CASE I.

FRANCIS LOTE, aged 35, was admitted into the General Hospital, at Calcutta, on the 1st of May, 1796.—At that time, he complained of general pains over his body, with all those symptoms which indicate an exhausted constitu­tion. On the 15th of May, he came under my care. At that time I found his mouth sore, from the use of Mercury; and he was much purged and griped. On the 3d of June, when I discontinued attending him, his complaints were considerably relieved, by the use of Opium. On the 21st of August, he again came under my care, in a state of extreme debility, with ex­cessive purging, and bloody stools. Du [...]ing the whole of this time, he had remained in the Hos­pital; but, from necessary arrangements, had fallen, during intervals, under the care of other [Page 55] gentlemen. During the last of these intervals, he was so extremely weak that, in the act of vo­miting, the right clavicle was fractured, which occasioned much pain. On that and the two successive days, I gave him eighty drops of Tinc­ture of Opium, morning, and evening. On the 24th, in the morning, as no effect seemed to be produced by the medicine, it was ordered to be given three times a day. At one o'clock P. M. the same day, I was called to him; and found him complaining of violent pain in the bowels, with incessant purging. He had taken the 2d draught about an hour before. The draught was ordered to be immediately repeated. At 9 P. M. he was not relieved; upon which 150 drops of Tincture of Opium was prescribed immediately and ordered to be repeated at 12 o'clock. A glyster, with 200 drops of Tincture of Opium was also given. On the 25th he was easier. The glysters, with 200 drops of Tincture of Opium, were continued every three hours, and the draught, with 150 drops, was repeated in the evening. On the 26th, in the morning, he was nearly in the same state; the glysters were continued, and the draughts ordered 3 times in the day. At 9 P. M. I found that the relief from the glysters, was merely temporary, that he had stools every hour, and no inclination to sleep. Four hundred drops of Tincture of Opium were [Page 56] ordered in glyster, every two hours, and a fourth draught of 200 drops to be taken at 12 o'clock. On the 26th he was easier; he had six or seven stools in the night, with less griping. Slept better than he had done, since he came to the Hos­pital. His pulse beat about 90 strokes in the minute; previous to this his pulse had been very quick and small, but the state of it was not particularly noted; he had 150 drops of Tinc­ture of Opium in the morning, and 200 at 12 o'clock. Four hundred drops were ordered in glyster, every three hours. One P. M. He had 5 stools since morning; the glysters were continued; and a draught of 200 drops or­dered to be taken at 4 o'clock. At 8 P. M. he had 13 stools since the last visit, with a good deal of pain in his bowels. He had not slept; was ordered a draught of four hundred drops of Tincture of Opium at ten o'clock. August the 28th, he had slept a little the preceding night; bowels were easier; pulse 80; had draughts of 200 drops every two hours, with the glysters occasionally. At 2 P. M. his pulse was 90; he was in other respects as before: had ta­ken three draughts. The draughts of 200 drops were repeated every hour. At 9 P. M. his pulse was still 90; he had dosed much, but had no sound sleep; he had taken 4 draughts. A draught of 400 drops was ordered to be given [Page 57] at 12 o'clock. On the 29th, his pulse was 80, and strong; he had 3 stools, with less pain; but slept little; the draughts of 200 drops were continued every hour.—2 P. M. had incessant stools since morning, with violent pain of the bowels; glysters of 400 drops were ordered eve­ry hour. 8 P. M. had four stools since 2 o'clock; had taken only one draught; his bowels were easy after the glysters; pulse 112.—Eight draughts, with 200 drops each, were ordered to be placed at his bed-side, of which he was direct­ed to take one every hour, during the night, with glysters of 500 drops every hour, in the intervals between the draughts.—30th, had six stools during the night. He was free from pain, and his pulse 80 and full; the draughts were continued every two hours, and the glysters occasionally. 9 o'clock P. M. he had eight or ten stools since morning, with some griping; pulse 90. The draughts were increased to 300 drops every two hours; and the glysters continued.—31st, had passed a good night; his pulse was 90; he had five stools; his medicines were continued as the day before. In the evening, he was nearly the same; no alteration was made in his medi­cines—September the 1st, he had six stools during the night, with griping: did not sleep; had no blood in his stools; for two days; the draughts of three hundred drops were given every hour, and the glysters of five hundred drops were conti­nued [Page 58] as before, and repeated according to his own discretion, as the tenesmus and griping might in­dicate.—8 P. M. he was much worse; had eight stools during the day, and no sleep; his pulse was 120, and he was so extremely weak, that I con­sidered him as approaching to dissolution. Draughts of 500 drops each, were ordered to be given every hour, and the glysters of 500 drops; to be continued as before.—2d, he had not slept, but felt himself better; pulse 104; his medicines were continued, in the same manner during the whole of that day. On the 3d, his pulse was 100; he had slept well the preceding night; his medicines were continued. On the 4th, he was much better, had dosed much, and had only two stools; the draughts were directed to be taken occasionally, as circumstances might indicate—This plan was continued until the 14th, at which time his mouth became sore, and the flow of saliva was increased, as if he had been using mercury. The draughts and glysters were, from that period, ordered to be repeated occasi­onally, according to his own discretion. On the 22d, the discharge of saliva continued in the same state.—On the 26th, he was better; and his bow­els easy.— 29th, he continued without pain, with two or three stools in the day, and his strength increasing. On the 30th, when I discontinued attending him, he had only two stools in the [Page 59] day, without pain; and felt a returning appetite. Being a sensible and steady man, he was, at that time, allowed to proportion the strength and frequency of the draughts and glysters according to his own judgment.—During the whole of the time that he was under my care, he had an al­lowance of wine from one to two or three bot­tles in the 24 hours, according to exigency.— From his good sense and punctuality, I have a perfect reliance upon his having conformed to my orders, in every particular, as far as it is possible for patients, in an hospital, to do.

THE treatment of this case may give some idea of the manner in which stimuli should be increased, in diseases of great exhaustion, until the quantity is ascertained, which is capable of producing the highest degree of excitement. It will shew the very great quantity of the most powerful stimuli that may be necessary, in some diseases of that state, in order to effect a cure; and is also an example of the mode in which the doses ought to be repeated. The soreness of the mouth, and the increased flow of saliva, evince that there is a greater similitude between the action of opium and mercury, than has yet been acknowledged. The soreness of the mouth and spitting commenced, after the quan­tity of opium was diminished. Upon resum­ing the draughts, the mouth became less sore, [Page 60] and the flow of salava decreased; and upon leaving them off, the soreness and spitting in­creased. This was repeatedly remarked by the patient himself. It should be observed, in or­der to prevent a rash imitation, where the cir­cumstances are not alike, that the tincture of opium employed; upon this occasion, was much weaker than what is usually made in Europe; that a very great degree of exhaustion had taken place; and that the doses were gradually increased, from eight drops to five hundred.

CASE II.

—DE HAES, aged 40, was admitted into the General Hospital, at Calcutta, on the evening of the 26th of August, 1796, with dysentery of eight days standing. He had about 30 stools in the day, containing slime, mixed with blood; and complained of much pain in his bowels. His pulse was 90 in the minute. At 9 o'clock P. M. he was ordered to rub in, half an ounce of Mercurial Ointment, with half a drachm of Calomel, and to take a hundred drops of Tinc­ture of Opium, to be repeated at 1 [...] o'clock—27th, the Ointment was omitted by neglect. He continued in the same state. Half an ounce [Page 61] of Mercurial Ointment, with a drachm of Ca­lomel, was ordered to be rubbed in immediately, and repeated at 12 o'clock. A hundred drops of Tincture of Opium was desired to be given every two hours.—1 o'clock P. M. he had ten stools since morning, with blood and slime. Had taken only two draughts. The Ointment was ordered to be repeated at 4 o'clock, a glys­ter with two hundred drops of tincture of opi­um to be given every two hours, and one bot­tle of wine to be taken in the course of the evening—8 P. M. pulse 100. He had six stools with less pain. The ointment was rubbed in, and glysters were regularly administered. The ointment was ordered to be again repeated at 9 o'clock, the glysters to be continued, a draught of a hundred and fifty drops of tincture of opium to be given immediately, and to be re­peated at 12 o'clock; and a bottle of Madeira to be given during the night.—28th, he had vo­mited several times during the night, but had only one stool; pulse 75. The ointment was ordered to be repeated, the glysters to be omit­ted, a draught with one hundred drops of tinc­ture of opium to be given, and the wine to be continued.—2 P. M. pulse 72; vomited twice since morning; he had only two stools, and the pain was less; he slept a little. The ointment, draught, and wine were repeated.—9 P. M. pulse [Page 62] 84, had vomited twice, and had six stools. He complained of virtigo; the ointment was repeated, a draught of two hundred drops of tincture of opium was ordered to be given at 12 o'clock, and the wine to be continued.—29th, his pulse was 80 and full. He had ten stools, consisting of slime and blood. The ointment and wine were continued, and a draught, with one hun­dred drops of tincture of opium, ordered every two hours—9 P. M. his pulse was 80, he had six stools, and frequent vomitting, particularly after taking the Maderia wine. The ointment was repeated, two hundred drops of tincture of opium ordered every two hours, and port wine to be given in lieu of the Madeira.—30th, pulse 74. He had two stools, vomited only once, and slept a little. The ointment and wine were repeated, and the draughts with two hundred drops, continued every third hour.—9 P. M. he had several stools in the course of the day, with much pain. No return of vomiting; pulse 100. The ointment was repeated with two drachms of calomel. Draughts of two hundred drops each, were ordered to be continued every two hours. The port wine became disagreeabie to him, and Medeira was again given—31st, pulse 84; had only two stools, and slept well. His mouth was a little sore. The ointment was repeated with one drachm of calomel, and the draughts [Page 63] were continued every third hour.—9 P. M. pulse 80, he had eight stools. His skin and tongue were moist, and he began to spit a little. He had slept some during the day. The oint­ment, draughts, and wine were continued. September the 1st, pulse 76, he had only one stool, slept well, and was better in every respect. The ointment was repeated, with half a drachm of calomel; and the draughts and wine were continued.—8 P. M. continued better. He had no pains, excepting in going to stool. The dis­charge of salava was considerable. He had slept during the day. The ointment was omitted. A draught of two hundred drops of tincture of opium was ordered at 12 o'clock; and the wine was continued.—2d, he had only one stool during the night; pulse 68; the ointment was repeated without the calomel; and the wine continued—8 P. M. he had slept during the day, and spit considerably; the draught of two hun­dred drops was repeated at 12 o'clock, and the wine continued.—3d, he had slept well, and had no stool; the ointment as entirely omitted; and the evening draught and wine were conti­nued.—From that period the wine, and draughts occasionally, were continued until the 30th of September, at which time I left him in an ad­vanced state of convalescence.

