the use of purgatives. In the earlier stages of this modification of the disease, indeed, it is highly necessary and proper to ascertain, by the operation of some mild medicine, that there is no accumulation of feculent matter; but we have seen in the most satisfactory manner that the bowels may be entirely without feculent matter, though the evacuations have consisted entirely of bloody mucus from an early period of the disease. In such cases as these, the use of purgatives must be unnecessary: and, when the inflammation is extensive, producing a morbid irritability of a great part of the canal, we can scarcely doubt that they must be injurious. Though the evacuations, in such cases, may be of an unnatural appearance, it is to be remembered that this is the result of morbid secretion, not to be corrected by purgatives, but to be removed only by curing the disease on which they depend.

In regard to the dysentery of this country, the most extensive field of observation has been in Ireland, and we have the advantage of a full and able account of it by Dr. Cheyne. According to the extensive experience of this eminent physician, the remedy " least equivocal in its effects, and the most uniformly useful," was bloodletting. The mercurial treatment was tried in all its forms, but often failed; and it did not appear worthy of the same degree of confidence as in other climates. In some cases, the mouth could not be affected; in others, the worst description of mercurial mouth was produced. But even when salivation took place at an early period, it was in many instances unequal to the cure; and in cases in which the disease was supposed to have passed into the ulcerative stage,

Dublin Hospital Reports, vol. iii.

mercury was injurious. Of the cases which were not accompanied by much pain or fever, many got well with a saline purgative, followed by two or three doses of Dover's powder; and even of the more severe cases, attended with fever and tenderness of the abdomen, many recovered under the same remedies preceded by bloodletting. But in many cases, purgatives seemed greatly to aggravate all the sufferings of the patient. They often failed in producing any change in the appearance of the motions; while, on the other hand, a large feculent loose stool was not unfrequently passed after a bleeding, by patients who, for several days before, had passed nothing but mucus mixed with blood. The practical result of Dr. Cheyne's observation seems to be, that the mode of treatment most generally useful was,-bloodletting, followed by calomel and opium, and this by the balsam of capaiva, with farinaceous diet; but next to full bleeding, his chief reliance seems to be in opium; and on a review of his whole experience in the epidemic to which his valuable paper refers, he says, "were the same cases again to be placed under my care, I would not hesitate to give opium in doses of four or five grains, as it was the opium chiefly that seemed to arrest the progress of the inflammation; and whatever, in such a case, procured respite to the patient from agony, sometimes proved of permanent benefit."

The preceding observations were written, and ready to go to press, before I had an opportunity of seeing the second volume of Mr. Annesley's splendid work on the Diseases of India. It gives me much satisfaction to find that they agree, in all the more essential respects, with his observations in regard to dysentery. The point on which I am chiefly disposed to differ from this eminent writer, or I ought rather to say, in which I am disposed to think

5

that his treatment is not entirely adapted to the dysentery of this country, is in the frequent or almost daily use of purgatives. I have already stated my opinion on this subject, and the grounds which induce me to believe that the use of purgatives in dysentery is a practice requiring the utmost discretion, being in some cases proper, in others unnecessary, and in not a few decidedly injurious. I have also stated the experience of Dr. Cheyne, that purgatives in many cases produced no beneficial result, and in others greatly aggravated all the sufferings of the patient. The subject is one of the highest practical importance, and deserving to be investigated with the utmost attention.

Mr. Annesley begins the treatment of dysentery in a robust patient with free general and topical bleeding, and a large dose of calomel combined with opium or Dover's powder,-in debilitated habits, topical bleeding is employed. These are followed at the distance of a few hours by a purgative of castor oil, or jalap and cream of tartar, and a purgative injection. The calomel and opium are also repeated after a few hours interval; and this treatment is assisted by warm fomentations, warm bath, and anodyne injections in very small bulk. These remedies are afterwards repeated according to circumstances, with blistering on the abdomen if necessary; and a purgative is generally given every morning. In the more advanced stages of the disease, when there is reason to believe that ulceration has taken place, he trusts chiefly to blistering, anodyne injections, Dover's powder with camphor and catechu, nitric acid, and the external application to the abdomen of the nitro-muriatic solution.

Mr. Annesley gives no countenance to the empirical and indiscriminate use of mercury, which has become so much in fashion with some writers in all stages and all conditions of dysentery. He gives calomel with opium in

the early stages, along with the necessary evacuations, but chiefly as a purgative. "When given late in the disease with the intention of affecting the system, or when its exhibition is continued with this intention for too long a period, it often seems to precipitate the malady to an unfavourable termination, by inducing or keeping up irritative fever, and lowering the powers of life." In regard to the difficulty often experienced in affecting the system with mercury in the early stages, he states, that it is occasioned by the existence of active inflammation, and that the appearance of mercurial action in these cases is often to be regarded as a sign rather than a cause of the resolution of the disease. In many instances, both of simple dysentery, and of dysentery combined with disease of the liver, he has seen the mercurial action take place in the fullest manner, and yet the disease was not only not arrested, but seemed to run its course more rapidly to an unfavourable termination. And even in the milder cases which got well under the constitutional effects of mercury, there was often a protracted recovery from the diminished energy of the powers of life, occasioned more by the mercurial action than by the disease.

Since the publication of the first edition of this volume, I have found decided benefit, in several dysenteric affections, from the use of sulphur; and to several friends who have employed it at my suggestion, it has appeared to have a very beneficial effect in various affections of the mucous membrane. It has generally been given in small doses, such as 10 grains, repeated three times a day, combined with small opiates, or with Dover's powder; and in the chronic cases frequently with angustura. M. Mayer, in Hufeland's Journal, has strongly recommended a nitrate of soda as of most remarkable efficacy in dysentery. It is

probable also, that the internal use of borax might be useful in certain states of the disease.

§ II. TREATMENT OF THE CHRONIC CASES.

In the chronic form of the disease, the morbid conditions which we have chiefly to contend with are either the chronic fungoid inflammation, or ulceration. The treatment is extremely precarious, and but few of the cases comparatively do well. The remedies which appear to be most generally useful are the following: lime water; vegetable bitters and astringents, especially the cusparia and logwood; preparations of iron; small quantities of mercury with opium, especially calomel with Dover's powder, or small doses of calomel with opium and ipecacuan; the resins, as turpentine, balsam of capaiva or tolu, with small opiates; sulphur with opium; nitric acid; various combinations of these remedies with each other, as a strong decoction of cusparia with nitric acid and laudanum. peated blistering on the abdomen is often very beneficial, also bandaging with a broad flannel roller, and tepid saltwater bath. Sulphate of copper has lately been recommended by Dr. Elliotson in various protracted affections of the bowels; and in any trials of it which I have had an opportunity of making in this class of diseases, it appears to be a remedy deserving of much attention. It is given in doses, at first, of half a grain, combined with an equal quantity of opium, and is gradually increased, if necessary, sometimes to the extent of gr. iii. with half a grain or a grain of opium, three times a-day.

Re

In the treatment of all the affections of this class, much depends upon the most rigid attention to diet. Animal food in every form seems in general to be hurtful; and the