Vog. 300.
The pica is also very generally symptomatic of other diseases, as of worms, chlorosis, pregnancy, &c.; and is therefore chiefly to be combated by the removal of the primary affection. It may, however, be observed, that peculiar longings occurring in certain diseases, as for example in fevers, often point out a natural cure. The indulgence of such appetites to a moderate degree is seldom productive of any inconvenience, and often followed by the best consequences.—Hence there are some practitioners who think that such craving should very generally be indulged; particularly when the patient can assign no reason whatever for such particular longings, but is merely prompted by an uncommon and inexplicable desire.
Genus CIV. Satyriasis.
Satyriasis, Sauv. gen. 228. Lin. 81. Sag. 340.
Satyriasis is a violent desire of venery in men, even so that reason is depraved by it. The pulse is quick, and the breathing short; the patient is sleepless; thirsty, and... Dysorexia, and loathes his food; the urine is evacuated with difficulty, and a fever soon comes on. These symptoms, however, are probably not so much the consequence of satyriasis, as merely concomitant effects resulting from the same cause. And indeed this affection is most frequently the concomitant of a certain modification of insanity. The nature and cause of this affection are in most instances very little ascertained; but as far as we are acquainted with the treatment, it agrees very much with the affection next to be mentioned, which, of the two, is the most common occurrence.
**Genus CV. NYMPIOMANIA.**
**Furor Uterinus.**
Nymphomania, Sauv. 229. Sag. 341. Satyriasis, Lin. 81.
The furor uterinus is in most instances either a species of madness or a high degree of hysteric. Its immediate cause is a preternatural irritability of the uterus and pudenda of women (to whom the disorder is proper), or an unusual acrimony of the fluids in these parts.—Its presence is known by the wanton behaviour of the patient; she speaks and acts with unrestrained obscenity; and as the disorder increases, she scolds, cries, and laughs, by turns. While reason is retained, she is silent, and seems melancholy, but her eyes discover an unusual wantonness. The symptoms are better and worse until the greatest degree of the disorder approaches, and then by every word and action her condition is too manifest.—In the beginning a cure may be hoped for; but if it continue, it degenerates into a mania.—In order to the cure, blood-letting is commonly recommended in proportion to the patient's strength. Camphor in doses of 15 or 20 grains, with nitre, and small doses of the tincture of opium, should be repeated at proper intervals. Some venture to give cerusa acetata in doses from three to five grains. Besides bleeding, cooling purges should also be repeated in proportion to the violence of symptoms, &c. What is useful in maniacal and hypochondriac disorders, is also useful here, regard being had to sanguine or phlegmatic habits, &c. When the delirium is at the height, give opiates to compose; and use the same methods as in a phrenitis or a mania. Injections of barley-water, with a small quantity of hemlock-juice, according to Riveius, may be frequently thrown up into the uterus; this is called specific; but matrimony, if possible, should be preferred. For although this cannot be represented as a cure for the disease when in an advanced state, yet there is reason to believe that it has not frequently prevented it where it would otherwise have taken place.
**Genus CVI. NOSTALGIA.**
Vehement Desire of revisiting one's Country.
Nostalgia, Sauv. gen. 226. Lin. 83. Sag. 338.
This is to be reckoned a species of melancholy; and unless it be indulged, it very commonly proves not only incurable but even fatal. Although it cannot be considered as altogether peculiar to any nation, yet it is observed to be much more frequent with some than with others; and it has particularly been remarked among Swiss soldiers in the service of foreign states.
**Sect. II. APPETITUS DEFICIENTES.**
Anepithymiae, Sauv. Class VI. Ord. II. Sag. IX. Ord II. Privativi, Lin. Class VI. Order III. Adynamiae, Vog. Class VI.
**Genus CVII. ANOREXIA.**
Want of Appetite.
Anorexia, Sauv. gen. 162. Lin. 116. Vog. 279. Sag. 268.
The anorexia is symptomatic of many diseases, but seldom appears as a primary affection; and it is very generally overcome only by the removal of the affection on which it depends.
**Genus CVIII. ADIPSIA.**
Want of Thirst.
Adipsia, Sauv. gen. 162. Lin. 117. Vog. 281. Sag. 269.
This by Dr Cullen is reckoned to be always symptomatic of some distemper affecting the sensorium commune.
**Genus CIX. ANAPHRODISIA.**
Impotence to Venery.
Anaphrodisia, Sauv. gen. 164. Sag. 270. Atecnia, Lin. 119. Agenesis, Vog. 283.
For this, see the article Impotence in the alphabetical order.
**Order III. DYSCINESIÆ.**
**Genus CX. APHONIA.**
Loss of Voice.
Aphonia, Sauv. gen. 166. Lin. 115. Vog. 253. Sag. 272.
The loss of voice may proceed from various causes. If one of the recurrent nerves, which are formed by the par vagum and the nervus accessorius, and reach the larynx, be cut, the person is capable of only as it were a half-pronunciation; but if both be cut, the speech and voice are both lost. The loss of speech happening in hysterical patients is also called aphonia; but more properly that loss of speech is thus named which depends on some fault of the tongue.
Since the motion of any part is destroyed, or lessened at least, by the interception of the nervous fluid in its passage thither, and since the nerves destined for the motion of the tongue arise principally from the fifth pair, it appears that the seat of this disorder is in the fifth pair of nerves, and that the immediate cause Dumb people are generally born deaf; in which case the distemper is incurable by medicine: though even such people may be taught not only to read and write, but also to speak and understand what others say to them. From some observations on the method in which this has been accomplished, we may refer the reader to the article DUMBNESS, in the alphabetical order. But in these cases, admitting of cure in the manner above alluded to, the dumbness proceeds principally, if not solely, from the deafness. For when it proceeds from a defect of any of the organs necessary for speech, the tongue for instance, it is always incurable; but if it arise from a palsy, the medicines applicable in that case will sometimes restore the speech.
GENUS CXII. PARAPHONIA.
Change in the Sound of the Voice.
Paraphonia, Sauv. gen. 168. Cacophonía, Sag. 274. Raucedo, Lin. 146. Raucitas, Vog. 252. Asaphia, &c. Vog. 250, 251, 254, 255, 256.
The voice may be changed from various causes. In males it becomes much more hard about the time of puberty; but this can by no means be reckoned a disease. In others it proceeds from a catarrh, or what we call a cold; it arises also from affections of the nose and palate, as polypi, ulcers, &c., in which case the cure belongs properly to SURGERY. In some it arises from a laxity of the velum pendulum palati and glottis, which makes a kind of snoring noise during inspiration. The cure of this last case is to be attempted by tonics and such other medicines as are of service in diseases attended with laxity.
GENUS CXIII. PSELLISMUS.
Defect in Pronunciation.
Psellismus, Sauv. gen. 167. Lin. 139. Sag. 273. Traulotis, &c. Vog. 258, 259, 260, 261.
Of this disease (if such it may be called), there are many different kinds. Some cannot pronounce the letter S; others labour under the same difficulty with R, L, M, K, &c.; while some who can with sufficient ease pronounce all the letters, yet repeat their words, or the first syllables of them, in such a strange manner, that they can scarce be understood. Very frequently these defects arise entirely from habit, and may then be got the better of by those who have the resolution to attempt it; as we are told that Demosthenes the celebrated orator got the better of a habit of stammering by declaiming with pebbles in his mouth. Sometimes, however, pronunciation may be impeded by a wrong conformation of the tongue or organs of speech; and then it cannot by any pains whatever be totally removed.
GENUS CXIV. STRABISMUS.
Squinting.
Strabismus, Sauv. gen. 116. Lin. 304. Vog. 514. Sag. 222.
Description. Dyscinesie. Description. This disease shows itself by an uncommon contraction of the muscles of the eye; whereby the axis of the pupil is drawn towards the nose, temples, forehead, or cheeks, so that the person cannot behold an object directly.
Causes, Prognosis, &c. I. This disease may proceed from custom and habit; while in the eye itself, or in its muscles, nothing is preternatural or defective.
Thus children by imitating those that squint, and infants by having many agreeable objects presented to them at once, which invite them to turn one eye to one and the other eye to another, do frequently contract a habit of moving their eyes differently, which afterwards they cannot so easily correct. Infants likewise get a custom of squinting by being placed obliquely towards a candle, window, or any other agreeable object capable of attracting their sight: for though, to see the object, they may at first turn both eyes towards it; yet, because such an oblique situation is painful and laborious, especially to the most distant eye, they soon relax one of the eyes, and content themselves with examining it with the eye that is next it; whence arises a diversity of situation and a habit of moving the eyes differently.
In this case, which may admit of a cure if not too much confirmed, it is evident, that objects will be seen in the same place by both eyes, and therefore must appear single as to other men; but because, in the eye that squints, the image of the object to which the other eye is directed falls not on the most sensible and delicate part of the retina, which is naturally in the axis of the eye, it is easy to see that it must be but faintly perceived by this eye. Hence it is, that while they are attentive in viewing any object, if the hand be brought before the other eye, this object will be but obscurely seen, till the eye change its situation and have its axis directed to it; which change of situation is indeed very easy for them, because it depends on the muscles of the eyes, whose functions are entire; but, by reason of the habit they have contracted of moving their eyes differently, the other eye is at the same time frequently turned aside, so that only one at a time is directed to this object.
II. The strabismus may proceed from a fault in the first conformation, by which the most delicate and sensible part of the retina is removed from its natural situation, which is directly opposite to the pupil, and is placed a little to a side of the axis of the eye; which obliges such people to turn away the eye from the object they would view, that its picture may fall on this most sensible part of the organ.
When this is the case, the disease is altogether incurable, and the phenomena that arise therefrom differ in nothing from the phenomena of the former case, excepting only that here, 1. The object to which the eye is not directed will be best seen; which is the reverse of what happens when this disease arises barely from habit and custom. 2. No object will appear altogether clear and distinct: for all objects to which the eye is directed, by having their image painted in the retina at the axis of the eye, where it is not very sensible, will be but obscurely seen; and objects that are placed so far to a side of the optic axis as is necessary for making their image fall on the most sensible and delicate part of the retina, must appear a little confused, because the several pencils of rays that come therefrom fall too obliquely on the crystalline to be accurately collected in so many distinct points of the retina; though it must be acknowledged, that this confusion will, for the most part, be so small as to escape unobserved.
III. This disease may proceed from an oblique position of the crystalline, where the rays that come directly to the eye from an object, and that ought to converge to the point of the retina, which is in the axis of the eye, are, by reason of the obliquity of the crystalline, made to converge to another point on that side of the visual axis where the crystalline is most elevated; and therefore the object is but obscurely seen, because its image falls not on the retina at the axis of the eye, where it is most sensible: But the rays that fall obliquely on the eye, will after refraction, converge to this most sensible part of the retina; and, by converging there, must impress the mind with a clear idea of the object from whence they came. It is for this reason that the eye never moves uniformly with the other, but turns away from the object it would view, being attentive to the object to which it is not directed. When this is the case, it is in vain to expect any good from medicine.
The symptoms which naturally arise from it are,
1. The object to which the eye is directed will be but faintly seen, because its image falls on the retina where it is not very sensible. 2. The object to which the eye is not directed, by having its image painted on the retina at the axis of the eye, will be clearly perceived. But, 3d. This same object must appear somewhat indistinct, because the pencils of rays that flow from it are not accurately collected in so many distinct points in the retina, by reason of their oblique incidence on the crystalline. 4. It must be seen, not in its proper place, but thence translated to some other place situated in the axis of vision. And, 5. Being thus translated from its true place, where it is seen by the other eye that does not squint, it must necessarily appear double; and the distance between the places of its appearance will be still greater, if the crystalline of the other eye incline to the contrary side.
IV. This disease may arise from an oblique position of the cornea; which, in this case, is generally more arched and prominent than what it is naturally.
When the eye has this conformation, no object to which it is directed can be clearly seen, because its image falls not on the retina at the axis of the eye; and therefore the eye turns aside from the object it would view, that its image may fall on the most sensible part of the retina.
When the strabismus proceeds from this cause, the prognostic and the phenomena that attend it will be much the same as in the case immediately preceding; from which nevertheless it may be distinguished by the obliquity of the cornea, which is manifest to the senses, and if the cornea be also more arched and prominent than what it is naturally, which is commonly the case, the eye will also be short-sighted.
V. This want of uniformity in the motions of our eyes, may arise from a defect, or any great weakness, VI. Another cause from which the strabismus may proceed, lies in the muscles that move the eye. When any of those muscles are too short or too long, too tense or too lax, or are seized with a spasm or paralysis, their equilibrium will be destroyed, and the eye will be turned towards or from that side where the muscles are faulty.
In this case, the disease frequently yields to medicine, and therefore admits of favourable prognostic; excepting only when, by a fault in the first conformation, any of the muscles are longer or shorter than their antagonist; in which case, if ever it should happen, no medicine can be of any use.
As to what concerns the optical phenomena, they are the same here as in case first: only when the disease commences not till, by custom and habit, the uniform motion of the eyes has been rendered necessary, all objects do for some time appear double; but in time they appear single.
Lastly, This want of uniformity in the motions of our eyes may proceed from a preternatural adhesion or attachment to the eyelids: of this we have an instance in Langius. And that the same thing may also be occasioned by a tumour of any kind within the orbit, pressing the eye aside, and restraining it from following the motions of the other, is so evident, that instances need not be brought to prove it. Here also the case may admit of a favourable prognostic; and as for what concerns the optical phenomena, they must be the same as in the ease immediately preceding.
The cure, in confirmed cases, is to be effected by mechanical contrivances, by which the person may be obliged to look straight upon objects, or not see them at all; or at least that he may see with uneasiness and confusedly when he squints. In the 68th volume of the Philosophical Transactions we have an account of a confirmed case of squinting of a very uncommon kind. The patient was a boy of five years old, and viewed every object which was presented to him with but one eye at a time. If the object was presented on his right side, he viewed it with his left eye; and if it was presented on his left side, he viewed it with his right eye. He turned the pupil of that eye which was on the same side with the object in such a direction that the image of the object might fall on that part of the bottom of the eye where the optic nerve enters it. When an object was held directly before him, he turned his head a little to one side, and observed it with but one eye, viz. that most distant from the object, turning away the other in the manner above described; and when he became tired of observing it with that eye, he turned his head the contrary way, and observed it with the other eye alone, with equal facility; but never turned the axis of both eyes on it at the same time. He saw letters which were written on bits of paper, so as to name them with equal ease, and at equal distances, with one eye as with the other. There was no perceptible difference in the diameter of the irises, nor in the contractility of them after having covered his eyes from the light. These observations were carefully made by writing single letters on shreds of paper, and laying wagers with the child that he could not read them when they were presented at certain distances and in certain directions.
As from these circumstances it appeared that there was no defect in either eye, which is frequently the case with persons who squint, and hence that the disease was simply a depraved habit of moving his eyes, the disease seemed capable of a cure. A paper gnomon was made for this purpose, and fixed to a cap; and when this artificial nose was placed over his real nose, so as to project an inch between his eyes, the child, rather than turn his head so far to look at oblique objects, immediately began to view them with that eye which was next to them. But having the misfortune to lose his father soon after this method was begun to be followed, the child was neglected for six years, during which time the habit was confirmed in such a manner as seemed to leave little room to hope for a cure. The same physician, however, being again called, attempted a second time to remove the deformity by a similar contrivance. A gnomon of thin brass was made to stand over his nose, with a half circle of the same metal to go round his temples: these were covered with black silk, and by means of a buckle behind his head, and a cross piece over the crown of his head, this gnomon was worn without any inconvenience, and projected before his nose about two inches and a half. By the use of this machine he soon found it less inconvenient to view all oblique objects with the eye next to them than the eye opposite to them.
After this habit was weakened by a week's use of the gnomon, two bits of wood, about the size of a goose quill, were blackened all but a quarter of an inch at their summits; these were frequently presented to him to look at, one being held on one side the extremity of his black gnomon, and the other on the other side of it. As he viewed these, they were gradually brought forwards beyond the gnomon, and then one was concealed behind the other: by these means, in another week, he could bend both his eyes on the same object for half a minute together; and by continuing the use of the same machine, he was in a fair way of being cured when the paper was written.
Dr Darwin, who writes the history of the above case, adds, that all the other squinting people he had occasion to attend, had one eye much less perfect than the other: these patients, says he, are certainly curable by covering the best eye many hours in a day; as by a more frequent use of the weak eye, it not only acquires a habit of turning to the objects which the patient wishes to see, but gains at the same time a more distinct vision; and the better eye at the same time seems to lose somewhat in both these respects, which also facilitates the cure.
Genus CXV. CONTRACTURA.
Contractions of the Limes.
Contractura, Sauv. gen. 119. Lin. 299. Sug. 225. Obstipitas, Sauv. gen. 11. Caput Caput obstipum, Vog. 513. Digitium, Vog. 221.
The contraction of various muscles of the body is generally the consequence of some other disease, as the rheumatism, gout, scurvy, or palsy, especially that species of the latter which follows the colica Pictorum. It is exceedingly difficult of cure; though the warm medicinal waters are much recommended, and have sometimes done great service. Of late electricity has been found to perform surprising cures in this way.
ORDER IV. APOCENOSES.
Apocenos, Vog. Class II. Ord. II. Fluxus, Sauv. Class IX. Sag. Class V. Morbi evacuatorii, Lin. Class IX.
GENUS CXVI. PROFUSIO.
Flux of Blood.
Profusio, Lin. 239. Haemorrhagia, Vog. 81. Boerh. 218.
The disease commonly known by the name of bloody flux, is the putrid or contagious dysentery, a disease which has already been treated of. But independent of the discharge of blood which then takes place, haemorrhagy may take place from the alimentary canal as well as from other parts of the system. In such instances, however, if we except the place from which the discharge occurs, the phenomena are very much the same as in menorrhagia, haemoptysis, and other haemorrhagies already treated of; while the disease is to be combated on the same principles and by the same remedies.
GENUS CXVII. EPHIDROSIS.
Excessive Sweating.
Ephidrosis, Sauv. gen. 258. Sag. gen. 194. Sudor, Lin. 208. Hydropedesis, Vog. 121.
This is generally symptomatic; and occurs in almost all fevers, but especially in the latter stages of the hectic. Sometimes it is a primary disease arising merely from weakness; and then easily admits of a cure by the use of the cinchona, the cold bath, and other tonics.
GENUS CXVIII. EPIPHORA.
Flux of the Lachrymal Humour.
Epiphora, Sauv. gen. 259. Lin. 172. Vog. 99. Sag. 195.
This by Sauvages is described as an involuntary effusion of tears without any remarkable itching, heat, or pain. It follows long-continued ophthalmias; or it may be occasioned by immoderate study, or anything that weakens the eyes: hence it comes on about the age of 50 years, when the eyesight naturally becomes weak. It in general grows worse in the winter-time, and is very hard to cure. Some authors recommend purgatives, and blisters on the nape of the neck, in order to draw off the abundant humours; but as the disease evidently proceeds from weakness, it would rather seem proper to pursue a contrary method. Sauvages recommends to the patients to abstain from study, wine, and salted meats; and also to avoid smoke or wind, and at night to foment the eyes with an infusion of four cloves in two ounces of proof-spirit.—Hungary water, rose water with sulphate of zinc dissolved in it, &c. have also been recommended.
GENUS CXIX. PTYALISMUS.
Salivation.
Ptyalismus, Sauv. gen. 261. Lin. 176. Vog. 103. Sag. 197.
A salivation is often symptomatic, but rarely a primary disease. Dr Cullen is of opinion, that when the latter happens to be the case, it arises from laxity; and then is to be cured by astringents and tonics. In the Medical Transactions we have the following account of a salivation brought on by a foreign substance irritating one of the parotid glands.
In the month of April 1751, a young lady about the age of 16 years, of a delicate habit, but subject to no particular complaints, perceived the beginning of a disease which afterwards proved most obstinate and loathsome, viz. an incessant spitting. The quantity of this discharge was different at different times, varying from one pint to two pints and a half in 24 hours. As to its quality, it seemed to be no other than the ordinary secretion of the salival glands. By so large and constant an evacuation, her strength became extremely impaired, and the most efficacious medicines had proved useless. She had taken large quantities of cinchona, both alone and combined with preparations of iron: and afterwards the fetid gums, opium, amber, alum, and the Neville-Holt water, had in succession been given her. In the mean time an exact regimen had been prescribed: she had been ordered to ride constantly; and to confine herself to a mucilaginous diet, such as veal, calves feet, &c. Likewise a gentle opening medicine had now and then been interposed. The disease still continued unaltered, she had afterwards tried the tinctura saturnina; and had, at the same time, been encouraged to chew cinchona, and to swallow the saliva. But all these attempts had been vain; and after she had taken some or other of the medicines above mentioned until the end of September 1753, namely, above two years, it appeared to her physician, Sir George Baker, unreasonable to expect relief in such a case from any internal medicines whatever.
He now conceived a suspicion, that some extraneous body having accidentally found its way into the meatus auditorius, might possibly be the cause of this extraordinary secretion, by keeping up a continued irritation in the parotid glands. With this view he examined her ears, and extracted from them a quantity of fetid wool. How, or when, it came thither, no account could be given.
To this substance he attributed the beginning of the salivation, notwithstanding that the disease did not immediately abate on the removal of the wool; as it appeared to be no improbable supposition that the discharge charge might be continued by the force of habit, though the original cause no longer remained.
It seemed, therefore, expedient to introduce some other habit, in the place of the increased secretion of saliva; which habit might afterwards be gradually left off. With this intention, he prevailed on the patient to chew perpetually a little dry bread, and to swallow it with her spittle. In a few weeks, it became necessary for her to chew the bread only at certain hours in the day; and thus, after two months, she became entirely free from a most disgustful and tedious disorder.
It is worthy of observation, that, at first, the swallowing of so much saliva frequently occasioned a nausea; and that then, for a few hours, she was obliged to spit it out as usual; and that during the greatest part of the time, when she chewed the bread, she had a stool or two every day more than common.
**Genus CXX. ENURESIS.**
*An involuntary Flux of Urine.*
Enuresis, Sauv. gen. 264. Lin. 195. Vog. 113. Sag. 200.
