will of course be the business of the surgeon ; but
it becomes your duty in such cases to urge an
early application to the surgeon, and to assure the
patient, which you may do with the greatest confi-
dence, that the relief from intense pain will be
immediate, and the mitigation of after suffering im-
measurably greater than from any other kind of
practice whatever.
2 ON BRUISES, WHITLOWS, &C.
Another common accident to a finger, which may
be mentioned as appropriately here as elsewhere, is
the accidental confinement of a ring with so much
tightness as to prevent the withdrawal of it by any
ordinary means. This sometimes arises from some
sudden swelling of the finger, at other times from
slow and gradual growth of the finger in size,
when the person has neglected to remove the ring
for years. But the inconvenience arises more fre-
quently from the person's own indiscretion in
forcing on a ring that is too small, when the in-
effectual attempts to withdraw it increase the evil
by bringing on soreness and inflammatory swell-
ing. In all these cases first try the effect of cold by
immersing the hand in ice-cold water ; if this does
not alone reduce the swelling, hold the hand up so
as to encourage the return of the venous blood,
and at the same time apply cold by means of wet
rag. If this also fails, make trial of the following
ingenious device, which, I have lately been inform-
ed, very frequently proves successful. Wrap a
piece of packthread closely and tightly round and
round the finger, beginning at its extremity until
you reach the ring, then insert the end of the string
by means of a fine blunt bodkin or other such in-
strument under and through the ring, draw it
tight, and then begin to untwist the string from
around the finger, and you will gradually bring
down the ring at the same time. When all these
means fail, the ring must be filed off, as the conse-
ON BRUISES, WHITLOWS, &C. 83
quence of its retention will be ulceration, and per-
haps mortification.
If, in very severe cases of bruise in soft parts,
you apprehend that any portion of the skin be
actually destroyed, that is, that the blood-vessels
and nerves are so injured as not to be able to
recover their healthy actions, you must promote
the suppuration, which is nature's constant pro-
cess for the removal of such parts, by warm fomen-
tation and poultices ; but of such severe cases I
need say no more, as the surgeon ought assuredly
to supersede you here again.
I shall take this opportunity of saying a few
words on the subject of what professional men de-
nominate bed-sores, as there is a strong analogy
between them and the severe cases of bruise.
When a patient is long confined in the horizontal
posture in fever, or other acute disease, where the
strength becomes so reduced that the poor sufferer
is incapable of sustaining any other than the recum-
bent posture, it is not uncommon for some spot
about the buttocks, or at the bottom of the back, to
assume the appearance of a bruise ; and, in conse-
quence of the low state of the vital powers, the part
soon dies, the subjacent cellular substance also
sloughs, and frequently the most extensive bed-
sore is the consequence. Long-continued pressure
on the part may be considered as one of the excit-
ing causes, and this constitutes the analogy between
bed-sores and bruises ; but I must proceed to ac-
84 ON BRUISES, WHITLOWS, &C.
quaint you with this important fact, that this con-
sequence occurs but rarely, unless also, from un-
consciousness in the patient, or unpardonable
negligence in the attendants, or both combined,
the part is allowed to be frequently, and to remain
long, wet with the natural excretions of the body,
which irritate the skin even when sound, but much
more so when previously bruised or excoriated by
continued pressure.
I have introduced this subject to put you upon
the alert in directing the preventive means in every
case of long-continued confinement to bed, and
particularly where the patient, either from disease
or from great age, is not at all, or but slightly, con-
scious of the calls of nature. Alteration in position
or removal from one bed to another should be per-
severed in as long as practicable, frequent renewal
of dry clothes, and, above all, sponging with warm
water, and careful drying with soft linen afterwards,
must never be omitted in such cases. As soon as
any part of the skin is excoriated by the long-con-
tinued pressure, or if it only looks more red, and is
become tender, you must defend the part by the ap-
plication of diachylon or soap plaster spread on soft
leather, and the plaster must always be sufficiently
large to cover much more than the excoriated part,
otherwise the edges of the plaster, by irritating the
already tender skin, would increase the mischief.
Remember this axiom, that almost every sore of the
description now under consideration is the conse-
ON BRUISES, WHITLOWS, &C. 85
quence of neglect. Be vigilant, therefore, when in
attendance upon the sick poor, where this is more
likely to occur ; neglect not to inquire frequently
into these matters, urge the attendants continually
to do their duty, and remonstrate where necessary.
When the mischief has occurred, poultices must be
applied, and frequently renewed. Warm spirits of
wine and camphor, or warm hrandy sprinkled over
the poultice, will excite the action of the vessels,
and tend to check the further progress of the mis-
chief. Some surgeons have extolled yeast poul-
tices, or have recommended the grounds or lees of
beer to be applied as poultices in such cases. Of
whatever your poultice consist, it is of much mo-
ment that it be warm, and often renewed. If there
is much foetor, cover the part first with rag dipped
in a solution of chloruret of lime, or of chloruret of
sodium, and apply the poultice over this ; when the
sloughing has taken place, treat it as any other
sore, always holding in mind, that the general de-
bility requires a nutritious diet, and the irritation de-
mands the occasional use of opiates, if the peculia-
rity of the attendant disease does not forbid their use.
SPRAIN is an altered condition of a muscle, a
tendon, or the ligament of a joint, produced by
violence, and rendering motion painful. Bruises,
as we have just observed, are always the conse-
quence of external violence, and show themselves
by external marks, and may occur on any part of
the surface of the body ; sprains, on the contrary,
86 ON BRUISES, WHITLOWS, &C.
being generally the effects of undue or unnatural
exertions of some of the muscles, may occur inde^
pendently of external violence. They are also fre-
quently unattended by outward marks of injury,
and can only occur in the course of the muscles,
and principally at the tendinous extremity of a
muscle, or in the neighbourhood of a joint
When a man slips in walking, or from any cause
feels that he is losing his balance, he makes an un-
usual effort to recover himself, and in this effort he
over-exerts some one or more muscles, and is said
to receive a sprain ; the part immediately, or very
soon, becomes the seat of pain ; it may be in the
loins, or in one of the extremities ; and this pain
is considerably aggravated by an attempt at mo-
tion ; and for a long time afterwards motion of
the part will excite pain.
Again, a person in falling puts out his hand to
save himself, and by the violent exertion of some of
the muscles of the arm, or it may be by the jar or
shock of the hand upon the ground, some of the
muscles or their tendons about the wrist, the elbow,
or the shoulders, are sprained ; or the ligaments con-
nected with any of these joints may be stretched
or otherwise injured. The pain is sometimes imme-
diately intense, at other times but slight at first,
and very severe afterwards, although there may be
no fracture or displacement of a bone, and not even
the external appearance of a bruise.
If a person in running or jumping trips against a
ON BRUISES, WHITLOWS, &C. 87
stone, or alights on uneven ground ; or, if when
riding on horseback his horse stumbles, and he
makes an unwonted effort of some of the muscles to
preserve his balance, he experiences either immedi-
ately, or soon after the accident, considerable pain
in the foot, the leg, the knee, the hip, or the loins,
and will, perhaps, for a long time afterwards, feel
painfully the effects of such a sprain.
In these accidents there is very frequently no
external sign of injury at the time, and, if the
mischief be but slight, there will frequently be none
afterwards ; but in other cases the usual appear-
ances of a bruise will, in a day or two, be discerni-
ble, although there may have been no blow or ex-
ternal pressure ; and in all cases of severity there
will be more or less of swelling, and other symp-
toms of inflammation, particularly if the ligaments
about a joint have partaken of the violence.
As the nature of the accidents which produce
sprains are so various, so the nature of the injury
sustained is not always the same. In a majority of
cases, there is, in all probability, a rupture of some
of the small muscular fibres, sometimes a rupture
of a fasciculus of these fibres, or the whole of a
small muscle, or of its tendon. The frequent con-
comitant appearance of a bruise is sufficient proof,
that in these cases small blood-vessels are rup-
tured. The speedy swelling, which sometimes
ensues, arises, in all probability, from the rupture
88 ON BRUISES, WHITLOWS, &C.
of lymphatics ; and there is no reason to doubt, but
that in other cases more deep-seated vessels, both
sanguineous and lymphatic, are ruptured, when no
corresponding appearances display themselves ex-
ternally. The pain so constantly accompanying
sprains, bespeaks the implication of nervous fila-
ments in the original injury, and indeed the rup-
ture of the smallest fasciculus of muscular fibres
implies the rupture of the nerves and vessels
which enter into its structure.
The Treatment of sprains may, for convenience,
be divided into three heads, corresponding with
three distinct stages in the progress of the case.
Upon the immediate receipt of the injury, if the
case be slight, rest and fomentation with warm
water is all that is at first required ; but in cases
of greater severity, the rest must be absolute, and
the application of leeches, as well as of fomentation,
must immediately be had recourse to. The warmth
may be preserved through the night by a large
poultice, once or twice repeated ; a smart purgative
should be administered as early as can be done
without the risk of disturbing the patient in the
night-time, and the diet should be somewhat
reduced. These latter are precautionary mea-
sures, and are recommended not only with a
view of lessening the chance of supervening inflam-
mation, but also to prevent the sudden change from
activity to perfect rest from disturbing the general
ON BRUISES, WHITLOWS, &C. 8!)
health ; and they are therefore applicable, upon the
same principle, to every kind of accident requiring
confinement.
After one or two days the injured part, particu-
larly if a great joint, as the ankle or the knee, be
implicated in the mischief, will feel hot, look red,
be more or less swollen, and the patient will de-
scribe the pain as having more of the throbbing
than of the aching character. This constitutes the
second stage, and the practice now consists in the
repeated application of leeches, and, as soon as the
bleeding is over, the continued application of cold
evaporating lotions, as formerly described, and re-
commended in all local inflammations. The num-
ber of leeches, and frequency of their application,
must of course be determined by the degree of
severity of the case; and repeated doses of ape-
rients, with common fever saline draughts in the
intervals, will be called for, if these symptoms of
inflammation appear to disturb the general health.
The continuance of this stage, and consequently of
this practice, will of course vary, but absolute rest
must be enjoined until the inflammatory symptoms
have subsided.
After the subsidence of the above symptoms
there will be stiffness, and more or less of pain on
motion, or attempt at motion, and this constitutes
the third stage. It may be said to commence when
all inflammatory symptoms have disappeared, as
swelling, redness, and pain when the limb is at
90 ON BRUISES, WHITLOWS, &C.
rest; but the appropriate practice should not be
adopted all at once, or in too great a hurry. A
soap plaster to confine the action of the injured
parts, and moderate exercise for a few days, is all
that should be allowed. The degree of pain in
attempting motion will vary with the seat of the
injury, and according to the degree of violence of
preceding symptoms ; and it will sometimes require
great fortitude in the patient to persevere in the
attempt, as much as is required to promote the
cure. The further practice in this stage is
friction, frequent motion of the part to be effected
by another, if not sufficiently performed by the
patient himself, and the douche, or stream of water,
pumped or poured upon the part.
Friction cannot be better performed than by the
naked hand, but it must be persisted in for two or
three hours daily ; and as it can seldom if ever be
performed by the patient, some friend, servant, or
nurse, must be instructed how to perform this rub-
bing, as recommended by the late Mr. Grosvenor,
surgeon, at Oxford ; and which is now pretty gene-
rally known under the name of Grosvenor's rub-
bing system. It consists in simple rubbing with
the hand, so as to press considerably with the ball
of the thumb, and in continuing it uniformly for a
long time, which much practice only can enable
any one to do. If the skin becomes tender with
all this rubbing, it will be well to dust the part
with hair-powder at the commencement of the ope-
ON BRUISES, WHITLOWS, &C. 91
ration. Embrocations or liniments for the purpose
of friction are not of much, if of any intrinsic value,
though greatly esteemed by some surgeons, and
highly extolled by every Lady Bountiful. When,
however, I apprehend that embrocations will induce
a more persevering application of friction, I am in
the habit of prescribing them, and I know of none
better than the compound soap liniment, or opi-
deldock.
The second piece of practice recommended in
this stage of a sprain is free and frequent motion ;
and to be effectual, it will require not only great
perseverance, but considerable fortitude. After
the inflammatory stage is over, during which mo-
tion was forbidden, the first efforts will necessarily
be attended with more or less of pain, and if the
resolution of the patient fail, a contracted or stiff
joint may be the consequence. The scientific surgeon
will be at no loss to devise the proper means, and
give the necessary instructions, for promoting that
degree of forcible motion to the joint, which each
particular case may require ; and it may frequently
become your duty to urge and encourage the pa-
tient to submit to present pain with a view to secure
future ease and comfort. It is in such cases that
professed bone-setters and other quacks so frequent-
ly obtain a surreptitious credit. The patient, finding
no improvement because he will not submit or per-
severe in the painful efforts prescribed, forms some
notion of a fracture or a dislocation of the bone, or
92 ON BRUISES, WHITLOWS, &C.
at any rate of some injury which the surgeon has
failed to ascertain. With this conviction he resorts
to the bone-setter, who, to enhance the importance
of his own services, assures the patient that his
conjecture is well grounded, proceeds to explain
the nature and situation of the pretended fracture
or dislocation, and, having obtained his acquies-
cence, he uses the greatest degree of rude violence
in extending and twisting the limb in every direc-
tion ; by such means he now and then effects a
sudden cure by the forcible rupture, perhaps, of
some preternatural adhesion, the consequence of
previous inflammation, which a perseverance in the
judicious advice of the surgeon would either have
prevented forming, or have afterwards elongated or
broken down with less than half the pain now in-
flicted. In a majority of cases, however, these rude
efforts fail, and leave the patient, after immense
suffering, in a worse plight than before, by inducing
fresh inflammation, and more obstinate contraction.
Yet so easy is it for impudence and ignorance to
practise on the credulous, that a few successful
cases will establish the pretender's fame, where,
in all probability, the earlier directions of the sur-
geon, if persisted in with fortitude, would have
effected the object with much less of suffering ; and
the unsuccessful cases, however numerous, are all
most artfully attributed to the want of skill in the
surgeon first consulted. Let me here caution you,
and the public too, against giving preference, in
ON BRUISES, WHITLOWS, &C. 93
any case, to uneducated boasting pretenders, in a
science which demands the highest order of talent
and education. And further, let me advise the
timid surgeon never to neglect a case of sprain in
this third stage, nor to cease his exertions and best
endeavours, by forcible extension and flexion, fre-
quently repeated, to give freedom to the limb,
even at the risk of being stigmatised as unfeel-
ing.
The third piece of practice in these cases is the
douche, or stream, or jet, of water, warm or cold,
upon the affected part. The practice of pumping
on a sprained ankle or a sprained wrist is very
old, and its efficacy, in many cases, very credibly
attested. In every fashionable watering-place will
be found ingenious modes of applying the douche
of either hot or cold, simple or medicated water, in
a full or gentle stream, from a greater or smaller
height ; and at home all this variety in the mode of
its application may be very well attained by a large
pitcher, or a watering-pot without its rose. It
should be used once a day ; the water should be a
little warm in winter, and cold in summer ; but the
regulation of temperature, the length of time, and
height from which it should be poured, will be
easily ascertained by you in each particular case,
when I state that the immediate effect should be
somewhat short of numbness and absolute pain ;
and the speedy result should be that agreeable
glow in the part, which in general bathing is
94 ON BRUISES, WHITLOWS, &C.
esteemed the criterion of benefit, when diffused
over the whole frame. After every application of
the douche, the part should not only he dried, but
well rubbed for half an hour or more, and the prac-
tice should be continued as long as the benefit,
which is derived from it, is perceptible, or until
the strength of the part be fully re-established.
CONCUSSION comes next to be considered. The
term implies a shock, and in surgery it may be de-
fined, an injury to some internal part of a living
body inflicted by sudden external violence, not ne-
cessarily accompanied by an external wound. It
may or may not be connected with fracture or dis-
location, or it may be accompanied by bruise or
sprain.
The external violence is almost always a blow,
or a fall ; which latter indeed may be considered a
blow, the force proceeding in this case from the
momentum of the patient's body instead of the mo-
mentum of the instrument, which, in the other
case, inflicts the blow. The nature of the injury
is the same.
Concussion of the Brain is the most common
accident of this kind, and certainly it is the most
important We also meet with concussions of the
spine, and concussions of the trunk. In this order
we shall proceed to treat of them.
When a person receives a blow on the head, or
falls upon his head, and is stunned by the accident,
he has experienced a concussion of the brain. It
ON BRUISES, WHITLOWS, &C. 95
was supposed by surgeons of old, and perhaps
many entertain the same notion still, that in such
an accident no appreciable injury has been sus-
tained in the texture of the brain, but surely it is
more philosophical to suppose that in every such
concussion there is for the time a deviation from
the natural and healthy structure of the brain.
This deviation may in some cases be extravasation
of blood from ruptured vessels, and this may be
minute or extensive. In other cases, no doubt, it
is only a transient change in the circulation, occa-
sioning slight congestion of blood in the vessels of
one point, with perhaps a diminished quantity in
another.
The effects of such concussion are sometimes so
slight and transitory, that in a single minute, or
less, consciousness returns, and no further inconve-
nience is experienced, or perhaps a slight headache,
or trifling degree of mental stupor, may continue
for a shorter or longer period. In severer cases
the sufferer remains for a longer time unconscious,
and his senses return very gradually ; he first of all
recognises some person about him ; he ascertains
from surrounding objects where he is, or that he is
in a strange place ; he has a confused notion that
some accident has happened ; in a little time he
recollects where he was, or whence he started, some
hours ago ; and at length he traces in thought cir-
cumstantial occurrences down to the moment, or,
what is frequently the case, down only to within
96 ON BRUISES, WHITLOWS, &C.
a few minutes of his accident. This degree of con-
cussion is frequently attended with vomiting, and
indeed this affection of the stomach succeeding to
an injury of the head is very indicative of concus-
sion of the brain. In still severer cases conscious-
ness does not return for some days, or never fully
returns. Symptoms of apoplexy, or palsy, of in-
flammation of the brain, or of high cerebral excite-
ment without inflammation, may supervene, which
may prove speedily fatal, or ultimately terminate
in epilepsy, fatuity, or other chronic affection of
the brain ; or those severe symptoms may terminate
in slow but perfect recovery. With none of those
formidable consequences of concussion have we
anything to do. It is indeed only as to the treat-
ment to be adopted immediately after the accident
that I shall make any observations, for in all cases
of a severe grade I conjure you to consign the suf-
ferers, as speedily as may be, into the surgeon's
hands.
If then you be a witness of such an accident as
has been described above, or if you arrive upon the
spot immediately afterwards, and find the patient
senseless, or but partially restored to conscious-
ness, you will first examine his countenance, feel
his pulse, and ascertain the temperature of his
body. In every case, unless the countenance be
pale, the pulse feeble, and the skin cold, proceed
immediately to bleed your patient, and take away
from twenty to thirty ounces of blood, according to
ON BRUISES, WHITLOWS, &C. 97
the natural stamina and previous health of the suf-
ferer ; convey him home ; and prescribe rest, low
diet, and a moderate dose of physic. If, on the
contrary, you find the pulse feeble, countenance
pale, and skin cold, give a little brandy and water,
put on additional clothing, remove him, as speedily
as can be, to a warm room, and prepare, where it
can be done, a warm bath. Watch, however, the
amount of re-action ; and if, after an hour or two,
the pulse becomes full, the heat of skin above the
natural standard, and particularly if he complain of
headache, proceed without hesitation, if the surgeon
has not yet arrived, to a moderate or a full bleed-
ing, according to the amount of this re-action, and
adopt rest, quietude, and a low diet.
It may not be amiss to observe here, though it
is unconnected with concussion of the brain, that
the feeble pulse, pallid countenance, and coldness
here described, together with sickness, are also
particularly liable to occur, where a more delicate
and peculiarly sensible part is injured, either by
pressure against the saddle, by the horse's foot, or
otherwise, in cases of falls in riding ; and in such
cases, unconsciousness, when it occurs, arises from
syncope, or fainting, and of course requires warmth
and cordials. The immediate local treatment is
warm fomentation, and suspension of the part by
proper bandages, and afterwards leeches and cold
lotions, if the part remains tender, with rest in the
horizontal posture.
98 ON BRUISES, WHITLOWS, &C.
When a person receives a blow, or falls rather
upon his back than his head, he is, perhaps, but
little, if at all, stunned, he gets upon his legs, stag-
gers, and falls again, his pulse is feeble, and per-
haps irregular, his countenance is pallid, and he
feels faint, but soon recovers sufficiently to walk
home with some assistance. These are the symp-
toms of concussion of the spine, or of concussion
of the trunk. The immediate practice is brandy
and water in moderation, the warm bath, and rest.
He will soon, if not at first, complain of some local
pain, and the seat of this will mainly direct you in
forming an opinion of the precise nature of the
case. If it is over any part of the spine, you may
deem it a case of concussion of the spinal marrow,
and may expect a continuance of disturbed circu-
lation ; and anticipate, if the injury be severe, symp-
toms of partial paralysis, or some derangement of
one or other of the vital functions. The state of
the pulse often forbids general bleeding in such
cases, even after warmth has been restored, and
the natural colour of the countenance has returned;
but you will never err in ordering leeches and warm
fomentations to the pained part, if the surgeon has
not by this time arrived to release you from your
responsibility.
If the local pain complained of after such an
accident be in the chest, if the breathing be inter-
rupted, or the action of the heart irregular, or if a
spitting of blood ensue, you are sure that this is a
ON BRUISES, WHITLOWS, &C. |99
case of concussion of the trunk, and particularly
of the chest ; with such symptoms you need not
hesitate to bleed, and that largely. In other cases
of concussion of the trunk, where the above symp-
toms are not at all, or but very feebly, developed,
particularly when the accident has happened to an
aged person, serious mischief is sometimes sus-
tained, and the surgeon or medical practitioner alone
can be supposed competent to decide as to the
precise nature and extent, of the mischief, and con-
sequently to direct the appropriate practice.
In concussions of the trunk, the mischief is fre-
quently sustained by some one viscus, or internal
organ in particular, and is made apparent by cor-
responding symptoms, as by vomiting of blood
when the stomach is injured, by bloody urine from
mischief done to the kidneys or bladder. I remem-
ber to have been called, many years ago, to a young
man, who, running in the dark, came in violent con-
tact with an upright post ; the shock threw him to
the ground, he was taken up and assisted in walk-
ing home, but was soon attacked with severe pain
in the body, and died in two or three days of peri-
toneal inflammation. The injury sustained here
was a rupture of one of the small intestines, and
consequent escape of its contents into the cavity of
the abdomen. The only external injury was a
slight bruise. In a similar manner the stomach,
the spleen, the liver, the kidney, and the bladder,
have been ruptured or lacerated ; and when the
F2
100 ON BRUISES, WHITLOWS, &C.
injury sustained has not been to this amount, some
of these viscera have received a shock that has de-
ranged their functions, and led to serious illness,
acute or chronic, calling for the best judgment of a
surgeon or physician to remove, or perhaps only to
palliate.
Of FRACTURES I shall, as I observed before, say
but little, as, in every ascertained case of fracture,
as well as in all doubtful cases, the consequences
of mismanagement are too obvious, and too serious,
to admit of any conscientious man hesitating for a
moment as to the propriety of sending for the most
skilful surgeon in the neighbourhood. It may,
however, sometimes be highly serviceable that you
be able to pronounce whether there be fracture or
not ; as your opinion may decide the question of
sending for a surgeon promptly, and it is of con-
siderable consequence that a fracture or a disloca-
tion be speedily reduced, before swelling and in-
flammation are set up.
I shall enumerate the most evident proofs of
fracture, so that in such cases you may not be at a
loss to form a judgment.
Those fractures are called compound, which are
accompanied with an external wound communi-
cating with the broken bone ; and, in a great pro-
portion of such cases, the bone either protrudes
through the skin, or lies so near the surface, that it
may be seen or felt upon an examination of the
wound. Such cases, therefore, admit of no doubt
ON BRUISES, WHITLOWS, &C. 101
as to the existence of the fracture. Other fractures
are called simple, and the existence of such is not
always easy of detection. It is often, however, less
difficult to decide that no fracture exists; for in-
stance, if the arm be broken, it hangs down by the
side, and the patient has not the power to raise it,
and, when you attempt to raise it, you give con-
siderable pain : again, if the thigh-bone or both the
bones of the leg be fractured, he cannot stand upon
that limb, or, by any exertion of his own, move it
forwards for the purpose of walking. Now we
know that other injuries of these parts may pro-
duce the same inability of motion, particularly
some time after the accident, and we cannot from
this alone decide that there is fracture ; but if, on
examination of a case some time after the acci-
dent, you find this inability ; or if the patient de-
clares that he cannot use the arm or stand upon
the leg, which assertion is not unfrequently made
to carry on some imposture ; if, I say, upon minute
investigation and by cross-questioning, you learn
that he did walk immediately after the accident,
or that he could then raise his arm to his head,
you may feel quite assured that there is no frac-
ture. The same observation holds good of disloca-
tion of any of the larger joints. The most decided
and only satisfactory positive evidence of simple
fracture is the sensation of grating, called techni-
cally crepitus, which is commonly perceptible not
only to the patient himself upon motion of the part,
102 ON BRUISES, WHITLOWS, &C.
but to another person handling the injured limb.
After carefully removing the clothes, then take the
extremity of the limb in one hand, and grasp the
limb with the other hand above the injured part,
and move both hands in a semi-rotatory fashion, or,
holding the lower portion of the limb in one hand,
press with the fingers of the other over the suspected
seat of fracture, producing at the same time gentle
rotatory motion of the extremity, and you will, in
almost every case of fracture, feel and often hear
the grating of the broken ends of the bone against
each other. Sometimes the fracture is detected by
a preternatural hollow or depression between the
retracted portions of the fractured bone.
In injuries of the chest you endeavour to ascer-
tain whether there be fracture of a rib by feeling
with your fingers for crepitus, and by paying parti-
cular attention to the patient's breathing. If he
breathe short, and complain of pain on a full in-
spiration at the precise part where the blow was
received, if coughing or sneezing produce pain in
the same spot, and particularly if coughing and
spitting of blood have come on since the accident,
you may, without hesitation, pronounce that there
is fracture of a rib, and in the latter case a wound
of the lungs by the fractured bone.
In fracture of the collar-bone, it almost always
happens that one of the fractured ends slips over
and rides on the other, in which case the nature of
the accident is at once apparent.
ON BRUISES, WHITLOWS, &C. 108
It is not an uncommon occurrence, immediately
upon the receipt of a fracture, for the person to
faint away, in which case the horizontal posture, a
little cold water, or a little sal volatile, will speedily
restore him. Sometimes the patient, soon after
the accident, is seized with coldness and a shiver-
ing fit, in which case you may give a little hot
brandy and water, and, as soon as may be, strip off
his clothes, and put him into a warm bed.
In stripping off the clothes from fractured limbs,
let great care be taken that some discreet person
support the limb steadily whilst another slips off,
or, if there be the least difficulty, cuts off, the boot,
trouser, or coat, as the case may be, always hold-
ing in remembrance that the slightest motion in a
fractured limb produces considerable pain.
A bed or a couch is the properest resting-place
in cases of fracture of the leg or thigh, as the
recumbent is the only easy posture ; and you need
not be anxious to extend the limb, as most unpro-
fessional persons would advise, but let it be in a
relaxed position till the arrival of the surgeon.
I may here observe, that in all cases of accident,
where constant and long confinement to bed may
be anticipated, the ease and comfort of the patient
will be best consulted by laying him upon a hard
mattress in preference to a feather-bed.
If the arm be broken above the elbow, the recum..
bent posture will be the easiest, with the fractured
part supported by a pillow ; if below the elbow, a
104 ON BRUISES, WHITLOWS, &C.
sling made of a large silk handkerchief, suspended
round the neck, will best support the arm, and the
patient may remain sitting up; the sling should
be sufficiently broad to extend from above the elbow
to below the wrist, and care must be taken that
the hand be not allowed to fall below the level of
the wrist.
We shall now finish the subject of fractures with
an observation or two on fracture of the skull. The
different bones of the head may be depressed as
well as fractured, and in young subjects they are
often depressed without fracture. In most cases of
fracture, indeed, one portion of the bone is pressed
down below the level of the other, and this uneven-
ness of surface under the scalp often renders the
fracture sufficiently apparent, where there is no
wound in the scalp. But, when the scalp is much
wounded, the fracture, if it exist, may be detected
both by the eye and the finger. But whether such
be the case or not, keep my former advice in view ;
and if called to a person who, after a blow or a
fall upon the head, remains insensible, be satisfied
that the case is of too serious a nature to remain
under your management. You may, as I said be-
fore, bleed such a patient, then convey him home,
and -put him to bed; if the scalp is wounded wash
away the blood, cut away or shave off the hair
around the wound, encourage the bleeding, if
any, by warm sponging, and await the arrival of
the surgeon.
ON BRUISES, WHITLOWS, &C. 105
On the subject of DISLOCATIONS I shall say still
less. Total inability to bend any of the joints, with
acute pain upon a forcible attempt made by another
person to perform such motion, occurring imme-
diately upon the receipt of an accident, is enough
to excite strong suspicion of dislocation, and a sur-
geon should be sent for without loss of time, that
he may have the advantage of performing the ope-
ration of reduction before swelling and inflamma-
tion of the surrounding parts have taken place,
which would both aggravate the pain and render the
immediate reduction more difficult, or even impos-
sible.
If the shoulder be supposed to be dislocated,
and you are sure there is no fracture, no harm
will arise from your trying this simple experiment,
which will sometimes occasion the replacement of
the bone in the socket. Gently raise the extended
arm by the wrist and elbow, until it is elevated a
little above the horizontal line, and then allow it
suddenly to fall by its own weight; upon which
the head of the bone will sometimes resume its
place in the socket ; but if it does not succeed the
first time, I do not advise you to repeat the experi-
ment ; nor do I sanction you in making any at-
tempt at reducing this or other dislocations by pull-
ing at, or extending the limb, as much anatomical
skill is requisite to conduct such attempts in a pro-
per way.
We may perhaps make one exception to this
F5
106 ON BRUISES, WHITLOWS, &C.
caution, it being a case of the greatest emergency.
Few surgeons admit the possibility of a dislocation
of the vertebrae of the neck without instant death.
I am, however, not prepared to deny all truth to the
many recorded and reported cases of sudden relief
instantly obtained by attempts at extending the
neck under such appalling circumstances. Let us
suppose a person to be thrown from his horse with
violence, to pitch upon his head, and to lie sense-
less on the ground, with his head bent in a very un-
natural manner, and that the head cannot be re-
stored to its natural or straight position by mode-
rate efforts; I should certainly, under such cir-
cumstances, endeavour to produce extension by
pulling at the head, whilst another person was
drawing down the trunk by the shoulders ; or, if
none was by to help me, I should put my feet or
my knees upon the shoulders, and pull the head
with my hands, to make the necessary extension of
the neck. Knowing the natural strength of the
muscles and ligaments of those parts, I should feel
no apprehension of doing harm, and I think it pro-
bable that sometimes a partial dislocation of one
of the vertebrae may have occurred, and may have
been thus reduced; although I do at the same
time admit, that most of the cases which we hear
of in conversation, have been cases of persons only
stunned by their falls, and perhaps more speedily
aroused by the violence of those rude efforts at
extension.
ON ABSCESSES, BOILS, CARBUNCLES, &C. 107
LETTER VI.
ON ABSCESSES, BOILS, CARBUNCLES, ULCERS, WARTS,
AND CORNS.
My DEAR SON,
HAVING in my introductory letter professed that I
should not adopt any nosological or other systema-
tic arrangement, I need offer no excuse for bring-
ing together subjects so heterogeneous in this,
which I intend to be my last letter on the surgical
department of our subject ; but shall proceed to
treat of whatever remains worthy of consideration,
and which promises to be conducive to the object
at which I aim, as the different topics occur to my
recollection.
By ABSCESS is meant a collection of matter or
pus formed and confined in any part of the body.
It is called an external abscess, when situated in
the fleshy parts, or in the cellular substance under
the skin, or in the lymphatic glands, or in any
other part which is so near the surface, that the
intervening parts, between the original seat of in-
flammation and the surface of the body, become
gradually absorbed in the natural progress of the
case, and the matter makes its exit externally. It
is called an internal abscess, when situated with-
in any of the great cavities, or in some viscus, as
the lungs, liver, kidney, &c. ; in which cases the
108 ON ABSCESSES, BOILS, CARBUNCLES, &C.
matter only now and then finds its way into the
natural cavities which contain the viscus ; or now
and then, by adhesive inflammation and succeed-
ing ulceration, into other natural passages, as the
bowels, the bladder, or the air-vessels of the lungs.
The formation of matter is always the conse-
quence of previous inflammation, and the quality
of the matter is influenced by a great variety of
causes. The matter formed in a fleshy part, and
in an otherwise healthy person, is a whitish cream-
like fluid, soft, smooth, inodorous ; when formed
amongst ligaments and tendons, it is thinner, and
somewhat discoloured ; when formed in contact
with diseased bone, it is usually discoloured and
always tainted ; and when formed in contact with
the large intestine, as in an abscess, called from its
form the horse- shoe abscess, in the immediate
neighbourhood of the rectum, its smell is most
nauseous ; and when such an abscess is opened, the
stench is intolerable, though the matter in other
respects is what is called healthy. This peculiarity
is attributable to the long-continued absorption
of sulphuretted hydrogen through the coats of the
rectum, by the process lately termed endosmose.
In constitutions tainted with scrofula or syphilis,
the matter has peculiar qualities ; and in small-pox
it is well known that the matter formed in each
pustule has the specific quality of communicating
the disease, though in its external appearance it
differs not from common pus.
ON ABSCESSES, BOILS, CARBUNCLES, &C. 109
In every case of internal abscess, anatomical
knowledge is required to ascertain its precise seat,
its extent, its real importance, and consequently its
proper treatment. Of such, therefore, I shall say
nothing ; and shall confine my observations to the
more simple form of external abscess. This is only
distinctly and satisfactorily ascertained, when a
sense of fluctuation is perceptible per tactum.
This is always preceded by pain, heat, and throb-
bing in the part, and by soreness or tenderness on
firm pressure over it; and sometimes by redness
on the surface. The more deeply seated the in-
flammation, the longer it is before fluctuation can
be felt ; and the more diffuse it is, the less distinct,
generally speaking, is the sensation of a contained
fluid. When an abscess is forming near the sur-
face, the throbbing pain, the swelling, the super-
ficial redness, and sense of fluctuation of the con-
tained fluid more quickly succeed each other, and
the matter sooner approximates the surface. And
when a lymphatic gland near the surface, as in the
neck, in the arm-pit, or in the groin, is the seat of
inflammation and suppuration, a circumscribed hard
tumor with but slight pain, and uneasiness on
motion implying the action of muscles in its neigh-
bourhood, are the first symptoms ; and these draw
the patient's attention often long before the forma-
tion of matter.
Of the management of abscesses I shall treat
briefly, because they can never be supposed to re-
110 ON ABSCESSES, BOILS, CARBUNCLES, &C.
quire instant attention, and proper surgical aid may
therefore always be procured ; and what few ob-
servations I do make, will refer principally to
the means to be adopted in their early stage.
When any painful tumor is accompanied with a
sensation of heat and throbbing, you cannot do
wrong in applying leeches, and encouraging the
bleeding by warm poultices ; you may also without
hesitation order a full dose of calomel and rhubarb,
with a draught of salts and senna. If the symp-
toms subside, repeat this treatment in a day or two;
but whether, in the intermediate time and after-
wards, you should keep the parts cold by lotions of
goulard or vinegar and water, or warm by means
of fomentations and poultices, is a matter not fully
decided : my own practice is to resort to that
which soothes and gives most ease to the patient,
which, generally speaking, is the application of
warmth ; and when resorted to early, it is as effica-
cious in discussing the tumor as the application of
cold. When the tumor is an enlarged gland in the
neck, makes slow progress, and is not very painful,
I have known it frequently and speedily dispersed
by a blister over its surface. When fluctuation is
evident in an abscess, fomentations and poultices
are universally recommended, until either nature or
the surgeon effects an outlet for the matter, and
indeed afterwards they constitute the chief local
treatment. I may just observe, that in an enlarged
superficial gland, of the neck for instance, an early
ON ABSCESSES, BOILS, CARBUNCLES, &C. Ill
opening is advisable ; that, in deep-seated ^collec-
tions of matter under a fascia, an opening should
also be made assoonasfluctuation is positively ascer-
tained ; but that, in other abscesses not deep-seated,
it is better to wait, not only till fluctuation is dis-
tinctly felt, but until the skin becomes thin on some
portion of the surface, and the tumor points. Thus
you may form some judgment as to the proper
time of opening an abscess, but when you think
that time has arrived, I advise your sending for a
surgeon, if you have not done so before ; for, with
your limited knowledge of anatomy, you can never
be sure that injury to important parts lying con-
tiguous may not be risked, neither will I pretend
to instruct you how to be able always to distinguish
the presence of pus in an abscess from blood in an
aneurism, seeing even able surgeons have now and
then been wofully deceived.
BOILS are hard, deep-red, inflamed, and very
painful tumors, having their seat in the skin and
subjacent cellular membrane. In the progress of
a boil, a small vesicle forms on the apex, which is
exquisitely painful, from which issues a drop or two
of lymph, forming at first a greyish and then a dark-
coloured scab ; when this scab bursts or breaks,
matter is at first discharged, which is usually bloody,
and ultimately a core or soft membranous mass,
consisting of cellular membrane as it were soaked
in pus. After this tedious process, the cavity fills
up slowly, and the hard swelling gradually sub-
112 ON ABSCESSES, BOILS, CARBUNCLES, &C.
sides. Boils occur on many parts of the body, but
particularly on the neck, back, and buttocks. A
simple boil may appear under circumstances of the
most robust health and strength ; but when several
have appeared either simultaneously, or in quick
succession, I have observed it to be in persons
otherwise out of health, and particularly such as
are suffering, or have lately suffered, from fatigue
and anxiety.
The treatment usually recommended is to fo-
ment and poultice freely, until fluctuation can be
felt within the tumor, then to open it with a lancet,
to squeeze out the crude matter, and further to
continue the poultice as long as there is any dis-
charge ; or, for the convenience of the patient, an
adhesive plaster may be kept on by day, and a
poultice applied at night. The cure is expedited
by pressing the tumor at each dressing to force out
the matter, and this is particularly necessary, if, in-
stead of being lanced, the boil has been allowed to
break spontaneously. Such is the treatment when
a boil proceeds to suppuration ; but I have so often
succeeded in discussing boils by early attention,
that where a person is troubled with a succession
of them, and is therefore aware of its nature as
soon as a small, hard, and painful little tumor is
distinguishable, I strongly recommend the immedi-
ate application of a leech to the spot, and the next
day the application of the lunar caustic over and
around the inflamed tubercle, avoiding of course the
ON ABSCESSES, BOILS, CARBUNCLES, &C. 113
leech-bite. The frequent consequence of such
practice is the cessation of pain, and speedy dis-
appearance of the tumor.
CARBUNCLES are in their nature so much like ex-
tensive ill-conditioned boils, that it is often difficult
to draw the line ; and cases of middle character
sometimes occur, which one eminent surgeon would
call a boil, and another equally eminent a carbun-
cle, and which I have known a more wary or sa-
gacious surgeon denominate a Carbuncular Boil.
A carbuncle, like a boil, appears at first in the
form of a small painful pimple, but an extensive
hard and deep-seated tumor is soon discoverable
round its base, sometimes as large as a saucer.
Frequently several pimples appear on the same
tumor ; and as the carbuncle advances to suppu-
ration, it breaks, and discharges at each pimple,
and a similar core is ultimately formed, and pre-
sents itself at each opening. Carbuncle too, like
boil, is sometimes solitary, and in other cases many
of them occur in the same patient simultaneously,
or in quick succession. When, therefore, you see a
large deep-red and deep-seated tumor under the
skin, usually on the neck or between the shoulders,
in its progress opening by ulceration of the skin at
several points, and discharging bloody matter, and
afterwards a pulpy membranaceous core, you may
denominate it a carbuncle. It occurs only in very
old or otherwise debilitated persons, is itself a sign
of a constitution that is giving way, and although
114 ON ABSCESSES, BOILS, CARBUNCLES, &C.
the pain is not so much complained of as in boils,
probably from less of keenness in the sensibility of
such patients : it sometimes hastens the final catas-
trophe, and is therefore frequently said to termi-
nate fatally.
The local treatment is nearly the same as for
boil ; fomentation, poultice, and an early opening
of the tumor. The fomentation may be made
more stimulating by sprinkling the flannel with
hot brandy, both before and after the opening of
the tumor. When the discharge is very offen-
sive, the chloride of sodium may be used as a cor-
rective, and the yeast poultice substituted for that
of bread or linseed meal. On the subject of open-
ing the tumor it may be said, that it ought never
to be omitted, it cannot be done too soon, if fluc-
tuation be at all perceptible, and it should be free,
that the whole core may be speedily evacuated.
The matter should be pressed out at each dress-
ing, and the fomentation and poultice continued
through the whole progress of the case. The
constitutional treatment consists in supporting the
strength by bark and a nutritious diet.
Old ULCERS, or sores, particularly on the lower
extremities, are of frequent occurrence, and you
will often be called upon by your poorer neighbours
to supply them with what they term healing salves
for the purpose of dressing such sores. You need
be at no loss to recommend some infallible salve or
cerate, if you can credit the high encomiums passed
ON ABSCESSES, BOILS, CARBUNCLES, &C. 115
upon advertised nostrums or old nurses' recipes. I
caution you, however, against giving credit to any
such general professions, and I can assure you,
that in many cases dry lint is better than any
salve ; and that in almost every case the mode of
dressing an old sore, and the proper management
of the patient's general health, is of much greater
importance than the nature of the ointment, with
which your lint or linen rag is spread for the dress-
ing of the sore.
Old ulcers may have arisen from accidental
wounds indisposed to heal, or from spontaneous
boils, abscesses, or eruptions ; or they may be the
natural effect of certain morbid conditions of the
whole system, venereal, scorbutic, scrofulous, or
cancerous. Of such general taints in the constitu-
tion, and their local effects, I do not mean to treat
in this place, but shall confine myself to the consi-
deration of what is generally understood by the
term simple ulcer, which is usually divided into
three kinds the purulent, the indolent, and the
irritable ; but as these conditions of the sore are
very frequently observed in the same case at differ-
ent periods, induced by irregularities in the habits
of the patient, or superinduced upon the accession
of some general constitutional disease, I shall treat
of old ulcers, such as are likely to come under your
cognisance, under one head noticing, however,
such peculiarities as require a difference in their
mode of management.
116 ON ABSCESSES, BOILS, CARBUNCLES, &C.
If you are requested to undertake the treatment
of an ulcer on the leg, and upon examination you
find it covered with a thick healthy-looking matter ;
if the edges are regular, not much or not at all
elevated ; and the granulations or new growths are
small, conical, and firm, and not disposed to bleed
upon slight pressure ; and particularly if you see a
delicate white film around the edge of the sore,
and on the tips of the little conical granulations,
you may be sure that this ulcer is in a healthy con-
dition, and that some impropriety in the manage-
ment must have interfered with and retarded its
healing. The following is the most approved
method of dressing such an ulcer. Apply, first, a
pledget of dry lint of the size of the ulcer, for
nature, in the production of a healthy pus, furnishes
the sore with what is better than any salve; and
apply over the dry lint a larger pledget spread
with simple cerate, to prevent evaporation, and the
consequent stiffening of the under-dressing. The
evil to be dreaded from the dry pus and hardened
lint is the removal of the fine film, before alluded
to, from the edges of the sore, and from the tips of
the granulations, which delicate film is the matrix
of the new skin. For the same reason I must
caution you against wiping or even washing such a
sore, the matter being the most sanative dressing,
and the new skin, or rather its embryo, being very
easily detached. Over the larger pledget it is advis-
able to apply a compress of linen rag, and over
ON ABSCESSES, BOILS, CARBUNCLES, &C. 117
this a calico roller to keep all in its place, and to
defend the sore from external violence. This
healthy ulcer need not be dressed oftener than
once in two days.
We will now suppose that you are requested to
look at an ulcer that is cup-shaped, with hard ele-
vated edges, the sore itself smooth, dry, and not
very sensitive when touched ; the patient is in all
probability past the meridian of life, and you will
very likely find the veins of the leg swollen, or, as
we term them, varicose in many places. Such an
ulcer, if you inquire into its history, is of long
standing, has probably appeared more than once to
be nearly healed, the hollow having been filled
with granulations ; but that it has suddenly altered
in its condition, the granulations, which were soft
and flabby, having been speedily re-absorbed, and
the size of the sore having as suddenly been en-
larged. Such a change is likely to occur again,
unless the patient is guarded against irregularities
in his habits, and the local treatment of the sore be
properly conducted. If the patient is out of health,
this circumstance must be attended to, and every
excess in diet or potation, habitual or occasional,
must be carefully avoided.
The local treatment of this cup-shaped ulcer in
its present state consists in stimulating the surface
of the sore, and in the proper application of tight
bandages. If the hollow of the ulcer be dry and
glassy, I sprinkle the surface with red precipitate
118 ON ABSCESSES, BOILS, CARBUNCLES, &C.
in fine powder, and fill up the hollow with either
dry lint, or lint spread with red precipitate oint-
ment. If the edges be covered with hardened
cuticle, I remove the hard scales with the edge of
a spatula, and then draw the point of a stick of
lunar caustic moistened over the callous edges,
and finish the dressing by the application of the
adhesive plaster bandage, and then the calico
roller. The dressings should not be removed
oftener than once in two days ; and when the ulcer
assumes a moist appearance, which will usually be
the case after one or two such dressings, you may
omit the powder, and only apply the red precipi-
tate ointment to the interior of the sore ; and you
need not repeat the caustic to the edges, unless
they are very much elevated and indurated. Should
the sore in its progress exhibit soft and broad gra-
nulations, and these be disposed to bleed, you
should apply lint moistened in a solution of lunar
caustic instead of the ointment, or touch them
slightly at each dressing with either blue vitriol or
lunar caustic, and continue the use of the same
ointment, until the granulations assume a healthy
appearance. These observations are, in my opi-
nion, of considerable importance in the manage-
ment of such ulcers ; but the application of the
straps and bandage, for which I am now about to
give directions, is of infinitely more importance
still, and some surgeons trust wholly to them,
being perfectly indifferent whether any dressing be
ON ABSCESSES, BOILS, CARBUNCLES, &C. 1 19
applied or not to such sores as we are now describ-
ing. I am, however, decidedly of opinion that such
dressings as we have described are useful, until the
hollow of the ulcer begins to secrete a healthy-
looking pus, and to show signs of commencing gra-
nulations, after which it is very immaterial whether
the dressings be continued or not.
The objects to be attained by the plaster ban-
dage are, first, a firm and even pressure over the
edges and surface of the ulcer ; secondly, the con-
traction of the sore, and consequently diminution
of the cicatrix or scar, by bringing the sound skin
at the sides of the ulcer into closer approximation ;
and lastly, uniform and firm pressure over the
whole limb, with a view of supporting and improv-
ing the condition of the varicose veins, and perhaps
debilitated lymphatics also.
The adhesive plaster is to be cut into straps of
two inches in breadth, and sufficiently long to go
round the limb, and to wrap about four inches over.
The sore having been carefully freed of superfluous
matter, not by washing or rough sponging, but by
gently absorbing it by means of a little soft lint ; the
sound skin around the ulcer having been carefully
washed and dried, and the hair, if in abundance,
having been removed by a razor, the middle of the
strap is to be applied to the sound part of the
limb opposite to, and a little lower than, the inferior
part of the ulcer, and the ends drawn over the sore
with as much gradual extension as the patient can
120 ON ABSCESSES, BOILS, CARBUNCLES, &C.
well bear; other straps are then to he applied in
the same way, each above and in contact with the
other, until the whole surface of the sore, and the
limb at least two inches below, and two or three
inches above the diseased part, are completely
covered.
The calico roller, which is to be applied over the
plaster, should be from three to four inches wide,
and from four to six yards long, according to the
size of the leg. It must be applied with great
exactness ; and if you wish to excel in this piece of
surgery, you must apply to your surgical friend to
give you a practical lesson or two, which will be
of ten times the value of my description. The first
circle of the roller should be round the ankle, as
near as possible to the foot, the second and third
round the foot, the fourth and fifth round the ankle
again, and then others spirally round the leg up to
the knee, each circle at about three-fourths of an
inch from the lower edge of the preceding, turning
down the upper edge of the roller for about half the
circumference of the leg in the three or four circles
that surround the calf, in order to make the roller
lie smooth at this part I have observed before,
that once in two days is often enough to remove the
dressing ; but should the ulcer, from irregularity of
diet, intemperance, or other cause, begin to assume
a less healthy appearance, and yet not sufficiently
so as to require an alteration in the local treatment,
and should the discharge in consequence become
ON ABSCESSES, BOILS, CARBUNCLES, &C. 1'21
considerable, should it be thin and offensive, and,
particularly should the weather be hot, remove the
dressings daily.
When you are not allowed, or from any cause are
not able, to make use of the adhesive bandage, you
will find flannel preferable to calico ; and having
first dressed the ulcer as directed above, and co-
vered it with a compress of linen rag, you may
trust with confidence to the firm and even pressure
of the flannel roller ; or, where the expense is not
an object, you may substitute Churton's stocking
bandage, made of cotton, soft and elastic, wove ex-
pressly for rollers.
For the purpose of producing uniform pressure
on the sides and bottom of these cup-shaped ulcers,
some surgeons now fill up the cavity at each dres-
sing with melted wax, applying a small compress
upon it, and the usual bandages over this The
plan is said to answer well, and is so easy of appli-
cation, that should the ulcer not heal so readily as
you could wish under the former treatment, you
will do well to adopt it.
Ulcers, as I observed before, sometimes assume
a less healthy appearance than what I have been
describing, and require, at least for a time, a very
different treatment. The margin, instead of being
circular, becomes irregular, and the ulcer extends
itself by the encroachment of this irregular margin
upon the sound skin in a serpentine line, perhaps
only on one side of the ulcer. If the margin is
G
1'22 ABSCESSES, BOILS, CARBUNCLES, &C.
elevated, it is at the same time undermined ;
the discharge is thin and usually copious, sometimes
bloody, and often offensive in smell. If the ulcer
be large, its surface consists of various distinct
hollows or cavities ; the granulations, if any, are
apt to bleed ; and the pain of such a sore is very
considerable at all times, usually aggravated, how-
ever, in the evening or at night. Such are the
characters of what have been denominated irritable
ulcers.
Every ulcer may, by mismanagement or by irre-
gularities in the habits of the patient, be made to
assume for a time these peculiarities ; and for this
reason the majority of cases admitted into hospitals
are, at the time of admission, of this description,
and require for a few days at least the appropriate
treatment of this species of ulcer ; but there are
some cases also which from peculiarity of constitu-
tion assume this character, and require the pecu-
liar treatment of irritable ulcers through their
whole progress. The local treatment of such sores
is by anodyne fomentations and poultices ; the con-
stitutional by anodynes and alteratives. A decoc-
tion of poppies makes the best fomentation, and
linseed meal brought to the proper consistence by
a strong decoction of poppies, the best poultice.
These sores should be washed at every dressing
with a sponge and some of the warm fomentation ;
if the fcetor is considerable, a rag wetted in a solu-
tion of chloruret of sodium may be laid immediately
ABSCESSES, BOILS, CARBUNCLES, &C. 123
over the sore ; or, if this gives pain, over the poul-
tice. These are the appropriate dressings till the
ulcer re-assumes the character of the healthy, or of
the indolent sore above described, when the treat-
ment will be, as recommended for them respec-
tively ; but, as I have observed before, in some
cases the irritable character still remains unaltered,
and the peculiar treatment here recommended,
namely, the anodyne fomentations and poultices,
must consequently be persevered in till the cure is
completed.
The constitutional treatment consists in giving
opium or henbane every night, with or without
calomel or blue pill ; and rhubarb with soda, and
perhaps quinine through the day, according to the
constitutional peculiarities, which professional judg-
ment can alone appreciate.
