*i£*£- \r- .ar-Jt*..*. 3fR*3&R* W ■*»., iïr"' K'S&tfW? ;-1 •.»■.• ri N: AN ^ n! \ Ni V V! « v« ^ N v N V "k . '-» V - V t <:* ■s ' ? .) <; v: \s K ^ NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland htm* FIRST LINES O F T H E/'*r matofe, or apopledtic. XXII. We hâve ftill to add, that, fometimes, early in the cold ftage, a headach cornes on ; but which, more commonly, is not felt till the hot ftage be formed, and then it is ufually attended with a throbbing of the tem- ples. The headach continues till the fweat breaks out ; but as this flows more freely, that gradually goes off. At the famé time with the headach, there are commonly pains of the back, and of fome of the great joints ; and thefe pains hâve the famé courfe with the headach. XXIII. Thefe are nearly the whole, and are, at leaft, the chief of the phenomena which more conftantly appear in the paroxyfm of an intermittent fever j and we hâve pointed out their ordinary concourfe and fucceflîon. With OF PHYSIC. n With refpect to the whole of them, however, it is to be obferved, that, in différent cafés, the feveral pheno- mena are in différent degrees ; that the feries of them is more or lefs complète ; and that the feveral parts or ftages in the time they occupy, are in a différent pro- portion to one another. XXIV. It is very feldom that the difeafe confifts of a fingle paroxyfm, fuch as we hâve now defcribed ; and it more generally happens, that, after the feries of phenomena mentioned, and after a certain length of time free from them, the famé feries of phenomena again arife, and obferve the famé courfe ae before ; and thefe ftates of fever and Apyrexia often continue to alternate with one another for many times. In thefe cafés, the length of time from the end of one paroxyfm to the beginning of another, is called an Intermission, and the length of time from the beginning of one paroxyfm to the be- ginning of another next fucceeding, is called an In- terval. XXV. When the difeafe confifts of a number of paroxyfms, it is generally to be obferved, that the intervais between them are ncarly equal ; but thefe intervais are of dif- férent lengths in differentfcafes. The moft ufual in- terval is that of forty-eight hours, which is named the Tertian period. The next moft common is that of feventy-two hours, and is named the Quartan period. Some other intervais alfo are obferved, particularly one of twenty-four hours, named therefore the Quotidian, and this is not infrequent ; but ail other intervais longer than that of the quartan are extremely rare, and pro- bably are only irregularities of the tertian or quartan periods. XXVI. The paroxyfms of pure intermittent fevers are always finifhed 12 PRACTICE finifhed in lefs than twenty-four hours ; and, though ?t happens, that there are fevers which conflit of rcpeated paroxyfms, without any entire intermiflion between them ; yet, in fuch cafés, it is obferved, that, though the hot and fweating ftages of the paroxyfms do not entirely ceafe before the twenty-four hours from their beginning hâve expired, they fuffer, however, before that time, a confiderable abatement or Remission of their violence, and, at the return of the quotidian pe- riod, a paroxyfm is in fome fhape renewed, and runs the famé courfe as before. This conftitutes what is called a Rémittent Fever. XXVII. When in thefe rémittents the remifïïon is con- fiderable, and the return of a new paroxyfm is diftindtly marked by the fymptoms of a cold ftage at the beginning of it ; fuch fevers retain ftrictly the appellation of .Ré- mittents. But, when it happens, as in certain cafés, that the remiflion is not confiderable, is perhaps without fweat, and that the returning paroxyfm is not marked v' by the moft ufual fymptoms of a cold ftage, and chiefly by the aggravation or Exacerbation of a hot ftage, the difeafe is called a Continued Fever. XXVIII. In fome cafés of continu*! fever, the remiftions and cxacerbations are fo inconfiderable as not to be eafily obferved or diftinguifhed ; and this has led phyficians to imagine, that there is a fpecies of fever fubfifting for feveral days together, and feemingly confifting of one paroxyfm only. This they hâve called a Continent Fever ; but, in a long courfe of pradtice, we hâve not had an opportunity of obferving fuch a fever. XXIX. With refpect to the form, or Type of fevers, this furthcr may be obferved, that the quartan, while it has the longeft interval, has, at the famé time, the longeft and ' O F P H Y S I C l3 and moft violent cold ftage ; but, upon the whcle, the fhorteft paroxyfm: That the tertian, having a fhorter interval than the quartan, has, at the famé time, a fhorter and lefs violent cold ftage ; but a longer par- oxyfm : And, laftly, that the quotidian, with the fhorteft interval, has the leaft of a cold ftage ; but the longeft paroxyfm. XXX. The type of fevers is fometimes changed in their courfe. When this happens, it is generally in the fol- lowing manner : Both tertians and quartans change into quotidians, quotidians into rémittents, and thefe laft become often of the moft continued kind. In ail thefe cafés, the fever has its paroxyfms protradted longer than ufual, before it changes into a type of more fréquent répétition. . * XXXI. From ail this, a prefumption arifes, that every fever confifts of repeated paroxyfms, and differs from others only in the circumftances and répétition of the par- oxyfms ; and, therefore, that it was allowable for us to take the paroxyfm of a pure intermittent as an ex- ample and model of the whole. C H A P. II. Of the PROXIMATE CAUSE of FEVER. XXXII. The proximate caufe of fever feems hithcrto to hâve eluded the refeàrch of phyficians ; and we fhall not prétend «4 PRACTICE prétend to afcertain it in a manner that may remove every difficulty ; but fhall endeavour to make an approach towards it, and fuch as we hope may be of ufe in con- dudting the pradtice in this difeafe. XXXIII. As the hot ftage of fevers is fo conftantly preceded by a cold ftage, we prefume that the latter is the caufç of the former ; and, therefore, that the caufe of the cold ftage is the caufe of ail that follows in the courfe of the paroxyfm. XXXIV. To difcover the caufe of the cold ftage of fevers, we may obferve, that it is always preceded by ftrong marks of a gênerai debility prevailing in the fyftem. The fmallnefs and weaknefs of the pulfe, the palenefs and coldnefs of the extrême parts, with the fhrinking of the whole body, fufficiently fhew that the action of the heart and larger arteries is, for the time, extremely weakened. At the famé time, the languor, inactivity, and debility of the animal motions, the imperfect fen- fations, the feeling of cold, while the body is truly warm, and fome other fymptoms, ail fhew that the energy of the brain itfelf is, on this occafion, greatly weakened ; and we prefume, that, as the weaknefs of the action of the heart can hardly be imputed to any other caufe, this weaknefs alfo is a proof of the dimi- nifhed energy of the brain. XXXV. We fhall hereafter endeavour. to fhew, that the moft noted of the remote caufes of fever, as contagion, mi- afmata, cold, and fear, are of a fedative nature ; and, therefore, render it probable, that a debility is induced. When the paroxyfms of a fever hâve ceafed to be re- peated, they may be again renewed ; and are moft com- monly renewed, by the application of debilitating powers. And, further, the debility which fubfifts in the animal motions, OF P H Y S I C. '5 motions, and other fundtions through the whole of fever, renders it pretty certain, that fedative or de- bilitating powers hâve been applied to the body. XXXVI. It is therefore évident, that there are three ftates which always take place in fever, a ftate of debility, a ftate of eold, and a ftate of heat ; and, as thefe three ftates re- gularly and conftantly , fucceed each other, in the order we hâve mentioned them, it is prefumed, that they are in the feries of caufe and effedt with refpect to one another. This we hold as a matter of fadt, even although we fhould not be able to explain in what manner, or by what mechanical means thefe ftates feverally produce each other. XXXVII. How the ftate of debility produces fome of the fym- ptoms of the cold ftage, we cannot particularly explain, but refer it to a gênerai law of the animal ceconomy, whereby it happens, that powers, which hâve a ten- dency to hurt and deftroy the fyftem, often excite fuch motions as are fuited to obviate the effects of the noxious power. This is the vis medicatrix nature, fo famous in the fchools of phyfic ; and it is probable, that many of the motions excited in fever are the effects of this power. XXXVIII. That the increafed action of the heart and arteries, which takes place in the hot ftage of fevers, is to be confidered as an effort of the vis medicatrix nature, has been long a common opinion among phyficians ; and we are difpofed to affert, that fome part of the cold ftage may be imputed to the famé power. We judge fo, be- caufe the cold ftage appears to be univerfally a means of producing the hot ; becaufe cold, externally applied, has very often fimilar effects ; and more certainly ftill, becaufe it feems to be in proportion to the degree of tre- mor 16 PRACTICE mor in the cold ftage, that the hot ftage procceds more or lefs quickly to a termination of the paroxyfm, and to a morte complète folution, and longer, intermiflion. See XXJX, XXXIX. It is to be particularly obferved, that, in the time ôf the cold ftage of fever, there feems to be a fpafm in- duced every where on the extremities of thet arteries, particularly of thofe upon the furface of the body. This appears from the fuppreffion of ail excrétions, and from the fhrinking of the external parts ; and although this may, perhaps, be imputed, in part, to the weaker action of the heart, in propelling the blood into the extrême veffels ; yet, as thefe fymptoms often continue after the action of the heart is reftored, there is reafon to believe, that a fpafmodic conftridtion has taken place ; that it fubfifts for fome time, and fupports the hot ftage ; for this ftage ceafes with the flowing of the fweat, and the return of other excrétions, which are marks ofthc relaxation of veffels formerly conftricted. XL. This then may be the idea of fever ; that a fpafm of the extrême veffels, however indUced, may prove an irritation to the heart and arteries ; and that this con- tinues till the fpafm is relaxed or overcome. There are many appearances which fupport this opinion j and there is little doubt that a fpafm does take place, and proves an irritation to the heart ; and therefore may be con- fidered as a principal part in the proximate caufe of fever. It will ftill, however, remain a queftion, what is the caufe of this fpafm, whether it be diredtly pro- duced by the remote caufes of fever, or if it be only a part of the opération of the vis medicatrix naturae. XLI. We are difpofed to be of the latter opinion, firft, be- caufe it remains ftill certain, that a debility lays the foundation O F P.H Y S I C. n foundation of fever ; fecondly, becaufe, fuppofing this uncertain, we can more eafily perceive how debility in*- duces fpafm, than how fpafm produces the debility, which always, more or lefs, appears ; and, thirdly, we, efpecially, conclude, that the fpafm dépends upon the debility ; becaufç we perceive, that the degree of fpafm formed, and the obftinacy of its continuance, dépend, in many cafés, upon the power of the caufes inducing debility, and upon the debility induced ; for the more powerful the debilitating caufes, and the greater the debility produced, the paroxyfms are the longer, and the more frequently repeated. XLII. From hence we are led to believe, that, togetherwith the fpafm, there is an atony fubfifting in the extrême veflels, and that the relaxation of the fpafm requires the reftoring of the tone and action of thefe. XLIII. Some illuftration and proof of this we expedt will arife, from confidering the fymptoms which take place with refpect to the fundtions of the ftomach in fevers, fuch as the anorexia, naufea, and vomiting. (XIV.) The connection or confent, which we obferve between the perfpiration and the appetite in healthy perfons, renders it probable, that the tone of the extrême veffels on the furface of the body, and that of the mufcular fibres of the ftomach, are connected or confenting with each other ; and that, therefore, in fevers, the want of appetite or of tone in the mufcular fibres of the ftomach, may dépend upon the atony of the extrême veffels on the furface of the body. Further, that, in fevers, an atony affects the fibres of the ftomach, appears from the naufea and vomiting which fo frequently occur, and which fo commonly dépend upon a ftate of debility in the ftomach. Laftly, that the debility of the ftomach which pro- duces vomiting, dépends upon an atony of the extrême veffels on the furface of the body, appears particularly C • hom i8 PRACTICE from a fadt obferved by Dr. Sydenham. In the attack of the plague, a vomiting happens, which prevents any medicine from remaining upon the ftomach. And Dr. Sydenham tells us, that he could not overcome this vomiting but by external means, applied to produce a fweat or détermination to the furface of the body. The connection between the ftate of the ftomach, and that of the extrême veffels on the furface of the body, appears from this alfo, that the vomiting, which fo fre- quently happens in the cold ftage of ffcvers, commonly ceafes upon the coming on of the hot, and very cer- tainly, upon any fweat's coming out. (XIV.) Itis, indeed, probable, that the vomiting in the cold ftage of fevers, is one of the means, employed by nature, for reftoring the détermination to the furface of the body ; and it is a circumftance affording a proof, both of this and of the gênerai connection between the ftomach and furface of the body, that emetics thrown into the ftomach, and.operating there, in the time of the cold ftage, com- monly put an end to it, and bring on the hot ftage. It alfo affords a proof of the famé connection, that cold water taken into the ftomach produces an increafe of heat on the furface of the body, and is very often a convenient and effectuai means of producing fweat. We draw a proof of the famé connection from this alfto, that cold applied to the furface of the body, when it docs not ftop perfpiration, is always a powerful means of exciting appetite. It may likewife be confidered, vvhethcr the fever, fo conftantly accompanying the di- geftion of food in the ftomach, be not induced by filling the ftomach, by relaxing its mufcular fibres, and thereby inducing an atony of the extrême veffels. Upon the whole, we think it fufficiemly probable, that the fymptoms of an anorexia, naufea, and vomiting, dépend upon an atony fubfifting in the extrême veffels on the furface of the body, and that this, therefore, is a principal circumftance in the proximate caufe of fever. XLIV. It may feem difHcult to explain how an atony and fpafm can fubfift, at the famé time, in the famé veffels ; but, O F P H Y S I C. T9 but, whatever difficulty there may be in accountino for this, we confider itas a matter of fadt, and at the famé time think it may be found analogous to what happens upon other occafions in.the fyftcm, wherewe often ob- ferve atony producing fpafm. XLV. This atony we fuppofe to dépend upon a diminution of the energy of the brain ; and that this diminution takes place in fevers, we conclude, not only, as before, from the debility prevailing in fo many of the fundtions of the body, mentioned above, but particularly from fymptoms which are peculiar to the brain itfelf. (XXXIV.) Delirium is a fréquent fymptom of fever; and as, from the phyfiology and pathology, we learn, that this fymptom commonly dépends upon fome in- equality in the excitement of the brain or intelledtual organ ; we hence conclude, that, in fever, it dénotes fome diminution in the energy of the brain. Delirium, indeed,- feems often to dépend upon an increafed impetus of the blood in the veffels of the brain, and therefore attends phrenitis. It frequently appears alfo in the hot ftage of fevers, accompanied with a headach and throb- bing of the temples. But, as the impetus of the blood in the veffels of the head is often confiderably increafed, by exercife, external heat, parlions, and other caufes, without occafioning any delirium, it muft be fuppofed, that the famé impetus, in the café of fever, produces delirium; for this reafon only, that, at the lame time, there is fome caufe which diminifhes the energy of the brain, and prevcnts a free communication between the parts concerned in the intelledtual fundtions. Upon the famé principles alfo, we fuppofe there is another fpecics of delirium, which dépends more entirely on the di- minifhed energy of the brain; and may therefore arife when there is no unufual increafe of the impetus of the blood in the veffels of the brain. Such feems to be the delirium occurring at the beginning of the cold ftage of fevers, or in the hot ftage of fuch fevers as fhew ftrong marks of debility in the whole fyftem. XI/VT, 2Z PRACTICE XLVI. Upon the whole, our doctrine of fever is explicitly this. The remote caufes (XXXV.) are certain fedative powers applied to the nervous fyftem, which, diminifh- ing the energy of the brain, thereby produce a debility in the whole of the fundtions, (XXXIV.) and parti- cularly in the adtion of the extrême veffels. (XLII. XLIII.) Such, however, is, at the famé time, the nature of the animal ceconomy, (XXXVII.) that this debility proves an indirect ftimulus to the fangui- ferous fyftem ; whence, by the intervention of the cold ftage, and fpafm connedted with it, (XXXVIII. XXXIX.) the action of the heart and larger arteries is increafed, (XXXIX.) and continues fo. (XL.) till it has had the effedt of reftoring the energy of the brain, of extending this energy to the extrême veffels, of re- ftoring, therefore, their adtion, and thereby efpecially ovércoming thç fpafm affecting them ; upon the remov- ing of which, the excrétion of fweat, and other marks of the relaxation of excretories, take place. XLVII. This doctrine will, as we fuppofe, ferve to explain not only the nature of fever in gênerai, but alfo the various caufes of it which occur. Before proceed in g, however, to this, it may be proper to point out the opi- nions, and, as we judge, the miftakes which hâve for- merly prevailed on this fubjedt. XLVIII. , It has been fuppofed that a lentor or vifcidity prevail- ing in the mafs of blood, and ftagnating in the extrême veffels, is the caufe of the cold ftage of fevers and its confequences. But there is no evidence,pf any fuch vifcidity previoufly fubfifting in the fiuids ; and as it is very improbable that fuch a ïtate of them can be fudden- iy produced, the fuddennefs with which paroxyfms come O F P H Y S 1 C. 21 come on, renders it more likely that the phenomena dé- pend upon fome caufe adting upon the nervous fyftem, or the primary moving powers of the animal ceco- nomy. XLIX. Another opinion, which has been very univerfally received, is, that a noxious matter introduced into, or generated in the body, is the proximate caùfe of fever, and that the increafed action of the heart and arteries, which makes fo great a part of the difeafe, is an effort of the vis medicatrix naturae to expel this morbific matter, and, particularly, to change or concodt it, fo as to render it either altogether innocent, or, at leaft, fit for being more eafily thrown out of the body. This doctrine, however, although of as great antiquity as any of the records of phyfic now remaining, and al- though it has been received by almoft every fchool of medicine, yet appears to me to reft upon a very uncer- tain foundation. There are fevers produced by cold, fear, and other caufes, with ail the effential circum- ftances of fever, and terminating by fweat, and yet, at the famé time, without any évidence or fufpicion of morbific matter. There hâve been fevers fuddenly cured by a hemorrhagy, fo moderate as cannot carry out any confiderable portion of a matter diffufed over the whole mafs of blood ; nor can we conceive how the morbific matter could be collected or determined to pafs off by fuch an outlet as in that café is opened. Even fuppofing a morbific matter were prefent, there is no explanation given in what manner the concodtion of it is performed ; nor is it fhewn, that any fuch change does in fadt take place. In certain cafés it is indeed évi- dent, that a noxious matter is introduced into the body, and proves the caufe of fever ; but, even in thefe cafés, it appears, that the noxious matter is thrown out again, without having fuffered any change ; that the fever often terminâtes before the matter is expelled ; and that, up- on many occafions, without waiting the fuppofed time of concodtion, the fever can be cured, and by remédies uhich do not fefcm to ôperate upon the fluids, or to pro- duce any évacuation. L. 22 PRACTICE L. While we thus reafon againft the notion of fevers be- ing an effort of nature, for concodting and expelling a morbific matter, we by no means intend to réfute, that the caufe of fever frequently opérâtes upon the fluids, and particularly, produces a putrefcent ftate of them. We acknowledge, that this is frequently the café ; but, at the famé time, we maintain, that fuch a change of the fluids is not commonly the caufe of fever ; that very often it is an effedt only ; and that there is no reafon to believe the termination of the fever to dépend upon the expulfion of the putrid matter. LI. Another opinion which has prevailed, remains ftill to be mentioned. In intermittent fevers, a great quantity of bile is commonly thrown out by vomiting ; and this is fo frequently the café, that many hâve fuppofed an unufual quantity of bile, and perhaps a pecuiiar quality of it, to be the caufe of intermittent fevers. This, however, does not appear to be well founded. Vomit- ing, by whatever means excited, if often repeated, with violent ftraining, feems to be powerful in emulging the biliary dudts, and commonly throws out a great deal of bile. This will happen efpecially in the café of inter- mittent fevers. For, as in the ftate of debility and cold ftage of thefe fevers, the blood is not propelled in the ufual quantity into the extrême veffels, and particularly into thofe on the furface of the body, but is accumulated in the veffels of the internai parts, and particularly in the vena portarum ; fo this may occafion a more copi- ous fecretion of bile. The circumftance, however, which chiefly occafions the appearance of bile in thefe v cafés is, the influence of warm climates and feafons. Thefe feldom fail to produce a ftate of the human body, in which the bile is difpofed to pafs off, by its fecre- tories, in greater quantity than ufual, and perhaps, alfo, changed in its quality, as appears from the difeafe of choiera, which fo frequently occurs in warm feafon6. This O F P H Y S I C. n This difeafe, however, occurs often without fever ; and we fhall hereafter render it fufficiently probable, that intermittent/fevers, for the moft part, arife from another caufe, that is, marfh effluvia ; while at the famé time, there is no évidence of their arifing from the ftate of the bile alone. The marfh effluvia, how- ever, commonly operate moft powerfully in the famé feafon that produces the change of the bile ; and, there- fore, confidering the vomiting, and other circumftances of the intermittent fevers which hère concur, it is not furprifing, that autumnal intermittents are fo often attended with effufions of bile. This view of the fub- jedt does not lead us to confider the ftate of the bile, as the caufe of intermittents, but merely as a circumftance accidentally concurring with them, from the ftate of the feafon in which they arife. What attention this requires in the conduct of the difeafe, we fhall con- fider hereafter. LU. From this view of the principal hypothefes which hâve been maintained hitherto, with refpect to the proxi- mate caufe of fevers, it will appear, that thefe do not arifè from changes in the ftate of thç fluids ; while, on the other hand, almoft the whole of the phenomena of fevers lead us to believe, that they chiefly dépend upon changes in the ftate of the mpving powers of the ani- mal fyftem. Though we fhould not be able to explain ail the circumftances of fevers, it is at leaft of fome advantage to be led into the proper train of inveftigation, We hâve attempted to purfue it ; and fhall now en- deavour to apply the doctrine we hâve delivered, to the explaining the diverfityof fevers. CH A P. 24 ^ PRACTICE i C H A P. III. Of the DIFFERENCE-of FEVERS, and its CAUSES. LUI. , With the moft part of phyficians, we fuppofe, that, in every fever, there is a power applied to the body, which has a tendency to hurt and deftroy it, and pro- duces certain motion? in it, which deviate from the na- tural ftate ; and, at the famé time, in every fever which has its full courfe, we fuppofe, that, in confequence of the conftitution of the animal œconomy, there are certain motions excited, which hâve a tendency to ob- viate the effects of the noxious power, or to correct and remove it. Both thefe kinds of motions are confidered as conftitûting the difeafe. The latter, which are of falutary tendency, and confidered as the opérations of the vis medicatrix natutre, we (hall hereafter call the Reaction of the fyftem. LIV. From what has been delivered above, (XLVI.) it appears,, that, in fever, the circumftances of debility, fpafm, and reaction, are chiefly to be confidered ; and therefore, according as thefe are différent in degree, and différent in proportion to one another, they will exhibit the chief différences of fevers. LV. To apply this more exadtly, we maintain, that every fever of more than one day's duration, confifts of re- peated paroxyfms ; and that the différence of fevers, from O F P H Y S I C. 25 from the différence of the circumftances, (LIV.) appears in the diffcrent ftate of paroxyfms, and in the différent circumftances of their répétition. (XXXI.) LVI. That fevers generally confift of repeated paroxyfms, we hâve alledged above (XXIV. XXVI. XXVIII. XXXI.) to be a matter of fact ; but muft hère endeavour to confirm it, by afligning the caufe. LVIL In every fever, in which we can obferve any number of feparate paroxyfms, we conftantly remark that every paroxyfm is finifhed in lefs than twenty-four hours ; but, as we cannot perceive any thing in the caufe of fevers determining to this, we muft fuppofe it to dépend on fome gênerai law of the animal œconomy. Such a law feems to be that which fubjedts the œconomy, in many refpects, to a diurnal révolution. Whether this dépends upon the original conformation of the body, or upon certain powers conftantly applied to it, and inducing a habit, we cannot pofitively détermine ; but the returns of fleep and watching, of appetites and ex- crétions, and the changes which regularly occur in the ftate of the pulfe, fhew fufficiently, that, in the human body, a diurnal révolution takes place. LVIII. It is this diurrtal révolution which we fuppofe déter- mines the duration of the paroxyfms of fevers ; and thefe paroxyfms being fo univerfally limited, as in (LVII.) while no other caufe of this can be aflîgned, renders it fufficiently probable, that their duration dé- pends upon, and is determined by, the révolution men- tioned. That thefe paroxyfms are connected with that révolution, appears further from this, that, though the intervais of paroxyfms are différent, in différent eafes, the times of the acceffion of paroxyfms are D generally- 26 PRACTICE generally fixed toone time of the day ; fo that Quo- tidians come on in the morning, Tertians at noon, and Quartans in the afternoon. LIX. It is ftill to be remarked, that, as Quartans and Tertians are apt to become Quotidians, thefe to pafs into the ftate of Rémittents, and thefe laft to become Conti- nued; and that, even in the continued form, daily ex- acerbations and remiflions are generally to be obferved ; ail this fhews fo much the power of diurnal révolution, that when, in certain cafés, the daily exacerbations and remiflions are with difficulty diftinguifhed, we may ftill prefume, that the gênerai tendency of the œconomy prevails, that the difeafe ftill confifts of repeated par- oxyfms, and, upon the whole, that there is no fuch dif- eafe as that which the fchools hâve called a Continent fever. We expedt that this doctrine will be confirmed by what we fhall fay hereafter, concerning the periodical movements obferved in continued fevers. LX. It being thus proved, that every fever, of more than one day's duration, confifts of repeated paroxyfms ; we, in the next place, remark, that the répétition of par- oxyfms dépends upon the circumftances of the paroxyfms which are already formed. This appears from what is obferved in (XXIX. and XXX.) ; for from thefe it appears, that the longer paroxyfms are protradted, they are the fooner repeated; and, therefore, that the caufe of the fréquent répétition is to befought for in the caufe of the protraction of paroxyfms. LX1. The duration of the, hot ftage, in which the reaction is operating to take off the fpafm formed in the cold ftage, is that upon which the duration of the whole paroxyfm chiefly dépends. We may, therefore, fufpedt, that the longer duration of the hot ftage is owing either to O F P H Y S I C; 27 to the obftinacy of the fpafm, or to the weaknefs of the reaction ; and it is probable, that fometimes the one, and fometimes the other of thefe circumftances, takea place. LX1I. Though the caufe of fpafm may be the famé in dif- férent perfons, it is obvious that the degree of it pro- duced may be greater or lefs, according to the irritability of each particular perfon ; and, therefore, the réaction in fever being given, the paroxyfm,- or continuance of the hot ftage, may be longer or fhorter, according to fi the degree of fpafm that has been formed. LXIII. One caufe of the obftinacy of fpafm in fevers, may, I think, be clearly perceived. In inflammatory difeafes, there is a diathefis phlogiftica prevailing in the body, and this diathefis we fuppofe to confift in an increafed tone of the whole arterial fyftem. When, therefore, this diathefis accompanies fever, as it fometimes does, h may be fuppofed to give occafion to the fébrile fpafm's being formed more ftrongly, and thereby to produce more protradted paroxyfms. Accordingly, we find, that ail inflammatory fevers are of the continued kind ; and that ail the caufes of the diathefis phlogiftica hâve a tendency to change intermittent into continued fevers. As continued fevers, therefore, are often attended with the diathefis phlogiftica, we conclude, that, in many cafés, this is the caufe of their continued form. LXIV, In many fevers, however, there is no évidence of any diathefis phlogiftica being prefent, or of any other caufe of more confiderable fpafm ; and in fuch fevers we muft impute the protraction of paroxyfms, and the continued form of the fever, to the weaknefs of reaction. That this caufe takes place, we conclude from hence, that, in many cafés of fever, wherein the feparate paroxyfms are 28 PRACTICE the moft protradted, and the moft difficultly obferved, we find the moft confiderable fymptoms of a gênerai de- bility; and therefore, we conclude, that, in fuch cafés, the protradted paroxyfms and continued form dépend upon a weaker reaction ; owing either to the caufes of debility applied having been of a more powerful kind, or from circumftances of the patient's conftitution, favourfng their opération. LXV. Upon thefe principles, we make a ftep tqwards ex» plaining in gênerai the différence of fevers, and with fome probability; but muft own, that there is much doubt and difficulty in applying the doctrine to particular cafés. It applies tolerably well to explain the différent ftates of intermittents, as they are more purely fuch, or as they approach more and more to the continued form: But feveral difficulties ftill remain with refpect to many circumftances of intermittents ; and more ftill with refpect to the différence of thefe continued fevers, which are formed from intermittents, and thofe which wehave diftinguifhed in our Nofology, as more efpecially enT titled to the appellation of Continued. See Syn. Nof< Meth. P. IV. Ch. I. Sedt. IL LXVL The charadter of continued fevers, given in the place referred to, is hardly fufficient. To make the diftino» tion more accurate, it is neceffary to add, that the fevers of a continued form, which, however, ftill belong to the fedtion of intermittents, may be diftinguifhed by their having paffed from an intermittent or rémittent form, to that of a continued ; by their fhewing fome tendency to become intermittent, or at leaft rémittent ; by their being known to hâve been occafioned by marfh miafmata; by the nature of the prevailing épidémie; and, for the moft part, by their having but one paroxyfm, or one exacerbation and remiffion, in the courfe of twenty-four hours. On the other hand, continued fevers, to bemore ftridtly fo called, may be diftinguifhed °by O F P H Y S I C. 29 by their ïhewing little tendency to become intermittent or rémittent in any part of their courfe, and efpecially after the firft week of their continuance ; by their being occafioned by human contagion, at leaft, by other caufes than the marfh miafmata ; by the nature of the prevail- ing épidémie ; and by their having pretty conftantly an exacerbation and remiffion twice in the courfe of every twenty four hours. LXVII. From the view given (LXIII. and LXIV.) of the caufes of the protraction of paroxyfms ; and, therefore, of the form of continued fevers, ftridtly fo called, it feems probable, that the remote caufes of thefe operate by occafioning either a phlogiftic diathefis, or a weaker reaction ; for we can obferve, that the moft obvious différence of continued fevers dépends upon the prevail- ing o£ one or other of thefe ftates. LXVIII. Continued fevers hâve been confidered as of great diverfity ; but phyficians hâve not been happy in màrk- ing thefe différences, or in reducing them to any gênerai heads. The diftindtions of the antients are not well underftood, and, fo far as either they, or the modem nofologifts, hâve diftinguifhed continued fevers by a différence of duration, their diftindtions are not well founded, and do not apply in fuch a manner as to be of any ufe. We think it agreeable to obfervation, and to the principles above laiddown, (LXIII. LXIV.) to diftinguifh continued fevers, according as they fhew either an inflammatory irritation, or a weaker réaction. LXIX. This diftindtion is the famé with that of fevers into the Inflammatory and Nervous ; the diftindtion at prefent moft generally received in Britain. To the firft, as a genus, we hâve given the name of Synocha ; to the fécond that of Typhus; and, little ftudious whether 3° PRACTICE whether thefe names be authorifed by the antient ufe of the famé terms, we dépend upon their being underftood by the charadters annexed to them in our Nofology, which we think are founded on obfervation. LXX. By thefe charadters we think continued fevers may be diftinguifhed in pradtice, and, if they may, the prin- ciples above laid down will be confirmed. LXXL Befides thefe différences of continued fever, now mentianed, we are not certain of having obferved any other that can be confidered as fundamental. But the moft common form of continued fevers, in this climate, feems to be a combination of the two gênera mentioned ; and we hâve therefore given fuch a genus a place in oui Nofology, under the title of Synochus. We think, however, that the limits between the Synochus and Typhus, will be with difficulty afligned ; and we are difpofed to believe, that the Synochus arifes from the famé caufes as the Typhus, and is therefore only a va-? riety of it. LXXII. The Typhus feems to be a genus comprehending feveral fpecies. Thefe, however, are not yet well af- certained by obfervation ; and, in the mean time, we can perceive that many of the différent cafés obferved do not imply any fpecific différence, and feem to be merely varieties, arifing from a différent degree of power in the caufe, from différent circumftances of the climate or feafon in which they happen, or, from différent cir- cumftances in the conftitution of the perfons affedted, LXXIII. Some effects arifing from thefe circumftances, requirc to be particularly explained. One is an unufual quantity of O F PHYSIC, 3* ©f bile appearing in the courfe of the difeafe. This abundanee of bile may pofi.bly attend fome continued fevers, ftridtly fo called ; but it more commonlyj for the reafonsaboveexplained, attends intermittents; and, we believe, it might hâve been enumerated among the marks diftinguifhing the latter kind of fevers from the former. But, though an unufual quantity of bile fhould appear with continued fevers, we confider it in this café, as in that of intermittents, as a coïncidence only, owing to the ftate of the feafon, producing-no différent fpecies or fundamental diftindtion, but merely a variety of the difeafe. LXXIV. Another effedt of the circumftances occafionally va- rying the appearance of typhus, is a putrefcent ftate of the fluids. Both the antients and the modems, who are in gênerai much difpofed to follow the former, hâve diftinguifhed fevers as putrid and non-putrid ; but the notions of the antients, on this fubjedt, were not fuf- ficiently correct to deferve much notice j and it is only of late that the matter has been more accurately obferved, and better explained. From the diffolved ftate of the blood, as it appears whendrawn out of the veins, or as it appears from the red blood's being difpofed to be effufed, and run off by various outlets, and from feveral other fymptoms, we hâve now no doubt that a real putrefcency of the fluids takes place in fevers. This putrefcency, however, often attends intermittent, as well as continued fevers, and, of the continued kind, both the fynochus and typhus, and ail of them in very différent degrees ; fo that, whatever attention it may deferve in pradtice, there is no fixing fuch limits to it as to admit of eftablifhing a fpecies under the title of Putrid. LXXV. Befides differing by the circumftances already men- tioned, fevers differ alfo by their being accompanied with fymptoms which belong to difeafes of the other orders 32 V PRACTICE orders of pyrexiîe. This fometimes happens in fuch a manner, as to render it difficult to fay which of the two difeafes is the primary one. Commonly, however, it may be afcertained by the knowledge of the remote caufe, and of the prevailing épidémie, or by obferving trie feries and fucceifion of fymptoms. LXXVI. Moft of our fyftems of phyfic hâve marked, as a primary orie, a fpecies of fever, under the title of Hectic ; but, as it is deferibed, we hâve never feen it as a primary difeafe. We hâve conftantly found itas a fymptom of fome topical affection, moft commonly of an internai fuppuration ; and, as fuch, we fhall confider it in another place. LXXVII. The diftindtion of the feveral cafés of intermittent fever we hâve not profecuted hère, as we fuppofe it may be readily underftood from what is faid above, (XXV. XXVI. and XXVII.) and more fully from the Me- thodical Nofology, P. IV. Cl. I. Sed. I. C H A P. IV. Of the REMOTE CAUSES of FEVER. LXXVIII. As fever has been confidered as confifting chiefly in an increafed action of the heart and arteries, phyficians hâve fuppofed, that certain dired ftimulants, fitted to produce this increafed adtion, are the remote caufes of fever. O F P H Y S I C. 33 Fever. In many cafés, however, there is no évidence of iuch ftimulants being applied, and, in the cafés in which they are applied, they either produce only. a temporary frequency of the pulfe, which cannot be confidered as a difeafe ; or, if they do produce a per- manent fébrile ftate, it is by the intervention of a topical inflammation, which produces a difeafe différent from l what is ftridtly called a fever. LXXIX. That direct ftimulants are the remote caufes of fever, feems farther improbable ; becaufe the fuppofition does not account for the phenomena attending the acceffion of fevers ; and becaufe other remote caufes can with greater certainty be aflïgned. LXXX. As fevers are fo generally épidémie, it is probable, that fome matter floating in jhe atmofphere, and ap- plied to the bodies of men, ought to be confidered as the remote caufe of fevers. Thefe matters prefent in the atmofphere, and acting upon men, may be confidered either as Miasmata, or as Contagions. LXXXI. Miafmata may arife from vaiious fources, and be of différent kinds ; but we know little of their variety or of their feveral effects. We know with certainty only one fpecies of miafma, which can be coçfuLred as the caufe of fever; and from the univerfality of this, it may be doubted if there be any other. • LXXXII. The miafma, fo univerfally the caufe of fever, is that which arifes from marfhes or moift ground, adted upon by heat. So many obfervations hâve now been made with refpect to this, in fo many différent régions of the earth, that there is neither any doubt of its being in E gênerai 3+ PRACTICE général a caufe of fevers, nor of its being very uni- verfally the caufe of intermittent fevers, in ail their différent forms. The fimilarity of the climate, feafon, and foil, in which intermittents arife, and the fimilarity of the difeafes, arifing in différent régions, concur in proving that there is one common caufe of thefe difeafes, and that this is the marfh miafma. What is the particular nature of this miafma, we know not ; nor do we certainly know whether or not it differs in kind : But it is probable that it does not ; and that it differs only in the degree of its power, or perhaps in its quantity, in a given fpace. LXXXIII. Contagions are next to be confidered ; and thefe alfo hâve been fuppofed to be of great variety. It is poffible they may be fo ; but that they truly are, does not ap- pear clearly from any thing we know at prefent. The number of gênera and fpecies of contagioUs difeafes, of the clafs of pyrexiae, at prefent known, is not very great. They belong to the order of Fevers, of Exan- themata, or of Profluvia. Whether there be any be- longing to the order of Phlegmafiae, is doubtful ; and, though it fhould be fuppofed, it will not much increafe the number of contagious pyrexiae. Of the contagious exanthemata and profluvia, the number of fpecies is nearly afcertained ; and each of them is fo far of a determined nature, that, though they hâve now been obferved and diftinguifhed for many âges, and in many différent parts of the earth, they hâve been always found to retain the famé charadter, and to differ only in circumftances, which may be imputed to feafon, climate, and other ex- ternal caufes, or to the peculiar conftitution of the feveral perfons affedted. It is, therefore, probable, that, in each of thefe fpecies, the contagion is of one fpecific nature, and that the number of contagious exanthemata or profluvia is hardly greater than the number of fpecies taken notice of in our fyftems of nofology. LXXXIV. O F P H Y S I C 35 LXXXIV. While the contagious exanthemata and profluvia are thus limited, if we fhould fuppofe the contagious py- rexiae to be ftill of great and unlimited variety, it muft be with refpedt to the gênera and fpecies of continued fevers. But, if we are right in limiting, as we hâve done, the gênera of thefe fevers, it will be probable that the contagions which produce them are not of-great variety ; and this will be much confirmed, if we can render it probable, that there is one principal, perhaps one common fouice of fuch contagions. LXXXV, To thispurpofe it is now well known, that theefHuvia conftantly arifing from the living human bcdy, if long retained in the famé place, without being diffufed in the atmofphere, acquire a fingular virulence, and, in that ftate, applied to the bodies of men, become the caufe of a fever which is very contagious. The late obfervations on jail and hofpital fevers hâve fully proved the exiftence of fuch a caufe ; and it is fufficiently obvious, that the famé virulent matter may be produced in many other places. At the famé time, the nature of the fevers arifing renders it probable, that the virulent ftate of human effluvia is the^ommon caufe of fuch fevers, as they differ only in a ftate of their fymptoms, which may be imputed to the circumftances of feafon, climate, &c. concurring with the contagion, and modifying its force. LXXXVI. With refpect to thefe contagions, though we hâve fpoken of them above, as of a matter floating in the at- mofphere, it is proper to obferve hère, that they are never found to act but when they are near to the fources from whence they arife; that is, either near to the bodies of men, from which they immediately iffue, or near to fome fubftances, which, as having been near to the bodies of men, are imbued with their effluvia, and in wh'ich 36 PRACTICE which fubftance thefe effluvia are fometimes retained in an active ftate for a very long time. The fubftances thus imbued with an active matter^ may be called Fomites ; and it appears to me probable, that contagions, as they arife from fomites, are more powerful than as they arife immediately from the human body. ta LXXXVII. We havc now rendered it probable, that the remote caufes of fevers (VIII.) are chiefly Miafmata or Con- tagions, and neither of them of great variety. We hâve fuppofed that miafmata are the caufe of intermittents, and contagions the caufe of continued fevers, ftridtly fo named ; but we cannot, with propriety, employ thefe gênerai terms. The notion of contagion properly im- plies, a matter arifing from the body of man under difeafe; and that of miafma, a matter arifing from other fub- ftances. But, as the caufe of continued fevers may arife from other fubftances than the human body, and may, in fuch cafés, be called a Miafma ; and as other miafmata alfo may produce contagious difeafes, it will be proper to diftinguifh the caufes of fevers, by ufing the terms Marfh, or Human Effluvia, rather thaa the gênerai ones Miafma, or Contagion. LXXXVIIL Though ve hâve endeavoured to fhew that fevers generally arife from marfh or human effluvia, we can- not, with any certainty, exclude fome other remote caufes, which are commonly fuppofed to hâve at leaft a fhare in producing fevers. We proceed, therefore, to inquire concerning thofe caufes ; and the firft to be taken notice of is, the power of cold applied to the human body. LXXXIX. The opération of cold on a living body, is fo différent in différent circumftances, as to beof diificult explana- tion ; O F PHYSIC. 37 tion ; and this, therefore, is attempted with fome dif- fidence. Cold, in certain circumftances, has manifeftly a fe- dative power. It can extinguifh the vital principle entirely, either in particular parttf, or in the whole body j and, confidering how much the vital principle of animais dépends upon heat, it cannot be doubted that the power of cold is always more or lefs directly fe- dative. But it is equally manifeft, that, in certain circum- ftances, cold proves a ftimulus to the living body, and particularly to the fanguiferous fyftem. And, befides the fedative and ftimulant powers of cold, it is manifeftly alfo a powerful aftringent, caufing a contraction of the veffels on the furface of the body* and thereby producing palenefs, and a fuppreffion of perfpiration. It is likewife probable that this conftric- tion is in fome meafure communicated to the whole body, and that thereby the application of cold proves a tonic power with refpect to the whole fyftem. ■ XC. Thefe feveral effects of cold do not ail take place at the famé time, but may be varioufly combined. The ftimulant power taking place, obviâtes the effects that might otherwife hâve arifen from the fedative, and, in fome meafure, thofe from the aftringent power. But the ftimulant and tonic powers of cold are commonly conjoined, and the former, perhaps, dépend in part upon the latter. XCI. In what circumftances thefe différent effects of cold efpecially take place, it is difficult to détermine j but the morbid effects may be obferved to be chiefly of four kinds. One is a gênerai inflammatory diathefis of the fyftem ; which is commonly accompanied with rheumatifm, or other phlegmafia. A fécond is a catarrhal affection ; a third is gangrené ; and a fourth is a proper fever. In producing 38 PRACTICE producing this laft, the opération of cold generally concurs with that of marfh or human effluvia. In ail its opérations, cold feems to adt more power- fully, in proportion as the body, and particularly the vi^our of the circulation, is previoufly more weakened. XCII. Befides cold, there are other powers which feem to be the remote caufes of fever, as Fear, Intempérance in Drinking, Excefs in Venery, and other caufes, which evidently weaken the fyftem. But, whether any of thefe fedative powers be al one the remote caufe of fever, or if they only pperate either as they concur with the opéra- tion of marfh or human effluvia, or as they give an op- portunity to the opération of cold, are queftions not to be pofitively anfwered. XCIII. As we hâve now mentioned the chief of the remote caufes of fevers, we can further obferve, that thefe will arife more or lefs readily, according as miafmata and contagions are more or lefs powerful, or as they are more or lefs favoured by the concurrence of cold, and other fedative powers. C H A P V. Of the PROGNOSIS of FEVERS. XCIV. As fevers, by (XLVI. and LUI.) confift of both morbid and falutary motions and fymptoms, the ten- dency of the difeafe to a happy or a fatal iflue, or the prognoftic in fevers, has been eftabliihed, by marking the O F P H Y S I C. 39 the prevalence of the morbid or falutary fymptoms ; and it might be properly fo eftabliihed, if we could certainly diftinguifh between the one and the other of thefe kinds of fymptoms ; but the opération of the re-adtion, or falutary efforts of nature, in curing fevers, is ftill in- volved in fo much obfcurity, that I cannot explain the feveral fymptoms of it fo clearly as to apply them to the eftablifhing of prognoftics ; and this, I think, may be done better, by marking the fymptoms which fhew the tendency to death in fevers. XCV. This pjan of the prognoftics in fevers muft proceed upon our knowledge of the caufes of death in gênerai, and in fevers more particularly. The caufes of death, in gênerai, are either direct or indirect. The firft are, thofe which directly attack and deftrôy the vital principle, as lodged in the nervous fyftem, or deftroy theorgans immediately connedted with it. The fecbnâ, or the indirect caufes of death, are thofe which interrupt fuch fundtions as are neceffary to the circulation of the blood, and thereby neceffary to the due continuance and fupport of the vital principle. Of thefe gênerai caufes, thofe which operate more particularly in fevers feem to be, firji, the violence of ré- action, which, either by repeated violent excitements, deftroys the vital power itfelf; or, by its violence, deftroys the organization of the brain neceffary to the action of the vital principle ; or, by the famé violence, dt-ftroys the organization of the parts more immediately neceffary to the circulation of the blood. Secondly, The caufe of death in fevers may be a poifon, that is, a power capable of deftroying the vital principle ; and this poifon may be either the miafma or contagion which was the remote caufe of the fever, or it may be a putrid matter generated in the courfe of the fever. In both cafés, the opération of fuch a power appears either as adting chiefly on the nervous fyftem, inducing the fymptoms of de- bility ; or, as adting upon the mafs of blood, inducing a putrefcent ftate in it, and in the fluids derived from it. XCVI. 40 PRACTICE XCVI. From ail this, we think the fymptoms fhewing the tendency to death in fevers, may be difcovered by their being either the fymptoms of violent re-aclion, of great debility, or of ajirong tendency to putréfaction in the fluids ; and, upon this fuppofition, we proceed now to mark thofe fymptoms more particularly. XCVII. The fymptoms which dénote the violence of re- action, are, i. The increafed force, hardnefs, and fre-f quency of the pulfe. 2. The increafed heat of the body. 3. Thofe fymptoms which are the marks of a gênerai inflammatory diathefis, and more efpecially thofe of a particular détermination to the brain, lungs, or other important vifeera. 4. Thofe which are the marks of the caufe of violent réaction ; that is, of a ftrong fpafm, ap- pearing in the fuppreffion of excrétions. XCVIII. The fymptoms which dénote a great degree of de- bility, are, In the Animal Functions; 1. The weaknefs of the voluntary motions ; 2. The irregularity of the voluntary motions, depending on their debility ; 3. The weaknefs of fenfation ; 4. The weaknefs and irregularity of the intelledtual opérations. In the Vital Functions ; 1. The weaknefs of the pulfe; 2. The coldnefs or fhrinking of the extremities; 3. The tendency to a deliquium animi in an eredt pofture ; 4. The weaknefs of refpiration. In the Natural Functions; i. The weaknefs of the ftomach, as appearing in anorexia, naufea, and vomiting ; 2. Involuntary excrétions, depending upon a palfy of the fphindters ; 3. Difficult déglutition, de- pending upon a palfy of the mufcles of the fauces. XCIX. O F P H Y S I C. +i XCIX. Lajlly, The fymptoms expreffing the putrefcent ftate of the fluids, are, i. In the ftomach, the loathing of animal food, naufea, and vomiting, great thirft, and a defire of acids. 2. In the mafs of blood ; A. the blood drawn out of the veins not coagulated as ufual; B. hemorrhagy from différent parts, without marks of increafed impetus ; C. effufions under the fkin or cuticle, forming petechiae, maculae, and vibices ; D. effufions of a yellow ferum under the cuticle. 3. In the ftate of the excrétions, fréquent, loofe, and fœtid ftools; high-coloured turbid urine; fcetid fweats; and the fcetor of blifters. 4. The cadaverous fmell of the whole body. C. Thefe feveral fymptoms hâve very often, each fingly, a fhare in determining the prognoftic ; but more efpecially by their concurrence and particular combination with one another. CI. On the fubject of the Prognoftic, it is proper to ob- ferve, that many phyficians hâve been of opinion, that there is fomething in the nature of fevers which generally détermines them to be of a certain duration,; and, there- fore, that their terminations, whether in health or in death, happen at certain periods of the difeafe rather than at othërs. Thefe periods are called the Critical Days, carefully marked by Hippocrates and other an- tient phyficians, and alfo by many modems of the greateft eminence in pradtice ; whilft, at the famé time, many modems of no inconfiderable authority, deny their taking place in the fevers of thefe northern régions which we inhabit. F CIL 42 PRACTICE CIL I am of opinion that the doctrine of the antients, and particularly that of Hippocrates, on this fubjedt, was well founded ; and that it is juft and true, even with refpect to the fevers of our climate. CIIL I am of this opinion, firjl, becaufe I obferve, that the animal œconomy is readily fubjedted to periodical movements, both from its own conftitution, and from habits which are readily produced in it. Secondly, Be- caufe I obferve periodical movements to take place in the difeafes of the human body with great conftancy and exactnefs, as in the café of intermittent fevers, and many other difeafes. CIV. Thefe confideratiorts render it probable, that exact periodical movements may take place in continued fevers; and I think there is évidence of fuch movements adtu- ally taking place in thefe fevers. CV. The critical days, or thofe on which we fuppofe the termination of continued fevers efpecially to happen, are, the third, fifth, feventh, ninth, eleventh, fourteentb, feventeenth, and twentieth. We mark none beyond this laft ; becaufe, though fevers are fometimes protradted beyond this period, it is, however, more rarely; and we hâve not a fufficient number of obfervations to afcer- tain the courfe of them ; and further, becaufe it is probable, that, in fevers long protradted, the move- ments become lefs exact and regular, and are therefore lefs eafily obferved. CVI. O F P H Y S I C. 43 CVI. That the days now mentioned are the critical days, is, we think, proved by the particular fadts which are found in the writings of Hippocrates. From thefe, as çolledted from the feveral writings of that author by Mr. de Haen, it appears, that of one hundred and fixty- three inftances of the termination of fevers which hap- pened on one or other of the firft twenty days of the difeafe, there are one hundred and feven, or more than two-thirds of the whole number, which happened on one or other of the eight days above mentioned ; that none happened on the fécond or thirteenth day ; and upon the eighth, tenth, twelfth, fifteenth, fixteenth, eighteenth, and nineteenth, there are but eighteen in- ftances of terminations, or one ninth of the whole. CVII. As the terminations which happen on the feven days laft mentioned, upon the whole, are few, and, upon any one of them, fewer than thofe which happened on any of our fuppofed critical days, there are, therefore, nine days which may be called Non-critical ; while, on the other hand, the many terminations which hap- pened on the feventh, fourteenth, and twentieth days, both give a proof of critical days in gênerai, and that thefe are the chief of them. Hereafter we fhall mention an analogy that renders the power of the other critical days fufficiently probable. CVIII. It appears further, that as, of the terminations which were final and falutary, not a tenth part happened on the non-critical days ; and of the terminations which were final and fatal, though the greater number hap- pened on the critical days, yet above a third of them happened on the non-critical ; fo it is probable, that the teridency of the animal œconomy is to obferve the critical days, and that it is by the opération of fome violent 44 PRACTICE violent and irregular caufe, the courfe of things is fome- times turnedto the non-critical. CIX. What has been faid, rénders it fufficiently probable, that it is the gênerai tendency of the animal œconomy to détermine the periodical movements in fev :rs to be chiefly on the critical days. But, at the famé time, we muft acknowledge it to be a gênerai tendency only, and that, in particular cafés, many circumftances may occur to difturb the regular courfe of il. Thus, though the chief and more remarkable exacerbations in continued fevers happen on the critical days, there are truly exacer- bations happening every day, and thefe, from certain caufes, may become confiderable and critical. Further, though intermittent fevers are certainly very ftrongly determined to obferve a tertian or quartan period, we know, there are circumftances which prevent them from obferving thefe periods exadtly, and render them either anticipating or poftponing fo much, that the days of paroxyfms come to be quite changed ; and it is allowable to fuppofe, that the like may happen with refpect to the exacerbations of continued fevers, and thereby difturb the regular appearance of critical days. A particular inftance of this occurs with refpect to the fixth day of fevers. In the writings of Hippocrates, there are many inftances of terminations happening on the fixth day ; but it is not therefore reckoned among the critical days ; becaufe, of the terminations happening on that day, there is not one of a finally falutary kind ; that the greater number are fatal ^ and that ail the reft are imperfedt, and followed with a relapfe. Ail this fhews, that fome violent caufe had, in thefe cafés, produced a déviation from the ordinary courfe of nature; that the terminations on the fixth day are nothing more than anticipations of the feventh, and therefore a proof of the power of this laft. CX. O F P H Y S I C. 45 CX. The doctrine of critical days has been much em- barraffed by fome diffonant aécounts of it, which appear in the writings imputed to Hippocrates. But this may be accounted for from thèfe writings being Jtruly the Works of différent perfons, and from the moft genuine of them having fuffered many corruptions ; fo that every thing, which is inconfiftent with the fadts above laid down, may be imputed to one or other of thefe caufes. CXI. This further has efpecially dift'urbed the doctrine of critical days, that Hippocrates himfelf attempted, perhaps too haftily, to eftablifh gênerai rules, and to bring the doctrine to a gênerai theory, drawn from Pythagorean opinions concerning the power of numbers. It is this which feems to hâve produced the doctrines of odd days, and of a quatemary and feptenary period, which appear fo often in the writings of Hippocrates. Thefe, how- ever, are inconfiftent with the fadts above laid down ; and, indeed, as Afclepiades and Celfus hâve obferved, are inconfiftent in themfelves. CXII. We think, therefore, the critical days above affigned are truly the critical days of Hippocrates, and may be confiftently'explained in the following manner. CXIII. From the univerfality of tertian or quartan periods in intermittent fevers, we cannot doubt of there being, in the animal œconomy, a tendency to obferve fuch periods ; and the critical days above mentioned are confiftent with this tendency of the œconomy, as ail of them mark either tertian or quartan periods. Thefe periods, however, are not promifcuoufly mixed, but occupy conftantly their feveral portions in the proçrefs of 46 PRACTICE of the difeafe; fo that, from the beginning to the eleventh day, a tertian period takes place ; and, from the eleventh to the twentieth, and perhaps longer, a quartan period is as fteadily obferved. CXIV. What détermines the periods to be changed about the eleventh day, we hâve not clearly perceived ; but the fadt is certain ; for there is no inftance of any termi- nation on the thirteenth, that is, the tertian period next following the eleventh ; but, upon the fourteenth, feventeenth, and twentieth, which mark quartan pe- riods, there are forty-three inftances of terminations, and fix only on ail the intermediate days between thefe. This prevalence of a quartan period Ieaves no rôom for doubting, that the twentieth, and not the twenty- firft, is the critical day marked by Hippocrates, though the laft is mentioned as fuch in the common édition of the Aphorifms, taken, from an erroneous manufcript, which Celfus alfo feems to hâve copied. cxv. A confiftency with the gênerai tendency of the fyftem renders the feries of critical days we hâve mentioned, probably the true one ; and the only difficulty that re- mains in finding what we hâve delivered tobe the famé with the genuine doctrine of Hippocrates is, the fré- quent mention of the fourth as a critical day. There are, indeed, more inftances of terminations happening on this day than on fome of thofe days we hâve afferted to be truly critical ; but its inconfiftency with the more gênerai tendency, and fome other confiderations, lead us to refufe its being naturally a critical day, and to think, that the inftances of terminations, which hâve really occurred on the fourth day, are to be reckoned among the other irregularities which happen in this matter. CXVI. O F P H Y S I C. 47 CXVI. We hâve thus endeavoured to fupport the doctrine of critical days, chiefly upon the particular fadts to be found in the writings of Hippocrates : We might alfo produce many other teftimonies of both antient and mo- dem times ; but we muft own that fome of thefe may be fufpedted to hâve arifen rather from a vénération of Hippocrates than from accurate obfervation. CXVII. With refpect to the opinions of many modems whd refufe the prevalence of critical days, we think they are to be little regarded ; for we know the obfervation of the courfe of continued fevers to be difficult and fal- lzcious; and therefore the regularityof that courfe may hâve often efcaped inattentive and prejudiced obfervers. CXVIII. Our own obfervations amount to this, that fevers with moderate fymptoms, generally eafes of the fynocha, frequently terminate in nine days or fooner, and very conftantly on one or other of the critical days which fall within that period ; but, it is very rare, in this climate, that cafés of either the. typhus or fynochus terminate before the eleventh day ; and, when they do terminate on this day, it is for the moft part fatally. When they are protradted beyond this time, I hâve very conftantly found that their terminations were upon the fourteenth, feventeenth, or twentieth day. In fuch cafés, the falutary terminations are feldom attended with any confiderable évacuation. A fweating frequently appears, but is feldom confiderable ; and I hâve hardly ever obferved critical and decifive termina- tions, attended with vomiting, évacuations by ftool, or remarkable changes in the urine. The folution of the difeafe is chiefly to be difeerned from fome return of fleep and appetite, the ceafing of delirium, and an abate- ment of the frequency of the pulfe. By thefe fymptoms we 48 PRACTICE we can often mark a crifis of the difeafe; but it feldom happens fuddenly and entirely, and it is moft commonly from fome favourable fymptoms on one critical day, that we can announce a more entire folution on the next following. Upon the whole, I am perfuaded, that, if obfer- vations fhall be made with attention, and without pré- judice, I fhall be allowed to conclude with the words of the learned and fagacious Gaubius, * Fallor, ni fuacon- ftiterit Hippocrati audtoritas, Galeno fides, Na- turje virtus et ordo.' C H A P. VI. Of the METHOD of C U R E in FEVERS. SECT. I. Ofthe CURE of CONTINUED FEVERS. CXIX. As it is allowed, that, in every fever which has its full courfe, there is an effort of nature of a falutary tendency, it might be fuppofed that we fhould leave the cure of fevers to the opérations of nature, or that our art fhould be only diredted to fupport and regulate thefe opérations, and that we fhould form. our indications accordingly. This plan, however, we cannot adopt, becaufe the opérations of nature are very precarious, and are not fo well 9 O F P H Y S I C. 49 well underftood as to enable us to regulate them pro- ■perly. We think, that trufting to thefe opérations has often given occafion to a négligent and inert pradtice ; and we believe that an' attention to the opérations of narure may be often fuperfeded by art. cxx. Our plan, therefore, fhall be, to confider the proxi- mate caufe of fever, and to form our indications of cure upon the means pf obviating the tendency to death in fevers. From what has been formerly laid down on the fubjedt of the prognoftic, we form three gênerai indications in the cure of continued fevers, and the one or other of thefe is to be employed as the circumftances of the fever (XCVII. XCVIII. orXCIX.) fhall direct. The firft is, to moderate the violence of re-action. The fécond is, to remove the caufes, or obviate the effects of debility. And, » The third is, to obviate or correct the tendency of the fluids to putréfaction. CXXL The firft indication may be anfwered, that is, the vio- lence of réfaction may be moderated, i. By ail thofe means which diminifh the action of the heart and arteries. 