This is a distemper which frequently affects children, otherwise healthy, when asleep; and is extremely disagreeable. Often it is merely the effect of laziness, and may be driven off by proper correction; but sometimes it proceeds from an atony or weakness of the sphincter of the bladder. Many ridiculous cures have been prescribed for it, and among the rest field-mice dried and powdered. Tonics are frequently of use; but sometimes the distemper proves obstinate, in spite of every thing we can use. In the London Medical Observations we find blisters much recommended in this disease when applied to the region of the os sacrum. A girl of 13 years of age had been subject to an enuresis for four years. She could retain her water but a very little while in the day-time, but it flowed continually in the night. She had taken Peruvian bark and elixir of vitriol in considerable quantities; also valerian and the volatile julep, without effect. She was severely threatened, as the physician suspected it might arise from a bad habit; but this producing no effect, a blister was applied to the os sacrum, which in 24 hours totally removed the disease. A man aged 32, having been seized with an incontinence of urine and palsy of the lower extremities in consequence of taking a quack medicine, was cured of the incontinence of urine in 24 hours by one blister, and of the palsy itself by another. A woman of 50 having been seized with an enuresis and paralytic affection of the right thigh and leg in consequence of a sprain, was cured of both by a single blister. Several other cases are mentioned, by which the power of blisters in removing this distemper seems to exceed that of every other medicine whatever.
**Genus CXXI. GONORRHOEA.**
Gonorrhoea, Sauv. gen. 208. Lin. 200. Vog. 118. Sag. 204.
The gonorrhoea is a flux of viscid matter of various colours, from the urethra in men and the vagina in women. It commonly proceeds from coition with a person infected with the venereal disease, and is one of the most common forms under which that disease shows itself.
**Description.** The first symptoms of the disease in men are commonly a sensation at the end of the penis not unlike a flea-bite, together with a fulness of the lips of the urethra, and some degree of tension in the penis, the urinary canal feeling as if tightened, and the urine flowing in a small and unequal stream: a little whitish mucus is to be seen about the orifice of the urethra, and oozing from it when slightly pressed, especially if the pressure be made on the spot where the soreness is most felt. The discharge soon increases in quantity, and varies in its colour according to the degree of inflammation. The patient feels a sensation of heat and pain in evacuating his urine, particularly at certain spots of the urethra, and above all towards its orifice; and the involuntary erections to which he is subjected from the stimulus, particularly when warm in bed, occasion a distortion or curvature of the penis, attended with exquisite pain. When the inflammation is violent, the glans appears tumid and transparent, the tension extends through the whole of the penis, the perineum is affected with swelling and redness, and even the loins, buttocks, and anus, sympathize and afford a very uneasy sensation. Sometimes the prepuce inflames about the end of the penis, and cannot be drawn back, occasioning what is called a phymosis; at other times, as in the paraphymosis, it remains in an inflamed state below the glans, so that it cannot be drawn forwards; and, if the stricture and inflammation be violent, may terminate in gangrene. Now and then, especially when there is a phymosis, we may perceive a hard chord extending along the back of the penis. This is an inflamed lymphatic, and may be considered as a prelude to a bubo. When, however, a bubo does appear, almost universally some ulceration is previously to be discovered about the preputium, or glans penis; which gives ground to presume that some other contagious matter besides that of gonorrhoea may have been applied to the urethra. For it is certain that matter capable of communicating the contagion of gonorrhoea to a female, is often copiously applied to the whole glans penis of a male for several days together, without giving either ulceration or bubo.
In mild cases, the seat of the disease is in the urethra, not far from its orifice; but it frequently happens that the virus insinuates itself much higher up, so as to affect Cowper's glands, the prostate, and parts very near to the neck of the bladder.
In the generality of cases, the inflammation goes on increasing for several days, commonly for a week or a fortnight; after which the symptoms begin to abate; and the running, when left to itself, gradually lessens in quantity, and becomes whiter and thicker, till at length it totally stops. The colour of the mucus, however, is by no means a certain guide in these cases: for in many patients it is of a yellowish, and sometimes of a greenish hue to the very last; but in general it becomes more consistent towards the close of the disease.
In women, the external parts of generation being fewer and more simple, the disease is less complicated than... than in men. Sometimes the vagina only is affected; and when this happens, the symptoms are very trifling: but in general it comes on with an itching and sensation of heat as in the other sex; and is attended with inflammation of the nymphae, inside of the labia, clitoris, carunculae myrtiformes, the orifice and sometimes the whole of the meatus urinarius. Very often the deep-seated glands of the vagina are affected, and it is sometimes difficult to distinguish the discharge of a gonorrhoea from that of the fluor albus.
Causes, &c. Many ingenious arguments have been advanced to prove, that the gonorrhoea and the lues venerea are different affections, originating from two distinct species of virus; and this controversy still, perhaps, remains to be decided by future facts. Certain it is, that in 19 of 22 cases of gonorrhoea, no symptom whatever of syphilis appears; and that the disease readily admits of cure without having recourse to those remedies which are universally requisite for combating the contagion of syphilis. It is by no means wonderful, that in some cases both contiguities, supposing them different, should be communicated at the same time. Nay, cases are by no means rare, where the contagion of itch, though essentially different from both, has been communicated with either. But as undeniable proof that the contagion in both cases is precisely the same, it has been alleged by some, that the matter of a chancre introduced into the urethra will generate a gonorrhoea, and that the discharge from a gonorrhoea will produce chancre, bubo, and every other symptom of syphilis. On the other hand, however, it is contended, that when experiments of this nature are conducted with the greatest accuracy, the matter of syphilis uniformly produces syphilis, and that of gonorrhoea, gonorrhoea only. Without pretending to decide on which of these experiments the greatest dependence is to be put, we may only observe, that while an almost inconceivably small portion of syphilitic matter applied to the glans penis, from connection with an infected female, infallibly produces syphilis if it be not speedily removed, the matter of gonorrhoea, in every instance of that disease, is applied to the whole surface of the glans penis for many days together without producing almost any bad effect whatever. From this, therefore, there is ground for inferring, either that it is not capable of being absorbed, or that if absorbed it is innocent.
But while there have been disputes with regard to the peculiar nature of the matter in gonorrhoea, there have also been controversies with respect to the source from whence it is derived. While some suppose it to be principally purulent matter arising from ulcerations, others assert that no such ulceration is ever produced in the urethra by gonorrhoea. They contend that the increased secretion in these cases is exactly similar to what happens in the catarrh. But the comparison will by no means hold good in every particular: in the latter the whole membrane of the nose is equally irritated; whereas in the gonorrhoea, only particular parts of the urethra seem to be affected. The disease, in the generality of cases, seldom extends more than an inch and a half along that canal, and in many is confined (at least in the beginning) to a small spot about an inch from the extremity of the glans. The discharge is produced from that part of the urethra where the pain is felt; and the patient, when he voids his urine, feels no smarting till it reaches the inflamed spot; but as the disorder increases, the inflammation affects a greater number of points, just in the same manner as chancres affect different parts of the glans. It might be supposed that dissection would at once clear up this matter, and put an end to the dispute; but this is far from being the case. Dr Simmons has seen several urethras opened in persons who had a gonorrhoea at the time of their death: in three of them the surface of the urethra, as in the cases related by Morgagni, appeared for some way down of a slight red colour, and in all of them was covered with mucus; but without any appearance of ulceration, except in two dissections at Paris, in which most of the gentlemen present were convinced that they saw evident marks of it; but Dr Simmons says that the appearances were to him net sufficiently satisfactory to enable him to decide with certainty on the subject. On the other hand, when we consider that the discharge in a gonorrhoea is sometimes tinged with blood, and that when this happens a little blood vessel is no doubt ruptured, we can have no reason to doubt that an ulceration may, and sometimes does, happen in these cases; especially as we often observe an excoriation near the orifice of the urethra. It is certain, that wherever there is considerable inflammation, there will be danger of ulceration. Besides, from a neglected or badly treated gonorrhoea, we often see fistulas in perineo, and other ulcers of the urethra, penetrating through its substance, and affording a passage to the urine. And there can be no doubt that slight ulcerations of this canal often occur, and are afterwards perfectly obliterated, in a similar manner to what happens in the papillae of the tongue, the tonsils, &c. Such an obliteration will the more readily take place in a part like the urethra, defended with mucous, and not exposed to the air, which is known to have no little effect in hardening a cicatrix.
But whether ulcers take place or not, whether the virus of gonorrhoea be precisely of the same kind with that which gives syphilis, or of a different kind, there is reason from the phenomena of the disease to conclude, that the matter first acts by mixing with the mucus at the extremity of the urethra; and that from thence it is propagated upwards, particularly where the excretories of mucus are most numerous; and that on the parts to which it is applied, it operates as a peculiar irritating cause. The consequences of this irritation will be inflammation and an increased secretion of mucus; and so far the complaint will be local. In ninety-nine cases of an hundred, a local affection of this kind constitutes the whole of the disease; and of this inflammation, ulcerations within the urethra, strictures, and other local affections, may be the consequence. But whether a disease of the habit ever takes place, unless when the contagion of syphilis is communicated with that of gonorrhoea, still remains to be determined by future observations and experiments.
Nothing can be more variable than the period at which the disease makes its appearance after infection. Perhaps, at a medium, we may place it between the 4th and 14th day: but in some cases it happens within From what has been said of the manner in which the contagious matter in gonorrhoea acts, and of the influence it exerts on those parts with which it comes in contact, it follows, that the prevention of gonorrhoea must depend on the removal of the contagious matter, as soon as that can be done; and where this is either altogether neglected or not properly accomplished, that the cure must depend on counteracting the inflammation which this contagious matter excites, and the consequences which result from it.
The first of these intentions may be most certainly and most easily accomplished by careful lotion of all the parts to which the contagious matter has any chance of being applied. These parts, at least on the first application of the matter, are readily accessible; for even in men there is no reason to believe that it at first penetrates to any extent in the urethra. This washing of the parts should be performed as soon as possible; because then the matter is both most accessible and least involved with mucus: but although washing cannot be accomplished at an early period, it should not be neglected afterwards; for from the disease uniformly commencing, even when it does not appear till a considerable time after the application of the contagious matter, with a peculiar sense of titillation at the external parts, particularly in men at the extremity of the urethra, there is reason to believe that the contagious matter attached to the mucus may remain latent there for a very considerable time. For the purpose of washing, with a view to the prevention of this disease, recourse may be had to almost any watery fluid, provided it be not so stimulant as to produce bad effects from injuring the parts. Pure water, properly applied, is perhaps one of the best lotions; but there can be no doubt that its power in removing the contagious matter may be somewhat increased by such additions as render it a more powerful solvent of mucus. With this intention, one of the most powerful additions is the vegetable alkali, either in its mild or caustic state. In the latter state it is the most active, but in the former it is most safe; and the carbonas potassae of the Edinburgh pharmacopoeia, to the extent of half a dram, dissolved in six or eight ounces of water, is one of the best lotions that can be employed. The purpose of removing the contagion may often also be effectually answered from washing with water impregnated with soap; for there the alkali, though in a caustic state, is prevented from exerting any disagreeable effects, in consequence of its being combined with oily matters.
With the view of preventing gonorrhoea, some have advised, that the alkali either in its mild or caustic state, properly diluted with water, should be injected into the urethra: and there can be no doubt, that by this means the contagious matter, when it has entered the urethra, may be removed. A removal may also be effected by the injection of a weak solution of corrosive sublimate, which seems to act not by dissolving the mucus but by producing an augmented secretion. But at a very early period of the disease, injections are probably unnecessary; and if it has made any considerable progress, they are dangerous: for from the augmented sensibility of the part, even very gentle ones are apt to excite a high degree of inflammation.
There are practitioners who, supposing that the body possesses powers to expel the virus, and that the disease has a certain period to run through its several stages of progress, acme, and decline, are for leaving the cure to nature; or at least content themselves with assisting her by an antiphlogistic regimen, gentle evacuations, and the like.
That in many cases the disorder admits of a natural cure, there can be no doubt; the increased secretion of mucus carrying off the virus faster than it is formed, till at length the infection is wholly removed: But it is equally certain, that in every case, by the application of suitable remedies to the inflamed part, we may shorten the duration of the complaint, and abridge the sufferings of the patient, with the same certainty and safety as we are enabled to remove the effects of an ophthalmia or any other local inflammation, by proper topical applications. General remedies, such as occasional blood-letting, a cooling diet, the liberal use of diluting liquors, and mild purges, are by all allowed to be useful, and even necessary. Astruc was of opinion that in these cases blood-letting ought to be repeated five or six times; and there are still many practitioners who depend much on repeated evacuations of this sort for a removal of the inflammation. But there is, perhaps, not one case in ten in which it is at all requisite; and this small number of cases will consist only of the strong and plethoric: in such, when the chordoe is frequent and painful, and the pulse hard and full, the loss of from eight to twelve ounces of blood will be beneficial, but it will be seldom necessary to repeat the operation. The inflammation in these cases is kept up by the local stimulus of the virus and the urine; and all that we can expect from venesection is to moderate the pain and the frequency of erection. In persons of a delicate habit, and of an irritable fibre, the evacuation will do no good; but if repeated will certainly be liable to do harm, by increasing irritability, and of course rendering the patient more susceptible of stimulus.
The utility, and even the necessity, of a cooling regimen, are sufficiently obvious; wine and spirituous liquors, spiceries, a fish-diet, much animal-food, and salted and high-seasoned dishes of every sort, will constantly add to the complaint. The patient should eat meat only once a day, and that sparingly. He should abstain from hot suppers. Milk, mild vegetables, and fruit, should constitute the principal part of his diet while the inflammatory symptoms continue. Everything that tends to excite the venereal imagination should be studiously avoided; for whatever promotes erections of the penis will increase the inflammation, and of course add fuel to the disease. For the same reasons much walking or riding on horseback will be hurtful, from the irritation kept up in the perineum by such means. Violent exercise of any kind, or any thing that is liable to increase the heat and the momentum of the blood, will of course be improper.
The drinking freely of mild, cooling, mucilaginous liquors, such as linseed tea, orgeat, whey, milk and water, almond emulsion, and the like, will be extremely useful, by diluting the urine, and preventing its salts from stimulating the urethra. When the heat and pain in making water are very considerable, mucilaginous substances substances are found to have the best effect, particularly the gum tragacanth. It is a common practice to give equal quantities of this gum or gum arabic and nitre, and to dissolve nitre in the patient's drink, with a view to lessen the inflammation. But in these cases nitre is always improper: it is known to be a powerful diuretic, its chief action being upon the urinary passages; so that the stimulus it occasions will only serve to increase the evil it is intended to alleviate. Superatartrite of potass, on account of its diuretic quality, will be equally improper. Our view here is not to promote a preternatural flow of urine; for the virus, being insoluble in water, cannot easily be washed away by such means; but our object ought to be, to render the urine that is secreted as mild and as little stimulating as possible.
Mild purges, which constitute another material part of the general remedies, are no doubt extremely useful when exhibited with prudence; but it is well known that the abuse of purgative medicines in this disease has been productive of numerous evils. Formerly it was a pretty general practice to give a large dose of calomel at bed-time, three or four times a-week; and to work it off the next morning with a strong dose of the pilulae coccae, or some other drastic purge. This method was persevered in for several weeks; in consequence of which the patient often found himself troubled with an obstinate gleet, and perhaps his constitution materially injured; the effect of such a method being (especially in irritable habits) to weaken the stomach and bowels, and lay the foundation of hypochondriacal complaints. Violent purging likewise often occasions strangury, and other troublesome symptoms.
The cathartics employed in these cases should be gentle; such as Rochelle salt, manna, tartarised alkali, and the like. They should be given only in a dose sufficient to procure two or three stools, and be repeated only every two or three days. The daily use of the purgative electuaries that are still given by some practitioners, serves only to keep up a continual irritation on the bladder, and of course to prolong the inflammation.
The topical remedies that are used consist chiefly of different sorts of injections, the ingredients of which are extremely various; but their modes of operation may in general be referred to their mucilaginous and sedative, or to their detergent, stimulating, and astringent qualities. In the hands of skilful practitioners, great advantages may doubtless be derived from the use of these remedies; but, on the other hand, the improper and unseasonable administration of them may prove a source of irreparable mischief to the patient.
We know that mucilaginous and oily injections will tend to allay the local inflammation; and that a sedative injection, such as a solution of opium, will lessen the irritability of the parts, and of course produce a similar effect; the utility of such applications is therefore sufficiently obvious.
A detergent injection, or one that will act upon the mucus of the urethra, increase the discharge of it, wash it away, and with it the venereal virus that is blended with it, can only be used as a prophylactic before the symptoms of infection have made their appearance. But great circumspection is necessary in the use of this kind of injection. If it be too weak, it can be of no efficacy; and if it be too strong, it may prove dangerous to the patient. A suppression of urine has been brought on by the improper use of an injection of this kind. When the symptoms of inflammation have once made their appearance, the stimulus of such an injection must be extremely hazardous. Excoration of the urethra has but too often been produced by remedies of this sort in the hands of adventurous and unskilful practitioners.
While the inflammation of the urethra continues, everything that stimulates it must be hurtful. If the injection excites a painful sensation in the urethra, as is but too often the case, it will be liable to produce swollen testicles, difficulty in making water, excoriation, and other effects of increased inflammation: if, by its stringency, the running be checked before the virus that excited the discharge be properly subdued, the patient will be exposed to fresh dangers; and perhaps to a variety of local complaints, such as obstructions in the urethra, and abscesses in perinaeo, which are well known to be sometimes owing to applications of this sort improperly managed.
When the inflammation has subsided, gently stimulating and astringent injections may be used with safety, and with considerable advantage: for as the inflammation is at first excited by the stimulus of the venereal virus, so when the former begins to lessen, we may be assured that the activity of the latter has abated in proportion; and, in general, when the inflammatory symptoms are entirely removed, it will be found, that the mucus is no longer of an infectious nature, but is merely the effect of an increased secretion and of relaxation. Mild astringents will therefore serve to brace and strengthen the vessels secreting mucus, and in this way will lessen the discharge, and greatly promote the cure. It is certain, that in the greater number of cases, a gonorrhoea, which if treated by internal remedies alone, would continue for five or six weeks, or longer, may, when judiciously treated with injections, be cured in a fortnight, and very often in less time. The great aim, therefore, of the practitioner ought to be at first to make use of such injections only as will tend to lubricate the surface of the urethra, and to counteract and destroy the stimulus of the virus: as the inflammation abates, he may add some gently astringent preparation to a mucilaginous and sedative injection; taking care that its astringency be suited to the state of the disease, and to the irritability of the patient. Amongst a great variety of substances, mercury in different forms is one of those that is the most frequently employed in injections. All these mercurial injections have more or less of astringency; and, according to Dr Simmons, it is solely to this property that we are to ascribe their effects; for the idea of their correcting the venereal virus was originally introduced, and has, he thinks, been continued, upon mistaken principles.
Calomel, mixed with the mucus discharged in a gonorrhoea, has no more power in destroying the infectious properties of that mucus than cerusse or any other preparation would have. A diluted solution of sublimate injected into the urethra, will, like a solution of verdigrise, or blue vitriol, or any other styptic, constringe the mouths of the laecæ; but this is all that it will do, for it will never lessen the infectious nature of the virus. This same thing may be observed of crude crude mercury extinguished by means of mucilage, or of mercurial ointment, blended with the yolk of an egg, and which, when thrown up into the urethra, will act nearly in the same manner as balsam of copaiva, or any other stimulating injection. The stimulus of mercury, however, has often been found of considerable efficacy; and in women, when the vagina only was affected, after washing the parts well, the cure has been accomplished by rubbing them repeatedly with mercurial ointment.
As the gonorrhoea is only a local affection, it may be inferred, that the internal use of mercury is unnecessary towards the cure. Very often indeed this complaint may be removed without having recourse to mercurials. Sometimes patients have been met with whose general health has been greatly impaired by a long continued use of mercury in such cases, while the original disease, the gonorrhoea, was rendered much worse by it. In some it has degenerated into a gleet, that was cured with extreme difficulty; in others it has brought on a variety of distressing symptoms. In cases of gonorrhoeas, therefore, whenever mercury is administered, it ought to be, not with a view to expedite the cure, but merely to obviate the dangers of syphilis. When the infection is apparently slight, and the inflammation and the symptoms trifling, we may proceed without the assistance of mercury, especially if the patient be of a weak, relaxed, and irritable habit, likely to be injured by mercurial medicines. On the other hand, when the discharge is violent, the inflammation considerable, or the seat of the disease high up in the urethra, it is perhaps the most prudent plan to give mercurials in small doses, and in such forms as seem the best adapted to the constitution of the patient.
The pilulae hydrargyri, as prepared according to the receipts inserted in the last edition either of the London or Edinburgh Pharmacopoeias, in both of which the mercury is rendered active merely by triture, may perhaps be considered as one of the mildest and most efficacious forms under which mercury can be exhibited by the mouth. Its efficacy will depend on its not irritating the bowels, and thus passing off by stool; care must likewise be taken to prevent its affecting the mouth. Of the chemical preparations of mercury, the mildest and least irritating is calomel. It may be given from gr. iib. to gr. iii. at bed-time, occasionally interposing a mild purgative to prevent it from salivating; but in general the mercurial pill just mentioned is to be preferred.
When there is no chancre or bubo, no appearance in short of syphilitic infection, it would be improper to administer corrosive sublimate, the mercurius calcinatus, or any other of the more acrid preparations of mercury.
After a gonorrhoea proceeding from venereal causes has been removed, another kind of running without pain, called the gonorrhoea mucosa, or gleet, sometimes remains. Sometimes it arises from a constriction and excoriation of the urethra, and frequently it is the effect of an enlargement and diseased state of the prostate. In each of these cases, as the gleet is the effect of irritation, the cure will depend on the removal of the local disease that occasions it. But there is another species of gleet that seems to depend chiefly on relaxation. It is in general free from infection, and is most common in those who have had long and frequent gonorrhoeas. It is likewise often the effect of a debilitated habit, from severe purging, or a long continued use of mercurials. A discharge of this kind is more frequent in women than in men; or, at least, the fluor albus, after a gonorrhoea, will often be mistaken for a gleet.
When there is no reason to suspect remaining contagion, astringent injections will be of the greatest service. It will be necessary, at the same time, to attend to the health of the patient, by employing cinchona, chalybeate waters, cold bathing, and such other remedies as will tend to strengthen the system: and indeed by the use of these, particularly by the cinchona, such runnings are often successfully combated in those who from apprehension of dangerous consequences cannot be prevailed upon to employ injections. When there is no tendency to inflammation, the balsam of copaiva may be prescribed with advantage in large doses. Dr Simons says he once saw a complaint of this sort removed by applying a blister to the perineum, after it had resisted a variety of other remedies. In the Medical Observations also we have an account of a gleet and incontinence of urine removed at once by a blister to the os sacrum. In general, however, the other methods above mentioned will be sufficient to remove it, though sometimes it will continue for a long time in spite of all our endeavours to check it.—Other kinds of gonorrhoea, in which the semen itself is ejected, especially during sleep, may be cured by tonics and a mild cooling regimen.