[Page 64]THE great quantity of mercury that was used, in this case, in conjunction with opium and wine, shew what a high degree of stimulant power may sometimes be required to effect a cure, in the state of exhaustion, which consti­tutes dysentery.

CASE III.

JACOB MEYER, aged 35, was admitted into the General Hospital, at Calcutta, on the 23d of August, 1796, with pain of bowels and frequent stools. These complaints appeared at first to be slight; and seemed for sometime, to give way to ordinary doses of calomel and opi­um. On the 29th he became worse; and the same treatment was persevered in, but without effect. On the 1st of September, calomel and opium, of each two grains, every second hour, and a draught of eighty drops of tincture of opium, twice a day, were prescribed. The symptoms still increased in force. On the 3d, he had very frequent stools with violent pain in the bowels; and could not bear the least pres­sure on the caput coli. His pulse was 132, thirst extreme, tongue furred; and he had no sleep. Half an ounce of mercurial ointment, [Page 65] and one drachm of calomel were rubbed in. The calomel and opium were given every hour. On the 4th his pulse was 120, he had vomited through the night, tongue brown and furred. The ointment was rubbed in, and to be repeat­ed at 12 o'clock; the pills of calomel and opium were continued.—9 P. M. pulse 130; he had several stools during the day; tongue dry; he thought that he spit more than usual, but his mouth did not seem affected; one ounce of ointment and two drachms of calomel were rubbed in, and the pills were continued.—On the 5th his pulse was 120, he complained of violent pain in his bowels; the medicines were continued as the day before.—6th, his pulse was 100; he complained of violent pain on pressing the arch of the colon, had frequent stools with profuse perspiration, and appeared to be much alarmed and dejected; no increase of the quan­tity of saliva; the ointment and pills were con­tinued in the same manner.—7 P. M. his pulse was 124; in other respects as before; he was immersed in the warm bath, and afterwards had one ounce of ointment, with half an ounce of calomel rubbed in; the pills were continued. —7th, pulse 112; complaints were nearly as the day before. He had an eruption upon the skin, such as usually appears, when salivation cannot be produced, after having used a large quantity [Page 66] of mercury. The warm bath, with the oint­ment and calomel, were repeated; and the ca­lomel in the pills was increased to four grains.— 8 P. M. pulse 128, he had incessant stools, accompanied by violent pains of the abdomen; his tongue was brown and furred, and skin co­vered with profuse moisture. The bath was ordered to be repeated, and an ounce of oint­ment, with two ounces of calomel, to be rubbed in, immediately after the bath. A scruple of colomel and six grains of opium were ordered to be given every second hour—8th, pulse 112; he had incessant stools, with violent pain. He felt ease from the warm bath; had taken five doses of the calomel and opium. The warm bath was ordered to be repeated three times in the day, the ointment and calomel to be again rub­bed in, and the pills to be continued.—8 P. M. pulse 120, there was no increase in the quantity of saliva from the mercury, he had incessant stools with blood, and was extremely debilitated. Had taken six doses of the calomel and opium in the course of the day. Could not bear the least pressure upon the colon. The warm bath was ordered to be repeated, and afterwards two ounces of ointment, with four ounces of calomel, to be rubbed in. The calomel and opium to be given every hour—9th, pulse 112 and small. He had stools innumerable. The medicines were [Page 67] continued. 9 P. M. his pulse was almost im­perceptible, and extremities cold. The medi­cines were continued as far as circumstances would admit. 10th at 1 o'clock, A. M. he ex­pired.

THE body of this patient was either not op [...] ed, or the appearances upon dissection were neglected to be noted down, at the time; and were consequently forgotten. But from the analogy between this case and all the others, in which the mouth could not be affected, in the usual manner, by mercury, there can scarcely be a doubt that the colon and rectum, if not the whole of the abdominal viscera were in a state of local disease. The cases of dissection, des­cribed by Mr. Maclean, will explain this point more fully. Of many cases of dysentery, and other diseases, that were opened by us, in which salivation could not be produced by mercury, there was not one without confirmed local disease of the viscera, either of the thorax or abdomen, or both.

THOSE, who may look upon the quantity of medicine here prescribed as extraordinary, should consider, that when a patient is evidently in­curable, by the common practice, it becomes the duty of the practitioner to depart from it. [Page 68] An opposite conduct is dictated, much more by a sly regard to reputation, than an earnest and conscientious desire of saving the lives of patients. Nothing can be more easy than to take shelter under customary forms.

CASE IV. EXTRACTED FROM THE JOURNAL OF THE ENGLISH EAST INDIA COMPANY's SHIP NORTHUMBERLAND.

MR. —, Cadet, aged 17,—tall, of a slender make, and consumptive habit; June 13th, 1791, he had, since the commencement of the voyage, in April 1791, been much indis­posed with sea-sickness; for the last ten days, had feverish symptoms, and for two days a diar­rhoea; his skin was hot and dry, tongue foul and parched, pulse quick and small.—He was order­ed to take two table spoonsful every hour of a mixture, consisting of a hundred drops of tinc­ture of opium, and one pint of water, with an ounce of cinnamon water.—In the evening, there was a remission of the diarrhoea; but it re­turned on the 14th, the mixture having been dis­continued [Page 70] in the night. ^* One grain of opium was ordered to be taken every hour.—15th, after hav­ing taken five pills, his skin became moist, his pulse full, he fell asleep (about 8 o'clock P. M.), and continued free from diarrhoea all night. He had perspired profusely, and his tongue and lips were less parched;—having complained of thirst, he was ordered wine and water for drink.—16th, the opium having been injudiciously discontinu­ed on the 15th, all his symptoms returned; his tongue was foul and parched, his pulse quick and small, his skin hot and dry; he was considerably purged, and had much thirst; one grain of opi­um was ordered to be taken every hour.—On the 17th, the pills having been again imprudent­ly discontinued in the night, he appeared rather confused, his strength was much exhausted, and his complaints remained the same. The pills were ordered to be repeated, and continued through the night. ^† He was allowed mutton or [Page 71] chicken broth, and sago alternately, as his fan­cy directed; and wine and water for drink.— 18th, the pills were regularly taken, day and night, excepting in the intervals of sleep; his pulse was slower and more full: and he was in other respects better, but weak, his skin was covered with a healthy moisture; he com­plained of some soreness of his mouth and throat; he had eat some biscuit, soaked in tea, for break­fast, and was ordered sago for dinner and sup­per, the pills were continued.—19th, his pulse was stronger, an eruption appeared on his face, such as often happens after taking opium or mer­cury.—He complained that his mouth was very sore, and was ordered to have a gargle; the pills, &c. were continued as before.—20th, he was better, the pills, sago, &c. were regularly taken, and he drank plentifully of wine and wa­ter; his thirst was diminished; the pills and re­gimen were ordered to be continued as before.— 21st, he was stronger, and declared himself in eve­ry respect better; the only complaints that re­mained were a soreness of the mouth and fauces, [Page 72] and some swelling of the face; the pills, &c. were continued.—22d, soreness of the mouth and throat were troublesome; he spit more freely than usual, the increased flow of saliva somewhat resembling that which takes place after the use of mercury. ^* He appeared in other respects so much better, that the pills were discontinued. ^† —23a, he had slept tolerably; but his skin was hot, and he complained of debility. No medi­cines were prescribed.—24th, slept ill, and was much harassed with a cough and spitting; his pulse was quick and irregular, and he was op­pressed with clammy sweats,—half a grain of opium was prescribed every half hour, and bark in wine was given in the intervals. Regimen as before. From that period to the 27th, his me­dicines were punctually administered; his cough, spitting, and clammy sweats were diminished; his pulse, skin, and tongue were nearly in a heal­thy state; and the diarrhoea entirely stopped.— 28th, he was stronger, had a good appetite, and [Page 73] could sit up; his medicines, &c. were continued. After this, it was thought unnecessary to make daily reports in the Journal. His medicines were continued for some days, and gradually left off as he approached the healthy state.

