Vi'iVlW 11 •••.'iVi :;:;:::;:::;¥;;:::v::::::v:; 'i'i'i l r.r.'.'.'.Vi •«»,,,,i I ••-:•:•>-.vi NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrke \ X FIRST LINES ,// PRACTICE of PHYSIC. B Y WILLIAM CULLEN, M. D. »< i Profeflbr of the Pra&ice of Phyfic in the Univerfity of Edinburgh | Firft Phylician to his Britannic Majefty fpt Scotland ; Fellow of the Royal College of Pbyficians of Edinburgh ; Of the Royal Societies of London and of Edinburgh, Of the Royal Society of Medicine of Paris, &c. &•:. Sec. A NEW EDITION. From the Laft Bj|itisk Edition, Revised, Corrected and Enlarged, by the Author. IN T H R E E i V O L U M E S; ....', V ol. Il\ <*;.,] ; V^icT. ? ^HM % printed at WORCESTER, Massachusetts, ^ by ISAIAH THOMAS. « Sold at his Bookstore in WORCESTER, and by him and Company in BO S TON. MDCCXC. ^7 >< J CONTENTS of VOL. III. PART II. BOOK III. Page Of SPASMODIC AF- FECTIONS, without FEVER 9. S E CjT. t I. Of the Spasmodic Affections of the Animal Functions - 11 Chap. I. Of Tetanus - - 13 Chap. II. Of Epikpfy - 33 Chap. III. Of the Chorea, or Dance of St. Vitus - - 66 SEC T7\ II, &~ Of the Spasmodic Affections of the Vital Functions - 70 Chap. iv CONTENTS. 4 Page Chap. IV.* +Of the Palpitation of the . Heart - - - 70 Chap. V. Of Dyfpnoza> or Difficult Breathing - - 75 Chap. VI. Of Aflhma - 79 Chap. VII. Of the Chincough, or Hoopingeough - - 94 SECT. III. Of the Spasmodic Affections in the Natural Functions - 109 f Chap. VIII. Of the Pyrofis, or what is named in Scotland the Water Brafh 109 Chap. IX. Of the Colif . 114 P Chap. X. Of the Cholera - 126 0 Chap. XI. Of Diarrhcea> or Loofe- nefs ~ J - " *32 Chap. » Though I have thought it proper to divide this book mto feaions, I think it neceflary, for the convenience of reference?, &$*$ any part of the body. MCCLI. ND^R^this title I am to comprehend all the difeafes which confifl in motu ab- normi ; thatT^finiH^reter- natural Hate of the contrac- tion and motion of the muf- cular or moving fibres in MCCLII. JO PRACTICE MCCLII. It will hence appear, why, under this title, I have comprehended many more difeafes than Sauvages and Sagar have comprehended under the title of Spafmi, or than Linnaeus has done under the title of Motorii. But I ex . pea it will be obvious, that, upon this occa- Con, it would not be proper toconfine our view to the afFeaions of voluntary motion only; and if thofe Nofologifts have introduced into the clafs of Spafmi, Palpitatio and Hyfteria, it will be with e'qpjal propriety that Afthma, Col- ica, and many orfair difeafes, are admitted. MCCLIII. It has been hitherto the method of our No- fologifts to. divide the Spafmi into the two orders of Tonici anti Clonici, Spaftici and Agitatorii; or, as mafW at prefent ufe the terms, into Spafms fltiaiy fo called, and Conyulfions. I find, 'however, that many, and indeed moil of the difeafes to be confid- ered under our title of Spafmodic AfFeaions, in refpea of Tonic or Clonic contraaions, arC °jL? mixj^Xmd : And, therefore, I can- not rttkr^fne ufual general divifion; but have attempted another, by arranging the feveral Spafmodic Difeafes according as they affea the feveral funaions, Animal, Vital, or Natural. ' SECT. OF PHYSIC. it SECT. I. of the SPASMODIC AFFECTIONS of the ANIMAL FUNCTIONS. MCCLIV. Agreeable to the lan- guage of the ancients, the whole of the dif- eafes to be treated of in this fe&iolPmight be termed Spafmi ; and many o^the moderns continue to apply the terrain the fame man- ner : But I think it convenient to diftinguifh the terms of Spafm and Convulfion, by apply- ing the former, ftriaiy{ith ; but they occur moft fre- quently in the wanned climates, and moft commonly in the warmed feafons of fuch climates. Thefe "complaints afFea all ages, fcxes, temperaments, and complexions. The caufes from whence Jhey commonly proceed, Are cold and moifture applied to the body while it is very warm,and efpecially the fudden viciflitudes of heat anc^cold. Or, the difeafe is produced by punaures, lacerations, or oth- er lefions of nerves in ahy part of the body. There are* probably, Jbme other caufes of this difeafe ~, but they* are neither diftinaiy known, nor well ascertained. Though the caufes mentioned do, upon occafion, afFea all forts of perfons, they feem however to attack perfons .©imiddle age more frequently than the older or younger, the male fex more fre- quently than the female, and the robuft and vigorous more frequently than the weaker. MCCLIX-. OF PHYSIC. 15 MCCLIX. , .,4 • If the difeafe proceed from cold, it com- monly comes on in a few days after the ap- plication of fuch cold ; but, if it arife from a punaure or other lefion of a nerve, the difeafe does not commonly come on for many days after the lefion has happened, very often when there is neither pain nor uneafinefs remaining in the wounded or hurt part, and very fre- quently when the wound has been entirely healed up. MCCLX. .*' The difeafe fometimes comes on fuddenly to a violent degree, but more generally it ap- proaches by flow degrees to its violent ftate, In this cafe it comes o# with a fenfe of ftiff- nefs in the back part of the neck, which, grad- ually increasing, renders the motion of the head difficult and panful. As the rigidity of the neck comes on and increafes, there is commonly at the fame time a fenfe of un- eafinefs felt about the root of the tongue; which, by degrees, becomes a difficulty of fwal- lowing, and at length an entire interruption of it. While the rigidity of the Heck goes on in- creafing, there arifes a pain, often violent at the lower end of the fternum, and from thence fhooting into the back. When this pain arifes, all the mufcles of the neck, and partic- B 2 ularly t6 TRA-CTICE -tilarly thofe of the back part of it, are imme- diately affeaed with fpafm, pulling the head ftrongly backwards. At the fame time, the mufcles that pull up the lower jaw, which up- on the firft approaches of the difeafe were af- feaed with fome fpaftic rigidity, are now gen- erally affeaed with more violent fpafm, and *{et the teeth fo clofely together that they do not admit of the fmalleft opening. This is what has been named the Locked Jaw, and is often the principal part of the clifeafe. "Wjien the difeafe has advanced thus far, the pain at the bottom of the fternum re- turns very frequently, and with it the fpafnrs 'of the hind neck andjlower jaw are renewed with violence and much pain. As the difeafe thus proceeds, a greater number of mufcles tome to be affeaed with fpafms. After thofe -of the neck> thofe along the whole of the fpine become affeaed,i tending the trunk of the body ftrongly backwards ; and this is ■what has been named the Opiflhot nos. In the lower extremities, both the flexor and extenfor mufcles are commonly at the fame time affeaed, and keep the limbs rigidly extended. Though the extenfors of the head and back are ufually the moft ftrongly affea- ed, yet the flexors, or thofe mufcles of the neck that pull the head forward, and the mufcles that fliould pull down the lower jaw, ,. are often at the fame time ftrongly affeaed with fpafm. During the whole of the dif- eafe, the abdominal mufcles are violently af- feaed OF P H Y.S I C. *7 feaed with fpafm, fo that the belly is ftrong-r * ly retraaed, and feels, hard as a piece, of board. At length the flexors of the head and trunk become fo ftrongly affeaed as to balance the cxtenfors, and to keep the head* and trunk ftraight, and rigidly extended, ineapable of being moved m any way ;, and* it is to this . ftate the term of Tetanus has been ftri&ly ap- plied. At the fame time, the arms, little af- feaed before,, are now rigidly-extended.; the whole of the mufcie3 belonging to them being affeaed with fpafms, except thofe that move the fingers, which often to the laft retain fome mobility. The tongue/ alfo long retains its mobility i but at- length it alfo becomes af- t feaed with fpafms, wljjch, attacking certain of ' its fnufcles only, often thruft it violently out -between the teeth. At the- height of the difeafe, every organ of voluntary motion feems to be affeaed ; and amongft the reft, the mufcles of the face. The forehead is drawn up into furrows, the eyes, fometimes distorted, are commonly rigid, and immoveable in their fockets ; the nofe is drawn up, and the cheeks are drawn back- wards towards the ears, fo that the whole countenance expreffes the moil violent grin- ning. Under thefe univerfal fpafms, a vio- lent convulfion commonly comes on, and puts an end to life. % .ygr B $ MCCLXXiZ 18 PRACTICE 1;,^/ MCCLXL Thefe fpafms are every where attended with moft violent pains. The utmo-ft vio- lence of fpafm is, however, not conftant ; but, after fubfifting for a minute or two, the muf- cles admit of fome remiffion of their contrac- tion, although of no fuch relaxation as can allow the adtion of their antagonifts. This remiffion of contraaion gives alio fome re- miffion oXpain ; but neither is of long dura- tion. Fronrtime to time, the violent con- traaions and pains are renewed fometimes every ten or fifteen trtinutes, and that often without any evident exciting caufe. But fuch exciting caufes frequently occur ; for almoft every attempt to motion, as attempt-' ing a change of pofture, endeavouring to fwallow, and even to (peak, fometimes gives occafion to a renewal of the fpafms over the whole body. MCCLXII. The attacks of this'difeafe are feldom at- tended with any fever. When the foafms are general and violent, the pulfe is contra ft- ed,jiurried, and irregular; and the refpira- tion is affected in like manner : But, during the remiffion, both the pulfe and refpiration ^fually return to their natural ftate. The heat of the body is commonly not increafed ; frequently OF PHYSIC. 19 frequently the face is pale, with a cold fweat upon it ; and very often the extremities are cold, with a cold fweat over the whole body. \Vhen, howe\rer, the fpafms are frequent and violent, the pulfe is fometimes more full and frequent than natural ; the face is iluihed, and a warm fweat is forced, out over the whole body. MCCLXIIT. Although fever be not a condant attend:*r.t of this difeafe,. efpecially when arifing from.a lefion of nerves ; yet, in,thofe cafes proceed- ing from cold, a fever fometimes has fuper- vened, and is faid to have, been attended with inflammatory fymptoms.. Blood has been often drawn in this difeafe,, but it never ex- hibits any inflammatory cruft ; and all ac- counts feem to agree, that the blood drawn feems to be of a loofer texture than ordinary, and that it does ncft coagulate in the uiu.J manner. V MCCLXIV: In this difeafe the head is feldom affeaed with delivium, or even confufion of thought, till the laft ftage of it ; when, by the repeat eft fliocks of a violent diftemper, every funaion of the fydem is greatly difordered. B4 MCCLXW 20 PRACTICE MCCLXV. It is no lefs extraordinary, that, in this vi- olent difeafe, the natural funftions are not either immediately cr confiderably affeaed. Vomitings fometimes appear early in the dif- eafe, but commonly they are not continued ; and it is ufual enough for the appetite of hunger to remain through the whole courfe of the difeafe ; and what food happens to be taken doiKfl, feems to be regularly enough di- geded. The excretions are fometimes affea- ed, but not always. The urine is fometimes fuppreffed, or is voided with difficulty and pain. The belly is coftive : But, as we have hardly any accounts excepting of thofe cafes in which opiates have been largely employed, it is uncertain whether the coftivenefs has been the effea of the opiates or of the difeafe. Jn feveral inftances of this difeafe, a miliary eruption has appeared upon the fkin ; but whether this be a fymptom of the difeafe, or the effea of a certain treatment of it, is unde- termined. In the mean while, it has not been obferved to denote either fafety or danger, or to have any effea in changing the courfe of the diftemper. MCCLXVI. This difeafe has generally proved fatal ; and this indeed may be juftly fuppofed to be . J the OF PHYSIC. 21 the confequence of its nature : But, as wc know, that, till very lately, phyficians were not well acquainted with a proper method of cure ; and that, fince a more proper method has been known and praaifed, many have re- covered from this difeafe ; it may be therefore concluded, that the fatal tendency of it is not fo unavoidable as has been imagined... -^S In judging of the tendency of this difeafe, , 1 in particular cafes, we may remark, that, when ariiing from lefions of the nerves, it is com- monly more violent, and of more difficult .' cure, than when proceeding from cold ; that the difeafe which comes on fuddenly, and advances - quickly to a violent degree, is al- - ways more dangerous than that which is flow- er in its progrefs. Accordingly, the difeafe often proves fatal before the fourth day ; and, xvhen a patient has paffed this period, he may be fuppofed to be in greater fafety, and in general the difeafe.as the fafer the longer it lias continued. It isj however, to be partic- ularly obferved, that, even for many days after the fourth, the difeafe continues to be dangerous ; and even after fome considerable abatement of its force, it is ready to recur again with its former violence and danger. It never admits of any fudden, or what may be called a critical folution ; but always re- cedes by degrees only, and it is often very long before the whole of the fymptoms dis- appear. Vol. 3. B5 MCCLXVII. PRACTICE MCCLXVII. From the hiftory of the difeafe now def- cribed, it will be evident, that there is no room for diftinguifliing the tetanus, opiflhotonos, and trifmui or: locked jaw, as different fpecies of >^this difeafe, fince tbey all arife from the fame caufes, and are almod condantly conjoined in the fame perfon. I have no doubt that the emprojlhotonos belongs alfo to the fame genus ; and as the ancients have frequently 1 mentioned it, we can have no doubt of its having occurred.; But, at the fame time, it is certainly in thefe da.y^ a rare occurrence ; and, as I have never feen it, nor find any hidories in which this particular^ date of the fpafms is faid to have prevailed, I cannot mention the other circumflances which particularly attend it, and may didinguifh it from the other va- rieties of tetanic complaints. MCCLXVIII. This difeafe has put on dill a different form from any of thofe above mentioned. The fpafms have been fometimes confined to one fide of the J»ody only, and which bend it ftrongly to that fide. This is what has been named by Sauvages the TeUnus Lateralis, and by fome late writers the Pleurofthotonos.< ^^^This form of the difeafe has certainly appear- ed very feldom; and, in any of the accounts given OF PHYSIC. *3 given of it, I cannot find any circumdances that would lead me to confider it as any other than a variety of the fpecies already mention- ed,, or to take further notice of it here.- MCCLXIX. The.pathology of this difeafe I cannot in j any meafure attempt ; as the ftruaure of moving fibres, the ftate of them under differ- ent degrees of contraaion, and particularly the ftate of the fenforium, as varioufly deter- mining the motion of the nervops power, are all matters very imperfeaiy, or not at all, known to me. In fuch^fituation, therefore, the endeavouring to give any rules of prac- tice, upon a fcientific plan, appears to me vain and fruitlefs-; and towards direains; the cure Of this difeafe, we muft,be fatisfied with hav- ing learned fomething ufeful from analogy, confirmed by experience. w6clxx. , When the difeafe is known to arife from the lefion of a nerve in any part of the body, the firft, and, as-1 judge, the moft important flep to be taken towards the ctire,is^by every polfible means to cut off that part from all eommunicatitw with the fenforium, either by cutting through the nerves in their courfe, cqs perhaps by dedroying, to a certain lengtb\^ thew affeaed part or extremity. J B6< MCCLXXI. -i PRACTICE MCCLXXI. When the cure of the difeafe is to be at- tempted by medicine, experience has taught us that opium has often proved an effeaual remedy*; but that, to render it fuch, it mud •be given in much larger quantities than have been employed in any other cafe ; and in thefe larger quantities, it may, in this difeafe, be given more fafely than the body has been known tol^ear in any other condition. The praaice has been, to give the opium either in a folid or a liquid form, not in any very large dofe at once, but in moderate dofes, frequent- ly repeated, at the interval of one, two, three, or more hours, as the violence of the fymp- toms feems to require. Even when large quantities have been given in this way, it ap- pears that the opium does not operate here in the fame manner as in moft other cafes ; for, though it procure fome remiffion of the fpafms and pains, it harfily induces any fleep, or occafions that ftupor, intoxication, or de- lirium, which it often does in other circum- ftances, when much fmaller quantities only have been given. It is therefor© very prop- erly'obferved, that, in tetanic afFeaions, as the opium mows none of thofe effeas by which it may endanger life, there is little or ro reafon for being fparing in the exhibition cf it; and it may be given, prfck&ly f^puld be OF PHYSIC. $5 be given, as largely and as fad as the fymp- toms of the difeafe may feem to demand. It is particularly to be obferved, that though the firft exhibitions of the opium may have produced fome remiffion of the fymp- toms, yet the effeas of opium do not long continue in the fyftem ; and this difeafe be- ing for fome time ready to recur, it is com- monly very neceffary, by the time that the ef- feas of the opium given may be fuppofed to be wearing off, and efpecially upon the lead appearance of a return of the fpafms, to re- peat the exhibition of the opium iff the fame quantities as before. This practice is to be continued while the difeafe continues to fhow any difpofition to return ; and it is only after the difeafe has already fubfifted for fome time, and when confide fable and long contin- ued remiflions have taker^ place, that the dof- es of the opium may be diminifhed, and the intervals of exhibiting them be more consid- erable, f MCCLXXII. The adminiftering of opium in this man- ner, has in many cafes beei* fuccefsful; and probably would have been equally fo in many others, if the opium had not been,too fparingly employed, either from the timidity of praaitioners, or from its exhibition' being prevented by that interruption of deglutition * j which fo often attends this difeafe. This lat- V^gjf ter 26 P R A C T I C E ter circumdance direas, that the medicine fhould be immediately and largely employed upon the firft approach of the difeafe, before : the deglutition becomes difficult ; or that, if this opportunity be loft, the medicine, in fuf- ficient quantity, and with due frequency, fhould be thrown into the body by glyder; which, however, does not feem to have beert hitherto often praaifed. MCCLXXIII. It is highly probable, that, in this difeafe, the inteftines are affeaed with the fpafm that prevails fo much in other parts of the fyftem ; and therefore, that codivenefs occurs here as a fymptom of the difeafe. Itr is probably alfo increafed by the opium, which is here fo largely employed ; and, Jrom whichever of thefe caufes it arifes, it certainly mud be held to aggravate the difeafe, and that a relaxation of the intedinal canal will contribute to a re- laxation of the fpafms elfewhere. This con- fideration direas the frequent exhibition of laxatives while the power of deglutition re- mains, or the frequent exhibition of glyders when it does not ; and the good effecls of both have been frequently obferved. MCCLXXIV. It has been with fome probability fuppof- ed, that the operation of opium in this dif- eafe, OF PHYSIC. 27 eafe, may be much affided by joining with k fome other of the mod powerful antifpafmod*. ics. The mod promifing are rnufk and cam- phire ; and fome praaitioners have been of opinion, that the former has proved very ufe- ful in tetanic complaints. But, whether it be from its not having been employed of a gen- uine kind, or in fufficient quantity, the great advantage and propriety of its ufe are not yet clearly afcertained. It appears tomeprob-^ able, that analogous to what happens with refpea to opium, both mufk and camphire might be employed in this difeafe, in much larger quantities than they commonly have been in other cafes. MCCLXXV. Warm bathing hns been commonly em- ployed as a remedy in this difeafe, and often with advantage ; but, fo^far as I know, it has not alone proved a cure ; and, in fome cafes, whether it be from the motion of the body here required, excitingjthe fpafms, or from the fear of the bath, wrn\Jj fome perfons were feized with, I cannot deteimine ; but it is al- lowed, that the warm bath hath in fome cafes done harm, and even occafioned death v Par- tial fomentations have been much commend- ed, and, I believe, upon good grounds : And I have no doubt but that fomentations of the feet and legs, as we now ufually apply them in fevers, might, without much ftirring of the patient, 28 PRACTICE patient, be very affiduoufly employed with MCCLXXVI. Unauous applications were very frequent- ly employed in this difeafe by.the ancients: And fome modern praaitioners have consid- ered them as very ufeful. Their effects,. however, have not appeared to be considera- ble ; and, as a weak auxiliary only, attended with fome inconvenience, they have been very much negieaed by the Britifh prac- titioners-.^ MCCLXXVII. Bleeding has been formerly employed in this difeafe ; but of late it has been found prejudicial, excepting in a few" cafes, where, in plethoric habits, a fever has fupervened. In general, the date of men's bodies in warm climates is unfavourable to bloodletting ; and, if we may form indications from the date of the blood drawn out of the veins, the date of this in tetanic difeales would forbid bleeding in them. J. MCCLXXVIII. Bliftering alfo has been formerly employed in this difeafe ; but feveral praaitioners affert, that OF P h\ S I C. 29 that bliders are condantly hurtful, and they are now generally omitted. MCCLXXIX. Thefe are the praaices that hitherto have been generally employed ; but of late we are informed by feveral Wedindia praaitioners, ^T*m that in many indances they have employed w mercury with great advantage. We are told, that it mud be employed early in the difeafe ; that it is mod conveniently adminid^red by unaion, and fhould be applied in that way in large quantities, fo that the body may be foon filled with it, and a falivation raifed, which is to be continued till the fymptoms yield. Whether this method alone be gen- erally fufficient for the cure of the difeafe, or if it may be affided by the ufe of opium, and require this in a certain meafure to be joined with it, I have pot yet certainly learned, MCCLXXX. I have been further informed, that the te- tanus, in all its different degrees, has been cured by giving internally the Piffelaeum Bar- badenfe, or, as it is vulgarly called, the Bar- badoes Tar. I think it proper to take notice of this here, although I am not exaaiy in- formed what quantities of this medicine are to be given, or in what circumdances of the difeafe it is moft properly to be employed, *MCCLXXX. 30 PRACTICE *MCCLXXX. In the former edition of this work, among the remedies of tetanus I did not mention the' ufe of cold bathing ; becaufe, though I had heard of this, I was not informed of fuch fre- quent employment of it as might confirm my opinion of its general efficacy ; nor was I fuf- ftciently informed of the ordinary and proper adminidration of it. But now, from the in- formation of many judicious praaitioners who have frequently employed it, I can fay, that it is a remedy which in numerous trials has been found to be of great fervice in this difeafe; and that, while the ufe of the am- biguous remedy of warm bathing is entirely' laid afide, the ufe of cold bathing is over the whole of the Wedindies commonly employ- ed. The adminidration of it is fometimes by bathing the perfon in the fea, or more fre-.^ quently by throwing cold water from a bafon or bucket upon the patient's body, and over the whole of it: When this is done, the body is carefully wiped dry, wrapped in blankets, and laid abed, and at the fame time a large dofe of an opiate is given. By thefe means a considerable remiffion of the fymptoms is obtained ; but this remiffion, at fird, does not commonly remain long, but returning again in a few hours, the repetition both of the bath- ing and the opiate becomes neceffary. By thefe repetitions, however, longer intervals of eafe- ^ OF PHYSIC. 31 cafe are obtained, and at length the difeafe is entireiy cured ; and this even happens fome- times very quickly. I have only to add, that it does not appear to me, from any accounts I have yet had, that the cold bathing has been fo frequently employed, or has been found fo commonly fuccefsful in the cafes of tetanus in confequence of wounds, as in thofe from the application of cold. MCCLXXXI. Before concluding this chapter, it is proper for me to take fome notice of that peculiar cafe of the tetanus, or trifmus, which attacks certain infants foon after their birth, and has been properly enough named the Trifmus Nafcentium. From the fubjeas it affeas, it feems to be a peculiar difeafe : For thefe are infants not above two weeks, and commonly tfore they are nine days, old ; infomuch at, in countries where the difeafe is fre- quent, if children pafs the period now men- tioned, they are considered as fecure againd its attacks. The fymptoni of it chiefly taken notice of, is the trifmus, or locked jaw, which is by the vulgar improperly named the Fall- ing of the Jaw. But this is not the only fymptom, as, for the mod part, it has all the fame fymptoms as the Opidhotonos and Te- tanus driaiy fo called, and which occur in the other varieties of tetanic complaints above defcribed. Like the other varieties of teta- nus, 32 PRACTICE nus, this is mod frequent in warm climates; but it is not, like thofe arifing from the appH- cation of cold, entirely confined to fuch warm climates, as indances of it have occurred in mod of the northern countries of Europe. In thefe latter it feems to be more frequent in certain didrias than in others ; but in what manner limited, I cannot determine. It feems to be more frequent in Switzerland than in France. I am informed of its frequently Occurring in the Highlands of Scotland ; but I have never met with any indance of it in the low country. The particular caufes of it are not well known ; and various conj-eaur© have been offered ; but none of them are fat. isfying. It is a difeafe that has been almoft conftantly fatal; and this, alfo, commonly in the courfe of a few days. The women are fp much perfuaded of its inevitable fatality, that they feldom or never call for the atuftance of our art. This has occafioned our being Iit|j| acquainted with the hiftory of the difeafe, or with .the effeas of remedies in it. Analogy, however, would lead us to employ the fame remedies that have proved ufeful in the other cafes of tetanus f and the few experiments that are yet recorded, feem to approve of, fuch a praaice. Chap. O F PHYSIC. 3a C H A P. II, Of Epilepsy. MCCLXXXII. IN what fenfe I ufe the term Convulfion, I Have explained abOve in MCCLVI. The convulsions that affea the human body are in feveral refpeas various ; but I am to confider'here only the chief and moft frequent form in which they appear, and which is in the difeafe named Epikpfy. This may be defined, as confifting in convulfions of the greater part of the mufcles of voluntary motion, attended with a lofs of fenfe, and tiding in a ftate of infenfibility and feeming fleep. MCCLXXXIIi. The general form or principal circum- dances of this difeafe, are much the fame in all the different perfons whom it affeas. It comes by fits, which often attack perfons\ feemingly in perfea health ; and, after lad- ing for fome time, pafs off, and leave the per- fons again in their ufual date. Thefe fits are fometimes 34 PRACTICE fometimes preceded by certain fymptoms, which, to perfons who have before experienc- ed fuch a fit, may give notice of its approach, as we fha!l hereafter explain ; but even thefe preludes do not commonly occur long before the formal attack, which in moft cafes comes on fuddenly without any fuch warning. The perfon attacked lofes fuddenly all fenfe and power of motion ; fo that, if Handing, he falls immediately, or perhaps, with convul- fions, is thrown to the ground. In that fit- uation he is agitated with violent convulfions, varioufly moving his limbs and the trunk of his body. Commonly the limbs on one fide of the body, are more violently or more coni fiderably agitated than thofe upon the other. In all cafes the mufcles of the face and eyes are much affeaed, exhibiting various and vi- olent didortions of the countenance. The tongue is often affeaed, and thru ft out of the mouth; while the mufcles of the lowerja^ are alfo affeaed ; and, fhutting the moutrr with violence while the tongue is thn.ift out between the teeth, that is often grievoufly wounded. While thefe corfVulfions continue, there is commonly at the fame time a frothy moidure iffuing from the mouth. Thefe convulfion* have for fome moments fome remiffions, but are fuddenly again renewed with great vio- lence. Generally, after no long time, the • convulfions ceafe altogether ; and the perfon for fome time remains without motion, but in a ftate (j t r n * o a u. 35 a ftate of abfolute infenfibility, and under the appearance of a profound fleep. After fome continuance of this feeming fleep, the perfon fometimes fuddenly, but for the mod part by degrees only, recovers his fenfes and power of motion ; but without any memory of what had paffed from his being fird feized with the fit. During the convulfions, the pulfe and refpiration are hurried and irregular ; but, when the convulfions ceafe, they return to their ufual regularity and healthy date. This is the general form of the difeafe ; and it varies only in different perfons, or on dif- ferent occafions in the fame perfon, by the phenomena mentioned being more or lefs vi- olent, or by their being of longer or fhorter duration. MCCLXXXIV. With refpea to the proximate caufe of this difeafe, I might fay, that it is an affeclion of the energy of the brain, which, ordinarily un- der the direaion of the will, is here, without any concurrence of it, impelled by preternat- ural caufes. But I could gp no farther : For, as to what is the mechanical condition of the brain in the ordinary exertions of the will, I have no diflina knowledge; and therefore mud be alfo ignorant of the preternatural date of the fame energy of the brain underV the irregular motions here produced. To form, therefore, the indications of a cure, from 36 PRACTICE a knowledge of the proximate caufe of this difeafe, I mud not attempt; but, from a dili- gent attention to the remote caufes which firft induce and occasionally excite the difeafe, I think we may often obtain fome ufeful direc- tions for its cure. It fhall therefore be my bufinefs now, to point out and enumerate thefe remote caufes as well as I can. MCCLXXXV. The remote caufes of epile^fy may be con- sidered as occasional or predifponent. There are, indeed, certain remote caufes which aft independently of any predifpofition ; but, as we cannot always diftinguifh thefe from the others, I fhall confider the whole under the ufual titles of Occafional or Predifponent. MCCLXXXVI. The occafional caufes may, I think, be properly referred to two general heads ; the Jirfl being of thofe which feem to aa by di- reaiy dimulating and exciting the energy of the brain; and the fecond, of thofe which feem to aa by weakening the fame. With refpea to both, for the brevity of exprefling a fa$, without meaning to explain the manner in which it is brought about, I fhall ufe the pferms of Excitement and Collapfe. And though it be true, that with refpea to fome of the caufes I am to mention, it may be a little S OF PHYSIC. 37 little uncertain whether they aa in the one Way or the other, that does not render it im- proper for us to mark, with refpea to others, the mode of their operating, wherever we can do it clearly, as the doing fo may often be of ufe in direaing our praaice. MCCLXXXVII. Fird, then, of the occafional caufes aaipg by excitement : They are either fuch as acf immediately and direaiy upon the brain it- felf; or thofe which are fird applied to the other parts of the body, and are from thence communicated to the brain. MCCLXXXVIII. The caufes of excitement immediately and direaiy applied to the brain, may be referred to the four heads of, 1. Mechanical Stimu- lants ; 2. Chemical Stimulants ; 3. Mental Stimulants ; and, 4. The peculiar Stimulus of Over Didention. MCCLXXXIX. The mechanical ftimulants may be, wound- ing indruments penetrating the cranium, and entering the fubdance of the brain ; or fplin.iv ters of a fraaured cranium, operating in the i fame manner; or fharp pointed oflifications, either arifing from the internal furface of the Vol. III. C cranium, 38 PRACTICE cranium, or formed in the membranes of the brain. MCCXC. Thechemical dimulants(MCCLXXXVIII) may be fluids from various caufes lodged in certain parts of the brain, and become acrid by dagnation or otherwife. MCCXCI. The mental irritations aaing by excites. ment, are, all violent emotions of the aaive kind, fuch as joy and anger. The fird of thefe is manifeftly an exciting power, aaing drongly, and immediately, on the energy or the brain. The fecond is manifedly, alfo, a power aaing in the fame manner. But it mud be remarked, that it is not in this man- ner alone anger produces its effeas : For it afcts, alfo, ftrongly on the fanguiferous fyftem, and may be a means of giving the dimulus of over didention ; as, under a fit of anger, the blood is impelled into the veffels of the head with violence, and in a larger quantity. MCCXCII. f Under the head of Mental Irritations, is to be mentioned, the fight of perfons in a fit of j epilepfy, which has often produced a fit of the like kind in the fpeaator. It may, indeed, be a queftion, OF P H Y S I C. 39 a quedion, Whether this effea be imputable to the horror produced by a fight of the feem- ingly painful agitations of the limbs, and of the didortions in the countenance of the epi- leptic perfon ; or if it may be afcribed to the force of imitation merely ? It is poffible, that. horror may fometimes pro luce the effea : But certainly much may be imputed to that propenfity to imitation, at all times fo power- ful and prevalent in human nature ; and fa often operating in other cafes of convulfive diforders, which do not prefent any fpeaacle of horror. MCCXCIII. Under the fame head of Mental Irritation, 1 think proper to mention as an indance of it, *he Epilepfia Simulata, or the Feigned Epi- lepfy, fo often taken notice of. Although this, at fird, may be entirely feigned, I have no doubt but that the repetition renders it at length real. The hidory of Quietifm and of Exorcifms leads me to this opinion ; and which receives a confirmation from what we know of the power of imagination, in renew- ing epileptic and hyderic fits. MCCXCIV. I come now to the fourth head of the irri- tations applied immediately to the brain, and which I apprehend to be that of the Over Dif- C 2 tention PRACTICE tention of the bloodveflels in that organ. That fuch a caufe operates in producing epij lepfy, is probable from this, that the diflection of perfons dead of epilepfy, has commonly dilcovered the marks of a previous congedion in the bloodveffels of the brain. This, per- haps, may be fuppofed the effea of the fit which proved fatal: But that the congedion was previous thereto, is probable from the epilepfy being fo often joined, with headach, mania, palfy, and apoplexy ; all of them dif- eafes depending upon a congedion in the veflels of the brain. The general opinion receives alfo confirmation from this circutn- ftance, that, in the brain of perfons dead of epilepfy, there have been often found tumours and effufions, which, though feemingly not fufficient to produce thofe difeafes which de- pend on the compreffion of a considerable- portion of the brain, may, however,* have been fufficient to comprefs fo many veflels as to render the others upon any occafion of a more than ufual turgefcence, or impulfe of the blood into the veflels of the brain more liable to an over didention. MCCXCV. Thefe confiderations alone might afford foundation for a probable conjecture with refpea to the effeas of over didention. But the opinion does not red upon conjeaure alone. That it is alfo founded in faa, ap- pears OF PHYSIC. 41 pears from hence, that a plethoric date is fa- vourable~ to epilepfy ; and that every occa- fional turgefcence, or unufual impulfe of the blood into the veffels of the brain, fuch as a fit of anger, the heat of the fun, or of a warm chamber, violent exercife, a furfeit, or a fit of intoxication, are frequently the immediately exciting caufes of epileptic fits* MCCXCVI. I venture to remark further, that a piece of theory may be admitted as a confirmation of this doarine. As I have formerly maintain- ed, that a certain fulnefs and tenfion of the veflels of the brain is neceffary to the fupport of its ordinary and condant energy, in the didribution of the nervous power ; fo it muft be diffidently probable, that an over diden- tion of thefe bloodveffelsJ may be a caufe of violent excitement. ' MCCXCVII. We have now enumerated the feveral re- mote or occafional caufes of epilepfy, aaing by excitement, and aaing immediately upon the brain itfelf. Of the caufes aaing by ex- citement, but aaing upon other parts of the body, and from thence communicated to the brain, they are all of them impreflions pro- ducing an exquifite or high degree either of pleafure or pain. C 3 Impreflions PRACTICE . Impreflions which produce neither the one nor the other, have hardly any fuch effeas ; unlefs when fuch impreflions are in a violent degree, and then their operation may be con- fidered as a mode of pain. It is, however,.to be remarked, that all ftrong impreflions which are fudden and furprifing, or, in other words, unforefeen and unexpeaed, have frequently the effea of bringing on epileptic fits, MCCXCVIII. There are certain impreflions made upon different parts of the body, which as they often operate without producing any fenfa- tion, fo it is uncertain to what head they be- long :. But it is probable that the greater part of them aa by excitement, and therefore fall to be mentioned here. The chief inftances are, The teething of infants ; worms ; acidity or other acrimony in the alimentary canal;, calculi, in the kidneys ; acrid matter in ab- fceffes or ulcers ; or acrimony diffufed in the mafs of blood, as in the cafe of fome conta- gions. MCCXCIX. Phyficians have found no difficulty in comprehending how direa ftimulants, of a certain force, may excite the aaion of the brain, and occafion epilepfy ; but they have hitherto taken little notice of certain caufes which OF PHYSIC. 43 which manifeftly weaken the energy of • the brain, and aa, as I fpeak, by collapfe. Thefe, however, have the effea of exciting the aaion of the brain in fuch a manner as to occafion epilepfy. I might, upon this fub- jea, fpeak'of the vis medicatrix nature ; and there is a foundation for the term : But, as I do not admit the Stahlian doarine of an ad- minidering foul, I make ufe of the term only as expreffing a faa, and would not employ it with the view of conveying an explanation of the manner in which the powers of collapfe mechanically produce their effcas. Iri the mean time, however,. I maintain, that there are certain powers of collapfe, which in effea prove dimulants, and produce epilepfy. MCCC. That there are fuch powers, which may be termed Indirea Stimulants, I conclude from hence, that feveral of the caufes of epilepfy are fuch as frequently produce fyncope, which we fuppofe alwayfc to depend upon caufes weakening the energy of the brain (MCLXXVI). It may give fome difficulty to explain, why the fame caufes fometimes occafion fyncope, and fometimes occafion the rcaaion that appears in epilepfy ; and I fhall not attempt to explain it: But this, I think, does not prevent my fuppofing that the one- ration of thefe caufes is by collapfe. That there are fuch caufes producing epilepfy, will, C 4 I think, 44 P- R A C T ICE I think,, appear very clearly from the partic- ular examples of them I am now to mention. MCCCI. 3 The fird to be mentioned, which I fuppofe to be of this kind, is hemorrhagy, whether fpontaneous or artificial. That the fame he- morrhagy which produces fyncope,. often at the fame time produces epilepfy, is well known ; and from many experiments and cbfervations it appears, that hemorrhagies oc- curring to fuch a degree as to prove mortal,. feldom do fo without firfiproducing, epilepfy. MCCCLI. Another caufe aaing, as I fuppofe, by col- lapfe, and therefore fometimes producing fyiv cope and fometimes epilepfy, is terror ; that is, the fear of fome great evil fuddenly prefent- ed. As this produces at the fame time a fud- den and confiderable emotion, (MCLXXX), fo it more frequently produces epilepfy than fyncope. MCCCIII. A third caufe aaing by collapfe, and pro- ducing epilepfy, is horror ; or a drong aver.? fion fuddenly raifed by a very difagreeable fenfation, and frequently arifing from a fym- pathy with the pain or danger of another per- fon. OF PHYSIC. 45 fon. As horror is often a caufe of fyncope, there can he no doubt of its manner of ope- rating in producing epilepiy ; and it may perhaps be explained upon this general prin- ciple, That as defire excites aaion and gives aaivity, fo averfion redrains from aaion, that is, weakens the energy of the brain ; and, therefore, that the higher degrees of averfion may have the effeas of producing fyncope or epilepfy. MCCCIV. A fourth fet of the caufes of epilepfy, which I fuppofe alfo to aa by collapfe, are certain odours, which occafion either fyncope or epilepfy ; and, with refpea to the former, I have given my reafons (MCLXXXII) for fuppofing odours in that cafe to aa rather as difagreeable than as fedative. Thefe reafons will, I think, alfo apply here ; and perhaps the whole affair of odours might be confider- ed as indances of the effea of horror, and therefore belonging to the lad head. *MCCCV. A fifth head of the caufes producing epi- lepfy by collapfe, is the operation of many fubftances confidered, and for the mod part properly confidered, as poifons. Many of thefe, before they prove mortal, occafion epi- lepfy. This effea, indeed, may in fome cafes be referred to the inflammatory operation Vol. 3. C 5 which 46 PRACTICE which they fometimes difcover in the ftomach and other parts of the alimentary canal; but, as the greater part of the vegetable poifons fhow chiefly a narcotic, or flrongly fedative power, it is probably by this power that they produce epilepfy, and therefore belong to this head of the caufes aaing by collapfe. MCCCVI. Under the head of the remote caufes pro- ducing epilepfy, we mud now mention that peculiar one whofe operation is accompanied with what is called the Aura Epileptica. This is a fenfation of fomething moving in fome part of the limbs or trunk of the body, and from thence creeping upwards to the head; and when it arrives there, the perfon is immediately deprived of fenfe, and falls in- to an epileptic fit. This motion is defcribed by the perfon's feeling it fometimes as a cold vapour, fometimes as a fluid gliding, and fometimes as the fenfe of a fmall infea creep- ing along their body; and very often they can give no difiina idea of their fenfation, otherwife than as in general of fomething moving along. This fenfation might be fup- pofed to arife from fome affeaion of the ex- tremity or other part of a nerve aaed upon by fome irritating matter ; and that the fen- fation, therefore, followed the courfe of fuch a nerve : But I have never found it following diftinaiy the courfe of any nerve ; and it generally OF PHYSIC. 47 generally feems to pafs along the teguments. It has been found in fome inftances to arife from fomething preffing upon or irritating* a particular nerve, and that fometimes in con- fequence of contufion or wound : But in- ftances of thefe are more rare ; and the more common confequence of contufions and wounds is a tetanus. This latter effea wounds produce, without giving any fenfa- tion of an aura or other kind of motion pro- ceeding from the wounded part to the head ; while, on the other hand, the aura producing epilepfy often arifes from a part which had never before been affeaed with wound or con- tufion, and in which part the nature of the irritation can feldom be difcovered. It is natural to imagine that this aura epi- leptica is an evidence of fome irritation or di- rea dimulus acting in the part, and from thence communicated to the brain, and fhould therefore have been mentioned among the caufes aaing by excitement ; but the re- markable difference that occurs in feemingly like caufes producing tetanus, , givek fome doubt on this fubjea. MCCCVII. Having now enumerated the occafional caufes of epilepfy, I proceed to confider the predifponent. As fo many of the above mentioned caufes aa upon certain perfons, and not at all upon others, there mud be fup- C 6 pofed 4$ PRACTICE pofed in thofe perfons a predifpofition to.this difeafe : But in what this predifpofition con- fids, is .not to be eafily ascertained. MCCCVIII. As many of the occafional caufes are weak impreffions, and are applied to moft perfons with little or no effea, I conclude, that the perfons affeaed by thofe caufes are more ea- fily moved than others ; and therefore, that, in this cafe, a certain mobility gives the pre- difpofition. It will, perhaps, make this mat- ter clearer, to fhow, in the firft place, that there is a greater mobility of constitution in fome perfons than in others. MCCCIX. This mobility appears moft clearly in the ftate of the mind. If a perfon is readily elat- ed by hope, and as readily deprefled by fear, and pafles eafily and quickly from the one date to the other ; if he is eafily pleafed, and prone to gaiety, and as eafily provoked to anger, and rendered peevifh ; if liable, from flight impreffions, to drong emotions, but te- nacious of none ; this is the boyifh tempera- ment, qui colligit ac ponit iram temere, et mu- tator in horas; this is the varium et mutabili Joemina ; and, both in the boy and woman every one perceives and acknowledges a mo- bility of mind. But this is neceflarily con- neaed OF PHYSIC. 