2. By thofe means which take off the fpafm of the extrême veffels, which we fuppofe to be the chief caufe of violent re-action. CXXII. The adtion of the heart and arteries may be di- minifhed, i. By avoiding or moderating thofe irritations which, in one degree or other, are almoft conftantly applied to the body. 2. By the ufe of certain fedative powers. G 3. By 50 PRACTICE 3. By diminifhing the tenfion and tone of the arterial fyftem. CXXIII. The irritations (CXXII. 1.) almoft conftantly ap- plied are, the impreffions made upon our fenfes; the exercife of the body and mind; and the taking in of aliments. The avoiding of thefe as much as pofTible, or the moderating of their force, makes what is pro- perly called the Antiphlogistic Regimen, proper to be employed in almoft every continued fever. CXXIV. I The condudt of this regimen is to be diredted by the following rules and confiderations. 1. Impreffions on the external fenfes, as ftimulant to the fyftem, and a chief fupport of its activity, fhould be avoided as much as poffible ; thofe, efpecially, of more confiant application, thofe of a ftronger kind, and thofe which give pain and uneafinefs. No impreffion is to be more carefully guarded againft than that of external heat ; and, at the famé time, every other means of increafing the heat of the body is to be fhunned. Both thefe précautions are to be obferved as foon as a hot ftage is fully formed, and to be attended to during its continuance, except in certain cafés, where a détermination to fweating is neceffary, or where the ftimulant effects of heat may be compenfated by cir- cumftances which détermine it to produce a relaxation and revulfion. 2. Ail motion of the body is tobe avoided, efpecially that which requires the exercife of its own mufcles ; and that pofture of the body is to be chofen which cmploys the.feweft mufcles, and which keeps none of them lono- in a ftate of contraction. Speaking, as it accélérâtes refpiration, is particularly to be avoided. It is to be obferved, that every motion of the body is more ftimulant, in proportion as the body is weaker. 3. The exercife of the mind alfo is a ftimulus to the body ; and therefore, ail impreffions which lead to thought, O F P H Y S I C. 5i thought, and thofe, efpecially, which may excite émotion or paffion, are to be carefully avoided. With refpect to avoiding impreffions of ail kinds, an exception is to be made in the café of a delirium coming on, when the prefenting of accuftomed objects may in- terrupt and divert the irregular train of ideas then arifing in the mind. 4. The prefence of récent aliment in the ftomach proves always a ftimulus to the fyftem, and ought, therefore, to be as moderate as poffible. A total ab- ftinence for fome time may be of fervice ; but, as this cannot be long continued with fafety, we muft avoid the ftimulus of aliment, by chufing that kind which gives the leaft. We fuppofe that alimentary matters are more ftimulant, according as they are more alkalefcent ; and, this leads to avoid ail animal, and to ufe only vegctable food. Our drinks alfo may prove ftimulant ; and therefore, aromatic and fpirituous liquors are to be avoided 4 and, in anfwering the prefent indication, ail fermented li- quors, except thofe of the loweft quality, are to be abftained from. Watery liquors, rendered more grateful by the addition of acids, we fhall hâve occafion hereafter to mention as a remedy. CXXV. Befides thofe ftimulant powers more conftantly ap- plied, there are others, which, though occafion al only, yet, as they commonly accompany fevers, muft be at- tended to and removed. One is, the fenfe of thirft, which, as a powerful ftimulus, in one way or other, ought always to be removed. Another ftimulus frequently arifes from crudities, or corrupted humours in the ftomach ; and it is to be re- moved by vomiting, dilution, or the ufe of acids. A third ftimulus often arifes from the preternaturaj rétention of fœces in the inteftines ; and ought to be removed by fréquent laxative clyfters. A fourth ftimulus to be conftantly fufpedted in fevers is, a gênerai acrimony of the fluids, as produced by the increafe 5* PRACTICE increafe of motion and heat, joined with an interruption of the excrétions. This acrimony is to be obviated or removed by the taking in of large quantifies of mild antifeptic liquors. CXXVL The avojding of irritation in ail thefe particulars, (CXXIII. and CXXIV.) conftitutes the antiphlogiftic regimen abfolutely neceffary for moderating the violence of re-action ; and, if we miftake not, is proper in every circumftance of continued fevers, as the employment of ftimulants is generally uncertain, and the meafure of the application of thofe above mentioned is not eafily afeertained. CXXVII. A fécond head of the means (CXXI. i.) of moderating the violence of re-action, comprehends certain fedative powers, which may be employed to diminifh the adtivity of the whole body, and particularly that of the fan-» guiferous fyftem, The firft of thefe to be mentioned is, the application of cold. Heat is the chief fupport of the adtivity of the animal fyftem ; and the fyftem is, therefore, pro- vided, in itfelf, with a power of generating heat. But, at the fanae time, we obferve, that this would go to excefs, were it not conftantly moderated by a cooler température in the furrounding atmofphere. When, therefore, the generating power of heat in the fyftem is increafed, a$ is commonly the café in fevers, it is ne- ceffary not only to avoid ail further means of increafing it, but it feems proper alfo to apply air of a cooler température ; or, at leaft, to apply it more entirely and freely than in a ftate of health. Some late experiments in the fmall-pox, and in continued fevers, fhew, that the free admiffion of cool air to the body is a powerful remedy in moderating the violence of re-adtion ; but what is the mode of its opération, to what circumftances -ç fever it is peculiarly adapted, or what limitations it requires, O F P H Y S I C. 53 requires, we fhall not venture to détermine, till we fhall be more particularly inftrudted by further expérience. CXXVIII. A fécond fedative power which may be employed in fevers, is that of certain medicines known in the writings on the Materia Medica, under the title of Réfrigé- rants. The chief of thefe are acids of ail kinds, when fufficiently diluted, and which are, in feveral refpedts, remédies adapted to continued fevers. Thofe efpecially in ufe are, the Vitriolic and Vegetable ; and, on many accounts, we prefer the latter. CXXIX. Another fet of réfrigérants are, the Neutral Salts, formed of the vitriolic, nitrous, or vegetable acids, with alkalines, either fixed or volatile. Ail thefe neu- trals, while they are diffolved in water, generate cold ; but, as that cold ceafes foon after the folution is finifhed, and as the faits are generally exhibited in a diffolved ftate, their réfrigérant power in the animal body does not at ail dépend upon their power of generating cold with water. The neutral chiefly employed as a ré- frigérant, is Nitre ; but ail the others, compounded as above mentioned, partake more or lefs of the famé quality. CXXX. Befides thefe neutrals, fome metallic faits alfo hâve been employed as réfrigérants in fevers ; and particularly the Sugar of Lead. We think the réfrigérant powers of this are not well afcertained ; and its deleterious qua- lifies are too well known to admit of its being freely ufed. CXXXL The third gênerai head (CXXII. 3.) of the means to be employed for moderating the violence of re-adtion, comprehends 54 PRACTICE comprehends the means of diminifhing the tenfion, tone, and adtivity of the fanguiferous fyftem. As the adtivity of this fyftem dépends, in a great meafure, upon the tone, and this again upon the tenfion of the veffels, given to them by the quantity of fluids they contain, it is évident that the diminution of the quan- tity of thefe muft diminifh the adtivity of the fangui- ferous fyftem. CXXXII. The quantity of fluids contained in the fanguiferous fyftem may be diminifhed moft conveniently by the éva- cuations of blood-letting and purging. CXXXIII. Nothing is more évident, than that blood-letting is one of the moft powerful means of diminifhing the ac- tivity of the whole body, and efpecially of the fangui- ferous fyftem ; and it muft therefore be the moft effectuai means of moderating the violence of re-adtion in fevers. Taking this as a fadt, we omit inquiring into its mode of opération, and fhall only confider in what circum- ftances of fevers it is moft properly to be employed. C XXXIV. When the violence of re-adtion, and its confiant at- tendant, a phlogiftic diathefis,- are fufficiently évident; when thefe conftitute the principal part of the difeafe, ' and may be expedted to continue through the whole of itas in the cafés of fynocha; then blood-letting is the principal remedy, and may be employed as far as the, fymptoms of the difeafe may feem to require, and the conftitution of the patient will bear. It is, however, to be attended to, that a greater évacuation than is ne- ceffary, may occafion a flower recovery, may render the perfon more liable to a relapfe, or may bring on other difeafes. cxxxv. O F P H Y S I C 55 CXXXV. In the café of fynocha, therefore, there is little doubt about the propriety of blood-letting ; but there are other cafés of fever, as the fynochus, in which a violent re- action and phlogiftic diathefis appear, and prevail during fome part of the courfe of the difeafe ; while, at the famé time, thefe circumftances do not conftitute the principal part of the difeafe, nor are to be expedted to continue during the whole courfe of it ; and we know, that, in many cafés, the ftate of violent re-adtion is to be fucceeded, fooner or later, by a ftate of debility, from the excefs of which the danger of the difeafe is chiefly to arife. It is, therefore, neceffary, that, in many cafés, blood-letting fhould be avoided ; and even although, during the inflammatory ftate of the difeafe, it may be proper, the évacuation fhould not be fo large as to increafe the ftate of debility which is to follow. CXXXVI. The employing, therefore, of blood-letting, in cer- tain fevers, requires much difcernment and fkill, and is to be governcd by the confideration of the following circumftances : i. The nature of the prevailing épidémie. 2. The nature of the remote caufe. 3. The feafon and climate in which the difeafe occurs. 4. The degree of phlogiftic diathefis prefent. 5. The period of the difeafe. 6. The âge, vigour, and plethoric ftate of the patient. 7. The patient's former difeafes and habits of blood- letting. 8. The appearance of the blood drawn out. 9. The effects of the blood-letting that may hâve been already practifed. CXXXVII. When, by the confideration of thefe circumftances, blood-letting is determined to be neceflary, we muft ob- ferve, 56 PRACTICE ferve, that it is more effectuai, as the blood is more fud- denly drawn off, and. as the body is, at the famé time, more free from ail irritation, and, therefore, when it is in a pofture in which the feweft mufcles are in adtion. CXXXVIIL Another évacuation by which the quantity of fluids contained in the body can be confiderably diminifbed, is that of purging. CXXXIX. ' If we confider the quantity of fluids conftantly pre- fent in the cavity of the inteftines, and the quantity which may be drawn from the innumerable excretories that open into this cavity, it will be obvious that a very great évacuation can be made by purging ; and, if this bedone by a ftimulus that is not at the famé time com- municated to the reft of the body, it may, by emptying both the cavity of the inteftines, and the arteries which furnifh the excrétions poured into it, induce a con- fiderable relaxation in the whole fyftem ; and is therefore fuited to moderate the violence of re-action in fevers. CXL. But it is to be obferved, that, as the fluid drawn from the excretories opening into the inteftines is not ail drawn immediately from the arteries, and as what is even more immediately drawn from thefe, is drawn off flowly ; fo the évacuation will not, in proportion to its quantity, occafion fuch a fudden depletion of the red veffels as blood-letting does ; and therefore, cannot operate fo powerfully in taking off the phlogiftic diathefis of the fyftem. CXLI. At the famé time, the évacuation may induce a con- fiderable degree of debility ; and, therefore, in thofe cafés O F P H Y S I C. 57 cafés in which a dangerous ftate of debility is likely to occur, purging is to be employed with a great deal of caution ; and this caution is more difficult to be obferved than in the café of blood-letting. CXLÏI. As we fhall obferve prefently, that it is of great importance in the cure of fevers, to reftore the déter- mination of the blood to the veffels on the furface of the body, fo purging, as in fome meafure taking off that détermination, feems to be an évacuation not well adapted to the cure of fevers. CXLIII. If, notwithftanding thefe doubts, (CXL. CXLI. and CXLÎI.) it fhall be afferted, that purging, from the exhibition of purgatives, has often been ufeful in fevers, I would maintain, that this has not happened trom a large évacuation ; and, therefore, not by mo- derating the violence of re-action, except in the café of a more purely inflammatory fever. In other cafés, we hâve feen a large évacuation by purging, of mifchievous confequence ; and if, upon occafion, a more moderate évacuation has appeared to be ufeful, we alledge that it has been, only by taking off the irritation of retained fœces, or by evacuating corrup.ted humours which hap- pened to be prefent in the inteftines : And, indeed, for both thefe purpofes, fréquent laxatives may be properly employed. In intermittent fevers, alfo, to relieve the congeftions formed in the abdominal vifeera, we judge purgatives to be often neceffary. CXLIV. Another fet of means, (CXXI. 2.) for moderating the violence of re-adtion in fevers, are thofe fuited to take off the fpafm of the extrême veffels, which we believe to be the irritation that chiefly fupports the re- adtion. H CXLV. 58 PRACTICE CXLV. For taking off this fpafm of the extrême veffels, the means to be employed are either internai or external. CXLVI. The internai means (CXLV.) are, i. Thofe which détermine the force of the circulation to the extrême veffels on the furface of the body, and, by reftoring the tone and adtivity of thefe veffels, over- come the fpafm on their extremities. 2. Thofe medicines which hâve the power of taking off fpafm in any part of the fyftem, and which are known under the title of Antispasmodics. CXLVII. Thofe remédies which are fit to détermine to the furface of the body, are, I. Diluents. 2. Neutral Salts. 3. Sudorifics. 4. Emetics. CXLVIII. • Water enters, in a large proportion, into the com- pofition of ail the animal fluids, and a large quantity of it is always diffufed through the whole of the common mafs. In a found ftate, the fluidity of the whole, mafs dépends upon the quantity of water prefent in it. Water, therefore, is the proper diluent of our mafs of blood, and other fluids are diluent only in proportion to the quantity of water they contain. CXLIX. Water may be faid to be the vehicle of the feveral excreted fluids; and, in a healthy ftate, the fulnefs of the extrême veffels, and the quantity of excrétion, are in O F P H Y S I C. 59 in proportion to the quantity of water prefent in the body. But in fever, though the excrétions are in fome meafure interrupted, they continue in fuch quantity as to exhale the more fluid parts of the blood ;. and, while a portion of them is, at the famé time, neceffarîly re- tained in the larger veffels, the fmaller and the extrême veffels, both from the deficiency of fluid, and their own contradted ftate, are lefs filled, and therefore allowed to remain in that condition. CL. To remedy this contradted ftate, nothing is more ne- ceffary than a large fupply of water, or watery fluids, taken in by drinking, or otherwife ; for, as any fuper- fluous quantity of water is forced off by the feveral ex- cretories, fuch a force applied may be a means of di- lating the extrême veffels, and of overcoming the fpafm affedting their extremities. CLL Accordingly, the throWing in of a large quantity of watery fluids has been, at ail times, a remedy much employed in fevers ; and, in no inftance more remark- ably, than by the Spanifh and Italian phyficians, in the ufe of what they call the Diaeta aquea. QUI. This. pradtice confifts in taking away every other kind of aliment and drink, and in giving in divjded portions every day, for feveral days together, fix or eight pounds of plain water, generally cold, but fometimes warm. Ail this, however, is to be done only after the difeafe has continued for fome time, and, at leaft, for a week. CLIII. A fécond means of determining to the furface of the body, is by the ufe of neutral faits. (CXLVII. 2.) Thefe neutrals, in a certain dofe, taken into the ftomach, produce, 6o PRACTICE produce, foon after, a fenfe of heat upon the furface of -the body; and, if the body be covered clofe, and kept warm, a fweat is readily brought out. The famé me- dicines taken during the cold ftage of a fever, very often put an end to the cold ftage, and biing on a hot one; and they are alfo remarkable for ftopping the vomiting which fo frequently attends the cold ftage of fevers. AU this fhews, that neutral faits hâve a power of determin- ing the blood to the furface of the body, and may, there- fore, be of ufe in taking off the fpafm which fubfifts there in fevers. CLIV. The neutral moft commonly employed in fevers, is that formed of an alkali, with the native acid of ve- getables ; but ail the other neutrals hâve more or lefs of the famé virtue ; and perhaps fome of them, particularly the ammoniacal faits, poffefs it in a ftronger degree. , CLV. As cold water taken' into the ftomach, often fhews the famé diaphoretic effects with the neutral faits, it is piobablethat the effedtof the latter dépends upon their réfrigérant powers mentioned above. (CXXIX.) What is the effedt of the neutral faits, given when they are forming, and in a ftate of effervefcence ? CLVI. A third means of determining to the furface of the body, and taking off the fpafm fubfifting there, i.s by the ufe of fudorifics, and of fweating. (CXLV1I 3.) CLVIL The propriety of this remedy has been much dif- puted ; and fpecious arguments may be adduced both for and againft the pradtice. In favour of the pradtice, it may be faid, 1. That O F P H Y S I C. 61 I. That, in healthy perfons, in every café of in- creafed adtion of the heart and artenes, a fweating takes place, and is, feemingly, the means of preventing the bad effects of fuch increafed action. 2. That, in fevers, their moft ufual folution and termination is by fpontaneous fweating. 3. That, even when excited by art, it has been found ufeful, at certain periods, and in certain fpecies of fever. CLVIII. Upon the other hand, it may be urged againft the pradtice of fweating, 1. That in fevers, as a fpontaneous fweating does not immediately come on, there are fome circumftances différent from thofe in the ftate of health, and which may render it doubtful whether the fweating can be fafely excited by art. 2. That, in many cafés, the pradtice has been at- tended with bad confequences. The means com- monly employed hâve a tendency to produce an'inflam- matory diathefis ; which, if not taken off by the fweat fucceeding, muft be increafed with much danger. Thus fweating, employed to prevent the acceffions of inter- mitting fevers, has often changed them into a continued form, which is always dangerous. 3. The utility of the pradtice is doubtful, as fweating, when it happens, does not always give a final déter- mination, as muftbe manifeft in the café of intermittents, and in many continued fevers, whichyrare fometimes, in the beginning, attended with fweatings which do not prove final; and, on the contrary, whether they be fpontaneous or excited by art^ feem often to aggravate the difeafe. CLIX. From thefe confiderations, it is very doubtful, if the pradtice of fweating can be admitted very generally ; but, at the famé time, it is alfo doubtful, if the failure of the pradtice, or the mifchiefs faid to hâve arifen from it, hâve not been owing to the improper condudt of the pradtitioner. 62 PRACTICE pradtitioner. With refped to the laft, it is almoft agreed among phyficians, I. That fweating has been generally hurtful, when excited by ftimulant, heating, and inflammatory me- dicines. 2. That it has been hurtful, when excited by much external heat, and continued with a great increafe of the heat of the body. 3. That it is always hurtful, when it does not re- lieve, and rather increafes the frequency and hardnefs of the pulfe, the anxiety and difficulty of breathing, the headach, and delirium. 4. That it is always hurtful, if it is urged, when the fweat is not fluid, and when it is partial, and on the fuperior parts of the body only. CLX. In thefe cafés, it is probable, that either an inflam- matory diathefis is produced, which increafes the fpafm on the extrême veffels, or that, from other caufes, the fpafm is too much fixed to yield eafily to the increafed adtion of the heart and arteries ; and, upon either fup- pofition, it muft be obvious, that urging the fweat may produce déterminations to fome of the internai parts, with very great danger. CLXI. Though the dofcbts ftarted (CLVIII.) are to be at- tended to ; and though the pradtices (CLIX.) hâve been found hurtful, and are therefore to be rejedted, it ftill remains true, 1. That fweating has certainly been often ufeful iii preventing the acceffion of fevers, when the times of it hâve been certainly forefeen, and a proper condudt em- ployed. 2. That, even after fevers hâve in fome meafure come on, fweating has interrupted their progrefs, when pro- perly employed, either at the very beginning of the difeafe, or during its approach and graduai formation. 3. That, O F P H Y S I C. 63 3. That, even after pyrexiae hâve continued for fome time, fweating has been fuccefsfully employed in curing them, as particularly in the café of rheumatifm. 4. That certain fevers, produced by a very powerful fedative contagion, hâve been generally treated moft fuc- cefsfully by fweating. CLXII. Thefe inftances (CLXI.) are in favour of fweating, but give no gênerai rule ; and it muft be left to further expérience to détermine, how far any gênerai rule can be eftabliihed in this-matter. In the mean time, if the pradtice of fweating is to be attempted, we can venture to lay down the following rules for the condudt of it, 1. That it fhould be excited without the ufe of ftimulant, inflammatory medicines. 2. That it fhould be excited with as little external heat, and with as little increafe of the heat of the body as poffible. 3. That, when excited, it fhould be continued for a due length of time, not lefs than twelve hours, and fometimes for twenty-four or forty-eight hours ; always, however, fuppofing that it proceeds without the circumftances (CLIX. 3. 4.) 4. That, for fome part of the time, and as long as the perfon can eafily bear, it fhould be carried on without admitting of fleep. 5. That it fhould be rendered univerfal over the whole body ; and, therefore, particularly, that care be taken to bring the fweating to the lower extremities. 6. That the pradtice fhould be rendered fafer by mo- derate purging, excited at the famé time. 7. That it fhould not be fuddenly checked by cold any how applied to the body. CLXIII. When attention is to be given to thefe rules, the fweating may be excited, 1. By warmbathing, or a fo- mentation of the lower extremities. 2. By fréquent draughts of tepid liquors, chiefly water, rendered mort grateful 64 PRACTICE grateful by the addition of a light aromatic, or more powerful, by that of a fmall quantity of wine. 3. By giving fome dofes of neutral faits. 4. - Moft effedtually, and perhaps moft fafely, by a large dofe of an opiate, joined with a portion of neutral faits, and of an emetic. CLXIV. The fourth means of determining tothe furface of the body, and thereby taking off the fpafm affedting the extrême veffels. (CXLV1I. 4.) is by the ufe of emetics. CLXV. Emetics, and particularly antimonial emetics, hâve been employed in the cure of fevers, ever fince the in- troduction of chemical medicines; but, for a long time, they were employed by chemiftsand chemical prac- titioners only ; and, although of late their ufe has be- come very gênerai, their efficacy is ftill difputed, and their manner of operating is not commonly explained. CLXVI. Vomiting is, in many refpedts, ufeful in fevers ; as it évacuâtes the contents of the ftomach ; as it emulges the biliary and pancreatic dudts, and évacuâtes the con- tents of the duodénum, and perhaps alfo of a larger portion of the inteftines ; as it agitâtes the whoje of the abdominal vifeera, it expedes the circulation in them, and promûtes their feveral fecretions ; and, laftly, as it agitâtes alfo the vifeera of the thorax, it has like effedts there. Ail thefe feveral effedts are procured with ad- vantage, in many cafés and circumftances of fever, but do not properly fall under our view hère, where we are to confider only the effedt of vomiting in determining to the furface of the body. CLXVII. This effedt we do not impute to the exercife of vomiting in agitating the whole body, but to the par- ticular O F P H Y S I C. 65 ticular opération of emetics upon the mufcular fibres of the ftomach, whereby they excite the action of the ex- trême arteries on the furface of the body, and thereby effectually détermine the blood to thefe veffels, remove the atony, and take off the fpafm affecting them. CLXVIII. ' That fuch is the power of emetics, will appear from the feveral confiderations mentioned above (XLIII.) ; and, therefore, that they are remédies well fuited to the cure of fevers. CLXIX. Emetics, for that purpofe, are adminiftered in two différent ways; that is, either in fuch dofes as may ex- cite full and repeated .vomitings, or in fuch dofes as may excite ficknefs and naufea only, with little or no vomiting at ail. CLXX. Full vomiting is beft fuited to the feveral purpofes mentioned (CLXVI.) ; and is alfo well fuited to déter- mine to the furface of the body, and thereby to obviate the atony and fpafm which lay the foundation of fever. Thus, vomiting excited a little before the expedted ac- ceffion of the paroxyfm of an intermittent, has been found to prevent the paroxyfm altogether. It has been obferved alfo, that, when contagion has been applied to a perfon, and firft difcovers its opération, a vomit given will prevent the fever, which otherwife was to hâve been expedted. CLXXI. Thefe are advantages to be obtained by exciting vomiting at the firft approach of fevers, or of the par- oxyfms of fevers ; and they may alfo be applied after fevers are formed, to take off, perhaps entirely, the atony and fpafm, or, at leaft, to moderate thefe, fo that the fever may proceed more gently and fafely. I CLXXII. 66 PRACTICE CLXXII. It is feldom, however, that vomiting is found to pro- duce a final folution of fevers ; and, after they are once formed, it is commonly neceffary to repeat the Vomiting feveral times ; but this is attended with inconveniency, and fometimes with difadvantage. The opération of fuil vomiting is tranfitory, and the exercife of vomiting îs a debilitating power; and, therefore, when the vomit- ing does not remove the atony and fpafm very entirely, it may give occafion to their récurrence with greater force. CLXXIII. For thefe reafons, after fevers are full y formed, phy- ficians hâve thought proper to employ emetics in nàu- feating dofes only. Thefe arc capable of exciting the action of the extrême veffels, and their opération is more permanent. At the famé time, they often fhew their power by exciting fome degree of fweat, and their ope- ration is rendered more fafe, by their commonly producing fome évacuation by ftool. CLXXIV. Thefe are the advantages to be procured by naufeating dofes of emetics ; and it only remains "to mention, what are the medicines moft fit to be employed ; what are the moft proper times for exhibiting, and what the beft manner of adminiftering them. CLXXV. The emetics chiefly in ufe at prefent, are, Ipecacuanha and Antimony. The firft may be employed for every purpofe of emetics, particularly thofe mentioned (CLXVI.) ; and alfo, either in larger or fmaller dofes, for determining to the furface of the body j but, even in very fmall dofes, it fo readily excites vomiting, as to be, with difficulty, employed for the purpofe of nau- feating only ; and, however employed, there is reafon to O F P H Y S I C. 67 to fufpect, that its effects are lefs permanent, and lefs powerfully communicated from the ftomach to the reft of the fyftem, than thofe of Antimony. CLXXVI. This laft, therefore, is generally preferred ; and its préparations, feemingly various, may ail be referred to two heads ; one comprehending thofe in which the re- guline part is in a condition to be acted upon by acids ; and, therefore, on meeting with acids in the ftomach, becomes active ; and another, comprehending thofe préparations in which the reguline part is already joined with an acid, rehdering it adtive. CLXXVII. Of each kind there are great numbers, but not dif- fering effentially from one another. It will be enough for us to compare the Calx Antimonii Nitrata of the Edinburgh Difpenfatory, with the Emetic Tartar of the famé. Which of thefe is beft fuited to the cure of fevers, as above explained, feems .doubtful ; but it ap- pears to me, that, though the firft may hâve fome ad- vantages from its flower opération, and may thereby feem to be more certainly fudorific and purgative, the un- certainty of its dofe renders it inconvénient, and has often given occafion to thetimid tobe difappointed, and to the bold to do mifchief. While, on the other hand, the dofe of the Emetic Tartar can be exadtly afcer- tained ; and we think it may be exhibjted in fuch a manner, as to produce ail the advantages of the other. CLXXVIII. Whichfoever of thefe préparations be employed, we think tije moft proper time for exhibiting them, is the time of acceffions, or a little before it, when that can be certainly known. In continued fevers, the exacer- bations are not always very obfervable ; but there is reafon to believe, that one commonly happens about noon, or foon after it, and another in the evening ; and 68 PRACTICE that thefe, therefore, are the moft proper times for ex- hibiting emetics. CLXXIX. With refpect to the manner of adminiftration, that of the Calx Nitrata is fimple, as the whole of what is thought a proper dofe is given at once, and no more can be properly given till the next acceffion. The- admi- niftration of the Emetic Tartar is différent. It is to be given in final 1 dofes, not fufficient to excite vomiting; and thefe dofes are to be repeated, after fhort intervais, for feveral times, till ficknefs, naufea, and fome, but not much, vomiting, come on. The différence of adr miniftration muft dépend upon the dofe, and the length of the interval at which it is given. If it be intended that the medicine fhould certainly operate by ftool, the dofes are made fmall, and the intervais long. On the contrary, when vomiting is proper, or when much purging ought to be avoided, and, therefore, fome vo- miting muft be admitted, the dofes are made larger, the intervais fhorter. CLXXX. With refpedt to both kinds of préparations, the ré- pétition is to be made at the times of acceffion, but not very often ; for, if the firft exhibitions, duly managed, hâve little effedt, it is feldom that the after exhibitions hâve much ; and it fometimes happens, that the repeated vomiting, and efpecially repeated purging, does harm, by weakening the patient. CLXXXI. The other fet of internai medicines, which we fup- pofe may be ufeful in taking off the fpafm of the extrême veffels, are thofe named Antifpafmodic. How many of thefe may be properly employed, I am uncertain, and their mode of opération is involved in great obfcurity. It is certain, however, that opium, camphor, mufk, and perhaps fome others, hâve been employed in feVers with O F P H Y S I C. 69 with advantage ; but, the circumftances in which they are efpecially proper and fafe, I find it difficult to af- certain ; and, therefore, cannot venture hère to lay down any gênerai doctrine concerning them. CLXXXII. The external means (CXLV.) fuited to take off the fpafm of the extrême veffels, are Blistering and Warm Bathing. CLXXXIII. What are the effedts of bliftering, fo frequently em- ployed in fevers, is not yet agreed upon among phy- ficians ; and many différent opinions hâve been main- tained on this fubjedt, drawn not only from reafoning, but alfo from pretended expérience. We muft not, however, enter into controverfy ; but fhall deliver our own opinion in a few words. CLXXXIV. I think, that the fmall quantity of cantharides ab- forbed from a bliftering plafter, is not fufficient to change the confiftence of the mafs of blood ; and, therefore, that fuch a quantity can neither do good, by refolving phlogiftic lentor, if it exifts, nordo.harm, by increafing thediflôlution of the blood arifing from a putrid tendency in it. We therefore neglect, entirely, the effedts of cantharides upon the fluids. CLXXXV. The inflammation produced by the application of can- tharides to the fkin, affords a certain proof of their ftimulant power ; but, in many perfons, the effedt of that ftimulus is not confiderable \ in many it is not communicated to the whole fyftem ; and, even when it does take place in the whole fyftem, it feems to be taken off, very entirely, by the effufion and évacuation of ferum from the bliftered part. I think, therefore, that neither 79 PRACTICE neither much good is to bc expedted, nor much harm to be appréhendée!, from the ftimulant power of bliftering j and the certainty of this conclufion is eftablifhed, by the great benefit arifing from the proper pradtice of bliftering in inflammatory difeafes. CLXXXVI. Much has been imputed to the évacuation made by bliftering; but it is never fo confiderable as to affect the whole fyftem; and therefore can, neither by a fudden dcpletion, relax the fanguiferous fyftem, nor, by any revulfion, affect the gênerai diftribution of the fluids. CLXXXVIL The évacuation, however, is fo confiderable as to affect the neighbouring veffels; and the manifeft utility of bliftering near the part affedted, in inflammatory dif- eafes, leads us to think, that bliftering, by deriving to the fkin, and producing an effufion there, relaxes the fpafm of the deeper.feated veffels. It is in this manner we fuppofe that the tumour of a joint, from an effufion into the cellular texture under the fkin, takes off the rheumatic pain formerly affedting that joint. CLXXXVIIL Analogous to this, we think the good effedt of bli- ftering in continued fevers, arifes from its relaxing the fpafm of the extrême veffels, by a communication of the bliftered part with the reft of the fkin ; and this is illuftrated by the effedt of bliftering in colic and dyf- entery. CLXXXIX. We think, that bliftering may be employed at any period of continued fevers ; but that it will be of moft advantage in the advanced ftate of- fuch fevers, when, the re-adtion being weaker, ail ambiguity from the fti- mulant power of bliftering is removed, and when it may O F P H Y S I C. 7* may beft concur with other circumftances tendincr to a final folution of the fpafm. cxc. From the view of this matter, given in (CLXXXVI. CLXXXVII.) it will appear, that the part of the body to which blifters ought to be applied, is indiffèrent, ex- cept upon the fufpicion of topical affection, when the bliftering is to be made as near as poffible to the part af- fedted. CXCI. Whether Sinapisms, and other Rubefacientia, adt in a manner analogous to what we hâve fuppofed of bliftering, may be doubtful ; but their effects in rheu- matifm and other inflammatory difeafes, render it pro- bable. CXCII. The other external means of taking off the fpafm of the extrême veffels, is Warm Bathing. 1 tiis was fre- quently, and in différent circumftances, employed by the antients ; but has, till very lately, been neglected by modem phyficians. As the heat of the bath ftimu- lates the extrême veffels, and, with the concurrence of moifture, alfo relàxesthem, it feems to be a fafe ftimu- lus, and well fuited to take off the fpafm affedting thefe veffels. CXCIII. It maybe applied to the whole body, by immerfion ; but this is, in many refpedts, inconvénient ; and, whe- ther fome of the inconveniences of immerfion might not be avoided by a vapour-bath, we hâve not iearned from expérience ; but we know, from much expérience, that moft of thepurpofes of warm bathing can be obtained, by a fomentation of the legs and feet, if properly ad- miniftered, 72 PRACTICE miniftered, and continued for a due length of time, not lefs than an hour. CXCIV. The marks of the good effects of fuch a fomentation, are, the patient's bearing it eafily, its relieving delirium, and inducing fleep. excv! We hâve now confidered the feveral means of fatis- fying the firft gênerai indication in the cure of fevers, and proceed to the fécond, (CXX. 2.) which is to remove the caufe, or obviate the effects of debility. CXCVI. Moft of the fedative powers inducing debility, ceafe to adt foon after they hâve been firft applied ; and, there- fore, the removing them is not an objedt of our prefent indication. There is only one which may be fuppofed to continue to adt for a long time, and that is, the con- tagion applied ; but we know nothing in the nature of contagion that can lead us to any meafures for removing or corredting it. We know only its effects as a fedative , power inducing debility, or as a ferment inducing a tendency to a putréfaction in the fluids. The obviating the laft will be confidered under our third gênerai in- dication, and the firft only is to be confidered hère. CXCVII. The debility induced in fevers by contagion, or other caufes, appears, efpecially, in the weaker energy of the brain ; but in what this confifts, or how it may be diredtly reftored, we do not well know ; but as Nature, feemingly for this purpofe, excites the action of the heart and arteries, we afcribe the continuance of debility to the weaker re-action of the fanguiferous fyftem ; and the means, therefore, which we employ for obviating debility, are immediately diredted to fupport and increafe the O F P H Y S I C. 73 the action of the heart and arteries ; and the remédies employed are, Tonics or Stimulants. CXCVIIL In contagious difeafes, we know, both from the effedts which appear, and from diffections, that the tone of the heart and arteries is confiderably diminifhed ; and that tonic remédies, therefore, are properly indicated. We are to confider them as of two kinds ; the firft being the power of cold ; the fecond that of tonic medicines. CXCIX. The power of cold, as a tonic, we hâve mentioned above (LXXXIX.) ; and it is employed, in fevers, in two ways ; either as thrown into the ftomach, or as applied to the furface of the body. ce. As we hâve faid above, that the tonic power of cold can be communicated from any one part to every other part of the fyftem, fo it will be readily allowed, that the ftomach is a part as fit for this communication as any other ; and that cold drink, therefore, taken into the ftomach, may prove an ufeful tonic in fevers. CCI. This, the expérience of ail âges has confirmed ; but, at the famé time, it has been frequently obferved, that, in certain circumftances, cold drink, taken into the ftomach, has proved very-hurtful ; and, therefore, that the ufe of cold drink in fevers requires fome limitations. What thefe limitations fhould be, and what are ail the circumftances which may forbid the ufe of cold drink, is difficult.to détermine ; but it feems clearly forbidden, in ail cafés where a phlogiftic diathefis prevails in the fyftem, and more efpecially when there are topical af- fections of an inflammatory nature. K CIL 74 PRACTICE CCII. The other method of employing cold as a tonic, is, by applying it to the furface of the body. The ap- plication of cold air to the furface of the body, as a réfrigérant power fit to moderate the violence of ré- action, wé hâve fpoken of above (CXXVII.) ; but probably it may hère be confidered alfo properly as a to- nic, and ufeful in eafes of debility. CCIII. Not only cool air, but cold water alfo, may be ap- plied to the*furface of the body, as a tonic. The an- tients frequently applied it with advantage, to particular parts, as a tonic ; but it is a difeovery of modem times, that, in the café of putrid fevers, attended with much debility, the body may be wafhed ail over with coïd water. CCIV. This was firft practifed at Breflaw in Silefia, as appears from a differtation, under the title of Epidcmia verna quae Wratiflaviam, anno 1737> afflixit, to be found in the appendix to the Atla nat. curiof. vol. X. And from other writers it appears, that the pradtice has paffed into fome of the neighbouring countries ; but in this ifland, fo far as I know, we hâve as yet had no ex- périence of it. ccv. The medicines which hâve been employed in fevers as tonics, are various. If the Saccharum Saturni has been found ufeful, it is, probably, as a tonic, rather than as a réfrigérant ; and the Ens Veneris, or other préparations of iron which hâve been employed, can adt as tonics only. The préparations of copper, from their effects in epilepfy, are" prefumed to poffefs a tonic power ; but, whether their ufe in fevers be founded upon their tonic or their emetic powers, may be uncertain. The OF PHYSIC. 75 The ufe of arfenic and of allum, in intermittent fevers, feems manifeftly to dépend upon their tonic power. And, upon the whole, there, no doubt, may occur eafes of continued fevers, which may be cured by tonics taken from the foffil kingdom ; but the ufe of thefe has been rare, and the effects uncertain, and phyficians hâve employed, more commonly, the vegetable tonics. CCVI. A great variety of thefe has been employed in the cure of intermittent fevers ; but how many of them may be employed in continued fevers, or in what circumftances of thefe fevers, is not well afcertained ; and we fhall now only confider the queftion with' refpect to the moft celebrated of thefe tonics, the Peruvian bark. CCVII. This bark has been commonly confidered as a fpecific, or as a remedy of which the opération was not un- derftood. But it is certainly allowable to inquire into this matter; and we think it may be explained. ÇCVIIL To this purpofe we obferve, that, as in many cafés, the effedts of the bark are perceived foon after its being taken into the ftomach, and before it can poffiblybe con- veyed to the mafs of blood, we may conclude, that its effects do not arife from its operating on the fluids; and muft, therefore, dépend upon its operating on the nerves of the ftomach, and being thereby communicated to the reft of the nervous fyftem. This opération feems to be a tonic power, the bark being a remedy in many eafes of debility, particularly in gangrené ; and, as the ré- currence of the paroxyfms of intermittent fevers dé- pends upon a récurrence of atony, (XXXIV. etfeq.) ; fo probably the bark, by its tonic power, prevents the récurrence of thefe paroxyfms; and this is greatly con- firmed by our obferving, that many other tonic medicines &nfwer the famé purpofe. CCIX. 76 PRACTICE CCIX. If the opération of the bark may bc thus explained, from its poffeffmga tonic power, we can eafily perceive why it is improper when a phlogiftic diathefis prevails j and, from the famé view, we can afcertain in what cafés of continued fever it may be admitted. Thefe eafes, are either after confiderable remiflions hâve appeared, when it may beemployed to prevent the return of exa- cerbations, on the famé footing as it is ufed in inter- mittent fevers; or in the advanced ftate of fevers, when ail fufpicion of an inflammatory ftate is l'emoved, and a gênerai debility prevails in the fyftem; and its being then employed is fufficiently agreeable to the prefent pradtice. ccx. With refpect to the ufe of the bark, we think proper to add, that good effedts are to be expedted from it, al- moft only when given in fubftance, and in large quantity. CCXI. Another fet of medicines to be employed for obvi- ating debility and its effedts, are the direct ftimulants (CXCVIL). Thefe, in fome meafure, increafe the tone of the moving fibres ; but are différent from the tonics, as they more diredtly excite and increafe the adtion of the heart and arteries. This mode of their opération renders their ufe ambiguous ; and when an in- flammatory diathefis is prefent, as fo often happens in the beginning of fevers, the effects of thefe ftimulants may be very hurtful ; but it ftill remains probable, that, in the advanced ftate of fevers, when debility prevails, they may be ufeful, CCXII. What are the ftimulants which may be moft properly employed, we are uncertain, as the ufe of them, in this âge, O F P H Y S I C. 77 âge, has been rare ; but we are difpofed to think that, of ail kinds, wine is the beft. CCXIIL Wine has the advantage of being grateful to the palate and -ftomach, and of having its ftimulant parts fo much diluted, that it canbe conveniently given in fmall dofes ; and therefore it may be employed with fufficient caution ; but it is of little fervice, unlefs taken pretty largely. CCXIV. It may be fufpedted, that wine has an opération analogous to that of opium ; and on good grounds. But we can diftindtly mark its ftimulant power only, which renders its effedts in the phrenitic delirium ma- nifeftly hurtful, and, in the mild delirium, depending on debility, as remarkably ufeful. CCXV. Thefe are the means of anfweringour fécond gênerai indication (CXX. 2.) ; and we now proceed to the third, which is to obviate or to correct the terldency of the fluids to putréfaction. CCXVI. This may be done, 1. By avoiding any new application of putrid or pu- trefcent matter. 2. By evacuating the putrid or putrefcent matter al- ready prefent in the body. 3. By corredting the putrid or putrefcent matter re- maining in the body, by diluents and anîifeptics* 4. By fupporting the tone of the veflèls, and thereby refifting further putréfaction, or obviating its effects. 5. By moderating the violence of re-action, confi- dered as a means of increafing putréfaction. CCXVII. 78 PRACTICE CCXVII. The further application of putrid or putrefcent mat- ter may be avoided, i. By removing the patient from places filled with corrupted air. 2. By preventing the accumulation of the patient's own effluvia, by a confiant ventilation, and by a fré- quent change of bed-cloaths and body-linen. 3. By the careful and fpeedy removal of ail excre- mental matters from the patient's chamber. 4. By avoiding animal food. CCXVIII. The putrid or putrefcent matter, already prefent in the body, may be evacuated partly, by frequently eva- cuating the contents of the inteftines, and moreeffectu- ally, ftill, by fupporting the excrétions of perfpiration and urine, by the plentiful ufe of diluents. CCXIX. The putrid or putrefcent matter, rémaining in the body, may bq rendered more mild and innocent, by the ufe of diluents ; or may be corredted by the ufe of antifeptics. Thefe laft are of many anJ various kinds ; but, which of them are conveniently applicable, or more particularly fuited to the cafe of fevers, is not well afcertained. Thofe moft certainly applicable and ufeful, are, acefcent aliments, acids of ail kinds, and neutral faits. CCXX. The progrefs of putréfaction may be confiderably retarded, and its effects obviated, by fupporting the tone of the veffels ; and this may be done by tonic remédies ; the chief of which are, Cold, and Peruvian bark, both fufficiently treated of above. (CXCIX.—CCX.) CCXXL O F P H Y S I C. 79 CCXXI. The violence of re-adtion increafing the tendency to putréfaction, may be moderated by the feveral means full/ treated of above. (CXXL—CXCIV.) CCXXII. , We hâve now finifhed the confideration of the three gênerai indications to be formed in the cure of continued fevers, and hâve mentioned moft of the remédies which hâve been, upon any occafion, employed. It was ne- ceffary, in the firft place, to confider thefe remédies fepa- rately, and to explain their opération more generally ; but, from what we hâve now delivered, compared with what has been faid above, concerning the différence of fe- vers, and the fignification of their feveral fymptoms in forming the prognoftic, I expedt it will not be difficult to feledt and combine the feveral remédies mentioned, fo as to adapt them to the feveral Tpecies and circumftances of continued fevers. We think it may be ufeful for Students to hâve the wholeof the Cure of Continued. Fevers brought under one View, as in the following Table. In^the CURE of CONTINUED FE- VERS, THE INDICATIONS ARE, I. To moderate the violence of re-adtion, which may be done, by i, Diminifhing the action of the heart and arteries, by A. Avoiding or moderating thofe irritations which are almoft conftantly applied to the body, as, a. The impreffions made upon our fenfes, particularly, a. Increafed heat, whether arifing from aa. External heat, or, bb. The accumulation of the heat of the body. b.- The exercife of the body, c. The exercife of the mind, d. The taking in of aliments, e. Particular irritations, arifing from et. The fenfe of thirft, b. Ciudities 8o PRACTICE b. Crudities, or corrupted humours in-the ftomach, c. The preternatural rétention of fœces, d, A gênerai acrimony of the fluids. B. Employing certain fedative powers, as a. Cold, b. Réfrigérants, the chief of which are, a. Acids of ail kinds, b. Neutral faits, c. Metallic faits. C. Diminifhing the tenfion and tone of the arterial fyftem, by a. blood-letting, b. Purging. 2. Taking olf the fpafm of the extrême veffels, by A. Internai means, which are a. Thofe remédies which détermine to the furface, as, a. Diluents, b. Neutral faits, c. Sudorifics, d. Emetics. b. Thofe remédies rtamed Antifpafmodics. B. Extjernal means, as a. Bliftering, b. Warm bathing. II. To remove the caufes, or obviate the effects of debi- lity, by i. Suppofting and increafing the action of the heart and arteries, by A. Tonics, as a. Cold. b. Tonic medicines, which are either a. Foffil, as aa. Saccharum faturni, &c. or, b. Vegetable, as, aa. Peruvian bark. B. Stimulants, as, a. Aromatics, &c. b. Wine. III. To obviate or correct the tendency of the fluids to pu- tréfaction, by i. Avoiding the application of putrid or putrefcent mat- ter, by A. Removing the patient from places filled with cor- rupted air, B, Avoiding O F P H Y S I C. 81 B. Avoiding the accumulation of the patient's own ef- fluvia, by a. A confiant ventilation, b. Frequently changing the bed-cloaths and body- linen. C. Removing carefully and fpeedily ail excremental matters, D. Avoiding animal food. 2. Evacuating the putrid or putrefcent matter already pre- fent in the body, by A. Evacuating frequently the inteftines, B. Supporting the excrétions of perfpiration and urine, by a. Diluents, b. Neutral faits. 3. Correcting the putrid or putrefcent matter remaining in the body, by A. Diluents, B. Antifeptics. 4. Refifting farther putréfaction, or obviating its effects, by Supporting the tone of the veflels, by Tonic remédies. 5. Moderating the violence of re-action, confidered as a means of increafing putréfaction, as in I. A. B. C, SECT. IL Of the CURE of INTERMITTENT FEVERS. CCXXIIL It ftill remains to confider the cure of intermittent fevers ; and, with refpect to thefe, , we form alfo three gênerai indications. 1. In the time of intermiffion, to prevent the récur- rence of paroxyfms. L 2. In 82 PRACTICE 2. In the time of paroxyfms, to condudt thefe fo as to obtain a final folution of the difeafe. 3. To take off" certain circumftances which might prevent the fulfilling of the two firft indications. CCXXIV. The firft indication may be anfwered in two ways ; 1. By increafing the action of the heart and arteries fome time before the period of accefiion, and fupporting that increafed action till the period of the acceffion be over, and thus to prevent the récurrence of the atony and fpafm of the extrême veflels which give occafion to the récurrence of paroxyfms. 2. By fupporting the toneof the veffels, and thereby preventing atony, and the confequent fpafm, without increafing the adtion of the heart and arteries, the ré- currence of paroxyfms may be prevented. ccxxv. For the purpofe mentioned in (CCXXIV. 1.) the action of the heart and arteries may be increafed ; 1. By various ftimulant remédies, internally given, or externally applied, and that, without exciting fweat. 2. By the famé remédies, or others fo managed as to excite fweating, and to fupport that fweating till the period of acceffion be for fome time paft. 3. By emetics, fupporting, for the famé time, the tone and adtion of the extrême veffels. CCXXVI. The tone of the extrême vefTels may be fupported without increafing the action of the heart and arteries, (CCXIV. 2.) by various tonic medicines, as, 1. Aftringents alone, 2. Bitters alone, 3. Aftringents and bitters conjoined, 4. Aftringents and aromatics conjoined, 5. Certain metallic tonics i and, Laftlv, Opiates. A good O F P H Y S I C. 83 A good deal of exercife, and as full a diet as the con- dition of the patient's appetite and digeftipn may allow of, will be proper during the time of intermiflion, and may be confidered as belonging to this head. CCXXVII. Of ail the tonic remédies mentioned, (CCXXVI.) the moft célébrated, and perhaps the moft certainly ef- fectuai, is the Peruvian bark, the tonic power of which we hâve endeavoured to demonftrate above, (CCVIII.) and hâve, at the famé time, explained its ufe in conti- nued fevers. In intermittents, the famé obfervation, as made in (CCX.) is more efpecially proper ; and thefe further obfervations or rules may be offered hère : 1. That the bark may be employed with fafety at any period of intermittent fevers, providing that, at the famé time, there be neither a phlogiftic diathefis pre- vailing in the fyftem, nor any confiderable or fixed con- geftion prefent in the abdominal vifeera. 2. The proper time for exhibjting the bark in inter- mittent fevers, is, during the time of intermiflion ; and it is to be abftained from in the time of paroxyfms. 3. In rémittents, though no intire apyrexia occurs, the bark may be given during the remiflions ; and it fhould be given, even though the remiflions be incon- fiderable, if, from the known nature of the épidémie, intermiffions or confiderable remiflions are not to be • foon expedted, and that great danger is apprehended from repeated exacerbations. 4. In the café of genuine intermittents, while a due quantity of bark is to be employed, the exhibition of it ought to be brought as near to the time of acceffion as the condition of the patient's ftomach will allow. 5. In ail eafes of intermittents, it is not fufficient that the récurrence of paroxyfms be ftopped for once by the ufe of the bark j a relapfe is commonly to be ex- pedted, and fhould be prevented by the exhibition of the bark, repeated at proper intervais. CCXXVIII. 84 PRACTICE CCXXVIII. Our fécond indication for condudting the paroxyfms of intermittent fevers, fo as to obtain a final folution of the difeafe, may be anfwered, i. By exhibiting emetics during the time of the cold ftage, or at the beginning of the hot. 2. By opiates given during the time of the hot ftage. CCXXIX. The circumftances which may efpecially prevent the fulfilling of thofe two indications, and therefore givc occafion to our third, are, a phlogiftic diathefis pre- vailing in the fyftem, and congeftions fixed in the ab- dominal vifeera. The firft muft be removed by blood- letting, and the antiphlogiftic regimen j the fécond, by vomiting and purging. B O O K B O O K IL Of INFLAMMATIONS, or PHLEGMASIl. C H A P. I. Of INFLAMMATION in général. SECT. I. Of the PHENOMENA of IN- FLAMMATION. CCXXX. WHEN any part upon the furface of the body is affedted with unufual rednefs, heat, pain, and tumour, we name the difeafe an Inflammation or Phleg- mafia. Thefe fymptoms of inflammation are never confiderable, without the whole fyftem being, at the famé time, affedted with pyrexia. CCXXXI. As the external, fo likewife the internai parts may be affected with inflammation; and we judge them to be fo, when, together with pyrexia, there is a fixed pain 86 PRACTICE pain in any internai part, attended with fome interrup- tion in the exercife of its functions. ; CCXXXII. We judge of the prefence of inflammation alfo from the ftate of the blood drawn out of the veins. When the blood, after cooling and concreting, fhews a portion of the gluten feparated from the reft of the mafs, and lying on the furface of the craffamentum ; as fuch fe- paration happens in ail cafés of inore évident phlegmafia ; fo, in ambiguous cafés, we, from this appearance, joined with other fymptoms, conclude the prefence of inflammation. At the famé time, it muft be obferved, that, as feveral circumftances in blood-letting may pre- vent this feparationof gluten from taking place in bloed otherwife difpofed to it ; fo we cannot always conclude, from the want of fuch appearance, againft the prefence of inflammation. CCXXXIII. We cannot eafily give any other gênerai hiftory of the phenomena of inflammation than what is contained in tbe three preceding paragraphs ; and the variations which may take place in its circumftances, will occur to be more properly taken notice of under the feveral heads of the particular gênera and fpecies, to be here- after mentioned. We proceed, therefore, to inquire into the proximate caufe of inflammation in gênerai. SECT. * O F P H Y S I C. *7 SECT. IL Of the PROXIMATE CAUSE of INFLAMMATION. CCXXXIV. The phenomena, of inflammation (CCXXX.), ail concur in fhewing, that there is an increafed impetus of the blood in the veflèls of the part affected ; and as, at the famé time, the action of the heart is not always confiderably increafed, we prefume, that the increafed impetus of the blood in the particular part, is owing efpecially to the increafed action of the veffels of the part itfelf. ccxxxv. The caufe of this increafed action in the veflèls of a particular part is, therefore, what we are to enquire af- ter, and to confider as the proximate caufe of inflam- mation. In many cafés, we can manifeftly perceive, that inflammation arifes from the application of ftimu- lant fubftances to the part. When the application of fuch ftimulants, therefore, is évident, we feek for no other caufe of inflammation ; but as, in many cafés, fuch application is neither- évident, nor, with any pro- bability, to be fuppofed, we muft, in fuch cafés, feek /or fome other caufe of the increafed impetus of the blood in the veffels of the part. CCXXXVI. Many phyficians hâve fuppofed, that an obftrudtion of the extrême veffels, any how produced, may prove a caufe 88 PRACTICE caufe of inflammation : But many difficultés attend this doctrine. i. The fuppofition of an error loci is not at ail probable ; for the motion of the blood in the extrême veflèls is fo weak and flow, as readily to admit a rétro- grade courfe of it ; and, therefore, if a particle of blood fhould happen to enter a vefîel whofe branches will not allow its partage, it will be moved backwards till it meet with a veffèl fit for tranfmrtting it ; and the fréquent ramifications and anaftomofes of the extrême arteries are very favourable to this. 2. The fuppofition of a preternatural lentor, or vif- cidity of the blood, is not well founded ; for it is pro- bable, that nature has fpecially provided againft a ftate of the fluids, fo incompatible with the exercife of the moft important functions of the animal œconomy. While motion continues to prevent any feparation of parts, and heat continues to preferve the fluidity of the more vifcid, there feems to be always fo large a proportion of water prefent, as to give a fufficient fluidity to the whole. 3. We prefume, that no gênerai lentor does ever take place ; becaufe, if it did, it muft fhew more confiderable effects than commonly appear. 4. There are no experiments diredtly in proof of a preternatural lentor prevailing in the mafs of blood ; nor is there any évidence of certain parts of the blood occafionally acquiring a greater denfity and force of co- hefion than ordinary ; neither is there any proof of the denfer, or more cohérent parts being prefent in the mafs of blood in fuch greater proportion than ufual, as to occafion a dangerous fpiflitude. The experiments of Dodtor Browne Langrifh on this fubject affbrd no con- clufion, having been made on certain parts of the blood feparated from the reft, without attending to the cir- cumftances of blood-letting, which very much alter the ftate of the feparation and concrétion of the blood drawn out of the veins. 5. In the particular café of inflammation, there are feveral circumftances which render it probable, that the blood is then more fluid than ufual. 6. Though an obftruction fhould be fuppofed to take place, it will not be fufficient for producing the effects appearing OFPHYSIC. 