Order V. EPISCHESSES.
Genus CXXII. OBSTIPATIO.
Costiveness.
Obstipatio, Lin. 166. Vog. 128. Sag. 221.
Costiveness is sometimes occasioned by debility in dyspeptic persons, sometimes it is the effect of rigidity, and sometimes it is symptomatic of the colic. It may proceed from an affection of the liver; drinking rough red wines, or other astringent liquors; too much exercise, especially on horseback: it may likewise proceed from a long use of cold insipid food, which does not sufficiently stimulate the intestines. Sometimes it is owing to the bile not descending to the intestines, as in the jaundice: and at other times it proceeds from diseases of the intestines themselves, as a palsy, spasms, tumors, &c.
Excessive costiveness is apt to occasion pains of the head, vomiting, colics, and other complaints of the bowels. It is peculiarly hurtful to hypochondriac and hysterical persons, as it generates wind and other distressing symptoms.
Persons who are generally costive should live upon a moistening and laxative diet; as roasted or boiled apples, pears, stewed prunes, raisins, gruels, with currants, butter, honey, sugar, and such like. Broths with spinach, leeks, and other soft pot-herbs, are likewise proper. Rye-bread, or that which is made of a mixture of wheat and rye together, ought to be eaten. No person troubled with costiveness should eat white bread alone, especially that which is made of fine flour. Epicheses flour. The best bread for keeping the belly soluble is what in some parts of England they call meslin. It is made of a mixture of wheat and rye, and is very agreeable to those who are accustomed to it.
Costiveness is increased by keeping the body too warm, and by every thing that promotes the perspiration; as wearing flannel, lying too long in bed, &c. Intense thought, and a sedentary life, are likewise hurtful. All the secretions and excretions are promoted by moderate exercise without doors, and by a gay, cheerful, sprightly temper of mind.
The drink should be of an opening quality. All ardent spirits, austere and astringent wines, as port, claret, &c. ought to be avoided. Malt liquor that is fine and of a moderate strength is very proper. Butter-milk, whey, and other watery liquors, are likewise proper, and may be drank in turns, as the patient's inclination directs.
Those who are troubled with costiveness ought, if possible, to remedy it by diet, as the constant use of medicines for that purpose is attended with many inconveniences, and often with bad consequences. In time the custom becomes necessary, and generally ends in a total relaxation of the bowels, indigestion, loss of appetite, wasting of the strength, and death.
The learned Dr Arbuthnot advises those who are troubled with costiveness to use animal oils, as fresh-butter, cream, marrow, fat broths, &c. He likewise recommends the expressed oils of mild vegetables, as olives, almonds, pistaches, and the fruits themselves; all oily and mild fruits, as figs; decoctions of mealy vegetables; these lubricate the intestines; some saponaceous substances which stimulate gently, as honey, hydro-mel, or boiled honey and water, unrefined sugar, &c. are useful.
The doctor observes, that such lenitive substances are proper for persons of dry atrabiliarian constitutions, who are subject to stricture of the belly and the piles, and will operate when stronger medicinal substances are sometimes ineffectual; but that such lenitive diet hurts those whose bowels are weak and lax. He likewise observes, that all watery substances are lenitive; and that even common water, whey, sour-milk, and better-milk, have that effect:—That new milk, especially asses milk, stimulates still more when it sours on the stomach; and that whey, turned sour, will purge strongly:—That most part of fruits are likewise laxative; and that some of them, as grapes, will throw such as take them immoderately, into a cholera morbus, or incurable diarrhoea.
When the body cannot be kept open without medicine, gentle doses of rhubarb may be taken twice or thrice a-week. This is not near so injurious to the stomach as aloes, jalap, or the other drastic purgatives so much in use. Infusions of senna and manna may likewise be taken, or half an ounce of tartarised alkali dissolved in water gruel. About the size of a nutmeg of lenitive electuary taken twice or thrice a-day, generally answers the purpose very well.
Genus CXXIII. ISCHURIA.
-Suppression of Urine.
Ischuria, Sauv. gen. 293. Lin. 167. Vog. 129. Sug. 212. Home's Clinical Experiments, sect. xv.
This disease is distinguished into various species, according as the seat of it is in the kidneys, the ureters, the bladder, or the urethra; and hence these species are named renalis, ureterica, vesicalis, and urethralis.
1. Ischuria renalis, or a suppression of urine from an affection of the kidneys, happens but rarely; however, Dr Home in his Clinical Experiments describes such a case. In the end of December 1774, a man of a full habit, aged 35, was seized with shivering, coldness, and severe cough. Three days after, his urine appeared high-coloured, was passed with pain, and in small quantity. About the 8th of January 1775, he was attacked with violent pains in the small of his back, over the whole abdomen, and in the ankles, with pain in the region of the liver when pressed. A general swelling was afterwards observed all over the body, but chiefly in the ankles and abdomen, which last was tense and hard. These were attended with vomiting, bad appetite, and considerable thirst. When he entered the clinical ward (January 21st), the cough, sickness, and vomiting, had gone off, but the suppression of urine remained. The little which he made was passed with his stools, so that Dr Home saw it but once; and then it was pale, and had a white powder at bottom. The pains and swellings which retained the impression of the finger, continued; he had a headache, and a very slow pulse, beating only 48 strokes in a minute. He had taken a great many diuretic medicines before his admission. The day after his reception, he was seized with a spontaneous diarrhoea, which continued during the remainder of his life. Crystals of tartar were exhibited in doses of half an ounce each morning; at bed-time he took 20 drops of tincture of opium with a scruple of nitre, and continued this course for eight days without any increase of urine. The stronger and heating diuretics were then tried, as an infusion of juniper berries and pills of garlic; but they were attended with no manifest advantage. Whenever the pulse became so strong that he could bear bleeding, eight ounces of blood were taken away, which was sixty. This was thrice repeated; he appeared easier after each bleeding, his pulse bore it well, and the swellings and other symptoms abated. The heating diuretics, in this state, were given up, and a mixture of vinegar and nitre was substituted in their place, in each dose of which, taken every two hours, there was a scruple of nitre. Fermentations were applied to the region of the kidneys, and camphorated oil was afterwards rubbed on the part. He was ordered the semicupum, which, from a deficiency of water in the hospital at that time, he got only once; and which then seemed to have a good effect, as he passed a gill of urine when he was in it. Notwithstanding this, however, the disease continually gained ground; he became comatose, delirious, and died ten days after his admission. On dissection, the kidneys were found of an irregular form; some watery vesicles appeared on their surface, containing black gritty particles like fine sand; and the lower part of the right kidney was considerably inflamed. The pylorus, part of the duodenum, and a considerable part of the small intestines, were much inflamed. In the abdomen were found about five pounds of fluid, and in the cavities of the thorax about half a pound. The lungs were a little inflamed, and full of small tubercles on their surface and in their substance; the heart was large, and a polypus in each ventricle. About six ounces of fluid were found in the pericardium: in the brain nothing preternatural appeared, except about an ounce of water in each ventricle.
Dr Home seems to have been at a loss for the remote cause of this suppression of urine, which manifestly had its immediate origin from the kidneys having lost the power of performing their functions. He thinks the inflammation which appeared in the right kidney was scarce sufficient to have occasioned the distemper, as the other would have supplied its place: for which reason also he thinks that the ischuria was owing to a general affection of the system; and that it was of an arthritic nature, the patient having been troubled with complaints of that kind for a long time before.
2. The ischuria ureterica is also a rare disease, unless the obstruction proceeds from a stone or clot of blood stopping up the passage. Gravel or stones, indeed, are very frequently formed in the kidneys: and, by falling into the ureters, occasion an ischuria, with violent pain, and symptoms more or less urgent in proportion to the size and shape of the stones. Sometimes it is attended with coldness of the extremities, nausea, vomiting, and spasmodic constriction of the precordia, a difficulty of making water, constipation of the belly, difficulty of breathing, stupor of the thigh, retraction of the testicle, inquietude, loss of strength, syncope, and convulsion fits. When the violent pain has continued for several days and nights without intermission, and has brought the patient exceeding low, and the suppression of urine is complete, with coldness of the extremities and convulsions of the tendons, death is at hand. Nor is it a good sign when the stone continues long in the ureter; for then the appetite decays, a nausea and retching to vomit supervene, and the patient is consumed with a hectic heat. Sometimes the pain is attended with an inflammation of the stomach and intestines; and sometimes the disease ends in a dropsy of the breast, or lethargy, which soon carry off the patient.
The indications of cure are, to exclude the stone as easily as possible, and prevent the breeding of others. If the patient be of a sanguineous temperament, Sydenham recommends to take away ten ounces of blood from the affected side; and then to give the patient a gallon of posset-drink in which two ounces of marshmallow roots have been boiled, injecting at the same time an emollient glyster. After the posset drink has been vomited up, and the glyster returned, give a pretty large dose of an opiate. But if the patient be old or weak, or subject to nervous affections, bleeding may be omitted, especially if his urine at the beginning of the fit be coffee-coloured, and mixed with gravel; but as to the other things, the cure is the same. Huxham highly recommends an emollient bath prepared of a decoction of marshmallow root, lintseed, fenugreek seed, and flowers of chamomile, to which may be added a few white poppy seeds. By the use of this bath he says he has seen the most cruel fit of the gravel suddenly ended, when neither copious bleeding nor opiates had the least effect. Mild diuretics are also of service. Hoffman recommends dulcified spirit of nitre as proper to relax the spasmodic stricture. It is to be taken with suitable distilled waters and syrup of poppies; or in broth, with a few spoonfuls of oil of sweet almonds. Turpentine glysters are also accounted very serviceable; and may be prepared with ten ounces of a decoction of chamomile, with half an ounce of turpentine dissolved in the yolk of an egg, and about as much honey. The sal diureticus, or acetis potassae, is much esteemed by some, when taken along with an opiate. But when the stone is too big to pass, Arbuthnot recommends a cool and diluent diet to hinder the further growth of it. Whey, infusion of lintseed, decoction of marshmallows, and gently resolving diuretics, are also proper. To put a stop to the vomiting, the compound tincture of benzoin, formerly named balsamum traumaticum, has sometimes been used with success, when almost every other means have failed.
3. The ischuria vesicalis may arise from a stone in the bladder; and this indeed is the most common cause of it: but there are certain cases, in which, though the usual quantity of urine, or perhaps more, be passed, the patient dies from the retention of a still greater quantity in the bladder. Of this Dr Hume gives the following instances. A man of 58 years of age, of a strong spare habit, and never subject to the gravel, had, during the winter of 1777, a cough with expectoration, which went off in the beginning of 1778. About the 17th of February 1778 he felt some difficulty in passing his urine, and much pain about the region of the bladder. He continued in this way for ten days, after which he became easier on application of some medicines. The abdomen then swelled, and he had pains in his loins and thighs. On the 3d of March he was admitted into the clinical ward; his abdomen was then swelled and tense; and an evident fluctuation was felt, which some that touched him thought was sonorous and produced by wind. A tumor was discovered between the navel and spine of the os ilium on the left side, which gave him much pain, especially when pressed. This tumor became more easily felt after the swelling of the abdomen decreased, seemed round, and very near as large as the head of a child. It appeared very much on the left side, even when the patient lay on the right, and it then became dependent. He passed urine frequently, and rather more than in health, as it was computed at four pints a day. It was always clear, and of a light colour. His body had a strong disagreeable smell; his skin was dry, belly bound, and his appetite entirely gone, so that he had hardly taken any food for 12 days. His legs swelled slightly for some days in the evening. His pulse was generally regular, sometimes slower than natural, and sometimes a little quicker; being once felt at 64, and another time at 92. He was often seized, especially after eating or drinking, with hiccup; which increased and lasted till his death. On the 23th day of his disease, after some doses of squills, the general swelling of his abdomen fell, became much softer, and more distinctly discovered the swelling of the left side. The next day a vomiting came on; he became delirious, and died the day following. The body being opened, it appeared that the tumor which was so distinctly felt on the left side of the abdomen, was owing to a distention of the bladder with urine. Its fundus reached to about the division of the aorta into Epischées, the iliacs; it entirely filled the pelvis, and contained between five and six pounds of urine of a pale colour.
On examining the external surface, its neck, and the beginning of the urethra, were found to be surrounded with a scirrhosity, which impeded the evacuation of the urine. The bladder itself was much thickened, but not more in one part than another. The ureters entered naturally; but were much thickened in their upper half near the kidney. The kidneys were somewhat enlarged; particularly the left, which had several watery vesicles on its external surface. These organs were not in their usual situation; but lay close on each side of the spine, and very near the aorta: so that the renal vessels were very short. What was very singular, the lower end of each arose over the spine, and they were united together by their membranes, the aorta passing beneath the union. The bladder had pressed considerably on this part; and the peritoneum covering them was considerably thicker than natural. The lungs adhered everywhere to the pleura, and in some places very firmly: they were of a loose texture and black colour; and the veins of the lower extremities were turgid with blood. It does not appear that this patient got any medicines farther than a few dried squills, which diminished the swellings and brought off much wind. He also got a mixture of musk, and afterwards of opium, for his hiccup; but without success. His disease was mistaken for an ascites; and the catheter was not tried: but in another case the use of this instrument was apparently of more service than any internal medicines. This last patient was about 90 years of age, and laboured under symptoms very similar to those already mentioned. When admitted into the clinical ward, he had the hypogastric region swollen, and difficulty of passing his water; but without pain, vomiting, or hiccup. He had lost all appetite; was thirsty, and constive. His pulse was 110, and weak. In the evening about three English pints of pale clear urine were drawn off by means of the catheter: the next day all the symptoms were gone off or abated. After this he continued to pass some urine, sometimes voluntarily, sometimes involuntarily and insensibly: but so much always remained behind, that his bladder was constantly full, unless when the urine was drawn off, which was done twice every day. The urine was sometimes pale, sometimes of a deep red colour; and once there was some blood mixed with it, which perhaps might have been occasioned by the catheter. About the sixth day the urine was very putrid, with much purulent like matter at the bottom, and was passed with more pain. About the 11th, the putrid smell went off. The next day all the urine passed insensibly except what was drawn off; and an hiccup, though not very severe, had come on. In this way he continued without fever, though frequently troubled with the hiccup, especially during those nights in which the urine had not been drawn off. A month after admission, the bladder, with the assistance of the catheter, was almost entirely, though insensibly evacuated, and the hiccup had left him; he had no other complaint but that of voiding his urine insensibly, the natural effect of a scirrhous bladder, and which was probably incurable. With this patient the hot bath and mercurials were tried, in order to soften the scirrhosity of the bladder, but without effect.
4. The ischuria urethralis arises from some tumor obstructing the passage of the urethra, and thus hindering the flow of the urine. It is no uncommon distemper, and often follows a gonorrhoea. Dr Home gives us an example of this also.—The patient was a man of 60 years of age, who had laboured under a gonorrhoea six months before, and which was stopped by some medicines in two or three days. He felt soon afterwards, a difficulty in passing his urine, which gradually increased. About 10 days before his admission into the clinical ward, it was attended with pains in the glans, and ardor urinae; he had passed only about eight ounces the day before his admission, and that with very great difficulty; and the hypogastric region was swelled and pained. On introducing the catheter, three pounds of urine were drawn off, by which the pain and swelling were removed. The instrument required force to make it pass the neck of the bladder, and blood followed the operation: and the finger, introduced into the anus, felt a hard tumor about its neck. He was treated with mercurial pills and ointment, by which the swelling about the neck of the bladder soon began to decrease; but at the same time a swelling of the right testicle appeared. He was vomited with four grains of turbithe-mineral, the subsulphas hydrargyri flavus of the present pharmacopoeia, which operated gently; and here Dr Home observes, that though these vomits are little used, from a mistaken notion of their severity, he never saw them operate with more violence than other vomits, or than he could have wished. The swelling diminished in consequence of the emetic and some external applications; and the cure was completed by bleeding and a decoction of mezereon root.
GENUS CXXIV. DYSURIA.
DIFFICULTY OF DISCHARGING URINE.
Dysuria, Sauv. gen. 265. Lin. 57. Vog. 164. Sag. 213.
Stranguria auctorum.
A difficulty of making water may arise from many different causes; as from some acrid matter in the blood, cantharides, for instance; and hence a strangury very often succeeds the application of blisters. In many cases it arises from a compression of some of the neighbouring parts; of the uterus, for instance, in a state of pregnancy. Or it may arise from a spasmodic affection of the bladder, or rather its sphincter; or from an inflammation of these parts, or others near them. Hence the disease is distinguished into so many species, the cure of which is to be attempted by remedies indicated by their different causes.
But the most common, as well as the most dangerous species is that arising from a calculous concretion, or STONE IN THE BLADDER.
Dysuria calculosa, Sauv. sp. 12.
The signs of a stone in the bladder are, pain, especially about the sphincter; and bloody urine, in consequence Episodes of riding or being jolted in a carriage; a sense of weight in the perineum; itchiness of the glans penis; slimy sediment in the urine; and frequent stoppages in making water; a tenesmus also comes on while the urine is discharged: but the most certain sign is, when the stone is felt by the finger introduced into the anus, or by sounding.
Causes, &c. It is not easy to say what the particular causes are which occasion the apparently earthly particles of the fluids to run together, and form those calculous concretions which are found in different parts of the body, and especially in the organs for secreting and discharging the urine.
The gout and stone are generally supposed to have some affinity, because gouty people are for the most part afflicted with the gravel. But perhaps this is in part owing to their long confinement, and to lying on the back, which people who labour under the gout are often obliged to submit to; since the want of exercise, and this posture, will naturally favour the stagnation of gross matters in the kidneys; besides, there are many instances of people severely afflicted with the stone for the greatest part of a long life, who have never had the least attack of the gout.
There is, however, good reason for believing, that some farther connection takes place between the two diseases; and when treating of the gout we have already given some account of the opinion of an ingenious anonymous author, who has endeavoured to prove, that both the one and the other depend on a peculiar acid, the concreting, lithic, or uric acid, which is always present in blood; and which may be precipitated from thence by various causes, such as the introduction of other acids, or the like. When thus precipitated, he supposes it to produce the whole phenomena of both diseases. The objections we formerly stated to his theory of gout, do not equally militate against that of calculus; and it is at least certain, from the best chemical analysis, that what are commonly called urinary calculi, and have been considered as entirely an earthy matter, consist principally of acid in a solid state united only with a small proportion of earth or mucus. We may, therefore, whether this hypothesis be altogether well founded or not, justly view lithiasis as depending, in a great measure, on the separation of an acid from the blood.
Whatever may be the particular cause of the disposition to lithiasis, the kidneys appear to be the most likely places for particles to concrete or run together, because of the great quantity of blood which passes through the renal arteries, and which comes immediately from the heart, fraught with various newly received matters, that have not undergone much of the action of the vessels, and therefore cannot as yet be supposed to be thoroughly assimilated.
Anatomists who have carefully examined the kidneys in the human subject, particularly M. Bertin, inform us, that there are two sets of tubuli uriniferi; the one continued directly from the extremities of the renal artery, and the other springing from that vesicular texture which is conspicuous in the kidneys.
It is in this vesicular part of the kidney that we presume the particles of the concreting matter first stagnate and coalesce: for it is hardly to be supposed, that such solid matters could be allowed to stop in the extremities of the renal arteries, since the blood, and the urine separated from it, must flow through these vessels with great degrees of force and velocity; but in the intermediate vesicle the particles may lie, and there attracting each other, soon come to acquire sensible degrees of magnitude, and thus become sand or gravel. As long as this sand or gravel formed in the vesicular part of the kidney lies quiet, there will be no pain or uneasiness, until the concretions become large enough to press either on the adjoining tubuli, or on the blood-vessels; then a sense of weight, and a kind of obtuse pain in the loins, will be felt. But when the small pieces of concreting matter shall be dislodged and washed off by the force of the circulating fluids, or loosened by some spasmodic action of the moving fibres in these parts, they will in their passage create pain, raise different degrees of inflammation, or perhaps lacerate some blood-vessels, and cause bloody urine. When these little concretions happen to be detained in the pelvis of the kidney, or any other place where a flow of urine continually passes, they soon increase in size, and become calculi, from the constant accession of particles, which are attracted by the original bit of sand, which thus becomes the nucleus of a stone.
It is an opinion which Hippocrates first advanced, and which has been almost universally adopted by his followers, and has remained till lately uncontroverted, that the stone and gravel are generated by the use of hard water. From the quality, which the waters of certain springs possess, of depositing a large earthy sediment, either in the aqueducts through which they are conveyed, or in the vessels in which they are boiled or preserved, it was conjectured, that in passing through the kidneys, and especially whilst retained in the bladder, they would let fall their grosser particles, which by the continued apposition of fresh matter, connected by the animal gluten, and compacted by the muscular action of that organ, would in time form a calculus sufficiently large to produce a train of the most excruciating symptoms. And this reasoning a priori has been supposed to be confirmed by facts and experience; for not to mention the authority of Hippocrates, Dr Lister has observed, that the inhabitants of Paris are peculiarly subject to the stone in the bladder. Nicholas de Blegny has related the history of one who was dissected at Paris, in whom the pylorus, a great part of the duodenum, and the stomach itself, were found incrusted with a stony matter, to the thickness of a finger's breadth. And it is well known, that the water of the river Seine, with which that city is supplied, is so impregnated with calcareous matter, as to incrustate, and in a short time to choke up, the pipes through which it runs. But on the other hand it is objected, that the human calculus is of animal origin, and by chemical analysis appears to bear very little analogy to the stony concretions of water: and though it be allowed, that more persons are cut for the stone in the hospitals at Paris than in most other places; yet upon inquiry it is found, that many of those patients come from different provinces, and from towns and villages far distant from the Seine.