49 neaed with an analogous date of the brain ; that is, with a mobility, in refpea of every impreffion, and therefore liable to a ready al- ternation of excitement and collapfe, and of both to a confiderable degree. MCCCX. There is, therefore, in certain perfons, a mobility of conditution, generally derived from the date of original damina, and more exquifite at a certain period of life than at others ; but fometimes arifing from, and par- ticularly modified by, occurrences in the courfe of life. MCCCXI. This mobility confids in a greater degree of either fenfibility or irritability. Thefe conditions, indeed, phyficians confider as fo neceffarily connected, that the conditution with refpea to them, may be confidered as one and the fame : But I am of opinion that they are different; and that mobility may fometimes depend upon an increafe of the one, and fometimes on that of the other. If an aftion excited, is, by repetition, rendered more eafily excited, and more vigorously per- formed, I confider this as an increafe of irri- tability only. I go no farther on this fubjea. here, as it was only neceffary to take notice of the cafe juft now mentioned, for the pur- PRACTICE pofe of explaining why epilepfy, and convul- fions of all kinds, by being repeated, are mora eafiLy excited, readily become habitual, and are therefore of more difficult cure. MCCCXII. However we may apply the didinaion of fenfibility and irritability, it appears that the mobility, which is the predifponent caufe of epilepfy, depends more particularly upon de- bility, or upon a plethoric date of the body. MCCCXIII. What fhare debility, perhaps by inducing fenfibility, has in this matter, appears clearly from hence, that children, women, and other perfons of manifed debility, are the mod fre- quent fubjeas of this difeafe. MCCCXIV. The effeas of a plethoric date in difpofing to this difeafe appears from hence, that ple- thoric perfons are frequently the fubjeas of it: That it is commonly excited, as 1 have faid above, by the caufes of any unufual turgef- cence of the blood ; and that it has been fre- quently cured by diminifhing the plethoric ftate of the body. That a plethoric ftate of the body fhould difpofe to this difeafe, we may under dand from OF P H Y S I C. 51 from feveral confiderations. 1/?, Becaufe a plethoric ftate implies, for the mod part, a laxity of the folids, and therefore fome debil- ity in the moving fibres, zdly, Becaufe, in a plethoric date, the tone of the moving fi- bres depends more upon their tendon, than upon their inherent power : And as their ten- sion depends upon the quantity and impetus of the fluids in the bloodveffels, which are very changeable, and by many caufes fre- quently changed, fo thefe frequent changes mud give a mobility to the fyffem. $dlyt Becaufe a plethoric date is favourable to a congedion of blood in the veffels of the brain, it mud render thefe more readily affeaed by every general turgefcence of the blood in the fyftem, and therefore more efpecially difpofe to this difeafe. MCCCXV. There is another circumdance of the body difpofing to epilepfy, which I cannot fo well account for ; and that is, the date of fleep : But whether I can account for it or not, it appears, in faa, that this date gives the dif- pofition I fpeak of; for, in many perfons lia- ble to this difeafe, the fits happen only in the time of fleep, or immediately upon the per- son's coming out of it. In a cafe related by De Haen, it appeared clearly, that the difpo- fition to epilepfy depended entirely upon the ftate of the body in fleep. MCCCXVI. 5« PRACTICE MCCCXVI. Having thus confidered the whole of the remote caufes of epilepfy, I proceed to treat of its cure, as I have laid it is from the con- fideration of thofe remote caufes only that we can. obtain any direaions for our praaice in this difeafe. I begin with obferving, that as the difeafe may be confidered as fympathic or idiopathic,. I mud treat of thefe Separately, and judge it proper to begin with the former. MCCCXVII. When this difeafe is truly fympathic, and depending upon a primary affeaion in fome other part of the body, fuch as acidity or worms in the alimentary canal, teething, or other fimilar caufes, it is obvious, that fuch • primary affeaions mud be removed for the cure of the epilepfy ; but it is not our bufi-j nefs here to fay how thefe primary difeafes are to be treated. MCCCXVIII. There is, however, a peculiar cafe of fym- pathic epilepfy; that is, the cafe accompa- ]■ * nied with the aura epileptica, as defcribed in MCCCVI, in which, though we can perceive by the aura epileptica arifing fiom a particu- lar O F P H Y S I C. 5# lar part, that there is fome affeaion in that part; yet, as in many fuch cafes we cannot perceive of what nature the affeaion is, I can only Offer the following general direaions. ifly When the part can with Safety be en- tirely dedroyed, we fhould endeavour to do fo try cutting it out, or by dedroying it by the application of an a&Ual oro potential cautery. *2dly, When the part cannot be properly dedroyed, that we fhould endeavour to cor- rea the morbid affeaion in it by bliftering, or by eftablifhing an iffue upon the part. $dlyy When thefe meafures cannot be exe- cuted, or do not fucceedr if the difeafe feems to proceed from the extremity of a particular nerve which we can eafily come at in its courfe, it will be proper to cut through that nerve, as before propofed on the fubjea of tetanus. 4thly, When it cannot be perceived that the aura arifes from any precife place or point, fo as to direa to the above mentioned operations; but, at the fame time, we can perceive its progrefs along the limb ; it fre- quently happens that the epilepfy can be pre- vented by a ligature applied upon the limb, above the part from which the aura arifes : And this is always proper to be done, both becaufe the preventing a fit breaks the habit of the difeafe, and becaufe the frequent com- preffion renders the nerves lefs fit to propa- gate the aura. MCCCXIX. 54 PRACTICE MCCCXIX. The cure of idiopathic epilepfy, as I have faid above, is to be dire6ted by our knowledge of the remote caufes. There are therefore two general indications to be formed : The firft is, to avoid the occafional caufes; and the Second is, to remove or correa the pre- difponent. This method, however, is not always pure- ly palliative ; as in many cafes the prcdifpo-a nent may be confidered as the only proximate- ! caUfe, fo our fecond indication may be often: confidered as properly curative. MCCCXX. From the enumeration given above, it will I be manifeft, that for the moft part the occa- fional caufes, fo far as they are in our power, need only to be known, in order to be avoid- ed ; and the means of doing this will be fuf- ficiently obvious. I fhall here, therefore, of- fer only a few remarks. MCCCXXI. One of the moft frequent of the occafional caufes is that of oyer diftention (MCCCXIV), which, fo far as it depends upon a plethoric ftate of the fyftem, I fhall fay hereafter how J it is to be avoided. But as, not only in the plethoric, OF PHYSIC. 53 plethoric, but in every moveable conditution, occafional turgefcence is a frequent means of exciting epilepfy, the avoiding therefore of fuch turgefcence is what ought to be mod condantly the objea of attention to per- fons liable to epilepfy. MCCCXXII. Another of the mod frequent exciting cauC- •s of this difeafe are, all drong impreffions fuddenly made upon the fenfes ; for as fuch impreflions, in moveable conditutions, break in upon the ufual force, velocity, and order of the motions of the nervous fydem, they thereby readily produce epilepfy. Such im- preffions therefore, and efpecially thofe which are fuited to excite any emotion or paffion of the mind, are to be mod carefully guarded againft by perfons liable to epilepfy. MCCCXXIII. In many cafes of epilepfy, where the pre- difponent caufe cannot be correaed or re- moved, the recurrence of the difeafe can only be prevented, by the ftriaeft attention to avoid the occafional ; and as the difeafe is often confirmed by repetition and habit, fo the avoiding the frequent recurrence of it is of the utmoft importance towards its cure. Thefe are the few remarks I have to offer with refpea to the occafional caufes; and muft 5.6 PRACTICE muft now obferve, that, for the moft part, the complete, or, as it is called, the Radical Cure, is only to be obtained by removing or cor- reaing the predifponent caufe. MCCCXXIV. I have faid above, that the predifponent caufe of epilepfy is a certain mobility of the fenforium ; and that this depends upon a plethoric ftate of the fyftem, or upon a .cer- tain ftate of debility in it. MCCCXXV. How the plethoric ftate of the fyftem is to be correaed, I have treated of fully above in DCCLXXXIII etfeq. and I need not re- peat it here. It will be enough to fay, that it is chiefly to be done by a proper manage- ment of exercife and diet ; and, with refpefii: to the latter, it is particularly to be obferved here, that an abftemious courfe has been fre- quently found to be the moft certain means of curing epilepfy. MCCCXXVI. Considering the nature of the matter pour- ed out by iffues, thefe may be fuppofed to be a conftant means of obviating the plethoric ftate of the fyftem; and it is, perhaps, there-; fore, that they have been fo often found ufe- ful 1 OF PHYSIC. 57 ful in epilepfy. Poffibly, alfo, as an open iffue may be a means of determining occafion- al turgefcences to fuch places, and therefore of diverting them in fome meafure from their aaion upon the brain ; fo alfo, in this man- ner, iffues may be ufeful in epilepfy. MCCCXXVII. It might be fuppofed that bloodletting would be the moft effeaual means of correa-i ing the plethoric ftate of the fyftem ; and fuch it certainly proves when the plethoric ftate has become confiderable, and imme- diately threatens morbid effeas. It is there- fore, in fuch circumdances, proper and necef- fary : But as we have faid above, that blood- letting is not the proper means of obviating a recurrence of the plethoric date, and, on the contrary, is often the means of favouring it; fo it is not a remedy advifable in every cir- cumdance of epilepfy. There is, however, a cafe of epilepfy in which there is a periodical or occafional recurrence of the fulnefs and turgefcence of the fanguiferous fydem, giving occafion to a recurrence of the difeafe. f In fuch cafes, when the means of preventing plethora have been negleaed, or may have proved ineffeaual, it is abfolutely neceffary for the praaitioner to watch the returns of thefe turgefcences, and to obviate their effeas hy the only certain means of doing it, that is, by a large bloodletting. MCCCXXVIIL 58 PRACTICE MCCCXXVIII. The Second caufe of mobility which we have afligned, is a date of debility. If this is owing, as it frequently is, to original con- formation, it is perhaps not poffible to cure it; but when it Jias been brought on in the courfe of life, it poffibly may admit of being mended ; and, in either cafe, much may be done to obviate and prevent its effeas. xMCCCXXIX. The means of correaing debility, fo far as it can be done, are, The perfon's being much in cool air $ the frequent ufe of cold bath- ing ; the ufe of exercife, adapted to the ftrength and habits of the perfon ; and, pen* haps, the ufe of aftringent and tonic medi- cines. Thefe remedies are fuited to ftrengtheri the inherent power of the Solids or moving fibres J But as the ftrength of thefe depends alfo up- on their tenfion, fo when debility has pro* ceeded from inanition, the ftrength may be reftored, by redoring the fulnefs and tenfion of the veuils by a nourifhing diet ; and we have had inftances of the propriety and fuc* cefs of fuch a praaiee. MCCCXXX, OF PHYSIC. 59 MCCCXXX. The means of obviating the effeas of de- bility, and of the mobility depending upon it, are the ufe of tonic and antifpafmodic rem- edies. The tonics are, Fear, or fome degree of terror ; aftringents ; certain vegetable and metallic tonics; and cold bathing. MCCCXXXI. That fear, or fome degree of terror, may be of ufe in preventing epilepfy, we have a remarkable proof in Boerhaave's cure of the epilepfy, which happened in the Orphan- houfe at Haerlem. See Kauu Boerhaave's treatife, entitled Impetum Faciens, § 406. And we have met with feveral other inftances of the fame. A§ the operation of horror is in many ref- peas analogous to that of terror, feveral Seem- ingly fuperftitious remedies have been em- ployed for the cure of epilepfy ; and, if they nave ever been fuccefsful, I think it muft be imputed to the horror they had infpired. MCCCXXXII. f Of the aftringent medicines ufed for the -cure of epilepfy, the moft celebrated is the vifcus quercinus, which, when given in large quantities, 6o PRACTICE quantities, may poffibly be ufeful; but I be- lieve it was more efpecially fo in ancient times, when it was an objea of fuperftition. In the few indances in which I have Seen it employed, it did not prove of any effea. MCCCXXXIII. Among the vegetable tonics, the bitters arc to be reckoned ; and it is by this quality that I fuppofe the orange tree leaves to have been ufeful : But they are rtot-always fo. MCCCXXXIV. The vegetable tonic, which from its ufe in analogous cafes is the mod promifing, is the Peruvian bark ; this, upon occafion, has been ufeful, but has alfo often failed. It is efpec- ially adapted to thofe epilepfies which recur at certain periods, and which are at the fame time without the recurrence of any plethoric ftate, or turgefcence of the blood ; and in fuch periodical cafes, if the bark is employed fome time before the expeaed recurrence, it may be ufeful : But it mud be given in large quantity, and as near to the time of the ex- peaed return as poffible. MCCCXXXV. OF PHYSI'C, 61 MCCCXXXV. The metallic tonics feem to be more pow- erful than the vegetable, and a great variety of the former have been employed. Even arfenic has been employed in the cure of epilepfy ; and its ufe in intermittent fevers gives an analogy in its favour. Preparations of tin have been formerly rec- ommended in the cure of epilepfy, and in the cure of the analogous difeafe of hyfteria ; and feveral confiderations render the virtues of tin, with refpea to thefe difeafes, probable : But I have had no experience of its ufe in fuch Cafes. A much Safer metallic tonic is to be found in the preparations of iron ; and we have Seen fome of them employed in the cure of epilepfy, but have never found them to be effeaual. This, however, I think, may be imputed to their not having been always em- ployed in the circumdances of the difeafe, and in the quantities of the medicine, that were proper and neceffary. MCCCXXXVI. Of the metallic tonics, the moft celebrated and the moft frequently employed is copper^ under various preparation. What prepara- tion of it may be the moft effeaual, I dare Vol. III. D not 62 PRACTICE not determine; but of late the cuprum am* tnoniacum has been frequently found fuc- cefsful. MCCCXXXVII. Lately the flowers of zinc have been rec- ommended by a great authority as ufeful in all convulsive diforders ; but in cafes of epi» lepfy, I have not hitherto found that medi«H8 ufeful. MCCCXXXVIII. There have been of late fome inftances of the cure of epilepfy by the accidental ufe of mercury ; and if the late accounts Of the cure of tetanus by this remedy are confirmed, it will allow us to think that the fame may be adapted alfo to the cure df certain cafes of epilepfy. MCCCXXXIX; With refpea to the employment of any of the above mentioned tonics in this difeafe, it mud be obferved, that in all cafes where the difeafe depends upon a conftant or occafional plethoric ftate of the fyftem, thefe remedies are likely to be ineffeaual; and if fufficient evacuations are not made at the fame time; thefe medicines are likely to be very hurtful* MCCCXL; O F ' P H Y S I C. 63 MCCCXL. The other Set of medicines which re have mentioned as fuited to obviate the effeas of the too great mobility of the fyftem, are the medicines named antifpafmodics. OF thefe there is » long lift in the writers on the Ma- teria Medica, and by thefe authors recom- mended for the cure of epilepfy. The great- er part, however, of thofe taken from the veg- etable kingdom^ are manifeftly inert and in- fignificant. Even the root of the wild vale*- rian hardly Supports its credit. MCCCXLI. Certain fubftances-taken from the animal kingdom feem to be much more powerful: And of thefe the chief, and Seemingly the moft powerful, is mufk ; which, employed in its genuine ftate, and in due quantity, has often been an effeaual remedy. It is probable alfo, that the oleum animate\ as it has been named, when in its pureft ftatej and exhibited at a proper time, may be an ef- feaual remedy. MCCCXLII. In many difeafes, the moft powerful anti- fpafmodic is certainly opium ; but the pro- priety of its ufe in epilepfy has been difputed D 2 among 64 PRACTICE among phyficians. When the difeafe de- pends upon a plethoric date in which bleed- ing may be neceffary, the employment of opium is likely to be very hurtful j but, when there is no plethoric or inflammatory date pre lent, and the difeafe feems to depend upon irritation or upon increafed irritability, opium is likely to prove the mod certain remedy. Whatever effeas in this and other convulfive diforders have been attributed to the hyofcy- amus, mud probably be attributed to its pof- fefling a narcotic power fimilar to that of opium. MCCCXLIII. With refpea to the ufe of antifpafmodics, it is to be obferved, thatthey are always mod ufeful, and perhaps only ufeful, when em- ployed at a time when epileptic fits are fre- quently recurring, or near to the times of the acceffion of fits which recur after confiderable intervals. MCCCXLIV. On the fubjea of the cure of epilepfy, I have only to add, that as the difeafe in many cafes is continued by the power of habit only, and that in all cafes habit has a great fhare in increafing mobility, and therefore in contin- uing this difeafe; fo the breaking in uport fuch habit, and changing the whole habits of the OF PHYSIC. 65 the fyftem, is likely to be a powerful remedy in epilepfy. Accordingly, a confiderable change of climate, diet, and other circum- dances in the manner of life, has often proved a cure of this difeafe. MCCCXLV. After treating of epilepfy, I might here treat of particular convulfions, which are to be didinguifhed from epilepfy by their being more partial : That is, affeaing certain parts of the body only, and by their not being at- tended with a lofs of fenfe, nor ending in fuch a comatofe ftate as epilepfy always does. MCCCXLVF. Of fuch convulfive affeaions many differ- ent inftances have been obferved and record- ed by phyficians. But many of thefe have been manifeftly fympathic affeaions, to be cured only by curing the primary difeafe up- on which they depend, and therefore not to be treated of here : Or, though they are fuch as cannot be referred to another difeafe, as many of them however have not any fpecific charaaer with which they occur in different perfons, I mud therefore leave them to be treated upon the general principles I have laid down with refpea to epilepfy, or fhall lay down with refpea to the following convulfive D 3 diforder; 66 PRACTICE diforder ; which as having very conftantly in different perfons a peculiar charaaer, I think neceflary to treat of more particularly. Chap. * III. , Of the Chorea or Dance of St. Vitus.. MCCCXLVII, i .; THIS difeafe affeas both fexes, and al- mod only young perfons. It generally hap- pens from the age of ten to that of fourteen years. It comes on always before the age of puberty, and rarely continues beyond that period, MCCCXLVIII. It is chiefly marked by convulfive motion*, fomewhat varied in different perfons, but nearly of one kind in all; affecting the leg and arm on the fame fide, and generally on one fide only. MCCCXLIX. Thefe convulfive motions commonly firft affea the leg and foot. Though the limb be at 'OF PHYSIC. 67 at reft, the foot is often agitated bv convulfive motions, turning it alternaL^iy outwards and inwards. When walking is attempted, the affeaed leg is Seldom lifted as ufual in walk- ing, but is dragged along as if the whole limb were paralytic ; and when it is attempted to be lifted, this motion is unfteadily performed, the limb becoming agitated by irregular con- vulfive motions. MCCCL. The arm of the fame fide is generally af- feaed at the fame time ; and, even when no voluntary motion is attempted, the arm is fre- quently agitated with various convulfive mo- tions. But efpecially when voluntary mo- tions are attempted, thefe are not properly executed, but are varioufly hurried or inter- rupted by convulfive motions in a direaion contrary to that intended. The mod com- mon inftance of this is in the perfon's at- tempting to carry a cup of liquor to his mouth, when it is only after repeated efforts, interrupted by frequent convulfive retraaions and deviations, that the cup can be carried to the mouth. MCCCLI. It appears to me, that the will often yields to thefe convulfive motions, as to a propen- fity, and thereby they are often increafed, D 4 while 68 PRACTICE while the perfon affeaed feems plea fed with increafing the furprife and amufement which his motions occafion in the bydanders. MCCCLII. In this difeafe the mind is often affeaed' with fome degree of fatuity ; and often fhows the fame varied, defultory, and caufelefs emo- tions which occur in hyfteria. MCCCLIII. Thefe are the mod common circumdances of this difeafe ; but at times, and in different perfons, it is varied by fome difference in the convulfive motions, particularly by thefe af- feaing the head and trunk of the body. As in this difeafe there feem to be propensities to motion, fo various fits of leaping and running occur in the perfons affeaed ; and there have been indances of this difeafe, confiding of fuch convulfive motions, appearing as an epi- demic in a certain corner of the country. In fuch indances, perfons of different ages are affeaed, and may feem to make an exception to the general rule above laid down ; but dill the perfons are, for the mod part, the young of both fexes, and of the more manifedly moveaLT* conditutions. MCCCLIV. OF PHYSIC. 69 MCCCLIV. The method of curing this difeafe has been varioufly propofed. Dr. Sydenham propos- ed to cure it by alternate bleeding and purg- ing. In fome plethoric habits I have found fome bleeding ufeful; but in many cafes I have found repeated evacuations, efpecially by bleeding, very hurtful. In many cafes, I have found the difeafe, in fpite of remedies of all kinds, continue for many months ; but I have alfo found it often readily yield to tonic remedies, fuch as the Peruvian bark, and chalybeates. The late Dr. De Haen found feveral per- fons labouring under this difeafe cured by the application of elearicity. Vol. 3. D5 SECT. 7° PRACTICE *' SECT. II. of the SPASMODIC AFFECTIONS 01 the VITAL FUNCTIONS. Chap, IV.* Of the Palpitation of the Heart. MCCCLV. /1HE motion thus named is a contraaion or fyftole of the heart, that is per- formed with more rapidity, and generally alfo with more force than ufual; and when at the fame time the heart ftrikes with more than ufual violence againft the infide of the ribs, producing often a confiderable found. MCCCLVI. This motion, or palpitation, is occafioned by a great variety of caufes, which have been recited * Though I have thought it proper to divide this book into fe&ions, I think it neceffary, for the convenience of references, to number the chapters from the beginnings OF PHYSIC. 71 recited with great pains by Mr. Senac and others; whom, however, I cannot follow in all the particulars with fufficient difcernment, and therefore fhall here only attempt to refer all the feveral cafes Of this difeafe to a few general heads. MCCCLVII. The firft is of thofe arifing from the appli- cation of the ufual flimulus to the heart's con- traaion ; that is, the influx of the venous blood into its cavities,, being made with more velocity, and therefore, in the fame time, in greater quantity than ufual. It feems to be in this manner that violent exercife occafions palpitation. MCCCLVIII. A fecond head of the cafes of palpitation, is of thofe arifing from any refiftance given to the free and enfcre levacuation of the ven- tricles of the hearth y Thus a ligature made upon the aorta occafions palpitatiohs of the moft violent kind. Similar refiftances, either in the aorta or pulmonary artery, may be readily imagined ; and fuch have been often found in the dead bodies of perfons who, during life, had been much affect-ed with pal- pitations. To this head are to be referred all thofe cafes of palpitation arifing from caufes pro- D 6 ducing ;2 PRACTICE ducing an accumulation of blood in the great veffels near to the heart. MCCCLIX. A third head of the cafes of palpitation, is of thofe arifing from a more violent and rapid influx of the nervous power into the mufcular fibres of the heart. It is in this manner that I fuppofe various caufes aaing in the brain,f and particularly certain emotion^ of the mind, occafion palpitation. MCCCLX. A fourth head of the cafes of palpitation, is of thofe arifing from caufes producing a weaknefs in the aaion of the heart, by dimin- ifhing the energy of the brain with refpea to it. That fuch caufes operate in producing palpi- tation, I prefume from^^gnce, that all the*fev- eral caufes mentioned.above (MCLXXVII etfeq.) as in this mannoVproducing fyncope, do often produce palpitation. It is on this ground that thefe two difeafes are affeaioM frequently occurring in the fame perfon, as the fame caufes may occafion the one or the other, according to the force of the caufe and mobility of the perfon aaed upon. It feems to be a law of the human economy, that a degree of debility occurring in any funaion, ©ften produces a more vigorous exertion of OF -PHYSIC. 73 the fame, or at lead an effort towards it, and that commonly in a convulfive manner. I apprehend it to be the convulfive aaion, frequently ending in fome degree of a fpafm, that gives occafion to the intermittent pulfe fo frequently accompanying palpitation. MCCCLXI. A fifth head of the cafes of palpitation may perhaps be of thofe arifing from a peculiar irritability or mobility of the heart. This, indeed, may be confidered as a predifponent caufe only, giving occafion to the aaion of the greater part of the caufes recited above. But it is proper to obferve, that this predifpo- fition is often the chief part of the remote caufe ; infomueh that many of the caufes pro- ducing palpitation would not have this effea but in perfons peculiarly predifpofed. This head, therefore, of the cafes of palpitation, often'requires to be ^linguifhed from all the red. ' ^K MCCCLXII. * After thus marking the feveral cafes and caufes of palpitation, I think it neceffary, with a view to the cure of this difeafe, to obferve, that the feveral caufes of it may be again re- duced to two heads. The fird is, of thofe confiding in, or depending upon, certain or- ganic affeaions of the heart itfelf, or of the"1 great 74 PRACTICE great veffels immediately conneaed with it. The fecond is, of thofe confiding in, or de- pending upon, certain affeaions fubfiding and aaing in other parts of the body, and aft. ing either by the force of the caufe, or in con- fequence of the mobility of the heart. MCCCLXIII. With refpea to the cafes depending upon the firft fet.of caufes, I muft repeat here what, I faid with refpea to the like cafes of fyncope, that I do not know any means of curing them. They, indeed, admit of fome pallia- tion, firfl, by avoiding every circumfiance that may hurry the circulation of the blood ; and, fecondly, bj* every means of avoiding a plethoric ftate of the fyftem, or any occafion- al turgefcence of the blood. In many of thefe cafes, bloodletting may give a tempo* rary relief: But in fo far as debility and mo- bility are concerned^iri fuch cafes this reme- dy is likely to do harm?* MCCclLxiV. With refpea to the cafes depending upon the other Set of caufes, they may be various, and require very different meafures : But I can here fay in general, that thefe cafes may be confidered as of two kinds ; one depending ^ upon primary affeaions in other parts- of the « body, and aaing by the force of the particu- lar OF PHYSIC. lar caufes; and another depending upon a ftate of mobility in the heart itfelf. In the firft of thefe, it is obvious, that the cure of the palpitation muft be obtained by curing the primary affeaion ; which is not to be treated of here. In the Second, the cure rhuft be obtained, partly by diligently avoiding the occafional caufes, partly and chiefly by cor- reaing the mobility of the fyftem, and of the heart in particular ; for doing which we have treated of the proper means elfewhere. Chap. V. Of Dyspnoea, or Difficult Breath- ing. MCCgLXV. THE exercife of refpiratidjn, and the or* gans of it, have fo conftant and considerable a connexion with almoft the whole of the other funaions and parts of the human body, that upon almod every occafion of difeafe, refpiration mud be affeaed. Accordingly fome difficulty and diforder in this funaion, are in faa fymptoms very generally accom- panying difeafe. MCCCLXVI. 76 PRACTICE MCCCLXVI. Upon this account, the Symptom of diffi- cult breathing deferves a chief place and an- ample confideration in the general fydem of Pathology ; but what ftiare of confideration it ought to have in a treatife of Praaice,. I find) it difficult to determine. MCCCLXVII. On this fubjea, it is, in the fird place nec~ effary to didinguifh between the. fymptomatiq and idiopathic affeaions ; that is, between thofe difficulties of breathing which are fymp- toms only of a more general affeaion, or of a difeafe fubfiding primarily in other parts than the organs of refpiration, and that difficulty of breathing which depends upon a primary" affeaion of the lungs themfelves. The va- rious cafes of fymptomatic dyfpncea I have taken pains to enumerate in my Methodical, Nofology, and it will be obvious they are fuch as cannot be taken notice of here. MCCCLXVIII. In my Nofology I have alfo taken pains to point out and enumerate the proper, or at lead the greater part of the proper, idiopathic cafes of dyfpncea; but from that enumeration it will, I think, readily appear, that few, and indeed OF FHYSIC. 77 indeed hardly any, of thefe cafes will admit or require much of our notice in this place. MCCCLXIX. The Dyfpncea Sicca, fpecies, 2d; the Dyf- pncea Aerea,fp. 3d, the Dyfpncea Terrea,fp.. 4th, and Dyfpncea Thoracica, fp. 7th, are fome of them with difficulty known, and are all of them difeafes which in my opinion do not admit of cure. All, therefore, that can. ; be faid concerning them here is, that they may admit of fome palliation ; and this, I think, is to be obtained chiefly by avoiding a ple- thoric date of the lungs, and every circum- ftance that may hurry refpiration. MCCCLXX. Of the Dyfpncea Extrinfeca,fp. Sth, I can fay no more, but that thefe external caufes marked in the Nofology, and perhaps fome others that might have like effecls, are to be carefully avoided ; or, when they have been applied, and their effeas have taken place, the difeafe is to be palliated by the means mentioned in the laft paragraph. MCCCLXXL The other fpecies, though enumerated as idiopathic, can hardly be confidered as fuch, or as requiring to be treated of here- The 7cr PRACTICE The Dyfpncea Catarrhalis, fp. if, may he confidered as a fpecies of catarrh, and is pret, ty certainly to be cured by the fame remedies as that fpecies of catarrh which depends rath- er upon the increafed afflux of- mucus to the bronchiae, than upon any inflammatory ftate in them. The Dyfpncea Aquofa,fp. §th, is certainly to be confidered as a fpecies of dropfy, and is to be treated by the fame remedies as the other fpecies of that difeafe. The Dyfpncea Pinguedinofa, fp. 6th, is in like manner to be confidereel as a fymptom or local effea of the Polyfarcia, and is only to be cured by correaing the general fault ot! the fyftem. MCCCLXXII. From this view of thofe idiopathic cafes of dyfpncea, which are perhaps all I could prop. erly arrange under this title, it will readily .< appear that there is little room for treating of them here : But there is ftill one cafe of dif- ficult breathing, which has been properly diftinguifhed from every other under the title of Aflhma ; and as it deferves our particular attention, I fhall here Separately confider it. Chap. OF PHYSIC. 79 Chap. VI. Of Asthma. MCCCLXXIII. THE term of Aflhma has been commonly applied by the vulgar, and even by many writers on the Praaice of Phyfic, to every cafe of difficult breathing, that is, to every fpecies of Dyfpncea. The Methodical No- fologifts, alfo, have diftinguiffied Afthma from Dyfpncea chiefly, and almoft Solely, by the former being the fame affeaion with the lat- ter, but in a higher degree. Neither of thefe applications of the term feems to have been correa or proper. I am of opinion, that the term Adhma may be moft properly applied, and Should be confined, to a cafe of difficult fc breathing that has peculiar fymptoms, and depends upon a peculiar proximate caufe^ which I hope to affign with fufficient certain- ty. It is this difeafe I am now to treat of, and it is nearly what Praaical Writers have generally diflinguifhed from the other cafes of difficult breathing, by the title of Spaf- modic Adhma, or of Aflhma convuljivum ; although, by not didinguifhing it with Suf- ficient 3a PRA«CTICE ficient accuracy from the other cafes of Dyfc pncea, they have introduced a great deal of confufion into their treatifes on this fubjeft. MCCCLXXIV. f The difeafe I am to treat of, or the Aflh- ma to be driaiy fo called, is often a heredw tary difeafe. It feldom appears very early in life, and hardly till the time of puberty, or after it. It affeas both fexes, but mod fre- quently the male. I have not obferved it to be more frequent in one kind of tempera- ment than in another; and it does not feem to depend upon any general temperament of the whole body, but upon a particular confti- tution of the lungs alone. It frequently at- tacks perfons of a full habit; but it hardly ever continues to be repeated for fome length* of time without occasioning an emaciation of the whole body. MCCCLXXV. The attacks of this difeafe are generally in* the night time, or towards the approach of night; but there are alfo fome inftances of their coming on in the courfe of the day. At whatever time they come on, it is for the moft part fuddenly, with a fenSe of tightnefs and ftriaure acrofs the breaft, and a fenfe of ftraitnefs in the lungs impeding inspiration.1* The perfon thus attacked, if in a horizontal situation,, OF PHYSIC. 8i fituation, is immediately obliged to get into fomcwhat of an erea pofture, and requires a free and cool air. The difficulty of breath- ing goes on for fome time increasing ; and both infpiration and exfpiration are perform- ed flowly, and with a wheezing noife. In violent fits, fpeaking is difficult and uneafy. There is often fome propenfity to coughing, but it can hardly be executed. MCCCLXXVI. Thefe fymptoms often continue for many hours together, and particularly from mid- night till the morning is far advanced. Then commonly a remiffion takes place by degrees; the breathing becomes lefs laborious and more full, fo that the perfon can fpeak and cough with more eafe ; and, if the cough brings up fome mucus, the remiffion becomes imme- diately more considerable, and the perfon falls into a much wifhed for fleep. MCCCLXXVII. . During thefe fits the pulfe often continues in its natural ftate ; but in fome perfons the fits are attended with a frequency of pulfe, and with fome heat artd thirft, as marks of fome degree of fever. If urine be voided at the beginning of a fit, it is commonly in con- fiderable quantity, and with little colour or odour j but, after the fit is over, the urine voided 82 PRACTICE voided is in the ordinary quantity, of a high colour, and fometimes depofites a Sediment, In fome perSons, during the fit the face is a little flulhed and turgid ; but more common. ly it is Somewhat pale and fhrunk. MCCCLXXVIII. After fome fleep in the mornings the pa- tient, for the reft of the day* continues to hav* more free and eafy breathing, but it is Seldom entirely fuch* He ftill feels fome tightnefs acrofs his breaft, cannot breathe eafily in a horizontal pofture^ and can hardly bear any motion of his body, without having hil breathing rendered more difficult and uneafy, In the afternoon he has an unufual flatulencf of his ftomach, and an unufUal drowfine6| I and, very frequently, thefe fymptoms precede the firft attacks of the difeafe. But* whether thefe fymptoms appear or hot, the chfficulty of breathing returns towards the evening; and then Sometimes gradually increafes, till it Decomes as violent as in the night before : Or if, during the day^the difficulty of breathing has been moderate, and the perfon gets fome fleep in the firft part of the night, he is, how- ever, waked about midnight or at fome time between midnight and two o'clock in the morning ; and is then fuddenly feized with a fit of difficult breathing, which runs the fame courfe as the night before. MCCQLXXIX. OF PHYSIC, 83 MCCCLXXIX. In this manner fits return for Several nights iucceffively ; but generally, after fome nights paffed in this way, the fits differ more con- siderable remiffions. This efpecially hap- pens when the remiffions are attended with a more copious expeaoration in the mornings, and that this continues from time to time throughout the day. In thefe circumftances, afthmatics, for. a long time after, have not only more eafy days, but enjoy alfo nights of entire fleep, without the recurrence of the difeafe. MCCCLXXX. When this difeafe, however, has ortce taken place in the manner above defcribed, it is ready to return at times for the whole of life after. Thefe returns, however, happen with different circumftances in different perfons* MCCGLXXXI. In fome perfons the fits are readily ex- cited by external heat, whether of the weather or of a warm chamber, and par- ticularly by warm bathing. In fuch perfons fits are more frequent in dimmer, and partic- ularly during the dog days, than at other tolder feafon*. The fame perfons are alSo teadilv $4 PRACTICE readily affeaed by changes of the weathety efpecially by fudden changes made from a colder to a warmer, or, what is commonly the fame thing, from a heavier to a lighter attn'oG. phere. The fame perfons are alfo affected by every circumftance Straitening the capacu ty of the thorax, as by any ligature made, or even by a plafter laid, upon it; and a like ef* fea happens from any increafed bulk of the ftomach, either by a full meal, or by air col- leaed in it. They are likewife much affeft* ed by exercife, or whatever elfe can hurry the circulation of the blood. MC'CCLXXXI'I. As afthmatic fits feem thus to depend upon fome fulnefs of the veffels of the lungs, it is probable that an obftruaion of perfpiration, and the blood being lefs determined to the Surface of the body, may favour an accumu* lation in the lungs, and thereby be a means of exciting aflhma. This feems to be the cafe of thofe afthmatics who have fits moft frequently in the winter feaSon, and who have commonly more of a catarrhal affeaion ac- companying the afthma; which therefore oc- curs more frequently in winter, and more manifeftly from the application of cold. MCCCLXXXIII. Befide thefe cafes of afthma excited by heat or cold, there are others, in which the fits are efpecially OF PHYSIC. «85 efpecially excited by powers applied to the nervous fyftem j as by paffions o£ the mind, by particular odours, and by irritations of fmoke and duft. That this difeafe is an affeaion of the ner- vous fyftem, and depending upon a mobility of the moving fibres of the lungs, appears pretty clearly from its being frequently con- neaed with other fpafmodic affeaions de- pending upon mobility ; fuch as hyderia, hy- pochondriafis, dyfpepfia, and atonic gout. MCCCLXXXIV. From the whole of the hiftory of afthma now delivered, I think it will readily appear, that the proximate caufe of this difeafe is a preternatural, and in fome meafure a fpaf- modic, conftriaion of the mufcular fibres of the bronchiae ; which not only prevents the dilatation of the bronchias neceffary to a free and full inspiration, but gives alfo a rigidity which prevents a full and free exfpiration. This preternatural condriaion, like many other convulfive and fpafmodic affeaions, is readily excited by a turgefcence of the blood, or other caufe of any unufual fulnefs and dif- tention of the veffels of the lungs. MCCCLXXXV. This difeafe, as coming by fits, may be gen- erally diftinguifhed from moft other fpecies Vol. III. E of &6*' PRACTICE of dyfpncea, whofe caufes being more con- stantly applied, produce therefore a more condant difficulty of breathing. There may, however, be fome fallacy in this matter, as Ibme of thefe caufes may be liable to have abatements and intenfities, whereby the dyf- pncea produced by them may feem to come by fits ; but I believe it is feldom that fuch fits put on the appearance of the genuine adhmatic fits defcribed above. Perhaps, however, there is dill another cafe that may give more difficulty ; and that, is, when Sev- eral of the caufes, which we have affigned as caufes -of feveral of the fpecies of difficult breathing referred to the genus of Dyfpnopa, may have the effea of exciting a genuine adhmatic fit. Whether this can happen to any but the peculiarly predifpofed to afthma, I am uncertain ; and therefore, whether, in any fuch cafes, the afthma may be confidered as fymptomatic ; or if, in all fuch cafes, the adhma may not dill be confidered.and treated as an idiopathic difeaSe. MCCCLXXXVI. The adhma, though often threatening im- mediate death, feldom occafions it; and many > perfons have lived long under this difeafe. In many cafes, however, it does prove fatal; fometimes very quickly, and perhaps always at length. In fome young perfons it has ended foon, by occafioning a phthifis pulmo- naliss OF PHYSIC. 87 nalis. After a long continuance, if often ends in a hydrothorax ; and commonly, by occa- sioning fome aneurifm of the heart or great veffels, it thereby proves fatal. MCCCLXXXVII. As it is feldom that an adhma has been en- tirely cured ; I therefore cannot propofe any method of cure which experience has approv- ed as generally fuccefsfuL But the difeafe admits of alleviation in feveral refpeas from the ufe of remedies ; and my bufinefs now fhall be chiefly to offer fome remarks upon the choice and ufe of the remedies which have been commonly employed in cafes of adhma. MCCCLXXXVIII. As the danger of an adhmatic fit arifes chiefly from the difficult tranfmiffion of the blood through the veffels of the lungs, threat- ening fuffocation ; fo the mod probable means pf obviating this feems to be bloodletting; and therefore, in all violent fits, praaitioners have had recourfe to this remedy. In fird at- tacks, and efpecially in young and plethoric perfons, bloodletting may be very neceffary, and is commonly allowable. But it is alfo evident, that, under the frequent recurrence of fits, bloodletting cannot be frequently re- peated without exhauffing and weakening the E 2 patient 88 PRACTICE patient too much. It is further to be ob- ferved, that bloodletting is not fo neceffary as might be imagined, as the paflage of the blood through the lungs is not fo much interrupted « as has been commonly fuppofed. This I particularly conclude from hence, that, in- dead of the fuffufion of face, which is the ufual effea of fuch interruption, the face, in adhmatic fits, is often Shrunk and pale. I conclude the fame alfo from this, that, in adhmatic fits, bloodletting does not com- monly give fo much relief as, upon the con- trary fuppofition, might be expeaed. MCCCLXXXIX. As I have alleged above, that a turgefcencs ' of the blood is frequentl^the exciting caufe of adhmatic fits, fo it might be fuppofed, that a plethoric date of the fydem might have a great Share in producing a turgeScence of the blood in the lungs; and efpecially, therefore, that bloodletting might be a proper remedy in adhma. I allow it to be fo in the fird at- tacks of the difeafe : But as the difeafe, by cbntinuing, generally takes off the plethoric' date of the fydem ; fo, after the difeafe has continued for fome time, I allege that blood- letting becomes lefs and lefs neceffary. MCCCXC. Upon the fuppofition of affhmatics being in a plethoric date, purging might be fuppof- ed OF PHYSIC. 