On January 23d, 1812, I first saw E. P. at the desire of the professional gentleman who attended her. I then learnt that she had been, at different times, attended by physicians of the first eminence, who had most judiciously prescribed; and, however flattered I felt by an appeal to my humble exertions, I nevertheless entered with much diffidence upon the treatment of a case of such long duration, and which had been under such able management. Although there was every appearance of much organic mischief, yet it seemed probable that if the extraordinary morbid acidity existing in the digestive organs could be arrested, one source of irritation would be cut off, and some relief would thus be obtained. There was clearly a very diseased secretion impairing the chylopoietic functions, and thus giving to the nerves of the stomach that great sensibility and irritability by which all food was immediately rejected. From careful inquiry, it did not appear that this idea had been put in force: it was therefore agreed, after a consultation between her surgeon and myself, that we should make trial of this mode of proceeding. The following prescription was accordingly written:

R. Infus. Flor. Anthemid. Zifs.

Pulv. Rad. Ipecac. gr.j.

Potassæ Subcarbonat. j. M.*

This was given as an emetic, to be worked off with cold beef tea, and repeated every second morning. With the same intention of correcting acidity and allaying irritation, pills containing gr. ij. Extracti Conii and one of the Potassa Fusa was directed to be taken every six hours, and the obstinate costiveness which prevailed was obviated by the occasional exhibition of Gamboge and Extract. Colocynth Comp. This plan was followed till the 15th of February, when being informed that the patient imagined it gave some relief to the uneasy sensations of her stomach, the ingesta not returning so very speedily as before, a large spoonful of Aqua Calcis was ordered occasionally, and a tea-spoonful of Magnesia to be added to each quantity of beef tea taken to work off the alkaline emetic, and the Potassa Fusa was increased to gr. ij. in each of the pills taken every six hours. This antacid treatment not only suggested itself from the very great acetous secretions into the stomach, but also from a singular case of severe vomiting with great acidity cured by magnesia, as published in the 3d volume of the Med. Obs. and Inquiries, by the late Dr. Watson. Whatever relief,

* Such was the condition of the stomach, that the draught would have produced vomiting without the Ipecac., which accounts for the smallness of the quantity of this root.

3

however,

however, to the sensations of her stomach E. P. might have felt, it did not appear to me that any great advantage was obtained, although she took at times from two to three grains of the Potassa Fusa; and at one time, after taking the alkaline emetic, vomiting was constantly kept up with pure beef tea and magnesia for five hours: but notwithstanding this, the last vomiting was as acid as the first.

I think it appears very clearly from this, that the great acidity in the stomach did not arise from acetous fermentation in that organ, but was actually secreted; for there was no time for the acetous fermentation to take place, considering the continued vomiting for five hours almost without intermission.* In Dr. Watson's case, it is clear there was acetous fermentation from debility of the stomach, and consequent deficiency in the powers of the gastric juice. After vomiting for a time, the mutton broth was returned in the same state in which it was taken, and the patient was subsequently cured by bark and steel. I was then convinced that the alkaline treatment would be of no essential use, seeing that the acidity was owing to a morbid action in the chylopoietic organs, resulting most probably from morbid structure. This plan, therefore, which had been submitted to with the most patient resignation, was given up in despair: the case, nevertheless, still continued to occupy a good deal of my thoughts. In turning over in my mind the whole of the symptoms again and again, more particularly the circumstances under which the vomiting commenced, which was during a course of mercury, and two days after the salivation commenced, I began to suspect that that mineral was probably in some way connected with this long-continued and very distressing symptom. I had met with no analogous case in my own practice to guide me, but on looking over my commonplace-book, I found a reference to the Med. Obs. and Inquiries for some cases, the symptoms of which were very similar to those of E. P., and which had come on under the use of mercury. I therefore read these cases with some care, and therein discovered a very strong similarity in the origin, progress, and nature, of the symptoms of the case under my care. With this conviction on my inind, I formed the resolution of urging the propriety of again resorting to a mercurial course. I took the first opportunity of stating to my patient (who resides many miles from Bedford) the desire I had that she would again make use of mercury-she readily consented.

Several years ago, Dr. Bardsley, of Manchester, published a volume of Medical Reports, in which he stated some anoma

* Sue Sir John Pringle's Experiments on Alimentary Fermentation,

lous

lous cases of disease arising during the use of mercury, which resisted every mode of treatment till mercury to salivation was again resorted to, when the diseases were cured. I immediately wrote to that physician, and pointed out to him the cases in the 3d and 6th vols. of the Medical Observations.* Reflecting on E. P.'s case, and recollecting the correspondence that had passed between Dr. Bardsley and myself, in reference to the cases published by Sir J. Silvester and Dr. Dobson, it occurred to me that the severity of E. P.'s present symptoms might have originated from a similar cause, viz. a deranged state of the functions of the chylopoietic organs, induced by some error during the mercurial course. entered upon in 1810. After mature deliberation, the plan was immediately enforced, March 2, 1812, the mercurial ⚫intment was ordered to be rubbed in twice a-day, and directions were given for strict confinement to bed, with other precautions, in order to prevent any injury that might pos-: sibly arise under the peculiar circumstances of the case from the use of this active mineral. In order to preserve the stomach in as much tranquillity as possible, it was agreed that nothing whatever should be given by the mouth, (except opening pills when necessary;†) and that to support the system nourishing glysters should be given. This part of the plan, however, was found to be impracticable, the glysters not remaining even with the addition of Tinct. Opii. Care too was taken that the glysters should be thrown up very quietly, to give the greater chance of their being retained by not distending the intestine too suddenly; and in the pills the simple extract of colocynth was directed, lest the aloes in the compound form might with the glyster-pipe irritate the anus too much. The mercurial ointment was used for six weeks, besides occasionally taking pills composed of Hydrarg. Submuriat. and Extract. Conii, and Hydrarg. c. creta, with Extract. Hyoscyami, when the mouth

became sore.