Dr Percival conjectures, that though this disease may chiefly depend upon a peculiar disposition to concrete in Episthesis in the animal fluids, which in many instances is hereditary, and in no instance can with certainty be imputed to any particular cause; yet hard water is at least negatively favourable to this diathesis, by having no tendency to diminish it. The urine of the most healthy person is generally loaded with an apparently terreous matter, capable in favourable circumstances of forming a calculus; as is evident from the thick crust which it deposits on the sides of the vessels in which it is contained. And it seems as if nature intended by this excretion to discharge all the superfluous salts of the blood, together with those earthy particles, which are either derived from our aliment, and fine enough to pass through the lacteals, though insuperable by the powers of circulation, or which arise from the abrasion of the solids, or from the dissolution of the red globular part of our fluids. Now water, whether used as nature presents us with it, or mixed with wine, or taken under the form of beer or ale, is the great diluter, vehicle, and menstruum, both of our food, and of the saline, earthy, and excrementitious parts of the animal juices. And it is more or less adapted to the performance of these offices, in proportion to its degree of purity. For it must appear evident to the most ordinary understanding, that a menstruum already loaded, and perhaps saturated with different contents, cannot act so powerfully as one which is free from all sensible impregnation. Nor is this reasoning founded upon theory alone; for it is observed, that Malvern water, which issues from a spring in Worcestershire, remarkable for its uncommon purity, has the property of dissolving the little sabulous stones which are often voided in nephritic complaints. And the solution too, which is a proof of its being complete, is perfectly colourless. Hence this water is drunk with great advantage in disorders of the urinary passages. And during the use of it, the patient's urine is generally limpid, and seldom deposits any sandy sediment. Yet notwithstanding this appearance of transparency, it is certainly at such times loaded with impurities, which are so diluted and dissolved as not to be visible. For it is attended with a strong and fetid smell, exactly resembling that of asparagus. Hoffman mentions a pure, light, simple water in the principality of Hennecberg, in Germany, which is remarkable for its efficacy in the stone and gravel; and a water of similar virtues was discovered not many years ago in the Black forest, near Osterod, which upon examination did not afford a single grain of mineral matter. Indeed it is worthy of observation, that most of the springs which were formerly held in great esteem, and were called holy wells, are very pure, and yield little or no sediment.
Dr Percival informs us that a gentleman of Manchester, who had been long subject to nephritic complaints, and often voided small stones, was advised to refrain from his own pump-water, which is uncommonly hard, and to drink constantly the soft water of a neighbouring spring; and that this change alone, without the use of any medicine, has rendered the returns of his disorder much less frequent and painful. A lady also, much affected with the gravel, was induced by the perusal of the first edition of Dr Percival's Essay, to try the effect of soft water; and by the constant use of it remained two years entirely free from her disorder.
In nephritic cases, distilled water would be an excellent substitute for Malvern water, as the following experiment evinces.
Two fragments of the same calculus nearly of equal weight, were immersed, the one in three ounces of distilled water, the other in three ounces of hard pump-water. The phials were hung up close together in a kitchen-chimney, at a convenient distance from the fire. After 14 days maceration, the calculi were taken out, and carefully dried by a very gentle heat. The former, viz. that which had been immersed in distilled water, was diminished in its weight a grain and a half; the latter had lost only half a grain.
It is the passage of these calculi from the kidneys down into the bladder, which occasions the pain, vomiting, and other symptoms, that constitute what is usually termed a fit of the gravel or stone.
When an inflammation is actually raised, the disease is known by the name of nephritis, and has been already treated of.
As soon as the stone passes through the ureter, and falls into the bladder, the pain and other nephritic symptoms cease; and every thing will remain quiet, either till the stone be carried into the urethra, or until it has remained long enough in the bladder to acquire weight sufficient to create new distress.
If a stone happen to be smooth and of a roundish form, it may lie in the bladder and acquire considerable bulk before it can be perceived by the patient; but when it is angular, or has a rugged surface, even though it may be small in size, yet it seldom fails to raise pain, and occasion bloody urine, or the discharge of a slimy fluid, with tenesmus, and difficulty in making water.
There have been various attempts made to dissolve the stone; and there are certainly some articles which have this effect when applied to them out of the body; but the almost total impossibility of getting these conveyed to the kidneys, renders it extremely doubtful whether a solvent ever will be discovered. Of all the articles employed for this purpose, no one perhaps has had greater reputation than fixed alkaline salt in its caustic state, particularly under the form of the lixivium caustum, or aqua potassae, as it is now called; but this being of a very acrid nature, it requires to be well sheathed by means of some gelatinous or mucilaginous vehicle. Veal-broth is as convenient as any for this purpose; and accordingly it is used by those who make a secret of the caustic alkali as a solvent of calculus.
Mr Blackrie, who has taken much pains in this inquiry, has proved very satisfactorily, that Chitrick's nostrum is no other than soup-leses given in veal-broth, which the patients send every day to the doctor, who returns it mixed up with the medicine, in a close vessel secured by a lock.
It is not every case, however, that either requires or will bear a course of the caustic alkali. Some calculi are of that soft and friable nature, that they will dissolve even in common water; and there are cases wherein it appears that the constant use of some very simple decoction or infusion of an insignificant vegetable, has brought away large quantities of earthy matter, in flakes which apparently have been united together in layers to form a stone. Dr Macbride assu These sure us, that a decoction of raw coffee, only 30 berries in a quart of water, boiled till it acquired a deep greenish colour, taken morning and evening to the quantity of eight or ten ounces, with ten drops of sweet spirit of nitre, had the powerful effect of bringing away, in the course of about two months, as much earthy matter in flakes as filled a large tea-cup. The patient was far advanced in years; and, before he began this decoction, had been reduced to great extremities by the continuance of pain and other distressing symptoms: he was purged occasionally with oleum vicini.
Very lately the alkali in a mild state, and in a different form, has been much used by many calculous patients, and with great advantage, under the form of what is called alkaline aerated water, the aqua supercarbonatis potassae of the present edition of the Edinburgh Pharmacopoeia. For the introduction of this medicine, or at least for its extensive use, we are chiefly indebted to the ingenious physician Dr William Falconer of Bath. He has lately published an account of the Aqua Mephitica Alkalina, or solution of fixed alkaline salt, saturated with fixable air, in calculous disorders; which contains a number of cases strongly supporting the benefit to be derived from it. But whether the good effects obtained in these instances are to be explained from its operating as a solvent of calculus, seems to be extremely doubtful. There are indeed cases in Dr Falconer's treatise, of patients in whom, after using it for a considerable time, no stone could be detected by sounding, although it had been discovered in that way before they began the employment of it. But in many instances, the relief has been so sudden, that it may be concluded, that notwithstanding the case obtained, the calculus still remained. In such cases, it probably removed from the urine that quality by which it gives to the calculus fresh accretions, producing that roughness of its surface by which it is chiefly capable of acting as a stimulus. For the distressing symptoms resulting from stone are chiefly to be attributed to the inflammatory and spasmodic affections which it induces; and when its surface is least capable of operating as a stimulus, these of course will be least considerable. It is therefore not improbable, that this remedy produces relief, by preventing fresh additions being made to the calculus.
An infusion of the seeds of daucus sylvestris sweetened with honey, is another simple and much celebrated remedy; it has been found to give considerable ease in cases where the stomach could not bear any thing of an acrid nature. The leaves of the uva ursi were strongly recommended by the late celebrated De Haen; and this, whatever its way of operating may be, seems to have been productive of good effects in some instances. There is no reason to believe that it has any influence in dissolving calculus; and indeed it seems to be chiefly useful in these instances where ulcerations take place in the urinary passages.
In the Edinburgh Medical Commentaries, vol. iii., we have an account of a method used by the inhabitants of Arabia Petraea for curing the stone, to which they are very much subject, and which the author (an English gentleman of experience and candour) affirms he has seen frequently performed with success. By means of a catheter, they inject into the bladder a weak ley of alkali with the purified fat of a sheep's tail, and Dysuria. a proper quantity of opium, all put together. Their catheters are made of gold; and in performing the operation they introduce them quite into the bladder; so that the composition is safely conveyed to the stone without hurting any other part. But when a stone is situated in the kidney, they have no method of cure.
If this method of curing by injection could be safely practised, it would no doubt have the advantage over that of taking alkalis by the mouth, where the medicine is not only much weakened, but the constitution of the patient runs the risk of being greatly injured. But from some experiments mentioned in the second volume of the Medical Transactions, and still more from the chemical analysis of urinary concretions, lately published by Fourcroy and other modern chemists, it appears that the human calculi are very different from one another in their natures. Some, for instance, will easily yield to an alkaline menstruum, and very little to an acid; while others are found to resist the alkali, and yield to the acid; and some are of such a compact nature, that they yield neither to acids nor alkalis. An attention, however, to the fragments, scales, or films, which the stone may cast off, and also to the contents and sediment of the urine, may lead to the discovery of what solvent is proper, or whether the stone can be dissolved by any. To use either alkalis or acids improperly may be hurtful; though there may be such kinds of calculi as demand the alternate use of acids and alkalis; nay, there may be found calculi of opposite kinds in the same subject.
In such cases as will not allow us to think of dissolving the stony concretions, and where the only object is to palliate and procure ease from time to time, little more can be done than to keep the bowels open occasionally by some gentle cathartic, and wash off as much of the loose gravelly matter and slime as can be removed by such mild diuretic infusions and decoctions as shall be found to pass freely and sit well on the stomach. Persons afflicted with the stone should be careful in respect of their diet, and studiously avoid all heavy and flatulent food, as well as high sauces that are apt to turn rancid. For the same reason, butter and acids are to be shunned; for these often create heartburning, and every thing that offends the stomach raises the nephritic pain; such is the sympathy that obtains between the digestive and the uropoietic organs.
There have been surgeons bold enough to entertain an idea of cutting even into the kidney, in order to extract a stone: this, however, except in cases where an abscess has been formed, and nature points out the way, is both very uncertain and very hazardous. But cutting into the bladder for the same purpose, is an ancient and well known operation, and often crowned with success. A description, however, of this operation belongs to the article Surgery, to which we refer; and here shall only make this remark, that a surgeon should never begin his operation, until he and his assistants are perfectly satisfied, from actually feeling the stone, that there is one in the bladder; because it has sometimes happened, that when the incision has been made, no stone could be found: and the patient having died in consequence of the operation, and the body Episcches body being opened, it has appeared that the symptoms which occasioned the belief of a stone in the bladder arose from some other cause.
When a dysuria proceeds from any acrimonious matter thrown into the blood, it may be readily cured by bleeding, emollient oysters, cooling and diluting drinks with gum arabic or gum tragacanth, linseed tea, or the warm bath. When it arises from inflammations of the bladder or parts adjoining to it, we are to regard it only as a symptomatic affection; and the remedies used to remove the primary disease will also remove the dysuria. Sometimes it may arise from an ulcer of the bladder; in which case it is generally incurable; a mild nutritious diet will, however, protract the patient's life; and even render that life tolerable, by alleviating symptoms.
Genus CXXV. Dyspermatismus.
Difficult Emission of Semen.
Dyspermatismus, Sauv. gen. 260. Sterilitas, Lin. 171. Sag. 211. Agenesis, Vog. 283.
This impediment proceeds generally from obstructions in the urethra, either by tumors in itself, or in the cavernous bodies of the penis; in which case the treatment is the same as in the ischuria urethralis; sometimes it is owing to a kind of epileptic fit which seizes the man in the venereal act; and sometimes the semen, when ejected from the proper receptacles, is again absorbed, or flows into the bladder, and is expelled along with the urine. The last case it is very difficult, or even impossible, to cure; as proceeding from scirrhi, or other indissoluble tumors of the verumontanum, or the neighbouring parts. It is also, in general, incurable. In some it proceeds merely from too violent an erection; in which case emollient and relaxing medicines will be of service; and we have an example of a cure performed by means of these in the first volume of the Edinburgh Medical Essays.
Genus CXXVI. Amenorrhoea.
Suppression of the Menses.
Amenorrhoea, Vog. 130. Dysmenorrhoea, Lin. 168. Sag. 218.
This obstruction, with many other symptoms, as dyspepsia, yellowish or greenish colour of the skin, unusual appetites, &c., constitutes the chlorosis already treated of, a disease which seldom or never appears without a suppression of the menses. In Dr Home's Clinical Experiments we find the virtues of several emenagogues set forth in the following manner. Chalybeates seldom or never succeeded: they were always found more useful in diminishing the evacuation when too violent, than in restoring it when deficient. The Amantinure of black hellebore proved successful only in one of nine or ten cases, though given to the length of four tea-spoonfuls a-day, which is double the quantity recommended by Dr Mead. Compression of the crural artery, recommended by Dr Hamilton in the Physical and Literary Essays, vol. ii. proved successful only in one of six cases. From the effects produced by this compression, it has the strongest appearance of loading the uterus with blood; from the sensations of the patient it produces the same effects as the approach of the menses, and has every appearance in its favour; yet does not succeed. Dr Home supposes that the uterus is most frequently in too plethoric and inflammatory a state; in which case, this remedy will do more hurt than in a state of inanition; however, he owns, that in the case in which it did succeed, the patient was plethoric and inflammatory. Venesection is recommended as an excellent remedy; the doctor gives three instances of its success, and says he could give many more. It acts by removing the plethoric state of the uterus, relaxing the fibres, and giving the vessels full play; so that their action overcomes all resistance, and the evacuation takes place. It is of no great moment from whence the blood is taken: the saphenic vein has been supposed to empty the uterus most; but it is difficult to get the proper quantity from it, and the quantity of the discharge cannot be so well measured. The powder of savine is a most powerful remedy; and proved successful in three cases out of four in which it was tried. It was given to the quantity of half a dram twice a-day. It is a strong topical stimulus, and seems improper in plethoric habits. Madder-root, according to Dr Home, is a very powerful medicine in this disease; and proved successful in 14 out of 19 cases in which it was tried, being sometimes exhibited in the quantity of two scruples, or a dram, four times a-day. It has scarcely any sensible effects; never quickens the pulse, or excites inflammatory symptoms; on the contrary, the heat, thirst, and other complaints abate; and sometimes these symptoms are removed, though the disease be not cured; but when it succeeds, the menses appear from the third to the 12th day.
We have now considered all those diseases enumerated in Dr Cullen's Nosology, the cure of which is to be attempted chiefly by internal medicines. The other genera either require particular manual operations, or a very considerable use of external applications; and therefore more properly fall under the article Surgery. To this, therefore, we shall refer the genera which fall under the three last orders of the class of locales, viz. the tumores, ectopie, and dialyseis; and we shall add, by way of Appendix, a few observations on some important affections to which Dr Cullen has not given a place in his system, or which practitioners in general are not agreed in referring to any one particular genus which he has mentioned.
Dr Heberden was the first who described this disease, though it is an extremely dangerous, and, by his account, not very rare affection. It seizes those who are subject to it when they are walking, and particularly when they walk soon after eating, with a most disagreeable and painful sensation in the breast, which seems to threaten immediate destruction; but the moment they stand still, all the uneasiness vanishes. In all other respects the patients at the beginning of this disorder are well, and have no shortness of breath; from which the angina pectoris is totally different. After it has continued some months, the fits will not cease instantaneously on standing still; and it will come on not only when the patients are walking, but when they are lying down, and oblige them to rise up out of bed every night for many months together. In one or two very inveterate cases, it has been brought on by the motion of a horse or carriage, and even by swallowing, coughing, going to stool, speaking, or by any disturbance of mind. The persons affected were all men, almost all of whom were above 50 years of age, and most of them with a short neck and inclining to be fat. Something like it, however, was observed in one woman, who was paralytic; and one or two young men complained of it in a slight degree. Other practitioners have observed it in very young persons.
When a fit of this sort comes on by walking, its duration is very short, as it goes off almost immediately upon stopping. If it comes on in the night, it will last an hour or two. Dr Heberden met with one in whom it once continued for several days; during all which time the patient seemed to be in imminent danger of death. Most of those attacked with the distemper died suddenly; though this rule was not without exceptions; and Dr Heberden observed one who sunk under a lingering illness of a different nature.
The os sterni is usually pointed to as the seat of this malady. It seems as if it was under the lower part of that bone, and at other times under the middle or upper part, but always inclining more to the left side; and in many cases there is joined with it a pain about the middle of the left arm, which appears to be seated in the biceps muscle.
The appearance of Dr Heberden's paper in the Medical Transactions very soon raised the attention of the faculty, and produced other observations from physicians of eminence; particularly Dr Fothergill, Dr Wall of Worcester, Dr Haygarth of Chester, and Dr Percival of Manchester. It also induced an unknown sufferer under the disease to write Dr Heberden a very sensible letter, describing his feelings in the most natural manner; which, unfortunately, in three weeks after the date of this anonymous epistle, terminated in a sudden death, as the writer himself had apprehended.
The youngest subject that Dr Fothergill ever saw afflicted with this disorder was about 30 years of age; and this person was cured. The method that succeeded with him was a course of pills, composed of the mass of gun pill, soap, and native cinnabar; with a light chalybeate bitter: this was continued for some months, after which he went to Bath several successive seasons, and acquired his usual health: he was ordered to be very sparing in his diet; to keep the bowels open; and to use moderate exercise on horseback, but not to take long or fatiguing walks.
The only symptom in this patient that is mentioned, was a stricture about the chest, which came on if he was walking up hill or a little faster than ordinary, or if he was riding at a very brisk trot; for moderate exercise of any kind did not affect him; and this uneasy sensation always obliged him to stop, as he felt himself threatened with immediate death if he had been obliged to go forward.
It is the sharp constrictive pain across the chest which (according to Dr Fothergill's observation) particularly marks this singular disease; and which is apt to supervene upon a certain degree of muscular motion, or whatever agitates the nervous system.
In such cases as fell under the inspection of Dr Fothergill, he very seldom met with one that was not attended with an irregular and intermittent pulse; not only during the exacerbations, but often when the patient was free from pain and at rest; but Dr Heberden observes, that the pulse is, at least sometimes, not disturbed; and mentions his having once had an opportunity of being convinced of this circumstance, by feeling the pulse during the paroxysm.
But no doubt these varieties, as well as many other little circumstances, will occur in this disease, as they do in every other, on account of the diversity of the human frame; and if those which in general are found to predominate and give the distinguishing character be present, they will always authorise us in giving the name to the disease: thus, when we find the constrictory pain across the chest, accompanied with a sense of strangling or suffocation; and still more, if this pain should strike across the breast into one or both arms; we should not hesitate to pronounce the case an angina pectoris.
As to the nature of this disease, it appears to be purely spasmodic: and this opinion will readily present itself to any one who considers the sudden manner of its coming on and going off; the long intervals of perfect ease; the relief afforded by wine and spirituous cordials; the influence which passionate affections of the mind has over it; the case which comes from varying the posture of the head and shoulders, or from remaining quite motionless; the number of years for which it will continue, without otherwise disordering health; its bearing so well the motion of a horse or carriage, which circumstance often distinguishes spasmodic pains from those which arise from ulcers; and, lastly, its coming on for the most part after a full meal, and in certain patients at night, just after the first sleep, at which time the incubus, convulsive asthma, and other diseases, justly attributed to the disordered func- tions of the nerves, are peculiarly apt to return or to be aggravated.
From all these circumstances taken together, there can be little doubt that this affection is of a spasmodic nature: but though it should be admitted, that the whole distress in these cases arise from spasm, it may not be so easy to ascertain the particular muscles which are thus affected.
The violent sense of strangling or choking, which shows the circulation through the lungs to be interrupted during the height of the paroxysm; and the peculiar constrictive pain under the sternum, always inclining (according to Dr Heberden's observation) to the left side; together with that most distressing and alarming sensation, which, if it were to increase or continue, threatens an immediate extinction of life; might authorise us to conclude that the heart itself is the muscle affected: the only objection to this idea is, that the pulse is not always interrupted during the paroxysm. The appearances in two of the dissections, favour the opinion that the spasm affects the heart; as in one subject the left ventricle was found as empty of blood as if it had been washed; and in another, the substance of the heart appeared whitish, not unlike a ligament; as it should seem, in both cases, from the force of the spasm squeezing the blood out from the vessels and cavities.
If this hypothesis be allowed, we must conclude that the spasm can only take place in an inferior degree, as long as the patient continues to survive the paroxysm; since an affection of this sort, and in this part, of any considerable duration or violence, must inevitably prove fatal: and accordingly, as far as could be traced, the persons who have been known to labour under this disease have in general died suddenly.
The dissections also show, that whatever may be the true seat of the spasm, it is not necessary for the bringing of it on, that the heart, or its immediate appendages, should be in a morbid state; for in three out of the six that have as yet been made public, these parts were found in a sound state.
On opening the body of the poor gentleman who wrote the letter to Dr Heberden, "upon the most careful examination, no manifest cause of his death could be discovered; the heart, in particular, with its vessels and valves, were all found in a natural condition."
In the case communicated by Dr Percival to the publishers of the Edinburgh Medical Commentaries, "the heart and aorta descendens were found in a sound state." And in Dr Haygarth's patient, "on opening the thorax, the lungs, pericardium, and heart, appeared perfectly sound." Not to mention Dr Fothergill's patient (R. M.), in whose body the only morbid appearance about the heart was a small white spot near the apex. Thus the cause, whatever its nature might have been, was at too great a distance, or of too subtle a nature, to come under the inspection of the anatomist. But there was a circumstance in two of the subjects that is worthy of remembrance; and which shows that the crisis of the blood, while they were living, must have been greatly injured, namely, its not coagulating, but remaining of a cream-like consistence, without any separation into serum and crassamentum.
From all that we have seen hitherto published, it does not appear that any considerable advances have been made towards the actual cure of this anomalous spasm.
The very judicious and attentive Dr Heberden (to whom the public are highly indebted for first making the disorder known) confesses, that bleedings, vomits, and other evacuations, have not appeared to do any good: wine and cordials taken at bed-time, will sometimes prevent or weaken the fits; but nothing does this so effectually as opiates: in short, the medicines usually called nervous or cordial, such as relieve and quiet convulsive motions, and invigorate the languishing principle of life, are what he recommends.
Dr Wall mentions one patient, out of the 12 or 13 that he had seen, who applied to him early in the disease, and was relieved considerably by the use of antimonial medicines joined with the fetid gum: he was still living at the time the doctor wrote his paper, (November 1772), and going about with tolerable ease. Two were carried off by other disorders; all the rest died suddenly.
Dr Fothergill's directions are chiefly calculated with the view to prevent the disorder from gaining ground, and to alleviate present distress. Accordingly he enjoins such a kind of diet as may be most likely to prevent irritability: in particular, not to eat voraciously: to be very abstemious in respect to every thing heating; spices, spirits, wines, and all fermented liquors: to guard most scrupulously against passion, or any vehement emotions; and to make use of all the usual means of establishing and preserving general health: to mitigate excesses of irritability by anodynes; or pains, if they quicken the circulation: to dispense flatulencies when they distend the stomach, by moderate doses of carminatives; amongst which, perhaps, simple peppermint water may be reckoned one of the safest. But since obesity is justly considered as a principal predisposing cause, he insists strongly on the necessity of preventing an increase of fat, by a vegetable diet, and using every other practicable method of augmenting the thinner secretions.
These were the only means recommended by the practitioners mentioned above for opposing this formidable disease: but Dr Smyth of Ireland has, we are told, discovered that it may be certainly cured by issues, of which Dr Macbride gives the following instance.