CHILBLAINS are the effect of inflammation in parts
distant from the centre of circulation, as the hands
and feet, induced by alternate exposure to very
high and very low temperature. To avoid chil-
blains, therefore, the hands and feet should be
warmly clothed in winter; and sudden exposure of
them to the heat of the fire, when cold, should be
carefully avoided ; and besides this, the languid
circulation in these extreme parts should be pro-
moted by active exercise, and by friction with sti-
mulants. Certain constitutional peculiarities pre-
dispose to chilblains, and therefore we see a preva-
lence of them in some families rather than in
124 ABSCESSES, BOILS, CARBUNCLES, &C.
others ; and they always prevail most in childhood.
Such children, therefore, as are particularly predis-
posed to chilblains, should be habituated to brisk
walking exercise in cold weather, and to such
amusements as promote exercise in the hands,
shuttlecock for instance, or rackets, and all games
at ball. The feet and hands should be occasionally
washed in the winter season in tepid water, with a
small quantity of flower of mustard mixed in it.
The feet should be well rubbed with spirits of wine
and camphor every morning, and clothed in wash-
leather socks. Great caution is also necessary to
avoid the warmth of the fire, when the hands and
feet are more than usually cold ; friction with a
warm hand being under such circumstances the
most desirable mode of restoring warmth.
The early symptoms of chilblains are redness,
heat, itching, and swelling, and the treatment in
this stage is bathing the part three or four times
a day with cold water, or spirits and water, till the
heat and itching have abated, well drying the part,
and covering it, as before stated, with soft leather ;
and also in adopting with greater care the measures
recommended above as preventive.
The second stage is greater swelling, increased
heat, smarting and burning pain as well as itching,
and a purplish hue instead of the former red colour
of the skin. The application of cold may now be
more constant by means of spirituous embrocations,
as goulard and spirits of wine; care, however, must
ABSCESSES, BOILS, CARBUNCLES, &C. 125
still be taken not to carry the plan beyond the re-
duction of the preternatural heat, after which the
part may be lightly covered, but may now by no
means be allowed to approach the fire.
The further progress of chilblains is the forma-
tion of small vesicles, which burst and leave ex-
coriations, which excoriations often change to ill-
conditioned ulcers, thus constituting the last stage.
The ulcers, as well as the surrounding parts, are
exceedingly painful, the itching and smarting are
intense, the discharge is at first somewhat bloody,
and they possess, in short, all the characters of ir-
ritable ulcers. While these ulcers are sloughing,
that is, extending by the death and removal of con-
tiguous parts, poultices are the best application,
and it will be serviceable to bathe the surface of the
sore with tincture of myrrh, or warm brandy, each
time that the poultice is removed, which should be
done three times a day. When the sloughing pro-
cess is over, which will usually be in three or four
days, stimulating ointments may be substituted for
the poultices, mild at first, as yellow basilicon, and
afterwards more stimulating, as the red precipitate
ointment. It may be further observed, that as
the parts in the immediate neighbourhood of the
ulcer exhibit more or less the chilblain appearance,
they must be treated according to the directions
previously given, with more or less vigour.
WARTS and CORNS may be considered by some
too slight and trivial deviations from health to de-
1'26 ABSCESSES, BOILS, CARBUNCLES, &C.
serve admission, even into a work of this descrip-
tion ; but as they are the source of considerable
inconvenience, particularly the latter, I shall not
hesitate to offer a few plain and simple directions
for the treatment of them.
Warts are adventitious growths, commencing in
the substance of the skin, or on its surface, and
are covered with the natural cuticle ; as they rise
above the surface of the skin they become broad
and rough, and sometimes lobulated. They appear
much more frequently on the hands than elsewhere,
but sometimes on the eyelids and other parts of
the face, as also now and then on other parts of the
body.
If the wart is pedunculated, or has a very slender
base, it is easily removed by tying a horse hair or
fine silk thread round it ; or it may be snipped off'
with a pair of fine scissars. When the wart is broad
at its base, its removal may generally be effected
by rubbing its surface with such stimulants as the
following : sal-ammoniac, blue vitriol, powdered
savine leaves, or a compound powder of equal parts
of savine leaves and verdigris. The wart should
be moistened, and the rubbing repeated twice a
day, unless it becomes very tender and painful, in
which case the application may be suspended for a
few days.
Warts are most common on the hands of children
or very young persons, and they usually disappear
spontaneously after a longer or shorter period,
ABSCESSES, BOILS, CARBUNCLES, &C. 1'27
which has made them a fruitful source of imposi-
tion and trickery; so much so, that almost every
village has a wart charmer, who pretends to remove
them by her own calculations and spells, inde-
pendent of any application whatever to the warts
themselves.
Corns are very like warts, being hard but not
horny preternatural growths, having their origin
in the skin. Their situation, however, is always
on the feet ; they are flatter and more painful
than warts, they disappear spontaneously much
less frequently than warts, they are also removed
with much more difficulty, and they are oftener the
source of inflammation in the surrounding skin.
It is probable that all these points of difference
may arise from the constant pressure to which
corns are subjected, as by walking when situated
on the sole of the foot, but more particularly by
the custom so generally adopted of wearing tight
shoes. This pressure is, I know, by many deemed
the cause, and the sole cause, of the origin of corns;
but to this I do not accede, as I have seen corns
so situated, that the pressure of a tight shoe could
not aflect them ; and I have also known instances
of very troublesome corns in families, where the
greatest care was taken to avoid the pressure of
tight shoes. I freely admit, however, that pressure
from tight shoes or some other source is the cause
of all the pain and misery occasioned by the pre-
sence of corns, and that without removing this pres-
128 ABSCESSES, BOILS, CARBUNCLES, &C.
sure no treatment will materially abate the pain, or
permanently remove the evil.
Long-continued rest and the removal of all pres-
sure would, indeed, I have no doubt, not only re-
lieve temporarily, but allow of the absorption of the
corn itself, and thus remove the evil altogether, as
is so continually taking place with warts ; but as
strict confinement will never be submitted to, we
must content ourselves with such directions for the
management of corns, as will preserve them tolerably
free from pain.
When corns are exquisitely tender, and the sur-
rounding skin looks red, it is absolutely necessary
to wear a loose slipper, and rest the foot upon a
stool for a day or two, and to bathe it freely with
weak goulard. The remaining management con-
sists in removing and preventing pressure upon
the sensible skin at the base or origin of the corn,
as well as pressure upon the corn itself. The for-
mer is to be effected by the total or partial extrac-
tion or destruction of the corn ; and the best means
of doing this are first to soften the corn by soaking
it for half an hour or more in hot water, and then
to pick it, or carefully undermine it, by means of a
dull-pointed probe, or a dull lancet, and a pair of
forceps. This requires great patience, and is
best done by another person. Care should be
taken not to draw blood ; the picking or scratch-
ing should commence at the outer circumference of
the hardened cuticle, should be carried all the way
ABSCESSES, BOILS, CARBUNCLES, &C. 129
round, and penetrate deeper as you approach the
centre, the operator having from the first grasped
the body of the corn by means of the forceps in the
left hand, and using all the time a little force in
pulling it outwards. With great care a consider-
able portion of the corn may be thus extracted,
but I doubt whether the whole is ever thus with-
drawn, unless when the corn is very superficial ;
and on this account I advise that this attempt at
extraction be always followed by a slight applica-
tion of lunar caustic ; unless where the last strokes
of the operation drew blood or caused pain, under
which circumstances the caustic would be followed
by too much inflammation. This tedious process
of picking should be repeated once or twice after
intervals of only a few days, and before the corn is
sufficiently grown to be again subject to pressure,
and consequently to be painful.
Some persons recommend the cutting of corns,
and most people, I believe, adopt this plan, as the
most expeditious and least troublesome. It should
be done with a sharp knife, or lancet, by repeated
very superficial cuts ; and care should be taken
not to draw blood, not because, as is vulgarly be-
lieved, both as regards warts aud corns, that the
blood will generate others in the neighbourhood,
but because it occasions unnecessary pain, and, by
inducing some inflammation, renders it injudicious
to repeat the cutting for some time to come. I
would further advise that after this operation the
G 5
LSO ABSCESSES, BOILS, CARBUNCLES, &C.
caustic should be rubbed over the cut surface, and
the operation repeated daily, or at intervals of two
or three days, till as much of the corn is destroyed
as can fairly be reached by the cutting instru-
ment. I do, however, myself, prefer the former
operation of picking as both safer and more
effectual.
We now proceed to describe the various contri-
vances, which may be resorted to for the removal
or prevention of pressure, which I have stated
above to be the sine qua non, both in removing
and preventing the pain attendant upon corns; and
which ought, therefore, to be attended to immedi-
ately after either of the above operations, and ought
to be afterwards permanently persisted in, until
there is reason to believe that the corns have en-
tirely disappeared. Tight shoes, the great bane of
all, must be scrupulously avoided ; and where the
corn is situated on the side of the foot, or is pro-
minent on one of the toes, much ease may be given
by directing the shoemaker to attend to the cir-
cumstance, and to give a little more room in that
point. The best guide will be an old shoe much
worn, as the leather or other material will usually
have stretched, and given way at this point. If
the corn be on the sole of the foot, a false or inner
sole to the shoe should be made with a correspond-
ing hollow. When the corn is between the toes, a
small bolster may be contrived to keep the toes
separate, or this may be done by a very narrow slip
SUSPENDED ANIMATION. 131
of adhesive plaster round one of the toes, so as not
to cover or press upon the corn. And lastly, when
the corn is on the upper part of the foot or toes, or
on the side of the foot, several pieces of plaster
should be applied over the corn, each with a hole
cut in its centre corresponding to the size of the
corn, until the plaster rises above the surface of the
corn, which will then as it were lie in a hollow,
protected from all pressure. In cases where the
corn is already depressed below the surface, a
simple plaster laid over it will afford considerable
protection, and it is in such cases only that the
various advertised corn-plasters can be of much
service.
LETTER VII.
ON SUSPENDED ANIMATION FROM DROWNING,
HANGING, SUFFOCATION, AND CHOKING ; AND
ON POISONS.
MY DEAR SON,
HAVING concluded that part of my subject which
may be considered as strictly surgical, and being
about to enter upon the medical department, I
must again remind you, that my object goes no
further than to prepare you, in the first place, to
act discreetly upon sudden emergencies, whether
132 SUSPENDED ANIMATION.
they be such as form the subject of the present
letter, or as they may regard sudden seizures, as
fits of various descriptions, and the early symptoms
of other important and dangerous diseases ; and in
the second place to enable you to assist your poor
neighbours in the management of those trivial dis-
orders, the care of which they are accustomed to
undertake themselves, or commit to the manage-
ment of old nurses. You will not, therefore, ex-
pect that I shall give you instructions for the treat-
ment of more grave disorders, as apoplexy or epi-
lepsy for example, except as regards the steps that
are to be taken previously to the possible arrival of
a medical man ; neither shall I enter fully into the
medical treatment of such diseases as measles or
scarlet fever, though I shall endeavour to enable
you to detect their early symptoms, and to direct
the management of very mild cases.
Again, as regards typhus and remittent fever,
inflammations of important organs, and many other
dangerous diseases, I would dissuade you from ever
undertaking the entire management of such cases,
for they require all the judgment of the regularly-
educated and experienced practitioner ; but if I can
teach you to discern the first symptoms of such
formidable cases, and can prepare you to take an
early step in the treatment of them, both the pa-
tient and the medical practitioner will have reason
to thank you for your promptness, and you will
yourself have the satisfaction of knowing that you
SUSPENDED ANIMATION. 133
have mitigated after symptoms, and, perhaps,
warded off' danger.
On the treatment of agues, colds, coughs, chronic
eruptions, and a variety of other ailments, which
the poor are disposed generally to manage, or rather
mis-manage for themselves, I shall give you more
full and ample directions, that yon may have the
power, as I am sure you will have the inclination,
to substitute rational means of cure for their crude
and often baneful mode of treatment, and thus to
snatch many from the risk of long-protracted ail-
ment, and perhaps from the ruin of their constitu-
tions.
This first letter of this second series, as it may
be termed, will be devoted to the consideration of
certain appalling cases of sudden death, and sus-
pended animation, to which you may be liable to
be called, both to direct the medical treatment
when it can be available, and to give evidence in
other cases at a coroner's inquest, or before any
other judicial tribunal.
That you may more easily understand the cause
of death in certain cases, and the rationale of the
directions, which I am about to give, where anima-
tion is only suspended, I shall premise a concise
description of the natural process of Respiration
in man and all warm-blooded animals.
RESPIRATION is the reception of air into the
lungs, and its expulsion from the lungs ; the former
act is termed 7/zspiration, the latter
134 SUSPENDED ANIMATION.
By the action of certain muscles, which elevate and
depress the shoulders, protrude and draw back the
breastbone, and straighten and relax the muscular
and membranous partition, called the diaphragm,
which divides the chest from the abdomen, the
cavity which contains the lungs is alternately in-
creased and diminished in all its dimensions. When
it is increased, the air as naturally rushes into the
lungs, and by the same laws, as it does into the
body of a pair of bellows, when by raising one
handle you increase the dimensions of the cavity.
And again, when the cavity of the chest is dimi-
nished, the air is as necessarily expelled. This
constitutes the mechanism of respiration ; but the
air thus received into the lungs, and the blood
which in its transmission through the lungs comes
nearly into contact with the air, are both ma-
terially altered in their chemical qualities. And
so necessary is this chemical change in the quality
of the blood to the maintenance of life, that if it
becomes in any degree interrupted, disease follows.
and, if suspended only for a very few minutes, death
is the inevitable consequence. In this way does
life become extinct in drowning, hanging, and suf-
focation, and also in choking, when any substance
sticks in the throat, and so presses upon the wind-
pipe as to prevent breathing.
In all such cases, however, you are not to be
deterred from making attempts at recovery, al-
though a much longer time than that above speci-
SUSPENDED ANIMATION. 135
fied has elapsed since the person was supposed to
have sunk under the surface of the water, or to
have been suspended by the cord ; for it frequently
happens that the drowning person has risen un-
observed to the surface, and, in the latter case, that
the cord has only constricted the windpipe imper-
fectly. In every such case, therefore, where signs
of commencing putrefaction have not appeared,
some attempts at resuscitation should be made.
Here I may casually observe, that when con-
sulted, which you are very likely to be in all doubt-
ful cases in your parish, as to the propriety of
interring a corpse which has not assumed the
usual appearances of commencing putrefaction, you
may bear in mind the following brief observations.
There is no single unequivocal proof of death but
putrefaction, the early signs of which are the pe-
culiar odour termed the cadaverous smell, the ap-
pearance of livid spots and patches, particularly on
the parts on which the corpse rests, and the in-
creasing distention of the stomach and belly. The
other appearances most indicative of death, and
which, if all or most of them are present, may be
considered as conclusive, are these :
1st. The cessation of breathing, the best test of
which, though not absolutely certain, is the per-
fect stillness on the surface of a small pan of
water placed for this purpose on the chest of the
corpse.
2nd. The want of pulsation in the heart, the
136 SUSPENDED ANIMATION.
most accurate mode of ascertaining which is by the
application of a stethoscope, or, what is a good sub-
stitute for it, a half-quire of letter-paper rolled up
into a cylinder. One end of the stethoscope or its
substitute being placed firmly over the heart, and
the ear applied to the other end, the slightest ac-
tion of the heart will be audible.
3rd. The coldness of the corpse; in estimating
which as a sign of death, it must be taken into due
consideration, that the body loses its heat in many
cases of suspended animation, particularly when it
has been immersed in water.
4th. Rigidity. The rigidity of death may be
distinguished from the rigidity produced by intense
cold, by the hard and brittle feel of the skin in the
latter case, and by the crackling noise, when you
move the frozen limb ; and it may be distinguished
from the rigidity, which is the consequence of
spasm, by the limb in the latter case resuming its
former position when forcibly moved, whereas the
rigid limb of the corpse retains any position into
which it may be brought. The test of rigidity,
therefore, if not of putrefaction, ought to be waited
for before interment.
5th. The cadaverous countenance formed by the
hollow or sunken eye, sharp nostril, wrinkled fore-
head, temples and cheeks pressed in, and the livid
colour. Of these particularities the soft, flaccid,
cloudy, and sunken appearance of the eye is the
most characteristic of death.
SUSPENDED ANIMATION. 137
In cases of DROWNING the body should be care-
fully, and not rudely, drawn from the water, should
be immediately stripped, wiped dry, and covered
with some of the by-standers' clothes, unless a
house be very near at hand. The position of the
body, from the moment it is taken out of the water,
should be constantly the horizontal, with the head
a little elevated, and the chin supported from the
chest. No shaking, no suspending by the heels,
is to be allowed. The body when brought into
the house should be wrapt in a blanket, and be
laid on a mattress or bed upon a low table. The
room should, be warmed by a fire if the weather
be cold, all unnecessary attendants be dismissed,
and the process for resuscitation be immediately
commenced.
This consists in the application of warmth, con-
tinued friction, and an attempt at artificial breath-
ing, all which may be adopted at one and the same
time ; and afterwards in the cautious use of stimu-
lants. To obtain the first object, let the blanket
in which the body is to be wrapt, be made hot by
a warming pan or other means, wrap the feet in
hot flannels till bricks can be heated, which may
then be covered with flannel and applied to the
soles. A bladder half filled with hot water may
also be applied to the pit of the stomach, and a
similar one under each arm-pit. Two persons may
at the same time be constantly employed in rub-
ing with their hands such parts of the body as can
138 SUSPENDED ANIMATION.
be got at without exposure ; and two others may
attempt, in the best way they can, to imitate the
natural breathing. This latter very important
operation will be best done by a professional man,
and by means of the Humane Society's apparatus ;
and we take it for granted that in every case both
has been instantly sent for from the nearest sta-
tion. Before the arrival, however, of the surgeon
or the apparatus, you may have recourse to the
following means. Obtain the smallest pair of bel-
lows at hand, use them once or twice to blow out
any dirt or dust that may be in them, wrap some
soft rag round the nozzle, and apply it to one of
the nostrils, whilst an assistant closes the other
nostril and mouth with his hand. Having used the
bellows two or three times, and watched for the
expansion of the chest ; if it is perceived to heave
or appears distended, then gently press upon the
ribs and the pit of the stomach to expel the air, the
assistant at the same time allowing the nostril and
mouth to be open. Repeat the use of the bellows
with the nostril and mouth closed, and the same
pressure with the nostril and mouth open, alter-
nately for many times, so as to imitate as nearly as
you can the natural breathing; and persist in it
for two or three hours, even if no signs of returning
life are apparent; but should the action of the
heart or the pulse at the wrist be felt, should a sigh
be heard, or a twittering of any of the muscles of
the face be perceived, continue the artificial breath-
SUSPENDED ANIMATION. 139
ing, desisting occasionally for a few seconds to
watch for the repetition of these signs of returning
animation; and if they be repeated and become
stronger, desist then altogether from the artificial
respiration ; and now, and not before, begin to
apply with great caution some of the following sti-
mulants. A feather dipt in vinegar may be intro-
duced into the nostrils to excite sneezing, and thus
rouse the action of the muscles of respiration; a
tea-spoonful of hot brandy may be put into the
mouth as a stimulus to the sensible membrane
covering the tongue and palate, even before the
return of the power of swallowing; a mustard
plaster may be applied to the pit of the stomach
for a few minutes, and others also to the soles of
the feet, and the friction of the whole body should
be still more perseveringly conducted. Upon a
further improvement, as the opening of the eyes,
deep sighing, and more regular heaving of the chest,
all the above stimulants may be desisted from, save
warmth; and as soon as it can be swallowed, the
administration of small quantities of warm wine and
water, and afterwards of broth, gruel, or milk por-
ridge, will be both safe and beneficial. The greatest
quietude and care in nursing will afterwards be
required for a day or two, to prevent excess in the
reaction, which might lead to inflammation or other
mischief.
In HANGING the cause of death is the same as in
drowning, namely, the exclusion of air from the
140 SUSPENDED ANIMATION.
lungs, or the stoppage of breathing; and not, as
some have supposed, apoplexy from a stoppage of
the blood in the head. The treatment of a person
who has been suspended by a cord round the neck,
must altogether be precisely the same as has been
recommended in cases of drowning, except that
an attempt may, in the first place, be made to
bleed in the arm, or, if a surgeon be at hand,
in the jugular vein, with a view of relieving the
vessels of the brain, which are in such cases
probably distended, though not so as to produce
apoplexy.
Should you ever be called upon to give an opi-
nion as to whether a person found dead in a state
of suspension has had his death caused by hang-
ing, or has had the cord tied round his neck after
death, you may frequently satisfy yourself upon
this point by an examination ; for when the mark
round the neck, where the cord was applied, is of
a deep purple colour, you may conclude that it
was applied before death ; but the converse of this
does not hold good, because the purple mark does
not take place in all who are hanged ; but it
never takes place when the cord is applied after
death.
SUFFOCATION may take place either from ex-
posure to some noxious air, or from the exclusion
of air altogether. Instances of the former kind are
not uncommon from inconsiderate confinement in
rooms heated by charcoal, from persons falling
SUSPENDED ANIMATION. 141
asleep very near to or upon kilns of burning lime,
or from incautiously venturing into common sewers,
or wells, without first ascertaining the state of the
air by the test of lowering a lighted caudle. The
most common occurrence of the second species of
suffocation is when an infant is, from carelessness
or ignorance, so covered with bed-clothes, or over-
laid by the nurse, as to exclude the access of fresh
air to the lungs. In all cases of suffocation the
treatment is the same as before described in cases
of drowning, with this additional observation, that
the recovery is frequently expedited by first ex-
posing the body to the air, and frequently dashing
cold water over it.
When called to a person found dead, or appa-
rently dead, where the probability of drowning,
hanging, and suffocation is entirely out of the ques-
tion, and where no marks of external violence can
be discovered, you will be led to suspect INTOXICA-
TION ; and if there is a smell of spirits or other fer-
mented liquors , about his person, your suspicions
will almost amount to certainty, and particularly so,
if you discover proofs of his having recently thrown
up the contents of his stomach, and if these again
emit the odour of beer, wine, or spirits. In such a
case you should place the head in a natural posi-
tion, throw water in the face, endeavour to admi-
nister an emetic, and then, if there be no signs of
life, use all the means above recommended for the
recovery of persons recently drowned. The imme-
14*2 SUSPENDED ANIMATION.
diate cause of suspended animation, or death, in
such cases of intoxication, is sometimes apoplexy,
and sometimes syncope or fainting. When a purple
and bloated countenance, with blood-shot eyes, indi-
cate the former, an attempt should be made to
bleed in the arm, or if a surgeon be at hand, in the
jugular vein; if, on the contrary, the countenance
be pallid, warmth, stimulants to the nostrils, and
the occasional dashing of cold water, should be the
expedients first resorted to.
The term CHOKING is applied to the accident of
something sticking in the throat, whether it be a
body too large to pass readily into the stomach,
and being therefore detained in some part of the
oesophagus or gullet, in the act of swallowing, or
whether it be something which has accidentally
passed from the mouth into the trachea or into the
windpipe.
In the former case, the alarm and danger arise
from the obstructing substance pressing upon the
windpipe, which lies in front of, and in close con-
tact with, the gullet; the removal of which may
be attempted in various ways, according to the na-
ture of the substance, and its position. In a great
majority of cases the substance is some article of
food, and it is usually situated so low, as to make
it more easy to push it down into the stomach than
to bring it up by the mouth. The instrument
used by the surgeon for this purpose is a small
ball of sponge at the end of a long piece of whale-
SUSPENDED ANIMATION. 143
bone, and is called a probang ; but as the intro-
duction of it requires some care to avoid its pass-
ing into the windpipe, I do not advise your at-
tempting it but in extreme cases, and when a sur-
geon cannot be procured. What is first to be
done is to look into the throat, to see whether the
substance is within reach of the finger, as is very
frequently the case when children are choked by
incautiously attempting to swallow large pieces of
apple, orange, pudding, meat, or any other kinds
of food. In all such cases you will use your
own discretion as to pushing the obstructing mat-
ter downwards, or attempting to withdraw it; the
latter of course being most desirable, if as easily
accomplished. The best position for a patient
whose breathing is thus obstructed, is the hori-
zontal one with the head elevated. When the
offending matter cannot be reached, it is advis-
able still to introduce the finger into the throat
with a view of exciting the action of vomiting.
But should these means fail, and the patient's
face become turgid and livid, and should no sur-
geon have arrived, you must devise the best means
you can to form a substitute for the probang, with
which to reach the offending matter, and push it
forward into the stomach. A pliable twig or piece
of cane, if whalebone be not at hand, must be pre-
pared by tying a hard ball of linen, if you have no
sponge, at its thinnest extremity ; and this must be
done by boring or burning one or more small holes
144 SUSPENDED ANIMATION.
in the cane, as the only means of securely fastening
the sponge, and avoiding the danger of its coming
off in the gullet. The ball having been soaked in
oil, you proceed to introduce it by first inserting
the fore-finger of your left hand over the tongue to
its root, and then sliding the probang along the
finger to direct it over the opening of the wind-
pipe ; and having thus got it fairly into the gullet,
you thrust it down upon the obstructing body
with the requisite force to push it forward. If the
substance be anything that is digestible, no further
precaution is called for ; if it be a coin, a marble,
or anything of that kind, which has been accidently
swallowed, you must refrain from the common
practice of giving castor oil, or any other purga-
tive, to promote its expulsion ; for the passage o
such a solid body through the intestines will be
most safely effected by its being enveloped in the
ordinary contents of the canal in even a more con-
sistent and solid state than usual, and not in the
liquid state, which would be the consequence of a
dose of physic. The only directions therefore to
be given, are to abstain from much drink or fluid
food, to live on pudding, porridge, bread and meat,
and to watch carefully for the expulsion of the
offending matter, that the mind of the patient may
be relieved from all anxiety.
If the substance sticking in the throat be a
rough or pointed body, as a bone, a pin, or a nail,
pain rather than suffocation is the consequence,
ON SUSPENDED ANIMATION. 145
and the danger arises from the inflammation to be
apprehended, if the body cannot speedily be re-
moved. The most desirable mode of relief in this
case will be by the withdrawal of the substance up-
wards, which will be attempted by the surgeon in-
troducing the other end of the probang, which
is always provided with a hook for that purpose ;
and as the danger in these cases is not so very
pressing, I recommend you in every such accident,
to put the patient into the hands of the medical
practitioner.
When any foreign substance, solid or fluid, be it
ever so small, as for example, a crumb of bread or
a drop of water, passes into the windpipe, it imme-
diately occasions distressing cough, and interrupted
respiration from spasm of the muscles at the top
of the windpipe, and this, as I observed before,
is also called choking, but is altogether a different
kind of accident from the one we have just been
considering. The substance here is always small,
and is usually a dry crumb of bread, or a drop of
fluid, drawn accidentally into the windpipe in the
act of inspiration, which frequently occurs from an
incautious attempt at speaking whilst in the act of
swallowing. Quietude on the part of the sufferer,
and to refrain wholly from speaking, is all that can
be recommended. It may be doubted whether the
common practice of taking a little drink really
does any good, but as it is unattended by any evil,
it may be resorted to. When you reflect that the
H
146 ON POISONS.
offending matter is in the windpipe, and that the
drink goes down the gullet, it is perfectly clear,
that it cannot be washed down, as is commonly
believed ; still, however, it is possible, that the act
of swallowing the drink may, by suspending for
the time the action of breathing, allow the muscles
of respiration to recover more readily from the
state of spasm, into which they have been thrown
by the irritation from the offending matter. With
this view, therefore, the drink should be swallowed
as slowly as possible, and with the same view a
voluntary suspension of breathing, as long as can be
done under these circumstances, tends to lessen and
to shorten the state of distress. Nature, however,
generally removes the offending cause by the efforts
of the cough, which is invariably produced.
Paralytic patients are very liable to this species
of choking, and I have known a large piece of food
slip into the windpipe of such a person, and pro-
duce imminent danger of suffocation. In such an
extreme case a surgeon, if at hand, would be justi-
fied in performing the operation of cutting an open-
ing into the windpipe.
On the subject of POISONS I shall endeavour to
avoid prolixity, and shall, therefore, notice only
such as are the most frequently resorted to, either
wilfully by the suicide, or intentionally by the
murderer ; or such as are most liable to be acci-
dentally or by mistake taken into the stomach.
The suicide who decides upon poisoning him-
ON POISONS. 147
self, almost always selects either arsenic, corrosive
sublimate, or laudanum. The same poisons are
also sometimes taken by mistake ; but a frequent
cause of death in this latter way, particularly of late,
has been the mistake of taking oxalic acid for
Epsom salts. Poisoning from wilful adulteration
of articles of diet, and from carelessness or igno-
rance in those who prepare our food, is most fre-
quently occasioned by some preparation of arsenic,
of copper, or of lead. The articles now enumerated
are, therefore, what I shall more particularly notice,
and shall conclude the subject by some cursory ob-
servations on a few other poisons.
The symptoms produced by arsenic taken into
the stomach, are constriction of the throat, pain in
the stomach and bowels, vomiting, and frequently
purging, both evacuations being often bloody.
The breathing also becomes difficult, the pulse
small, hard, and quick, and the thirst incessant;
the extremities are cold ; and death is usually pre-
ceded by convulsions. No antidote to this poi-
son has yet been discovered. The treatment con-
sists in giving large quantities of sugar and water
or linseed tea, with a view of promoting the vomit-
ing, which is always present, and of sheathing
the coats of the stomach; and then in freeh-
and frequently washing out the stomach with
the same mucilaginous fluids, by means of the
stomach-pump. If the violent symptoms are sub-
dued, which only takes place, however, when the
H 2
148 ON POISONS.
quantity of arsenic has been small, broth or other
light diet may be given. The pains in the
stomach and bowels which remain, call for the free
application of leeches, and other treatment appli-
cable to inflammation of these parts.
The means of detecting arsenic are various,
but the following are most easy of application.
Throw some of the suspected matter in a dry
state upon red hot iron, and if arsenic be present,
you will perceive an odour strongly resembling
that of garlic. Draw a broad stroke upon white
paper with the suspected matter in a fluid state,
then draw a stick of lunar caustic over the mois-
tened paper several times, and, if arsenic be pre-
sent, the streak will assume a rough curdy and
yellow appearance, which after a time becomes
brown.
Persons recovering from an over-dose of arsenic,
are sometimes left paralytic, and often with chronic
inflammation of stomach and bowels.
The symptoms after taking Corrosive Sublimate,
which is a preparation of mercury, are precisely
similar to those from arsenic. The antidote is
white of egg. Mix the whites of twelve eggs with
a quart of water, beat them up, and give a wine-
glassful every two or three minutes, so as to favour
vomiting. If eggs are not at hand, give milk, or
sugar and water in large quantities, till the eggs
be procured. If vomiting has not yet been freely
produced by the poison, or by the egg and water,
ON POISONS. 149
or other drinks taken into the stomach, the back of
the fauces, or throat, should be irritated by the
finger or by a feather, and an emetic of any kind
that is at hand, should be given immediately.
The means of detecting corrosive sublimate will
be understood by the following characters. When
exposed to heat in its solid form, it is entirely eva-
porated. It is soluble in water, and still more so
in spirits ; and when a solution of it is added to a
solution of ammonia, it is precipitated white, when
to a solution of potash yellow, and when to lime-
water orange.
We now come to the consideration of poisoning
by laudanum, or other preparations of opium.
This is frequently the means resorted to by suicides,
and no doubt for this reason, that in certain doses
it is known to produce sleep, stupor, and perfect
insensibility. When taken, however, in sufficient
doses to prove fatal, death is usually preceded by
distressing spasms and horrible convulsions. Opium
in its various forms, being in such continual use as
a medicine, is the poison too, which is most fre-
quently swallowed by mistake ; its dangerous and
sometimes fatal effects also from an over-dose are a
frequent consequence of ignorance and rashness.
The symptoms of an over-dose, are drowsiness,
stupor, and an unconquerable disposition to sleep ;
and if the quantity taken be sufficient to prove fatal,
and no means of relief are resorted to, the state of
stupor becomes so great, that no efforts are avail-
150 ON POISONS.
able to arouse the sufferer to consciousness ; dis-
tressing sickness comes on at intervals, and violent
contortions and convulsions at length close the
scene
To opium we have no antidote. The early treat-
ment consists in evacuating the poison by emetics,
and by the stomach-pump, and in arousing the pa-
tient to exertion by walking him about, and by every
other means in our power ; and further in the use of
stimulating glysters, which will both rouse the pa-
tient, and expel such part of the poison, as may
have passed into the lower bowels. The secondary
treatment, which, be it impressed strongly on your
mind, is not only not applicable, but is actually de-
trimental, till after the efforts made to evacuate the
stomach and bowels have been effectual, is the fre-
quent administration of a glass of lemonade or
vinegar and water, and a cup of very strong coffee.
When, therefore, you are satisfied that a person
has taken this poison, you will immediately give
as an emetic, a scruple of white vitriol, or four
grains of tartar emetic, if either are at hand ; but
if not, three table-spoonfuls of flour of mustard
mixed with water, or as much common salt. In
the mean time it is to be hoped, that the sur-
geon has been sent for with orders to bring that
most useful and efficacious instrument the stomach
pump.
When by either of these means the stomach
has been thoroughly emptied, and washed out, and
ON POISONS. 151
the bowels emptied by two or three copious ca-
thartic glysters, you will proceed to give the acid
drink or coffee every quarter or half hour at first,
and then at longer and longer intervals, allowing
the patient now to indulge in sleep in these inter-
vals, if the propensity still continues.
We have no chemical tests, by which to prove
the presence of opium ; but the smell of it in the
breath of the patient, and more particularly in the
matter first thrown off the stomach, will frequently
confirm the suspicions excited by the peculiarities
of the symptoms.
There is an acid obtained by the chemical action
of nitric acid on sugar, which was on that account
called acid of sugar ; it is now known by the name
of oxalic acid. As sold in the shops under either
of these names, it is a white crystallised salt, very
much like Epsom salts in appearance, but in-
tensely acid and acrid to the taste. In the dose of
half an ounce, it has frequently proved fatal in
less than an hour; and there is no doubt, but
that a much less dose would destroy life. Another
salt in crystals but of a brownish appearance, sold
under the treacherous name of salt of lemons, is a
compound of oxalic acid and an oxalate of lime,
and is also a poison. Oxalic acid and acid of sor-
rel have been identified by the chemist, though
procured by different processes, the latter having
been long since manufactured in Switzerland from
the juice of the sorrel.
152 ON POISONS.
This oxalic acid, or acid of sugar, or acid of sor-
rel, having been of late introduced into use in the
cleaning of brass furniture, and still more fre-
quently in the composition of a fluid for cleaning
boot-tops, has been sometimes taken into the sto-
mach by mistake ; it has also been occasionally had
recourse to for the purpose of suicide or murder.
The mistake has always arisen from its very strong
resemblance in appearance to Epsom salts. The
taste will in a moment discover the mistake, or sa-
tisfy a doubt, when it arises, or prevent the occur-
rence of mistake, if constantly had recourse to by
way of precaution before drinking off a dose of salts.
The taste of oxalic acid is, as its name denotes, and
as I have stated above, sour, and it is also acrid,
whereas the taste of Epsom salts is a decided
bitter.
The symptoms, after taking oxalic acid, are a
burning sensation in the throat and stomach, often
bloody vomiting, an extreme general debility al-
most amounting to paralysis, and a remarkably
feeble and often imperceptible pulse ; and when the
dose is large death occurs in a few minutes, or in
almost every such case within the hour. In some
instances there has been numbness down the back,
and in the lower extremities, and in others very
acute pain in the same parts.
Should the mistake be immediately detected, the
antidote is maynesia or chalk, which form with the
oxalic acid insoluble and harmless salts ; but not
ON POISONS. 153
so, be it well remembered, either potash or soda,
for the salts produced by a combination of these
with oxalic acid, are readily soluble and decidedly
poisonous. Mix the magnesia or chalk with just
sufficient water to make it drinkable, and give a
wine-glassful every two or three minutes, till the
patient has swallowed two or three ounces of the
magnesia or chalk. Vomiting need not be excited,
nor the stomach pump used, at least not till after the
administration of the above antidote.
The best test of the presence of oxalic acid is
lunar caustic. Boil the contents of the stomach,
or the matter ejected from the stomach by vomit-
ing, previously to the administration of the antidote,
in water for half an hour ; add some potash, and
then filter through paper. To this solution add a
few drops of a solution of lunar caustic ; and, if
oxalic acid has been present, you will have a dense
white precipitate, which, when collected on a fil-
ter, dried, and heated, becomes brown on the edge>
fulminates faintly, and is dispersed.
Copper., in its metallic state, is not poisonous,
but some of its combinations are so ; for instance,
verdigris, which is a salt produced by the combina-
tion of vinegar with copper ; and also the salt so
well known in commerce under the name of blue
vitriol, or copperas, which is a sulphate of copper,
or a combination of copper with the sulphuric acid
or oil of vitriol. The circumstance under which
poisoning by copper generally takes place is by the
H 5
154 ON POISONS.
introduction of artificial verdigris or acetate of
copper into the stomach with our food ; this verdi-
gris being produced in copper vessels not well
tinned, or not at all tinned, when such are left with
acid, or with greasy matter in contact, and are
afterwards used in cooking without attention to
cleanliness. The same substance is occasionally
formed and taken into the stomach by the equally
culpable negligence of leaving soups or stews in
coppers, or copper saucepans, to cool, and to be
cooked up again upon another occasion. Another
cause of accident from copper is the practice
adopted by many of putting copper coins into
pickles and preserves for the purpose of improving
or heightening their green colour.
The symptoms produced by verdigris thus taken,
if the quantity be small, are pains in the stomach
with sickness and vomiting, the matter thus ejected
being acrid, often of a coppery taste, and some-
times of a greenish or blueish colour. If the quan-
tity be larger, or the person who partakes of the
food thus prepared, be of a naturally feeble consti-
tution, or previously disposed to bowel affections, the
above symptoms are much more violent in degree,
the stools become bloody, spasms or cramps come
on with cold clammy sweats, convulsions, and
death.
The treatment consists in giving the whites of
eggs, as recommended after taking corrosive subli-
mate ; and in promoting vomiting by introducing
ON POISONS. 155
the finger down the throat, or by any ordinary
emetic, if the symptoms arise soon after the poison
has been taken, and by the use of the stomach
pump as soon as it can be procured. Should the
symptoms arise many hours after the suspected food
has been taken, the white of eggs should still be
given ; cathartic, and then anodyne glysters, should
next be administered; and, lastly, the treatment
for ordinary inflammation should be adopted, as
leeching, fomenting, &c.
Another preparation of copper, which acts as a
poison in moderate doses, is, as I have before
stated, blue vitriol or sulphate of copper. In the
small dose of one or two grains it operates as an
emetic ; when taken in larger doses it produces the
whole train of symptoms above described, and re-
quires the same treatment.
The test of the presence of verdigris in any fluid
is the addition of a small quantity of liquid ammo-
nia, or of sal-volatile, which immediately occasions
a pale azure-coloured precipitate, which is re-dis-
solved by an excess of the ammonia, forming then
a deep violet-blue transparent fluid. An easy test
of the presence of blue vitriol is a piece of polished
iron. Pour boiling water on the suspected matter,
and filter it through paper, suspend a key or the
blade of a knife in the filtered fluid, and if copperas
or blue vitriol be present, the iron will assume a
coppery hue, and the fluid a greenish tint.
Poisoning with lead occurs more frequently
156 ON POISONS.
from accident than design, and seldom from any
other preparations than white lead, and sugar of
lead, each of these articles being in frequent use in
the arts, and the latter being sometimes employed
for fraudulent purposes. White lead is the basis
of most of the paints commonly employed, and as it
affects the human frame injuriously through the
lungs and the skin, as well as when taken into the
stomach, we often find manufacturers of white lead,
plumbers, and painters, who are all much exposed
to the fumes or emanations of white lead, and
also to contact with it in the preparation and
the use of their paints, seriously and sometimes
fatally affected with the disease called painter's
colic. The symptoms of this disease are frequent
recurrence of colicky pains, at first slight, hut af-
terwards intensely severe, with dry mouth, sick-
ness, and vomiting of bitter matter of a dark green
or almost black colour. Pains in various other
parts are also very common, as in the arms and
legs ; and occasional sensations of numbness and
muscular feebleness alternate with the pains. The
bowels are usually costive, and the excrement is
passed in hard round pellets, like that of sheep.
To these symptoms succeed in most cases, sooner
or later, either apoplexy, or partial palsy, particu-
larly of the arms and hands, with a wasting of the
flesh. The disease is frequent amongst painters,
plumbers, lead smelters, colour makers, and other
artisans, whose business leads them either to con-
ON POISONS. 1")7
stant exposure to the fumes, or constant handling
of lead in any of its preparations ; and the same
symptoms are the consequence of the protracted
use of wine, cyder, or any article of food that is
impregnated with this metal
Should you ever he called to a person labouring
under a sudden attack of painter's colic, you must
resort immediately to purgatives and anodynes in
full doses ; an ounce or more of Epsom salts, or an
ounce and a half of castor oil in the first place, and a
quarter of an hour afterwards a small tea-spoonful
of laudanum ; but should the salts or the oil be re-
jected, give the laudanum immediately, and repeat
the purgative in half an hour.
Sugar of lead, which is an acetate of lead, is
said to be frequently used to diminish the acidity
of light wines, and also in the clarifying of wines
and spirits. Goulard's lotion is also an acetate of
lead in a liquid state ; and these preparations are
therefore the occasional sources of poisoning by
lead, either through ignorance or mistake. When
a large dose of these or other preparations of lead
is taken into the stomach, it produces sickness, vo-
miting, and violent pains both in the stomach and
bowels, like an over-dose of corrosive sublimate, or
other metallic irritant.
The antidotes are sulphate of soda or Glauber's
salt, sulphate of alumine or alum, and the carbo-
nates of potash or soda, which should be therefore
administered freely in an abundance of warm water,
158 ON POISONS.
and if they do not speedily produce vomiting you
may give, as an emetic, the sulphate of zinc or
white vitriol, the proper dose of which is a scruple.
A substance called Barytes or Baryta, has of
late been much used to poison rats. It is a white
ponderous earth, usually sold in powder. It is very
poisonous, and being, as I before stated, frequently
called for, may become the source of poisoning by
accident or otherwise. The symptoms produced
by taking barytes are, a sense of burning in the
stomach, vomiting, griping, purging, paralysis, con-
vulsions, and death.
The antidote is either Epsom or Glauber's salt, of
which somewhat more than the quantity of barytes
taken will by chemical decomposition and recom-
bination produce an insoluble and inert salt, which
will pass off by the bowels. Should the poison,
however, have been taken long enough to produce
pain and sickness, besides giving a full dose of salts
dissolved in water, you should order mild mucila-
ginous drinks, as milk, barley water, &c. : and not
omit to use the stomach pump as soon as it can be
procured. In addition to which you must also
apply leeches to the stomach, and use every other
means for subduing inflammation.
The berries of deadly nightshade have often been
gathered and eaten by children. They produce
nervous tremors and symptoms resembling intoxi-
cation, as well as vomiting and griping, and the
pupil of the eye becomes remarkably dilated. If
ON POISONS. 159
the quantity eaten be sufficient, and a very few ber-
ries will be sufficient, the above symptoms are soon
succeeded by convulsions and death. The treat-
ment consists in the immediate administration of an
emetic or the use of the stomach pump, then a brisk
cathartic, and lastly repeated doses of vinegar, as
recommended after opium. Nearly the same symp-
toms are produced by hemlock, thorn apple, and
tobacco, and a similar treatment is called for.
Mussels and some other fish have been occasion-
ally known to disagree, producing sickness, giddi-
ness, swelling of the face with an eruption like the
nettle rash ; and sometimes more alarming symp-
toms, as violent pains in the stomach and bowels,
convulsions, and even death. The treatment is an
emetic, a purgative, then twenty or thirty drops of
ether on a lump of sugar ; and if the distressing
symptoms have not soon subsided, ten or fifteen
drops of laudanum may be given in a little brandy
and water.
It is well known that many species of mushroom
are poisonous, the symptoms produced by them are
pain of stomach and bowels, thirst, vomiting, faint-
ing fits, convulsions, and death; at other times
tremors, drowsiness, deep sleep, and paralysis.
These various symptoms will sometimes show them-
selves in a few minutes, or perhaps in an hour or
two; but at other times not till the next day.
Emetics, the stomach pump, and then purgatives
must in every such case be assiduously employed.
160 ON POISONS.
After the offending matter may be supposed to
have been evacuated, mucilaginous drinks, fomen-
tations, and leeching will be required, if pain and
soreness remain in the stomach and bowels ; but
ether and laudanum in brandy and water if cramp,
convulsions, or tremors continue.
We shall now take a slight review of the subject
of poisons, with a view of impressing it strongly on
your mind. When called to a person, who has
been suddenly seized with vomiting and violent
colicky pains, particularly if neither cholera nor
bilious fever prevail at the time ; or if your patient
is in a state of stupor with quick breathing, dilated
pupil, and a full quick pulse ; be alive to the pro-
bability of something deleterious or poisonous hav-
ing been taken into the stomach; and if your
inquiries raise suspicion in the minds of others, use
your best judgment in pursuing the investigation.
If any poisonous substance has been taken by mis-
take, you will in all probability by the assistance of
the patient or his friends soon make the discovery,
and ascertain the nature of the poison. If it has
been taken with suicidical intentions, the deluded
patient, if able to communicate, will, very generally,
under the pressure of his sufferings, and probable
alteration of his views, disclose the secret, and ac-
quaint you with the nature of the poison he has
swallowed. Should the secret, however, be not
thus disclosed, search made by an attendant, whilst
you are taking the first steps to relieve the patient,
ON POISONS. 161
will frequently lead to the discovery of the phial,
the cup, or the paper, which had contained the
poison, and which may still retain sufficient traces
of it for the detection of its nature. In the next
place, attention to the matter vomited will oc-
casionally give you the required information ;
laudanum for example, or other preparations of
opium, will be detected by the smell White arsenic,
if taken in large quantities, will frequently be seen in
small particles amongst the more solid matters first
ejected ; in which case this matter should be thrown
into a basin of clean water, and stirred about, and,
if any white particles of matter speedily subside,
they should be carefully preserved for further ex-
amination. The same observations will apply to
white lead, corrosive sublimate, barytes, and indeed
to any poison that is but little soluble, or that has
been taken in large quantity. Many other poison-
ous substances, as the nightshade berries, mush-
rooms, verdigris, or other preparation of copper ;
oxalic acid, or essential salt of lemons; sugar of
lead, or as it is sometimes called, extract of saturn,
or goulard, the common name for a liquid prepara-
tion of the same sub-acetate of lead ; or barytes, the
white earthy powder now much employed in the
destruction of vermin ; may at once be detected in
the matter thrown up from the stomach.
In all cases of poisoning, endeavour first to as-
certain whether the poison taken is one of those
for which an antidote has been discovered; and
126 ON POISONS.
that you may under such circumstances have im-
mediate recourse to the one that is appropriate,
and to impress this part of the subject more strongly
on the memory, I here place the poisons and anti-
dotes in a tabular form.
Poisons. Antidotes.
Corrosive sublimate White of eggs.
Verdigris White
Oxalic acid -| t Magnesia
or > . , . ; -? or
Salt of lemons. J IChalk.
Sugar of lead
or
Goulard.
Glauber's salts
or
Carbonate of potash
or
Carbonate of soda.'
/"Glauber's salts
Barytes < or
vEpsom salts.
If the antidote is not at hand, endeavour to ex-
cite vomiting immediately, but still procure and
administer the antidote as speedily as possible.
In all other cases of poisoning, that is from sub-
stances for which antidotes have not been discovered,
if sickness and vomiting are present, promote it by
copious draughts of warm liquids, and let these be
of a bland mucilaginous kind, as sugar and water,
barley-water, thin gruel, or linseed-tea ; particularly
where the poison has produced pains in the stomach
and bowels, and bloody evacuations. When the
poison has not produced vomiting, an emetic is the
ON POISONS. 163
first thing to be thought of; and, if the patient is
in a state of stupor or drowsiness, it must be a very
strong one, as four grains of tartar emetic, twenty
grains of white vitriol, two grains of blue vitriol, or
half a dram of ipecacuanha ; if none of these be at
hand, two or three table-spoonfuls of flour of
mustard in a pint of warm water may be given, or
the same quantity of common salt The vomiting
may frequently be expedited by putting the finger
down the throat, or by tickling the back of the
fauces, or root of the tongue with a feather. It
may here be observed that the stomach pump is
applicable in every case of poison taken by the
mouth, except where an antidote is at hand ; and
even in these cases too, if symptoms of recovery do
not satisfactorily show themselves after the adminis-
tration of a reasonable quantity of the appropriate
antidote. It will be your duty, therefore, invari-
ably to send for the nearest surgeon, with instruc-
tions to bring with him this inestimable contrivance,
the use of which and the after-treatment of the
patient will be, of course, confided to his manage-
ment
164 ON FITS, OR SUDDEN SEIZURES, &C.
LETTER VIII.
ON FITS, OR SUDDEN SEIZURES. FAINTING FITS,
CONVULSIVE FITS, HYSTERIC FITS, ST. VITUs's
DANCE, EPILEPTIC FITS, APOPLEXY, PALSY, IN-
SANITY, DELIRIUM TREMENS, ANGINA PECTORIS,
ASTHMA.
MY DEAR SON,
THE term FIT is in common parlance applied to
almost every sudden seizure, either of bodily or
mental ailment ; as a fit of apoplexy and a fit of ague.
I shall, however, not include the latter in the present
group, because it properly belongs to fevers ; and
I shall as in former letters, bring together certain
diseases connected by similarity of symptoms, as
fits of convulsion and St. Vitus's Dance, although
the latter cannot properly be called a fit. We
shall now treat the subject in the order adopted as
the heading of this letter, and you will at once per-
ceive, that it includes a great variety of maladies,
in which your judgment is likely to be called upon
to direct the early treatment, and in which, to do
this promptly and discreetly will often be to save
life.
Syncope or fainting, as the consequence of loss
of blood, has already been spoken of; but fainting
fits are very common under a variety of other cir-
cumstances, and particularly in persons debilitated
ON FITS, OR SUDDEN SEIZURES, &C. 165
by long continued disease or otherwise, when such
persons attempt to make some exertion beyond
their strength. There are many persons, who,
from some slight organic defect, congenital or not,
about the heart or large vessels, are particularly
liable through life to faint or swoon away upon
very trivial occasions of either bodily exertion, or
mental agitation. Others, again, from some pecu-
liar idiosyncracy, independent ef any organic affec-
tion, and often from some mental association, faint
away upon exposure to certain sights, odours, or
sounds, as the sight of blood, the smell of fragrant
flowers, the noise of trumpets or cannon, or the har-
monious sound of a grand orchestra of music.
Fainting is easily distinguishable from other fits.
Its symptoms are paleness of countenance, pulse
and action of the heart very feeble if not altogether
imperceptible, respiration so slight as scarcely to
be perceived, loss of consciousness with absence of
convulsions except in some cases at the moment of
recovery from the swoon. After a longer or
shorter interval, from a minute or two to some hours,
perhaps, with only occasional partial recoveries,
consciousness gradually returns with slight motions
of the lips and eyelids, sighing, more distinct
breathing, and almost always with a general and
copious perspiration.
The treatment consists in placing your patient in
the horizontal posture on a bed, a couch, or on the
floor, in dashing cold water over the face, admitting
166 ON FITS, OR SUDDEN SEIZURES, &C.
cool air, stimulating the nostrils with volatile salts,
burnt feather, or common snuff, and in applying
mustard plasters for a few minutes to the soles of
the feet, or inside of the legs, if the syncope lasts
long, and is not relieved by the other expedients.
As soon as the patient is able to swallow, you may
give a little cold water, either by itself, or having
in it a teaspoonful or two of sal-volatile, or the
same quantity of spirits.
Convulsions frequently occur as symptoms of
other diseases, as of Tetanus, Hydrocephalus, Hy-
drophobia, &c, and they constitute an important
part of others, as of Epilepsy, Convulsive Hysteria,
St. Vitus's dance, &c. but in treating here of con-
vulsive Jits, it is my intention to confine myself to
sudden seizures of spasm, or in other words, of in-
voluntary contraction and relaxation of muscles,
more or less general, not necessarily connected
with other diseases, and differing from epilepsy in
not being followed by stupor, and in not recurring
periodically.