89 appearing in inflammation. An obftrudtion of one veflel does not, as has been imagined, increafe the velocity of the blood in the neighbouring veflèls which are free j and, in fadt, it appears from many obfervations and expe- riments, that confiderable obftrudtions may be formed, and may fubfift, without producing the fymptoms of in- flammation. CCXXXVII. Obftrudtion, therefore, is not to be confidered as the primary caufe of inflammation ; but, at the fâme time, it is fufficiently probable, that fome degree of obftruc- tion does take place in every café of inflammation. The diftention, pain, rednefs, and tumour attending inflam- mation, are only to be explained by fuppofing, that the extremities pf the arteries do not readily tranfmit the unufual quantity of blood, impelled into them by the increafed action in the courfe of thefe veffels. Such an obftrudtion may be fuppofed to happen in every café of an increafed impetus of the blood ; but it is probable, that, in the café of inflammation, there is alfo a pre- ternatural refiftence to the free paflage of the fluids. CCXXXVIII. From the doctrine of fever, we are led to believe, that an increafed action of the heart and arteries is not fupported for any length of time, by any other means than a fpafm affecting the extrême veflèls j and that the famé fpafm takes place in inflammation, feems probable from hence, that every confiderable inflammation is in- troduced by a cold ftage, and is accompanied with that and the other circumftances of pyrexia ; and it feems alfo . probable, that fomething analogous te this occurs even in the café of thofe inflammations, which feem lefs confiderable, and to be purely topical. CCXXXIX. From ail this, the nature of inflammation mayvoften be explained in the following manner. Some caufes of M inequality 9o PRACTICE inequality in the diftribution of the blood may throw an unufual quantity of it upon particular veflèls, to which it muft neceflarily prove a ftimulus. But, further, it is probable, that, to relieve the congeftion, the vis medi- catrix naturœ increafes ftill more the adtion of thefe vef- fels, which it effedts, by the formation of a fpafm on their extremities, as in ail other fébrile difeafes. CCXL. A fpafm, therefore, of the extrême arteries, fup- porting an increafed action in the courfe of them, may be confidered as the proximate caufe of inflammation, at leaft, in ail eafes not arifing from direct ftimuli applied. CCXLI. That, in inflammation, there is the concurrence of a conftridtion of the extrême veffels, with an increafed action in the other parts of them, feems probable, from the confideration of Rheumatifm. This is a fpecies of inflammation which is often manifeftly produced, either by cold applied to over-diftended veflèls, or by caufes of an increafed impetus, and over-diftention in veflèls previ- oufly conftricted. Hence, the difeafe efpecially appears at feafons liable to fréquent and confiderable viciffitudes of heat and cold. To this we may add, that the parts of the body moft frequently affedted with inflammation, are thofe expofed, both to over-diftention, from a change in the diftribution of the fluids, and, at the famé time, to the immédiate action of cold. Hence, quinfies and pneumonie in- flammations are more fréquent than any others. CCXLIL That a fpafm of the extrême veflèls takes place in inflammation, we prefume further from what is at the famé time the ftate of the whole arterial fyftem. In every confiderable inflammation, though arifing in one part only, an affection is communicated to the whole fyftem, in confequence of which an inflammation is readily O F P H Y S I C. 91 readily produced in other parts befides that firft affected. This gênerai affection is well known to phyficians, un- der the name of the Diathesis Phlogistica. It appears moft commonly in perfons of the moft rigid fibres j is often manifeftly induced by the tonic, or aftringent powers of cold ; is increafed by aU tonic and ftimulant powers applied to the body ; is always attended with a hardnefs of the pulfe; and is moft eftedtually taken off, by the relaxing power of blood-letting. From thefe circumftances, it feems probable, that the diathefis phlogiftica confifts in an increafed tone, orcontradtility, and perhaps contraction of the mufcular fibres of the whole arterial fyftem. Such a ftate of the fyftem pre- fumes a fpafm of the extrême veflèls, and the gênerai ftate commonly arifes from that begun in a particular part ; though it be alfo probable, that the gênerai ftate may arife and fubfift, for fome time, without the ob- vious inflammation of any particular parts. CCXLIII. We hâve thus endeavoured, in the café of inflam- mation, to explain the ftate of the whole fyftem, as well as that of the part more particularly affected, and this laft, as in its firft formation ; but, when it fubfifts for fome time, various changes take place in the part af- fected, of which we muft now take notice. SECT. III. Of the TERMINATIONS of IN- FLAMMATION. CCXLIV. If an inflammation be cured while the ftate and texture of the part remain entire, the difeafe is faid to be ter- minated by Resolution. This happens when the previous 92 PRACTICE previous congeftion and fpafm hâve been in a moderate degree, and the increafed impetus of the blood has been tufficient to overcome the fpafm, to dilate the veflèls, and to remove the congeftion, fo that the part is reftored to its ordinary and healthy ftate. A refolution takes place alfo when the increafed im- petus of the fluids has produced an increafed exhalation into the adjoining cellular texture, or, an increafed ex- crétion in fome neighbouring part, and has thereby re- lieved the congeftion in the veffels, and relaxed the fpafm of the inflamed part. Laftly, a refolution may take place, when the in- creafed impetus of the blood in the whole fyftem occa- fions fuch an évacuation, which, though in a diftant part, may prove fufficient to take off the phlogiftic dia- thefis of the whole fyftem, and thereby relieve the con- geftion and fpafm of the particular part affected by in- flammation. CCXLV. The tumour which appears in inflammation may be imputed in part to the congeftion of fluids in the veflèls; but is owing chiefly to an effufion of matter into the adjoining cellular texture, and, accordingly, tumours feldom appear but in parts adjoining to a lax cellular texture. If, in this café, the matter effufed be only a larger quantity of the ordinary exhaled fluid, this, when the free circulation in the veflèls is reftored, will be readily abforbed, and the ftate of the part will become the famé as before. But, if the increafed impetus of the^ blood in an inflamed part dilate the exhalant veflèls to fuch a degree, that they pour out an entire ferum, this will not be fo readily re-abforbed ; and, from the experiments of Sir John Pringle and Mr. Gaber, we learn, that, under ftagnation, the ferum may undergo a particular change, by having the gluten prefent in it changed into a white, opaque, moderately vifcid, mild liquor, which we name Fus. When this change hap- pens in the inflamed part, as it is at the famé time at- tended with an abatement of the rednefs, heat, and pain which formerly diftinguifhed the inflammation, the dif- eafe is faidto be terminated by Suppuration ; and an inflamed O F P H Y S I C. 9j inflamed part containing a collection of pus, is called an Abscess. CCXLVI. In inflammation, the tendency of it to fuppuration may be difcovered, by the continuance of the- inflam- mation, without the fymptoms of refolution ; by fome remiffion of the pain of diftention ; and by the pain be- ing of a throbbing kind, more diftindtly connected with the pulfation of the arteries; by the pulfe of the. arte- ries being fuller and fofter, and often, by the patient's being affedted frequently with cold fhiverings. The period at which this takes place is not determined, but is fometimes fooner, fometimes later. When the tendency is determined, the time neceffary to a' complète fuppura- tion is diffèrent in diffèrent cafés. When pus is com- pletely formed, the pain formerly in the part entirely ceafes, and a weight is felt in it. If the collection is formed immediately under the fkin, the tumour becomes pointed, the part becomes foft, and the fluctuation of the fluid within can be commonly perceived; and, at the famé time, for the moft part, the rednefs of the fkin formerly prevailing is entirely gone. CCXLVII. In abfceflès, while the-pus is formed of one part of the matter which had been effufed, the other and thin- ner parts are re-abforbed, fo that, in the abfcefs, when opened, a pus alone appears. This pus, however, is not the con ver ted gluten, alone; for the converfion of this being the effedt of a particular fermentation, which may affect the folid fubftance of the part, and perhaps every folid of animal bodies ; fo it moft readily, and particularly, affedts the cellular texture, and thereby a great deal of this is eroded, and forms a part of the pus ; and it generally happens alfo, that fome of the fmaller red veflèls are eroded, and fome red blood appears mîxed with the pus in abfceflès. Upon the whole, the in- ternai furface of an abfcefs is to be confidered as an ul- cerated part. ' CCXLVIIL 94 PRACTICE CCXLVIII. This account of fuppuration explains, why an ab- fcefs, when formed, may either fpread into the cellular texture of the neighbouring parts, or, by eroding the incumbent téguments, be poured out upon the furface of the body, and produce an open ulcer. CCXLIX. The matter of abfceflès, and of the ulcers following them, is various, according to the nature of what is effufed, and which may be, i. A matter thinner than ferum. 2. An entire and pure ferum. 3. A quantity of red globules. 4. A matter furnifhed by particular glands feated in the part. It is the fécond only which affords a proper pus, the effufion whereof, whether in abfceflès or ulcers, feems to be the peculiar effedt of an inflammatory ftate of the veflèls ; and from this Caufe it is, that, when ulcers do not produce a proper pus, a circumftance always ab- folutely neceffary to their healing, we, in many cafés, bring the ulcers to a ftate of fuppuration, by the ap- plication of ftimulants exciting inflammation, fuch as balfams, mercury, copper, &c. CCL. When the matter effufed into the cellular texture of an inflamed part, is tainted with a putrid ferment, this produces, in the effufed matter, a change, approaching more or lefs to a complète putréfaction. When this is in a moderate degree, and affects only the fluids effufed, with the fubftance of the cellular texture, the part is faid to be affected with Gangrené ; but, if the pu- tréfaction affect alfo the veffels and mufcles of the part, the difeafe is faid to be a Sphacelus. CCLL O F P H Y S I C. 95 CCLI. A gangrené, and its confequences, may arife from a putrid ferment adting on the matter, which is moft com- monly effufed ; but it may alfo arife from the peculiar nature of the matter effufed being difpofed to putré- faction ; as particularly feems to be the café of the red globules of the blood effufed in a large quantity. In a third manner alfo, a gangrené feems frequently to arife, from the vicient excitement of the inflammation de- ftroying the tone of the veffels ; whereby the whole fluids ftagnate, and run into putréfaction, which taking place in any degree, deftroys further the tone of the veflèls, and fpreads the gangrené. CCLII. In inflammation, the tendency to gangrené may be apprehended from an extrême violence of pain and heat in the inflamed part, and from a great degree of pyrexia attending the inflammation. The actual coming on of gangrené may be perceived by the colour of the inflamed part changing from a cléar to a dark red, by blifters arifing upon the part, by the part becoming foft, flaccid, and infenfible, and by the ceafing of ail pain while thefe appearances take place. ' . As the gangrené procçeds, the colour of the part becomes livid, and, by degrees, quite black, the heat of the part entirely ceafes, the foftnefs and flaccidity of the part increafes, it lofes its confiftence, exhales a ca- daverous fmell, and may then be confidered as affedted with fphaçelus. CCLIII. Gangrené is thus a third manner in which inflam- mation terminâtes, and the fchools hâve commonly marked a fourth termination of inflammation ; which is, by a fchirrus, or an indolent hardnefs of the part formerly affected with inflammation. This, however, is a rare occurrence, and does not feem to dépend fo much 9t PRACTICE much upon the nature of inflammation, as upon the cir- cumftances of the part affedted. It is in glandular parts chiefly that fchirrofity is obferved, and which is owing to the parts readily admitting a ftagnation of «the fluids. We hâve obferved, that inflammation feldom induces fchirrus, which more commonly arifes from other caufes, and when inflammation fupervenes, which it is fooner or later apt to do, it does not fo commonly increafe as change the fchirrofity, into fome kind of abfcefs. From thefe confiderations, it does not feem neceffary to take any further notice of fchirrus, as a termination of in- flammation. CCLIV. There are, however, fome other terminations of in- flammation not commonly taken notice of, but now to be mentioned. One is, by the effufion of a portion of the entire mafs of blood, either by means of rupture or anaftomofis, into the adjoining cellular texture. This happens efpecially in inflammations of the lungs, where the effufed matter, by compreffing the veffels, and ftopping the circulation, occafions a fatal fuffocation ; and this is perhaps the manner in which peripneumony moft commonly proves fatal. CCLV. Another kind of termination is, that of certain in- flammations on the furface of the fkin, when there is poured out under the cuticle a fluid, too grofs to pafs . through its pores, and which therefore feparates it from the fkin, and raifes it up into the form of a veficle con- taining the effufed fluid ; and by which effufion the pre- vious inflammation is taken off. CCLVI. Befides thefe already mentioned, T believe there is ftill another manner in which inflammation terminâtes. When the internai parts are affedted with inflammation, there appears almoft always upon their furface an ex- fudation, O F P H Y S I C. 97 fudation, which appears partly in a vifcid concrétion upon their furface, and partly in a thin ferous fluid, ef- fufed into the cavities in which the inflamed vifeera are placed. Though thefe appearances very conftantly ac- company thofe inflammations which hâve proved fatal, it is, however, probable, that like circumftances may attend thefe inflammations terminated by refolution, and may contribute to that event, as there are inftances of pneumonie inflammation terminating in a hydrothorax. SECT. IV. Of the REMOTE CAUSES of INFLAMMATION. CCLVII. The remote caufes of inflammation may be reduced to four heads. i. The application of ftimulant fubftances, among which are to be reckoned the action of fire, or burning. 2. External violence operating mechanically in wounding, bruifing, or overftretching the parts. 3. Extraneous fubftances, lodged in any part of the body, though they be neither of an acrid quality, nor of a pointed form. 4. Cold, in a certain degree, not fufficient imme- diately to produce gangrené. It will not be difficult to underftand, how thefe re- mote caufes, fingly, or in concurrence, produce the proximate caufe of inflammation. N CCLVIII. 98 PRACTICE CCLVIIL We cannot perceive, that, in diffèrent cafés of in- flammation, there is any différence in the ftate of the proximate caufe, except in the degree ; and, though fome différence of inflammation may arife from the dif- férence of its remote caufes, this is not neceffary to be taken notice of hère ; becaufe the diffèrent appearances which attend diffèrent inflammations, may be referred, for the moft part, to the différence of the part affected, as will appear, whenwe fhall confider the feveral gênera and fpecies marked in the Nofology. In treating of thefe, we fhall find a more proper occafion for taking notice of the diffèrent ftates of the proximate, or of the différences of the remote caufe, than by treating of them in gênerai hère. SECT. V. Of the CURE of INFLAM- MATION. CCLIX. The indications of cure in inflammation are différent, according as it may be ftill capable of refolution, or may hâve taken a tendency to the feveral other termina- tions above mentioned. Its tendency to thefe laft is not always at firft obvious ; and, therefore, upon the firft appearance O F P H Y S I C. 99 appearance of inflammation, the cure ofit, by refolution, is always to be attempted. The indications of cure, for this purpofe, are, i. To remove the remote caufes, when they are évident, and continue to operate. 2. To take off the phlogiftic diathefis affedting the whole fyftem, or the particular part. 3. To take off the fpafm of the particular part, by remédies applied to the whole fyftem, or to the part itfelf. CCLX. The means of removing the remote caufes will readily occur, from confidering the particular nature and cir- cumftances of the diffèrent kinds. Acrid matters muft be removed, or their action muft be prevented, by the application of demulcents. Compreffing and over- ftretching powers muft be taken away, and, from their feveral circumftances, the means of doing fo will be be obvious, CCLXI. The means of taking off the phlogiftic diathefis of the fyftem are the famé with thofe for diminifhing the violence of re-action in fever, which are mentioned and treated of from (CXX.) to (CXLIIL), and therefore need not be repeated hère. CCLXII, The means of taking off the fpafm of the particular part are much the famé as thofe mentioned above, for taking off the fpafm of the extrême veflèls in the café of fever, and which are treated of from (CXLIV.) to (CXCIV.) Only it is to be obferved, that topical bleedings are hère efpecially indicated, and that fome of the other remédies are to be directed more exactly to the part particularly affected ; the management of which will be more properly confidered when we fhall treat of particular inflammations. CCLXIIL ioo PRACTICE CCLXIII. When a tendency to fuppuration (CCXLVI.) is diftindtly perceived, as we fuppofe it to dépend upon the effufion of a fluid, which cannot be eafily reabforbed, fo it becomes neceffary that this fluid be converted into pus as the only natural means of obtaining its évacuation ; and, as the effufion is, perhaps, feldom made without fome rupture of the veffels, to the healing of which a pus is abfolutely neceffary ; fo, in the cafe of a tendency to fuppuration, the indication of cure always is, to promote the produdtion of a perfcdt pus as quickly as ^ poffible. CCLXIV. For this purpofe, various remédies, fuppofed to poffefs a fpecific power, have been propoftd ; but we cun per- ceive no fuch power in any of them ; and, in my opinion, ail that can be done is, to favour the fuppuration by fuch applications, as may fupport a moderate heat in the part, as by fome tenacity mav confine the perfpiration of the part, and as, by an emollient quality, may weaken the cohefïon of the téguments, and favour their erofion. CCLXV. As in the cafe of certain effufions, a fuppuration is not only unavoidable, but defireable, itmay be fuppofed, that moft of the means of refolution formerly mentioned fhould be avoided ; and accord ingly our pradtice is com- monly fo directed. But, as we obferve, on the one hand, that a certain degree of increafed impetus, or of the original fymptoms of inflammation, is neceffary to produce a proper fuppuration, foit is then efpecially ne- ceffary to avoid thofe means of refolution which may diminifh too much the force of the circulation. And, on the other hand, as the impetus of the blood, when violent, is found to prevent the proper fuppuration, fo, in fuch cafés, though a tendency to fuppuration may have O F P H Y S I C. 101 have begun, it may be proper to continue thofe means of refolution which moderate the force of the circulation. With refpect to the opening of abfceflès, when com- pletely formed, we refer to the writings on furgery. CCLXVI. When an inflammation has taken a tendency to gan- grené, that event is to be prevented by every poffible means ; and thefe muft be diffèrent according to the nature of the feveral caufes occafioning that tendency, which may be underftood from what has been already faid of thefe caufes. After a gangrené has in fome de- gree taken place, it can be cured only by the feparation of the dead from the living parts. This, in certain circumftances, can be performed, and moft properly, by the knife. In other eafes, it can be done by exciting a fuppu- ratory inflammation on the verge of the living part, whereby its cohefion with the dead may be every where broken off, fo that the latter may fall off by itfelf. While this is doing, it is proper to prevent the further putréfaction of the part, and its fpreading wider. For this purpofe, various antifeptic applications have been propofed ; but we are of opinion, that, while the té- guments are entire, thefe applications can hardly have any effedt; and, therefore, that the fundamental pro- cédure muft be to fcarify the part fo as to reach the living fubftance, and, by the wounds made there, to excite the fuppuration required. By the famé incifions alfo, we give accefs to antifeptics, which may both prevent the progrefs of the putréfaction in the dead, and excite the inflammation neceffary on the verge of the living part. CCLXVII. When the gangrené procèeds from a lofs of tone, and when this, communicated to the neighbouring parts, prevents that inflammation which, as we have /aid, is neceffary to the feparation of the dead part from the living, it will be proper to obviate this lofs of tone by tonic 102 PRACTICE tonic medicines given internally ; and, for this purpofe, the Peruvian bark has been found to be efpecially ef- fectuai. That this medicine opérâtes by a tonic power, we have endeavoured to prove above (CCVIII.) ; and, from what is faid in (CCIX.) the limits of its ufe alfo may be learned. When the gangrené arifes from the violence of inflammation, the bark may not only fail of proving a remedy, but may do harm ; and its power as a tonic is efpecially fuited to thofe cafés of gangrené, which proceed from an original lofs of tone, as in the cafe of palfy and cedema, or in thofe cafés of inflam- mation where a lofs of tone takes place, while the original inflammatory fymptoms are removed. CCLXVIIL The other terminations of inflammation, either do not admit of any treatment, except that of preventing them by the means of refolution, or they belong to a treatife of furgery, rather than to this place. And, therefore, having thus delivered the gênerai doctrine, we proceed now to confider the particular gênera and fpecies of inflammation. We have hinted above, that the différence of inflammation arifes chiefly from the différence of the part affected ; and we have, in the firft place, arranged them, as they are cutaneous, vifceral, or articular ; in which order we are now to confider them. C H A P. O F P H Y S I C. 103 C H A P. IL Of INFLAMMATION more STRICTLY CUTANEOUS. CCLXIX. Cutaneous inflammations are of two kinds, com- monly diftinguifhed by the names of Phlegmon and Erysipelas. Of the latter there are two cafés, which ought to be diftinguifhed by diffèrent appellations. When the dif- eafe is an affection of the fkin alone, and very little of the whole fyftem, or when the affedtion of the fyftem is only fymptomatical of the external inflammation, we fhall give the difeafe the name of Erythema; and, when the external inflammation is an exanthema, and fymptomatical of an affection of the whole fyftem, we fhall then name the difeafe Erysipelas. CCLXX. It is the erythema only that we are to confider hère. For the différence ,of the appearances in the phlegmon and erythema, we refer to our Nofology ; and we fhall hère only obferve, that the différence of thefe appear- ances feems to dépend on the diffèrent feat of the in- flammation. In the phlegmon, the inflammation feems to affect efpecially the veflèls on the internai furface of the fkin communicating with the lax fubjacent cellular texture ; whence a more copious effufion, and that too of ferum, convertible into pus, takes place. In the erythema, the affection is of the veffels on the external furface çf the fkin, communicating with the rete mu- cofum, which does not admit of any effufion, but what feparates the cuticle, and gives occafion to the formation 104 PRACTICE of a blifter, while the fmaller fize of the veffels admits only of the effufion of a thin fluid, very feldom con- vertible into pus. Befides thefe différences in the circumftances of thefe two kinds of inflammation, it is probable that they differ alfo with refpect to their caufes. Erythema is the effedt of ail kinds of acrids externally applied to the fkin ; and, when it arifes from an internai caufe, it is from an acrimony poured out on the furface of the fkin under the cuticle. In the phlegmon, an acrimony is not commonly évident. CCLXXI. Thefe différences in the feat and caufes of the phleg- mon and erythema, being admitted, it will appear, that the erythema muft affect thofe internai parts only, whofe furfaces are covered with an epithelion, or membrane, analogous to the cuticle. The famé différence of caufes, and of the feat now marked, will alfo explain what has been delivered by pradtical writers, with refpect to the cure of thefe diffèrent cutaneous inflammations. But we fhall not profecute this hère, becaufe it falls under the province of furgery, which, in this courfe, we can- not enter into. For the famé reafon, we fhall not fay any thing of the variety of external inflammation, which might otherwife be confidered hère. C H A P. III. Of OPHTHALMIA, or INFLAM- MATION of the EYE. CCLXXII. The inflammation of the eye may be confidered as of two kinds, according as it is leated in the membranes of the O F P H Y S I C. Î05 the bail of the eye, when we name it Ophthalmia Membranarum, or as it is feated in the febaceous glands placed in the tarfus, or edges of the eye-lids, in which cafe it may be termed Ophthalmia Tarsi. Thefe two kinds are very frequently connedted to- gether, as the one may readily excite the other ; but they are ftill to be diftinguifhed according as the one or the other may happen to be the primary affection. CCLXXIIL The inflammation of the membranes of the eye af- fedts efpecially, and moft frequently, the adnata, and appears in a turgefcence of its veflèls ; fo that the red veflèls which are naturally there, become not only in- creafed in fize, but many more appear than did in a na- tural ftate. This turgefcence of the veffels is attended with pain, efpecially upon the motion of the bail of the eye; and this irritation, like every other, applied to the furface of the eye, produces an effufion of tears from the lachrymal gland. The inflammation commonly, and chiefly, affedts the adnata fpread on the anterior part of the bulb of the eye ; but ufually fpreads alfo along the continuation of the adnata on the infïde of the palpebrae ; and, as that is extended on the tarfus palpebrarum, the excretories of the febaceous glands opening there are alfo frequently affedted. When the affection of the adnata is confi- derable, it may be communicated to the fubjacent mem- branes of the eye, and even to the retina itfelf, which thereby acquires fo great a fenfibility, that every im- preffion of light becomes painful. CCLXXIV. The inflammation of the membranes of the eye is in diffèrent degrees, according as the adnata is more or lefs affedted, or according as the inflammation is either of the adnata alone, or of the fubjacent membranes alfo ; and, upon thefe différences, différent fpecies have been eftabliihed, and diffèrent appellations given to them. But we fhall not profecuté the confideration of thefe, O being io6 PRACTICE being of opinion, that ail the cafés of the Ophthalmia membranarum diffcr only in degree, and are to be cured by remédies of the famé kind, more or lefs employed. CCLXXV. The proximate caufe of Ophthalmia is not diffèrent from that of inflammation in gênerai ; and the diffèrent circumftances of Ophthalmia may be explained by the différence of its remote caufes, andby the diffèrent parts of the eye which it happens to affect ; as may be un- derftood from what has been already faid. We now proceed to confider the Cure. CCLXXVI. The Ophthalmia membranarum requires the remédies proper for inflammation in gênerai ; and, when the deeper-feated membranes are affected, and efpecially when a pyrexia is prefent, large gênerai bleedings may be neceffary. But this laft is feldom the cafe; and, for the moft part, the Ophthalmia is an affection purely lo- cal, accompanied with little or no pyrexia. General bleedings, therefore, have little effedt upon it, and the cure is chiefly to be obtained by topical bleedings, that is, blood drawn from veflèls near the inflamed part; and opening the jugular vein or the temporal artery, may be confidered as in fome meafure of this kind. It is commonly fufficient to apply a number of leeches round the eye; and it is perhaps Setter ftill to draw blood by cupping and fcarifying upon the temples. In many cafés, the moft effectuai remedy is, that of fcarifying the internai furface of the inferior eye-lid, and cutting the turgid veffels upon the adnata itfelf, CCLXXVII. Befides blood-letting, purging, as a remedy fuited to inflammation in gênerai, has been confidered as pecu- liarly adapted to inflammations in any of the parts of the head, and therefore to Ophthalmia ; and it is fome- times ufeful ; but, for the reafons given before with refpect O F P H Y S I C. 107 refpect to gênerai bleeding, purging in the cafe of Oph- thalmia does not prove ufeful in any proportion to the évacuation excited. CCLXXVIII. For relaxing the fpafm in the part, and taking off the détermination of the fluids to it, bliftering near the part has commonly been found ufeful. CCLXXIX. Ophthalmia, as an external inflammation, admits of topical applications. Ail thefe, however, which en- creafe the heat and relax the veffels of the part, prove hurtful ; and the admiffion of cool air to the eye, and the application of cooling and aftringent medicines, which at the famé time do not produce irritation, prove ufeful. ÇCLXXX. In the cure of Ophthalmia, much care is requifite to avoid ail irritation, particularly that of light ; and the only and certain means of doing this, is by keeping the patient in a very dark chamber. CCLXXXL Thefe are the remédies of the Ophthalmia membra» narum ; and, in the Ophthalmia tarfi, fo far as it is produced by the Ophthalmia membranarum, the famé remédies may be neceffary. As, however, the Oph- thalmia tarfi may often dépend upon an acrimony de- pofited in the febaceous glands of the part, fo it may require various internai remédies according to the variety of the acrimony in fault, for which we muft refer to- thé Confideration of fcrophula, fyphilis, or other difeafes with which this Ophthalmia may be connected ; and, where thefe fhall not be évident, certain remédies, more generally adapted to the évacuation of acrimony, fuch as mercury, may be employed. CCLXXXIL io8 PRACTICE CCLXXXII. In the Ophthalmia tarfi, it almoft conftantly happens, that fome ulcérations are formed on the tarfus. , Thefe require the application of mercury or copper, which alone may fometimes cure the whole affedtion ; and they may be ufeful even when the difeafe dépends upon a fault of the whole fyftem. CCLXXXIIL Both in the Ophthalmia membranarum, and in the Ophthalmia tarfi, it is neceffary to obviate that gluing together of the eye-lids which commonly happens in fleep ; and which may be done by infinuating a little of any mild undtuous medicine between the eye-lids before the patient fhall go to fleep. C H A P IV. Of PHRENSY, or PHRENITIS. CCLXXXIV. This is an inflammation of the parts contained in the cavity of the cranium, and may affect either the mem- branes of the brain, or the fubftance of the brain itfelf. Nofologifts have thought, that the two cafés might be diftinguifhed by diffèrent fymptoms, and therefore by diffèrent appellations ; but we do not find this confirmed by obfervation and diffedtion ; and therefore fhall treat of both cafés under the title of Phrenfy, or Phrenitis. CCLXXXV. OF P H Y S I C. 109 CCLXXXV. An idiopathic phrenfy is a rare occurrence, a fym- pathic more fréquent, and the afcertaining either the one or the other is, on many occafions, difficult, as the fymptoms by which the difeafe is moft commonly judged to be prefent, appear fometimes without internai inflam-r mation; and diflèctions have fhewn, that the brain had been inflamed, when few of the peculiar fymptoms of inflammation had appeared before. CCLXXXVI. The fymptoms by which it may be moft certainly known are, an acute pyrexia, a violent head-ach, a rednefs of the face and eyes, an impatience of light or noife, a confiant watching, and a delirium impetuous and furious. Some nofologifts have thought thefe fym- ptoms peculiar to an inflammation of the membranes, and that-the inflammation of the fubftance of the brain was to be diftinguifhed by fome degree of coma attending it. It is for this reafon that in the Nofology I have added the typhomania, to the charadter of Phrenitis ; but, upon farther reflection, I find no proper founda- tion for this ; and, if we pafs from the charadters above delivered, there will be no fixing the variety that occurs. CCLXXXVII. The remote caufes of phrenfy, are ail thofe which di- redtly ftimulate the membranes, or fubftance, of the brain, and particularly ail thofe which increafe the im- petus of the blood in the veflèls of the brain. The paflions of the mind, and certain poifons, are amongft the remote caufes of phrenfy ; but, in what manner they operate, is not well underftood. CCLXXXVIII. The cure of phrenfy is the famé with that of inflam- mation in gênerai ; but hère the moft powerful remédie^ are 110 PRACTICE are to be immediately employed. Large and repeated bleedings are efpecially neceffary, and thefe too taken from veflèls as near as poffible to the part affedted. The opening of the temporal artery has been recommended, and with fome reafon ; but the pradtice is attended with inconvenience ; and we believe that the opening the jugular veins may prove more effectuai ; with which, however, may be joined, the drawing of blood from the temples by cupping and fcarifying. CCLXXXIX, It is probable that purging may be of more ufe in this than in fome other inflammatory affedtions, as it may operate by revulfion. For the famé purpofe of re- vulfion, warm pediluvia are a remedy, but fomewhat ambiguous. The taking pff the force of the blood in the veffels of the head by an erect pofture, is commonly ufeful. eexc. Bliftering is generally ufeful in this difeafe, but chiefly, when applied near to the part affedted. CCXCI. Every part of the antiphlogiftic regimen is hère ne- ceffary, and particularly the admiffion of cold air. Even cold fubftances applied clofe to the head, have been found ufeful, and the application of fuch réfrigérants as vinegar is certainly proper. CCXCII. It appears certain, that opiates are hurtful in every inflammatory ftate of the brain; and it is to be obferved, that, from the ambiguity mentioned in(CCLXXXV.) theaccounts of practitioners, with regard to thejuvantia and laedentia in this difeafe, are very uncertain. CHAP. OF PHYSIC. C H A P V. Of'the QUINSY, or CYNANCHE. CCXCIIL This name is applied to every inflammation of the in- ternai fauces ; but thefe are diffèrent according to the part which may be affected, and the nature of the in- flammation. In our Nofology, therefore, after giving the character of the Cynanche as a genus, we have dif- tinguifhed five diffèrent fpecies, which muft hère like- wife be feparately confidered. SECT. I. Of the CYNANCHE TONSIL- LARIS. CCXCIV. This is an inflammation of the mucous membrane of the fauces, affedting efpecially that congeries of mucous follicles which forms the tonfils, and from thence fpreading along the vélum and uvula, fo as frequently to affect every part of the mucous membrane. CCXCV. lia PRACTICE CCXCV. The difeafe appears by fome tumor and rednefs of the parts, is attended with a painful and difficult dé- glutition ; a troublefome clamminefs of the mouth and throat ; a fréquent, but difficult, excrétion of mucus ; and the whole is accompanied with pyrexia. CCXCVI. This fpecies of quinfy is never contagious ; it ter- minâtes frequently by refolution, fometimes by fup- puration, but hardlyeverby gangrené, although in this difeafe fome floughy fpots fometimes appear upon the fauces. CCXCVII. This difeafe is commonly occafioned by cold externally applied, particularly about the neck. It affedts efpeci- ally the young and fanguine, and a difpofition to it is often acquired by habit. It occurs efpecially in fpring and autumn, when viciffitudes of heat and cold fre- quently take place. The inflammation and tumor are commonly at firft moft confiderable in one tonfil, and afterwards abating in that, increafe in the other. CCXCVIIL In the cure of this inflammation, fome bleeding may be proper ; but large gênerai bleedings will feldom be neceffary. The opening of the ranular veins feems to be an infignificant remedy ; and leeches fet upon the ex- ternal fauces are of more efficacy. CCXCIX. This inflammation may be often relieved by moderate aftringents, and particularly by acids applied to the in- flamed parts. In many cafés, nothing has been found to give O F P H Y S I C. "3 give more relief than the vapour of warm water received into the fauces. ccc. The other remédies of this difeafe are rubefacient, or bliftering medicines, applied externally to the neck, and with thefe, the employment of antiplogiftic purgatives, as well as every part of the antiphlogiftic regimen, ex- cept the application of cold. ceci. This difeafe, as we have faid, often terminâtes by refolution, frequently accompanied with fweating; which is therefore to be prudently favoured and' en- couraged. CCCIL When this difeafe fhall have taken a tendency to fup- puration, nothing will be more ufeful than the fréquent taking into the fauces the fteams of warm water. When the abfcefs is attended with much fwelling, jf it break not fpontaneoufly, it fhould be opened by a lancet ; and this does not require much caution, as even the inflam- matory ftate may be relieved by fome fearification of the tonfils. I have never feen any cafe requiring bron- chotomy. SECT, P iH PRACTICE SECT. IL Of the CYNANCHE MALIGNA. CCCIII. This is a contagious difeafe, feldom fporadic, and commonly épidémie. It attacks perfons of ail âges, but more commonly thofe in a young and infant ftate. It attacks perfons of every conftitution, when expofed to the contagion, but moft readily the weak and infirm. CCCIV. The difeafe is ufually attended with a confiderable pyrexia, and the fymptoms of the acceffion of this, fuch as, fréquent cold fhiverings, ficknefs, anxiety, and vomiting are often the firft appearances of the dif- eafe. About the famé time, a ftiffnefs is felt in the neck, with fome uneafinefs in the internai fauces, and fome hoarfenefs of the voice. The internai fauces, when viewed, appear of adeep red colour, with fome tumourj but this laft is feldom confiderable; and déglutition is feldom difficult or painful. Very foon, a number of white or afh-coloured fpots appear upon the inflamed parts. Thefe fppts fpread and unité, covering almoft the whole fauces with thick floughs, which falling off, difeover ulcérations. While thefe fymptoms proceed in the fauces, they are generally attended with a coryza, which pour s out a thin acrid and feetid matter, exco- riating the noftrils and lips. There is often alfo, efpe- cially in infants, a fréquent purging, and a thin acrid matter flows from the anus, excoriating this and the neighbouring parts. ccev. O F PH'YSIC. U5 cccv. With thefe fymptoms, the pyrexia proceeds with a fmall, fréquent, and irregular pulfe, and there is oc- curring a manifeft exacerbation every evening and fome remiffion in the mornings. A great debility appears in the animal fundtions, and the fenforium is affected with delirium, frequently with coma. CCCVL On the fécond day, or fometimes later, efflorefcences appear upon the fkin, which are fometimes in fmall points, hardly eminent; but, for the moft part, in patches of a red colour, fpreading and uniting, fo as to cover the whole fkin. They appear fift about the face and neck, and, in the courfe of fome days, fpread by degrees to the lower extremities. The fcarlet rednefs is often confiderable on the hands and extremities of the fingers, which feel ftiff and fwelled, This éruption is often irregular as to the time of its appearance, its ftea- dinefs, and the time of its continuance. It ufually continues four days, and goes off by fome defquamation of the cuticle ; but neither on its firft appearance, nor on its defquamation, does it always produce a remiffion of the pyrexia, or of the other fymptoms. CCCVII. The progrefs of the difeafe dépends on the ftate of the fauces and of the pyrexia. When the ulcers on the faucea, by their livid and black colour, by the fcetor of the breath, and by many marks of acrimony in the fluids, fhew a tendency to gangrené, this takes place to a confiderable degree, and the fymptoms of a putrid fever conftantly increafing, the patient dies often on the third day, fometimes later, but for the moft part, before the feventh. The acrimony poured out from the dif- eafed fauces muft neceffarily, in part, pafs into the pha- rynx, and there fpread the infection into the cefophagus, and fometimes through the whole of the alimentary canal, ïi6 PRACTICE canal, propagating the putréfaction, and often exhaufting the patient by a fréquent diarrhoea. The acrid matter poured out in the fauces being again abforbed, frequently occafions large fwellings of the lymphatic glands about the neck, and fometimes, to fuch a degree, as to occafion a fuffocation. It is feldom that the organs of refpiration efeape en- tirely unhurt, and very often the inflammatory affection is communicated to them. It appears from diflèctions, that, in the Cynanche maligna, the larynx and trachea are often affected in the famé manner as in the Cynanche trachealis ; and it is probable, that, in confequence of that affection, the Cynanche maligna often proves fatal by fuch a fudden fuffocation as . happens in the proper Cvnanche trachealis ; but there is reafon to fufpedt that diffectors have not always diftinguifhed properly between the two difeafes. CCCVIIL Thefe are the feveral fatal terminations of the Cy- nanche maligna, which, however, do not always take place. Sometimes the ulcers of the fauces are of milder nature, and the fever is more moderate, and of a lefs putrid kind. And when, upon the appearance of the efflorefeence on the fkin, the fever fuffers a remiffion ; when the efflorefeence continues for three or four days, till it has fpread over the whole body, and ends then by a defquamation giving a further remiffion of the fever; this often terminâtes entirely, by gentle fweats, on or before the feventh day ; and the reft of the difeafe ter- minâtes in a few days more, by an excrétion of floughs from the fauces, while fleep, appetite, and the other marks of health, entirely. return. From this, and the preceding paragraph, the prognoftics in this difeafe may be readily learned. CCCIX. In the cureof this difeafe, its feptic tendency is chiefly tobe kept in view. The debility, with which it is at- tended. renders ail évacuations by bleeding and purging improper, O F P H Y S I C. 117 improper, except in a few inftances where the debility is lefs, and the inflammatory fymptoms more con- fiderable. The fauces are to be preferved from the ef- fedts of the acrid matter poured out upon them, and are therefore to be frequently wafhed out by antifeptic gar- gles or injections ; and the feptic tendency of the whole fyftem fhould be guarded againft and corredted by internai antifeptics, efpecially by the Peruvian bark given in fub- ftance from the beginning, and continued through the courfe of the difeafe. Emetics, both by vomiting and naufeating, prove ufeful. When any confiderable tu- mour occurs, blifters applied external ly will be of fervice, and, in any cafe, may be fit to moderate the in- ternai inflammation. SECT. III. Of the CYNANCHE TRA- CHEALIS. CCCX. This name has been given to an inflammation of the glottis, larynx, or upper part of the trachea, whether it affect the membranes of thefe parts, or the mufcles adjoining. It may arife firft in thefe parts, and continue to fubfift in them alone, or it may come to affedt thefe parts from the Cynanche tonfillaris or maligna fpreading into them. CCCXI. In either way it has been a rare occurrence, and few inftances of it have been marked and recorded by phy- ficians. It is to be known by a peculiar croaking found of the voice, by difficult refpiration, with a fenfe of ftraitening u8 PRACTICE ftraitening about the larynx, and by a pyrexia at- tending it. CCCXII. From the nature of thefe fymptoms, and from the diffedtion of the bodies of perfens who had died of this difeafe, there is no doubt of its being of an inflam- matory kind. It does not however always run the courfe of inflammatory affections, but frequently pro- duces fuch an obftrudtion of the paffage of the air, as fuffocates, and thereby proves fuddenly fatal. CCCXIII. If we judge rightly of the nature of this difeafe, it will be obvious, that the cure of it requires the moft powerful remédies of inflammation, to be employed upon the very firft appearance of the fymptoms. When a fuffocation is threatened, whether any remédies can be employed to prevent it, we have not had expérience to détermine. CCCXIV. The accounts which books have hitherto given us of inflammations of the larynx, and the parts connedted with it, amount to what we have now faid ; and the in- ftances recorded have, almoft ail of them, happened in adult perfons ; but there is a peculiar affection of this kind happening to infants, which has been little taken notice of till lately. Dr. Home is the firft who has given any diftindt account of this difeafe; but, fince he wrote, feveral other authors have taken notice of it, and have given diffèrent opinions concerning it. Concerning this diverfity of opinions, I fhall not at prefent inquire, but fhall deliver the hiftory and cure of this difeafe, in fo far as thefe have arifen from my own obfervation, from that of Dr. Home, and of other fkilful perfons in this neighbourhood. CCCXV. O F P H Y S I C. 119 cccxy. This difeafe feldom attacks infants till after they have been weaned. After this period, the younger they are, the more they are liable to the difeafe. The frequency of it becomes lefs as children become more advanced ; and there are no inftances of children above twelve years of âge being affected with it. It attacks children of the midland countries, as well as thofe who live near the fea. It does not appear to be contagious, and its attacks are frequently repeated in the famé child. It is often manifeftly the effedt of cold applied to the body; and therefore appears moft frequently in the winter and fpring feafons. It very commonly cornes on with the ordinary fymptoms of a catarrh ; but fometimes the peculiar fym- ptoms of the difeafe fhew themfelves at the very firft. - CCCXVI. Thefe peculiar fymptoms are the following : A hoarfenefs, with fome fhrillnefs and ringing found, both in fpeaking and coughing, as if the noife came from a brazen tube. At the famé time, there is a fenfe of pain about the larynx, fome difficulty of refpiration, with a whizzing found in infpiration, as if the paffage of the air were ftraitened. The cough which attends it, is commonly dry ; and, if any thing be fpit up, it is a matter of a purulent appearance, and fometimes films, refembling portions of a membrane. With ail thefe fymptoms, there is a frequency of pulfe, a reftlefîhefs, and an uneafy fenfe of heat. When the internai fauces are viewed, they are fometimes without any appearance of inflammation, but frequently a rednefs, and even fwelling appears, and fometimes there is an appearance of matter like to that rejedted by coughing. Together with the fymptoms now deferibecf, and particularly with great difficulty of breathing, and a fenfe of ftrangling in the fauces, the patient is fometimes fuddenly taken off. CCCXVII. 120 PRACTICE CCCXVII. Many diffections have been made of infants who had died of this difeafe, and almoft conftantly there has ap- peared a preternatural membrane lining the whole in- ternai furface of the upper part of the trachea, and cx- tending in the famé manner downwards into fome of its ramifications. This preternatural membrane may be eafily feparated, and fometimes has been found feparated in part from the fubjacent proper membrane of the tra- chea. This laft is commonly found entire, that is, without any appearance of erofion or ulcération, but it frequently fhows the veftiges of inflammation, and is covered by a matter refembling pus, like to that rejected by coughing; and very often a matter of the famé kind is found in the bronchiae, fometimes in confiderable quantity. CCCXVIII. From the remote caufes of this difeafe; from the catarrhal fymptoms commonly attending it ; from the pyrexia conftantly prefent with it ; from the famé kind of preternatural membrane being found in the trachea, when the Cynanche maligna is communicated to it; and from the veftiges of inflammation on the trachea dif- covered upon diffedtion, we muft conclude, that this difeafe confifts in an inflammatory affection of the mu- cous membrane of the larynx and trachea, producing an exfudation analogous to that found on the furface of inflamed vifeera, and appearing partly in a membranous cruft, and partjy in a fluid refembling pus. CCCXIX. Though this difeafe confifts- in an inflammatory af- fection, it does not commonly end either in fuppuration or gangrené. The troublefome circumftance of it feems to confift in a fpafm of the mufcles of the glottis, threatening fuffocation. cccxx. O F P H Y S I C. 121 cccxx, When this difeafe terminâtes in health, it is by re- folution of the inflammation, by a ceafing of the fpafm of the glottis, by an expectoration of the matter ex- fuding from the trachea, and of the crufts formed there* and frequently it ends without any expectoration, or at leaft with fuch only as attends an ordinary catarrh. CCCXXI. When the difeafe ends fatally, it is by a fuffocation feemingly depending upon a fpafm affedting the glottis j but fometimes, probably, depending upon a quantity of matter filling the bronchiae. CCCXXIÎ. As we fuppofe the difeafe to be an inflammatory af- fection, fo we attempt the cure of it by the ufual re- médies of inflammation,and which for the moft part we have found effectuai. Bleeding, both gênerai and to- pical, has often given immédiate relief, and, by being repeated, has entirely cured the difeafe. Bliftering alfo, near to the part affected, has been found ufeful. Upon the firft attack of the difeafe, vomiting, immediately after bleeding, feems to be of confiderable ufe, and fometimes fuddenly removes the difeafe. In every ftage of the difeafe, the antiphlogiftic regimen is neceffary, and particularly the fréquent ufe of laxative glyfters. Though we fuppofe that a fpafm affedting the glottis is often fatal in this difeafe, we have not found anti- fpafmodic medicines to be of any ufe. S E C T„ CL • 122 PRACTICE SECT. IV. Of the CYNANCHE P H A- RYNGiEA. cccxxni. In the Cynanche tonfillaris the inflammation of the mucous membrane often fpreads upon the pharynx, and into the beginning of the œfophagus, and thereby ren- ders déglutition more difficult and uneafy; but fuch a cafe does not require to be diftinguifhed as a diffèrent fpecies from the common Cynanche tonfillaris, and only requires that blood-letting, and other remédies, fhould be employed with greater diligence than in ordinary eafes. We have never feen any cafe in which the in- flammation began in the pharynx, or in which this part alone was inflamed; but pradtical writers have taken notice of fuch a cafe, and to them, therefore, I muft refer, both for the appearances which diftinguifh it, and for the method of cure. SECT. V. Of the CYNANCHE PARO- T I D M A. CCCXXIV. This is a difeafe known to the vulgar in every country of Europe, but has been little taken notice of by mé- dical » O F P H Y S I C. 123 dical writers. It is often épidémie, and manifeftly con- tagious. It cornes on with the ufual fymptoms of pyrexia which is foon after attended with a confiderable tumour of the external fauces and neck. This tumour appears firft as a glandular moveable tumour at the corner of the lower jaw ; but the fwelling foon becomes unïformly diffufed oyer a great part of the neck, fometimes on one fide only, but more commonly on both. The fwelling continues to increafe till the fourth day; but from that period it déclines, and in a few days more paffes off en- tirely. As the fwelling of the fauces recèdes, fome tumour affedts the tefticles in the malefex, or thebreafts in the female. Thefe tumours are fometimes large, hard, and fomewhat painful ; but are feldom either very painful or of long continuance. The pyrexia attending this difeafe is commonly flight, and recèdes with. the fwelling of the fauces; but fometimes, when the fwelling of the tefticles does not fucceedto that of the fauces, or when the prie or the other has been fuddenly repreflèd, the pyrexia becomes more confiderable, is often attended with delirium, and has fometimes proved fatal. CCCXXV. As this difeafe commonly runs its courfe without either dangerous or troublefome fymptoms ; fo it hardly requires any remédies. An antiphlogiftic regimen, and avoiding cold, are ail that will be commonly neceffary. But when, upon the receding of the fwellings, the pyr- exia cornes to be confiderable, and threatens an affedtion of the brain, it will be proper, by warm fomentations, to bring back the fwelling, and, by vomiting, bleeding, or bliftering, to obviate the confequences of its abfe|ice. C H A P. 124 PRACTICE C H A . P. VI. Of PNEUMONIC INFLAM- MATION. CCCXXVI. Under this title I mean to comprehend the whole of the inflammation affedting either the vifeera of the tho- rax, or the membrane lining the interior furface of that cavity; for neither do our diagnoftics ferve to afcertain exadtly the feat of the difeafe, nor does the différence in the feat of the difeafe give any confiderable différence in the ftate of the fymptoms, or lead to any différence in the method of cure. CCCXXVII. Pneumonie inflammation, however various in the feat of it, feems to me to be always known and diftinguifhed by the following fymptoms ; pyrexia, difficult breathing, cough, and pain in fome part of the thorax ; but thefe fymptoms are on diffèrent occafions varioufly modified. CCCXXVIII. The difeafe almoft; always cornes on with a cold ftage, and is accompanied with the other fymptoms of pyrexia, though, in a few inftances, the pulfe may be not more fréquent, nor the heat of the body increafed beyond what is natural. Somefimes the pyrexia is from the be- ginning accompanied with the other fymptoms; but frequently the pyrexia is formed for fome hours before the other fymptoms become confiderable, and particu- larly before the pain be felt. For the moft part, the pulfe O F P H Y S I C. 125 •pulfe is fréquent, full, ftrong, hard, and quick; but, in a few inftances, efpecially in the advanced ftate of the difeafe, the pulfe is weak and foft, and at the famé time irregular. CCCXXIX. The difficulty of breathing is always prefent, and moft confiderable in infpiration, both becaufe the lungs do not eafily admit of a full dilatation, and becaufe the dilatation aggravâtes the pain attending the difeafe. The difficulty of breathing is alfo greater when the patient is in one pofture of the body rather than another. It is generally greater when he lies upon the fide affected ; but fometimes the contrary happens. Very often the patient cannot lie eafy upon either fide, and can find eafe only when lying on the baçk ; and fometimes he cannot breathe eafily, except when in fomewhat of an eredt pofture. CCCXXX. A cough always attends this difeafe ; but, in diffèrent cafés, is more or lefs urgent and painful. It is fome- times dry, that is, without any expectoration, efpecially in the beginning of the difeafe ; but more commonly it is, even from the firft, moift, and the, matter fpit up various, both in confiftence and colour; and frequently it is ftreaked with blood. CCCXXXL The pain attending this difeafe, is, in diffèrent cafés, felt indiffèrent parts of the thorax, but moft frequently in one fide. It has been faid to affect the right fide more commonly than the left ; but this is not certain ; while, on the other hand, it is certain, that the left fide has very often been affedted. The pain is fometimes felt as if it were under the fternum, fometimes in the back, between the fhoulders, and, when in the fides, its place has been higher or lower, more forward or backward ; but the place of ail others moft frequently affected, is about i26 PRACTICE about the fixth, or feventh rib, near the middle of its length, or a little more forward. The pain is often fevere and pungent, but fometimes more dull and obtufe, with a fenfe of weight rather than of pain. It is moft efpecially fevere and pungent when occupying the place laft mentioned. For the moft part, it continues fixed in one place, but fometimes fhoots from the fide to the fcapula, on one hand, or to the fternum and claviclc on the other. CCCXXXII. The diffèrent ftate of fymptoms now mentioned does not always afcertain exadtly the feat of the difeafe. To me it feems probable, that the difeafe is always feated, or at leaft begins in fome part of the pleura, taking that membrane in its greateft extent, as now commonly un- derftood ; that is, as covering not only the internai fur- face of the cavity of the thorax, but alfo as forming the mediaftinum, and as extended over the pericardium, and over the whole furface of the lungs. CCCXXXIIL There is therefore little foundation for diftinguifhing this difeafe by diffèrent appellations taken from the part which may be fuppofed to be chiefly affected. Theterm Pleurify might be properly applied to every cafe of the difeafe; and is very impropèrly limited to that inflam- mation which begins in. and chiefly affedts the pleura coftalis. We believe that fuch a cafe does truly occur ; but we alfo believe it to be a rare occurrence, and that the difeafe much more frequently begins in, and chiefly affedts the pleura invefting the lungs, producing ail the fymptoms fuppofed to belong to what has been called the Pleuritis vera. CCCXXXIV. Some phyficians have imagined, that there is a cafe of pneumonie inflammation, particularly entitled to the appellation of Peripneumony, and that is, the cafe of an 1 inflammation O F P H Y S I C. ïif inflammation beginning in the parenchyma, or cellular texture of the lungs, and having its feat chiefly there. But it feems to me very doubtful, if any acute inflam- mation of the lungs, or any difeafe which has been called peripneumony, be of that kind. It feems probable, that every acute inflammation begins in membranous parts ; and, in every diffedtion of perfons dead of peri- pneumony, the external membrane of the lungs, or fome part of the pleura, has appeared to have been con- fiderably affected. CCCXXXV. An inflammation of the pleura covering the upper furface of the diaphragm, has been diftinguifhed by the appellation of Paraphrenitis, as fuppofed to be attended with the peculiar fymptoms of delirium, rifus fardonicus, and other convulfive motions ; but it is certain, that an inflammation of that portion of the pleura, and affedting alfo even the mufcular fubftance of the diaphragm, has often taken place without any of the fymptoms men- tioned ; and I have met neither with diffedtions, nor any accounts of diffedtions, which fupport the opinion, that an inflammation of the pleura covering the dia- phragm, is attended with delirium more commonly than any other pneumonie inflammation. CCCXXXVL With refpect to the feat of pneumonie inflammation, we muft obferve further, that, although it may arife and fubfift chiefly in one part of the pleura only, it is how- ever frequently communicated to other parts of the famé, and commonly communicates a morbid affection to the whole extent of it. 4 CCCXXXVIL The remote caufe of pneumonie inflammation is, commonly, cold applied to the body, obftrudting per- fpiration, and determining to the lungs, while at the famé time the lungs themfelves are expofed to the action 128 PRACTICE q{ cold. Thefe circumftances operate efpecially when an inflammatory diathefis prevails in the fyftem ; and, therefore, upon perfons of the greateft vigour ; in cold climates ; in the- winter-feafon ; and particularly in the fpring, when viciffitudes of heat and cold are fréquent. The difeafe, however, may arife in any feafon when fuch viciffitudes take place. Other remote caufes alfo may have a fhare in this matter, fuch as every means of obftrudting, ftraining* or otherwife injuring the pneumonie organs. The pneumonie inflammation has been fometimes fo much an épidémie, as to occafion a fufpicion of its de- pending upon a fpecific contagion ; but we have not met with any évidence in proof of this. See Morgagni de caufiset fedibus morborum, epift. 