"A. B. a tall well-made man; rather large than otherwise; of healthy parents, except that there had been a little gout in the family; temperate; being very attentive to the business of his trade (that of a watchmaker), led a life uncommonly sedentary; had, from his boyhood upwards, been remarkably subject to alarming inflammations of his throat, which seized him, at least, once in the course of the year; in all other respects well.
"In 1767, (then 48 years of age), he was taken, without any evident cause, with a sudden and very dispiriting throbbing under the sternum. It soon afterwards increased, and returned upon him every third or fourth week, accompanied with great anxiety; very laborious breathing, choking, a sensation of fulness and distention in the head, a bloated and flushed countenance, turgid and watery eyes, and a very irregular and unequal pulse. The paroxysm invaded..." vaded, almost constantly, while he was sitting at dinner: now and then he was seized with it in the morning, when walking a little faster than usual; and was then obliged to stop, and rest on any object at hand. Once or twice it came on in bed; but did not oblige him to sit up, as it was then attended with no great difficulty in breathing. In the afternoon fits, his greatest ease was from a supine posture; in which he used to continue motionless for some hours, until quite spent and worn out with anguish, he dropt into a slumber. In the intervals between these attacks, which at length grew so frequent as to return every fourth or fifth day, he was to appearance in perfect health.
Thus matters continued for more than two years; and various antispasmodics were ineffectually tried for his relief. In 1769, there supervened a very sharp constrictory pain at the upper end of the sternum, stretching equally on each side, attended with the former symptoms of anxiety, dyspnea, choking, &c., and with an excruciating cramp, as he called it, that could be covered with a crown-piece, in each of his arms, between the elbow and the wrist, exactly at the insertion of the pronator teres; the rest of the limb was quite free. The fits were sometimes brought on, and always exasperated, by any agitation of mind or body. He once attempted to ride on horseback during the paroxysm; but the experiment was near proving fatal to him. The difference of season or weather made no impression upon him. Still, in the intervals, his health was perfectly good; except that his eyes, which before his illness were remarkably strong and clear, were now grown extremely tender: and that his sight was much impaired. He had no flatulence of stomach, and his bowels were regular.
In this situation, February 22, 1770, he applied to me for assistance. I had seen, I believe, eight or ten of these frightful cases before. Two of the patients dropt dead suddenly. They were men between 40 and 50 years of age, and of a make somewhat fleshy. The fate of the others I was not informed of; or, at least cannot now recollect.
Having found the total inefficacy of blisters and the whole class of nervous medicines in the treatment of this anomalous spasm, I thought it right to attempt the correcting or draining off of the irritating fluid in the case now before us. To this purpose, I ordered a mixture of lime-water with a little of the compound juniper-water, and an alternative proportion of Huxham's antimonial wine: I put the patient on a plain, light, perspirable diet; and restrained him from all viscid, flatulent, and acrimonious articles. By pursuing this course, he was soon apparently mended; but after he had persisted regularly in it for at least two months, he kept for some time at a stand. I then ordered a large issue to be opened on each of his thighs. Only one was made. However, as soon as it began to discharge, his amendment manifestly increased. The frequency and severity of the fits abated considerably; and he continued improving gradually, until, at the end of 18 months he was restored to perfect health: which he has enjoyed, without the least interruption, till now, except when he has been tempted (perhaps once in a twelvemonth) to transgress rules, by making a large meal on salted meat, or indulging himself in ale or rum-punch, each of which never failed to disorder him from the beginning of his illness: and even on these occasions, he has felt no more than the slightest motion of his former sufferings; insomuch that he would despise the attack, if it did not appear to be of the same stock with his old complaint. No other cause has had the least ill effect on him.
Though rum was constantly hurtful, yet punch made with a maceration of black currants in our vulgar corn-spirit, is a liquor that agrees remarkably well with him.
He never took any medicine after the issue began to discharge; and I have directed that it shall be kept open as long as he lives. The inflammations of his throat have disappeared for five years past; he has recovered the strength and clearness of his sight; and his health seems now to be entirely re-established."
Dr Macbride, in a letter to Dr Duncan, published in the Edinburgh Medical Commentaries, gives the following additional observations on this disease.
Within these few weeks I have, at the desire of Dr Smyth, visited, three or four times, a very ingenious man who keeps an academy in this city, of about 34 years of age, who applied to the doctor for his advice in January last.
I shall give you his symptoms as I had them from his own mouth, which appear to me to mark his case to be an angina pectoris, and as deplorable as any that I have read of. It was strongly distinguished by the exquisite constrictory pain of the sternum, extending to each of his arms as far as the insertion of the deltoid muscle, extreme anxiety, laborious breathing, strangling, and violent palpitation of the heart, with a most irregular pulse. The paroxysms were so frequent, that he scarcely ever escaped a day, for six or seven years, without one. They were usually excited by any agitation of mind or body, thought slight. He had clear intervals of health between the fits. The distemper seems hereditary in him, as he says his father was affected in the same manner some years previous to his death. He has a strong gouty taint, which never showed itself in his limbs; and he has led a life of uncommon sedentariness, from intense application to mathematical studies, and attention of mind, and passion, even from his boyish years. These circumstances may, perhaps, account for his having been taken with this disease at so early an age as 17.
A large issue was immediately opened in each of his thighs. In a month afterwards he began to mend, and has gone on improving gradually. He can now run up stairs briskly, as I saw him do no later than yesterday, without hurt; can bear agitation of mind; and has no complaint, excepting a slight oppression of the breast, under the sternum, which he feels sometimes in a morning, immediately after dressing himself, and which he thinks is brought on by the motion used in putting on his clothes; though for a complete week preceding the day on which I saw him last, he told me that he had been entirely free from all uneasiness, and was exulting that he had not had such an interval of ease for these last seven years.
Doctor Smyth also showed me, in his adversaria, the case of a gentleman who had been under his care in 1762, which he had forgotten when my book went Puerperal went to the press, and which he was reminded of the fever. other day by a visit from his patient. It was a genuine angina pectoris, brought on by a very sedentary life, and great vexation of mind, clearly marked by the exquisite pain under the sternum, that extended acutely to the upper extremities, particularly along the left arm, together with the other symptoms of dyspnoea, anxiety, palpitation of the heart, &c. recited in the case above. The disorder went off in 1762, by large spontaneous discharges from the piles, but returned upon him severely in 1765. Issues in his thighs were then recommended to him, but not made. But, whether it was by the persuasion of some friend, or of his own accord, he went into a course of James's powder, in small alternative doses, combined with a little castor and asafoetida. This he persisted in for about six weeks; in the meanwhile, he had large acrimonious gleecings from the scrotum, and a plentiful discharge of ichor from the anus.—From this time he began to find his complaints grow less and less distressing, and he has now been totally free from them for six years past.
The Puerperal or Childbed Fever.
This species of fever, as its name imports, is peculiar to women in childbed; and is usually the most fatal of all the disorders to which the sex is liable. But, notwithstanding the prevalence of it in all ages, its real nature has remained, to the present time, a subject of much dispute and uncertainty. The critical period of its invasion, when febrile convulsions are apt to be excited by various accidents, and the equivocal symptoms which accompany it, have even afforded room for questioning whether it be a primary or a secondary disease. Some writers have considered it as proceeding entirely from an inflammation of the uterus; others have imagined it to be the consequence of an obstruction to the secretion of the milk; while the greater number has been inclined, for reasons equally if not more plausible, to impute it to a suppression of the lochia. If we examine this fever attentively, however, according to its natural course, and independently of all the accidental concomitant symptoms with which it is not essentially connected, we may safely pronounce it to be a primary disease of a particular nature, and perhaps not the necessary consequence of any of the causes above mentioned.
This fever is most generally incident to women within 48 hours after delivery, though it may supervene on the fourth or fifth day, and sometimes considerably later. It is preceded, like other fevers, by a rigor, which is commonly violent; and when happening during the time of labour, may be confounded with the pains of parturience. In its earlier stage it is attended with the signs of inflammation. A great pain is felt in the back, hips, and the region of the uterus; which, in the part last mentioned, is accompanied with the sense of heat and throbbing. A sudden change in the quality or quantity of the lochia now also takes place; the patient is frequently troubled with a tenesmus; and the urine, which is very high-coloured, is discharged in small quantity and with pain. At the first attack of the fever, the woman is generally seized with a vomiting of porraceous matter, as in the cholera morbus, to which disease it then bears a strong resemblance.—Puerperal fever instead of this symptom, there is sometimes only a nausea, or loathing at the stomach, with a disagreeable taste in the mouth. The belly swells to a considerable bulk, and becomes susceptible of painful sensations from the slightest impression. The tongue is generally dry, though sometimes moist, and covered with a thick brownish fur. When the fever has continued a few days, the symptoms of inflammation usually subside, and the disease acquires a more putrid form. At this period, if not at the very beginning of the disorder, a bilious or putrid diarrhoea, of a dangerous and obstinate nature, supervenes, and accompanies it through all its future progress; each motion to stool being preceded by a temporary increase, and followed by an alleviation of pain. The patient usually nauseates all kind of food and drink, except what is cold and acidulated. A brown or blackish sordes, the consequence of putrid exhalations, adheres to the edges of the teeth; a troublesome hiccup is at length produced, which greatly exacerbates the pains of the abdomen; petechiae or vibices also appear, with sometimes a military eruption, but which produces no mitigation of the disease. Through the whole course of the fever, the patient is affected with great anxiety and dejection of spirits.
Such in general is the course of the puerperal fever; the symptoms of which, however, may be often varied, according to the constitution of the patient, the degree of the disease, and its earlier or later invasion. When the woman is naturally weak, or her strength has been greatly reduced by immoderate evacuations after delivery; when the disease is violent, and immediately follows that period; its progress and termination are proportionally rapid and fatal. In such unfortunate circumstances, many have been known to expire within 24 hours from the first attack of the disease; nay, there are some instances where the rigor has concluded the scene. The catastrophe, however, is most generally suspended for some days; and the number of these is variable, though the 11th from the commencement of the fever may justly be fixed as the period which is usually decisive. In whatever stage of the disease an unfavourable termination may happen, it would seem as if the commencement of the patient's recovery were not marked by any critical revolution of the fever, as depending on an alteration of the humours; but that the cure is gradually effected, either by a spontaneous vomiting, or a long-continued discharge by stool of that porraceous matter, the existence of which in the stomach is usually evinced at the first attack of the disease. The most unfavourable prognostic, therefore, arises from such a weakness of the patient as renders her unable to support so tedious an evacuation as that by which the fever is overcome. When the lochia return to their former state, when the swelling and tenderness of the abdomen abate, and there is a moisture on the skin, we have reason to hope for a happy termination of the disease.
Though the puerperal fever may generally be ascertained from the description which has been given, and chiefly by that remarkable tenderness of the abdomen which particularly distinguishes it; yet, as some of its symptoms may be confounded with those arising from other diseases, and which require a different method Appendix.
MEDICINE.
The pains of the abdomen, attending the childbed fever, may be distinguished from those called after-pains, by their uninterrupted continuance through the course of the disease, though sometimes they suffer exacerbations; whereas, in the latter, they often totally intermit. They are also distinguished by the absence of fever with concomitant symptoms in the one, and their evident existence in the other.
Many circumstances evince a dissimilarity between the puerperal and miliary fevers, notwithstanding the symptoms of anxiety and oppression are common to both; insomuch that the nature of the approaching disease may be ascertained at the very commencement of its attack. In the puerperal fever the rigor is more violent, of longer duration, and not interrupted, as it is in the other. The pulse is fuller and stronger; the skin is more hot; and the tongue, whether moist or dry, though generally the latter, is not of a white, but brownish appearance; and the urine is also higher coloured. Eruptions, which are critical in miliary fevers, procure no mitigation of the puerperal fever, and cordials generally increase it.
When the original attack of the puerperal fever happens to coincide with the febrile commotion which is excited in childbed women by the milk, the nature of it may at first be misapprehended; but the concomitant symptoms, and greater violence of the disease, must in a short time dissipate such an error.
From all the most accurate accounts of this disease, and from the period at which it generally commences, there seems reason to conclude, that it owes its rise more immediately to accidents after delivery. For it is allowed that it may follow a labour under the best and most favourable circumstances, though endeavours to dilate the os internum are supposed frequently to produce it. The more immediate causes generally assigned by authors are a stoppage of perspiration, the too free use of spices, and the neglect of procuring stools after delivery; sudden frights, too hasty a separation of the placenta, and binding the abdomen too tight. The putrid appearance, however, which this disease so soon assumes, affords ground to suspect that the predisposing cause of it is a vitiated state of the humours; for it is generally observed to be most prevalent in an unhealthy season, and among women of a weakly and scorbutic constitution. But from its prevalence in some particular hospitals, while others in the same city are entirely free from it, there can be little doubt that it is often communicated by contagion from one female to another. This opinion is corroborated also by many other circumstances; particularly by the means by which it has been removed from hospitals. It would seem, however, that this contagion does not act on the female system without a certain predisposition, and that this predisposition is induced by those changes to which the female habit is subjected in consequence of delivery.
Within these few years this fever has been treated of by several writers, most of whom have differed from each other in their sentiments of the nature of the disease. The first in the order of publication is Dr Denman, who seems to be of opinion, that it may derive its origin either from a redundancy or too great acrimony of the bile, the secretion of which appears to be much interrupted in the time of gestation. In Dr Manning's treatise on this fever, he mentions its being highly probable that such a cause contributes greatly to produce the disease, especially where the putrid tendency of the humours is increased by wholesome air and diet.
It has likewise been the fate of the puerperal fever, that no disease has more divided the sentiments of physicians in regard to the method of cure. The apparent indications and contra-indications of bleeding, and other remedies, arising from the complication of inflammatory and putrid symptoms; the equivocal appearance of the vomiting and purging, as whether they be critical or symptomatical; and the different causes whence symptoms similar to each other may arise in pregnant women; all these circumstances concur to involve the subject in great obscurity and indecision. If we carefully attend to the several characteristics of the disease, however, so as to be able to distinguish it from every other puerperal complaint, and observe at the same time the usual manner of its declension, our judgment may be guided in the method of cure by the salutary efforts of nature. But, in order to obtain a clearer view of the genuine indications, it will be proper to consider them under the several lights in which they have been generally agitated by authors.
One of the most essential points to be ascertained in the cure of the childbed fever, respects the propriety of bleeding. A free use of the lancet has been generally regarded as the most successful expedient in practice; and there are some instances of critical haemorrhages which would seem to confirm its utility. But Dr Denman thinks we may safely affirm from experience, that for one who will be benefited by large bleeding, a much greater number will be injured, and that even almost irretrievably. Nor can this seem surprising, when we consider the situation of childbed women. In most, the evacuations consequent upon delivery are sufficient to diminish any undue superabundance of the fluids; and if, as frequently happens, the disease be produced by too hasty a separation of the placenta, the consequence of which is generally a very copious discharge of blood, we can never suppose that nature will be assisted in overcoming the febrile commotion, by the farther evacuation of the vital fluid, through the defect of which she is now rendered unequal even to the ordinary support of the animal economy. We may appeal to every practical physician, how much he has known the pulse to sink, and what a train of nervous symptoms he has observed to succeed an excess of the discharge above mentioned. Besides, it is an axiom in physic, that a remedy which cures any disorder, will always prove sufficient to prevent it; and therefore, if bleeding were the proper cure in the childbed fever, the disease ought to have been prevented by a large evacuation of blood, when that happened previous to its attack. Experience, however, in this, as in all other diseases, is the only unerring guide we can follow; and whoever regulates his practice by fact and observation, will be convinced that bleeding, especially in a large quantity, is, in general, very far from being attended with success. Bleeding Puerperal fever is seldom proper, except in women of plethoric constitutions, and in whom the signs of inflammation rise high. Nor even in such patients ought it to be repeated without great caution, and the existence of strong indications. Bleeding, when used in proper circumstances, may unquestionably palliate the fever; but that it often shortens the duration of it, appears to be a matter of much doubt. On this account the practice becomes still more suspicious and exceptionable, when we consider that by venesection improperly used the patient's strength may be so far reduced as not to support the tedious looseness by which the disease is generally carried off. Though bleeding, however, ought in general to be used with great caution, there are certainly many cases in which it is both necessary and advantageous.
The genuine nature and effects of the looseness in this disease, is another controverted point of the highest importance, and which merits the most attentive inquiry. Physicians, observing that women who die of the puerperal fever are generally molested with that evacuation, have been induced to consider this symptom as of the most dangerous and fatal tendency; and what, therefore, we should endeavour by every means to restrain. In this opinion, however, they would seem to have been governed by too partial an observation of facts. For experience certainly authorises the assertion, that more women appear to have recovered of the childbed fever, through the intervention of a diarrhoea, than have been destroyed by that cause. If it also be considered, that purging is usually almost the only sensible evacuation in the more advanced state of the disease, and is that which accompanies it to its latest period, we shall have the strongest reason to think that it is critical rather than symptomatical, and ought therefore to be moderately supported, instead of being unwarily restrained. Nay, the advantage which is found to attend vomiting as well as purging in the earlier stages of the disease, would seem to evince that the matter discharged by these evacuations is what chiefly foments the disease. Emetics and purgatives, therefore, in the opinion of Dr Manning, are the only medicines on which any rational dependence is to be placed in this fever; at least, they are certainly such as are found the most successful. It is an established rule in practice, to prescribe a vomit at the beginning of every fever attended with any nausea or loathing of the stomach, and where there is not any reason to apprehend an inflammation of that organ. Nor does the state of childbed women afford the smallest ground for prohibiting our recourse to the same expedient in answering a similar indication.
It is so seldom a physician is called during the rigor preceding the puerperal fever, that he has few opportunities of trying the effects of remedies in that early state of the disease. When such occur, however, we should endeavour as much as possible to abate and shorten that period, as the succeeding fever is generally found to bear a proportion to the violence and duration of it. For this purpose, warm diluting drinks should be plentifully used, with a small quantity of volatile spirits or brandy. When Dr Manning apprehended such an accident, he sometimes ordered the nurse to give immediately a dish or two of warm sack-whey; taking care that it was not too strong, which is a caution that ought always to be remembered; for though a free use of the more cordial and spirituous kinds of liquors might perhaps soon abate the rigor, there is danger to be feared from their influence on the approaching fever, especially in women of a strong and healthy constitution. In all cases, warm applications to the extremities, such as heated bricks, towels, or toasted grains in a linen bag, may be used with perfect safety, and some advantage.
When the hot fit is advanced, the first thing Dr Manning orders is some emollient injection, as chicken-water, or water and milk, which ought to be frequently repeated through the course of the disease. These prove beneficial, not only by promoting the discharge from the intestines, which seems in fact to be the solution of the disease; but also by acting as a kindly fomentation to the uterus and adjacent parts. With this intention they are particularly serviceable when the lechia are suppressed. Great care, however, is requisite in administering them, on account of the tenderness and inflammatory disposition, which at that time render the parts in the pelvis extremely susceptible of pain.
The next step in the method of cure ought to be to promote the discharge of the morbid matter both by the stomach and intestines. This intention may be answered by a remedy prescribed by Dr Denman—Two grains of tartrite of antimony rubbed up with a scruple of the powder of lapilli cancerum.
Of a powder thus prepared, Dr Denman gives from two to six grains, and repeats it as circumstances require. If the first dose do not procure any sensible operation, he repeats it in an increased quantity at the end of two hours, and proceeds in that manner; not expecting any benefit but from its sensible evacuation.
Should the disease be abated, but not removed, (which sometimes happens), by the effect of the first dose, the same medicine must be repeated, but in a less quantity, till all danger be over. But if any alarming symptoms remain, he does not hesitate one moment to repeat the powder, in the same quantity as first given; though this be seldom necessary, if the first dose operates properly.
It is to be observed, says Dr Denman, that as the certainty of cure depends upon the proper repetition of the medicine, the method of giving it at stated hours does not appear eligible. If the first dose produce any considerable effect by vomiting, procuring stools, or plentifully sweating, a repetition of the medicine in a less quantity will seldom fail to answer our expectations; but great judgment is required in adapting the quantity first given to the strength of the patient and other circumstances. We are not to expect that a disease which from the first formation carries so evident marks of danger, should instantly cease, even though a great part of the cause be removed.
Frequent doses of the saline draughts ought also to be given, which not only promote the evacuation by the intestines, but likewise increase the salutary discharges of urine and perspiration. These medicines are particularly serviceable in subduing the remains of the fever, after its violence has been broken by the more efficacious remedies above mentioned; but when they are used even in the decline of the disease, gentle laxatives of rhubarb and magnesia, as advised by Dr Denman, Denman, ought to be frequently interposed, since, as he justly observes, without stools we can do little service.
Although the discharge by the intestines appears to have the most salutary effect in this disease; yet when the stomach has not been properly unloaded of offensive matter, though a great nausea and sickness had indicated the expediency of such an evacuation at the beginning of the fever, the continuance of the looseness is sometimes so long protracted as in the end to prove fatal. In this alarming state of the disease, when the stools are very frequent and involuntary, and all appearances threaten danger, Mr Denman says, that a clyster of chicken-water injected every one, two, or three hours, or as often as possible without fatiguing the patient too much, with a cordial diaphoretic draught taken every six hours, has produced better effects than could be expected.
While these medicines are employed, we should endeavour to mitigate the pains of the belly by relaxing applications. During the course of the disease, the patient ought to drink freely of diluting liquors, and abstain from every thing of a heating quality, unless great faintness should indicate the use of a small quantity of some cordial medicine.
Such is the practice recommended in this disease by Dr Denman. We shall now take a cursory view of the sentiments of succeeding writers on this subject.
According to Dr Hulme, the proximate cause of the puerperal fever is an inflammation of the intestines and omentum; for the confirmation of which opinion he appeals to dissections. He supposes the chief predisposing cause of the disease to be the pressure of the gravid uterus against the parts above mentioned. The omentum, says he, in the latter stage of pregnancy, must either be flat, which is its natural situation, or be rumpled or carried up by the gravid uterus in folds or doublings. When the latter is the case, which he observes is probably not seldom, the danger of a strangulated circulation will be greater.
Mr White, who has also written on this disease, judiciously remarks, that were Dr Hulme's hypothesis well founded, the disorder ought rather to take place before delivery, and be immediately removed at that period: That it would likewise most generally happen to women at their first labour, when the abdominal muscles are less yielding, and the pains more violent; the contrary of which is most frequently experienced to be the case.
It also deserves to be remarked, that, upon Dr Hulme's supposition, we cannot account for the disease being more common and fatal in large towns and in hospitals, than in the country and private practice, while other inflammatory disorders are more endemic among those who live in the latter than the former situation. Even admitting the friction of the intestines and omentum against the uterus to be as violent as Dr Hulme supposes, is it not highly improbable, that any inflammation could be occasioned by the pressure of such soft substances upon each other? Or, were this effect really produced, ought not the puerperal fever to be more common and fatal after the most laborious deliveries? But this observation is not supported by experience.