89 ed to prove a remedy in this difeafe r But; both becaufe the fuppofition is not commons ly well founded, and becaufe purging is fel- dom found to relieve the veffels of the thorax, this remedy has not appeared to be well fuit- ed to adhmatics ; and large purging has al- ways been found to do much harm. But as adhmatics are always hurt by the dagnation and accumulation of matters, in the aliment- ary canal, fo coftivenefs muft be avoided, and an open belly proves ufeful. In the time of fits, the employment of emollient and mode- rately laxative glyders has been found to give eonfiderable relief. MCCCXCI. As a flatulency of. the domach, and other fymptoms of indigedion, are frequent attend- ants of adhma, and very- troublelome to adh- matics ; fo, both for removing thefe fymp- toms, and for taking off all determination to the lungs, the frequent ufe of gentle vomits is proper in this difeafe. In certain cafes, where a fit was expeaed to come on in the courfe of the night, a vomit given in the evening has frequently feemed to prevent it. MCCCXCII. Blidering between the fhoulders, or upon the bread, has been frequently employed to relieve afthmatics ; but in the pure fpafmodic E 3 afthma 90 PRACTICE afthma we treat of here, I have rarely found blifters ufeful, either in preventing or reliev- ing fits. MCCCXCIII. Iffues are certainly ufeful in obviating pleth- ora ; but as fuch indications feldom arife in caSes of afthma, fo iffues have been feldom found ufeful in this difeafe. MOCCXCIV. As afthmatic fits are fo frequently excited by a turgefcence of the blood, fo the obviating and allaying of this by acids and neutral falts, ■ feems to have been at all times the objea of praaitioners. See Floyer on the Aflhma. MCCCXCV. Although a plethoric -ftate of the fyftem may feem to difpofe to afthma, and the occar fional turgefcence oS the blood may Seem to be frequently the exciting caufe of the fits ; yet it is evident, that the difeafe muft have arifen chiefly from a peculiar conditution in the moving fibres of the bronchias, difpofing them upon various occafions to fall into a fpafmodic condriaion ; and therefore, that the entire cure of the difeafe can only be ex- peaed from the correaing of that predifpofir tion, or from correaing the preternatural mobility OF PHYSIC. ga mobility or irritability of the lungs in that refpea. MCCCXCVI. In cafes wherein this predifpofition de- pends upon original conformation, the cure mud be difficult, and perhaps impoffible ; but it may perhaps be moderated by the ufe of antifpafmodics. Upon this footing, various remedies of that kind have been commonly employed, and particularly the fetid gums ; but we have not found them of any consid- erable efficacy, and have obferved them to foe fometimes hurtful by their heating too much. Some other antifpafmodics which might be fuppofed powerful,' fuch as mufk, have not been properly tried. The vitriolic ether has been found to give relief, but its effeas are not lading. MCCCXCVII. As in other fpafmodic affeaions, fo in this, the mod certain and powerful antifpafmodic is opium. I have often found it effeaual, and generally Safe ; and if there have arifen doubts with refpea to its Safety, I believe they have arifen from not didinguifhing between certain plethoric and inflammatory cafes of dyfpncea, improperly named Afthma, and the genuine fpafmodic adhma we treat cf here. E 4 MCCCXCVIII. 9* PRACTICE MCCCXCVIII. IX. As in many cafes this difeafe depends upon> a predifpofition which cannot be corrected by our art, fo in fuch cafes the patient can^ortly efcape the difeafe by avoiding the occafional or exciting caufes, which I have endeavoured to point out above. It is, however, difficult to give any general rules here, as different adhmatics have their different idiofyncrafies with refpea to externals. Thus, one adh- matic finds himfelf eafied living in the midft of a great city, while another cannot breathe but in the free air of the country. In the latter cafe, however, mod adhmatics bear the* air of a low ground, if tolerably free and dry, better than that of the mountain. MCCCXCIX. In diet alfo, there is fome difference to be made with refpea to different adhmatics. None of them bear a large or full meal, or any food that is of flow and difficult Solution in the domach ; but many of them bear an- imal food of the lighter kinds, and in mode- rate quantity. The ufe of .vegetables which readily prove flatulent, are always very hurt- ful. In recent adhma, and efpecially in the young and plethoric, a fpare, light, and cool diet is proper, and commonly neceffary ; but, after the difeafe has continued for years, adh- matics O F P'HYSI C. 93 matics commonly bear, and even require, a tolerably full diet, though in all cafes a very full diet is very hurlfuL J i MCCCC. In drinking, water, or cool watery liquors, is the only fafe and fit drink for adhmatics ; and all liquors ready to ferment, and become flatulent, are hurtful to them. Few adhmat- ics can bear any kind of drong drink ; and any excefs in fuch is always very hurtful to them. As adhmatics are commonly hurt by taking warm or tepid drink ;. fo, both upon that account and upon account of the liquors weakening the nerves of the domach, neither tea nor coffee is proper in this difeafe.. MCCCCI. Adhmatics commonly bear no bodily mo- tion eafily but that of the mod gentle kind. Riding, however, on horfeback, or going in a carriage, and eSpecially Sailing, are very often ufeful to adhmatics. 4 Vol. 3. E 5 Citap. 9± PRACTICE Chap. VII. Of the Ciiincough, or Hoopingcough. * MCCCCII. THIS difeafe is commonly epidemic, and manifedly contagious. It feems to proceed from a contagion of a fpecific nature, and of a fingular quality. It does not, "like moft other contagions, neceffarily produce a fever; nor does it, like mod others, occafion any ' eruption, or produce oth'erwife any evident change in the date of the human fluids. It has, in common with the catarrhal contagion, and with that of the meafles, a peculiar de- termination to the lungs ; but with particular effeas there, very different from thofe of the other two ; as will appear from the hidory of this difeafe now to be delivered. MCCCCIII. This contagion, like feveral others, affects perfons but once in the courfe of their lives ; and therefore, neceffarily, children are molt commonly the fubjea.s of this difeafe : But there are many indances of it occurring in perfons OF PHYSIC. 95 perfons confiderably advanced in life ; thoiigh. it is probable, that the further that pv rio'.i are advanced in life, they are the lefs liable to be affeaed with this contagion. MCCCCIV. The difeafe commonly comes on with the ordinary fymptoms of a catarrh arifing from cold ; and often, for many days, keeps entire- ly to that appearance ; and I have had in- ftances of a difeafe which, though evidently arifing from the chincough contagion, never put on any other form than that of a com- mon catarrh. This, however, feldom happens ; for, gen- erally, in the fecond, and at fartheft in the third week after the attack, the difeafe puts on* its peculiar and charaaeridic fymptom, a convulfive cough. This is a cough in which the exfpiratory motions peculiar to coughing are made with more frequency, rapidity, and violence, than ufual. As thefe circumdances, however, in different indances of coughing, are in very different degrees ; fo no exact limits can be put to determine when the cough can be ftriaiy faid to be convulfive ; and it is therefore; efpecially by smother circumdance that the chincough is diflinguifhed from every other form of coi*gh. This circumdance is, when many exfpiratory motions have been Convulsively made, and thereby the air is in •great'quantity throwniout of the Lungs, a full ini I K 6 infpiration 96 PRACTICE infpiration is neceffarily and fuddenly made; which, by the air ruining in through the glot- tis with unufual velocity, gives a peculiar found. This found is Somewhat different in different cafes, but is in general called a Hoop ; and from it the whole of the difeafe is called the Hoopingcough. When this So- norous infpiration has happened, the convul- five coughing is again renewed, and continues in the fame manner as before, till a quantity of mucus is thrown up from the lungs, or the contents of the domach are thrown up by vomiting. Either of thefe evacuations com- monly puts an end to the coughing, and the patient remains free from it for fome time after. Sometimes it is only after feveral al- ternate fits of coughing and hooping that ex- pectoration or vomiting "takes place ; but it is commonly after the fecond coughing that thefe happen, and put an end to the fit. MCCCCV. When the difeafe, in this manner, has tak- en its prcper form, it generally continues for a long time after, and generally from one month to three; but fometimes much longer, and that with very various circumdances. MCCCCVI. The fits of coughing return at various in- tervals, rarely obferving any exaa period. They OF PHYSIC. 97 They hapfltn frequently in the courfe of the day, and more frequently dill in the courfe of the night. The patient has commonly fome warning of their coming on ; and, to avoid that violent and painful concuffion which the coughing gives to the whole body, he clings fad to any thing that is near to him, or demands to be held fad by any perfon that he can come at. When the fit is over, the patient fometimes breathes fad, and feems fatigued for a little after : But in many this appears very little ; and children are commonly fo entirely re- lieved, that they immediately return to their play, or what elCe they were occupied in before. MCCCCVlL If it happens that the fit of coughing ends in vomiting up the contents of the domach, the patient is commonly immediately after feized with a drong craving and demand Sor Sood, and takes it in very greedily. MCCCCVIIL At the fird coming on of this difeafe, the expeaoration is fometimes none at all, or of a thin mucus only ; and while this continues to be the cafe, the fits of coughing are more violent, and continue longer : But commonly the expeaoration Soon becomes considerable, • and gS PRACTICE and a very thick mucus, often id|§reat quan- tity, is thrown up ; and as this is more readily brought up, the fits of coughing are of Shorter duration. MCCCCIX. The violent fits of coughing frequently in- terrupt the free tranfmiflion of the blood through the lungs, and thereby the free re- turn of blood from the veflels of the head. This occafions that turgefcence and fuffufion of face which commonly attends the fits of coughing, and feems to occafion alfo thofe eruptions of blood from the nofe, and even from the eyes and ears, which fometimes happen in this difeafe. MCCCCX. This difeafe often takes place in the man- ner we have now defcribed, without ariy py- rexia attending it ; but, though Sydenham had feldom obferved it, we have found the difeafe very frequently accompanied with py- rexia, fometimes from the verv beginning, but more frequently only after the difc?fe had continued for Some time. When it'does ac- company the diSeaSe, we have not found it appearing under any regular' intermittent form. It is condantly in Some decree pref- ent • but with evident exacerbations towards evfeniftig)' continuing till netit morn J r. ti ■'■■■■ ""*> MCCCCXI. O F P H Y S I C. 99 MCCCCXI. Another fymptom very frequently attend- ing the chincough, is a difficulty of breath- ing ; and that not only immediately before and after fits of coughing, but as conftantly prefent, though in different degrees in differ- ent perfons. I have hardly ever Seen an in- stance of a fatal chincough, in which a con- siderable degree of pyrexia and dyfpncea had not been for fome time conftantly prefent. MCCCCXII. When by the power of the contagion this difeafe has once taken place, the fits of cough- ing are often repeated, without any evident exciting caufe : But, in many cafes, the con- tagion may be confidered as giving a predif- pofition only; and the frequency of fits de- pends in fome meafure upon various exciting caufes ; fuch as, violent exercife ; a full meal; the having taken in food of difficult folution ; irritations of the lungs by duft, fmoke, or dif- agreeable odours of a drong kind ; and efpec- ially any confiderable emotion of the mind. MCCCCXIII. Such are the chief circumdances of' this difeafe, and it is of various event ; wh'.ch, however, ioo PRACTICE however, may be commonly forefeen by at-. tending to the following confiderations. The younger that children are, they are in the greater danger from this difeaSe ; and of thofe to whom it proves fatal, there are many more under two years old than above it. . The older that children are, they are the more Secure againd an unhappy event; and this I hold to be a very general rule, though I own there are many exceptions to it; Children born of phthifical and adhmatic parents are in the greated danger from this difeafe. When the difeafe, beginning in the form of a catarrh, is attended with fever and difficult breathing, and with little expeaoration, it often proves fatal, without taking on the form of the hoopingcough ; but, in mod of fuch cafes, the coming on of the convulfive cough and hooping, bringing on at the fame time a more free expeaoration, generally removes the danger. When the difeafe is fully formed, if the fits are neither frequent nor violent, with mod- erate expeaoration, and the patient, during the intervals of the fits, is eafy, keeps his ap- petite, gets fleep, and is without fever or dif- ficult breathing, the difeafe is attended with no danger; and thefe circumdances becoming daily more favourable, the difeafe very foon Spontaneously terminates. An expectoration, either very Scanty or very copious, is attended with danger ; efpec- ially OF PHYSIC. ioi rally if the latter circumdance is attended with great difficulty of breathing. Thofe cafes in which the fits terminate by a vomiting, and are immediately followed by a craving of food, are generally without danger. A moderate hemorrhagy from the nofe often proves Salutary ; but very large hemor~ rhagies are generally very hurtful. This difeafe coming upon perfons under a date of much debility, has very generally an unhappy event.. The danger of this difeafe fometimes arifes from the violence of the fits of coughing, oc- casioning apoplexy, epilepfy, or immediate fuffocation : But thefe accidents are very rare ; and the danger of the difeafe feems generally to be in proportion to the fever and dyfpncea attending it. MCCCCXIV. The cure of this difeafe has been always confidered as difficult, whether the purpofe be to obviate its fatal tendency when it is vi- olent, or merely to fhorten the courfe of it when it is mild. When the contagion is re- cent, and continues to aa, we neither know how to correa, nor how to expel it ; and therefore the difeafe neceffarily continues for fome time : But it is probable, that the con- tagion in this as in other inftances ceafes at length to aa ; and that then the difeafe con- tinues, PRACTICE tinues, as in other convulfive affeaions, by the power of habit alone. MCCCCXV. From this view of the matter I maintain,. that the praaice muft be different, and adapt- ed to two different indications, according to the period of the difeafe. At the beginning of the difeafe, and for Some time after, the remedies to be employed muft be fuch as may obviate the violent effeas of the difeafe, and the fatal tendency of it; but, after the difeafe has continued for fome time, and is without any violent Symptoms, the only remedies which can be required are thoSe which may interrupt its courSe, and put an entire flop to it Sooner than it would have Spontaneously ceaSed. MCCCCXVI. For anfwering the firft indication. In ple- thoric fubjeas, or in others, when from the circumftances of the cough and fits it appears that the blood is difficultly tranfmitted through the lungs, bloodletting is a neceffary remedy ; and it may be even neceffary to repeat it, ef- pecially in the beginning of the difeafe : But, as fpafmodic affeaions do not commonly ad- mit of much bleeding, fo it is feldom proper in the chincough to repeat this remedy often. MCCCCXVII. OF PHYSIC. - MCCCCXVII. As codivenefs frequently attends this dif- eafe, fo it is neceffary to obviate or remove it by laxatives employed ; and keeping an open belly is generally ufeful : But large evacuations in this way are commonly hurt- ful. MCCCCXVIII. To obviate or remove the inflammatory de- termination to the lungs that fometimes oc- curs in this difeafe, bliftering is often ufeSul, and even repeated bliftering has been of fer- vice ; but iffues have not fo much effea, and fhould by no means fuperfede the repeated bliftering that may be indicated. When blifters are proper, they are more effeaual when applied to the thorax, than when ap- plied to any diftant parts. MCCCCXIX. Of all other remedies, emetics are the moft ufeful in this difeafe ; both in general by in- terrupting the return of fpafmodic affections, and in particular by determining very power- fully to the Surface of the body, and thereby taking off determinations to the lungs. For thefe purpofes, I think, full vomiting is fre- quently to be employed ; and, in the inter- vals 104 PRACTICE vals neceffary to be left between the times of full vomiting, naufeating dofes of the anti- monial emetics may be ufeful. I have never found the fulphur auratum, fo much praifed by Cloffius, to be a convenient medicine, on account of the uncertainty of its dofe ? and the tartar emetic employed in the manner di- reaed by the late Dr. Fothergill, has appear- ed to be more ufeful. MCCCCXX. Thefe are the remedies to be employed in the firft ftage of the difeafe for obviating its fatal tendency, and putting it into a fafe train. But in the fecond dage, when I fuppofe the contagion has ceafed to aa, and that the dif- eafe continues merely by the power of habit, a different indication arifes, and different remedies are to be employed. MCCCCXXI. This difeafe, which often continues for a long time, does not, in my opinion, continue during the whole of that time in confequence of the contagion's remaining in the body, and continuing to aa in it. That the difeafe does often continue long after the contagion has ceafed to aft, and that too by the power of habit alone, appears to me probable from hence, that terror has frequently cured the difeaSe ; that any considerable change in the OF PHYSIC. 105 ftate of the fyftem, fuch as the coming on of the fmall pox, has alfo cured it ; and, laftly, that it has been cured by antifpafmodic and tonic medicines ; whilft none of all thefe means of cure can be fuppofed either to cor- rea or to expel a morbific matter, though they are evidently fuited to change the ftate and habits oS the nervous fyftem. ' MCCCCXXII. From this view we are direaed to the in- dication that may be formed, ^nd in a great meafure to the remedies which may be em- ployed in what we fuppofe to be the fecond ftage of the difeafe. It may perhaps be al- leged, that this indication of fhortening the courfe of the difeaSe is not very important or neceffary, as it SuppoSes that the violence or danger is over, and, in conSequence, that the difeaSe will Soon Spontaneously ceaSe. The laft Supposition, however, is not well founded ; as the difeafe, like many other con- vulfive and Spafmodic affeaions, may con- tinue for a long time by the power of habit alone, and by the repetition of paroxyfms may have hurtful effects ; more efpecially as the violence of paroxyfms, and therefore their hurtful effeas, may be much aggravated by various external caufes that may be accident- ally applied. Our indication, therefore, is proper; and we proceed to confider the fev- 106 PRACTICE eral remedies which may be employed to anfwer it. MCCCCXXIII. Terror may poffibly be a powerful rem- edy, but is is difficult to meafure the degree of it that fhall be produced ; and, as a flight degree of it may be ineffeaual, and a high degree of it dangerous, I cannot propofe to employ it. MCCCCXXIV. The other remedies which we SuppoSe Suit- ed to our Second indication, and which in- deed have been frequently employed in this difeafe, are antifpafmodics or tonics. Of the antifpafmodics, caftor has been par- ticularly recommended by Dr. Morris ; but in many trials we have not found it effeaual. With more probability mufk has been em- ployed : But whether it be from our not hav- ing it of a genuine kind, or not employing it in fufficiently large dofes, I cannot determine; but we have not found it commonly fuccefs- ful. Of antifpafmodics, the moft certainly powerful is opium : And when there is no confiderable fever or difficulty of breathing prefent, opium has often proved ufeful in moderating the violence of the chincough; but I have not known it employed fo as en- tirely to cure the difeaSe. If OF PHYSIC. 107 If hemlock has proved a remedy in this difeafe, as we muft believe from Dr. Butter's accounts, I agree with that author, that it is to be confidered as an antifpafmodic. Upon this fuppofition, it is a probable remedy ; and from the accounts of Dr. Butter and fome others, it feems to have been often ufeful : but, in our trials, it has often difappointed us, perhaps from the preparation of it not having been always proper. MCCCCXXV. Of the tonics, I confider the cupmofs, for- merly celebrated, as of this kind ; as alfo the bark of the mifletoe : But I have had no ex- perience of either, as I have always trufted to the Peruvian bark. I confider the ufe of this medicine as the mod certain means of curing the difeafe in its fecond dage ; and when there has been little fever prefent, and a fufficient quantity of the bark has been giv- en, it has feldom failed of Soon putting an end to the difeaSe. MCCCCXXVI. When convulfive diSorders may be fup- poSed to continue by the Sorce of habit alone, it has been found that a confiderable change in 108 PRACTICE in the whole of the circumdances and manner of life has proved a cure of fuch difeaSes ; and analogy has applied this in the caSe of the chincough fo Sar, that a change of air has been employed, and fuppofed to be ufeful. In feveral indances I have obferved it to be fo ; but I have never found the effeas of it durable, or fufficient to put an entire flop to the difeafe. on SECT. OF PHYSIC. 109 S E C T. III. » of the SPASMODIC AFFECTIONS in the NATURAL FUNCTIONS. Chap. VIII. Of the Pyrosis, or what is named in/Scotland the Water Brash. MCCCCXXVII. 1 HE painful fenfations re- ferred to the domach, and which are proba- bly occafioned by real affeaions of this organ, are of different kinds. Probably they proceed from affeaions of different natures, and fhould therefore be diffinguifhed by different appel- lations ; but I mud own that the utmod precif- ion in this matter will be difficult. In my eflay towards a methodical r^ofology, I have, how- ever, attempted it. For thofe pains that are either acute and pungent, or accompanied with a fenSe of didention, or with a fenfe of condriaion, if they are at the fame time not attended with any fenfe of acrimony or heat, Vol. III. F I employ no PRACTICE I employ the appellation of Gadrodynia. To exprefs thofe painful or uneafy fenfations which feem to arife from a fenfe of acrimony* irritating the part, or from fuch a fenfe of heat as the application of acrids, whether ex- ternally or internally applied, often gives, I rrnploy the term of Cardialgia ; and by this 1 particularly mean to denote thofe feelings which arc expreffed by the term Heartburn in the Englifh language. I think the term Soda has been commonly employed by prac- tical writers to expreSs an affeaion attended with feelings of the latter kind. MCCCCXXVIII. Befide the pains denoted by the*terms Gaf- trodynia, Periadynia, Cardialgia, and Soda, there is, I think, another .painful fenfation different from all of thefe, which is named by Mr. Sauvages Pyrofis Suecica; and his ac- count of it is taken from Linnaeus, who names it Cardialgia Sputatoria. Under the title of Pyrofis Mr. Sauvages has formed a genus, of which the whole of the fpecies, except the eighth, which he gives under the title of Py- rofis Suecica, are all of them fpecies of the Gadrodynia or of the Cardialgia ; and if there is a genus to be formed under the title of Py- rofis, it can in my opinion comprehend only the fpecies I have mentioned. In this cafe, indeed, I own that the term is not very prop- er ; but my averfion to introduce new names has- OF PHYSIC. in has made me continue to employ the term of Mr. Sauvages. MCCCCXXIX. The Gadrodynia and Cardialgia I judge to be for the mod part fymptomatiq affections ; and therefore have given them no place in this work: But the Pyrofis, as an idiopathic difeafe, and never before treated of in any fydem, I propofe to treat of here. MCCCCXXX. It is a difeafe frequent among pepple in lower life ; but occurs alfo, though more rarely, in people of better condition. Though frequent in Scotland, it rs by no means fo frequent as Linnaeus reports it to be in Lap- land. It appears mod commonly in perfons under middle age, but feldom in any perfons before the age Of puberty. When it has once taken place, it is ready to recur occa- sionally for a long time after ; but it feldom appears in perfons confiderably advanced in life. It affeas both Sexes, but more frequent- ly the female. It fometimes attacks pregnant women, and fome women only when they are in that condition. Of other women, it more frequently affeas the unmarried ; and of the married, mod frequently the barren. I have had many indances of its occurring in women labouring under a fluor albus. F2 MCCCCXXXI. 112 PRACTICE MCCCCXXXI. The fits of this difeafe ufually come on in the morning and forenoon, when the dpmach is empty. The fird fymptom of it is a pain at the pit of the domach, with a fenSe of con- driaion, as if the domach was drawn towards the back ; the pain is increafed by railing the body into an cre£t podure, and therefore the body is bended forward. This pain is often very Severe.; and, after continuing for fome time, it brings on an eruaation of a thin wa- tery fluid in confiderable quantity. This fluid has fometimes an acid tade, but is very often abfolutely infipid. The eruaation is Sor Some time Srequently repeated j and does not immediately give relief to the pain which preceded it, but does fo at length, and puts an end to the fit. MCCCCXXXII. The fits of this difeaSe commonly come on without any evident exciting cauSe; and I have not Sound it deadily conneaed with any particular diet. It attacks perfons ufing an- imal food, but I think more frequently thofe living on milk and farinacea. It feems oSten to be excited by cold applied to the lower ex- tremities ; and is readily excited by any con- fiderable emotion of mind. It is often with- out any fymptoms of dyfpepfia. MCCCCXXXIIL OF PHYSIC. , 113 MCCCCXXXIII. The nature oS this affeaion is not very ob- vious ; but I think it may be explained in this manner : It feems to begin by a fpafm of the mufcular fibres oS the Stomach ; which is aSterwards, in a certain manner, communicat- ed to the blood veflels and exhafants, So as to increaSe the impetus of the fluids in thefe vef- fels, while a condriaion takes place on their extremities. While therefore the increafed impetus determines a greater quantity than ufual of fluids into thefe veflels, the conffric- tion upon their extremities allows only the pure watery parts to be poured out, analo- gous, as I judge, in every refpea, to what happens in the diabetes hydericus. MCCCCXXXIV. The praaice in this difeafe is as difficult as the theory. The paroxyfm is only to be cer- tainly relieved by opium. Other antifpaf- modics, as vitriolic ether and volatile alkali, are fometimes of Service, but not condantly fo. Although opium and other antifpaf- modics relieve the fits, they have no effect in preventing their recurrence. For this pur- poSe, the whole of the remedies of dyfpepfia have been employed without SucceSs. Of the ufe of the nux vomica, mentioned as a rem- edy by Linnaeus, I have had no experience. F.3 Chap. "4 PRACTICE C H A P. IX. Of the Colic MCCCCXXXV. THE principal fymptom of this difeafe, is a pain felt in the lower belly. It is feldom fixed and pungent in one part, but is a pain- ful didention in fome meafure fp reading over the whole of the belly ; and particularly with a fenfe of twilling or wringing ground the navel. At the fame time, with this pain, the navel and teguments of the belly are frequent- ly drawn inwards, and often the mufcles of the belly are fpafmodically contracted, and this in Separate portions, giving the appear- ance of a bag full of round balls. MCCCCXXXVI. Such pains, in a certain degree, fometimes occur in cafes of diarrhoea and cholera ; but thefe are lefs violent and moretranfitory, and are named Gripings. It is only when more violent and permanent, and attended with coftivenefs, that they conftitute colic. This is alfo commonly attended with vomiting, which OF P H Y 5 i C. 115 which in many cafes is frequently repeated, efpecially when any thing is taken down into the ftomach ; and in fuch vomitings, not only the contents of the ftomach are thrown up, but alSo the contents of the duodenum, and therefore frequently a quantity of bile. MCCCCXXXvft. In fome cafes of colic, the periftaltic mo- tion is inverted through the whole length of the alimentary canal, in fuch a manner that' the contents of the great guts, and therefore ftercoraceous matter, is* thrown up by vom- iting ; and the fame inverfion appears ftill more clearly from this, that what is thrown into the return by glyfter is again thrown out by the mouth. In thefe circumdances of in- verfion the difeafe has been named Ileus, or the Iliac Paffion ; and this has been fuppof- ed to be a peculiar difeafe diflina from colic; but :o me it appears that the two difeafes are owing to the fame proximate caufe, and have the fame fymptoms, only in a different degree. MCCCCXXXVIII. The colic is often without any pyrexia at- tending it. Sometimes, however, an inflam- mation comes upon the part of the inteflTne efpecially affeaed ; and this inflammation aggravates all the fymptoms of the dileafe, being probably what,bringson the mod con- F 4 fiderable n6 PRACTICE fiderable inverfion of the periftaltic motion j and, as the dercoraceous vomiting is what efpecially didinguifhes the ileus, this has been confidered as always depending on an inflam- mation of the inteltines. However, I can af- firm, that as there are inflammations of the inteftines wittaut dercoraceous vomiting, fo I have Seen irntances oS dercoraceous vomit- ing without inflammation ; and there is there- fore no ground for didinguifhing ileus from colic, but as a higher degree of the fame af- feaion. MCCCCXXXIX. The fymptoms of the colic, and the diffec- tions of bodies dead of this difeafe, fhow very clearly that it depends upon a fpafmodic con- driaion of a part of the intedines ; and that this therefore is to be confidered as the prox- imate caufe of the difeaSe. In Some of the diffeaions of perfons dead of this difeafe, an intus fufception has been remarked to have happened ; but whether this be conftantly the caSe in all the appearances oS ileus, is not certainly determined. MCCCCXL. The colic has commonly been confidered as being of different fpecies, but I cannot follow the writers on this fubjea in the diftinaions they have eftablifhed. So far, however, as a difference OF PHYSIC. 117* difference of the remote caufe conftitutes a difference of fpecies, a didinaion may per- haps be admitted ; and accordingly in my Nofology I have marked feven different fpe- cies : But I am well perfuaded, that in all thefe different fpecies the proximate rjaufe is the fame, that is, a fpafmodic condriaion of a part of the intedines ; and confequently, that in all thefe cafes the indication of cure is the fame, that is, to remove the conduc- tion mentioned. Even in the feveral fpecies named Stercorea, Callofa, and Calculofa, in which the difeafe depends upon an obdruc- tion of intedine, I am perfuaded that thefe obdruaions do not produce the fymptoms of colic, excepting in fo far as they produce fpaf- modic condriaions of the intedines ; and therefore, that the means of cure in thefe cafes, fo far as they admit of cure, mud be obtained by the fame means which the gen- eral indication above mentioned Suggeds. MCCCCXLI.. The cure, then, of the colic univerfally, is to be obtained by removing the fpafmodic condriaions of the intedines ; and the rem- edies fuited to this purpofe may be referred to three general heads : 1. The taking off the fpafm by various an- tifpafmodic powers. Vol. 3. F5 2. The n8 PRACTICE 2. The exciting the aaion of the intedines by purgatives. 3. The employing mechanical dilatation. MCCCCXLII. Before entering upon a more particular ac- count of thefe remedies, it will be properto obferve, that in all cafes of violent colic, it is advifeable to praaife bloodletting ; both as it may be ufeful in obviating the inflammation which is commonly to be apprehended, and even as it may be a means of relaxing the fpafm of the intedine. This remedy may perhaps be improper in perfons of a weak and lax habit, but in all perfons of tolerable vigour it will be a fafe remedy ; and in all cafes where there is the lead fufpicion of an inflammation aaually coming on, it will be abfolutely neceffary. Nay, it will be even proper to repeat it perhaps feveral times, if, with a full and hard pulfe, the appearance of the blood drawn, and the relief obtained by the fird bleeding, fhall authorife fuch repe- tition. MCCCCXLIII. The antifpafmodic powers that may be employed, are, the application of heat in a dry or humid form, the application of blif- ters, the ufe of opium, and the ufe of mild oils. The O^F PHYSIC. 119 The application of heat, in a dry form, has been employed by applying to the belly of the patient a living animal, or bladders filled with warm water, oHtegs of Subflances which long retain their heat; and all thefe have Sometimes been applied with Succefs ; but none of them feem to me fo powerful as the application-of heat in a humid form. This may be employed either by the im- mersion of a great part of th<% body in warm water, or by fomenting the belly with cloths wrung out of hot water. The immerfion has advantages from the application of it ? to a greater part of the body, and particularly to the lower extremities : But immerfion cannot always be conveniently praaiSed, and fomen- tation may have the advantage of being long- er continued ; and it may have nearly all the benefit of immerfion, if it be at the fame time applied both to the belly and to the lower extremities. MCCCCXLIV. Fronrconfidering that the teguments of the lower belly have fuch a connexion with the mteftines, as at the fame time to be affeaed with fpafmodic contraaions, we perceive that bliders applied to the belly may'have the ef- fea of taking off the fpafms both from the mufcles of the belly and from the intedines ; and accordingly, blidering has often been em- F 6 ployed 120 PRACTICE ployed in the colic with advantage. Anal- ogous to this, rubefacients applied to the belly have been frequently found ufeful. «r MCCCCXLV. The ufe of opium in colic may feem to be an ambiguous remedy. Very certainly it may for fome time relieve the pain, which is often fo violent, and urgent, that it is difficult to abdain Srom the uSe of fuch a remedy. At the fame time, the ufe of opium retards or fufpends the peridaltic motion fo much, as to allow the intedines to fall into conftriaions ; and may therefore, while it relieves the pain, render the caufe of the difeafe more obftinate. On this account, and further as opium pre- vents the operation of purgatives fo often nec- effary in this difeafe, many praaitioners are averfe to the uSe oS it, and Some entirely re- jea the uSe ojf it as hurtful. There are, however, others who think they can employ opium in this diSeaSe with much advantage. In all cafes where the colic comes on with- out any previous coftivenefs, and arifes from cold, from paffions of the mind, or other caufes which operate efpecially on the ner- vous fydem, opium proves a fafe and certain remedy; but in cafes which have been pre- ceded by long codivenefs, or where the colic, though not preceded by codivenefs, has how- ever continued for fome days without a dool, fo that a dagnation of faeces in the colon is to be OF PHYSIC. 121 be fufpeaed, the ufe of opium is of doubtful effea. In fuch cafes, unlefs a ftool has been firft procured by medicine, opium cannot be employed but with Some hazard of aggravat- ing the diSeaSe. However, even in thofe circumftances of coftivenefs, when, without inflammation, the violence of the fpafm is to be fufpeaed, when vomiting prevents the ex-' hibition of purgatives, and when with all this the pain is extremely urgent, opmm is to be employed, not only as an anodyne, but alfo as an antifpafmodic, neceffary to favour the operation of purgatives ; and may be fo. em- ployed, when, either at the fame time with the opiate, or not long after it, a purgative can be exhibited. Is the hyofciamus, as often fhowing, along with its narcotic, a.purgative quality, better fuited to this difeafe than opium ? MCCCCXLVI. i It is Seemingly on good grounds that fev- eral praaitioners have recommended the large ufe of mild oils in this diSeaSe, both as anti- spasmodics and as laxatives ; and, where the palate and ftomach could admit them, I have found them very ufeSul. But as there are few Scottifh Stomachs that can admit a large uSe of oils, I have had few opportunities of employing them. MCCCCXLVII. P R A C T I C E MCCCCXLVII. The fecond fet of remedies adapted to the cure of colic, are purgatives ; which, by ex- citing the aaion of the interlines, either above- or below the obftruaed place, may remove the conftriaion ; and therefore thefe purga- tives may be given either by the mouth, or thrown by glyfter into the anus. As the dif- eafe is often Seated in the great guts ; as glyf- ters, by having a more fudden operation, may give more immediate relief; and as purga- tives given by the mouth are ready to-be re- jeaed by vomiting ; fo it is common, and in- deed proper, to attempt curing the colic in the fird place by glyders. Thefe may at firft be of the mildeft kind, confifting of a large bu*lk of water, with fome quantity of a mild oil; and fuch are fometimes fufficiently effi- cacious : However, they are not always fo ; and it is commonly neceffary to render them more powerfully ftimulant by the addition of neutral falts, of which the moft powerSul is the common or marine Salt. If thefe faline glyfters, as fometimes happens, are rendered again too quickly, and on this account or oth- erwife are found ineffeaual, it may be proper, inftead of thefe falts, to add to the glyfters an infufion of fenna, or of fome other purgative that can be extraaed by water. The anti- mojaial wine may be fometimes employed in glyners with advantage. Hardly any glyfters are OF PHYSIC. 123 are more effeaual than thofe made of turpen- tine properly prepared. When all other in- jeaions are found ineffeaual, recourfe is to be had to the injeaion of tobacco fmoke ; and, when even this fails, recourfe is to be had to the mechanical dilatation to be men- tioned hereafter. MCCCCXLVIII. As glyders often fail altogether in relieving this difeafe, and as even when they give Some relief they are often imperfea in producing a complete cure ; So it is generally proper, and oSten neceffary, to attempt a more entire and certain cure by purgatives given by the mouth. The more powerful of thefe, or, as they are called, the Draftic»Purgatives, may be Some- times neceffary ; but their uSe is to be avoid- ed, both becauSe they are apt to be rejeaed by vomiting, and becauSe when they do not Succeed in removing the obdruction they are ready to induce an inflammation. Upon this account it is ufual, and indeed proper, at lead in the firft place, to employ the milder and lefs inflammatory purgatives. None have fucceeded with me better than the cryftals of tartar, becauSe this medicine may be conve- niently given, in Small but repeated doSes, to a confiderable quantity ; and under this man- agement it is the purgative lead ready to be rejeaed by vomiting, and much lefs fo than the other neutral Salts. If a ftronger purga- 124 P R A C T I C E tive be required, jalap, properly prepared, is lefs offenfive to the palate, and fits better up- on the domach, than moft other powerful purgatives. On many occafions of colic, nothing is more effectually purgative than a large dofe of calomel. Some praaitioners have attempted to remove the obftruaion of the inteftines by antimonial emetics exhibited in Small dofes, repeated at proper intervals ; and when thefe dofes are not entirely rejeaed by vomiting, they often prove effectual pur- gatives. , When every purgative has failed, the ac- tion of the inteftines has been effeaually ex- cited by throwing cold water on the lower extremities. MCCCCXLIX. The third means of overcoming the SpaSm of the inteftines in this difeaSe, is by employ- ing a mechanical dilatation ; and it has been frequently fuppofed that quickfilver, given in large quantity, might operate in this manner. I have not, however, found it fucceSsful; and the theory of it is with me very doubtful. Some authors have mentioned the ufe of gold and filver pills, or balls, fwallowed down ; but I have no experience of fuch practices, and I cannot fuppofe them a probable means of relief. MCCCCL. OF PHYSIC. 125 MCCCCL. Another means of mechanical dilatation, and a more probable meafure, is by injeaing a large quantity of warm water by a proper Syringe, which may throw it with Some force, and in a continued ftream, into the reaum. Both from the experiments reported by the late Mr. De Haen, and from thofe I myfelf have had occafion to make, I judge this rem- ^ edy to be one of the moft powerful and ef- fectual. MCCCCLI. J have now mentioned all the feveral means that may be* employed for the cure of the colic, confidered as a genus ; but beSore I Suit this Subjea, it may be expeaed that I lould take notice of fome of the fpecies which may feem to require a particular con- fideration. In this view it may be expeaed that I fhould efpecially take notice of that fpecies named the Colic of Poitou, and par- ticularly known in England by the name of the Devonfhire Colic. MCCCCLII. This fpecies of the difeafe is certainly a peculiar one, both in refpea of its caufe and its effeas; but, as to the firft, it has been lately «26 PRACTICE lately fo much the fubjea of inveftigation, and is fo well afcertained by the learned phy- ficians Sir George Barker and Dr. Hardy, that it is unneceffary for me to fay any thing ef it here. With refpea to the cure of it, fo far as it appears in the form of a colic, my want of ex- perience concerning it does not allow me to fpeak with any confidence on the fubjea ; but, fo far as I can learn from others, it ap- pears to me, that it is to be treated by all the feveral means that I have propofed above for the cure of colic in general. How far the peculiar effeas of this difeafe are to be certainly forefeen and obviated, I have not properly learned ; and I muft leave the matter to be determined by thoSe who have had fufficient experience in it. Chap. X. Of the Cholera. MCCCCLIII. IN this difeafe, a vomiting and purging concurring together, or frequently alternating with one another, are the chief fymptoms. The OF PHYSIC. 127 The matter rejeaed both upwards and down- wards appears manifeftly to confift chiefly of bile. MCCCCLIV. From this laft circumftance I' conclude, that the diSeaSe depends upon an increaSed fecretion of bile, and its copious effufion into the alimentary canal ; and, as in this it irri- tates and excites the motions above mention- ed, I infer, that the bile thus effufed in larger quantity is at the fame time alfo of a more acrid quality.. This appears likewife from the violent and very painful gripings that at- tend the difeafe, and which we^can impute only to the violent fpafmodic, contraaions of the inteftines that take pladj, here. TheSe fpafms are commonly communicated to the abdominal mufcles, and very frequently to thofe of the extremities. MCCCCLV. In the manner now defcribed, the difeafe frequently proceeds with great violence, till the ftrength of the patient is> greatly, and often fuddenly, weakened ; while a coldnefs of the extremities, cold fweats, and faintings, coming on, an end is put to the patient's life, Some- times in the courSe of one day. In other cafes the difeaSe is leSs violent, continues for a day or two, and then ceafes by degrees; though 128 PRACTICE though fuch recoveries feldom happen with- out the affidance of remedies. MCCCCLVI. The attacks of this difeafe are feldom ac- companied with any fymptoms of pyrexia ; and though, during the courfe of it, both the pulfe and refpiration are hurried and irregu- lar, yet thefe fymptoms are generally So en- tirely removed by the remedies that quiet the fpafmodic affeaions peculiar to the difeafe, as to leave no ground for fuppofing that it had been accompanied by any proper py- rexia. MCCCCLVII. This is a difeafe attending a very warm ftate of the air ; and, in very warm climates, it may perhaps appear at any time of the year: But even in fuch climates it is moft frequent during their warmeft SeaSons ; and in temperate climates, it appears only in the warm feafons. Dr. Sydenham confidered the appearances of this difeafe in England to be confined to the month of Auguft ; but he himSelf obferved it to appear fome- times towards the end of fummer, when the feafon was unufually warm ; and that, in proportion to the heat, the violence of the difeafe was greater. Others have obferved that it appeared more early in fummer, and always OF PHYSIC. 