The disease, as thus defined, is almost entirely
confined to infants and young children, and is usu-
ally induced by some irritation either in the gums
from teething, or in the stomach or bowels, from
undigested food, worms, or unhealthy secretions ;
or by irritation of the system generally on the ac-
cession of some important eruptive disease, as scar-
let-fever, measles, or small-pox.
I need not more particularly describe the symp-
ON FITS, OR SUDDEN SEIZURES, &C. 167
toms, as you can never be at a loss in deciding the
presence of a convulsive fit, after having once wit-
nessed it I may, however, apprise you that the
term inward jits is unmeaningly applied by nurses
to all inexplicable cases of infantile distress ; and
that it conveys no precise notion, unless when ap-
plied, as it sometimes is, to those minor and
partial convulsions, in which the involuntary action
of the muscles of thef ace produces a twittering of
the lips and eyelids, and an unnatural distorted ex-
pression of the features of the face ; and then, be
it remembered, it is often the harbinger of more ge-
neral convulsions. Neither will it be necessary for
me to attempt to discriminate between simple
idiopathic convulsive fits, dependent upon the
causes above mentioned, and the convulsions ac-
companying water in the head or other serious
cerebral disorder, as it is only on the emergency of
the sudden seizure that you can with propriety un-
dertake to direct the treatment, and these latter im-
portant cases will, it is hoped, have already been
taken charge of by proper medical attendants, be-
fore convulsions have been added to the catalogue
of other symptoms.
When called to a case of infantile convulsions,
the remedies to be immediately resorted to are
few indeed. The warm bath is the only one, which
can with propriety be recommended in all cases.
When a sufficient quantity of hot water is not at
hand, as soon as a small quantity can be procured,
168 ON FITS, OR SUDDEN SEIZURES, &C.
the child may be wrapt in a blanket wrung out of
this, and covered with another dry blanket, till the
bath is prepared. The heat of the wet blanket
must be somewhat under that which can be borne
by the back of your hand with comfort. When the
bath is ready, immerse the child in it at a tempera-
ture of 98 or 100, and let him remain in it half an
hour, if he does not sooner faint away.
During the preparation and administration of
the bath you will make those inquiries, which may
lead to the discovery of the probable cause of the
attack. If the child has been sick, and if you find
that the food has been improper, either in quantity
or in quality, or if the child is at the breast of a
nurse who is out of health, you may conclude that
the stomach is the seat of irritation ; if the legs of
the child are drawn up, if he has been previously
cross, and still cries in the intervals of the con-
vulsions, and if the bowels be either unusually
costive, or the reverse, with motions of an unnatural
appearance, you may infer that the irritation is in
the bowels. In both these cases you will do well
to order a purgative glyster, which may be given
either before or whilst the child is in the bath. It
may consist of a tea-spoonful of castor-oil, or an
ounce of senna-tea in a tea-cupful of gruel for an
infant under a year old, or, if these be not at hand,
of a tea-spoonful of common salt, and another of
brown sugar in the same quantity of gruel. To a
child between one and two years old, double the
ON FITS, OR SUDDEN SEIZURES, &C. 169
quantity of the above ingredients may be adminis-
tered, and to a child of four or five years three
times the quantity. Soon after the glyster I ad-
vise you to give a dose of calomel and rhubarb ;
but I am far from recommending the frequent repe-
tition of this dose without professional sanction.
One grain of calomel and four of rhubarb may be
given to an infant, double the quantity to a babe a
year or two old, and three or four times this dose
to children above five.
If the age of the patient lead to the suspicion of
teething, you must not fail to examine the mouth,
and should you find the gums hot and swollen, you
should lose no time, but proceed immediately to
lance the gums yourself, if you feel competent, or
else send for the nearest surgeon. An incision with
a lancet through the skin down to the rising tooth,
requires but little skill ; and, after having once or
twice seen it performed by a surgeon, you need not
be afraid to undertake it yourself.
Should the child be of a fat and gross habit,
should the turgescence of the countenance be con-
siderable during the fits, with protruding and per-
haps blood-shot eyes, and should these appearances
not subside in the intervals, general bleeding is de-
sirable. If a medical man be at hand, an ounce or
two of blood should be taken from the jugular vein ;
but if not, and if, from the smallness of the vein
in the arm, or, as very frequently happens in fat
children, from the vein being too deep-seated to bi-
i
170 ON FITS, OR SUDDEN SEIZURES, &C.
discerned, you are unable to adopt a general bleed-
ing, you will do well to apply two, three, or four
leeches to one of the temples. I say to one of the
temples, because I have always found the bleeding
by leeches in children so much more conveniently
managed, when all the leeches are applied to one
spot, and the general effect upon the circulation
is the same. It may be computed that each leech
on an average draws half an ounce of blood, in-
cluding the oozing after the leech has done suck-
ing.
If the convulsions have recurred several times,
and irritation is suspected to be in the bowels,
from five to ten drops of laudanum in a table-
spoonful or two of gruel should be administered by
way of glyster in the first instance, and then the
calomel and rhubarb given by the mouth ; or, if
there be any obstacle or objection to the glyster,
two, three, or four drops of laudanum may be
given with the purgative medicine.
I would further observe that in all cases of con-
vulsions in infants, or young children, if the fits
recur after the warm bath, the purgatives and the
bleeding, anodyne medicines may with propriety
be resorted to.
These are all the directions which I think it ne-
cessary to give for the immediate treatment of con-
vulsive fits in very young children ; and the after
management, with a view to obviate recurrences,
should always be directed by professional men.
ON FITS, OR SUDDEN SEIZURES, &C. 171
When convulsions occur in children more than
three or four years of age, our attention should be
more particularly drawn to the state of the stomach
and bowels. They are frequently the immediate
consequence of some recent indiscretion, either in
the quantity or quality of the food, in which case
an emetic ought, of course, to be the first thing ad-
ministered, and then a brisk purgative. If no such
indiscretion has been recently committed, we may
frequently, in such cases, be led to the suspicion of
irritation in the bowels from undigested crudities,
which will be best removed by a full dose of calo-
mel and jalap, four or five grains of the former
with ten or twelve grains of the jalap.
A word or two may not be misplaced here as to
the best mode of administering these drugs to chil-
dren of this age, as it is often a matter of some
difficulty to do it, either by force or persuasion.
The calomel, either alone or with a little sugar,
may be given between two thin slices of bread and
butter without detection, and the jalap will be alto-
gether disguised, given in a little coffee sweetened
with brown sugar.
Should our inquiries lead to the suspicion of
worms as a source of irritation, the appropriate
remedies, hereafter to be spoken of, must be had
recourse to.
It has before been stated that convulsions occa-
sionally usher in the eruptive diseases, as scarlet
fever, measles, and small-pox. This must be more
1 2
172 ON FITS, OR SUDDEN SEIZURES, &C.
particularly had in view with patients of the age
we are now contemplating, and when such diseases
are prevailing. Under such a suspicion an emetic
may be first given, and then a purgative.
When a young woman is suddenly seized with
convulsions, particularly if induced by terror, not
an uncommon occurrence, you may consider the
case as one of convulsive hysteria. And when
adults of either sex are attacked with convulsions,
attended with foaming at the mouth, and succeeded
by stupor, particularly if they are subject to such
attacks, you may consider the disease as epilepsy;
which diseases will be treated next in order.
HYSTERIA, anglice Hysterics, is described by
medical authors as a very Proteus, imitative of al-
most every other disease in the nosology. Very
learned physicians have written histories of its
imitative powers, and have attempted to describe
its anomalous varieties; and celebrated surgeons
have of late gone so far as to speak and write
about hysteric knees, and hysteric breasts. It
does not require much sagacity to foretel, that all
this will, in a few years, be deemed arrant non-
sense ; and to have thus huddled together an
immense variety of distinct disorders, under the
title of Hysteria, will be deemed, and truly so, a
proof of ignorance. What these learned and cele-
brated gentlemen have written on this subject will
then, in the estimation of some, detract from the
high renown they have so deservedly attained by
ON FITS, OR SUDDEN SEIZURES, &C. 173
their general discernment and practical improve-
ments. I would, however, rather say, that to have
drawn distinctions between certain neuralgic or
certain inflammatory diseases for instance, and
those at present anomalous disorders which resem-
ble them in many points, but not in all, was neces-
sarily the first step towards giving a decided cha-
racter and appropriate place in nosology to the
latter ; and that to have made a proper diagnosis
between the destructive disease in the joints, long
known by the appellation of white swelling, and
the equally painful and sometimes swollen state of
the same structures, lately designated (erroneously
I will allow) hysterics, will deserve to be considered
the first important step towards understanding the
true nature, and attaining to the proper treatment
of this latter disease, which will, I apprehend, soon
receive an appropriate name and suitable place in
our nosology, as distinct from hysteria properly so
called, as from white swelling.
True however it is, that the symptoms of hysteria
are various ; indeed the hysteric fits of scarcely two
patients are precisely alike ; one shrieks, another
sings and dances, a third is continually in partial
swoons, and a fourth laughs and talks nonsense : at
least these are the prominent symptoms in parti-
cular cases.
I shall, therefore, in this little work, adapted
only for unprofessional readers, do no more than de-
scribe the symptoms, and give the treatment of
174 ON FITS, OR SUDDEN SEIZURES, &C.
hysteric fits as they most frequently occur, and
these I shall divide into simple and convulsive.
I have before stated that these fits occur almost
exclusively in young females ; when therefore you
are called to such a person, and find her in a half-
conscious state, but unable to control her actions,
throwing herself about unmeaningly into all sorts
of attitudes, sobbing, sighing, choking with the
sensation of a ball in the throat, laughing and
crying in turns; at one moment quiet, appa-
rently unconscious, and approaching to syncope,
and then suddenly starting upon her legs, or
screaming as with sudden pain, or bursting into
laughter, you may make up your mind to its being
a case of simple hysterics ; you may dismiss all fear
as to its result, and proceed to treat it in the ordi-
nary way, by dashing water plentifully in the face
of the patient, speaking to her sharply, but not in
real anger; for though the stern manner of a
stranger or superior may enable her to control
her actions in some degree, and thus to shorten
the fit, it is incorrect to suppose that a female,
in the paroxysms of such a fit, can by a volun-
tary exertion shake off the symptoms; though I
will admit that if she be subject to such attacks,
she may sometimes prevent their occurrence when
forewarned of their approach.
The only other remedial means to be had re-
course to during the paroxysm, are the application
of volatile and fetid odours to the nostrils, as of
ON FITS, OR SUDDEN SEIZURES, &C. 175
burnt feathers, hartshorn, or the volatile spirits of
assafetida, and the giving to drink a little cold
water, or hartshorn, or sal volatile in water. It is
advisable too, where it can be safely done, to leave
the patient on the floor, or on the bed, apparently
neglected or unattended to; for there is usually
consciousness enough to be aware of this circum-
stance, and there will often be much more dispo-
sition to shake off the symptoms, if not violent,
when the friends display this indifference.
The exciting causes of hysteric fits are chiefly
the various affections of the mind, as fear, terror,
pleasing excitements, sudden joy, anxiety, or dis-
tress of mind. And the proper preventive treat-
ment consequently is the regulation of the mind,
and avoidance of the above mental affections in
their excess.
Convulsive hysterics are much more alarming
in appearance, a source of greater suffering to the
patient, and of greater distress to her friends. The
fit sometimes comes on suddenly, and the first at-
tack is frequently the effect of sudden fright ; some-
times the fit is preceded by a fixed local pain in the
side, in the head, or one of the extremities, and a
person already the subject of such fits may be
thrown into a paroxysm by any sudden affection of
the mind. The convulsions are sometimes partial,
as of an arm or leg, but frequently general, distort-
ing the whole frame, sometimes accompanied with
loud screams, sometimes with incoherent talking,
176 ON FITS, OR SUDDEN SEIZURES, &C.
and at other times with fits of laughter. The convul-
sions are often so strong as to require three or four
stout persons to prevent injury. The distinctive
characters of these fits are, that the patient is occa-
sionally, if not at all times, conscious of what is
said, and knows the persons who are about her :
that the action of the heart is not much disturbed,
the pulse being frequently quite natural : that the
breathing, though occasionally hurried during the
convulsions, is in other respects perfectly natural,
and, in the intervals of the convulsive paroxysms,
altogether natural ; and that the pupil of the eye is
not permanently dilated, or remarkably contracted.
The treatment may be the same as in simple hy-
sterics, with the addition of mustard plasters to the
feet or ankles, the administration of an assafetida
glyster, and, if the convulsions are strong and last-
ing, a general bleeding from the arm, provided, I
should add, the patient is strong and healthy.
Whoever has once witnessed the strange gesti-
culations and involuntary motions of a person labour-
ing under CHOREA, or ST. VITUS'S DANCE, can never
afterwards be at a loss to recognise the disease. The
patient is usually a boy or a girl, of from five to
fifteen years of age. The disease comes on gra-
dually ; it shows itself at first by occasional jerks
or involuntary motions of an arm or of a leg, and by
occasional slight distortions of the muscles of the
face. In a few days or weeks it is observed that
the child walks unsteadily, that his gait is awkward,
ON FITS, OR SUDDEN SEIZURES, &C. 177
that, in advancing, one leg almost crosses the other,
and that one or both arms are at the same time
tossed about irregularly and involuntarily. In a
majority of cases these irregular muscular contrac-
tions occur only in the limbs of one side, or at least
most prominently on one side of the body ; and the
distortions of the face are either confined to, or
are most remarkable on the same side. As the
disease advances, the little patient has considerable
difficulty in feeding himself, for, in lifting anything
from the table and raising it to his mouth, the
action is irregular, and the motion consequently
not in a straight line ; the spoon or fork misses the
mouth, or the fluid from the cup is spilt, and it is
not till after many vain attempts that the object is
at last attained. These involuntary actions, how-
ever, may, in some cases, be arrested for a short
time by fixing the patient's attention to some inte-
resting object, and they usually cease altogether
during sleep. From the commencement of the
complaint the general health is impaired, and as it
advances the patient grows pale and thin ; the ap-
petite is precarious, or altogether fails ; the temper
becomes fretful, the usual animation disappears,
and the child becomes indifferent to its customary
sports. Should the proper medical treatment not
be adopted, worse consequences may sooner or later
ensue, for patients thus neglected are sometimes
seized with paralysis or epilepsy, and at other times
they sink gradually into a state of idiocy.
i 5
178 ON TITS, OR SUDDEN SEIZURES, &C.
In the early stage of the complaint, however,
great hopes of perfect recovery may be entertained.
Brisk purging is first to be resorted to ; and as
Chorea is sometimes dependent upon, or combined
with irritation in the bowels from the presence of
worms, I generally have recourse to the use of oil of
turpentine, our best worm medicine, with the early
doses of purgatives ; thus I order of the rectified oil
of turpentine, or, as it is sometimes called, spirits
of turpentine, from half an ounce to an ounce, ac-
cording to the age of the little patient, in the same
quantity or a little more of either gruel or water,
early in the morning, the patient being desired to
remain in bed an hour or two afterwards; and
the following morning I give a full dose of calomel
and jalap. If worms are discharged, I repeat both
doses in the same manner after an interval of three
days ; and if no worms are discharged, I repeat
the calomel and jalap only, but persevere in its use
on alternate days for two or three weeks, if the
evacuations do not assume an uniformly healthy
appearance in a shorter period, which is seldom
the case. If there be headache, it will be advisable
to apply leeches to the temples occasionally during
the course of purgative medicines. If the disease
be not entirely subdued, or very materially miti-
gated, by this practice, I now prescribe steel and
bark, and the use of the shower-bath, still, how-
ever, administering a powerful cathartic every third
or fourth day. In cases of such a degree of seve-
ON FITS, OR SUDDEN SEIZURES, &C. 179
rity and duration, it is presumed that regular pro-
fessional aid will have been called in to direct the
details of this course of tonics. Exercise in the
open air, amusing occupations, and cheerful so-
ciety, are important adjuvants ; the diet should be
plain but generous, and an overloaded stomach must
be carefully avoided. This treatment very seldom
fails, but where it does, 1 would suggest to the
medical attendant a continued course of calomel
and rhubarb, in moderate doses, twice a day, with
an occasional full dose, but without the steel and
bark ; the former to be perseveringly persisted in
with the double view of moderate purging, and of
affecting the system with the mercury ; a plan of
treatment which I have known to succeed in very
obstinate cases.
EPILEPSY, or the falling sickness, comes next to
be considered ; and as the sad sufferers under this
affliction in the humbler walks of life are very fre-
quently abandoned to their fate, as regards profes-
sional assistance, your kind offices will frequently
be required, or I should rather say, that your sym-
pathy for their sufferings will frequently excite in
you a strong desire to try the efficacy of remedial
measures. This disease frequently occurs in in-
fancy and early childhood, and when the patient
survives the first attacks, it sometimes becomes ha-
bitual or constitutional through even a long life. The
peculiarities of an epileptic fit are strong general
convulsions, coming on suddenly, sometimes with a
180 ON FITS, OR SUDDEN SEIZURES, &C.
violent scream, always with immediate loss of con-
sciousness ; sometimes, however, preceded by a
momentary warning of either giddiness, local pain,
or slight partial convulsions. The patient usually
foams at the mouth, and the froth is often bloody
from the accidental biting of the tongue or lips,
during the convulsive closing of the teeth. The
eyeballs protrude, and are frightfully distorted ; the
whole countenance is generally turgid and livid.
The convulsions and distortions after a longer or
shorter period subside, consciousness slowly re-
turns, and a state of drowsiness, stupor, and some-
times of sound sleep, succeeds, lasting in a greater
or less degree for many hours.
The epileptic fit may, however, be of every de-
gree of violence, from a momentary loss of con-
sciousness, and the slightest possible convulsions,
and with so sudden a recovery, that the patient
himself is scarcely conscious of its occurrence, to
that appalling degree of universal spasm and dis-
tortion, and temporary annihilation of intellect,
which seems to threaten instant destruction ; and
one such paroxysm may last for hours, or one of
much shorter duration may be quickly succeeded
by others for many hours together.
As various also may be the permanent effects of
repeated attacks of epilepsy. One patient will retain
through life his wonted brilliancy of intellect and
full corporeal powers, whilst another will gradually
dwindle into idiocy, and premature decrepitude.
ON FITS, OR SUDDEN SEIZURES, &C. 181
The most frightful and alarming attacks of epi-
lepsy occur in childbed, either immediately before
or during delivery, and it is then called puerperal
epilepsy, or puerperal convulsions.
After this short description of a very formidable
disease, we now proceed to the treatment of it.
When called to witness an attack of epilepsy in an
infant or very young child, immerse the patient as
speedily as you can in a warm bath, apply leeches
to the temples, give a brisk purgative of calomel,
rhubarb, and magnesia, and promote its operation
by the immediate administration of a glyster. When
sufficient hot water is not at hand for the purpose
of a bath, wrap the little patient in a blanket wrung
out of hot water.
When the patient is an adult, first loosen the
usual wrappings about the throat, place him in a
situation and position in which his convulsive mo-
tions will inflict the least injury, and endeavour to re-
strain them as far as may be done without violence.
If there is an opportunity of inserting a roll of linen,
or a wedge of soft wood between the teeth, it will
prevent injury to the tongue. Cold water should
be dashed in the face, and cold air admitted freely,
if the room be close and hot. If the patient has
had but few previous fits, you may proceed to
bleed him, and more particularly if any person pre-
sent informs you that on former occasions it has
proved of service. Nothing more than I have now
advised can be done for the patient's immediate
18*2 ON FITS, OR SUDDEN SEIZURES, &C.
relief, and I would here caution you against inter-
fering in any way with the gradual and natural
subsidence of the symptoms, the consequent state
of drowsiness or sleep, and the progressive restora-
tion to consciousness.
If you are requested, as will frequently be the
case, to suggest some preventive plan of treatment,
you must take the particular case into full consi-
deration, and promise to do the best you can ; but
I think it my duty to apprise you, that in old and
confirmed cases of epilepsy, our confidence in me-
dicine is not great, and that the efficacy in vari-
ous drugs, highly extolled by particular authors, is
so uncertain and precarious, that our practice is
more empirical in this than in almost any other
disease. I will, however, give you a few general
directions as to the management of such patients,
and then describe the routine of practice, which I
myself adopt, when confirmed cases come under
my care, assuring you at the same time, that
although I find many cases benefited, and some
ultimately cured, I can never say a priori which of
my remedies is most likely to succeed. We are on
that account not warranted in desisting from me-
dical treatment, until the whole of this or some
such routine has been assiduously worked out.
The diet of an epileptic patient should be plain,
light, and nutritious ; meat in moderation once a
day, but not savoury or high seasoned ; milk, or
milk-porridge night and morning ; no beer, wine,
ON FITS, OR SUDDEN SEIZURES, &C. 183
or spirits. A great deal of moderate exercise in
the open air, with moderately warm clothing, is
desirable; heated and crowded rooms are to be
avoided. The patient should sleep in an airy
room, with his head and shoulders elevated, and
without a night-cap ; and he should daily souse
or well wash his head with cold water in the sum-
mer, and with tepid water in the winter, taking care
to rub it thoroughly dry with a coarse towel; and
he should wear a light cap or hat. He ought also
to pay as much attention to the keeping of his
feet warm, both by day and night, as to keeping of
his head cool.
If an epileptic patient is subject to the headache,
particularly if headache usually precedes a fit, much
advantage may be expected from cupping between
the shoulders, or the application of leeches to the
forehead or temples; and when it has been ob-
served that the fit recurs at stated intervals of two,
three, or four weeks, the patient also being tolerably
robust, such local bleeding is to be resorted to a
few days previous to the expected attack.
In some cases a fit is always preceded, or rather
ushered in, by an unpleasaut or painful sensation in
a distant part, which more or less rapidly rises to
the head : this is termed the epileptic aura ; and
when there is time for the application of a tight
bandage above the seat of this morbid sensation,
the fit has occasionally been thereby prevented.
In other patients, a severe local pain of a more
184 ON FITS, OR SUDDEN SEIZURES, &C.
permanent character, or the spasmodic contraction
of a finger, or the clenching of one fist, or the suc-
cessive closing of the fingers, first of one hand, and
then of the other, precede every attack of epilepsy,
and particularly in cases of a mixed character, par-
taking both of convulsive hysteria and epilepsy.
In such instances, particularly of local pain, 1
have occasionally put off the fit by taking away a
small quantity of blood, (sometimes even an ounee
or two has sufficed,) but I do not advise a frequent
recourse to even this small abstraction of blood, as
the necessity for it seems to increase by its adop-
tion. I once had a case partly under my care,
where severe hysterico-epileptic attacks were
almost invariably preceded by an acute pain under
one breast, and where it was found after some con-
tinuance of the disease, that the opening a vein in
the arm, so effectually and so instantly removed
the pain, and prevented the fit, that the patient,
before consciousness left her, so earnestly entreated
to be bled, that it was seldom resisted, and the
necessity occurring more and more frequently, she
was bled to a few ounces three or four times a
week, until general dropsy was the consequence.
In other cases of a similar character, particu-
larly where successive contractions of the fingers
indicated the approach of a fit, I have often given
a full dose of opium with advantage ; but this prac-
tice, as well as the bleeding, I only recommend as
an occasional means of breaking the chain of symp-
ON FITS, OR SUDDEN SEIZURES, &C. 185
toms, and thus affording an opportunity of pur-
suing uninterruptedly the preventive course of me-
dicine now about to be laid down.
The only medicines which I shall mention
under this head, are spirits of turpentine, lunar
caustic, and ammoniated copper. I might enume-
rate a long list of active medicines equally well
recommended, and each of which has occasionally
succeeded ; but 1 shall confine myself to the above,
as constituting the routine I myself almost invari-
ably adopt in my public practice, and beyond
which, if they all prove unsuccessful, I very seldom
find the patience of the invalid or of his friends at
all willing to persist.
Of those medicines which I have selected, I am
constrained to admit that I cannot a priori in any
particular case give the preference to either, unless,
indeed, I have reason to suspect the presence
of worms ; that is, if the patient, for example, be
under the adult age, have a tumid abdomen, and if
his appetite be irregular and capricious ; in which
case I decidedly prefer the turpentine, and begin
with it in large doses, alternating it with brisk ca-
thartics.
After three or four such doses, or without this
previous treatment, where worms are not suspected,
1 order about twenty drops of the oil of turpentine
in either a mucilaginous mixture, or in simple pep-
permint water, three times a day. If the fits abate
in frequency or violence, I persevere for an inde-
186 ON FITS, OR SUDDEN SEIZURES, &C.
finite period ; but if no benefit be derived from its
use after five or six weeks, I desist, and commence
the use of argentum nitratum, or lunar caustic
made into pills with the crumb of bread, each pill
containing one-eighth of a grain. I begin the
course with one pill three times a day, and after a
few days I increase the dose to two pills, then to
three, and lastly to four pills for a dose. This re-
medy may be persevered in without fear, and
without any particular precaution, for one, two, or
three months ; or as long indeed as it has a decided
influence in mitigating the paroxysms, and length-
ening the intermissions. Should no such bene-
ficial result ensue, I seldom persist in its use more
than a month or six weeks, after which I have re-
course to my third remedy, the ammoniated copper,
cuprum ammoniatum, beginning with half a grain
three times a day : this also is best administered
in the form of pills ; the dose may be increased, and
its use persisted in, according to the rules laid
down for the last medicine.
I shall conclude my description of this empirical
practice with the observation, that when one of
these remedies, having at first displayed evident
good effects, ceases to produce further benefit, I
substitute another for a time, and then return to
the former, and in this way I have sometimes rung
the changes on these three remedies for many
months with decided advantage, and occasionally
cured my patient by means of all of them, when
one would not have accomplished the purpose.
ON FITS, OR SUDDEN SEIZURES, &C. 187
I am now about to treat of another most ap-
palling sudden seizure, or fit, as it is usually called,
which differs from epilepsy, even when this latter
occurs in its severest grade. Unlike epilepsy, it
frequently proves fatal in its first, second, or third
attack, sometimes immediately, at other times after
a few hours. In its ulterior consequences, when
not fatal, it also differs from epilepsy in leaving its
victim greatly shattered either in intellect or in
corporeal powers, or in both. You will readily
understand that I am alluding to APOPLECTIC FITS, or
APOPLEXY. The suddenness of the seizure has also
assigned to it another name, particularly when the
patient survives the first danger, and is left with
corporeal and mental powers much impaired, the
lower class always designating such a sufferer
planet-struck.
A person apparently in good health is seized
suddenly, perhaps in his bed unconsciously whilst
asleep, or he falls suddenly back when sitting in
his chair, not unfrequently whilst at his meals, or
soon after his dinner ; or he falls as suddenly to
the ground, when walking or riding, in a state of
perfect insensibility : if not instantly deprived of
life, which is sometimes the case, he lies motionless
and powerless, with stertorous or noisy breathing,
sometimes with eyes partly closed, but oftener
staring or protruding, and his face and neck livid
and swollen.
This state is distinguishable from epilepsy by
188 ON FITS, OR SUDDEN SEIZURES, &C,
the absence of convulsions and contortions of the
body, by a full and slow state of the pulse, and the
noisy breathing. The patient is insensible to
noises, incapable of motion, and the pupil of the
eye, which is usually much dilated, does not con-
tract when exposed suddenly to a strong light.
The condition of the patient very much resembles
the temporary annihilation of sense and motion in
beastly intoxication, from which indeed it is some-
times very difficult to distinguish it, when informa-
tion on this point is not attainable from his com-
panions. It may, however, here be observed, that
the pulse in a drunken man is often quick, and
never preternaturally slow, and that the smell of
the breath and the nature of the matter brought
off the stomach, for sickness usually attends this
state of intoxication, will often detect the cause of
his insensibility. Let it, however, be remembered
that when intoxication proves fatal, it is often by
inducing apoplexy.
The seizure, as I have now described it, when not
speedily fatal, may still prove so in a few hours or
a few days. In such severe cases it is often ac-
companied with paralysis or loss of power on one
side, or in one limb, with either total loss of speech
or very imperfect articulation, which state of para-
lysis only becomes apparent on the subsidence of
the total insensibility which accompanied the first
seizure.
An apoplectic attack, however, is not always
ON FITS, OR SUDDEN SEIZURES, &C. 189
sudden, and the seizure in its severe form has usu-
ally been preceded by minor attacks, or by well-
marked premonitory symptoms, such as severe
darting pains in the head, giddiness, flashes of light
or sparks before the eyes, somnolency with an un-
usual degree of snoring when asleep, momentary
loss of consciousness, forgetfulness of words, par-
ticularly of names of persons and places, and also
prickling or numbed sensations, cramps, or even
temporary paralysis of a finger, a hand, or an arm.
When such symptoms occur in persons of full
habit, and florid or purplish complexion, with short
neck and a strong bounding pulse, we have the
greatest reason to apprehend sooner or later a for-
midable attack of apoplexy, and particularly so, if
such a person will persist in the indulgence of high
living.
Whether the severe attack of apoplexy above
described has been sudden and unexpected, or has
been preceded by some of the usual warnings, its
graver symptoms having subsided, or been subdued
by vigorous medical treatment, the paralytic state
remains, the speech is imperfect, the temper is be-
come irritable, the memory is impaired, and all the
functions of the mind are more or less affected.
The future improvement in such cases is slow, as
regards both the corporeal and mental lesion, and
the amount of permanent recovery varies in every
possible degree.
I would further observe, that the paralytic symp-
190 ON FITS, OR SUDDEN SEIZURES, &C.
toms sometimes come on suddenly without the ge-
neral apoplectic symptoms ; that is, a person may
awake in the morning unconscious of indisposition,
until he makes the attempt to get out of bed, and
then he finds that he has lost the power of moving
an arm or a leg ; or when he is called in the morn-
ing and attempts to speak, his utterance is imper-
fect, and his mouth is observed to be drawn to one
side. Similar occurrences may arise suddenly in
the day-time, without any or much derangement of
the other functions. Such a case is called a para-
lytic Jit or seizure, or the sufferer is said by the
vulgar to be planet-struck. Professional men, how-
ever, are accustomed to consider all cases of para-
lysis as milder cases of apoplexy : and having made
this observation, I shall proceed to give a brief sum-
mary of the means to be adopted when you are called
to cases either of apoplectic or paralytic seizure ;
for it would be foreign to the object of a work like
the present, either to detail all the variety of symp-
toms, or to dwell upon the minutiae of practice, in
all the innumerable grades of apoplectic and para-
lytic seizures which occur in practice, particularly
as, from their importance and duration, they must,
soon after the first seizure, come under the care of
professional men.
In all graver attacks of apoplexy, whilst the as-
sistants are by your directions raising and support-
ing the head, wiping the froth and saliva from the
mouth, and loosening or removing the coverings of
ON FITS, OR SUDDEN SEIZURES, &C. 191
the neck, you will proceed to examine the head, if
an external injury be suspected ; and you will make
the necessary inquiries as to any preceding de-
bauch, if you have the least suspicion of intoxica-
tion. Satisfied as to the reality of an apoplectic-
seizure, you will without loss of time open a vein
and bleed largely. If, after the abstraction of a
pound or a pound and a half of blood, you perceive
no signs of returning motion and consciousness,
you may, in a stout robust habit, take away double
that quantity. The next step will be to strip and
place your patient in bed, with his head and shoul-
ders considerably elevated, regulating the tempera-
ture of the room and the quantity of bed-coverings
by the season of the year and the external warmth
of the patient's body, so as to preserve a moderate
and genial warmth ; and to avoid an over-heated or
crowded room. If the patient can be made to swal-
low, give him a strong purgative, ten or twelve
grains of calomel with half a drachm of jalap, and
follow it up with a quarter of an ounce of Epsom
salts in a small quantity of water, to be repeated
every hour or two till the bowels begin to be moved.
In two or three hours from the first bleeding, you
are to decide upon the propriety of opening the
vein a second time. If the patient had some return
of consciousness, if the breathing became less noisy,
if he made some attempt at speech or at motion
during the bleeding, or immediately after it, and if
these symptoms of improvement have not pro-
192 ON FITS, OR SUDDEN SEIZURES, &C.
gressed since, and if you now find the pulse slow
and strong, do not hesitate to draw away another
basinful of from a pound and a half to two pounds.
In addition to this bold practice, put a blister be-
tween the shoulders, and mustard poultices to the
inside of the legs, and you may reasonably expec-t
the thanks of the medical practitioner, who ought
in the first instance to have been summoned, and
will in all probability have by this time arrived.
To him you will of course consign the future
medical treatment of the case ; but, in your future
attentions to such patients, you may greatly aid
the views of the surgeon by encouraging the friends
of the patient to persevere in the proposed plan of
treatment, and by enforcing his instructions ; for
the friends and neighbours, who have probably been
very anxious, and very active in adopting the re-
commendations hitherto, will be very apt to relax,
if the patient does not soon show signs of material
amendment, or does not continue to progress in
improvement. With this observation, I now con-
clude my instructions relative to your duties in
sudden and serious apoplectic seizures.
We will now suppose that, in your frequent in-
tercourse with your parishioners, you have observed
in some one of your neighbours some or all of the
following precursory or premonitory symptoms of
apoplexy, severe headaches, or frequent sudden
pains in the head, accompanied with flashes of light
or sparks before the eyes, noises in the ears, and
ON FITS, OR SUDDEN SEIZURES, &C. 193
pulsations or throbbing throughout the head, with
a full and strong pulse at the wrist, momentary
loss of consciousness, great drowsiness, occasional
loss of memory, perhaps a numbness or prickling
sensation in an arm or a leg, or even a temporary
paralysis. These symptoms are most apt to occur
in persons who are more than forty years of age,
are of robust habits, and have flushed or deeply
florid countenances, and, as you well know, in per-
sons of indolent and self-indulgent habits.
In such a case your whole influence will be re-
quired, and will be properly directed, to induce the
patient to abandon such habits, and to adopt in
their stead activity, sobriety, and abstemiousness.
You may also with propriety and advantage recom-
mend one general bleeding ; and afterwards occa-
sional cupping between the shoulders, and a brisk
purge whenever indicated by more than usual
drowsiness or headache, or a recurrence of any of
the other symptoms enumerated above. Total ab-
stinence from fermented liquor, and great modera-
tion in eating, must in general be insisted upon.
These are the broad rules applicable to nine cases
out of ten ; but now and then apoplectic threaten-
ings are apparent in persons of feeble stamina, and
temperate habits, connected perhaps with irregula-
rity in the circulation from altered structure in the
heart or large vessels, or in the vessels of the head
itself, or with great derangement of the digestive
organs, or with some other chronic constitutional
K
194 ON FITS, OR SUDDEN SEIZURES, &C.
ailment. In such complicated cases you will of
course not be left to your own judgment ; but even
here you may fearlessly resort to local bleeding, an
open blister on the neck, and to mild aperient me-
dicines in the necessary absence of professional ad-
vice. Regularity in the daily habits of such a
patient, the prevention of all mental excitement or
alarm, quietude, early hours, moderate exercise,
light employment, plain and moderately nutritious
diet, with cheerful society, are in every way to be
encouraged ; and over all these circumstances it is
to be supposed that you may exercise more con-
trol than the physician or the surgeon.
We will, in the next and last place, make a few
observations on cases of paralysis or palsy of some
standing, in which the patience of the poor sufferer
has been perhaps exhausted by the inefficacy of the
remedies, and where the medical attendant has in
consequence ceased his efforts, and medical treat-
ment and medical management have for a time
been very nearly, if not wholly, abandoned. In
such cases you will do much good by continually
repeating your admonitions, and urging the pro-
priety of persevering efforts on the part of the
patient to move and use the paralytic limb. Even
where frequent attempts at voluntary motion, as
the raising of a paralytic arm, have failed again and
again, I have known at length the power unexpec-
tedly restored, in a very slight degree of course at
first, apparently by the repetition of these efforts of
ON FITS, OR SUDDEN SEIZURES, &C. 195
the will. You will often too find opportunities of
persuading to a continuance of, or a return to, the
use of friction, on which considerable reliance may
he placed if assiduously persevered in. Simple
friction with the hand, or with a ball or roll of
flannel, or with a flesh-brush may be recommended ;
and when the patient or the patient's friends begin
to relax in these efforts, you must use all your in-
fluence and ingenuity to urge them to its continu-
ance by the adoption of stimulants, as warm brine,
essence of mustard, or flour of mustard in warm
water, or decoction of horse-radish root, and va-
rious embrocations, as hartshorn and oil in the
proportion of one to four, tincture of cantharides
and oil in the same proportion, or the linimentum
ammonias of the shops. By judiciously varying
these, and exciting confidence in each for a time,
you may prolong the practice of friction, which is
to be the object of your own confidence ; and re-
member that the plan may be advantageously per-
severed in as long as improvement continues to be
apparent, and do not allow yourself to be discou-
raged by the slowness of the recovery. The fric-
tion should be prescribed to be repeated two or
three times a day for an hour each time. - If you
possess an electrical machine, these are the cases in
which its efficacy should be tried ; and if its use
does not produce headache, or materially increase
the fulness of the pulse, it may be persevered in
for several weeks, the patient being placed on the
K2
196 ON FITS, OR SUDDEN SEIZURES, &C.
insulated stool, and sparks drawn from the affected
part for about a quarter or half an hour daily. The
medicine in which I have most faith in cases of the
description now under consideration, is strichnine,
a preparation from mix vomica ; but as it is a very
active medicine, I advise you never to administer it
but under professional direction, and I only men-
tion it here, that you may suggest it to the surgeon
in attendance. It may be given in pills, beginning
with a quarter of a grain for a dose three times a
day, and gradually increasing the dose to a grain.
Its observable effects are involuntary startings,
jerkings, or slight convulsions in the muscles of
the paralysed limb, and if these do not occur in a
few days, the medicine should not be longer perse-
vered in.
To complete this letter or lecture, call it which
you will, on fits or sudden seizures, I shall make a
few observations on some other disorders which
often come on at first so suddenly, and still oftener
experience so sudden an aggravation of symptoms
in persons liable to the particular disease, as to be
termed Jits ; and which therefore you may be not
unfrequently called upon to witness, before profes-
sional aid can be obtained. Two of these, being
diseases of the brain, come naturally enough to be
considered immediately after apoplexy ; and other
two, which have their seat in the chest, shall be
treated of afterwards.
The first, mania, or madness, is in most cases
ON FITS, OR SUDDEN SEIZURES, &C. 197
an hereditary disease ; the other, called in our No-
sologies, Delirium tremens, is in almost every case
the consequence of excessive indulgence in drink-
ing ; the trivial name of tremens being given to it
from the nervous trembling of the voluntary mus-
cles, which accompanies it, keeping the eyes, hands,
and other parts in constant motion, which, how-
ever, is only a part of that universal agitation and
restlessness which characterises the disorder, and
distinguishes it in a great degree from insanity,
which it otherwise greatly resembles. It is de-
signated by many, very appropriately, Brandy
fever, from its usual exciting cause ; and, from the
violent disturbance of the mental powers, it is at
other times called Brain fever.
A fit of INSANITY in persons predisposed to this
most distressing malady sometimes comes on so
suddenly, and particularly in the night-time, that
the patient, having retired apparently in his
usual health, jumps out of bed in the middle of the
night under some imaginary alarm, disturbs the
family, threatens, and perhaps effects, some se-
rious mischief to himself or others, or seeks refuge
from some imaginary danger, or dwells with horror
on some supposed dreadful risk incurred, or injury
sustained. In such a dilemma, the friend who can
command a firm authoritative manner, and whilst
looking the patient stedfastly in the face, will seize
his arm, and lead him resolutely back to his bed,
need not dread his violence ; neither will he, gene-
198 ON FITS, OR SUDDEN SEIZURES, &C.
rally speaking, experience much difficulty in ac-
complishing his object, and retaining him in safety
till further assistance shall arrive. When the vio-
lent madman once discovers that he is mastered,
whether it be by main force or by a resolute de-
portment, he crouches and submits, moodiness ^uc-
ceeds to violence, he watches every movement of
those about him with suspicion, and, brooding over
his supposed wrongs, he seeks now to effect by
stratagem what before he openly professed to be
his object, and attempted to accomplish by force.
The future management of such a patient, both
moral and medical, is altogether foreign to the pro-
posed object of these letters ; and on the subject of
the immediate medical treatment at the time of a
sudden accession of a fit of insanity such as I
have described, I only deem it necessary to caution
you against the practice of bleeding, which used to
be generally, and is still occasionally, resorted to
by medical men, but which in nine cases out of
ten aggravates the symptoms. I may further ad-
vise you to confine your treatment to personal re-
straint, cold applications to the head, and, if pro-
fessional assistance is not immediately expected, to
the administration of a powerful emetic.
Although the urgent symptoms, as above de-
scribed, frequently burst forth suddenly, and take
the friends of the patient by surprise, yet a watch-
ful and a practised eye will usually discover, some
days or even weeks previous to such an outbreak,
ON FITS, OH SUDDEN SEIZURES, &C. 199
an unusual appearance, an altered manner, and a
change of temper in the patient, which, occurring
in a person hereditarily predisposed to the disease,
ought to induce a great degree of care and watch-
fulness in the friends, even when he has never be-
fore laboured under the disease ; but more particu-
larly so, if he has formerly been so afflicted. And
if the premonitory symptoms, which I am about to
describe for the purpose of putting you on your
iruard, are strong and not evanescent, even per-
sonal restraint becomes a duty before violent symp-
toms burst forth.
These premonitory symptoms are unusual watch-
fulness at night; an acknowledgment that he can-
not command his thoughts, but that strange and
unaccountable fancies present themselves in an in-
controllable manner ; also, that he hears various
noises, particularly of persons talking ; that he can
distinguish their conversation, which is almost
always in reference to himself: all which, however,
he acknowledges in the day-time must have been a
delusion. After a time these delusions are stronger
and more permanent, and at length he stamps upon
some one of them the conviction of reality. His
conduct in the day-time is at first but little altered,
and it is only the very observant who can detect
any difference from its usual tenour. His atten-
tion, however, to his accustomed employments is
less steady ; his eye wanders, his temper is more
irritable, his countenance occasionally gloomy, but
200 ON FITS, OR SUDDEN SEIZURES, &C.
at other times lighted up with more than its accus-
tomed animation. His conversation is at times
remarkable for its flashes of humour, wit, and repar-
tee. After a while he becomes peevish and easily
irascible, and when not thus excited he is gloomy
and suspicious, and at length he displays an entirely
altered character. The serious and sedate man be-
comes gay and hilarious, the steady tradesman
becomes speculative, the timid rider a Nimrod, the
economical man becomes extravagant, the indolent
man active and restless, the good-natured person
tyrannical and suspicious, and the affectionate en-
tertain and cherish dislike and hatred towards the
persons formerly most esteemed, loved, and ad-
mired. A slight inattention from such a one is
styled a gross insult ; offence, taken on very slight
or no grounds at all, becomes deadly hatred ; dire
revenge is brooded over, meditated, contrived, and
sometimes perpetrated at the very first outbreak ;
or if despondency as to his own temporal or eter-
nal state has become the prevailing peculiarity,
suicide attempted, or unhappily effected, gives to
the friends the first conviction of the patient's dis-
ordered state of mind, or at least the first serious
alarm. How important then is it, that the premo-
nitory symptoms should be duly appreciated, care-
fully watched, and promptly treated both morally
and medically ; and how many a melancholy event
may be prevented by a sufficiently early resort to
watchfulness, and perhaps restraint !
ON FITS, OR SUDDEN SEIZURES, &C. 201
In deciding upon a case of insanity, in which
your judgment is very likely to be called upon to
aid in the consultation of friends, always hold this
in remembrance, that it is not so much the parti-
cular incongruous acts, or the particular incoherent
and frivolous expressions, which may be brought
against the patient, as their incongruity and ineo-
herency in regard to, and in relation to, the former
deportment of the individual in question. For
instance, were you to see an active and hardy
sailor climbing up the outside of your church-
steeple, you would not for a moment suspect him
of madness, however you might declaim against his
fool-hardiness ; but if your rector or your church-
warden were seen doing the same thing for no
other professed object than to gain applause for
boldness or agility, it would go far towards esta-
blishing the fact of the insanity of either. I well
remember, many years ago, being the first to pro-
nounce a respectable attorney to be insane, from
the circumstance of his suddenly becoming, and
boasting himself to be, a bon-vivant, and as sud-
denly assuming the character of a fox-hunter,
though I had daily before my eyes another attorney
of the same propensities, whom I knew to be both
sane and shrewd; but the first gentleman had
always been previously a man of sedate habits, and
very observant of all the decorums of society; where-
as he now not only had his dinner-parties more
frequently, but, on Sundays as well as other days,
K5
'202 ON FITS, OR SUDDEN SEIZURES, &C.
his wonted taciturnity was exchanged for incessant
volubility, and his fox-hunting was pursued with-
out judgment or discretion. A few days proved
to all his friends that my prognosis was correct.
Should you receive a hasty summons to one of
your parishioners of acknowledged intemperate
habits, with this addition to the message, to urge
you to immediate attendance, that he is raving mad,
or that he has been wild and delirious and unma-
nageable all night, you may prepare yourself to
find a case, not of madness, but of DELIRIUM TRE-
"\IENS. On your arrival the patient recognises you
with a hasty greeting, answers to your inquiries,
that he is quite well, attempts to rise from his bed,
offers familiarly to shake hands, and talks with vo-
lubility ; but all is done with excessive agitation ;
his hands tremble, his eyes wander restlessly into
every corner of the apartment, his eyelids twitter,
he bites or picks his lips incessantly ; if permitted,
he tries to dress himself, but bungles sadly in his
efforts, mistaking one article of dress for another,
and putting them ridiculously out of place. When
no longer roused by your first appearance and by
your inquiries, but left wholly to himself, he picks
at the bed-clothes, not unconsciously like a patient
in an advanced stage of typhus fever, but like a
person annoyed by something disagreeable, his eyes
following his fingers in hunting for the supposed
objects ; and he perhaps asks the attendant to re-
move the nasty creeping things away from him.
OS FITS, OK SUDDEN SEIZURES, &C. 203
He frequently addresses imaginary persons, or
holds discourse with the devil or his imps, or, his
thoughts running in a more cheerful strain, he in-
sists upon it that merry dancing is going on in his
room, or perhaps some military spectacle. He
talks aloud on these subjects, addresses the parties
supposed to be present, and, if not restrained, he
continually makes efforts to join the gay, or avoid
the hideous creations of his own sensorium. At
other times such a patient will shriek, call aloud
for help, sing and laugh by turns, or he will spit
at, and try to bite, his attendants.
Such an attack or paroxysm as we have nov
described, is most apt to take place in the night ;
or similar disturbance, but in a much slighter de-
gree, may have occurred on two or three successive
nights, before it has attained such a degree of un-
mauageableness, or has continued so far into the
morning, as to induce the friends to call in the aid
of either doctor or neighbours. It is also most apt
to occur a day or two after more than his usual in-
dulgence in spirituous potations.
As regards the treatment in delirium tremens,
I have always found that a soothing, coaxing man-
ner has tended more to tranquillise the patient,
than the stern and resolute deportment recom-
mended in treating of insanity, so much so, that I
have sometimes succeeded in procuring calmness
and even sleep, by holding and stroking the patient's
hand, closing his eyelids with my fingers, and talk-
204 ON FITS, OR SUDDEN SEIZURES, &C.
ing to him as to a restless child, when you are
coaxing it to go to sleep. Restraint, however,
must in many cases be resorted to, when the former
plan fails ; and then the ordinary strait waistcoat
is more lenient, as well as more effectual, than the
forcible manual restraint of three or four persons,
constantly exerted.
The medical treatment, which may be confided
to your judgment upon the emergency, is to apply
cold to the head ; and to administer opium or lau-
danum, first in a very full dose, and afterwards in
repeated smaller doses. The dietetic treatment is
to allow, in regulated quantities, the very stimulus
that has been his bane, and has produced the disease
under which he now labours.
The cold may be applied by a continual renewal
of cloths, or of a thick cotton or woollen night-cap,
soaked in vinegar and water, or in any kind of
spirits and water ; or, if the season affords the op-
portunity, the free application of snow or ice may
be had recourse to.
The first dose of an opiate may be a dram or a
tea-spoonful of laudanum, or three grains of solid
opium ; after which the third or fourth part of this
quantity may be repeated every four hours.
I would further observe, that when frequent
retching or vomiting occurs, which is not unusual,
I find very small doses of calomel, frequently re-
peated, to be the most available medicine, say half
a grain every ten minutes, for three or four sue-
ON* FITS, OR SUDDEN SEIZURES, &C. 205
eessive hours. Under these circumstances too, I
mean when the sickness is urgent, I forbid the
loading of the stomach, even with liquids, and in-
deed I enjoin complete abstinence for many hours.
A single tea-spoonful of brandy may be occasionally
given, with a desire that it be held in the mouth
as long as possible, and allowed to be swallowed
gradually with the saliva ; and the dryness of the
mouth may be relieved by washing it with toast and
water, which is not to be swallowed.
The stimulus to be allowed in ordinary cases,
where vomiting is not an urgent symptom, may be
cold weak punch, or white-wine negus, or simple
brandy and water, or wine and water, or otherwise
a little wine or brandy in gruel or sago, according
to the patient's wishes, regulating the quantity from
one table-spoonful to three of the spirits, or from
one to three glasses of wine, every four hours, ac-
cording to the previous habits of the patient ; re-
membering this, that the more intemperate and
inveterate have been his habits, the more of his
accustomed stimulus will he require.
I need say no more on the treatment of such a
case, whilst it can with any propriety be under
your direction, unless it be to guard you against
the practice of general bleeding, violent purging,
or the administration of an emetic, all of which I
have occasionally known to be had recourse to, and
particularly bleeding, but I must add, never with
advantage, and often with the effect of aggravating
206 ON FITS, OR SUDDEN SEIZURES, &P.
all the symptoms. The application of leeches to
the forehead and temples is less objectionable ; and
when the eyes are suffused with redness, and the
patient complains of pain in the head, I am not
prepared to say that they will not prove ser-
viceable.
The two other diseases, which I proposed to de-
scribe in this letter, are Angina Pectoris, and Asth-
ma; the former coming on in fits of acute pain in the
chest, the latter in paroxysms of oppressed breath-
ing. ANGINA is usually a disease of advanced life,
seldom occurring in persons under fifty ; its attack
is very sudden, and the frequency of its recurrence
very uncertain ; a fit of it comes on with a sensa-
tion of tightness across the chest, which soon
amounts to acute pain in the region of the heart,
striking across to the other side, and generally
down one or both arms. The action of the heart
is much embarrassed, as is indicated by a hurried,
unequal, and intermitting pulse ; the countenance
shows great anxiety and distress, and in severe
cases is bedewed with a cold, clammy sweat. When
the seizure comes on during walking, the patient is
obliged to stop, turns naturally from the wind, if it
be in his face, catches hold of something for sup-
port, and does not venture to advance till the
paroxysm begins to abate. The early attacks
usually come on when the patient is making some
great exertion, as walking against a brisk wind,
particularly up an ascent; or when subjected to
ON FITS, OR SUDDEN SEIZURES, &C. 207
great alarm, or during a paroxysm of rage; and
the severity and duration of a fit in the early stage
of the disease is usually moderate, indeed some-
times only momentary. In its advanced stage,
however, much slighter exciting causes are suffi-
cient to bring on a fit; as stooping to tie a shoe,
crossing a cold passage in the winter season, slight
disturbance of temper, or an overloaded stomach ;
and the fits are both more severe, and of longer
duration.
Mild attacks are usually over before any re-
medial means can be resorted to, and your advice
can only extend to pointing out the ordinary ex-
citing causes with an admonition to avoid them,
and a caution to the patient to adopt very regular
habits, both in diet and in exercise. When the
fit lasts for some minutes, warm brandy and water,
;i wine-glassful of peppermint, water, or a tea-
spoonful of sal-volatile, whichever be at hand, will
often shorten the paroxysm; but such patients
should be constantly provided with a small phial of
ether and laudanum in equal proportions, so much
diluted with water, that one half, or any other given
portion of it, may be an efficient dose, which under
ordinary circumstances may be about thirty drops
of each ; and when former experience has taught
the patient to expect a smart attack, this dose may
be taken at the first moment of his seizure, and
may be repeated, if necessary, an hour afterwards.