21. art. 26. CCCXXXVIIL The pneumonie^ like other inflammations, may ter- minate by refolution, fuppuration, or gangrené ; but it bas alfo a termination peculiar to itfelf, as has been hinted above, (CCLIV.) and which is, when it is at- tended with an effufion of blood into the cellular texture of the lungs, which foon interrupting the circulation of the blood through this vifeus, produces a fatal fuffo- cation. This indeed feems to be the moft common ter- mination of pneumonie inflammation, when itendsfa- tally ; for, upon the diffedtion of almoft every perfon dead of that difeafe, it has appeared that fuch an effufion had happened. CCCXXXIX. From the famé diffedtions, we learn, that pneumonie inflammation commonly produces an exfudation from the internai furface of the pleura, which appears partly as a foft vifeid cruft, often of a compact membranous form, covering every where the furface of the pleura, and par- ticularly thofe parts where the lungs adhère to the pleura coftalis, or mediaftinum ; and this cruft feems always to be the cernent of fuch adhefions* Th« O F P H Y S I C. 129 The/ame exfudation fhews itfelf alfo by a quantity of a ferous fluid commonly found in the cavity of the tho- rax ; and fome exfudation or effufion is ufually found to have been made alfo into the cavity of the pericardium. CCCXL. It feems probable alfo, that a like effufion is fometimes . made into the cavity of the bronchiae ; for, in fome per- fons who have died after labouring under a pneumonie inflammation for a few days only, the bronchise have been found filled with a confiderable quantity of a ferous and thickifh fluid, which I think muft be confidered rather as the effufion above mentioned, having had its thinner parts taken off by refpiration, than as a pus fo fuddenly formed in the inflamed part. CCCXLI. It is, however, not improbable, that this effufion, as Well as that, made into the cavities of the thorax and pericardium, may be a matter of the famé kind with that which, in other inflammations, is poured into the cel- lular texture of the parts inflamed, and there converted into pus; but, in the thorax and pericardium, it does not always put on that appearance, becaufe the cruft covering the furface prevents the abforption of the thinner part. This abforption, however, may be com- penfated in the bronchiae, by the drying power of the air; and therefore the effufion into them may put on a more purulent appearance. In many cafés of pneu- monie inflammation, when the Sputa are very copious, it is difficult to fuppofe, that the whole of them proceed from the mucous follicles of the bronchiae. It feems probable that a great part of them may proceed from the effufed ferous fluid we have been mentioning; and this too will account for the fputa being fo often of a purulent appearance. Perhaps the famé thing will ac- count for that purulent expectoration, and that pu- rulent matter found in the bronchiae, which the learned Mr. de Haen fays he had often obferved, when there was no ulcération of the lungs; and this explanation is R at J 130 PRACTICE at leaft more probable than Mr. de Haen's fuppofition of a pus formed in the circulating blood. CCCXLII. To conclude this fubject, we are of opinion, that the effufion into the bronchiae, which we have mentioned (CCCXL.) often concurs with the effufion of red blood (CCCXXXVIIL) in occafioning the fuffocation which fatally terminâtes pneumonie inflammation ; that the effufion of ferum alone may have this effedt; and, that the ferum poured out in a certain quantity, rather than any debility in the powers of expectoration, is the caufe of that ceafing of expectoration which précèdes the fatal event; for, in many cafés, the expectoration has ceafed, when no other fymptoms of debility have appeared, and when, upon diffedtion, the bronchiae have been found full of liquid matter. ' Nay, it is even probable, that, in fome cafés, fuch an effufion may take place, without any fymptoms of violent inflammation ; and, in other eafes, the effufion taking place may feem to remove the fymptoms of inflammation which had ap- peared before, and thus account for thofe unexpedted fatal terminations which have fometimes happened. Per- haps this effufion will account alfo for many of the phenomena of the Peripneumonia Notha. CCCXLIII. Pneumonie inflammation feldom terminâtes by refo- lution, without being attended with fome évident évacu- ation. An hemorrhage from the nofe happening on fome of the firft days of the difeafe, has fometimes put an end to it ; and it is faid, that an évacuation from the hemorrhoidal veins, a bilious évacuation by a ftool, and an évacuation of urine, with a copious fediment, have feverally had the famé effedt ; but fuch occurrences have been rare and unufu"al. The évacuation moft frequently attending, and feem- ing to have the greateft effedt in promoting refolution, is an expectoration of a thick white or yellowifh matter, a little O F P H Y S I C. I31 a little ftreaked with blood, copious, and brought up without much or violent coughing. Very frequently the refolution of this difeafe is attended with, and perhaps produced by a fweat, which is warm, fluid, copious, over the whole body, and at- tended with an abatement of the frequency of the pulfe, of the heat of the body, and of other fébrile fymptoms. CCCXLIV. The prognoftics in this difeafe are formed from the ftate of the principal fymptoms. (CCCXXVII.) A violent pyrexia is always dangerous. The danger, however, is chiefly dënoted by the dif- ficulty of breathing. When the patient can lie on one fide only ; when he can lie on neither fide, but upon his back only; when he cannot breathe with tolerable eafe, 1 except when the trunk of his body is eredt ; when, even in this pofture, the breathing is very difficult, and at- tended with a turgefcence and flufhing of the face, with partial fweats about the head and neck, and an irregular pulfe ; thefe circumftances mark the difficulty of breath- ing in diffèrent degrees, and, confequently, in pro- portion, the danger of the difeafe. A fréquent violent cough aggravating the pain, is al- ways the fymptom of an obftinate difeafe. As we believe that the difeafe is hardly eyer refolved, without fome expectoration, fo a dry cough muft be always an unfavourable fymptom. As the expectoration defcribed (CCCXLIII.) is a mark that the difeafe is proceedingto a refolution, fo an expectoration, which has not thefe conditions, muft de- note at leaft a doubtful ftate of the difeafe; but the marks taken from the eolqur of the matter are for the moft part fallacious. An acute pain, very much interrupting infpiration, is always the mark of a violent difeafe, but not of â more dangerous difeafe than an obtufe pain, attended with very difficult refpiration. When the pains which at firft had affected one fide only, fhall afterwards fpread into the other, or, when leaving 132 PRACTICE leaving the fide firft affected, they entirely pafs into the other, thefe are always marks of a dangerous difeafe. A delirium coming on during a pneumonie inflam- mation, is always a fymptom denoting much danger. CCCXLV. When the termination of this difeafe proves fatal, it is on one or other of the days of the firft week, from the third to the feventh. This is the moft common cafe; but, in a few inftances, death has happened at a later period of the difeafe. When the difeafe is violent, but admitting of refo- lution, this alfo happens frequently in the courfe of the firft week ; but, in a more moderate difeafe, the refo- lution is often put off to the fécond week. The difeafe generally fuffers a remiffion on fome of the days from the third to the feventh ; which, however, may be often fallacious, as the difeafe fometimes returns again with as much violence as before, and in fuch cafe with great danger. Sometimes the difeafe difappears on the fécond or third day, while an eryfipelas makes its appearance on fome external part; and, if this continues fixed, the pneu- monie inflammation does not recur. If the difeafe continue beyond the fourteenth day$ it generally terminâtes in a fuppuration. CCCXLVI. The confideration of this termination by fuppuration, is referred to our chapter on Phthifis. The termination by gangrené is much more rare than has been imagined ; and, when it does occur, it is ufually Joined with the termination by effufion, (CCCXaXVIIL) and the fymptoms of the one are hardly to be diftinguifhed from thofe of the other. CCCXLVIL The cure of pneumonie inflammation muft proceed upon the gênerai plan (CCLIX) ; but the importance of O F P H Y S I C. 133 of the part affedted, and the danger to which it is ex- pofed, requires that the remédies be fully, as well as early, employed. CCCXLVIII. The remedy chiefly to be depended upon is that of bleeding at the arm, which will be performed with moft advantage in the arm of the fide affedted, but may be done in either arm, as may be moft convenient for the patient or the furgeon. The quantity muft be fuited to the violence of the difeafe, and the vigour of the pa- tient; and, generally, ought to be as large as this laft circumftance will allow. The remiffion of pain, and the relief of refpiration, during* the flowing of the blood, may limit the quantity to be then drawn ; but, if thefe fymptoms of relief d® nbt appear, the bleeding fhould be continued till the fymptoms of a beginning fyncope come on. It is feldom that one bleeding, how- ever large, will prove a cure of this difeafe; and, though the pain and difficulty of breathing may be much relieved by the firft bleeding, thefe fymptoms commonly, and after no long interval, recùr ; often with as much vio- lence as before. In the event of fuch récurrence, the bleeding is to be repeated, even in the courfe of the famé day, and perhaps to the famé quantity as before. Sometimes the fécond bleeding may belarger than the firft. There are perfons who, by their conftitution, are ready to faint even upon a fmall bleeding; and, in fuch perfons, this may prevent the drawing fo much blood at firft as a pneumonie inflammation may require ; but,, as the famé perfons are fometimes found to bear after-bleed- ings better than the firftj this allows the fécond and fub- fequent bleedings to be larger, and to fuch a quantity as the fymptoms of the difeafe may feem to require. CCCXLIX. Itis according to the ftate of the fymptoms, that bleedings are to be repeated ; and they will be more effectuai when " pradtifed in the courfe of the firft three days than afterwards ; but they are not to be omitted, al though 134 PRACTICE although four days of the difeafe may have already elapfed. If the phyfician fhall not have been called in fooner, or if the bleedings fhall not have been large enough during the firft days, or even although thefe bleedings fhall have procured fome remiffion ; yet, upon the récurrence of the urgent fymptoms, bleeding fhould be repeated at any period of the difeafe, efpecially within the firft fortnight ; and even afterwards, if a tendency to fuppuration be not évident, or if, after a feeming folution, the difeafe fhall have again returned. CCCL. With refpect to the quantity of blood which ought, or which with fafety may be taken away, no gênerai rules can be delivered, as it muft be very diffèrent, ac- co/ding to the ftate of the difeafe, and the conftitution of the patient. In an adult maie of tolerable ftrength, a pound of blood, Averdupois, is a full bleeding. Any quantity above twenty ounces is a large, and any quan- tity below twelve, a fmall bleeding. A quantity of from four to five pounds, in the courfe of two or three days, is generally as much as fuch patients will fafely bear ; but, if the intervais between the bleedings, and the whole of the time during which the bleedings have been employed has been long, the quantity taken upon the whole may be greater, CCCLL. When a large quantity of blood has been already taken from the arm, and it is doubtful if more can be taken with fafety in that manner, fome blood may ftill be taken by cupping and fcarifying. Such a meafure will be efpecially proper, when the continuance or ré- currence of pain, rather than the difficulty of breathing, becomes the urgent fymptom ; and then the cupping and fcarifying fhould be made as near to the pained part as can conveniently be done. CCCLII. O F P H Y S I C. *35 CCCLII. An expectoration takes place fometimes very early in this difeafe ; but if, notwithftanding thereof, the urgent fymptoms fhould ftill continue, the expectoration muft not fuperfede the bleedings we have mentioned ; and, during the firft days of the difeafe, its folution is not to be trufted to the expectoration alone. It is in a more advanced ftate only, and when the fymptoms have fuf- fered a confiderable remiffion, that we may truft the en- tire cure to a copious and free expectoration. CCCLIII. During the firft days of the difeafe, we do not find that bleeding ftops expectoration. ' On the contrary, we have often found bleeding promote it; and it is in a more advanced ftate of the difeafe only, when the patient, by large évacuations, and the continuance of the difeafe, has been already exhaufted, that bleeding feems to ftop expectoration. We are of opinion, that even then bleeding does not ftop expedtoration, fo much by weakening the powers of expectoration, as by favouring the ferous effufion into the bronchiae, (CCCXL.) and thereby preventing it. CCCLIV. While the bleedings we have mentioned fhall be em- ployed, it will be neceffary to employ alfo every part of the antiphlogiftic regimen, (CXXIII. ÇXXIV.) and particularly to prevent the irritation which might arife from any increafe of heat. For this purpofe, it will be proper to keep the patient out of bed, while he can bear it eafily, and, when he cannot, to cover him very lightly while he lies in bed. The température of his chamber ought not to exceed fixty degrees of Fahren- heit's thermometer ; and whether it may be at any time colder, I am uncertain. CCCLV. 136 PRACTICE CCCLV. Mild and diluent drinks, moderately tepid, at leaft never cold, given by fmall portions at a time, ought to be adminiftered plentifully. Thefe drinks may be im- pregnated with vegetable acids. They may be properly accompanied alfo with nitre, or fome other neutrals ; but thefe faits fhould be given feparately from the drink. It has been alledged, that both acids and nitre are ready to excite coughing, and in fome perfons they cer- tainly have this effedt ; but, except in perfons of a pe- culiar habit, we have not found their effects in exciting coughs fo confiderable or troublefome as to prevent our feeking the advantages otherwife to be obtained from thefe medicines. CCCLVI. Some pradtitioners have doubted, if purgatives can be fafely employed in this difeafe ; and indeed a fponta- neous diarrhoea occurring in the beginning of the dif- eafe has feldom proved ufeful ; but we have found the moderate ufe of cooling laxatives generally fafe ; and we have always found it ufeful to keep the belly open by fréquent emollient clyfters. CCCLVIL To excite vomiting by emetics, wejudgetobea dan- gerous pradtice in this difeafe; but we have found it ufeful to exhibit naufeating dofes ; and, in a fomewhat advanced ftate of the difeafe, we have found fuch dofes have proved the beft means of promoting expedtoration. CCCLVIII. Fomentations and poultices applied to the pained part have been recommended, and may be ufeful ; but the ap- plication of them is often inconvénient, and we omit it entirely O F P H Y S I C. 137 entirely for the fake of the more effectuai remedy, bliftering. Very early in the difeafe, a blifter fhould be applied as near to the pained part as poffible. But as, when the irritation of a blifter is prefent, it renders bleeding lefs effectuai ; fo the application of the blifter fhould be delayed till a bleeding fhall have been employed. If the difeafe be moderate, the blifter may be applied immedi- ately after the firft bleeding; but, if the difeafe be violent, and it is prefumed that a fécond bleeding may be neceffary foon after the firft, it will then be proper to delay the blifter till after the fécond bleeding, when it may be fuppofed that any farther bleeding may be poft- poned till the irritation arifing from the blifter fhall have ceafed. It may be frequently neceffary in this difeafe to repeat the bliftering, and, in that cafe, the plafters fhould always be applied fomewhere on the thorax ; for, when applied to more diftant parts, they have little ef- fedt. The keeping the bliftered parts open, and màking what is called a perpétuai blifter, has much lefs effedt than a frefh bliftering. CCCLIX. .As this difeafe often terminâtes by an expectoration, fome means of promoting this have been often propofed ; but none of them appear to be very effedtual, and fome of them, being acrid ftimulant fubftances, cannot be very fafe. The gums ufually employed feem too heating; fquills feem to be lefs fo ; but they are not very powerful, and fometimes inconvénient, by the confiant naufea they induce. The volatile alkali may be of fervice as an expec- torant ; but it fhould be referved for an advanced ftate of the difeafe. Mucilaginous and oily demulcents appear to be ufeful, by allaying that acrimony of the mucus which occafions too fréquent coughing; and which coughing prevents the ftagnation and thickeûing of the mucus, and thereby its becoming mild. S The 138 PRACTICE The receiving the fteams of warm water into the lungs, impregnated with vinegar, has often proved ufeful in prorhoting expectoration. But, of ail other remédies, the moft powerful for this purpofe, are antimonial medicines, given in nau- feating dofes, as in (CCCLVII.) Of thefe, however, we have not found the kermès minerai more efficacious than emetic tartar, or antimonial wine; and the dofe of the kermès is much more uncertain than that of the others. CCCLX. Though a fpontaneous fweating often proves the crifis of this difeafe, it ought not to be excited by art, unlefs with much caution. At leaft, we have not yet found it either fo effectuai or fafe as fome writers have alledged. When, after fome remiffion of the fymptoms, fpontaneous fweats of a proper kind arife, they may be encouraged ; but it ought to be without much heat, and without ftimulant medicines. If, however, the fweats be partial and clammy only, and a great difficulty of breathing ftill remain, it will be very dangerous to en- courage them. CCCLXI. Phyficians have differed much in opinion with regard to the ufe of opiates in pneumonie inflammations. To me it appears, that, in the beginning of the difeafe, and before bleeding and bliftering have produced fome remiffion of the pain, and of the difficulty of breathing, opiates have a very bad effedt by their increafing the difficulty of breathing, and other inflammatory fym- ptoms. But, in a more advanced ftate of the difeafe, when the difficulty of breathing has abated, and when the urgent fymptom is a cough, proving the chief caufe of the continuance of the pain, and of the want of fleep, opiates may be employed with great advantage and fafety. The interruption of the expedtoration, which they feem to occafion, is for a fhort time only; and they feem often to promote it, as they occafion a ftagnation O F P H Y S I C. *39 ftagnation of what was by fréquent coughing diflipated infenfibly, and therefore give the appearance of what phyficians have called Concodted Matter. CCCLXIL We might hère give a fedtion on the Carditis and Pericarditis, or the inflammations of the Heart and Pericardium ; but they hardly require a particular con- fideration. An acute inflammation of the Pericardium is almoft always a part of the famé pleuritic affection we have been treating of, and is not always diftinguifhed by any diffèrent fymptoms ; or, if it be, does not require any diffèrent treatment. The famé may be faid of an acute inflammation of the heart itfelf; and, when it happens that the one or other is difcovered by the fymptoms of palpitation or fyncope, no more is implied, than that the remédies of pneumonie inflammation fhould be employed with greater diligence. From diffedtions, which fhew the heart and peri- cardium affedted with erofions, ulcérations, and ab- fceflès, we difeover, that thefe parts had before been affected with inflammation ; and while, at the famé time, no fymptoms of pneumonie inflammation had appeared, jt may be alledged, that thofe inflammations of the heart and pericardium fhould be confidered as difeafes independent of the pneumonie. This indeed is juft; but the hiftory of fuch cafés proves, that the inflammation had been of a chronic kind, and hardly difeovering themfelves, by any peculiar fymptoms, or, if attended with fuch as marked an affection of the heart, thefe are, at the famé time, fuch as have been known frequently to arife from other caufes than inflammation. There is, therefore, upon the whole, no room for our treating more particularly of the inflammation of tho heart or pericardium. C H A P. 140 PRACTICE C H A P. VIL Of the GASTRITIS, or INFLAM- MATION of the STOMACH. CCCLXIIL Among the inflammations of the abdominal région, we have given a place in our Nofology to the Peritonitis, comprehending under this title, not only the inflam- mations affedting the peritonaeum lining the cavity of the abdomen, but thofe alfo affedting the extenfions of this membrane in the omentum and mefentery. We are not, however, to treat of them hère, becaufe we cannot fay by what fymptoms they are always to be known ; and farther, becaufe, when known, they do not require any remédies befides thofe of inflammation in gênerai. We proceed, therefore, to treat of thofe inflammations which, affedting vifeera of peculiar functions, both give occafion to peculiar fymptoms, and require fome peculi- arities in the method of cure. We begin with the in- flammation of the ftomach. CCCLXIV. The inflammation of the ftomach is of two kinds, Phlegmonic, or Eryfipelatous. The firft may be feated in what is called the Nervous Coat of the ftomach, or in the peritonaeum invefting it. The fécond is always feated in the Villous coat and cellular texture im- mediately fubjacent. CCCLXV. O F P H Y S I C. 141 CCCLXV. The phlegmonic inflammation of the ftomach, or what has been commonly treated of under the title of Gaftritis, is known by an acute pain in fome part of the région of the ftomach, attended with pyrexia, fréquent vomiting, efpecially upon any thing being taken down into the ftomach, and frequently with hiccup. The pulfe is commonly fmall and hard, and there isa greater lofs of ftrength in ail the functions than in the cafe of almoft any other inflammation. CCCLXVI. This inflammation may be produced by various caufes ; as, by external contufion ; by acrid s of various kinds taken into the ftomach ; frequently by very cold drink taken into it, while the body is very warm, and fometimes by over-diftention, from the having taken in a large quantity of food of difficult digeftion. Ail thefe may be confidered as external caufes ; but the difeafe fometimes arifes alfo from internai caufes not fo well underftood. It may arife from inflammations of the neighbouring parts communicated to the ftomach, and then is to be confidered as a fymptomatic affection. It may arife alfo from various acrimony generated within the body, either in the ftomach itfelf, or in other parts, and poured into the cavity of the ftomach. Thefe are caufes more diredtly applied to the ftomach j but there are others originating perhaps- elfewhere, and affedting the ftomach only fympathically. Such feem to have acted in the cafe of putrid fevers and exanthematic pyr- exiae, in which we have found, upon diffedtion, the ftomach to have heen affected with inflammation. CCCLXVII. From the fenfibility of the ftomach, and its commu- nication with the reft of the fyftem, it will be obvious, that the inflammation of this organ, by whatever caufes produced, may be attended with fatal confequences. Particularly, 14* PRACTICE Particularly,. by the great debility which it fuddenly produces, itmay prove fuddenly fatal, without running the common courfe of inflammations. When it lafts long enough to follow the ordinary courfe of other inflammations, it may terminate by refolution, gangrené, or fuppuration. The fchirrofities which are often found to affect the ftomach, arc feldom known to be the confquences of inflammation. CCCLXVIII. The tendency of this difeafe to admit of refolution, may be known by its having arifen from no violent caufe, by the moderate ftate of the fymptoms, and by a graduai remiffion of thefe fymptoms in the courfe of the firft, or, at moft, of the fécond week of the difeafe. CCCLXIX. The tendency to gangrené may be fufpedted from the violence of the fymptoms not yiclding to the remédies employed during the firft days of the difeafe ; and that a gangrené has already begun, may be known from the fudden remiffion of the pain, while the frequency of the pulfe continues, and, at the famé time, becomes weaker, accompanied with other marks of the increafing debility of the whole fyftem. CCCLXX. The tendency to fuppuration may be known by the fymptoms continuing, but in a moderate degree, for more than one or two weeks, and by a confiderable remiffion of the pain, while a fenfe of weight and an anxiety ftill remain. When an abfcefs has been formed, the frequency of the pulfe is at firft abated ; but foon after it is again increafed, with fréquent cold fhiverings, and with marked exacerbations in the afternoon and evening, followed by night fweatings, and other fymptoms of hectic fever. Thefe at length prove fatal, unlefs the abfcefs O F P H Y S I C. J43 abfcefs open into the cavity of the ftomach, the pus be evacuated by vomiting, and the ulcer foon healed. CCCLXXI. It appears, from the diffedtion of dead bodies, that the ftomach very often has been affedted with inflam- mation, when the charadteriftic fymptoms of it had not appeared ; and therefore we cannot lay down any gênerai rules for the cure of this difeafe. CCCLXXII. It is only in the cafe of phlegmonic inflammation, as charadterifed in (CCCLXV.), that we can advife the cure or refolution to be attempted by large and repeated bleedings employed early in the difeafe ; and from thefe we are not to be deterred by the fmallnefs of the pulfe ; for, after bleeding, it commonly becomes fuller and fofter. After bleeding, a blifter ought to be applied to the région of the ftomach, and the cure will be affifted by fomentations of the whole abdomen, and by fréquent emollient and laxative clyfters. CCCLXXIII. The irritability of the ftomach, in this difeafe, will admit of no internai medicines being thrown into it ; and, if any can be fuppofed neceffary, they muft be ex- hibited in clyfters. The giving of drink may be tried ; but it ought to be of the very mrldeft kind, and in very fmall quantifies at a time. CCCLXXIV. Opiates, in whatever manner exhibited, are very hurtful during: the firft days of the difeafe ; but, when the violence ofthe difeafe fhall have abated, and when the violence of the pain and vomiting recur at intervais only, opiates given in clyfters may be cautioufly tried, and fometimes have been employed with advantage. CCCLXXV. 144 PRACTICE CCCLXXV. A tendency to gangrené in this difeafe is to be obviated only by the means juft now propofed ; and, when it does adtually fupervene, admits of no remedy. CCCLXXVI. A tendency to fuppuration is only to be obviated by the famé means employed early in the difeafe. After a certain period, it cannot be prevented by any means whatever ; and, when adtually begun, muft be left to nature ; the only thing that can be done by art, being to avoid ail irritation. CCCLXXVII. Eryfipelatous inflammations of the ftomach, are more fréquent than thofe of thephlegmonic kind. It appears, at leaft, from diffedtions, that the ftomach has often been affected with inflammation, when neither pain nor pyr- exia had before given any notice of it ; and fuch we judge to have been chiefly of the eryfipelatous kind. This kind of inflammation alfo, is efpecially to be ex- pedted from acrimony of any kind applied to the ftomach, and would certainly occur more frequently from fuch a caufe, were not the interior furface of this organ com- monly defended by mucus exfuding in large quantity from thenumerous follicles placed immediatly under the villous coat. On many occafions, however, the exfu- dation of mucus is prevented, or the liquid poured out is of a lefs vifcid kind, fo as to be lefs fitted to défend the fubjacent nerves ; and it is in fuch cafés that acrid matters may readily produce an eryfipelatous affection of the ftomach. CCCLXXVIII. From what has been faid, it muft appear, that an eryfipelatous inflammation of the ftomach may frequently oçcur, O F P H Y S I C. H5 occur, but will not always difcover itfelf, as it fome- times takes place without pyrexia, pain, or vomiting, CCCLXXIX. There are cafés, however, in which it may he dif- covered. The affection of the ftomach fometimes fpreads into the œfophagus, and appears in the pharynx, and on the whole internai furface of the mouth. When, there- fore, an eryfipelatous inflammation affedts the mouth and fauces, and there fhall be at the famé time in the ftomach an unufual fenfibility to ail acrids, and alfo a fréquent vomiting, there can be little doubt of the ftomach's being affected with the famé inflammation that has appeared in the fauces. Even when no inflam- mation appears in the fauces, «if fome degree of pain be felt in the ftomach, if there be a want of appetite, an anxiety, and fréquent vomiting, and unufual fenfibility with refpect to acrids, fome thirft, and frequency 6f pulfe, there will thenbe room to fufpedt an inflammation of the ftomach ; and we have known fuch fymptoms, after fome time, difcover their caufe more clearly by the inflammation's appearing in the fauces or mouth. Eryfipelatous inflammation is often difpofed to fpread from one place to another on the famé furface, and, in doing fo, to leave the place it had at firft occupied. Thus, we have known fuch an inflammation fpread fuc- cefîively along the whole length of the alimentary canal, occafiom'ng in the inteftines diarrhoea, and in the ftomach vomitings, the diarrhœa ceafing when the vomitings come on, and, on the other hand, the vomitings on the coming on of the diarrhœa. CCCLXXX, When an eryfipelatous inflammation of the ftomach is difcovered, it is to be treated differently according to ' the différence of its caufes and fymptoms. When it is owing to acrid matters taken in by the mouth, and thefe may be fuppofed ftill prefent in the ftomach, they are to be wafhed out by throwing in a large quantity of warm and mild liquids, "md by ex- T citing i46 PRACTICE citing vomiting. At the famé time, if the nature of the acrimony and its proper corredtor be known, this fhould be thrown in ; or, if a fpecific corredtor be not known, fome gênerai demulcents fhould be employed. CCCLXXXI. Thefe meafures, however, are more fuited to prevent than to cure inflammation, after it has taken place. When this laft may be fuppofed to be the cafe, if it be attended with a fenfe of heat, with pain and pyrexia, according to the degree of thefe fymptoms, the meafures propofed in (CCCLXXII. et feq.) are to be more or lefs employed. CCCLXXXII. When an eryfipelatous inflammation of the ftomach has arifen from internai caufes, if pain and pyrexia ac- company the difeafe in perfons not otherwife weakened, fome bleeding may be employed ; but, as the affection often arifes in putrid difeafes, and in convalefcents from fever, in fuch cafés, bleeding is not admiffible, ail that can be done being to avoid irritation ; and only throwing into the ftomach what quantity of acids, and of acefcent aliments, it fhall be found to bear. In fume conditions of the body, in which this difeafe arifes, the Peruvian bark and bitters may feem to be indicated ; but an.eryfi- pelatous ftate of the ftomach does not commonly allow of them. C H A P. O F P H Y S I C. 147 C H A P. VIII. Of the ENTERITIS, or INFLAM- MATION of the INTESTINES. COtLXXXIII. The inflammation of the inteftines,, like that of the ftomach, may be either phlegmonic, or eryfipelatous ; but, on the fubject of the latter, I have nothing to add to what I have faid m the laft ehapter ; and fhall hère therefore treat of the phlegmonic inflammation only. CCCLXXXIV, This inflammation may be known to be prefent by a fixed pain in the abdomen, attended with a pyrexia, coftivenefs, and vomiting. Pradtical writers mention the pain in this cafe as felt in diffèrent parts of the ab- domen, according to the diffèrent feat of the inflam- mation; and fo indeed it fometimes happens, but very often the pain fpreads over the whole belly, and is felt more efpecially about the navel. CCCLXXXV, The enteritis and gaftritis arife from like caufes ; but, the former, more readily than the latter, from cold ap- plied to the lower extremities, or to the belly itfelf. The enteritis has likewife its peculiar caufes, as fuper- vening upon the fpafmodic colic, incarcerated hernia, and volvulus. CCCLXXXVI. x48 P'R A C T I C E CCCLXXXVL Inflammations of the inteftines have the famé termi- nations as thofe of the ftomach, and, in both cafés, the feveral tendencies are tobe difcovered by the famé fym- ptoms (CCCLXVIII. ÇCCLXIX. CCÇLXX.) CCCLXXXVII. The cure of the enteritis is in général the famé with thatof the gaftritis (CCCLXXII. et feq.) ; but, in the former, there is commonly more accefs to the intro- duction of liquids, of acid, acefccnt, and other cooling remédies, and even of laxatives ; but, as a vomiting fo frequently attends the enteritis, care muft be taken not to excite that vomiting by either the quantity or the quality of any thing thrown into the ftomach. CCCLXXXVIII. Under the title of Enteritis, it has been common with pradtical writers to treat of the remédies proper for the colic, and its higher degree, named Iléus ; but, though it be true that the enteritis and colic frequently accom- pany each other, we ftill hold them to be diftindt dif- eafes, to be often occurring feparately, and accordingly to require and admit of diffèrent remédies. We fhall therefore delay fpeaking of the remédies proper for the colic till we fhall come to treat of this difeafe. CCCLXXXIX. What occurs to be faid with refpect to the fup- puration, or gangrené, occurring in the enteritis, may be fufficiently underftood from what has been faid on the famé fubjects with refpedt to the gaftritis. C H A P. OP PHYSIC, 14g C H A P. IX. Of the HEPATITIS, or INFLÀM* MATION of the LIVER. CCCXC. The inflammation of the liver feems to be of tw« kinds, the one acute, the other chronic. CCCXCL The acute is attended with pungent pain, confiderable pyrexia, a fréquent, ftrong, and hard pulfe, and high çoloured urine., CCCXCIL The chronic hepatitis very often exhibits none of thefe fymptoms, (CCCXCL) and we only difcover it to have happened by our finding large abfceflès in the liver, which are prefumed to be the effedt of fome degree of inflammation. As this chronic inflammation is not to be certainly known, and therefore does not lead to any certain pradtice, we omit treating of it hère, and fhall only treat of what relates to the acute fpecies of the hepatitis. CCCXCIII. The acute hepatitis may be known by a pain more or lefs acute in the right hypochondrium, increafed by preffing upon the part. The pain is very often in fuch a part of the fide as to make it appear as that of a pleu- rify; and frequently, like that, is increafed on infpi- ration. 150 PRACTICE ration. The difeafe is fometimes alfo attended with a cough, which is commonly dry, but fometimes humid. When the pain thus refembles that of a pleurify, the patient cannot lie eafily except upon the fide affected. In every kind of acute hepatitis, the pain is often ex- teoded to the clavicle, and to the top of the fhoulder. The difeafe is attended fometimes with hiccup, and fometimes with vomiting. Many pradtical writers have mentioned the jaundice, or a' yellow colour of the fkin and eyes, as a very confiant fymptom of the hepatitis ; but expérience hath fhown, that the difeafe may often occur without any fuch fymptom. CCCXCIV. The remote caufes of hepatitis are not always to be difeerned, and many have been affigned on a very uncer- tain foundation. It is to be obferved, that, in many cafés of pneumonie inflammation, the liver appears con- fiderably enlarged, and fometimes the pneumonie inflam- mation is joined with the hepatitis, cccxcv. Ithas been fuppofed that the hepatitis may be an af- fection either of the extremities of the hepatic artery, or thofe of the vena portarum ; but of the laft fup- pofition there is neither évidence nor probability. CCCXCVI. It feems probable that the acute hepatitis is always an affection of the external membrane of the liver, and that the parenchymatic is of the chronic kind. The acute difeafe may be feated either on the convex or on the concave furface of the liver. In the former cafe, a more pungent pain and hiccup may be produced, and the refpiration is more confiderably affected. In the latter, there occurs lefs pain, and a vomiting is pro- duced, commonly by fome inflammation communicated to the ftomach. The inflammation of the concave fur- face of the liver may be readily communicated to the gall- O F P H Y S I C. 151 gall-bladder and biliary dudts ; and this perhaps is the only cafe.of idiopathic hepatitis attended with jaundice. CCCXCVII. The hepatitis, like other inflammations,. may end by refolution, fuppuration, or gangrené ; and the tendency to the one or the other of thefe events may be known from what has been delivered above (CCXLIV. CCXLV. CCXLVI. CCL. CCLI. CCLII. CCCLXVIIL CCCLXIX. CCCLXX.) CCCXCVIIL The refolution of hepatitis is often the confequence of, or is attended with évacuations of diffèrent kinds. A hemorrhagy fometimes from the nofe, and fometimes from the hemorrhoidal veflèls, gives a folution of the difeafe. Sometimes a bilious diarrhœa contributes to the famé event; and the refolution of the hepatitis, as of the other inflammations, is attended with fweating, and with an évacuation of urine, depofiting a copious fediment. Can this difeafe be refqlved by expectoration ? It would feem to be fometimes cured by an eryfipelas ap- pearing in fome external part. CCCXCIX. When this difeafe has ended in fuppuration, the pus collected may be difcharged by the biliary dudts ; or, if the fuppurated part does nat any where adhère clofely to the neighbouring parts, the pus may be difcharged into the cavity of the abdomen ; but if, during the firft. ftate of inflammation, the affedted part of the liver fhall have formed a clofe adhefion to fome of the neighbouring parts, the difcharge of the pus after fuppuration may be various, according to the diffèrent feat of the abfcefs. When feated on the convex part of the liver, if the adhefion be to the peritonaeum lining the common tégu- ments, the pus may make its way through thefe, and be difcharged outwardly; or, if the adhefion fhall have been to the diaphragm, the pus may penetrate through Î52 PRACTICE thrs, and into the cavity of the lungsj and through this may be difcharged by coughing. When the abfcefs of the liver is feated on its concave part, in confequence of adhefions, the pus may be difcharged into the ftomach or inteftines; and into thefe laft,either diredtly, or by the intervention of the biliary dudts. CCCC. The prognoftics in this difeafe are eftablifhed upon the gênerai principles relating to inflammation, upon the particular circumftances of the liver, and upon the particular ftate of its inflammation. CCCCL The cure of this difeafe muft proceed upon the gênerai plan, by bleeding, more or lefs, according to the ur- gency of pain and pyrexia; by the application of blifters; by fomentations of the external parts in the ufual man- ner, and of the internai parts by fréquent emollient clyfters; by frequently opening the belly by means of gentle laxatives; and by diluent and réfrigérant re- médies. CCCCII. When a fuppuration has been formed, and the abfcefs points outwardly,* the. part muft be opened, the pus evacuated, and the ulcer healed, according to the or- dinary rules for cleanfing and healing fuch abfceffes and ulcers. CCCCIII. We might hère confider the fplenitis, or inflammation of the fpleen. It does not, however, feem neceffary, becaufe the difeafe very feldom occurs. When it does, it may be readily known by the charadter given in our Nofology ; and its various event, and the pradtice it requires,' may be underftood from what has been faid above on the inflammations of the other abdominal vifeera. C H A P. O F P H Y S I C. 153 C H A P. X. Of the NEPHRITIS, or INFLAM- MATION of the KIDNEYS. CCCCIV. This difeafe, like other internai inflammations, is always attended with pyrexia, and is efpecially known from the région of the kidney being affected by a pain, commonly obtufe, fometimes pungent. This pain is not increafed by the motion of the trunk of the body fo much as a pain of the rheumatic kind affedting the famé région. The pain of the nephritis may be often diftin- guifhed by its fhooting along the courfe of the ureter, and is frequently attended with a drawing up of the tefticle, and with a numbnefs of the limb on the fide af- fected ; altho', indeed, thefe fymptoms moft commonly attend the inflammation arifing from a calculus in the kidney or in the ureter. The nephritis is almoft con- ftantly attended with fréquent vomiting, and often with coftivenefs and colic pains. The ftate of the urine is commonly changed ; it is moft commonly of a deep red colour, is voided frequently, and in a fmall quantity, at a timè. In more violent cafés, the urine is fome- times colourlefs. ccccv. The remote caufes of this difeafe may be various ; as external contufion ; violent or long continued riding ; ftrains of the mufcles of the back incumbent on the kidneys ; various acrids in the courfe of the circulation conveyed to the kidney ; and perhaps fome other internai caufes not yet well known. The moft fréquent is that U of . of calculous matter obftrudting the tubuli uriniferi, or calculi formed in the pelvis of the kidneys, and either fticking there, or fallen into the ureter. CCCCVI. The various event of this difeafe may be underftood from what has been delivered on the fubjedt of other inflammations. CCCCVII. Writers, in treating of the cure of nephritis, have commonly at the famé time delivered the cure of the Calculus renalis ; but, though this may often produce nephritis, it is to be confidered as a diftinct and feparate difeafe ; and the treatment of it muft be referved to its proper place. Hère we fhall treat of the cure of the nephritis vera, or idiopathica only. CCCCVIII. The cure of this proceeds upon the gênerai plan, by bleeding, external fomentation, fréquent emollient clyfters, antiphlogiftic purgatives, and by the free ufe of mild and demulcent liquids. The ufe of blifters is hardly admiffible, or, at leaft, will require great care to avoid any confiderable abforption of the cantharides. CCCCIX. The cyftitis, or inflammation of the bladder, is fel- dom a primary difeafe, and is therefore not to be treated of hère. The treatment of it, fo far as neceffary to be explained, may be readily underftood from what has been already delivered. ccccx. Of the vifceral inflammations, there remains to be confidered the inflammation of the utérus; but we omit it O F P H Y S I C. 155 it hère, becaufe the confideration of it cannot be fe- parated from that of the difeafes of child-bearing women. C H A P. XL Of the R H E U M A T I S M. CCCCXL Of this difeafe there are two fpecies, the one named the acute, the other the chronic rheumatifm. CCCCXII. It is the acute rheumatifm which efpecially belongs to this place, as, from its caufes, fymptoms, and methods of cure, it will appear to be a fpecies of phlegmafia or inflammation. CCCCXIIL This difeafe is fréquent in cold, and more uncommon in warm climates. It appears moft frequently in autumn and fpring, lefs frequently in winter, while the froft is confiant, and very feldom during the heat of fum- mer. It may occur, however, at any feafon, if vicifr fitudes of heat and cold be for the time fréquent. CCCCXIV. For the moft part, the acute rheumatifm arifes from the application of cold to the body when any how un- ufually warm ; or when the cold is applied to one part of the body, whilft the other parts are kept warm ; or, laftly, when the application of the cold is long con- tinued, 156 PRACTICE tinued, as it is when wet or moift cloaths are applied to any part of the body. ccccxv. Thefe caufes may affect perfons of ail âges ; but the rheumatifm feldom appears either in very young or in elderly perfons, and moft commonly occurs from the • âge of puberty to that of thirty-five years. CCCCXVI. Thefe caufes (CCCCXIV.) may alfo affeâ perfons of any conftitution, but they moft commonly affect thofe of a fanguine tempérament. CCCCXVIL This difeafe is particularly diftinguifhed by pains af- fedting the joints, for the moft part the joints alone, but fometimes affedting alfo the mufcular parts. Very often the pains fhoot along the courfe of the mufcles, from one joint to another, and are always much increafed by the action of the mufcles belonging to the joint, or joints affedted. CCCCXVIII. The larger joints are moft frequently affedted, fuch as the hip-joint and knees of the lower, and the fhoul- ders and elbows of the upper extremities. The ankles and wriffs are alfo frequently affected ; but the fmaller joints, fuch as thofe of the toes or fingers, feldom fuffer. CCCCXIX. This difeafe, although fometimes confined to one part of the body only, yet very often affedts many parts of it; and then it begins with a cold ftage, which is im- mediately fucceeded by the other fymptoms of pyrexia, and particularly by a fréquent, full, and hard pulfe. Sometimes O F P H Y S I C. 157 Sometimes the pyrexia is formed before any pains are perceived, but more commonly pains are felt in particular parts, before any fymptoms of pyrexia appear. CCCCXX. When no pyrexia is prefent, the pain may be con- fined to one joint only ; but, when any confiderable pyrexia is prefent, although the pain may be chiefly in one joint, yet it feldom happens but that the pains affect feveral joints, often at the very famé time, but for the moft part fhifting their place, and, having abated in one joint, become more violent in another. They do not commonly remain long in the famé joint, but fre- quently fhift from one to another, and fometimes return to joints formerly affected ; and in this manner the dif- eafe often continues for a long time. CCCCXXL The pyrexia attending this difeafe has an exacerbation every evening, and is moft confiderable during the night, when the pains alfo become more violent; and it is at the famé time that the pains fhift their place from one joint to another. The pains feem to be alfo increafed during the night, by the body being covered more clofely, and kept warmer. CCCCXXII. A joint, after having been for fome time affected with pain, commonly becomes affected alfo with fome fwelling and rednefs, which is painful to the touch. It feldom happens, that a fwelling coming on does not alleviate the pain, which had been before in the joint ; but the fwelling does not always take off the pain entirely, nor fecure the joint againft a return of it. CCCCXXIII. This difeafe is commonly attended with fome fweating, which occurs early in the courfe of the difeafe, but is feldom 158 PRACTICE feldom free or copious, and feldom either relieves from the pains, or proves critical. CCCCXXIV. In the courfe of this difeafe the urine is high coloured, and in the beginning without fediment; but, as the dif- eafe advances, and the pyrexia has more confiderable remiflions, the urine depofits a lateritious fediment. This, however, does not prove entirely critical ; for the difeafe often continues long after fuch a fediment has appeared in the urine. CCCCXXV. When blood is drawn in this difeafe, it always ex- hibits the appearancejnentioned (CCXXXII.) CCCCXXVI. The acute rheumatifm, though it has fo much of the nature of the other phlegmafiae, differs from ail rhefe hi- therto mentioned, in this, that it is not liable to ter- minate in fuppuration. This almoft never happens in rheumatifm; but the difeafe fometimes produces effufions of a tranfparent gelatinous fluid into the fheaths of the tendons. If we may be allowed to fuppofe that fuch effufions are fréquent, it muft alfo happen, that the effufed fluid is commonly re-abforbed ; for it has feldom happened, and never.% indeed to my obfervation, that confiderable or permanent tumours have been produced, or fuch as required to be opened, and to have the con- tained fluid evacuated. Such tumours have indeed oc- curred toothers, and the opening made in them has pro- duced ulcers difficult to heal. Vide Storck. Ann. Med. IL CCCCXXVII. In the circumftances mentioned from (CCCCXVII, to CCCCXXIV.), the difeafe often continues for feveral O F. P H Y S I C. *59 feveral weeks. It feldom, however, proves fatal ; and it rarely happens that the pyrexia continues to be con- fiderable for more than two or three weeks. While the pyrexia abates in its violence, if the pains of the joints continue, they are lefs violent, more limited in their place, being confined commonly to one or a few joints only, and are lefs ready* to change their place. CCCCXXVIII. When the pyrexia attending rheumatifm has entirely ceafed, when the fwelling, and particularly the rednefs of the joints, are entirely gone, but there are pains which ftill continue tp affect certain joints, which re- main ftiff, which feel uneafy upon motion, on changes of weather, or in the night time only, the difeafe is named the Chronic Rheumatifm, as it very often con- tinues for a long time. As the' chronic is commonly the fequel of the acute rheumatifm, we think it proper to treat of the former alfo in this place. CCCCXXIX. The limits between the acute and chronic rheu- matifms, are not always exadtly marked. When the pains are ftill ready to fhift their place, when they are efpecially fevere in the night-time, when, at the famé time, they are attended with fome degree of pyrexia, and with fome fwelling, and efpecially fome rednefs of the joints ; the difeafe is to be confidered as partaking of the nature of the acute rheumatifm. But, when there is no degree of pyrexia remaining, when the pained joints are without rednefs, when they are cold and ftiff, when they cannot eafily be made to fweat, or when, while a free and warm fweat is brought out on the reft of the body, it is only clammy and cold on the pained joints ; and when, further, the pains of thefe are increafed by cold, and relieved by heat applied to them, the cafe is to be confidered as that of a purely chronic rheumatifm. ccccxxx. i6o P R A C T I CE CCCCXXX. The chronic rheumatifm may affect différent joints, but is efpecially ready to affect thofe joints which are furrounded with many mufcles, and thofe of which the mufcles are employed in the moft conftant and vigorous exertions. Such is the cafe of the vertebrae of the loins, the affection of which is named Lumbago, or of the hip-joint, when the difeafe is named Ifchias, or Sciatica. CCCCXXXI. Violent ftrains and fpafms occurring on fudden and fomewhat violent exertions, bring on rheumatic afff fecTions, which at firft partake of the acute, but very foon change into the nature of the chronic rheumatifm. Such are frequently the lumbago, and other affections which feem to be more feated in the mufcles, than in the joints, as the torticolis or obftipitas catarrhalis of Sau- vages, and the pleuritis fpuria, or the pleurodyne ple- thorica and rheumatica of the famé author. CCCCXXXII. We have thus delivered the hiftory of rheumatifm, and fuppofe that, from what has been faid, the remote caufes, the diagnofis, and prognofis of the difeafe, may be underftood. The diftindtion of the rheumatic pains from thofe refembling them, which occur in the fyphilis and fcurvy, will be obvious, either from the feat of thofe pains, or from the concomitant fymptoms peculiar to thefe difeafes. The diftindtion of rheumatifm from goût will be more fully underftood from what is to be delivered in the following chapter. CCCCXXXIIL With refpect to the proximate caufe of rheumatifm, there have been various opinions. It has been imputed to a peculiar acrimony ; of which, however, I can find no évidence ; and the confideration of the remote caufes, the O F P H Y S I C. 161 the fymptoms, and cure of the difeafe, renders the fup- pofition very improbable. The caufe of an Ifchias nervofa affigned by Cotunnius, appears to me hypo- thetical, and is not fupported by either the phaenomena or method of cure. That, however, a difeafe of a rheumatic nature may be occafioned by an acrid matter applied to the nerves, is évident from the tooth-ach, a rheumatic affection generally arifing from a carious tooth. That pains refembling thofe of rheumatifm may arife from deep feated fuppurations, we know from fome eafes depending on fuch a caufe, and which, in their fym- ptoms, refemble the lumbago or ifchias. We believe, however, that, by a proper attention, thefe cafés de- pending on fuppuration, may be commonly diftinguifhed from the genuine cafés of lumbago and ifchias, and, from whatis faid in (CCCCXXVL), we judge itto be a t leaft improbable, that a genuine lumbago or ifchias fhould ever end in fuppuration. CCCCXXXIV. The proximate caufe of rheumatifm has been by many fuppofed to be a lentor of the fluids obftructing the veflèls of the part ; but the-famé confiderations as in CCXXXVI. 2, 3, 4, and 5, will apply equally hère for rejedting the fuppofition of a lentor. CCCCXXXV. While we cannot, therefore, find either évidence or reafon for fuppofing that the rheumatifm dépends upon any change in the ftate of the fluids, we muft conclude that the proximate caufe of acute rheumatifm, is the famé with that of other inflammations not depending upon a direct ftimulus. CCCCXXXVI. In the cafe of rheumatifm we fuppofe, that the moft common remote caufe of it, that is, cold applied, ope- rates efpecially on the veffels of the joints, thefe being * X lefs i62 PRACTICE lefs covered by a cellular texture than thofe of the inter- médiare parts of the limbs. We fuppofe farther, that the application of cold produces a conftridtion of the extrême veffels, and at the famé time, an increafe of tone or phlogiftic diathefis, in the courfe of them, from which arifes an increafed impetus of the blood, and, at the famé time, a refiftance to the free paffage of it, and confcquently inflammation and pain. Further, we fup- pofe, that the refiftance formed, excites the vis me- dicatrix to a further increafe of the impetus of the blood ; and, to fupport this, a cold ftage arifes, a fpafm is formed, and a pyrexia and phlogiftic diathefis are pro- duced in the whole fyftem. CCCCXXXVII. According to this explanation, the caufe of acute rheumatifm appears to be exadtly analogous to that of inflammations dependfng on an increafed afflux of blood to a part, while it is expofed to the action of cold. But there feems to be further, in the cafe of rheu- matifm, fome peculiar affection of the fibres of the mufcles. Thefe fibres feem to be under fome degree of rigidity, and therefore lefs eafily admit of motion, and are pained upon the exertions of it, This alfo feems to be the affection which gives opportunity to the pro- pagation of pains from one joint to another, and which are moft feverely felt in the extremities terminating in the joints, becaufe, beyond thefe, ofcillations are not propagated. This affedtion of the mufcular fibres, explains well in what manner ftrains and fpafms produce rheumatic af- fections; and, upon the whole, fhews, that, with an inflammatory affection of the fanguiferous fyftem, there is alfo in rheumatifm a peculiar affedtion of the mufcular fibres, which has a confiderable fhare in producing the phenomena of the difeafe. CCCCXXXVIII. Having thus given our opinion of the proximate caufe of rheumatifm, we proceed to treat of the cure. CCCCXXXIX. O F P H Y S I C. 163 CCCCXXXIX. Whatever difficulty may occur with refpedt to the ex- planations given (CCCCXXXVI. CCCCXXXVII.) this remains certain, that in acute rheumatifm, there is an inflammatory affection of the parts, and a phlogiftic diathefis in the whole fyftem, and upon thefe is founded the method of cure, which fréquent expérience has approved. ' CCCCXL. The cure therefore requires, in the firft place, an an- tiphlogiftic regimen, and, particularly, a total abfti- nence from animal food, and from ail fermented or fpirituous liquors; fubftituting a mild vegetable or milk diet, and the plentiful ufe of bland diluent drinks. CCCCXLL Upon the famé principle (CCCCXXXIX) blood. letting is the chief remedy of acute rheumatifm. The blood is to be drawn in large quantity, and the bleeding is to be repeated in proportion to the frequency, fullnefs, and hardnefs of the pulfe, and the violence of the pain. For the moft part, large and repeated bleeding, during the firft days of the difeafe, feem to be neceffary, and accordingly have been very much employed ; but to this fome bounds are to be fet ; for very profufe bleedings occafion a flow recovery, and, if not abfolutely effectuai, are ready to produce a chronic rheumatifm. CCCCXLIL To avoid that debility of the fyftem, which gênerai bleedings are ready to occafion, the urgent fymptom of pain may be often relieved, by topical bleedings ; and, when any fwelling and rednefs have come upon a joint, the pain of it may be' very certainly relieved by topical bleedings; but, as the continuance of the difeafe feems to dépend more upon the phlogiftic diathefis of the whole fyftem, 164 PRACTICE fyftem, than upon the affedtion of particular parts, fo topical bleedings will notfupply the place of the gênerai bleedings propofed above. CCCCXLIII. To take off the phlogiftic diathefis prevailing in this difeafe, purging may be ufeful, if procured by medicines which do not ftimulate the whole fyftem, fuch as the neutral faits, which have in fome meafure a réfrigérant power. Purging, however, is not fo powerful as bleeding in removing phlogiftic diathefis; and, when the difeafe has become gênerai and violent, fréquent ftools are in- convénient, and even hurtful, by the motion and pain which they occafion. CCCCXLIV. In acute rheumatifm, applications to the pained parts are of little fervice. Fomentations, in the beginning of the difeafe, rather aggravate than relieve the pains. The rubefacients and camphire are more effectuai in relieving the pains ; but generally they only fhift the pain into another part, and do not prove any cure of the gênerai affection. Bliftering alfo may be very effedtual in removing the pain from a particular part ; but wîN be of little ufe, except where the pains are much confined to one part. CCCCXLV. The feveral remédies mentioned from (CCCCXXXIX, to CCCCXLIV.) moderate the violence of the difeafe, and fometimes remove it entirely; but they fometimes fail in this, and leave the cure imperfect. The at- tempting a cure by large and repeated bleedings, is at- tended with many inconveniences (fee CXXXIV.) ; and the moft effedtual and fafe method of curing this difeafe, is, after fome gênerai bleedings for taking off, or at leaft diminifhing the phlogiftic diathefis, to employ fweating, condudted by the rules laid down (CLXIL andCLXIII.) CCCCXLVI. O F P H Y S I C. 165 CCCCXLVL Opiates, except where they are directed to procure fweat, always prove hurtful in every ftage of this difeafe. ccccxlvii. The Peruvian bark has been fuppofed a remedy in fome eafes of this difeafe; but we have feldom found it ufeful, and, in fome cafés, hurtful. ' It appears to me to be fit in thofe cafés only in which the phlogiftic dia- thefis has much abated, and, at the famé time, the ex- acerbations of the difeafe are manifeftly periodical, with confiderable remiflions interpofed. CCCCXLVIII. Calomel, and fome other préparations of mercury, have been recommended in the acute rheumatifm ; but I believe they are ufeful only in eafes approaching to the nature of the chronic. CCCCXLIX. Having now treated fully of the cure of the acute rheumatifm, we proceed to treat of the cure of the chronic, which is fo frequently a fequel of the former. CCCCL. The phenomena of the purely chronic • rheumatifm mentioned in (CCCCXXVIII. and CCCCXXIX.) lead me to conclude, that its proximate caufe is an atony, both of the blood-veffels and of the mufcular fibres of the part affected, together with fuch a degree of rigidity, and contraction in the latter, as frequently attend them in a ftate of atony. CCCCLL 166 PRACTICE CCCCLI. Upon this view of the proximate caufe, the gênerai indication of cure muft be to reftore the adtivity and vigour of the vital principle in the part ; and the re- médies for this difeafe, which expérience has approved of, are chiefly fuch as are manifeftly fuited to the indi- cation propofed. CCCCLII. Thefe remédies are either external or internai. The external are, the fupporting the heat of the part, by keeping it conftantly covered with flannel ; the in- creafing the heat of the part by external heat, applied either in a dry or in a humid form ; the diligent ufe of the flefh-brufh, or other means of friction ; the appli- cation of eledtricity in fparks or fhocks ; the ap- plication of cold water by affufion or immerfion ; the application of effential oils of the moft warm and penetrating kind; the application of fait brine; and, laftly, the employment either of exercife, of the part itfelf, fo far as it can eafily bear ; or by riding, or other mode of geftation. CCCCLIII. The internai remédies are, i. large dofes of effential oils drawn from refinous fubftances, fuch as turpentine ; 2. fubftances containing fuch oils, as guaiac ; 3. volatile alkaline faits ; 4. thefe, or other medicines directed to procure fweat, (CLXIII.) and, laftly, calomel, or other préparation of mercury, in fmall dofes, continued for fome time. CCCCLIV. Thefe (CCCCLII. and CCCCLIII. ) are the remé- dies fuccefsfully employed in the purely chronic rheu- matifm; and there are ftill others recommended, as bleeding, gênerai and topical, burning, bliftering, and iffues ; O F P H Y S I C. 167 iffues ; but thefe appear to me to be chiefly, perhaps only, ufeful when the difeafe ftill partakes of the nature of acute rheumatifm. C H A P. XII. Of the GOUT. CCCCLV. The Goût, not only as it occurs in diffèrent perfons, but even as it occurs in the famé perfon at diffèrent times, is a difeafe of fuch various appearance, that it is difficult to render the hiftory of it complète and exact, or to give a charadter of it that will univerfally apply. However, I fhall endeavour to defcribe the difeafe as it moft commonly appears, and to mark the varieties of it as well as I can. From fuch a hiftory we expedt, that a gênerai charadter may be given, and fuch we think is the following, as intended for the next édition of our Nofology. Gen. XXIII. P O D A G R A. Morbus haereditarius, oriens fine caufa externa évidente, fed praeeunte plerumque ventriculi affedtione infolita ; pyrexia; dolor ad articulum et plerumque pedis pollici, certe pedum et manuum juncturis, potiffimum infeftus ; per intervalla revertens, et fsepe cum ventriculi et internarum partium affèctionibus alternans. CCCCLVI. The Goût is generally a hereditary difeafe ; but fome perfons, withont hereditary difpofitjon, feem to acquire itj i6g PRACTICE it ; and, in fome, a hereditary difpofition may be coun- teradted by various caufes. Thefe circumftances may occafion exceptions to our gênerai pofition ; but the fadts fupporting it are very numerous. CCCCLVII. This difeafe attacks the maie fex efpecially ; but it fometimes, though more rarely, attacks alfo the female. The females liable to it are thofe of the more robuft and full habits ; and it very often happens to fuch before the menftrual évacuation has ceafed. I have found it oc- curring in feveral females, whofe menftrual évacuations were more abundant than ufual. CCCCLVIII. This difeafe feldom attacks Eunuchs ; and, when it does, feems to be thofe who happen to be of a robuft habit, tolead an indolent life, and tolivevery full. CCCCLIX. The goût attacks efpecially men of robuft and large bodies, men of «large heads, of full and corpulent habits, and men whofe fkins are covered with a thicker rete mucofum, which gives a coarfer furface. CCCCLX. If, with the antients, we might afcertain, by certain terms, the tempéraments of men, I would fay, that the goût attacks efpecially men of a cholerico-fanguine tempérament, and that it very feldom attacks the purely fanguine or melancholic. It is, however, very diflicult to treat this matter with due precifion. CCCCLXI. The goût feldom attacks perfons employed in con- fiant bodily labour, or perfons who live much upon vegetable aliment. CCCCLXII. O F P H Y S I C. 169 CCCCLXIL The goût does not commonly attack men, till after the âge of five and thirty; and generally not till a ftill later period. There are indeed inftances of the goût occurring more early ; but thefe are few, in comparifon of the numbers which agrée with what we have given as the gênerai rule. When the difeafe does appear early in life, it feems to be in thofe in whom the hereditary dif- pofition is very ftrong, and to whom the remote caufes, to be hereafter mentioned, have been applied in a con- fiderable degree. CCCCLXIII. As the goût is a hereditary difeafe, and affedts efpe- cially men of a particular habit, its remote caufes may be confidered as predifponent and occafional. CCCCLXIV. The predifponent caufe, fo far as expreffed by ex- ternal appearances, we have already marked ; and phy- ficians have been very confident in aflïgning the occa- fional caufes ; but, in a difeafe depending fo much upon a predifpofition, the affigning occafional caufes muft be uncertain ; as, in the predifpofed, the occafional caufes may not always appear, and, in perfons not predifpofed, they may appear without effedt. This uncertainty muft particularly affect the cafe of the goût ; but I fhall offer what appears to me moft probable on the fubject. CCCCLXV. The occafional caufes of the goût feem to be of two kinds. Firft, thofe which induce a plethoric ftate of the body. Secondly, thofe which, in plethoric habits, induce a ftate of debility. Y CCCCLXVL i;o P R A C T I C F CCCCLXVL Of the firft kind are, a fedentary indolent manner of life, and a full diet of animal food. Thefe circum- ftances commonly précède the difeafe, and if there fhould be any doubt as to their effects in producing it, the fadt, however, will be rendered fufficiently probable by what has been obferved in (CCCCLXI.) CCCCLXVII. Of the fécond kind of occafional caufes which in- duce debility are, excefs in venery ; intempérance in the ufe of intoxicating liquors; indigeftion produced either by the quantity or the quality of aliments ; much application to ftudy or bufinefs ; night watching ; ex- ceffive évacuations; the ceafing of ufual labour; the fudden change from a very full, to a very fpare diet ; the large ufe of acids and acefeent»; and, laftly, cold applied tothe lower extremities. CCCCLXVIII. The firft (CCCCLXVI.J feem to zù bv increafing the predifpofition. The laft (CCCCLXVII.) are commonly the exciting caufes, both of the firft attacks, and of the répétitions of the difeafe. CCCCLXIX. It is an inflammatory affection of fome of the joints which efpecially conftitutes what we call a paroxyfm of the goût. This fometimes cornes on fuddenly, without any warning, but is generally preceded by feveral fym- ptoms ; fuch as the ceafing of a fweating which the feet had been commonly affected with before; an unufual coldnefs of the feet and legs ; a fréquent numbnefs, al- ternating with a fenfe of prickling along the whole of the lower extremities; fréquent cramps of the mufcles of the legs; and an unufual turgefcence of the veins. CCCCLXX. O F P H Y S I C. 171 CCCCLXX. While thefe fymptoms take place in the lower ex- tremities, the whole body is affedted with fome degree of torpor and languor, and the functions of the ftomach, in particular, are more or lefs difturbed. The appetite is diminifhed, and flatulency, or other fymptoms of in- digeftion, are felt. Thefe fymptoms, and thofe of (CCCCLXIX.) take place for feveral days, fometimes for a week or two, before a paroxyfm cornes on ; but commonly, upon the day immediately preceding it, the appetite becomes greater than ufual. CCCCLXXI. The circumftances of paroxyfms are the following, They come on moft commonly in the fpring, and fooner or later, according as the vernal heat fucceeds fooner or later to the winter's cold ; and, perhaps, fooner or later alfo, according as the body may happen to be more or lefs expofed to viciffitudes of heat and cold. CCCCLXXII. The attacks are fometimes felt firft in the evening, but more commonly about two or three o'clock of the morning. The paroxyfm begins with a pain affedting one foot, moft commonly in the bail or firft joint of the great toe, but fometimes in other parts of the foot. With the coming on of this pain, there is commonly more or lefs of a cold fhivering, which, as the pain in- creafes, gradually ceafes, and is fucceeded by a hot ftage of pyrexia, which continues for the famé time with the pain itfelf. From the firft attack, the pain becomes, by degrees, more violent, and continues in this ftate with great reftleffnefs of the whole body, till next midnight, after which it gradually remits ; and, after it has con- tinued for twenty-four hours from the commencement of the firft attack, it commonly ceafes very entirely, and, with the coming on of a gentle fweat, allows the patient to fall afleep. The patient, upon coming out of his 172 PRACTICE fleep in the morning, finds the pained part affected with fome rednefs and fwelling, which, after having continued for fome days, gradually abate. CCCCLXXIII. When a paroxyfm has thus come on, although tho violent pain after twenty-four hours be confiderably abated, the patient is not entirely relieved from it. For fome days he has every evening a return of more con- fiderable pain and pyrexia, and which continue with more or lefs violence till morning. After continuing in this manner for feveral days, the difeafe fometimes gocs entirely off, not to return till after a long interval. CCCCLXXIV. When the difeafe, after having thus remained for fome time in a joint, ceafes very entirely, it generally leaves the perfon in very perfedt health, enjoying greater eafe and alacrity in the functions of both body and mind, than he had for a long time before experienccd. CCCCLXXV. At the beginning of the difeafe, the returns of it are fometimes only once in three or four years ; but, as it advances, the intervais become fhorter, and at length, the attacks areannual ; afterwards come twiceeach year, and at length recur feveral times during the whole courfe of autumn, winter, and fpring ; and as, when the fits are fréquent, the paroxyfms become alfo longer, fo, in the advanced ftate of the difeafe, the patient is hardly ever tolerably free from it, except perhaps for two or three months in fummer. CCCCLXXVI. The progrefs of the difeafe is alfo marked by the , parts which it affedts. At firft, it commonly affedts one foot only, afterwards, every paroxyfm affedts both feet, the one after the other ; and, as the difeafe proceeds, it O P P H Y S I C. *73 it not only affedts both feet once, but after having ceafed in the foot which was fecondly attacked, returns again into the firft, and perhaps a fécond time alfo into the other. Its changes of place are not only from one foot to another, but from the feet into other joints, efpecially thofe of the upper and lower extremities ; fo that there is hardly a joint of the body that, on one occafion or other, is not affected. It fometimes affedts two diffèrent joints at the very famé time, but more com- monly is at any one time fevere in a fingle joint only, and paffes fucceffively from one joint to another ; fo that the patient's affliction is often protradted for a long time. CCCCLXXVII. When the difeafe has often returned, and the paroxyfms have become very fréquent, the pains are commonly lefs violent than they were at firft ; but the patient is more affected with ficknefs, and the other fymptoms of the atonie goût, which fhall be hereafter mentioned. CCCCLXXVIII. After the firft paroxyfms of the difeafe, the joints which have been affedted are entirely reftored to their former fupplenefs and ftrength ; but, after the difeafe has recurred very often, the joints affected do neither fo fuddenly nor entirely recover their former ftate, but con- tinue weak and ftiff, and thefe effects at length proceed to fuch a degree, that the joints lofe their motion entirely. CCCCLXXIX. In many perfons, but not in ail, after the difeafe has frequently recurred, concrétions of a chalky nature are formed upon the outfide of the joints, and for the moft part immediately under the fkin. The matter feems to be depofited, at firft, in a fluid form, afterwards becoming dry and firm. In their firm ftate, thefe concrétions are a friable earthy fubftance, very entirely fojuble in acids. After they have been formed, they contribute, with other circumftances, to deftroy the motion of the joint. CCCCLXXX. *74 PRACTICE CCCCLXXX. In moft perfons who have laboured under the goût for many years, a nephritic affection cornes on, and difcovers itfelf by ail the fymptoms which ufually attend calculous concrétions in the kidneys, and which we fhall have occafion to defcribe in another place. Ail that is ne- ceffary to be obferved hère rs, that the nephritic affection alternâtes with paroxyfms of the goût, and that the two affections, the nephritic and the gouty, are hardly ever prefent at the famé time. This alfo may be obferved, that children of gouty or nephritic parents, commonly inherit one or other of thefe difeafes ; but which ever may have been the principal difeafe of the parent, fome of the children have the one, and fome the other. In fome of them, the nephritic affection occurs alone, without any goût fupervening ; and this happens to be frequently the cafe of the fcmale children of gouty parents., CCCCLXXXI, In the whole of the hiftory already given, we have deferibed the moft common form of the difeaiè, and which therefore, however diverfified in the progrefs of it, may be ftill called the regular ftate of the goût. Upon occafion, however, the difeafe affumes différent appearances ; but, as we fuppofe the difeafe to dépend always upon a certain diathefis, or difpofition of the fyftem ; fo every appearance which we can perceive to dépend upon that famé difpofition, we ftill confider as a fymptom and cafe of the goût. The principal cir- cumftance, in what we term the Regular Goût, is the inflammatory affection of the joints ; and, whatever fymptoms we can perceive to be connected with, or to dépend upon, the difpofition which produces that inflam- matory affedtion, but without its taking place, or being prefent at the famé time, we name the Irregular Goût. CCCCLXXXII. O F P H Y S I C. 175 CCCCLXXXII. Of fuch irregular goût there are three diffèrent ftates, which we name the atonie, the rétrocèdent, and the mif- placed goût. CCCCLXXXIII. 