IN the above case, the medicines were regu­larly given, either by a friend of the patient's, who took a particular interest in his welfare, by Mr. RIDGES, then surgeon's mate of the Nor­thumberland, or by myself.—The relapses which always took place, upon suddenly laying the me­dicines aside, or with-holding them even for a night, shew the necessity of repeating the doses, with the utmost regularity and care. The sore­ness of the mouth, together with the increased flow of saliva, after the use of opium, was not a peculiar circumstance. Upon that subject, the following remark appears in my Journal:— ‘In many cases, in which opium was freely giv­en, for a length of time, a considerable in­crease in the flow of saliva, was observed to take place, and to continue long after the me­dicine was laid aside. But in cases, where a considerable spitting had before existed, opium as well as mercury had the effect of lessening it.’ These facts, with the explanation of them, will be considered in another place.

CASE V. EXTRACTED FROM THE JOURNAL OF THE ENGLISH EAST INDIA COMPANY's SHIP NORTHUMBERLAND.

ENSIGN G—, 36th regiment, a stout healthy man, about 25 years of age, went up, in a fit of playfulness, to the main-top-mast-head, on the evening of the 10th of June, 1791. Af­ter having remained there a short time, he fell asleep upon the cross-trees, and about mid-night fell down upon the quarter-deck. In the fall, he first struck with his hip, as was supposed, against an iron stauncheon in the main-top, which bent; he then came upon the mizzen-stay, which took him, as far as could be collected from the confus­ed intelligence of some people upon deck, about the middle of the abdomen; and from the stay he fell upon the quarter-deck. He was, as may well be supposed, entirely insensible; much blood was discharged from his mouth, nose, ears, and even from his eyes; in this state he was carried down to his cabbin; upon examina­tion, no fracture was found; the whole conse­quences of the fall seemed to consist of contusi­ons or concussion, the marks of which were very [Page 75] general over his body. His pulse was small, but regular. There happened to be in the ship four professional gentlemen, besides myself. They all seemed of opinion, that Mr. G. should imme­diately lose blood. Some of them insisted upon it, with much earnestness; and the by-standers, knowing that to be the common practice, joined in urging a compliance. I replied, that, how­ever common the practice might be, I was con­vinced of its being entirely wrong; and that I would not, even with the sanction of a majority, do what I was certain must endanger the life of my patient. But that if any of the gentlemen present, chose to take charge of Mr.—G, they might have an opportunity of bleeding him, with propriety, if convinced in their conscience that it was right; and I would give them my opinion when asked. This offer was not accepted. Mr. G. was not bled. In the course of two hours from the accident, he became sensible; was sick at stomach, and vomited. This, as a symptom of concussion usually enumerated, would far­ther indicate, according to the hypotheses of the schools, and the practice of hospitals, copious blood-letting. That, however, did not alter my plan. I was aware indeed that, if the pati­ent died, his death would be attributed to the non-observance of customary forms. But I was [Page 76] also persuaded that, if he lived, after having been copiously bled, it would be in spite of the blood-letting. He was my friend, as well as my patient; and in defiance of obloquy, I deter­mined to do what appeared to me best, in order to save his life. Externally the most powerful stimulating substances were applied, in concourse or succession. For four days he could not move in bed, without excruciating pain. He had small opiates occasionally, wine, and nourishing food; and once half an ounce of sal catharticus amarus, so as to produce one stool. Nothing more was done. He had not an unfavourable symptom. The pains gradually abated; and on the eighth day, from the fall, he was carried upon deck in a chair.

THAT there was absolutely a considerable de­gree of concussion in this case appears, from his having wholly lost the sight of one eye, although, when the marks of contusion had disappeared from that side of his face, the eye looked almost as well as the other. He complained at times of headach, which was always relieved by wrapping up his head in warm cloths.

THE issue of this, as well as of every other case of contusion or concussion, which I have seen treated, either in or out of hospitals, convinced [Page 77] me, that blood-letting is not only unnecessary but pernicious. In private practice, I fear, a mean and criminal compliance with vulgar prejudice, in order to conciliate vulgar favour, too often influences practitioners, whose better judgments would lead them to reject intirely so deplorable a remedy:—a remedy of which the use is not only contrary to all principle; but which, so far as I know, cannot adduce a single uncontrovert­ible fact, in proof of its utility.

CASE VI.

WILLIAM HOLLOWAY, aged 22, was admitted into the General Hospital, at Calcutta, on the 3d of September, 1796, with symptoms of typhus fever, of several days standing. At bed time, he took two grains of opium, and six grains of calomel.—4th, he had slept a little; his tongue was parched and black; pulse 96, he had two stools on the 3d. Six grains of calomel, and six grains of powder of jallap, were ordered to be given every four hours.—5th, in addition to his former symptoms, he complained of cough and pain of breast. He had only one stool, since he began to take the powders. The powders. [Page 78] were ordered to be repeated, and a draught, with sixty drops of tincture of opium to be given at bed time.—9 o'clock, P. M. he had not yet taken the draught prescribed for him in the morning; the pain of his breast was more severe; he had no stool for twenty-four hours; was ordered a glyster with one ounce of castor oil, and one ounce of Glauber's salts; and afterwards to take the draught.—6th, he had no stool from the glyst­er. His pulse was 116; his tongue furred and black, and his mouth exceedingly parched; he was a little confused, and had a slight degree of subsultus tendinum. Two ounces of the common infusion of senna was ordered every hour, and a glyster, double the strength of the former, every second hour until he should have a stool or two.— 7 o'clock P. M. he had one copious stool, after having taken several doses of the infusion, and two or three glysters. Four grains of opium and four grains of calomel were ordered to be taken at 8 o'clock, and to be repeated at 12— On the 7th, he conceived himself better; pulse 108; his tongue was still furred and skin hot. He was allowed twelve glasses of wine in the day. Ten grains of calomel, and fifteen grains of powder of jallap, were prescribed every four hours.—9 o'clock, P. M. his skin was very hot, pulse only 100; he had taken three of the pow­ders, [Page 79] and had 3 stools; he complained that his tongue was sore. It was still furred and black in the middle. He was ordered a draught, with a hundred drops of tincture of opium, at 8 o'clock, and again at twelve.—8th, his pulse was 100, and heat of skin more moderate; but his tongue remained foul; he expressed a wish for porter. ^* A bottle of porter was allowed him; —and the wine was continued. The powders and draughts were repeated.—9th, he remained nearly in the same state; but complained of a severe cough. He had two stools. All his me­dicines were continued as the day before.—10th, he had no cough, and rested well; his pulse was 112; he had no stool; two ounces of infusion of senna were ordered to be taken every hour through the day, and the draughts to be repeated at night.—11th, his pulse was 116, tongue very foul, and mouth parched; he had slept but lit­tle; and had no stool since the 9th.—A glyster, with two ounces of castor oil, and two ounces of Glauber's salts, was ordered to be given imme­diately, and to be repeated according to circum­stances. The powders were given as before.— 7 o'clock, P. M. his pulse was only 100; tongue [Page 80] cleaner, and moist.—He had one stool after hav­ing taken two glysters. He remarked that he had, for the first time, a distinct paroxysm of fever in the afternoon. The draughts were given as usual.—12th, his pulse was 92, and his skin nearly of a healthy temperature; his tongue remained a little furred; he had no stool. The glysters, powders, and draughts, were directed to be given in the same manner as the day before.— 13th, when I visited him, he was sound asleep, seemed easy, and his skin cool. The medicines were ordered to be continued.—7 o'clock P. M. his pulse was 76; skin moist and cool; he had two stools, and was inclined to sleep. The draughts were continued.—14th, he was not so well as the day before; his pulse was 96 in the morning, and 92 in the evening, and his tongue rather foul. The medicines were continued. On the 15th, his skin, tongue, and pulse, ap­proached nearly to the healthy standard. He expressed a desire to eat, and was ordered to have chicken broth. The powders and draughts were continued. On the 16th, he had no fe­verish symptom, his tongue was sore at the edges, and there was an increased flow of saliva. The powders were omitted, and the draughts conti­ed. From that period, he was convalescent, and only took one draught occasionally at night. On [Page 81] the 23d, he was free from complaint, and dis­charged from the Hospital.—During the whole of the time, he was allowed wine and porter, as at first prescribed.

THIS case is not given as an uncommon one, either in respect to the violence of the disease, or the quantity of medicines that were prescrib­ed. The history of it shews, that the sum of sti­mulant power first applied, was inadequate to effect a cure, even in a case of slight disease; for the symptoms by no means approached to the severity of typhus gravior. In every fever, what­ever be its nosological description, the same plan would have been pursued, increasing or dimi­nishing the force of the exciting powers, in pro­portion to the degree of indirect debility. If such a quantity, as was used here, be necessary for the cure of mild typhus, what powerful sti­muli must often be required in typhus gravior, dy­sentery, or plague?