Dr Hulme, in favour of his own hypothesis, alleges that it gives a satisfactory answer to the question, "Why all lying-in women have been, and ever will be, subject to this disease?" In this proposition, however, the doctor supposes such an universality of the disease as is not confirmed by observation. It is affirmed upon undoubted authority, that in many parts of Britain the puerperal fever is hardly known; whereas, were it really produced by the causes he assigns, it would be equally general and unavoidable.
But how peculiarsoever this author's sentiments are in respect of the proximate cause of this disease, they have not led him to any method of cure different from the established practice. On this subject Dr Hulme divides his observations into two parts; comprehending under the former the more simple method of treatment, and under the latter the more complex. He sets out with remarking, that the patient being generally costive at the beginning of the disease, an emollient opening clyster will often give immediate relief; but if this should not prove effectual, recourse must be had to cathartics. Those which he found answer his purpose best, were the sal catharticus amarus, the oleum ricini, emetic tartar, and antimonial wine. When the bowels have been sufficiently cleared and the pain abates, he advises encouraging a gentle diaphoresis by medicines which neither bind the body nor are heating; such as small doses of ipecacuan, emetic tartar, and antimonial wine, combined with an opiate in a moderate dose, and given once or twice in the course of 24 hours; administering the saline draughts in the intermediate spaces. If, preceding or during this course, a sickness at stomach or vomiting attend, he advises assisting the efforts of nature, by drinking plentifully of chamomile tea, warm water, or any other diluting liquor. He concludes with recommending a cooling regimen, rest of body, and tranquillity of mind; prohibiting all kinds of bandage upon the abdomen, and enjoining particular attention to the state of the bowels, which ought to be kept gently open for some time, even after the disorder seems to be gone off, till the patient be quite out of danger.
So much for the simple treatment: we now proceed to the second part, where he describes the method of practice when the disease is in its more irregular and complicated state.
When a diarrhoea accompanies the disease, he observes that it ought by no means to be checked, but supported, by ordering the patient to drink plentifully of mild aperient liquors. If the pain of the hypogastric region be attended with stitches in the sides or over the pit of the stomach, and a pulse that resists the finger pretty strongly, he remarks that bleeding would then be highly necessary: declaring, however, his opinion, that, in the puerperal fever, bleeding is to be considered only as a secondary means of relief, though the first in point of time; and it ought to be advised with great caution; and that the greatest dependence is always to be placed upon evacuations by stool.
Mr White imputes the puerperal fever to a putrescent disposition of the humours, contracted during pregnancy, and fomented by the hot regimen commonly used by women in childbirth. In conformity to this opinion, the chief means which he recommends for preventing the disease is a cool regimen and free circula- Puerperal fever, which he evinces to be of the greatest importance. In respect of bleeding, he informs us, that, upon the strictest inquiry, he cannot find that those who have bled the most copiously have had the greatest success, either in private or hospital practice. He even seems to question the propriety of this evacuation in any case; but approves of emetics, cathartics, and clysters, for cleansing the prima via, and likewise of such medicines and diet as will correct the putrid humours: adding, that an upright posture and free ventilation are at all times useful, and absolutely necessary, both for the prevention and cure of the disease.
Another writer who treats of the childbed fever is Dr Leake, who has published the result of his observations on this disease from April 1768 to the autumn of the year 1770; but chiefly from December 1769 to May 1770, during which period the childbed fever prevailed much about London.
Dr Leake tells us that this fever generally commenced the evening of the second or morning of the third day after delivery, with a rigor or shivering fit. Sometimes it invaded soon after delivery; and at other times though rarely, it has seized so late as the fifth or sixth day. Now and then it seemed to be occasioned by catching cold, or by errors in diet; but oftener by anxiety of mind. Sometimes the thirst was great; though the tongue had, in general, a better appearance at the beginning than is common in other fevers. It was seldom ever black or very foul; but, as the disease advanced, became white and dry, with an increase of thirst; and at last was of a brownish colour towards the root, where it was slightly covered with an inspissated mucus. The loss of strength was so great and sudden, that few of the patients could turn in bed without assistance, even so early as the first or second day after the attack. The lochia, from first to last, were not obstructed, nor deficient in quantity; neither did the quality of this discharge seem to be in the least altered from its natural state; a presumption, says the author, that the uterus was not at all affected. Of this he was convinced by making a considerable pressure above the pubes with the hand, which did not occasion pain; but when the same degree of pressure was applied higher, between the stomach and umbilical region, it became almost intolerable. A perfect crisis seldom if ever happened in this fever, which he imputes to the great oppression of the vital powers, whereby they were rendered unable to produce such an event. When the disease proved mortal, the patient generally died on the 10th or 11th day from the first attack. In those who died of the fever, the omentum was found suppurrated; an inflammation of which part, or of the intestines, Dr Leake concludes to be the proximate cause of the disease.
In consequence of this idea of the cause of the disease, Dr Leake affirms that venesection is the only remedy which can give the patient a chance for life. But, though it be the principal resource to be depended upon at the beginning of the fever, he observes that it will seldom prove of service after the second or third day; and if directed yet later, will only weaken and exhaust the patient; when, matter having begun to form in the omentum, the progress of the disease can no longer be prevented by that evacuation. At this period the blood begins to be tainted by the absorption of the purulent fluid; and the fever, from being inflammatory, is changed into a putrid nature.
After bleeding in such a quantity as the symptoms require, he advises that the corrupted bile be evacuated and corrected as soon as possible; that the diarrhoea, when excessive, be restrained by emollient antidyse clysters and gentle sudorifics, or even by opiates and mild astringents, when the patient's strength begins to sink under the discharge; and, lastly, that where the signs of the putrefaction or intermission take place, antiseptics and the cinchona may be administered.
The great uniformity of the symptoms in all Dr Leake's patients might authorise an opinion, that the fever which he describes was in a great measure a disease sui generis, and depended much upon the constitution of the air preceding and during the period in which the fever prevailed.
Dr Kirkland has also made judicious observations on this subject. He rejects the opinion that the puerperal fever is a disease sui generis, and arises always from the same cause. The particular situation of childbed women, he acknowledges, occasions a similarity in the appearance of all the febrile symptoms: but he affirms that the same kind of fever may be produced by various causes; for instance, by an inflammation of the uterus or abdomen, by putrid blood or other matter, and putrid miasms. The symptoms, he observes, will vary according to the time of seizure. If the fever happen in three or four days after delivery, all the symptoms usual to the situation of the patient will make their appearance; but if it do not invade till the milk has been secreted, and the lochial discharge be nearly finished, the symptoms, if the breasts are properly drawn, will, for the most part, be those only which are common to that kind of disorder by which the fever has been produced.
With respect to the cure of puerperal fevers, Dr Kirkland advises the antiphlogistic method when they arise from inflammation; but when this method fails of success, and a diarrhoea supervenes, the disease has changed its nature, having become more or less putrid, and requires a very different treatment.
His observations relative to the management of the diarrhoea merit attention. No one, says he, would purge and bleed to cure the colliquative fever arising from the absorption of matter in large wounds; and yet the only difference is, that in the puerperal fever the matter absorbed from the uterus, &c. acts with more violence, because the blood is commonly thinner and the habit in a more irritable state. We see, continues he, that absorbed matter purges as effectually as if any purging medicine had been given by the mouth; and may we not therefore do harm by additional purging, when there has been a large evacuation, especially as purges in this case are incapable of entirely removing the fomes morbi?
He considers cinchona as the principal remedy, as soon as the pulse sinks, the heat is lessened, and the stomach will bear it. If this increase the diarrhoea beyond moderation, he joins with it small doses of laudanum; but if the diarrhoea should entirely stop without the fever going off, in place of laudanum he advises a proper quantity of rhubarb. Should the diarrhoea, notwithstanding the use of the medicines proposed, become Appendix.
MEDICINE.
Puerperal come so violent as to endanger the patient, he agrees with Mr White in recommending the columbo root, which is a warm cordial, and removes the irritability of the stomach and intestines more powerfully than any other bitter he knows.
Of this disease also, as it appeared in Derbyshire and some of the adjacent provinces, an account has been published by Dr Butter. Concerning the causes and nature of the disease, he observes, that pregnancy seems to add much to the natural sensibility of the female constitution; because at this period women are often subject to a train of nervous symptoms, which never molest them at other times. During gestation likewise, the appetite is for the most part keen, while the digestion appears to be impaired; and this weakness is increased not only by improper food, of which the woman is frequently desirous, but also by the inactivity attending her situation. To these circumstances, it is added, that the intestinal passage being interrupted by the uterine pressure, costiveness generally prevails. From the several observations here enumerated, Dr Butter concludes, that the proximate cause of the puerperal fever is a spasmodic affection of the first passages, with a morbid accumulation in their cavity; and upon this supposition he endeavours to account for the various symptoms of the disease.
In treating of the method of cure, he lays down two indications; the former of which is to promote two, three, or four stools daily, in a manner suited to the strength of the patient, till such time as they resume a natural appearance. The second indication is to relieve all uneasy symptoms, such as heat, thirst, headache, &c.
With respect to the opinion entertained by Dr Butter of the cause of the puerperal fever, it nearly coincides with that of Mr White. But however plausible it may appear, we are not entirely satisfied that a disease attended with so peculiar symptoms as the puerperal fever can depend principally upon an irritability, which is not restricted either to the pregnant or puerperal state.
The late Dr Thomas Young professor of midwifery in the university of Edinburgh, although he published nothing on the subject of the puerperal fever, wrote a very ingenious dissertation respecting it, which was read in the Philosophical Society of Edinburgh. In that dissertation, after giving a very accurate account of the symptoms of the disease, which coincides very nearly with the account given by others, he endeavours to show, that the puerperal fever, strictly so called, is in every instance the consequence of contagion; but he contends, that the contagious matter of this disease is capable only of producing its effect, in consequence of a peculiar predisposition given by delivery and its consequences. In support of this doctrine, he remarks, that for many years the disease was altogether unknown in the lying-in ward of the Royal Infirmary at Edinburgh; but that after it was once accidentally introduced into the hospital, almost every woman was in a short time after delivery attacked with it; although prior to delivery, she may have lain, even for weeks together, not only in the same ward with the infected, but even in the very next bed. He remarks, that it was only eradicated from the hospital in consequence of the wards being entirely emptied, thoroughly ventilated, and new painted. After these processes, puerperal females in the hospital remained as free from this disease as formerly. The puerperal fever, according to Dr Young, has very generally a strong tendency to the typhoid type; although he allows, that in the beginning it is not unfrequently attended with inflammatory symptoms, and even with topical inflammation, particularly in the intestinal canal. On this idea, he considers the puerperal fever as admitting of the same variety of treatment with other affections depending on contagion, in which sometimes an inflammatory, sometimes a putrescent tendency, prevails; such, for example, as smallpox or erysipelas. But from the prevailing putrescent tendency in this affection, he considers the free access of cool air, with the liberal use of antiseptics, as being very generally requisite.
It deserves to be remarked, that though the several writers who treat of this subject have conducted their method of cure conformably to their particular idea of the cause of the disease, respecting which their sentiments are very different, they seem to have been equally successful in the treatment of their patients. Indeed the several writers differ less from each other in their method of cure than might be expected, where so great an opposition of theoretical sentiment prevails. For after endeavouring to establish indications correspondent to their particular systems, those who contend for the expediency of promoting the intestinal discharge, dissuade not from having recourse to phlebotomy when the disease is attended with inflammatory symptoms; while, on the other hand, the most strenuous advocates for bleeding admit the utility of the former evacuation. It appears, therefore, that a due regulation of the alvine discharge is necessary through the whole course of the fever, but venesection only sometimes.
WORMS.
Those infesting the human body are chiefly of three kinds: the ascarides, or small round and short white worms; the teres, or round and long worm; and the tenia, or tape-worm.
The ascarides have usually their seat in the rectum.—The teretes or lumbrici are about a span long, round and smooth: they are seated for the most part in the upper small intestines; but sometimes they are lodged also in the stomach, and in any part of the intestines, even to the rectum.—The tape-worms are from two to forty feet long, according to the testimony of Platerus; they generally possess the whole tract of the intestines, but especially the ileum: they very much resemble a tape in their appearance, whence the name of tape-worm: but another species of this genus, from the resemblance of each joint to a gourd seed, has the name of the gourd-worm.
In the Medical Transactions, vol. i. Dr Hetherden gives a very accurate account of the symptoms produced by the ascarides, from an eminent physician who was troubled with them all his life. They brought on an uneasiness in the rectum, and an almost intolerable itching in the anus; which sensations most usually came on in the evening, and prevented sleep for several hours. They were attended with heat, sometimes so considerable as to produce a swelling in the rectum both... both internally and externally; and if these symptoms were not soon relieved, a tenesmus was brought on, with a mucous dejection. Sometimes there was a gripping pain in the lower part of the abdomen, a little above the os pubis. If this pain was very severe, a bloody mucus followed, in which there were often found ascarides alive. They were also sometimes suspected of occasioning disturbed sleep, and some degree of headache.
On this case Dr Heberden observes, that the general health of the patient did not seem to have suffered from the long continuance of the disease, nor the immediate inconveniences of the disorder itself to have increased. "It is (says he) perhaps universally true, that this kind of worms, though as difficult to be cured as any, yet is the least dangerous of all. They have been known to accompany a person through the whole of a long life, without any reason to suspect that they had hastened its end. As in this case there was no remarkable sickness, indigestion, giddiness, pain of the stomach, nor itching of the nose, possibly these symptoms, where they have happened to be joined with the ascarides, did not properly belong to them, but arose from some other causes. There is indeed no one sign of these worms, but what in some patients will be wanting."
The above-mentioned patient used purging and irritating clysters with very little success. One dram and a half of tobacco was infused in six ounces of boiling water; and the strained liquor being given as a clyster, occasioned a violent pain in the lower part of the abdomen, with faintness and a cold sweat: this injection, though retained only one minute, acted as a smart purge, but did little or no good. Lime-water was also used as a clyster; which brought on a costiveness, but had no good effect. Six grains of salt of steel were dissolved in six ounces of water, and injected. This clyster in a few minutes occasioned an aching in the rectum, gripped a little without purging, and excited a tenesmus. Some few ascarides were brought off with it; but all of them were alive. The uneasy sensation in the rectum did not abate till some warm milk was thrown up. Whenever the tenesmus or mucous stools were thought worth the taking notice of, warm milk and oil generally gave immediate relief. If purging was necessary, the lenient purges, such as manna with oil, were, in this particular case, made use of: rhubarb was found too stimulating.—But, in general, the most useful purge, and which therefore was most usually taken, was cinnabar and rhubarb, of each half a drachm: this powder seldom failed to bring away a mucus as transparent as the white of an egg, and in this many ascarides were moving about. The cinnabar frequently adhered to this mucus, which did not come off in large quantities, when a purge was taken without cinnabar. Calomel did no more than any other purge which operates briskly would have done; that is, it brought away ascarides, with a great deal of mucus. Oil given as a clyster sometimes brought off these animalcules: the oil swam on the surface of the mucus, and the ascarides were alive and moving in the mucus itself, which probably hindered the oil from coming in contact with them and killing them.
Dr Heberden also observes, that mucus or slime is the proper nest of the ascarides, in which they live, and is perhaps the food by which they are nourished; and it is this mucus which preserves them unhurt, though surrounded with many other liquors, the immediate touch of which would be fatal. It is hard to satisfy ourselves by what instinct they find it out in the human body, and by what means they get at it; but it is observable in many other parts of nature, as well as here, that where there is a fit soil for the hatching and growth of animals and vegetables, nature has taken sufficient care that their seeds should find the way thither. Worms are said to have been found in the intestines of still-born infants. Purges, by lessening this slime, never fail to relieve the patient: and it is not unlikely, that the worms which are not forced away by this quickened motion of the intestines, may, for want of a proper quantity of it, languish, and at last die; for if the ascarides are taken out of their mucus, and exposed to the open air, they become motionless, and apparently die in a very short time. Dr Heberden supposes that the kind of purge made use of is of some consequence in the cure of all other worms as well as ascarides; the animals being always defended by the mucus from the immediate action of medicines; and that therefore those purges are the best which act briskly, and of which a repetition can be most easily borne. Purging waters are of this sort, and jalap especially for children; two or more grains of which, mixed with sugar, are most easily taken, and may be repeated daily.
From Dr Heberden's observations, we may easily see why it is so difficult to destroy these animals; and why anthelmintics, greatly celebrated for some kinds, are yet so far from being specifics in the disease. As the worms which reside in the cavities of the human body are never exposed to the air, by which all living creatures are invigorated, it is evident, that in themselves they must be the most tender and easily destructible creatures imaginable, and much less will be requisite to kill them than any of our common insects. The most pernicious substances to any of the common insects are oil, caustic fixed alkali, lime, and lime-water. The oil operates upon them by shutting up the pores of their bodies; the lime, lime-water, and caustic alkali, by dissolving their very substance. In the case of intestinal worms, however, the oil can have very little effect upon them, as they are defended from it by the moisture and mucus of the intestines; the like happens with lime-water: and therefore it is necessary that the medicine should be of such a nature as to destroy both mucus and insects together; for which purpose the caustic fixed alkali is at once safe and efficacious; nor is it probable that any case of worms whatever could resist the proper use of this medicine. A very large dose of any salt indeed will also destroy the mucus and destroy the worms; but it is apt to inflame and excoriate the stomach and intestines, and thus to produce worse distempers than that which it was intended to cure. Dr Heberden gives the following remarkable case of a patient cured of worms by enormous doses of common salt, after trying many other remedies in vain. In February 1757, the patient was seized with uncommon pains in his stomach, attended with nausea, vomiting, and constipation of bowels, and an almost total loss of sleep and appetite. He soon became much emaciated, and could neither stand nor walk upright; his belly grew small and hard, and closely retracted, insomuch that the sternum covered the navel, and the latter could scarce be discovered or felt by the finger: his urine was always milky, and soon deposited a thick white sediment; his excrements were very hard and lumpy, resembling those of sheep, only of a brown colour; nor had he ever a stool without some medicine or other to procure it. In this situation he continued four years; during which time he had been in an infirmary, attended by eminent physicians, but was dismissed as incurable. At last he was advised by a neighbour to drink salt and water, as he said he knew one cured by it who had for many years been afflicted with the same kind of pains in the belly and stomach. As his distemper was now almost insupportable, he willingly tried the experiment. Two pounds of common salt were dissolved in as little water as possible, all which he drank in less than an hour. Soon afterwards he found himself greatly oppressed at the stomach, grew extremely sick, and vomited violently; on the fourth straining he brought up about half a pint of small worms, part ascarides, and the rest resembling those worms which are called the botis, and frequently met with in the stomach of horses, but much smaller, and about the size of a grain of wheat. The salt soon began to operate downwards, and he had five or six very copious fetid stools, tinged with blood; and in them discharged near an equal quantity of the same kind of worms he had vomited. Being greatly fatigued with the violence of the operations, he fell into a calm sleep, which lasted two hours, during which he sweated profusely, and awoke much refreshed. Instead of his usual pains, he now only complained of a rawness and soreness of his gullet, stomach, and bowels, with an almost unquenchable thirst; to allay which, he drank large quantities of cold water, whey, butter-milk, or whatever he could get. The urine he now passed was small in quantity, and rendered with very great difficulty, being highly saturated with the salt, from whence arose a most troublesome dysuria and strangury. However these symptoms gradually abated by a free use of the liquors above mentioned; and on the third morning he was so well recovered, that he took two pounds more of salt, dissolved in the like quantity of water. The effects were nearly similar to the former; only that most of the worms were now burst, and came away with a considerable quantity of slime and mucus. The drought, strangury, &c., returned with their former violence, but soon yielded to the old treatment. He sweated very copiously for three days, slept easily, and by that time could extend his body freely: on the fifth day he left his bed, and, though very weak, could walk upright; his strength and appetite soon returned, and he became robust and well.
The anthelmintic medicines which have been recommended by one person or other, are in a manner innumerable; but the principal are,
1. Quicksilver. This is very efficacious against all kinds of worms, either taken in the form of calomel or corrosive sublimate. Even the crude metal boiled in water, and the water drunk, has been recommended as an almost certain cure. But this, it is evident, can receive no impregnation from the mercury. If, therefore, it have any effect, it must be from some foreign and accidental impregnation. In most instances there can be no objection to mercury, but only that it is not endowed with any attenuating quality whereby the mucus in which these insects reside can be dissolved. It therefore fails in many cases, though it will most certainly destroy worms where it can get at them.
2. Powder of tin. This was for some time celebrated as a specific, and indeed we may reasonably expect good effects from it; as by its weight and grittiness it rubs off the mucus and worms it contains from the coats of the intestinal canal, in which case they are easily evacuated by purgatives. In order to produce any considerable effects, it must be given in a large dose.
3. Geoffreia inermis, or cabbage bark. This remedy is used by the inhabitants of Jamaica. The first account of it which appeared in this country was published in the Physical and Literary Essays, vol. ii. by Mr Duguid surgeon in that island. He acquaints us, that the inhabitants of Jamaica, young and old, white and black, are much infested with worms, especially the long round sort; the reason of which, he thinks, is the quantity of sweet viscid vegetables which they eat. On dissecting a child of seven months old, who died of vomiting and convulsions, twelve large worms were found; one of them filled the appendix vermiformis, and three of them were entwined in such a manner as to block up the valvula Tulpii, so that nothing could pass from the small to the great guts.—The cabbage bark, however, he tells us, is a safe and effectual remedy, and the most powerful vermicide yet known; and that it frequently brings away as many worms by stool as would fill a large hat. He owns that it has sometimes violent effects; but this he ascribes to the negroes who make the decoction (in which form the bark is used) too strong, and not to the remedy itself.