1 The firft is when the gouty diathefis prevails in the fyftem, but, from certain caufes, does not produce the inflammatory affedtion of the joints. In this cafe, the morbid fymptoms which appear, are chiefly affedtions of the ftomach, fuch as lofs of appetite, indigeftion, and its various circumftances pf ficknefs, naufea, vomiting, flatulency, acid erudtations, and pains in the région of the ftomach. Thefe fymptoms are frequently accom- panied with pains and cramps in feveral parts of the trunk, and the upper extremities of the body, which are relieved by the difcharge of wind from the ftomach. Together with thefe affections of the ftomach, there commonly occurs a coftivenefs ; but fometimes a loofe- nefs, with colic pains. Thefe affections of the alimentary canal are often attended with ail the fymptoms of hypo- chondriafis, as déjection of mind, a confiant and anxious attention to the flighteft feelings, an imaginary aggra- vation of thefe, and an apprehenfion of danger from them. In the famé atonie goût, the vifeera of the thorax alfo are fometimes affected, and palpitations, faintings, and afthma, occur. In the head alfo, occur headachs, giddinefs, apopledtic and paralytic affections. CCCCLXXXIV. When the feveral fymptoms now mentioned, occur in habits having the marks of a gouty difpofition, this may be fufpedted to have laid the foundation of them ; and efpecially, when, either in fuch habits, a manifeft tendency to the inflammatory affection has formerly appeared ; or when the fymptoms mentioned are intér- im xed 176 PRACTICE mixed with, and are relieved by fome degree of the inflammatory goût. In fuch cafés there can be no doubt of confidering the whole as a ftate"of the goût. CCCCLXXXV. Another ftate of the difeafe we name the rétrocèdent goût. This occurs when an inflammatory ftate of the joints has, in the ufual manner, come on, but without arifing to the ordinary degree of pain and inflammation, or at leaft, without thefe continuing for the ufual time, or without their receding gradually in the ufual manner; thefe affedtions of the joint fuddenly, and entirely ceafe, while fome internai part becomes affected. The internai part moft commonly affected is the ftomach, which then is affected with anxiety, ficknefs, vomiting, or violent pain ; but fometimes the internai part is the heart, which gives occafion to a fyncope; fometimes it is the lungs, which are affected with afthma; and fometimes it is the head, giving occafion to apoplexy or palfy. In ail thefe cafés there can be no doubt of the fymptoms being ail a part of the famé difeafe, however différent the affedtion may feem to be in the parts which it attacks. CCCCLXXXVI. The third ftate of irregular goût, which we name the mifplaced, is when the gouty diathefis, inftead of pro- ducing the inflammatory affection of the joints, pro- duces an inflammatory affection of forre internai part, and which appears from the famé fymptoms that attend the inflammations of thofe parts, arifing from other caufes. Whether the gouty diathefis does ever produce fuch inflammation of the internai parts, without having firft produced it in the joints, or, if the inflammation of the internai part be always a tranflation from the joints pre- vioufly affedted, we dare not détermine; but, even fup- pofing the latter to be always the cafe, we think the différence of the affection of the internai part muft ftill diftinguifh O F P H Y S I C. 177 diftinguifh the mifplaced from what we have named the rétrocèdent goût. CCCCLXXXVII. What internai parts may be affected by the mifplaced goût, I cannot precifely fay, becaufe I have never met with any cafés of the mifplaced goût in my pradtice; and I find no' eafes of it diftindtly marked by pradtical writers, except that of a pneumonie inflammation. CCCCLXXXVIII. There are two cafés of a tranflated goût ; the one of which is an affection of the neck of the bladder, pro- ducing pain, ftrangury, and a catarrhus veficae : The other is an affedtion of the rectum, fometimes by pain alone in that part, and fometimes by hemorrhoidal fym- ptoms. In gouty perfons, I have known fuch af- fections alternate with inflammatory affedtions of the joints : But whether to refer thofe affections to the ré- trocèdent, or to the mifplaced goût, I will not prefume to détermine. CCCCLXXXIX. From the hiftory which I have now delivered of the goût, I think it may be difeerned under ail its various appearances. It is, however, commonly fuppofed, that there are cafés in which it may be difficult to diftinguifh goût from rheumatifm, and it is poffible there may be fuch cafés ; but, for the moft part, the two difeafes may be diftinguifhed with great certainty, by obferving the predifpofition, the antécédents, the parts affected, the récurrences of the difeafe, and its connection with the fyftem ; which circumftances, for the moft part, appear very diffèrent! y in the two difeafes. Z CCCCXC. . 178 PRACTICE CCCCXC. With refpedt to the goût, our next bufinefs is to in- veftigate its proximate caufe, which muft be a diflicult tafk, and I attempt it with fomediffidence. CCCCXCI. Upon this fubject, the opinion which has, generally prevailed i<, that the goût depeads upon a certain mor- bific matter, always prefent in the body ; and that this matter, by certain caufes, thrown upon the joints or other parts, produces the feveral phenomena of the difeafe. CCCCXCII. This doctrine, however antient and gênerai, appears to me very doubtful ; for, Firft, there is no direct évidence* of any morbific matter being prefent in perfons difpofed to the goût. There are no experiments or obfervations which fhew that the blood, or other humours of gouty perfons, are in any refpedt diffèrent from thofe of others. Previous to attacks of the goût, there appear no marks of any morbid ftate of the fluids ; for the difeafe generally at- tacks thofe perfons who have enjoyed the moft perfect health, and appear to be in that ftate when the difeafe cornes on. At a certain period of the difeafe, a peculiar matter indeed appears in gouty perfons, (CCCC- LXXIX.) ; but this, which does not appear in every inftance, and which appears only after the difeafe has fubfifted for a long time, feems manifeftly to be the effedt, not the caufe of the difeafe. Further, though there be certain acrids which, taken into the body, feem to excite the goût, (CCCCLXVII.) it is probable, that thefe acrids operate otherwife in exciting the difeafe, than by affording the material caufe of it. In gênerai, there- fore, there is no proof of any morbific matter being the caufe of the goût. Secondly, O F P H Y S I C. »79 % Secondly, the fuppofitions concerning the particular nature of the matter producing the goût, have been fo various, and fo contradidtory to each other, as to allow us to conclude, that there is truly no proof of the exiftence of any ofthem. With refpect to many of thefe fuppofitions, they are fo inconfiftent with chemical phi- lofophy, and with the laws of the animal œconomy, that they muft be entirely rejedted. Thirdly, the fuppofition of a morbific matter, as the caufe is. not confiftent with the phenomena of the dif- eafe, particularly with its fréquent and fudden tranfla- tions from one part to another. Fourthly, the fuppofition is further rendered im- probable by this, that, if a morbific matter did exift, its opération fhould be fimilar in the feveral parts which it attacks ; whereas it feems to be very diffèrent, being ftimulant, and exciting inflammation in the joints, but fedative and deftroying the tone in the ftomach : Which, upon the fuppofition of particular matter adting in both eafes, is not to be explained by any différence in the part affected. Fifthly, fome fadts, alledged in proof of a morbific matter, are not fufficiently confirmed, fuch as thofe which would prove the difeafe to be contagious. There is, however, no proper évidence of this, the fadts given being not only few, and exceptionable, and the négative obfervations innumerable. Sixthly, fome arguments brought in favour of a mor- bific matter, are founded upon a miftaken explanation. The difeafe has been fuppofed to dépend upon a morbific matter, becaufe it is hereditary. But the inference is not juft ; for moft hereditary difeafes do not dépend upon any morbific matter, but upon a particular con- formation of the ftrudture of the body, tranfmitted from the parent to the offspring ; and this laft appears to be particularly the cafe in the goût. It may be alfo ob- ferved, that hereditary difeafes, depending upon a mor- bific matter, appear always much more early in life than the goût commonly does. Seventhly, the fuppofition of a morbific matter being the caufe of the goût, has been hitherto ufelefs, as it has not ftfggefted any fuccefsful method of cure. Par- ticular i8o PRACTICE ticular fuppofitions have often corrupted the pradtice, and have frequently led from thofe views which might be ufeful, and from that pradtice which expérience had approved. Further, though the fuppofition of a mor- bific matter has been generally received, it has been as generally neglected in pradtice. When the goût has affected the ftomach, nobody thinks of correcting the matter fuppofed to be prefent there, but merely of rc- ftoring the tone of the moving fibres. Eighthly, the fuppofition of a morbific matter is quite fuperfluous ; for it explains nothing, without fuppofing that matter to produce a change in the ftate of the moving powers, and a change in the ftate of the moving powers, produced by other caufes, explains every cir- cumftance without the fuppofition of a morbific matter ; and, to this purpofe, it may be obferved, that many of the caufes (CCCCLXVII.) exciting the goût, do not operate upon the ftate of the fluids, but diredlly and folely upon that of the moving powers. Laftly, the fuppofition of a morbific matter is fuper- fluous ; becaufe, without that, the difeafe can be ex- plained in a manner more confiftent with its phenomena, with the lawsof animal œconomy, and with the method of cure which expérience has approved. We now pro- ceed to give this explanation ; but, before entering upon it, we muft prcmife fome gênerai observations. CCCCXCIII, The firft obfervation is, that the goût is a difeafe of the whole fyftem, or dépends upon a certain gênerai conformation and ftate of the body, which manifeftly appears from the fadts mentioned from (CCCCLVI. to CCCCLXIL). But the gênerai ftate of the fyftem dépends chiefly upon the ftate of its primary moving powers ; and therefore the goût may be fuppofed to be an affection of thefe chiefly. CCCCXCIV. My fécond obfervation is, that the goût is manifeftly an affedtion of the nervous fyftem ; in which the primary moving OF P H Y S I C. 181 moving powers of the whole fyftem are lodged. The occafional or exciting caufes (CCCCLXVII.) are al- moft ail, fuch as adt diredtly upon the nerves and nervous fyftem ; and the greater part of the fymptoms of the atonie or rétrocèdent goût are manifeftly affections of the famé fyftem. (CCCCLXXXIII. CCCCLXXXV.) This leads us to feek for an explanation of the whole of the difeafe in the laws of the nervous fyftem, and par- ticularly in the changes which may happen in the balance of its feveral parts, ccccxcv. My third obfervation is, that the ftomach, which has fo univerfal a confent with the reft of the fyftem, is the internai part that is the moft frequently, and often very confiderably, affected by the goût. The paroxyfms of the difeafe are commonly preceded by an affection of the ftomach (CCCCLXX.); many of the exciting caufes (CCCCLXVII.) adt firft upon the ftomach ; and the fymptoms of the atonie and rétrocèdent goût (CCCCLXXXIII. CCCCLXXXV.) are almoft com- monly and chiefly affections of the famé organ. This obfervation leads us to remark, that there is a balance fubfifting between the ftate of the internai, and that of the external parts ; and, in particular, that the ftate of the ftomach is connected with that of the external parts, (XLIII.) fo that the ftate of tone in the one, may be communicated to the other. CCCCXCVI. Thefe obfervations being premifed, I fhall now offer the following pathology of the goût. In fome perfons there is a certain vigorous and ple- thoric ftate of the fyftem (CCCCLXVII.), which at a certain period of life, is liable to a lofs of tone in the extremities (CCCCLXIX.). This is in fome meafure communicated to the whole fyftem, but appears more efpecially in the functions of the ftomach (CCLXX). When this lofs of tone occurs while the energy of the brain ftill retains its vigour, the vis medicatrix naturae is excited to 182 PRACTICE to reftore the tone of the parts j and accompl ifhes it, by ex- citing an inflammatory affection in fome part of the extre- mities. When this has fubfifted for fome days, the tone of the extremities, and of the whole fyftem, are reftored, and the patient returns to his ordinary ftate of health (CCCCLXXIV.).. f CCCCXCVII. This is the courfe of things, in the ordinary form of the difeafe, which we name the regular goût; but there are circumftances of the body, in which this courfe is interrupted or varied. Thus, when the atony (CCCCLXIX. CCCCLXX.), has taken place, if the réaction (CCCCXCVI.) do not fuccced, the atony continues in the ftomach, or perhaps in other internai parts, and produces that ftate which we have, for reafons now obvious, named the atonie goût. CCCCXCVIIL A fécond cafe of varjation in the courfe of the goût is, when to the àtony, the reaction and inflammation have to a certain degree fucceeded, but from caufes either internai or external, the tone of the extremities, and perhaps of the whole fyftem, is weakened ; fo that the inflammatory ftate, before it had either proceeded to the degree, or continued for the time requifite for reftoring the tone of the fyftem, fuddenly and entirely ceafes j Whence the ftomach, and other internai parts, relapfe into the ftate of atony ; and perhaps have that increafed by the atony communicated from the extremities : Ail which appears in what we have termed the rétrocèdent ftate of the goût. CCCCXCIX. A third cafe of variation from the ordinary courfe of the goût, is, when to the atony ufually preceding, an inflammatory reaction fully fucceeds : But has its ufual détermination to the joints by fome circumftances pre- vented; and is therefore diredted to fome internai part, where O F P H Y S I C. 183 where it produces an inflammatory affedtion, and that ftate of things which we have namea the Mifplaced Goût. D. We have thus offered an explanation of the circum- ftances of the fyftem in the feveral ftates of the goût ; ■ and this explanation we fuppofe to be confiftent with the phenomena of the difeafe, and with the laws of the animal œconomy. There are indeed feveral queftions which might be put with refpect to the theory of the difeafe ; any anfwers to which we have not given. But, though we could perhaps give an anfwer to many of thefe queftions, it does not hère appear neceffary, as at prefent we intend only to eftablifh fuch gênerai fadts with regard to this difeafe, as may lay a foundation for the cure of it, fo far as expérience has enabled us to profecute it. Proceeding, therefore, upon the feveral, parts of the pathology given, as fo many matters of fadt we fhall now confider what may be attempted towards the cure of the difeafe. DI. In entering upon this, we muft obferve, in the firft place, that a cure has been commonly thought im- poflible ; and we acknowledge it to be .very probable, that the goût, as a difeafe of the whole habit, and very often depending upon original conformation, cannot be cured by medicines, the effects of which are always x very tranfitory, and feldom extend to the producing any confiderable change of the whole habit. du. It would perhaps have been happy for gouty perfons, if this opinion had been implicitly received by them ; as it would have prevented their having been fo often the dupes of felf-interefted pretenders, who have either amufed them with inert medicines, or have rafhly em- ployed thofe of the moft pernicious tendency. I am much difpofed to believe the impoffibility of a cure of i»4 PRACTICE the goût by medicines ; and more certainly ftill incline to think, that, whatever may be the poffible power of medicines, yet no medicine for curing the goût has hi- therto been found. Although almoft every âge has pre- fented a new remedy, ail hitherto offèred have, very foon after, been either negledted as ufelefs, or condemned as pernicious. DIII. Though unwilling to admit the power of medicines, yet I contend, that a great deal can be done towards the cure of the goût, by a regimen : And from what has been obferved (CCCCLXL), I am firmly perfuadcd, that any man who, early in life, will enter upon the confiant pradtice of bodily labour, and of abftinence from animal food, will be preferved entirely from the difeafe. Whether there be any other means of radically curing the goût, I am not ready to détermine. There are hiftories of eafes of the goût, in which it is faid, that, by great émotions of mind, by wounds, and by other accidents, the fymptoms have been fuddenly relieved, and never again returned ; but how far thefe accidentai cures might be imitated by art, or would fucceed in other cafés, is at leaft extrcmely uncertain. DIV. The pradtices proper and neceffary in the treatment of the goût, are to be confidered under two heads : Firjî, As they are to be employed in the intervais of paroxyfms ; or, fecondly, As during the time of thefe. DV. In the intervais of paroxyfms, the indications are, to prevent altogether the return of paroxyfms, or at leaft to render them lefs fréquent, and more moderate. During the time of paroxyfms, the indications are, to moderate the violence, and fhorten the duration of them as much as can be done with fafety. DVI. O F P H Y S I C. 185 DVI. It has been already obferved, that the goût may be entirely prevented by confiant bodily exercife, and by a low diet; and I am of opinion, that this prévention may take place even in perfons who have a hereditary difpofition to the difeafe. I muft add hère, that even when the difpofition has difcovered itfelf by feveral paroxyfms of inflammatory goût, I am perfuaded, that labour and abftinence will abfolutely prevent any returns of it for the reft of life. Thefe, therefore, are the means of anfwering the firft indication to be purfued in the intervais of paroxyfms ; and I muft hère offer fome remarks upon the proper ufe of thefe remédies. DVIL Exercife in perfons difpofed to the goût, is diredted to two purpofes : One of thefe is the ftrengthening of the tone of the extrême veflèls, and the other, the guarding againft the plethoric ftate. For the former, if exercife be employed early in life, and before intempérance has weakened the body, a very moderate degree of it will anfwer the purpofe ; and, for the latter, if abftinence be at the famé time obferved, little exercife will be neceffary. DVIIL With refpect to exercife, this in gênerai is to be ob- ferved, that it fhould never be violent ; for, if violent, it cannot be long continued, and muft always endanger the bringing on an atony in proportion to the violence of the preceding exercife. DIX. It is alfo to be obferved, that the exercife of geftation, though confiderable and confiant, if it be entirely without bodily. exercife, will not anfwer the purpofe in preventing the goût. For this end, therefore, the A a exercife 186 PRACTICE exercife muft be in fome meafure that of the body, ancf muft be moderate, but, at the famé time, confiant and continued thro' life. t>x. In every cafe and circumftance of the goût irt which the patient retains the ufe of his limbs, bodily exercife, in the intervais of paroxyfms, will always be ufeful ; and, in the beginnings of the difeafe, whçn the dif- pofition to it is not yet ftrong, exercife may prevent a paroxyfm which otherwife might have come on. In more advanced ftates of the difeafe, however, when there is fome difpofition to a paroxyfm, much walking will br'mg it on ; either as it weakens the tone of the lower extrenlities, or as it excites an inflammatory difpofition in them ; and thus it feems to be, that ftrains or con- tufions often bring on a paroxyfm of the goût. DXI. Abftinence, the other part of our regimen (DlII.) for preventing the goût, isof moredijficult application. If an abftinence from animal food be entered upon early in life, while the vigour of the fyftem is yet entire, we have no doubt of its being both fafe and effectuai ; but, if the motive for. this diet fhall not have occurred till the conftitution'fhall have been broken by intempérance, or by the décline of life, a low diet may then endanger the bringing on an atonie ftate. DXII. Further, if a low diet be entered upon only in the dé- cline of life, and be at the famé time a very great change in the former manner of living, the withdrawing of an accuftomed ftimulus of the fyftem may readily throw this into an atonie ftate. DXIIL O F P H Y S I e. 187 DXIIL The fafety of an abftemious courfe may be greater or lefs according to the management of it. It is animal food which efpecially difpofes to the plethoric and inflam» rhatory ftate, and that food is to be therefore efpecially avoided ; but, on the other hand, it is vegetable aliment of the loweft quality that is in danger of weakening the fyftem too much, by not affording fufficient nouriihment, and more particularly, of weakening the tone of the ftomach by its acefcency. It is therefore a diet of a middle nature that is to be chofen ; and milk is preoifely of this kind, as containing both animal and vegetable matter. As approaching to the nature of milk, and as being a vegetable matter containing the greateft portion of nourifhment, the farinaceous feeds are next to .be chofen, and are the food moû proper to be joined with milk. DXIV. With refpect to drink, fermented liquors are ufeful only when they are joined with animal food, and that by their acefcency ; and their ftimulus js only neceffary from cuftom. When, therefore, animal food is to be avoided, fermented liquors are unneceffary ; and, by increafing the acefcency of vegetables, thefe liquors may be hurtful. The ftimulus of fermented, or fpirituous liquors, is not neceffary to the young and vigorous, and, when much employed, impairs the tone of the fyftem. Thefe liquors, therefore, are to be avoided, except fo far as cuftom and the declining ftate of the fyftem may have rendered them neceffary. For preventing or mo- derating the regular goût, water is the only proper drink. , DXV. With refpect to an abftemious courfe, it has been fuppofed, that an abftinence from animal food and fer- mented liquors, or the living upon milk and farinacea alone 188 PRACTICE alone for the fpace of one year, might be fufficient for a radical cure of the goût : And it is poffible that, at a certain period of life, in certain circumftances of the conftitution, fuch a meafure might anfwer the purpofe. But this is very doubtful ; and itismore probable, that the abftinence muft, in a great meafure, be continued, and the milk diet be perfifted in for the reft of life. It is well known, that feveral perfons who had entered on an abftemious courfe, and had been thereby delivered from the goût, have, however, upon returning to their former manner of full living, had the difeafe return upon them with as much violence as before, or in a more ir- regular, and more dangerous form. DXVI. Tt has been alledged, that, for preventing the return of the goût, blood-letting, or fearifications of the feet frequently repeated, and at ftated times, may be prac- tifed with advantage ; but of this I have had no expérience. DXVII. Exercife and abftinence are the means of avoiding the plethoric ftate which gives the difpofition to the goût, and are therefore the means propofed for preventing paroxyfms, or at leaft for rendering them lefs fréquent, and more moderate. But many circumftances prevent the fteadinefs neceffary in purfuing thefe meafures ; and, therefore, in fuch eafes, unlefs great care be taken to avoid the exciting caufes, the difeafe may frequently return ; and, in many cafés, the preventing of paroxyfms is chiefly to be obtained by avoiding thofe exciting caufes enumerated in (CCCCLXVII.). The condua ne- ceffary for avoiding them, will be fufficiently obvious to perfons acquâinted with the doctrines of the Hygieine, which we fuppofe to have been delivered in another place. DXVIII. O F P H Y S I C, 189 DXVIII. A due attention in avoiding thofe feveral caufes, will certainly prevent fits of the goût ; and the taking care that thofe exciting caufes be never applied in a great degree, will certainly render fits more moderate when they do come on. But, upon the whole, it will appear, that a ftridt attention to the whole conduct of life, is in this matter neceffary; and, therefore, when the pre- difpofition has taken place, it will be extremely difficujt to avoid the difeafe. DXIX. I am indeed firmly perfuaded, that, by obviating the predifpofition, and by avoiding the exciting caufes, the goût may be entirely prevented : But, as the meafures neceffary for this purpofe will, in moft cafés, be purfued with difficulty, and even with reludtance, men have been very defirous to find a medicine which might anfwer the purpofe, without any reftraint on their manner of living. To gratify this defire, phyficians have propofed, and to take advantage of it, empirics have feigned many remédies, as we have already obferved. Of what nature feveral of thefe remédies have beeir, I cannot certainly fay; but, of thofe which are unknown, we conclude, from their having been only of temporary famé, and from their having foon fallen into negledt, that they have been either inert or pernicious, and therefore I make no inquiry after them ; and fhall now remark only upon one or two known remédies for the goût which have been lately in vogue. DXX. One of thefe is what has been named in England, the Portland Powder. This is not a new medicine, but is mentioned by Galen, and, with fome little variation in its compofition, has been mentioned by the writers of almoft every âge fince that time. It appears to have been at times in fafhion, and to have again fallen into negledt ; 190 PRACTICE negledt ; and I think that this laft has been owing to its having been found to be, in many inftances, pernicious. In every inftance which I have known of its exhibition for the length of time prefcribed, the perfons who had taken it were indeed afterwards free from any inflam- matory affection of the joints ; but they were affected with many fymptoms of the atonie goût ; and ail, foon after finifhing their courfe of the medicine, have been attacked with apoplexy, afthma, or dropfy, which proved fatal. DXXT. - Another remedy which has had the appearance of preventing the goût, is, an alkali in various forms, fuch as the fixed alkali, both mild and cauftic, lime-water, foap, and abforbent earths. Since it became common to exhibit thefe medicines in nephritic and calculous cafés, it has often happened, that they were given to thofe who were at the famé time fubjedt to the goût ; and it has been obferved, that, under the ufe of thefe medicines, gouty perfons have been longer free from the fits of their difeafe. That, however, the ufe of thefe medicines has entirely prevented the returns of goût, I do not know ; becaufe I never pufhed the ufe of thofe medicines for a lon'g time, being apprehenfive that the long continued ufe of them might produce a hurtful change in the ftate of the fluids, DXXII, With refpect to preventing the goût, I have only one other remark to offer. As the preventing the goût dé- pends very much on fupporting the tone of the ftomach, and avoiding indigeftion ; fo coftivenefs, by occafioning this, is very hurtful to gouty perfons. It is therefore neceffary for fuch perfons to prevent or remove coftivôr nefs, and, by a. laxative medicine, when need fui ; but it is at the famé time proper, that the medicine employed fhould be fuch as may keep' the belly regular, without much purging. Aloetics, rhubarb, magnefia alba, or flowers O F P H Y S I C. t9i flowers of fulphur, may be employed, as the one or the other may happen to bebeft fuited to particular perfons. DXXIII. Thefe are the feveral meafures from (DV. toDXXII.) to be purfued in the intervais of the paroxyfms ; and we are next to mention the meafures proper during the time of them. DXXIV. As during the time of paroxyfms the body- is in a feverifh ftate, no irritation fhould then be added to it ; and every part, therefore, of the antiphlogiftic regimen, (CXXIV. CXXV.) except the application of cold, ought to be ftridtly obferved. . Another exception to the gênerai rule may occur, when the tone of the ftomach is weak, and when the patient has been before much accuftomed to the ufe of ftrong drink ; for then it may be allowable, and even neceffary, to give fome animal food, and a little wine. DXXV. That no irritation is to be added to the fyftem during the paroxyfms of goût, except in the cafés mentioned, is entirely agreed upon among phyficians : But it is a more difficult matter to détermine, whether, during the time of paroxyfms, any meafures may be purfued to moderate the violence of reaction and of inflammation. Dr. Sydenham has given it as his opinion, that the more violent the inflammation and pain, the paroxyfms will be the fhorter, as well as the interval between the pre- fent and next paroxyfm longer ; and, if this opinion be admitted as juft, it will forbid the ufe of any remédies which might moderate the inflammation ; which is, to a certain degree, undoubtedly neceffary for the health of the body. On the other hand, acute pain preflès for relief; and, although a certain degree of inflammation may feem abfolutely neceffary, it is not certain but that a moderate degree of it may anfwer the purpofe : And 192 PRACTICE it is even probable, that, in many eafes, the violence of inflammation may weaken the tone of the parts, and thereby invite a return of paroxyfms. It feems to me to be in this way, that, as the difeafe advances, the paroxyfms become more fréquent. DXXVI. From thefe laft confiderations, it feems probable, that, during the time of paroxyfms, fome meafures may be taken to moderate the violence of the inflam- mation and pain, and particularly, that in firft par- oxyfms, and, in the young and vigorous, blood-letting at the arm may be pradtifcd with advantage : But I am perfuaded, that this pradtice cannot be repeated often with fafety, becaufe blood-letting not only weakens the tone of the fyftem, but may'alfo contribute to produce Plethora. I believe, however, that bleeding by leeches on the foot, and upon the inflamed part, may be prac- tifed, and repeated with greater fafety ; and I have known inftances of its having been practifed with fafety, to moderate and fhorten paroxyfms ; but how far it may be carried, we have not had expérience enough to dé- termine. , DXXVII. Befides blood-letting, and the antiphlogiftic regimen, it has been propofed to employ remédies for moderating the inflammatory fpafm of the part affected, fuch as warm bathing and emollient poultices. Thefe have fometimes been employed with advantage and fafety ; but, at other times, have been found to give occafion to a retroceffion of the goût. DXXVIII. Bliftering is a very effectuai means of relieving and difeuffing a paroxyfm of the goût ; but has alfo fre- quently had the effedt of rendering it rétrocèdent. DXXIX. O F P-HYSIC. 193 DXXIX. The ftinging with nettles I confider as analogous to bliftering; and I think it probable that it would be attended with the famé danger. DXXX. The burning with moxa, or other fubftances, I con- fider as a remedy of the fàme kind. I have had, indeed, no évidence of this proving hurtful ; but neither have I had any proper évidence of its having proved a radical cure* DXXXL Camphirej and fome aromatic oils, have the power of allayingthe pain, and of removing the inflammation from the part affedted ; but thefe remédies commonly make the inflammation only fhift from one part to another, and therefore with the hazard of its falling upon a part where it may be more dangerous, and they have fometimes rendered the goût rétrocèdent. DXXXIL From thefe refledtions fDXXX et feq.) it will ap- pear, that fome danger muft attend every external appli- cation to the parts affedted, during a paroxyfm ; and that therefore the common pradtice of committing the perfon to patience and flannel alone, is eftabliihed upon the beft foundation. DXXXIIL Opiates give the moft certain relief from pain, but, when given in the beginning of gouty paroxyfms, oc- cafion thefe to return with greater violence. When, however, the paroxyfms fhall have abated in their vio- lence, bift ftill continue to return, fo as to occafion painful and reftlefs nights, opiates may be then given Bb with 194 PRACTICE with fafety and advantage, efpecially in the cafe of perfons advanced in life, and who have been often affected with the difeafe. DXXXIV. When, after paroxyfms have ceafed, fome fwelling and ftiffnefs fhall remain in the joints, thefe fymptoms are to be difcuffed by the diligent ufe of the flefh-brufh. DXXXV. Purging, immediately after a paroxyfm, will be always employed with the hazard of bringing it on again. DXXXVI. I have now finifhed what has occurred to be faid upon the means 'of preventing and curing the regular goût j and fhall now confider its management when it has become irregular, of which I have obferved there are three diffèrent cafés. DXXXVII. In the firft cafe,! which I have named the atonie goût, the cure is to bé accomplifhed by carefully avoiding ail debilitating caufes, and by employing, at the famé time, (he means of ftrengthening the fyftem in gênerai, and the ftomach in particular. DXXXVIII. For the avoiding debilitating caufes, I muft refer to the doctrines of the Hygieine, as in (DXVIL). DXXXIX. For ftrengthening the fyftem in gênerai, I muft re- commend fréquent exercife on horfeback, and moderate walking. Cold bathing alfo may anfwer the purpofe, and may be fafely employed, if it appear to be powerful in t O F P H Y S I C. 195 in ftimulating the fyftem, and be not applied when the extremities are threatened with any pain. For fupporting the tone of the fyftem in gênerai, when threatened with atonie goût, fome animal food ought to be employed, and the more acefeent vegetables ought to be avoided. In the famé cafe, fome wine alfo may be neceffary ; but it fhould be in moderate quantity, andof the leaft acefeent kinds ; and, if every kind of wine fhall be found to increafe the acidity of the ftemach, ardent fpirits and water muft be employed. DXL. For ftrengthening the ftomach, bitters and the Pe- ruvian bark may be employed ; but care muft be taken that they be not conftantly employed for any great length of time. The moft effectuai medicine for ftrengthening the ftomach is iron, which may be employed under various préparations ; but, to me, the beft appears to be the ruft in fine powder, which may be given in very large dofes. For fupporting the tone of the ftomach, aromatics may be employed ; but fhould be ufed with caution, as the fréquent and large ufe of them may have an oppofite effedt, and they fhould therefore be given only in com- pliance with former habits, or for palliating prefent fymptoms. When the ftomach happens to be liable to indigeftion, gentle vomits may be frequently given, and proper laxa- tives fhould be always employed to obviate, or to re- move coftivenefs. DXLI. In the atonie goût, or in perfons liable to it, to guard ■ againft cold is efpecially neceffary ; and the moft certain means of doing this, is by repairing to a warm climate during the winter feafon. DXLII. 196 PRACTICE DXLIL In the more violent cafés of the atonie goût, bliftering the lower extremities may be ufeful ; but that remedy fhould be avoided when any pain threatens the extremities. In perfons liable to the atonie goût, iffues may be efta- blifhed in the extremities, as, in fome meafure, a fup- plement to the difeafe. DXLIII. A fécond cafe of the irregular goût, is that which I have named the Rétrocèdent. When this affedts the ftomach and inteftines, relief is to be inftantly attempted by the free ufe of ftrong wines, joined with aromatics, and given warm ; or, if thefe fhall not prove powerful enough, ardent fpirits muft be employed, and are to be given in a large dofe. In moderate attacks, ardent fpirits, impregnated with garlic, or with afa fœtida, may be employed ; or, even without the ardent fpirits, a folution of afa fœtida, with the volatile alkali, may anfwer the purpofe. Opiates are often an effectuai remedy, and may be joined with aromatics, as in the Electuarium Thebaicum ; or they may be ufefully joined with volatile alkali and camphire. Mufk has likewife proved ufeful in this difeafe. When the affection of the ftomach is accompanied with vomiting, this may be encouraged, by taking draughts of warm wine, at firft with water, and after- wards without it ; having at length recourfe, if ne- ceffary, to fome of the remédies above mentioned, and particularly the opiates. In like manner, if the inteftines be affedted with diarrhœa, this is to be at firft encouraged, by taking plentifully of weak broth ; and when this fhall have been done fufficiently, the tumult is to be quieted by opiates. DXLIV. O F P H Y S I C. 197 DXLIV. When the rétrocèdent goût fhall affedt the lungs, and produce afthma, this is to be cured by opiates, by an- tifpafmodics, and, perhaps, by bliftering on the breaft or back. DXLV. When the goût, leaving the extremities, fhall affect the head, and produce pain, vertigo, apoplexy, or palfy, our refources are very precarious. The moft probable means of relief*is, bliftering the head; and, if the goût fhall have receded very entirely from the extre- mities, blifters may be applied to thefe alfo. Together with thefe blifterings, aromatics, and the volatile alkali, may be thrown into the ftomach. DXLVI. The third cafe of the irregular goût is what I name the Mifplaced, that is, when the inflammatory affection of the goût, inftead of falling upon ther extremities, falls upon fome internai part. In this cafe, the difeafe is to be treated by blood-letting, and by fuch other re- médies as would be proper in an idiopathic inflammation of the famé parts. DXLVII. Whether the tranflation fo frequently made from the extremities to the kidneys, is to be confidered as an inftance of the mifplaced goût, feems, as we have faid before, uncertain ; but I am difpofed to think it fome- thing diffèrent ; and therefore am of opinion that, in the Nephralgia Çalculofa produced upon this occafion, the remédies of inflammation are to be employed no farther than they may be otherways fometimes neceffary in that difeafe, arifing from other caufes than the goût. B O OK t 198 PRACTICE B O O K III. Of EXANTHEMATA, or ERUP- TIVE FEVERS. DXLVIII. TH E difeafes comprehended under this title, which make the third order of Pyrexiae in our Nofology, are generally fuch as do not arife but upon occafion of a fpecific contagion applied, which firft produces fever, and then an éruption upon the furface of the body ; and, in refpedt of both, a difeafe, which, for the moft part, affedts perfons but once in the courfe of their lives. DXLIX. Whether the charadter of the order may be thus limited, or if the order may be allowed to comprehend the eruptive fevers produced by a matter generated in the body itfelf, as alfo thofe cafés of éruption which do not dépend upon contagion,, or upon a matter generated before the fever,,but are fymptoms only of certain con- ditions of fever, we fhall not détermine hère. We leave thefe queftions for a nofological difcuffion, to be entered into in another place; and proceed now to confider the particular difeafes which are commonly enumerated under the title of Exanthemata, or Eruptive Fevers. C H A P. OF P H Y S I C. 199 C H A P. I. Of ERYSIPELAS, or St. AN- THONY's FIRE. DL. In (CCLXIX.) I mentioned the diftindtion which I propofed to make between the difeafes to be named the Erythema and Eryfipelas; and from thence it will ap- pear, that Eryfipelas, as an Erythema following fever, may have its place hère. DLL We fuppofe the eryfipelas to depçnd on a matter ge- nenerated within the body, and which, analogous to the other cafés of exanthemata, is, in confequence of fever, thrown out upon the furface. We own it may be dif- ficult to apply this to every particular cafe of eryfipelas ; but we take the cafe in which it is generally fuppofed to apply, thatis, the cafe of the eryfipelas of the face; which we now, therefore, proceed to treat of. DLII. The eryfipelas of the face cornes on with a cold fhivering, and other fymptoms ôf pyrexia. The hot ftage of this is frequently attended with a confufion of head, and fome degree of delirium ; and almoft always with drowfinefs, or perhaps coma. The pulfe is always fréquent, and commonly full and hard. DLIII. 200 PRACTICE DLIIL When thefe fymptoms have continued for one, two, or at moft three days, there appears, on fome part of the face, a rednefs, fuch as that defcribed under the title of Erythema (fee Synopf. Nofolog.). This red- nefs, at firft, is of no great extent, but gradually fpreads from the part it firft occupied to the other parts of the face, till it has affedted the whole ; and frequently from the face, it fpreads over the hairy fcalp, ordefcends on fome part of the neck. As the rednefs fpreads, it commonly leaves, or at leaft is abated in, the parts it had before occupied. Ail the parts which the rednefs affedts are, at the famé time, affedted with fome fwelling, which continues fometimes after the rednefs has abated. The whole face becomes confiderable turgid ; and the eye-lids are often fo much fwelled, as entirely to fhut up the eyes. DLIV. When the rednefs and fwelling have proceeded for fome time, there commonly arife, fooner or later, blifters of a larger or fmaller fize, on feveral parts of the face. Thefe contain a thin colourlefs liquor, which fooner or later runs out. The furface of the fkin, in the bliftered places, fometimes becomes livid and blackifh ; but this livor feldom goes deeper than the furface, or difcovers any degree of gangrené affedting the fkin. On the parts of the face not affedted with blifters, the cuticle fuffers, towards the end of the difeafe, a confiderable defquamation. Sometimes the tumour of the eye-lids ends in a fup- puration. DLV. The inflammation coming upon the face does not produce any remiffion of the fever which had before prevailed ; and fometimes the fever increafes with the fpreading and increafing inflammation. DLVL O F P H VY S I C. 201 à DLVI. The inflammation commonly continues for eight or tfen days ; and, for the famé time, the fever and fym- ptoms attending it alfo continue. DLVII. In the progrefsof the difeafe, the delirium and coma attending it fometimes go on increafing, and the patient dies apoplectic on the feventh, ninth, or eleventh day of the difeafe. In fuch cafés, it has been commonly fuppofed, that the difeafe is tranflated from the external to the internai parts. But I have not feen a cafe, in which it did not appear to me, that the affedtion of the brain was merely a communication from the external affedtion, as this continued increafing, at the famé time with the internai* DLVIII. When the fatal event does not take place, the inflam- mation, after having affected the whole of the face, and, perhaps, the other external parts of the head, ceafes ; and with that the fever alfo; and, without any other crifis, the patient returns to his ordinary ftate of health. DLIX This difeafe is not commonly contagious ; but, as the difeafe may arife from an acrid matter externally applied, fo, it is poffible, that the difeafe may fometimes be com- municated from one perfon to onother. Perfons who have once laboured under this difeafe are liable to returns of it. DLX. The event of this difeafe may be forefeen from the ftate of the fymptoms which dénote more or lefs affection •f the brain. If neither delirium nor coma come on, C c the 202 PRACTICE the difeafe is feldom attended with any danger ; but, when thefe fymptoms appear early in the difeafe, and are in a confiderable degree, the utmoft danger is to bc apprehended. DLXL As this difeafe often arifes in the part, at the famé time with the coming on of the pyrexia; as we have known it, with ail its fymptoms, to arife from an acri- mony applied to the part ; as it differs from pure Ery- thema, by being attended with a full, and frequently with a hard pulfe ; as the blood drawn in this difeafe fhews the famé cruft upon its furface, as appears in the phlegmafiae; and, lajîly, as the fwelling of the eye-lids, in this difeafe, frequently ends in a fuppuration ; fo, from ail thefe confiderations, it feems doubtful, if this difeafe be properly, in Nofology, feparated from the Phlegmafiae. At any rate, I take the difeafe we have defcribed, to be what phyficians have named the Ery- fipelas Phlegmonodes, and that it partakes a great deal of the nature of the Phlegmafiae. DLXII. Upon this conclufion, the eryfipelas of the face is to be cured very much in the famé manner as phlegmonic inflammations, by blood-letting, cooling purgatives, and by employing every part of the antiphlogiftic regi- men ; and our expérience has confirmed the fitnefs of this method of cure. DLXIIL The évacuations of blood-letting and purging, are to be employed more or lefs, according to the urgency of fymptoms, particularly thofe of the pyrexia, and of thofe which mark an affection of the brain. As the pyrexia continues, and often increafes with the inflam- mation of the face ; fo the évacuations mentioned may be employed at any time in the courfe of the difeafe. DLXIV. O F P H Y S I C. 203 DLXIV. In this, as in other difeafes of the head, it is proper to put the patient, as often as he can eafily bear it, into fomewhat of an eredt pofture. DLXV. As, in this difeafe, there is always an external affection, and as, in many eafes, there is no other ; fo various ex- ternal applications have been propofed to be made to the part affedted ; but almoft ail of them are of doubtful effedt. The nartotic, réfrigérant, and aftringent appli- cations, are fufpedted of difpofing to gangrené. Spi- rituous applications feem to increafe the inflammation ; and ail oily or watery applications feem to occafion its fpreading. The application which feems to be the moft fafe, and whatis now moft commonly employed, is that of a dry mealy powder, frequently fprinkled upon the inflamed parts. DLXVI. An eryfipelas phlegmonodes frequently appears on other parts of the body, befides the face ; and fuch other eryfipelatous inflammations frequently end in fup- puration. Thefe cafés are feldom dangerous. At coming on, they are fometimes attended with drowfinefs, and even with fome delirium ; but this feldom happens ; and thefe fymptoms do not continue after the inflammation is formed. I have never feen an inftance of the tranf- lation of an inflammation from the limbs to an internai part ; and, though thefe inflammations of the limbs be attended with pyrexia, they feldom require the famé évacuations as the eryfipelas of the face. At firft they are to be treated by dry mealy applications only ; and ail humid applications, as fomentations, or poultices, are not to be applied, till, by the continuance of the difeafe, by the increafe of fwelling, or by a throbbing felt in the part, it appears that the difeafe is proceeding to fup- puration. DLXVII. 204 PRACTICE DLXVII. We have hitherto confidered eryfipelas as in a great meafure of a phlegmonic nature ; and, agreeably to that opinion, we have propofed our method of cure. But, it is probable, that an eryfipelas is fometimes attended with, or is a fymptom of a putrid fever ; and, in fuch eafes, the évacuations propofed above may be imprbper, and the ufe of the Peruvian bark may be neceffary ; but I cannot be explicit upon this fubjedl, as fuch putrid cafés have not come under my obfervation. C H A P. . IL Of the PLAGUE. sect. i. Of the PHENOMENA of the PLAGUE. DLXVIII. The plague is a difeafe which always arifes from contagions ; which affedts many perfons about the famé time ; proves fatal to great numbers ; generally pro- duçes fever ; and, in moft perfons, is attended with bu- boes or carbuncles. DLXIX. O F P H Y S I C. 205 , DLXIX. Thefe are the circumftances which, taken together, give the charadter of the difeafe ; but it is attended with many fymptoms almoft peculiar to it, which, in diffèrent perfons, are greatly diverfified in number and degree, and fhould be particularly ftudied. We fhould wifh to lay a foundation for this ; but we think it unfit for a per- fon who has never feen the difeafe to attempt a particular hiftory of it. For this, therefore, we muft refer to the authors who have written on the fubject ; but we allow only thofe to be confulted, who have themfelves feen and treated the difeafe in ail its diffèrent forms. DLXX. From the accounts of fuch authors, it appears to me, that the circumftances which particularly diftinguifh this difeafe, and efpecially the more violent and dangerous ftates of it, are, iji, The great lofs of ftrength in the animal functions, which often appears early in the dif- eafe. idly, The ftupor, giddinefs, and confequent ftag- gering, which refembles drunkennefs, or the head-ach, and various delirium, ail of which fymptoms dénote a great diforder in the functions of the brain. idly, The anxiety, palpitation, fyncope, and efpe- cially the weaknefs and irregularity of. the pulfe, which dénote a confiderable difturbance in the action of tho heart. 4thly, The naufea and vomiting, particularly the vomiting of bile, which fhews an accumulation of vitiated bile in the gall-bladder, and biliary dudts, and from thence derived into the inteftines and ftomach ; ail of which fymptoms we fuppofe to dénote a confiderable fpafm, and lofs of tone in the extrême 'veffels on the furface, of the body. Sthly, The buboes or carbuncles, which dénote an acrimony prevailing in the fluids ; and, lajily, The petechiae, hemorrhagies, and colliquative diarrhœa, which 206 PRACTICE which dénote a putrefcent tendency prevailing to a great degree in the mafs of blood. PLXXI. From the confideration of ail thefe fymptoms, it ap- p;ars, that the plague is efpecially diftinguifhed by a fpecific contagion, often fuddenly producing the moft confiderable fymptoms of debility in the nervous fyftem, or moving powers, and of ageneral putrefcency in the fluids ; and it is from the confideration of thefe circum- ftances as the proximate caufe, that I think both the prévention and cure of the plague muftbe directed. DLXXII. If this difeafe fhould revifit the northern parts of Europe, it is probable, that, at the famé time, there will not be a phyfician alive, who, at the firft appear- ance of the difeafe, can be guided by his former expé- rience, but muft be guided by his ftudy of the writers on this fubject, and by analogy. It is, therefore, I hope, allowable for me, upon the famé grounds, to give hère my opinion with refpect to both the prévention and cure of this difeafe. SECT. IL Of the PREVENTION of the PLAGUE. DLXXIIL With refpedt to the prévention : As we are firmly perfuaded that the difeafe never arifes in the northern parts O F P H Y S I C. 207 parts of Europe, but in confequence of its being im- ported from fome other country, fo the firft meafure neceffary, is the Magiftrate's taking care to prevent the importation ; and this may generally be done by a due attention to bills of health, and to the proper performance of quarantains. DLXXIV. With refpect to the latter, we are perfuaded, that the quarantain of perfons may, fafely, be much lefs than forty days ; and, if this were allowed, the exécution of the quarantain would be more exact and certain, as the temptation to break it would be, in a great meafure, avoided. DLXXV. With refpect to the quarantain of goods ; it cannot be perfedt, unlefs the fufpedted goods be unpacked, duly ventilated, and other means be employed for correcting the infection they may cari y ; and, if ail this be pro- perly done, it is probable, that the time commonly pre- fcribed for the quarantain of goods might alfo be fhortened. DLXXVI. A fécond meafure, in the way of prévention, is required, when an infection has reached and» prevailed in any place, to prevent that infection from fpreading into other places. This can be done only by preventing the inhabitants, or the goods of any infected place, from going out of it, till they have undergone a proper qua- rantain. DLXXVIL The third meafure for prévention, to be employed with great care, is to prevent the infedtion from fpreading among the inhabitants of the place in which it has arifen ; and the meafures neceffary for this are to be di- re dted 208 PRACTICE rected by the doctrine laid down in (LXXXVI.) ; and from that dodtrinex we infer, that ail perfons who can avoid any near communication with irrfedted perfons, or goods, may be faved from the infection. DLXXVIII. For avoiding fuch communication, a great deal may be done by the Magiftrate. i. By allowing as many of the inhabitants as are free from infection, and are not neceffary to the fervice of the place, to go out of it. 2. By difchargingall aflèmblies, or unrreceffary intercourfe of the people. 3. By rendering fome neceffary com- munications to be performed without contact. 4. By making fuch arrangements and provifions as may render it eafy for the families remaining to fhut themfelves up in their own houfes. 5. By allowing perfons to quit houfes in which an infection appears, upon condition that they go into lazarettos. 6. By ventilating and pu- rifying, or deftroying, at the public expence, ail infedted goods. Lajily, By avoiding hofpitals, and providing feparate apartments for infedted perfons. The exécution of thefe meafures will require a great authority, and much vigilance and attention on the part of the magiftrate ; but it is not our province to enter into any détail on this fubjedt of the public police. DLXXIX. The fourth znàmlajl part of the bufinefs of prévention, refpects the condudt of perfons neceffarily remaining in infedted places, efpecially thofe obliged to have fome communication with perfons infedted. DLXXX. Of- thofe obliged to remain in infedted places, but not obliged to have any near communication with the fick, they may be preferved by avoiding ail near com- munication with other perfons, or their goods ; and, it is probable, that a fmall diftance will ferve, if, at the famé O F P H Y S I C. 209 famé time, there be no ftream of air to carry the effluvia of perfons, or goods, to fome diftance. DLXXXI. For thofe who are neceffarily obliged fo have a near communication with the fick, it is proper to let them know, that fome of the moft powerful contagions do not operate but when the bodies of men expofed to it are in certain cijcumftances, which render them more liable to be affedted by it ; or, when certain caufes concur to excite the power of it ; and, therefore, by avoiding thefe circumftances and caufes, they may often efcape infection. DLXXXIL The bodies of men are efpecially liable to be affected by contagions, when they are any how confiderably weakened, as they may be by want of food, and even by a fcanty diet, or one of little nourifhment ; by. in- tempérance in drinking, which, when the ftupor of intoxication is over, leaves the body in a weakened ftate ; by excefs in venery ; by great fatigue ; or, by any confiderable évacuation. DLXXXIII. The caufes which, concurring with -contagion, render it more certainly adtive, are cold, fear, and full living. The feveral means, therefore^ of avoiding or guarding againft the action of cold," are to be carefully ftudied. DLXXXIV. Againft fear the mind is to be fortified as well as pof- fible ; by giving them a favourable idea of the power of prefervative means ; by deftroying the opinion of the in- curable nature of the difeafe; by occupying mens minds with bufinefs or labour ; and, by avoiding ail objedts of D d fear, 2io PRACTICE fear, as funerals, paffing bells, and any notice of the death of particular friends. DLXXXV. A full dietof animal food increafes the irritability of the body, and favours the opération of contagion ; and indigeftion, whether from the quantity or quality of food, is very favourable to the famé. DLXXXVI. Befides giving attention to the feveral means (DLXXXI. DLXXXII.) which favour the opération of contagion, it is probable, that fome means may bc employed for ftrengthening the bodies of men, and thereby enabling them to refift contagion. For this purpofe, it is probable, that the moderate ufe of wine, or of fpirituous liquors, may have a good effedt. It is probable alfo, that exercife, when it can be em- ployed, if it be fo moderate as to be neither heating nor fatiguing to the body, may be employed with advantage. Ferions who have tried cold bathing, and commonly feel the invfgorating effects of it, if they are any ways fecure againft their having already received infection, may poffibly be enabled to refift it by the pradtice of cold bathing. It is probable, that fome medicines, alfo, may be ufeful in enabling men to refift infection, but, among thefe, we can hardly admit the numerous alexipharmics1 formerly propofed, or, at leaft, very few of them, and thofe only of tonic power ; among which we reckon the Peruvian bark ; and it is, perhaps, the moft effectuai. If any thing is to be expedted from antifeptics, I think camphire, whether internally or externally employed, is one of the moft promifing. Every perfon is to be indulged in the ufe of any means of prefervation, which he has conceived a good opinion of, whether it be a charm or a medicine, if the latter bc not diredtly hurtful. Whether OF PHYSIC. 