THE intervals, I think, at which the medicines were repeated, are too long. The duration of the action of each dose of mercury or jallap is not, perhaps near so much as four hours—pro­bably not more than one. But whatever it be, such is the period exactly, at which doses ought to be repeated.

[Page 82]IN this, as well as in many cases, both of dy­sentery and fever, I have given castor oil, jallap, and other cathartics, with a view simply to in­crease the excitement. In so far as they effect that, and thereby invigorate the functions of life, they are proportionally as useful as opium, aether, mercury, brandy, wine, or bark. But the purging I conceive to be proportionally as in­jurious a consequence, and as much a mark of in­direct debility, as the headach, sickness, and vom­iting, which follow an excessive or irregular use of these substances. This subject is considered at greater length elsewhere.

CASE VII.

JOHN BROWN, aged 28, was admitted in­to the General Hospital, at Calcutta, on the 10th of July, 1796, with typhus fever—He had besides a sore leg, and chancres. His fever, although apparently slight, was very obstinate. In the course of two months, he was several times almost cured, by small and frequently repeated quantities of opium, mercury, wine, and bark, varied accor­ding to circumstances. But, seemingly in conse­quence of internal local affection, he as often re­lapsed, without any apparent cause. His fever, [Page 83] from continued became remittent, and from re­mittent intermittent. On the 24th of September, suspecting the existence of local disease, I repre­sented to him the necessity of undergoing such a course of mercury as to affect his mouth, to which he had hitherto expressed an insuperable aversion. He had, for some days previously, taken calomel in small doses; and had latterly two emetics, at his own request. ^* On that day, he was ordered to take ten grains of calomel, and fifteen grains of jallap every four hours.—25th, he had taken three powders in the course of the day, and was exces­sively [Page 84] purged and griped through the night ^†. He had no fever. Two grains of opium, and four grains of calomel were directed to be taken every three hours, through the day, and four grains of each at bed time.—26th, the same plan was con­tinued; and he had no return of fever.—27th, he had no fever, and his mouth was very sore. The pills were ordered to be given every six hours.— 28th, his head, face, tongue and throat, were much swelled; he had a considerable discharge of blood from the mouth and fauces, and some purging. In this case, the medicines were by no means cor­rectly exhibited. But it is probable also, that they were not regularly taken. Salivation, or, in cases of local disease, where salivation cannot be produced, a discharge of blood from the mouth and fauces, does not take place, while the mercu­ry is regularly taken, but when it is either sudden­ly laid aside, or given at improper intervals. ^* The [Page 85] following mixture was prescribed—tincture of o­pium three hundred drops—water one pint—pep­permint-water and sugar, as much as will make the mixture agreeable—an ounce of it to be taken every hour. The pills were omitted. On the 29th and 30th, he continued the mixture; his mouth was better; he had no fever, and but little purging; and his pulse was 86.—October the 1st, his pulse was 76, and of good strength; his mouth was much better; and he had no return of fever. The tincture of opium was diminished to two hun­dred drops.—From that period, he recovered strength, and had no return of fever. The mix­ture was gradually decreased in strength and dis­continued. On the 16th of October, he was dis­charged, apparently well.

THERE are several inferences to be drawn from this case. The obstinacy of the fever convinced me, that it depended upon local disease, and de­termined me to give mercury in large doses. The discharge of blood from the mouth and fauces, without a previous increased flow of saliva, was an additional proof of the existence of internal local affection. And, altho' this patient left the Hos­pital apparently well, I am convinced, from the circumstances mentioned, as well as from an ir­regularity of his bowels, that his abdominal vis­cera were in a diseased state, and that his exemp­tion [Page 86] from general disease was merely temporary. From these observations, I would not be under­stood to infer, that mercury acts as a specific in re­moving local disease; but that, by supporting the exeitement of the whole body, it invigorates each particular part, and thus occasions, to a certain extent, the regeneration of those organs, which may have been injured by disease.

THIS is not the only instance, in which the good effects of opium have been experienced, where an excessive salivation, or a discharge of blood from the fauces, after the use of mercury, had taken place. As these symptoms happen from too sudden a subduction, or an irregular re­petition of the mercury; so they may be either obviated or removed, by a proper application of the same power. But as the prejudices of pa­tients will seldom admit of a continuance of the medicine, in these cases, it is absolutely neces­sary to substitute some other stimulant power, equiv­alent in force. Those which I have found to an­swer best, are opium blisters, and the warm bath. Other stimuli, justly proportioned, might no doubt answer equally well. But from the end­less hypotheses of the art, no successful attempts have yet been made to ascertain their relative powers. This is a discovery, which, however distant, I am yet sanguine enough to expect. [Page 87] For, in the medical as in the moral world, at­tachment to principles instead of persons, may be expected to increase, with the progress of knowledge.

CASE VIII.

HENRY DOLLAWAL, aged 26, was admitted into the General Hospital, on the even­ing of the 22d of October, 1796. He had, for a fortnight before, complained of headach, pain of loins, hoarseness, and cough, &c. pulse 58. He was ordered to take two grains of opium and four grains of calomel, at 9 o'clock, P. M. and again at twelve.—on the 23d, he was somewhat easier. Pulse as before. He had no stool. One grain of opium and three grains of calomel, were given every three hours; and several glysters of castor oil.—9 o'clock P. M. he had one stool. The opium and calomel were desired to be re­peated as the night before. Pulse 64.—24th, he thought himself better; but his cough continued severe. Pulse 56. He was desired to take four grains of colomel every three hours.—9 o'clock P. M. he was not sensible that the pills produced any effect. Four grains of opium and ten grains of calomel were ordered to be taken immediate­ly, [Page 88] and repeated at 12 o'clock.—25th, he was seized in the morning with violent spasms. Pulse 64. He was put into the warm bath, which was ordered to be repeated according to circumstan­ces. Afterwards, two grains of opium and four grains of calomel were directed to be taken eve­ry two hours, day and night.—26th, he was much better, and had no cough. The pills were continued.—27th, he thought himself better. His pulse beat only 44 strokes in the minute. The pills were repeated every three hours.— 28th, his mouth was gently affected. Two grains of opium and two grains of calomel were given every three hours.—29th, he was in every respect better, had some slight spitting, and felt a returning appetite. Pulse 68.—One grain of opium and one grain of calomel were given eve­ry four hours.—On the 30th, he was discharged well.

AN uncommonly flushed countenance, and what is called a plethoric habit, together with an unusual slowness of pulse, hoarseness, cough, and pains, would have indicated, according to the common practice, blood-letting and other evacu­ations, in this case. The powers, however, by which a cure was effected, proved, that these symp­toms depended upon a state of indirect debili­ty; and that the use of debilitating powers, would have been improper. For the same rea­son, [Page 89] it may be inferred, that a peculiar slowness, as well as a quickness of the pulse, sometimes takes place in a state of indirect debility. Every departure of the pulse from the healthy standard, whether in quickness or slowness, depends upon debility; as well as every deviation from health, in any of the other functions. Costiveness, as well as purging, depends upon debility of the in­testinal canal. This is shewn from patients affect­ed with the same disease having, in some cases a quickness, in others, a slowness of pulse; in some cases purging, in others costiveness; and all of them being cured by the same means. It is farther corroborated by the proof, that such a state as that of excessive excitement, cannot take place. As blood-letting is the abstraction of a high stimulant power, it must be shewn that diseases of evcessive excitement exist, before it can be admitted as a remedy. Or if it be con­tended that blood-letting is useful in diseases of debility, it must be shewn that it acts as a stimu­lant power. Mere assertions that it has been found useful, do not amount to a sufficient refuta­tion of this reasoning.

THERE was an error of some importance in the treatment of this case, which affords the most convincing proof of the necessity of repeating the doses of medicines, at certain regular inter­vals, and by a certain rule.—On the morning of the 25th,—after having taken four grains of [Page 90] opium and ten grains of calomel, at nine and at twelve o'clock, the preceding night, the pati­ent was seized with violent griping and spasms. This symptom, as I have had frequent opportu­nities of observing, was undoubtedly owing to the doses not having been repeated at proper inter­vals. If a dose of equal strength, or one somewhat smaller, had been given at three, and another still smaller, at six o'clock in the morn­ing, the state of indirect debility, constituting spasm, would not have taken place. As these symptoms may be occasioned, or prevented, at pleasure, the fact is incontrovertible. In this case, they immediately yielded to the stimulant power of the warm bath,—another proof that they arose from a state of indirect debility, oc­casioned by a deficient frequency or force, in the application of stimulant powers. Opium, calo­mel, camphor, aether, or castor oil, given in just proportions, would have produced the same effect with the warm bath. But external appli­cations may often, with great advantage and con­veniency, be alternated, or conjoined, with in­ternal remedies.

CASE IX.