Mr Anderson, surgeon in Edinburgh, has also given an account of this bark and its operation, in a letter to Dr Duncan, published in the Edinburgh Medical Commentaries, volume iv. p. 84. From this account it appears, that there are two different kinds of cabbage bark; the one much paler than the other; the pale kind operates much more violently than the other. It often occasions loose stools, great nausea, and such like symptoms, attended with great uneasiness in the belly: in one or two instances it was suspected of inducing syncope. The darker coloured kind resembles the cassia lignea, though it is of a much coarser texture. This kind, Mr Anderson thinks, may be exhibited in any case where an anthelmintic is necessary; the dangerous symptoms might have followed either from the use of the first kind, or from an over-dose of the second. The usual method of preparing the medicine is by boiling two ounces and a half of the bark in two quarts of water to a pint and a half. Of this a tea-spoonful may be given at first in the morning, gradually increasing the quantity till we come to four or five table-spoonfuls in a day. When exhibited in this manner, Mr Anderson informs us, that he never saw it produce any violent symptoms, and has experienced the best effects from it as an anthelmintic. After the use of this decoction for eight Worms or nine mornings successively, a dose of jalap with calomel must be given, which seldom fails to bring away the worms, some dead, some alive. If at any time the decoction produce more than one or two loose stools, a few drops of liquid laudanum may be given; and, in general, Mr Anderson gave 15 or 20 drops of the spirit of lavender with each dose.
In a letter from Dr Rush, professor of chemistry at Philadelphia, to Dr Duncan of Edinburgh, the following account is given of another preparation of this medicine. "It has long (says he) been a complaint among physicians, that we have no vermifuge medicine which can be depended upon. Even calomel fails in many cases where there are the most pathognomonic signs of worms in the bowels. But this complaint, it is hoped, is now at an end. The physicians of Jamaica have lately found, that the cabbage-bark, as it is called in the West Indies, made into a syrup with brown sugar, is an infallible antidote to them. I have used above 30 pounds of it, and have never found it fail in one instance. The syrup is pleasant; it sometimes pukes, and always purges, the first or second time it is given."
The most accurate botanical description of the geoffreana inermis, or the tree furnishing the worm bark, as it has often been called, is that which was published some years ago in the Philosophical Transactions by Dr Wright, formerly physician at Jamaica, now of Edinburgh, who also highly extolls this remedy as an anthelmintic.
Notwithstanding these encomiums, however, the cabbage bark has not come into general use in Britain. But diseases from teretes, or lumbrici as they are often called, the species of worm against which this bark is employed, much less frequently occur in Britain than in some other countries. When they do occur, in almost every instance they readily yield to more gentle and safe anthelmintics; and the worms may not only be expelled by calomel, but by the vegetable biters; as the powder of the artemisia santonica, or the like.
4. Couchage, or cow-itch. This is the Dolichos urens or pruriens of Linnaeus; and the principles on which it acts have been already explained under the article Dolichos. It is somewhat similar to the powder of tin, but bids fair for being more efficacious. It might at first appear to occur as objections to this medicine, that by the hairs of it entangling themselves with one another, calculi might be formed in the intestines, or obstructions equally bad; or if the sharp points or hooks with which it abounds were to adhere to the nervous coats of the intestines themselves, they might occasion a fatal irritation, which could not be removed by any means whatever. But from the experience of those who have employed it extensively in practice, it would appear that these objections are entirely theoretical: and that it may be employed with perfect safety. The spiculae, gently scraped off from a single pod, and mixed with syrup or molasses, are taken for a dose in the morning fasting. This dose is repeated in this manner for two or three days without any sensible operation; but even a very slight purgative taken afterwards has been found to discharge an almost incredible quantity of worms. And according to Dr Bancroft, who has given a very particular account of its use in his Natural History of Guiana, it is one of the safest and most certain anthelmintics yet discovered; but as well as the bark of the Geoffreana, it has hitherto been very little used in Britain, probably from its not being necessary.
5. Indian pink. This plant, which is the Spigelia marilandica of Linnaeus, is also an American plant, and was first recommended in the Edinburgh Physical and Literary Essays by Dr Garden of Charlestown in South Carolina. He is of opinion that a vomit ought always to precede the use of it; and informs us, that half a dram of it purges as briskly as the same quantity of rhubarb. At other times he has known it produce no effect on the belly though given in very large quantity: In such cases it becomes necessary to add a grain or two of sweet mercury, or some grains of rhubarb; but then it is less efficacious than when it proves purgative without addition. The use of it, however, in small doses, is by no means safe; as it frequently produces giddiness, dimness of sight, convulsions, &c. The addition of a purgative, indeed, prevents these effects; but at the same time, as already observed, it diminishes the virtue of the medicine. The doctor therefore recommends large doses, as from them he never knew any other effect than the medicine's proving emetic or violently cathartic. The dose is from 12 to 60 or 70 grains of the root in substance, or two, three, or four drams of the infusion, twice a day. This medicine has also had its day, and is now very far from being considered as a specific.
The long round worms seem to be the most dangerous which infest the human body, as they often pierce through the stomach and intestines, and thus bring on a miserable death. The common symptoms of them are nausea, vomiting, looseness, fainting, slender intermittent pulse, itching of the nose, and epileptic fits. By the consumption of the chyle they produce hunger, paleness, weakness, costiveness, tumor of the abdomen, eructations, and rumbling of the intestines; but it is from the perforation of the intestines that the disease proves so frequently fatal. A child may be known to have worms from his cold temperament, paleness of the countenance, livid eyelids, hollow eyes, itching of the nose, voracity, startings, and grinding of the teeth, in sleep; and more especially by a very fetid breath. Very frequently, however, they are voided by the mouth and anus, in which case there is no room for doubt. In the Medical Commentaries, vol. ii., we have an account of the intestines being perforated by a worm, and yet the patient recovered. The patient was a woman troubled with an inflammation in the lower part of the abdomen. The pain was so violent, that for six days she slept none at all; the tumor then broke, discharged upwards of a pound of thin watery sanies, immediately after which the excrements followed. The next day she was extremely low; her pulse could scarcely be felt; the extremities were cold; and there was a considerable discharge from the wound, which had already begun to mortify. She got a decoction of cinchona with wine, which alleviated the symptoms; but in removing the mortified parts a worm was found among them six inches long, and as thick as an eagle's quill. By proper applications, the discharge of excrements ceased, and she recovered perfect health. She was sensible of no accident giving rise to The *tenia*, or tape-worm as it is called, is one of those most difficult to be removed from the human body. It is of two kinds, *tenia solium* and *tenia lata*; for a description of which see the article *Tenia*.—The reason of its being so difficult to cure is, that though portions of it are apt to break off and be discharged, it is endowed with a power of reproduction, so that the patient is little or nothing better. The symptoms occasioned by it are not different from those above described. A specific against the *tenia lata* has been lately so much celebrated in France, that the king thought proper to purchase it from the proprietor (Madame Nouffer), and the account of it has been translated into English by Dr Simmons. The patients are required to observe no particular regimen till the day before they take the specific. That day they are to take nothing after dinner till about 7 o'clock; after which, they are to take the following soup: "Take a pint and a half of water, two or three ounces of good fresh butter, and two ounces of bread cut into thin slices: add to this salt enough to season it, and then boil it to the consistence of panada." About a quarter of an hour after this, they take a biscuit and a glass of white wine, either pure or mixed with water; or even water alone, if they have not been accustomed to wine. If the patient has not been to stool that day, (which, however, is not usual with patients in this way), the following clyster is to be injected. "Take a small quantity of the leaves of mallows, and boil them in a sufficient quantity of water, mixing with it a little salt, and when strained off add two ounces of olive oil." Next morning, about eight or nine hours after the supper above mentioned, the specific is to be taken. This is no other than two or three drams of the root of male fern, *polypodium filix mas* of Linnæus, gathered in autumn, and reduced to fine powder. It is to be taken in any distilled water, or in common water. This medicine is apt to occasion a nausea: to avoid which, Madame Nouffer allows her patients to chew any thing that is agreeable, but forbids any thing to be swallowed; or they may smell to vinegar, to check the sickness: but if, notwithstanding this, the specific be thrown up, a fresh dose must be swallowed as soon as the sickness is gone off, and then they must try to sleep. About two hours after this the following bolus is to be taken. "Take of the panacea of mercury 14 times sublimed, and select resin of scammony, each ten grains; of fresh and good gamboge, six or seven grains: reduce each of these substances separately into powder, and then mix them with some conserve into a bolus." This composition is to be swallowed at two different times, washing it down with one or two dishes of weak green-tea, after which the patient must walk about his chamber. When the bolus begins to operate, he is to take a dish of the same tea occasionally, until the worm be expelled; then, and not before, Madame Nouffer gives him broth or soup, and he is directed to dine as is usual after taking physic. After dinner he may either lie down or walk out, taking care to conduct himself discreetly, to eat but little supper, and to avoid every thing that is not of easy digestion.
The cure then is complete; but it is not always effected with the same quickness in every subject. He who has not kept down the whole bolus, or who is not sufficiently purged by it, ought to take, four hours after it, from two to eight drams of Epsom salt dissolved in boiling water. The dose of this salt may be varied according to the temperament and other circumstances of the patient.
If the worm should not come away in a bundle, but in the form of a thread (which particularly happens when the worm is involved in much tenacious mucus), the patient must continue to sit upon the close-stool without attempting to draw it away, drinking at the same time warm weak tea: sometimes this alone is not sufficient, and the patient is obliged to take another dose of purging salt, but without varying his position till the worm be wholly expelled.
It is unusual for patients who have kept down both the specific and purging dose, not to discharge the worm before dinner-time. This, however, sometimes happens when the dead worm remains in large bundles in the intestines, so that the faeces becoming more limpid towards the end of the purging, pass by it without drawing it with them. The patient may in this case eat his dinner; and it has been observed, that the food, joined to the use of a clyster, has brought about the expulsion of the worm.
Sometimes the worm is brought away by the action of the specific alone, before the patient has taken the purging bolus: when this happens, Madame Nouffer gives only two-thirds of it, or substitutes the salt in its stead.
Patients must not be alarmed by any sensation of heat or uneasiness they may feel during the action of the remedy, either before or after a copious evacuation, or just as they are about to void the worm. These sensations are transitory, and go off spontaneously, or by the assistance of the vapour of vinegar drawn in at the nose.
They who have vomited both the specific and bolus, or who have kept down only a part of them, sometimes do not void the worm that day. Madame Nouffer therefore directs them to take again that night the soup, the wine and biscuit; and if circumstances require it, the clyster. If the worm do not come away during the night, she gives them early the next morning another dose of the specific, and, two hours afterwards, six drams or an ounce of purging salt, repeating the whole process of the preceding day; excepting the bolus, which she suppresses.
She observes, that very hot weather diminishes in some degree the action of her remedy; she therefore prefers the month of September for administering it; but as she has not been always able to choose the season, and has been sometimes obliged to undertake the cure of patients in the hottest days of summer, she then gave her specific very early in the morning; and with this precaution she saw no difference in its effects.
On the day appointed for the trial of this medicine before the commissioners nominated by the king of France, it was exhibited to five different persons; but only one of them was certainly known to have the *tenia lata* by having discharged parts of it before. That person was cured; the second voided a potion of the *tenia solium*; the third some *ascariides*, with a part of the *tenia solium*; the fourth and fifth voided no worms; but the last considered much of the viscid slime he voided to be worms in a dissolved state.
This trial was thought sufficient to ascertain the efficacy of the medicine, and further trials were made by those to whom the secret was communicated. The first voided two tenia, after much vomiting and 18 or 20 stools; the second had no vomiting, but was as violently purged, and discharged two worms; the third had 20 copious stools during the night, and discharged the worm in the morning; and the filth was affected in much the same manner. Some others who were not relieved, were supposed not to have a tenia.
This specific, however, is not to be considered as a new discovery; the efficacy of fern in cases of tenia having been known long ago. Theophrastus prescribes its root, in doses of four drams, given in water sweetened with honey, as useful in expelling flat worms.—Dioscorides orders it in the same dose, and adds, that its effects are more certain when it is mixed with four oboli (40 grains) of scammony or black heliobore; he particularly requires that garlic should be taken before hand. Pliny, Galen, Oribasius, and Aëtius, ascribe this same virtue to fern; and are followed in this by Avicenna, and the other Arabian physicians. Dorenstenius, Valerius Cordus, Dodoneus, Mathiolus, Dalechampius, who commented on Dioscorides, or copied him in many things, all mention the fern-root as a specific against the tenia. Sennertus, and Burnet after him, recommended in similar cases an infusion of this plant, or a dram of its powder, for young persons, and three drams for adults. Simon Paulus, quoted by Ray and Geoffroy, considers it as the most efficacious of all poisons against the flat worm, and as being the basis of all the secret remedies extolled by empirics in that disease. Andry prefers distilled fern-water to the root in powder; or he employs it only in the form of an opiate, or mixed with other substances.
These are not the only authors who have mentioned the tenia; many others have described this worm, the symptoms it excites, and the treatment proper to expel it. Almost all of them mention the fern-root, but at the same time they point out other remedies as possessing equal efficacy. Amongst these we find the bark of the root of the mulberry-tree, the juice of the auricula murus, the roots of chamaeleon niger, ginger, zedoary; decoctions of mugwort, southernwood, wormwood, penny-royal, origanum hyssop, and in general all bitter and aromatic plants, &c. Some of them direct the specific to be simply mixed and taken in wine or honey and water; others join to it the use of some purgative remedy, which they say adds to its efficacy. Oribasius, Sylvius, &c. distinguish the specific that kills the worm, from the purgative that evacuates it, and direct them to be given at different times. Sennertus gives a very satisfactory reason for adopting this method. If we give, says he, the purgative medicine and the specific at the same time, the latter will be hastily carried off before it can have exerted its powers on the worm; whereas, if we give the specific first, and thus weaken the worm, it will collect itself into a bundle, and, being brought away by means of the purge, the patient will be cured. The cure will be more speedy if the prime vicie have been previously lubricated. These precautions are all of them essential to the success of the remedy, nor are they neglected by Madame Nouffer in her method of treatment. The panada and injection she prescribes the night before, to lubricate the intestines, and prepare the prime vicie. The fern root, taken in the morning, kills and detaches the worm; of this the patients are sensible by the cessation of the pain in the stomach, and by the weight that is felt in the lower belly. The purgative bolus administered two hours after this, procures a complete evacuation; it is composed of substances that are at once purgative and vermifuge, and which, even when administered alone, by different physicians, sometimes succeeded in expelling the worm. If this purgative appear to be too strong, the reader is desired to recollect, that it produced no ill effects in either of the cases that came under the observation of the physicians appointed to make the trials; and that in one of those cases, by diminishing the dose, they evidently retarded the evacuations.—Regard however, they observe, is to be had both to the age and the temperament of the patient; and the treatment should always be directed by a prudent and experienced physician, who may know how to vary the proportions of the dose as circumstances may require. If the purgative be not of sufficient strength, the worm, after being detached by the specific, remains too long a time in the intestines, and becoming soon corrupted, is brought away only in detached portions: on the other hand, if the purgative be too strong, it occasions too much irritation, and evacuations that cannot fail to be inconvenient.
Madame Nouffer's long experience has taught her to distinguish all these circumstances with singular adroitness.
This method of cure is, as we have seen, copied in a great measure from the ancients: it may be possible to produce the same effects by varying the remedies; but the manner of applying them is by no means indifferent: we shall be always more certain of success if the intestines be previously evacuated, and if the specific be given some time before the purgative bolus. It is to this method that Madame Nouffer's constant success is attributed.
Her remedy has likewise some power over the tenia solium; but as the wings of this worm separate from each other more easily than those of the tenia lata, it is almost impossible for it to be expelled entire. It will be necessary therefore to repeat the treatment several times, till the patient cease to void any portions of worms. It must likewise be repeated, if, after the expulsion of one tenia solium, another should be generated in the intestinal canal. This last case is so rare, that it has been supposed that no person can have more than one of these worms; and for this reason it has been named solitary worm, which, being once removed, could never be renewed or replaced by a second: but experience has proved, that this notion is an ill-founded prejudice; and we know that sometimes these worms succeed each other, and that sometimes several of them exist together. Two living teniae have frequently been expelled from the same patient. Dr De Haen relates an instance of a woman who voided 18 teniae at once. In these cases the symptoms are usually more alarming; and the appetite becomes excessive, because these worms derive all their nourishment from the chyle. If too austere and ill-judged a regimen deprivates deprives them of this, they may be expected to attack even the membranes of the intestines themselves. This evil is to be avoided by eating frequently.
Such are the precautions indicated in this disease. The ordinary vermifuge remedies commonly procured only a palliative cure, perhaps because they were too often improperly administered. But the efficacy of the present remedy, in the opinion of the French physicians, seems to be sufficiently confirmed by experience. To the above account, however, it seems proper to subjoin the following observations by Dr Simmons.
"A Swiss physician, of the name of Herrenschwand, more than 20 years ago, acquired no little celebrity by distributing a composition of which he styled himself the inventor, and which was probably of the same nature as Madame Nouffer's. Several very eminent men, as Tronchin, Hovius, Bonnet, Cramer, and others, have written concerning the effects of this remedy. It seems that Dr Herrenschwand used to give a powder by way of preparation, the night before he administered his specific. Nothing could be said with certainty concerning the composition either of one or the other. The treatment was said sometimes to produce most violent effects, and to leave the patients in a valetudinary state. Dr De Haen was dissuaded by his friends from using it, because it disordered the patients too much. It will be readily conceived, now that we are acquainted with Madame Nouffer's method, that these effects were occasioned wholly by the purgative bolus. It is not strange, that resin of scammony or jalap, combined with mercurius dulcis and gamboge, all of them in strong doses, should in many subjects occasion the greatest disorders. It seems likely, however, that much of the success of the remedy depends on the use of a drastic purge. Some of the ancients who were acquainted with the virtues of the fern root, observed that its efficacy was increased by scammony. Resinous purges, especially when combined with mercury, have often been given with success in cases of tenia. Dr De Haen saw a worm of this sort five ells long expelled by the resin of jalap alone. Dr Gaubius knew a woman who had taken a variety of anthelmintic remedies without any effect, though she had voided a portion of tenia an ell and a half long previous to the use of these medicines: but at length, after taking a purge of singular strength, she voided the worm entire. Many other instances of the same kind are to be met with in authors. Other remedies have occasionally been given with success. In Sweden, it has been a practice to drink several gallons of cold water, and then to take some drastic purge. Boerhaave says, that he himself saw a tenia measuring 300 ells expelled from a Russian by means of the sulphate of iron.
From some late accounts, there is reason to believe that Dr Herrenschwand's remedy for tenia does not so exactly agree with that of Madame Nouffer as Dr Simmons seems to imagine. According to the account given us by a gentleman who had his information from Dr Herrenschwand himself, it consists entirely of gamboge and fixed vegetable alkali.
Of Poisons.
Of many poisons we have already treated, but there are some of which nothing has hitherto been said. Among the most fatal of these are the bites and stings of serpents, scorpions, &c. According to Dr Mead, the symptoms which follow the bite of a viper are, an acute pain in the place wounded, with a swelling, at first red, but afterwards livid, which by degrees spreads farther to the neighbouring parts; with great faintness, and a quick, low, and sometimes interrupted pulse; great sickness at stomach, with bilious convulsive vomitings, cold sweats, and sometimes pains about the navel. Frequently a sanguineous liquor runs from the small wound, and little pustules are raised about it: the colour of the whole skin in less than an hour is changed yellow, as if the patient had the jaundice. These symptoms are very frequently followed by death, especially if the climate be hot, and the animal of a large size. This is not, however, the case with all kinds of serpents. Some, we are assured, kill by a fatal sleep; others are said to produce an universal haemorrhage and dissolution of the blood; and others an unquenchable thirst. But of all the species of serpents hitherto known, there is none whose bite is more expeditiously fatal than that of the rattlesnake. Dr Mead tells us, that the bite of a large serpent of this kind killed a dog in a quarter of a minute; and to the human species they are almost equally fatal. Of this serpent it is said, that the bite makes the person's skin become spotted all over like the skin of the serpent; and that it has such a motion as if there were innumerable living serpents below it. But this is probably nothing more than a dissolution of the blood, by which the skin becomes spotted as in petechial fevers; at the same time that the muscles may be convulsed as in the distemper called hieranosos, which was formerly thought to be the effect of evil spirits: but it is even not improvable that observers have been somewhat misled by fancy and superstition when they thought that they detected such appearances.
It has justly appeared surprising to philosophers, how such an inconsiderable quantity of matter as the poison emitted by a viper at the time of biting should produce such violent effects. But all inquiries into this matter must necessarily be uncertain; neither can they contribute anything towards the cure. It is certain that the poison produces a gangrenous disposition of the part itself, and likewise seemingly of the rest of the body; and that the original quantity of poison continues some time before it exerts all its power on the patient, as it is known that removing part of the poisonous matter by suction will alleviate the symptoms. The indications of cure then are three: 1. To remove the poisonous matter from the body; Or, 2. If this cannot be done, to change its destructive nature by some powerful and penetrating application to the wound: And, 3. To counteract the effects of that portion already received into the system.
The poisonous matter can only be removed from the body by sucking the wound either by the mouth, or by means of a cupping glass; but the former is probably the more efficacious, as the saliva will in some measure dilute and perhaps obviate the poison. Dr Mead directs the person who sucks the wound to hold warm oil in his mouth, to prevent inflammation of the lips and tongue: but as bites of this kind are most likely to happen in the fields, and at a distance from houses, the want of oil ought by no means to retard the operation, as the delay of a few minutes might prove Poisons prove of the most fatal consequence; and it appears from Dr Mead's experiments, that the taking the poison of a viper into the mouth undiluted, is attended with no worse consequences than that of raising a slight inflammation. A quick excision of the part might also be of very great service.
The only way of answering the second indication is, by destroying the poisoned part by a red-hot iron, or the application of alkaline salts, which have the power of immediately altering the texture of all animal substances to which they are applied, provided they are not covered by the skin; and as long as the poison is not totally absorbed into the system, these must certainly be of use.
To answer the third indication, Dr Mead recommends a vomit of ipecacuanha, encouraged in the working with oil and warm water. The good effects of this, he says, are owing to the shake which it gives to the nerves, whereby the irregular spasms into which their whole system might be drawn are prevented. After this the patient must go to bed, and a sweat must be procured by cordial medicines; by which the remaining effects of the poison will be carried off.