129 always fooner or later, according as the great heats Sooner or later let in. MCCCCLVIII. From all thefe circumftances, it is, I think, very evident, that this diSeaSe is the effea of a warm atmofphere, producing fome change in the ftate of the bile in the human body : And the change may confift, either in the matter of the bile being rendered more acrid, and thereby fitted to excite a more copious fe- cretion ; or, in the fame matter, its being prepared to paSs off in larger quantity than uSual. ¥■ MCCCCLIX. It has been remarked, that in warm cli- mates and feafons, after extremely hot and dry weather, a fall of rain cooling the atmof- phere feems efpecially to bring on this dif- eafe ; and it is very probable that an ob- ftruaed perfpiration may have alSo a fhare in this, though it is alSo'certain that the diSeaSe does appear when no change in the temper- ature of the air, nor any application of cold, has been obferved. MCCCCLX. It is poffible, that, in fome cafes, the heat tf the feafon may give only a predifpofition, and 13° PRACTICE and that the difeafe may be excited by certain ingefta or other caufes ; but it is equally cer- tain, that the difeafe has occurred without any previous change or error, either in diet, or in the manner of life, that could be ob- ferved. MCCCCLXI. The Nofologids have conftituted a Genus under the title of Cholera, said under this have arranged as fpecies every affeaion in which a vomiting and purging of any kind happened to concur. In many of thefe fpe- cies, however, the matter evacuated is not bilious ; nor does the evacuation proceed from any caufe in the date of the atmof- phere. Further, in many of thefe fpecies alfo, the vomiting which occurs is not an ef- fential, but merely an accidental fymptom from the particular violence of the uifeafe. The appellation of Cholera therefore Should, in my opinion, be confined "to the difeafe I have defcribed above ; which by its peculiar caufe, and perhaps alfo by its fymptoms, is very different from all the other fpecies that have been affociated with it. I believe that all the other Species arranged under the title oS Cholera by Sauvages or Sagar, may be properly enough reSerred to the genus of Di- arrhoea ; which we are to treat of in the next chapter. The OF P H Y S I^C. 131 The diftinaion I have endeavoured to eftablifh between the proper Cholera, and the other diSeaSes that have Sometimes got the Same appellation, will, as I judge, Super- sede the queftion, Whether the Cholera, in temperate climates, happens at any other Seafon than that above affigned ? MCCCCLXII. In the cafe of a genuine cholera, the cure of it has been long eftablifhed by experience. In the beginning of the diCeale, the evacu- ation of the redundant bile is to be favoured by the plentiful exhibition of mild diluents, both given by the mouth, and injeaed by the anus ; and all evacuaijt medicines, employed in either way, are not only fuperfluous, but commonly hurtful. mCccclxiii. When the redundant bile appears to be fufficiently wafhed out, and even before that, if the fpafmodic affeaions of the alimentary canal become very violent, and are commu- nicated in a confiderable degree to other parts of the body, or when a dangerous debility feems to be induced, the irritation is to be immediately obviated by opiates, in fufficient- ly large dofes, but in fmall bulk, and given either by the mouth or by glyfter. MCCCCLXIV. 132 PRACTICE MCCCCLXIV. Though the patient be in this manner re- lieved, it frequently happens, that when the operation of the opium is over, the difeaSe Shows a tendency to return ; and, Sor at lead fome days after the fird attack, the irritabili- ty of the intedines, and their difpofition to ^ fall into painful fpafmodic con tract ionsg.feem to continue. In this fituation, the repetition of the opiates, for perhaps feveral days, may come to be neceffary ; and as the debility commonly induced by the difeafe favours the difpofition to SpaSmodic afFeaions, it is often ufeful and neceffary, together with the opiates, to employ the tonic powers of the Peruvian bark. V Chap. XI. Of Diarrhoea or Looseness* MCCCCLXV. THIS difeafe confids in evacuations by ftool, more frequent and of more liquid mat- ter than ufual. This leading and charaaer- idic Symptom is fo diverfified in its degree, in its caufes, and in the variety of matter evac- uated. OF PHYSIC. 135 uated, that it is almod impoffible to give any general hidory of the difeafe. MCCCCLXVI. It is to be didinguifhed from dyfentery, by not being contagious ; by being generally without fever ; and by being with the evacu- tion of the natural excrements, which are, at lead for fome tin^ retained in dyfentery. The two difeaSes have been commonly didin- guifhed by the gripings being more violent in the dySentery; and they are commonly lefs violent and lefs frequent in diarrhoea : But as they frequently do occur in this alfo, and Sometimes to a confiderable degree, So they do not afford any proper diftinction. MCCCCLXVIL A diarrhoea is to be didinguifhed from cholera chiefly.by the difference of their cauf- es ; which, in cholera, is of one peculiar kind ; but in diarrhoea is prodigioufly diverfified, as we fhall fee prefently. It has been common to didinguifh cholera by the evacuation down- wards being oS bilious matter, and by this be- ing always accompanied with a vomiting of the Same kind ; but it does not univerfally apply, as a diarrhoea is fometimes attended with vomiting, and even of bilious matter. Vol. III. G MCCCCLXVIlt. PRACTICE MCCCCLXVIII. The difeafe of diarrhoea, thus didinguifh- ed, is very greatly diverfified ; but in all cafes, the frequency of dools is to be imputed to a preternatural increafe of the peridaltic mo- tion in the whole, or at lead in a confiderable portion, of the intedinal canal. This increaf- ed aaion is in different degrees, is often con- vulfive and fpafmodic, and at any rate is a motus abnormis : For which reafon, in the Methodical Nofology, I have referred it to the order of Spafmi, and accordingly treat of it in this place. MCCCCLXIX. Upon the fame ground, as I confider the difeafe named Liefitery to be an increafed peridaltic motion over the whole of the in- tedinal canal, arifing from a peculiar irrita- bility, I have cor fidered it as merely a fpecies of diarrhoea. The idea of a laxity of the in- tedinal canal being the caufe either of lientery, or other fpecies of diarrhoea, appears to me to be without foundation, except in the Single caSe of frequent liquid dools from a palfy of the fphinflcr ani. MCCCCLXX. The increafed aaion of the peridaltic mo- tion, I confider as always the chief part of the proximate OF PHYSIC. 135 proximate caufe of diarrhoea : But the dif- eafe is further, and indeed chiefly, diverfified by the different caufes of this increafed ac- tion ; which we are now to inquire into. MCCCCLXXI. The feveral caufes of the increafed aaion of the intedines may be referred, I think, in the fird place, to two general heads. The frfl is, of the difeafes of certain parts of the body which, either from a confent of the intedines with thefe parts, or from the re- lation which the intedines have to the whole fydem, occafion an increafed aaion in the intedines, without the transference of any dimulant matter from the primary difeafed part to them. The fecond head of the caufes of the in- creafed aaion of the intedines is of the flim- uli of various kinds, which are applied direa- iy to the inteftines themfelves. MCCCCLXXII. That affeaions of other parts of the fydem may affea the intedines without the transfer- ence or application of any dimulant matter, we learn from hence, that the paffions of the mind do in fome perfons excite diarrhoea. G 2 MCCCCLXXIII. 131S PRACTICE MCCCCLXXIH. That difeafes in other parts may in like manner affea the inteftines, appears from the dentition of infants frequently exciting diar- rhoea. I believe that the gout often affords another indance of the fame kind ; and prob- ably there are others alfo, though not well afcertained. *> MCCCCLXXIV. The ftimuli (MCCCCLXXI) which may be applied to the intedines are oS very various kinds ; and are either, 1. Matters introduced by the mouth. 2. Matters poured into the intedines by the Several excretories opening into them. 3. Matters poured from certain preternat- ural openings made into them in certain dif* eafes. MCCCCLXXV. Of thofe (MCCCCLXXIV, 1.) introduc- ed by the mouth, the fird to'be mentioned are the aliments commonly taken in. Too great a quantity of thefe taken in, often prevents their due digedion in the domach ; and by being thus Sent in their crude, and probably* acrid, date to the intedines, they frequently excite diarrhoea* The OF PHYSIC. 137 The fame aliments, though in proper quan- tity, yet having too great a proportion, as fre- quently happens, of Saline or Saccharine mat- ter along with "them, prove dimulant to the intedines, and excite diarrhoea. But our aliments prove efpecially the cauf- es of diarrhoea, according as they, from their own nature, or from the weaknefs of the ftom- ach, are difpofed to undergo an undue de- gree of fermentation there, and thereby be- come ftimulant to the inteftines. Thus acef- cent aliments are ready to produce diarrhoea; but whether from their having any direaiy purgative quality, or only as mixed in an over proportion with the bile, is not well de- termined. MCCCCLXXVL Not only the acefcent, but alfo the putref- cent difpofition of the aliments, feems to oc- cafion a diarrhoea ; and it appears that even the effluvia of putrid bodies, taken in any way in large quantity, have the fame effea. Are oils or fats, taken in as a part of our aliments, ever the caufe of diarrhoea ? and if fo, in what manner do they operate ? MCCCCLXXVII. The other matters introduced by the mouth, which may be caufes of diarrhoea, are thofe thrown in either as medicines, or poi- G 3 Sons 138 PRACTICE Sons that have the faculty of dimulating the alimentary canal. Thus, in the lid of the Materia Medica, we have a long catalogue of thofe named purgatives ; and in the lid of poifons, we have many poffefled of the fame quality. The former, given in a certain quantity, occafion a temporary diarrhoea ; and given in very large dofes, may occafion it in excefs, and continue it longer than ufual, producing that fpecies of diarrhoea named a Hypercatharfis. MCCCCLXXVIII. The matters (MCCCCLXXIV, 2.) pour- ed into the cavity of the intedines from the excretorfes opening into them, and which may occafion diarrhoea, are either thofe from the pancreatic or biliary dua, or thofe from the excretories in the coats of the intedines them- Selves. MC'CCCLXXIX. What changes may happen in the pancre- atic juice, I do not exaaiy know ; but I fup- poSe that an acrid fluid may iffue from the pancreas, even while dill entire in its flruc- ture ; but more eSpecially, when it is in a Sup- purated, fchirrous, or cancerous date, that a very acrid matter may be poured out by the pancreatic dua, and occafion diarrhoea. MCCCCLXXX. OF PHYSIC. 139 MCCCCLXXX. We know well, that from the biliary dua the bile may be poured out in greater quan- tity than ufual ; and there is little doubt of its being alfo fometimes poured out of a more than ordinary acrid quality. It is very prob- able, that in both ways the bile is frequently a caufe of diarrhoea. Though I have Said above that diarrhoea may be commonly didinguifhed Srom chol- era, I mud admit here, that as the caufes pro- ducing that date of the bile which occafions cholera, may occur in all the different poffible degrees of force, fo as, on one occafion, to produce the mod violent and didinaiy mark- ed cholera; but, upon another, to produce only the gentled diarrhoea ; which, however, will be the fame difeafe, only varying in de- gree : So I think it probable, that in warm climates, and in warm SeaSons, a diarrhoea bit- iofa oS this kind may frequently occur, not to be always certainly didinguifhed from chol- era. However this may be, it is fufficiently probable, that, in fome cafes, the bile, with- out having been aaed upon by the heat of the climate or feaSon, may be redundant and acrid, and prove therefore a particular caufe of diarrhoea. G4 MCCCCLXXXI. 140 PRACTICE MCCCCLXXXI. Befide bile Srom the Several cauSes and in the conditions mentioned, the biliary dua may pour out pus, or other matter, Srom ab- fceffes in the liver, which may be the caufe of diarrhoea. Praaical writers take notice of a diarrhoea wherein a thin and bloody liquid is discharg- ed ; which they fuppofe to have proceeded from the liver, and have therefore given the difeaSe the name of Hepatirrhcea : But we have not met with any indance of this kind ; and therefore cannot properly fay any thing concerning it. MCCCCLXXXII. A fecond Set of excretories, from which matter is poured into the cavity of the intef- tines, are thofe from the coats of the intedines themfelves ; and are either the exhalants pro- ceeding direaiy from the extremities of ar- teries, or the excretories from the mucous fol- licles : And both thefe fources occur in pro- digious number over the internal furface of the whole intedinal canal. It is probable that it is chiefly the effufion from thefe fources which, in mod indances, gives the matter of the liquid dools occurring in diar- rhoea. MCCCCLXXXIII. OF PHYSIC. 141 MCCCCLXXXIII. * The matter from both fources may be pour- ed out in larger quantity than uSual, merely by the increaSed aaibn of the intedines, whether that be excited by the paffions of the mind (MCCCCXXII), by dileafes in other parts of the fydem (MCCCCLXXI, 1.), or by the various dimulants mentioned MCCCCLXXV, and following ; or the quantity of matter poured out may be in- creafed, not fo much by the increafed aaion of the intedines, as by an increafed afflux of fluids from other parts of the fydem* Thus, cold applied to the furface of the body, and fuppreffing perfpiration, may de- termine a greater quantity of fluids to the in- tedines. Thus, in the ifchuria renalis, the urine tak- en into the bloodveflels is fometimes deter- mined to pafs off again by the intedines. In like manner, pus or Serum may be ab- sorbed Srom the cavities in which they have been dagnant, and be again poured out into the intedines, as Srequently happens, in par- ticular with reSpea to the water of dropfies. MCCCCLXXXIV. It is to be obferved here, that a diarrhoea may be excited not only by a copious afflux of fluids from other parts of the fydem, but Vol. 3. 65 likewife PRACTICE likewife by the mere determination of various acrid matters from the mafs of blood into the cavity of the inteftines. Thus it is SuppoSed that the morbific matter oS fevers is Sometimes thrown out into the cavity of the inteftines, and gives a critical diarrhoea : And whether I do or do not admit the doarine of critical evacuations, I think it is probable that the morbific matter of the exanthemata is fre- quently thrown, upon the inteftines, and oc- cafions diarrhoea. MCCCCLXXXV. It is to me further probable, that the pu- trefcent matter diffufed over the mafs of blood in putrid difeafes, is frequently poured out by the exhalants into the inteftines, and proves there the caufe, at leaft in part, of the diarrhoea So commonly attending theSe diSeaSes. MCCCCLXXXVI. Upon this Subjea of the matters poured into the cavity of the inteftines, I have chief- ly confidered them as poured out in unufual quantity : But it is probable that, for the molt part, they are alfo changed in their quality, and become of a more acrid and ftimulant nature ; upon which account eSpecially it is, that they excite, or at leaft increafe, a diar- rhoea. MCCCCLXXXVIL OF PHYSIC. , f 143 MCCCCLXXXVII. How far, and in what manner, the exha- lant fluid may be changed in its nature and quality, we do not certainly know : But with refpea* to the fluid from the mucous excre- tories, we know, that, when poured out in unufual quantity, it is commonly, at the lame time, in a more liquid and acrid form ; and may'prove> therefore, confiderably irritating. MCCtCLXXXVIII. Though the copious effufion of a more liquid and acrid matter from the mucous ex- cretories, be probably owing to the matter being poured out immediately as it is Secreted from the blood into the mucous follicles, without being allowed to Stagnate in the lat- ter, So as to acquire that milder quality and thicker confiftence we commonly find in the mucus in its natural ftate ; and although we might SuppoSe that the excretions of a thin and acrid fluid fhould always be the effecj of every determination to the mucous follicles, and of every dimulant applied to them ; yet it is certain, that the reverfe is Sometimes the caSe ; and that, Srom the mucous Sollicles, there is frequently an increafed excretion of a mucus, which appears in its proper form of a mild, vifcid, and thickifh matter. This commonly occurs in the cafe of dyfentery ; G 6 and ii4 PRACTICE and it has been obferved to give a fpecies of diarrhoea, which has been properly named the Diarrhoea Mucofa. MCCCCLXXXIX. A third fource of matter poured into the cavity of the inteftines, and occafioning diar- rhoea (MCCCCLXXIV, 3.), is from thofe preternatural openings produced by difeaSes in the inteftines or neighbouring parts. Thus the bloodveffels on the internal furface of the inteftines may be opened by erofion, rupture, or anaftomofis, and pour into the cavity their blood, which, either by its quantity or by its acrimony, whether inherent, or acquired by Stagnation, may fometimes give a diarrhoea evacuating bloody matter. This is what I think happens in that difeafe which has been called the Melana or Morbus Niger. MCCCCXC. Another preternatural fource of matter poured into the cavity of the inteftines, is the rupture of abfeeffes Seated either in the coats oS the inteftines themSelves, or in any of the contiguous vifcera, which, during an inflamed ftate, had formed an adhefion with fome part of the inteftines. The matter thus poured into their cavity may be various ; purulent or fanious, or both together, mixed at the fame time with more or lefs of blood; and in OF PHYSIC. 145 in each of thefe ftates may be a caufe of diar- rhoea. MCCCCXCI. Amongft the ftimuli that may be directly applied to the inteftines, and which, by in- creasing their periftaltic motion, may occafion diarrhoea, I muft not omit to mention worms, as having frequently that effect. MCCCCXCIL I muft alfo mention here a ftate of the in- teftines, wherein their periftaltic motion is < preternaturally increafed, and a diarrhoea produced ; and that is, when they are affea- ed with an erythematic inflammation. With refpea to the exiftence of fuch a date,, and its occafioning diarrhoea, fee what is Said above in CCCXCVIII and Sollowing. Whether it is to be confidered as a particular and dif- tina caSe of diarrhoea, or is always the fame with fome of thofe produced by one or other of the caufes above mentioned, I have not been able to determine. MCCCCXCIII. Laftly, by an accumulation of alimentary or of other matter poured into the cavity of the inteftines from feveral of the fources above mentioned, a diarrhoea may be efpecially oc- cafioned 146 PRACTICE cafioned when the abSorption of the laaeals,, or of other abforbents, is prevented, either by an obftruaion of their orifices, or by an ob- ftruaion of the mefenteric glands, through which alone the abforbed fluids can be tranf- mitted. In one inftance of this kind, when the chyle prepared in the ftomach and duodenum is not abforbed in the courfe of the inteftines, but paffes off in confiderable quantity by the anus, the difeafe has been named Morbus CceU iacus, or limply and more properly Coeliaca; which accordingly I have confidered as a fpe- cies of diarrhoea. MCCCCXCIV. I have thus endeavoured to point out the various fpecies of difeafe that may come un- der the general appellation of Diarrhoea ; and from that enumeration it will appear, that many, and indeed the greater part of the cafes of diarrhoea, are to be confidered as fympa- thetic affeaions, and to be cured only by curing the primary difeafe upon which they depend ; of which, however, I cannot prop- erly treat here. From our enumeration it will alfo ap'pear, that many of the cafes of di- arrhoea which may be confidered as idiopath- ic, will not require my faying much of them here. In many indances, the difeafe is as- certained, and alfo the caufe affigned, by the condition of the matter evacuated; fo that what OF PHYSIC. H7 what is neceffary to correa or remove it will be fufficiently obvious to praaitioners of any knowledge. In fhort, I do not find that I can offer any general plan for the cure of di- arrhoea ; and all that I can propofe to do on this fubjea, is to give fome general remarks on the praaice that has been commonly fol- lowed in the cure of this difeaSe. MCCCCXCV. The praaice in this diSeaSe has chiefly pro- ceeded upon the Suppofition of an acrimony in the fluids, or of a laxity in the Simple and moving fibres of the intedines ; and the rem- edies employed have accordingly been, Cor- reaors of particular acrimony, general de- mulcents, evacuants by vomiting or purging^ adringents, or opiates. Upon each of thefe kinds of remedy I fhall now offer fome re- marks. MCCCCXCVI. An acid acrimony is, upon feveral occa- fions, the caufe of diarrhoea, particularly in children ; and in fuch cafes the abforbent earths have been very properly employed. The common, however, ar 1 promifcuous ufe of thefe, has been Very injudicious ; and where there is any putreScency, they mud be hurtSul. MCCCCXCVII. 148 PRACTICE MCCCCXCVII. The cafes in which there is a putrid or pu- trefcent acrimony prevailing, have been, I think, too Seldom taken notice of; and, there- fore, the ufe of acids too feldom admitted. The acrimony to be fufpeaed in bilious cafes, is probably of the putrefcent kind. MCCCCXCVIII. The general correaors of acrimony are the mild diluents and demulcents. The former have not been fo much employed in diarrhoea as they ought; for, joined with demulcents, they very much increafe the effeas of the latter: And although the demulcents, both mucilaginous and oily, may by themfelves be ufeSul, yet without the affiftance of diluents they can hardly be introduced in fuch quan- tity as to anfwer the purpofe. MCCCCXCIX. As indigeftion and crudities prefent in the ftomach, are fo often the caufe of diarrhoea, vomiting mud therefore be frequently very ufeful in this difeafe. In like manner, when the difeafe proceeds, as it often does, from obftruaed peripiration, and increafed afflux of fluids to the intedines, vomiting is perhaps the mod effeaual means of OF PHYSIC. 149 of redoring the determination of the fluids to the furface of the body. It is poffible alfo, that vomiting may give fome inverfion of the peridaltic motion, which is determined too much downwards in diar- rhoea ; fo that upon the whole it is a remedy which may be very generally ufeful in this difeafe. MD. Purging has been fuppofed to be more uni- verfally neceffary, and has been more gen- erally praaifed. This, however, in my opin- ion, proceeds upon very midaken notions with refpea to the diSeaSe ; and Such a prac- tice Seems to me Sor the mod part Superflu- ous, and in many caSes very hurtful. It goes upon the fuppofition of an acrimony prefent in the intedines, that ought to be carried out by purging : But, if that acrimony has either been introduced by the mouth, or brought into the intedines from other parts of the body, purging can neither be a means of cor- reaing nor of exhauding it; and mud rather have the effea of increafing its afflux, and of aggravating its effeas. From whatever fource the acrimony which can excite a diarrhoea proceeds, it may be SuppoSed Sufficient to evacuate itSelf, fo far as that can be done by purging ; and as in cholera, fo in the fame kind of diarrhoea, it will be more proper to affiff the evacuation by diluents and demul- cents, 150 PRACTICE cents, than to increafe the irritation by pur- gatives. MDI. If, then, the ufe of purgatives in diarrhoea may be confidered, even when an acrimony is prefent, as Superfluous, there are many other cafes in which it may be extremely hurtful. If the irritability of the intedines fhall, from affea.ions in other parts of the fydem, or other caufes, have been already very much increaf- ed, purgatives mud neceffarily aggravate the difeafe. In the cafe of lientery, nobody thinks of giving a purgative ; and in many cafes of diarrhoea approaching to that, they mud be equally improper. I have already obferved, that when diarrhoea proceeds from an afflux of fluids to the intedines, whether in too great quantity, or of an acrid quality, purgatives may be hurtful ; and whoever, therefore considers the numerous and various fources from which acrid matter may be pour- ed into the cavity of the intedines, will readi- ly perceive, that, in many cafes of diarrhoea, purgatives may be extremely pernicious. There is one cafe in particular to be taken notice of. When, from a general and acrid diffolution of the blood, the Serous fluids run off too copioufly into the cavity of the intef- tines, and excite that diarrhoea which attends the advanced date of heaic fever, and is prop- erly called a Colliquative Diarrhoea; I have, in OF P H-Y S I C. 151 in fuch cafes, often feen purgatives given with the mod baneful effeas. There is dill another cafe of diarrhoea in which purgatives are pernicious ; and that is, when the difeafe depends, as we have alleged it fometimes may, upon an erythematic in- flammation c? the intedines. I need hardly add, that if there be a cafe of diarrhoea depending upon a laxity of the Solids, purgatives cannot there be of any Ser- vice, and may do much harm. Upon the whole, it will, I think, appear, that the ufe of purgatives in diarrhoea is very much limited ; and that the promifcuous ufe of them, which has been fo common, is injudicious, and often pernicious. I believe the praaice has been chiefly owing to the ufe of purgatives in dyf- enteric cafes, in which they are truly uSeSul; becauSe, contrary to the caSe of diarrhoea, there is in dyfentery a confiderable condric- tion oS the intedines. MDII. Another Set of remedies employed in diar- rhoea are adringents. There has been fome hefitation about the employment of thefe in recent cafes, upon the fuppofition that they might occafion the retention of an acrid mat- ter that fhould be thrown out. I cannot, however, well underdand or affign the cafes in which fuch caution is neceffary; and I think that the power of adringents is feldom fo 152 PRACTICE fo great as to render their ufe very danger- ous. The only difficulty which has occurred to me, with refpea to their ufe, has been to judge of the circumdances to which they are efpecially adapted. It appears to me to be only in thofe where the irritability of the in- tedines depends upon a lofs of tone : And this, I think, may occur either from the de- bility of the whole fydem, or from caufes act- ing on the intedines alone. All violent or long continued fpafmodic and convulfive af- feaions of the intedinal canal neceflarjly in- duce a debility there ; and fuch caufes often take place, from violent irritation, in colic,, dyfentery, cholera, and diarrhcea. MDIII. The lad of the remedies of diarrhoea that remain to be mentioned are opiates. The fame objeaions have been made to the ufe of thefe, in recent cafes of diarrhcea, as to that of adringents ; but on no good grounds: For the effect of opiates, as adringent, is never very permanent; and an evacuation depend- ing upon irritation, though it may be for fome time fufpended by opiates, yet always returns very foon. It is only by taking off irritability that opiates are ufeful in diarrhoea; and therefore, when the difeafe depends upon an increafe of irritability alone, or when, though proceeding from irritation, that irri- tation OF PHYSIC. 153 tation is correaed or exhauded, opiates are the mod ufeful and certain remedy. And though opiates are not fuited to correa or re- move an irritation applied, they are often of great benefit in fufpending the effeas of that irritation whenever thefe are violent: And, upon the whole, it will appear, that opiates may be very frequently, and with great pro- priety, employed in the cure of diarrhoea. Chap. XIL Of the Diabetes. MDIV. THIS difeafe confids in the voiding of aft Unufually large quantity of urine. As hardly any fecretion can be increafed without an increafed aaion of the Veffels con- terned in it, and as fome indances of this dif- eafe are attended with affeaions manifedly fpafmodic, I have had no doubt of arranging the diabetes under the order of Spafmi. MDV. This difeafe is always accompanied with £ jjreat degree of thirds and therefore with the. taking 154 PRACTICE taking in of a great quantity of drink. This in fome meafure accounts for the very extra- ordinary quantities of urine voided : But Still, independent of this, a peculiar difeafe certainly takes place ; as the quantity of urine voided does almoft always exceed the whole of the liquids, and fometimes the whole of both Solids and liquids, taken in. MDVI. The urine voided in this diSeafe is always very clear, and at firft fight appears entirely without any colour; but viewed in a certain light, it generally appears to be flightly tinged with a yellowifh green, and in this refpea has been very properly compared to a Solution of honey in a large proportion of water. Examined by the tade, it is very generally found to be more or lefs fweet; and many ex- periments that have now been made in dif- ferent indances of the difeaSe fhow clearly that Such urine contains, in confiderable quantity, a Saccharine matter which appears to be very exaaiy of the nature of common fugar. MDVII. Doaor Willis feems to me to have been the fird who took notice of the fweetnefs of the urine in diabetes, and almoft every phy- fician of England has fince taken notice of the OF PHYSIC. 155 the fame. It is to be doubted, indeed, if there is any cafe of idiopathic diabetes in which the urine is of a different kind. Though neither the ancients, nor, in the oth- er countries of Europe, the moderns, till the latter were direaed to it by the Englifh, have taken notice of the fweetnefs of the urine, it does not perfuade me, that either in ancient or in modern times the urine in diabetes was of another kind. I myfelf, indeed, think I have met with one inftance of diabetes in „ which the urine was perfoaiy in lipid ; and it would feem that a like obfervation had oc- curred to Dr. Martin Lifter. I amperfuad- ed, however, that fuch inftances are very rare; and that the other is by much the more com- mon, and perhaps the almoft univerfal occur- rence. I judge, therefore, that the prefence oS Such a Saccharine matter may be confidered as the principal circumstance in idiopathic diabetes; and it gives at leaft the only caSe of that difeafe that I can properly treat of here, for I am only certain that what I am further to mention relates to fuch a cafe. MDVIII. The antecedents of this difeafe, and confe- quently the remote caufes of it, have not been well ascertained. It may be true that it fre- quently happens to men who, for a long time before, had been intemperate in drinking ; that it happens to perfons of a broken consti- tution, i55 PRACTICE tution, or who, as we often exprefs it, are in a cacheaic ftate ; that it fometimes follows in- termittent fevers ; and that it has often oc- curred from excefs in the drinking of min- eral waters. But none of thefe cauSes apply Very generally to the caSes that occur : Such CaSes are not always, nor even frequently, fol- lowed by a diabetes ; and there are many in- ftances of diabetes which could not be refer- red to any of them. In moft of the cafes of this difeafe which I have met with, I could not refer it to any particular caufe. MDIX. This difeafe commonly tomes on {lowly, and almoft imperceptibly, without any pre- vious diforder. It often arifes to a confider- able degree, and fubfifls long without being accompanied with evident diforder in any particular part of the fyftem. The great thirft which always, and the voracious appe- tite which frequently, occurs in it, are often the only remarkable fymptoms. Under the continuance of the difeafe, the body is often greatly emaciated ; and a great weaknefs alfo prevails. The pulfe is commonly Srequent; and an obfcure fever is for the molt part prefr ent. When the diSeaSe proves Satal, it gen- erally ends with a Sever, in many circum- ftances, particularly thoSe of emaciation and debility, refembling a heaic* MDX* OF PHYSIC. 157 MDX. The proximate caufe of this difeaSe is not certainly or clearly known. It Seems to have been Sometimes conneaed with calculous af- feaions of the kidneys ; and it is poffible, that an irritation applied there may increafe the fecretion of urine. It perhaps often does fo; but how it fhould produce the lingular change that takes place in the ftate of the urine, is not to be eafily explained. It cer- tainly often happens, that calculous matters are long prefent in the urinary paffages, with- out having any Such effea as that of produc- ing diabetes in any Shape. Some have fuppofed that the difeafe oc- curs from a relaxed ftate of the Secretory vef- fels of the kidneys ; and indeed the diffeaions of perfons who had died of this difeaSe have fhown the kidneys in a very flaccid ftate. This, however, is probably to be confidered as rather the effect than the cauSe of the difeaSe. That no topical affeaion of the kidneys has a fhare in producing this difeafe, and that a fault in the affimilation of the fluids is rather to be blamed, I conclude from hence, that even the folid food taken in, increafes the quantity of the urine voided, at the fame time with an increafe of the faccharine matter above mentioned. Vol. III. . H MDXI. i58 PRACTICE MDXI. The diabetes has been fuppofed to be ow- ing to a certain ftate of the bile ; and it is true, that this difeafe has fometimes occurred in perfons who were at the fame time affeaed with difeafes of the liver: But this concur- rence does not often take place ; and the dia- betes frequently occurs Separately Srom any affeaion of the liver. In twenty inftances of diabetes which I have Seen, there was not in any one of them any evident affeaion of the liver. The explanation that has been offered of the nature and operation of the bile, in pro- ducing diabetes, is very hypothetical, and no wife Satisfying. MDXII. As I have already Said, I think it probable, that in moft cafes the proximate caufe of this difeafe is fome fault in the aflimilatory powers, or in thofe employed in converting aliment- ary matters into the proper animal fluids. This I formerly hinted to Dr. Dobfon, and it has been profecuted and published by him ; but I muft own, that it is a theory embarraff- ed with Some difficulties which I cannot at prefent very well remove. MDXIII. OF PHYSIC. 151 MDXIII. The proximate caufe of diabetes being fo little known or afcertained, I cannot propofe any rational method of cure in the difeafe. From the teftimony of feveral authors, I be- lieve that the difeafe has been cured : But I believe alfo, that this has feldom happened ; and when the difeafe has been cured, I doubt much if it was effeaed by the feveral reme- dies to which thefe cures have been afcribed. In all the indances of this difeafe which -I my- felf have Seen, and in Several others oS which I have been informed, no cure of it has ever bt^n made in Scotland, though many indances of it have occurred, and in mod of them the remedies recommended by authors have been diligently employed. I cannot, therefore, with any advantage, enter into a detail of thefe remedies ; and as the diSeaSe, together with its Several circumdances, when they fhall hereafter occur, is likely to become the fub- jea of diligent invedigation, I avoid going farther at prefent, and judge it prudent to SuSpend my opinion till I fhall have more ob- servations and experiments upon which I can form it more clearly. H2 Chap, 160 PRACTICE Chap, XIII. Of the Hysteria, or the Hysteric Dis- ease. MDXIV. THE many and various fymptoms which have been fuppofed to belong to a difeaSe un- der this appellation, render it extremely dif- ficult to give a general charaaer or definition of it. It is, however, proper in all cafes to attempt fome general idea; and therefore, by taking the mod common form, and that con- currence of fymptoms by which it is princi- pally didinguifhed, I have formed a charac- ter in my fydem of Methodical Nofology, and fhall here endeavour to illudrate it by giving a more Sull hidory of the phenomena. MDXV. The difeafe attacks in paroxyfms or fits. Thefe commonly begin by fome pain and ful- nefs felt in the left fide of the belly. From this a ball feems to move with a grumbling noife into the other parts of the belly ; and, making as it were various convolutions there, feems to move into the ftomach; and more didinaiy OF PHYSIC. 161 didinaiy dill rifes up to the top of the gullet, where it remains for fome time, and by its preffure upon the larynx gives a fenfe of Suf- focation. By the time that the difeafe has proceeded thus far, the patient is affeaed with a dupor and infenfibility, while at the fame time the body is agitated with various convulfions. The trunk of the body is wreathed to and fro, and the limbs are va- rioufly agitated; commonly the convulfive motion of one arm and hand, is that of beat- ing, with the clofed fid, upon the bread very violently and repeatedly. This date contin- ues for fome time, and has during that time fome remiffions and renewals of the convul- five motions ; but they at length ceaSe, leav- ing the patient in a dupid and Seemingly Sleeping date. More or lefs Suddenly, and frequently with repeated fighing and fobbing, together with a murmuring noife in the belly, the patient returns to the exercife of fenfe and motion, but generally without any recollec- tion of the feveral circumdances that had taken place during the fit. MDXVI. This is the form of what is called an hyjlerh faroxyfm, and is the mod common form ; but its paroxyfms are confiderably varied in dif- ferent perfons, and even in the Same perSon at different times. It differs, by having more or fewer of the circumdances above mention- H 3 ed j 162 PRACTICE ed ; by thefe circumdances being more or lefs violent; and by the different duration of ""the whole fit. ' 'Before the fit, there is Sometimes a fudden and unufually large flow of limpid urine. At the coming on of the fit, the domach is fome- times affeaed with vomiting, the lungs with confiderable difficulty of breathing, and the heart with palpitations. During the fit, the whole of the belly, and particularly the navel, is drawn ftrongly inwards ; the fphinaer am is fometimes fo firmly condriaed as not to admit a fmall glyder pipe, and there is at the fame time an entire fuppreffion of urine. Such fits are, from time to time, ready to re- cur ; and during the intervals, the patients are liable to involuntary motions, to fits of laugh- ing and crying, with fudden tranfitions Srom the one to the other; while Sometimes falfe imaginations, and fome degree of delirium, alfo occur. MDXVII. Thefe affeaions have been fuppoSed pecu- liar to the Semale Sex ; and indeed they moft commonly appear in females : But they fome- times, though rarely, attack alSo the male Sex ; never, however, that I have obServed, in the Same exquifite degree. In the Semale Sex, the difeafe occurs efpec- ially from the age of puberty to that of thirty five years j and though it does fometimes, yet very OF PHYSIC. 163 very feldom appears before the former or after the latter of thefe periods. At all ages, the time at which it mod read- ily occurs is that of the mendrual period. :.r The difeafe more efpecially affeas the.jtfc- males of the mod exquifitely fanguine *fi& plethoric habits, and frequently affeas thole of the moft robud and mafcuhne conditu- It affeas the barren more than the breed- ing women, and therefore frequently young widows. It occurs efpecially in thofe females who are liable to the Nymphomania ; and the Nofologids have properly enough marked one of the varieties of this difeafe by the title of Hyjleria Libidinofa; Iii the perfons liable to the fits of this-dif- eafe, it is readily excited by the paflions of the mind, and by every confiderable emotion, efpecially thofe brought on by furprife. The perfons liable to this difeafe acquire often fuch a degree of fenfibility, as to be drongly affeaed by every impreffion that comes upon them by SurpriSe. MDXVIII. In this hidory, there appears to be a con- currence of fymptoms and circumdances prop- erly marking a very particular difeafe, which I think may be didinguifhed from all others. It feems to me to have been improperly con- H 4 fidered 164 PRACTICE fidered by phyficians as the fame with fome other difeafes, and particularly with hypo- chondriafis. The two difeafes may have fome Symptoms in common, but for the moft part are confiderably different. Spafmodic affections occur in both difeaf- es ; but neither fo frequently, nor to fo great a degree, in hypochondriasis as in hyfteria. Perfons liable to hyfteria are Sometimes af- feaed at the fame time with dyfpepfia. They are often, however, entirely free from it; but I believe this never happens to perfons af- feaed with hypochondriasis. TheSe different circumStances mark Some difference in the two diSeaSes ; but they are Still more certainly diftinguifhed by the tem- perament they attack, and by the time of life at which they appear to be moft exquifitely formed. It has been generally fuppofed, that the two difeafes differ only in refpea oS their ap- pearing in different Sexes. But this is not well founded : For although the hyfteria ap- pears moft commonly in Semales, the male fex is not abfolutely free Srom it, as I have obServed above ; and although the hypochon- driasis may be moft Srequent in men, the in- ftances of it in the female fex are very common. MDXIX. From all thefe confiderations, it muft, I think, appear, that the hyfteria may be very well, O'F PHYSIC. 165 well, and properly, didinguifhed from hypo- chondriasis. Further, it Seems to me to have been with great impropriety, that almod every degree of the irregular motions of the nervous fydem has been referred to the one or other of thefe two difeafes. Both are marked by a pecu- liarity of temperament, as well as by certain fymptoms commonly accompanying that; but fome of thefe, and many others ufually mark- ed by the name of nervous fymptoms, may, from various caufes, arife in temperaments different Srom that which is peculiar to either hyderia or hypochondriasis, and without be- ing joined with the peculiar Symptoms of ei- ther the one or the other difeafe : So that the appellations of Flyderic and Hypochondriac are very inaccurately applied to them. Un- der what view thefe Symptoms are otherwife- to be confidered, I am not ready to deter- mine ; but mud remark, that the appellation of Nervous Difeafes is too vague and unde- fined to be of any ufeful application. MDXX. Having thus endeavoured to didinguifh hyderia from every other difeafe, I fhall now attempt its peculiar pathology. With refpea to this, I think it will, in the fird place, be obvious, that its paroxyfms begin by a con- vulfive and fpafmodic affeaion of the alimen- tary canal, which is afterwards communicated Vol. 3. » H 5 to 166 PRACTICE to the brain, and to a great part of the nervous fydem. Although the difeafe appears to be- gin in the alimentary canal, yet the connexion which the paroxyfms fo often have with the mendrual flux, and with the difeaSes that de- pend on the date of the genitals, fhows, that the phyficians have at all times judged rightly in confidering .this difeaSe as an affeaion of the uterus and other parts of the genital fydem. MDXXI. With regard to this, however, I can go no farther. In what manner the uterus, and in particular the ovaria, are affeaed in this dif- eafe ; how the affeaion of thefe is communi- cated, with particular circumdances, to the alimentary Canal; or how the affeaion of this, riling upwards, affeas the brain, fo as to oc- cafion the particular convulfions which occur in this diSeaSe, I cannot pretend to explain. But although I cannot trace this diSeaSe to its fird cauSes, or explain the whole of the phenomena, I hope, that with refpea to the general nature of the difeafe, I may form fome general conclusions, which may Serve to direft our condua in the cure oS it. i r MDXXII. ■:.-..• ! Thus, Srom a consideration:of thepredifpo- nent and occafional caufes it wilf, I think, ap- . ■■ .-.year, OF PHYSIC. 