ROBERT WILLIAMSON, aged 25, was admitted into the General Hospital, at Calcutta, [Page 91] on the 28th of October, with a quick and small pulse, laborious breathing, pain of back, loins, &c. His face was turgid; and his eyes red and starting. His tongue was foul and furred. He reported that he was attacked with fever, seven or eight days before, which had become more severe and continued for the last two days. Some medicines had been taken before he came into the Hospital.—At 3 o'clock P. M. when I first saw him, ten grains of calomel were order­ed to be taken every three hours. At 10 P. M. his pulse was 112, and his breathing exceeding­ly laborious. A scruple of calomel was ordered to be given immediately, and to be repeated at one o'clock, A. M. A blister was applied to his sternum. On the 29th of October, his pulse was 120, with burning heat of skin. His tongue felt like a rough board. He had one small stool in the morning. Ten grains of calomel were or­dered to be repeated every three hours.—At 9 o'clock P. M. his pulse was 124. He had one stool ^*; his breathing was laborious, his eyes [Page 92] starting, and he seemed in all other respects worse. Three grains of opium and twelve grains of calomel were desired to be given immediately, and repeated at twelve o'clock. October the 30th, he died at 4 o'clock, A. M.

UPON dissection, the thoracic viscera were found adhering to each other, in such a manner as to form but one mass. The lungs adhered to the pleurae, mediastinum, and diaphragm; the heart to the pericardium; and the pericardium to all the surrounding parts. The adhesions were remarkably strong as well as general. The lungs were of a darker blue than usual. Upon a gene­ral view of the abdominial viscera, they appear­ed to be sound. The scrotum was gangrenous. In one of the arms, there was the mark of a re­cent incision, made by a lancet.

THIS was undoubtedly a case of the most vio­lent peripneumony. According to the common practice, the patient would have been repeatedly bled. Would the abstraction of blood have pro­duced a resolution of the adhesions, which were found in the thorax? The greatest partizan of the practice, I think, would scarcely affirm it. According to the confused notions entertained of peripneumony being a disease of excessive ex­citement, it becomes necessary, in order to pre­serve some appearance of consistency, to divide [Page 93] the disease into different stages; and to use a different or even an opposite plan of treatment, in each. Is it possible that any disease can vary in its progress, excepting in degree? And if not, ought the powers applied for the cure to be varied, in the progress of any disease, except­ing in their degree of force? These would ap­pear to be the conclusions of reason and com­mon sense. But to overturn such flimsy ar­guments, come in medical hypotheses and say ‘inflammation we suppose arises from an increas­ed impetus of the blood in the part affected, and is therefore to be cured by diminishing the quantity of that blood. In peripneumo­ny, there is an inflammation of the lungs; and in order to cure the disease, the impetus of the blood in the lungs must be lessened by blood-letting.’ To this curious fabric of "reasoning, I will just oppose a single fact.— There is not an inflammation, with which we are acquainted, that is not to be cured (as far as it is curable) by the application of stimulant pow­ers,—as warm fomentations, tincture of opium, tincture of cantharides, camphorated spirits, aether, volatile alkali, and mercury. If any per­son seriously doubts the fact, it will be an easy matter to submit it to the test of experiment.— And if there be any other reason, for persever­ing in the practice of blood-letting, than be­cause it is derived from the hypotheses of the [Page 94] schools, and is conformable to custom, let it be produced. That blood-letting had been used, in this case, previous to the patient's having been sent into the hospital, appears probable from the incision in the arm:—that he was purged is known. As catharticks, however, produce an increased degree of excitement, before the debili­tating operation of purging succeeds, their stimu­lant effects will often more than counterbalance the indirectly debilitating effects, which after­wards arise. But as blood-letting is a directly debilitating operation,— the abstraction of an ordinary and powerful stimulus,—it must always be highly injurious. In diseases of direct debility, as far as they can become subjects of medical treat­ment, it must add to the accumulation; in those of indirect debility, it must increase the exhausti­on ( ^*). It is upon the supposition alone that some diseases depend upon a state of excessive excite­ment, that blood-letting can ever be thought admissible. And that such a state does not exist has, in my opinion been fully proved. I know it will be urged, by individuals, that they have found blood-letting useful. But this, like many other medical facts, is mere assertion, not proof. Whatever has been useful in one case, must be useful in every similar case of dis­ease. But it is not so with blood-letting.—It [Page 95] has not invariably been found useful in any one disease. We may therefore, I think, fairly con­clude, that it has never been useful in any one case of disease. If it be said that this is reason­ing, and that experience; let me be permit­ted to ask whether just reasoning and real experi­ence can ever differ? It is impossible.—Whate­ver is true in theory, must be right in practice. To inculcate a contrary opinion is the grand shield of empiricism. Circumstances delivered as facts, from the presumed experience of indivi­duals, ought never to weigh against principles, which are deduced from numerous and undoubt­ed facts, and which can be put to the test of ex­periment by all mankind.

THE quantity of calomel given here was large. But after taking two scruples at two doses, and allowing time for the operation of purging from indirect debility to take place, only one scanty stool was produced. This shews clearly, that, although the quantity was large, in proportion to what is usually given, it was by no means sufficiently large in proportion to the exhaustion of excitability that had taken place; or, in other words, to the violence of the disease. Altho' it be extremely doubtful whether the excitability can ever be accumulated to the healthy standard, by any degree of stimulant power, when so many [Page 96] principal organs have become unable to perform their functions; yet it is certain that, in order to give a patient, in such cirumstances, the only chance of cure, the stimuli should be increased in power, until they produce some effect. In this case, therefore, the medicines should have been both increased in quantity, and more frequently repeated. But as, in every kind of practice, the prejudices of patients, or carelessness of attend­ants, will frequently render it impossible strictly to adhere to the application of principles, we can only make such an approach to them, as these, and other circumstances, will permit.

HAD it not been my wish to bring the theory and practice of this doctrine to the fullest and fair­est proof of discussion and experiment, this is one of those cases which I would have suppress­ed. It is to be regretted that writers do not oft­ener think it necessary to publish their unsuccess­ful, as well as their successful cases.

CASE X.

ROBERT WOODSIDE, aged 25, was admit­ted into the General Hospital, at Calcutta, on the 24th of October, with a dysentery of a fortnights [Page 97] standing. He had 10 or 12 stools in the day, with blood; and complained much of headach, pain of loins, griping, and tenesmus. He lay ea­siest on his right side. His pulse was 108: and he had frequently a flush in both cheeks. I be­gan by giving him small doses of calomel, fre­quently repeated; frictions of mercurial oint­ment; and draughts of 70 or 80 drops of tinc­ture of opium, repeated according to circumstan­ces, through the night. In the course of a few days, the calomel was increased to six grains, with two grains of opium, every two hours; an ounce and a half of ointment was rubbed in at four times, in the course of the day; and draughts, with two hundred drops of tincture of opium ^* in each, were given, every second hour, during the night. The calomel was occasionally alter­nated with camphor, and the tincture of opium with aether. Blisters were applied, and glysters of castor oil frequently given. These applications were made in concourse or succession; and increas­ed or diminished in strength, according to the judgment formed of the state of the excitement, at the time. For a fortnight he seemed to get bet­ter; [Page 98] at one time, the purging rather decreased, and he had no blood in his stools. But from his mouth not being affected, so as to produce an in­creased flow of saliva, after having used an uncom­mon quantity of mercury; from frequent sickness and vomiting; his always lying on the right side; some degree of silliness and anxiety; an occasion­al flush of the cheeks; and his having no appear­ance of getting better upon the whole; I conclud­ed, although there was no apparant enlargement, that his liver was diseased. ^* The medicines, how­ever, were continued, with a view of supporting the excitement, with as much equality as possible. He continued nearly in the same state as at first de­scribed, until the 14th of November, when his pulse (which had varied throughout from 64 to 108, with intermissions occasionally) increased in frequency to 120. His tongue became very dry and glossy. On the 15th, together with his other symptoms, he had a severe hiccup, and intermis­sion of the pulse after every 7th or 8th beat. On the 16th the hiccup was severe and incessant; his pulse 116, and intermittent; he had no power in his extremities—and at ten o'clock P. M. he died.

[Page 99]IN tedious illness, patients naturally get dis­gusted with their medicines in the course of some weeks, or their attendants become negligent. Although both these circumstances happened, in some degree, in this case, the directions were upon the whole observed with much punctuality. From the beginning a cure was not expected. For in every similar case, of between twenty and thirty that were opened by myself, and some by Dr. Yates, the appearances of local disease were so much alike, that I can now almost venture to pronounce, from the symptoms, in what state the viscera will be found, upon dissection. In this case, I was so certain the liver was diseased, that it was mentioned in the daily report some time before his death. Upon dissection, there were found several abscesses in both lobes of the liver, communicating with each other, and con­taining, in all, about one pound of matter, of a thick consistence and white colour. On the upper surface, there were five or six ulcers, com­municating with the abscesses. The edge of the right lobe, a part of the colon in contact with it, and part of the diaphragm, at its origin from the cartilages of the ninth and tenth ribs, were all sphacelated. The intestines, omentum, &c. were adhering throughout.

ARE flushed cheeks a symptom common to persons, whose viscera are diseased, whether of [Page 100] the thorax or abdomen? I have frequently ob­served it in both.