In still more protracted cases I can recommend
208 ON FITS, OR SUDDEN SEIZURES, &C.
another remedy, which I have found so decidedly
and almost invariably successful in the frequent at-
tacks, to which a valued friend and patient of mine
has been for some years subjected, that I deem it a
duty to mention it in this place. The remedy is
an emetic. The patient now referred to seldom
passes an interval of a fortnight without a seizure ;
a very slight cause suffices to bring it on, and
indeed it occasionally seizes him without any
assignable exciting cause at all ; the pain at the
heart, across the chest, and down both arms, is in-
tense, a cold clammy perspiration bedews the whole
surface., and the pulse suddenly rises, in frequency
from about 60 to 120, and from being moderately
full and steady it becomes small, irregular, flutter-
ing, and intermitting. This state of things we have
reason to believe, from former experience, would
last for several hours, and when the attacks were
formerly treated with ether and opium, very full
doses were required, and much serious disturbance,
mental as well as corporeal, was the consequence
not only for hours, but for a day or two afterwards.
For a long time past emetics have been substituted ;
and now, when a paroxysm of pain comes on, with
the altered state of the pulse, which uniformly at-
tends it, and which indicates the oppressed state of
the action of the heart, that moment an emetic is
given, and its speedy effect insured by drinking
warm water or weak chamomile tea. Sometimes the
first effectual retching, or act of vomiting is instantly
ON FITS, OR SUDDEN SEIZURES, &C. 209
followed by relief, but oftener this does not take
place till the effort has been repeated ouce or twice;
it however uniformly happens, that after an act of
vomiting, the pain is gone in a moment, the patient
expresses himself quite well, and the pulse, which
was quick, irregular, and fluttering, becomes in
less than a minute slower and firmer, and in two
or three minutes quite natural. This relief is
equally speedy and complete, whether the stomach
were loaded with food or otherwise, so that it is
the violent effort of vomiting that relieves the
overloaded heart, and stimulates it to action.
Neither does it signify much of what the emetic
consists ; at first I was in the habit of giving
mustard and salt as the most expeditious in its
operation, but the patient becoming disgusted with
the quantity necessary to be taken, I have lately
substituted one grain of tartar emetic, and ten of
ipecacuanha, which proves equally effectual, and
is very nearly, if not quite as speedy in its opera-
tion.
ASTHMA is usually a disease of middle age, un-
less it be, as now and then is the case, connected
with, and dependent upon, original malformation
of the heart, or an unnatural conformation of the
chest, in which case it usually makes its first ap-
pearance in childhood. Asthma, whether con-
nected with malformation or not, is a hurried, op-
pressed, and noisy state of the breathing, coming on
in paroxysms, and leaving the patient quite well in
210 ON FITS, OH SUDDEN SEIZURES, &C.
the intervals, in many cases; whilst in others there
may be observed at all times an imperfect state of
respiration, namely, a little thickness or wheezing,
and a more confined dilatation of the chest than
natural in inspiration. An asthmatic attack, or a fit
of asthma as it is called, usually, however, consists
of two, or three, or more aggravated paroxysms of
difficult breathing coming on for as many succes-
sive nights, with alleviation during the day-time,
but not a perfect freedom of respiration till the
expiration of these three or four days, after which
the patient may remain free from another attack
for many weeks or many months.
A peculiar state of atmosphere is a frequent ex-
citing cause of an asthmatic attack; damp foggy
weather will induce it in some, a north-east wind
in others ; some asthmatics are liable to an attack
when spending only a single night in London, or
other large town, whilst some few are more ex-
empt from attacks under these circumstances than
when in the country ; particular odours will excite a
paroxysm in some, and exposure to the dust in cer-
tain manufactories, as feather-dressers, file-makers,
and others, will bring it on in most persons who
are predisposed to it. A single indigestible meal,
and particularly a hearty supper, is another fre-
quent exciting cause ; and such as are habitually
inattentive to the quality and quantity of what
they eat and drink, have the most frequent and
most severe attacks. But the most common ex-
ON FITS, OR SUDDEN SEIZURES, &C. 211
citing causes, after all, are just such as would in-
duce in other persons an ordinary cold, as exposure
to cold or damp in any form. The breathing, when
asthma comes on, is so distressing as to make the
patient sit up in his bed, change his posture again
and again, release himself from bed-clothes, or
anything that is tight across his chest, withdraw
the curtains, or rise and walk about the room, and
seek an open window, or perhaps the open air. The
wheezing is attended with occasional coughing, and
at length the expectoration of some viscid phlegm
greatly relieves the patient, he breathes tolerably
easy for a while, and after a little more coughing
and expectoration the paroxysm ends.
The disease is seldom, if ever, fatal of itself, but
when long continued it often induces other dis-
oases, as local or general dropsy, and thus shortens
life.
The preventive treatment consists in avoiding
all the exciting causes, which have been enume-
rated above, in seeking air and climate that agree
best with the individual, and in taking vigorous ex-
ercise. When a paroxysm is threatening, or has
actually commenced, I recommend an emetic late
in the evening, and small nauseating doses of ipe-
cacuanha, as two grains every four hours, during
the day. Should the asthmatic breathing recur
the same night after the emetic, recourse may be
had to the smoking of stramonium, which almost
deserves the title of specific in asthma : and, at all
212 ON FITS, OR SUDDEN SEIZURES, &C.
events, a pipe of it should be smoked the three or
four following evenings before going to bed, and
again in the night if the asthma comes on. The
stramonium or thorn-apple, grows wild in many
parts of the country, and is easily cultivated in our
gardens ; every part of the plant possesses a nar-
cotic quality, but the leaves, and leaf-stalks, and
stems are the parts usually dried and cut into small
shreds for smoking. One common pipeful is usu-
ally enough to be smoked at once, and caution
should be given that three or four pipes would be
attended with very hurtful if not dangerous re-
sults. This is found to be so valuable a remedy to
asthmatics, that to instruct any poor neighbour who
is so afflicted, both in the growth and in the use of
it, would be doing a very great act of kindness.
Strong coffee during an attack of asthma is always
an agreeable beverage, and has sometimes greatly
relieved the spasmodic breathing. Ether is some-
times useful during a paroxysm, of which a small
tea-spoonful in water is a proper dose ; but I ought
to observe, that I have now and then known this to
aggravate the distress; I have also myself met
with one instance, and other practitioners have ob-
served the same, where the odour and smallest
particle of ipecacuanha taken in with the breath
would bring on an attack of asthma. In some cases
that I have met with in practice, little or no benefit
has accrued from any of the remedies here pro-
posed ; and under such circumstances I once
ON FITS, OR SUDDEN SEIZURES, &C. 213
ordered a lady in her first attack of asthma to he
removed, after three or four days and nights of
oppressed breathing, to a friend's house, twenty
miles further inland, with the happiest result ; the
very first night after the removal being passed in
perfect freedom from the asthma.
In the long intervals between the paroxysms a
tonic plan has been recommended, as small doses
of steel and bark, or a course of chalybeate waters ;
and by others much stress is laid upon the con-
tinued use of small doses of ipecacuanha in vinegar ;
but this part of the treatment must be left to the
judgment of the medical practitioner. Any great
change in the habits and mode of life, as well as in
the locality of the patient's residence, has been
found to lessen, if not to obliterate the disease ;
and I should always recommend to persons of
sedentary employment to adopt, if possible, a more
active mode of life. Where the patient can make
a change of residence too, I would advise as great
a contrast as possible ; thus the fenman should
emigrate to a high country, and vice versa , the
countryman should seek the city, and the citizen
the country ; and a further change of clime by tra-
velling abroad may be reasonably tried as an expe-
riment, where it can be easily effected.
214
LETTER IX.
ON FEVERS CONTINUED, REMITTENT, INTERMIT-
TENT OR AGUES ; NEURALGIA OR NERVOUS PAINS.
MY DEAR SON,
HAVING now taken a review of all such accidents,
and all such sudden seizures of illness, as are likely
to be brought before you in your medico-pastoral
duties, you may at first be disposed to think that I
have completed the object I had in view in writing
these letters ; but there will, as I observed in my
introductory letter, be very many cases of other
diseases so mild, at least in their origin, as not to
be deemed worthy of calling in professional aid for
the treatment of them, but in which you may, if
properly instructed, give useful advice ; there will
also occur many examples of illness of greater im-
portance ignorantly unnoticed, or through ignorance
mismanaged, in which you may be of service. Be-
sides which, in many ailments of a chronic nature
you will frequently find, that, from perhaps a ne-
cessary consideration of the expense, or from some
other cause, medical attendance ceases and medi-
cines are discontinued long before the patient has
perfectly recovered ; here of course your skill and
your medicine-chest may be legitimately made
available for good purposes; and lastly I would
observe, that in most instances of slight deviation
from health, and during convalescence after illness
OX FEVERS. 215
of a more serious character, much advantage may
accrue, or mischief be averted, by your being com-
petent to give judicious advice on the subject of
dietetics.
On all these accounts, and with a view to pre-
pare you for all such occurrences, I deem it meet
to take now a review of many other diseases which
have not been treated of in my former letters ;
only such a cursory review, however, as will afford
me the desired opportunities of making practical
remarks with a bearing to the above observations.
I forewarn you, therefore, not to expect a detailed
account of such diseases, as regards either their
history, a full detail of their symptoms, or the
minutiae of their medical treatment ; and my reader
must not expect to rise from the perusal of the
letters which follow, with such a knowledge of the
diseases noticed in them, as will enable him to dis-
tinguish between acute and sub-acute inflammation
of the various internal organs and tissues between
the different grades of malignancy in epidemic-
fevers, measles, small-pox, cholera, or the like ; or
with such a knowledge of their treatment, as will
enable him to supersede the regular practitioner.
My object will be fully attained if I can make
you comprehend with tolerable accuracy the fol-
lowing particulars : first, when any case of one of
the diseases about to be reviewed is so mild, that
you may venture to prescribe and trust to your
simple remedies ; and when so severe, that it be-
216 ON FEVERS.
comes your duty to urge the patient or his friends
to send for medical aid ; secondly, how to prescribe
with some advantage in the commencement of cer-
tain cases of greater severity, where professional
aid from any cause cannot be had ; thirdly, to know
what remedies may be tried in a variety of chronic
ailments, which would otherwise be wholly neglec-
ted or mismanaged ; and fourthly, by what rules to
regulate the diet, the exercise, and the clothing of
various invalids and convalescents.
The present letter will be devoted to the consi-
deration of FEVERS.
In common parlance we say that a person is
feverish or has fever, when the skin is hot and his
pulse quick, not transiently as after exercise, but
permanently for one, or two, or more hours succes-
sively. The concomitant symptoms are usually a
sense of general uneasiness and fatigue, headache
and watchfulness, a foul tongue, with thirst and
loss of appetite. These symptoms are usually pre-
ceded or ushered in with general or partial rigors
or chilliness, or a complete shaking fit; and they
are very frequently, though by no means uniformly,
succeeded by perspiration, which produces abate-
ment of heat, headache, thirst, and quickness of
pulse.
This succession of stages, namely the cold, hot,
and sweating stage, constitutes a paroxysm of fever.
When such a paroxysm invades a previously healthy
person, and is not the precursor of local mischief!,
ON FEVERS. 217
we term the fever idiopathic ; but if the patient has
met lately with any severe accident, or has heen
labouring under previous disease, as consumption,
local inflammation, or abscess, or if the paroxysm
of fever is accompanied with, or immediately suc-
ceeded by, local pains and other signs of inflamma-
tion, we call the fever symptomatic.
In cases of idiopathic fever, the symptoms above
enumerated are frequently preceded by a day or
two of slight general indisposition ; and when all
or a considerable portion of the above symptoms
are grouped together, and continue for several days
or weeks with but little of intermission or abate-
ment, and at the same time without much aggrava-
tion of symptoms, they constitute simple fever.
Many cases of such simple fever occur in previ-
ously healthy persons, particularly in the summer
season ; and after a day or two, or perhaps a little
longer period, the fever gradually subsides, and
health is gradually restored.
If the pulse is full, the headache severe and
throbbing, the eyes ferretty, and the heat of skin
intense, the fever is termed inflammatory. Fevers
of this description occur mostly in stout healthy
persons, and are not connected with contagion or
atmospheric influence.
When the urgency of the first symptoms, instead
of subsiding after a few days, is observed to in-
crease, when the pulse becomes more rapid, and at
the same time small and feeble, when the skin is
L
218 ON FEVERS.
dry and of a biting heat, the tongue parched, and
perhaps thickly coated, or perhaps intensely red,
with or without a list or streak of darker hue in
the centre or on either side of its centre, with dark
sordes or dry mucus about the teeth, when the
senses are more perturbed and low delirium comes
on, and the prostration or loss of strength is great,
we denominate the fever typhus.
The simple, the inflammatory, and typhus fevers,
thus slightly sketched, are called continued fevers,
from there being a certain degree of persistency in
their symptoms through the progress of the dis-
ease.
But when there are marked intervals of remis-
sion, and recurrences more or less regular of exa-
cerbation, each instance of exacerbation usually
commencing with chilliness, followed by heat and
then perspiration, the patient, however, not. feeling
well or even very greatly relieved, or free from
fever in the intervals, we call such fever remittent.
Again, when the symptoms constituting a pa-
roxysm of fever are succeeded by a return of health,
or at least of freedom from fever, and when after a
certain number of hours or days the paroxysm re-
curs, we pronounce this a case of intermittent
fever or ague, which are synonymous terms ; and,
according to the length of the interval between the
accession of one paroxysm and another, we have
quotidians, tertians, quartans, with certain varieties
of each.
ON FEVERS. 219
I would here observe that remittents and inter-
mittents are the prevailing fevers of our fenny
country, and exceed the number of cases of conti-
nued fever in the proportion perhaps of four to
one; and I would apprise you that these fevers,
with their various consequences immediate and re-
mote, will constitute a considerable portion of your
pastoral practice.*
Before dismissing these introductory remarks, I
would further observe, that the same simple pa-
roxysm of fever may be followed in two or three
days by some specific determination to the skin, in
the form of an eruption, as in small-pox, measles,
and scarlatina, which are therefore called eruptive
fevers. There are also other diseases somewhat
analogous to these, ushered in by a paroxysm of
fever, in which the specific determination is to other
particular textures, as in rheumatic fever to the
tendons of muscles and joints, in cholera to the
mucous membrane of the stomach and small intes-
tines, in dysentery to that of the large intestines,
and in ulcerated sore throat to the mucous mem-
brane of the throat. The same simple paroxysm
of fever is also the usual precursor of acute inflam-
mation, whether of the skin as in erysipelas (St.
Anthony's fire) ; of the cellular membrane, the
fleshy parts, or tendinous expansions, where inflam-
mation often runs high and terminates in extensive
abscess ; or in the attacks of inflammation of any
In the Isle of Ely.
L2
220 ON FEVERS.
important viscus or its investing membrane, com-
prising all the cases of inflammation of the lungs,
heart, stomach, liver, &c. Thus you will perceive
that there is something in the commencement of
almost all acute diseases that is alike, something
analogous in the first general constitutional distur-
bance.
These acute inflammations, however, as well as
the eruptive fevers, and the diseases just mentioned,
will be treated of separately in future letters, and I
shall now enter upon the consideration of those
diseases, which nosologists have in their artificial
systems denominated fevers, and which, as I have
stated before, are divided into continued, remittent,
and intermittent
Congestive fever, a term frequently made use of
by recent authors, not signifying a separate genu?,
but only a variety of any fever, in which local pain
or tenderness or disturbed function indicates a
preternatural determination of blood to, or perhaps
subacute inflammation of, such tissue or organ, need
not be treated of separately.
The symptoms of a simple paroxysm have been
sufficiently, though very briefly, stated in the early
part of this letter. They are in a majority of cases
nearly the same at the commencement of the dis-
ease, whether it shall afterwards in its progress
exhibit the form of continued, remittent, or inter-
mittent, except that all the three stages are most
distinct in an intermittent; that the first or cold
ON FEVERS. 221
stage is frequently only chilliness rather than shi-
vering or shaking, in both remittent and continued
fever, and that the third or sweating stage is often
altogether wanting in continued fever.
As the symptoms are pretty uniform, so also is
the practice, in the beginning of fevers, at least so
far as I need impart the particulars of it for your
guidance ; and therefore what I am now about to
observe, applies to the commencement of all fevers.
It was once a very general practice, and still is
with some physicians, to begin the treatment with
an emetic, but I prefer in most cases the exhibition
of a purgative, as pills of calomel and colocynth
followed by salts and senna, or salts alone. If a
fever is ever cut short by medical treatment, I am
of opinion that this will prove as effectual as the
emetic ; and as it is of consequence to keep the
stomach quiet during the progress of the disease,
and as the effect of an emetic at the commencement
is sometimes to produce, and still more commonly
to keep up, an irritable state of stomach when pre-
sent, 1 prefer, as I said before, the purgative.
It was once a rule too of almost universal appli-
cation, both at the commencement and during the
progress of fever, to give an emetic to a patient
who is vomiting, and a cathartic to a patient
who is griped and purged, with a view, as it was
said, of assisting nature to throw off the offending
matter; and such is still the reasoning amongst
the class of patients to whom you will be called ;
but this is very far from being a good rule, and I
222 ON FEVERS.
advise you under the former circumstances not to
administer an emetic, unless you are satisfied that
the patient has very lately eaten a hearty meal, or
that the sickness came on immediately after eating
something which might reasonably be expected to
disagree ; and I also recommend in the latter case,
that is, where a natural purging accompanies the
first symptoms of fever, that you do not order a
purgative until you have considered, whether it
may not be proper first to allay the pain and irri-
tation in the bowels by means which I shall pre-
sently explain to you.
If you see your patient during the cold stage,
you will never err in ordering him to a warm bed,
and giving him hot diluents, as tea, plain gruel, or
toast and water as hot as he can sip it ; and if there
be no local pain, no cough, and no delirium, you
may add a little wine or spirits. In the hot stage,
when there is usually much thirst, you may allow
your patient to drink freely of water, cold or warm,
as is most agreeable to him, not being afraid of
the former, for it will frequently prove the most ef-
fectual and most speedy means of producing per-
spiration ; and you are constantly to bear this in
mind, that the sooner you bring on the third or
sweating stage, the sooner you give relief to the
patient. During this third stage the drink should
again be warm, and great care should be taken to
prevent a chill.
In continued fever after this first paroxysm, the
skin remains hot, and if there has been perspiration,
ON FEVERS.
which is not always the case, it soon becomes dry
again ; the pulse is quick, and continues so, with
but slight variations, through the whole course of
the disease, or till convalescence commences, a pe-
riod which varies from a few days to several weeks.
If the case does not speedily terminate in convales-
cence, then the tongue, at first clammy and slightly
furred, becomes thickly coated, dry, and parched,
and sometimes assumes other morbid appearances ;
the appetite is soon impaired or altogether fails;
there was at first listlessness and then restlessness
through the day, with watchfulness and perhaps
delirium at night ; this listlessness and inactivity is
now succeeded by prostration of strength, which
gradually increases as the disease goes on ; and a
variety of other symptoms may occur either at the
commencement of the fever, or sooner or later in
its progress ; but as our treatment is almost wholly,
or altogether, adapted to meet particular symptoms,
I shall in the further consideration of the subject,
after giving one or two general directions, refer to
such symptoms as most frequently occur, or de-
mand more particular attention ; and shall blend
the treatment with the description of them without
reference to any particular order ; and I would here
observe, that you may consider the practical direc-
tions as equally applicable to such symptoms,
whether they occur in continued, remittent, or in-
termittent fever, unless the contrary is specially-
stated. I shall afterwards conclude the letter with
224 ON FEVERS.
such observations as I may have to make on the
peculiarities of each type or species of fever.
When the fever commences with the symptoms
of a simple paroxysm as above described, and no
new feature arises in its progress, having given the
strong cathartic as there specified, you next pre-
scribe a simple fever draught every four hours,*
acidulated water, toast and water, or plain water
for drink ; perfect rest and quiet, a cool apartment
and low diet. The cathartic should be repeated in
two or three days if the symptoms have not abated,
and a dose of the aperient mixture at other times,
if the bowels are not sufficiently open.
The preternatural Jieat will be greatly allayed
by the use of cold or tepid water externally applied.
The cold affusion, or pouring of cold water over
the whole surface of the naked body by means of
the shower-bath, a common garden watering pan,
or a large pitcher, may be had recourse to with
great advantage in the early stage of continued
fever, applied at a time when the skin is intensely
hot; and at a later period of the disease, the same
mode of application with warm water may be sub-
stituted, and in still more advanced cases, where
the strength of the patient is much exhausted, ab-
lution with a sponge and tepid water will have the
like good effects, of proving agreeable and refresh-
ing to the patient, and frequently of procuring
perspiration, and consequent reduction both of fe-
* See Appendix, for this and all other prescriptions.
OK FEVERS. 225
verish heat and the frequency of the pulse. The
daily use of ablution in some form ought never to
be omitted in every case of fever, and the more ge-
nerally over the surface the better. In remittents,
however, where there is almost universally a per-
spiration at some period of the day, and a stronger
disposition to chilliness, cold affusion is not appli-
cable, and the time for tepid affusion or simple ab-
lution must be cautiously selected, being only pro-
per when the skin is hot and dry.
If the headache be severe at the commencement
of fever, and be not relieved by the full operation
of the first cathartic, you should apply leeches to
the forehead and temples, from ten to twenty in an
adult, and afterwards keep the head cold with a
towel soaked in vinegar and water. Headache in
the later period of fever accompanied with delirium
and a feeble pulse will more frequently be relieved
by an anodyne given at night, as thirty drops of
laudanum in a fever draught, and a blister between
the shoulders, and the same application of cold to
the head ; but as it requires some nicety of discri-
mination to decide between the leeches and the
laudanum, or whether both may not be requisite,
leave it, where you can, to the judgment of a pro-
fessional man. Another affection of the head, which
frequently occurs as a symptom of protracted fever,
particularly of typhus, is coma or insensibility,
sometimes resembling a calm deep sleep, but
more frequently disturbed sleep, the patient
L5
226 ON FEVERS.
still picking or fumbling about the bed-clothes,
and muttering indistinctly as in low delirium, to
which it commonly succeeds. It is always an
alarming symptom, though sometimes when resem-
bling deep sleep it is the precursor of an amended
state. As to the practice in such cases, little can
or need be done ; blisters should be applied to the
ankles if the coma be very deep, and the patient
should be now and then roused to take, if it be
possible, a little brandy gruel, or a cordial medicine,
as a few grains of carbonate of ammonia in white
wine.
In all such cases of coma or insensibility, as well
as extreme feebleness, the greatest attention to
cleanliness becomes necessary in consequence of
the unconsciousness of the patient to the calls of
nature; nothing short of frequent change of nap-
kins, frequent washing and careful drying, with
occasional change of posture, will in such cases
prevent the most distressing and dangerous bed-
sores. It will require all your powers of persua-
sion to induce the attendants upon the poor to pay
this requisite attention.
When a fever sets in with, or is very soon ac-
companied by, a distressing cough and short breath-
ing, which is often the prevailing character of fevers
in the winter and spring, and particularly so
amongst children, you must bleed without hesita-
tion, and you have only to decide whether it be by
the lancet or by leeches. If your patient be an
ON FEVERS. 227
adult or above childhood, the fever not far advanced,
and the general prostration of strength not great,
use the lancet. In very young children apply
leeches; two, three, or four hi an infant two
months old will produce the good effects of a gene-
ral bleeding. The next remedy in importance in
such cases is antimonium tartarisatum, emetic tar-
tar, the dose and its frequency being to be regu-
lated by the age of the patient and its evident ef-
fects. A quarter of a grain every four hours will
usually produce nausea and occasional sickness,
with a diminution in the frequency of the pulse,
which are the effects to be desired, and which will
almost assuredly be attended with abatement of the
cough and other distressing symptoms. The oc-
currence of vomiting after the first or second such
dose of the antimonial is a common occurrence, of
which the attendant should be apprised, and at the
same time encouraged to persist in its use, with the
assurance that such an effect seldom occurs after-
wards. Half the above dose may be given to an
infant ; but I would here observe that in very young
children this medicine must not be persevered in
so long, nor so uninterruptedly, as in older patients,
but must be omitted as soon as a pallid counte-
nance, cold clammy extremities, and yawning, indi-
cate faintness and exhaustion. A fever with the
above symptoms may be called catarrhal or bron-
chitic fever, and at its commencement may be con-
sidered and treated as bronchitis or inflammation
228 ON FEVERS.
of the air tubes in the lungs ; but you must expect
a continuation of fever of the continued or remit-
tent type, as the case may be, after you have sub-
dued the inflammatory symptoms. And this leads
me to offer a general observation on the treatment
of all fevers accompanied with local inflammation,
that at the commencement of the case your first
bleeding and other means of depletion may be ge-
nerally to the same extent as in simple or uncom-
bined inflammation of the same part, but that you
must be very cautious of a repetition of the same
means. It is almost an invariable rule with me,
where idiopathic fever is well marked, to trust to
leeches for any further loss of blood that may be
required after one general bleeding. But I would
here offer another observation, that in our fenny
country the usual symptomatic fever attending or-
dinary inflammations is very apt to assume a remit-
tent character, and to require a corresponding
change of treatment, to which I shall hereafter
advert.
When a fever sets in with frequent vomiting or
purging, or both, it is termed a bilious fever, and
is mostly of the remittent type. This is the cha-
racter of a great proportion of our autumnal fevers,
and in some years prevails as an epidemic to an
alarming extent. If vomiting, or distressing sick-
ness and retching with little or no vomiting, is the
early attendant of fever, I find nothing so effectual
in relieving this symptom as very small doses of
ON FEVERS. 229
calomel very frequently repeated, as half a grain
either in a minute pill or in powder every ten mi-
nutes for the first hour, and afterwards every half
hour till you have given in all ten or twelve grains.
When diarrhoea or purging is the urgent symp-
tom, either with or without vomiting, if the evacua-
tions be very dark or what are usually denominated
bilious, or, what is almost equally common, if they
be very pale from a deficiency of bile, I adopt the
same treatment as in case of sickness, provided
there be little or no pain ; but if, as is often the
case, griping pains in the stomach or bowels, or
spasm or cramp in other parts, occur with the
vomiting or purging, I add to each of the small
pills one-twelfth of a grain of opium ; or if, in cases
where there is little or no pain, the calomel alone
has not in a few hours subdued the sickness or
purging, I then give the combination of calomel
and opium ; again, if the pains or the cramp are
very intense, I give a full dose of opium at the
commencement of the treatment, a pill with two,
three, or four grains ; or a small or full-sized tea-
spoonful of laudanum, in which case I order the
laudanum to be put into the mouth alone, retained
there some time, and then gradually swallowed with
the saliva ; after which I give the calomel alone or
with the opium as directed above. In all these
cases of sickness I insist upon absolute abstinence
for many hours, only allowing the attendant thirst
to be allayed by rinsing the mouth with water, or
230 ON FEVERS.
toast and water. After the sickness abates, I first
of all allow one table-spoonful of gruel with one
tea-spoonful of brandy in it, to be given at intervals
of an hour, for four or five successive hours ; and
afterwards the same quantity of thin panada with a
tea-spoonful of wine, or else two table-spoonfuls of
beef tea or strong broth every two hours. This
strict attention to the ingesta is necessary for a day
or two, and sometimes longer, to prevent a return
of the sickness.
These directions will suffice for your early ma-
nagement of bilious fever; and as the seizures in
some seasons are very sudden, as well as very nu-
merous, you will do well in such seasons to keep
in readiness a good supply of the small calomel
pills, some with and some without opium.
As the after management of fever cases should
always be committed to professional men, I shall
only further observe as regards these bilious
symptoms, that should they occur in a later stage
of the disease, as they occasionally do, or should
they unexpectedly recur after having been once
subdued, you may, in the absence of the profes-
sional man, safely adopt the practice above recom-
mended.
When a simple diarrhoea or purging accompanies
fever, the evacuations indicating no morbid state of
the bile, the common chalk mixture with or without
a few drops of laudanum will usually allay it ; or if
the skin be at the time dry, six or eight grains of
ON FEVERS. 231
Dover's powder once in twelve or twenty-four hours
may prove more effectual.
When the patient has frequent and urgent calls
to use the night-table, with more or less of smarting
pain attending the efforts, with but very scanty
evacuations, and these consisting principally or
wholly of discoloured slime or mucus, which symp-
toms constitute what professional men call tenes-
mus, small starch injections with a few drops of
laudanum will alleviate the symptom ; but great at-
tention is requisite in such cases to satisfy yourself
that there is not still an accumulation of feculent
matter notwithstanding these very frequent dejec-
tions, and so great discrimination is then necessary
to select the appropriate remedies, that you ought
very unwillingly to undertake the charge. Should
this, however, be sometimes unavoidable, examine
the lower part of the belly, where partial disten-
sion or more general fulness will sometimes con-
vince you of the fact ; make minute inquiries as to
the quantity and quality of the food taken, and,
where you can, examine the evacuations of the
last day or two ; and if you have good reason to
suspect accumulation, give either castor oil or ca-
lomel and rhubarb ; the former if the last foecal
evacuation was natural in colour, the two last com-
bined if the colour was either too pale or morbidly
dark.
Sometimes the frequent slimy or mucus stools
are at the same time bloody, constituting a dysen-
232 ON FEVERS.
leric affection ; here also small starch opiate injec-
tions once or twice daily will alleviate, and calomel
or the grey powder combined with Dover's powder
may be given two or three times daily, and leeches
applied to the fundament will aid in promoting the
cure. The pain, irritation, and frequent purging
having been checked, the same observations apply
here as in mucus diarrhoea, as to the administration
of purgatives.
There is, besides the above peculiarities in the
state of the alvine discharges, another, which is
almost peculiar to the remittent fever, and is in
some seasons a very common and frightful feature
in the epidemic, I mean the discharge of pure blood.
I have often seen a quart thus passed at once, and
frequent repetitions of it afterwards in smaller
quantities for many days, producing syncope or
fainting, and a general pallid or exsanguineous ap-
pearance; and I have more than once witnessed
the death of the patient consequent upon such
copious evacuation of blood, whilst he was still sit-
ting on the night-table. Of the appropriate treat-
ment of this symptom I speak with diffidence, for
although I have seen many such cases recover, and
some even after very copious discharges, I have
seen many others terminate fatally after every
variety of treatment. I am, however, inclined to
prefer the occasional administration of full doses of
calomel, as twelve or more up to twenty grains
once in twelve or twenty-four hours, and the con-
ON FEVERS. 233
tinued use of nitre-muriatic acid with small doses
of laudanum, say five drops of nitric and ten of
muriatic acid with four of laudanum, in a small
tumbler of sweetened water every three hours.
All the variety of symptoms, which we have
hitherto described, occur often in fevers, both of
the continued and remittent type, but very seldom
indeed in genuine intermittents ; and when these,
and the other symptoms formerly grouped toge-
ther under the designation of typhus, occur in cases
of the remittent type, we denominate it typhoid
remittent.
I have formerly alluded to the terms congestive
and congestion as applied to fever, or to the symp-
toms of fever ; and in further pursuing my practical
remarks I now observe, that when there is in the
commencement or progress of fever uneasiness or
dull pain, with tenderness on pressure in the region
of any important viscus, there is said by some
authors to be congestion of that viscus, and the
appropriate treatment is local bleeding and fomen-
tation. Such pain and tenderness at the pit of the
stomach indicates congestion of that organ, and is
usually attended with vomiting and increase of un-
easiness after eating, and with a dry red tongue.
Leeches, fomentation, and a blister, are the exter-
nal remedies ; cold drink, and effervescing draughts,
with a few drops of laudanum, the peculiar internal
treatment. When the pain and tenderness are felt
in the right side below the ribs, with occasional
234 ON FEVERS.
pain between or on the shoulders, the congestion
is in the liver, bilious vomiting or purging are
frequent attendants, the tongue is thickly coated,
usually of a buff or yellowish tinge, the urine high
coloured and loaded, and a yellow tinge sometimes
pervades the skin. The local treatment is the
same as in other congestions, and the internal
remedies are those recommended in bilious fevers,
to which this additional observation may be made,
that full doses of calomel are more called for, and
freer purging will be useful than in a similar type
and degree of fever without hepatic congestion. A
congestive state of the spleen is a very common
attendant upon protracted intermittent, and in ad-
dition to the usual local depletion demands also
full doses of calomel and brisk purging ; and also a
long continuance of alteratives after the intermit-
tent or ague has been cured. It is my custom, on
dismissing dispensary patients of this description,
to give them half-a-dozen or more of five-grain blue
pills, and a sufficient quantity of Epsom salts, with
directions to take one of the pills every fourth night,
and half an ounce of salts the following morning,
and this practice I find more influential in prevent-
ing relapses than a longer continuance of the qui-
nine or other ague medicine. The congestion of
other organs in fevers requires no peculiar treat-
ment that I am aware of, beyond the local bleeding
and fomentation.
The diet during the progress of fever cannot be
ON FEVERS. 235
too simple ; and if the anxiety of the nurse does
not lead her to urge the patient beyond his inclina-
tion, there is little fear of its being carried beyond
what is prudent, either in quantity or quality, for
nature very kindly takes away the appetite when
the powers of digestion fail, and when eating would
consequently disorder the stomach, and aggravate
the fever. The patient's desire for cold water or other
cooling drink may be indulged ad libitum, except
in cases of sickness. A little plain gruel or milk-
porridge, with now and then a little weak broth, a
cup of tea or coffee with a little sopped toast, bis-
cuit, or plain cake, when wished for by the patient,
and a moderate quantity of ripe fruit, furnish a bill
of fare amply sufficient for every case of fever,
until convalescence has commenced, unless in veiy
severe cases where the prostration of strength is
great, and the quantity that can be taken is very
small, in which cases strong broth, or arrow-root,
with a little wine or brandy, or the yolk of an egg,
either in a cup of tea or in a little milk, or in wine
and water, may be administered, a table-spoonful
at a time ; but even in such cases more mischief is
to be apprehended by over-stimulating than under-
stimulating.
When convalescence is established, very great
care is required not to overload or over-stimulate
the stomach. Light food and in small quantities
must be your constant theme ; and no wine or even
beer is to be granted to the incessant applications
236 ON FEVERS.
of your poorer patients and their friends, unless
you find a little stimulus necessary to promote
digestion, when they commence eating solid animal
food. Warm clothing in the winter season, and
avoidance of cold draughts of air, during conva-
lescence, are matters of great moment, particularly
where cough has been a leading symptom during
the illness ; and your precautionary admonitions
to patients, on first being able to leave the house,
after remittent fever in particular, must be urgent
and incessant, that they do not expose themselves
to a cold north-east wind, which is a most fruitful
source of relapse. It is a very common, indeed
almost constant practice, to give tonics or strength-
ening medicines to patients recovering from typhus
or continued fever; and in what is called genteel
practice, this is with some propriety persevered in
during convalescence, first, because the temptation
amongst such patients to take improper articles
of diet, and too great a variety, is much greater
than amongst the poor, and therefore this artificial
stimulus is useful ; and, secondly, because it is a
means of protracting the watchful attendance of
a medical eye, to guard against and obviate such
irregularities, and many other little errors, into
which such convalescents are apt to fall. But as
regards the medical treatment of convalescents,
such as will fall within the scope of your practice,
tonics, stimulants, and stomachics, may all be dis-
pensed with as soon as a return of appetite leads
ON FEVERS. 237
them to resume their ordinary diet, or enables
them to take with zest a basin of broth or milk
porridge, or, what is a great favourite with them,
onion gruel.
An alterative aperient, as a blue pill at night
followed by a Seidlitz draught the following morn-
ing, may now and then be required ; but seldom, if
ever, will there be occasion for other medicine,
after even the severest attacks of continued fever.
What I have here said by no means applies, how-
ever, to convalescents after remittent and intermit-
tent fevers ; and this leads me now to make some
important observations on the peculiarities of these,
our fenny and marshy endemics, with which I pro-
mised to conclude this letter.
The characteristic of remittent, as I have before
observed, is an evident remission, and a marked
recurrence of fever, taking place once, or more
frequently twice, daily. This recurrence, or rather
increase of fever, usually commences with chilli-
ness, which is often only observable in the lower
extremities, is sometimes so partial as to be dis-
tinctly felt only on the inside of the legs or of the
thighs, and is occasionally confined to a cold, and
at the same time a benumbed sensation over the
back of the head, or along one of the extremities ;
the most common periods for its recurrence 1 have
observed to be about one or two o'clock in the
morning, and again at the same hours in the after-
noon. The increased heat which succeeds the
238 ON T FEVERS.
chilliness, is attended with greater quickness of the
pulse, more thirst, and an augmentation or return
of any accidental prominent symptom of the parti-
cular case, whether it be cough, diarrhoea, delirium,
or any other symptom. A return of perspiration
at the conclusion of each paroxysm is perhaps the
most uniform and most observable of any of the
symptoms; but it affords in a majority of cases
very little immediate relief to the patient's feelings
of indisposition. The remission, however, which
presently succeeds, varies in every possible degree,
being sometimes scarcely observable, and conse-
quently leaving the practitioner in doubt, whether to
denominate it a case of remittent or continued
fever. Again, the remission is frequently so nearly
complete, as to make the case assimilate itself to
intermittent ; and very often you will meet with
cases, where the exacerbation is so well marked on
alternate days, as to resemble strongly the tertian
ague ; but still, the fever being never altogether
absent, such cases must be considered remittents
with a tertian type.
Here it may not be amiss to observe, that in our
marshy country it is never an uncommon occur-
rence, and that in some seasons, when ague and
remittent fever prevail more than usually, it is
almost a constant occurrence, that the symptomatic
fever attendant upon any other disease, whether an
ordinary inflammation of lungs, liver, peritonaeum,
or other part, or the hectic fever of consumption,
ON FEVERS. 239
&c., should iii its progress assume a remittent cha-
racter, and particularly so in cases where repeated
bleedings have been called for. The appropriate
practice in such cases is a matter of the greatest
nicety, and requires greater discrimination and
judgment than I can hope to communicate to my
unprofessional readers ; but I may observe gene-
rally, that the patient's health will seldom be re-
stored without recourse to small and repeated doses
of quinine or arsenic.
You must also be prepared to meet with remit-
tent fever of every grade as to severity ; and of
greater latitude as to duration, than typhus or other
continued fever. I have often at the same time
had one patient in the same family lying prostrate
on his bed in extreme danger, and another creep-
ing about the house, and perhaps attending to his
ordinary avocations, with a foul tongue, disordered
secretions, feverish heat, quickened pulse, and all
the other symptoms of mild remittent. As to du-
ration, one patient is sometimes either dead or
quite well in three or four days, and another lin-
gers under the disease with decided paroxysms, or
with only indistinct exacerbations, for many weeks
or even months ; and in such cases of chronic
remittent you are never safe from a sudden aggra-
vation of all the symptoms. Besides which, there
is a strong disposition in these fevers to relapse
after a promising and even long-continued conva-
lescence. It is by no means an uncommon occur-
240 ON FEVERS.
rence for a patient to be under the influence of
remittent fever, with hut few and short intervals
of health, for one or even two years, and then
to shake off all his varied morbid symptoms of
this Proteus of the fens, and enjoy his wonted
vigorous health and buoyant spirits.
The practice in remittent fever varies, as you
may naturally suppose, as much as the symptoms ;
requiring more of the same management as typhus
or other continued fever, as it approaches to it in
character ; and being to be treated more or less
with the appropriate remedies of ague, as it ap-
proximates to intermittent. I may, however, ob-
serve, that in remittents of every grade, depletion,
either by general or local bleeding, is borne worse
than in continued fever; a single venesection at
the commencement, if not peremptorily called for
by local congestion, insuring a tedious protracted
case. Moderate mercurial purgatives, and alte-
rative doses of the same, are more frequently
required, and a decided mercurial influence on
the system is in many protracted cases the most
certain means of bringing about a favourable
change. The most important consideration, how-
ever, in the treatment is to know when and how to
administer the preparations of bark and arsenic,
remedies which, in intermittents, constitute our
sheet-anchors, and in remittents, when well timed,
cut short what would otherwise prove protracted
cases, and often suddenly arrest the progress of
ON FEVERS. 241
fever, and unexpectedly restore health, where, a few
hours before, alarming symptoms even threatened
the patient's life. Nothing but long experience
and accurate observation can give to the practi-
tioner a decided judgment upon this matter, and
you must therefore never presume to decide upon
this point in severe cases, but abide the judgment
of your professional neighbour; and I lay some
stress upon the word neighbour, for the most expe-
rienced physician from an upland district, where
continued fever prevails, would prove a tyro in the
treatment of our fen-remittent. I must, however,
endeavour to give some general rules for your
guidance in the less severe, and in the well-de-
fined cases, where these remedies are called for.
The more complete the remission of fever, and
the more distinctly marked the accession of a fresh
paroxysm, the more certainly may you expect ad-
vantage from quinine or arsenic ; but a still stronger
guide, I would observe, is the degree of regularity in
the time of the returns of such paroxysms. Again,
the appearance of the tongue affords an important
guide. When it is thickly coated, as is usually the
case at the commencement of remittent, you must
not venture upon these remedies ; but should the
brisk calomel cathartic, which is here indicated,
after a first or second dose, have the effect of break-
ing this crust, and of partially dislodging it, you
may immediately throw in a full dose or two of qui-
nine without waiting for the perfectly clean tongue,
M
242 ON FEVERS.
which may, perhaps, never take place, as the suc-
ceeding paroxysm will frequently produce a new
film over those parts, which were so recently be-
coming clean, and the opportunity of administering
the quinine be for ever lost. With a dry, parched,
or deep-red tongue, quinine is inadmissible in full
doses with a view of influencing the progress of the
fever ; though it may, in advanced cases, with such
a tongue, be sometimes serviceable in small doses,
as a stimulant or cordial, and with a view to support
the failing strength.
A still more important guide in the administra-
tion of the remedies now under consideration is
the state of the alvine excretions ; when these are
unnatural, the appropriate remedies must be stea-
dily persevered in according to the directions given
in a former part of this letter, and the use of qui-
nine be suspended until an evident improvement
in their appearance has been effected, unless in-
deed decided remissions occur, giving a character to
the case nearly approaching to that of an intermit-
tent, under which circumstance one full dose of
quinine may be thrown in during each intermis-
sion, but frequently repeated doses must be ab-
stained from.
The proper doses of quinine, and the precise
times for administering them, are a matter of some
moment, though it is one upon which, at present,
there is considerable discrepancy of opinion amongst
medical men in the treatment of remittent fever,
ON FEVERS. 243
as well as of ague. When the remission is incom-
plete, and of short duration, and the febrile heat
during the exacerbation great, if the state of the
secretions, the appearance of the tongue, or regu-
larity in the periods of exacerbation, authorise the
administration of quinine at all, I prefer a full dose,
say four grains once in each intermission, and about
an hour before the expected chilliness ; but I desist
after two or three doses, if the succeeding pa-
roxysm is at all augmented in severity, or if it is
not either postponed or mitigated in some degree.
If the remission is more complete, and of longer
duration, I prefer giving two doses, of two grains
each, at an interval of one, two, or three hours, in
each intermission, with saline or antimonial febri-
fuges during the paroxysms. In more chronic
cases, where the symptoms of fever are milder, and
the intermissions not well defined, I administer
single grain doses of quinine with a simple febri-
fuge every four hours, giving a strict injunction to
omit the dose of quinine, if at any time the heat
of skin is considerable. I am not a friend to the
eight, ten, or twelve grain doses under any circum-
stances in remittent fever, and have scarcely ever
been driven to the necessity of having recourse to
such large doses in intermittents.
Since the discovery of this excellent preparation
of bark, of which I have been speaking, I am very
little in the habit of employing either the bark in
substance, or any other preparation of it. And as
M 2
244 ON FEVERS.
to Fowler's solution of arsenic, upon which I used
formerly principally to rely for the cure of ague,
and which formerly I prescribed in remittent under
similar circumstances, and with nearly the same
restrictions, which I have noticed above as neces-
sary to be observed in the administration of qui-
nine, I now very rarely give it, except with a view
to economy. If, however, in remittent I entertain
some doubts as to the propriety of giving quinine,
or have reason to believe that it has aggravated
the feverish symptoms, I do make trial of the solu-
tion of arsenic in doses of six or eight drops either
in water or in the fever medicine, but I must ac-
knowledge that I seldom find it to answer a good
purpose, where quinine has failed. In long-pro-
tracted cases of remittent, where the liver is plainly
in fault, I have not unfrequently pushed the use of
mercury so far as to affect the mouth, and with the
happiest effects ; but to judge under what circum-
stances this practice should be resorted to implies
more professional acumen than I can suppose you
to possess, or than I can hope to communicate to
you by any plain and simple directions.
I now proceed to treat more particularly of the
cure of ague., and as I have observed above, that a
variety of extraneous symptoms, such as diarrhoea,
cough, delirium, &c., may accompany the paroxysms
of ague, as well as remittent and typhus fever, I
must now further observe that when they do arise,
they are to be treated in the same way. In briefly
ON FEVERS. 245
communicating to you my experience, and my plan
of treatment in simple ague, and its multifarious
consequences, I would not have you suppose, that
I consider it in any respect novel, or in any degree
preferable to the plan of other practitioners ; but it
is usual for every one, who has numerous cases
continually occurring, to adopt a certain routine of
practice, subject of course to various modifications
under particular circumstances, and the routine,
which I usually observe, I now submit for your
guidance. When ague in either a quotidian, ter-
tian, or quartan form takes place for a first time, or
after an interval of years, in a tolerably healthy
subject, I content myself with giving a full dose of
calomel and colocynth with salts after the first
paroxysm ; and if the tongue becomes cleaner, and
particularly if an eruption comes out about the
mouth, and if the second paroxysm is less severe
than the first, I still satisfy myself with giving an-
other but smaller dose of calomel and colocynth,
or, perhaps, a milder mercurial purgative, as a blue
pill with colocynth and a dose of seidlitz, knowing,
as I do from experience, that a spontaneous cure
under such circumstances frequently takes place
after one or two paroxysms ; particularly if it be a
tertian ague, and in the spring season. Should a
third fit of ague succeed, however, I commence
with the appropriate remedies ; or if the patient
has previously had ague at no long interval of
time, I do not wait for even a second paroxysm.
246 ON FEVERS.
As to the appropriate remedies for ague, amongst
the vast number, popular and professional, of which
each has its advocates, I may here observe, that
sulphate of quinine stands pre-eminent, and that,
since the fortunate discovery of this preparation,
the bark in substance and all other preparations
from it are nearly discarded. When this expensive
chemical drug is not attainable, as will usually be
the case in gratuitous practice, Fowler's solution of
arsenic, or, as it is commonly called, the tasteless
ague drops, affords the best, and indeed a very ex-
cellent substitute ; or to meet the necessity of eco-
nomical views without altogether abandoning the
superior advantages of quinine, you may follow the
plan, which I usually adopt in my dispensary prac-
tice, and commence the cure with quinine, trusting
to the efficacy of arsenic for preventing the recur-
rence of the ague, after the paroxysm has been
once interrupted ; or in other cases you may alter-
nate the use of these two drugs. Of other reme-
dies I shall say but little ; and shall dismiss the
subject of popular nostrums with these brief obser-
vations ; that such as operate on the imagination,
viz. the wearing of amulets, the swallowing of spi-
ders, and the like, so frequently fail, that it is, to
say the least, risking the loss of valuable time ;
and that such as succeed by making strong impres-
sion upon the nervous system, are frequently so
rude or so powerful, as to risk the safety of the
patient by superinducing some more dangerous
ON FEVERS. 247
disease ; of which description are the sudden plung-
ing of the patient into a river or a pond, or the
daily large dose of pepper in ardent spirits.
In quotidian, or daily ague, then, give two grains
of quinine, either in a pill or with a few drops
(three or four) of diluted sulphuric acid in water
every morning early, and eight or ten drops of the
solution of arsenic either in water, or in an infusion
of quassia (a cheap and useful vehicle, where for any
reason you may wish to medicate the dose,) three
times a day. If after two days the ague still re-
turns, double the daily dose of quinine ; and should
this fail, which will seldom be the case, attend with
greater minuteness to the state of the secretions,
and if the motions are unnatural, combine with the
above treatment the alterative plan of giving a blue
pill, or two grains of calomel, every night, and a
seidlitz draught every morning. In a few cases
you will have occasion to increase the morning
dose of quinine to six, eight, or ten grains, and now
and then you will meet with an obstinate casej
which resists even this dose, when recourse must
be had to the varied use of other ague remedies,
which will be enumerated presently.
In tertian ague, in which the paroxysm returns
on alternate days, and which is by far the most
frequent form, having given one or two calomel
purges as described above, begin with two grains
of quinine three times a day ; and, as soon as de-
cided impression has been made, give only one
'248 ON FEVERS.
dose of quinine, and two or three of arsenic daily,
paying proper attention to the excretions, and
treating any deviation from their natural appear-
ance according to rules already laid down. Indeed in
all old standing cases you will do well to give a blue
pill on alternate nights and a seidlitz next morn-
ing during the whole treatment both before and
after the cessation of the ague fits ; and indeed I
would here, as I have in [a former part of this
letter, again observe, that in discharging old or
long-protracted cases, it is almost an invariable
rule with me to furnish them with several such
doses, and to impress upon them the importance
of continuing their use once or twice a week for
about a month after leaving off the quinine or
arsenic ; being well assured, as I am, that relapses
are the frequent consequence of disordered hepatic
or alvine secretions, though the immediate exciting
cause may be an improper meal, an exposure to
wet and cold, or a single over-potation ; and being
also convinced that an opportune dose of the above
alterative has frequently obviated such a result.
Should the above doses of our appropriate re-
medies however fail, double the dose of quinine,
and add two or three more drops to each dose of
arsenic. Should you still not succeed, try the
efficacy of one very large dose of the former re-
medy, say twelve, sixteen, or even twenty grains, a
few hours before the expected paroxysm ; and in
case of this failing, try the efficacy of a pill con-
ON FEVERS. 249
taining two or three grains of opium, and four of
James's powder, to be taken three or four hours
before the expected fit. Should this opiate succeed
in preventing the paroxysm, it need not be re-
peated; but should it only postpone or mitigate
its severity, repeat the pill on the approach of an-
other paroxysm ; the same observation applies also
to the repetition of the very large dose of quinine.
In all these cases the intermediate smaller doses
of either quinine or arsenic, or both, are to be per-
severed in.
In quartan ague, where the paroxysm returns
on each third day properly speaking, or after in-
tervals of seventy-two hours, and which you will
generally find to resist the above remedies more
frequently than the other forms of ague, you will,
nevertheless, adopt the same plan of treatment at
the commencement, resorting to the very large dose
of quinine, or opium, sooner ; and indeed from the
first, if you are undertaking a case of long stand-
ing. In quartan too you must pay early and mi-
nute attention to the secretions, and examine your
patient with a view to other sequelae or conse-
quences of ague, which I shall proceed to notice
immediately after the enumeration, which I am
now about to give, of a few other remedies, to
which I occasionally resort when quinine and
arsenical solution fail me. Opium I have already
mentioned, and have stated that two or three grains
may be given on the approach of the cold stage.
M 5
250 ON FEVERS.
A pretty powerful emetic, as two grains of emetic
tartar with twelve grains of ipecacuanha, may, in
other cases, be given about an hour before the
expected fit, and may be repeated two or three
times under the same circumstances, unless it
should have wholly suspended the paroxysm the
first time. Bleeding in the cold fit has been re-
commended, and I have known it to succeed in
one or two obstinate cases ; but I do not advise its
adoption, except where visceral congestion is
evinced by the occurrence of fulness, pain, and
tenderness on pressure, particularly during the
paroxysm, in the region of the stomach, spleen, or
liver. Small doses of white vitriol, three grains
every four hours, or a pill containing a quarter of a
grain of ammoniated copper, three times a day,
or a quarter of a grain of blue vitriol in a pill three
times a day, may either of them be tried, or each
in succession, where the common remedies have
failed. In some obstinate cases, which have long
resisted the ordinary treatment, and where the
yellow tinge displays disease of the liver, or where
a peculiar lead-colour of countenance denotes dis-
ease of the spleen, I have succeeded by persisting
in a regular course of mercury, till the mouth be-
came sore, and then giving some one of the usual
ague medicines. When it can be effected, a change
of air or removal from the fens to a higher and drier
country will expedite and almost insure recovery.