167 pear, that the chief part of the proximate caufe is a mobility of the fydem, depending generally upon its plethoric date. MDXXIII. Whether this difeafe ever arifes from a mo- bility of the fydem, independent of any ple- thoric date of it, I cannot pofitively deter- mine ; but in many cafes that have fubfided for fome time, it is evident that a fenfibility, and confequently a mobility, are acquired, which often appear when neither a general plethora can be fuppofed to fubfid, nor an occafional turgefcence to have happened. However, as we have Shown above, that a dif- tention of the veffels of the brain-feems to oc- cafion epilepfy, and that a turgefcence of the blood in the veflels of the lungs feems to pro- duce afthma ; fo analogy leads me to fuppofe, that a turgefcence of blood in the uterus, or in other parts of the genital fydem, may occafions the fpafmodic and convulfive mo- tions which appear in hyderia. It will, at the fame time, be evident, that this affeaion of the genitals mud efpecially occur in ple- thoric habits; and every circumdance men- tioned in the hidory of the difeaSe Serves to confirm this opinion with refpea to its prox- imate caufe. ___aJO 03 C. H6 MDXX1V. i63 PRACTICE MDXXIV. From this view of the fubjea, the analogy of hyderia and epilepfy will readily appear ; and why, therefore, I am to fay that the indi- cations of cure are the fame in both. As the indications, fo the feveral means of anfwering them, are fo much the Same in both 'difeafes, that the Same observations and di- reaions, with regard to the choice and em- ployment of thefe remedies, that have been delivered above on the fubjea of epilepfy, will apply pretty exaaiy to hyderia ; and therefore need not to be repeated here. Chap. IX. Of Canine Madness and Hydrophobia. MDXXV. THIS difeafe has been fo exaaiy and fully defcribed in books that are in every body's hands, that it is on- no account neceffary For me to give any hidory of it here ; and with refpea to the pathology of it, I find that I can fay nothing fatisfying to myfelf, or that I can expea to prove fo to others. I find alfo, with OF PHYSIC. 169 with refpea to the cure of this difeafe, that there is no fubjea in which the fallacy of ex- perience appears more drongly than in this. From the mod ancient to the prefent times, many remedies for preventing and curing this difeafe have been recommended under the fanaion of pretended experience, and have perhaps alfo kept their credit for fome time : But Succeeding times have generally, upon the fame ground of experience, dedroyed that credit entirely ; and mod of the remedies for- merly employed are now fallen into abfolute neglea. In the preSent age, Some new rem- edies have been propoSed, and have expe- rience alleged to vouch for their efficacy ; but many doubts dill remain with reSpea to this : and though I cannot determine in this matter from my own experience, I think it incum- bent on me to give the bed judgment I can form with refpea to the choice of the reme- dies at prefent recommended. MDXXVI. I am, in the fird place, firmly perfuaded, that the mod certain means of preventing the confequences of the bite, is to cut out, or oth- erwife dedroy, the part in which the bite has been made. In this every body agrees ; but with this difference, that Some are of opinion that it can only be effeaual when it is done very foon after the wound has been made, and they therefore neglea it when this opportu- nity 170 PRACTICE, &c. nity is miffed. There have been, however, no experiments made proper to determine this matter : And there are many confidera- tions which lead me to think, that the poifon is not immediately communicated to the fyf- tem ; and therefore, that this meafure of de- droying the part may be praaifed with ad- vantage, even many days after the bite has been given. MDXXVII. Whilft the ftate of our experience, with refpea to feveral remedies now in ufe, is un- certain, I cannot venture to affert that any of thefe is abfolutely ineffeaual ; but I can give it as my opinion, that the efficacy of mercury, given very largely, and perfifted in for a long time, both as a means of prevent- ing the difeaSe, and of curing it when it has aaually come on, is better fupported by ex-. perience than that of any other remedy now propofed, or commonly employed. sjflU. -nnorroo i'.di nsd.v Ji .:->>.0 y ; * BOOK BOOK IV. of VESANLE, or of the DISOR- DERS of the INTELLECTUAL FUNCTIONS. C H A P. I. OF VESANIi^T IN GENERAL. MDXXVIII. THE Nofologids, Sauvages and Sagar, in a clafs of difeaSes under the title of Vesani*, have comprehended the two orders, of Hallucinationes or Falfe Per- ceptions, and of Morofitates or Erroneous Appetites and Paffions ; and in like manner, _Linnaeus in his clafs of Mentales, corref- iponding to the Vefaniae of Sauvages, has oemt- prehenc[e4. the two: ordets. of Jmagir&rti.and. ,f Paihetici, 172 PRACTICE Pathetici, nearly the Same with the Halluci- nations and Morofitates of that author. This, however, from feveral confiderations, appears to me improper ; and I have there- fore formed a clafs of Vefaniae nearly the fame with the Paranoias of Vogel, excluding from it the Hallucinationes and Morofitates, which I have referred to the Morbi Locales. Mr. Vogel has done the like, in Separating from the Paranoias the falfe perceptions and erroneous appetites ; and has thrown thefe into another clafs, to which he has given the title of Hyperaedhefes. MDXXIX. It is indeed true, that certain hallucinationes and morofitates are frequently combined with what I propofe to confider as driaiy a vefa- nia or an erroneous judgment ; and fome- times the hallucinationes feem to lay the foun- dation of, and to form almod entirely, the vefania. But as mod part of the hallucina- tiones enumerated by the Nofologids are af- feaions purely topical, and induce no other error of judgment befide that which relates to the Single objea of the fenfe or particular or- gan affeaed ; fo thefe are certainly to be Sep- arated from the difeaSes which con fid in a more general affeaion of the judgment. Even when the hallucinationes condantly ac- company or feem to induce the vefania, yet being fuch as arife from internal caufes, and may OF PHYSIC. 173 may be prefumed to arife from the fame caufe as the more general affeaion of the judgment, they are therefore to be confidered as fymp- toms of this only. In like manner I judge with refpea to the morofitates, or erroneous paffions, that ac- company vefania ; which, as confequences of a falfe judgment, mud be confidered as arifing from the fame caufes, and as Symptoms only, of the more general affeaion. There is, indeed, one cafe of a morofitas which Seems to induce a veSania, or more gen- eral affeaion of the judgment; and this may lead us to confider the vefania, in this cafe, as a fymptom of an erroneous appetite, but will not afford any good reafon for comprehend- ing the morofitates in general under the ve- faniae, confidered as primary diSeaSes. The limitation, therefore, of the clafs of Vefaniae to the lefions of our judging fac- ulty, feems from every confideration to be proper. The particular difeafes to be comprehend- ed under this clafs, may be didinguifhed ac- cording as they affea perfons in the time of waking or fleeping. Thofe which affea men awake, may again be confidered, as they con- fift in an erroneous judgment, to which I fhall give the appellation of Delirium ; or as they confift in a weaknefs or imperfeaion of judgment, which I fhall name Fatuity. I be- gin with the confideration of Delirium. MDXXX. 174 PRACTICE MDXXX. As men differ greatly in the foundnefs and force of their judgment, fo it may be proper here to afcertain more precifely what error or imperfeaion of our judging faculty is to be confidered as morbid, and to admit of the ap- pellations of Delirium and Fatuity. In do- ing this, I Shall firft confider the morbid errors of judgment under the general appellation Of Delirium, which has been commonly employ- ed to denote every mode of fuch error. MDXXXI. As our judgment is chiefly exercifed in difcerning and judging of the feveral relations of things, I apprehend that delirium may be defined to be,—In a perfon awake, a falfe or mistaken judgment of thofe relations of things, which, as occurring moft frequently in life, are thofe about which the generality of men form the fame judgment ; and particularly when the judgment is very different from what the perfon himfelf had before ufually formed. * MDXXXII. With this mistaken judgment of relations there is frequently joined Some falfe percep- tion of external objeas, without any evident fault OF PHYSIC. fault in the organs of fenfe, and which feems therefore to depend upon an internal caufe ; that is, upon the imagination arifing from a condition in the brain prefenting objeas which are not aaually prefent. Such falfe perceptions muft neceffarily occafion a de- lirium, or an erroneous judgment, which is to be confidered as the difeafe. MDXXXIII. Another circumdance, commonly attend- ing delirium, is a very unufual affociation of ideas. As, with refpea to mod of the affairs of common life, the ideas laid up in the mem- ory are, in mod men, affociated in the fame manner ; So a very unuSual affociation, in any individual, mud prevent his Forming the or- dinary judgment of thofe relations which are the mod conHlfen foundation of affociation in the memory : And thereFore this unufual and commonly hurried affociation of ideas, ufual- ly is, and may be confidered as, a part of de- lirium. In particular it may be confidered as a certain mark of a general morbid affec- tion oF the intelleaual organs, it being an in- terruption or perverfion of the ordinary ope- rations of memory, the common and necef- fary foundation of the exercife of judgment. MDXXXIV. A third circumdance attending delirium, is an emotion or paffion, fometimes of the angry, 176 PRACTICE angry, fometimes of the timid kind ; and from whatever caufe in the perception or judgment, it is not proportioned to Such cauSe, either in the manner formerly cudomary to the perfon himfelf, or in the manner ufual with the generality of other men. MDXXXV. Delirium, then, may be more fhortly defin- ed,—In a perfon awake, a falfe judgment arifing from perceptions of imagination, or from falfe recolleaion, and commonly pro- ducing disproportionate emotions. Such delirium is of two kinds; as it is com- bined with pyrexia and comatofe affeaions ; or, as it is entirely without any fuch combi- nation. It is the latter cafe that we name In- fanity ; and it is this kind of delirium only that I am to treat of here. MDXXXVI. 'Infanity may perhaps be properly confid- ered as a genus comprehending many differ- ent Fpecies, each of which may deferve our attention ; but before proceeding to the con- fideration of particular fpecies, I think it proper to attempt an invedigation of the caufe of infanity in general. MDXXXVII. OF PHYSIC. MDXXXVII. In doing this, I fhall take it for granted, as demonftrated elfewhere, that although this difeafe feems to be chiefly, and fometimes folely, an affeaion oF the mind ; yet the con- nexion between the mind and body in this caFe is Fuch, that theFe affeaions of the mind mud be confidered as depending upon a certain ftate oF our corporeal part. See Halleri Prim. Lin. Phyfiolog. § dlxx. SeeBoerhaavii Ind. Med. §dlxxxi. DCXCVI. MDXXXVIII. Admitting this proposition, I mud in the next place affume another, which I likewife fuppofe to be demondrated elfewhere. This is, that the part of our body more immediate- ly conneaed with the mind, and therefore more efpecially concerned in every affeaion -of the intellectual funaions, is the common origin of the nerves ; which I fhall, in what follows, fpeak of under the appellation of the Brain. MDXXXIX. Here, however, in affuming this lad prop- ofition, a Very great difficulty immediately prefents 178 P R A C T I. C E prefents itfelf. Although we cannot doubt that the operations of our intellect always de- pend upon certain motions taking place in the brain (fee Gaub. Path. Med. § 523) ; yet thefe motions have never been the objeas of our fenfes, nor have we been able to perceive that any particular part of the brain has more concern in the operations of our intellea than any other. Neither have we attained any knowledge of what fhare the feveral parts of the brain have in that operation ; and therefore, in this fituation of our Science, it mud be a very difficult matter to diScover thoSe dates oS the brain that "may give occa- fion to the various date of our intelleaual funaions. MDXL. It may be obferved, that the different date of the motion of the blood in the veffels oF the brain has fome fhare in affeaing the opera- tions of the intellea ; and phylicians, in Seek- ing Sor the cauSes of the different dates of our intelleaual funaions, have hardly looked fur- ther than into the date of the motion of the bjood, or into the condition of the blood it- felf : ^t it is evident that the operations of the intelleaual funaions ordinarily go on, and are often confiderably varied, without our being able to perceive any difference ei- ther in the motions or in the condition of the hlood. MDftLI. OF PHYSIC. .MDXLI. Upon the other hand, it is very probable that the date of the intelleaual funaions de- pends chiefly upon the date and condition of what is termed the Nervous Power, or, as we fuppofe, of a fubtile very moveable fluid, in- cluded or inherent, in a manner we do not clearly underdand, in every part of the me- dullary fubdance oS the brain and nerves, and which in a living and healthy man is capable ©f being moved from every one part to every other of the nervous fydem. MDXLII. With refpea to this power, we have pretty clear proof that it frequently has a motion from the Sentient extremities of the nerves to*. wards the brain, and thereby produces fenfa- tion ; and we haVe the fame proof, that in confequence of volition the nervous power has a motion from the -brain into the mufcles or organs of motion. Accordingly, as fenfa- tion excites our intelleaual operations, and volition is the effea oF thefe, and as the con- nexion between fenfation and volition is al- ways by the intervention of the brain ana* of intelleaual operations ; fo we can hardly doubt, that thefe latter depend upon certain motions, and the various modification of thefe motions, in the brain. MDXLIII. 180 PRACTICE MDXLIII. To afcertain the different ftates of thefe motions may be very difficult; and phyfi- cians have commonly confidered it to be fo very myfterious, that they have generally deS- paired of attaining any knowledge with re- gard to it: But I confider fuch abfolute deS- pair, and the negligence it inSpires, to be al- ways very blameable ; and I fhall now ven- ture to go Some length in the inquiry, hoping that fome Steps made with tolerable firmneSs may enable us to go ftill Surther. MDXLIV. To this purpoSe, I think it evident, that the nervous power, in the whole as well as in the feveral parts of the nervous fyftem, and par- ticularly in the brain, is at different times in different degrees oF mobility and Force. To thefe different ftates, I beg leave to apply the terms of Excitement and Collapfe. To that ftate in which the mobility and force are fuf- ficient for the exercife of the funaions, or when thefe ftates are any way preternaturally increaSed, I give the name oS Excitement ; and to that ftate in which the mobility and force are not fufficient for the ordinary exer- ciSe of the funaions, or when they are dimin- ished from the ftate in which they had been before, I give the name of Collapfe. I beg, however, OF PHYSIC. 1S1 however, it may be obferved, that by thel'e terms I mean to expreSs matters oS faa only ► and without intending, by thefe terms, to ex- plain the circumftance or-condition, mechan- ical or phyfical, of the nervous power or fluid in thefe different ftates. MLXXLV. That theFe different ftates oF excitement and collapFe take place on different occafionss muft, I think, be manifeft from numberlefs phenomena of the animal economy : But it is efpecially to our .prefent purpofe to obferve, that the different ftates of excitement and col- lapfe, are in.no inftance more remarkable, than in the different ftates oF waking and sleeping. In the latter, when quite com- ** plete, the motion and mobility of the nervous power, with refpea to the whole of what are called the Animal Funaions, entirely ceafe, or, as I would exprefs it, are in a ftate of col- lapfe ; and are very different From the ftate of Waking, which in healthy perfons I would call a ftate of general and entire excitement. MDXLVI. This difference in the States of the nervous £>ower in sleeping and waking being admitted, I muft in the next place obferve, that when thefe dates are changed from the one into the otheri as commonly happens every day, the Vol. III. I change 1*2 PRACTICE change is hardly ever made indantaneoufly, but almod always by degrees, and in fome length of time only : And this may be ob- served with refpea to both fenfe and motion* Thus when a perfon is falling afleep, the fen- fibility is gradually diminished :. So that, al- though fome degree of fleep has come on, Slight impreffions will excite FenFation, and bring back excitement; which the Fame, pr even dronger impreffions, will be infufficient .'o produce when the date of fleep has con- tinued longer, and is, as we may fay, more complete. In like manner, the power of vol- untary motion is gradually diminished. In fome members it fails Sooner than in others ; and it is Some time beSore it becomes general and confiderable over the whole. The fame gradual progrefs may be remark- ed in a perSon's coming out of fleep : The ears in this cafe are often awake before the eyes are opened or fee clearly, and the fenfes are often awake before the power of voluntary motion is recovered; and it is curious to ob- ferve, that, in fome cafes, fenfations may be excited without producing the ordinary affo- ciation of ideas. See Mem. de Berlin, 1752. MDXLVII. From all this, I think it will clearly ap- pear, that not only the different dates oF ex- citement and collapfe can take place in differ- ent degrees, but that they can take place in different OF PHYSIC. 183 different parts oF the brain, or at leaft, with reFpea to the different Funaions, in different degrees. As I preSume that almod every perSon has perceived the gradual approach of Sleeping and waking, I likewife fuppofe every perfon has obferved, that, in fuch intermediate date of unequal excitement, there almod always occurs more or lefe of delirium, or dreaming, if any body choofes to call it fo. There are in this date falfe perceptions, falfe aflbciations, falfe judgments, and disproportionate emo- tions ; in fhbrt, all the circumdances by which. I have above defined delirium. This clearly Shows that delirium may de- pend, and I fhall hereafter endeavour to prove that it commonly does depend, upon fome inequality in the excitement of the brain ; and that both thefe affertions are Founded on this, that, in order to the proper exercife of our intelleaual functions, the excitement mud be complete, and equal in every part of the brain. For though w6 cannot fay that the vediges of ideas are laid up in different parts of the brain, or that they are in Some meafure diffufed over the whole, it will Sollow upon either fuppofition, that as our reafon- ing or intelleaual operations always require the orderly and exact recolleaion or memory of affociated ideas ; Fo, if any part of the brain is not excited, or not excitable, that rec- olleaion cannot properly take place, while at the fame time other parts of the brain, more I 2 excited 1S4 PRACTICE excited and excitable, may give falfe percep* tions, aflbciations, and judgments. MDXLVIII. It will Serve to illudrate this, that the coI» lapfe in fleep is more or lefs complete ; or that the fleep, as we commonly fpeak, is more or lefs profound : And therefore, that in many cafes, though fleep takes place to a con- fiderable degree, yet certain impreffions do dill take effea, and excite motions, or, iF you will, Fenfations in the brain ; but which fen- Sations, upon account oF the collapFed date of fo great a part of the brain, are generally of the delirious kind, or dreams, confiding of falfe perceptions, aflbciations, and judgments, that would have been correaed iF the brain had been entirely excited. Every one, I believe, has obferved, that the mod imperfea fleeps are thofe chiefly attend- ed with dreaming ; that dreams, therefore, mod commonly occur towards morning, when the complete date of fleep is pafling away } and Further, that dreams are mod commonly excited by drong and uneafy impreffions made upon the body. I apprehend it may alSo be an illustration of the fame thing, that, even in waking hours^ we have an inftance of an unequal date of ex- citement in the brain producing delirium. Such, I think, occurs in the cafe of fever. In this, it is manifeft, that the energy of the brain. OF PHYSIC. 185 brain, or its excitement, is confiderably di- minished with reSpea to the animal Sunaions : And it is accordingly upon this ground that I have explained above, in XLV, the delir- ium which So commonly attends fever.. To what I have there faid I fhall here only add, that it may ferve to confirm my doarine, that the delirium in fever comes on at a certain period of the diSeaSe only, and that we can commonly difcern its approach by a more than ufual degree of it appearing in the time of the patient's falling into or coming out c£ fleep. It appears, therefore,, that delirium, when it firft comes on in fever, depends upon an inequality of excitement; and it can hard- ly be doubted, that the delirium which comes at length to prevail in the entirely weakened date of fevers, depends upon the fame caufe prevailing in a more confiderable degree. MDXLIX. From what has been now delivered, I hope it will be fufficiently evident, that delirium may be, and frequently is, occafioned by an inequality in the excitement of the brain. How the different portions of the brain may at the fame time be excited or collapfed in different degrees, or how the energy of the brain may be in different degrees oF Force, with reSpea to the Several animal, vital, and natural Sunaions, I cannot pretend to ex- plain ; but it is Sufficiently evident in faa, I 3 that 186 PRACTICE that the brain may be at one and the fame time in different conditions with refpea to thefe funftions. Thus in inflammatory dif- eafes, when by a dimulus applied to the brain the force of the vital functions is preternat- urally increafed, that of the animal is either little changed, or confiderably diminifhed. On the contrary, in many cafes of mania, the force of the animal functions depending al- ways on the brain, is prodigioufly increafed, while the date of the vital function in the heart is very little or not at all changed. I mud therefore fay again, that how difficult Soever it may be to explain the mechanical or phyfical condition of the brain in fuch cafes, the faas are fufficient to fhow that there is fuch an inequality as may didurb our intel- leaual operations. MDL. I have thus endeavoured to explain the general caufe of Delirium ; which is of two kinds, according as it is with, or without, py- rexia. Of the fird I take no further notice here, having explained it as well as I could above in XLV. I proceed now to confider that delirium which properly belongs to the clafs of Vefa- niae, and which I fhall treat of under the gen- eral title of Infanity. MDLI. OF PHYSIC. 187 MDLL In entering upon this fubjea, it imme- diately occurs, that in many indances of infanity, we find, upon diffeaion after death, that peculiar circumdances had tak- en place in the general condition of the brain. In mafty cafes, it has been Sound of a drier, harder, and firmer confidence, than what it is ufually of in perfons who had not. been affeaed with that difeafe. In other caSes, it has been found in a more humid, Soft, and flaccid ftate; and in the observa- tions oS the late Mr. Meckel,* it has been Sound confiderably changed in its denfity or Specific gravity. Whether theSe different ftates have been obServed to be uniformly the fame over the whole of the brain, I cannot certainly learn ; and I fufpea the diffeaors have not always accurately inquired into this circumdance : But in Several indances, it ap- pears that thefe dates had been different in different parts oF the brain ; and indances of this inequality will afford a confirmation of our general doarine. The accurate Morgagni has obferved, that in maniacal perfons the medullary portion of the * Memoir, de Berlin pour l'annee 1764. It appeared in many inftances of infane perfons, that the medullary fubftance of the cerebrum was drier, and of a lefs fpecif- ic gravity, than in perfons who had been always of a found judgment. 14 188 PRACTICE the brain is unuSually dry, hard, and firm : And this he had So frequently obferved, that he was difpofed to confider it as generally the cafe. But in mod of the particular indances which he has given, it appears, that, for the moft part, while the cerebrum was of an un- ufually hard and firm confidence^ the cere- bellum was of its ufual foStneSs, and in many oS the caSes it was unuSually SoSt and flaccid. In Some other caSes, Morgagni obServes, that 'while a part of the cerebrum was harder and firmer than ordinary, other parts of it were preternaturally Soft. MDLII. Thefe obfervations tend to confirm our general doarine : And there are others which I think will apply to the fame purpofe. Upon the diffeaion oF the bodies oF per- fons who had laboured under infanity, various organic affeaions have been difcovered in particular parts of the brain ; and it is fuf- ficiently probable, that fuch organic affeaions might have produced a different degree oF excitement in the free and affeaed parts, and mud have interrupted in Some meafure the free communication between the feveral parts of the brain, and in either way have occafion- ed inSanity. There have occurred So many indances of this kind, that I believe phyficians are gen- erally difpoSed to SuSpea organic lefions of OF PHYSIC. 189 of the brain to exid in almod every cafe of infanity. MDLIII. This, however, is probably a midake : For we know tfyat there have been many indances of infanity from which the perfons have en- tirely recovered ; and it is difficult to fup- pofe that any organic lefions of the brain had in fuch cafe taken place. Such tranfitory caSes, indeed, render it probable, that a date of excitement, changeable by various cauf- es, had been the*caufe of fuch indances of inianity. MDLIV. It is indeed further afferted, that in many inftances of infane perfons, their brain had been examined after death, without fhowing that any organic lefions had before Subsided in the brain, or finding that any morbid date of the brain then appeared. This, no doubt, may Serve to Show, that organm lefions had not been the cauSe of the difeafe ; but it does not allure us that no morbid change had tak- en place in the brain : For it is probable, that the difleaors were not always aware of its be- ing the general condition of hardnefs and den- sity, as different in different parts of th« brain, that was to be attended to, in order to diiicov- er the caufe of the preceding difeafe ; and Vol. 3. I $ therefore iqo PRACTICE therefore many of them had not with this view examined the date of the brain, as Mor- gagni feems carefully to have done. MDLV. Having thus endeavoured t© invefligate the caufe of infanity in general, it were to be wifhed that I could apply the d6arine to the didinguifhing the Several Species oS it, accord- ing as they depend upon the different date and circumdances oF the brain, and thereby to the edablifhing oFa Scientific and accurate- ly adapted method oS cure. TheSe purpoSes, however, appear to me to be extremely diffi- cult to be attained ; and I cannot hope to execute them here. All I can do is to make Some attempts, and offer Some refleaions, which Surther observation, and greater Sagaci- ty, may hereafter render more ufeful. MDLVI. The ingenious Dr. Arnold has been com- mendably employed in didinguifhing the dif- ferent fpecies of infanity as they appear with refpea to the mind ; and his labours may hereafter prove ufeful, when we fhall come to know fomething more of the different dates of the brain correfponding to thefe different ftates of the mind ; but at prefent I can make little application of his numerous diflinaions. It appears to me that he has chiefly pointed out O.F PHYSIC. 191 out and enumerated didinaions, that are merely varieties, which can lead to little or no variety of praaice : And I am efpecially led to form the latter conclufion, becaufe thefe varieties ^appear to me to be often combined together* and to be often changed into one another, in the fame perSon ; in whom we mud therefore fuppofe a general caufe of the difeafe, which, fo Sar as it can be known, mud edablifh the pathology, and eSpecially direa the praaice. MDLVII. In my limited views oS the different dates of infanity, I mud go on to confider them un- der the two heads of Mania and Melancholia : And though I am fenfible that theSe two gen- era do not comprehend the whole of the fpe- cies of infanity, I am not clear in affigning the other Fpecies which may not be compre- hended under thoFe titles. I fhall, however, endeavour, on proper occafions as I go along, to point them out as well as I can. 16 CHAP. 192 PRACTICE C II A P. II. of MANIA, or MADNESS. ■ MDLVIII. 1 HE circumdances which I have mentioned above in MDXXXV, as condituting delirium in general, do more eSpecially belong to that kind oS it which I fhall treat of here under the title of Mania. There is fometimes a falfe perception or imagination of things prefent that are not; but this is not a conftant, nor even a frequent, attendant of the difeafe. The falfe judgment* is of relations long before laid up in the mem- ory. It very often turns upon one Single Fubjea : But more commonly the mind ram- bles from one Fubjea to another, with an equally SalSe judgment concerning the moft part oS them ; and as at the fame time there is commonly a falfe affociation, this increafes the confufion of ideas, and therefore the falfe judgments. What for the mod part more efpecially didinguifhes the difeafe, is a hurry of mind, in purfuing any thing like a train of thought, and in running from one train of thought OF PHYSIC. 193 thought to another. Maniacal perfons are in general very irafcible ; but what more par- ticularly produces their angry emotions is, that their SalSe judgments lead to Some aaion which is always pufhed with impetuofity and violence; when this is interrupted or restrain- ed, they break out into violent anger and fu- rious violence againd every perSon near them, and upon every thing that dands in the way of their impetuous will. The falfe judgment often turns upon a midaken opinion of fome injury fuppofed to have been formerly re- ceived, or now fuppofed to be intended : And it is remarkable, that fuch an opinion is often with refpea to their former cleared friends and relations ; and therefore their refentment and anger are particularly direaed towards theSe. And although this Should not be the caSe, they commonly Soon loSe that reSpea and regard which they Sormerly had for their friends and relations. With all thefe cir- cumdances, it will be readily perceived, that the difeaSe mud be attended very conftantly with that incoherent and abfurd Speech we call raving. Further, with the circumdances mentioned, there is commonly joined an un- ufual force in all the voluntary motions ; and an inSenfibility or refi dance oS the force of all impreffions, and particularly a refidance of the powers of fleep, of cold, and even of hun- ger ; though indeed in many indances a vo- racious appetite takes place. MDLIX. 194 PRACTICE MDLIX. It appears to me, that the whole of thefe circumdances and fymptoms point out a con- fiderable and unufual excefs in the excite- ment of the brain, efpecially with refpea to the' animal funaions ; and it appears at the fame time to be manifedly in fome meaSure unequal, as it very often takes place with refi pea to thefe funaions alone, while at the fame time the vital and natural are common- ly very little changed from their ordinary healthy date. MDLX. How this excefs of excitement is produced, it may be difficult to explain. In the va- rious indances of what Sauvages has named the Mania Metaftatica, and in all the indances I have mentioned in my Nofology under the title of the Mania Corporea, it may be fup- pofed that a morbid organic affeaion is pro- duced in Fome part oF the brain ; and how that may produce an increaSed or unequal excitement in certain parts of it, I have en- deavoured to explain above in MDLII. But I mud at the fame time acknowledge, that fuch remote caufes of mania have very rarely occurred; and that therefore fome other cauS- es oS the diSeaSe mud be Sought Sor. The OF PHYSIC. 195 The effeas of violent emotions or paffions of the mind have more frequently occurred as the remote caufes of mania ; and it is fuf- ficiently probable, that fuch violent emotions, as they do often immediately produce a tem- porary increafe of excitement, fo they may, upon fome occafions of their permanent in- herence or frequent repetition, produce a more confiderable and more permanent ex- citement, that is, a mania. With reSpea to thoSe caufes of mania which arife in conSequence oS a melancholia which had previoufly long Subfiffed ; whether we confider that melancholia as a partial in- Sanity, or as a long perfiding attachment to one train of thinking, it will be readily per- ceived, that in either cafe fuch an increafe of excitement may take place in fo confiderable a degree, and in fo large a portion of the brain, as may give occafion to a complete mania. MDLXI. Thefe confiderations with regard to the re- mote caufes appear to me to confirm fuffi- ciently our general doarine of increafed and unequal excitement in the mania which I have defcribed above ; but I mud own, that I have not exhauded the Subjea, and that there are cafes of mania of which I cannot aS- fign the remote caufes : But although I can- not in all cafes explain in what manner the mania ig6 PRACTICE mania is produced, I prefume, from the ex- planation given, and efpecially from the Symptoms enumerated above, to conclude, that the diSeaSe deScribed above depends up- on an increaSed excitement of the brain ; an opinion in which I am the more confirmed, as I think it will point out the proper method of cure. At lead I think it will mod clearly explain the operation of thofe remedies, which, fo far as I can learn from my own experience and that of others, have proved the mod fuc- ceSsSul in this difeafe ; and, to illudrate this, I now enter upon the confideration of thefe remedies, and to make fome remarks upon the proper manner of employing them. MDLXII. Redraining the anger and violence of mad- men is always neceffary for preventing their hurting themfelves or others : But this re- ftraint is alfo to be confidered as a remedy. Angry paffions are always rendered more vi- olent by the indulgence of the impetuous motions they produce ; and even in madmen the feeling of reftraint will fometimes prevent the efforts which their paffion would othenvife occafion. Reftraint, therefore, is uft-ful, and ought to be complete ; but it fhould be exe- cuted in the eafieft manner poffible for the pa- tient, and the drait waidcoat anfwers every purpofe better than any other that has yet been thought of. The redraining madmen by OF PHYSIC. 197 by the force of other men, as occafioning a condant Struggle and violent agitation, is often hurtful. Although, on many occafions, it may not be fafe to allow maniacs to be up- on their legs or to walk about, it is never de- sirable to confine them to a horizontal fitua- tion ; and whenever it can be admitted, they fhould be more or lefs in an erea pofture. Although there may be no fymptoms of any preternatural fulnefs or increafed impetus of blood in the veffels of the brain, a horizontal pofture always increafes the SulneSs and ten- fion of thefe veffels, and may thereby increafe the excitement of the brain. MDLXIII. The reftraint mentioned requires confine- ment within doors, and it fhould be in a place which preSents as few objeas of fight and hearing as poffible ; and particularly, it fhould be removed from the objeas that the patient was formerly acquainted with, as thefe would more readily call up ideas and their various aflbciations. It is for this reafon that the confinement of madmen fhould hardly ever be in their uSual habitation ; or if they are, that their apartment fhould be Stripped of all its former furniture. It is alfo for the moft part proper, that maniacs Should be without the company of any of their former acquaint- ance ; the appearance of whom commonly excites emotions that increetfe the difeafe. Strangers *g8 PRACTICE Strangers may at firft be offenfive ; but in a> little time they come to be objeas cither of indifference or of fear, and they Should not be frequently changed. MDLXIV. Fear being a paffion that diminishes excite- ment, may therefore be oppofed to the excefs of it; and particularly to the angry and iraf- cible excitement of maniacs. Thefe being more fufceptible of fear than might be ex- peaed, it appears to me to have been com- monly ufeSul. In moft caSes it has appeared to be neceffary to employ a very conftant im- preffion of fear ; and therefore to infpire them with the awe and dread of fome particular perfons, eSpecially of thofe who are to be con- ftantly near them. This awe and dread is therefore, by one means or other, to be ac- quired ; in the firft place, by their being the authors oSall the restraints that may be occa- sionally proper ; but Sometimes it may be neceffary to acquire it even by Stripes and blows. The Sormer, although having the ap- pearance oS more Severity, are much SaSer than Strokes or blows about the head. Nei- ther of them, however, fhould be employed further than feems very neceffary, and fhould be trufted only to thofe whofe diScretion can be depended upon. There is one caSe in which they are Superfluous ; that is, when the maniacal rage is either not fuSceptible of fear, or OF PHYSIC. 190, or incapable of remembering the objeas of it; for in fuch inftances, ftripes and blows would be wanton barbarity. In many caSes. of a moderate difeafe, it is of advantage that the perfons who are the authors of reftraint and punifhment Should be upon other occa- fions the beflowers of every indulgence and gratification that is admiffible; never, however, negleaing to employ their awe when their indulgence Shall have led to any abuSe.. MDLXV. Although in mania, no particular irritation nor SulneSs of the fydem feem to be prefent, it is plain, that the avoiding all irritation and means of fulnefs is proper ; and therefore, that a diet neither dimulating nor nourifhing is commonly to be employed. As it may even be ufeSul to diminifh the fulnefs of the fydem, fo both a low and a Spare diet is likely in mod caSes to be oS Service. MDLXVI. Upon the Same principle, although no un- ufual fulnefs of the body be prefent, it may be of advantage to diminifh even its ordinary fulnefs by different evacuations. Bloodletting, in particular, might be Fup- pofed ufeful ; and in all recent cafes of ma- nia it has been commonly praaifed, and I think with advantage ; but when the difeaSe has 200 PRACTICE has fubfided for fome time, I have Seldom found bloodletting of Service. In thofe in- ftances in which there is any frequency or fulnefs of pulfe, or any marks of an increafed impetus of the blood in the veffels of the head, bloodletting is a proper and even a nec- effary remedy. Some praaitioners, in Fuch cafes, have preferrod a particular manner of bloodletting, recommending arteriotomy, fcar- iSying the hind head, or opening the jugular vein ; and where any SulneSs or inflammatory diSpofition in the veffels oF the brain, is to be SuSpeaed, the opening of the veffels neared to them is likely to be oF the greated Fervice. The opening, however, oF either the temporal artery or the jugular vein in maniacal perfons is very often inconvenient; and it may gen- erally be fufficient to open a vein in the arm, while the body is kept in Somewhat of an erea podure, and Such a quantity of blood drawn as nearly brings on a deliquium animi, which is always a pretty certain mark of fome diminution of the fulnefs and tenfion of the veffels of the brain. MDLXVII. For the fame purpofe of taking off the ful- nefs and tenfion of thefe veffels of the brain, purging may be employed ; and I can in no other view underdand the celebrated ufe of hellebore among the ancients. I cannot, however, fuppofe any fpecific power in hel- lebore ; OF PHYSIC. 201 lebore ; and can by no means find that, at lead the black hellebore, is fo efficacious with us as it is faid to have been lit Anticyra. As codivenefs, however, is commonly a very con- ftant and hurtful attendant of mania, purga- tives come to be fometimes very neceffary; and I have known Fome benefit obtained from the frequent ufe of pretty draftic purgatives. In this, however, I have been frequently dis- appointed ; and I have found more advantage from the frequent ufe of cooling purgatives, particularly the Soluble tartar, than from more dradic medicines. MDLXVIII. Vomiting has alfo been frequently employ.* ed in mania ; and by determining powerfully to the furface of the body, it may poffibly di- minifh the fulnefs and tenfion of the veffels, and thereby the excitement oF the brain; but I have never carried the uFe of this remedy fo far as might enable me to judge properly of its effeas. Whether it may do harm by im- pelling the blood too forcibly into the veffels of the brain, or whether by its general agita- tion of the whole fydem it may remove that inequality of excitement which prevails in mania, I have not had experience enough to ^determine. MDLXIXi 202 PRACTICE MDLXIX. Frequent Shaving of the head has been found of Service in mania, and by promoting perfpiration it probably takes off from the excitement of the internal parts. This, how- ever, it is likely, may be more effeaually done by blidering, which more certainly takes,off the excitement of fubjacent parts. In recent cafes it has been Sound uSeful by inducing fleep ; and when it has that effea, the repe- tition of it may be proper : But in maniacal cafes that have laded Sor Some time, blidering has not appeared to me to be of any Service ; and in fuch cafes alfo I have not found per- petual bliders, or any other form of iffue, prove ufeSul. MDLXX. As heat is the principal means of fird ex- citing the nervous fydem, and edablifhing the nervous power and vital principle in animals; "fo, in cafes of preternatural excitement, the application of cold might be fuppofed a prop- er remedy : But there are many indances of maniacs who have beeri expofed for a great length of time to a confiderable degree of cold without having their fymptoms anywlfe relieved. This may render in general the application of cold a doubtful remedy ; but it is at the fame time certain, that maniacs have OF PHYSIC. have often been relieved, and fometimes en- tirely cured, by the ufe of cold bathing, ef- pecially when adminidered in a certain man- ner. 