CASE XI.

THOMAS KELLAN, aged 28, was ad­mitted into the General Hospital, at Calcutta, on the 2d of October, 1796, with dysentery of five weeks standing, accompanied by pain in the region of the liver. He had the usual symptoms of griping, tenesmus, and a discharge of blood; generally lay either upon his right side, or in a sitting position; in the latter of which he found most ease. He was frequently sick, and vomit­ed. His tongue was white and furred; and his pulse 104. Four grains of calomel, and one grain of opium were given every hour. One ounce of mercurial ointment, and half an ounce of calomel were rubbed in. On the 4th, he was easier, and had slept well. His tongue and pulse remained as before. The ointment was ordered to be rub­bed in, morning and evening, and the pills to be continued ^*; he was allowed eight glasses of [Page 101] wine in the twenty four hours ^*.—Eight o'clock P. M. he had slept much during the day; pulse 120; he was in other respects much as before.— 5th, his pulse was 120, and he complained of weakness. He had six or seven stools, without blood; and was much inclined to dose. He complained of considerable pain, and burning sensations, in the region of the liver. A blister was ordered to be applied; and two grains of opium, with eight grains of calomel, to be given every hour. He was allowed twenty glasses of wine in the twenty four hours.—6th, he had tak­en ten doses of the opium and calomel. Was much vomited and purged, and had some degree of fever during the night ^†; but was then bet­ter. Pulse 108. The pain in the region of the liver was somewhat relieved. A pill of one grain of opium and four of calomel was ordered to be taken every hour; a draught with one hun­dred and fifty drops of tincture of opium, to be given at eight o'clock P. M.; and to be repeated at twelve. The ointment was continued.—7th, he slept well, and had only two stools. Had taken seven pills, and the draughts; pulse 100. [Page 102] The pills, ointment, and draughts, were conti­nued.—8th, he was considerably better; had five or six stools. He had taken eleven pills, and the draughts. The pills, ointment, and the draughts reduced to 100 drops, were continued. —9th, he had taken ten pills, and one draught; had some stools yesterday, but none last night. Pulse 100: no sickness. The medicines were continued.—10th, having begun to get indiffer­ent about taking his medicines, they were varied, in order to humour him. Instead of the pills, a mixture consisting of half an ounce of tincture of opium, and one pint of water, was given, in divided portions, in the day. This was again alternated with pills. Blisters were repeatedly applied, and the draughts were continued; but the pain and burning sensations over all his ab­domen sickness and vomiting; frequency of stools with blood; smallness of the pulse, &c. seemed to be rather increasing. On the 14th, the tincture of opium in the mixture was increas­ed to an ounce and a half, to one pound of wa­ter, of which he was ordered to take an ounce every half hour; the ointment was omitted, and the draughts continued. On the 15th, he said that he had been easier the day before; but, hav­ing become irregular in taking his draughts, he was frequently purged and griped at night. From that period till the 23d, the opium and calomel, from two to four grains of the one, and [Page 103] from six to ten grains of the other, were alter­nated with the mixture; the ointment was rub­bed occasionally; and the draughts, with from 60 to 100 drops of tincture of opium were giv­en at night, or 3 or 4 grains of opium, which­ever he seemed inclined to prefer. From the 23d of October, to the 18th of November, he appeared to be so much better, that, although confident of the existence of much internal local disease, I was not without hopes, that it was of such a degree as to admit of a reproduction of parts. His pulse varied from 80 to 96. The doses of medicines were considerably diminished. Camphor, four grains every two hours, was al­ternated occasionally with the calomel and opi­um. Glysters, with one ounce of castor oil, were sometimes given every hour, or every two hours; and two pounds of decoction of bark, with an ounce of powder, was given in the day. The ointment, and calomel pills were gradually di­minished, to two drachms of the former, four times in the day; and two grains of the latter, every two hours. His sickness and vomiting still recurred. The burning sensations of the abdomen continued. And he was sensible of a feverish exacerbation every third day.—Nov. the 17th, the pills were omitted, and the other medicines continued.—18th, he had not taken any of his medicines the day before. Complain­ed [Page 104] of the offensive smell of his breath. This was evidently occasioned by leaving off the medi­cines. Being tired of all those to which he had been accustomed, I thought it might be of use to try the effects of hepar sulphuris, to remove the offensive smell of his breath, and prescribed one drachm three times a day. The other me­dicines (viz. decoction of bark, glysters, and draughts) were at the same time, desired to be continued.—20th, he had frequent sickness, and vomiting; much purging, and great thirst. No appetite; and a sense of burning heat in his stomach and intestines. Common flowers of sul­phur had been given, instead of the hepor sul­phuris. They were desired to be omitted. Two pounds of decoction of bark, with half an ounce of aether, was given, in the course of the day; and the draughts were repeated.—22d, his symp­toms continued as before. There was an evi­dent enlargement of the right lobe of the liver; but no perceptible undulation. From that pe­riod, he had two pounds of decoction of bark, with two hundred drops of tincture of opium, in the day; the draughts occasionally at night; calomel, castor oil, and other medicines were also given, and alternated, so as to prevent, as much as possible, his being disgusted with a same­ness of treatment. But the symptoms were ra­ther increasing in violence. The purging became [Page 105] more severe, with blood in his stools; sickness and vomiting more frequent; he complained much of heart-burn; and had sometimes feverish paroxysms, which seemed to be of a quartan type. There was, from the beginning, a flush in both cheeks, like those of a consumptive person. He complained of insensibility of the back, and weakness of the extremities. From all these cir­cumstances, and from no increased flow of saliva having been produced by the mercury, I conclud­ed that there was such a degree of local disease, as to render the case incurable, by any treatment that was possible, in such a situation, to be pur­sued. It was, however, persisted in, with as much regularity as was practicable. He conti­nued gradually sinking, until the 2d of December, when he died.

UPON dissection, the left lung was found ad­hering strongly to all the neighbouring parts. Its substance was unusually dry, hard, and yel­low; and appeared as if it had not, for some time, transmitted blood, or performed its proper functions. The liver weighed about five pounds ^*, was considerably indurated, but had undergone no suppuration. The other abdominal viscera were adhering, in such a manner as to form but one mass; with the exception of the spleen, which [Page 106] had a sound appearance.—The coecum, colon, and rectum, were ulcerated throughout their whole extent. The ulcers were, in many places, an inch in diameter; and had penetrated the two inner coats. It is somewhat remarkable that, in between thirty and forty cases of dysentery which I have seen opened, there was not, in a single in­stance, any of the scybala mentioned by authors, as a symptom of that disease.

THE uncommon quantity of mercury that was here used, without being followed by any affecti­on of the mouth, was a sufficient proof that there existed a lesion of organs, which, if curable, re­quired the application of still higher powers than those that were employed. Even in external lo­cal affections, it is now well known, that a cure depends more upon the support of the general ex­citement, than upon local applications. The cure then, of internal local disease, were it even possible to apply local remedies, must still be per­formed by the application of powers, calculated to support the general excitement.

WE have yet, perhaps, no adequate idea of the degree of power, that may sometimes be re­quired, to produce this effect. But it is very certain that, while in some cases by far too little, in others by far too much of stimulant power is applied. Mercury, for instance, in cases of dy­sentery, is generally used in too small proporti­ons, [Page 107] while in venereal cases, it is by much too freely given. Half a grain of calomel, or less, given every two or three hours, will in a short time effect a cure in ordinary cases of chancre, gonorrhoea, or even a certain degree of syphilis. In these cases, there is seldom any great degree of organic lesion, at least of those organs which are most essential to life. It is only when some of the primary organs are in a state of local dis­ease, that a great and long continued application, of high stimulant powers, becomes necessary, in order to re-produce health. Of this, dysentery is one of the most familiar and fatal examples.

The diminution of the medicines that was made at one period, upon the prospect of the pa­tient being better, was injudicious. Although, in such a case, no plan would probably have suc­ceeded, a perseverance in the regular application of high exciting powers, would have given him one chance of recovery.

THE offensive state of his breath, of which he complained on the 18th of November, was evi­dently occasioned by the subduction of the medi­cines. This is a symptom of indirect debility, as well as salivation, purging, sweat, or any other effect of an irregular application, or sudden sub­duction, of mercury. That these effects are so frequently produced, by the ordinary mode of ex­hibiting [Page 108] that medicine, ought not to surprise us. It is also obvious that if, when given at random, this and other medicines of high stimulant pow­er so frequently produce good effects, their salu­tary effects, when applied according to just prin­ciples, may be expected to surpass any thing, of which we can yet form an idea.

CASE XII.