It has been confidently asserted by many, that the American Indians are possessed of some specific remedy by which they can easily cure the bite of a rattlesnake. But Mr Catesby, who must have had many opportunities of knowing this, positively denies that they have any such medicine. They make applications indeed, and sometimes the patient recovers; but these recoveries he ascribes to the strength of nature overcoming the poison, more than to the remedies made use of. He says, they are very acute in their prognostics whether a person that is bit will die or not; and when they happen to receive a bite in certain parts of the body, when the teeth of the animal enter a large vein, for instance, they quietly resign themselves to their fate, without attempting anything for their own relief. Indeed, so violent and quick is the operation of this poison, that unless the antidote be instantly applied, the person will die before he can get to a house. It would seem therefore eligible for those who are in danger of such bites, to carry along with them some strong alkaline ley, or dry alkaline salt, or both, which could be instantly elapt on the wound, and by its dissolving power would destroy both the poison and the infected parts. Strong cordials also, such as ardent spirits, volatile alkali, &c. might possibly excite the languid powers of nature, and enable her to expel the enemy, which would otherwise prove too powerful. This seems to be somewhat confirmed from the account we have in the Philosophical Transactions of a gentleman bit by a rattlesnake, who was more relieved by a poultice of vinegar and vine-ashes put to his wound than any thing else. The vine-ashes being of an alkaline nature, must have saturated the vinegar, so that no part of the cure could be attributed to it; on the other hand, the ashes themselves could not have been saturated by the small quantity of acid necessary to form them into a poultice; of consequence they must have operated by their alkaline quality.—Soap ley, therefore, or very strong salt of tartar, may reasonably be thought to be the best external application, not only for the bites of vipers, but of every venomous creature; and in fact we find dry salt universally recommended both in the bites of serpents and children of mad dogs. Dr Mead recommends the fat of vipers immediately rubbed into the wound; but owns that it is not safe to trust to this remedy alone.
Some years ago the volatile alkali was strongly recommended by M. Sage of the French academy, as a powerful remedy against the bite of a viper; and, by a letter from a gentleman in Bengal to Dr Wright, it would appear that this article, under the form of the eau de luce, which is very little if anything different from the spiritus ammoniae succinatus of the London Pharmacopoeia, has been employed with very great success against this affection in the East Indies: but from the trials made with it by the abbé Fontana, published in his Treatise on the Poison of the Viper, it would appear that it by no means answered his expectation; and the efficacy of this, as well as of the snake pills mentioned under the article HYDROPHOBIA, still requires to be confirmed by further experience.
MELÆNE.
This is a distemper not very common, but it has been observed by the ancient physicians, and is described by Hippocrates under the name of morbus niger. It shows itself by a vomiting and purging of black tar-like matter, which Hippocrates, Boerhaave, and Van Swieten, supposed to be occasioned by atra bilis. But Dr Home, in his Clinical Experiments, endeavours to show that it is owing to an effusion of blood from the mesenteric vessels, which, by its stagnation and corruption, assumes that strange appearance. The disease, he says, frequently follows haemorrhage; and those of a scorbutic habit are most subject to it. It is an acute disease, and terminates soon; yet it is not attended with any great degree of fever. In one of Dr Home's patients the crisis happened on the eighth day by diarrhoea; in another, on the 14th, by sweat and urine; and a third had no evident critical evacuation.
As to the cure, Dr Home observes, that bleeding is always necessary where the pulse can bear it; nor are we to be deterred from it by a little weakness of the pulse, more than in the enteritis. Emetics are hurtful, but purgatives are useful. But the most powerful medicine for checking this haemorrhage is the sulphuric acid; and, that this might be given in greater quantity, he mixed it with mucilage of gum arabic; by which means he was enabled to give double the quantity he could otherwise have done. The cold bath was tried in one instance, but he could not determine whether it was of any service or not. The cure was completed by exercise and cinchona.
Of the DISEASES of CHILDREN.
Dr Buchan observes, that from the annual registers of the dead, it appears that about one half of the children born in Great Britain die under twelve years of age; and this very great mortality he attributes in a great measure to wrong management. The particulars of this wrong management enumerated by him are,
1. Mothers not suckling their own children. This, he owns, it is sometimes impossible for them to do; Diseases of but where it can be done, he affirms that it ought never to be omitted. This, he says, would prevent the unnatural custom of mothers leaving their own children to suckle those of others; on which he passes a most severe censure, and indeed scarce any censure can be severe enough upon such inhumanity. Dr Buchan informs us, "He is sure he speaks within bounds, when he says not one in an hundred of these children live who are thus abandoned by their mothers." For this reason he adds, that no mother should be allowed to suckle another's child till her own be fit to be weaned. A regulation of this kind would save many lives among the poorer sort, and would do no harm to the rich; as most women who make good nurses are able to suckle two children in succession upon the same milk.
2. Another source of the diseases of children is the unhealthiness of parents: and our author insists that no person who labours under an incurable malady ought to marry.
3. The manner of clothing children tends to produce diseases. All that is necessary here, he says, is to wrap the child in a soft loose covering; and the softness of every part of the infant's body sufficiently shows the injury which must necessarily ensue by pursuing a contrary method.
4. A new-born infant, instead of being treated with syrups, oils, &c. ought to be allowed to suck the mother's milk almost as soon as it comes into the world. He condemns the practice of giving wines and spirituous liquors along with the food soon after birth; and says, that if the mother or nurse has a sufficient quantity of milk, the child will need little or no other food before the third or fourth month. But to this it may reasonably be objected, not only that the nursing would thus be very severe on the mother; but if the child be left thus long without other food, it will not easily relish that food for some time, and its stomach is apt to be easily hurt by a slight change of diet after it has been long accustomed to one thing. The human species are unquestionably fitted by nature for a mixed aliment, both from the vegetable and animal kingdom. And the analogy of other animals belonging to the class of mammalia for whom milk is equally provided at the earliest periods of life, would lead us to the conclusion, that mixed aliment is well fitted for the human species even in the earliest periods of infancy. The lamb is no sooner dropt than, by natural instinct, it crops the grass as well as it sucks its mother. And the stomach in the human species, immediately after birth, can digest other food as well as milk. Neither can it be shown, that the strongest and most healthy infants are those which get no other food but the mother's milk during the first months of their life. In fact, children are evidently of a weak and lax habit of body, so that many of their diseases must arise from that cause; all directions which indiscriminately advise an antiphlogistic regimen for infants as soon as they come into the world, must of necessity be wrong. Many instances in fact might be brought to show, that by the propertious method of starving infants, and at the same time treating them with vomits and purges, they are often hurried out of the world. Animal food indeed, particularly under the form of broths, is excessively agreeable to children, and they ought to be indulged with it in moderation. This will prove a much better remedy for those acidities with which children are often troubled, than magnesia alba, crabs eyes, or other absorbents, which have the most pernicious effects on the stomachs of these tender creatures, and pall the appetite to a surprising degree. The natural appetites of children are indeed the best rule by which we can judge of what is proper or improper for them. They must no doubt be regulated as to the quantity; but we may be assured that what a child is very fond of will not hurt it, if taken in moderation. When children are sick, they refuse every thing but the breast; and if their distemper be very severe, they will refuse it also, and in this case they ought not to be pressed to take food of any kind; but when the sickness goes off, their appetite also returns, and they will require the usual quantity of food.
According to Dr Armstrong, inward fits, as they are called, are in general the first complaint that appears in children; and as far as he has observed, most, if not all infants, during the first months, are more or less liable to them. The symptoms are these: The child appears as if it was asleep, only the eyelids are not quite closed; and if you observe them narrowly, you will see the eyes frequently twinkle, with the white of them turned up. There is a kind of tremulous motion in the muscles of the face and lips, which produces something like a simper or a smile, and sometimes almost the appearance of a laugh. As the disorder increases, the infant's breath seems now and then to stop for a little; the nose becomes pinched; there is a pale circle about the eyes and mouth, which sometimes changes to livid, and comes and goes by turns; the child starts, especially if you attempt to stir it though ever so gently, or if you make any noise near it. Thus disturbed, it sighs, or breaks wind, which gives relief for a little; but presently it relapses into the dozing. Sometimes it struggles hard before it can break wind, and seems as if falling into convulsions; but a violent burst of wind from the stomach, or vomiting, or a loud fit of crying, sets all to rights again. As the child increases in strength, these fits are the more apt to go off spontaneously and by degrees; but in case they do not, and if there is nothing done to remove them, they either degenerate into an almost constant drowsiness, (which is succeeded by a fever and the thrush), or else they terminate in vomitings, sour, curdled, or green stools, the watery gripes, and convulsions. The thrush indeed very often terminates in these last symptoms. As these complaints naturally run into one another, or succeed one another, they may be considered, in a manner, as only different stages of the same disease, and which derive their origin from the same cause. Thus, the inward fits may be looked upon as the first stage of the disorder; the fever, and thrush (when it happens), as the second; the vomitings, sour, curdled, green or watery stools, as the third; and convulsions as the last.
As to the cause of these complaints, he observes, that in infants the glandular secretions, which are all more or less glutinous, are much more copious than in adults. During the time of sucking, the glands of the mouth and fauces being squeezed by the contraction of the muscles, pour forth their contents plentifully; which afterwards mixing with the mucus of the gullet Diseases of the stomach, renders the milk of a slimy consistence, by which means it is not so readily absorbed into the lacteals; and as in most infants there is too great an acidity in the stomach, the milk is thereby curdled, which adds to the load; hence sickness and spasms, which, being communicated by sympathy to the nerves of the gullet and fauces produce the convulsive motions above described, which go commonly by the name of inward fits. The air, likewise, which is drawn in during suction mixing with the milk, &c., in the stomach, perhaps contributes towards increasing the spasms above mentioned. Dr Armstrong is the more induced to attribute these fits to the causes now assigned, that they always appear immediately after sucking or feeding; especially if the child has been long at the breast, or fed heartily, and has been laid down to sleep without having first broken wind. Another reason is, that nothing relieves them so soon as belching or vomiting; and the milk or food they throw up is generally either curdled, or mixed with a large quantity of heavy phlegm. If they be not relieved by belching or vomiting, the fits sometimes continue a good while, and gradually abate, according as the contents of the stomach are pushed into the intestines; and as soon as the former is pretty well emptied, the child is waked by hunger, cries, and wants the breast; he sucks, and the same process is repeated.—Thus, some children for the first weeks are kept almost always in a doze, or seemingly so; especially if the nurses, either through laziness or want of skill, do not take care to rouse them when they perceive that it is not a right sleep, and keep them awake at proper intervals. This dozing is reckoned a bad sign amongst experienced nurses; who look upon it as a forerunner of the thrush, as indeed it often is; and therefore, when it happens, we ought to be upon our guard to use the necessary precautions for preventing that disorder.
For these disorders, the only remedy recommended by Dr Armstrong is antimonial wine, given in a few drops according to the age of the infant. By this means the superabundant mucus will no doubt be evacuated; but at the same time we must remember, that this evacuation can only palliate, and not cure the disease. This can only be effected by tonics; and, when from inwards fits and other symptoms it appears that the tone of the stomach is very weak, a decoction of cinchona, made into a syrup, will readily be taken by infants, and may be safely exhibited from the very day they come into the world, or as soon as their bowels are emptied of the meconium by the mother's milk or any other means.
Dr Clarke observes, that fractures of the limbs and compressions of the brain, often happen in difficult labours; and that the latter are often followed by convulsions soon after delivery. In these cases, he says, it will be advisable to let the navel-string bleed two or three spoonfuls before it be tied. Thus the oppression of the brain will be relieved, and the disagreeable consequences just mentioned will be prevented. But if this has been neglected, and fits have actually come on, we must endeavour to make a revulsion by all the means in our power; as by opening the jugular vein, procuring an immediate discharge of the urine and meconium, and applying small blisters to the back, legs, or behind the ears. The semicupium, too, would seem to be useful in this case, by driving the oppressive load of fluids from the head and upper parts.
It sometimes happens after a tedious labour, that the child is so faint and weak as to discover little or no signs of life. In such a case, after the usual cleansing, the body should be immediately wrapped in warm flannel, and briskly tossed about in the nurse's arms, in order, if possible, to excite the languid circulation. If this fail, the breast and temples may be rubbed with brandy or other spirits; or the child may be provoked to cry, by whipping, or other stimulating methods, as the application of onion, or salt and spirit of hartshorn, to the mouth and nostrils. But after all these expedients have been tried in vain, and the recovery of the child absolutely despaired of, it has sometimes been happily revived by introducing a short catheter or blowpipe into the mouth, and gently blowing into the lungs at different intervals. Such children, however, are apt to remain weak for a considerable time, so that it is often no easy matter to rear them; and therefore particular care and tenderness will be required in their management, that nothing may be omitted which can contribute either to their preservation or the improvement of their strength and vigour.
All the disorders which arise from a retention of the meconium, such as the red gum, may easily be removed by the use of gentle laxatives; but the great source of mortality among children is the breeding of their teeth. The usual symptoms produced by this are fretting; restlessness; frequent and sudden startings, especially in sleep; costiveness; and sometimes a violent diarrhoea, fever, or convulsions. In general, those children breed their teeth with the greatest ease, who have a moderate laxity of the bowels, or a plentiful flow of saliva during that time.
In mild cases, we need only, when necessary, endeavour to promote the means by which nature is observed to carry on the business of dentition in the easiest manner. For this purpose, if a costiveness be threatened, it must be prevented, and the body kept always gently open; the gums should be relaxed by rubbing them frequently with sweet oils, or other softening remedies of that kind, which will greatly diminish the tension and pain. At the same time, as children about this period are generally disposed to chew whatever they get into their hands, they ought never to be without something that will yield a little to the pressure of their gums, as a crust of bread, a wax candle, a bit of liquorice root, or such like; for the repeated muscular action, occasioned by the constant biting and gnawing at such a substance, will increase the discharge from the salivary glands, while the gums will be so forcibly pressed against the advancing teeth, as to make them break out much sooner, and with less uneasiness, than would otherwise happen. Some likewise recommend a slice of the rind of fresh bacon, as a proper masticatory for the child, in order to bring moisture into its mouth, and facilitate the eruption of the teeth by exercising the gums. If these means, however, prove ineffectual, and bad symptoms begin to appear, the patient will often be relieved immediately by cutting the inflamed gum down to the tooth, where a small white point shows the latter to be coming forward. When the pulse is quick, the skin hot and dry, and the child of a sufficient age and strength, emptying the vessels by bleeding, Diseases of ing, especially at the jugular, will frequently be necessary here, as well as in all other inflammatory cases; and the belly should be opened from time to time by emollient, oily, or mucilaginous clysters. But, on the contrary, if the child be low, sunk, and much weakened, repeated doses of the spirit of hartshorn, and the like reviving medicines, ought to be prescribed. Blister applied to the back, or behind the ears, will often be proper in both cases. A prudent administration of opiates, when their use is not forbidden by costiveness or otherwise, is sometimes of great service in difficult teething, as, by mitigating pain, they have a tendency to prevent its bad effects, such as a fever, convulsions, or other violent symptoms; and often they are absolutely necessary, along with the testaceous powders, for checking an immoderate diarrhoea.
When cathartics are necessary, if the child seems too tender and weak to bear their immediate operation, they should be given to the nurse; in which case they will communicate so much of their active powers to the milk as will be sufficient to purge the infant. This at least certainly holds with regard to some cathartics; such, for example, as the infusion of senna, particularly if a very weak infusion be employed, and not used to such an extent as to operate as a purgative to the nurse.
As most young children, if in health, naturally sleep much, and pretty soundly, we may always be apt to suspect that something is amiss when they begin to be subject to watchings and frights; symptoms which seldom or never occur but either in consequence of some present disorder not perceived, or as the certain forerunners of an approaching indisposition. We should immediately, therefore, endeavour to find out the cause of watchfulness, that we may use every possible means to remove or prevent it; otherwise the want of natural rest, which is so very prejudicial to persons of all ages, will soon reduce the infant to a low and emaciated state, which may be followed by a hectic fever, diarrhoea, and all the other consequences of weakness. These symptoms, being always the effects of irritation and pain, may proceed, in very young infants, from crudities or other affections of the prime via producing flatulencies or gripes; about the sixth or seventh month, they may be owing to that uneasiness which commonly accompanies the breeding of the teeth; and after a child is weaned, and begins to use a different kind of food, worms become frequently an additional cause of watchings and disturbed sleep. Hence, to give the necessary relief on these occasions, the original complaint must first be ascertained from the child's age and other concomitant circumstances, and afterwards treated according to the nature of the case. Women and nurses are too apt to have recourse to opiates in the watchings of children, especially when their own rest happens to be much disturbed by their continual noise and clamour. But this practice is often prejudicial, and never ought to have place when the belly is in the least obstructed.
There is no complaint more frequent among children than that of worms, the general symptoms of which have been already enumerated; but it must be observed, that all the symptoms commonly attributed to worms, may be produced by a foulness of the bowels. Hence practitioners ought never to rest satisfied with administering to their patients such medicines as are possessed only of an anthelmintic quality, but to join them with those which are particularly adapted for cleansing the prime via; as it is uncertain whether a foulness of the bowels may not be the cause of all the complaints. This practice is still the more advisable, on account of viscid humours in the intestines affording lodgement to the ova of worms; which, without the convenience of such a receptacle, would be more speedily discharged from the body.
The difficulty of curing what is called a worm fever, arises, according to Dr Musgrave, from its being frequently attributed to worms, when the cause of the disorder is of a quite different nature. He does not mean to deny that worms do sometimes abound in the human body, nor that the irritation caused by them does sometimes produce a fever; but he apprehends these cases to be much more uncommon than is generally imagined, and that great mischief is done by treating some of the disorders of children as worm cases, which are really not so. Dr Hunter is of the same opinion on this point. He has, we are told, dissected great numbers of children who have been supposed to die of worm fevers, and whose complaints were of course treated as proceeding from worms, in whom, however, there appeared, upon dissection, to be not only no worms, but evident proofs of the disorder's having been of a very different nature.
The spurious worm fever, as Dr Musgrave terms it, has, in all the instances he has seen of it, arisen evidently from the children having been indulged with too great quantities of fruit. Every sort of fruit eaten in excess will probably produce it; but an immoderate use of cherries seems to be the most common cause of it. The approach of this disorder has a different appearance, according as it arises from a habit of eating fruit in rather too large quantities, or from an excessive quantity eaten at one time. In the former case, the patient gradually grows weak and languid; his colour becomes pale and livid; his belly swells and grows hard; his appetite and digestion are destroyed; his nights grow restless, or at least his sleep is much disturbed with startings, and then the fever soon follows, in the progress of which, the patient grows comatose, and at times convulsed; in which state, when it takes place to a high degree, he often dies. The pulse at the wrist, though quick, is never strong or hard; the carotids, however, heat with great violence, and elevate the skin so as to be distinctly seen at a distance. The heat is at times considerable, especially in the trunk; though at other times, when the brain is much oppressed, it is little more than natural. It is sometimes accompanied by a violent pain of the epigastric region, though more commonly the pain is slight, and terminates in a coma; some degree of pain, however, seems to be inseparable from it, so as clearly to distinguish this disorder from other comatose affections.
When a large quantity of fruit has been eaten at once, the attack of the disorder is instantaneous, and its progress rapid; the patient often passing, in the space of a few hours, from apparently perfect health, to a stupid, comatosc, and almost dying state. The symptoms of the fever, when formed, are in both cases nearly the same; except that, in this latter sort, a little purulent matter is sometimes discharged, both by vomit Diseases of urine and stool, from the very first day. The stools, in both cases, exhibit sometimes a kind of curd resembling curdled milk; at other times a floating substance is observed in them; and sometimes a number of little threads and pellicles, and now and then a single worm.
Strong purgatives, or purges frequently repeated, in this disorder, are greatly condemned by Dr Armstrong, as they in general not only aggravate the symptoms already present, but are sometimes the origin of convulsions. Bloodletting is not to be thought of in any stage of the disorder.
Although frequent purging, however, be not recommended, yet a single vomit and purge are advised in the beginning of the disorder, with a view to evacuate such indigested matter and mucus as happens to remain in the stomach and bowels. These having operated properly, there is seldom occasion for repeating them; and it is sufficient, if the body be costive, to throw up, every second or third day, a clyster, composed of some grains of aloes, dissolved in five or six ounces of infusion of chamomile.
The principal part of the cure, however, depends upon external applications to the bowels and stomach; and as the cause of the disorder is of a cold nature, the applications must be warm, cordial, and invigorating; and their action must be promoted by constant actual heat.
When any nervous symptoms come on, or remain after the disorder is abated, they are easily removed by giving a pill with a grain or two of asafoetida once or twice a-day.
The diagnostics of worms are very uncertain; but, even in real worm cases, the treatment above recommended would, it is imagined, be much more efficacious than the practice commonly had recourse to. As worms either find the constitution weakly, or very soon make it so, the frequent repetition of purges, particularly mercurials, cannot but have a pernicious effect. Bear's-foot is still more exceptionable, being in truth to be ranked rather among poisons than medicines. Worm seed and bitters are too offensive to the palate and stomach to be long persisted in, though sometimes very useful. The powder of coralline creates disgust by its quantity; and the infusion of pink root is well known to occasion now and then vertiginous complaints and fits.
Fomenting the belly night and morning with a strong decoction of rue and wormwood, is much recommended. It is a perfectly safe remedy, and, by invigorating the bowels, may therefore have some influence in rendering them capable of expelling such worms as they happen to contain. After the fomentation, it is advised to anoint the belly with a liniment, composed of one part of essential oil of rue, and two parts of a decoction of rue in sweet oil. It is, however, a matter of great doubt whether these external applications, in consequence of the articles with which they are impregnated, exert any influence on the worms themselves.
The diet of children disposed to worms should be warm and nourishing, consisting in part at least of animal food, which is not the worse for being a little seasoned. Their drink may be any kind of beer that is well hopped, with now and then a small draught of porter or negus. A total abstinence from butter is not so necessary, perhaps, as is generally imagined. Poor cheese must by all means be avoided, but such as is rich and pungent, in a moderate quantity, is particularly serviceable. In the spurious worm fever, the patient should be supported occasionally by small quantities of broth; and, at the close of it, when the appetite returns, the first food given should be of the kinds above recommended.
The diet here recommended will, perhaps, be thought extraordinary, as the general idea is at present, that, in the management of children, nothing is so much to be avoided as repletion and rich food. It is no doubt an error to feed children too well, or to indulge them with wine and rich sauces; but it is equally an error to confine them to too strict or too poor a diet, which weakens their digestion, and renders them much more subject to disorders of every kind, but particularly to disorders of the bowels. In regard to the spurious worm fever, if it be true that acid fruits too plentifully eaten are the general cause of it, it follows as a consequence, that a warm nutritious diet, moderately used, will most effectually counteract the mischief, and soonest restore the natural powers of the stomach. Besides, if the disorder does not readily yield to the methods here directed, as there are many examples of its terminating by an inflammation and suppuration of the navel, it is highly advisable to keep this probability in view, and, by a moderate allowance of animal food, to support those powers of nature, from which only such a happy crisis is to be expected.
Besides these, many other diseases might here be mentioned, which, if not peculiar to infants, are at least peculiarly modified by the infant state. But into details respecting these we cannot propose to enter. It is sufficient to say, that due regard being paid to age and constitution, the cure is to be conducted on the same general principles as in the adult state.