'This feems to confid, in throwing the madman into the cold water by SurpriSe ; by detaining him in it Sor Some length of time ^ and pouring water frequently upon the head, while the whole of the body except the head -is immerfed in the water ; and thus managing the whole procefs, So as that, with the affid- ance of fome fear, a refrigerant effea may be produced. This, I can affirm, has been often ufeful; and that the external application of * cold may be of fervice, we know further, from the benefit which has been .received in fome maniacal cafes from the application of ice and Snow to the naked head, and from the appli- cation of the noted Clay Cap. Warm bathing alfo has been recommended by fome praaical writers ; and in Some rigid melancholic habits it may poffibly be ufeful, or as employed in the manner prefcribed by Some, of immerfing the lower parts of the body in warm water, while cold water is pour- ed upon the head and upper parts. Of this praaice, however, I have had no experience ; and in the common manner of employing warm bathing I have found it ratner hurtful to maniacs. MDLXXI. According to my fuppofition that the diS- eaSe depends, upon an increafed excitement of the 204 PRACTICE the brain, efpecially with refpea to the ani- mal funaions, opium, fo commonly powerSul in inducing deep, or a confiderable collapSe as to theSe Sunaions, fhould be a powerSul remedy of mania. That it has truly proved fuch, I believe from the tedimony of Bernard Huet, whofe praaice is narrated at the end of Wepferi Hidoria Apopkaicorum. I leave to my readers to dudy this in the work I have referred to, where every part of the praaice is fully, and, as it appears to me, very judicioufly delivered. I have never indeed carried the trial fo far as Seems to be requifite to an entire cure : But I have frequently em- ployed in fome maniacal caSes, large dofes of opium ; and when they had the effea of in- ducing fleep, it was manifedly with advan- tage. At the fame time, in fome cafes, from doubts, whether the difeaSe might not depend upon Some organic lefions of the brain, when the opium would be Superfluous ; and in oth- er caSes, from doubts, whether there might not be fome inflammatory affeaion joined with the mania, when the opium would be hurtful, I have never pufhed this remedy to the extent that might be neceffary to make an entire cure. MDLXXII. Camphire has been recommended as a rem- edy of mania, and there are indances alleged of its having performed an entire cure. As it OF PHYSIC. it appears Srom the experiments of Beccari.i that this fubdance is poffeffed of a Sedative and narcotic virtue, theSe cures are not alto- gether improbable : But in Several trials, and even in large doSes, I have Sound no benefit from it ; and excepting thofe in the Philo- fophical Tranfaaions, N° 400, I have hard- ly met with any other tedimonies in its fa- vour. MDLXXIII. I have been informed that fome maniacs have been cured by being compelled to con- dant and even hard labour; and as a Sorced attention to the condua of any bodily exer- cife, is a very certain means of diverting the mind from purfuing any train of thought, it is highly probable that fuch exercife may be ufeful in many cafes of mania. I mud conclude this fubjea with obferv- ing, that even in feveral cafes of complete ma- nia, I have known a cure take place in the courfe of a journey carried on for fome length of time. MDLXX1V. Thefe are the remedies which have been thiefly employed in the mania that has been above defcribed, and I believe they have been employed promiScuoufly without Suppofing that the mania was to be didinguifhed into Vol. III. K different £06 PRACTICE different fpecies. Indeed I am not ready 10 fay how far it is to be fo didinguifhed, but I fhall offer one obfervation which may poffibly merit attention. It appears to me, that there are two differ- ent cafes of mania that are efpecially different according to the original temperament of the perfons whom the difeafe affeas. It perhaps occurs mod frequently in perfons of a melan- cholic or atrabilarian temperament ; but it certainly does alfo often occur in perfons of that very oppofite temperament which phy- sicians have named the Sanguine. Accord- ing as the difeafe happens to occur in perfons of the one or other of thefe temperaments, I apprehend it may be confidered as of a differ- ent nature ; and I believe, that accurate ob- fervation, employed upon a fufficient number of cafes, would difcern fome pretty condant difference, either of the fymptoms, or at lead of the date of fymptoms, in the two cafes. I imagine that falfe imaginations, particular averfions and refentments, are more fixed and fteady in the melancholic than in the fan- guine ; and that Somewhat inflammatory is more commonly joined with mania in the Sanguine than in the melancholic. If fuch difference, however, does truly take place, it will be obvious, that it may be proper to make fome difference alSo in the praaice. I am of opinion, that in the mania of Sanguine perfons, bloodletting and other antiphlogistic meafures are more proper, and have been more OF PHYSIC. more ufeful, than in the melancholic. I likewife apprehend that cold bathing is more ufeful in the fanguine than in the melanchol- ic : But I have not had experience enough to afcertain thefe points with fufficient confi- dence. I have only to add this other obfervation, that maniacs of the fanguine temperament re- cover more frequently and more entirely than thofe of the melancholic. K2 CHAP. 208 PRACTICE C H A P. III. or MELANCHOLY, and other forms of INSANITY. MDLXXV. Melancholy has been commonly confidered as a partial infanity ; and as Such it is defined in my NoSology ; But I now entertain doubts if this be alto- gether proper. By a partial infanity, I un- derdand a falfe and midaken judgment up- on one particular fubjea, and what relates to it ; whilft, on every other fubjea, the perfon" affeaed judges as the generality of other men do. Such cafes have certainly occurred j but, I believe, few in which the partial infan- ity is driaiy limited. In many caSes of gen- eral infanity, there is one fubjea of anger or fear, upon which the falfe judgment more par- ticularly turns, or which is at lead more fre- quently than any other the prevailing objea of delirium : And though, from the incon- iidency which this principal objea of delirium mud produce, there is therefore alfo a great deal of infanity with regard to mod other ob- jeas ; yet this lad is in very different degrees, both in different perfons, and in the fame per- OF PHYSIC. fon at different times. Thus perfons con- fidered as generally infane, will,, however, at times, and in fome cafes, pretty condantly judge properly enough of prefent circum- stances and incidental occurrences ; though, when thefe objeas engaging attention are not prefented, the operations of imagination may readily bring back a general confufion, or re-, call the particular objea of the delirium. From thefe confiderations,. I am inclined to conclude, that the limits between general and partial infanity cannot always be fo exaaiy affigned, as to determine when the partial af- feaion is to be confidered as giving a peculiar fpecies of difeaSe,, different from a more gen- eral infanity. MDLXXVJ: When inSanity, neither driaiy partial, nor entirely nor condantly general, occurs in per- fons of a fanguine temperament, and is at- tended with agreeable, rather than with angry or gloomy emotions, I think fuch a difeafe muft be confidered as different from the Ma- nia defcribed above ; and alfo, though par- tial, mud be held as different from the proper Melancholia to be mentioned hereafter. MDLXXVII. Such a difeafe, as different from thofe de- fcribed MDLIV, requires, in my opinion, a K 3 different 2io PRACTICE different adminidration of remedies ; and it will be proper for me to take particular no- tice of this here. Although it may be neceffary to redrain fuch infane perfons as we have mentioned MDLXXVI, from purfuing the objects of their falfe imagination or judgment, it will hardly be requisite to employ the fame force of reftraint that is neceffary in the impetuous and angry mania; It will be generally Suf- ficient to acquire fome awe over them, that may be employed, and Sometimes even be neceffary, to check the rambling of their imag- ination, and incoherency of judgment. MDLXXVIIL The redraint jud now mentioned as necef- fary will generally require the patient's being confined to one place, for the fake of exclud- ing the objeas, and more particularly the perfons, that might excite ideas conneaed with the chief objeas of their delirium. At the fame time, however, if it can be perceiv- ed there are objeas or perfons that can call off their attention From the purfuit of their own difordered imagination, and can fix it a little upon fome others, thefe lad may be fre- quently prefented to them : And for this rea- fon, a journey, both by its having the effea of interrupting all train of thought, and by pre- fenting objeas engaging attention, may often be ufeful. In fuch cafes alfo, when the in- fanity, OF PHYSIC. 2ii fonity, though more efpecially fixed upon one midaken fubjea, is not confined to this alone, but is further apt to ramble over other fub- jeas with incoherent ideas, I apprehend the confining or forcing fuch perfons to fome eonflant uniform, labour,, may prove an ufe- ful remedy.. MDLXXIX. When fuch cafes as in MDLXVI occur in fanguine temperaments, and may thereforo approach more nearly to Phrenitic Delirium -r fo, in proportion as the fymptoms of this ten- dency are more evident and confiderable, bloodletting and purging will be the more proper and neceffary. mdlxxx: To this fpecies of infanity, when occurring in fanguine temperaments, whether it be more or lefs partial, I apprehend that cold bathing is particularly adapted ; while, in the partial infanity of melancholic perfons, as I Shall fhow hereafter, it is hardly admiffible. MDLXXXI, Having thus treated of a fpecies of infan- ity, different, in my apprehenfion, from both the Mania and Melancholia, I proceed to K 4 confider 212 PRACTICE confider what feems more properly to belong to this laft. MDLXXXII. The diSeaSe which I name Melancholia is very oSten a partial inSanity only. But as in many inftances, though the SalSe imagination or judgment Seems to be with reSpea to one Subjea only ; yet it Seldom happens that this does not produce much inconfiftency in the other intelleaual operations : And as, between a very general and a very partial inSanity, there are all the poffible intermediate de- grees ; So it will be often difficult, or perhaps improper, to didinguifh Melancholia by the character oS Partial InSanity alone. If I midake not, it mud be chiefly didinguifhed by its occurring in perSons of a melancholic temperament, and by its being always attend- ed with fome Seemingly groundlefs, but very anxious, fear. MDLsXXXIII. To explain the caufe of this, I mud ob- ferve, that perSons of a melancholic tempera- ment are for the moft part of a Serious thought- ful diSpofition, and diSpoled to Sear and cau- tion, rather than to hope and temerity. Per- fons of this caft are lefs moveable than others by any impreflions ; and are therefore capa- ble of a clofer or more continued attention to one OF PHYSIC. 213 one particular objea, or train of thinking. They are even ready to be engaged in a con- stant application to one Subjea ; and are re- markably tenacious of whatever emotions they happen to be affeaed with. MDLXXXIV. Thefe circumftances of the melancholic: charaaer, feem clearly to fhow, that perfons ftrongly affeaed with it may be readily feiz- ed with an anxious fear ; and that this, when much indulged, as is natural to fuch perfons, may eafily grow into a partial infanity. MDLXXXV. Fear and dejeaion of mind, or a timid and defponding difpofition,. may arife in certain ftates, or upon certain occafions, of mere de- bility : And it is upon this footing, that I fup- pofe it fometimes to attend dyfpepfia. But in thefe cafes, I believe the defpondent dif- pofition hardly ever arifes to a confiderable degree, or proves fo obftinately fixed as when it occurs in perfons of a melancholic tem- perament. In thefe lad, although the fear proceeds from the fame dyfpeptic feelings as in the other cafe, yet it will be obvious, that the emotion may riSe to a more confiderable de- gree ; that it may be more anxious, more fix- ed, and more attentive ; and therefore may exhibit all the various circumdances which I Vol. 3. K 5 have si4 PRACTICE have mentioned in MCCXXII to take place in the diSeaSe named Hypochondriasis. MDLXXXVI. In confidering this fubjea formerly in dif- tinguifhing Dyfpepfia from Hypochondriasis, although the Symptoms affeaing the body be very much the Same in both, and even thole af- feaing the mind be Somewhat Similar, I Sound no difficulty in didinguifhing the latter diSeaSe, merely from its occurring in perSons of a mel- ancholic temperament. But I mud now ac- knowledge, that I am at a lofs to determine how in all cafes hypochondriasis and melan- cholia may be didinguifhed from one another,, whild the fame temperament is common to both. MDLXXXVII. I apprehend, however, that the didinaion may be generally afcertained in the following manner. The hypochondriasis I would confider as being always attended with dyfpeptic fymp- toms : And though there may be, at the fame time, an anxious melancholic fear arifing from the feeling of thefe fymptoms ; yet while this fear is only a midaken judgment with refpea to the date of the perfon's own health, and to the danger to be from thence apprehended, I would dill confider the difeafe as a hypochon- driasis, • OF PHYSIC. 2:5 drialis, and as diflina from the proper melan- cholia. But when an anxious fear and def- pondency arifes from a miitaken judgment with refpea to other circumdances than thofe of health, and more efpecially when the per- fon is at the fame time without any dyfpep- tic fymptoms, everv one will readily allow this to be a difeafe widely different From bot! dyFpepfia and hypochondriafis ; and it is^. what I would driaiy name Melancholia. MDLXXXVIII.. In this there feems little difficulty : But as an exquifitely melancholic temperament may induce a torpor and flowneSs in the aaion of the domach, fo it generally produces fome dyfpeptic fymptoms; and from thence there may be fome difficulty in didinguifhing fuch a cafe from hypochondriafis. But I would maintain, however, that when the charaaers of the temperament are drongly marked ; and more particularly when the falfe imagination turns upon other fubjeas- than that of health,. or when, though relative, to the perfon's own body, it is of'a groundlefs. and 'abfurd kind ; then, notwithdanding the appearance of fome dyfpeptic Symptoms, the caSe is dill to be confidered as that of a melancholia, rather than a -hypochondriasis. K6 MDLXXXIX. 2x6 PRACTICE MDLXXXIX. The difeafe of melancholia, therefore, man- ifedly depends upon the general temperament of the body : And although, in many perfons, this temperament is not attended with any morbid affeaion either of mind or body ; yet when it becomes exquifitely formed, and is in a high degree, it may become a difeaSe af- feaing both, and particularly the mind. Jt will therefore be proper to confider in what this melancholic temperament efpecially con- fids ; and to this purpofe, it may be obferv- ed, that in it there is a degree oS torpor in the motion oS the nervous power, both with reS- pea to SenSation and volition ; that there is a general rigidity oS the Simple Solids ; and that the balance of the Sanguiferous fydem is up- on the fide of the veins. But all thefe cir- cumdances are the direaiy oppofite of thofe oS the Sanguine temperament ; and mud therefore alfo produce an oppofite ftate of mind. MDXC. It is this date of the mind, and the date of the brain correfponding to it, that is the chief objea of our prefent confideration. But what that date of the brain is, will be fuppof- ed to be difficult to explajn ; and it may per- haps feem rafh in me to attempt it. I will, OF PHYSIC. 217 I will, however, venture to fay, that it is probable the melancholic temperament of mind depends upon a drier and firmer tex- ture in the medullary fubdance of the brain j and that this perhaps proceeds from a certain want of fluid in that fubdance, which appears from its being of a leffer fpecific gravity than ufual. That this date of the brain in melan- cholia does aaually exid, I conclude, firft, from the general rigidity of the whole habit ; and, fecondly, from diffeaions, fhowing Such a date of the brain to have taken place in ma- nia, which is often no other than a higher de- gree of melancholia. It does not appear to me anywife difficult to SuppoSe, that the Same ftate oS the brain may in a moderate degree give melancholia ; and in a higher, that ma- nia which melancholia So often paffes into ; efpecially if I fhall be allowed further to fup- pofe, that either a greater degree of firmnefs in the fubftance of the brain may render it fufceptible of a higher degree of excitement, or that one portion of the brain may be liable to acquire a greater firmnefs than others, and confequently give occafion to that inequality of excitement upon which mania fo much de- pends. MDXCI. I have thus endeavoured to deliver what appears to me mod probable with refpea to the proximate caufe of melancholia j and al- though 218 P R A C T I C i:". though the matter fhould in fome refpeas re- main doubtful, I am well perfuaded that thefe obfervations may often be employed to direa our praaice in this difeafe, as I Shall now en- deavour to Show. MDXCII. In mod of the indances of melancholia, the mind is to be managed very much in the fame manner as I have advifed above with regard to hypochondriafis ; but as in the cafe of proper melancholia, there is commonly a falfe imagination or judgment appearing as a par- tial infanity, it may be further neceffary in Fuch cafes to employ fome artifices for cor- reaing fuch imagination or judgment. MDXCIII. The various remedies for relieving the dyf- peptic fymptoms which always attend hypo- chondriasis, will feldom be either requisite or proper in melancholia. There is only one of the dyfpeptic fymp- toms, which, though there Should be no oth- er, is very condantly prefent in melancholia, and that is codivenefs. This it is always proper and even neceffary to remove ; and I believe it is upon this account that the ufe of purgatives has been found fo often ufeful in melancholia. Whether there be any purga- tives peculiarly proper in this cafe, I dare not positively determine ; but with refpea to the choice. * OF PHYSIC. 219 choice of purgatives in melancholia, I am of the fame opinion that I delivered above on this fame fubjea with refpea to mania. MDXCIV. With refpea to other remedies, I judge that bloodletting will more feldom be proper in melancholia than in mania ; but how far it may be in any cafe proper, mud be deter- mined by the fame confiderations as in the cafe of mania. ♦ MDXCV. The cold bathing that I judged to be fb very ufeful in feveral cafes of infanity, is, I believe, in melancholia, hardly ever fit to be admitted ; at lead while this is purely a par- tial affeaion, and without any marks of vio- lent excitement. On the contrary, upon ac- count of the general rigidity prevailing in mel- ancholia, it is probable that warm bathing may be often uSeful. MDXCVI. With refpea to opiates which I have fup- pofed might often be ufeful in cafes of mania, I believe they can Seldom be properly em- ployed in the partial infanities of the melan- cholic, except in certain indances of violent excitement, when the melancholia approach- es nearly to the ftate of mania. MDXCVII. 220 P R A C T I C E, &c. MDXCVII. In fuch cafes of melancholia approaching to a ftate of mania, a low diet may fometimes be neceffary ; but as the employing a low diet almoft unavoidably leads to the ufe of vege- table food, and as this in every torpid ftate of the ftomach is ready to produce fome dyfpep- tic fymptOms, fuch vegetable food ought, in moderate cafes of melancholia, to be ufed with fome caution. Though exercife, as a tonic power, is not proper either in hypochondriafis or melan- cholia ; yet, with reSpea to its effeas upon the mind, it may be extremely uSeful in both, and in melancholia is to be employed in the fame manner that I have advifed above in the caSe of hypochondriafis. MDXCVIII. Having now delivered my doarine with refpea to the chief forms of infanity, I fhould in the next place proceed to confider the other genera of Amentia and Oneirodynia, which in the Nofology I have arranged un- der the order of Vefaniae : But as I cannot pretend to throw much light upon thefe fubjeas, and as they are feldom the objeas of praaice, I think it allowable for me to oafs them over at prefent; and the particular cir- cumdances of this work in fome meafure re- quires that I fhould do So. PART MDXCIX. NDER this title I propofe to effablifh a clafs of difeafes, which confift in a depraved ftate of the whole, or of a con- fiderable part, of the habit of the body, without any prima- ry pyrexia or neurofis combined with that ftate. MDC. The term Cachexy has been employed by Linnaeus and Vogel, as it had been formerly by other authors, for the name of a particular difeaSe : But the diSeaSe to which theSe au- thors P R A C T I C E, Sec. thors have affixed it, comes more properly under another appellation; and the term of Cachexy is more properly employed by Sau- vages and Sagar for the name of a clafs. In this 1 have followed the laft mentioned no- fologids, though I find it difficult to give fuch a charaaer of the clafs as will clearly apply to all the fpecies I have comprehended under it. ' This difficulty would be dill great- er, if, in the clafs I have edablifhed under the title of Cachexies, I were to comprehend all the difeaSes that thoSe other noSologids have done ; but I am willing to be thought deficient rather than very incorrea. ThoSe difficulties, however, which dill remain in methodical nofology, mud not affect us much in a treatife of practice. If I can here prop- erly didinguifh and defcribe the Several Spe- cies that truly and moft commonly exift, I fhall be the leSs concerned about the accuracy oF my general' claffification : Though at the fame time this, I think, is always to be at- tempted ; and I fhall purfue it as well as I can. BOOK BOOK I. ©f EMACIATIONS. MDCI. Emaciation, or a con- siderable diminution of the bulk or plump- nefs of the whole body, is for the moft part only a Symptom of difeafe, and very feldom to be confidered as a primary and idiopathic affeaion. Upon this account, according to my general plan, Such a Symptom might per- haps have been omitted in the Methodical Nofology : But both the uncertainty of con- cluding it to be always fymptomatic, and the confiftency of fyftem, made me introduce in- to the Nofology, as others had done, an order under the title of Marcores; and this renders it requifite now to take fome notice of fuch difeafes. MDCII. 824 PRACTICE MDCII. Upon this occafion, therefore, I hope it may be ufeful to investigate the feveral caufes of emaciation in all the different cafes of dif- eafe in which it appears. And this I attempt, as the fured means of determining how far it is a primary, or a fymptomatic affeaion only y and even in the latter view, the invedigation; may be attended with fome advantage. MDCIII. The caufes of emaciation may, I appre- hend, be referred to two general heads ; that is, either to a general deficiency of fluid in the veflels of the body, or to the particular deficiency of the oil in the cellular texture of it. Thefe caufes are frequently combined together; but it will be proper, in the firft place, to confider them Separately. MDCIV. As a great part of the body of animals is made up of veflels filled with fluids, the bulk of the whole muft depend very much on the Size of thefe veffels, and the quantity oF fluids preFent in them: And it will thereFore be fufficiently obvious, that a deficiency of the fluids in theSe veffels muft, according to its degree, occafion a proportionate diminution OF PHYSIC. 225 of the bulk of the whole body. This, how- ever, will appear dill more clearly, from con- fidering that in the living and found body the veffels every where Feem to be preternaturally didended by the quantity oF fluids prefent in them ; but being at the fame time eladic, and condantly endeavouring to contraa themfelves, they mud, on the withdrawing of the didending force, or, in other words, upon a diminution of the quantity of fluids, be in proportion contraaed and diminifhed in their fize : And it may be further obferved, that as each part of the vafcular fydem communi- cates with every other part of it; fo every de- gree of diminution of the quantity of fluid, in any one part, mud in proportion diminifh the bulk of the vafcular fyftem, and conse- quently of the whole body. MDCV. The diminution and deficiency of the fluids may be occafioned by different caufes : Such as, firft, by a due quantity of aliments not be- ing taken in ; or by the aliment taken in, not being of a fufficiently nutritious quality. Of the want of a due quantity of aliment not be- ing taken into the body, there is an inftance in the Atrophia laftantium Sauvagefii, fpecies 3 ; and many other examples have occurred of emaciation from want of food, occafioned by fooverty, and other accidental cauSes. With £26 PRACTICE With refpea to the quality of food, I ap- prehend it arifes from the want of nutritious matter in the food employed, that perfons liv- ing very entirely on vegetables are feldom of a plump and fucculent habit. MDCVI. A fecond caufe of the deficiency of fluids may be, the aliments taken in not being con- veyed to the bloodveffels. This may occur from a perfon's being affeaed with a Frequent vomiting; which, rejeaing the food foon after it had been taken in, mud prevent the necef- fary Supply of fluids to the bloodveffels. Another caufe, frequently interrupting the conveyance of the alimentary matter into the bloodveffels, is an obdruaion of the conglo- bate or lymphatic glands of the mefentery, through which the chyle mud neceffarily pafs to the thoracic dua. Many indances of ema- ciation, Seemingly depending upon this caufe, have been obferved by phyficians, in perfons of all ages, but efpecially in the young. It has alfo been remarked, that fuch cafes have mod frequently occurred in fcrophulous per- fons, in whom the mefenteric glands are com- monly affeaed with tumour or obdruaion, and in whom, generally at the Same time, Scrophula appears externally. Hence the Tabes fcrophulofa Synop. Nofolog. vol. ii. p> 266 : And under theSe I have put as Synon- imes Tabes glandularis, Sp. 10 ; Tabes mefen* terica^ OF PHYSIC. 227 terica, fp. 9 ; Scrophula mefenterica, fp. 4 ; Atrophia infantilis, fp. 13; Atrophia rachiu ica, fp. 8 ; Tabes rachialgica, fp. 16. At the fame time, I have frequently found the cafe occurring in perfons who did not Show any external appearance of fcrophula, but in whom the mefenteric obdruaion was after- wards difcovered by difleaion. Such alfo I fuppofe to have been the cafe in the difeaSe frequently mentioned by authors under the title of the Atrophia infantum. This has re- ceived its name from the time of life at which it generally appears ; but I have met with in- dances of it at fourteen years of age afcer- tained by diffeaion. In feveral fuch cafes which I have Seen, the patients were without any Scrophulous appearances at the time, or at any period of their lives before. In the cafe of phthifical perfons, I fhall hereafter mention another caufe of their ema- ciation ; but it is probable that an obdruaion of the mefenteric glands, which fo frequently happens in fuch perfons, concurs very power- fully in producing the emaciation that takes place. Although a fcrophulous taint may be the mod frequent caufe of mefenteric obflruc- tions, it is fufficiently probable that other kinds of acrimony may produce the fame, and the emaciation that follows. It may perhaps be fuppofed, that the in- terruption of the chyle's palling into the bloodveffels may be fometimes owing to a fault 228 PRACTICE fault of the abforbents on the internal furface of the intedines. This, however, cannot be readily afcertained : But the interruption of the chyle's palling into the bloodveffels may certainly be owing to a rupture of the tho- racic dua ; which, when it does not prove foon fatal, by occafioning a hydrothorax, muft in a Short time produce a general ema- ciation. MDCVII. A third caufe of the deficiency of the fluids may be a fault in the organs of digeftion, aa not duly converting the aliment into a chyle fit to form in the bloodveffels a proper nu- tritious matter. It is not, however, eafy to afcertain the caSes of emaciation which are to be attributed to this caufe ; but I apprehend that the emaciation which attends long fub- fiding cafes of dyfpepfia, or of hypochondri- asis, is to be explained chiefly in this way. It is this which I have placed in the NoSol- j ogy under the title oS the Atrophia debilium ; and of which the Atrophia nervofa, Sauv. fp. 1, is a proper indance, and therefore put there as a fynonime. But the other tides of Atro- phia lateralis, Sauv. fp. 15, and Atrophia fen* His, Sauv. fp. 11, are not fo properly put there, as they mud be explained in a differ- ent manner* MDCVIIL OF PHYSIC. 229 MDCVIII. A fourth caufe of a deficiency of the fluids in the body, may be exceffive evacuations made from it by different outlets ; and Sau- vages has properly enumerated the following fpecies, which we have put as fynonimes un- der the title of Atrophia inanitorum ; as, Tabes nutricum, fp. 4, Atrophia nutricum, fp. 5, Atrophia d leucorrhcea, fp. 4, Atrophia ab alvifluxu, fp. 6, Atrophia d ptyalifmo, fp. 7, and laffly, the Tabes d fanguifluxu ; which, it is to be obferved, may arife not only from fpontaneous hdhiorrhagies or accidental wounds, but alfo from bloodletting in too large a quantity, and too frequently re- peated. Upon this fubjea it feems proper to ob- ferve, that a meagre habit of body frequently depends upon a full perfpiration being con- dantly kept up, though at the fame time a large quantity of nutritious aliment is regu- larly taken in. MDCIX. Befides this deficiency of fluids from evac- uations by which they are carried entirely out of the body, there may be a deficiency oS fluid and emaciation in a confiderable part of the body, by the fluids being drawn into one part, or colkaed into one cavity ; and of this we Vol. III. L have 230 PRACTICE have an indance in the Tabes d hydrope, Sauv. fP- 5- MDCX. In the Methodical Nofology,* among the other fynonimes of the Atrophiainanitorum I have Set down the Tabes dorfalis ; but wheth- er properly or not, I at prefent very much doubt. In the evacuation confidered as the -^ cauSe of this tabes, as the quantity evacuat- ed is never fo great as to account Sor a gen- eral deficiency of fluids in the body, we mud Seek Sor another explanation of it. And whether the effeas of the evacuation may be accounted for, either from the quality of the fluid evacuated, or from the Singularly ener- vating pleaSure attending the evacuation, or from the evacuation's taking off the tenfion oF parts, the tenfion of which has a lingular power in Supporting the tenfion and vigour of the whole body, I cannot positively deter- mine ; but I apprehend that upon one or other of thefe fuppofitions the emaciation at- tending the tabes dorfalis mud be accounted ' for; and therefore that it is to be confidered as an indance of the Atrophia debilium, rather than of the Atrophia in.anitorum. MDCXI. A fifth caufe of a deficiency of fluids and of emaciations in the whole or in a particular part OF PHYSIC. 231 , part of the body, may be the concretion of the Small veffels, either not admitting of fluids, or of the fame proportion as before; and this feems to me to be the cafe in the Atrophia fenilis, Sauv. Sp. 2. Or it may be a pally of the larger trunks of the arteries rendering them unfit to propel the blood into the Small- er veffels ; as is frequently the cafe of para- lytic limbs, in which the arteries are affeaed as well as the mufcles. The Atrophia late- ralis, Sauv. fp. 15, feems to be of this nature. MDCXII. A fecond general head of the caufes of emaciation I have mentioned in MDCII to fee a deficiency of oil. The extent and quan- tity of the cellular texture in every part of the body, and therefore how confiderable a part it makes in the bulk of the whole is now well known. But this fubdance, in different circumdances, is more or lefs filled with an oily matter ; and therefore the bulk of it, and in a great meafure that of the whole body, muft be greater or lefs according as this fubdance is more or lefs filled in that manner. The deficiency of fluids, for a reafon to be imme- diately explained, is generally accompanied with a deficiency of oil : But phyficians have commonly attended more to the latter caufe of emaciation than to the other, that being ufually the mod evident; and I fhall now en- deavour to affign the feveral caufes of the ^ L 2 deficiency ,* ^ 232 PRACTICE deficiency of oil as it occurs upon different occafions. MDCXIIL The bufinefs of fecretion in the human body is in general little underflood, and in no indance lefs fo than in that of the Secretion oS oil Srom blood which does not appear pre- viously to have contained it. It is poffible, £ therefore, that our theory of the deficiency of oil may be in feveral refpeas imperSea ; but there are certain faas that may in the mean time apply to the preSent purpoSe. MDCXIV. Fird, it is probable, that a deficiency of oil may be owing to a date of the blood in ani- mal bodies lets fitted to afford a fecretion of oil, and confequently to Supply the wade oS it that is condantly made. This date of the > blood mud efpecially depend upon the date of the aliments taken in, as containing lefs of oil or oily matter. From many obfervations * made, both with refpea to the human body and to that of other animals, it appears pretty " clearly, that the aliments taken in by men and * domedic animals, according as they contain more of oil, are in general more nutritious, and in particular are better fitted to fill the < cellular texture of their bodies with oil. I might illuftrate this, by a minute and partic- I ular OF PHYSIC. 233 ular confideration of the difference oF ali- mentary matters employed ; but it will be enough to give two inftances. The one is, that the herbaceous part of vegetables, does- not fatten animals, fo much as the feeds of vegetables, which manifeftly contain in any given weight a greater proportion of oil; and a fecond inftance is, that in general Vegetable aliments do not fatten men So much as animal Sood, which generally contains a larger pro- portion of oil. It will be obvious, that upon the fame principles a want of food, or a lefs nutritious food, may not only occafion a general defi- ciency of fluids (MDCIV), but mud alfo af- ford lefs oil, to be poured into the cellular texture.. In fuch cafes, therefore, the ema- ciation produced, is to be attributed to both. thefe general caufes*. MDCXV. A (iecond cafe of the deficiency of oil may be explained in this manner. It is prettv manifed, that the oil of the blood is fecreted and deposited in the cellular texture in great- er or leffer quantity, according as the circula- tion of the blood is fader or flower ; and therefore that exercife, which haflens the cir- culation of the blood, is a frequent caufe of emaciation. Exercife produces this effea in two ways, id, By increafing the perfpira- tion, and thereby carrying off a greater quan- L 3 tity 234 PRACTICE tity of the nutritious matter, it leaves lefs of it to be depofited in the cellular texture ; thereby not only preventing an accumulation of fluids, but, as I have Said above, caufing a ^ general deficiency of thefe, which mud alfo V caufe «. deficiency of oil in the cellular tex- ture. 2dly, It is well known, that the oil de- % pofited in the cellular texture is upon many occafions, and For various purpofes of the economy, again abforbed, and mixed or dif- ^ fufed in the mafs of blood, to be from thence perhaps carried entirely out of the body by the feveral excretions. Now, among other purpofes of the accumulation and reabforp- tion of oil, this feems to be one, that the oil is requifite to the proper aaion of the moving fibres in every part of the body ; and there-, ; . fore that nature has provided for an abforp- j tion of oil to be made according as the aaion of the moving fibres may demand it. It will thus be obvious, that the exercife of the muf- cular and moving fibres every where, mud occafion an abforption of oil ; and conse- quently that Such exercife not only prevents the Secretion of oil, as has been already faid, ' but may alfo caufe a deficiency oS it, by oc- casioning an abSorption of what had been depofited ; and in this way, perhaps efpecial- v ly, does it produce emaciation. ' MDCXVI. A third cafe of the deficiency of oil may occur from the following caufe. It is prob- able, OF PHYSIC. 235 able, that one purpofe of the accumulation of oil in the cellular texture of animals is, that it may, upon occafion, be again abforbed from thence, and carried into the mafs of blood, for the purpofe of enveloping and cor- reaing any unufual acrimony arifing and ex- iding in the date of the fluids. Thus, in mod indances in which we can difcern an acrid date of the fluids, as in Scurvy, cancer^ Syphilis, poiSons, and Several other difeafes, we find at the fame time a deficiency of oil and an emaciation take place ; which, in my apprehenfion, mud be attributed to the ab- sorption of oil, which the prefence of acrimo- ny in the body excites. It is not unlikely that certain poifons intro- duced into the body, may fubfid there ; and, giving occafion to an abforption of oil, may lay a foundation for the Tabes a veneno, Sauv. fp. 17. MDCXVII. A fourth cafe of emaciation, and which I would attribute to a fudden and confiderable abforption of oil from the cellular texture, is that of fever, which fo generally produces emaciation. This may perhaps be in part attributed to the increaSed perSpiration, and thereSore to the general deficiency of fluids that may be fuppofed to take place : But whatever fhare that may have in producing the effea, we can, from the evident fhrinking L 4 and 236 PRACTICE and diminution of the cellular fubdance, wherever it falls under our observation, cer- tainly conclude, that there has been a very confiderable abforption of the oil which had been before depofited in that fubdance. This explanation is rendered the more probable from this, that I fuppofe the abforption mentioned is neceffarily made for the purpofe of enveloping or correaing an acrimony, which manifeftly does in many, and may be SuSpeaed to arife in all, caSes of fever. The mod remarkable indance of emaciation oc- curring in fevers, is that which appears in the cafe of heaic fevers. Here the emaciation may be attributed to the profufe fweatings that commonly attend the difeaSe : But there is much reaSon to believe, that an acrimony alio is preSent in the blood ; which, even in the beginning of the difeafe, prevents the fe- cretion and accumulation of oil ; and in the more advanced dates of it, mud occafion a more confiderable abforption of it ; which, from the Shrinking of the cellular fubdance, feems to go farther than in almod any other indance. Upon the fubjea of emaciations from a de- ficiency of fluids, it may be obferved, that every increafed evacuation excites an abforp- tion from other parts, and particularly from the cellular texture ; and it is therefore prob- able, that a deficiency of fluids, from increaf- ed evacuations, produces an emaciation, not only by the wade of the fluids in the vafcu- lar Of P H Y S I C. 237 lar fydem, but alfo by occafioning a confider- able abSorption from the cellular texture. MDCXVIII. I have thus endeavoured to explain tha feveral cafes and caufes of emaciation ; but I could not profecute the confideration of thefe here in the order they are Set down in the Methodical NoSology. In that work I was engaged chiefly in arranging the Species of Sauvages ; but it is my opinion now, that the arrangement there given is erroneous, in both combining and Separating Species improper- ly : And it Seems to me more proper here to take notice of difeafes, and put them together,. according to the affinity of their nature, rath- er than by that of their external appearances. I doubt, if even the diflinaion of the Tabes and Atrophia, attempted in the Nofology, will properly apply j. as I think there are certain difeafes of the fame nature, which fometimes appear with, and fometimes with- out, fever. MDCXIX. After having confidered the various caSes of emaciations, I fhould perhaps treat of their cure : But it will readily appear, that the greater part of the cafes above mentioned are Vol. 3. L 5 purely 238 PRACTICE, Sec. purely fymptomatic, and consequently that the cure of them mud be that of the primary difeafes upon which they depend. Of thofe cafes that can anywife be confidered as idio- pathic, it will appear that they are to be cur- ed, entirely by removing the remote caufes ; the means of accomplishing which muft be fufficiently obvious. BOOK 239 BOOK II. of INTUMESCENTIiE, or GENER- AL SWELLINGS. MDCXX. iHE fwell'ings to be treated of in this place, are thofe which extend over the whole or a great part of the body ; or fuch at lead, as, though of fmall extent, are however of the fame nature with thofe that are more generally extended. The Swellings comprehended under this ar- tificial order, are hardly to be didinguifhed from one another otherwife than by the mat- ter they contain or confid of : And in this view I have divided the order into four Sec- tions, as the Swelling happens to contain, if, L6 Oil; 24o PRACTICE 0 Oil; 2d, Air ; %d, A watery fluid ; or, 4th, As the increafed bulk depends upon the en- largement of the whole fubftance of certain parts, and particularly of one or more of the abdominal vifcera. CHAP. OF PHYSIC. 241 CHAP. I. of ADIPOSE SWELLINGS. MDCXXI. XHE only difeafe to be men- tioned in this chapter, I have, with other No- fologifts, named Polyfarcia ; and in Englifh it may be named Corpulency, or, more ftria- ly, Obefity; as it is placed here upon the common Suppofition of its depending chiefly upon the increafe of oil in the cellular texture of the body. This corpulency, or obefity, is in very different degrees in different perfons, and is oSten confiderable without being con- fidered as a diSeaSe. There is, however, a certain degree of it, which will be generally allowed to be a difeaSe ; as, Sor example, when it renders perSons, from a difficult ref- piration, uneafy in themfelves, and, from the inability of. exercife, unfit for difcharging the duties of life to others : And for that reafon I have given fuch a difeafe a place here. Many phyficians have confidered it as an objea of praaice, and as giving, even in no very high degree, a difpofition to many diSeaSes ; I am of opinion that it fhould be an objea of prac- tice 242 PRACTICE tice more frequently than it has been, and i therefore that it merits our confideration j here. •»", MDCXXII. It may perhaps be alleged, that I have not been fufficiently correa, in putting the difeafe l of corpulency as an intumefcentia pinguedi-" * noSa, and thereSore implying its being an in- creafe of the bulk of the body from an accu- mulation of oil in the cellular texture only. I am aware of this objeaion : And as I have already faid, that emaciation (MDCII) de- pends either upon a general deficiency of flu- ids in the vafcular Syltem, or upon a deficien- j cy of oil in the cellular texture ; fo I fhould j perhaps have obServed Sarther, that the cor- pulency, or general fulnefs of the bod), may depend upon the fulnefs of the vafcular fyf- tem as well as upon that of the cellular tex- ture. This is true ; and for the fame reafons I ought, perhaps, after Linnaeus and Sagar, to have Set down plethora as a particular dif- eafe, and as an inftance of morbid intumef- cence. I have, however, avoided this, as Sau- vages and Vogel have done; becaufe I ap- prehend that plethora is to be confidered as a date of temperament only, which may indeed difpofe to difeafe ; but not as a difeafe in it- . felf, unlefs, in the language of the Stahlians, ^ it be a plethora commota, when it produces a difeafe accompanied with particular fymp- j toms, i OF fHYSIC. 243 toms, which give occafion to its being didin- guifhed by a different appellation. Further, it appears to me, that the fymptoms which Linnaeus, and more particularly thofe which Sagar employs in the charaaer of plethora, never do occur but when the intumeScentia pinguedinoSa has a great fhare in producing them. It is, however, very neceffary to ob- ferve here, that plethora and obefity are gen- erally combined together; and that in Some caSes of corpulency it may be difficult to de- termine which of the caufes has the greated fhare in producing it. It is indeed very pof- fible that a plethora may occur without great obefity ; but I apprehend that obefity never happens to a confiderable degree without pro- ducing a plethora adfpatium in a great part of the fydem of the aorta, and therefore a plethora ad molem in the lungs, and in the veffels of the brain. MDCXXIII. In attempting the cure of polyfarcia, I am of opinion, that the conjunaion of plethora and obefity, in the manner jud now men- tioned, fhould be condantly attended to ; and when the morbid effeas oF the plethoric hab- it are threatened, either in the head or lungs, that bloodletting is to be praaiSed : But at the Same time it is to be obServed, that per- fons of much obefity do not bear bloodletting well; and when the circumdances I have mentioned 244 PRACTICE mentioned do not immediately require it, the praaice upon account of obefity alone, is J hardly ever to be employed. The fame re- 1 mark is to be made with refpea to any other *] evacuations that may be propofed for the 1 cure of corpulency :' For without the other 1 means I am to mention, they can give but a very imperfea relief; and, in fo far as they either empty or weaken the fydem, they may vl favour the return of plethora, and the increafe 1 of obefity. MDCXXIV. Polyfarcia, or corpulency, whether it de- pend upon plethora or obefity, whenever it either can be confidered as a diSeaSe, or threatens to induce one, is to be cured, or the effeas oF it are to be obviated, by diet and exerciSe. The diet mud be Sparing ; or rather, what is more admiffible, it mud be fuch as affords little nutritious matter. It mud therefore be chiefly, or almod only, of vegetable matter, and at the very utmod of milk. Such a diet Should be employed, and ^ generally ought to precede exercife ; for obe- fity does not eafily admit of bodily exercife,; which is*, however, the only mode that can be \ very effeaual. Such, indeed, in many cafes, may feem difficult to be admitted ; but I am of opinion, that even the mod corpulent may be brought to bear it, by at fird attempting it very moderately, and increafing it by degrees very OF PHYSIC. 245 very flowly, but at the fame time perfifling in fuch attempts with great condancy. MDCXXV. As thefe, though the dnly effeaual meaf- ures, are often difficult to be admitted or car- ried into execution, fome other means have been thought of and employed for reducing corpulency. Thefe, if I midake not, have all been certain methods of inducing a faline date in the mafs of blood ; for fuch I fuppofe to be the effeas of vinegar and of Soap, which have been propoSed. The latter, I believe, hardly pafles into the bloodveffels, without being reFolved and formed into a neutral Salt, with the acid which it meets with in the dom- ach. How well acrid and Saline Subdances are fitted to diminifh obefity, may appear from what has been faid above in MDCXV. What effeas vinegar, Foap, or other fub- ftanceS employed, have had in reducing cor- pulency, there have not proper dpportunities of obferving occurred to me : But I am well perSuaded, that the inducing a Saline and acrid ftate of the blood, may have worSe confe- quences thgn the corpulency it was intended to "correa ; and that no perSon fhould hazard theSe, while he may have recourfe to the more SaSe and certain means of abstinence and ex- erciSe. CHAP. 246 PRACTICE CHAP. II. t of FLATULENT SWELLINGS. MDCXXVI. 