JOHN CLUFF, aged 30, was admitted into the General Hospital, at Calcutta, on the 18th of November, 1796, with a dysentery of some days standing. He had incessant calls to stool, passed blood, with severe griping, tenes­mus, and prolapsus ani. His thirst was intense; and he seemed in dreadful agony, from lancinat­ing pains. Six grains of opium, and eight grains of calomel, were ordered to be given every hour; a glyster, with three ounces of castor oil, and three ounces of warm water every hour; and half an ounce of mercurial ointment to be rub­bed in, four times in the day. A bottle of Ma­deira, in two quarts of barley water, was pre­scribed for drink. At twelve o'clock, A. M. he had taken two of the pills, and seemed easier. [Page 109] In consequence of a consultation, the pills were or­dered to be omitted, and two ounces of the follow­ing mixture to be given every half hour;—viz. Sal. Cathart. Amar. ten drachms, Crem. Tart. two drachms, Tart. Emetic two grains, water one pint. A draught, with one hundred drops of tincture of opium, was ordered at eight o'clock, and another at twelve. November the 19th, after having taken the mixture, he was both vo­mited and purged. These operations continued occasionally during the night, and were not en­tirely stopped by the draughts. His pulse was 92, tongue foul, and thirst intense; he complain­ed of great pain across the umbilical region; and passed blood in his stools. The mixture was ordered to be repeated; the ointment and glysters to be continued; warm fomentations to be used; and three draughts, with one hundred and fifty drops of tincture of opium in each, were ordered to be given at night, at intervals of three hours. No­vember the 20th, he was much better. His tongue, however, was foul. The glysters did not seem to produce much effect. The mix­ture, ointment and draughts were ordered to be repeated; and the glysters to be disconti­nued.—21st, having, on the evening of the 19th, taken his three draughts at once, in the course of yesterday, he became rather confused; and was dissuaded, by one of his comrades, from tak­ing [Page 110] the draughts the night before as prescribed. He appeared much confused; but the purging was less severe. The mixture, ointment, and draughts, with one hundred drops in each, were desired to be repeated. 22d, he was again dis­suaded, with the best intentions however, from taking his draughts; in consequence of which his confusion increased, and he ran about the ward, in a state of considerable derangement, all night. I represented to his friend, who had with-held the medicines through kindness, the danger of persevering in such conduct; and en­treated that he would exhibit the doses exactly as they were prescribed, which he afterwards punctually did. But in order to ensure a com­pliance, I thought it best occasionally to vary the remedies, and to use such as should fall in with the prejudices of the patient and his friend. Accordingly one drachm of jallap was immedi­ately given. The warm bath was desired to be used three times a day; and after the bath, two drachms of mercurial ointment to be rub­bed in each time.—When the operation of purg­ing should commence, after the exhibition of the jallap, a pill, consisting of four grains of opium, and six of calomel, was directed to be given every hour; and to be continued through the night, in lieu of the draughts.—23d, in the course of [Page 111] the preceding day and night, he had taken nine pills, consisting of four grains of opium and six of calomel each. He slept well; had little purg­ing; and was free from pain. He only complained of weakness and thirst. The pills were re­duced to two grains of opium, and four grains of calomel, every two hours. The ointment was continued; and the bath and glysters omitted.— 24th, he was better. He still passed some blood by stool, and had a difficulty in making water. He complained that his mouth was sore. These symptoms I judged to have arisen, either from the subduction of stimulus the day before having been two great, or the patient having neglected to take the quantity that was prescribed. The medicines were desired to be continued; and the patient was particularly enjoined to take them regularly.—25th, his mouth was less sore, he had fewer stools, and no blood in them; his skin was moist and his pulse 80.—26th, pulse 88, and smaller. Purging and griping continued. By mistake, he had no pills during the night. This fully accounted for the alteration since the day before. He was ordered to have a quart of de­coction of bark, with two hundred drops of tinc­ture of opium, to be taken in divided doses through the day. Two drachms of mercurial ointment, and one drachm of calomel, were rub­bed [Page 112] in four times in the day ^*. On the 27th, he was rather better; the medicines were continu­ed; on the 28th, he was much the same; the decoction, with two hundred drops of tincture of opium, was continued.—He did not always take the whole of the decoction; but generally more than two thirds of it. The ointment was diminished to one drachm four times in the day; and two draughts, with eighty drops of tincture of opium in each, were ordered to be given in the night.—29th, he had taken the draughts and slept well; had only one stool; pulse 84;— tongue clean; he felt some degree of oppression about the pit of the stomach; a blister was appli­ed; the ointment was omitted; the decoction of bark, with tincture of opium, was ordered to be continued; and the draughts to be re­duced to sixty drops. From that period, he continued to get better. The stimuli were in­creased, or diminished, according to cir­cumstances; and on the 12th of December, he was discharged without any complaint, except­ing a little griping at times. At his own request, he had a small phial of tincture of opium, and some pills, with directions how to take them, if [Page 113] required, before he could join his ship at Dia­mond Harbour.

WHEN, in consequence of consultations, as happened in this case, cathartics were exhibited, I endeavoured so to manage them, as regularly to support the excitement; and to prevent, as far as possible, the state of indirect debility, which con­stitutes vomiting and purging, by exhibiting other stimuli, on the commencement of these opera­tions. But this is generally very difficult to ac­complish, principally from the ideas, which pa­tients traditionally imbibe, of the utility of these operations.

ACCORDING to the hitherto uncertain state of the art, it is not surprizing that consultations, in which, to use the words of an elegant writer," learned physicians neutralize their plans, ^*" should seldom be productive of benefit to patients. They are too often scenes of mutual complaisance, in which he, who has most to gain, sacrifices most of his opinion. This has been a subject of much re­gret to sensible men of the profession; and such scenes have consequently been avoided by many of them. It is no mean proof of the truth of the medical principles, asserted in these pages, that [Page 114] two persons, who thoroughly understand them, will differ, but in a very small degree, in their ap­plication to practice. In this respect, I have known a coincidence so perfect, that it could, in no other manner, be accounted for. Their general adop­tion, then, would banish that vulgar adage, which, at present, not undeservedly attaches a degree of ridicule to the cultivators of the healing art, "doc­tors differ."

IN the report of the 24th of November, it is ob­served, that the patient had a difficulty in making water, and a soreness of the mouth, which were judged to have arisen, either from the subduc­tion of stimulus, on the 23d, having been too great, or his having neglected to use the quantity prescribed. This is not hypothesis; but a clear induction of facts. It is certain, that a difficulty of making water, is a symptom that arises from a state of indirect debility, whether that succeeds the exhibition of cantharides, opium, or any other stimulant power. It is also true, that it may be cured by opium, the warm bath, or cantharides. The general mode of applying blisters is such, as often to induce that state; and is therefore im­proper. Blisters of a small size, frequently repeat­ed, will produce a regular excitement, like succes­sive frictions of mercurial ointment. But they ought not to lay on the skin ten or twelve hours; [Page 115] nor so long as to be succeeded by vesication, which is a state of indirect debility. Neither is it neces­sary that [...]hey should be applied, in preference, to any particular spot. For, although they make the first, and a somewhat greater impression, upon the part, with which they come immediately in con­tact; yet, to whatever part of the body they are ap­plied, their action will extend to every other. The action of stimuli upon the excitability, may be compared to an electric shock, which, seemingly at the same instant of time, affects every person in company,—the nearest and the most distant from the phial. When the modus operandi of the one is ascertained, we may expect to ascertain the mo­dus operandi of the other.

IN the preceding, as well as in many other ca­ses, medicines were often exhibited improperly; sometimes from omissions in prescribing, some­times from negligence or mistakes of attendants, and sometimes from the prejudices of the patient.

WITH any number of patients, there cannot be much difficulty in prescribing, according to the old plan of practice, which consists in giving cer­tain fixed doses of medicines, in every disease, whatever be its degree. But justly to proportion the application of stimulant powers, to the ex­haustion of the excitability of each patient, re­quires more exertion of judgment and considera­tion, on the part of the practitioner, and a stric­ter conformity with directions, on the part of the [Page 116] patient, and of the attendants. It is evident then that, in an hospital, it requires an unusual degree of exertion to apply these principles to practice, in from thirty to forty bad cases of disease, daily. But it is their introduction only that is difficult. Once generally admitted, their application would be attended with as much facility, and certainly with more pleasure, because with more success, than any routine of empiricism.

CASE XIII.