The sequelae or consequences of intermittents, to
ON FEVERS. 251
which I have adverted, and which are very apt to
succeed to long-protracted remittents also, are first
structural as well as functional derangement of se-
veral of the viscera ; and secondly, a morbid state
of some portion of the nervous system, producing
a vast variety of neuralgic affections, as intermit-
tent face-ache, brow ague, intermittent sciatica,
and other acute local pains.
Of the visceral diseases, enlargement of the
spleen is perhaps the most common, constituting
the large hard tumor in the left side of the body,
vulgarly called ague-cake. I have seen it most
frequently in children ; it requires a frequent re-
petition of brisk calomel purges, in conjunction
with the appropriate ague medicine, if ague still ac-
companies this morbid state ; or a course of steel
medicine, if the ague has been subdued ; six grains
of calomel made into pills, with colocynth, followed
by an ounce of salts, may be given to an adult every
third morning ; and, after two or three such doses,
a tea-spoonful of the rust of iron should be taken
three times a day in a little thick gruel on the in-
termediate days.
Chronic disease of the liver is perhaps the most
common sequela, both of remittent and ague, in
adults. It is discoverable by occasional pains, and
tenderness on pressure, by fulness, and sometimes
by permanent hardness and irregularity over the
region of the liver, the greater portion of which
lies on the right side of the pit of the stomach,
252 ON FEVERS.
close under the ribs. The attendant symptoms
are a yellow tinge of the skin, particularly about the
temples and the eyes, high-coloured urine, and
variable discoloration of foeces, which are in some
cases very pale clay-coloured, in others muddy-
brown, in others deep green, and in others again,
of a deep brown like tar, or even black ; besides
which the tongue is foul, the appetite precarious,
and vomiting not unfrequent. For this state of
hepatic derangement, a continued course of mer-
curial medicines is necessary, and my usual formula
is one grain of blue pill, with four of extract of
dandelion, taken with a mixture containing in each
dose four grains of soda and four of rhubarb, in
infusion of quassia, with a little syrup of ginger, or
with a few grains of ginger in powder. This dose
is to be repeated three times a day, and persevered
in for several weeks, giving occasionally a mode-
rate calomel cathartic with a full dose of rhubarb,
say four grains of the former and half a drachm of the
latter. When the stomach is irritable, the mixture
may be taken in a state of effervescence by increas-
ing the dose of carbonate of soda to a scruple, and
adding at the moment of taking it a table-spoonful
of lemon juice, or a scruple of tartaric acid previ-
ously dissolved in water; or the minute doses of
calomel, recommended in bilious remittent may
occasionally be resorted to in such cases of irritable
stomach, if the matter vomited be morbid bile.
When there is much tenderness over the liver, the
ON FEVERS. 253
application of leeches to the part is indispensable,
and may be required to be repeated occasionally
during the treatment. The same ought also to
have been observed in the treatment of painful en-
largement of the spleen. With all our care and
attention, however, this state of the liver is fre-
quently not to be cured, particularly in persons
above the middle age, and in those who have led
intemperate lives, and in whom, therefore, this
chronic disease in all probability commenced previ-
ous to any attack of ague.
And here I will make a more general observa-
tion, which is equally applicable to every species
of fever ; that whatever organ or function of the
body is at the time, or has been previously, the
seat of morbid derangement, or may be said to be
habitually subject to disorder, will be sure to be
particularly disturbed during the progress of fever.
Thus vomiting in the dyspeptic, bilious symptoms
in the intemperate, high delirium in such as have
formerly laboured under delirium tremens, or in
those hereditarily predisposed to insanity, rheuma-
tic pains in rheumatic subjects, inordinate action
of the heart, where there is structural disease of that
organ, diarrhoea or purging in some, and dysentery
in others, as they may have been previously af-
fected, will constitute important or leading features
in their present attack of fever. These should
always be the subject of inquiry, with a view both
of regulating our practice, and of aiding us in
254 ON FEVERS.
estimating the danger of the case ; as, generally
speaking, where such predisposition can be de-
tected, there is less harm to be apprehended, than
when such symptoms are the genuine offspring of
the fever.
The disorders of the nervous system, attended
with severe local pain, and therefore called neu-
ralgia, next claim our attention. They are fre-
quently concomitants as well as the sequelae both
of remittent fevers and of agues; and very fre-
quently they constitute the disease itself, in which
case they are by some denominated masked ague.
The brow ague, which is an intense pain over one
or both eyes, is not an unfrequent occurrence in
ague districts. The attacks of pain occur at pretty
regular intervals, as a tertian, or quotidian, or a
double tertian, or double quotidian ; the paroxysm
is sometimes ushered in by yawning, aud a sense of
either local or general chilliness, which is some-
times succeeded by feverish heat, but more fre-
quently by the paroxysm of pain only. Instead of
the brow, one cheek, or one side of the face, or one
side of the whole head, may be the seat of the pain,
and at other times, the pain is confined to the eye-
ball, in which case the vessels of the eye are some-
times turgid with red blood, and the case is called
intermittent ophthalmia.
These neuralgic diseases greatly resemble tic
douloureux in their varied seat, and in the severity
of the pain, but differ from it in their recurrence at
ON FEVERS. 255
regular intervals, in not being easily, if at all, ex-
citable at other times by a slight motion, a slight
touch, or by the accidental action of a neighbouring
muscle, as is the case in tic douloureux ; and it
differs also, very fortunately, in being much more
under the control of medicine.
Sciatica is perhaps always a neuralgic affection,
though most authors consider it a species of rheu-
matism ; in its more chronic form, however, it is
certainly to be treated as neuralgic; its seat is
the large sciatic nerve, running down the back of
the thigh, and calf of the leg to the instep. Neu-
ralgia, sometimes, has its seat in the viscera; thus
I have seen neuralgia of the heart, lungs, liver,
bowels, uterus, and ovaries, simulating in these in-
stances a variety of important, diseases, and only to
be distinguished from them by the periodicity of
the returns of pain, and almost complete cessation
of soreness and tenderness, as well as of pain, be-
tween the paroxysms.
The pain and tenderness of the part affected
have frequently induced the medical practitioner
to bleed at the arm in such cases, but never, I be-
lieve, with advantage, and often with the effect of
protracting the disease; the same may be said even of
local bleeding, whether by cupping or by leeches.
The only successful practice is to give the same
medicine as in ague, with the addition of anodynes.
If the stomach is disordered, I begin with an
emetic : if the secretions are unhealthy, I commence
256 ON FEVERS.
with one or two doses of calomel and colocynth,
and in some cases I have recourse to both ; and
my first trial of the appropriate neuralgic medicine
is usually a combination of quinine, with the ex-
tract of hemlock, two grains of the former with
three or four of the latter, every three hours. If
the recurrence of pain is not mitigated in the course
of the first day or two, I conjoin the use of opium
and calomel, by giving two or three, or even four
grains of each on the approach of every paroxysm,
and the quinine and hemlock in the intervals.
After three or four days, if the improvement is not
considerable, I resort to the free use of the sub-
carbonate of iron, or prepared rust of iron, instead
of the quinine and hemlock. I have seen the most
decided benefit from this medicine, particularly in
neuralgia of the face, and of the sciatic nerve. The
dose is a small tea-spoonful of the powder in a
little thick gruel, or honey, or treacle, if sweets be
preferred; and this is to be repeated every three
or four hours, and may be persevered in for several
successive days, giving a moderate cathartic occa-
sionally, if the bowels are costive. The solution of
arsenic stands third in the class of antineuralgic
medicines with me, and then any of the other ague
remedies which have been before enumerated.
Warm anodyne fomentations, and stimulating or
anodyne plasters, are the external remedies, of
which I have had most experience; and I have
seen some cases decidedly benefited by acupunc-
ON FEVERS. 257
turation. The fomentation should be a strong de-
coction of poppy heads and chamomile flowers ; the
stimulating plaster may be the emplastrum cale-
faciens of the shop ; and the emplastrum bella-
donna is the best anodyne plaster. But I must
not omit to mention the use of an ointment made
of two grains of a new and powerful drug, called
veratria, to a drachm of hog's lard, which I have
lately used with great benefit in a variety of neu-
ralgic cases. One-third of this ointment is to be
well rubbed in over the part affected, night and
morning, or on the approach of the pain, for two or
three successive days. Of the use of the needles I
must make this unsatisfactory acknowledgment,
that J have never been able to say, a priori, whether
their use would prove beneficial or not ; but I can
attest in their favour, that I have often been sur-
prised at their efficacy. I therefore recommend
you, in every obstinate case, to suggest to the sur-
geon the trial of this unaccountable but sometimes
surprisingly successful remedy.
There is another state of the system consequent
upon a protracted case, either of remittent fever or
ague, to which I must advert before entirely leav-
ing the subject. This is a peculiar state of inva-
lidism, with very variable symptoms, usually mild,
but particularly prone to be aggravated by very
slight exciting causes, and occasionally running
into decided remittent or intermittent, and thus
constituting relapse after relapse, of greater or less
258 ON FEVERS.
violence. These variable symptoms are sometimes
of the nervous class, as an irritable state of temper,
despondency of mind, wandering pains, tingling, or
even a benumbed sensation in an arm or leg,
partial cold and clammy perspiration of the hands,
the knees, the inside of the thighs, or of the face
only, with a momentary shivering, produced by the
slightest draught of cold air, or a more complete
rigour by a blast from the north-east. In other pa-
tients, the variable symptoms arise from temporary
functional disturbance, produced from very trifling
causes, as sickness, diarrhoea, heartburn, palpitation,
and disturbed sleep, with more or less of chilliness
succeeded by increased heat, and either partial or
general dampness or perspiration, with a sense of
syncope or faintness, and a great apprehension of
not doing well.
This state of things, notwithstanding the strictest
attention to diet, clothing, and exercise, and the
promptest treatment of even minute deviations
from health in the various secretions, will some-
times continue for one, two, or three years, and
then terminate in a perfect restoration of health.
I have, however, only seen this protracted inva-
lidism which in my dispensary reports I denomi-
nate, for want of a more appropriate term, chronic
remittent, where the patient has continued to reside
in an aguish district, or has remained exposed to
the same source of malaria which induced the
original attack ; and nothing effects so certain, so
ON FEVERS. 259
sudden, and so permanent a recovery, as change
of air, by which I mean a lengthened removal to
what we fen-men call the high country. This
change of residence is almost a " sine qua non," and
I never venture to promise my patients a recovery
without it. The improvement is often so sudden,
that the patient is sensible of it the very first night
after leaving home, and in two or three days his
appetite is no longer capricious ; he eats heartily,
digests well, sleeps undisturbed, loses his disposi-
tion to clammy perspirations, and begins to increase
in strength, and to recover his long lost buoyancy
of spirit, and elasticity of mind. The duration of
his residence in a congenial air must in most cases
be regulated by private considerations ; and as, in a
majority of cases, the physician is required to say
how short a banishment from home and its impor-
tant avocations will suffice, I can only make these
general observations, that a fortnight will do much
good, but will not secure him from a relapse soon
after his return, particularly in the winter and
spring season ; that a month will suffice in summer,
and six weeks in winter, in a majority of cases ;
and further, that one absence of this duration is
more effectual than the same, or even somewhat
longer period, divided into two absences, with a
short intervening residence at home.
As circumstances frequently make even this
short absence from home impracticable, I must
not omit to give a few general instructions for the
260 ERUPTIVE FEVERS, &C.
management of such protracted cases of indisposi-
tion. Warm clothing, careful avoidance of exposure
to cold, particularly in damp weather, and during
the prevalence of north or north-east winds, regular
exercise without much fatigue, plain but generous
diet, with an additional glass of sound beer or por-
ter, or port wine, according to the circumstances
and previous habits of the patient, cheerful com-
pany, recreation, and amusement, all tend greatly
to prevent an aggravation of symptoms, and to
promote recovery. The medical treatment must, of
course, vary with the symptoms, and be regulated
by their degree of severity ; but this must always
be held in view, that a blue pill and seidlitz draught
will be required once or twice a week, to maintain
a healthy state of the secretions ; and that this with
mild tonics, as grain doses of quinine, or a few
drops of diluted sulphuric acid, or of steel drops in
water, twice or thrice a day, for a week or ten days
at a time, at longer or shorter intervals, will ordi-
narily prove the most efficacious treatment.
LETTER X.
ERUPTIVE FEVERS AND CHRONIC ERUPTIONS.
OF those specific fevers which are attended with
an eruption on the skin, I shall first speak of SCAR-
ERUPTIVE FEVERS, &C. 261
LATINA, or SCARLET FEVER ; and be it here observed,
that these terms are synonymous, and that scarla-
tina is not, as many imagine, the diminutive of
scarlet fever, designating a milder disease. The
term specific, as used in this place, means a fever
arising from a contagion sui generis, producing only
a disease of like kind. The symptoms of scarlet
fever are those of an ordinary paroxysm of fever ;
usually attended with, or very speedily succeeded
by, sore throat, and on the second or third day, by
scarlet efflorescence, first in patches about the
elbows, then on the bosom, and in a few hours over
the whole or greater part of the surface of the body.
The paroxysm of fever usually occurs between the
end of the first and beginning of the third day after
exposure to the contagion, but sometimes a little
later. The matter of this contagion would appear
to be both very subtle, and very permanent, or
lasting; for I have known instances of children
taking the disease on coming into contact with
others, who had the disease many weeks previously;
or immediately upon taking possession of apart-
ments, where scarlet fever patients had resided
many months before; notwithstanding the use of
the warm bath, and the substitution of fresh clothes
in the former cases; and the careful adoption of
airing, painting, and white-washing in the latter
cases.
Persons of all ages who have not had the disease
are liable to it, and it is a very rare circumstance
262 ERUPTIVE FEVERS, &C.
for the same person to have it a second time.
Upon this subject, however, I have an observation
to offer, which may enable you to explain many
apparent contradictions to this law. I have said
above, that a sore throat as well as an efflorescence
on the skin, is a usual attendant of scarlet fever :
now it is not uncommon for persons exposed to the
infection to have one of these symptoms, and not
the other, in which case such persons so frequently
have a second attack of the disease, that I do not
pronounce a patient safe from a future attack, who
has not both the eruption and the sore throat.
The peculiar sore throat of scarlet fever, too, may
occur frequently in the same person, and I know
some, who have long ago had the genuine disease,
so subject to ulcerated throat, that an attendance
upon a scarlet fever patient always induces an at-
tack. These secondary attacks of sore throat are
frequently ushered in by a very smart paroxysm of
fever, but never prove fatal, nor the fever severe
after the first few hours; but such attacks fre-
quently give rise to the opinion that these persons
have had more than one attack of scarlet fever.
Scarlet fever, like every other infectious disease,
has its seasons of prevalence, and also its localities,
being very general throughout the kingdom in some
years, and at other times very prevalent in certain
places, whilst many other districts are wholly ex-
empt from it. Populous cities are seldom if ever
without a few cases, and thus is the contagious
ERUPTIVE FEVERS, &C. 263
matter kept afloat, to be freely disseminated under
certain unknown atmospheric influences favourable
to its propagation ; though I am not prepared to
maintain that this, or any other contagion, never
now arises spontaneously, that is, either from the
same undiscovered combination of circumstances,
or from the same almighty creative fiat which may
have first called each specific contagion into ex-
istence.
Scarlet fever is sometimes ushered in with a
convulsive fit, and the first paroxysm of fever is
frequently attended with vomiting, particularly in
children ; the pulse is more rapid in this than in
any other fever, being frequently in young children
150 or 160 in the minute, and sometimes so quick
as not to be accurately measured ; the tongue is
peculiarly red in most cases, or the bright red
papillae are seen standing out prominent from a
cream-coloured crust; the whole lining membrane
of the mouth, fauces and throat, as far as it is dis-
cernible, is in severe cases at first bright red, and
then deep purple, with numerous aphthae or small
ulcers, covered with tenacious ash-coloured crusts,
similar to what in children are called by nurses the
thrush, and also with one or more large and deep
foul ulcers at the back of the throat ; the inflam-
mation and ulceration often extend over the mucous
membrane lining the nostrils, producing a distres-
sing and very disagreeable discharge from the nose ;
often, too, it extends to the back of the throat, by
264 ERUPTIVE FEVERS, &C.
a duct called the eustachian tube, to the delicate
structure of the ear, producing ear-ache, abscess,
and discharge of matter from the external ear,
always with temporary, and not unfrequently with
permanent deafness. When the inflammation ex-
tends in another direction, and affects the glottis,
or commencement of the windpipe, it produces the
peculiar breathing, and other symptoms of croup ;
and I have a perfect recollection of this epidemic
once prevailing, particularly in the neighbourhood
where you now reside, in which many children
vith severe scarlet fever died of this croupy af-
fection.
The eruption is not always an efflorescence only,
for sometimes a numerous crop of minute vesicles
accompanies the diffused redness, producing a
roughness over the surface. The rash, in some
mild cases, is scarcely discernible, and in many
others is so evanescent as to require frequent ex-
aminations to detect it ; you will in such cases be
most likely to discover it in the evening, or at
night, at which time there is most fever. After
three or four days the rash fades away, and the
cuticle or scarf skin gradually desquamates or peels
off; and, in very severe cases, the nails also fall off
wholly, or in part.
This fever may be of every degree of intensity,
and, like every other epidemic, varies in this re-
spect in different visitations. In the year 1803 it
prevailed greatly, proved very fatal, and in some
ERUPTIVE FEVERS, &C. 265
few cases which I saw, the patient died on the se-
cond day of the disease. At other times, I have
known it pass through a family without being de-
tected but by the desquamation of the cuticle, or
until some one case, severer than the others, ar-
rested the attention.
The treatment of mild cases consists simply in
confining the patient to a light diet, and giving mild
aperient saline medicines. In severer cases you
must meet the prominent symptoms with a similar
treatment to that recommended in other fevers
already described. The great heat of skin will be
essentially relieved by cold affusion or cold spong-
ing in the early stage, and by warm sponging in
the latter stages. The delirium will require leech-
ing, and, if it occur early in the disease, in a robust
person, and when the prevailing epidemic has not
proved remarkable for its typhoid character, one
general bleeding may be ventured upon ; but an
opiate, as I stated in treating of other fevers, will
more effectually relieve the delirium in severe and
advanced cases, particularly when accompanied
with a parched tongue, brown sordes about the
teeth, and great prostration of strength. Calomel
cathartics will be required in every case, where
there is not a natural diarrhoea ; and gargles must
be freely used, where the throat is much affected ;
a dram of muriatic acid in half a pint of water
makes a good gargle ; and the popular one, made
of sage-tea vinegar and port wine, is nowise ob~
N
266 ERUPTIVE FEVERS, &C.
jectionable. When children cannot be made to
gargle, I always insist upon the use of a syringe,
and you will be doing an essential service by en-
forcing this point, and instructing the attendant
practically how to use the syringe. One holding
half an ounce is the proper size, made either of
pewter or bone ; it should be inserted well over
the tongue, squirted out smartly, and repeated three
or four times a day, three or four syringefuls being
used each time. In all other respects the treat-
ment may be regulated by the instructions which I
have given in treating of remittents, or of fevers
generally.
There is one remarkable sequela or consequence
of scarlatina, which occurs frequently, and there-
fore deserves particular mention, which is dropsy.
At an uncertain period after convalescence, it may
be some days or some weeks, the eyelids become
swollen, particularly in the morning, the whole face
in another day or two oedematous, that is, pale,
swollen, and pitting or dinting on pressure ; about
the same time the feet and ankles swell towards
night, in another day or two the skin is everywhere
tense, and pressure with the finger, or any ordinary
ligature of the dress, leaves pits and indentations.
This general state of dropsy is called anasarca; it
is often very slight, and easily removed by proper
remedies ; sometimes it is rapid in its progress,
and advances to an alarming and dangerous extent.
I well remember one case of a boy, about twelve
ERUPTIVE FEVERS, &C. 267
years of age, after a severe attack of scarlatina,
crawling into the fields to glean, in a very hot day
during harvest, as thin and emaciated as can well
be conceived, and being brought home in the even-
ing bloated and swollen to such an excess, that his
clothes were all necessarily unbuttoned, his eye-
lids were nearly closed, and his breathing most la
borious; he was unable to lie down, and was
altogether in a state of great danger. The purga-
tive medicines, on which I most rely in this species
of dropsy, were speedily administered, and dili-
gently persevered in, with the happiest result A
tea-spoonful of the following electuary was given
every hour, with the addition of six grains of calo-
mel to the first dose, until the boy had been more
than twenty times to the night-table ; and in the
morning I found him lying on his back, breathing
freely, and the swelling altogether gone. The de-
bility, which remained, was of course exceedingly
great, but the gradual and judicious administration
of a nourishing diet, with bark and steel medicines,
and an occasional cathartic, ultimately restored him
to perfect health. The electuary consisted of a
dram of jalap, half a dram of ginger, and an ounce
of cream of tartar, with as much syrup as to give it
the proper consistence. I have here given an ex-
treme case, both as to rapidity and extent of symp-
toms, and also as to the celerity with which they
were removed. Slighter cases are not uncommon ;
they always demand early attention, and may be
N2
*268 ERUPTIVE FEVERS, &C.
usually cured by the moderate use of the same
remedies; the dose, however, should always be re-
gulated by its effects, four or five watery evacua-
tions daily being required for the cure of even
slight cases. Sometimes the dropsy is not confined
to the cellular substance under the skin, but water
is deposited in the cavities, as the abdomen, the
chest, or the ventricles of the brain, constituting
very dangerous and often fatal disorders, the treat-
ment of which comes not within the scope of my
present plan, and which I therefore dismiss with
this observation, that I have found the same purg-
ing mode of treatment most efficacious in dropsy of
the belly, digitalis in dropsy of the chest, and small
doses of calomel and digitalis in dropsy of the
brain succeeding to scarlet fever.
Another consequence, or rather in many cases
concomitant, of scarlet fever, is glandular swellings
about the neck and throat. These often appear
early in the disease, dependent, no doubt, upon
the ulcerated condition of the mouth and fauces;
sometimes they commence later in the disease, and
in either case are the source of much distress and
inconvenience, long after the fever has subsided,
and the patient become convalescent. These swell-
ings are to be treated in the same way that other
glandular swellings are managed. In the early
stage apply leeches and cold lotion, but as soon as
fluid is perceptible, adopt warm fomentation and
poultices ; and let the matter be evacuated by
ERUPTIVE FEVERS, &C. 269
puncture with a lancet, as soon as ever the tumor
points, or even sooner, if the fluctuation be very
evident.
The second eruptive fever, to which I shall draw
your attention, is the MEASLES. This also very
seldom occurs a second time to the same individual,
and is therefore generally a disease of childhood.
The earliest symptoms are usually a slight chilli-
ness, succeeded by fever, with sneezing and watery
eyes, and then cough, and perhaps a sensation of
roughness and slight soreness of the throat; all
which being also the early symptoms of a severe
cold, we can at its commencement be led to suspect
measles only by the known presence of the specific
contagion, and the known liability of the patient to
receive it. The fever, however, is more perma-
nent than in a common cold, and increases in in-
tensity, except in very mild cases, and on the third
or fourth day an eruption appears in patches, not
unlike that of scarlet fever, except that at first the
patches are smaller, and consist rather of nume-
rous spots than a diffused efflorescence ; and after-
wards, when it assumes more the nature of efflores-
cence, the patches affect somewhat of a serpentine
figure, and only occasionally spread over the whole
surface. This peculiarity in the eruption, with the
presence of the catarrhal symptoms, and absence
of ulceration of the throat, will seldom leave it diffi-
cult, even for a tyro, to hesitate in determining
between measles and scarlet fever. The catarrhal
270 ERUPTIVE FEVERS, &C.
symptoms, as cough, pain in the chest, and hurried
breathing, with the accompanying fever, when they
increase, constitute the danger in most cases of
measles. An aggravated state of these symptoms
is very apt to take place in cold seasons, or from
imprudent exposure to cold and damp in any season,
and particularly in children predisposed to con-
sumption, or other chest disease. Measles, as has
been observed of other epidemics, has its seasons
of prevalence, is very often a mild and trivial dis-
ease, and in many other instances, and in particular
seasons, it is formidable, and very fatal.
Besides the danger arising from an aggravation
of the chest-symptoms, as mentioned above, consti-
tuting inflammation of the bronchi or air-cells of the
lungs, and which is by far the most frequent source
of danger, particularly in the winter and spring,
there is in some epidemics, or seasons of prevalence,
a strong disposition in the fever of measles to as-
sume a typhoid character ; this is more particularly
what is meant by the common expression of a bad
sort of measles, and the same applies to scarlet
fever, and also to small-pox, and perhaps to all
other epidemics. On what peculiarity of season
or state of atmosphere this typhoid disposition de-
pends, we cannot fully explain, but it has been ob-
served to occur most frequently in hot autumnal
weather, and after seasons of general dearth. It
sometimes happens, that there is at the same time
a strong disposition to both the inflammatory and
ERUPTIVE FEVERS, &C. 271
typhoid symptoms, and this combination consti-
tutes the most unmanageable and most fatal va-
riety of measles. The eruption, which in ordinary
cases gradually fades away about the fourth day,
and is followed by slight desquamation of the
scarf-skin, either suddenly disappears in these un-
toward cases, or becomes of a dull brown or livid
colour.
The treatment of measles, you will readily con-
ceive, after what has been already said of the dif-
ferent character and intensity of its symptoms,
must of course greatly vary, and that according to
the degree and the preponderance of the inflamma-
tory or typhoid symptoms.
In very mild cases, all that is required is, to
keep the patient in the house for a few days, to
administer mild aperient febrifuge medicines, and to
put them upon a moderately low diet. In cases a
little severer, attended with cough and somewhat
more fever, I order my patients to keep in bed
great part of the day, and not to leave the bed-
room at all ; I endeavour to procure a gentle per-
spiration by warm gruel and weak tea through
the day, and by immersing the legs in warm water
at night, and then giving a dose of James's powder
or other antimonial.
It is common in an ordinary cold, and under
other circumstances, to talk of putting the/ee into
warm water as a piece of medical treatment, and
usually the prescription is literally attended to, a
272 ERUPTIVE FEVERS, &C.
shallow foot-bath being employed, and with so little
water, that literally the feet only can be immersed
in it. I am in the habit of ordering the whole
legs to be immersed in a deep bucket full of water,
as hot as can be comfortably borne, and the pa-
tient's whole body to be enveloped in a blanket,
which at the same time covers the bath or bucket.
The effect of such an immersion for ten minutes
is usually to bring on a general and pretty profuse
perspiration, and thus to answer in many cases the
full effect of a general warm-bath.
When the severity of the cough and an accom-
panying pain in any part of the chest, with hurried
breathing and quick pulse, indicate inflammation,
one general bleeding, or abundant leeching, must
immediately be had recourse to, according to the
age and constitution of the patient, and antimonials
in full doses, namely, a quarter of a grain of emetic
tartar every four hours to an adult, with all the
other remedies for bronchitis, must be vigorously
employed.
When, however, great prostration of strength,
muttering delirium, brown sordes about the teeth,
a dry tongue, and a sudden retrocession or livid
appearance of the eruption, proclaim a typhoid cha-
racter, the warm-bath, a little warm wine and
water, sal-volatile in the fever medicine, and small
doses of quinine, will be required ; and should these
symptoms be at the same time accompanied with a
distressing cough and hurried breathing, the utmost
ERUPTIVE FEVERS, &C. 273
judgment and greatest attention of the regular
practitioner will be requisite to decide upon the
proper treatment.
We now come to consider the subject of SMALL-
POX, and, before describing the disease, shall make
a few observations on the great preservative from
its worst effects, the vaccine disease, or cow-pox.
Before the fact was made known to the medical
profession and the public at large, that the con-
tagion of small-pox loses its influence over the con-
stitution of persons, who have either accidentally
or purposely been subjected to a disease called the
cow-pox, the former was with reason dreaded as
one of the severest maladies, and its prevalence as
an epidemic one of the most dreadful inflictions, to
which a populous country could at any time be sub-
jected.
Dr. Jenner, by patient inquiry, first satisfied
himself of the truth of a prevailing notion amongst
the dairy farmers of Gloucestershire, that milkers,
who contracted a disease on the hands from the
sore teats of the cows, were exempt from the influ-
ence of small-pox ; and then by original experi-
ments he convinced himself that artificial inocula-
tion with matter from such pustules on the cow's
teat produced a similar pustule on the part inocu-
lated in the human subject, attended with a slight
constitutional disturbance, which together were
productive of the same preventive effect against
small-pox ; and, lastly, by further experiments, he
N5
274 ERUPTIVE FEVERS, &C.
arrived at the conclusion that matter, or rather
lymph, for it is a thin transparent fluid, taken from
the artificial pustule or vesicle thus produced in
man, was equally efficacious as that originally ob-
tained from the cow itself.
Dr. Jenner has, by the publication of this truly
philosophic discovery and investigation, conferred
an invaluable boon on mankind ; and if posterity do
not derive from it all the benefit it is calculated to
afford, the fault will not rest with the immortal
Jenner.
It is a pretty general failing with us, upon all
occasions, to be too sanguine of expected good,
and then too much dejected by the disappointment
necessarily arising from our own exalted expecta-
tions ; and such conduct now threatens to deprive
us of much of the advantage that might otherwise
be derived from vaccination.
The public were no sooner in possession of the
fact, that very many vaccinated patients exposed
afterwards to small-pox infection had really resisted
its influence, than they illogically jumped at the
conclusion, that it would never fail of having such
protecting influence. The medical public, with
the great Jenner himself, partook of this sanguine
expectation, and must bear the blame of having
supported and propagated this hasty and erroneous
conclusion. In the course of a few years, however,
several cases of small-pox occurred after vaccina-
tion ; these were at first referred by the advocates
ERUPTIVE FEVERS, &C. 275
of complete exemption to inattention in the vaccina-
tors, or a want of discrimination between a genuine
and a spurious vaccine pustule, which had this fact
for its basis, that vaccination does sometimes pro-
duce an irritable ulcer, either from constitutional
disturbance, or from accidental injury to the pus-
tule, which does not at all afford the promised
protection. In the progress of a few more
years, however, failures were observed in persons
vaccinated by eminent surgeons, and even by Jenner
himself, where the pustule had been pronounced
genuine, and full protection had been promised :
such cases drove the profession reluctantly to ac-
knowledge, what they ought in the first instance
soberly to have expected, that the protection afford-
ed by vaccination would not prove greater, but
promised to be equally complete with that afforded
by a first attack of small-pox itself, either in the
natural way, or by inoculation. And in support of
this deduction so very many cases of secondary
small-pox were brought forward and well attested,
as to satisfy both the supporters and opponents of
vaccination, that the protection afforded by small-
pox itself is not so complete as had been gene-
rally apprehended before such inquiry was insti-
tuted. It may, however, be still fairly maintained
of small-pox, as also of measles, scarlet fever, and
hooping-cough, that second attacks are only the
exceptions to a general rule.
In the experience afforded us by nearly forty years
276 ERUPTIVE FEVERS, &C.
of extensive vaccination, during which many small-
pox epidemics have prevailed in various districts,
it must be allowed that we have further ascer-
tained that vaccination fails of its full protection
from small-pox more frequently, than natural or
inoculated small-pox fails to protect from a second
attack, though in what proportion we have not the
means of ascertaining; but we have at the same
time obtained satisfactory proofs, that in a vast ma-
jority of the cases of small-pox after vaccination,
the disease is so mitigated as to be a very trivial
ailment ; and further be it observed, there is reason
still to doubt whether severe cases of small-pox
after vaccination are in greater proportion than
severe secondary cases of the disease after the na-
tural or inoculated small-pox.
Such, however, I repeat, is the proneness of man
to be too much depressed by disappointment, as
well as too much elated by promised good, that the
reputation of vaccination is now undeservedly losing
ground with the public at large ; and the practice,
especially in this kingdom, the birth-place of the
discovery, is less general amongst the poor than it
was a few years ago, so that we are now in some dan-
ger of losing the immense benefits of the Jennerian
discovery, which it is calculated to afford, because
it has failed to fulfil all the high-wrought expecta-
tions which we had unwarrantably indulged in.
To obviate an event so much to be lamented, as
far as lies within our humble efforts, we will now
"ERUPTIVE FEVERS, &C. 277
consider the facts dispassionately, and endeavour
soberly to draw just inferences. The natural
small-pox is at all times a disease to be dreaded,
and is universally acknowledged to be, in certain
seasons and localities, a very fatal pestilence. The
introduction of inoculation, by which I mean small-
pox inoculation, is acknowledged on all hands to
have produced a much milder disease in a consi-
derable majority of those persons who submitted
to it, and it may thus have saved thousands of in-
dividuals, who would have fallen a sacrifice to the
disease in its natural form ; but still it is a fact, that
inoculated small-pox is frequently a severe disease,
and often leaves indelible marks of its having been
so, and that many inoculated patients have died ;
in some seasons one case in thirty ; and upon an
average of seasons, one in two hundred has been
supposed to prove fatal. Now, as before the intro-
duction of inoculation the visitation of the small-
pox was only occasional, and thousands of persons
passed through life without encountering its influ-
ence, it can hardly be doubted that many of those
individuals who died after inoculated small-pox,
would have altogether escaped the disease. When,
in connexion with this fact, we further take into
consideration, that through the medium of inocula-
tion small-pox infection was kept constantly afloat,
and that the natural disease was thereby rendered a
permanent instead of an occasional visitant, annu-
ally carrying off many victims, who heedlessly
278 ERUPTIVE FEVERS, &C.
neglected inoculation, it becomes a matter of great
doubt, whether the discovery and introduction of
artificial inoculation decreased, or increased, the
total mortality by small-pox.
Now let us see how the matter stands as regards
vaccination. The constitutional disturbance from
this cause is so slight, that not even the least incon-
venience ensues in a vast majority of cases ; serious
indisposition has been recorded in but a very few
cases, and I believe that only one or two instances
of death have been attributed to this cause ; and
when we consider how suddenly and unexpect-
edly infants and young children are sometimes
carried off, it is rather matter of astonishment that
in the many hundreds of thousands vaccinated, sud-
den deaths during the progress of the cow-pox
should not very frequently occur from other and
ordinary causes, many of which, if they did happen,
would undoubtedly be attributed to the vaccination.
Some medical men on this ground support the
opinion, that vaccination with its attendant febricula
is at the time a protection from other disorders,
and there is some reason in the argument. At all
events, we may deduce from above thirty years' ex-
perience in vaccination, that its immediate effect is
not to increase the number of deaths, which inocu-
lation for small-pox decidedly does.
In the second place, cow-pox not being, like small-
pox, an infectious disorder, it may be had recourse
to under any circumstance and at all times without
ERUPTIVE FEVERS, &C. 279
endangering the population at large, or increasing
in the slightest degree the risk of the heedless who
neglect, or of the objectors who conscientiously
decline, either to inoculate or to vaccinate.
A third argument in favour of cow-pox, which
arises, like the last, from the absence of infection, is
this, that the more general its adoption the less
pabulum remains for epidemic small-pox, conse-
quently the less extensive its ravages, and the
greater number of localities will be altogether ex-
empt from its visitations ; indeed there is reason to
believe that were vaccination general, small-pox
would cease to be a fatal or dangerous disease, if it
were not as some medical philosophers maintain it
would be totally eradicated.
On the other side of the argument, we admit that
late experience has proved the fact, that very many
cases of mild or modified small-pox after vaccination
occur during the prevalence of epidemic small-pox,
and that the proportion of these is greater than
after inoculated small-pox ; we will admit also that
many of these cases are very severe ; and a few
very few fatal cases have been satisfactorily at-
tested. These aggravated and fatal cases, however,
are by no means in a greater proportion, if so great,
after vaccination as after inoculation ; and the dis-
order is so trivial in the great majority of cases of
small-pox after vaccination, that it would not prove
in my mind a formidable objection, were we to ad-
mit that every person exposed to small-pox infection
280 ERUPTIVE FEVERS, &C.
after vaccination would have the disorder in this
modified form.
After such a review of the argument, I have no
hesitation in strenuously advocating vaccination,
both on the grounds of individual safety to the
party vaccinated, and of public benefit, in as far as
it diminishes the frequency as well as extensiveness
of epidemic small-pox, and thus decreases the dan-
ger and fatality amongst the unprotected; and it
becomes the duty of every one entertaining these
views to recommend its adoption wherever he pos-
sesses influence. It is therefore particularly in-
cumbent upon you, in your pastoral duties, to place
the question in its proper light before the unedu-
cated and the uninformed. You may confidently
assure them that the cow-pox, notwithstanding nu-
merous instances of mild small-pox occurring after
it, is perfectly innocent in itself, which is not the
case with inoculated small-pox, and is equally suc-
cessful in warding off or preventing danger from
natural small-pox as inoculation itself; and you
may further explain to them how effectual it must
necessarily prove in preventing any future visitation
of bad small-pox in the parish, if every individual
now in it, who is liable to small-pox, would submit
to vaccination, and if every infant afterwards was to
be protected in the same way soon after its birth.
On the subject of enforcing vaccination, I may
state as a fact, that in Russia, Prussia, Bavaria,
and other countries, where the legislative enact-
ERUPTIVE FEVERS, &C. 281
inents are most strict, natural small-pox is now sel-
dom seen ; and I will venture this observation, that
such enactments for the public safety do not inter-
fere more with the liberty of the subject than many
which now exist in this country, which, by laying a
restraint on personal conduct, provide for the safety
of the individual, as well as avert danger from the
public, such as the prohibition of riding on the
shafts of wagons, &c.
The trustees of our public charities ought at all
events to use their influence, and the public could
not reasonably object to previous vaccination being
required by them of every applicant for admission,
whether into our national and other charity schools,
into asylums, alms-houses, or other charitable in-
stitutions ; and the proper officers ought also to be
empowered to enforce vaccination upon all inmates
of our poor-houses and our prisons, as has long
been practised on admissions both into the army
and the navy.
The usual negligence as to such matters amongst
the poor, operating with a want of confidence in
vaccination, tends to make natural small-pox more
prevalent in this country now, than it was fifteen
or twenty years ago ; hundreds of deaths take place
from it annually in one or other of our large towns,
and it is an occasional epidemic visitant in every
part of the kingdom, proving fatal in many seasons
to about one in four of those who take it. In Nor-
wich about one thirteenth of the whole population
282 ERUPTIVE FEVERS, &C.
had natural small-pox in the year 1819, as stated in
the admirable history of that epidemic written by
Mr. Cross, an eminent surgeon of that city, and
five hundred and thirty individuals died of it.
The symptoms which precede the eruption of
natural small-po.v are those of general febrile indis-
position, usually severe. The illness sometimes
commences suddenly with pain at the pit of the
stomach and vomiting, or with acute pain across
the loins. After forty-eight hours, an eruption of
small red papulae or spots begins to make its ap-
pearance, at first on the face, and successively on
the trunk and extremities, fresh spots continuing
to make their appearance for two or three days.
Each pimple becomes a vesicle, gradually enlarges,
and is distended with fluid, which is at first a clear
lymph, but gradually assumes the appearance of
opaque pus or matter. As the pock thus matu-
rates, it becomes surrounded with a crimson areola,
and itself assumes a remarkable and characteristic
depression on its centre ; this process of maturation
occupies from six to eight days, after which the
pock shrivels up and becomes a scab, which falls
off in eight or ten days more, and in many cases
leaves a scar or pock-mark. The number of these
papulae or pocks vary in different cases from a
dozen or a score to so many thousands of them, as
to cover the whole surface of the body ; when mo-
derate in number they constitute a case of distinct,
and when so numerous as to run into one another,
ERUPTIVE FEVERS, &C. 283
a case of confluent, small-pox. Although the degree
of previous fever, called the eruptive fever, bears
no proportion to the amount of eruption, being
frequently severe in distinct small-pox, yet the de-
gree of confluence forms a criterion by which to
judge of the severity which will attend the secon-
dary fever, and its correspondent danger. Upon
the appearance of the eruption, the preceding fe-
brile symptoms are greatly relieved ; but as the in-
flammation around the base of the pustules and the
suppurative process advances, symptoms of secon-
dary fever appear, and progress to more or less of
danger, assuming an inflammatory or typhoid cha-
racter, according to the constitution of the patient,
the season of the year, and the peculiar character of
the epidemic.
The treatment of small-pox must be regulated by
the same directions which were given for treating
the different kinds of fever, there being no specific
remedies for the cure of this disease. You may
therefore discountenance entirely the saffron tea,
saffron stays, raw bacon applied externally to the
throat, and the sheep-trottle drink, all of which I
have not only heard extolled, but known to be ac-
tually employed.
Calomel cathartics with saline aperients, and the
usual fever medicines, with attention to cool apart-
ments and a light diet, will be all that is required
in mild and moderately severe cases. Where sleep-
lessness and low delirium attend the secondary
284 ERUPTIVE FEVERS, &C.
fever, I am even more frequently inclined to give
an opiate every night than under similar circum-
stances in simple fever, and I usually give at the
same time two grains of calomel. Bark has been
recommended in the severest cases of small-pox,
and I think I have seen the same good effects from
moderate doses of it as in typhus or typhoid remit-
tent, in which I have advised one or two grains of
the sulphate of quinine three or four times a day
as a tonic.
The inoculated small-pox is now seldom, and
ought never to be, seen. 1 shall therefore give no
description of it, and shall only observe, that when
inoculation was practised severe cases of the dis-
ease were not unfrequent, particularly in some
seasons, and that about one case in two hundred
proved fatal on the whole average of inoculations.
VACCINATION, or the operation of inoculating with
vaccine lymph, is in itself so simple, the necessary
attention to the progress of the vaccine pustule so
completely within your power, and the rules for
discriminating between a genuine and spurious
pustule may be so satisfactorily laid down to the
comprehension of every man of education, that you
need have no doubts or fears as to your becoming
a safe and successful vaccinator ; and the means of
obtaining gratuitous vaccination for the poor are
now so universal, principally owing to the praise-
worthy liberality of our profession, that delicacy
towards your friends, the surgeons of your neigh-
ERUPTIVE FEVERS, &C. 285
bourhood, need not deter you from the under-
taking.
In addition to the all-important consideration of
saving your parish from future visitations of small-
pox, and thus becoming the instrument of preventing
much suffering and saving many lives, I would urge
this argument upon you for undertaking the office
of gratuitous vaccinator of the poor, that you may
prevent its falling into the hands of ignorant, un-
educated, and interested persons, who, if they are
aware of the importance of watching the progress
of the disease, will not bestow the necessary time,
and who are in all probability altogether ignorant
of the essential characters in the pustule, which
promise safety and protection.
Persons may be vaccinated at any age, but as it
is on every account desirable that it be done in in-
fancy, I would state the period between three
weeks and three months as the most eligible, or at
any rate before the time of teething. It is of im-
portance that the patient be in good health, and
free at the time from any eruption on the skin,
either of which circumstances will be sufficient
reason for postponing the operation, unless there is
immediate danger from the infection of small-pox,
in which case I would admit no consideration what-
ever to be a sufficient reason for its postponement.
It is always best to vaccinate with lymph imme-
diately as it is taken from another patient, but
when this cannot be done, it is of importance to
286 ERUPTIVE FEVERS, &C.
have the lymph as fresh as possible, being then
less liable to fail. It is best preserved between two
pieces of glass, or on bone or ivory points in a well
closed phial.
In selecting a vaccine pustule from which to take
your lymph, take care that it be a perfect one, and
not advanced beyond the stage when it contains
thin transparent lymph ; make three or four super-
ficial punctures with the point of a clean lancet
held slantingly, that you may not wound the bottom
of the pustule, wait patiently till the minute points
of lymph from the distinct cells have collected into
drops on the surface, and then either imbue your
ivory points with it, or moisten your piece of glass
by gently drawing it over the surface of the pus-
tule, immediately apply another plate of glass, and
preserve them in close contact. I would here ob-
serve, that you should not take lymph from a soli-
tary pustule, lest, by breaking it up before it has
gone through all its stages, you endanger its full
protective influence. This is a sufficient reason
for always making more than one incision in every
person you vaccinate, and it is a good rule never
to make less than two or more than four, by which
means you are almost certain of having one or two
pustules to supply you with fresh lymph, and one
left to pass unbroken through all its stages.
When you vaccinate, it is immaterial whether
you puncture the arm by many slight touches with
the point of the lancet held perpendicularly, or
ERUPTIVE FEVERS, &C. 287
elevate the scarf-skin or cuticle by a cautious in-
sertion of the lancet-point horizontally ; but it is
of moment that you do it so delicately as not to
draw blood at all, or only in the slightest degree
possible. If you use lymph preserved on glass, you
first moisten it by breathing on it if it be fresh, or
by rubbing it with a single drop of water if it be
old and very dry, either with the ivory point which
thus becomes armed, or with the lancet, but I pre-
fer the former ; you then carefully insert the point
under the raised scarf-skin and wipe off the lymph
into the wound or scratch, or you rub its surface
over the little punctures, if you have adopted that
plan, which has its advocates. If you prefer arming
the lancet-point, this may be done before making
the punctures or elevating the scarf-skin ; but still,
to be more secure, lymph should be again applied
as directed above, and particularly if a drop or
two of blood has effused, as the lymph may thus
have been washed away. Care must afterwards be
taken to prevent the contact of the infant's clothes
before the arm is dry, and as regards the operation
nothing further is required to be observed.
To watch the progress of the vaccination satis-
factorily, you ought to see your patient on the
fourth or fifth day, and every two or three days
afterwards, till the crust or scab is fully formed,
that you may be assured of its passing through all
its stages according to the following description,
without interruption from either constitutional
288 ERUPTIVE FEVERS, &C.
causes or external violence. A small red spot is
apparent on the second or third day after vaccina-
tion, which is slightly elevated, and on the fifth or
sixth a small vesicle is formed of a pearly hue with
a slight central depression. On the eighth or ninth
day the vesicle is surrounded by a vivid red areola,
which rapidly spreads, so that in a day or two more
it is about an inch and a half in diameter. The
vesicle is now at its height, consisting of numerous
cells, which are filled with a transparent lymph ; it
is circular and still exhibits the depression in its
centre, and the areola remains hard and tumefied
for two or three days, and then begins gradually to
fade and subside. The vesicle begins to darken
first at its centre, and changes in a few days to a
hard, smooth, mahogany-coloured crust, which falls
off in the third week, leaving a superficial indented
cicatrix or scar.
What has been termed modified small-pox is an
eruptive disease which frequently occurs during the
prevalence of small-pox, and has been observed to
occur in persons who have had small-pox natural
or inoculated, as well as in those who have been
vaccinated. The disease is sometimes ushered in
with as severe an attack of fever as genuine small-
pox, but frequently the symptoms are so mild as
scarcely to attract attention. After three or four
days the eruption appears, which runs through its
progress much more rapidly than the genuine dis-
ease; the constitutional symptoms subside when
ERUPTIVE FEVERS, &C. 289
the eruption appears ; on the fourth or fifth day the
pocks or vesicles, which contain some a thin pellu-
cid, and others a straw-coloured fluid more or less
opaque, begin to shrivel up, and in a few days more
the scabs fall off, there having been no inflammatory
blush round the basis of the pock, and no secondary
fever. The treatment, if any be required, will be
to give a dose or two of salts during the fever, to
prescribe a light diet, and to keep the patient cool
and quiet.
The CHICKEN-POCK, swine-pock, horn-pock, and
blister- pock are generally allowed to be all varieties
of the same disease ; and indeed the spurious or
modified small- pox which I have just described as
occurring in very many persons upon exposure to
small-pox contagion, after having been vaccinated,
or having previously passed through small-pox
either natural or artificial, has been supposed upon
high authority to be identically the same with
chicken-pox, and all arising from small-pox infec-
tion. However this may be, I must impress these
facts upon you : first, that an unprotected child,
by which I mean one that has not had either cow-
pox or the genuine small-pox, may have the erup-
tive disease we call chicken-pox, and still remain
liable to genuine small-pox ; and secondly, that any
person having at different times chicken-pox and
small-pox or cow-pox, may, upon after exposure to
small-pox infection, have the modified variety of the
latter disease. Further observations and experi-
o
290 ERUPTIVE FEVERS, &C.
raents are still required to clear up the doubts
that at present exist, with regard to the identity or
specific differences, and the protective powers, of
these milder eruptive diseases. The varieties de-
pend upon the form of the vesicle, which is some-
times a minute transparent dot upon a reddish or
slightly inflamed base, sometimes pointed and some-
what larger, at other times flatter and much larger.
The contents of the vesicle are at first transparent,
but in a day or two become straw-coloured, and
about the fourth day dry up, and in another day or
two become small brownish scabs. The disease
is usually so slight as to demand no medical treat-
ment, but sometimes there is a little fever requiring
mild aperients and an unstimulating diet.
Having now treated of eruptive fevers which are
produced by specific contagion, and which as a ge-
neral rule occur only once in the same individual,
and are therefore most commonly the diseases of
childhood, the transition is easy to other eruptions
on the skin ; and I shall first give some account of
those, which, though sometimes ushered in by con-
stitutional disturbance, are not necessarily accom-
panied by fever, are seldom, if ever, contagious
may occur more than once in the same individual,
and which, running through a certain course, may in
that sense be termed acute. These are erysipelas
or St. Anthony's fire, miliaria, urticaria or nettle-
rash, and herpes. And I shall afterwards make a
few observations on some of those eruptions which
ERUPTIVE FEVERS, &C. 291
may in contradistinction be called chronic, because
they last for an indefinite period unless restrained
by proper medical treatment, as porrigo or ring-
worm of the head, scabies or itch, lepra, and pso-
riasis called also humid tetters.
Under the title of ERYSIPELAS or St Anthony's
fire, I shall for brevity and perspicuity's sake treat
of several varieties of eruption commonly known
under this term, though distinguished, and very
properly so, in systematical works. They are al-
ways, unless in very slight cases, ushered in by one
or two days of mild fever and disordered stomach,
and some persons are so much more subject to the
complaint than others, that they seldom pass
through a spring and summer without a sponta-
neous attack. In many persons too the disposition
is so strong that the bite or sting of insects, and more
particularly the bite of leeches, is uniformly followed
by erysipelas in the part, extending sometimes
over the whole face or over a limb, and running its
usual course of many days. In the milder form the
eruption consists of one or more red patches, some-
times oval or circular, sometimes irregular in their
circumference, frequently smooth throughout, at
other times with a hard elevated border, or with a
rough and papulated surface. These patches ap-
pear indiscriminately on the face, trunk or extre-
mities ; the oval patches with hard elevated borders
being most frequent on the front of the legs. The
duration of the redness and swelling is from two or
o2
292 ERUPTIVE FEVERS, &C.
three days to as many weeks, when both gradually
subside, and a slight desquamation of the cuticle
follows. The treatment is an aperient, as mag-
nesia and epsom salts, once a day, a mild cooling
diet, rest when the patches are on the legs, and a
weak lotion of goulard applied frequently to the
part, cold in summer, but warm in the winter sea-
son, or what is a better criterion, of that degree of
temperature which is most agreeable to the feelings
of the patient.
Erysipelas in a severer form is marked with more
general constitutional disturbance ; the sensation of
burning heat in the part is more intense, there is
considerable tumefaction, and when the face is the
part attacked, which is the most usual seat of these
severe cases, the eyelids are so swollen as to be
entirely closed. The eruption usually appears at
the end of the second day of the fever, and in two
or three more days, there are numerous small, or
a few large, blebs or blisters on the inflamed sur-
face, which burst and desiccate on the second or
third day after their appearance. In another va-
riety the surface is perceived to be slightly rough
on the first or second day, and, instead of vesicles
or blebs, numerous small pustules cover it on the
third or fourth day, which discharge a thin acrid
matter, forming a yellowish scab or crust, which
does not fall off in less than ten days or a fortnight.
The treatment in these severer forms of the disease
must vary according to the intensity of the consti-
ERUPTIVE FEVERS, &C. '293
tutional symptoms ; and I must apprise you, that
when the face or scalp is pretty extensively inflamed,
very formidable, alarming, and even dangerous symp-
toms sometimes arise, as delirium, with a rapid pulse
and high fever; and all such cases require, of
course, the aid of the most skilful practitioner.