211 Whether iffues be ufeful in preferving from the effedts of contagion, or in moderating thefe, I cannot détermine from the obfervations I have yet read. DLXXXVII. As the atmofphere, in gênerai, or any confiderable portion of it, is not tainted or impregnated with the matter of contagions, fo the lightingpf fires over a great part of the infedted city, or other gênerai fumigations in the open air, are of no ufe for preventing the difeafe, and may be perhaps hurtful. DLXXXVIII. It would probably contribute much to check the pro- grefs of infection, if the poor were enjoined to make a fréquent change of cloathing, and were provided for that purpofe ; and if they were, at the famé time, en- gagea to make a fréquent ventilation of their houfes and furniture. SECT. III. Qf the CURE OF THE PLAGUE. DLXXXIX. In the cure of the plague, the indications are the famé as thofe of fever in gênerai ; CXX.) but they are not ail equally neceffary and important hère. DXC, The meafures for moderating the violence of reaction, which operate by diminifhing the adtion of the heart and 212 PRACTICE and arteries, (CXXI. i.) have feldom any place hère, excepting fo far as the antiphlogiftic regimen is generally proper. Some phyficians, indeed, have recommended bleeding, and there may be cafés in which bleeding may be ufeful ; but, for the moft part, it is unneceffary, and in many cafés it might be very hurtful. Purging has ajfq been recommended ; and, in fome degree, it may be ufeful in drawing off the bile, or other putrefcent matters frequently prefent in the inteftines ; buta large évacuation this way may certainly be hurtful. DXCI. The moderating the violence of réaction, fo far as it can be done by taking off the fpafm of the extrême veflèls, (CXXL 2.3. is a meaiure of the utmoft neceffity in the cure of the plague ; and the whole of the means (CXLVI. 1. CXLVII.) fuited to this indication, are extremely proper. DXCII. The giving an emetic at the very firft approach of the difeafe, would probably be of great fervice ; and, it is probable, that, at fome other periods of the difeafe, emetics might be ufeful, both by evacuating bile, abundant in the alimentary canal, and by taking.off the fpafm of the extrême veffels. DXCIII. From fome principles with refpect to fever in gênerai, and with refpect to the plague in particular, I am of opinion, that, after the exhibition of the firft vomit, the body fhould be difpofed to fweat, which fhould be raifed to a moderate degree only, but continued for at leaft twenty-four hours, or more, if the patient bears it eafily. DXCIV. Thi«ifweating ihouid be excited and condudted agree- ably to the rules laid down in (CLXII.)- It is to be promoted O F P H Y S I C. 213 promoted by the plentiful ufe of diluents, rendered more grateful by vegetable acids, or more powerful, by being impregnated with fome portion of neutral faits. DXCV. To fupport the patient under the continuance of the fweat, a little weak broth, acidulated with juice of le- mons-, may be given frequently, and fometimes a little wine, if the heat of the body is not confiderable. DXCVL If fudorific medicines are judged to be neceffary, opiates are the moft effectuai and fafe ; but they fhould not be combined with aromatics ; and, probably, may be more effectuai, if joined with a portion of emetics, and of neutral faits. DXCVII. If, notwithftanding the ufe of emetics and fudorifics in the beginning, the difeafe fhould ftill continue, the cure muft turn upon the ufe of means for obviating debility and putrefcency ; and, for this purpofe, the various remédies propofed above, (CXCVII. to CCXXI) may ail be employed, but efpecially the tonics ; and of thefe the chief are cold drink, and the Peruvian bark. DXCVIII. In the cure of die plague, fome attention is due to the management of buboes and carbunclcs ; but we do not touch this, as belonging to the province of furgery. C H A P. 2I4 PRACTICE C H A P. III. Of the SMALL-P OX. DXCIX. The fmall-pox is a difeafe arifing from a contagion of a fpecific nature, which firft produces a fever, and, on the third or fourth day of that, produces an éruption of fmall inflamed pimples. They are afterwards formed into puftules, containing a matter, which, in the courfe of eight days from the éruption, is changed into pus. After this the matter is dried, and falls off in crufts. DC. This is a gênerai idea of the difeafe ; but there are two particular forms, or varieties of it, well known under the appellations of the Diftinct and Confluent, which require to be fpecially defcribed. DCI. In the former, or diftinct fmall-pox, the eruptive fever is moderate, and appears to be evidently of the inflammatory • kind, or what we name a fynocha. It generally cornes on about mid-day, with fome fymptoms of a cold ftage, and commonly with a confiderable lan- guor and drowfinefs. A hot liage is foon formed, and becomes more confiderable on the fécond and third day. During this courfe, children are liable to fréquent ftàrtings from their flumbers ; and adults, if they are kept-a-bed, are difpofed to much fweating. On the third day children are fometimes affected with one or two epileptic fits. Towards the end of the third day, the éruption commonly appears, and gradually increafes during O F P H Y S I C. 2*5 during the fourth ; appearing firft upon the face, and fucceffively on the inferior parts, fo as to be compleated over the whole body on the fifth day. From the third day the fever abates, and againft the fifth it entirely ceafes. The éruption appears firft in fmall red fpots, hardly eminent, but by degrees rifing into pimplcs. Thefe are generally upon the face in fmall number-; but, even when more numerous, they are feparate and diftinct from one another. On the fifth or fixth day, a fmall veficle, containing an almoft colourlefs, or whey- coloured fluid, appears upon the top of each pimple. For two days thefe veficles increafe in breadth only, and there is a fmall hollow pit in their middle, fo that it is only againft the eighth day that they are raifed into fpheroidical pullules. Thefe veficles or puftules, from their firft formation, continue to be furrounded with an exadtly circular inflamed margin, which, when the puftules are numerous, diffufes fome inflammation over the neighbouring fkin, fo as to give fomewhat of a da- mafk rofe colour tothe fpaces between the puftules. As the puftules increafe in fize, if they be numerous on the face, the whole of the face, againft the eighth day, becomes confiderably fwelled ; and, in particular, the eye-lids are fo much fwelled, as entirely to fhut the eyes. -As the difeafe thus proceeds, the matter in the puftules becomes, by degrees, more opaque and white, and at length of a yellowifh colour. On the eleventh day, the fwelling of the face is abated, and the puftules feem quite full. On the top of each a darker fpot appears ; and at this place the puftule, on the eleventh day, or foon after, is fpontaneoufly broken, and a portion of the matter oozes out ; in confequence of which, the puftule is fhrivelled, and fubfides, while the matter oozing out dries, and forms a cruft upon its furface. Sometimes a little only of the matter oozes out, and what remains in the puftule becomes thick, and even hard. After fome days, both the crufts and the harciened puftules fall off, leaving the fkin which they covered of a brown red colour ; and it is only after many days that this part refumes its natural colour. In fome cafés, where the matter of the puftules has been more liquid, the crufts formed by it are later in falling off, and the part they 2i6 PRACTICE they covered fuffers fome defquamation, and a fmall hollow or pit is left in it. This is the courfe of things on the face ; and fuc- ceffively, the puftules on the reft of the body take the famé. The matter of the puftules, on the arms and hands, is frequently abforbed ; fo that, at the height of the difeafej thefe puftules appear as empty vendes. On the tenth and eleventh days, as the fwelling of the face fubfides, a fwelling arifes in the hands and feet ; but which again fubfides, as the puftules come to ma- turity. When the puftules on the face are numerous, fome degree of pyrexia appears on the tenth and eleventh days, but difappears again after the puftules are fully ripened ; or, perhaps, remains in a very- flight degree till the puftules on the feet have finifhed their courfe. It is feldom that any fever continues longer in the diftinct fmall-pox. When the puftules on the face are numerous upon the fixth or feventh day, fome uneafinefs in the throàt, with a hoarfenefs of the Voice, cornes on, and a thin liquid is poured out from the mouth. Thefe fymptoms increafe with the fwelling of the face; and the liquids of the mouth and throat becoming thicker, are more difficultly thrown out ; and there is, at the famé time, fome dif- ficulty of fwallowing, fo that liquids taken in to be fwallowed are frequently rejected, or thrown out by the nofe. But ail thefe affections of the fauces are abated, as the fwelling of the face fubfides. DCII. In the other form of fmall-pox, or what is called the Confluent, the courfe of the difeafe is, in gênerai, the famé with that we have defcribed ; but the fymptoms of every ftage are more violent, and feveral of the circum- ftances are diffèrent. The eruptive fever is particularly more violent ; the pulfe is more fréquent and more contradted, approaching to that ftate of pulfe which is found in the typhus, The. coma is more confiderable, and there is frequently a de- lirium. Vomiting, alfo, is a common fymptom, efpe- O F P H Y S I C. 217 çially at the coming on of the difeafe. In very young infant-, epileptic fits are fometimes fréquent on the firft days of the difeafe, and fometimes prove fatal before-any éruption appears ; or they ufher in a very confluent and putrid fmall-pox. DCIIL The éruption appears more early on the third day, and it is frequently preceded, or accompanied, with an eryfipelatous efflorefeence. Sometimes the éruption ap- pears in clufters, like that of the meafles. When the éruption is compleated, the pimples are always more numerous upon the face, and, at the famé time, fmaller and lefs eminent. Upon the éruption, the fever fuffers fome remiffion, but never goes off entirely ; and, after the fifth or fixth day, it increafes again, and continues confiderable through the remaining courfe of the difeafe. The veficles formed on the top of the pimples appear fooner ; and, while they increafe in breadth, they do not retain a circular, but are every way of an irregular figure. Many of them run into one another, infomuch that very often the face is covered rather with one veficle than with a number of puftules. The veficles, fo far as they are any ways feparated, do not arife to a fpheroidical form, but remain flat, and fometimes the whole of the face is of an even furface. When the puftules are in any meafure feparated, their circumference is not bounded by an inflamed margin, and the part of the fkin that is free from puftules is commonly pale and flaccid. The liquor that is in the puftules changes from aclear to an opaque appearance, and becomes whiteifh or brown- ifh, but never acquires the yellow colour and thick con- fiftence that appears in the diftinct fmall-pox. The fwelling of the face which attends the diftinct pox when they are numerous, and almoft then only, always attends the confluent, cornes on more early, and arifes to a greater degree, but abates on the tenth day, and on the eleventh ftill more. At this time the puftules or veficles break, and fhrivelling pour out a liquor, which is formed into brown or black crufts, which do not fall off for many days after. Thofe of the face, in falling off, leave the parts they covered fûbject to a de- fquamation, which pretty certainly produces pittings. E e On 218 PRACTICE On the other parts of the body, the puftules of the confluent pox are more diftinct than upon the face, but never acquire the famé maturity and confidence of pus, as in the properly diftindt kind. The falivation, which fometimes only attends the diftindt fmall pox, very conftantly attends the confluent; and both the falivation, and the affection of the fauces above mentioned, are, efpecially in adults, in a higher degree. In infants, a diarrhœa cornes frequently in place of the falivation. In the confluent pox, there is often a confiderable pu- trefcency of the fluids, as appears from petechige, from ferous veficles, under which the fkin fhews a difpofition to gangrené,, and from bloody urine, or other haemorr- hagy, ail of which fymptoms frequently accompany this difeafe. • In the confluent fmall-pox, the fever, which had only fuffered a remiffion from the éruption to the maturation, at, or immediately after this period, is often renewed again with confiderable violence. This is what has been called the fecondary fever, and is, in diffèrent cafés, of various duration and event. DCIV. We have thus endeavoured to deferibe the various circumftances of the fmall-pox ; and, from the dif- férence of thefe circumftances, the event of the difeafe may be determined. The whole of the prognofis may be nearly comprifed in the following propofitions. The more exadtly the difeafe retains the form of the diftinct kind, it is the fafer ; and the more compleatly the difeafe takes the form of the confluent kind, it is the more dangerous. It is only when the diftindt kind fhews a great num- ber of puftules on the face, or otherwife, by fever or pu- trefcency, approaches to the circumftances of the con- fluent, that the diftinct kind is attended with any danger. In the confluent fmall-pox there, is always danger; and this is always more confiderable and certain, as the fever ismore violent and permanent, and efpecially as the marks a^hd fymptoms of putrefcency are more évident. When O F P H Y S I C. 219 When the putrid difpofition is very great, the difeafe fometimes proves fatal before the eighth day ; but in moft eafes it is on the eleventh that death happens ; and fometimes it is put off till the fourteenth or feven- teenth day. Though the fmall-pox be not immediately fatal, the more violent kinds are often followed by a morbid ftate of the body, of various kind and evént. Thefe con- fequences, as I judge, may be imputed fometimes to an acrid matter produced by the preceding difeafe, and de- pofited in diffèrent parts ; and fometimes to an inflam- matory diathefis produced and determined to particular parts of the body. DCV. It is, I think, agreed among pradtitioners, that, in the diffèrent eafes of fmall-poxj the différence chiefly dépends upon the appearance of diftinct or confluent j and, from the above defeription of thefe kinds, it will appear, that they chiefly differ in the time of éruption, in the number of puftules produced, in the form of the puftules, in the ftate of the matter contained in them, in the continuance of the fever, and, lajily, in the .danger of the djfeafe. DCVI. In inquiring into the caufes of thefe différences, we might readily fufpedt, that it depended upon a différence of the contagion producing the difeafe; but this is not probable ; for there are innumerable inftances of the contagion arifing from a perfon labouring under the fmall-pox, of the diftinct kind, producing the con- fluent ; and, on the contrary. Since the pradtice of inoculation became fréquent, we have known the famé variolous matter, in one perfon, produce the diftinct, and, in another, the confluent fmall-pox. It is, there- fore, highly probable, that the différence of the fmall- pox does not dépend upon any différence of the contagion, but upon fome différence in the ftate of the perfons to whom 220 PRACTICE whom it is applied, or in the ftate of certain circunv fiances concurring with the application of the contagion. DCVIL To find out wherein the différence in the ftate of the perfons to whom the contagion of the fmall-pox is ap- plied, confifts, I obferve, that the différence between the diftindt and confluent fmall-pox confifts efpecially in the number of puftules produced, which, in the diftinct, are generally few; in the confluent always many ; if, therefore, we can find what, in the ftate of différent perfons, can give occafion to more or fewer puftules, we fhall probably be able to account for ail the other dif- férences of the diftinct and confluent fmall-pox. DCVIII. It is évident that the contagion of the fmall-pox is a ferment, with refpect to the human fluids, and affimilates a great part of them to its own nature ; and, it is pro- bable, that the quantity thus affimilated is, in proportion to their feveral bodies, nearly the famé in diffèrent per- fons. This quantity pafies again oijt of the body, partly by infenfible perfpiration, and partly by being .depofited in puftules ; but, if the quantities generated be nearly equal, the quantifies paffing out of the body by the two ways mentioned, are very unequal in diffèrent perfons ; and, therefore, if we cr.n find the caufes which détermine more to pafs by the one way than by the other, we may thereby find the caufes which give occafion to more puftules in one perfon than in another, DCIX. The caufes which détermine more of the variolous matter to pafs by perfpiration, or to form puftules, are probably certain circumftances of the fkin, which dé- termine more or lefs of the variolous matter to ftick in it, or to pafs freely through it. DCX. OF P H Y S I C. 221 DCX. The circumftance of the fkin, which feems to dé- termine the variolous matter to ftick in it, is a certain ftate of inflammation, depending. much upon the heat of it : Thus we have many inftances of parts of the body, from being more heated, having a greater number of puftules than other parts. In the prefent pradtice of inoculation, in which few puftules are produced, mUch feems to be owing to the care that is taken to keep the fkin cool. Parts covered with plafters, efpecially with thofe of a ftimulant kind, have more puftules than other parts. Further, certain circumftances, fuch as adult âge, and full living, determining to a phlogiftic dia- thefis, feem to produce a greater number of puftules ; and on the contrary. DCXL It is, therefore, probable, that an inflammatory ftate of the whole fyftem, and more particularly of the fkin, gives occafion to a greater number of puftules ; and the caufes of this may produce moft of the other circum- ftances of the confluent fmall-pox ; fuch as the time of éruption ; the continuance of the fever ; the effufion of a more putrefcent matter, and lefs fit to be converted into pus ; and, what arifes from this, the form and other circumftances of the puftules. DCXII. Having thus attempted to account for the chief dif- férence which occurs in the ftate of the fmall pox, we fhall now try the truth of our doctrine, by its appli- cation to pradtice. DCXIII. In confidering the pradtice, we confider it firft in gênerai, as fuited to render the difeafe more generally benign.and fafe, and this by the pradtice of inoculation. DCXIV. 3t22 PRACTICE DCXIV. It is not neceffary hère to defcribe the opération of inoculating ; and what we name the pradtice of inocu- lation, comprehends ail the feveral meafures which précède or follow that opération, and are fuppofed to produce its falutary effects, Thefe meafures are chiefly the foljowing : i. The choofing for the fubjedt of inoculation perfons otherwife free from difeafe, and not liable, from their âge, or otherwife, to any incidental difeafe. 2. Tlje choofing a perfon at a time of life the moft favourable to a mild difeafe. 3. The choofing for the pradtice, a feafon the moft favourable to a mild difeafer 4. The preparing the perfon to be inoculated, by cnjoining abftinence from animal food for fome time before inoculation. 5. The preparing the perfon by courfes of mercurial and antimonial medicines. It). The taking care at the time of inoculation to avoid cold, intempérance, fear, or other circumftances which might aggravate the future difeafe. 7. After thefe préparations and précautions, the choofing a fit matter to be employed in inoculation, by taking it from a perfon of a found conftitution, and free from any difeafe, or fufpicion of it ; by taking it from a perfon who has had the fmall-pox of the moft benign kind ; and, lajily, by taking the matter from fuch per- fons, as foon as it has appearcd in the puftules, either on the part inoculated, or on other parts of the body. 8. The introducing, by inoculation, but a fmall portion of the contagious matter. 9. After inoculation, the continuing the vegetable diet, and the employment of mercurial and antimonial medicines, and, at the famé time, employing fréquent purging. 10. Both before and after inoculation, taking care to avoid external heat, either from the fun, artificial fires, warm chambers, much clothing, or being much in bed ; and, O F P H Y S I C. 22J and, on the contrary, expofing the perfon to a free and cool air. n. Upon the appearance of the eruptive fever, the rendering that moderate by the employment of purgatives, by the ufe of cooling and antifeptic acids ; and efpe- cially, by expofing the perfon frequently to a cool, and even a cold air, at the famé time giving freely of cold drink. 12. After the éruption, the continuing the appli- cation of cold air, and the ufe of purgatives, during the courfe of the difeafe, till the puftules are fully ripened. DCXV. Thefe are the meafures propofed and pradtifed in the lateft and moft improved ftate of inoculation ; and the advantages obtained by the whole of the pradtice, or at leaft by moft of the meafures above mentioned, are now afcertained by a large expérience ; but it will ftill be ufeful, for the proper condudt of inoculation, to confider the importance and utijity of the feveral meafures above mentioned, that we may thereby more exadtly détermine upon what the advantages of inoculation more certainly dépend. DCXVI. As the common infection may often feize perfons under a difeafed ftate, which may render the fmall-pox more violent, it is évident, that inoculation muft have a great advantage, by avoiding fuch concurrence. But, as the avoiding of fuch concurrence may often, in the mean time, leave perfons expofed to the common in- fection, it is worth our pains to inquire what are the difeafed ftates which fhould reftrain from the pradtice of inoculation. This is not yet fufficiently afcertained by obfervation ; and we have frequently obferved, that the fmall-pox have often occurred with a difeafed ftate of the body, without being thereby rendered more violent ; particularly, we have obferved, that a fcrophulous habit, or even the prefence of fcrophula, did not render the fmall-pox < 224 PRACTICE fmall-pox more violent; we have obferved alfo, that feveral difeafes of the fkin are equally innocent. I am of opinion, thàt they are the difeafes of the fébrile kind, or ailments ready to induce or aggravate a fébrile ftate, that efpecially give the concurrence which is moft dan- gerous with the fmall-pox. I dare not attempt any gênerai rules ; but, I am difpofed to rrraintain, that, though a perfon be in a difeafed ftate, if that ftate be of uncertain nature and effedt, aud, at the famé time the fmall-pox be exceedingly rife, fo that it be extremely difficult to guard againft the common infection, we judge it will always be fafer to give the fmall-pox by inoculation, than to leave the perfon to take them by the common infection. DCXVIL Though inoculation has been pradtifcd with fafety Upon perfons of ail âges ; yet, from what has happened in fact, in the cafés of common infedtion, and from feveral other confiderations, we have reafon to conclude, that adults are more liable to a violent difeafe than per- fons of younger years. At the famé time, it is obferved, that children, in the time of their fiift dentition, are liable, from the irritation of that, to bave the fmall-pox rendered more violent ; and that infants, before the time of dentition, upon receiving the contagion of the fmall- pox, are liable to be affedted with epileptic fits, which frequently prove fatal ; it is, therefore, upon tht whole, évident, that, though circumftances may admit, and approve of inoculation at any âge ; yet, for the moft part, the pradtice will have advantage, in choofing per- fons at an âge, after the firft dentition is over, and before the time of puberty. DCXVIII. Though inoculation has been pradtifed with fafety at every feafon of the year ; yet, as it is certain, that the cold of winter may increafe the inflammatory, and the heats of fummer increafe the putrefcent ftate of the fmall-pox, it is highly probable that inoculation may have O F P H Y S I C. 225 have fome advantage, from avoiding the extrêmes either of cold or heat. DCXIX. As the ufe of animal food may increafe both the in- flammatory and putrefcent ftate of the human body, fo it muft render perfons, in receiving the contagion of the fmall-pox, lefs fecure againft a violent difeafe ; and, therefore, that inoculation may dérive fome advantage by enjoining abftinence from animal food for fome time before the inoculation is perfoftned ; but, I am of opinion, that a longer time is neceffary than is commonly pre- fcribed., DCXX. I cannot deny that mercurial and antimonial medicines may have fome effedt in determining to a more free per- fpiration, and, therefore, may be of fome ufe in pre- paring a perfon for the. fmall-pox ; but there are many obfervations which render their effedt doubtful. The quantifies of both thefe medicines, particularly the an- timony, commonly employed, is too inconfiderable to have any effects. It is true, that the mercurials have often heen employed more freely ; but even their falutary effedts have not been évident, and their mifchievous effects have fometimes been more fo. I doubt, therefore, upon the whole, if inoculation dérives any advantage from thefe pretended prepàratory côurfes. DCXXI. As it has been often obferved, in the cafeof almoft ail contagions, that cold, intempérance, fear, and fome other circumftances, concurring with the application of the contagion, have greatly aggravated the future difeafe, fo it muft be the famé in the cafe of the fmall-pox ; and, it is undoubted, that inoculation muft dérive a great, and perhaps its principal advantage, by avoiding the concurrences above mentioned. Ff DCXXII. 226 PRACTICE DCXXII. It has been commonly fuppofed that inoculation has de- rived fome advantage from the choice of the matter that is employed in it ; but, from what was obferved in (DCV.), it is very doubtful if any choice is neceffary, or can give any benefit in determining the ftate of the difeafe. DCXXIII. It has been fuppofed, by fome perfons, that inoculation has an advantage, by introducing a fmall portion only of the contagious matter ; but this refis upon an un- certain foundation. It is not known what quantity is introduced by the common infection, and it may be a fmall quantity only. Although it were larger than that thrown in by inoculation, it is not known that it would have any effedt. A certain quantity of ferment may be neceffary to excite fermentation in a given mafs ; but that quantity given, the fermentation and affimilation are extcnded to the whole mafs ; and we do not find that a greater quantity than is juft neceffary, either increafes the adtivity of the fermentation, or more certainly fe- cures the affimilation of the whole. In the cafe of the fmall-pox, a confiderable différence in the quantity of contagion introduced, has not fhewn any effects in modifying the difeafe. DCXXIV. Purging has the effedt of diminifhing the adtivity of the fanguiferous fyftem, and of obviating the inflammatory ftate of it ; and, therefore, it is probable, that the fré- quent ufe of cooling purgatives is a pradtice attending that of inoculation which may give confiderable ad- vantage ; and, probably, it does this alfo by diminifhing the détermination to the fkin. And, it appears to me, that mercurials and antimonials, as they are commonly managed, are only ufeful as they make a part of the purging courfe. DCXXV. O F P H Y S I C. 227 DCXXV. It is probable, that the ftate of the fmall-pox dépends very much upon the ftate of the eruptive fever, and particularly in avoiding the inflammatory ftate of the fkin ; and, therefore, it is probable, that the meafures taken for moderating the eruptive fever, and inflammatory ftate of the fkin, afford the greateft improvement which has been made in the pradtice of inoculation-. The tendency of purging, and the ufe of acids, to this pur- pofe, is fufficiently obvious ; and, upon the famé grounds we fhould fuppofe, that blood-letting might be ufeful ; but, probably, this has been omitted ; and, perhaps, other remédies might alfo be fo, fince we have found a more powerful and effedtual one in the application of cold air, and the ufe of cold drink. Whatever doubts or difficulties our theory might prefent to us on this fubject, they may be entirely neglected, as the pradtice of Indoftan had long ago, and the pradtice of this country has' lately, by a large and repeated expérience, afcertained the fafety and efficacy of this remedy ; and as it may, and can be more certainly employed with the pradtice of inoculation, than it can be in cafés of com- mon infection, it muft give a fingular advantage to the former. DCXXVI. The continuing, after the éruption, the application pf cold air, and the ufe of purgatives, has been efpe- cially the pradtice of inoculators ; but it cannot be otherwife faid to give any peculiar advantages to inocu- lation ; and, if I miftake not, the employment of pur- gatives has often led to an abufe. When the ftate of the éruption is determined, when the number of puftules is very fmall, and the fever has entirely ceafed, I fuppofe that the fafety of the difeafe is abfolutely afcertained, and further remédies abfolutely fuperfluous ; and, there- fore, that, in fuch eafes, the ufe of purgatives is un- neceffary, and may often be hurtful. DC XXVII. 228 PRACTICE DCXXVII. We have thus confidered the feveral circumftances and pradtices accompanying inoculation, and have en- deavoured to afcertain the utility and importance of each. Upon the whole, we hope, wc have fufficiently afcertained the utility and great advantage of this pradtice, par- ticularly confifting in this, that, if certain précautions, préparations, and remédies are of importance, ail of them can be employed more certainly with the pradtice of inoculation, than in the cafe of common infection. It remains now that we fhould make fome remarks on the conduct of the fmall-pox, as received by infection, or even when, in confequence of inoculation, the fym- ptoms fhall prove violent. The latter fometimes hap- pens, although every précaution and remedy have been employed. The caufe of this is not well known ; but, it appears to me, tobe commonly owing to a difpofition of the fluids to putrefcency. But, however this may be, it will appear, that, not only in the cafe of common infection, but even in that of inoculation, there may be occafion for ftudying the conduct of this difeafe, in ail the poffible varying circumftances of it. DCXXVIII. When, from the prevailing of fmall-pox as an épidémie, and, more efpeciaHy, when it is known, that a perfon not formerly affected with the difeafe has been expofed to the infection, if fuch perfon fhould be affected with the fymptoms of fever, there can be little doubt of its being an attack of the fmall-pox ; and, therefore, he is to be treated, in every refpect, as if the difeafe had been received by inoculation. He'is to be freely expofed to a cool air, to be purged, and to have cooling acids given liberally. DCXXIX. If thefe meafures moderate the fever, nothing more is neceffary; but, if the nature of the fever attacking a perfon O F P H Y S I C. 229 perfon be uncertain, or if, with fufpicions of the fmall- pox, the fymptoms of the fever be violent, or even if, knowing; the difeafe to be fmall-pox, the meafures mentioned (DCXXIV.) do not moderate the fever fuf- ficiently, it will be proper to let fome blood; and, it will be more efpecially proper, if the perfon be an adult of a plethoric habit, and accuftomed to full living. DCXXX. In the famé circumftances, we judge it will be always proper to give a vomit, as ufeful in the beginning of ail fevers, and more efpecially in this, where a déter- mination to the ftomach appears by pain, and fponta- neous vomiting. DCXXXI. It frequently happens, efpecially in infants, that, during the eruptive fever of the fmall-pox, convulfions occur. Of thefe, if only one or two fits appear on the evening preceding the éruption, they give a favourable prognoftic of a mild difeafe, and require no remedy ; but, if they occur more early, and be violent, and frequently repeated, they are very dangerous, and require a fpeedy remedy. For this purpofe, bleeding is hardly ever of fervice ; bliftering always cornes too late ; and the only remedy I have found effectuai, is an opiate given in a large dofe. ■» DCXXXIL Thefe are the remédies neceffary during the eruptive fever; and if, upon the éruption, the number of the pimples upon the face be very few and diftinct, the dif- eafe is no further of any danger, requires no remédies, and the purgatives which are continued, as was faid before, by fome pradtitioners, are often hurtful. But when, upon the éruption, the pimples on the face are very numerous, when they are not diftinct, and efpecially, if upon the fifth day the fever does not fuffer a confiderable 230 PRACTICE a confiderable remiffion, the difeafe will ftill require a great deal of attention. DCXXXIII. If, after the éruption, the fever fhall ftill continue, the avoiding of heat, and the continuing to expofe the body to a cool air, will ftill be proper. If the fever is confiderable, with a full and hard pulfe, in an adult perfon, a bleeding will be neceffary ; and, more cer- tainly, a cooling purgative. It is, however, feldom that a répétition of the bleeding is neceffary, as a lofs of ftrength commonly very foon cornes on ; but the répé- tition of a purgative, or the fréquent' ufe of laxative clyfters, is commonly ufeful. DCXXXIV. When a lofs of ftrength, with other marks of a putrefcent tendency of the fluids, appears, it will be neceffary to exhibit the Peruviaji bark in fubftance, and in large quantity. In the famé çafe, the free ufe of acids, and of nitre, is ufeful ; and, it is commonly proper, alfo, to give wine very freely. DCXXXV. From the fifth day of the difeafe, onward through the whole courfe of it, it is proper to give an opiate once or twice a day, taking care, at the famé time, to obviate coftivenefs, by purgatives, or laxative clyfters. DCXXXVI. In a violent difeafe, from the eighth to the eleventh day of it, it is proper tolay on blifters fucceffively, on diffèrent parts of the body, and that without regard to the parts being covered with puftules. DCXXXVII. O F P H Y S I C. 231 DCXXXVII. If, in this difeafe, the tumour of the fauces is con- fiderable, the déglutition difficult, the faliva and mucus vifcid, and with difficulty thrown out, it will be proper to apply blifters to the external fauces, and to employ diligently détergent gargles. DCXXXVIIL During the whole courfe of the difeafe, when any confiderable fever is prefent, the fréquent exhibition of antimonial medicines, in naufeating dofes, has been found ufeful ; and thefe, commonly, fufficiently anfwer the purpofe of purgatives. DCXXXIX. The remédies mentioned (from DCXXXI. to DCXXXVI.) are thofe frequently neceffary, from the fifth day, till the fuppuration is finifhed. But as, after that period, the fever is fometimes continued and in- creafed ; or, as fometimes, when there was little or no fever before, a fever now arifes, and continues with confiderable danger ; this is what is called the Secon- dary fever, and requires particular treatment. DCXL. When the fecondary fever follows the diftindt fmall- pox, and the pulfe is full and hard, the cafe is to be treated as an inflammatory affection, by bleeding and purging. But, if the fecondary fever follows the con- fluent fmall-pox, and is a continuance or exacerbation of the fever which had fubfifted before, it is to be con- fidered asof the putrid kind ; and in that cafe, bleeding is improper. Some purging may be neceffary ; but the remédies to be chiefly depended on, a» the Peruvian bark and acids. When the fecondary fever firft appears, whether it is after a diftinct or a confluent fmall-pox, it is ufeful to exhibit 232 PRACTICE exhibit an antimonial emetic in naufeating dofes, but in fuch manner as to produce fome vomiting. DCXLL For avoiding the pits which frequently follow the fmall-pox, many diffèrent meafures have been propofed, but none of them appear to bc fufficiently certain. C H A P. IV. ' Of the C H I C K E N - P O X. DCXLII. This difeafe feems to dépend upon a fpecific con- tagion, and to affect perfons but once in their lives. It is hardly ever attended with any danger ; but, as it feems frequently to have given occafion to the fuppo- fition of a perfon's having the fmall-pox twice, it is proper to ftudy this difeafe, and to diftinguifh it from the genuine fmall-pox. DCXLIII. This may be commonly done by attending to the following circumftances. The éruption of the chicken-pox cornes on with very little fever, or with one of no determined duration preceding it. The pimples of the chicken-pox, more quickly than thofe of the fmall-pox, are formed into little veficles or puftules. The O F P H Y S I C. 233 The matter in thefe puftules remains fluid, and never acquires the colour or confiftence of the pus which ap- pears in the puftules of the fmall-pox. The puftules of the chicken-pox are always? in three or four days from their firft appearance, formed into crufts. See Dodtor Heberden inMed. Tranfadt. vol. 1. art. xvii. C H A P. V. Of the MEASLES. DCXLIV. This difeafe alfo dépends upon a fpecific contagion, and affedts perfons but once in their lives. DCXLV. It appears moft frequently in children ; but no âge is exempted from it, if the perfons have not been fubjedted to it before. DCXLVI. It commonly appears as an épidémie, firft in the month of January, and ceafes foon after the fummer folftice; but various accidents, introducing the con- tagion, may produce the difeafe at other times of the year. DCXLVIL The difeafe always begins with a cold ftage, which is foon followed with a hot, with the ordinary fymptoms G g of 234 PRACTICE of thirft, heat, anorexia, anxiety, ficknefs and vo- miting ; and thefe are more or lefs confiderable in diffèrent cafés. Sometimes from the beginning, the fever is fharp and violent ; often, for the firft two days, it is obfcure and inconfiderable, but always becomes violent before the éruption, which commonly happens on the fourth day. DCXLVIII. This eruptive fever, from the beginning of it, is always attended with hoarfenefs, a fréquent hoarfe dry cough, and frequently with fome difficulty of breathing. At the famé time, the eye-lids are fomewhat fwelled, the eyes are a little inflamed, and pour out tears ; and, with this, there is a coryza, and fréquent fneezing. For the moft part, a confiant drowfinefs attends the be- ginning of this difeafe. DCXLIX. The éruption, as we have faid, commonly appears upon the fourth day, firft on the face, and fucceffively on the lower parts of the body. It appears firft in fmall red points ; but, foon after, a number of thefe appear in clufters, which do not arife in vifible pimples, but, by the touch, are found to be a little prominent. This is the cafe on the face ; but, in other parts of the body, the prominency, or roughnefs, is hardly to be perceived, On the face, the éruption rctains its rednefs, or has it increafed for two days ; but, on the third, the vivid rednefs is changed to a brownifh red ; and, in a day or two more the éruption entirely difappears, while a mealy defquamation takes place. During the whole time of the éruption, the face is fomewhat turgid, but feldom confiderably fwelled. DCL. Sometimes after the éruption has appeared, the fever ceafes entirely ; but this is feldom the cafe ; and more commonly the fever continues, or is increafed after the éruption, O F P H Y S I C. 235 éruption, and does not ceafe till after the defquamation. Even then, the fever does not always ceafe, but continues with various duration and effedt. DCLL Though the fever happens to ceafe upon the eruption's taking place, it is common for the cough to continue till after the defquamation, and fometimes much longer. In ail cafés, while the fever continues, the cough alfo continues, generally with an increafe of the difficulty of breathing ; and both of thefe fymptoms fometimes arife to a degree which dénotes a pneumonie affedtion. This may arife at any period of the difeafe ; but very often it does not come on till after the defquamation of the éruption. After the famé period, alfo, a diarrhœa frequently cornes on, and continues for fome time. DCLII. It is common for the meafles, even when they have not been of a violent kind, to be followed by inflam- matory affections, particularly ophthalmia and phthifis. DCLIII. If the blood be drawn from a vein, in the meafles, with the circumftances neceffary to favour the feparation of the gluten, this always appears feparated, and lying on the furface of the çraffamentum, as in inflammatory difeafes. DCLIV. For the moft part, the meafles, even when violent, are without any putrid tendency; but, in fome cafés, fuch a tendency appears both in the courfe of the difeafe, and efpecially after the ordinary courfe of it is finifhed. See Dr. Watfon, in London Med. Obfervations, vol. iv. art. xi. DCLV. 236 PRACTICE DCLV. From what is delivered (from DCXLIV. toDCLIII.) it will appear, that the meafles are diftinguifhed by a catarrhal affection, and by an inflammatory diathefis, to a confiderable degree ; and, therefore, the danger attending them arifes chiefly from the coming on of a pneumonie inflammation. DCLVI. From this confideration, it will be obvious, that the remédies efpecially neceffary, are thofe which may obviate and diminifh the inflammatory diathefis ; and, therefore, in a particular manner, blood-letting. This remedy may be employed at any time in the courfe of the difeafe, or after the ordinary courfe of it is finifhed. It is to be employed more or lefs, according to the urgency of the fymptoms of fever, cough, and dyf- pnoea ; and generally may be employed very freely. But, as the fymptoms of pneumonie inflammation feldom come on during ihe eruptive fever ; and, as this is fome- times violent, immediately before the éruption, though a fufficiently mild difeafe be to follow, bleeding is feldom very neceffary during the eruptive fever, and may often be referved for the times of greater danger, which are perhaps to follow. DCLVII. In ail cafés of meafles, where there are no marks of putrefcency, and where there is no reafon, from the known nature of the épidémie, to apprehend putref- cency, bleeding is the remedy to be depended upon ; but, affiftance may alfo be drawn from cooling purgatives; and particularly from bliftering on the fides, or between the fhoulders. DCLVIII. O F P H Y S I C. 237 DCLVIII. The dry cough may be alleviated by the large ufe of demulcent pedtorals, mucilaginous, ofly, or fweet. It may, however, be obferved, with refpect to thefe de- mulcents, that they are not fo powerful in involving and corredting the acrimony of the mafs of blood as has been imagined, and that their chief opération is by befmearing the fauces, and thereby defending them from the irritation of acrids, either arifing from the lungs, or diftilling from the head. DCLIX. For moderating and quieting the cough in this difeafe, optâtes certainly prove the moft effectuai means, when- ever they can be fafely employed. In the meafles, in which an inflammatory ftate prevails in a confiderable degree, opiates may be fuppofed to be inadmiffible ; and, in thofe cafés in which a high degree of pyrexia and dyfpnœa fhew either the prefence, or at leaft the danger of pneumonie inflammation, we think that opiates might be very hurtful ; but, in cafés in which, the dyfpnœa is not confiderable, and in which bleeding, to obviate or abate the inflammatory ftate, has been duly employed, in fuch cafés, while the cough and watch- fulnefs are the urgent fymptoms, we think that opiates may be fafely exhibited, and with great advantage. I think, further, that, in ail the exanthemata, there is an acrimony diffufed over the fyftem, which gives à confiderable irritation ; and, for obviating the effects of this, opiates are ufeful, and always proper, when no particular contra-indication prevails. DCLX. • When the defquamation of the meafles is finifhed, though then there fhould be no diforder remaining, phy- ficians have thought it neceffary to purge the patient feveral times, with a view to draw off the dregs of this difeafe, that is, a portion of the morbific matter which is 23« PRACTICE is fuppofed to remain long in the body. We cannot reject this fuppofition, but, at the famé time, cannot believe that the remains of the morbific matter, diffufed •over the whole mafs of blood, çan be wholly drawn off by purging ; and, we think, that, to avoid the confe- quence of the meafles, it is not the drawing off the morbific matter which we need to ftudy, fo much as to obviate and remove the inflammatory ftate of the fyftem which had been induced by the difeafe. With this laft view, indeed, purging may ftill be a proper remedy ; but bleeding, in proportion to the fymptoms of inflam- matory difpofition, is ftill more fo. DCLXL From our late expérience of the ufe of cold air in the eruptive fever of the fmall-pox, fome phyficians have been of'opinion, that the pradtice may be transferred to the meafles ; but we have not yet had expérience to dé- termine this. We are certain, that external heat may be very hurtful in the meafles, as in moft other inflam- matory difeafes ; and, therefore, that the body ought to be kept in a moderate température during the whole courfe of the meafles ; but how far, at any period of the difeafe, cold air may be applied with fafety, we are uncertain. Analogy, though fo often the refource of phyficians, is, in gênerai, fallacious ; and, further, though the analogy with the fmall-pox might lead to the application of cold air during the eruptive fever of the meafles, the analogy with catarrh feems to be againft the pradtice. When the éruption is upon the fkin, we have had many inftances of cold air making it difappear, and thereby producing much diforder in the fyftem ; and, we have alfo had fréquent inftances of thefe diforders being removed by reftoring the heat of the body, and thereby again bringing out the éruption. C H A P. O F P H Y S I C. 2# C H A P. VI. Of the SCARLET FEVER. DCLXII. It may be doubted if the fcarlet fever be a difeafe fpecifically diffèrent from the cynanche maligna above defcribed. The latter is almoft always attended with a fcarlet éruption ; and, in ail the inftances I have feen of what may be called the fcarlet fever, the difeafe has, in almoft every perfon affedted, been attended with an ul- cerous fore throat. • DCLXIII. This view of the matter may give fome doubt ; but I am ftill of opinion that there is a fcarlet fever, which is a difeafe fpecifically diffèrent from the cynanche ma- ligna. Doctor Sydenham has defcribed a fcarlet fever, which he had feen preVailing as an épidémie, with ail the cir- cumftances of the fever and éruption, withqut its being accompanied with any affedtion of the throat ; he at leaft does not take notice of any fuch affedtion, which fuch an accurate obferver could not mifs to have done, if any fuch fymptom, as we have commonly feen making a principal part of the difeafe, had attended thofe eafes which he had obferved. Several other writers have de- fcribed the fcarlet fever in the famé manner ; and I know phyficians who have feen the difeafe in that form ; fo that there can be no doubt of there being a fcarlet fever not neceflarily connected with an ulcerous fore throat, and therefore a difeafe diffèrent from the cynanche ma- liçna. DCLXIV. 2*o PRACTICE DCLXIV. But, further, although in ail the inftances of fcarlet fever which I have feen, and in the courfe of forty years I have feen it five or fix times prevailing as an épidémie in Scotland, the difeafe, in almoft ail the perfons affected, was attended with an ulcerous fore throat, or was what Sauvages names the Scarlatina Anginofa ; that, even in fome inftances, the ulcers of the throat were of a putrid and gangrenous kind, and, at the famé time, the difeafe, in ail its fymptoms, refembled, very exadtly, the Cynanche Maligna ; yet, I am ftill perfuaded, that not only the Scarlatina of Sydenham, but that even the Scarlatina Anginofa of Sauvages, is a diffèrent difeafe from the Cynanche Maligna ; and I have formed this opinion from the following confiderations. DCLXV. There is a fcarlet fever entirely free from any affedtion of the throat, which fometimes prevails as an épidémie ; and, therefore, that there is a fpecific contagion pro- ducing a fcarlet éruption without any détermination to the throat. Even the Scarlatina, which, from its matter being generally determined to the throat, may be properly termed Anginofa, has, injnany eafes of the famé épi- démie, been without any affection of the throat ; and, therefore, the contagion, may be fuppofed to be more efpecially determined to produce the éruption only. Though in ail the épidémies which I could alledge were thofe of the Scarlatina Anginofa, there have been fome cafés which, in the nature of the ulcers, and in other circumftances, exadtly refembled the cafés of the Cynanche Maligna ; yet, I have as conftantly obferved, that thefe eafes have not been above one or two in a hundred, while the reft have ail of them been with ulcers of a benign kind, and with circumftances hereafter to be defcribed, fomewhat diffèrent from thofe of the Cy- nanche Maligna. On O F P H Y S I C. 241 On the other hand, as I have two or three times feert the Cynanche Maligna epidemically prevailing, fo, among the perfons affedted, I have feen inftances of cafés as mild as the cafés of the Scarlatina Anginofa commonly are ; but hère the proportion was reverfed ; and thefe mild cafés were not one fifth of the whole, while the reft were of the putrid and malignant kind. It applies to the famé purpofe to obferve, that, of the Cynanche Maligna, moft of the inftances prove fatal, and, of the Scarlatina Anginofa, a very few of the cafés prove fo. ÎDCLXVi. From thefe confiderations, though it may appear that there is fome affinity between the Cynanche Maligna and Scarlatina Anginofa, it will ftill remain probable, that the two difeafes are fpecifically diffèrent. I have been at fome pains to eftablifh this opinion ; for, from ail my expérience, I find, that thofe two difeafes require a diffèrent treatment ; and I therefore, alfo, now proceed to mention more particularly the circumftances of the Scarlatina Anginofa. DCLXVIL The difeafe commonly appears aboUt the beginning of winter, and continues through that feafon ; it comes on with fome cold fhivering, and the other fymptoms of the fever which commonly introduces the other ex- anthemata. But hère there is no cough, nor the other catarrhal fymptoms which attend the meafles ; nor is there hère that anxiety and vomiting which commonly introducethe confluent fmall-pox, and which ftill more certainly introduce the Cynanche Maligna. Early in the difeafe, fome uneafinefs is felt in the throat, and frequently the déglutition is difficult, ge- nerally more fo than in the Cynanche Maligna. Upon looking into the fauces, a rednefs and fwelling appear, in colour and bulk approaching to the ftate of thefe fymptoms in the Cynanche Tonfillaris ; but hère, in the Scarlatina, there is always more or lefs of floughs, H h which 242 PRACTICE which feldom appear in the Cynanche Tonfillaris ; but the floughs are commonly whiter than thofe in the Cy- nanche Maligna. While thefe circumftances are feen in the fauces, on the third or fourth day a fcarlet éruption appears on the fkin, in the famé form as defcribed in (ÇCCVL). This éruption is commonly more confiderable and uni- verfal hère than in the Cynanche ; but it feldom pro- duces a remiffion of the fever ; the éruption is commonly fteady to the third or fourth day after its firft appearance, but then goes off, ending in a mealy defquamation. At this time the fever commonly fubfides ; and, generally, at the famé time, fome degree of fweat comes on. The floughs in the fauces, which appeared early in the difeafe, continue for fome days ; but then fallingoff, difcover the fwelling abated, and an ulcer formed on one or both tonfils, fhewing a laudable pus ; and foon after the fever has fubfided, thefe ulcers heal up entirely. For the moft part, this difeafe has much lefs of coryza attending it than the Cynanche Maligna; and, when there is a coryza attending Scarlatina, the matter dif- charged is lefs acrid, and has not the fœtid fmell which it has in the.other difeafe. In the Scarlatina, when the éruption has entirely dif- appeared, it frequently happens, that, a few days after, the whole body is affected with ah anafarcous fwelling, which, 'however, in a few days more, gradually fubfides. We have thus defcribed the moft common circum- ftances of the Scarlatina Anginofa ; and have only to add, that, during the time of its being épidémie, and efpecially upon its firft fetting in, there are always a few cafés, in which the circumftances of the difeafe approach very nearly to thofe of the Cynanche Maligna and it is only in thefe circumftances that the difeafe is attended with any danger DCLXVIII. With refpect to the cure of this difeafe, when the fymptoms of it are nearly the famé with thofe of the Cynanche Maligna, it requires exadtly the famé treat- ment as directed in (CCCIX.) DCLXIX. O F P H Y S I C. 24-3 DCLXIX. When the fcarlet fever appears, without any affection of the throat, the treatment of it is very fimpje, and is delivered by Dr. Sydenham. An antiphlogiftic regimen is commonly ail that is neceffary, avoiding, on one hand, the application of cold air, and, on the other, any increafe of external heat. DCLXX. In the ordinary ftate of the Scarlatina Anginofa, the famé treatment is commonly fufficient ; but as hère the fever is commonly more confiderable, and there is an affedtion of the throat, fome remédies may be often neceffary. DCLXXI. When there is a fomewhat high degree of fever, with a full pulfe, and a confiderable fwelling of the tonfils, bleeding is very proper, efpecially in adults ; and it has been frequently pradlifed with advantage ; but, as even in the Cynanche Tonfillaris, much bleeding is feldom neceffary, (CCXCVIII.) fo, in the Scarlatina, when the ftate of the fever, and the appearances of the fauces render the nature of the difeafe ambiguous, bleeding may be omitted, and, if not altogether, it at leaft fhould not be large, nor be repeated. DCLXXII. Vomiting, and efpecially naufeating dofes of emetics, notwithftanding the inflamed ftate of the fauces, have been found very ufeful in this difeafe. An open belly is proper in every form of this difeafe ; and when the naufeating dofes of emetics operate a little downwards, they are more ferviceable. DCLXXIII. 