ISAAC HUDSON, aged 30, was admit­ted into the General Hospital, at Calcutta, on the 31st of October, 1796, with the following symptoms: Pulse 132, and small. He had for some time feverish paroxysms, at 11 o'clock, A. M. and 11 P. M. which continued between two and three hours. Tongue foul; skin hot; his bowels were quite irregular, sometimes extremely loose, at other times excessively costive. He had a cough, with hoarseness; and pains of the bones and joints. Together with these com­plaints, he had chancres of a fortnight's stand­ing.—One grain of opium and one grain of calo­mel were prescribed every hour; and two drachms of mercurial ointment were ordered to [Page 117] be rubbed in, three times in the day. Novem­ber the 1st, pulse 96. The fever and purging continued. His pains were rather less severe. His tongue was very white. Ten grains of calo­mel were given every three hours. On the 2d, his pulse was 92. He had taken four doses of the calomel. His tongue was less soul. Eight grains of calomel were ordered every three hours, day and night.—3d, pulse 88; he had taken eight doses of the calomel. He had a sore throat and hoarseness, with an incipient spitting. The calomel was omitted, because it was deem­ed highly probable that he would not have taken it, if prescribed. Three grains of opium were given every hour. And three drachms of oint­ment were ordered to be rubbed in, three or four times in the day.—4th, his mouth and throat were very sore, and he spit some blood; from whence it was concluded, that he had omitted to take his medicines, or that he had used them in an irregular manner. A blister was applied to one of his cheeks; two grains of opium were giv­en every two hours; and a glyster, with one ounce of castor oil, was ordered every two hours. He was allowed four glasses of wine in the day. On the 5th, his mouth became very sore, and there was some increased flow of saliva. A blis­ter was applied to the other cheek; the pills and glysters were continued; and he was allowed six [Page 118] glasses of wine.—6th, his mouth became exceed­ingly sore, and his face more swelled. He had no stool; a blister ^* was applied to his breast. The pills were ordered to be continued, and a glys­ter, with two ounces of castor oil, to be given every second hour.—7th, he was much in the same state; the medicines were ordered to be con­tined. On the 8th, he had some difficulty of breathing, his pulse was exceedingly small, and he had fainting fits. Upon enquiry, it was found that he had lately neglected to take the medicines, which he himself confessed. In order to ensure compliance in this respect, a change was made in the medicines. He was put into the warm bath three times in the day. The glysters were con­tinued. And he had three draughts, with one hundred drops of tincture of opium in each, at regular intervals in the night. 9th, he was better; his pulse was 108 and stronger. Cough less severe; and swelling of the face abated. The bath, and glysters were ordered to be repeated; and a draught, with forty drops of tincture of opi­um, to be given every hour.—10th, he was much in the same state; the medicines were con­tinued. [Page 119] —11th, his breath was very foetid, and tongue much swelled; which evinced that he had been irregular in taking his medicines. A blister was applied to his neck, and the other medicines were continued—12th, he was rather better; the medicines were continued; and two drachms of ointment were ordered to be rubbed in, twice a day. ^* —14th, his mouth continued very sore, and he complained of weakness; one drachm of ointment was rubbed in three times in the day, and the other medicines continued.—15th, he seemed better, but complained of weakness; some blood was discharged from his mouth and fauces; he did not permit the ointment to be rubbed in, the day before. The ointment and glysters were continued; and he was enjoined to use his me­dicines regularly. The following mixture was given,—decoction of bark two poun [...]s, powder of bark one ounce, tincture of opium one hun­dred and fifty drops; the whole of it was order­ed to be taken, in divided portions, in the day. The draughts were continued as before. From that period, he got gradually better. His mouth became more or less sore, in the exact proporti­on of the regularity, with which he took his me­dicines. [Page 120] By that symptom, I could detect his irregularites. He continued, for some time, subject to purging, and slight paroxysms of fe­ver occasionally. But, by a perseverance in the same plan of treatment, diminution of the me­dicines, he remained, on the 13th of December, free from complaint, excepting a slight soreness of the mouth. And on the 14th, when I discon­tinued attending him, he was in an advanced state of convalescence.

THIS is one of those cases, which shew that sore­ness of the mouth, and salivation, do not arise from the action of mercury, when regularly appli­ed, and gradually decreased; but that these, and other symptoms of indirect debility, arise in con­sequence of its irregular application, or sudden subduction. This patient, like many others, was so sensible of the truth of the above observation that, after there was a necessity for using the warm bath, he took his medicines with much regulari­ty, until he became convalescent. He was, from repeated experience, convinced that the soreness of his mouth increased, upon the subduction of the mercury, opium, or warm bath.

FROM the beginning, I was doubtful of a recov­ery. For, a small and quick pulse, hoarseness and difficulty of breathing, and the very irregular state of his bowels, indicated that some degree of local [Page 121] affection, both of the thoracic and abdominal vis­cera, had taken place. From the issue, however, it appeared that they were of such a degree, as to admit of a regeneration of organs.

CASE XIV.

ABRAHAM JACKSON, aged 23, was admit­ted into the General Hospital, at Calcutta, on the 15th of November, 1796, with dysentery of a few days standing.—16th, he had four doses, con­sisting of ten grains of calomel each, through the night. Pulse 100; tongue white; skin hot. There was a considerable quantity of blood in his stools. Ten grains of calomel and four grains of opium, were ordered to be given every three hours; and a glyster, with two ounces of castor oil, every two hours. On the 17th, he was rather easier; but had been much griped through the night. ^* The glysters gave him ease. The pills were intended to have been continued through the night; but as it was not particularly expressed in the report, they were not given.—The pills were omitted; a glyster was given every hour; and common infu­sion [Page 122] of senna, with two grains of tartar emetic, in small doses, frequently repeated through the day. Draughts, with eighty drops of tincture of opium, were desired to [...]e given at bed time; and to be repeated, according to circumstances, through the night.—18th, he was rather better. One grain of opium and four grains of calomel were given every second hour. Two drachms of mercurial ointment were orde [...] [...]o be rubbed in, four times in the day. The glys [...]s and draughts were con­tinued.—19th, he had taken only one draught; and his head became confused towards morning ^*. He was much griped. Pulse 80. The draughts were omitted, from a conviction that he would not take them. The other medicines were continu­ed; and warm fomentations applied to the abdo­men.—20th, he had not slept well, and was much purged and griped. The pills were omitted; and a solution with ten drachms of salcatharticus ama­rus, and two grains of tartar emetic, was given, in small doses, through the day.—21st, from this period, he had a quart of decoction of bark, with one hundred drops of tincture of opium, daily; one drachm of mercurial ointment was rubbed in, [Page 123] four times in the day; and three draughts, with sixty drops of tincture of opium in each, were given at intervals during the night. He continu­ed to get better. On the 28th, he was so well, as to ask leave to go to town.—29th, having com­mitted excesses the day before, he had pains and other feverish symptoms. His pulse was above 100. He was ordered to have a mixture of sal cat [...]articus amarus; and the draughts were re­peated. 30th, he had a severe paroxism of fever in the night, and perspired profusely. Pulse 100. Two grains of opium and six grains of calomel, were given every second hour. Two drachms of mercurial ointment were directed to be rubbed in, every three hours ^*. December the 1st, he per­spired profusely, and had a paroxysm of fever in the night. Pulse 100. Three drachms of oint­ment, with one drachm of calomel, were ordered to be rubbed in, four times in the day. The pills were continued. And three draughts, with 60 drops of tincture of opium in each, were ordered to be given, in the course of the night.—2d, he was worse. His pulse was 112; he had a parox­ysm of fever, and some purging in the night. The ointment was continued. A pill, with four grains of opium and eight grains of calomel, was given [Page 124] every second hour in the day; and three draughts, with eighty drops of tincture of opium in each, in the night. On the 3d, he was better. Pulse only 100. On the 4th, his pulse was 96, and his mouth a little sore. 4th, 5th, and 6th, his medi­cines were continued; he was better; and had no fever. On the 7th, having discontinued his medi­cines the day before, his mouth became very sore, and an encreased flow of saliva commenced. The pills were ordered to be reduced to six grains of calo­mel, and three grains of opium; the draughts to be repeated; and the ointment to be omitted. But as I had no reliance on his taking the pills regular­ly, a quart of decoction of bark, with a hundred drops of tincture of opium, was ordered to be ta­ken in the day, to prevent his mouth from becom­ing excessively sore.—8th, did not take the pills on account, as he said, of his having some diffi­culty in swallowing them; but took the decoction and draughts; pulse 100; his mouth continued sore, and the flow of saliva increased. Three drachms of mercurial ointment were ordered to be rubbed in, four times in the day; and he was informed that, if he did not allow it to be regular­ly applied, his mouth would become much sorer. The decoction and draughts were continued; and the pills omitted.—9th, he spit freely; and seem­ed much better. The decoction and draughts were continued; and the ointment omitted. From that period, he was convalescent. And on the 14th of [Page 125] December, when I discontinued attending him, he had no complaint, excepting the soreness of his mouth; which, however, was rapidly decreasing.

WHEN the medicines were increased to a due degree, as on the 3d of December, the patient speedily got better; and had he continued to take them with regularity throughout, he would have got well much sooner. He had however taken a sufficient quantity, to be succeeded by an increased flow of saliva. And after that symptom occurred, he was considered as out of dan­ger.

IN the foregoing cases, in general, the state of the pulse has been noted with some care. The pulse in all its degrees of quickness, slowness, weakness, irregularity, and intermission, may be considered as a kind of thermometer, by which, together with the state of other functions, some judgment may be formed of the state of the ex­citement. A deviation from health in the state of the pulse, is one of the most constant symp­toms of indirect debility. But the surest crite­rion yet known, by which to estimate the degree of exhaustion, is the effect produced, by the sti­mulant powers, applied for the cure.

WHEN the effects of the mercurial ointment were not deemed sufficiently powerful, calomel [Page 126] was added. The ointment used was the strong­est; but the quick-silver was not always suffici­ently triturated. It is almost unnecessary to ob­serve that, in dangerous cases, mercury may at the same time be used, both internally and exter­nally, with advantage.

THE explanations annexed to the cases will, perhaps, appear unnecessarily copious; and, in some parts mere repetitions. But that was deemed the most familiar, and therefore, in some respects, the best mode of illustrating the subject. Examples will often place inferences in a clear point of view, when they might not be obvious from general reasoning.