The external application most frequently resorted
to in these severer cases is a dredging of fine flour,
and before vesications or pustules begin to dis-
charge, this is cooling and agreeable, but after-
wards it forms a hard crust, which proves a source
of fresh irritation, unless it be frequently removed.
I am in the habit of bathing the inflamed surface
with warm water, by means of a sponge, or with a
warm lotion of weak goulard, and after carefully
drying the surface, I dust it, where there is little
or no discharge, very slightly with hair powder or
fine flour through a muslin bag, and repeat this
process two or three times a day ; but if there is
much discharge from either blisters or pustules,
after the bathing I apply a thin cool bread and
water poultice, containing a little goulard lotion.
The general treatment in these severe cases must
be regulated by symptoms. Bleeding and brisk
purging will be required when the fever is inflam-
matory, opium and calomel, and bark where low
delirium and a small frequent pulse indicate typhus
or low fever.
Many medical men consider erysipelas contagi-
ous, and sometimes epidemic ; but it appears to me
294 ERUPTIVE FEVERS, &C.
that, under such circumstances, the erysipelas is
only a symptom of a contagious or epidemic fever ;
indeed, I have several times in the course of my
practice seen an epidemic fever, in which erysipelas
was a frequent, though by no means a constant
symptom.
MILIARIA, or miliary fever, is an eruption of very
small elevated pimples, over any or every part of
the body, occurring during the progress of other
diseases, when attended with profuse perspiration ;
as also in women during their confinement, if from
improper diet, superabundance of clothing, or ac-
cidental indisposition, they are brought into pro-
fuse perspiration. The only treatment required is
cool air, moderate clothing, and light diet.
URTICARIA, or nettle-rash, is a slightly elevated
eruption, in patches of various forms, white with
pinkish or red circumference, resembling the wheals
ordinarily produced by the stinging of nettles. It
is usually a slight and evanescent disease, disap-
pearing in a few hours, but sometimes it continues
for two or three days, and occasionally for as many
weeks. It is always more or less connected with a
disordered stomach ; and is frequently produced by
imprudence in eating too much of articles of food
that are indigestible ; and in some individuals it is
very apt to be induced by particular articles of diet,
and those of very different quality in different in-
dividuals. Some cannot eat fish of any kind with-
out its inducing an attack of the nettle-rash, others
ERUPTIVE FEVERS, &C. 295
have it only after eating some particular fish, as
salmon, mackerel, or skate ; and many persons are
sure of an attack after eating shell-fish, as lobsters
or oysters, and still more commonly after eating mus-
sels. The common edible mushroom, too, has been
known to produce the same effect, and certain fungi,
much resembling the common mushroom, and there-
fore often mistaken for it, almost invariably disagree,
and usually induce urticaria. In many persons it
follows upon eating some particular fruit, as straw-
berries ; I have heard of one individual, who could
not eat sweet almonds, and another who could not
eat barley-bread, without experiencing more or
less of this troublesome eruption. In some indi-
viduals this idiosyncrasy is so strong, that the
particular article invariably produces the effect ;
but in others only occasionally. In some cases the
only inconvenience is the accompanying itching,
but in others the patient is dreadfully sick, and
has very severe spasmodic pains in the stomach,
the whole surface of the body is swollen, but more
particularly the face, and the itching is accompa-
nied with intense smarting. In the milder cases
of this species of poisoning, a draught or two of
tepid water, with a tea-spoonful of magnesia, or
carbonate of soda, will be all that is needful ; but in
severer cases an emetic should invariably be given;
and if there is pain in the stomach after the opera-
tion of the emetic, a dose of laudanum will be
requisite, and with this, or immediately after it, a
296 CHRONIC ERUPTIONS.
fall dose of castor oil. In cases of urticaria or
nettle-rash from other causes than improper food,
or this peculiarity of constitution, the stomach is
nevertheless usually disordered, and magnesia or
carbonate of soda with a little rhubarb will be the
proper remedy, and the dose must be regulated by
age and other circumstances ; small doses fre-
quently repeated will succeed best, as four or five
grains of each three times a day in a little pepper-
mint-water.
HERPES is another of the eruptions which are
usually ushered in by a day or two of slight indis-
position, and most generally it runs its course
within a week or ten days, and is not infectious.
It consists of small vesicles in clusters, the vesicles
containing at first a clear, and afterwards an opaque
fluid, at length desiccating into brownish scabs, and
the clusters are surrounded by an inflamed state of
the skin. There are several varieties ; thus, when
the clusters assume a circular or oval form, and
the patch is gradually extended by the fresh erup-
tion of more vesicles at the circumference, as those
in the centre dry up and disappear, the disease is
vulgarly called ringworm ; but this is very different,
be it remembered, from ringworm of the head,
which will be treated of presently. Where the
herpetic clusters appear upon the back, loins, or
front of the body, and by spreading form a par-
tial circle or band round the body, the disease is
called shingles; and in this variety the vesicles are
CHRONIC ERUPTIONS. 297
larger, some being as big as small split-peas. In all
its varieties, this eruption is attended with smart-
ing as well as itching, and the pain is aggravated
by heat, and by irritating lotions or ointments. As
the disease usually terminates spontaneously in a
few days, little treatment, either local or general, is
required. A weak lotion of goulard, and, to pre-
vent irritation from the clothing, the simplest and
mildest ointment may be had recourse to; and
when the defined patches called ringworm are pro-
tracted, an astringent as common ink, or a solution
of green vitriol, which is more cleanly, may be ad-
vantageously employed as a lotion. The proportion
of green vitriol may be one dram to half a pint of
water. The general treatment consists in cool air,
a mild diet, and a gentle dose of physic.
The chronic eruptions, or those which have no
definite period for their duration, have been usu-
ally divided into the papular, pustular, vesicular,
and scaly ; but nature does not restrict herself to
such an artificial division, for in many cases we
have both pustules and vesicles, or pustules and
scales, or still other combinations. And as I do
not in this work pretend to systematise, or profess
to describe every variety of disease, I shall proceed
to treat of those which are of most common occur-
rence. The RED-GUM, red-gown, or tooth-rash, is
an eruption of numerous red papulae or pimples,
occurring in infants, most frequently on the cheeks,
but often too on the arms and other parts of the
o5
298 CHRONIC ERUPTIONS.
body. It depends upon irritation from teething,
or a disordered state of the stomach and bowels.
When it arises from the former, the lancing of the
gums becomes necessary, and in all cases ab-
sorbents and mild aperients are so, as a few grains
of magnesia and rhubarb where the bowels are
not relaxed, and a little prepared chalk where they
are in that state.
IMPETIGO, or the humid tetters, is arranged
amongst pustular eruptions, but it most frequently
consists of both small pustules and small vesicles
intermixed, the former so called from containing
pus or matter, the latter being minute blebs or
blisters, containing a thin fluid, like those of
herpes. This form of eruption takes place most
frequently on the lower extremities, but often on
the arms, face, or body : the smarting is intense,
and the discharge sometimes considerable, of a
thinner or thicker character as the pustules or
vesicles most prevail ; and the crusts or scabs thus
formed are sometimes very extensive. Tetters,
like herpes, sometimes appears in circular or oval
patches, and sometimes occupies one side of one
of the joints of a finger ; and at other times ex-
tends irregularly over the surface, whether on the
face, the body, or the limbs. This disease is more
chronic or lasting than herpes, and usually more
severe, particularly when there are vesicles like
those of herpes intermixed with the pustules
proper to tetters. Medicated applications are of
CHRONIC ERUPTIONS. 299
little avail, particularly in the severe cases; all
but the most mild and simple aggravating the
pain, and not expediting a cure. Cooling the part
with goulard lotion after gentle ablution with thin
gruel, and then the application of rags besmeared
with cream, or sweet oil, or with simple ointment,
or white lead ointment, constitute my usual ex-
ternal treatment in the severer cases; but when
the inflammatory appearance is less, and the smart-
ing not intense, considerable advantage is derived
from the diluted red precipitate ointment, or from
sulphur ointment, or from a mixture of the two in
equal parts. The internal treatment consists in
mild diet, avoidance of fermented liquor, gentle
aperients of sulphur and cream of tartar, a tea-
spoonful of each once or twice a day ; and when
the disease is chronic and the parts not very irri-
table, a short course of Plummer's pill and sarsa-
parilla, five grains of the former twice a day, with
a tea-spoonful of the extract of sarsa in half a pint
of water.
The RING-WORM OF THE HEAD, and what is com-
monly called scald-head, are considered by most
writers as only varieties of the same disease, or at
least species of the same genus, the former being
confined to patches, usually circular and well de-
fined, the latter being more diffuse and extending
over the greater part of the scalp, and both varie-
ties, be it remembered, are contagious. It is for
the most part a pustular disease, but occasionally
300 CHRONIC ERUPTIONS.
scaly, and sometimes vesicles are also intermixed.
The appearances are so well known that I need
not describe them, and the success of medical treat-
ment is so precarious, that I doubt I shall be able
to say little on that point that is satisfactory. As,
however, it is likely that you will meet with very
many cases among your poorer neighbours, I am
bound to give you the result of my practice.
When consulted for a slight scurfy or scabby
eruption on the scalp, which has appeared only a
few days, I am content with extreme cleanliness.
I see that the hair over the whole surface of the
patch or patches is cut as close as possible with
a pair of fine scissars, and I order the part to be
washed with tepid water night and morning. If it
is dry and scurfy, I direct the washing to be done
first with soap and water, and afterwards with
plain water ; if the patch be moist, and the part
sore and tender, a piece of sponge should be em-
ployed, and the process should be that of foment-
ing rather than of washing, and it should be con-
tinued longer ; and lastly, if it be covered by a
hard scab, this should be anointed with soft lard
after each fomentation. A perseverance in this plan
for a week or two will suffice for the removal of many
suspicious looking spots, and I believe will even
remove some incipient cases of ringworm. If, how-
ever, improvement is not apparent in that time,
other means must be resorted to, and still sooner
if there appears to be any augmentation of the
CHRONIC ERUPTIONS. 301
malady. Now of these other means it must be
here observed, that no one of them uniformly suc-
ceeds ; indeed I may go so far as to say, that every
one of them very frequently fails ; they must there-
fore be tried in succession; and I shall enumerate
only such of the many scores of vaunted receipts
as I have myself seen frequently to succeed. If
the scalp is very sore, moist, and scabby, cover the
whole of the affected part with a warm poultice,
and renew it three times a day, washing and fo-
menting the part each time with warm water for
half an hour. When the scabs are thus in a great
measure removed, and the inflammation abated,
which will probably be the case in two or three
days, order the whole scalp to be shaved, and
apply an ointment of equal parts of sulphur-
ointment, tar-ointment, and the diluted ointment
of red precipitate. This compound ointment is to
be gently rubbed over every part that is diseased
night and morning, and the same parts, or the
whole scalp, must be thoroughly cleansed with
soap-suds, by means of a sponge or a piece of flan-
nel, every morning before the application of the
ointment. Persevere in this practice as long as
any amendment is perceptible, or till the cure be
completed.
If the scalp, instead of being covered with pus-
tules and scabs, is moist with a thin disagreeably
faint-smelling ichorous discharge, which aggluti-
nates the hair into a tangled mass, that cannot be
302 CHRONIC ERUPTIONS.
touched without giving pain, after poulticing,
bathing, and cutting off as much hair as possible?
apply an ointment of cocculus indicus, in prefer-
ence to any other, for a week or ten days, which
will sometimes effect the cure ; but should this not
be the case, you must order the compound oint-
ment above spoken of, not neglecting to shave the
whole head as soon as the excessive tenderness of
the scalp will permit. And here I may observe
that shaving, general or partial, according to the
extent of the disease, ought to be repeated once in
ten days during the progress of the cure.
Should the patches or the whole scalp upon the
first presentation of the case be dry and scurfy, or
the pustules, if any, be small, and the surface not
very sore or irritable, you may at once commence
the treatment with the application of the com-
pound ointment to all the parts, or to the whole
scalp, previously shaved. The other applications
which I can recommend, and which must be em-
ployed after the above have ceased to produce im-
provement, are the tar-ointment alone, the strong
red precipitate ointment, a lotion of pyroligneous
acid, or of aquafortis, or a solution of lunar caustic.
The pyroligneous acid, or the concentrated vinegar
of the shops, may be used diluted with an equal
quantity of water ; the aquafortis with three times
the quantity ; and of the lunar caustic ten grains
should be dissolved in an ounce of water; either of
which may be carefully applied to the patches daily,
CHRONIC ERUPTIONS. 303
or every other day, with a camel-hair brush. An-
other remedy has been lately introduced, of which
I have as yet had no experience ; it is called kreo-
sote, and is a concentrated preparation of tar in the
form of a colourless transparent liquid. As an
application in ringworm of the head it is made into
an ointment, by adding twenty drops to an ounce
of simple lard. As the disease is often very tedious,
and very difficult of cure, much patience, perse-
verance, and diligence in the use of these remedies,
will be required, and the one must succeed the
other, and each be resorted to again and again,
whenever you are satisfied that no progress is being
made towards a cure. If the general health of the
patient be amiss, the appropriate treatment must
of course be adopted, for the local disease will sel-
dom improve during a disordered state of the con-
stitution. Indeed it may be considered as usually
necessary to give an alterative and a mild aperient
occasionally during the cure.
SCABIES or ITCH also is both a pustular and vesi-
cular eruption, sometimes the pustules, at other
times the vesicles predominating. This circum-
stance, together with the varying size of the pus-
tules, often makes it difficult to decide whether a
case is one of itch or not. When, however, you
see either small vesicles or mattery pustules of
every size, from a pin's point to that of a pea,
irregularly scattered over the arms and hands, par-
ticularly between the fingers, when the patient
304 CHRONIC ERUPTIONS.
complains of considerable itching, or you see proofs
of this in the bloody points produced by scratching,
you need scarcely hesitate ; and if more than one
in the same family shows the same appearances,
you may confidently pronounce the disease to be
the itch. Happily you have in all these cases a
certain remedy, a true specific in the sulphur oint-
ment. Considerable care, however, in its use, is
required to insure its efficacy. I consider four
ounces of the ointment the proper quantity for an
adult ; my directions are, that a fourth part be
sedulously rubbed in each night, for four successive
nights, over the arms and legs especially, from
above the knees and elbows to the extreme points,
and also over any other part of the body where the
least eruption of a suspicious character appears.
The more the patients submit to confinement to
their chambers, or even to their beds, during the
four days, the better, so that they may be living in
the sulphureous vapour. Not till two days after
the completion of the friction do I permit my pa-
tients to wash thoroughly, and then a complete
warm bath is desirable. At any rate the whole
surface of the body should be washed with soap
and warm water. After this, clean bed-linen and
wearing apparel is of course absolutely necessary,
and the greatest care and attention must be en-
forced to remove whatever has been worn of linen
or woollen, of bed or of body clothing, to the wash-
tub, or to be scoured with soap and water.
CHRONIC ERUPTIONS. 305
Another inspection of the patient is now re-
quired, and. although in a majority of cases the
patient, as well as yourself, will feel assured that a
perfect cure has been effected by this dressing,
some judgment is occasionally required to decide
the point. The doubt often arises from the pre-
sence of recent scratches, or that of vesicles or
pustules recently cured, but not entirely obliterated*
and sometimes from a pimply eruption produced
by the friction and the ointment; and at other
times from the co-existence of some other chronic
eruption. An accurate examination by an expe-
rienced eye will, however, usually decide the
point, and where there is at first a doubt, a delay
of a few days will be sure to clear it up. Should
there then be proofs of the disease being only par-
tially removed, which may occur in perhaps one
case out of forty, a second course of the ointment,
with the same care and precautions, will effectually
eradicate the disease. I do not mention any other
remedy, because in none other can you place the
same implicit confidence ; and because in your prac-
tice, as in my dispensary practice, it may be uni-
versally adopted.
We shall now conclude our observations on chro-
nic eruptions with a slight consideration of the
scurfy or scaly diseases of the skin. The slightest
is the formation of minute thin scales, never form-
ing crusts, but falling off in the form of very small
white bran-like powder upon the least friction.
306 CHRONIC ERUPTIONS.
It sometimes occurs on other parts of the body, but
most frequently on the scalp, and is there called
dandriffe. It is a slight disease, and calls for no
other treatment than frequent ablution with soap
and water and slight friction.
The more severe scaly eruptions are LEPRA and
PSORIASIS ; they are both commonly called scorbutic.
The former or lepra, which has no corresponding
name in our language, begins as small red elevated
spots, and soon shows a slightly scaly surface. The
redness gradually disappears as the scaliness in-
creases, and the size of the spots augments. The
spots, or patches as they are now become, still
maintain distinct circular appearances with reddish
elevated edges ; they appear most frequently about
the elbows and the knees, and the patches are there
sufficiently numerous to coalesce. Spots and
smaller patches, however, are usually seen over
other parts of the body, and about the margin of
the scalp, and even amongst the hair. It is attended
with itching, but not with smarting ; and its dura-
tion is uncertain. It seldom wholly disappears
without medical treatment, and frequently re-ap-
pears in the same person at distant intervals, when
it has been cured. The number and size of the
patches will also vary at different times, whether
the patient be under medical treatment or not.
The treatment, which I have found most successful,
is the internal administration of the solution of
arsenic, about five drops for a dose, three times a
CHRONIC ERUPTIONS. 307
day, and the external application of tar-ointment
gently rubbed over the patches at night, and washed
off with a sponge and soap-suds in the morning.
When this does not produce decided improvement,
I lay aside the tar-ointment, and use the compound
of this with sulphur and red precipitate ointment
as recommended for scald-head ; and when an
alternation of these two unguents, steadily perse-
vered in for several weeks, has failed, or only par-
tially succeeded, I have substituted the strong mer-
curial ointment for the tar-ointment, but for a
few days only at a time, and at different intervals.
The use of this latter ointment requires caution ;
and it must not be rubbed over a large surface,
or persevered in long, for it will then assuredly
induce sore mouth and salivation. The internal
treatment may be varied by sometimes giving a
Plummer's pill night and morning, at other times
a tea-spoonful of extract of sarsa in a tumbler
of water twice a day, and occasionally by a ten
days' course of both these remedies.
The other variety of scaly eruption, Psoriasis,
is called the dry or scaly tetter. In its mildest
form it only differs from lepra in being less ele-
vated, more irregular in its circumference, and
without the red elevated margin. But in its more
usual form it is a severer disease than lepra ; the
patches are larger, the skin under the scales more
inflamed and irritable, and chopped ; it is attended
with smarting as well as intense itching ; and, owing
308 CHRONIC ERUPTIONS.
to the scratching perhaps, which is a consequence
of this, the surface is frequently moist with bloody
serum, and the whole becomes inflamed, chopped,
and very painful. It frequently appears about the
face and ears ; but no part of the body is exempt
from its attacks. It frequently occurs on the arms
or legs, and spreads till it occupies almost the
whole limb. The treatment in moderately mild
cases is the same as for lepra ; but, in the severer
cases, simple warm fomentations, as with decoction
of marsh-mallows or chamomile-flowers, or anodyne
fomentations with decoction of poppy-heads, and
afterwards warm poultices over the worst portions
of the eruption, afford most comfort. Great atten-
tion in diet is requisite, it should be mild and mo-
derate all high-seasoned dishes, and pickles, and
fermented liquors should be abstained from. Mild
aperients are useful, as sulphur precipitatum, or as
it is vulgarly called milk of sulphur, a tea-spoonful
in a little milk twice a day, or two tea-spoonfuls of
cream of tartar every morning. And when by such
means the inflammatory symptoms have been mo-
derated, the same treatment may be adopted, both
topical and constitutional, as in lepra. The sulphu-
reous waters, as those of Harrowgate, are very ser-
viceable in all these scaly eruptions, taken inter-
nally, as well as used externally. The best sub-
stitute for such natural sulphureous waters is ob-
tained by the addition of one tea-spoonful of very
finely-powdered liver of sulphur to every four gal-
CATARRH AND INFLUENZA. 309
Ions of water, used either for washing or for general
bathing. And to imitate the Harrowgate water for
drinking, pour a pint of boiling water on a tea-
spoonful of the same preparation of sulphur, stir it,
let it cool, and filter through paper; of this solu-
tion put ten drops into a half-pint tumbler of water,
and take this quantity two or three times daily for
two or three weeks.
LETTER XI.
CERTAIN EPIDEMIC DISEASES NOT TREATED OF AS
FEVERS.
MY DEAR SON,
HAVING now treated of fevers, continued and
remittent, and also of eruptive fevers, which to-
gether constitute the greater proportion of epidemic
diseases, we naturally enough proceed to the con-
sideration of other specific constitutional disorders,
which prevail occasionally as epidemics. The prin-
cipal of these are influenza, cholera, and hooping-
cough, and with these I shall, as I have done on
former occasions, introduce some of their congeners :
thus, as allied with influenza, I shall consider
catarrh or common cold, and catarrhal fever; and
with the epidemic or Indian cholera, I shall treat
of our common autumnal cholera, dysentery, and
310 CATARRH AND INFLUENZA.
ordinary diarrhoea, and after hooping-cough I shall
make the few observations I have to offer on croup
and sore throat.
First, then, of CATARRH, CATARRHAL FEVER, and
INFLUENZA. When a person is more or less sud-
denly seized with sneezing, and at first a dry and
stuffed state of the nostrils, and then with a co-
pious discharge of mucus from the same parts,
which discharge is at the beginning thin and trans-
parent, and afterwards thick and opaque, that per-
son is labouring under a catarrh, or common cold.
The disease is a mild or moderate inflammation of
the mucus membranes of the nostrils, and is some-
times so mild as to be unattended by any con-
stitutional disturbance, and to be transient in
its duration; at other times headache and slight
fever, with a sensation of weariness and languor,
are its concomitants; and as undue exposure to
cold is the exciting cause, other symptoms may
arise according to the nature of the exposure, as
stiff neck, if that part has been exposed to a stream
or draught of cold air, and stiffness with pain of
some of the limbs, if they have been exposed to
cold and wet. The inflammation of the membrane
extends to the throat and chest, in many cases pro-
ducing hoarseness, sore throat, and cough. If
these latter symptoms are mild, we still call it a
case of catarrh or cold ; but if severe, they constitute
diseases known by other names, which will be
treated of hereafter. When the ordinary symptoms
CATARRH AND INFLUENZA. 311
of catarrh, as stated above, are unattended by fever,
or when the febrile symptoms are very slight, the
domestic medical treatment of bathing the feet,
taking a basin of tea or gruel at bed-time, and ab-
stinence from wine or beer or other stimulants, is
all that is requisite. If the throat be sore, a piece
of flannel wrapped round it at bed-time does good ;
if there be hoarseness as well, I further advise
steaming with the vapours of hot water, by holding
the head over a basin filled with boiling water, and
throwing over the head and chest a light flannel, so
as to enclose the basin also, which will be most
conveniently supported on the knees. And if this
be done at the same time that the feet and legs are
immersed in warm water, it will prove an excellent
substitute for a hot water or vapour bath, which
cannot often be conveniently obtained. As to the
possets, the caudles, and wine- wheys, of which every
Lady Bountiful and every old nurse has her favour-
ite recipe, I seldom recommend any of them ; as,
however, to produce a free and general perspira-
tion is the chief object to be desired, I do not ob-
ject to the adoption of one or other of them, where
the patient has from former experience satisfied
himself that such an effect will follow, and that too
without a previous hot and dry condition of the skin
with general febrile excitement. In many indivi-
duals nothing so certainly produces copious perspi-
ration, when labouring under a cold and sore throat,
with a hot and dry skin, as a large draught of cold
312 CATARRH AND INFLUENZA.
water, and it is under such circumstances both safe
and serviceable.
The exciting cause of catarrh being exposure to
cold, its frequency will of course be influenced by
the state of the weather ; and in the spring or be-
ginning of winter it is so very common, and often
affects so many in the same family, or the same
neighbourhood, as to have induced some medical
men to believe it to be contagious. At such sea-
sons it is also more severe, and the inflammation is
also more apt to extend to the throat and chest,
inducing cough and symptomatic fever. In such
cases the boundary between the catarrh and
bronchitis, or inflammation of the lining membrane
of the air-cells of the lungs, is scarcely definable,
and happily such distinction is of no importance,
for our practice must in each individual case be re-
gulated by the amount of symptoms ; and if a pa-
tient has a troublesome teazing cough with quick
breathing, sensation of heat and soreness in the
chest, a hot dry skin, and quick, hard, though per-
haps small pulse, it would be idle to dispute about
a name, and to inquire whether the attack began
with sneezing and other symptoms of catarrh, or
not. The practice must be decisive : bleeding and
nauseating doses of tartar emetic will be attended
O
with the same happy results, whether the doctors
christen the disease catarrh or bronchitis. In com-
mon parlance, however, we call only the milder
cases catarrh or cold, and the simple practice I
INFLUENZA. 313
have above directed, is all that is required in such
cases.
If, however, the cough accompanying a common
cold is troublesome, or remains after the first symp-
toms of catarrh have vanished, mucilaginous sub-
stances and slight anodynes may be safely had
recource to ; linseed-tea, gum arabic, Spanish
liquorice, fruit or other simple lozenges, are ex-
amples of the former : paregoric lozenges, syrup of
poppies, or half a tea-spoonful of paregoric elixir
three times a day, or one of the cough-pills, of
which the formula is to be found in the appen-
dix, are simple and serviceable examples of the
latter.
These directions will suffice for the management
of a simple cough, such as is often left as the re-
mains of a common cold, in a person otherwise
healthy ; but you will often be inquired of for
something good for a cough in persons very dif-
ferently circumstanced, as in asthmatic or con-
sumptive patients, or in such as labour under old
stomach or liver complaints. In such and various
other conditions of the lungs, where a distressing
cough is one of the symptoms, and perhaps one of
the most urgent, a variety of practice will neces-
sarily be called for, and permanent relief to the
cough cannot be expected but from such treatment
as is calculated to relieve the complaint, of which the
cough is only a symptom ; and you are therefore
now referred to what is said on this subject in treat-
p
314 INFLUENZA.
ing of asthma, consumption, indigestion, &c. ; and I
have only made these remarks here, that you may
not suppose, as many do, that there is, or can be, any
universal panacea for cough. I may, moreover,
here observe in addition to what I have said above,
that, when cough is attended with inflammatory
symptoms, anodynes are seldom admissible, and
antimonials, with or without bleeding as the
urgency of the case may require, will prove service-
able ; and on the contrary, when cough is unac-
companied by inflammatory action, anodynes, as
opium in its various forms, and henbane, may be
prescribed with advantage.
At the same seasons, when common catarrh pre-
vails, catarrhal symptoms very generally attend the
cases of ordinary fever, whether of the remittent or
continued type; and, as we are in the habit of giving
other trivial names to fevers from the prevailing
symptoms, I designate these cases catarrhal fever,
which I have noticed in a former letter. An ob-
servant physician will frequently have noticed this
and other changes in the character of the prevailing
fevers. At one season of the year, his fever pa-
tients will almost all have diarrhoea, or perhaps
bilious vomiting, or perhaps dysenteric symptoms ;
and at another season, or, so suddenly is the charac-
ter of the fever sometimes altered, in another week,
a majority of cases will have catarrhal, or even
bronchitic symptoms. Now, under each of these cir-
cumstances the treatment must vary ; and the more
INFLUENZA. 315
severe or urgent the cough, quick breathing, and
soreness or pain of chest, the more promptly and
assiduously must we resort to, and persevere in, the
treatment proper to catarrh and bronchitis, not
losing sight, however, of these two observations,
which from their importance I shall here repeat.
First, that bleeding in such cases will not be so
well borne, as in simple cases of inflammation of
the same tissues ; and secondly, that if the prevail-
ing fever be remittent, the bleeding, whether gene-
ral or local, will be most efficacious during the
paroxysm of fever; and the appropriate treatment
of remittent during the remissions, will not be in-
applicable or incompatible with the treatment for
bronchitis. It is in the management of such cases,
however, that the discriminating judgment of the
observant physician is particularly apparent ; and I
must acknowledge, that I am now travelling out of
the road which I had chalked out for my guidance
in these familiar letters.
As nearly allied to catarrh, and still more so to
catarrhal fever, I shall now treat of INFLUENZA.
This is an epidemic disease, which makes its ap-
pearance occasionally, but at no stated periods;
and it is confined to no particular season of the
year, though it occurs more frequently in the win-
ter or spring months. Its appearance is sometimes
confined to some large town or no very extensive
district, at other times it speedily traverses, though
by no regular route, a whole kingdom, and occa-
p 2
316 INFLUENZA.
sionally, as in the winter and spring of 1837, its
ravages extend over almost all the kingdoms of the
earth. It is supposed to depend upon some pecu-
liar state of atmosphere, because we can conceive
no other cause so extensive in its operation ; and
its progress is too rapid, or rather its appearance
in distant countries is so nearly synchronous, that
we cannot suppose it to be propagated by contagion
alone. The symptoms are usually very similar to
those of severe catarrh ; viz. sneezing and mucous
discharge from the nostrils, slight sore throat and
hoarseness, sensation of soreness in the chest, with
more or less of cough, and general lassitude, with
aching or fugitive pains in various parts of the
body. The invasion of the disease is, however,
more instantaneous than in an ordinary catarrh, and
is wholly independent of exposure to cold. Head-
ache, pains in or over the orbits of the eyes, more de-
cided fever with great and sudden prostration of
strength, further characterise the disease, and seem
to indicate the sudden application of miasma, or the
influence of some physical change in the constitution
of the atmosphere, of the nature of which we must
at present acknowledge our entire ignorance.
In the further progress of the disease, the cough
is attended with expectoration, the mucus from the
nose is more tenacious and opaque ; and in a ma-
jority of cases, the headache is now gone, the pain
of chest has much abated, and the languor has left
the patient on the second or third day ; but, in the
INFLUENZA. 317
severer cases, either the chest-affections increase
with very quick and difficult breathing and suppres-
sed expectoration, or the general febrile symptoms
are aggravated with low muttering delirium and
utter prostration of strength, and in many such cases
a fatal termination takes place within ten days or a
fortnight of the commencement of the disease. It
has been very generally remarked, that such fatal
terminations principally occur in those of previously
shattered or debilitated constitutions, particularly
where there has existed structural disease in the
heart or lungs.
As to the practice in influenza, there exists the
greatest possible discrepancy both as to popular re-
medies and what may be called family treatment,
and also amongst medical practitioners. It arises
here, as well as in most other cases, from the folly of
prescribing for the name of a disease, rather than for
the symptoms in each individual case. Some have
vehemently extolled, and others as vehemently con-
demned stimulants, as brandy and water, wine and
water, wine- whey, or warm possets; some have uni-
versally recommended bleeding, and others have uni-
versally decried it. My own observation amounts to
this: 1st. That in a majority of cases, the disease left
to itself would speedily and spontaneously subside,
and leave the patient quite well in a day or two,
and therefore, that in such mild cases the treatment
recommended for catarrh is all that is requisite,
namely, to avoid cold by staying within doors ; to
318 INFLUENZA,
immerse the feet in warm water ; where there is
soreness of the chest, to inhale the vapour of hot
water ; and at going to bed to take whatever is
most likely to induce perspiration, holding this in
mind, that as the ordinary effect of the miasma, or
whatever it be that produces influenza, is to de-
press the vital energies, we may more fearlessly
administer wine-whey, or wine and water for this
purpose, than in cases of common cold.
2ndly. That in moderately severe cases of influ-
enza considerable distress arises from tightness and
quickness of breathing, and a painful dry cough ; for
which symptoms no remedy is so speedily successful
as tartar emetic in quarter-grain doses; the first
dose of which will frequently produce vomiting and
instantly relieve headache, and induce perspiration;
and the continuance of it will speedily promote
expectoration, and relieve the breathing; after
which, but not sooner, warm wine and water, or
warm negus, may be moderately allowed to remove
languor.
Srdly. That when the cases of influenza are still
more severe, the practice must be altogether regu-
lated by the nature and severity of the symptoms. I
have seen cases of bronchial inflammation and of pul-
monary congestion, that have imperiously called for
venesection, and I have seen the vital powers so low
that ammonia, wine, or brandy, judiciously adminis-
tered, have saved the patients ; and I have seen other
cases, where both the febrile and chest-symptoms
CHOLERA, &C. 319
have been so under the influence of a remittent or
intermittent tendency, that quinine steadily perse-
vered in has been the only means of arresting the
disease. All these cases of severity must be left
to the care of professional men, and instead of de-
tailing the practice I must content myself with the
above observations, and a repetition of the impor-
tant fact, that influenza patients admit of less deple-
tion than the same symptoms occurring in genuine
catarrh and bronchitis would imperatively require.
Another wide-spreading epidemic disease, with
which we have only very lately become acquainted
in these latitudes, is the Indian or Spasmodic
CHOLERA. In its rapid and erratic progress
through the country it follows the same laws, if
laws they can be called, as influenza does. In
the suddenness of its attack, and in the immediate
prostration of the patient's strength, it also greatly
resembles it. It is therefore probable that each
disease takes its origin from a peculiar miasma, or
from some unascertained atmospherical peculiarity ;
and as the miasma of influenza determines to, or
more remarkably affects the mucous membrane of
the air passages, so the miasma of Asiatic cholera
peculiarly affects the mucous membrane of the
alimentary canal.
We have stated above, that influenza very much
resembles catarrh or common cold: now Asiatic
cholera seems to me to bear the same relation to
ordinary cholera that influenza bears to catarrh ;
320 CHOLERA, &C.
I shall therefore treat of common cholera before
proceeding to the consideration of this formidable
epidemic, and shall also dismiss with a few brief
observations the diseases called diarrhoea and dy-
sentery as its congeners.
The symptoms of ordinary Cholera, which is a
very common disease in the autumnal season, and
particularly in our fenny districts, are those of mild
fever, as lassitude, headache, quick pulse, and heat
of skin, speedily followed by, or instantly accom-
panied with, vomiting, purging, and spasmodic
pains of the legs and thighs, as well as in the sto-
mach and bowels. The matter vomited is usually
bilious, but at other times is without any tinge of
bile, and in some cases the nausea and retching is
most urgent and incessant without any vomiting,
except now and then of a little colourless mucus.
So the purging too generally brings away vitiated
bile of a dark green, or tarry brown, or of a pitchy
black colour; in many cases, however, the evacua-
tions are from the very first without any tincture
of bile, consisting of unusually pale faeculent matter,
or a pale turbid watery mucus. Thus the symp-
toms of cholera so nearly resemble those given
above as the symptoms of bilious remittent, that I
find a difficulty in marking the distinction. I may
observe, however, that there is less fever in cholera,
and it is little disposed to assume a remittent cha-
racter, though an attentive observer will usually
discover the ordinary symptoms of a mild paroxysm
CHOLERA, &C. 321
of fever ushering in the choleric symptoms, or occa-
sionally preceding them for twelve or twenty-four
hours ; and in our fenny district I have frequently
known the fever to be protracted after the cho-
leric symptoms have been subdued, and have now
and then observed it to assume a remittent cha-
racter. Again, the discharge from the bowels is,
perhaps, more frequently without bile in cholera
than in bilious fever, and the spasms are decidedly
more freqnent. As the symptoms of cholera do,
however, very much resemble those of bilious re-
mittent, so of course must the treatment be alike
in the same degree. The directions are very
simple, and will be found a counterpart of those
previously laid down for the choleric symptoms of
bilious remittent, consisting indeed in the frequent
repetition of very small doses of calomel, with or
without opium, as the case is, or is not, attended
with spasmodic pains. I usually begin with calo-
mel alone in very mild or moderately mild cases,
repeating half-grain doses every ten minutes, till
ten or twelve grains have been given ; but in cases
attended with spasm I combine a quarter of a
grain of opium with each dose of calomel ; and I
also do the same if calomel alone does not greatly
abate the symptoms after the first hour or hour
and a half. If the spasms are pretty general, and
very severe, I begin with a tea-spoonful of lauda-
num alone, or in a very little warm water, desiring
the patient to hold it in his mouth some time,
p5
3'22 CHOLERA, &C.
and to allow it to go slowly into the stomach,
mixed with the saliva. In genuine cholera the
symptoms soon subside under this treatment, and
under the almost entire abstinence from drinking
as well as eating which I universally prescribe;
for I only allow my patient to rinse the mouth with
toast and water when thirsty, and to swallow a
tea-spoonful of brandy with a table-spoonful of gruel
about once in two hours, till the retching has
subsided, and afterwards the gruel without the
brandy, or the same quantity of broth, at the same
intervals. After two or three days an aperient is
often required, and it may be a dose of rhubarb and
magnesia, or a dose of castor oil.
Should fever continue after the symptoms of
cholera have subsided, and more particularly if the
febrile symptoms recur at stated intervals, the case
becomes identical with bilious remittent fever,
which 1 have treated of before. And here I must
apprise you that cases of simple cholera, such as I
have been describing, and cases of bilious remit-
tent fever, frequently prevail at the same time, and
often occur in the same family either at the same
time or in quick succession.
Simple Diarrhoea, which consists in frequent
alvine discharges of the natural contents of the
bowels, often takes place without fever ; and when
protracted for more than a day or two, will require
the same treatment as directed above for diarrhoea
as a symptom of fever. If, however, any case proves
CHOLERA, &C. 323
unusually obstinate, and resists the treatment there
laid down, I recommend the trial of a pill to be
repeated every night, or night and morning, accord-
ing to the violence of the purging, consisting of
one grain of opium and two of sulphat of copper,
which is the blue copperas. The diet must be
attended to of course; vegetables are to be ab-
stained from, and fluids taken in small quantity ;
and arrow root, or, what is better, starch made pa-
latable with sugar and a little wine or brandy, may
be taken at bed-time.
Dysentery is a purging of bloody mucus attended
with griping pains, and usually with pain and ten-
derness on firm pressure over some part of the
belly. The alvine dejections are very frequent
and urgent, and attended with much painful strain-
ing. This disease, when accompanying fever either
of the typhoid or remittent character, as in the
description given of it by our military and naval
surgeons, ought rather to be considered a variety
of such fever, and may be called dysenteric fever,
for the treatment of which I refer you to my letter
on fevers. When it occurs as a chronic disease
independent of idiopathic fever, or remains as a
sequela of fever, a perseverance in the same reme-
dies, namely, calomel and Dover's powder, or the
grey powder instead of the calomel, with plain un-
seasoned diet and warm flannel clothing, is all I
have to suggest.
In Asiatic Cholera, as it prevailed in many
324 CHOLERA, &C.
parts of this country in 1832, the symptoms were
altogether more urgent, and much more frequently
fatal, than English cholera was ever known to be.
Its presence seemed altogether independent of
season ; it followed no regular laws in its progress
through the country. Its first seizure was marked
by the greatest possible prostration of strength,
and indeed many died in a very few hours from the
first baneful influence of the miasma upon the ner-
vous and sanguiferous system. There were, how-
ever, very many cases of somewhat less severity
than this, in most of which the symptoms were
incessant vomiting or purging, or both, with the
most painful spasms or cramps in the legs, arms,
or trunk, from which symptoms the disease ob-
tained the name of cholera ; but in other cases the
febrile symptoms, which were mostly of the typhoid,
or of the nervous character, were most predomi-
nant. Many other cases too occurred at the same
time when the cholera most prevailed, and in the
same localities, of simple continued fever, without
any cholera symptoms, which might be called either
typhus or nervous fever, but which was, in all pro-
bability, produced by the same peculiar miasma, or
by the same unappreciable atmospheric peculiarity
operating differently upon different constitutions.
The treatment of Asiatic cholera must vary with
the symptoms. In the severest cases, when the ac-
tion of the heart is scarcely to be felt, and the sur-
face of the body has become cold and of a livid hue,
CHOLERA, &C. 325
whether vomiting and purging are urgent or not,
excitants and stimulants must instantly be resorted
to ; warmth, by the hot-air bath, by wrapping the
body in blankets wrung out of hot water, by hot
bottles, hot bricks, or hot bags, whichever can be
most speedily procured, and at the same time ge-
neral friction and mustard-plasters over the region
of the heart and stomach, are amongst the external
means. If there is no vomiting, or the retching:
O' O
seems ineffectual, the administration of a powerful
emetic will sometimes relieve the heart from its
load, and speedily improve the pulse, and restore
the heat Where the vomiting and purging are in-
ordinate, and the fluids evacuated have that pecu-
liar appearance, which has been compared to thin
gruel or rice-water, so generally observed in this
disorder, calomel appears to me to be the most im-
portant medicine, and the dose should be two
grains every quarter of an hour, or at longer inter-
vals according to the urgency of the symptoms, with
or without opium according to the violence of the
spasms. Brandy, sal-volatile, or other stimulants,
must also be had recourse to in proportion to the
degree of faintness and exhaustion ; but you must
be cautioned against perseverance in opium and
stimulants after the reaction is once established,
that is, after the heart is relieved, the pulse raised,
and general warmth of the body restored.
After this short and hasty sketch of diseases af-
326 CHOLERA, &C.
fecting the mucous membranes, we cannot help ob-
serving a similarity in their whole history as well
as in their symptoms, between those affecting the
mucous membranes of the air-passages, and those
affecting the mucous membranes of the alimentary
canal, making due allowance for the disturbance of
the different functions performed in the two diffe-
rent parts of the mucous tissue ; and our attention
cannot but be drawn to the exact parallelism be-
tween catarrh, catarrhal fever, and influenza on the
one hand, and English cholera, bilious fever, and
the Asiatic cholera on the other. Catarrh, like
simple cholera, is produced by ordinary vicissitudes
in the weather, and generally by an imprudent ex-
posure to its effects, and both diseases are accom-
panied with very slight fever or none at all. Ca-
tarrhal fever and bilious, or, as it might with pro-
priety be called, cholera fever, are idiopathic fevers
accompanied by determination to the mucous mem-
branes ; to that of the air-passages in the former, as
to that of the alimentary canal in the latter. In-
fluenza again, like Asiatic cholera, depends upon
miasma or some unknown atmospheric peculiarity,
and traverses kingdoms with rapidity and by no
appreciable laws ; they both affect the nervous and
sanguiferous system very similarly, sometimes pro-
ducing only fever of the typhoid or low nervous
character, but most frequently accompanied by de-
termination to the mucous membranes ; the former,
HOOPING COUGH. 327
that is influenza, to those of the air-passages, and
the latter, that is cholera, to those of the alimen-
tary canal.
There is another disease of the air-passages,
which comes naturally to be considered in this
place, which is HOOPING-COUGH. This is generally
acknowledged to be contagious, that is, communi-
cable from one person to another independently of
atmospherical influence ; and yet, like most other
contagious diseases, it is more prevalent and be-
comes epidemic in some seasons at uncertain pe-
riods, and in this respect may be said to be influ-
enced either by miasma, or by some unknown at-
mospheric peculiarity. Hooping-cough, as it occurs
only once in the same individual, is most commonly
a disease of childhood. It usually commences with
general febrile symptoms, as headache, listlessness,
and heat of skin, but is very early accompanied
with cough, which is at first of an ordinary charac-
ter, and the case resembles one of catarrhal fever.
In many cases, however, the febrile symptoms are
so mild as not to be noticed, and a slight cough is
all that is observed for many days. After a little
time, however, the cough assumes its peculiar cha-
racter, and the whoop, occasioned by a long pro-
tracted inspiration, satisfies any one who has once
heard it that the disease is hooping-cough, or as it
is sometimes called kin-cough. In mild cases the
paroxysms or fits of coughing occur only once or
twice a day, a little phlegm is expectorated each
328 HOOPING COUGH.
time, the fever is slight or none at all, and after
one or two weeks the disease is gone without any,
or with very little disturbance to the constitution.
In severer cases the cough is frequent and each
paroxysm most distressing, the little sufferer cling-
ing to something for support, the breathing being
interrupted almost to suffocation, and the counte-
nance becoming turgid and approaching to lividity,
until the expectoration of some viscid phlegm, and
usually the disgorgement of the contents of the
stomach by vomiting, relieves the breathing, re-
stores the circulation, and removes all present ap-
prehension of danger. The recurrence of such
violent paroxysms may be only two or three times
a day, or as many times every hour ; and the at-
tendant fever may be of every degree of severity
indicative of more or less inflammation in the lungs,
from which, you ought to be apprised, the princi-
pal danger in hooping-cough arises, rather than
from the violence of the fits of coughing. In some
seasons there is much more tendency to this in-
flammation than in others, and then the fatality of
the disease is greatest. After the chief severity of
the attack is over, the disease becomes chronic, and
the peculiar spasmodic cough may occasionally be
heard for many weeks or even months. And there
is also a remarkable tendency in subsequent coughs
arising from common colds, to assume the hooping
character for months, and sometimes years, after-
wards.
HOOPING COUGH. 329
The treatment of this disorder, like every other,
varies of course according to its severity. The
utility of emetics, not only at the commencement,
but during the progress of the disease, is so gene-
rally acknowledged, that it may be laid down as a
rule to give an antimonial or ipecacuanha emetic as
soon as the disease is recognised. I am myself in
the habit of giving a combination of the two, say
one grain of tartar-emetic and ten of ipecacuanha
to a youth of ten or twelve years old, and half that
dose to a child of five, and so in proportion. In
mild cases nothing more is required than to avoid
full meals, attend to the state of the bowels, and to
repeat the emetic once or twice at intervals of five
or six days.
In somewhat severer cases, where the cough is
frequent and distressing, but none of the febrile
and inflammatory symptoms about to be detailed
are present, (of which fact you may be assured, if
the child is brisk and lively, and expresses himself
as being well in the intervals between the fits of
coughing,) besides giving the emetic at intervals of
four or five days, anti-spasmodics and external sti-
mulants are to be resorted to. A tea-spoonful of a
mixture of paregoric elixir, Hoffman's anodyne, and
oxymel of squills in equal proportions, may be
given to an adult, and half the quantity to a child
ten years old, every six hours in a little water ; a
blister should be immediately applied on the chest,
and after this is well, Roche's embrocation, or a
330 HOOPING COUGH.
liniment made by adding one part of tincture of
cantharides to five of opodeldock, is to be well rub-
bed over the chest once in twenty-four hours.
In detailing the treatment of the severest cases
of hooping-cough I need only advert to general
principles, as the judgment of the medical practi-
tioner, who ought in all such cases to be called in,
must adopt the appropriate remedies, in which he
will be regulated by the nature and severity of the
symptoms in each individual case. The danger
usually arises from bronchial inflammation, and the
treatment consequently consists in bleeding both
general and local, and in the free administration of
tartar-emetic. The symptoms of such inflamma-
tion are, very quick and painful breathing, with
quick and small pulse, and a hot skin. There is
also a short suppressed cough constantly harassing
the little patient, independent of the paroxysms or
fits of coughing, having the peculiarities of hooping-
cough. For more precise directions I refer you
back to what has been said of the treatment of
catarrhal fever, requesting you to hold in mind,
first, that the spasmodic character of the cough will
.authorise a somewhat earlier and freer use of ano-
dynes and anti-spasmodics in conjunction with tar-
tar-emetic; and secondly, that in some epidemics
the fever of hooping-cough has more of a typhoid
character than in others, which greatly aggravates the
danger, and will make the cautious practitioner have
recourse to bleeding with somewhat less freedom.
CROUP. 331
Hooping-cough, in its chronic form, does not
require confinement to the house, even in cold wea-
ther ; but as a fit of coughing is sometimes the con-
sequence of an overloaded stomach, or an over-
excited state of the circulation and respiration
from violent exercise, such exciting causes are con-
sequently to be avoided. And I may conclude with
the recommendation of a change of air, wherever it
can be effected, as highly conducive to freeing the
constitution from this chronic form of the disease.
There is another disease of the respiratory
organs, which also has by some been considered
epidemic ; and which, as it derives its name from
the peculiar sound in breathing, comes naturally
enough to be considered after hooping-cough; and
this is CROUP. It is a disease of infancy and child-
hood, very seldom if ever occurring after the age
of puberty. At its commencement it is an inflam-
mation and thickening of the edges of the rima
glottidis, or the chink at the top of the windpipe,
by which the sound of the voice is regulated ; and
hence in this disease the cough has a remarkably
hoarse ringing sound, as if made through a trum-
pet, and is followed by a sonorous inspiration
something like that of hooping-cough, but shriller ;
and the child's crying or speaking betrays hoarse-
ness in the intervals of the cough. As the disease
advances, inflammation runs along the mucous
lining of the windpipe, and through its ramifica-
tions in the lungs, and in some cases a muco-
332 CROUP.
purulent exudation from this membrane, becoming
tenacious in the upper part of the passages, forms
a membranous tube there, which still further im-
pedes the breathing, and is sometimes expectorated
either in shreds or in larger portions, which forms
one of the characteristics of croup in its advanced
stage. The parts implicated in this disease are so
delicately formed, and are so essential in breathing,
that if the appropriate treatment be not instantly
and vigorously adopted in a genuine and severe
case of it, a fatal termination will generally occur
on the second, third, or fourth day.
Croup, like other diseases arising from cold,
occurs most frequently in winter and spring. It is
most common on the east coast, and during the
prevalence of the east winds, and, from its frequency
in such situations, is treated of by some authors as
an endemic ; and, from its frequency at some sea-
sons, it has been considered by others as an epi-
demic.
Similar croupy symptoms, it is evident, must
arise where inflammation extends from other
parts to the chink of the windpipe, and therefore
they occasionally accompany scarlet fever, as I
have before observed, and malignant sore-throat,
if such a disease ever occurs without scarlet fever ;
and this circumstance it is, perhaps, that has in-
duced some physicians to call croup a contagious
disease. By a similar extension of inflammation
croup may be blended with bronchitis, or bronchitic
CROUP. 333
fever ; that is, croup may terminate in bronchitis, or
vice versa, bronchitis in croup. These considera-
tions will settle many discrepancies in the history
of the disease, as given by various authors, and will
simplify our views of such cases as we may meet
with.
I must further observe, that the children in par-
ticular families are remarkably prone to this dis-
ease, which arises probably from similar natural
conformation of the parts, as family peculiarities
of voice, in all probability, arise from the same cir-
cumstance; and it must be held in remembrance
too, that the same child is very disposed to have
a frequent recurrence of the disease; from which
two circumstances it arises, that many children,
and all the children of some families, never take
the least cold without having the croupy cough,
and the croupy breathing. This it is important
to know, because the same danger does not exist
in these cases, and the mere croupy sound of the
cough need not excite the same alarm, though
they still require some care, and much watching.
And these milder cases, where a croupy cough is
very distinctly marked, and yet ceases spontane-
ously in a very few hours, or after a day or two, are
in all probability what have given rise to the opi-
nion, that there are two kinds of croup, the one
inflammatory, the other spasmodic.
The symptoms of croup come on so suddenly
and unexpectedly, that a child, which has been
334 CROUP.
put to bed at its usual time, without any appre-
hension of indisposition, has given alarm to its
mother or attendant some time before midnight
by a single hoarse loud cough, without, perhaps,
awaking from its sleep. This is soon followed
by another and another, the child looks a little
flushed, and feels a little hot, and, if it awakes, it
shows peevishness, and its cry is hoarse, and its
breathing a little hurried. If the child's attend-
ant is a stranger to croup, no alarm is taken, and
the child sleeps through the night with little or no
more cough, is scarcely perceived to be at all ill
through the succeeding day, or only shows the symp-
toms of an ordinary cold ; but alarm will assuredly,
in many of these cases, be excited before the next
approaching midnight by a fearful aggravation of the
symptoms ; the cough, with its peculiar clangor,
becomes more frequent, the deep crowing inspira-
tion is well marked, the voice, whether in crying or
speaking, is hoarse, the pulse quick, and the skin
hot. The disease is now fully set in, and the dan-
ger, without the immediate adoption of remedial
measures, is imminent.
In detailing the treatment we will go back to
the very earliest symptoms, and suppose the anxi-
ous mother, taught, perhaps, by former sad expe-
rience to be alive to danger, not only upon the first
croupy sound, but upon observing in the course of
the afternoon the ordinary symptoms of cold, at-
tended with hoarseness, which is not a common
CROUP. 335
occurrence in young children, except where there
is a croupy disposition. The treatment consequent
upon this early alarm need only be to let the child's
supper be very scanty, to put it into a warm bath,
and to steam the mouth and throat by holding its
face over a basin of hot water, and to preserve an
equable and agreeable temperature in the room
through the night. The chief advantage, however,
from this early attention to the case, will be the
careful watching for the approach of other symp-
toms, and the preparation to meet them promptly.