244 PRACTICE DCLXXIIL In every form of the Scarlatina Anginofa, through the whole courfe of it, détergent gargles fhould be em- ployed, and more or lefs as the quantity of floughs, and the vifcid mucus in the fauces may feem to require. DCLXXIV. Even in the milder ftates of the Scarlatina Anginofa, it has been common with pradtitioners to exhibit the Peruvian bark through the whole courfe of the difeafe ; but we are aflured, by much expérience, that, in fuch eafes, it may be fafely omitted, though in cafés any ways ambiguous it may not be prudent to do fo. • DCLXXV. The anafarcous fwelling which frequently follows the Scarlatina Anginofa, feldom requires any remedy ; and, at leaft, the purgatives fo much inculcated, and fo corn-» monly practifed, foon take off the anafarca. C H A P. VIL Of the MILIARY FEVER. DCLXXVL This difeafe is faid to have been unknown to the antients, and that it appeared, for the firft time, in Saxony about the middle of the laft century. It is faid to have fince fpread from thence into ail the other coun- tries O F P H Y S I C. 24?5 tries of Europe ; and, fince the period mentioned, to - have appéared in many countries in which it had never appeared before. DCLXXVIL From the time of its having been firft taken notice of, it has been defcribed and treated of by many diffèrent writers, and by ail of them, till very lately, has been confidered as a peculiar idiopathic difeafe. It is faid to have been conftantly attended with pe- culiar fymptoms. It comes on with a cold ftage, which is often confiderable. The hot ftage, which follows, is attended with great anxiety, and fréquent fighing. The heat of the body becomes great, and foon produces profufe fweating, preceded, however, with a fenfe of pricking, as ofpin points in the fkin; and the fweat is of a peculiarly rank and difagreeable odour. The éruption appears, fooner or later, indiffèrent perfons, butât no determined period of the difeafe. It feldom or never appears upon thè face ; but appears firft upon the neck and breaft, and from thence often fpreads over the whole body. DCLXXVIII. The éruption named miliary is faid to be of two kinds, the one named the Red, the other the Whitc Miliary. The former, which in Englifh is ftridtly named a Rafh, is commonly allowed to be a fymptomatic affection ; and, as the latter is the only one that has any pré- tentions to be confidered as an idiopathic difeafe, it is this only that we fhall more particularly defcribe and treat of in this chapter. DCLXXIX. What is then called the White Miliary éruption, ap- pears at firft like the red, in very fmall red pimples, for the moft part diftinct, but fometimes cluftered together. Their little prominence is better diftinguifhed by the finger than by the eye. Soon after the appearance of this éruption, and, at leaft, on the fécond day, a fmall .veficle 246 PRACTICE veficle appears upon the top of the pimples. At firft the veficle is whey coloured, but foon becomes white, and ftands out like a little globule on the top of the pimple. In two or three days, thefe globules break, or are rubbed off, and are fucceeded by fmall crufts, which foon after fall off in fmall fcales. While one fet of pimples take this courfe, another fet arife to run the famé, fo that the difeafe often continues upon the fkin for many days together. Sometimes when one crop of this éruption has difappeared, another, after fome interval, is produced, And, it has been further obferved, that, in fome perfons, there is fuch a difpofition to this difeafe, that they have been affedted with it feveral times in the courfe of their lives. DCLXXX. This difeafe is faid to affedt both fexes, and perfons of ail âges artd conftitutions, but it has been obferved, at ail times, to affedt efpecially, and moft frequently, lying-in women. DCLXXXI. This difeafe is often accompanied with violent fym- ptoms, and has frequently proved fatal. The fymptoms, however, attending it are very various ; and they are, up- on occafion, every one attending fébrile difeafes; but I cannot find that any fymptom, or concourfe of fymptoms, are fteadily the famé in differ?nt perfons, fo as to give any fpecific charadter to the difeafe. When the difeafe is violent, the moft common fymptoms are phrenetic, co- matofe, and convulfive affections, which are alfo fym- ptoms of ail fevers treated by a very warm regimen. DCLXXXII. While there is fuCh a variety of fymptoms appearing in this difeafe, it is not to be expedted that any one par- ticular method of cure can be propofed ; and, ac- cordingly, we find, in diffèrent writers, diffèrent methods and remédies prefcribed ; fréquent difputes about the O F P H Y S I C. 247 moft proper, and thofe received and pradtifed by fomç, oppofed and defertedby others. DCLXXXIII, I have now given an account of what I have found delivered by authors who have confidered the white miliary fever as an idiopathic difeafe ; but, now, after having often obferved the difeafe, I doubt much if it ever be fuch an idiopathic as has been fuppofed j and I fufpedt that there is much fallacy in what hàs been de- livered on the fubjedt. DCLXXXIV. It appears to me very improbable that this was really a new difeafe, when it was firft confidered as fuch. There appear to me very clear traces of it in authors whp wrote long before that period ; and, though there were not, we know, that antient defcriptions were inaccurate and imperfedt, particularly with refpect to cutaneous affections ; and we know very well, that thpfe, affections which commonly appeared as fyrnptomatic only, were commonly negledted, or confounded together under a gênerai appellation. DCLXXXV. The antécédent fymptoms of anxiety, fighing, and pricking of the fkin, which have been fpoken of as pe- culiar to this difeafe, are,* however, common to many ,others, and, perhaps, to ail thofe in which fweatings are forced out by a warm regimen. Of the. fymptoms faid to be concomitant of this éruption, there are none which can be faid to be confiant and peculiar but that of fweating. This, indeed, al- ways précèdes and accompanies the éruption ; and, while the miliary éruption attends many diffèrent difeafes, it never, however, appears in any of thefe, but after fweating ; and, in perfons labouring under the famé difeafes, it does not appear, if in fuch perlons fweating is avoided. It is, therefore, probable, that the éruption is the effedt of 248 PRACTICE of fweating, and that it is the effedt of a matter not before prevailing in the mafs of blood, but generated, under particular circumftances, in the fkin itfelf. That it dépends upon particular circumftances of the fkin, appears further from hence, that the éruption feldom or never appears upon the face, although it affedts the whole of the body befides ; and that it comes upon thofe places efpecially which are more clofely covered ; and that it can be brought out upon particular.places by external applications. DCLXXXVI. It is to be obferved, that this eruptive difeafe differs from the other exanthemata in many circumftances ; in its not being contagioUs, and therefore never épidémie ; in this that the éruption appears at no determined period of the difeafe ; that the éruption has no determined duration ; that fucceffive éruptions frequently appear in the courfe of the famé fever ; and that fuch éruptions frequently recur in the courfe of the famé perfon's life. Ail this renders it very probable, that, in the miliary fever, the morbific matter is not a fubfifling contagion communicated to the blood, and thence, in confequence of fever and affimilation, thrown out upon the furface of the body, but a matter occafionally produced in the fkin, itfelf by fweating. DCLXXXVIL This conclufion is further rendered probable from hence, that, while the miliary éruption has no peculiar fymptoms, or concourfe of fymptoms belonging to it, it, upon occafion, accompanies almoft every fébrile dif- eafe, whether inflammatory or putrid, if thefe happen to be attended with fweating ; and from thence it may be prefumed, that the miliary éruption is a fymptomatic affection only, produced in the manner we have faid. DCLXXXVIIL O F P H Y S I C. 249 DCLXXXVIIL But, as this fymptomatic affection does not always .accompany every inftance of fweating, it may be proper to inquire, what are the circumftances which efpecially détermine this éruption to appear ? and to this I can give no full and proper anfwer. I cannot fay that there is any one circumftance which in ail cafés gives occafion to this éruption ; nor can I fay what différent caufes, in diffèrent cafés, may give occafion to it. There is only one obfervation I can make to the purpofe of this in- quiry ; and it is, that thefe perfons fweating, under fébrile difeafes, are efpecially liable to the miliary éruption, who have been previoufly weakened by large évacuations, particularly of blood. This will explain why it happens to lying-in women more frequently than toany other perfons ; and to confirm this explanation, I have obferved, that the éruption has happened to other women, though not in child-bed, but who had been much fubjedted to a fréquent and copious menftruation, and to an almoft confiant fluor albus. I have alfo ob- ferved it to have happened to men in fevers, after wounds, from which they had •fuffered a great lofs of blood. Further, that this éruption is produced by a certain ftate of debility, will appear probable, from its fo often attending fevers of the putrid kind, which are always attended with great debility. It is true, that it alfo fometimes attends inflammatory difeafes, when it may not be accounted for in the famé manner ; but I believe it may be obferved, that it efpecially attends thofe in- flammatory difeafes in which the fweats have been long protradted, or frequently repeated, and which have thereby produced a debility, and, perhaps, a debilitating putrid diathefis. DCLXXXIX. It appears fo clearly to me that this éruption is always a fymptomatic and fadtitious affedtion, that I am per- fuaded it may be, in moft eafes, prevented mereîy by I i avoiding 250 PRACTICE avoiding fweats. Spontaneous fweatings, in the be- ginning of difeafes, are very rarely critical ; and ail fweatings, not evidently critical, fhould be prevented ; and the promoting them, by increafing external beat, is commonly very pernicious. Even critical fweats fhould hardly be encouraged by fuch means. If, therefore, fpontaneous fweats arife, they are to be checked by the coolnefs of the chamber ; by the lightnefs and loofenefs of the bed-clothes; by the perfons laying out their arms and hands ; and by their taking cold drink ; and, in this way, I think I have frequently prevented miliary éruptions, which were otherwife likely to have appeared, particularly in lying-in women. DCXC. But, it may happeft, when thefe précautions have been negledted, or from other circumftances, that a mi- liary éruption does adtually appear ; and the queftion will then be put, how the cafe is to be treated ? It is a queftion of confequence, as I believe that the matter hère generated is often of a virulent kind ; it is often the offspring of putrefcency ; and, when treated by increafing the external heat of the body, it feems to acquire a virulence which produces thofe fymptoms mentioned in (DCLXXXL), and proves certainly fatal. It has been an unhappy'opinion with moft phyficians, that eruptive difeafes were ready to be hurt by cold, and that it was therefore neceffary to cover up the body very clofely, and thereby increafe the external heat. We now know that this is a miftaken opinion ; that in- creafing the external heat of the body is very generally mifçhievous ; and that feveral éruptions not only admit, but require the application of cold air. We, are per- fuaded, therefore, that the pradtice which formerly pre- vailed, in the cafe of miliary éruptions, of covering up the body clofe, and both by external means, and in- ternai remédies, encouraging the fweatings which ac- company this éruption, was highly pernicious, and commonly fatal. I am therefore of opinion, that, even when a miliary éruption has appeared, in ail cafés in which O F P H Y S I C. 251 which the fweating is not manifeftly critical, we fhould employ ail the feveral means of ftopping the fweating that are mentioned above ; and I have fometimes had occafion to obferve, that even the admiffion of cool air was fafe and ufeful. DCXCI. This is, in gênerai, the treatment of miliary érup- tions ; but, at the famé time, the remédies fuited to the primary difeafe are to be employed ; and, therefore, when the éruption happens to accompany inflammatory affections, and the fulnefs and hardnefs of the pulfe, or other fymptoms, fhew an inflammatory ftate prefent, the cafe is to be treated by blood-letting, purging, and other antiphlogiftic remédies. Upon the other hand, when the miliary éruption attends difeafes, in which debility and putrefcency prevail, it will be proper to avoid ail évacuations, and to employ tonic and antifeptic remédies, particularly the Peruvian bark, cold drink, and cold air. We fhall conclude this fubjedt with obferving, that the vénérable octogenarian pradtitioner, de Fifcher, when treating of this fubjedt, in laying down the indi- cations of cure, has given this as one of them : ' Ex- ' cretionis periphericae non primariam habere rationem.' C H A P. 252 PRACTICE - C H A P. VIII. Of the REMAINING EXAN- THEMATA. UR TIC A RI A, PEMPHIGUS, and A P H T H A. DCXCIL The Nettle Rafh is a name applied to two diffèrent difeafes. The one is the chronic éruption, defcribed by Dr. Herberden in the_ Médical Tranfactions, vol. i. art. xvii. which, as not being a fébrile diforder, does not belong to this place. The other is the Urticaria of our Synopfis, which, as- taken into every fyftem of Nofology as one of the Exanthemata Febrilia, is properly to be treated of hère. DCXCIII. I have never feen this difeafe as contagious and épi- démie ; and the few fporadic cafés of it which I have feen, have feldom taken that regular courfe defcribed by authors. At the famé time, as the accountsof diffèrent authors are not very uniform, and hardly confiftent, I cannot enter further into the confideration of this difeafe ; and, I hope, it is not very neceffary, as on ail hands it is agreed, that this difeafe is a mild one, and feldom requires the ufe of remédies. It is generally fufficient t to obferve an antiphlogiftic regimen, and to keep the patient in a température that is neither hot nor cold. DCXCIV. O F P H Y S I C. 253 DCXCIV. The Pemphigus, or Veficular fever, is a rare and uncommon difeafe, and very few inftances of it are re- corded in the writings of phyficians. I have never had occafion to fee it, and, therefore, it would be improper for me to treat of it myfelf, and I don't choofe to repeat after others, while the difeafe has yet been little obferved, and its charadter does not yet feem to be exadtly-afcer- tained. Vid. Adta Helvetica, vol. 2. p. 260. DCXCV. The Aphtha, or Thrufh, is a .difeafe better known • and, as it commonly appears in infants, it is fo well known as not to need our treating of it hère. As an idiopathic difeafe, affedting adults, we have not feen it; but it feems to be more fréquent in Holland ; and, there- fore, for the ftudy of it, we refer to Dr. Boerhaave, and his commentator Van Swieten,''whofe works are in every body's hands. DCXCVI. The Petechia has been, by ail our Nofologifts, enu- merated amongft the exanthemata ; but as we judge it, and as we belïlve that moft other phyficians judge it, to be always a fymptomatic affection only, we cannot give it a place hère. B O O K 254 PRACTICE B O O K IV. Of HEMORRHAGIES. C H A P. I. Of HEMORRHAGY in General. DCXCVII. IN eftablifhing a clafs, or order of difeafes, under the title of Hemorrhagies, the Nofologifts have em- ployed the fingle circumftance of an effufion of red blood, as the charadter of fucn a clafs or order. By thefe means, they haveaffociated difeafes, which in their nature are very diffèrent ; but, in every methodical diftribution, fuch arbitrary and unnatural aflbciations fhould be avoided as much as poffible. Further, by that management, the Nofologifts have fuppreffed or loft fight of an ufeful diftindtion before eftablifhed, and very well founded, which is that of Aclive and Pajfive He- morrhagies. DCXCVIII. We mean to reftore this diftindtion ; and, therefore, hère, under the title of Hemorrhagies, we comprehend thofe only which have been commonly called Active, that is, thofe which are attended with fome degree of pyrexia ; which feem always to dépend upon an increafed impetus of the blood in the veffels poqring it out, and which chiefly arife from an internai caufe. In this matter we follow OF PHYSÏC. 255 follow Dr. Hoffman, who joins the Active Hemorrha- gies with the fébrile difeafes ; and we have accordingly eftabliihed thefe hemorrhagies as an order in the clafs of pyrèxiae. From this order we exclude ail thofe effufions of red blood which are owing entirely to external vio- lence ; and ail thofe which, though from internai caufes, are however, without pyrexia, and feem to be owing to a putrid fluidity of the blood, to the weak- nefs, or to the erofion of the veffels, rather than to any increafed impetus of the blood in them. DCXCIX. With a view to treat of thofe proper hemorrhagies of which we have formed an order in our Nofology, we fhall firft treat of active hemorrhagy in gênerai ; and we judge the feveral gênera and fpecies, to be treated of par- ticularly afterwards, to have fo many circumftances in common with one another, that the gênerai confideration is both proper, and may be very ufeful. SECT. I. Of the PHENOMENA of HE- MORRHAGY. DCC. We begin firft with marking the phenomena of He- morrhagy, which are generally the following. Hemorrhagies happen efpecially in plethoric habits, and in perfons of a fanguine tempérament; they appear moft commonly in the fpring, or in the beginning of fummer. For 256 PRACTICE For fome time, longer or fhorter in diffèrent eafes, before the blood flows, there are fome fymptoms of ful- nefs and tenfion about the part from which the blood is to iflue. In fuch parts as fall under our view, there are fome rednefs, fwelling, and fenfe of heat, or of itching ; and, in the internai parts, from which blood is to flow, there is a fenfe of weight and heat ; and, in both cafés, various pains are often felt in the neigh- bouring parts. DCCI. When thefe fymptoms have fubfifted for fome time, fome degree of a cold ftage of fever comes on, and a hot ftage i s formed, during which the blood flows of a florid colour, in a greater or lefs quantity, and continues to flow for a longer or fhorter time ; but commonly, after fome time, the effufion fpontaneoufly ceafes, and with that the fever alfo. DCCII. During the hot ftage which précèdes a hemorrhagy, the pulfe is fréquent, quick, full, and often hard ; but, as the blood flows, the pulfe becomes fofter, and lefs fréquent. DCCIII. In hemorrhagies, blood drawn from a vein, upon its concreting, commonly fhews the gluten feparated, or a cruft formed, as in the cafés of phlegmafiae. DCCIV. Hemorrhagies, from internai caufes, having once happened, are apt, after a certain interval, to return ; fometimes very often, and frequently at ftated periods. DCCV. 0 F P H Y S I C, 257 DCCV. Thefe are, in gênerai, the phenomerta of hemorrhagy J and if, in fome cafés, ail of them be not exquifitely marked ; or if, perhaps, fome ôf them do not at ail ap- pear, it imports only, that, in diffèrent eafes, the fyftem is more or lefs generally affected ; and that, in fome cafés, there are purely topical hemorrhagies, as there ate purely topical inflammations. SECT. IL Of the PROXIMATE CAUSE of HEMORRHAGY. DCCVI. The pathology of hemorrhagy feems to be fufficiently obvious. Some inequality in the diftribution of the blood, occafions a congeftion in particular parts of the fanguiferous fyftem ; that is, a greater quantity of blood is poured into certain veffels than their natural capacity is fuited to receive. Thefe veffels become, thereby, preternaturally diftended ; and this diftention proves a ftimulus tothem, exciting their adtion to a greater degree than ufual, which, pufhing the blood with un- ufual force into the extremities of thefe veffels, opens them by Anaftomofis, or rupture ; and, if thefe ex- tremities be loofely fituated on external furfaces, or on the internai furfaces of certain cavities opening exter- nally, a quantity of blood flows out of the body. Kk DÊCVII. 258 PRACTICE DCCVII. This will, in fome meafure, explain the production of hemorrhagy ; but, it appears to me, that, in moft eafes, there is fomething more to be taken into the ac- count ; for it is probable, that, in confequence of con- geftion, a fenfe of refiftence arifes, and excites the adtion of the Vis Medicatrix Naturae ; and the exer- tions of this are ufually made by the formation of a cold ftage of fever, inducing a more vigorous action of the veffels ; and the concurrence of this exertion more ef- fedtually opens the extremities, and occafions the flow- ing out of the blood. DCCVIII. What is delivered in the two preceding paragraphs, feems to explain the whole phenomena of hemorrhagy, except the circumftance of its fréquent récurrence, which we apprehend may be explained in the following manner. The congeftion and confequent irritation are taken off by the flowing of the blood; which, therefore, after fome time, fpontaneoufly ceafes ; but, at the famé time, the internai caufes which before produced the unequal diftribution of the blood, commonly remain, and muft now operate the more readily, as the over- ftretched and relaxed veffels of the part will now more readily admit of a congeftion of blood in them, and, confequently produce the famé feries of phenomena as before. DCCIX. This may fufficiently explain the ordinary return Of hemorrhagy ; but there is ftill another circumftance, which, as commonly concurring, is to be taken notice of ; that is, the gênerai Plethoric ftate of the fyftem, which renders every caufe of unequal diftribution of more confiderable effedt. Though hemorrhagy may often dépend upon the ftate of the veffels of a particular part, favourable to a congeftion's being formed in them ; yet, O F P H Y S I C. 259 yet, in order to that ftate's producing its effedt, it is neceffary that the whole fyftem be in its natural plethoric condition ; and, if this fhould be in any degree beyond what is natural, it will more certainly détermine the effects of topical conformation to take place. The return of hemorrhagy, therefore, will be more certainly occafioned, if the fyftem becomes preternaturally ple- thoric ; but hemorrhagy has always a tendency to in- creafe the plethoric ftate of the fyftem, and, confequently, to occafion its own return. DCCX. To fhew that Hemorrhagy does contribute to produce or increafe the plethoric ftate of the fyftem, it is only neceffary to obferve, that the quantity of ferous fluids being given, the ftate of the excrétions dépends upon a Certain balance between the force of the larger arteries, propelîing the blood, and the refiftence of the excre- tories ; but the force of the arteries dépends upon their fullnefs and diftention, chiefly given to them by the quantity of red globules and gluten, which are, for the greateft part, confined to the red arteries ; and, there- fore, the fpoliation made by a hemorrhagy, being chiefly of red globules and gluten, the effufion of blood muft leave the red arteries more empty and weak. In con- fequence of the weaker adtion of the red arteries, the excrétions are in proportion diminifhed ; and, there- fore, the ingejia continuing the famé, more fluids will be accumulated in the veffels. It is by thefe means that the lofs of blood by hemorrhagies, whether artificial or fpontaneous, if within certain bounds, is commonly fo foon recovered ; but, as the diminution of the ex- crétions, from a lefs quantity of fluid being impelled into the excretories, gives occafion to thefe veflèls to fall into a contradted ftate ; fo, if this fhall continue long, thefe veflèls will become more rigid, and will' not yield to the famé impelling force as before. Though the arteries, therefore, by new blood colledted in them, fhall have recovered their former fullnefs, tenfion, and force, yet this force will not be in balance with the refiftence of the more rigid excretories, fo as to reftore the 26o PRACTICE the former ftate of excrétion; and, therefore, a further accumulation will take place in the arteries, and an in- creafe of their plethoric ftate be thereby induced. In this manner we perceive more clearly, that hemorrhagy, as producing a more plethoric ftate of the fyftem, has a tendency to occafion its own récurrence with greater violence ; and, as the renewal and further accumulation of blood require a determined time, fo, in the feveral répétitions of hemorrhagy, that time will be nearly the famé; and, therefore, the returns of hemorrhagy will be commonly atftated periods, as has been obferved fre- quently to happen. DCCXI. We have thus explained the nature of hemorrhagy in gênerai, as depending upon fome inequality in the dif- tribution of the blood, occafioning a congeftion of it in particular parts of the fanguiferous fyftem. It is indeed probable, that, in moft perfons, the feveral parts of the fanguiferous fyftern are in balance with one another, and that the denfity, and confequently the refiftence, in the feveral veffels, is in propor- tion to the quantity of blood that each fhould receive ; and hence it frequently happens, that no inequality in the diftribution of the blood fhall appear in the courfe of a long life. But, if we confider that the fangui- ferous fyftem is conftantly in a plethoric ftate, that is, that the veffels are conftantly diftended beyond that fize which they would be of, if they were free from any dif- tending force, we fhall perceive, that this ftate may be readily changed. For as, on one hand, the veffels are elaftic, and therefore under a confiant tendency to con- tradt farther upon the withdrawing of any part of the diftending force ; and, on the other hand, they are not fo rigid but that, by an increafe of the impetus of the blood in them, they may be more than ordinarily dif- tended ; fo we can perceive, that, in moft perfons, caufes of an increafed contraction or diftention may arife in one part or other of the fyftem, or that an un<- equal diftribution may take place ; and, in an exquifitely diftended or plethoric fyftem, a fmall inequality in the diftribution O F P H Y S I C. 261 diftribution of the blood may form thofe congeftions which give occafion to hemorrhagy. DCCXII. In this manner we explain how hemorrhagy may be occafioned at any period of life, or in any part of the body ; but hemorrhagies happen in certain parts more frequently than in others, and at certain periods of life more readily than at others ; and therefore, it may be required, in delivering the gênerai doctrine of he- morrhagy, that we fhould explain thofe circumftances which produce the fpecialities mentioned ; and we at- tempt it as follows. DCCXIII. The human body, from being of a fmall bulk at its firft formation, grows afterwards to a confiderable fîze. This increafe of bulk confifts, in a gr,eat meafure, in the increafe of the quantity of fluids, and a proportional en- largement of the containing veffels. But, at the famé time, the quantity of folid matter is alfo gradually in- creafed ; and, in whatever manner we may fuppofe this to be done, it is probable that the progrefs, in the whole of the growth of animal bodies, dépends upon the ex- tenfionof thearterial fyftem. DCCXIV. If this be fo, it will be equally manifeft, that the extenfion of the arterial fyftem dépends upon the quan- tity of fluids accumulated in it, and upon the force of the heart impelling the fluids, being fuch as to keep the arteries conftantly in a diftended ftate, and, therefore, always with a tendency to be extended in every dimenfion.. DCCXV. As the ftate of the animal folid is, at the firft for- mation of the body, very lax and yielding, fo the ex- tenfion of the fyftem proceeds, at firft, very faft; but, as 2Ô2 PRACTICE as the extenfion gives occafion to the appofition of more matter to the folid parts, thefe are, in proportion to their extenfion, coAftantly acquiring a greater denfity, and therefore giving more refiftance to their further ex- tenfion and growth. Accordingly, we obferve, that, as the growth of the body advances, the increafe of it, in any given time, becomes proportionally lefs and lefs, till at length it ceafes altogether. DCCXVI. _ This is the gênerai idea of the growth of the human body, till it attains the utmoft bulk which it is capable of acquiring ; but, it is to be obferved, that this growth does not proceed cqually in every part of the body, as it is for the purpofe of the œconomy that certain parts fhould be firft evolved, and that thefe alfo fhould acquîre their full bulk fooner than others. This appears par- ticularly with refpedt to the head, the parts of which appear tobe firft evolved, and fooneft to acquire their full fize. DCCXVIL To favour this unequal growth, it is prefumed, that the dimenfions or the laxity of the veflèls of the head, or that the direction of the force of the blood, are fuited to the purpofe ; but, it will alfo certainly follow, that, as the veffels of the head grow fafteft, and fooneft ac- quire their full fize, fo they will fooneft, alfo, acquire that denfity which will prevent their further extenfion. While, however, the force of the heart, and the quan- tity of the fluids, with refpedt to the whole fyftem,' remain the famé, the diftending and cxtending powers will be diredted to fuch parts as have not yet acquired the famé denfity and dimcnfions as thofe firft formed ; and thus the diftending and extending powers will proceed to operate till every part of the fyftem, in refpect of denfity and refiftence, fhall be brought to be in balance with every other, and till the whole be in balance with the force of the heart, fo that there can be no fur- ther growth in any particular part, unlefs fome pre- ternatural circumftance fhall happen to arife. DCCXVIII. O F P H Y S I C. 263 DCCXVIIL In this procefs of the growth of the body, as in gê- nerai it feems to dépend upon a certain balance between the force of the heart, or diftending power, and the refiftence of the folids ; fb it will appear, that, while the folids remain very lax and yield ing, fome occafional increafe of the diftending power may arife without pro- ducing any very perceptible diforder in the fyftem. But, it will alfo appear, that, in proportion as the diftending power and refiftence of the folids come to be more nearly in exact balance with one another, foany increafe of the diftending power will more readily produce a rup- ture of veflèls which do not readily yield to extenfion. DCXIX. From ail this, it muft appear, that the effects of any unufally plethoric ftate of the fyftem, will be diffèrent according as they fhall occur at diffèrent periods of the growth of the body. It is, therefore, évident, that, if the plethoric ftate arifes while the head is yet growing, and the détermination of the blood be ftill more to the head than to the other parts, the increafed quantity of the blood will be efpecially determined to the head ; and as there alfo, at the famé time, the balance between the diftending and extending powers is moft nearly adjufted, fo the détermination of the blood will moft readily pro- duce, in that part, a rupture of the veffels, or a he- morrhagy. Hence it is, that hemorrhagies of the nofe fo frequently happen in young perfons, and in thefe more readily, as they approach nearer to their acmé, or full growth ; or, it may befaid, perhaps more properly, as they approach nearer to the âge of puberty, when, perhaps, in both fexes, but efpecially in the female, a new détermination arifes in the fyftem. DCCXX. The détermination of a greater quantity of blood to the veflèls of the head, might be fuppofed to occafion a rupture 264 PRACTICE rupture of veffels in other parts of the head, as well as in the nofe ; but fuch a rupture does not commonly happen ; becaufe, in the nofe, for the purpofe of fenfe, there is a confiderable net-work of blood veffels ex- panded on the internai furface of the noftrils, and covered only with thin and weak téguments. From this circumftance it is, that, upon any increafed impetus of the blood, in the veffels of the head, thofe of the nofe are moft eafily broken ; and the effufion from the nofe being made, not only relieves the other extremities of the external carotid, to which thofe of the nofe chiefly belong, but relieves alfo, in a great meafure, the fyftem of the internai carotid ; for, from the internai carotid, certain branches are font to the nofe, are expanded on its internai furface, and probably inôfculated with the extremities of the external carotid ; fo that whichfoever of the extremities are broken, the vis derivationis of Haller will take place ; the effufion will relieve the whole fanguiferous fyftem of the head ; and the famé effufion will alfo commonly prevent a hemorrhagy hap- pening in any other part of the body. DCCXXL From thefe principles, it will appear why hemorrha- gies of the nofe, fo fréquent before the period of puberty, or of the acmé, feldom happen after thefe periods ; and" we muft obferve further, that, though they fhould hap- pen, they would not afford any objection to our prin- ciples, as fuch hemorrhagies might be imputed to a pe- culiar laxity, and perhaps to a habit acquired, with refpect to the veffels of the nofe, while the balance of the fyftem might be otherwife duly adjufted. DCCXXIL When the procefs of the growth of the body goes on regularly, and the balance of the fyftem is properly adjufted to the graduai growth of the whole, as well as to the fucceffive growth of the feveral parts, even a plethoric ftate dœs not produce any hemorrhagy, or at leaft any after that of the nofe; but if, while the ple- thoric O F P H Y S I C. 265 thoric ftate continues, any inequality alfo fhall fubfiftin any of the parts of the fyftem, congeftions hemorrhagic, or inflammatory, may readily be formed. DCCXXIII. In gênerai, it may be obferved, that, when the fe- veral parts of the fyftem of the aorta have attained their full growth, and are duly balanced with one another, if then any confiderable degree of plethora remain or arife, the nicety of the balance will be between the fyftems of the aorty and pulmonary artery, or between the veffels of the lungs, and thofe of ail the reft of the body : And though the leffer capàcity of the veffels of the lungs is commonly compenfated by the greater ve- locity of the blood in them ; yet, if this velocity benot always adjufted to the neceffary compenfation, it is pro- bable that a plethoric ftate of the whole body will al- ways be efpecially felt in the lungs ; and, thereforç, that a hemorrhagy, as the effedt of a gênerai plethora, might be frequently occafioned in the lungs, even though there were no fault in their conformation. DCCXXIV. In fome cafés, perhaps, a hemorrhagy from the lungs, or a hemoptyfis, does arife from the gênerai plethoric ftate of the body ; but a hemoptyfis more frequently does, and may be expedted to happen, from a faulty proportion between the capàcity of the lungs and that of the reft of the body. DCCXXV. When fuch a difproportion takes place, it will be évident, that a hemoptyfis will efpecially happen about the time that the body is approaching to its acmé ; that is, when the fyftem of the aorta has arrived at its ut- moft extenfion and refiftence, and when, therefore, the plethoric ftate of the whole muft efpecially affèa the lungs. L1 DCCXXVI, 266 PRACTICE DCCXXVI. Accordingly, it has been conftantly obferved, that, in fadt, the hemoptyfis efpecially happens about the time of the body's arriving at its acmé ; but we fay /alfo, that the hemorrhagy may happen fooner or later, as the balance between the veffels of the lungs, and thofe of the fyftem of the aorta, happen to be more or lefs exadtly adjufted to one another ; and it may often occur much-later than the period mentioned, when that balance, though not quite even, is not, however, fo ill adjufted, but that fome other concurring caufes are ne- ceffary to give it effrct. DCCXXVII. It was antiently obferved by Hippocrates, and has been confirmed by modem obfervation, that the he- moptyfis generally happens to men between the âge of fifteen and that of five and thirty ; that it may happen at any time between thefe two periods ; but that it feldom happens before the former, or after the latter ; and it is proper for us hère to inquire into the reafon of thefe two limitations. DCCXXVIII. With refpedt to the firft, the reafon of it has been already explained in {DCCXVIIL and DCCXIX.). With refpect to the fécond limitation, we expedt that the reafon of it will be underftood from the following confiderations. We have faid already, that the extenfion and growth of the body requires the plethoric ftate of the arterial fyftem ; and nature has provided for this, partly by giving a certain denfity and refiftence to the feveral ex- halants and excretories through which the fluids might pafs out of the red arteries ; partly by the conftitution of the blood being; fuch, that a great portion of it is unfit to pafs into the exhalants and excretories-; and partly, O F P H Y S I C. 267 partly, but efpecially, by a refiftence in the veins to the free paffage of the blood into them from the arteries. DCCXXIX. With refpedt to this laft, and chief circumftance, it appears from the experiments of Sir Clifton Wintrig- ham, in his Expérimental Inquiry, that the proportional denfity of the coats of the veins to that of the coats of the arteries is greater in young animais than in old ; and, therefore, it may be prefumed, that the refiftence to the paffage of the blood from the arteries into the veins is greater in young animais than in old ; and, while this refiftence continues, the plethoric ftate of the arteries muft be conftantly continued and fupported. But, as the denfity of the coats of the veffels, confifting chiefly of a cellular texture, is increafed by preffure, fo, in proportion as the coats of the arteries * are more expofed to preffure by diftenfion than thofe of the veins, the former, in the progrefs of the growth of the body, muft increafe much more in denfity than the latter; and, therefore, the coats of the arteries, in refpect of denfity and refiftence, muft come, in time, not only to be in balance with thofe of the veins, but to prevail over them ; and the experiments of the above mentioned in- fenious author fufficiently fhew that this truly happens. !y thefe means, the proportional quantifies of blood in the arteries and veins muft change, in the courfe of life. In younger animais, the quantity of blood in the ar- teries muft be proportionally greater than in old ones ; but, by the increafing denfity of the arteries, the quan- tity of blood in them muft be continually diminifhing, and that of the veins be proportionally increafing, and at length be in a proportionally greater quantity than that of the arteries. When this change happens in the proportional quantities of the blood in the arteries and veins, it is évident that the plethoric ftate of the arteries muft be in a great meafure taken off; and, therefore, that the arterial hemorrhagy is.no longer likely to hap- pen, and that, if a gênerai plethoric ftate afterwards take place in the fyftem, it muft efpecially appear in the veins. DCCXXX. 268 PRACTICE DCCXXX. The change wehave mentioned to happen in the ftate of the arterial and venous fyftems, is properly fuppofed to take place in the human body about the âge of thirty-five, when it is manifeft that the vigour of the body, which dépends fo much on the fullnefs and tenfion of the arterial fyftem, no longer increafes ; and there- fore it is, that the famé âge is the period after which the arterial hemorrhagy, hemoptyfis, hardly appears. It is true, there are inftances of the hemoptyfis happening at a later period, but it is for the reafons given, (DCCXI.^, which fhew that a hemorrhagy may happen at any period of life, from accidentai caufes forming congeftions, indépendant of thé ftate of the balance of the fyftem at particular periods of it. DCCXXXI. Wehave faid, (DCCXXIX.) that, after the âge of thirty-five, if a gênerai and preternatural plethoric ftate occurs, it muft efpecially appear in the venous fyftem ; and I muft now obferve, that this venous plethora may alfo give occafion to hemorrhagy. DCCXXXII. If a plethoric ftate of the venous fyftem takes place, it is prefumed, that it will efpecially, and, in the firft place, affect the fyftem of the vena portarum, in which the motion of the venous blood is more flow than elfe- Where ; in which the motion of the blood is little affifled by external compreffion ; and in which, from the want of valves in the veins which form the vena portarum, the motion of the blood is little affifled by the com- preffion that is applied ; while, from the famé want of valves in thofe veins, the blood is more ready to regur- gitate in them. Whether any régurgitation of the blood can produce any adtion in the veins, and which inverted, or diredted towards their extremities, can force thefe, and occafion hemorrhagy, may perhaps be difputed ; O F P H Y S I C. 269 but we think that a hemorrhagy produced by a plethoric ftate of the veins may be explained in another and more probable manner. If the blood is accumulated in the veins, from any refiftence to its proper courfe, this re- fiftence, and confequent fullnefs, muft alfo refift the free paffage of the blood from the arteries into the veins. This again muft produce fome congeftion in the extre- mities of the red arteries, and, therefore, fome increafed adtion in them, which muft be determined with more than ufual force, both upon the extremities of the arte- ries, and upon the exhalants proceeding from them ; and this force, may occafion an effufion of blood, either by anaftomofis, or rupture. DCCXXXIII. This is the account we would give of the hemorrhoidal flux, fo far as it is depending upon the ftate of the whole fyftem. This flux appears moft commonly to be from the extremities of the hemorrhoidal veflèls, which are the moft dépendent and diftant branches of thofe veins which form the vena portarum ; and, therefore, the moft readily affedted by every accumulation of blood in that fyftem of veins, and, confequently, by any gênerai plethora in the venous fyftem. DCCXXXIV. It is hère to be obferved, that we have fpoken of this hemorrhagy as proceeding only from the hemorrhoidal veffels, as it commonly does ; but it will be readily un- derftood, that the famé accumulation and refiftence to the venous blood may, from various caufes, affect many of the extremities of the vena portarum, which lie very fuperficially upon the internai furface of the alimentary canal, and give occafion to what has been called the Morbus Niger or Melana. DCCXXXV. Another part in which an unufually plethoric ftate of the veins may have particular effedts, and occafion he- morrhagy, 270 PRACTICE morrhagy, is the head. In this the venous fyftem is of a peculiar conformation, and fuch as feems intended by nature to give a flower motion to the venous blood there. If, therefore, the plethoric ftate of the venous fyftem in gênerai, which feems to increafe as life advances, fhould at length increafe to a great degree, it may very readily affect the venous veffels of the head, and give there fuch a refiftence to the arterial blood, as to dé- termine thistobe poured out from the nofe, or into the cavity of the cranium. The fpecial effedt of the latter effufion is to produce the difeafe named Apoplexy, and which, therefore, is properly named, by Dodtor Hoff- man, Hemorrhagia Cerebri ; and the explanation of its caufe, which we have now given, explains well why it happens, efpecially to men of large hcads and fhort necks, and to men in the décline of life, when the powers, promoting the motion of the blood, are much weakened. DCCXXXVI. We have thus attempted to give the hiftory of the plethoric and hemorrhagic ftates of the human body, as they occur at the diffèrent periods of life, and hope we have thereby explained not only the nature of hemorrhagy in gênerai, but alfo of the particular hemorrhagies which moft commonly appear, and as they occur fuc- ceffively at the différent periods of life. SECT. OF PHYSIC. 271 SECT. III. Of the REMOTE CAUSES of HEMORRHAGY. DCC XXXVII. In the explanation given, we have efpecially confidered the predifpofition to hemorrhagy ; but it is proper alfo^ and even neceffary, to take notice of the occafional caufes, which not only concur with the predifponent^ in exciting hemorrhagy, but may alfo fometimes be the foie caufes of it. , DCCXXXVIII. Thefe occafional caufes are, 1. External heat, which, rarefying the blood, gives or increafes the plethoric ftate of the body ; and the famé heat, as giving a ftimulus to the whole fyftem, muft urge any particular déterminations before eftabliihed, ftill further, or may urge any inequality, otherwife innocent, to excefs ; and, in either way, external heat ' may immediately excite hemorrhagies, to which there was a predifpofition, or form congeftions where there were none before, and thereby occafion hemorrhagy. 2. A confiderable and fudden diminution of the weight of the atmofphere, which feems to produce the famé effects with thofe of heat, by producing alfo an ex- panfion of the blood. 3. Whatever increafes the force of the circulation, and thereby the velocity of the blood, which may operate in the famé manner as heat, in urging not only previous déterminations with violence, but alfo in urging in- equalities, otherwife innocent, to excefs. Ail violent exercife, 272 PRACTICE exercife, therefore, and efpecially ail violent efforts, which not only by a larger and longer infpiration, but alfo by the fimultaneous adtion of many mufcles in- terrupting the free motion of the blood, impel it with unufual force into the extrême veffels more generally, and, according to the diffèrent poflures of the body, and mode of the effort, into certain veffels more par- ticularly. Among the caufes increafing the force of the circulation, anger, and other violent active paflions, are to be reckoned. 4. The violent exercife of particular parts of the body, already affedted with congeftions, or liable to them, which exercife may be confidered as a ftimulus applied to the veffels of that particular part. Thus, any violent exercife of refpiration may excite hemoptyfis, or occafion its return. ' 5. The poflures of the body increafing détermi- nations, or ligatures occafioning accumulations of the blood in particular parts of the body. 6. External violence producing hemorrhagy, and, by being frequently repeated, giving an habituai dé- termination into certain veffels. ' 7'. Cold, externally applied, as changing the diftri- bution of the blood, and determining it in greater quantity into the internai parts. SECT. IV. Of the CURE of HEMORRHAGY. DCCXXXIX. Having thus confidered the proximate and remote caufes of hemorrhagy in gênerai, our next bufinefs is to confider the cure in the famé manner. In O F P H Y S I C. 2/3 In entering upon this fubjedt, the firft queftion which prefents itfelf is, Whether hemorrhagies may be cured by art, or fhould be left to the conduct of nature ? DCCXL. The latter opinion was the favourite doctrine of the celebrated Dr. Stahl, and his follewers. They main- tained that the human body is much difpofed to a ple- thoric ftate ; and, in confequence, to many diforders which nature endeavours to obviate and relieve, by ex- citing hemorrhagy; that this, therefore, is often ne- ceffary to the balance and health of the fyftem ; that it is accordingly to be generally encouraged, and fometimes folicited, and is not to be fuppreffed, unlefs when it goes to great excefs, or happens in parts in which it may be dangerous. DCCXLI. Much of this dodtrirJPmay be admitted. The human body, on many occafions, becomes preternaturally ple- thoric, and the dangerous confequences of this ftate, which might be apprehended, feem to be obviated by a hemorrhagy taking place; and, further, the neceffityof hemorrhagy often appears from hence, that the fup- preffion of it feems to occafion many diforders. Ail this is true ; but there is a fallacy in the con- clufion drawn from it. DCCXLII. We maintain that hemorrhagy, either on its firft at- tack, or on its after récurrence, is never neceffary to the health of the body, but upon the fuppofition that we cannot otherwife prevent or remove the plethoric ftate which feems to require the évacuation ; but, as we judge it poffible to prevent or remove a plethoric ftate, fo we do not think that hemorrhagy is, in ail cafés, neceffary. In gênerai, we think that hemorrhagy is to be avoided, i. Becaufe it does not always happen in places where it is fafe. 2. Bçcaufe, often, while it may relieve a M m plethoric 1 274 PRACTICE plethoric ftate, it may, at the famé time, induce a very dangerous difeafe. 3. Becaufe it may often go to excefs, and either en- danger life, or induce a dangerous infirmity. And, lajîly, Becaufe it has a tendency to increafe the plethoric ftate it was meant to relieve, to occafion its own récurrence, and thereby to induce a habit, which, if left to the precarious and unequal opération of nature, may, from the fréquent errors of this, be attended with much danger. DCCXLIIL It is further to be confidered, that hemorrhagies do not always arife from the neceffities of the fyftem, but often proceed from incidental caufes, more than from predifpofition. We judge that ail fuch hemorrhagies may be immediately fuppreffed, and the répétition of fuch, as it induces a plethora, and a habit not other- wife neceffary, may be, with great advantage, prevented. DCCXLIV. Upon the whole of this fubjedt, I Conclude, that preternatural hemorrhagy, that is, every one but that of themenfes in females, is tobe avoided, and efpecially the returns of it prevented ; and I therefore now pro- ceed to fay how hemorrhagy, and its récurrences, may, and fhould be prevented. DCCXLV. From the principles delivered above, it will imme- diately appear, that the prévention, either of the firft attacks, or of the returns of hemorrhagy, will chiefly, and in the firft place, dépend upon the preventing or removing of any confiderable degree of a plethoric ftate which may happen to prevail in the body. It is true, that, where the hemorrhagy dépends upon the particular conformation of certain parts, rather than upon the gêne- rai plethoric ftate of the whole, the meafures for removing or preventing the latter may not always be fufficient for preventing O F P H Y S I C. 275 preventing hemorrhagy ; but, at the famé time, it will be évident, that déterminations, in confequence of the con- formation of particular parts, will always be urged more or lefs, in proportion to the greater or leffer plethoric ftate of the whole fyftem ; and, therefore, that, even in the cafés depending upon particular conformation, the preventing or removing of an unufually plethoric ftate, will always be a chief means of preventing he- morrhagy. It is to be taken notice of, further, that there mav be feveral inequalities in the balance of the fyftem, which may have little or no effedt, unlefs when the fyftem becomes preternaturally plethoric ; and, there- fore, that, in ail eafes, the preventing or removing of the plethoric ftate of the fyftem will be a chief means of preventing the firft attacks, or the returns of he- morrhagy. We are now, therefore, to fay how the plethoric ftate of the fyftem is to be avoided or removed. DCCXLVI. The fluids of the human body are in continuai wafte by the excrétions, but are commonly replaced by the aliments taken in ; and, if the quantity of aliments, in any meafure, exceed that of the excrétions, an in- creafe of the quantity of the fluids of the body, or a plethoric ftate, muft arife. This, to a certain degree, is neceffary for the growth of the body ; but, even then, if the proportion of the aliments to the excrétions be greater than is fuited to the growth of the body, and more certainly, if this difproportion continue after the growth is compleated, when an equality between the ingefia and the excréta" fhould be eftablifhed, a preter- natural plethoric ftate muft arife. In both eafes, it is évident, that the plethora muft be prevented or corredted by adjufting the ingefta and excréta to each other, which generally may be done, either by diminifhing the ingefta, or increafing the excréta. The former may be effedted by the management of diet, the latter by the manage- ment of exercife. DCCXLVII. 276 PRACTICE DCCXLVII. The ingefta may be diminifhed, either by giving aliment in lefs quantity than ufual, or by giving ali- ments of a lefs nutritious quality ; that is, aliments of a fubftance, which, under the famé bulk and wcight, contain lefs of a matter capable of being converted into animal fluids, and more of a matter ready to pafs off by the excrétions, and, confequently, lefs of a matter to be retained and accumulated in the veffels. The choiceof aliments fuited to thefe purpofes, muft be left to be diredted by the doctrines of the Materia Medica. DCCXLVIIL The increafing of the excréta, and thereby di- minifhing the plethoric ftate of the fyftem, is to be ob« tained by increafing the exercife of the body ; and ' generally for adjufting the balance between the ingefta and excréta, and thereby obviating the plethoric ftate, it is neceffary that exercife, in a due meafure, be very conftantly employed. DCCXLIX. The obferving of abftinence, and the employment of exercife, for obviating or removing the plethoric ftate of the body, we formerly, when treating of the goût, (DVI. DXV.) confidered pretty fully, fo that lefs is neceffary to be faid hère ; and, it is only now requifite to obferve, that the famé doubts, as in eafes of the goût, do not arife hère, with regard to the fafety of thofe meafures, which, in a plethoric ftate of the body difpofing to hemorrhagy, are always admiffible and pro- per. But hère it is to be obferved, that fome choice of the mode of exercife is neceffary, anti that it fhould be diffèrent, according to the particular déterminations which may happen to prevail in the fyftem. In gênera], in the cafe of plethora difpofing to hemorrhagy, bodily exercife O F P H Y S I C. 277 exercife will always be hazardous, and geftation more generally fafe. DCCL. Artificial évacuations may be employed to diminifh the plethoric ftate of the body; and when, at any time, the plethoric ftate has become confiderable, and imme- diately threatens a difeafe, thefe évacuations fhould be made to the quantity that the fymptoms feem to require. But it is conftantly to be attended to, that blood-lettings are improperly employed, to prevent a plethora, as they have a tendency to increafe it, whereby they require to be often repeated, and induce a habit which may be at- tended with much danger. DCCLI. While a plethora is avoided or removed, and thereby the predifpofition to hemorrhagy, the other meafures neceffary for preventing it, are thofe for avoiding the occafional caufes. Thefe are enumerated in (DCCXXXVIIL), and the means of avoiding them, fo far as within our power, are fufficiently obvious. DCCLII. We have now mentioned the means of preventing either the firft attacks, or the returns of hemorrhagy ; and muft next fay how it is to be managed when it has come on. DCCLIII. When a hemorrhagy has come on, which appears to have arifen from a preternaturally plethoric ftate, or from fome change in the balance of the fanguiferous fyftem, no meafures are to be immediately taken for fuppreffing it, as we may expedt that, when the quantity of blood neceffary for the relief of the fyftem is poured out, the effufion will fpontaneoufly ceafe. DCCLI V 278 PRACTICE DCCLIV. In many cafés, however, it may be fufpedted, that the quantity of blood poured out is not exadtly in pro- portion to the neceffities of the fyftem, either for re- lieving a gênerai plethora, or particular congeftions, but that it is often to a greater quantity than thefe re- quire. This we fuppofe to happen in confequence of an inflammatory diathefis prevailing, and of a fébrile fpafm being formed ; and, therefore, in many eafes, it is proper, as well as for the moft part fafe, to moderate the évacuation, and, when it threatens to go to excefs, to fupprefs it altogether. DCCLV. A hemorrhagy may be moderated by avoiding any irritation that might concur to increafe it ; and, there- fore, every part of the antiphlogiftic regimen is to be obferved ; and, in particular, external heat, both as it raréfies the fluids, and flimulates the folids, is to be carefully avoided ; and, it is probable, that, in ail eafes, a hemorrhagy may be moderated by cool air applied, and cold drink exhibited. DCCLVI. A fécond means for the famé purpofe, is the ufe of réfrigérant medicines, and particularly of acids and nitre. DCCLVII. A third means which has been frequently employed, is that of blood-letting. The propriety of this pradtice may be doubtful, as the quantity of blood poured out by the hemorrhagy, may be fuppofed to anfwer the pur- pofe of an évacuation in any other way ; and we are ready to allow, that the pradtice has been often fuper- fluous, and fometimes hurtful, by making a greater évacuation than was neceffary or fafe. At the famé time, O F P H Y S I C. 279 time, we apprehend it is not for the mère purpofe of evacuating, that blood-letting is to be practifed Nin the cure of hemorrhagy ; but that it is neceffary for taking off the inflammatory diathefis which prevails, and the fébrile fpafm that has been formed. In the cafe of hemorrhagy, therefore, when the pulfe is not only fréquent, but quick and full, and does not become fofter or flower upon the flowing of the blood, and that the effufion is profufe, and threatens to continue fo, I think that blood-letting may be neceffary, and that I have often found it ufeful. I believe further, that the par- ticular circumftances of venefedlion may render it more powerful for taking off the tenfion and inflammatory irritation of the fyftem, than any graduai flow from an artery. DCCLVIII. That a fpafm of the extrême veffels has a fhare in fupporting hemorrhagy, appears to me probable from hence, that bliftering has been found. often ufeful in moderating and fuppreffing hemorrhagy. DCCLIX. Do emetics and vomiting contribute to the cure of hemorrhagy ? See Dodtor Bryan Robertfon on the vir- tues and power of medicines. DCCLX. When a hemorrhagy is very profufe, and feems to endanger life, or even threatens to induce a dangerous infirmity, it is agreed on ail hands, that it is to be im- mediately fuppreffed by every means in our power ; and particularly, that, befides the means above mentioned for moderating hemorrhagy, aftringents, internai or ex- ternal where they can be applied, are to be employed. DCCLXL 280 PRACTICE DCCLXL The internai aftringents are either vegetable or foflil. The vegetable aftringents are feldom very powerful in the cure of any hemorrhagies, except thofe of the alimentary canal. The foflil aftringents are more powerful, but fome choice of the diffèrent kinds may be proper. The chalybeates, fo frequently employed, do not ap- pear to me to be very powerful. The préparations of lead are certainly more fo, but are otherwife of fo pernicious a quality, that they fhould not be employed but in cafés of the utmoft danger. The Tindtura Saturnina, or Antiphthifica, as it has been called, appears tobeof little power; but whether from the fmall portion of lead which it contains, or from the ftate in which the lead is in it, I am uncertain. The foflil aftringent that appears to me the moft pow- erful, and at the famé time the moft fafe, is alum. DCCLXII. External aftringents, when they can be applied, are more effedtual than the internai. The choice of thofe is left tothe furgeons. DCCLXIII. The moft powerful of ail aftringents appears to me to be cold, which may be employed either by applyingcold water to the furface of the body, or by throwing the famé into the internai parts. DCCLXIV. For fuppreffing hemorrhagies, many fuperftitious remédies and charms have been recommended, and faid to have been employed with fuccefs. We are of opi- nion, that the feeming fuccefs of thefe has been generally owing to the by-ftanders miftaking a fpontaneous ceafing of the hemorrhagy for the effedt of the remedy. But, at OF PHYSIO. 281 at the famé time, I believe, that thofe remédies have been fometimes ufeful, by impreffing the mind with horror, awe, or dread. DCCLXV. Upon occafion of profufe hemorrhagies, opiates have been employed with advantage; and, when the fullnefs and inflammatory diathefis of the fyftem have been pre- vioufly taken off by the hemorrhagy itfelf, or by blood- letting, I think opiates may be employed with fafety. DCCLXVI. For reftraining hemorrhagy, ligatures have been ap- plied upon the limbs, for retarding the return of the venous blood from the extremities; but they appear to me to be of uncertain and ambiguous ufe. DCCLXVII. In the cafe of profufe hemorrhagies, no pains are to be taken to prevent a Deliquium Animi, or fainting, as this happening is often the moft certain means of ftopping the hemorrhagy. DCCLXVIIL We have thus delivered the gênerai doctrine of he- morrhagy, and are now to confider the particular cafés of it. It may appear, that we have marked fewer of thefe than are commonly enumerated by the nofologifts ; but our reafon for differing from thefe authors, muft be left to a nofological difeuffion, to be entered into in another place more properly than hère. N n C H A P. 282 PRACTICE C H A P. IL Of the E P I S T A X I S, Or HEMORRHAGY of the NOSE. DCCLXIX. The ftate of the veffels upon the internai furface of the nofe being, fuch as mentioned (DCCXX.), renders a hemorrhagy from that more fréquent than from any other part of the body. DCCLXX. The blood commonly flows from one noftril only, and probably becaufe a hemorrhagy from one veflèl re- lieves the congeftion in ail the neighbouring veflèls. The blood flowing from both noftrils at the famé time, fhews a more confiderable difeafe. DCCLXXI. This hemorrhagy may occur at any time of life, but moft commonly happens to young perfons, as mentioned in (DCCXIX.), owing to the ftate of the balance of the fyftem peculiar to that âge. DCCLXXII. ,Though it generally happens to perfons before they have arrived at their full growth, and more rarely af- terwards ; yet fometimes it happens to perfons after their acmé, and during the ftate of manhood ; and it muft then be imputed to a" plethoric ftate of the fyftem ; O F P H Y S I C. 283 fyftem ; to a détermination of the blood by habit to the veffels of the nofe ; or to the particular weaknefs of thefe. DCCLXXIII. In ail thefe cafés, the difeafe may be confidered as an hemorrhagy purely arterial, and depending upon an arterial plethora; but, the difeafe fometimes occurs in the décline of life, when probably it dépends upon, and may be confidered as a mark of a venous plethora of the veffels of the head. See (DCCXXXV.) DCCLXXIV." This hemorrhagy happens at any period of life, in certain fébrile difeafes, which are altogether, or partly, of an inflammatory nature, and which fhew a particular détermination of the blood to the veffels of the head. Thefe difeafes often admit of a folution by this he- morrhagy, when it may be called critical. DCCLXXV, This hemorrhagy happens to perfons of every con- ftitution and tempérament, but moft frequently to thofe of a plethoric habit, and fanguine tempérament. It happens to both fexes, but moft frequently to the maie. DCCLXXVI. The difeafe fometimes comes on without any previous fymptoms ; particularly, when fome external violence has a fhare in bringing it on. But, when it proceeds entirely from an internai caufe, it is commonly preceded by head-achs, rednefs of the eyes, a florid cojour of the face, an unufual pulfation in the temples, a fenfe of full- nefs about the nofe, and an itching of the noftrils. A bound belly, pale urine, coldnefs of the feet, and cold fhivering over the whole body, are alfo fometimes among the preceding fymptoms. DCCLXXVII, 284 PRACTICE DCCLXXVII. From the weaknefs of the veflèls of the nofe, the blood often flows from them without any confiderable effort of the whole fyftem ; and, therefore, without any obfervable fébrile diCorder; which, however, in many cafés, is, in ail its circumftances, very difccrnible» DCCLXXVIII. i..'. A hemorrhagy of the nofe happening to young per- fons, is, and may generally be, confidered as a flight difeafe, of little confequence, and hardly rcquiring any remedy. But, even in young perfons, when it recurs very frequently, and is very copious, it will require particular attention. It is to be confidered as a mark of arterial plethoia ; as it may go to a dangerous excefs , and, as frequently returning, it increafes the plethoric ftate ; which, in a more advanced ftage of life, may give the blood a détermination to parts from which the htmorrhagy would be more dangerous. AU this will more particularly require attention, as the marks of plethora, and of particular congeftion, preceding the hemorrhagy, are more confiderable ; and as the flowing of the blood is attended with a more confiderable degree of fébrile diforder, DCCLXXIX, When the epiftaxis happens to perfons after their acmè, returning frequently, and flowing copioufly, it is always to be confidered as a dangerous difeafe, and as more certainly threatening the confequences mentioned in the laft paragraph. DCCLXXX. When this hemorrhagy happens in the décline of life, it may be confidered as in itfelf very falutary, but, at the famé time, as a mark of a very dangerous ftate of the fyftem ; that is, as a mark of a very ftrong tendency to O F P H Y S I C. 285 to a venous plethora in the veffels of the head ; and I have accordingly obferved it often followed by apoplexy, palfy, or fuch like difeafes. DCCLXXXI. When a hemorrhagy from the nofe happens in fébrile difeafes, as mentioned in (DCCLXXL), and is in pretty large quantity, it may be confidered as critical and falutary ; but it is very apt to be profufe, and even in this way dangerous. It fometimes occurs during the eruptive fçver of fe- veral exanthemata, and is in fuch cafés fometimes fa- lutary ; but if thefe exanthemata be accompanied with any putrid tendency, this hemorrhagy, like artificial blood-lettings, may have very bad effects. DCCLXXXII. Having thus explained the feveral circumftances of epiftaxis, I proceed to confider the management and cure of it. I fay the management, becaufe it has been ufually thought to require no cure, but that nature fhould be allowed to throw out blood in this way very fre- quently, and as often as it appears to arife from internai caufes, that is, from a ftate of the fyftem fuppofed to require fuch évacuation. DCCXXXIII. For the reafons given in (DCCLXXVIIL), I am oï opinion, that this difeafe is very feldom to be left to the conduct of nature ; and that, in ail cafés, it fhould be moderated by keeping the patient in cool air ; by giving cold drink ; by keeping the body and head eredt ; by avoiding any blowing of the nofe, fpeaking, or other irritation ; and, when the blood has flowed for fome time, and does not fhew any tendency to ceafe, a pror fufe bleeding is to be prevented by meafures employed to ftop it, fuch as preffing the noftril from which the blood flows, wafhing the face with cold water, or ap- plying this to fome other parts of the body. DCCLXXXIV. 286 PRACTICE DCCLXXXIV. Thefe meafures we judge to be proper even in the cafe of young perfons, in whom the difeafe is leaft ha- zardous, and even in firft attacks ; but thefe meafures will be ftill more proper, if the difeafe frequently re- curs, without any external violence ; if the returns fhall happen to perfons of a habit difpofed to be plethoric ; and, more particularly, if the marks of a plethoric ftate appear in the preceding fymptoms. (DCCLXXV.). DCCLXXXV. Even in young perfons, if the bleeding be very pro- fufe, and long continued, and more efpecially, if the pulfe become weak, and the face pale, we judge it pro- per to fupprefs the hemorrhagy by every means in our power. See (DCCLIX.), and following paragraphs. DCCLXXXVI. In the famé cafe of young perfons, when the returns of this hemorrhagy become fréquent, .and efpecially with the marks of a plethoric habit, we think it neceffary to advife fuch a regimen as may prevent a plethoric ftate. (DCCXLV.—DCCXLIX.). We would advife, at the famé time, to avoid ail circumftances which may détermine the blood more fully to the veffels of the head, or prevent its free return from them ; and, by keeping an open belly, to make fome dérivation from them. DCCLXXXVII. In adult perfons, liable to fréquent returns of the epiftaxis, the whole of the meafures propofed (DCCLXXXIL—DCCLXXXVI.), are more cer- tainly and freely to be employed. When, with the circumftances mentioned in (DCCLXXXIV.), the tendency to a profufe hemorrhagy appears, even in young perfons, a bleeding at the arm may be proper ; but O F P H Y S I C. 287 but will be ftill more allowable, proper, and even ne- ceffarv, in the cafe of adults hère mentioned. DCCLXXXVIII. In perfons of any âge liable to fréquent returns of this hemorrhagy, when the meafures propofed m (DCCLXXXVI.) fhall have been negledted, or from peculiar circumftances in the balance of the fyftem, fhall have proved ineffedual, and the fymptoms threaten- ing a hemorrhagy (DCCLXXVL) fhall appear, it will then be proper, by blood-letting, cooling purga- tives, and every part of the antiphlogiftic regimen, to prevent the hemorrhagy ; or, at, leaft, to prevent its being profufe when it does happen. DCCLXXXIX. In the circumftances juft now mentioned (DCC- LXXXVIII.), themearures propofed are proper, and even neceffary ; but it fhould, at the famé time, be obferved, that thefe are practifed with much lefs ad- vantage than thofe propofed in DCCLXXXVI.) ; be- caufe, though thefe propofed hère may prevent the coming on of the hemorrhagy for the prefent, they certainly, however, difpofe to the return of that ple- thoric ftate which required their being ufed, and there can be no proper fecurity againft returns of the difeafe, but by purfuingthe means propofed in (DCCLXXXVI.) DCCXC. When the hemorrhagy of the nofe happens to perfons approaching to their full growth, and its returns have been preceded by the fymptoms (DCCLXXVL), it may be fuppofed, that, if the returns can be prevented by the meafures propofed in (DCCLXXXVIII.), thefe will be fafely employed, as the plethoric ftate induced will be rendered fafe, by the change which is foon to take place in the balance of the fyftem. This, how- ever, cannot be admitted, as the évacuations practifed upon 288 PRACTICE upon this plan will have ail the confequenccs which we have faid may follow the récurrence of the hemorrhagy itfelf. b} DCCXCL When the hemorrhagy of the nofe fhall be found to make its returns at nearly flated periods, the meafures for preventing it (DCCLXXXVIII) may be pratfifcd with greater certainty ; and, upon every répétition of the évacuation by diminifhing the quantity of it, its ef- fedts* in inducing a plethora, may be in fome meafure avoided. When, indeed, the répétition of évacuations is truly unavoidable, the diminifhing of them upon every répétition is properly practifed, but it is a pradtice of nice and precarious management, and fhould by no means be trufted, fo far as to fuperfede the meafures pro- pofed in (DCCLXXXVI.), wherever thefe can be admitted. DCCXCIL When the hemorrhagy of the nofe happens in con- fequence of a venous plethora in the veffels of the head, as in (DCCLXXL), the flowing of the blood pretty largely may be allowed, efpecially when it happens after the fuppreffion or ceafing of the menftrual or he- morrhoidal flux. But, though the flowing ôf the blood is, on its firft occurring, to be allowed, there is nothing more proper than guarding againft the returns of it. This is to be done not only by the meafures propofed in (DCCLXXXVI.