About a week previous to the affection of the mouth, the following symptoms occurred:-She was seized about five in the morning with a most violent pain in her stomach and

*It is but justice to record the candid answer of Dr. Bardsley :"I am no less struck than yourself with the coincidence between the cases you referred me to and those I have published. Such uniformity of success among different practitioners will serve to enhance the merit of the practice. I was led to adopt it from a preconceived notion, and not from authority."

+ R. Gambogiæ, gr. iij. Rhæi, gr. xij. Potassæ Fusæ, gr. iv. Extract. Colocynth. gr. xij. Distribue ope syrupi in pilulas xij-ii vel iij pro dosi.

NO. 173.

bowels,

bowels, which lasted three hours, when she took a cup of warm green tea, which was instantly rejected, accompanied with a good deal of glareous matter, having the appearance in some parts of it of pus. A liquid stool soon followed, which contained the same kind of matter as that which was rejected by vomiting, in the opinion of her attending surgeon. For several days previous to this she was in considerable pain across the stomach, with a great sensation of weight, which was only relieved by large doses of opium. About five or six hours after this violent paroxysm, she took two table spoonsful of mutton broth, which to her unspeakable comfort did not come up; for this was the first food of any kind that had remained upon her stomach for fifteen months. Finding this quantity stay, it was repeated every two hours for three or four days, with similar good effects, and without any other food. From that time she has been able to retain food of any light kind, such as pudding, fish, sweetbread, &c. but these still create an uneasiness at the stomach, and meat is not relished.

On the 12th of April, two days after the cessation of the vomiting, I saw my patient. Whatever might be the exact state of the disease of the chylopoietic organs, there was no doubt that its diminution had been effected by the re-introduction of mercury into the system. Impressed with this idea, and believing that although the vomiting was checked, the causa morbi was not entirely subdued, and as the mouth was not as yet sore, I directed some more mercurial ointment might be used every night for another week.

On the 19th of April I again saw her, when the complete effects of the mercury were visible in the constitution. The stomach continued quiet, and she was able to take a mild nourishing diet, although she had no appetite for food, but felt an inclination for it when it was presented to her. A bitter draught was now prescribed twice a-day; and, as the bowels were extremely torpid, a suspicious circumstance, a bolus of gr. xij Extract Colocynth. Comp. was taken with each draught, and which scarcely moved the bowels once daily. From this time to May 1st, she continued nearly in the same state, except that she began to perspire most profusely, with a fluctuating state of the ptyalism, the mouth at times being free from soreness. The perspiration was so great as to make her feel faint, and to render it necessary to change her bed-linen twice in 24 hours, and the moisture dripped from them when they were wrung. She might he

Pulv. Rad. Columb. 3j. Rasur. Quassiæ, Bj. Aquæ Bul

lient, 3viij. Macera per horas ij et cola.

R. Liquoris Colati, 3x. Spt. Myristica, 3j. M.

said

said to be constantly in a warm bath; she was still confined to her bed, from the fear lest any check being given to the mercurial action, before that mineral was eliminated out of the constitution, might reproduce the vomiting. The bowels were still very torpid. She now took (May 1st) a draught of an infusion of quassia and senna, with the diluted sulphuric acid thrice a-day. With the use of these medicines the perspirations gradually subsided; but they continued very profuse for a long time, and the bowels were so obstinately costive, that very large doses of very active medicines were required to keep them moderately open; till at last she took, in the course of one day, at different times of it, 3j Pulv. Scammon., gr. vj Gambogia, and gr. iv Potasse Fusa, and had only one evacuation, and that not loose. She was now able to come down stairs, to go about the house, and take occasionally an airing in a chaise, although she felt very weak. Her stomach retains the light food she takes, but she feels an uneasy sensation after any thing of an animal kind is taken. In this state I saw her again on the 19th of June, and as she complained of feeling very weak, and as her more immediate professional attendant, who watched her with much care, assiduity, and kindness, stated the very obstinate torpor of her bowels, resisting more than the usual purgations, she was ordered an infusion of the cinchona twice a-day, with some active pills.f

May 31, 1813.-I this day saw E. P.; she still continues to retain food of the farinaceous and vegetable kind on her stomach, which she relishes, as also fruit, puddings, and sometimes bread and cheese; but after eating a meal, she feels an uneasiness about the region of the stomach; eats no meat, disliking it; is thirsty; the tongue is clean during the day, but white in the morning; sleeps generally well; has at times transient sharp pains shooting to the back from the stomach; is at times sick, with some vomiting, but rarely; feels also at

B. Rasur. Quassiæ, j. Cort. Angustur. Contus. 3ls. Folior. Sennæ, 3j. Aquaæ Bullient. viij. Macera per horas iij et cola. R. Liquoris Colati, 3ix. Spt. Myristica, 3j. Acid. Sulph. Dil. gtt. x, M.

My late much-respected friend, Dr. Pitcairn, first suggested to me, many years ago, the utility of combining an aperient in a small dose with bitters, as they produce a better effect that way than alone. Experience has fully confirmed to me the truth of this observation.

R. Pulv. Cinchona, 3fs. Aquæ Bullient. 3viij. Stent per horas xij et cola,

R. Liquoris Colati, 3vj. Lactis Amygdal. 3iij. M.

R. Extracti Elaterii, gr. vj. Gambogiæ, gr. xxiv. Extract. Colocynth. Comp. 3j, distribue in pilulas xxiv-ij-iij vel iv, pro dosi hora somni.