1 HE cellular texture of the I human body very readily admits of air, and allows the fame to pafs from any one to every other part of it. Hence Emphyfemata have often appeared from air colleaed in the eel- i lular texture under the fkin, and in feveral I other parts of the body. The flatulent fwell- ] ingsunder the fkin, have indeed moft com- monly appeared in confequence of air imme- / diately introduced from without : But in fome inftancjs of flatulent fwellings,""efpec- ially thofe of the internal parts not commu- nicating with the alimentary canal, fuch an introduaion cannot be perceived or fuppof- . ed ; and therefore, in thefe cafes, fome other caufe of the produaion and colleaion of air muft be looked for, though it is often not to be clearly afcertained. • j In every Solid as well as every fluid fub- ^ Stance which makes a part of the human body, there is a confiderable quantity of air in a fixed ftate, which may be again reftored to its OF PHYSIC. its elaftic ftate, and Separated from thoSe Sub- stances, by the power of heat, putreraaion, and perhaps other caufes.: But which of thefe -fc may have produced the feveral inftances of \\ pneumatofis and flatulent fwellings that have been recorded by authorS, I cannot pretend to afcertain. Indeed, upon account of thefe difficulties, I cannot proceed with any clear- neSs on the general Subjea of pneumatofis ; and, therefore, with regard to flatulent fwell- ings, I find it neceffary to confine myfelS to the confideration of thofe of the abdominal region alone ; which I fhall now treat of un- der fhe general name of Tympanites. MDCXXVII. The tympanites is a fwelling of the abdo- men ; in which the teguments appear to be much ftretched by Some diftending power . within,*and equally dretched in every pofture of the body. The fwelling does not readily yield to any preffure ; and in fo far as it does, very quickly recovers its former ftate upon the preffure being removed. Being Struck, it gives a Sound like a drum, or other ftretched animal membranes. No fluauation within is to be perceived : And the whole Feels leSs weighty than might be expeaed Srom its bulk. The uneafineSs oS the diftention is commonly relieved by the difcharge of air from the ali- mentary canal, either upwards or down- wards. MDCXXVIIL 248 PRACTICE MDCXXVIII. Thefe at* the charaaersby which the tym-m panites may be didinguifhed from the afcites^| or phyfconia ; and many experiments Show, that the tympanites always depends upon a preternatural colleaion of air, Somewhere within the teguments of the abdomen : But the feat of the air is in different cafes Some- what different; and this produces the differ- ent Fpecies oF the diSeaSe. One Species is, when the air colleaed is entirely confined within the cavity of" the ali- mentary canal, and chiefly in that of the in- I teftines. This fpecies, therefore, is named I the Tympanites inteflinalis, Sauv. fp. 1. It is, of all others, the moft common ; and to it eSpecially belong the charaaers given above. A Second Species is, when the air collected is not entirely confined to the cavity of the inteftines, but is alSo preSent between their coats ; and Such is that which is named by I Sauvages Tympanites enter op hyfodes, Sauv. Sp. < 3. This has certainly been a rare occurrence; and has probably occurred only in confe- quence of the tympanites inteflinalis, by the air eScaping from the cavity of the inteftines into the interdices of the coats. It is, how- , ever, poffible that an erofion of the internal coat of the intedines may give occafion to the air, fo condantly prefent in their cavity, to efcape into the interdices of their coats, though *OF PHYSIC. 249 though in the whole of their cavity there has been no previous accumulation. A third fpecies is, when the air is colleaed in the Sac of the peritonaeum, or what is com- monly called the cavity of the abdomen, that is, the fpace between the peritonaeum and vif- cera ; and then the difeafe is named Tympa- nites abdominalis, Sauv. fp. 2. The exidencc of fuch a tympanites, without any tympanites inteflinalis, has been difputed ; and it certain- ly has been a rare occurrence : But from fev- eral diffeaions, it is unquedionable that Fuch a diSeaSe has Sometimes truly occurred. A fourth Species of tympanites is, when the tympanites inteflinalis and abdominalis are joined together, or take place at the fame time. With refpea to this, it is probable that the tympanites inteflinalis is the primary difeafe ; and the other, only a confequence of the air efcaping, by an erofion or rupture of the coats of the intedines, from the cavity of thefe into that of the abdomen. It is in- deed poffible, that in confequence of erofion or rupture, the air which is fo condantly pref- ent in the intedinal canal, may efcape Srom thence in Such quantity into the cavity oS the abdomen, as to give a tympanites abdominalis, whild there was no previous confiderable ac- cumulation of air in1 the intedinal cavity it- felf; but" I have not faas to afcertain this mat- ter properly. A fifth fpecies has alfo been enumerated. It is when a tympanites abdominalis happens to 250 PRACTICE to be joined with the hydrops afcites; and fuch a difeaSe therefore is named by Sauvages Tympanites afciticus, Sauv. fp. 4. In molt cafes of tympanites, indeed, fome quantity of J Serum has, upon diffeaion, been found in the 1 fac of the peritonaeum; but that is not enough j to conditute the fpecies now mentioned ; and when the collection of Serum is more confid- erable, it is commonly where, both from the caufes which have preceded, and likewife from the fymptoms which attend, the afcites may be confidered as the primary difeafe; and therefore that this combination does not exhibit a proper fpecies of the tympanites. MDCXXIX. As this lad is not a proper fpecies, and as fome of the others are not only extremely rare, but even, when occurring, are neither primary, nor to be eafily didinguifhed, nor, as confidered in themfelves, admitting of any cure, I Shall nere take no further notice of them; confining myfelf, in what follows, to the confideration of the mod frequent cafe, and almoft the only objea of praaice, the tympanites inteflinalis. MDC&XX. With refpea to this, I cannot perceive that it arifes in any peculiar temperament, or de- pends upon any predifpofition, which can be difcerned. OF PHYSIC. 251 difcerned. It occurs in either fex, at every age, and frequently in young perfons. MDCXXXI. Various remote caufes of it have been af- figned : But many of thefe have not common- ly the effea oF producing this diSeaSe ; and although Some of them have been truly ante- cedents of it, I can in few inftances diScover the manner in which they produce the dif- eafe, and therefore cannot certainly afcertain them to have been caufes of it. MDCXXXII. The phenomena of this difeafe in its feveral Stages are the following. The tumour of the belly fometimes grows very quickly to a confiderable degree, and feldom in the flow manner the -afcites com- monly comes on. In Some caSes, .however, the tympanites comes on gradually, and is introduced by an unuSual flatulency of the ftomach and inteftines, with frequent borbo- rygmi, and > an uncommonly frequent expul- sion of air upwards and downwards. This ftate is alSo frequently attended with colic pains, efpecially felt about the navel, and up- on the fides towards the back ; but generally as the diSeaSe advances, theSe pains become leSs confiderable. As the diSeaSe advances,- there 252 ' PRACTICE there is a pretty conftant defire to diScharge air, but it is accomplished with difficulty ; and when obtained, although it give Some relief from the fenfe; of diftention, this relief is com- 4 monly tranfient and of Short duration. While the diSeaSe is coming onjbme inequality of tumour and tenfion may be perceived in dif- ferent parts of the belly ; but the diftention i foon becomes equal over the whole, and ex- hibits the phenomena mentioned in the char- aaer. Upon the firft coming on of the dif- eafe, as well as during its progrefs, the belly is bound, and the faeces difcharged are com- monly hard and dry. Tije urine, at the be- ginning, is ufually very little changed in quantity or quality Srom its natural ftate : But as the difeafe continues, it is commonly chang- ed in both refpeas ; and at length fometimes a ftranguary, and even an iSchuria, comes on. The difeaSe has Seldom advanced far, before the appetite is much impaired, and digeftion ill performed; and the whole body, except the belly, becomes confiderably emaciated. Together with thefe fymptoms, a third; and uneafy fenfe of heat at length come on, and a confiderable frequency of pulfe occurs, which continues throughout the courfe of the dif- eafe. When the tumour of the belly arifes to a confiderable bulk, the breathing becomes very difficult, with a frequent dry cough. With all thefe fymptoms the ftrength of the patient declines ; and the febrile fymptoms daily increafing, death at length enfues, fome- times OF P H Y S I C.* 253 times probably in con Sequence of a gangrene coming upon the inteftines. MDCXXXIII. The tympanites is commonly oS fome du- ration, and to be reckoned a chronic difeafe. It is very feldom quickly fatal, except where Such an affeaion Fuddenly ariFes in Fevers* To this Sauvages has properly given a differ- ent appellation, that of Meteorifmus ; and I judge it may always be confidered as a Symp- tomatic affeaion, entirely diftina From the tympanites we are now considering. MDCXXXIV. The tympanites is generally a fatal difeaSe, feldom admitting of cure ~ but what may be attempted in this way, I fhall try to point out, after I Shall have endeavoured to explain the proximate cauSe, which alone can lay the foundation of what may be rationally attempt- ed towards its cure. MDCXXXV. To afcertain the proximate caufe of tym- panites, is Somewhat difficult. It has been fuppofed in many caSes, to be merely an un- common quantity of air prefent in the ali- mentary canal, owing to the extrication and detachment of a greater quantity of air than Vol. III. M ufual a§4 PRACTICE ufual from the alimentary matters taken in, *Our vegetable aliments, I believe, always un- dergo fome degree of fermentation ; and in confequence, a quantity of air is extricated and detached from them in the ftomach and inteftines : But it appears, that the mixture of the animal fluids which our aliments meet with in the alimentary canal, prevents the fame quantity of air from being detached from them that would have been in their fermen- tation without fuch mixture ; and it is prob- able that the fame mixture contributes alfo to the reabforption of the air that had been be- fore in fome meafure detached. The extri- cation, therefore, of an unufual quantity of air from the aliments, may, in certain circum- stances, be fuch, perhaps, as to produce a tympanites ; fo that this difeafe may depend upon a fault of the digeftiv§ fluids, whereby they are unfit to prevent the too copious ex- trication of air, and unfit alfo to occafion that reabforption of air which in found perfons commonly happens. An unufual quantity ■of air in the alimentary canal, whether owing to the nature of the aliments taken in, or to the fault of the digeftive fluid, does certainly fometimes take place ; and may poffibly have, and in Some meaSure certainly has, a fhare in producing certain flatulent disorders of the al- imentary canal; but cannot be fuppofed to produce the tympanites, which often occurs when no previous diforder had appeared in the fyftem. Even in thoSe caSes of tympa- nites O F PHYSIC. 255 nites which are attended at their beginning with flatulent diforders in the whole of the alimentary canal, as we know that a firm tone of the inteftines both moderates the extrica- tion of air, and contributes to its reabforption or ready expulfion, fo the flatulent fymptoms which happen to appear at the coming on of a tympanites, are, in my opinion, to be refer- red to a lofs of tone in the mufcular fibres of the inteftines, rather than to any Sault in the digeftive fluids* MDCXXXVI. TheSe, and other confiderations, lead me to conclude, that the chief part of the proxi- mate caufe of tympanites, is a lofs of tone in the mufcular fibres of the inteftines. But further, as air of any kind accumulated in the cavity of the inteftines fhould, even by its own elasticity, find its way either upwards or downwards, and fhould alfo, by the affidance of infpiration, be entirely thrown out of the body ; fo, when neither the reabSorption nor the expulfion takes place, and the air is accu- mulated So as to produce tympanites, it is probable that the paffage of the air along the courfe of the intedines is in fome places of theSe interrupted. This interruption, how- ever, can hardly be SuppoSed to proceed Srom any other cauSe than SpaSmodic condriaions in certain parts of the canal; and I conclude, therefore, that fuch condriaions concur as M a part- 25B PRACTICE part in the proximate caufe of tympanites. Whether thefe fpafmodic conftriaions are to be attributed to the remote caufe of the dif- eafe, or may be confidered as the confequence of fome degree of atony firft arifing, I cannot with certainty, and do not find it neceffary to determine. MDCXXXVII. Having thus endeavoured to afcertatn the 'proximate caufe of tympanites, I proceed to treat of its cure ; which indeed has feldom Succeeded, and almoft never but in a recent diSeaSe. I muft, however, endeavour to fay what may be reafonably attempted ; what has commonly been attempted ; and what at- tempts have Sometimes Succeeded in the cure of this difeafe. MDCXXXVIII. It muft be a firft indication to evacuate the air accumulated in the inteftines : And for this purpofe it is neceffary that thofe constric- tions, which had efpecially Occafioned its ac- cumulation, and continue to interrupt its paf- fage along the courfe of the inteftines, Should be removed. As theSe, however, can hardly be removed but by exciting the periftaltic motion in the adjoining portions oS the inteS- tines, purgatives have been commonly em- ployed; but it is at the Same time agreed) OF PHYSIC. that the more gentle laxatives only ought to be employed, as the more draftic, in the over ftretched and tenSe ftate of the inteftines, are in danger of bringing on inflammation. It is for this reafon alSo, that glyfters have been frequently employed ; and they are the more neceffary, as the faeces colleaedare gen- erally found to be in a hard and dry ftate. Not only upon account of this ftate of the fasces, but, farther, when glyfters produce a confiderable evacuation of air, and thus fhow that they have fome effea in relaxing the fpafms of the inteftines, they ought to be re- peated very frequently. MDCXXXIX. In order to take off the conftriaions of the inteftines, and with Some view alSo to the car- minative effeas of the medicines, various an- tifpafmodics have been propofed, and com- monly employed -r but their effeas are Fel- dom confiderable, and it is alleged that their heating and inflammatory powers have fome- times been hurtful. It is, however, always proper to join fome of the milder kinds with both the purgatives and glyfters that are em- ployed ; and it has been very properly advif- ed to give always the chief of antifpafmodics, that is, an opiate, after the operation of pur- gatives is finifhed. M 3 MDCXL. 25S PRACTICE MDCXL. In confideration of the overftretched, tenfe, and dry ftate of the inteftines, and eSpecially of the fpafmodic condriaions that prevail/fo- mentations and warm bathing have been pro- pofed as a remedy ; and are faid to have been employed with advantage : But it has been remarked, that very warm baths-have not been found fo ufeful as tepid baths long con- tinued. MDCXLI. Upon the fuppofition that this difeafe de- pends efpecially upon an atony of the ali- mentary canal, tonic remedies feem to be properly indicated. Accordingly chalybe- ates, and various bitters, have been employ- ed ; and, if any tonic, the Peruvian bark might probably be ufeful. MDCXLII. But as no tonic remedy is more powerful than cold applied to the furface of the body, and cold drink thrown into the ftomach; fo fuch a remedy has been thought of in this dif- eafe. Cold drink has been conftantly pre- fcribed, and cold bathing has been employed with advantage ; and there have been feveral inftances of the difeafe being fuddenly and * entirely OF PHYSIC. 259 entirely cured by the repeated application of Snow to the lower belly. MDCXLIII. It is hardly neceffary to remark, that, in the diet oF tympanitic perSons, all Sorts of food ready to become flatulent in the ftomach are to be avoided ; and it is probable, that the foffil acids and neutral falts, as antizymicSj may be ufeful. MDCXLIV.. In obftinate and defperate cafes of tym- panites, the operation of the paracentefis has- been propofed : But it is a very doubtful remedy, and there is hardly any teftimony of its having been praaifed with SucceSs. It muft be obvious, that this operation is a rem- edy Suited eSpecially, and almoft only, to the tympanites abdominalis; the existence of which, separately from the inteflinalis, is very doubt- ful, at lead not eafily afcertained. Even if its exidence could be afcertained, yet it is not very likely to be cured by this remedy : And how far the operation might be SaSe in the tympanites inteflinalis, is not yet determined by any proper experience. JA 4 CHAP. 260 PRACTICE CHAP. III. *f WTATERY SWELLINGS, or DROP- SIES. MDCXLV. A PRETERNATURAL col- leaion of Serous or watery fluids, is often formed in different parts oF the human body; and although the difeafe thence arifing be diftinguifhed according to the different parts which it occupies, yet the whole oF Fuch col- leaions come under the general appellation of Dropfies. At the fame time, although the particular inftances of fuch colleaion are to be diftinguiffied from each other according to the parts they occupy, as well as by other cir- cumstances attending them ; yet all of them feem to depend upon Some general cauSes, very much in common to the whole. Before proceeding, therefore, to confider the Several fpecies, it may be proper to endeavour to af- fign the general caufes of dropfy. MDCXLVI. In perfons in health, a ferous or watery fluid feems to be conftantly poured out, or exhaled OF PHYSIC. 261 exhaled in vapour, into every cavity and in- terdice oS the human body capable of receiv- ing it ; and the Same fluid, without remaining long or being accumulated in theSe Spaces, Seems condantly to be Soon again abforbed from thence by veffels adapted to the pur- pofe. From this view of the animal econo- my, it will be obvious, that if the quantity poured out into any fpace, happens to- be greater than the abforbents can at the fame time take up, an unufual accumulation of fe- rous fluid will be made in fuch parts ; or though the quantity poured out be not more than ufual, yet if the abforption be anywife interrupted or diminished, from this caufe al- So an unuSual colleaion of fluids may be oc- cafioned. Thus, in general, dropfy may be imputed to an increafed effufion, or to a diminifhed abforption ; and I therefore proceed to in- quire into the feveral caufes of thefe. MDCXLVII. . An increafed effufion may happen, either from a preternatural increafe oF the ordinary exhalation, or From the rupture of veffels car- rying, or of facs containing, Serous or watery fluids. MDCXLVIII. The ordinary exhalation may be.increafed by various caufes,, and particularly by an in- Vol. 3. M 5 terruption f?6-2 practice terruptton given to the free return of the ve- nous blood from the extreme veffels of the body to the right ventricle of the heart. This interruption feems to operate by refiding the free paffage of the blood from the arteries into the veins, thereby increafing the force of the arterial fluids in the exhalants, and confe- quently the quantity of fluid which they pour out. MDCXLIX. *■ The interruption of the free return of the venous blood from the extreme veffels, may be owing **o certain circumftances affeaing the courfe • of the venous blood ; very fre- quently, to certain conditions in the right Ventricle of the heart itfelf, preventing it from receiving the ufual quantity of blood from the vena cava; or to obftmaions in the veffels of the lungs preventing the entire evacuation of the right ventricle, and thereby hindering its receiving the ufual quantity of blood from the cava. Thus, a polypus in the right ven- tricle of the heart, and the oflification of its valves, as well as all confiderable and perma- nent obdruaions of the lungs, have been found to be caufes of dropfy. MDCL. It may ferve as an illudration of the ope- ration of thefe general caufes, to remark, that the OF PHYSIC. 263 the return of the venous blood is in fome meafure redded when the pofture of the body is fuch as gives occafion to the gravity of the blood to oppofe the motion of it in the veins, which takes effea when the force of the cir- culation is weak ; and from whence it is that an upright pofture of the body produces or increafes ferous fwellings in the lower extrem- ities. MDCLI. Not only thofe caufes interrupting the mo- tion of the venous blood more generally, but, farther, the interruption of it in particular veins, may likewife have the effea of increaf- ing exhalation, and producing dropfy. The mod remarkable indance of this is, when con- fiderable obdruaions of the liver prevent the blood from flowing freely into it from the vena portarum and its numerous branches; and hence thefe obstructions are a frequent caufe of dropfy. MDCLII. Scirrhofities of the fpleen and other vifcera, as well as the fcirrhofity of the liver, have been confidered as caufes of dropfy ; but the manner in which they can produce the dif- eafe, I dp not perceive, except it may be where they happen to be near fome confid- erable vein, by the compreffion of which they may occafion fome degree of afcites ; or, by M 6 compreffing 264 PRACTICE compreffing the vena cava, may produce an anaSarca of the lower extremities. . It is in- deed true, that fcirrhofities of the fpleen and other vifcera, have been frequently discover- ed in the bodies oS hydropic perSons : But I believe they have been Seldom Sound unleSs when fcirrhofities of the liver were alio pref- ent ; and I am inclined to think, that the former have been the effeas oF the latter, rather than the caufe of the dropfy; or that, if fcirrhofities of the other vifcera have ap- peared in hydropic bodies when that of the liver was not prefent, they muft have been the effeas oF Some oF thoFe cauSes oF dropSy to be hereaSter mentioned ; and consequently to be the accidental attendants, rather than the cauSes, of fuch dropfies. MDCLIII. Even in Smaller portions of the venous fyftem, the interruption of the motion of the blood in particular veins has had the fame ef- fea. Thus, a polypus formed in the cavity of a vein, or tumours formed in its coats, pre- venting the free paffage of the blood through it, have had the effect oF producing dropSy in parts towards the extremity of Such veins. MDCLIV. But the cauSe moft Srequently interrupting the motion of the blood through the veins is, the compreffion of tumours exifting near to them; OF PHYSIC. 265 them ; Such as aneuriSms in the arteries, ab- Scefles, and Scirrhous or fteatomatous tumours in the adjoining parts. To this head, may be referred, the com- preffion of the defcending cava by the bulk of the uterus in pregnant women, and the compreffion of the fame by the bulk of water in the afcites ; both of which compreffions fre- quently produce ferous fwellings in the lower extremities. MDCLV. It may be fuppofed, that a gtneral preter- natural plethora of the venous fydem may have the effea of increafing exhalation ; and that this plethora may happen from the fup- preffion of fluxes, or evacuations of blood, which had for fome time taken place in the body, fuch as the menffrual and hemorrhoidal fluxes. A dropfy, however, from fuch a caufe, has been at leaft a rare occurrence ; and when it feems to have happened, I fhould fuppofe it owing to the Same caufes as the Suppreffion itSelf, rather than to the plethora produced by it. MDCLVI. ^ One of the moft frequent caufes of an in- creafed exhalation, I apprehend to be the laxity of the exhalant veflels. That fuch a caufe may operate, appears probable from this, that paralytic limbs, in which fuch a lax- ity ±66 PRACTICE ity is to be fufpeaed, are frequently affeaed with ferous, or, as they are called, cedematous fwellings. But a much more remarkable and frequent example of its operation occurs in the cafe of a general debility of the fyftem, which is fo often attended with dropfy. That a general debility does induce dropfy, appears fuffi- ciently from its being fo commonly the confe- quence of powerfully debilitating caufes ; fuch as fevers, either of the continued or in- termittent kind, which have lafted long ; long continued and Somewhat exceffive evacuations of any kinds ; and, in Short, almoft all difeafes that have been of long continuance, and have at the fame time induced the other fymptoms of a general debility. Among other caufes inducing a general de- bility of the fyftem, and thereby dropfy, there is one to be mentioned as frequently occur- ring, and that is, intemperance in the ufe of intoxicating liquors ; from whence it is that drunkards of all kinds, and efpecially dram drinkers, are fo affeaed with this difeafe. MDCLVII. That a general debility may produce a lax- ity of the exhalants, will be readily allowed; and that by this efpecially it occafions drop- fy, I judge from thence, that while mod of the caufes already mentioned are fuited to produce dropfies of particular parts only, the date OF PHYSIC. 167 ftate of general debility gives rife to an in- creafed exhalation into every cavity and in- terdice of the body, and therefore brings on a general difeafe. Thus, we have feen effu- fions of a ferous fluid made, at the fame time, into the cavity of the cranium, into that of the thorax and of the abdomen, and likewife into the cellular texture almod over the whole of the body. InTuch cafes, the operation of a general caufe discovered itSelS, by theSe Sev- eral dropfies increafing in one part as they diminished in another, and this alternately in the different parts. This combination, there- fore, of the different Fpecies of dropfy, or rather, as it may be termed, this univerfal dropSy, muft, I think, be reSerred to a general cauSe ; and in moft inftances, hardly any oth- er can be thought of, but a general laxity of the exhalants. It is this, therefore, that I call the hydropic diathefis ; which frequently ope- rates by itfelf ; and frequently, in fome meaf- ure, concurring with other caufes, is efpecial- ly that which gives them their full effect. This ftate of the fyftem, in its firft appear- ance, feems to be what has been confidered as a particular difeafe under the name of Cachexy; but in every inftance of it that has occurred to me, I have always confidered, and have al- ways found, it to be the beginning of general dropfy. MDCLVIII. The feveral caufes of dropfy already men- tioned may produce the difeafe, although there 268 PRACTICE there be no preternatural abundance oS Serous or watery fluid in the bloodveffels ; but it is now to be remarked, that a preternatural abundance of that kind may often give occa- fion to the difeafe, and more efpecially when fuch abundance concurs with the caufes above enumerated. One cauSe of fuch preternatural abundance may be an unufual quantity of water taken into the body. Thus an unufual quantity of water taken in by drinking, has fometimes oc- cafioned a dropfy. Large quantities of water, it is true, are upon many occafions taken in; and being as readily thrown out again by Stool, urine, or perfpiration, have not pro- duced any difeaSe. But it is alSo certain, that, upon Some occafions, an unuSual quan- tity oS watery liquors taken in has run off by the Several internal exhalants, and produced a dropSy! This Seems to have happened, ei- ther Srom the excretories not being fitted to throw out the fluid fo faft as it had been taken in, or from the excretories having been ob- ftruaed by accidentally concurring caufes. Accordingly it is faid, that the fudden taking in of a large quantity of very cold water, has produced dropfy, probably from the cold producing a constriction of the excretories. The proportion of watery fluid in the blood may be increafed, not only by the taking in a large quantity of water by drinking, as now mentioned, but it is poffible that it may be in- creafed alfo by water taken in from the at- mofphere OF PHYSIC. 269 mofphere by the fkin in an abforbing or im- bibing date. It is well known that the Skin may be, at lead, occasionally in Such a date ; and it is probable, that in»many caSes of be- ginning dropfy, when the circulation of the blood on the furface of the body is very lan- guid, that the fkin may be changed Srom a perSpiring, to an imbibing, date ; and thus, at lead, the diSeaSe may be very much in- creafed. MDCLIX. A Second cauSe of a preternatural abund- ance of watery fluids in the bloodveffels, may be, an interruption of the ordinary watery ex- cretions ; and accordingly it is alleged, that perFons much expofed to a cold and moid air are liable to dropSy. It is alSo Said, that an interruption, or confiderable diminution, of the urinary Secretion, has produced the diS- eaSe : And it is certain, that, in the caSe of an ifchuria renalis, the ferofity retained in the bloodveffels has been poured out into Some internal cavities, and has occafioned dropSy. MDCLX. A third caufe, of an over proportion of fe- rous fluid in the blood ready to run off by the exhalants, has been very large evacuations of blood, either fpontaneous or artificial. Thefe evacuations, by abdraaing a large proportion 270 PRACTICE of red globules and gluten, which arc the principal means of retaining ferum in the red veffels, allow the ferum to run off more read- ily by the exhalants : And hence dropfies I have been Frequently the conSequence oS Such evacuations. * It is poffible alSo, that large and long con- tinued iffues, by abdraaing a large propor-* tion of gluten, may have the fame effea. An over proportion oF the ferous parts of the blood, may not only be owing to the fpo- liation jud now mentioned, but may, I appre- hend, be likewife owing to a fault in the di- gesting and aflimilating powers in the ftomach and other organs ; whereby they do not pre- pare and convert the aliments taken in, in fuch a manner as to produce from them the due proportion of red globules and gluten ; but, Still continuing to Supply the watery , parts, occafion theSe to be in an over propor- tion, and consequently ready to run off in too large quantity by the exhalants. It is in this manner that we explain the dropSy, fo often attending chloro Sis: Which appears al- ways at firft by a pale colour of the whole body, Showing a manifeft deficiency of red blood ; which in that difeafe can only be at- tributed to an imperfea digeftion and affim- ilation. Whether a like imperfeaion takes place in what has been called a Cachexy, I dare not determine. This difeafe indeed has been commonly and very evidently owing to the OF PHYSIC. general caufes of debility above mentioned : And it being provable that the general debil- ity may affea the organs oF digeftion and af- fimilation ; fo the imperfea ftate of thefe funaions, occasioning a deficiency of red globules and gluten, may' often concur with the laxity «f the exhalants in producing dropfy. MDCLXI. Thefe are the feveral caufes of increafed exhalation, which I have mentioned as the chief caufe of the effufion producing drOpfy j but I have likewiSe obServed in MDCXLVII, that with the Same effea, an effufion may alFo be made by the rupture of veffels carrying watery fluids. In this way, a rupture of the thoracic dua, has given occafion to an effufion of chyle and lymph into the cavity of the thorax ; and a rupture of the laaeals has occafioned a like effufion into the cavity oS the abdomen ; and in either caSe, a dropSy has been produced. It is Sufficiently probable, that a rupture of lymphatics, in confequence of Strains, or the violent compreffion of neighbouring muf- cles, has occafioned an effufion ; which, be- ing diffufed in the cellular texture, has pro- duced dropFy. It belongs to this head of cauFes, to remark, that there are many inftances of a rupture or erofion of the kidneys, ureters, and bladder of PRACTICE of urine ; whereby the urine has been pour- ed into the cavity of the abdomen, and pro- duced an afcites. MDCLXII. Upon this fubjea, of the rupture of velTels carrying, or of veficles containing, watery flu- ids, I muft obServe, that the diffeaion of dead bodies has often Shown veficles formed upon the furface of many of the internal parts; and it has been fuppofed, that the rupture of fuch veficles, commonly named Hydatides, together with their continuing to pour out a watery fluid, has been frequently the caufe of dropfy. I cannot deny the poffibility of fuch a caufe, but fufpea the matter muft be explained in a different manner. There have been Frequently Found, in al- moft every different part oF animal bodies, colleaions oF Spherical veficles, containing a watery fluid ; and in many caSes oF Fuppoled dropSy, particularly in thoSe called the pre- ternatural encyfted dropfies, the Swelling has been entirely owing to a colleaion of fuch hydatides. Many conjeaures have been formed with regard to the nature and pro- duaion of thefe veficles ; but the matter at laft feems to be afcertained. It feems to be certain, that each of thefe veficles has within it, or annexed to it, a living animal of the worm kind; which feems to have the power of forming a veficle for the purpofe of its own economy, \ OF PHYSIC. economy, and of filling it with a watery fluid drawn from the neighbouring parts : And this animal has therefore been properly named by late naturalifts, the J'ania hydatigena. The origin and economy of this animal, or an account of the feveral parts of the human body which it occupies, I cannot profecute further here ; but it was proper for me, in de- livering the caufes of dropfy, to fay thus much of hydatides : And I mud conclude with ob- serving, I am well perSuaded, that mod of the indances. of preternatural encyded dropfies which have appeared in many different parts of the human body, have been truly collec- tions of fuch hydatides ; but how the fwell- ings occafioned by thefe are to be didinguifh- ed from other fpecies of dropfy, or how they are to be treated in praaice, I cannot at pref- ent determine. MDCLXIII. After having mentioned thefe, I return to confider the other general caufe of dropfy, which I have faid in MDCXLVI may be, An interruption or diminution of the abforp- tion that fhould take up the exhaled fluids from the feveral cavities and interdices of the body ; the cauSes of which interruption, how- ever, are not eafily ascertained. MDCLXIV. 274 PRACTICE MDCLXIV. It feems probable, that abforption may be diminished, and even ceafe altogether, from a lofs of tone in the abforbent extremities of the lymphatics. I cannot indeed doubt that a certain degree of tone or aaive power is neceffary in theSe abSorbent extremities; and it appears probable, that the Same general de- bility which produces that laxity of the ex- halant veffels, wherein I have fuppofed the hydropic diathefis to confid, will at the fame time occafion a lofs of tone in the abforbents j and therefore that a laxity of the exhalants will generally be accompanied with a lofs of tone in the abforbents ; and that this will have a fhare in the produaion of dropfy. Indeed it is probable that the diminution of abforption has a confiderable fhare in the matter ; as dropfies are of »:n cured by med- icines which Seem to operate by exciting the aaion of the abforbents. MDCLXV. It has been Suppofed, that the abforpticai performed by the extremities of lymphatics may be interrupted by an obftruaion of thefe veffels, or at lead oF the conglobate glands through which thefe veflels pafs. This, how* ever, is very doubtful. As the lymphatics have branches frequently communicating i OF PHYSIC. 275 with one another, it is not probable that the obdruaion of any one, or even feveral of thefe, can have any confiderable effea in in- terrupting the abforption of their extremities. And for the fame reaSfp, it is as little prob- able that the obftruaion of conglobate glands can have fuch an effea : At lead it is only an obdruaion of the glands of the mefentery, through which So confiderable a portion of the lymph paffes, that can poffibly have the effea of interrupting abforption. But even this we fhould not readily fuppofe, there be- ing reafon to believe that thefe glands, even in a confiderably tumefied date, are not en- tirely obdruaed : And accordingly I have known Several inftances of the mod part of the mefenteric glands being confiderably tu- mefied, without either interrupting the tranf- miffion of fluids to the bloodveffels, or occa- sioning any dropfy. An hydropic fwelling, indeed, feems often to affea the arm from a tumour of the axil- lary gland : But it feems to me doubtful, whether the tumour of the arm may not be owing to fome compreffion of the axillary vein, rather than to an obdruaion of the lymphatics. MDCLXVI. A particular interruption of abforption may be fuppofed to take place in the brain. As ho lymphatic veffels have yet very certainly been 276 PRACTICE been difcovered in that organ, it may be thought that the abforption, which certainly takes place there, is performed by the extrem- ities of veins, or by veffels that carry the fluid direaiy into the veins ; Fo that any impedi- ment to the Free motion oF the blood in the veins of the brain, may interrupt the abforp- tion there, and occafion that accumulation of Serous fluid which So Srequently occurs Srom a congedion of blood in thefe veins. But I give all this as a matter of conjeaure only. MDCLXVII. Having thus explained the general caufes of dropfy, 1 fhould proceed, in the next place, to mention the feveral parts of the body in which ferous colleaions take place, and So to mark the different Species of dropfy : But I do not think it neceffary For me to enter into any minute detail upon this fubjea. In many cafes, thefe colleaions are not to be afcertain- ed by any external fymptoms, and therefore cannot be the objeas. of praaice ; and many of them, though in fome meafure difcernible, do not Seem to be curable by our art. I the more eSpecially avoid mentioning very par- ticularly the Several Species, becaufe that has already been fufficiently done by Dr. D. Monro, and other writers, in every body's hands. I mud confine myfelf here to the confideration of thofe fpecies which are the mod frequently occurring and the mod com- mon OF PHYSIC. won objects of our praaice ; which are, the Anafarca, Hydrothorax, and Afcites ; and each of thefe I fhall treat in So many Separate fbaions, Sect. I. , 0/Anasarca. MDCLXVIII. THE AnaSarca is a Swelling upon the fur- face of the body, at fird commonly appearing in particular parts only, but at length fre- quently appearing over the whole. So far as it extends, it is an uniform fwelling over the whole member, at fird always Soft, and read- ily receiving the preffure of the finger, which forms a hollow that remains for fome little time after the preffure is removed, but at length rifes again to its former fulnefs. This fwelling generally appears, fird, upon the lower extremities ; and there too only in the evening, difappearing again in the morning. It is ufually more confiderable as the perfcn has been more in an erea podure during the day ; but there are many indances of the ex- ercife of walking preventing altogether its oth- erwife ufual coming on. Although this fwelling appears at fird only upon the feet Vol. III. N and 278 PRACTICE and about the ankles ; yet if the caufes pro- ducing it continue to aa, it gradually extends upwards, occupying the legs, thighs, and trunk of the body, and fometimes even the head. Commonly the fwelling of the lower extremities diminishes during the night; and in the morning, the fwelling of the face is moft confiderable, which again generally dis- appears almoft entirely in the courfe of the day. MDCLXIX. The terms of Anafarca and Leucophlegmatia have been commonly confidered as Synony- mous ; but fome authors have propoSed to confider them as denoting diftina difeaSes. The authors who are oS this laft opinion em- ploy the name of Anafarca for that difeafe which begins in the lower extremities, and is from thence gradually extended upwards in the manner I have juft now deScribed; while they term Leucophlegmatia, that in which the Same kind of fwelling appears even at firft very generally over the whole body. They feem to think alfo, that the two difeaSes pro- ceed Srom different cauFes ; and that, while the anaSarca may ariSe from the feveral caufes in MDCXLVIII—MDCLIX, the leuco- phlegmatia proceeds efpecially from a defi- ciency of red blood, as we have mentioned in MDCLX et feq. I cannot, however, find any proper foundation for this diftinaion. For Jk OF P FI Y S I C. 279 For although in dropfies proceeding from the cauSes mentioned in MDCLX etfq. the diS- eaSe appears in Some cafes more immediately affcaing the whole body ; yet that does not eftablifh a difference from the common cafe of anafarca : For the difeaSe, in all its circum- ftances, comes at length to be entirely the Same ; and in caSes occafioned by a deficiency of red blood, I have frequently obferved it to come on exaaiy in the manner of an anafar- ca, as above defcribed. MDCLXX. An anafarca is evidently a preternatural colleaion of ferous fluid in the cellular tex- ture immediately under the fkin. Some- times pervading the fkin itfelf, it oozes out through the pores of the cuticle ; and fome- times, too grofs to pafs by thefe, it raiSes the cuticle in bliflers. Sometimes the fkin, not allowing the water to pervade it, is compreff- ed and hardened, and at the Fame time Fo much diftended, as to give anaFarcous tu- mours an unufual firmnefs. It is in thefe laft circumftances alfo that an erythematic inflammation is ready to come upon anaSar- cous Swellings. .; MDCLXXI. An anafarca may immediately ariSe from any of the feveral cauSes of dropfy which N 2 aa 280 PRACTICE aa more generally upon the fyftem : And even when other fpecies of dropfy, from par- ticular circumftances, appear firft ; yet when- ever thefe proceed from any caufes more gen- erally affecting the Fyftem, an anafarca Soon- er or later comes always to be joined with them. MDCLXXIL The manner*in which this difeafe Common- ly firft appears, will be readily explained by what I have Said in MDCL reSpeaing the effeas oF the pofture of the body. Its grad- ual progrefs, and its affeaing, after fome time, not only the cellular texture under the fkin, but probably alfo much of the fame texture in the internal parts, will be understood part- ly from the communication that is readily made between the feveral parts of the cellular texture; but efpecially from the fame general caufes of the difeafe producing their effects in every part of the body. It appears to me, that the water of anafarcous fwellings is more readily communicated to the cavity of the thorax, and to the lungs, than to the cavity of the abdomen, or to the Vifcera contained in it. MDCLXXIII. An anafarca is almoft always attended with a Scarcity of urine ; and the urine voided, is, from OF PHYSIC. 281 Srom its Scarcity, always of a high colour; and from the fame cauSe, aSter cooling, readily lets fall \copious reddifh Sediment. This Scar- city of urine may fometimes be owing to an obftruaion of the, kidneys ; but probably is generally occafioned by the watery parts of the blood running off into the cellular tex- ture, and being thereby prevented from paff- ing in the ufual quantity to the kidneys. The difeaSe is alSo generally attended with an unuSual degree of thirft ; a circumftance I would attribute to a like abdraaion of fluid from the tongue and fauces, which are ex- tremely fenfible to every diminution of the fluids in thefe parts. MDCLXXIV. The cure of anafarca is to be attempted upon three general indications. 1. The removing the remote caufes of the difeafe. 2. The evacuation of the ferous fluid al- ready colleaed in the cellular texture. 3. The redoring the tone of the fydem, the loSs oS which may be confidered in many cafes- as the proximate caufe of the difeafe. MDCLXXV. The remote caufes are very often fuch as Snd not only been applied, but had alfo been removed, long before the difeafe came ®n. N 3 Although, 282 PRACTICE Although, therefore, their effea* remain, the caufes themfelves cannot be the objeas of praaice ; but if the caufes dill continue to be applied, fuch as intemperance, indolence, and fome others, they mud be removed. For the mod part, the remote cauSes are certain diSeaSes previous to the dropSy, which are to be cured by the remedies particularly adapt- ed to them, and cannot be treated oS here. The curing of thefe, indeed, may be often difficult; but it was proper to lay down the prefent indication, in order to Show, that when thefe remote caufes cannot be remov- ed, the cure of the dropfy mud be difficult, or perhaps impoffible. In many cafes, there- fore, the following indications will be to little purpofe ; and particularly, that often the ex- ecution of the fecond will not only give the patient a great deal of fruitlefs trouble, but commonly alfo hurry on his fate. MDCLXXVI. The fecond indication for evacuating the colleaed ferum, may be fometimes executed with advantage, and often, at lead, with tem- porary relief. It may be performed in two ways. Fird, by drawing off the water di- rectly from the dropfical part, by openings made into it for that purpofe : Or, Secondly, by exciting certain Serous excretions ; in con- Sequence of which, an abforption may be ex- cited in the dropfical parts, and thereby the ferum OF PHYSIC. 