As soon as croupy cough is heard, if it is the
child's first attack, an antimonial emetic should be
given, as one grain of emetic tartar to a child of
four or five years ; and the little patient should be
sufficiently guarded by clothing, from taking a chill
during its operation. If, after the emetic is worked
off, the child falls asleep, and is not again disturbed
by the cough, or but slightly so, I recommend no-
thing more than a dose of calomel and rhubarb in
the morning, two grains of the former and eight
of the latter to children from four to six or seven
years of age, a few drops of antimonial wine every
four hours, a scanty diet through the day, and a
restriction to the house, be the child apparently
ever so well. This early attention will, I am satis-
fied, in many cases arrest the attack and prevent
mischief, particularly in families where there is a
strong predisposition to the disease.
When, however, the individual has previously
336 CROUP.
had an attack, the emetic may be dispensed with on
the first night, as the case will, in all probability,
only prove one of common cold ; still, however, the
patient should be kept within doors through the
day, and the further progress of the case be anxi-
ously watched, that the emetic may be given the
succeeding evening, if the symptoms be at all aggra-
vated ; and in these cases, as well as in all primary
attacks, should the croupy cough occur again, and
the fever continue after the emetic, the application
of leeches to the throat, in the hollow just above
the breast-bone, should not be delayed, and the
number must vary from two to six, according to
age and robustness, two to an infant, and six to a
stout child four or five years old ; and above this
age four or five ounces of blood may be taken from
the arm, even at this early period of the disease ;
the antimonial must be given regularly, and the
calomel and rhubarb be repeated. These means
early had recourse to, and strenuously persevered
in, will, in a majority of cases, prove speedily suc-
cessful. When, however, the inflammation runs on
to the formation of the croupy membrane, and the
difficulty of breathing consequently increases almost
to suffocation, the only chance is in very full and
repeated doses of emetic tartar, as a quarter of a
grain, to a child three or four years old, every
quarter of an hour, till it produces vomiting,
to be resumed in the same way two hours after
the last vomiting, and thus persevered in for
CHILD-CROWING. 337
two or three days, if the difficulty of breathing is
so long continued.
There is another disease of infancy, which has
sometimes been confounded with croup, but the
noise is more like a momentary crowing, with a
temporary suspension of breathing and consequent
struggling ; it is not often accompanied with cough,
neither is there any hoarseness, or other signs of
either cold or fever. This is known to many nurses
under the name of CHILD-CROWING ; the fits occur at
uncertain intervals, and are usually attended with
a contraction of the thumb into the palm of the hand,
or a similar contraction of the toes; which may
arise either from spasmodic contraction of one set
of muscles, or from a paralytic relaxation of the
opposite ones ; and this doubling in of the thumbs,
with slight convulsive motions about the mouth,
occasionally occurs in the intervals between the fits
of crowing. Whether the seat of this disease be
the brain, or the nerves which supply the upper
part of the windpipe, it must always be looked
upon with alarm and apprehension, for, in one of
these momentary catches of the breath, the child
is often seized with general convulsions, and expires.
The late Dr. John Clarke, believing the disease
to arise, like ordinary convulsions, from a fulness of
blood in the head, recommended bleeding and purg-
ing, with as much freedom as the little patient
could bear; but the more modern view of the
cause and seat of the disease, namely, that the
Q
338 CHILD-CROWING.
muscles which open the chink of the windpipe are
in a state of partial paralysis, leads to a different
practice, and one which harmonises better with the
practice of other old authors. In the fit, which is
a struggling for breath, the child must be shaken
and even beaten with apparent roughness, so as to
induce crying if possible, which relieves the breath-
ing ; cold water may be dashed into its face to in-
duce sighing or sobbing; and the back of the
mouth, which is usually open, may be tickled with
a feather to excite vomiting. What further is to be
done, if the struggling continues, or if it returns,
which it sometimes does repeatedly, is to apply a
hot flannel to the stomach, till the warm bath, the
necessity for which should in such cases be antici-
pated, is prepared, and the child immersed in it
up to the chin. The warmth should be about 96,
and the child be kept in a quarter of an hour.
The treatment of such a case in the intervals must
be guided by circumstances. If the face is flushed
and the child is robust, two, three, or four leeches
may be applied to the temples ; if there be enlarged
glands about the throat, leech them ; and if there
be symptoms of catarrhal fever, which is sometimes
the exciting cause of child-crowing, apply leeches
to the chest, or if the child is about teething, lance
the gums freely. Should neither of these circum-
stances be apparent, give the child a tea-spoonful
of a solution of assafcetida two or three times a day,
with a powder of two grains of rhubarb, and three
SORE THROAT. 339
of carbonate of soda, till the crowing-fits have
ceased for several successive days ; and afterwards
give the above powder twice a day in infusion of
cascarilla for two or three weeks.
I shall conclude this letter with the considera-
tion of those inflammations of the fauces or back
part of the mouth, known under the common deno-
mination of SORE THROAT. Exposure to cold is the
general exciting cause, and getting wet in the feet,
be it remembered, produces sore throat quite as
frequently as exposure to a cold north-east wind.
In what I shall call a husky sore throat, the red-
ness about the internal fauces is dull, and ap-
proaches to a claretty colour rather than a bright
scarlet ; there is little or no swelling except of the
uvula, which is of the same dull red colour, and
somewhat swollen as well as relaxed or lengthened;
all the parts feel dry, but very little if at all pain-
ful, and there is no difficulty in swallowing. There
is usually a disposition to what is commonly called
a tickling cough, at first without expectoration, but
afterwards with a little simple mucus or phlegm.
A person having such a sore throat feels much
less of it whilst in the open air, though the wea-
ther be cold and frosty, but is sure to have an ag-
gravation of it upon returning to a warm room.
He not only feels no inconvenience during his
meals, but rather finds the mastication and deglu-
tition, when eating and drinking, to afford relief ; he
will, however, never fail to experience increased
Q2
340 SORE THROAT.
dryness, and more of the tickling cough, after he
has finished his meal, and that in proportion to the
quantity of stimulus he has indulged in. This sore
throat, not being of sufficient importance to induce
the patient to take much care of himself, is gene-
rally protracted many days, the inconvenience being
always aggravated in the evening ; and as the pa-
tient is during its continuance very susceptible of
cold, it is by no means an uncommon event, that in
the course of its progress he is attacked with
other symptoms of severe and general cold, or
catarrh, as sneezing, coughing, stiff neck, pains in
the face, or ear-ache, with head-ache and feverish
symptoms.
The method of treating a husky sore throat is to
keep within doors, put the feet in warm water, and
steam the throat at bed-time, to suck simple muci-
laginous and sub-acid substances, as gum arabic,
jujubes, damson cheese, or fruit lozenges, to ab-
stain from wine, beer, and other stimulants, and
to wrap a piece of flannel round the throat at
night.
The inflammation of the throat just described is
now and then accompanied with whitish grey
spots, studded over the back of the fauces and in-
side the cheeks, which soon, from the removal of
the film, become so many little superficial ulcers.
This constitutes what may be called the aphthous
sore throat, because the spots just described are
termed aphthae. It occurs most commonly in debi-
SORE THROAT. 341
litated and broken constitutions. The best appli-
cation to these little ulcers is the lunar caustic,
either by touching them with the fine point of a
piece of caustic itself, or by drawing over their sur-
faces a camel hair pencil wetted with a strong so-
lution of it, as of two grains in one dram of distilled
or rain water. This should be repeated once a day,
and a gargle of muriatic acid, or of cayenne pepper,
should be used every four or five hours ; a dram of
muriatic acid to a pint of water will be strong
enough, and four grains of finely powdered cayenne
pepper will be the proper quantity to be rubbed
down in a pint of water. The treatment in other
respects is to be the same as in the husky sore
throat.
A similar inflammation and ulceration occurs
still more frequently in feeble children, particularly
in connexion with disordered bowels, and is uni-
versally known by the name of thrush. Here the
aphthae appear indiscriminately over the tongue, the
inside of the lips, and the cheeks, as well as over
the fauces ; the best application is either a piece of
borax moistened and drawn over them, or a strong
solution of it in honey or simple syrup, that is, as
much as it can be made to dissolve, applied by
means of a camel hair brush or soft feather. But
here also, when the ulcers are deep, nothing dis-
poses them so soon to heal as the lunar caustic.
The next species of sore throat which I shall
describe, is the active inflammation and swelling of
342 SORE THROAT.
that part of the back of the mouth, on each side
called the tonsils. It is termed quinsy by some,
but that term is more commonly restricted to the
most severe cases, where the inflammation runs on
to suppuration or the formation of matter. This,
which we shall call the inflammatory sore throat,
is, like the former, induced by cold, is ushered in
with more general constitutional disturbance, is
distinguished by a bright red colour of the tonsils,
with considerable swelling, great difficulty of swal-
lowing, and some impediment in the breathing.
The swelling being almost entirely confined to the
parts called the tonsils, which lie on each side of
the open throat, as far back as the uvula, is easily
felt externally at the angles of the lower jaw, where
pressure gives considerable pain.
A liniment of sweet oil and hartshorn, or the
liniment of ammonia, should be rubbed on the ex-
ternal swelling night and morning, warm water
used as a gargle or internal fomentation, and three
of the cathartic pills with a dose of salts be ordered
to be taken immediately. If the inflammation and
swelling do not begin to abate in a day or two,
leeches should be applied over the external swell-
ings, followed by a repetition of warm poultices,
and the purgative should be repeated. If this does
not afford speedy relief, a surgeon having been
called in will proceed to scarify the tonsils with a
lancet, and the bleeding should be encouraged by
perseverance in the warm water gargling. Not-
SORE THROAT. 343
withstanding the use of all these means, the inflam-
mation in a few cases will run on to suppuration or
formation of matter, which constitutes the true
quinsy ; for the relief of which the surgeon is ad-
vised to open the abscess with a lancet, as soon as
he can satisfy himself that the tumor points, or is
soft with the contained pus. A variety of gargles
will be recommended by the nurses, but, in this in-
flammatory sore throat, the warm water is both most
agreeable and most serviceable; if, notwithstanding
its free use, the mouth and throat be still dry, I
have found in this as well as other sore throats,
where the same dryness exists, a powder of equal
parts of sugar and saltpetre put on the tongue
every two hours, half a tea-spoonful at a time, pro-
mote the secretion of saliva, and being swallowed
slowly in part, and partly used as a gargle and spat
out, prove useful by lubricating the parts, and per-
haps also by diminishing inflammation. Blisters
over the swollen parts are generally ordered in
severe cases, but I doubt whether they do not pro-
duce as much harm as good by increasing the heat,
stiffness, and the pain both in swallowing and
breathing. They also prevent the repetition of
leeching and fomentations, which I deem of more
importance.
Another species of sore throat is the ulcerated
throat^ to which some persons are particularly-
prone. The immediate exciting cause of this
species also is cold, but I think I have observed it
344 SORE THROAT.
to occur most frequently in persons who are
troubled with indigestion, or other stomach affec-
tions. It commences, like the last, with uneasiness
on one or both sides of the back of the throat, with
a sense of fulness, and some difficulty in swallow-
ing, and with occasional pricking pains. It is often
ushered in with, or preceded by, intense head-ache
and slight fever. On inspecting the throat, it is
discovered to be red over the whole of the back
part, and swollen in one or both tonsils, and on the
second, third, or fourth day, one or more ulcers are
discoverable on the swollen tonsils, usually super-
ficial, but sometimes deeper ; at first the ulcer has
a white film on its surface, but it presently assumes
in a majority of cases a clean and healthy appear-
ance. The duration varies from three or four to
ten or twelve days ; and in this respect, as well as
in the extent and depth of ulceration, the case is
much regulated by the usual healthiness or uu-
healthiness of the patient. This species of sore
throat bears the same relation to the last or inflam-
matory sore throat, that the aphthous bears to the
husky sore throat.
The best general treatment is to begin with an
emetic, then to give one or two of the alterative
pills at bed-time, and a seidlitz draught the follow-
ing morning, which pills and draught may be re-
peated after two days, if the patient be not by that
time very nearly well. The local treatment, where
there is much swelling, must be leeches under the
SORE THROAT. 345
angles of the jaw, warm fomentations, and warm
water gargling for the first day or two, and then
gargling with vinegar in sage tea, or with muriatic
acid and cold water, a dram to a pint. If the ulcers
do not very soon assume a healthy and healing ap-
pearance, they should be touched with lunar caus-
tic once in two days. In mild cases the leeches
may be dispensed with, and the acid gargle may be
used from the commencement.
It may perhaps elucidate the classification of sore
throats here adopted, and aid the reader in compre-
hending the distinctions, if I observe that the husky
sore throat is analogous to that which occurs in
measles and small-pox ; the second, or aphthous, to
that which occurs in the severer forms of scarlet
fever, and the fourth, to that which accompanies
milder cases of scarlet fever in healthy and robust
subjects. The last, indeed, is a very usual occur-
rence during the prevalence of scarlet fever in
nurses or others, who having formerly had the scar-
let fever are now exposed to the infection. In
some particular persons, too, this species of sore
throat occurs on all occasions when, by exposure
or otherwise, they experience sore throat at all.
Q 5
346
MY DEAR SON,
THE principal acute diseases, which remain to be
treated of, are the inflammations of the various in-
ternal organs termed viscera, and their investing
membranes ; and these will constitute the subject
of the present letter. These viscera are contained
in the three great cavities, the head, the chest, and
abdomen or body, which will therefore form, natu-
rally enough, a three-fold division of the subject.
The investing membranes are also the lining mem-
branes of the cavities, the one being a duplicature
of the other ; they are called serous, from the na-
ture of the fluid secreted on their surface, in con-
tradistinction to the mucous membranes, the diseases
of which we have already considered. The latter,
or mucous membranes, be it remembered, line the
air passages and the alimentary canal, and have
communication by natural outlets with the external
air. The serous membranes on the contrary line the
cavities, and cover the contained viscera, and have
no outlet or communication with the external air.
Upon this difference in their circumstances, de-
pend many distinctive characters in their diseases ;
as for instance, the admission or contact of the air
in its ordinary state, being natural to the mucous
ON INTERNAL INFLAMMATIONS. 347
membranes, produces no evil, but if admitted in
consequence of a wound into contact with a serous
membrane, it is apt to produce inflammation; and
again, the admission of noxious air or other noxious
matter by the natural inlets, is a most fruitful
source of the diseases of mucous membranes, from
which the serous are necessarily altogether exempt*
I may also further observe, that when the secretion
of the mucous membrane is preternaturally increased,
or morbid in its quality, it has a natural outlet, and
disease is thus frequently removed : whereas such
increase in the secretion of a serous membrane by
its accumulation constitutes dropsy, and its morbid
quality is the source of other diseased conditions.
Proceed we now to the consideration of INFLAM-
MATION OF THE BRAIN and its membranes, which is
called, by anatomists, the viscous or internal organ
of the head or skull. As the functions of the brain
are pre-eminently important, so are its diseases
formidable, and often fatal ; and none more so than
inflammation, whether of the brain itself, or of its
membranes, whether it be partial or general, acute
or chronic. Every function both of mind and body
is mediately or immediately dependent on the
brain, and is consequently liable to derangement, or
destruction, from any deviation in the natural con-
dition of that all-important organ. Pathologists
have of late made considerable advances in ascer-
taining the morbid symptoms, mental and corpo-
real, that are indicative of particular morbid lesions;
and also of their situation, whether in the investing
348 ON INTERNAL INFLAMMATIONS.
membranes, or the substance of the brain, whether
at the base or in either hemisphere, in the cerebrum
or cerebellum. Such knowledge is important to
the physician, but its details would be altogether
out of place in such a work as this. Indeed, so
formidable a disease as inflammation of the brain
can never with propriety become an object of prac-
tice to you, or such as you ; and in what I am
about to say, my only object is to put you on your
guard, that when you see such an assemblage of
symptoms, you may be fully aware of the danger,
and urge immediate resort to the best medical aid
that can be procured.
Inflammation of the membranes lining the skull
and covering the brain, seldom occurs without ex-
tending more or less to the brain itself, and there-
fore I shall give but a single description of symp-
toms indicative of acute inflammation within the
skull. Intense pain over a great portion of the
head, high excitement of the faculties, a flushed
countenance, protruding eyes, suffused with redness
and with contracted pupils, intolerance of light,
and various kinds of noises in the ear, strong arte-
rial pulsations in the neck, the temples, and within
the head, sleeplessness, delirium, and convulsions,
are the early symptoms; and then come the opposite
of these, torpor, dulness of the senses, dilated pu-
pils, prostration of muscular strength, paralysis, or
apoplectic coma. Sometimes the former set of
symptoms recurs, and is again succeeded by the
latter, before the scene is closed by death. These
ON INTERNAL INFLAMMATIONS. 349
various symptoms will be differently grouped, of
different intensity and duration, as the inflamma-
tion attacks this or that portion of the brain, and
as it is more or less extensive. When you see
several of the above symptoms attacking a person
previously in good health, and of a plethoric or full
habit, particularly if they occur after the free use
of ardent spirits, after undue exposure to cold, or
after excessive exertion of the mental faculties in
abstruse studies, send immediately for medical aid,
and as an hour's delay may be dangerous, bleed
him freely at the arm, and apply cold to the head,
and give an active cathartic.
Should some of the above symptoms come on
more gradually, and the pain of head be described
as more confined to a spot, and particularly if the pa-
tient has of late experienced a fall or a blow upon
the head, let your apprehensions be alive to in-
flammation of the brain of a more local character,
and delay not to place the patient under profes-
sional care.
There is an inflammation of a deep-seated por-
tion of the brain, to which children are more par-
ticularly liable, to which I would next draw your
attention. You have often heard of HYDROCEPHA-
LUS, or water of the head. This is a misnomer>
in as far as the deposition of water is the conse-
quence of previous inflammation, and indeed does
not always take place, if the early stage of the dis-
ease is met by prompt and proper treatment The
350 ON INTERNAL INFLAMMATIONS.
inflammatory attack in this disease is in a serous
membrane lining certain small deep-seated cavities
in the brain called ventricles. The subjects of the
disease are almost always young children under
twelve years of age, and most commonly under four
or five. It sometimes occurs in the progress of
simple fever, but is also very often an idiopathic
disease ; in which latter case the early symptoms
are unusual pettishness, and fretfulness in the day,
and restlessness at night, with complaining of head-
ache, if the child be old enough to express its feel-
ings. It shuns the light, startles at noises, and, if
very young, never seems easy but while the nurse
is carrying it about in her arms. Its countenance
is sometimes flushed, at other times unnaturally
pale, and the pulse is usually quick, though I have
lately witnessed a case in a young gentleman ten
years old, where the pulse was preternaturally slow
during the first ten days of the complaint, never
rising during that period above fifty beats in the
minute. The appetite is precarious, and the
bowels costive. After this state of matters has
lasted from three or four to six or eight days, the
child becomes more drowsy, but still talks deliri-
ously at times, the pulse becomes much slower and
unsteady, and the patient generally complains still
of head-ache. There is at this time, even in the
youngest children, a very characteristic movement
of the little hands to and fro over the forehead and
temples, without touching the head; the child
ON INTERNAL INFLAMMATIONS. 351
moans too, and sobs frequently. This stage of the
complaint varies in its duration from eight or ten
days to a fortnight, the patient remaining all this
time in its cradle or bed, prostrate on its back, but
tossing its head from side to side, and moving its
hands in the way described above, occasionally
screaming out " Oh ! my head, my head !" talking
deliriously when not roused by questions distinctly
and repeatedly put to it, and with a more constant
expression of distress in its countenance. It will
now generally be discovered to have a squint, or to
look cross-eyed, the squint being more or less
permanent ; and there is also occasional convulsion
of the muscles of the face. The pulse at length
becomes more variable in strength as well as fre-
quency, and occasionally intermits; sometimes there
is a sudden increase in its frequency, so that it
becomes too rapid to be distinctly counted, but
this is but for a short time, and it soon falls again
below its natural standard. More general convul-
sions now vary the distressing scene, and the coma
or state of stupor in the intervals is more deep,
with low inarticulate mutterings; and at some
period, generally between the fifteenth and twentieth
day of the disease, the fatal termination takes place.
The directions for the treatment of this formida-
ble disease are very simple ; and indeed they are
so, and are also very similar in all acute inflamma-
tions of internal parts ; but you must not hence in-
fer that you are qualified to enter upon the task
352 ON INTERNAL INFLAMMATIONS.
by no means ; for I must here repeat to you, that
the greatest acumen towards successful practice is
required to ascertain the nature of the individual
case, not to decide upon the appropriate remedies.
And I must observe of the disease before us, that
every one of the symptoms taken separately may,
and often does, take place under circumstances
very different from active inflammation, and that
sometimes two, three, or four of the symptoms here
detailed may be grouped together without deep-
seated inflammation of the brain, denominated hy-
drocephalus. You must therefore consider the his-
tory of the disease, which I have given, as a beacon
to excite alarm, and to urge you to press upon the
patient's friends the necessity of early professional
aid ; and when your professional friend has decided
that the patient is labouring under the formidable
disease which we are now treating of, you must
bear him out in the bold practice which he will re-
commend, and encourage the friends to submit to
what is proposed, by holding out reasonable hopes
of recovery, particularly if the disease be in its first
stage, for hydrocephalus is by no means the neces-
sarily fatal disease it is generally imagined to be.
The practice consists in bleeding, purging, af-
fecting the system with mercury, and applying cold
to the head. The bleeding must be both general
and topical ; from four to eight ounces of blood, ac-
cording to the age of the little patient, should be
taken from the arm, and from six to a dozen leeches
ON INTERNAL INFLAMMATIONS. 353
applied to the temples or forehead. Calomel com-
bined with jalap, and followed up by an aperient
mixture of salts, should be immediately commenced
with, and continued till brisk purging is effected.
The hair should be cut short, and the head enve-
loped in cloths kept wet and cold with vinegar and
water, and a blister may be applied between the
shoulders, but not on the head. After the bowels
have been acted upon six or eight times, calomel in
doses of one or two grains is to be given every two,
three, or four hours, according to the urgency of
the symptoms, and with this I am in the habit of
combining digitalis, giving a quarter of a grain of
the powder to a child of eight or nine years of age
with alternate doses of the calomel, that is once in
six or eight hours ; or sometimes I prescribe five
or six drops of the tincture in a saline draught, or
in a little dill- water or other aromatic. The digi-
talis is given in the early stage of the disease with
a view of reducing vascular action, and in the latter
stage as a diuretic. The general bleeding will
sometimes be to be repeated, and the leeching
always ; and the whole depleting and mercurial plan
of treatment is to be persevered in until great im-
provement is apparent, or until evident symptoms of
feebleness and sinking begin to show themselves.
The viscera or organs in the chest, which is the
second great cavity, are the heart and lungs, both
of which, with the serous membranes that invest
them, are not unfrequently the seat of inflammation.
,'354 ON INTERNAL INFLAMMATIONS.
INFLAMMATION OF THE HEART is called carditis,
and that of its investing membrane pericarditis, but
for all practical purposes they may be treated of to-
gether. When a person in previously good health is
seized suddenly, or immediately after a chill fit and
succeeding hot fit, with an acute and permanent
pain in the left side of the chest, without cough,
and with little, if any, difficulty of breathing, you
may reasonably suspect inflammation of the heart.
The other symptoms are a full hard pulse, some-
what quicker than natural, and sometimes irregular
or intermitting, and all the usual symptoms of high
inflammatory fever. The exciting cause of such an
attack of simple active inflammation of the heart is
either exposure to cold and moisture, excessive
bodily exertion, or imprudent indulgence in cold
drink whilst heated with exercise. It is, however,
a rare disease. The treatment of it is active deple-
tion by bleeding and purging, very low diet, mode-
ration in the quantity of drink even if it be plain
water, and complete rest or avoidance of exertion.
There is another species of inflammation of the
heart, or more frequently of the membrane that
covers it, which is of more common occurrence;
and this is rheumatism of the heart. It seldom, if
ever, comes on as an original attack of disease, but
during the progress of acute rheumatism, or, as it is
commonly called, rheumatic fever. At any period
of the acute stage of this painful disorder the heart
may suddenly become the seat of severe pain, and
ON INTERNAL INFLAMMATIONS. 355
the beating of it become inordinate both in frequency
and force ; in which case the pulse of course par-
takes of the same disturbed action, becomes rapid,
and full, but not always hard ; it is also generally
unequal and intermitting. It sometimes happens
that these symptoms arise simultaneously with the
cessation of the original rheumatic pains and swell-
ings of the joints, but this is by no means univer-
sally the case, for I have frequently seen the symp-
toms of carditis arise and become intense, without
any diminution of swelling, tenderness, or pain on
motion of the rheumatic limbs. Neither is it the
consequence of neglecting the bold depletory prac-
tice recommended for acute rheumatism, for I think
I may say, that I have observed in my own practice
that it has occurred most frequently where general
bleeding had been carried to the greatest extent ;
yet even in these cases the inflammatory nature of
the attack on the heart and heart-purse cannot be
doubted, as its consequences have been plainly de-
veloped by after-symptoms, and have been satisfac-
torily proved by examinations after death.
The treatment of rheumatic inflammation of the
heart requires great judgment, and I must caution
you against taking away blood to the extent recom-
mended in simple carditis. A few ounces drawn
from the arm will mitigate the pain and moderate
the tumultuous action of the heart, and this small
bleeding may be repeated daily, or on every alter-
nate day, till by this and other means the symptoms
336 ON INTERNAL INFLAMMATIONS.
of inflammation are subdued : the other means con-
sist in giving discreetly colchicum, digitalis, calomel,
and anodynes ; and in improving the previous low
regimen temperately, by giving now and then a
tea-cupful of strong broth, and even a little weak
wine and water, when the sensation of sinking re-
quires it. I prefer giving a moderately full dose of
colchicum, say forty drops of the wine of colchicum
once in twenty-four hours, rather than small doses
more frequently. Eight or ten drops of tincture of
digitalis with twenty of Hoffman's anodyne may be
given in a saline draught every six hours, and one
or two grains of calomel with the eighth of a grain
of opium also every six hours in the intervals be-
tween the doses of the former medicine. The or-
dinary effects of inflammation of the pericardium,
as of all serous membranes, are either adhesions,
or a deposition of serous fluid pellucid or opaque,
homogeneous or containing filaments or flocculi of
denser matter. The consequence of adhesions is a
disturbed action of the heart, and sometimes its
enlargement, for the removal of which no medical
treatment will avail, but a quiet life and avoidance
of everything likely to increase the action of the
heart must be strictly enjoined. For the dropsy of
the heart, digitalis with mild mercurials steadily
persevered in, will often prove a temporary and
sometimes a permanent cure.
I may now take leave of this subject by observ-
ing, that when rheumatism of the heart has once
ON INTERNAL INFLAMMATIONS. 357
taken place, palpitations and a hurried state of cir-
culation are ever after easily excited, and similar
attacks of a rheumatic character are more likely to
occur. I am also disposed to believe, that original
slight malformations of the heart dispose to its be-
coming the seat of rheumatic inflammation during
the attacks of rheumatic fever.
Inflammation of the mucous membrane lining the
air-tubes and air-cells of the lungs is called BRON-
CHITIS. We have already mentioned the symp-
toms and described its treatment, first in the letter
on fevers, where we stated that this species of in-
flammation is not an uncommon attendant on fevers
in certain seasons ; and again in the eleventh letter,
where we described catarrh or a common cold as
being a mild or moderate degree of bronchitis. We
must now therefore speak of it in its genuine form,
as unconnected with ordinary fever, and in a se-
verer grade than when denominated catarrh. It is
a disease of the cold months, and it usually invades
the patient after an undue exposure to cold and
wet. A sensation of tightness and soreness diffused
over great part of the chest, particularly in front
under the sternum or breast- bone, with so much
pain in taking a full inspiration as to make the
breathing very short and very quick, and the pain
so augmented by coughing as to induce the patient
to suppress it all he can, which gives it the cha-
racter described by the terms short, hacking, sup-
pressed cough, these together with alternate chilli-
ness and feverish heat, and a quick pulse with
358 ON INTERNAL INFLAMMATIONS.
transient and wandering pains, constitute the early
symptoms. The breathing soon becomes wheezy
and occasionally whistling, when carefully attended
to by placing the ear close to the patient's chest,
and the cough, at first dry, soon becomes attended
with copious expectoration of thin, glairy, saltish
mucus, but without relief to the soreness in the
chest or to the pain and distress in coughing. In
cases, which are to terminate favourably, the mucus
expectorated becomes in two or three days thicker,
more tenacious, and more opaque, the cough is now
not so incessant, the fever abates, and after an in-
definite period from one to two or three weeks the
cough and expectoration have gradually ceased,
and the breathing has become natural. In very
severe cases, particularly in young children, when
the disease is not controlled by medical treatment,
the cough does not decrease in frequency, the
wheezing increases, the breathing is more hurried
and laboured, the lips become purple, the extremi-
ties cold, clammy perspirations break out, and the
patient dies suffocated by the accumulation of mu-
cus, which he is unable to expectorate. The dan-
ger is considerably the greatest in very young and
in very old patients. In the latter the disease often
comes on more insidiously, the fever is not high,
and the powers of expectoration being feeble, the
patient seems to be carried off by suffocation, where
there has been but a very moderate degree of pre-
vious inflammation.
The treatment of bronchitis has been pretty fully
ON INTERNAL INFLAMMATIONS. 359
detailed in the letters formerly referred to, and I
need here only recapitulate, that after one pretty
copious bleeding in adults, and free leeching in
young children, the tartar emetic is to be mainly
relied on, alone in the early stage of the disease,
and combined with hyoscyamus, or paregoric elixir,
after the first few days. From a full-grown person
take away twenty ounces of blood, give two cathartic
pills and half an ounce of salts, and then a quarter
of a grain of tartar emetic every four hours ; con-
fine your patient to his bed, supply him with warm
tea, barley water, and thin gruel, and if there is
still much pain and soreness on the second day,
rub the tartar emetic ointment on the chest If
the cough comes on in distressing paroxysms, par-
ticularly in the night, so as to prevent sleep, and
after the mucus expectorated has become more
opaque, I do not hesitate to give one full anodyne,
as two grains of opium with four of antimonial pow-
der, and on the following nights from four to six
grains of extract of henbane. In infants the bleed-
ing must be by two or three leeches ; the first dose
of tartar emetic should be enough to act as a
vomit, say half a grain, and afterwards about a
twelfth of a grain every four hours. In very old
persons the bleeding must be moderate, unless it
can be had recourse to within a few hours from
the commencement of tightness, soreness, and
painful cough : in which case a bleeding to the ex-
tent of fourteen ounces will be borne well. The
360 ON INTERNAL INFLAMMATIONS.
tartar emetic must be given with caution, and not
persevered in if signs of feebleness, with more and
more noise in the breathing, indicate increasing
accumulation of mucus in the lungs ; but under
these circumstances three or four grains of ammo-
nia in a fever draught, with five grains of squill
pill, must be given every two or three hours. These,
however, are always cases of great danger, and re-
quire for their treatment all the judgment and acu-
men of the established practitioner.
INFLAMMATION OF THE PLEURA, which is the
lining membrane of the cavity of the chest, and
by its duplicature the investing or covering mem-
brane of the lungs, is called Pleurisy ; but for
practical purposes it need not be treated separately
from general and acute inflammation of the sub-
stance of the lungs, which is called Pneumonia.
When a patient is suffering acute deep-seated
pain in one side of the chest, which is increased
by a full inspiration, but not by moderate pres-
sure on that part of the surface of the chest corre-
sponding to the pain ; and when there is cough,
which is excited or aggravated by a deep inspi-
ration; and when these symptoms are attended
with a full hard pulse, feverish heat and thirst,
and a foul tongue; you may fairly infer inflam-
mation of the lungs, or of the pleura, or, as is
frequently the case, of both. The above symp-
toms have usually been preceded by shivering, and
the ordinary signs of a febrile paroxysm. I need
ON INTERNAL INFLAMMATIONS. 361
scarcely tell you that bleeding here is the sheet-
anchor. The extent to which it must be carried
is of course to be regulated by the violence of the
attack ; but you must bear in mind that in no other
disease is this remedy to be more freely or confi-
dently resorted to ; and as fainting from the loss of
blood is really desirable, the opening into the vein
should be large, and the patient should either stand
or sit erect during the operation. From twenty to
thirty ounces of blood will not be too much to be
drawn the first time, which will usually relieve or
for a time remove the pain. If the pain return, or
is aggravated, after ten or twelve hours, sixteen or
twenty ounces more may be drawn, and it very
seldom occurs that any further repetition is re-
quired. A recurrence of pain may, however, take
place in the progress of the disease, in which case
bleeding will still be the all-important remedy, and
particularly if a free expectoration has not been
established ; and at this period leeches may be ap-
plied over the seat of pain, when there is a doubt
as to the admissibility of another general bleeding.
Purging by calomel and colocynth and salts must
be effected early, to reduce the inflammatory ten-
dency. Tartar emetic in quarter-grain doses every
four or six hours is the next remedy, and tends
greatly to promote expectoration, which it is of great
importance to bring about early. If inflammation
is still supposed to be going on after two or three
days, I then think it advisable to commence with
R
362 ON INTERNAL INFLAMMATIONS.
two grain doses of calomel every four hours, com-
bining with each dose three or four grains of ex-
tract of henbane to allay the cough ; and if there
has been little or no sleep, I do not hesitate order-
ing a grain and a half or two grains of opium with
the night dose, provided that bleeding has been
freely resorted to ; but I very seldom repeat this
full dose, unless in protracted cases. A blister
should be applied over the seat of pain after the
first or second bleeding ; a strictly low diet must
of course be observed : and now I may say that I
have given you the bold outline of the treatment of
inflammation of the lungs ; leaving, however, many
minutiae of practice for the exercise of the judg-
ment of the medical practitioner in attendance. The
age and previous constitution of the patient, the
degree of violence of the attack, the early or late
period at which medical relief is first resorted
to, and a variety of other circumstances, will require
much consideration, and demand tact in the adop-
tion of remedial measures.
When inflammation is confined to a small portion
of the lungs, it is often insidious in its attacks, its
symptoms are much less violent, and are less under
the control of medical treatment. Its conse-
quences, if the inflammation be of a simple cha-
racter, and the proper remedies, as local bleeding,
blistering, moderate purging, and strict adherence
to a spare diet, have been timeously applied, are
seldom serious. If any consequences remain, they
ON INTERNAL INFLAMMATIONS. 363
are adhesions, and perhaps partial condensations,
which, though permanent, only slightly impede the
healthy office of the lungs. But when inflamma-
tion is excited in morbid growths, called tubercles,
seated in the substance of the lungs, then indeed
we have that destructive disease, so well known
throughout these isles under the name of con-
sumption.
CONSUMPTION is not of such frequent occurrence
in the fens, where we both reside, as in more ele-
vated situations, and it does not prevail so much in
an agricultural as in a manufacturing population.
You may, however, prepare yourself to meet with
many cases even in your present abode ; for, upon
looking into the tables of diseases kept at our dis-
pensary, I find upon an average of twenty years
not less than twenty-one cases annually recorded,
and this constitutes one in forty-two of all the
physician's patients.
Consumption occurs most frequently in persons
of fair and ruddy complexion, with light hair and
slender frame; it is intimately connected with
a scrofulous habit ; from which circumstances it
is apt to attack several individuals of the same
family, and is therefore called an hereditary disease.
It very commonly commences its ravages at that
interesting age between fifteen and twenty. It is
not absolutely confined, however, to any age, or to
any constitution. In its progress it is very various ;
sometimes running rapidly through all its stages,
364 ON INTERNAL INFLAMMATIONS.
and completing its fatal work in a few weeks, or
months, at other times occupying as many years.
The first symptom may be said to be a great sus-
ceptibility to take cold, and consequent frequent
occurrence of cough. The cough in its early stage
is usually of that character called a dry teazing
hacking cough ; and has not lasted long before the
patient looks more delicate than usual, is more
easily chilled by exposure to cold, is sooner fa-
tigued by exercise, is short of breath, and frequently
feels transient pains in the chest. The appetite
too is precarious, and the patient evidently loses
flesh. Sooner or later, after, perhaps, several
attacks of slight cold and cough, expectoration
commences, first of a simple frothy mucus, and
then of a thicker and more opaque mucus, which
still is not miscible with water, so as to make* it
turbid when stirred about in it. During the pro-
gress of one of these attacks of expectorating
cough, a little speck or streak of blood is per-
ceived on the surface of the expectorated mucus;
this mucus assumes more of a purulent appearance,
and at length it is genuine pus or matter, such as
is secreted from an abscess or ulcer. The friends
of the patient cannot now but see his altered mien ;
a pallid countenance with occasional febrile flushes,
a general falling off" of strength and flesh, from
which the disease has gained its name, a deep
sepulchral voice and cough, with profuse night
sweats, and frequently an exhausting diarrhoea or
ON INTERNAL INFLAMMATIONS. 365
purging; these are the fatal signs of confirmed
consumption drawing to its close. Sometimes in
a ruddy looking youth of either sex, of what is
called a sanguineous temperament, the first symp-
tom threatening consumption is a sudden copious
spitting or rather coughing of blood, commonly
designated the breaking of a blood-vessel. This,
however, does not imply that there must have
been any great or sudden exertion. It sometimes
comes on after exposure to cold and a return to a
heated apartment, sometimes during the febrile
reaction after a chill, but sometimes in the night,
or during complete repose in the day-time. This
profuse bleeding is very apt to recur after a few
days, or a few weeks ; and small quantities usually
appear in the sputa, or matter spit up, for several
days after each attack. Sooner or later such pa-
tients exhibit all the other signs of consumption
and the fatal termination is not long deferred, par-
ticularly if the patient be young, that is, under
twenty-five or thirty years of age.
In describing the treatment of this scourge of
English youth, of both sexes, we must acknow-
ledge, notwithstanding the many vaunts of cure
by regulars and irregulars, that we profess only to
point out means of occasionally suspending the
disease, and of now and then arresting its progress,
but never of repairing the ravages which it has
once committed on the delicate tissues of the lungs,
or of removing by remedial means the morbid tu-
366 ON INTERNAL INFLAMMATIONS.
bercles, with which the substance of the lungs is
studded in those persons who are predisposed to
the malady.
When it is suspected from family predisposition,
from constitutional peculiarities, or from other early
premonitory symptoms, that the seeds of consump-
tion, to speak figuratively, are already sown, it be-
hoves the friends to adopt such precautionary means
as are likely to ward off the mischief ; of these a very
important one is regular and healthful exercise,
avoiding violent exertions, but habituating the
constitution to sustain a moderate degree even of
fatigue in the ordinary amusements of childhood
and of youth. In the next place, the clothing
should be warm in the winter and spring by wear-
ing flannel next the skin by day, and calico by
night. The chest should be well defended by high
dresses, and the feet kept warm by socks, and stout
shoes when out of doors. Plentiful and frequent
ablution, succeeded by friction, is highly service-
able, as the shower-bath, once or twice a week, and
the daily sponging of the chest with vinegar and
water, tepid in winter, and cold in summer, and
followed by well rubbing the surface of the body
with a coarse towel, with flannel, or with the flesh-
brush. The diet should be nutritious but not sti-
mulant, as milk twice a day, and meat with potatoes
or other vegetables, and some sort of plain pud-
ding, once a day ; with toast and water or milk
and water for drink. I have purposely avoided
ON INTERNAL INFLAMMATIONS. 367
any recommendation to you to use the stethoscope
in ascertaining the presence or extent of consump-
tion, though I entertain the highest opinion of its
utility in the hands of experienced persons. The
external exploration of the chest by means of this
instrument and by percussion is one of the greatest
improvements in the study of disease, which this
age has to boast of; but to take advantage of it
requires more experience than any unprofessional
person can be supposed to have.
When the disease has made its appearance, the
medical treatment must be regulated by the nature
and violence of the symptoms, and must vary too
as the grouping together of the symptoms varies.
I with the ordinary appearance of a cold, there is
soreness of the chest, and quick breathing, as well
as quick pulse, give antimonials as directed for
bronchitic affections ; if there are pains in the
chest, aggravated by deep inspiration, add local
bleeding and blistering to the antimonial treatment.
Should there be cough without febrile disturb-
ance, allay it by anodynes, as the cough pills, or
paregoric elixir. When the fever is beginning to
assume a chronic character, returning every even-
ing, or twice in the four-and-twenty hours, with
flushed countenance, leaving much languor and
paleness in the intervals, and with a rapid pulse,
digitalis every eight hours, as ten or twelve drops
of the tincture in a saline draught, and half a
grain of quinine twice a day, given at times when
368 ON INTERNAL INFLAMMATIONS.
the fever is off, may be prescribed ; and if not
contra-indicated, the dose of each may be gradually
increased ; indeed the effect of digitalis is so un-
certain, that the dose should always be moderate
at first, and increased daily by five drops in each
dose, until the pulse is sufficiently reduced, un-
less giddiness, fainting, or sickness occur, in which
case the dose must be again diminished by five
drops. If in the progress of this malady a spit-
ting of blood occurs, it must be treated as directed
in my letter on hemorrhages ; and when, as also
frequently happens, a diarrhoea or purging takes
place, it must be restrained by chalk mixture
and laudanum, as directed on former occasions.
The profuse perspiration, which so frequently
occurs during sleep in the advanced cases of con-
sumption, is sometimes controlled by acids, as
ten or twelve drops of elixir of vitriol two or
three times a day ; and this I usually combine with
laudanum or henbane, when the cough and expec-
toration are at the same time urgent symptoms.
Thus, you see, all that I suggest in the treat-
ment of this disease, only goes to the mitigation
of symptoms, for I frankly confess that I know
of no panacea, no single remedy, for consumption,
nor indeed any defined plan that is applicable in
all cases; and as the judgment of the practitioner
must be exercised, to decide upon the appropriate
practice in each individual case, I shall close these
desultory observations by one or two other instruc-
ON INTERNAL INFLAMMATIONS. 369
tions for cases that are not arrived at a hopeless
stage. It frequently occurs that young females
predisposed to this disorder lose their colour, be-
come listless, and indisposed to take exercise, have
precarious appetites, and experience a diminution,
or perhaps total suppression of their accustomed
natural and healthful discharge. Whether this
morbid state occurs previously to any chest affec-
tion, or after one or more attacks of cough with
mucous expectoration, the proper treatment is to
give the compound steel pills or steel-drops,
with moderate doses of quinine ; and this may be
cautiously tried, even when the patient is labouring
under some cough, in which case the quinine may
be made into pills with the extract of henbane,
one grain of the former to three of the latter for
a dose, to be taken every six hours. In more ad-
vanced cases of the disease, when the expectora-
tion has just assumed a puriform appearance, but
does not bear all the characters of pure pus, it has
sometimes proved serviceable to open an issue, or
form a seton in the side over the part, where, from
the pain and other internal sensations, the patient
believes the principal mischief to be going on, and
the trial ought, therefore, always to be made.
In all cases, and in all stages of the disease, expo-
sure to cold is to be avoided, and, as far as can be
done, a regulated temperature should be main-
tained through the winter months; and I must,
before I conclude, say a few words on the subject
370 ON INTERNAL INFLAMMATIONS.
of a change of climate, though it can hardly be
supposed, that cases of consumption will often come
under your cognisance, where such a change of
abode is practicable. I have never seen or known
any good to result from removing a patient to a
distant clime, when the disease was far advanced ;
but I have known the greatest discomfort and dis-
tress arise to the patient, and the friends, from a
voyage to the West Indies, or to a less distant
region, under such circumstances. In the early
stage of the disease, or where the propensity to it
is indubitable, though the ravages have not com-
menced, I have no doubt of considerable benefit
being the result of removal to a warmer situation,
but it must be a protracted residence through
several years, or temporary ones for several succes-
sive winters, that can be expected to eradicate the
tendency. When, therefore, a patient can take up his
abode in the south of France, or some favourable
spot in Italy for five or six years, or when he can
sojourn in Devonshire, or at Hastings in Sussex,
or on the continent, from October till May, and
will repeat his visit for five or six successive win-
ters, I am a very strong advocate for its being done.
The contents of the third great cavity, the abdo-
men, are numerous; but as acute inflammation of
some of these viscera has but few distinctive marks,
and as the treatment of them varies but little, I shall
not describe them all separately. We shall begin
with PERITONITIS, which is an inflammation of the
ON INTERNAL INFLAMMATIONS. 371
peritoneum, the anatomical name for the serous
membrane which lines the whole cavity, and by
its various foldings covers separately every viscus.
This inflammation may commence on any part of
its surface, may be confined to the covering of
a single organ, or even only a portion of it, or it
may extend over the greater part, or even the
whole of the lining membrane. As the parietes
or external parts of the abdomen are soft, it will be
easy to satisfy yourself by gentle pressure as to the
seat and extent of the disease, by the tenderness
and pain which will be excited. Partial inflamma-
tion to a small extent is usually a chronic affection,
and not so easily detected ; but when an extensive
surface is inflamed, the disease is acute, the pain on
pressure over any part of the abdomen is great, the
whole body is distended, arid the patient is observed
to lie with his knees drawn up, this being his easiest
posture ; there has been chilliness if not shaking
preceding the feverish heat, the pulse is very quick,
and perhaps hard, but not so full as in other active
inflammations, the tongue is much furred, and
there is great thirst. After a restless and almost
sleepless night or two, if the progress of the disease
is not checked, the patient becomes delirious, the
pulse extremely rapid and small, the pain, which
had become intense, gradually abates, the body is
more distended, perspirations break out, which
afford no relief, the surface becomes cold and
clammy, the breathing is short, the muttering
372 ON INTERNAL INFLAMMATIONS.
delirium nearly constant, and the pulse more and
more feeble till death closes the scene. Early ab-
straction of blood is the grand remedy ; one copious
bleeding from the arm, if immediately followed by
the application of from twenty to forty leeches over
the tender part, will generally break the neck of
the disease ; but both must be repeated within four-
and-twenty hours, if great relief has not been
obtained. It must be here observed, that exten-
sive leeching is more serviceable in this than in
most active inflammations, and the repetition of
general bleeding is not well borne when the disease
is advanced. The medicines most to be depended
upon, after active purging, are calomel, antimony,
and opium combined. Two grains of calomel and
half a grain of opium in a pill, with the sixth
or eighth of a grain of emetic tartar in a fever
draught, may be given every four hours. Warm
fomentations after the leeches, first by poultices,
afterwards by flannels wrung out of hot water,
should be assiduously applied, till the pain and
tenderness have greatly abated, and then, and not
before, a large blister may be put on. A piece of
hot flannel slightly sprinkled with oil of turpentine,
and applied over a considerable portion of the ab-
domen, acts speedily as a rubefacient, and is often
very beneficial ; it should therefore not be neglected
whenever the bleeding, general and local, has
failed to produce abatement of pain in a satisfactory
degree.
ON INTERNAL INFLAMMATIONS. 373
The effect of this peritoneal inflammation, when
not subdued in its early stage, and when not
sufficiently extensive or severe to bring the case
speedily to a fatal termination, is either to produce
adhesion of parts, which ought to move freely over
each other; or to allow of the accumulation of
fluids in the cavity of the abdomen, constituting
dropsy. The former may be attended with some
inconvenience, and partial interruption to the func-
tions of the implicated organs ; but the latter is
always a severe and frequently a fatal malady,
which, however, will come presently to be con-
sidered more in detail,
ACUTE INFLAMMATION OF ANY OF THE DIFFER-
ENT VISCERA contained in the Abdomen, is gene-
rally ushered in by the same febrile symptoms, as
rigors or shiverings, succeeded by heat, full, hard,
and quick pulse, great pain and tenderness on
pressure over the inflamed organ, foul tongue,
headache and thirst ; but some peculiar symptom
or symptoms arising from disturbed action of the
particular organ, together with the locality of the
pain, will enable a skilful practitioner to define the
viscus affected. Thus pain at the pit of the sto-
mach, increased after eating or drinking, and
frequent vomiting, indicates inflammation of the
stomach ; a bilious countenance, loaded urine, dark
green or tarry brown fecal evacuations, with acute
pain on the right side just below the ribs, and a
sympathetic pain in the shoulder, are symptoms of
374 ON INTERNAL INFLAMMATIONS.
hepatitis, or inflammation of the liver; augmenta-
tion of deep-seated pain, or the temporary allevia-
tion of it, upon the sensation of flatus or other
matter moving about in the bowels, painful hard
distension confined to one portion of the bowels,
with costiveness, and perhaps vomiting, are the
characteristics of enteritis, or inflammation of the
bowels. Painful and frequent making of high-
coloured urine, with urgent pain in the loins, in-
creased on pressure, or at the lower and front part
of the body, points out inflammation of the kidneys
or of the bladder.
The practice in all these various inflammations
is to bleed both generally and locally, to use the
warm-bath and fomentations, to open the bowels
freely, and to give sudorific febrifuges. If the
stomach is inflamed, the mildest diluents should
be given, and these sparingly ; the fever-draughts
should be small in quantity, and given in a state of
effervescence; and when the vomiting continues
after leeching and fomentation, apply a blister to
the pit of the stomach, and add four or five drops
of laudanum to each effervescing draught.
In inflammation of the liver, calomel purges are
more particularly called for ; and if yellowness of
skin, and either too pale or too dark alvine dis-
charges, continue after the acute symptoms of
inflammation have been subdued, calomel, with or
without opium, must be persevered in two or three
times daily for a week or more.
ON INTERNAL INFLAMMATIONS. 375
When the kidney is the seat of inflammation,
and bloody urine, or gravelly deposit in the urine,
indicates irritation from calculous matter to be the
cause, soda pills, or solution of potash with lauda-
num, will be the appropriate remedy after cupping,
warm -bath, and moderate purging.
In inflammation of the bowels, besides copious
bleeding from the arm, and free evacuation of the
bowels, the warm-bath, external fomentation, and
simple warm -water glysters, once or twice daily,
are soothing ; and when inflammatory symptoms are
subdued, from forty drops to a dram of laudanum
may be added to the evening glyster ; and in these
cases great attention must be paid to satisfy your-
self that hardened lumps of faeces are not retained
in the bowels, which will sometimes be the case,
even though a natural purging is one of the symp-
toms ; these may sometimes be detected by careful
pressure over the abdomen ; and others may be
suspected, where one or more such lumps are de-
tected amongst the fluid faeces. Castor oil is an
excellent cathartic on such occasions.
Acute inflammation of the spleen requires no
particular treatment, and chronic inflammation of
that organ has been noticed as a consequence of
ague. Neither is there any occasion to particula-
rise the acute inflammation of those viscera which
are peculiar to the female sex, as they are to be
treated upon the general principles already laid
down.
376 ON INTERNAL INFLAMMATIONS.
It will ever be found in practice that for one case
of well-marked acute inflammation of any membrane
or viscus, whether of the chest or abdomen, you
will meet with many cases of moderate, or what is
called sub-acute inflammation, many cases where
the disease is partial in extent, occupying but a
small portion of the membrane, or the viscus, and
many cases of chronic inflammation, so defined
from the protractedness of the disease. All these
varieties occur of every grade, from the most severe
or acute to the most trifling, and the judgment of
the practitioner alone can decide the amount of
remedial measures required in each case. General
bleeding will seldom be called for, where the
disease has not caused general disturbance,
and local bleeding with blistering and fomenta-
tions will be the most efficacious means in all such
cases.
Of inflammation occurring in the various delicate
tissues, of which the EYE is anatomically composed,
I shall say very little, because it would be very pre-
posterous to suppose you acquainted with the com-
plicated structure of that important organ, and
without such knowledge it would be impossible
for you to comprehend any description of the
diseases to which it is liable, or to understand
the application of the various remedial measures
that are called for. I shall therefore only observe,
that should you ever be desired to inspect a com-
mon inflamed eye, where the part that should be
ON INTERNAL INFLAMMATIONS. 377
white is covered with red vessels, and there is great
intolerance of light, you cannot do wrong in order-
ing leeches, and administering a dose of physic, to
save time, ere the surgeon arrives; or should you
be consulted by a person who is habitually subject
to soreness of the edges of the eyelids, which are so
closed or glued together in a morning as to be
opened with difficulty, you may confidently recom-
mend the golden ointment, or what is equally effi-
cacious, and much cheaper, the red precipitate
ointment ; and this is to be applied by means of
a cainel-hair pencil charged with a little of the
ointment softened by heat, which is to be drawn
along the roots of the eyelashes every night at
bed-time.