-), but, as the effèas of a plethoric ftate of the veffels of the head are very uncertain, fo, upon any appearance of it, and efpecially upon any threatening of hemorrhagy, the plethora is to be re- moved, and the hemorrhagy to be obviated immediately by proper évacuations, as blood-letting, purging, and iffues, or by reftoring fuppreffed évacuations, where this can be done. C H A P. O F P H Y S I C. a8o C H A P. III. Of the HEMOPTYSIS, or HE- MORRHAGY from the LUNGS. SECT. !.. Of the PHENOMENA and CAUSES of HEMOPTYSIS. DCCXCIII. When blood thrown out from the mouth appears after fome affection of the breaft, and is brought out with more or lefs of coughing, we can have no doubt that it comes from the lungs, and this afcertains the difeafe we are now to treat of. But there are eafes in which the fource of the blood fpit out is uncertain ; and, therefore, fome other confiderations, to be mentioned hereafter, are often neceffary^to afcertain the exiftence of a hemoptyfis. DCCXCIV. The blood-veffels of the lungs are more numerous than thofe of any other part of the body of the famé bulk. Thefe veffels of the largeft fize, as they arife firom the heart, are more immediately, than in other parts, fub-divided into veffels of the fmallefè fize; and thefe fmall veffels are fpread out near to the internai O o furfaces 290 PRACTICE furfaces of the bronchial cavities, fituated in a loofc cellular texture, and covered by a tender membrane only ; fo that, confidering how readily and frequently thefe veflèls are gorged with blood, we may underftand why a hemorrhagy from thefe veffels is, next to that of the nofe, the moft fréquent of any ; and particularly, why any violent fhock given to the whole body fo readily oc- casions a hemoptyfis. DCCXCV. A hemoptyfis may be occafioned by external violence at any period of life ; and we have explained above (DCCXXIV.), why, in adult perfons, while the ar- terial plethora, nicely adjufted, prevails in the fyftem, thatis, from the âge of fixteen to that of five and thirty, a hemoptyfis may at any time be produced, merely by a plethoric ftate of the lungs. DCCXCVI. But, we have alfo obferved above, (DCCXXIV.), that a hemoptyfis more frequently arifes from a faulty proportion in the capàcity of the veffels of the lungs to thofe of the reft of the body. Thus it is often a here- ditary difeafe, which implies a peculiar and faulty con- formation. The difeafe too, efpecially happens to perfons who difcover the fmaller capàcity of their lungs, by the narrownefs of their cheft, and by the prominency of their ihoulders, which laft is a mark of their having been long liable to a difficult.refpiration. DCCXCVIL In fuch cafés too, the difeafe efpecially happens to perfons of a fanguine tempérament, in whom particu- larly the arterial plethora prevails. It happens, alfo, to perfons of a flender délicate make, of which a long rieck is a mark ; to perfons of much fenfibility, and irritability, and, therefore, of quick parts ; to perfons who have been formerly liable to fréquent hemorrhagies of the nofe j to perfons who have fuffered a fuppreffion O F P H Y S I C. 291 of any hemorrhagy they had formerly been liable to, the moft fréquent inflance of which is in females, who have fuffered a fuppreffion of their menftrual flux ; and, lajîly, to perfons who have fuffered the amputation of any confiderable limb. DCCXCVIII. In moft of thefe cafés, (DCCXCVIL), the difeafe efpecially happens to perfons about the time of their coming to their full growth, or foon after it, and this for the reafons fully fet forth above (DCCLXXV.) DCCXCIX. From ail that has been faid from (DCCXCIV. to DCCXCVIII.), the predifponent caufe of hemoptyfis will be fufficiently underftood, and the difeafe may hap- pen from merely the predifponent caufe arifing to a con- fiderable degree. But, in the predifpofed, it is often brought on by the concurrence of various occafional and exciting caufes. One of thefe, and perhaps a fréquent one, is external heat, which, even when in no great degree, brings on the difeafe in fpring, and the be- ginning of fummer, while the heat raréfies the blood more than it relaxes the folids, which had before been contradted by the cold of winter. Another exciting caufe is a fudden diminution of the weight of the at- mofphere, efpecially when concurring with any effort in bodily exercife. This effort, too, alone may often, in the predifpofed, be the exciting caufe ; and, more particularly, any violent exercife of refpiration. In the redifpofed, any degree of external violence alfo may ring on the difeafe, DCCC. Occafioned by one or other of thefe caufes (DCC- XCIX.), the difeafe comes on with a fenfe of weight, and anxiety in the cheft, fome uneafinefs in breathing, fome pain of the breaft, or other parts of the thorax, and fome fenfe of heat under the flernum ; and very often î 292 PRACTICE often before the difeafe appears, a faltifh tafte is per- ceived in the mouth. DCCCL Immediately before the appearance of blood, a degree of irritation is felt at the ,top of the larynx. To re- lieve this, a hawking is made, which brings up a little blood, of a florid colour, .and fomewhat frothy. The irritation returns ; and, in the famé manner, more blood of a like kind is brought up, with fome noife in the wind-pipe, as of air paffing through a fluid. DCCCIL This is commonly the manner in which the hemoptyfis firft begins ; but fometimes, at the very firft, the blood comes up bf coughing, or at leaft fomewhat of coughing accompanies the hawking mentioned. DCCCIII. The blood iffuing is fometimes at firft in very final 1 quantity, and foondifappears altogether ; but, in other cafés; efpecially when it repeatedly occurs, it is in greater quantity, and frequently continues to appear at times for feveral days together. Itis fometimes profufe, but rarely in fuch quantity as either by its excefs, or by a fudden fuffocation, to prove immediately mortal. It commonly either ceafes fpontaneoufly, or is ftopped by the remédies employed. DCCCIV. When blood is thrown out from the mouth, it is not always eafy to détermine.from what internai part it pro- ceeds ; whether from the internai furface of the mouth itfelf, from the fauces, or adjoining cavities of the nofe, from the ftomach, or from the lungs. It is, however, very neceffary to diftinguifh the différent eafes ; and, in moft inftances, it may be done by attending to the fol- lowing confiderations. DCCCV. O F P H Y S I C. 293 DCCCV. When the blood fpit out proceeds from fome part of the internai furface of the mouth itfelf, it comes out without any hawking or coughing ; and generally, upon infpedtion, the particular fource of it becomes évident. DCCCVI. When blood proceeds from the fauces, or adjoining cavitiesof the nofe, itmay be brought out by hawking, and fometimes by coughing, in the manner we have defcribed in (DCCCL and DCCCII.; ; and, in this way, a doubt may arife concerning its real fource. A patient often lays hold of thefe circumftances, to pleafe himfelf with the opinion of its coming from the fauces, and he may be allowed to do fo ; but a phyfician cannot readily be deceived, if he confider, that a bleeding from the fauces is more rare than one from the lungs ; that the former feldom happens but in perfons who have been before liable to a hemorrhagy of the nofe, or to fome évident caufe of erofion ; and, in moft cafés, by looking into the fauces, the diftillation of the blood from thence will be perceived. DCCCVII. When blood .proceeds from thC lungs, the manner in which it is brought up will commonly fhew from whence it comes ; but, independent of that, there are many circumftances which may concur to point it out, fuch as the period of life, the habit of body, and other marks of a predifpofition (DCCXCIV.—DCCXCVIII.) ; and together with thefe, the occafional caufes (DCCXCIX.) having been immediately before applied. DCCCVIII. When vomiting accompânies the throwing out of blood from the mouth, as vomiting and coughing often mutually excite each other; fo they may be frequently joined," 294 PRACTICE joined, and render it doubtful, whether the blood thrown out, proceed from the lungs, or from the fto- mach'. We may, however, generally décide, by con- fidering that blood does not fo frequently proceed from the ftomach as from the lungs ; that blood proceeding from the ftomach commonly appears in greater quantity than when it proceeds from the lungs ; that the blood proceeding from the lungs is ufually of a florid colour, and mixed with a little frothy mucus only ; whereas, the blood from the ftomach is commonly of a darker colour, more grumous, and mixed with the other con- tents of the ftomach ; that the coughing or vomiting, as the one or the other firft arifes in the cafés in which they are afterwards joined, may fometimes point out the fource of the blood ; and, laftly, that much may be learned from the circumftances and fymptoms which have preceded the hemorrhagy. Thofe which précède the hemoptyfis, enumerated (DCCC), are moft of them évident marks of an affection of the lungs. And, on the other hand, the hematemefis, or iffuing of blood from the ftomach, has alfo its peculiar fymptoms and circumftances preceding it ; as fome morbid affedtion of this organ, and, at leaft, fome pain, anxiety, and fenfe of weight, referred diftindtly to the région of the fto- mach. To ail this may be added, that the'vomiting of blood happens more frequently to females than to maies ; and to the former, in confequence of a fuppreffion of their menftrual flux. By attending to ail thefe con- fiderations (DCCCV.—DCCCVIIL), the prefence of the hemoptyfis may be commonly well afcertained. SECT. OF PHYHU 295 SECT. IL Of the CURE of HEMOPTYSIS. DCCCIX. This difeafe may fometimes be of not more danger than a hemorrhagy from the nofe, as, when it happens to females, in confequence of a fuppreffion of the menfes ; when, without any marks of a predifpofition, it arifes from external violence ; or, from whatever caufe arifing, when it leaves no cough, dyfpnœa, or other affection of the lungs, behind it. But, even in thefe cafés, a danger may arife, from too large a wound being made in the veffels of the lungs, from any quantity of red blood being left to ftagnate in the cavity of the bronchiae, and particularly, from any détermination of the blood being made into the veffels of the lungs, which, by renewing the hemorrhagy, may have thefe confequences. In every inftance, therefore, of hemoptyfis, the effufion is to be moderated by the feveral means mentioned (DCCLIV. DCCLVIIL). DCCCX. Thefe meafures are efpecially neceffary when the he- moptyfis arifes in confequence of predifpofition, and in ail cafés where there is the appearance of large effufion, or where the hemorrhagy frequently returns, the effufion is not only to be moderated, but to be entirely ftopped, and the returns of it prevented by every means in our power. See DCCLIX. DCCLXV. DCCCXI. 296 PRACTICE DCCCXL Two medicines have been frequently employed to ftop a hemoptyfis, or prevent the returns of it ; neither of which I can approve of. Thefe are chalybeates, and the Peruvian bark. As both of thefe contribute to in- creafe the phlogiftic diathefis of the fyftem, they can hardly be fafe in any cafe of active hemorrhagy, and I have frequently found them hurtful. DCCCXIL As the hemoptyfis which happens in confequence oi predifpofition, is always attended with a phlogiftic dia- thefis ; and, as the bad confequences of the difeafe are efpecially td be apprehended from the continuance of that diathefis, fo this is to be induftrioufly taken off by blood-letting, in greater or fmaller quantity, and more or lefs frequently repeated, according as the fymptoms fhall direct. At the famé time, cooling purgatives are to be employed, and every part of the antiphlogiftic regimen is tobe ftridtly enjoined. The réfrigérants may alfo be adminiftered, taking care, however, that the acids, and more efpecially the nitre, do not excite coughing. DCCCXIIL The avoiding of motion is generally a proper part of the antiphlogiftic regimen ; and, in the hemoptyfis, nothing is more necefiary than avoiding bodily exercife j but fome kinds of geftation, as failing, and travelling in an eafy carriage on fmooth roads, have often provea a remedy. DCCCXIV. Such is the treatment we can propofê for the he- moptyfis, confidered as merely a hemorrhagy ; but when, in fpite of ail our précautions, it continues to recur, it is often followed by an ulcération of the lungs, and a pbthifis 0 F P H Y S I C. 297 phthifis pulmonalis. This, therefore, we muft confider hère ; but, as it proceeds alfo from other caufes befides the hemoptyfis, we fhall treat of it more generally. C H A P. IV. Of the PHTPÎISIS PULMONALIS, O R CONSUMPTI0N of the LUNGS. SECT. I. Ofthe,PHENOMENA, and CAUSES gf the PHTHISIS PULMONALIS. DCCCXV. We define the pthifis pulmonalis to be an expec- toration of pus or purulent matter from the lungs, at- tended with a hedtic fever. As this is the principal fpecies of phthifis, we fhall frequently, in this chapter, employ the gênerai term of phthifis, though we ftridtly mean the phthifis pul- monalis. P p DCCCXVL 298 PRACTICE DCCCXVI. We have met with fome inftances of an expectoration of purulent matter, continuing for many years, ac- companied with very few fymptoms of hedtic, and, at leaft, without any hedtic exquifitely formed ; but, in none of thefe inftances were the perfons fo entirely free from fymptoms of hedtic, as to form any exception to our gênerai définition. DCCCXVIL In every inftanceof a phthifis pulmonalis, we fuppofe there is an ulcération of the lungs. The late Mr. de Haen is the only author that I know of who has advanced another opinion, and has fuppofed that pus may be formed in the blood-veffels, and be from thence poured into the bronchiae. Admitting his fadt, I have attempted an explanation of the appearance of pus without ul- cération. (CCCXLI.) But, after ail, I cannot help fufpedting the accuracy of his obfervations, muft en- tirely reject his explanation of it, muft allow that we ftill want fadts to fupport the explanation I had offèred, and doubt much if it will apply to any cafe of phthifis. Therefore I ftill conclude, agreeably to the faith of ail other diffedtions, and the opinion of ail phyficians, that the fymptoms mentioned in our définition dépend always upon an ulcération formed in the lungs. DCCCXVIII. It fometimes happens that a catarrh is attended with an expectoration of a matter fo much refembling pus, that phyficians have been often uncertain whether it was mucus or pus, and, therefore, whether the difeafe was a catarrh or a phthifis. It is often of confequence to dé- termine thefe queftions ; and we are of opinion that it may be generally done, with fufficient certainty, from the following confiderations, of which each particular is not always fingly decifive, but, when they are taken together, can hardly deceive us. 1. From O F P H Y S I C. 299 1. From the colour of the matter, as mucus is na- turally tranfparent, and pus always opake. When mucus becomes opake, as it fometimes does, it becomes white, yellow, or greenifh, but the latter colour is hardly ever fo confiderable in mucus as in pus. 2. From the confiftence, as mucus is more vifcid, and cohérent, and pus is lefs fo, and may be faid to be more friable. When mucus is thrown into water, it is not readily diffufed, but remains united in uniform and circular maflès ; but pus, in the famé circumftances, though not readily diffufed, does not remain founiformly united, and, by a little agitation, it is broken into ragged fragments. 3. From the odour, whiçh is feldom perceived in mucus, but frequently in pus. It has been propofed to try the odour of the matter expectorated by throwing it upon live coals ; but in fuch a trial, both mucus and pus give out a difagreeable fmell, and it is not eafy to diftinguifh between the two, 4. Trom the fpecific gravity compared with water ; and it is ufual for the mucus of the lungs to fwim on the furface of water, and for pus to fink in it. But, in this, we may fometimes be deceived ; as pus, which has entangled a great deal of air, may fwim, and mucus, that is free from air, may fink. 5. From the mixture which is difcernible in the matter brought up ; for, if a yejlow or greenifh matter appears furrounded with a lefs quantity of tranfparent, or lefs opake and coloured matter, the more ftrongly coloured matter may be generally confidered as pus ; as it is not eafy to underfland how one portion of the mucus of the lungs can be very confiderably changed, while the reft of it is very little fo, or remaîns in its ordinary ftate. 6. From the admixture of certain fubftances with the matter thrown out from the lungs. To this purpofe, we are informed by the experiments of the late Mr. Charles Darwin : a. That the vitriolic acid diffolves both mucus and pus, but moft readily the former : That, if water is added to fuch a folution of mucus, this is feparated, and either fwims on the furface, or, divided into flocculi, is fufpended in the liquor ; whereas, when water is added to a like folution of pus, this falls to 300 PRACTICE to the bottom, or, by agitation, is diffufed fo as to ex- hibit an uniformly turbid liquor. b. That a folution of the cauftic fixed alkali, after fome time, diflolves mucus, and generally pus ; and, if water be added to fuch folutions, the pus is precipitated, but the mucus is not. From fuch experiments, it is fuppofed that pus and mucus may be certainly diftinguifhed from tach other. 7. From the expedtoration's being attended with a hecti<âfever. A catarrh, or expectoration of mucus, is often attended with fever, but never, fo far as I have obferved, with fuch a fever as we are prefently to dc- fcribe as a hedtic. This, I am of opinion, is the moft certain mark of a purulent ftate in fome part of the body ; and, if other perfons have thought differently, I am perfuaded that it has been owing to this, that, pre- fuming upon the mortal nature of a confirmed or pu- rulent phthifis, they have confidered every cafe in which a recovery happened, as a catarrh only ; but, that they may have been miftaken in this, we fhall fhew hereafter. DCCC XIX. Having thus confidered the firft part of the charadter of the phthifis pulmonalis as a mark of an ulcération of the lungs ; and having juft now faid, that the other part of the charadter, that is, the hedtic fever, is a mark of the famé, it is proper now to confider this herc, as I had omitted it before (LXXVL). DCCCXX. A hedtic fever has the form of a rémittent, which has exacerbations twice every day. The firft of thefe occurs about noon, fometimes a little fooner or later ; and a flight remiffion of it happens about five afternoon. This is foon fucceeded by another exacerbation, gradually in- creafing, till after midnight ; but, after two o'clock of the morning, a remiffion takes place, which becomes more and more confiderable as the morning advances. The exacerbations are frequently attended with fome degree of cold fhivering, or, at leaft, the patient is ex- ceedingly O F P H Y S I C. 301 ceedingly fenfible to any coolnefs of the air, feeks ex- ternal heat, and often complains of a fenfe of cold, when, to the thermometer, his fkin is pieternaturally warm. Of thefe exacerbations, that of the evening is always the moft confiderable. DCCCXXI. It has commonly been given as a part of the charadter of a hedtic fever, that am exacerbation of it commonly appears after the taking in of food ; and it is true that dinner, which is taken at noon, or after it, does feem to occafion fome exacerbation. But this muft not make us judge the mid-day exacerbation to be the effedt of çating only ; for I have often obferved it to come on an hour before noon, and often fome hours before dinner, which, in this country now, is not taken till fome time after noon. It is, indeed, to be obferved, that, in al- moft every perfon, the taking in of food occafions fome degree of fever ; but I am perfuaded this would not appear fo confiderable in a hedtic, were it not that an exacerbation of fever is prefent from another caufe, and accordingly the taking in of food in the morning has hardly any fenfible effedt. DCCCXXII. We have thus defcribed the gênerai form of hedtic fevar, but many circumftances attending it are further to be taken notice of. The fever we have defcribed does commonly not fub- fift long, till the evening exacerbations become attended with fweatings, which continue to recur, and to prove more and more profuie, through the whole courfe of the difeafe. Almoft from the firft appearance of the hedtic, the urine is high coloured, and depofites a copious branny red fediment, which hardly ever falls clofe to the bottom of the veflèl. In the hedtic, the appetite for food is generally lefs impaired than in any other kind of fever. The thirft is feldom confiderable ; the mouth is commonly moift ; and, as the difeafe advances, the tongue becomes free from ail fur, appears very clean, 302 PRACTICE and, in the advanced ftages of the difeafe, the tongue and fauces appear to be fomewhat inflamed, and become more or lefs covered with aphthae. As the difeafe ad- vances, the red veffels of the adnata of the eye difappear, and the whole of the adnata becomes of a pearly white. The face is commonly pale ; but, during the exacer- bations, a florid red, and an almoft circumfcribed fpot, appear on the cheeks. For fome time, in the courfe of a hedtic, the belly is bound ; but, in the advanced ftages of it, a diarrhœa almoft always comes on, and continues to recur frequently fluring the reft of the dif- eafe, alternating in fome meafure with the fweatings mentioned above. The difeafe is always attended with a debility, which gradually increafes during the courfe of it. During the famé courfe, an emaciation takes place, and goes to a greater degree than in almoft any other cafe. The falling off of the hairs, and the adunque formof the nails, are alfo fymptoms of the lofs of nou- rifhment. Towards the end of the difeafe, the feet are often affected with cedematous fwellings. The exacer- bations of the fever are feldom attended with any head- ach, and fcarcely ever with delirium. The fenfes and judgment commonly remain entire to the very end of the difeafe ; and the mind, for the moft part, is confident, and full of hope. Some days before death, a delirium comes on, and commonly continues to the end. DCCCXXIII. The heaic fever now defcribed, (DCCCXXI. DCCCXXII.) as accompanying a purulent ftate of the lungs, is perhaps the cafe in which it moft frequently appears ; but I have never feen it in any cafe, when there was not evidently, or when I had not ground to fuppofe, there was a permanent purulency or ulcération in fome external or internai part. It was for this reafon that, in (LXXVI.) I concluded it to be a fymptomatic fever only. It appears to me to be always the effedt of an acrimony abforbed from abfceflès or ulcers ; but it is not equally the effedt of every fort of acrimony ; for the fcorbutic and cancerous often fubfift long in the body without producing a hectic. What is the precife ftate O F P H Y S I C. 303 ftate of the acrimony prodocing this, I cannot dé- termine, but it feems to be chiefly that of a vitiated purulency. DCCC XXIV. However this may be, it appears that the hedtic's depending in gênerai upon an acrimony, explains its peculiar circumftances. The fébrile ftate feems to be chiefly an exacerbation of that frequency of the pulfe, which occurs twice every day to perfons in health, and may be produced by acrimony alone. Thefe exacer- bations, indeed, do not happen without the proper cir- cumftances of pyrexia ; but, the fpafm of the extrême veffels in a hedtic does not feem to be fo confiderable as in other fevers ; and hence the ftate of fweat and urine which appear fo early and fo conftantly in hedtics. Upon the famé fuppofition, of an acrimony corrupting the fluids, and debilitating the moving powers, we think that moft of the other fymptoms may alfo be explained. DCCCXXV. Having thus confidered the charadteriftical fymptoms, and chief part of the proximate caufe of the phthifis pulmonalis, we proceed to obferve, that an ulcer of the lungs, and its concomitant circumftances of hedtic fever, may again arife from différent previous affections of the lungs j ail of which, however, as wejudge, .may be referred to five heads, that is, 1. To a hemoptyfis, 2. To a fuppuration of the lungs, in confequence of pneumonia, 3. To a catarrh, 4. To an afthma, or, 5. Toatubercle. Thefe feveral affections, as caufes of ulcers, we fhall now confider in the order mentioned. DCCCXXVI. It has been commonly fuppofed, that a hemoptyfis was naturally, and almoft neceffarily, followed by an ulcer of the lungs ; but we prefume to fay, that, in gênerai, this is a miftake ; for we have feen many in- ances of a hemoptyfis occafioned by external violence, without 304 PRACTICE without being followed by any ulcer of the lungs ; and we have alfo feen many inftances of hemoptyfis from an internai caufe, without any confequent ulcération. And this, not only when the hemoptyfis happened to young perfons, and recurred for feveral times, but when it has often recurred during the courfe of a long life ; and itis eafy to conceive that a rupture of the veflèls of the lungs, like that of the veffels of the nofe, may be often healed, as the furgeons fpeak, by the firft intention. It is probable, therefore, that it is a hemoptyfis in par- ticular circumftances only, which is neceffarily followed by x an ulcer ; but what thefe circumftances are it is difficult to détermine. It is poffible, that mcrely the degree of rupture, or frequently repeated rupture, pre- venting the wound to heal by the firft intention, may occafion an ulcer ; or it is poffible that red blood effufed, and not brought up entirely by coughing, may, by ftag- nating in the bronchiae, become acrid, and erode the parts. Thefe, however, are but fuppofitions, not fup- ported by any clear évidence. And, if we confider that thofe cafés of hemoptyfis which follow the predif- pofition (DCCXCVL—DCCXCVIII.) are thefe efpecially which end in a phthifis, we fhall be led to fufpedt that fome other circumftances concur hère to détermine the confequences of hemoptyfis, as we fhall hereafter endeavour to fhew. DCCCXXVIL Any fuppofition, however, wecan make, with refpedt to the innocence of a hemoptyfis, muft not fuperfede the meafures propofed above for the cure of it ; both becaufe we cannot certainly forefee what may be the confe- quences of fuch an accident, and becaufe the meafures propofed are fafe, as, upon every fuppofition, it is a diathefis phlogiftica, which may urge on every bad con- fequence that can be apprehended. DCCCXXVIIL The fécond caufe of an ulcération of the lungs to be confidered, is a fuppuration formed in confequence of pneumonia ; O F P H Y S I C. 305 pneumonia ; and we have referved for this place, though perhaps not very properly, to explain upon what oc- cafion, and with what fymptoms, this fuppuration occurs. DCCCXXIX. " When a pneumonia, with fymptoms neither very vi- olent, nor very flight, has continued for many days, it is to be feared it will end in a fuppuration; but this is not to be determined by the number of days ; for, not only after the fourth, but even after the tenth day, there have been examples of a pneumonia ending by a refolution 3 and, if the difeafe has fuffered fome intermiflion, and again recurred, there may be inftances of a refolution happening at a much later period from the beginning of the difeafe, than that juft nôw mentioned. DCCCXXX, But, if a moderate difeafe, in fpite of proper remé- dies employed, be protradted to the fourteenth day, without any confiderable remiffion, a fuppuration is pretty certainly to be expedted ; and it will be more certain ftill, if no figns of refolution have appeared, or if an expectoration which had appeared, fhall have again ceafed, and the difficulty of breathing has continued or increafed, while the other fymptoms have been rather abated. DCCCXXXL ' That, in a pneumonia, the effufion is made, which may lay the foundation of a fuppuration, we conclude from the difficulty of breathing becoming greater when the patient is in a horizontal pofture, or when the pa- tient can lie more eafily on the affected fide. DCCCXXXII. That, in fuch eafes, a fuppuration has adtually be- gun, we conclude from the patient's being frequently Q_ q affedted 306 PRACTICE affedted with flight cold fhiverings, and with a fenfe of cold felt fometimes in one, fometimes in another part of the body. We form the famé conclufion alfo from the ftate of the pulfe, which is commonly lefs fréquent and fofter, but fometimes quicker than before. dcccxxxiii. That a fuppuration is already formed, we conclude from there being a confiderable remiffion of the pain which had before fubfifted, while, at the famé tiene, the cough, and efpecially the dyfpnœa, continue, and are rather increafed. At the famé time the frequency of the pulfe is rather increafed, the feverifh ftate fuffers con- fiderable exacerbations every evening, and, by degrees, a hedtic, in ail its circumftances, comes to be formed. DCCCXXXIV. In this ftate of fymptoms, we conclude very confi- dently, that an abfcefs, or, as it is called, a vomica, is formed in fome part of the pleura, and moft frequently in that portion of it invefting the lungs. Hère purulent matter frequently remains for fome time, as if inclofed in a cyft ; but commonly not long, before it comes to be either abforbed, and transferred to fome other part of the body, or breaks through into the cavity of the lungs, or into that of the thorax. In the latter cafe, it produces the difeafe called empyema ; but it is when the matter is poured into the cavity of the bronchiae that it properly conftitutes the phthifis pulmonalis. In the cafeof empyema, the chief circumftances of a phthifis are indeed alfo prefent; but we fhall hère confider only that cafe in which the abfcefs of the lungs gives oc- cafion to a purulent expectoration. DCCCXXXV. An abfcefs of the lungs, in confequence of pneu- monia, is not always followed by a phthifis ; for fome- times a hedtic fever is not formed ; the matter poured into the bronchiae is a proper and benign pus, which frequeruly OF PHYSIC. 3°7 frequently is coughed up very readily, and fpit out; and, though this purulent expedtoration fhould continue for fome time, if it be without hedtic, the ulcer foon heals, and every morbid fymptom difappears. This has fo frequently happened, that we may conclude, that neither the accefs of the air, nor the confiant motion of the lungs, will prevent an ulcer of thefe parts from healing, if the matter of it be well conditioned. An abfcefs of the lungs, therefore, does not neceffarily produce the phthifis pulmonalis ; and, if it is followed by fuch a difeafe, it muft be in confequence of particular circumftances which corrupt the purulent matter pro- duced, render it unfuitable to the healing of the ulcer, and, at the famé time, make it afford an acrimony, v which, abforbed, produces a hedtic, and its confe- quences. DCCCXXXVI. The corruption of the matter of fuch abfceffes may be owing to feveral caufes, as, i. That the matter ef- fufed, during the inflammation had not been a pure ferum fit to be converted into a laudable pus, but had been joined with other matters which prevented that, and gave a confiderable acrimony to the whole : Or, 2. That the matter effufed, and converted into pus, merely by long ftagnation in a vomica, or by its connection with an empyema, had been fo corrupted, as to become unfit for the purpofe of pus, in the healing of the ulcer. Thefe feem to be poffible caufes of the corruption of matter in abfceffes, fo as to make it the occafion of a phthifis in perfons otherwife found ; but, it is probable that a pneumonie abfcefs efpecially produces phthifis when it happens to perfons previoufly difpofed to that difeafe, and therefore only as concurring with fome other caufes of it. DCCCXXXVII. 2 The third caufe fuppofed to produce a phthifis is a "' catarrh, which, in many cafés, feems, in length of time, to have the expedtoration of mucus proper to it, gradually 308 PRACTICE gradually changed to an expectoration of pus ; and, at the famé time, by the addition of a hedtic fever, the difeafe, which was at firft a pure catarrh, is changed into a phthifis. But this fuppofition is not eafily to be admitted. The catarrh is properly an affection'of the mucous glands of the trachea and bronchiae analogous to the coryza, and lefs violent kinds of cynanche ton- fillaris, which very feldom end in fuppuration. And, although a catarrh fhould be difpofed to do fo, the ulcer produced might readily heal up, as it does in the cafe of a cynanche tonfillaris ; and therefore fhould not produce a phthifis. DCCCXXXVIII. Further, the catarrh, as purely the effedt of cold, is generally a mild difeafe, as well as of fhort duration ; and there are, at moft, but very few cafés of the nu- merous inftances of it, which can be faid to have ended in a phthifis. In ail thefe cafés in which this feems to have happened, it is to me probable that the perfons affedted were peculiarly predifpofed to phthifis. And the beginning of phthifis fo often refembles a catarrh, that it may have been miftaken for fuch a difeafe. It often happens alfo, to increafe the fallacy, that the application of cold, which is the moft fréquent caufe of catarrh, is alfo frequently the exciting caufe of the cough, which proves to be the beginning of a phthifis. DCCCXXXIX. It is to me, therefore? probable, that a catarrh is very feldom the foundation of a phthifis ; but I would not pofitively affert that it never is fo ; for it is poffible that the cafés of more violent catarrh may have a pneumonie affedtion joined with them, which may end in a fup- puration ; or it may happen that a long continued ca- tarrh, by the violent agitation of the lungs in coughing, fhall produce fome of thefe tubercles which we are pre- fently to mention as the moft fréquent caufe of phthifis. DCCCXL. O F P H Y S I C. 309 DCCCXL. We would have it particularly to be obferved hère, that nothing we have faid in (DCCCXXXIX.) fhould allow us to negledt any appearance of catarrh, as is too frequently done ; for it may be either the beginning of a phthifis, which they miftake for a genuine catarrh, or that, even as a catarrh, continuing long, it may produce a phthifis, as in (DCCCXXXIX.) DCCCXLI. Many phyficians have fuppofed that an acrimony of the fluids eroding fome of the veffels of the lungs is a fréquent caufe of ulcération and phthifis ; but this ap- pears to me to be a mère fuppofition ; for, in any of the inftances of the production of the phthifis which I have feen, there was no évidence of any acrimony of the blood capable of eroding the veffels. It is true, in- deed, that, in many cafés, an acrimony fubfifting in fome part of the fluids is the caufe of the difeafe ; but it is, at the famé time, probable, that this acrimony opérâtes", by producing tubercles, rather than by any direct erofion. DCCCXLII. I have faid (DCCCXXV.) that an afthma may be confidered as one of the caufes of phthifis ; and, by afthma, I mean that fpecies which has been commonly named the fpafmodic. This difeafe frequently fubfifts very long without producing any other, and may have its own peculiar fatal termination, as we fhall explain hereafter. But I have feen it frequently end in a phthifis ; and, in fuch cafés, I fuppofe that it opérâtes in the manner I have alleged of catarrh, that is, by producing tubercles, and their confequences, which (hall be prefently mentioned. DCCCXLIIL 3io PRACTICE DCCCXLIII. We are now come to confider the fifth head of the caufes of phthifis, and which we fuppofe to be the moft fréquent of any. This we have faid, in gênerai, to be tubercles ; and, by this term, we mean certain fmall tumours, which have the appearance of indurated glands. Diffedtions have frequently fhewn fuch tu- bercles formed in the lungs ; and we fuppofe them to be at firft indolent, but, at length, they become in- flamed, and are thereby changed into little abfceffes, or vomicae, which breaking, and pouring their matter into the bronchiae, give a purulent expectoration, and thus lay the foundation of a phthifis. DCCCLXIV. Though the matter expedtorated on thefe occafions has the appearance of a pus, it is feldom that of a laudable kind ; and, as the ulcers do not readily heal, but are attended with a hedtic fever, for the moft part ending fatally, we prefume that the matter of the ulcers is imbued with a peculiarly noxious acrimony, which prevents their healing, and produces a phthifis, in ail its circumftances, as mentioned above. DCCCXLV. It is very probable that the acrimony, which thus difeovers itfelf in the ulcers, exifled before, and pro- duced the tubercles themfelves ; and itis to this acrimony that we muft trace up the caufe of the phthifis following thefe tubercles. This acrimony is probably in diffèrent cafés of différent kinds, and it will not be eafy to dé- termine its varieties ; but, to a certain length, we fhall attempt it. DCCCXLVL In one cafe, and a very fréquent one, of phthifis, it appears that the noxious acrimony is of the famé kind with O F P H Y S I C. 3" with that which prevails in the fcrophula. We con- clude this from obferving, that a phthifis, at its ufual periods, frequently attacks perfons who had been born of fcrophulous parents, that is, of parents who had been affedted with fcrophuja in their younger years ; that, very often, when the phthifis appears, there occur at the famé time fome lymphatic tumours in the external parts ; and very often I have found the tabès mefen- terica, which i* a fcrophulous affection, joined with the phthifis pulmonalis. To ail this I would add, that, even when no fcrophulous affection has either manifeftly preceded or accompanied a phthifis, this laft, however, moft commonly affedts perfons of a habit refembling the fcrophulous, that is, perfons of a fanguine, or a fan- guineo-melancholic tempérament, who have very fine fkins, rofy complexions-, large veins, and foft flefh ; and further, that in fuch perfons the phthifis comes on in the famé manner, as we fhall explain immediately, it does in perfons having tubercles. DCCCXLVIL Another fpecies of acrimony producing tubercles of the lungs, and thereby phthifis, may be faid to be the exanthematic. It is well known that the fmall-pox fome- times, and more frequently the meafles, lay the foun- dation of a phthifis. It is probable, alfo, that other exanthemata have the famé effedt ; and, from the phe- nomena of the difeafe, and the diffedtions of perfons who have died of it, it is probable that ail the exan- themata occafion a phthifis, by affording a matter which, in the firft place, produces tubercles. DCCCXLVIIL Another acrimony, which feems fometimes to produce a phthifis, is the ftphylitic ; but whether fuch an acri- mony produces phthifis in any other perfons than the previoufly difpofed, does not appear to me certain. DCCCXLIX. 312 PRACTICE DCCCXLIX. What other fpecies of acrimony, as from fcurvy, from pus abforbed from other parts of the body, from fup- preffed éruptions, or from other fources, may alfo pro- duce tubercles and phthifis, we cannot now décide, but muft leave it to be determined by perfons who have had expérience of fuch eafes. DCCCL. There is one peculiar cafe of phthifis, which, from our own expérience, we can take notice of. This is the cafe of phthifis from a calcareous matter formed in the lungs, and coughed up, frequently with a little blood, fometimes with mucus only, and fometimes with pus. How this matter is generated, or in what part of the lungs precifely it is feated, I acknowledge myfelf ig- norant. In three cafés of this kind which have oc- curred to me, there was, at the famé time, no appearance of ftony or earthy concrétions in any other part of the body. In one of thefe cafés, an exquifitely formed phthifis came on, and proved mortal ; while, in the other two, the fymptoms of phthifis were never fully formed, and, after fome time, merely by a milk diet, and avoiding irritation, the patients entirely recovered. DCCCLI. Another foundation for phthifis, analogous, as I judge, to that of tubercles, is that which occurs to certain artificers, whofe employments keep them almoft conftantly expofed to duft, fuch as ftone-cutters, millers, flax-dreffers, and fome others. We have not obferved, in this country, many cafés of phthifis which could be referred to this caufe ; but, from Ramazzini, Mor- gagni, and fome other writers, we muft conclude fuch cafés to be more fréquent in the fouthern parts of Europe. DCCCLIL O F P H Y S I C. 3*3 DCCCLII. Befides thefe now mentioned, there are probably fome other caufes producing tubercles, which have not yet been afcertained by obfervation j and there is probably, in the ftate of tubercles, a variety not yet accounted for; but ail this we muft leave to future obfervation and inquiry. DCCCLIII. It has been frequently fuppofed by phyficians, that the phthifis is a contagious difeafe, and I dare not affert that it never is contagious ; but, in many hundred in- ftances of the difeafe which I have feen, there has been hardly one I could judge tohave arifen from contagion. It is poffible that, in warmer climates, the effects of contagion may more readily appear. After having faid that a phthifis arifes from tubercles more frequently than from any other caufe, and after having attempted to affign the variety of thefe, I now proceed to mention the peculiar circumftances and fym- ptoms which ufually accompany the coming on of the difeafe from tubercles. DCCCLIV. A tuberculous and purulent ftate of the lungs has been obferved in very young children, and in fome others, at feveral diffèrent periods, before the âge of puberty and full growth ; but inftances of this kind are rare ; and the attack of a phthifis, which we have reafon to impute to tubercles, ufually happens at the famé period which we have affigned for the coming on of the he- moptyfis. DCCCLV. The phthifis from tubercles does alfo generally affect the famé habits as the hemoptyfis does, that is, perfons Of a flender make, of long necks, narrow chefts, and R r prominent 3H PRACTICE prominent fhoulders ; but very frequently the perfons liable to tubercles have lefs of the florid countenance, and of the other marks of an exquifitely fanguine tem- pérament, than the perfons liable to hemoptyfis. DCCCLVI. This difeafe, arifing from tubercles, ufually com- mences with a flight and fhort cough, which becoming habituai, is often little remarked by the perfons affected, and fometimes fo little as to be abfolutely denied by them. At the famé time, their breathing becomes eafily hurried by any bodily motion, their body grows leaner, and they become languid and indolent. This ftate fometimes continues for a year, or even for two years, without the perfon's making any complaint of it, excepting only that they are affedted by cold more readily than ufual, which frequently increafes their cough, and pro- duces fome catarrh. Thi^ again, however, is fome- times relieved, is fuppofed to have arifen from cold alone, and therefore gives no alaim either to the pa- tient, or to his friends, nor leads^ thçra tt**take any précautions. .». v DCCCLVIL Upon one or other of thefe occafions of catching cold, as we commonly fpeak, the cough becomes more confiderable, is particularly troublefome upon the pa- tient's lying down at night, and, in this ftate, continues longer than is ufual in the cafe of a fimple catarrh. This is more efpecially to call for attention, if the in- creafe and continuance of cough come on during the fummer feafon. DCCCLVI1I. The cough, which comes on as in (DCCCLVI.), is very often for a long time without any expectoration ; but, on the occafions, as in (DCCCLVIL), when it grows more confiant, it cornes to be, at the famé time, attended with an expedtoration, which is moft confi-, derable O F P H Y S I C. 3i5 derable in the mornings. The matter of this expedto- ration becomes, by degrees", more copious, more vifcid, and more opake ; at length of a yellow or greenifh co- lour, and of a purulent appearance. Thé whole of the matter, however, is not always. atsonce entirely changed in the manner now mentioned'; but, while ône part of it retains the ufual form of mucus, another fuffers the changes we have defcribed. DCCCLIX. When the «ough increafes, and continues very fré- quent through the night, and when the matter ex- pedtorated undergoes the changes we have mentioned, the breathing, at the famé time, becomes more difficult, and the emaciation and weaknefs go on alfo.increafing. In the female fex, according as the difeafe advances, and fometimes early in its progrefs, the menfes ceafe to flow ; and this circumftance we confider as commonly the ef- fedt of the difeafe, although the fex themfelves, are ready to believe it to be the foie caufe of the diforder. DCCCLX. When the cough comes on as in (DCCCLVI.), the pulfe is often natural, and, for fome time after, con- tinues to be fo ; but the fymptoms have feldom fubfifted long before the pulfe becomes fréquent, and fometimes to a confiderable degree, without much of the other fymptoms of fever ; but, at length, evening exacer- bations become remarkable, and, by degrees, the fever affumes the exquifite form of hedtic, as defcribed in (DCCCXX.—DCCCXXIL). DCCCLXI. . It is feldom that the cough, expectoration, and fever, go on increafing, in the manner we have defcribed, without fome pain being felt in fome part of the thorax. It is ufually, and moft frequently, felt at firft under the fternum, and that efpecially, or almoft only, upon oc- safion of coughing ; but very often, and that too, early in 316 PRACTICE in the courfe of the difeafe, a pain is felt on one fide, fometimes very conftantly, and fo as to prevent the perfon from lying eafily upon that fide ; but at other times the pain is felt only upon a full breathing, or upon coughing. Even when no pain is felt, it generally happens that phthifical perfons cannot lie eafily on one or other fide, without having their difficulty of breathing increafed, and their cough excited. DCCCLXII. The phthifis begins, and fometimes proceeds to its fatal iflue, in the manner defcribed in (DCCCLVI.-— DCCCLXL), without any appearance of hemoptyfis. Such eafes are, indeed, rare; but it i s very common for the difeafe to advance very far, and even to an évident purulency and hedtic ftate, without any appearance of blood in the fpittirrg ; fo that it may be affirmed, the difeafe is frequently not founded in hemoptyfis. At the famé time, we muft allow not only that it fometimes begins with a hemoptyfis, as faid in (DCCCXIV.), but farther, that it feldom happens that, in the progrefs of the difeafe, more or lefs of a hemoptyfis does not appear. Some degree of blood-fpitting does, indeed, appear fometimes in the ftate mentioned (DCCCLVI, DCCCLVIL), but more commonly in the more ad- vanced ftages of the difeafe only, and, particularly, upon the firft appearance of purulency. However this may be, in the phthifis from tubercles, it i s feldom that the hemoptyfis is confiderable, or requires any remédies différent from thofe which are otherways neceffary for the ftate of the tubercles. DCCCLXIII. We have now defcribed a fucceffion of fymptoms which, in diffèrent cafés, occupies more or Jefs time. In this climate, it very often takes up fome years, the fymptoms appearing efpecially in the winter and fpring, commonly becoming eafier, and fometimes almoft dif- appearihg, during the fummer; but returning again in winter, O F P H Y S I C. 3^7 winter, they at length, after two or three years, prove fatal, towards the end of fpring, or beginning of fummer. DCCCLXIV. In this difeafe, the prognofis is for the moft part un- favourable. Of thofe affedted with it, the greater num- ber generally die ; but there are alfo many of them who recover entirely, after having been in very unpromifing circumftances. What are, however, the circumftances, more certainly determining to a happy or to a fatal event, I have not yet been able to afcertain. DCCCLXV. The following aphorifms are the refult of my ob- fervations. A phthifis pulmonalis from hemoptyfis, is more fre- quently recovered than one from tubercles. A hemoptyfis is not only not always followed by a phthifis, as we have faid above, (DCCCXXVI.) but, even when followed by an ulcération, the ulcération is fometimes attended with little of hedtic, and frequently admits of being foon healed. Even when the hemoptyfis and ulcération have happened to be repeated, we have had inftances of perfons recovering entirely after feveral fuch répétitions. A phthifis from a fuppuration in confequence of pneumonie inflammation, is that which moft rarely oc- curs in this climate; and a phthifis dues not always follow fuch a fuppuration, when the abfcefs formed foon breaks and difeharges a laudable pus ; but, if the abfcefs continues long fhut up, and till after a con- fiderable degree of hedtic has been formed, a phthifis is then produced, equally dangerous as that from other caufes. A phthifis from tubercles has, I think, been re- covered ; but it is of ail others the moft dangerous, and when arifing from a hereditary taint, is almoft certainly 3i8 PRACTICE The danger of a phthifis, from whatever caufe it may have arifen, is moft certainly to be judged of by the degree to which the hedtic and its confequences have arrived. From a certain degree of emaciation, debility, profufe fweating, and diarrhœa, no perfon recovers. A mania coming on has been found to remove ail the fymptoms, and fometimes has entirely cured the difeafe; but, in other cafés, upon the going off of the mania, the phthifis has recurred, and proved fatal. The pregnancy of women has often retarded the pro- grefs of a phthifis ; but commonly it is only till after delivery, when the fymptoms of phthifis return with violence, and foon prove fatal. SECT. II. Of the CURE of P H T H I S I S. DCCCLXVI. From what has been juft now faid, it will readily appear, that the cure of the phthifis pulmonalis is ex- ceedingly difficult, and that the utmoft care and at- tention in the employment of remédies have feldom fuc- ceeded. It may be doubtful whether this failure is to be imputed to the imperfection of our art, or to the abfolutely incurable nature of the difeafe. I am extremely averfe in any cafe to admit of the latter fuppofition, and can al- ways readily allow of the former ; but, in the mean time, we muft mention hère what has been attempted towards curing or moderating the violence of this difeafe. DCCCLXVII. It will be ohvious, that, according to the diffèrent circumftances of this difeafe, the method of cure muft be O F P H Y S I C. 3*9 be diffèrent. Our firft attention fhould be employed in watching the approach of the difeafe, and preventing its v proceeding to an incurable ftate. In ail perfons of a phthifical habit, and efpecially in thofe born of phthifical parents, the flighteft fymptoms of the approach of phthifis, at the phthifical period of life, ought to be attended to. DCCCLXVIH. When a hemoptyfis occurs, though it be not always followed by ulcération and phthifis ; thefe, however, are always to be apprehended ; and every précaution is to be taken againft them. This is efpecially to be done by employ ing every means of moderating the he- morrhagy, and of preventing the return of it, as di- redted in (DCCCX. et feq.) ; and thefe précautions are always to be continued for feveral years after the oc- currence of the hemoptyfis. DCCCLXIX. The phthifis which follows a fuppuration from pneumonie inflammation, can only be prevented with certainty by obtaininga refolution of fuch inflammation, What may be attempted towards the cure of an abfcefs and ulcer which have taken place, we fhall confider afterwards. DCCCLXX. We have faid, it is doubtful if a genuine catarrh ever produces a phthifis ; but we have allowed that it poffibly may, and both upon this account, and upon account of the ambiguity which may arife, whether the appearing catarrh be a primary difeafe, or the effedt of a tubercle, we confider it as .of the utmoft confequence to euffe a catarrh as foon as poffible after its firft appearance. And more efpecially when it fhall linger, and continue for fome time, or fhall, after fome intermiflion, fre- quently return, the cure of it fhould be diligently at- tempted. The meafures requifite for this purpofe fhall be 320 PRACTICE be mentioned afterwards, when we come to treat of catarrh as a primary difeafe ; and, in the mean time, the means neceffary for preventing its producing a phthifis, we fhall mention immediately, as they are the famé with thofe we fhall point out, as neceffary for preventing a phthifis from tubercles. DCCCLXXL The preventing of a phthifis from afthma muft be by curing, if poffible, the afthma, or, at leaft, by mo- derating it as much as may be done ; and, as it is pro- bable that afthma occafions phthifis, by producing tubercles, the meafures neceffary for preventing phthifis from afthma, will be the famé with thofe neceffary in the cafe of tubercles, which we are now about to men- tion. DCCCLXXIL We confider tubercles as by much the moft fréquent caufe of phthifis ; and even in many cafés, where this feems to dépend on hemoptyfis, catarrh, or afthma, it does, however, truly arife from tubercles. It is upon this fubjedt, therefore, that I fhall have occafion to treat of the meafures moft commonly requifite for curing phthifis. DCCCLXXIII. When, in a perfon born of phthifical parents, of a phthifical habit, at the phthifical period of life, the fym- ptoms, in the fpring, or beginning of fummer, (DCCCLVI.) fhall appear in the flighteft degree, we may prefume that a tubercle, or tubercles, have been formed or are forming in the lungs, and therefore, that every means that we can devife for preventing their for- mation, or for procuring their refolution, fhould be em- ployed immediately, though the patient himfelf fhould overlook or negledt the fymptoms, as imputing them to accidentai cold. DCCCLXXIV. OF PHYSIC. 32l DCCCLXXIV. Thisis certainly the gênerai indication; but how it can be executed 1 cannot readily fay. I do not know that, at any time, phyficians have propofed any remedy capable of interrupting the formation of tubercles, or of refolving them when formed. The analogy of fcro- phula gives no affiftance on this fubjedt. In fcrophula the remedy feemingly of moft power is fea-water, or certain minerai waters; but thefe have generally proved hurtful in the cafe of tubercles of the lungs. I have known feveral inftances of mercury very fully employed . for certain difeafes, at a time when it was to be fufpedted, that tubercles were formed, or forming in the lungs ; but, though the mercury proved a cure for thofe other difeafes, it was of no fervice in preventing a phthifis ; and, in fome eafes, it feemed to hurry jt on. DCCCLXXV, Such appears to me to be the prefent ftate of our art with refpedt to the cure of tubercles ; but I do not de- fpere of a remedy for the purpofe being found hereafter. In the mean time, ail that at prefent feems to be within the reach of our art, is to take the meafures proper for avoiding the inflammation of tubercles. It is probable that tubercles may fubfift long without producing any diforder ; and I am difpofed to think, that nature fome- times refolves and difeuffes tubercles which have been formel, but that nature does this only while the tu- bercles remain in an uninflamed ftate ; and, therefore, that, in the cafe of tubercles, the meafures neceffary are chiefly thofe for avoiding the inflammation of them. DCCCLXXVI. The inflammation of a tubercle of the lungs is to be avoided upon the gênerai plan of avoiding inflammation, by blood-letting, and by an antiphlogiftic regimen, the chief part of which, in this cafe, is the ufeof a low diet, This fuppofes a total abftinence from animal S s food, 322 PRACTICE food, and the ufing of vegetable food almoft alone ; but it has been found that it is not neceffary for the patient to be confined to vegetables of the \veakeft nourifhment, but that it is enough the farinacea be employed, and, together with .thefe, milk. DCCCLXXVIL Milk has been generally confidered as the chief remedy in phthifis, and in the cafe of every tendency to it ; but, whether from its peculiar qualities, or from its being of a lower quality, with refpect to nourifhment, than any food entirely animal, is not certainly determined. The choice and adminiftration of milk will be properly di- rected, by confidering the nature of the milk of the feveral animais from which it may be taken, and the particular ftate of the patient, with refpect to the period and circumftances of the difeafe, and to the habits of his ftomach, with refpedt to milk. DCCCLXXVIII. A fécond means of preventing jhe inflammation of tlîe tubercles of the lungs, is, by avoiding'any par- ticular irritation of the affected part, which may arife from any violent exercife of refpiration ; from any con- fiderable degree of bodily exercife ; from any pofition of the body which ftraiténs the capàcity of the thorax ; and, laftly, from c O F P H Y S I C. 3*5 is, the employment of means for moderating inflam- mation, which we have already mentioned (DCCC- LXXVI. et feq.) DCCCLXXXV. The balfamics, whether natural or artificial, which have been fo commonly advifed in cafés of phthifis, ap- pear to me to have been propofed upon no good ground, and commonly to have proved hurtful. The refinous and acrid fubftance of myrrh lately recommended, has not appeared to me to be of any fervice, and, in fome cafés, to have proved hurtful. DCCCLXXXVI. Mercury, fo often ufeful in healing ulcers, has been fpecioufly enough propofed in this cafe ; but whether that it bé not adapted to the particular nature of the ulcers of the lungs occurring in phthifis, or that be- caufe it cannot have effedt hère, without exciting fuch an inflammatory ftate of the whole fyftem, as, in a hedtic ftate, proves very hurtful, I cannot détermine. Upon many trials which I have •feen made, ithas proved of no fervice, and commonly has appeared to be ma- nifeftly pernicious. DCCCXXXVII. The Peruvian bark has been recommended for feveral purpofes in phthifical eafes ; and is faid, on fome oc- cafions, to have been ufeful ; but I have feldom found it to be fo ; and as, by its tonic power, it increafes the phlogiftic diathefis of The fyftem, I have frequently found it hurtful. In fome cafés, where the morning remiflions of the fever were confiderable, and the noon exacerbations well marked, I have known the Peruvian bark given in large quantities, with the effedt of ftopping thefe exacerbations, and, at the famé time, of relieving the whole of the phthifical fymptoms ; but, in thefe cafés, the fever fhewed a confiant tendency to recur ; 326 PRACTICE and at length the phthifical fymptoms alfo returned, and proved quickly fatal. DCCCLXXXVIII. As antifej)tic and réfrigérant, acids of ail kinds are ufeful in cafés of phthifis ; but the native acid of ve- getables is more ufeful than the foflil, as it can be given in much larger quantifies, and more fafely than vinegar, being lefs liable to excite coughing. DCCCLXXXlX. Though our art can do fo little towards the cure of this difeafe, we muft, however, palliate the uneafy fym- ptoms of it as well as we can. The fymptoms efpecially urgent are the cough and diarrhœa. The cough may be in fome meafure relieved by demulcents, (DCXXVIII) but the relief obtained by thefe is imperfedt and tranfi- tory, and very often the ftomach is difturbed by the quantity of oily, mucilaginous, and fweet fubftances, which are on thefe occafions taken into it. DCCCXC. The only certain means of relieving the cough, is by employing opiates. Thefe, indeed, certainly increafe the phlogiftic diathefis of the fyftem, but commonly they do not fo much harm in this way, as they do fer- vice by quiet'ing the cough, and giving fleep. They are fuppofed to be hurtful, by checking expectoration ; but they do it for a fhort time only ; and after a found fleep, the expectoration in the morning is more eafy than ufual. In the advanced ftate of the difeafe, opiates feem to increafe the fweatings which occur ; but they com- penfate this, by the eafe they afford in a difeafe which cannot be cured. DCCCXCL OF P H Y S I C. 327 DCCCXCL The diarrhœa which happens in the advanced ftate of this difeafe, is to be palliated by moderate aftringents, mucilages, and opiates. Rhubarb, fo commonly prefçribed in every diarrhœa, and ail other purgatives, are extremely pernicious in the colliquative diarrhœa of hedlics. Frefh fubacid fruits, fuppofed to be always laxative, are often in the diarrhœa of hedlics, by their antifeptic quality, very ufeful. Ç H A P., y. Of the HŒMORRHOIS, O R ,.' Of the HEMORRHOIDAL SWELLING and FLUX. SECT. 1*\ > Of the PHENOMENA and CAUSES of the HŒMORRHOIS. DCCCXCII. A difcharge of blood from fmall tumours, on the verge of the anus, is the fymptom which generally con- ftitutes 1 y* PRACTICE ftitutes the hamorrhois, or, as it is vulgarly called, the haemorrhoidal flux. But a difcharge of blood from within the anus, when the blood is of a florid colour, fhewing it to have come from no great diftance, is alfo confidered as the famé difeafe; and phyficians have agreed in making two cafés, or varieties of the famé, under the names of external and internai haemorrhois. DCCCXCIII. In both cafés it is fuppofed, that the flow of blood is from tumours, previoufly formed, which are named haemorhoids or piles ; and it frequently happens, that the tumours exift without any difcharge of blood, in which cafe, however, they are fuppofed to be a part of the famé difeafe, and are, in that cafe, named Hae- morrhoides Czecae, or Blind Piles. DCCCXCIV. Thefe tumours, as they appear without the anus, are fometimes feparate, round, and prominent on the verge of the anus ; but frequently the tumour is only one tumid ring, forming, as it were, the anus pufhed without the body. DCCCXCV. Thefe tumours, and the difcharge of blood from them, fometimes come on as an affedtion purely topical, and without any previous diforder in other parts of the body j but it frequently happens, even before the tumours are formed, and more efpecially before the blood flows, that various diforders are felt in différent parts of the body, as headach, vertigo, ftupor, difficulty of breathing, ficknefs, cholic pains, pain of the back and Joins j and often, together with maie or fewer of thefe fymptoms, there oceurs a confiderable degree of pyrexia. The coming on of the difeafe with thefe fymptoms is ufually attended with a fenfe of fullnefs, heat, itching, and pain, in and about the anus. Sometimes O F P H Y S I C. 329 Sometimes the difeafe is preceded by a difcharge of ferous matter from the anus ; and fometimes this ferous difcharge, accompanied with fome fwelling, feems to be in place of the difcharge of blood, and to relieve the diforders of the fyftem we have mentioned. This fe- rous difcharge, therefore, has been named the Hae- morrhois Alba. DCCCXCVI. In the hîemorrhois, the quantity of blood difcharged is différent, upon différent occafions. Sometimes the blood flows only upon the perfon's going to ftool j and, commonly, in larger or leffer quantity, follows the dif- charge of the faeces. In other cafés, the blood flows without any difcharge of faeces ; and then, generally, in confequence of the previous diforders above men- tioned, when it is alfo commonly in larger quantity. This is often very confiderable ; and, by the répétition, fo great, as we could hardly fuppofe the bodyto bear but with the hazard of life. Indeed, though rarely, it has been fo great as to prove fuddenly fatal. Thefe confiderable difeharges occur efpecially to perfons who have been frequently liable to the T^ • ■?- 'ri . : I