For similar reasons I shall refrain from treating
of diseases of the ear ; but I may, without impro-
priety, recommend a very simple remedy in cases
of casual ear-ache, which is usually brought on by
cold, and is a common complaint in childhood;
it is to drop a little cold water into the ear, and,
if it relieves the pain for a time, to repeat it as
often as the pain recurs.
378
LETTER XIII.
ON VARIOUS CHRONIC AILMENTS.
MY DEAR SON,
BESIDES those chronic or protracted diseases which
have already fallen under our notice in connexion
either with sudden seizures, as epilepsy, St. Vitus's
dance, and hysterics ; or with eruptive or other
fevers, as all the varieties of chronic eruptions,
neuralgia, &c. ; there are many other disordered
states of the constitution, of a chronic character,
which have acquired specific names, the most im-
portant of which I shall treat of in this concluding
letter. The two first of these, rheumatism and
gout, I might perhaps with equal propriety have
included amongst acute diseases, and have treated
of them in former letters, as in that on fevers, or in
the last on inflammations ; but although they do
sometimes exhibit febrile and acute inflammatory
symptoms, they are so dependent upon peculiar
permanent conditions of the constitution, and con-
sequently produce such frequent and protracted
states of indisposition, that they may with equal
propriety at least be classed amongst chronic dis-
eases.
To begin then with RHEUMATISM ; it is a pain-
ful inflammatory affection of the tendons of muscles,
and other parts of a similar anatomical formation.
ON VARIOUS CHRONIC AILMENTS. 379
In the young and fall-blooded, where there is a
constitutional tendency to it, and particularly in
the early attacks of the disease, there is considera-
ble inflammatory swelling of one or more of the
large joints, and so much constitutional febrile dis-
turbance, that it has in this form acquired the
name of rheumatic fever. The exciting cause of
such an attack is usually exposure to cold, the first
effect of which upon the constitution is to set up
an inflammatory fever, which in many cases, but
not in all, commences with chilliness. Sometimes
with the first attack of the fever, but oftener on the
second or third day, come on severe pain, swelling,
and redness of some of the large joints, usually of
the knees, ankles, elbows, or wrists, rendering any
motion of them painful; the feverish heat conti-
nues with a quick, full, and hard pulse ; the pain
of the joints and the swelling and redness around
them increase, so that, if many parts are affected at
the same time, the patient is unable to turn over in
bed, or to move hand or foot. The tongue is thickly
coated with a white or cream-coloured fur, and its
edges are often of a bright red, the urine is high-
coloured, and deposits a brick-dust coloured sedi-
ment. Sleep is prevented by the pain, and the
restlessness is sometimes attended with delirium.
If uncontrolled by medicine, the duration of the
disease varies from a few days to two or three
weeks, and the convalescence is slow. Happily,
however, it may be much controlled by judicious me-
380 ON VARIOUS CHRONIC AILMENTS.
dical treatment, and convalescence be thus rendered
more speedy, and a chronic form of the disease,
which is its usual consequence, may be thus greatly
obviated.
After one general bleeding in most cases, or a
second within twelve hours if the fever is high, and
a full dose of cathartic pills and Epsom salts, we
may proceed to give colchicum, which, in rheuma-
tism as well as in gout, seems to have a specific in-
fluence over the disease. At the commencement
of the attack I prefer a full dose at bed-time to
smaller doses frequently repeated, and therefore
order from forty to sixty drops of the wine of col-
chicum, according to the violence of the attack, and
if the first dose is not productive of considerable
relief, and followed by some refreshing sleep, I
combine twenty or thirty drops of laudanum with
the same dose of colchicum next night. In the in-
tervals I usually order a quarter of a grain of tar-
tar emetic in a saline draught every four hours.
But if on the second or third day the local inflam-
mation is not materially subdued, I order a compe-
tent number of leeches, and give the colchicum in
smaller doses and more frequently, about fifteen
drops every six hours. Under these circumstances
I give an intervening dose of the tartar emetic, if
the inflammatory predisposition is strong, or four
grains of Dover's powder at the same intervals, if
the patient has but feeble stamina, or if the red-
ness and swelling are not proportionably great with
ON VARIOUS CHRONIC AILMENTS. 381
the pain. The bowels at the same time must be
kept freely open by a cathartic pill every night, and
a seidlitz draught every morning. The diet must
be low, and the drink simple diluents, as milk por-
ridge, plain gruel, tea, and barley-water. In se-
vere cases and robust constitutions, I do sometimes
repeat the general bleeding, but of this I am the
more cautious, because I think that I have ob-
served rheumatic inflammation of the heart, as
stated in a former letter, to be more apt to occur
where general bleeding has been most frequently
resorted to. Leeching, however, over the parts
most inflamed may be frequently repeated during
an attack of rheumatic fever, and this, with the sub-
sequent poulticing and warm fomentations, affords
the greatest relief, both of pain and swelling, that
can be obtained from external applications. In the
intervals of the leeching, and to the affected joints
not under treatment by leeching, an evaporating
lotion, applied warm, will prove soothing and agree-
able ; what I generally use for this purpose con-
sists of one part of spirits of wine and camphor to
five or six of weak goulard.
For one case of acute rheumatism, such as I
have now described, you will meet with scores of
cases of a more moderate character, or a more
chronic form. Persons not particularly liable to
rheumatism are frequently troubled with local pains
after exposure to cold streams of air, after getting
wet, or from travelling in cold damp weather.
38*2 ON VARIOUS CHRONIC AILMENTS.
These pains are of a rheumatic character, and when
they occur pretty extensively, nothing is so ser-
viceable as a. warm- water or vapour-bath ; and next
to that the application of warm water to the feet
and vapour to the head, as directed when treating
of colds. In combination with this, or where such
bath is not procurable, or not deemed necessary,
warm diluents should be taken at bed-time, as also
directed in the letter referred to. Where the
rheumatic pains are more partial, sponging with
warm water in the first instance, and wrapping the
part in flannel at night for the first few days, and
the application of some stimulant afterwards, as
brandy, hartshorn and oil, or warm water with a
little mustard in it, followed by brisk friction with
a coarse towel, and then covering the part with
flannel, will prove as serviceable as any of the hun-
dreds of recipes with which the newspapers and
periodicals and family receipt-books abound.
When persons, who are constitutionally liable to
attacks of rheumatism, are exposed to cold, damp,
fatigue, or distress of mind, or when their digestive
organs are from any other cause deranged, they
almost invariably are seized with pain and swelling
of some of the joints, and in such constitutions the
smaller joints are as subject to the attack as the
larger ones. In such cases leeches are to be ap-
plied to the parts in number proportioned to the
amount of inflammation; alterative doses of blue
pill and seidlitz are to be administered in modera-
ON VARIOUS CHRONIC AILMENTS. 383
tion, and the colchicum with or without opium
should be given at bed-time. It is in such cases as
these that a course of warm bathing at Bath or at
Buxton, with the regulated diet and early hours
usually observed by invalids at watering-places, is
more particularly serviceable. When in such con-
stitutions some one part remains afflicted with
rheumatic pains after the treatment here recom-
mended has subdued the local inflammation, and
improved the general health, external stimulants
and friction long persevered in, have frequently
very much mitigated, if not wholly removed, the
pain, and restored pliability to a stiffened limb.
Warm brine and then essence of mustard may be
first tried, and if these do not succeed, I recom-
mend the turpentine embrocation, which is to be
applied by means of a small painter's brush, and to
be washed off with soap and water as soon as
smarting or a tingling sensation in the part indi-
cates its rubefacient effect ; after which the flesh-
brush, or a ball of flannel which forms a good sub-
stitute, must be assiduously applied as long as the
friction can be well borne. The application of this
embrocation and the friction may be repeated two
or three times a week, or oftener according to its
effect. Rheumatism of the heart has been treated
of under inflammation of that organ ; and of an at-
tack of rheumatism in any other part I shall only
observe, that when its nature is satisfactorily ascer-
tained, the treatment by local bleeding and fomen-
384 ON VARIOUS CHRONIC AILMENTS.
tation, and by colchicum, opiates, and alterative ape-
rients internally, is to be pursued, as just now re-
commended for constitutional rheumatism of the
joints.
SCIATICA, which is a painful affection of the
thigh and leg without redness or swelling, and
which commences about the centre of one buttock
and runs along the outside of the thigh to the calf
of the leg, and sometimes to the instep, has been
very generally considered a rheumatic affection;
but I am inclined to look upon it rather as an ex-
ample of neuralgia, and have therefore made a few
observations on it under that head. In its acute
state it has been usual to bleed both generally and
locally, but not often, I think, with advantage. A
blister is sometimes serviceable, and after an ordi-
nary purgative I treat the acute cases by calomel
and opium ; and the chronic cases by rust of iron
and other neuralgic remedies, as directed in a for-
mer letter.
GOUT comes next to be considered, and although
it is a distinct disease from rheumatism, the attacks
are in many respects so alike, and the constitu-
tional ailments so similar, that my description of
gout will principally consist in drawing a parallel
between the two disorders, stating the points in
which they resemble each other, and those in which
they differ. Gout, like rheumatism, usually attacks
the joints, but the early fits of it more generally
seize the ball of the great toe ; whereas rheumatism,
ON VARIOUS CHRONIC AILMENTS. 385
in its first attacks more frequently seizes the larger
joints. The redness and swelling are much alike
in both, but the tenderness to the touch is greatest
in gout, whilst the pain on moving the limb is per-
haps most acute in rheumatism. The exciting
causes of rheumatism are external, as cold, wet,
and fatigue ; those of gout internal, as indulgence
in eating and drinking, and whatever else deranges
the functions of the stomach; and the latter is
much more frequently a hereditary disease. Gout
shows many monitory symptoms, as heartburn,
loss of appetite, and momentary twinges in the part
about to be attacked ; thus it is not unusual for a
gouty person to awake in the middle of the night
with considerable pain and tenderness in the ball
of the toe, which goes off after a few minutes or an
hour or two, but returns regularly for two or three
nights successively before an acute attack ; and in
the day-time the patient is troubled with various
stomach affections. Rheumatism, on the contrary,
commences in most cases within twenty-four hours
of the application of the exciting cause without any
premonitory symptoms, and progresses regularly
till the attack arrives at its height. When large
joints are the seat of gout, and the inflammation is
considerable, the constitution becomes disordered,
and fever is induced as in rheumatism ; but it sel-
dom occurs that more than one or two large joints
are affected at the same time, and therefore the
feverish symptoms are less violent than in acute
s
386 ON VARIOUS CHRONIC AILMENTS.
rheumatism, where the shoulders, elbows, wrists,
knees, and ankles, are sometimes all involved in
the same attack. Gout is a disease of the rich only,
rheumatism of rich and poor, but more particularly
of the latter. Gout very seldom attacks the young,
except where hereditary predisposition is strong,
and it often appears in its severest form in those
who are past the middle age, and in such as are in
other respects feeble and debilitated. Rheumatism,
on the contrary, in its acute form, is a disease of
the vigorous and the young. Both complaints are
equally apt to recur again and again in the same
persons, and we therefore speak of gouty constitu-
tions, and of rheumatic constitutions ; and I must
further acknowledge that, after all which has been
said of their dissimilarity, there are many cases in
which even able practitioners feel at a loss to de-
cide whether to call them rheumatism or gout ; and
for such cases they have invented the convenient
phrase, rheumatic gout ; whether to hide their ig-
norance, or because they really believe them to be
cases of the two diseases combined, I will not pre-
tend to say ; at all events, we find the phrase a
convenient one, as it often satisfies the inquisitive
patient or his friends.
The medical treatment of gout is almost precisely
the same as that of rheumatism, with the exception
of the general bleeding which is so often required
in rheumatism, but is seldom if ever admissible in
gout ; it consists principally in leeching and warm
ON VARIOUS CHRONIC AILMENTS. 337
evaporating lotions externally, and colchicum, saline
aperients, and alteratives internally. The common
practice of wrapping up gouty limbs in flannel is
never required, except perhaps in such patients as
have formerly experienced a sudden removal or re-
trocession, as it is called, of the disease to the sto-
mach or head; but in all other cases the warm
lotion recommended in acute rheumatism is also
the most agreeable and useful in gout. Eau me-
dicinale, a French nostrum so much vaunted as
a remedy for gout, is well known to be a prepara-
tion of colchicum ; and the wine of colchicum as a
known remedy should always be preferred, and is
to be administered precisely in the same manner
as recommended above in the treatment of rheu-
matism.
It has been already observed, that an attack of
gout is usually preceded by symptoms of indiges-
tion, and by slight momentary twinges of pain.
This, of course, offers the opportunity of adopting
important preventive practice, and I have known
several instances of gouty subjects keeping off at-
tacks for many months, and even years, by promptly
resorting under such circumstances to a blue pill
and seidlitz powders, two or three times within the
week, and taking a few grains of soda, rhubarb, and
ginger daily, an hour before dinner ; and by ob-
serving at the same time more strictly the plain
and moderate diet so necessary to be attended to
s2
388 ON VARIOUS CHRONIC AILMENTS.
at all times by persons of a gouty habit. By a plain
diet, I mean confinement to one or at most two
dishes at dinner, and those simple, and not highly
seasoned, as plain pudding and a joint of meat, or,
instead of the latter,, game or poultry ; meat only
once a day, total abstinence from malt liquor, and
light brisk wines, as champagne and its imitations,
and drinking only two glasses of good sound wine,
port or sherry, at dinner-time. By moderate as
applied to eating, I mean (to state the matter con-
cisely) that every gouty person should leave off
hungry ; and I believe that by following such
rules, and adopting a good deal of exercise, and
early hours, even a strong disposition to gout may
be materially counteracted. When severe pain
suddenly seizes a gouty patient in the stomach, it
is to be promptly treated by strong stimulants and
opiates, as forty or sixty drops of laudanum in a
glass of hot strong brandy and water, or by some
of the many gout-cordials, of which each gouty
subject has his favourite one. At the same time
it is necessary to immerse the foot, or other part,
where gouty pains and inflammation have of late
appeared, but from which the gout has now disap-
peared or been repelled, in warm water, and to
rub it with flour of mustard. Though it is well
known that the application of cold will often
relieve both the pain and swelling in gout, I
do not myself recommend it, because it is equally
ON VARIOUS CHRONIC AILMENTS. 389
well known that alarming and even fatal instances
of misplaced gout have sometimes resulted from the
practice.
INDIGESTION, which is a disturbed state of the
function of the stomach, is another chronic ailment;
and I shall proceed to make a few observations on
it in this place ; it is called dyspepsia by medical
authors, and this term is now pretty generally un-
derstood by patients of a higher grade, though not
by such as fall under your gratuitous care. In
some persons the process of digestion is naturally
feeble and imperfect, but in most persons labour-
ing under indigestion, it has been rendered so by
repeated irregularities in diet, either as to quantity
or quality. The ordinary symptoms are general
uneasiness after meals, a sense of fulness with fla-
tulency, or of soreness, with heat at the pit of the
stomach, and a tenderness on pressure in that part,
also eructation of wind, and sometimes of small
quantities of food in an acid or acrid state, and oc-
casionally nausea with sickness, and the rejection
of the whole or of a greater part of the food taken.
The concomitants are headache, costiveness, loss
of strength and flesh, inaptitude to mental exertion,
and a long catalogue of diseases, as gout, gravel,
blue devils, &c. &c.
When a person experiences many, or only one
or two of the above symptoms, it is time that he
set himself resolutely to work to correct the grow-
ing mischief, and before you say anything to him
390 ON VARIOUS CHRONIC AILMENTS.
on the subject of medical treatment, you ought to
assure him, that much more depends upon himself
than upon his doctor, both as to cure and preven-
tion. We shall suppose that you are at first con-
sulted in consequence of an aggravation of some of
the foregoing symptoms, that you find your patient
complaining of fulness at the stomach and tender-
ness on pressure, perhaps tightness across the
chest and oppression in the breathing, intense head-
ache, a foul tongue, nausea and retching ; and that
you further learn, that he has lately taken a full
and hearty meal. This is characteristically called
a surfeit ; you must immediately give an emetic,
the stomach will thereby be emptied, and the symp-
toms relieved ; but if the full meal has been taken
some hours before, you must instead of an emetic
give a brisk purgative, as two of the purging pills,
and immediately afterwards a draught containing a
scruple of magnesia and a scruple of rhubarb in
peppermint water. In both cases you should en-
join strict abstinence for twelve hours, and great
moderation ever after. It more frequently happens,
however, that you are consulted by persons labour-
ing under indigestion in the chronic form, and that
you find your patient with most of the symptoms,
formerly enumerated, occurring occasionally, and he
tells you that he is liable to heartburn, flatulency,
a precarious or uncertain appetite, acid or watery
eructations, costive bowels, sick headache, and
low spirits. You will be expected to prescribe ap-
ON VARIOUS CHRONIC AILMENTS. 391
propriate medicines for these various symptoms, as
carbonate of soda or magnesia for acidity, pepper-
mint for flatulency, aloetic pills for costiveness,
blue pills and seidlitz powders for bilious head-
ache ; and all this will be perfectly right as far as
it goes, but you must also here again insist upon
abstemiousness, both in eating and drinking; and
you must give precise directions as to future man-
agement, or you will render your patient no per-
manent service. A dyspeptic person, as such a
patient is called, should always rise from his meals
hungry, should take very little fluid, and that at
the conclusion of his meal ; and the quality of what
he takes must be nicely regulated ; your instruc-
tions on this point must of course depend greatly
upon his former habits, and upon his present mode
of life as to occupation, &c. If the patient is young,
however, and robust, whatever his former habits
have been, he ought now to confine himself to ani-
mal food in moderation once a day, to porridge, or
gruel, or boiled milk, morning and evening ; or, if
habit has rendered tea or coffee necessary, it should
be weak and in small quantity, and its hurtful
qualities mitigated by the addition of a considerable
portion of milk ; and he should either abstain al-
together from fermented liquors, or confine himself
to half a pint, or at most a pint, of home-brewed
table-beer at dinner-time. But to persons of feeble
constitution, or to those who have long habituated
themselves to stimulating diet and fermented li-
392 ON VARIOUS CHRONIC AILMENTS.
quors, meat may be allowed twice a day, as at
breakfast and dinner, if the dinner hour be late ; or
at dinner and supper, if the former be taken as
early as one or two o'clock. Half a pint of table-
beer or porter may be allowed at dinner and again
at supper, if he be a labourer, or a person actively
employed ; or one or two glasses of wine, or a little
weak brandy and water may be taken at the con-
clusion of dinner by patients of less active habits,
or by such as have formerly accustomed themselves
to either.
Of meats, it is now pretty generally known, that
beef is better than veal, mutton than lamb, that
game is more easily digested than butcher's meat,
and that all meat is rendered fitter for the stomach
by keeping. Soups and broth are not so nutritious
or easy of digestion as they are generally thought to
be, unless a good deal thickened by some farinaceous
matter, as pearl barley, oatmeal, split-peas, bread,
or potatoes. Fish is neither very nutritious nor
very digestible ; boiled or stewed eels are the most
so, and salmon the least so ; and all fried fish is
rendered unfit for a dyspeptic stomach. Sound
beer of moderate strength, such as is brewed from
twelve to fifteen gallons from the bushel of malt,
is, as I observed before, the fittest beverage for a
labouring or otherwise active man ; and to such a
person two half-pints may be allowed daily. When
wine is preferred to beer it should be sherry, and
the quantity most conducive to the health and com-
ON VARIOUS CHRONIC AILMENTS. 393
fort of a dyspeptic is two glasses, one taken with
water during dinner, and the other without water
at the conclusion of the meal. A person in the
enjoyment of health and a good stomach ought not
to indulge in more. When brandy is thought pre-
ferable, one table-spoonful in a quarter of a pint of
water is about the quantity, and it should be taken
at the conclusion of dinner; this will agree better
than either beer or wine with delicate persons,
whose circulation as well as digestion is feeble.
The matter of next importance to regimen is ex-
ercise. A person whose digestion is feeble will
not bear exercise well before breakfast ; but in the
summer time, where a walk before the sun's heat
be great is very desirable, I advise a dry biscuit or
toast to be eaten immediately upon rising, and to
very delicate persons, a cup of milk and water, and
then a brisk walk before the usual breakfast.
Those who are not occupied about domestic affairs
should take a second walk or a ride about three or
four hours after breakfast, and should never incur
great fatigue. In the summer an evening walk be-
fore the dew falls will be further desirable. Hav-
ing made these few general observations on the
importance of abstemiousness, on the digestibility
of various articles of diet, and on exercise, which
are of nearly equal importance to persons in health
as to dyspeptic invalids, I must revert again to the
medical treatment of the latter. When the symp-
s 5
394 ON VARIOUS CHRONIC AILMENTS.
toms of indigestion, as enumerated above, are
pretty uniformly present witho'iit a decided pre-
ponderance of any one, my practice is to give a
digestive pill an hour before dinner, or five or six
grains of carbonate of soda, the same of rhubarb,
and the same of ginger, twice a day in a little pep-
permint water, to which I add half a tea-spoonful
of sal-volatile if the extremities are cold, or the
pulse feeble. When there is much limpid and
tasteless fluid coming off the stomach by slight vo-
miting or by eructation, which constitutes the dis-
ease called water-brash, I find acids, as five or six
drops of elixir of vitriol in water, two or three times
a day, preferable to soda ; and if there is pain with
the water-brash, I add five drops of laudanum to
each dose. When there is uneasiness in the stom-
ach increased by pressure, and amounting to pain
after meals, I never neglect the application of
leeches from six to twelve to the pit of the stomach,
and afterwards a blister ; in such cases I give the
soda and rhubarb without the ginger, and with five
or six drops of laudanum twice or thrice a day. If
the food is frequently rejected, I try first small ef-
fervescing draughts with a few drops of laudanum,
and if these fail, I give four grains of the oxyde of
bismuth in a spoonful of thick gruel two or three
times a day, and often with great advantage ; and I
may here observe, that I have frequently seen this
latter remedy very serviceable in moderating the
ON VARIOUS CHRONIC AILMENTS. 395
vomiting, which usually attends the advanced
stage of either scrofulous or cancerous affection of
the stomach.
The SICK HEADACHE, which attends indigestion,
sometimes as a cause, sometimes as a consequence,
would, from its importance as well as frequency,
and from the circumstance of its becoming often a
habitual disorder, particularly in females of the
nervous temperament, deserve an ample conside-
ration here, for it is a bane to happiness and com-
fort in thousands of instances during several days
in every month, extending over a great portion of
the sufferer's lifetime. It is, however, in this
form of a habitual disease, rather rare amongst
that class of society to whose relief I am endea-
vouring to qualify you to administer; besides
which, I freely acknowledge, that I prescribe for
patients who are habitually tormented with this
disease with less satisfaction to myself, than for
almost any other description of patients, because I
can depend so little upon any plan that J have ever
adopted. I will, however, venture to give a few
general directions, as you must not infer, from
what I have just said, that sick headache never
occurs amongst the poor.
An occasional and severe attack of headache as
well as sickness is not an unusual penalty of indis-
cretion to the robust and healthy, as well as to the
feeble and dyspeptic, but is much more easily in-
duced in the latter ; and when sick headache is the
396 ON VARIOUS CHRONIC AILMENTS.
immediate consequence of over-indulgence in eating
or drinking, or both, supposing the sickness to have
been effectual in bringing away the offending matter,
or that sufficient time has elapsed for its passage
into the intestines, the safest prescription, though
not the most agreeable, is abstinence for twenty-
four hours from the time of the debauch, by which
time the stomach recovers its tone ; a moderate
meal will then be retained, and the headache will
cease. If, however, the patient will not fast, or
the intensity of suffering calls for some more imme-
diate relief, both sickness and headache will some-
times be relieved by taking small quantities of soda
water with white wine, or light biscuit soaked in
brandy ; and sometimes by a high-seasoned chop,
the quantity however taken at one time being very
small.
Habitual or constitutional sick headache is a
very different thing. It may be induced by the
slightest indiscretion in diet, by fatigue, watchful-
ness, anxiety, or any over-excitement, by changes
in the weather, by unavoidable deviations in the
natural functions of the body, and indeed not un-
frequently without any assignable cause. The
patient will often go to bed and to sleep without
apparently the least tendency to headache, and
awake in the morning with a very severe attack.
In many persons the pain usually commences after
sleep, and in such it is often anticipated by a
previous sensation of drowsiness. The pain in
ON VARIOUS CHRONIC AILMENTS. 397
the head, for it is generally rather that than head-
ache, is mostly confined to one spot at the com-
mencement, and travels from one side of the head
to the other in the course of the attack ; the attend-
ant sickness sometimes comes on before the head-
ache, and sometimes with it, but more frequently
is superinduced some hours after the pain has com-
menced. The duration of an attack varies from
one or two hours to as many days, its frequency
from once a week to once a month, or not so often,
the intensity from a moderate degree that does not
disqualify the sufferer from joining in society, to a
height that makes the patient call out with agony,
writhe to and fro, and feel alarmed for the pre-
servation of her senses. Females are by far more
subject to sick headache than men ; the middle
period of life is that in which it prevails ; as it
seldom commences before sixteen or eighteen, and
many are sufferers from it from that time till about
fifty, and then become healthy; others, however,
are only tormented with it for a small portion of
that time, and a few have the mortification to pass
over this climacteric without any diminution either
in the severity or frequency of its attacks.
The preventive treatment consists in a strict
observance of all the minutiae in the rules laid
down for dyspeptics as to diet and exercise, the
adoption of whatever is conducive to quiet cheer-
fulness, and to keep down excitement, and the
avoidance of every circumstance that is known, from
398 ON VARIOUS CHRONIC AILMENTS.
the patient's own experience, to bring on or acce-
lerate a paroxysm. The medical treatment during
an attack is first to encourage vomiting, where the
sickness predominates. This may be done some-
times by warm water alone, sometimes by the addi-
tion of about two tea-spoonfuls of common salt to
half a pint of water ; but if the sickness is accom-
panied with a feeble pulse and cold skin, immediate
vomiting should be insured by giving ten or twelve
grains of ipecacuanha. The effect of the vomiting
in stimulating the heart to increased action, and in
thus relieving the headache, is frequently instan-
taneous and complete. Where it is known from
former experience that vomiting will not relieve
the headache, or will perhaps increase its intensity,
which is sometimes the case, we must try another
mode of treatment, as soon as the attack is well set
in, which is to apply stimulants to the stomach, as
a tea-spoonful of sal- volatile in a small saline draught
every two hours, and a very small mutton chop
seasoned with cayenne pepper, and a wine glassful
of hot wine and water, both of which may be re-
peated in four or five hours. This dietetic part of
the practice is also applicable to such patients as
have already taken the emetic with advantage.
The whole plan is more particularly serviceable to
patients labouring under intense headache with
feeble pulse and cold extremities, induced by great
mental fatigue ; and in such cases the chop may be
larger, and a tumbler of wine and water substituted
ON VARIOUS CHRONIC AILMENTS. 399
for the wine-glass. I could write pages on the
lamentable want of success in my practice in this
disease, but have nothing more to add, that is
worth recording, on the subject of the adjuvantia
and shall therefore conclude with observing that
quiet, exclusion of light, and retiring early to bed
or to a couch, are found to render the attacks more
bearable ; and that the patient's own fancy may be
indulged in a first or second experiment as to
taking strong tea, strong coffee, ether, lavender
drops, camphor-julep, or the like, as each of these
has occasionally been found to afford relief.
I may, without much deviation from order, in-
troduce the few remarks I shall offer on the subject
of WORMS in the human body in this place, because
their presence is influenced by the state of the di-
gestion ; or, at all events, the inconveniences arising
from their presence are dependent upon a morbid
state of that important function. The presence of
worms in the bowels is perfectly compatible with
health; this is their natural habitation, they ori-
ginate here, they can live in no other situation,
and until disturbed by an unhealthy state of the
secretions, and consequent unnatural condition of
the contents of the bowels, they are generally sup-
posed to produce no inconvenience. During fevers
and other constitutional ailments they are disturb-
ed, and often killed, and pass off with the evacua-
tions, but it is chiefly during a faulty state of di-
gestion that they become numerous, and produce
400 ON VARIOUS CHRONIC AILMENTS.
inconvenience from their number and their bulk,
and the symptoms then induced by the worms,
blended with those of indigestion, are what are
usually described as signs of the presence of worms.
They are these ; pains in the stomach or bowels,
slimy evacuations, precarious appetite, tumid belly,
sallow or leaden complexion, swollen lip, with itch-
ing at the nose and also at the fundament. Be-
sides these, it is well known that various affections
of the brain and nervous system are occasionally
connected with the presence of worms, as convul-
sions, squinting, St. Vitus's dance, and an immense
variety of symptoms, which seem dependent upon
a morbid sensibility or excitability of the brain and
nerves; all of which, however, frequently occur
where no worms are present, and therefore can
only lead to a suspicion which nothing but the
expulsion of worms can set at rest.
There are as many as twelve species of worms
described, as inhabiting the human intestines, but
three only are common in this country, 1st, the
long cylindrical one, which very much resembles
the earth-worm, but is more pointed at the extre-
mities, and is very differently constructed about
the head, as well as its internal parts ; 2nd, the
small maw-worm or thread-worm, from a line and a
half to two lines in length : and 3rd, the tape-worm,
which is flat and jointed, and often many yards in
length.
The CYLINDRICAL WORM is very common, and, when
ON VARIOUS CHRONIC AILMENTS. 401
detected or suspected, is best expelled by the oil of
turpentine and strong doses of cathartics. To an
adult I give an ounce of the spirits of turpentine in
a wine-glassful of water before the patient rises in
the morning, and two hours before breakfast; and
whether it purges much or not, I give the next morn-
ing six grains of calomel and twenty of jalap. The
oil and powder are both to be repeated in three or
four days.
The MAW -WORM inhabits the lower part of the
bowels, producing intolerable itching, and coming
away often in large quantities both with the motions,
and at other times. The most successful mode of
procuring their discharge is by glysters of aloes or
turpentine, and by calomel jalap and aloes given
internally. I usually prescribe a tea-spoonful of
powdered aloes dissolved in a table- spoonful of hot
milk to be injected with a small syringe at bed-time,
and a full dose of the purging powder to be taken
the following morning, and both to be repeated twice
a week till the annoyance is got rid of. The pow-
der for an adult may be four grains of calomel, ten
of jalap, and five of aloes.
The TAPE-WORM is but occasionally met with, and
is to be suspected, when with the ordinary symp-
toms of worms you have severe transitory pains in
the belly, with great distension, and sometimes
tenderness. Turpentine is the most efficacious
remedy, and may be given in the same doses, and
followed by the same purgative, as ordered for the
402 ON VARIOUS CHRONIC AILMENTS.
cylindrical worm. Of other vermifuge medicines
I seldom use any, but may mention, that powdered
fern root in doses of a dram followed by a brisk
purge, and Indian pink a dram twice a day, with
a purge twice a week, are as efficacious as any. In
all cases of worms, the digestion must be attended
to, and the general health improved by tonics and
alteratives, as recommended when treating of indi-
gestion.
The disease known under the name of GRAVEL is
the morbid secretion of sandy or stony matter in
the kidneys. It is sometimes permanently lodged
in this organ, and is then called stone in the kidney ;
but generally it passes along the urinary duct, called
the ureter, from the kidney to the bladder, and, is
afterwards voided with the urine either in the form
of fine sand, white or dusky red, or of small stones
like gravel, of different colour and hardness accord-
ing to their chemical composition, which is various.
The persons afflicted with gravel are generally the
subjects of indigestion, and it is very commonly
connected also with gout. The symptoms of its
formation and lodgment in the kidney are uneasi-
ness and pain in the loins, more frequent desire to
make water, and sometimes the admixture of blood
with the urine. It is however seldom suspected
till, after some days of more pain than usual, sand
or gravel is passed with the urine, and found depo-
sited in the utensil. When passed in the form of
sand, there is more irritation than usual in the pas-
ON VARIOUS CHRONIC AILMENTS. 403
sages, and sometimes great pain ; when in the form
of gravel or small stones the pain is more acute,
being occasioned by the passage of them from the
kidney to the bladder. This pain occurs at inter-
vals, and is felt for one or two days, deep-seated
in the lower part of the body, inclining to one side,
darting downwards from one of the kidneys towards
the bladder, which lies in the front of the lower
part of the body. The pain, if severe, occasions
sickness and vomiting, frequent shuddering, and
incessant desire to make water. Such an attack is
termed a fit of the gravel, and is very often mis-
named by the common people a fit of the colic.
The small stone or piece of gravel sometimes lodges
for days in the bladder without occasioning much
uneasiness ; indeed it is now and then permanently
retained there, and forms the nucleus of a large
stone ; but generally speaking it is passed either
immediately or soon afterwards with little or more
pain according to its size and roughness, and occa-
sionally with so little that the noise it makes in fall-
ing into the pot gives the patient the first intimation
of what has occurred. Some patients have passed
scores of these small stones varying in size from a
pin's head to that of a horse bean.
The treatment during a fit of the gravel must be
to diminish pain and prevent inflammation. If the
symptoms are severe, 1 commence with cupping in
the loins, a large common purgative lavement or
glyster, and a warm bath ; and then give laudanum
404 ON VARIOUS CHRONIC AILMENTS.
and solution of potash in barley water, or if the vo-
miting forbid this, I administer a tea-spoonful of
laudanum in a pint of gruel by way of lavement.
The dose of solution of potash may be twenty drops
with ten of laudanum ; it may be taken in barley-
water, and repeated every four or six hours. The
cupping, the bath, and the lavement, may all be re-
quired to be repeated before the pain materially
abates, and sometimes a bleeding from the arm to
the amount of from sixteen to twenty ounces is pre-
ferable to cupping ; and occasionally, where the pa-
tient is robust, and the state of the pulse indicates
inflammatory action, both may be required.
In the more mild and chronic form of gravel you
will find soda pills, taken freely for four or five days
successively, very often efficacious in removing the
pain and irritation ; by freely I mean two pills three
or four times a day; and this is the prescription I
usually give to gravel patients, for future use, desir-
ing them to have recourse to the pills whenever the
symptoms of gravel come on : also to take a tea-
spoonful of magnesia, or half that quantity of car-
bonate of soda, at bed-time, whenever they feel
acidity at the stomach, to be careful in avoiding
whatever occasions such acidity, and to follow all
the rules laid down for the guidance of dyspeptics.
I shall now conclude this letter with some gene-
ral observations on DROPSY. This word, I dare say,
conveys to you the idea of a well-defined disease?
the symptoms of which may be easily stated, and
ON VARIOUS CHRONIC AILMENTS. 405
the disease thereby as easily recognised, and of
course the proper treatment as satisfactorily pointed
out. If so, however, I must now assure you, that
you are greatly mistaken. Dropsy means a collec-
tion of watery fluid called serum, in some part of
the system, in unusual quantity; but so far from
being a simple disease of itself, it ought rather to
be considered only a symptom of disease, and a
consequence of other disorders. It may occur in
every natural cavity of the body that is lined with
a serous membrane, as in the cavities called ventri-
cles of the brain, when it is called hydrocephalus ;
in the chest, when it is called hydrothorax; or in
the body, when it is called ascites. Serum may also
be collected in the duplicatures of the serous mem-
branes, thus forming dropsies of more confined
dimensions, as within the duplicature that forms
the heart-purse, when the disease is called hydrops
pericardii, and in many other parts where there is
a similar anatomical structure. Another seat of
dropsy is the cellular membrane wherever situated,
and as the cellular membrane under the skin has
extensive communications, it necessarily happens,
that when this is the seat of serous deposition, the
dropsical enlargement is very general, distending
the skin of the face, and particularly of the eyelids,
where it is naturally loose or in folds ; distending
als the skin over the chest, and the whole trunk,
and also that of the limbs, and particularly of the
lower limbs, where the collection of water is fa-
406 ON VARIOUS CHRONIC AILMENTS.
voured by gravitation. This more universal dropsy
is called by the profession anasarca.
There is still another kind of dropsy, where the
fluid is contained in distinct cysts or bags of mor-
bid growth of various sizes, from that of a pin's
head to a goose's egg, or larger, and occasionally
much larger. The very small ones are generally
pellucid, and lie together in masses ; the shape of
the larger cysts is almost always globular, and in
external appearance they sometimes very much
resemble eggs without the hard outer shell, the
cysts being white and opaque ; at other times they
are transparent. The contained fluid also varies
in appearance ; it is usually of a pale straw colour,
and pellucid, sometimes of a much deeper tint, or
of a chocolate colour, or of sanguineous hue, and
at other times white and turbid. The site of these
watery cysts, which are called hydatids, and which
most physiologists now maintain to be distinct ani-
mals, is so various, that there is scarcely a part of
the frame, or a variety of anatomical structure, in
which they have not been found. The most com-
mon situation, perhaps, is the cavity of the abdo-
men, where the collection is sometimes so immense
as to form the largest dropsical distension of the
body that ever occurs. They are often attached
to the liver or some other abdominal viscus ; they
are found also in the brain and in the lungs ; and
I have also seen a large collection of such hydatids
extracted, many of them whole, and all apparently
ON VARIOUS CHRONIC AILMENTS. 407
separate from each other, from a large tumor on
the back of a robust man. I may dismiss the consi-
deration of hydatids, for the present, by stating,
that we remain ignorant of the nature of these
growths, we know nothing of the cause of them,
and have no remedial means to offer for the cure of
them, except when they can be wholly extirpated,
of which I confess that I never saw an instance.
There is as great a variety in the symptoms attend-
ing dropsy as in the situation of the serous collec-
tion, and this arises as much from the previous
disease of which dropsy, in most cases, is only the
consequence, as from the impediment to the func-
tions of the neighbouring organs necessarily conse-
quent upon the presence and pressure of an unna-
tural quantity of fluid. Thus in case of water in
the head many of the symptoms, and much of the
danger, arise from the previous inflammation, and
many from the pressure of the fluid on the brain.
The same may be said of dropsy of the lung, dropsy
of the chest, dropsy of the heart, &c., where either
inflammation or venous congestion, or some other
morbid condition of those important organs, has
preceded the dropsy, and where the water, when
deposited, must mechanically disturb the action of
the lungs, heart, &c. You see, therefore, very
plainly, that for a full consideration of the subject,
a volume would not suffice, and you will agree with
me, that many species of dropsy are more properly
treated of, each under the disease that has given
408 ON VARIOUS CHRONIC AILMENTS.
rise to the dropsical effusion. This I have already
done in several instances, and shall therefore, in
this place, confine myself to a few observations on
dropsy of the chest, dropsy of the belly, and ana-
sarca, which I have before stated to be dropsy of
the cellular membrane.
When you hear a patient, who has long been an
invalid with chest affections, complaining of more
permanent difficulty of breathing, increased by ex-
ercise or any unusual exertion, and of inability to
lie down in bed without caution, and without more
than his usual number of pillows to support the
head ; when his sleep is disturbed with frightful
dreams ; when you see that his feet and ankles are
swollen at night, and he tells you that he makes
less than his usual quantity of water, you may infer
that he has water in the chest. Before you pre-
scribe for the dropsy, consider well the state of the
previous disease, and if chronic inflammation still
subsists, bleed and blister before you give the ap-
propriate remedies for the removal of the water,
which, in this form of dropsy, must be diuretics,
which are medicines that increase the flow of urine,
rather than purgatives. Of these, squills and blue
pill combined, or digitalis in some form or other,
will prove more frequently serviceable than others ;
but in some cases you must vary the diuretic, and
may run through the whole catalogue of them, be-
fore you find one that will materially increase the
flow of urine. As simple and efficacious formulae
ON VARIOUS CHRONIC AILMENTS. 409
of the medicines I have recommended, take the
following : half a grain of blue pill with four grains
of squill pill, to be taken every six hours, and a
tea-spoonful of sweet spirits of nitre in a little pep-
permint water after each ; or the same quantity of
blue pill with extract of dandelion three times a
day, and a single dose of squill, as four grains of
the powder at bed-time. When digitalis is ordered,
begin with ten drops of the tincture, or two drams
of the infusion in a little peppermint or ginger-tea
every eight hours, and increase the dose gradually
each day, until its effects are fully apparent in in-
creasing the quantity of urine, or until it produce
nausea, giddiness, and faintness, when the dose
must be immediately reduced, or what is safer, two
or three doses must be altogether omitted, and then
the medicine resumed in smaller doses.
Water in the cavity of the abdomen, called
ASCITES, can only be suspected when the quantity
is sufficient to produce some enlargement, of which
the patient is first made sensible by the tightness
of his dress, a sense of general fulness, and some
slight impediment to his breathing in the recum-
bent posture. Certainty is attained when the sur-
geon, by carefully tapping with his fingers on dif-
ferent parts of the distended abdomen, and at the
same time holding the palm of his other hand
steadily on some opposing part of the body, feels
distinctly the fluctuation or movement of the con-
tained fluid. The sensation thus produced is very
410 ON VARIOUS CHRONIC AILMENTS.
different from what is felt on tapping in the same
manner, either upon solid matter or a cavity con-
taining air ; and very little practice will enable you
thus to detect the presence of a fluid. The accom-
panying symptoms are general emaciation and
shrinking of the features, dropsical swelling of
the legs, feeble pulse, and paucity of urine. And
as this species of dropsy is almost always a conse-
quence of enlargement or other structural disease
of some one or more of the organs contained in
this cavity, you must necessarily have a variety
of symptoms dependent upon the deranged func-
tions of such organs..
The treatment of this species of dropsy is neces-
sarily complicated from the above circumstance;
and when you have satisfied yourself of the nature
of the disease, of which the dropsy is the conse-
quence, you must adopt the appropriate practice
for such disease, as well as use means for the
removal of the water. Of these latter means, pur-
gatives and diuretics must be first tried, particu-
larly the former ; and, if these fail, our ultimate
resort is the operation of tapping, and this, I must
acquaint you, is not in itself either a formidable or
dangerous operation ; but in a great proportion of
cases it proves only of temporary service, for this
reason, that the cause of the dropsical effusion re-
mains, and resists medical treatment. Still I am a
friend to the operation of tapping, not only because
the temporary relief is thus cheaply purchased, but
ON VARIOUS CHRONIC AILMENTS. 411
because it affords a better chance to our other re-
medial measures, and particularly so if had recourse
to early. These remedial measures are, as I have
stated above, purgatives and diuretics. Of the
former, elaterium, which is the feculent matter de-
posited from the natural juices obtained by pres-
sure from the fruit of the wild cucumber, is a most
efficient one, and a quarter of a grain given in a
pill every two hours for two or three times, will
generally be followed by numerous watery motions
and a corresponding diminution of the dropsy. The
same doses repeated twice a week will sometimes re-
duce the whole swelling in a few weeks. Croton oil is
another powerful cathartic applicable to such cases,
and may be given either alone, one or two drops
for a dose, made into pills with crumbs of bread, or
conjoined with castor oil, one drop to an ounce.
Calomel and jalap, in such doses as I have often
directed in other diseases, are to be preferred,
where the dropsy is connected with diseased liver;
these, with gamboge and scammony, will make up
our list of purgatives peculiarly applicable in the
treatment of ascites or dropsy of the belly. The
diuretics are numerous, and in case of failure from
purgatives they must be resorted to, of which those
that have been recommended in water of the chest
are the most important.
There are two varieties of abdominal dropsy to
which the above remarks do not apply ; the first of
these is the ovarian dropsy, where the collection
T 2
412 ON VARIOUS CHRONIC AILMENTS.
of water, amounting often to more than two gallons,
is in one of the ovaries, which are naturally small
bodies lying on either side of the uterus in females.
This variety is distinguished by the surgeon, first
from its situation, and from its occupying even
in its largest state more of one side of the body
than another ; and secondly, from its not having
been preceded by disease and derangement of other
abdominal viscera, and its being consequently
attended with less constitutional disturbance than
ordinary abdominal dropsy. Neither purgatives
nor diuretics have much, if any, influence in di-
minishing ovarian dropsy, and therefore should not
be long persevered in to the detriment of the gene-
ral health. Tapping should be had recourse to
early, and may be repeated as soon and as often as
the enlargement proves inconvenient. It has in
many cases been repeated some scores of times,
and the disease has now and then been ultimately
cured by such repeated tappings.
The second variety is the watery cysts called
hydatids, which I have described above, and which
I have never known to be either cured or relieved
by purgatives, diuretics, or any other medicines.
Here even tapping affords very partial relief, be-
cause the fluid being contained in distinct sacs or
bags, a single tapping can only empty one sac, or
at most two or three others that lie contiguous,
and which may therefore be sometimes broken down
by means of a probe introduced through the canula,
ON VARIOUS CHRONIC AILMENTS. 413
which is the instrument for drawing off the water.
It is therefore quite accidental, whether you draw
off a few ounces or a few pints, where the whole
collection would measure as many gallons ; it may
further be observed that the re-accumulation is
always rapid. Still even in such cases I have
known the patient desire many repetitions of the
operation, in consequence of even the small relief
it had previously afforded.
We now proceed to the consideration of ANA-
SARCA or general dropsy. The external signs of
this species of dropsy are so characteristic, that you
cannot easily mistake them. When the eyelids are
swollen and pallid in a morning, and the feet and
ankles at night, with a soft inelastic doughy feel,
pitting or dinting on pressure, you may feel assured
that the distension of the skin is owing to the de-
position of serum in the cellular tissue, and that
you have here the commencement of anasarca.
This partial swelling of the face and legs, which is
commonly termed oedema, is not an uncommon at-
tendant upon diseases of debility, and is frequently a
symptom in chlorosis, or, as it is vulgarly called, the
green sickness, in which latter case a brisk cathar-
tic or two of jalap and cream of tartar, with the
appropriate tonics, as steel and quinine, will usually
disperse the swelling. When this oedema of the
legs is a symptom of dropsy in the chest, or in the
abdomen, it will be removed by the treatment ap-
propriate to those disorders, when such disorders
414 ON VARIOUS CHRONIC AILMENTS.
are curable. In cases of more general anasarca,
the dropsical effusion soon distends the skin of the
whole lower limbs, then of the whole trunk ; and
this sometimes so rapidly, that in a few days the
patient becomes cumbrously large, and his breath-
ing is mechanically impeded. The secretion of
urine is uniformly scanty, and the remedies are
such, as will either increase largely the flow of
u/ine, or procure copious watery discharges from
the bowels. In a few cases, where the patient is
of a robust constitution, with the pulse full and
hard, or where the dropsical swelling is consequent
on suppressed perspiration, or repelled eruption of
the skin, a general bleeding may properly precede
the other remedies. I have found purgatives, par-
ticularly full doses of cream of tartar and jalap, as
half an ounce of the former, and half a drachm of
the latter, two or three times a day, more speedily
successful than diuretics, and sufficiently lowering
to remove the inflammatory state of the system,
which undoubtedly often accompanies anasarca ; I
have found this active purging speedily successful
in the rapid cases of watery deposition, which
sometimes occur after scarlet fever. If jalap and
cream of tartar fail, you must try elaterium and the
other purgatives recommended for ascites, with
more or less vigour, as the disease is more or less
urgent. In the slower and more partial deposi-
tions of course less active means are required, and
in such, perhaps, diuretics may be more suitable ;
ON VARIOUS CHRONIC AILMENTS. 415
and of these none is so efficacious as digitalis. In
obstinate cases, puncturing the legs with the
needles used for acupuncturation will relieve the
distension, and with less risk than punctures made
by the lancet ; but even these will sometimes be
followed by erysipelas and mortification in very
debilitated subjects. A more safe mode of produc-
ing a discharge of the fluid, though by no means
so uniformly successful, is to cover the legs with
cabbage leaves previously stript of their large fibres,
and rolled to make them more pliable. This will
sometimes produce a copious oozing, and trickling
of moisture from the surface, and considerably di-
minish the swelling ; the leaves should be removed
daily. The main dependence for a cure, however, is
upon the successful operation of purgatives or diure-
tics ; and the purging is often necessarily carried to
such an extent as to demand the use of tonic medi-
cines and a nourishing diet, so that it is not unusual
to give very strong purgatives for a day or two, and
then quinine or steel medicines for a few days to
renovate the strength, before repeating the purg-
ing medicines. With this imperfect because con-
cise account of a very important derangement in
the bodily health I conclude this letter, and with
this letter conclude my present correspondence ;
not, however, without informing you, that there
remain many diseases having appropriate names,
as well as many morbid deviations from health,
which have no place assigned them in our nosolo-
416 ON VARIOUS CHRONIC AILMENTS.
gical system, left undescribed in these letters ; some
of which it would have been improper to have in-
troduced, because the letters are designed for ge-
neral readers ; and others would have required
much deep consideration and extended inquiry,
which would not have been compatible with the
proposed size of the present work.
So difficult is it to condense, and at the same
time to be perspicuous, that I fear I have often
failed to make you comprehend my meaning, from
a desire not to be tedious, and sometimes have be-
come tedious from my desire to be explicit. Hop-
ing, however, that my attempt may prove in some
degree useful, I conclude with urging you again
to seek the superior aid of regularly educated
medical practitioners, whenever you entertain
doubts as to the nature of the disease or of the ap-
propriate treatment, as well as when you are sa-
tisfied of the urgency or importance of the accident
or disease which is brought before you.
Your affectionate Father,
F. SKRIMSHIRE.
Peterborough, June, 1838.
APPENDIX.
417
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APPENDIX.
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Or,
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half an ounce, to carbonate of potash twenty gi
an ounce and half of water
Sal ammoniac eleven parts, saltpetre ten, Glai
sixteen, powdered and rubbed together, and
added to water
Dried leaves of digitalis or foxglove a drachm, boi
half a pint, after four hours strain
Unslaked lime a quarter of a pound, pour on il
of water and stir ; after standing in a covered v
hours, bottle it and cork ; of this take the cl
for use
Lime water and olive oil, equal parts
Solution of subcarbonate of ammonia one part
two parts
Of the cocculus suberosus or indicus powdered
lard one ounce
Powdered opium one part, white lead two, powt
nut four, and lard eight
Oil of peppermint twenty drops on a large him
to be put into a pint of water
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422
APPENDIX.
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APPENDIX.
423
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^^.5'S 1 2^ -^- S 1 f ^ f
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iiti^fs&rsfrooooz* e, c^e.&, of
424
APPENDIX.
Doses for an Adult, and tTses.
externally alone, and in ointment,
externally in ulcers.
4 grains as a stomachic, \ drachm as an aperient.
10 grains ; aperient.
30 grains or more,
external in lotion.
5 grains, also in a gargle.
1 dram three times a day.
1 dram, stimulant.
8 grains, purgative,
to make tea or infusion ; aperient,
externally,
externally,
in seidlitz powders.
To make soda pills.
15 drops in gravel,
to make liniment of ammonia.
4 grains, diuretic.
10 grains, diuretic.
. i
Names.
il '^ 1 1
%& 3 1 1 1 : 'M.. '1 f .1
Druggist's
J| ||a ||| |g I | |
>j 3 OocJ^'P^p5c>jni r eU"!^a3^^
t*}-*3 X3 rC r^ cS *"" j ^o C > *- '9* * Q-^- "o "G
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APPENDIX.
425
Doses for an Adult, and Uses.
externally ; also 1 ounce in worms.
12 drops, a tonic.
10 grains, a tonic,
used for smoking.
grain in paralysis,
external, to stop bleeding.
1 grain with opium in internal haemorrhage,
a tea'spoonful aperient , also in ointment,
in elixir of vitriol, and the turpentine embrocation,
a tea-spoonful in dropsy,
in ringworm,
in fever draughts,
in seidlitz powders,
externally in hooping-cough,
externally in neuralgia,
externally,
in pile ointment, and white lead ointment,
externally in ulcers ; with turpentine in burns.
1 . .a .
a
K
'So
to
1=1
1 1 -i
111 ' Jilts ' ' 'III
*5 S S*'S "' oi'o 3 03 "-3.B' 5 *
iiiijiitiiiiljij
fJS|||||J|l||J:3
OH^QasWSfW^ ofe < & H > W S &
et'o
S
g 'S 2
Familiar N
S *?J" ' i " ' '
gSB fl | g
: till|||||l||||||||
By the same Author,
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