283 ferum abforbed and carried into the blood- veffels, may afterwards be direaed to run out, or may fpontaneoufly pafs out, by one or oth- er of the common excretions* • MDCLXXVII. In an anafarca, the openings into the drop- fical part are commonly to be made in fome part of the lower extremities; and will be moft properly made by many fmall punaures reaching the cellular texture. Formerly, confiderable incifions were employed for this purpofe : But as any wound made in- drop- fical parts, which, in order to their healing, mud neceffarily inflame and Suppurate, are liable to become gangrenous ; So it is found to be much Safer to make the openings by fmall punaures only, which may heal up by the fird intention. At the fame time, even with reSpea to theSe punaures, it is proper to obferve, that they fhould be made at Some didance from one another, and that care fhould be taken to avoid making them in the mod depending parts. MDCLXXVIII. The water of anafarcous limbs may be fometimes drawn off by pea iffues, made by eaudic a little below the knees : For as the great Swelling oS the lower extremities is chief- ly occafioned by the ferous fluid exhaled into N 4 the 284 PRACTICE the upper parts conftantly falling down to the lower; fo the iffues now mentioned, by evacuating the water From theSe upper parts, may very much relieve the whole of the dif- eafe. Unlefs, however, the iffues be put in before the difeafe is far advanced, and before the parts have very much lod their tone, the places of the iffues are ready to become af- feaed with gangrene. Some practical writers have advifed the employment of fetons for the fame purpofe that I have propofed iffues ; but I apprehend, that Fetons will be more liable than iffues to the accident jud now mentioned. MDCLXXIX. For the purpofe of drawing out ferum from anafarcous limbs, bliders have been applied to them, and fometimes with great fuccefs; but the blidered parts are ready to have a gangrene come upon them. Blidering is therefore to be employed with great caution; and perhaps only in the circumdances that I have mentioned above to be fit for the em- ployment of iffues. MDCLXXX. Colewort leaves applied to the fkin, readily occafion a watery exfudation from its furface ; and applied to the feet and legs affeaed with aifefarca, OF PHYSIC. 285 r anafarca, have fometimes drawn off the water very copioufly, and? with great advantage. Analogous, as I judge, to this, oiled filk hofeaput upon the feet and legs, fo as to flmt out all communication with the external air, have been found fometimes to draw a quanti- ty of water from the pores of the fkin, and are faid in this way to have relieved anafarcous fwellings : But in feveral trials made, I have never found either the application of thefe hofe, or that of the colewort leaves, of much Service. MDCLXXXI. The 2d means propofed in MDCLXXVI for drawing off the water From dropfical places, may be the employment of emetics, purgatives, diuretics, or fudorifics. MDCLXXXII. As Spontaneous vomiting has fometimes excited an abforption injhydropic parts, and thereby drawn off the waters lodged in them, it is reaSonable to Suppofe that vomiting ex- cited by art may haye the fame effea ; and accordingly it has been often praaifed with advantage. The praaice, however, requires that the drong antimonial emetics be em- ployed, and that they be repeated frequently after fhort intervals. Vol. 3. N5 MDCLXXXIII. 286 PRACTICE MDCLXXXIII. Patients fubmit more readily to the ufe of purgatives, than to that of emetics; and in- deed they commonly bear the former more eafily than the latter. At the fame time, there are no means we can employ to pro- cure a copious evacuation of ferous fluids with greater certainty than the operation of purgatives ; and it is upon thefe accounts that purging is the evacuation which has been mod frequently, and perhaps with mod fuc- cefs, employed in dropfy. It has been gen- erally found neceffary to employ purgatives oFthe more dradic kind ; which are common- ly known, and need not be enumerated here. I believe indeed, that the more dradic pur- gatives are the mod effeaual For exciting abforption, as their dimulus is mod readily communicated to the other parts of the fyS- tem ; but of late an opinion has prevailed, that fome milder purgatives may be employ- ed with advantage. This opinion- has pre- vailed particularly with regard to the crydals vulgarly called the Cream of Tartar, which in large doSes, frequently repeated, have fome- times anfwered the purpofe of exciting large evacuations both by dool and urine, and has thereby cured dropfies. This medicine, however, has frequently failed, both in its operation and effeas, when the dradic pur- gatives have been more fuccefsful. Praaitioners C OF PHYSIC. 287 Praaitioners have long ago obferved, that, in the employment of purgatives, it is requi- site they be repeated after as fhort intervals- as the patient can bear; probably for this reafon, that when the purging is not carried to the degree of foon exciting an abforption, the evacuation weakens the fydem, and there- by increafes the afflux of fluids to the hy- dropic parts. MDCLXXXIV. The kidneys afford a natural outlet For a great part of the watery fluids contained in the bloodveffels; and the,increafing the ex- cretion by the kidneys to a confiderable de- gree, is a means as likely as any other oF ex- citing an abforption in dropfical parts. It is upon this account that diuretic medicines have been always properly employed in the cure of dropfy. The various diuretics, that may be employed, are enumerated in every treatife of the Materia. Medica and of the Praaice of Phyfic, and therefore need not be repeated here. It happens, however, unluckily, that none of them are of very certain operation ; neither is it well known why they Sometimes fucceed, and why they fo often fail; nor why one medicine fhould prove of Service when another does not. It has been generally the fault of writers- upon the Praaice of Phyfic, that they give us inftances-of cafes in which certain medicines have proved very, effica- N 6 cious ?.88 PRACTICE nous, but neglea to tell us in how many oth- er mil anoes the fame have failed. n MDCLXXXV. It deferves to be particularly obferved herfe, ihat there is hardly any diuretic more certain- ly powerful than a large quantity of common water taken in by drinking. I have indeed obferved above in MDCLVIII, that a large quantity of water, or of watery liquors, taken in by drinking, has Sometimes proved a caufe of dropfy ; and praaitioners have been forJS) merly fo much afraid that watery liquors tak- en in by drinking-might run off into dropfical places and increafe the difeafe, that they have generally enjoined the abstaining as much as poffible, from fuch liquors. Nay, it has been further afferted, that by avoiding this Fupply of exhalation, and by a total abstinence from drink, dropfies have been entirely cured. What conclufion is to be drawn Srom theSe faas is, however, very doubtful. A dropfy arifing from a large quantity of liquids taken in to the body has been a very rare occurrence; and there are, on the other hand, innumerable inftances of very large quantities of water hav- ing been taken in and running off again very Quickly by dool and urine, without produc- ing any degree of dropfy. With refpea to the total abftinence from drink, it is a praaice of the mod difficult execution ; and therefore has been fo feldom praaifed, that we cannot poffibly OF PII-YSIC. 289 poffibly know how far it might prove effeoki— al. The praaice of giving drink very Span. ingly has indeed been oSten employed : But in a hundred indances, I have Seen it car- ried to a great length without any manifed advantage : while, on the contrary, the prac- tice of giving drink very largely has been found not only fafe, but very often effeaual in curing the difeafe. The ingenious and learned Dr. Millman has, in my opinion, been commendably employed in redoring the prac- tice of giving large quantities of watery liquors for the cure of dropfy. Not only from the indances he mentions from his own praaice, and from that of feveral eminent phyficians in other parts oS Europe, but alSo Srom many indances in the records of phyfic, oS the good effeas of drinking large quantities of mineral waters in the cure of dropfy, I can have no doubt of the praaice recommended by Dr. Millman being very often extremely proper. I apprehend it to be efpecially adapted to thofe cafes in which the cure is chiefly at- tempted by diuretics. It is very probable, that thefe medicines can hardly be carried in any quantity to the kidneys without being ac- companied with a large portion of water ; and the late frequent employment of the crydals of tartar has often mown, that the diuretic effea.s of that medicine are almod only re- markable when accompanied with a. large quantity of water ; and that without this, the diuretic effeas of the medicine feldom ap- pear. 290 PRACTICE • pear. I fhall conclude this fubjea with ob~ ferving,. that as there are fo many cafes of dropfy abfolutely incurable, the practice now Under confideration may often fail, >yet in mod cafes it may be fafely tried ; and if it appear that the water tak<-n in paifes readily by the urinary Secretion, and efpecially that it increafes the urine b :yond the quantity of drink taken in, the praaice may probably be continued with great advantage : But, on the contrary, if the urine be not increafed, or be not even in proportion to the drink taken in, it may be concluded, that the water thrown in runs off by the exhalants, and will augment the difeafe. MDCLXXXVI. Another fet of remedies which may be em- ployed for exciting a ferous excretion, and thereby curing dropSy, is that of fudorifics. Such remedies, indeed, have been fometimes employed : But however ufeful they may have been thought, there are few accounts of their havingeffeaed a cure; and although I have had Fome examples of their fuccefa, in mod indances of their trial they have been ineffeaual. Upon this Fubjea it is proper to take notice oF the Feveral means that have, been propoSed and employed For diffipating the humidity of the body ; and particularly that of heat ex- ternally apphed to the furface of it. . Of fuch applications OF PHYSIC. 20,1 applications I have had no experience ; and their propriety and utility mud red upon the credit of the authors who relate them. I fhall offer only this conjeaure upon the Fub- jea : That if fuch meafures have been truly ufeful, as it has feldom been by the drawing out of any tenfible humidity, it has probably been by their redoring the perfpiration, which is fo often greatly diminifhed in this difeafe ; or, perhaps, by changing the date of the fkin, from the imbibing condition which is alleged to take place, into that of perfpiring. MDCLXXXVIL When, by the feveral means now men- tioned, we fhall have fucceeded in evacuating the water of dropfies, there will then efpecial- }y be occafion Sor our third indication; which is, to redore the tone of the fyftem, the lofs of which is fo often the caufe of the difeafe. This indication, indeed, may properly have place from the very firft appearance of the difeafe; and certain meafures adapted to this purpofe may, upon fuch firft appearance, be emplojted with advantage. In many caSes of a moderate difeafe, I am perfuaded that they may obviate any future increafe of it. MDCLXXXVIII. Thus, upon what is commonly the firft Symptom of anafarca, that is, upon the ap- pearance PRACTICE pearance of what are called Oedematous Swellings of the feet and legs, the three rem- edies of bandaging, friaion, and exercife, have often been ufed with advantage. H MDCLXXXIX. That fome degree of external compreflioi1, is fuited to Support the tone of the veffels,*and particularly to prevent the effeas of the weight of the blood in dilating thofe of the lower extremities, muft be fufficiently evident; and the giving that compreffion by a bandage properly applied, has been often ufeful. In applying fuch a bandage, care is to be taken that the compreffion may never be greater on the upper than on the lower part of the limb; and this, I think, can hardly ever be fo cer- tainly avoided, as by employing a properly conftruaed laced flocking. MDCXC. Friaion is another means by'which the ac- tion of the bloodveffels may be promoted, and thereby the Stagnation of fluids in their ex- tremities prevented. Accordingly, the ufe of the flefh brufh has oftep contributed to dif- cufs oedematous fwellings. It appears to me, that friction, for the purpofes now mention- ed, is more properly employed in the morn- ing, when the fwelling is very much gone off, than in the evening, when any confiderable degree OF PHYSIC. 893 degree of it has already come on. I appre* hend alfo, that friaion being made from be- low upwards only, is more ufeful than when made alternately upwards and downwards. It has been common, inftead of employing the flefh brufh, to make the friction by warm and dry flannels ; and this may in fome cafes be the mod convenient: But I cannot per- ceive that the impregnation of thefe flannels with certain dry fumes is of any benefit, MDCXCI. With refpea to exercife, I mud obferve, that although perfons being much in an ereft podure during the day, may feem to increafe the fwelling which comes on at night; yet as the aaion of the mufcles has a great Share in promoting the motion of the venous blood, fo I am certain, that as much exercife in walk- ing as the patient can eafily bear, will often prevent that oedematous fwelling which much Standing, and even fitting, would have brought on. MDCXCII. Thefe meafures, however, although they may be ufeful at the coming on of a dropfy^ whofe caufes are not very powerful, will be often infufficient in a more violent difeafe ; and fuch therefore will require more powerful remedies. Thefe are, exercife and tonic medicines; 294 PRACTICE medicines ; which may be employed both during the courfe of the difeafe, and efpecial- ly after the water has been evacuated. MDCXCIII. Exercife is fuited to affiff in every Function of the animal economy, particularly to pro- mote perfpiration, and thereby prevent the accumulation of watery fluids in the body. I apprehend alfo, that it may be the mod ef- feaual means for preventing the fkin from being in an imbibing ftate ; and, as has been hinted above on the fubjea of Emaciation (MDCVII), I am perfuaded, that a full and large perfpiration will always be a means of exciting abforption in every part of the fyf- tem. Exercife, thereSore, promiSes to be highly uSeSul in dropSy ; and any mode of it may be employed that the patient can molt conveniently admit of. It fhould, howevei; always be as much as he can eafily bear; and in anafarca, the fhare which the exercife of mufcles has in promoting the motion of the venous blood, induces me to think that bodi- ly exercife, to whatever degree the patient can bear it, will always be the mod ufeful; From fome experience alfo, I am perfuaded, that by exercife alone, employed early in ths olifeafe, many dropfies may be cured. MDCXCIV. OF PHYSIC. 295 MDCXCIV. Befides exercife, various tonic remedies are properly employed to redore the tone of the fydem. The chief of thefe are, chalybeates, the Peruvian bark, and various bitters. Thefe are not only fuited to redore the tone of the fydem in general, but are particularly ufeful in drengthening the organs of digef- tion, which in dropfies are frequently very much weakened : And for the fame purpofe alfo aromatics may be frequently joined with the tonics. MDCXCV. Cold bathing is upon many occafions the mod powerful tonic we can employ ; but at the beginning of dropfy, when the debility of the fydem is confiderable, it can hardly be attempted with Safety. ASter, however, the water of dropfies has been very fully evacu- ated, and the indication is to drengthen the -fydem for preventing a relapfe, cold bathing may perhaps have a place. It is, at the fame time, to be admitted with caution ; and can Scarcely be employed till the fydem has oth- erwife recovered a good deal of vigour. When that indeed has happened, cold bath- ing may be very ufeful in confirming and completing it. MDCXCVI. 296 PRACTICE MDCXCVI. In perfons recovering from dropfy, while the feveral means now mentioned for Strength- ening the fydem are employed, it will be proper at the fame time to keep condantly in view the fupport of the watery excretions; and confequently the keeping up the perfpi- ration by a great deal of exercife, and contin- uing the full flow of the urinary excretions by the frequent ufe of diuretics. Sect. II. Of the Hydrothorax, or Dropsy of the Breast. MDCXCVII. THE preternatural colleaion of ferous fluid in the thorax, to which we give the ap- pellation of Hydrothorax, occurs more fre- quently than has been imagined. Its pref- ence, however, is not always to be very cer- tainly known ; and it often takes place to a confiderable degree before it be difcovered. mdcxcvii:. OF PHYSIC. »97 MDCXCVIII. Thefe colleaions of watery fluids in the thorax, are-found in different Situations. Very often the water is found at the fame time in both Sacs of the pleura, but frequent- ly in one of them* only. Sometimes it is found in the pericardium alone ; but for the moft part it only appears there when at the fame time a collection is prefent in one or both cavities of the thorax. In fome inftances, the colleaion is found to be only in that cel- lular texture of the lungs which Surrounds the bronchiae, without there being at the fame time any effufion into the cavity of the thorax. Pretty frequently the water colleaed con- lifts chiefly of a great number of hydatides in different fituations; fometimes Seemingly floating in the cavity, but frequently con- neaed with and attached to particular parts of the internal furface of the pleura. MDCXCIX* From the colleaion of water being thus in Various fituations and circumftances, Symp- toms ariSe which are different in different caFes ; and from thence it becomes often dif- ficult to afcertaih the prefence and nature of the affeaion. I fhall, however, endeavour here to point out the moft common Symp- toms, 298 PRACTICE toms, and eSpecially thoSe of that principal and moft Srequent form of the difeaSe, when the Serous fluid is preSent in both Sacs of the pleura, or, as we ufually Speak, in both cav- ities-of the thorax. MDCC. The difeaSe Srequently comes on with a fenSe of anxiety about the lower part of the fternum. This, before it has fubfifted long, comes to be joined with Some difficulty of breathing; which at firft appears only upon the perSon's moving a little Salter than ulual, upon his walking up an acclivity, or upon his aScending a Staircafe : But after fome time, this difficulty of breathing becomes more con- ftant and confiderable, eSpecially during the night, when the body is in a horizontal Situa- tion. Commonly, at the Same time, lying upon one fide is more eafy than upon the other, or perhaps lying upon the back more eaSy than upon either fide. TheSe circum- ftances are uSually attended with a Srequent cough, that is at firft dry ; buf which, after fome time, is accompanied with an expeao- ration of thin mucus. With all thefe fymptoms, the hydrothorax is not certainly difcovered, as the fame fymp- toms often attend other difeafes of the breaft. When, however, along with theSe Symptoms, there is at the Same time an oedematous Swell- ing of the feet and legs, a leucophlegmatic palenefs OF PHYSIC. 299 palenefs of the face, and a Scarcity of urine, the existence of a hydrothorax ca 1 be no longer doubtful. Some writers have told us, that fometimes in this difeafe, before the fwell- ing of the feet comes on, a watery fwelling of the fcrotum appears ; but I have never met with any inftance of this. MDCCI. Whilft the prefence of the difeafe is Some- what uncertain, there is a fymptom which fometimes takes place, and has been thought to be a certain characteristic of it ; and that is, when, foon after the patient has fallen afleep, he is fuddenly awaked with a fenfe of anxiety and difficult breathing, and with a violent palpitation of the heart. Thefe Seel- ings immediately Require an erea pofture ; and very oSten the difficulty of breathing con- tinues to require and to prevent fleep for a great part of the night. This fymptom I have frequently found attending the difeafe ; but I have alfo met with feveral inftances in which this fymptom did not appear. I muft remark further, that I have not found this fymptom attending the empyema, or any oth- er difeafe of the thorax ; and therefore, when it attends a difficulty of breathing, accompa- nied with any the fmalleft Symptom oS drop- fy, I have had no doubt in concluding the prefence of water in the cheft, and have al- ways 3oo PRACTICE ways had my judgment confirmed by the fymptoms which afterwards appeared. MDCCII. The hydrothorax, often occurs with very j few, or almoft none, of the fymptoms above 1 mentioned; and is not, therefore, very cer- tainly discovered till Some others appear. The moft decifive Symptom is a fluauation of water in the cheft, perceived by the patient himSelf, or by the phyfician, upon certain motions of the body. How far the method propofed by Auenbrugger will apply to aC , certain the prefence of water and the quantity of it in the cheft, I have not had occafion or opportunity to obferve. It has been faid, that in this difeafe fome tumour appears upon the fides or upon the back ; but I have not met with any instance of this. In one inftance of the difeafe, I found one fide of the thorax confiderably en- larged, the ribs Standing out farther on that fide than upon the other. A numbnefs and a degree of palfy in one or both arms, has been frequently obferved to attend a hydrothorax. Soon aSter this diSeaSe has made Some prog- reSs, the pulSe commonly becomes irregular, and Srequently intermitting : But this hap- pens in So many other difeaSes of the breaft, that unlefs when it is attended with fome other kj r r 11 i o i o. 301 other of the above mentioned fymptoms it cannot be confidered as denoting the hydro- thorax. MDCCIII. „ This difeafe, as other dropfies, is commonly .--..attended with third, and a Scarcity of urine, to be explained in the fame manner as in the cafe of anafarca (MDCLXXIII). The hy- drothorax, however, is Sometimes without thirft, or any other febrile fymptom ; al- though I believe this happens in the cafe of partial affeaions only, or when a more gen- eral affeaion is yet but in a flight degree. In both cafes, however, and more efpecially when the difeafe is confiderably advanced, Some degree of fever is generally prefent: And I apprehend k to be in fuch cafe, that the perfons affected are more than ufually fenfible to cold, and complain of the coldnefs of the air when that is not perceived by oth- er perfons. MDCCIV. The hydrothorax fometimes appears alone, without any other fpecies of dropfy being prefent at the fame time : And in this cafe the diSeafe, for the mod part, is a partial af- feaion, as being either of one fide of the thorax only, or being a colleaion of hydatides in one part of the cheft. The hydrothorax, Vol. III. O however, 302 PRACTICE . ' howevews very often a part of more univer- sal droply, and when at the fame time there is water in all the three principal cavities and in the cellular texture of a great part of the body. I have met with feveral inftances, in j which fuch univerfal dropfy began firft by an ] effufion into the thorax. The hydrothorax, however, more frequently comes on from an., » anafarca gradually increafing ; and, as I have faid above, the general diathefis feems often I to affea the thorax Sooner than it does either the head or the abdomen. ■ . MDCCV. This diSeaSe Feldom admits oF a cure, or even oS alleviation, from remedies. It com- | monty proceeds to give more and more diffi- i culty pf breathing, till the aaion of the lungs be entirely interrupted by the quantity of water effufed j and the fatal event frequently happens more fuddenly than was expeaed. ' In many of the inftances of a fatal hydrotho- ' rax, I have remarked a fpitting of blood to come on Several days before the patient died. MDCCVI. The caufe of hydrothorax is often mani- feftly one or other of the general caufes of dropfy pointed out above : But what it is that determines thefe general caufes to aft more efpecially in the thorax, and particular- U t PHYSIC. 303 ly what it is that produces the partial • collec- tions that occur there, I do not find to be ea- fily afcertained. MDCCVII. From what has been faid above, it will be evident, that the cur% of hydrothorax muft be very much the fame with that of anafarca ; and when the former is joined with the latter as an effea of the fame general diathefis, there can be no doubt of the method of cure being the fame in both. Even when the hydrotho- rax is alone, and the difeafe partial, from par- ticular caufes aaing in the thorax only, there can hardly be any other meafures employed, than the general ones propofed above. There is only one particular meafure adapted fo the hydrothorax ; and that is, the drawing off the accumulated waters by a paracentefis of the thorax. !> MDCCVIII. To what cafes this operation may be molt properly adapted, I find it difficult to deter- mine. That it may be executed with fafety, there is no doubt; and that it has been fome- times praaifed with fuccefs, feems to be very well vouched. When the difeafe depends upon a general hydropic diathefis, it cannot alone prove a cure, but may give a temporary relief; and when other remedies feem to be O 2 employed 304 PRACTICE employed with advantage, the drawing off the wafer may very much favour a complete cure. I have; not, however, been fo fortiK , nate as to See it praaifed with any fuccefs; and even where it was moft promifing, that is, in cafes of partial affeaion, my expectations have ■ been disappointed from it. S e c t. III. Of Ascites, or Dropsy of the Lower Belly. MDCCIX. \ 1 THE name of Afcites is given to every coU ■ leaion of waters caufing a general Swelling ( and didention oS the lower belly ; and Such colleaions are more Srequent than thofe Ivhich happen in the thorax-; MDCCX. The colleaions in the lower belly, like thofe of the thorax, are found in different situa- tions. Mod commonly they are in the facdf the peritonaeum, or general cavity of the ab- domen : But they Often begin by facs formefl upon, and conneaed with, one or other of the vifcera; and perhaps the mod frequent inftances OF PHYSIC. 305 inftances of this kind occur in the ovaria of females. Sometimes the water of afcites is found entirely without the peritonaeum, and. between this and the abdominal mufcles. MDCCXL Thefe colleaions conneaed with particular vifcera, and thofe formed without the perito- naeum, form that difeafe which authors hive termed the encyjled dropfy, or'hydrops facedtvs. * Their precife feat, and even their exiflenct, is very oSten difficult to be aScertained. They are generally Sormed by colleaions of hy- datides. MDCCXII. In the moft ordinary caSe, that of abdom- inal dropfy, the fwelling at firft is in fome meafure over the whole belly, but generally appears moft confiderable in the epigaftrium. As the diSeaSe, however, advances, the Swell- ing becomes more uniform over the whole. The diftention, and fenfe of weight, though confiderable, vary a little according as the pofture of the body is changed; the weight being felt the moft upon the fide on which the patient lies, while at the fame time on the oppofite fide the didention becomes Some- what lefs. In almod all the indances of af- cites, the fluauation of the water within, may be perceived by the praaitioner's feeling, and O 3 fometimes 306 PRACTICE fometimes by his hearing. This perception of fluauation does not certainly diftinguifh the different dates of dropfy ; but Serves very well to didinguidi dropSy from tympanites, from cafes of phyfconia, and from the date of pregnancy in women. MDCCXIII. An afcites frequently occurs when no other fpeciesiof dropfy does at the fame time ap- pear ; but fometimes the afcites is a part only of univerfal dropSy. In this caSe, it ufually comes on in confequence of an anafarca, grad- ually increafing; but its being joined with I anafarca, doesmnot always denote any general diathefis, as Sor the moft part an aScites Soon- er or later occafions oedematous Swellings of the lower extremities. When the collection of water in the abdomen, from whatever caufe, becomes confiderable, it is always at- tended with a difficulty of breathing : But this fymptom occurs often when, at the fame time, there is no water in the thorax. The afcites is fometimes unaccompanied with any Sever; but Srequently there is more or lefs of Sever preSent with it. The diSeaSe is never confiderable, without being attended with thirft and a Scarcity of urine. MDCCXIV. In the diagnofis of afcites, the greateft dif- ficulty that occurs, is in difcerning when the water OF PHYSIC. 307 water is in the cavity-of the abdomen, or when it is in the different ftates of encyfted dropfy above mentioned. There is, perhaps, no cer- tain^means of afcertaining this in all cafes; but ai^many we may attempt to form fome judgment* with regard to it. When the antecedent circumftances give fuSpicion of a general hydropic diathefis ; when at the Same time Some degree of dropSy appears in other parts of the body ; and when, from its firft appearance, the fwelling has been equally over the whole belly, we may gen- erally prefume that the water is in the cavity of the abdomen. But when an afcites has not been preceded by any remarkably cachec- tic ftate of the fyftem, and when at its begin- ning the tumour and tenfion had appeared in one part of the belly more than another, there is reafon to fufpea an encyfted dropfy. Even when the tenfion and tumour of the belly have become general and uniform over the whole.; yet if the fyftem of the body in gen- eral appear to be little affeaed ; if the pa- tient's ftrength be little impaired ; if the ap- petite continue pretty entire, and the natural fleep be. little interrupted; if the menfes in females continue to flow as ufual; if there be yet no anafarca ; or, though it may have al- ready taken place, if it be Still confined to the lower extremities, and there be no leucophleg- matic-palenefs or fallow colour in the counte- nance ; if there be no fever, nor fo much thirft, or Scarcity of urine, as occur in a 'O 4 more 308 PRACTICE more general affeaion ; then, according as more of thefe different circumftances take place, there will be the Stronger ground for iuppofing the afcites to be of the encyfted kind. The chief exception to be made from this as a general rule, will, in my opinion, be when the afcites may, with much probability, be prefumed to have come on in confequence of a Scirrhous liver; which, I apprehend, may occafion'a colleaion of water in the cavity of the abdomen, while the general fyftem of the body may not be otherwife much affeaed. fi • ■ MDCCXV. With refpea to the cure of afcites when of j the encyfted kind, it does not, fo far as I know, admit of any. When the colleaion of water i is in the abdominal cavity alone, without any other fpecies of dropfy prefent at the fame time, I apprehend the afcites will always be of difficult cure ; for it may be prefumed to depend upon a fcirrhofity oS the liver, or oth- er confiderable affeaion of the abdominal vif- cera, which I conceive to be of very difficult cure, and therefore the afcites depending up- on them. At the fame time, fuch cafes may often admit of a temporary relief by the par- acentefis. MDCCXVI, OF PHYSIC. 309 MDCCXVI. When the afcites is a part of univerfal drop- fy, it may, as far as other cafes of that kind * can, admit of a cure ; and it will be obviou^j^* that fuch a cure mud be obtained by the fame means as above propofed for the cure of gen- eral anafarca. It frequently happens, that the afcites is at- tended with a diarrhcea ; and,, in that cafe, does not admit of the ufe of purgatives-fo Sreely as caSes of anafarca commonly do. It is therefore often to be treated by diuretics almod alone. The diuretics that may be employed, are chiefly thofe above mentioned ; but in afcites^ a peculiar one has been found out. It is a long continued gentle friaion of the fkin over the whole of the abdomen, by the fingers dipped in oil. This has fometimes been ufe- ful in exciting an increafed flow of urine ; but in mod of the trials of it which I have known made, it has failed in producing that effea. MDCCXVII. The afcites admits of a particular means t for immediately drawing off the colleaed waters ; and that is the well known operation of the paracentefis of the abdomen. In what circumdances of afcites this operation can moft propei ly be propofed, it is difficult to ^ Vol. 3. O 5 determine; 310 PRACTICE determine ; but, fo far as I can judge, it muft be regulated by very much the fame confid- erations as thofe above mentioned with regard to the paracentefis of the thorax. The manner of performing the paracentefis of the abdomen, and the precautions to be taken with refpea to it, are now fo commonly known, and delivered in fo many books, that it is altogether unneceffary for me to offer any direaious upon that fubjea here ; efpecially aSter the full and judicious information and direaions given by Mr. Bell, in the fecond volume of his Syflem of Surgery. CHAP. OF PHYSIC. 311 CHAP. IV. of GENERAL SWELLINGS, arising FROM AN INCREASED BULK OF THE whole SUBSTANCE of particular PARTS. MDCCXVIII. UPON the Subjeas of this chapter, feveral nofological difficulties occur, and particularly with refpea to admitting the Phy/conia into the order of General Swellings. At prefent, however, it is not neceffary for me to difcuSs this point, as I am here to omit entirely the consideration of PhySconia ; both becaufe it can Seldom admit of any fuccefsful praaice, and becaufe I cannot deliver any thing ufeful either with regard to the patholo- gy or praaice in fuch a difeaSe. MDCCXIX. The only other genus of difeafe compre- hended under the title of the prefent chapter, is the Rachitis; and this being both a proper example of the clafs of Cachexy, and of the 0 6 , order 3i2 PRACTICE order of Intumefcentia: or General Swellings, I fhall offer fome obfervations with regard to it. Of Rachitis, or Rickets. MDCCXX. . THIS difeafe has been fuppofed to have appeared only in modern times, and not above two hundred years ago. This opinion, not- withdanding it has-been maintained by per- fons of the moft refpeaable authority, ap- pears to me, from many confiderations, im- probable ; but it is a point of too little confe- quence to detain my readers here. The only application of it which deferves any notice is, that it has Ud to a notion of the difeaSe having ariSen from the lues venerea, which had cer- tainly made its fird appearance in Europe not very long before the date commonly af- figned for the appearance of rachitis : But I fhall hereafter Show, that the fuppofed con- nexion between the Siphylis and Rachitis is without foundation. MDCCXXI. In delivering the hidory of the Rickets, 1 mud, in the firft place, obferve, that with ref- pea to the antecedents of the difeaSe, every thing fo be found in authors upon this fub- jea, afapears to me .to reft upon a very un- certain OF PHYSIC. 3*3 certain foundation. In particular, with ref- pea to the State of the parents whole offspring become affeaed with this difeafe, I have met with many indances of it, in children from feemingly healthy parents ; and have met likewife with many indances of children who never became affeaed with it, although borit oF parents who, according to the common ac- counts, fhould have produced a rickety ofiv Spring : So that, even making allowance for the uncertainty of fathers, I do not find the general opinion of authors upon this fubjea to be properly fupported. *■.* « MDCCXXII. The difeafe, however, may be juflly,con- fidered as proceeding from parents ; for it oSten appears in a great number Y)f the Same family : And my observation leads me to judge, that it originates more frequently from mothers than from fathers. So far as I can refer the difeafe of the children to the date of the parents, it has appeared to me mod com- monly to arife Srom Some weaknefs, and pretty frequently Srom a Scrophulous habit, in the mother. To conclude the Subjea, I mud re- mark, that in many caSes I have not been able to diScern the condition of the parents, to which I could refer it. When nurfes, other than the mothers, have been employed to Suckle children, it has been fuppofed that Such nurSes have frequently given 3i4 PRACTICE given occatfion to the difeafe : And when nurfes have both produced and have fuckleql children who became rickety, there may be ground to SuSpea their having occafioned the difeafe in the children of other perfons : But I have had few opportunities of afcertaining this matter. It has in fome meafure appear- ed to me, that thofe nurfes are moft likely to produce this difeafe, who give infants, a large quantity of very watery milk, and who con- tinue to Suckle them longer than the ufual time. Upon the whole, however, I am of opinion, that hired nurfes Seldom occafion this diSeaSe, unlefs when a prediSpofition to it has proceeded Srom the parents. MDCCXXI1I. With regard to the other antecedents, which have been uSually enumerated by authors as the remote cauSes of this difeafe, I judg< the accounts given to be extremely fallacious; and I am very much perfuaded, that the cir- cumftances in the rearing of children, have lefs effea in producing rickets than has been imagined. It is indeed not unlikely, that fome of thefe circumftances mentioned as re- mote caufes may favour, while other circum- ftances may refill, the coining on of the dif- eafe ; but at the fame time, I doubt if any of the former would produce it where there was no predifpofition in the child's original con- stitution. This opinion of the remote caufe-s, I have OF PHYSIC. 315 I have formed from obferving, that the diS- eaSe comes on when none of thefe had been applied ; and more frequently that many of them had been applied without occafioning the difeafe. Thus the learned Zeviani al- leges, that the difeafe is produced by an acid from the milk with which a child is fed for the firft nine months of its life : But almoft all children are fed with the fame food, and in which alfo an acid is always produced; while, at the fame time, not one in a thoufand of the infants fo fed becomes affeaed with the rick- ets. If, therefore, in the infants who become affeaed with this difeaSe, a peculiarly noxious acid is produced, we muft Seek for fome pe- culiar caufe of its produaion, either in the quality of the milk, or in the constitution of the child; neither of which, however, Mr. Zeviani has explained. I cannot indeed be- lieve that the ordinary acid of milk has any fhare in producing this difeafe, becaufe I have known many inftances of the acid being produced and occafioning various diforders, without, however, its ever producing rickets. Another of the remote caufes commonly affigned, is the child's being fed with unfer- mented farinaceous food. But over the whole world children are fed with fuch farinacea, while the'difeafe of rickets is a rare occur- rence : And I have known many inftances where children have been fed with" a greater than ufual proportion of fermented farinacea, and alfo a greater proportion of animal food, without 316 PRACTICE without theSe preventing the diSeaSe. In my apprehenfion, the like obfervations might be made with reSpea to moft of the circum- ftances that have been mentioned as the re- mote caufes of rickets. MDCCXXIV. Having thus offered my opinion concern- ing the fuppofed antecedents of this difeafe, I proceed now to mention the phenomena oc- curring after it has aaually come on. The difeafe feldom appears before the ninth month, and feldom begins after the fecond year, of a child's age. In the interval between thefe periods, the appearance of the difeafe is fometimes Sooner, fometimes later ; and commonly at firft the diSeaSe comes on Slowly. The firft appearances are a flaccidity" of the flefh, the body at the fame time becom- ing leaner, though food be taken in pretty largely. The head appears large with refpect to the body ; with the fontanelle, and per- haps the futures, more open than ufual in children of the fame age. The head contin- ues to grow larger; in particular, the fore- head becoming unufually prominent • and,at the fame time the neck continues flender, or feems to be more fo, in proportion to the head. The dentition is flow, or much later than ufual ; and thofe teeth which come out, readily become black, and frequently again fall out. The ribs lofe their convexity, and become OF PHYSIC. 3*7 become flattened on the fides ; while the fter- num is pufhed outward, and forms a fort of ridge'. At the fame time, or perhaps Sooner, the epiphySes at 'the Several joints of the limbs become fwelled ; while the limbs be- tween the joints^ appear, or perhaps aaually become, more flender. The bones feem to be every where flexible, becoming variously distorted; and particularly the Spine of the back becoming incurvated in different parts of its length. If the child, at the time the difeafe comes on, had acquired the power of walking, it becomes dail/more feeble in its motions, and more averfe to the exertion of them, lofing at length the power of walk- ing altogether. Whilft theSe fymptoms go on increafing, the abdomen is always Sull, and preternaturally tumid. The appetite is often good, but the Stools are generally frequent and loofe. Sometimes the faculties of the mind are impaired, and ftupidity or fatuity prevails ; but commonly a premature fenfi- bility appears, and they acquire the faculty of fpeech Sooner than uSual. At the firft coming on of the difeafe, there is generally no ^ fever attending it; but it feldom continues long, till a frequent pulfe, and other febrile fymptoms, come to be conftantly prefent. With theSe Symptoms the diSeaSe proceeds, and continues in Some inftances for Some years ; but very often, in the courfe of that time, the difeafe ceafes to advance, and the health is entirely eftablifhed, except that the diftorted w limbs 318 PRACTICE limbs produced during the difeafe continue for the reft of life. In other cafes, however, the diSeaSe proceeds increafing till it has af- feaed almoft every funaion of the animal economy, and at length terminates in death. The variety of fymptoms wtych in fuch cafes appear, it does not feem neceffary to enume- rate, as they are not effential to the constitu- tion oF the diSeaSe, but are merely confe- quences of the more violent conditions of it. In the bodies of thofe who have died, various morbid affeaions have been discovered in the internal parts. *Moft of the vifcera of the abdomen have been found to be preternatur- ally enlarged. The lungs have alfo been found in a morbid date, feemingly from fome inflammation that had come on towards the end of the difeafe. The brain has been com- monly found in a flaccid date, with effufions of a ferous fluid into its cavities. Very uni- verfally the bones have been found very Soft, and fo much foftened as to be readily cut by a knife. The fluids have been always found in a diflblved date, and the mufcular parts very foft and tender ; and the whole of the dead body without any degree of that rigidity which is fo common in almoft all others. MDCCXXV. From thefe circumftances of the difeafe, it feems to confift in a deficiency of that matter which fliould form the folid parts of the body. This OF PHYSIC. 319 This eSpecially appears in the faulty date of offification, Feemingly depending upon the de- v,j ficiency of that matter which fhould be depof- 1, ited in the membranes which are dedined to ..;| become bony, and fhould give them their due firmne^ and bony hardnefs. It appears that I this matter is not fupplied in due quantity ; but that in place of it, a matter fitted to in- creafe their bulk, particularly in the epiphy- ses, is applied too largely. Wrhat this defi- ciency of matter depends upon, is difficult to be afcertained. It may be a fault in the or- gans of digedion and affimilation, which pre- vents the fluids in general Srom being prop- • erly prepared ; or it may be a Sault in the or- gans of nutrition, which prevents the fecretion oS a proper matter to be applied. With reS- pea to the latter, in what it may confift, I am entirely ignorant, and cannot even difcern that fuch a condition exids : But the former caufe, both in its nature and exidence, is more readily perceived ; and it is probable that it has a confiderable influence in the matter ; as in rachitic perfons a thinner date of the blood, both during life and after death, So commonly appears. It is this date of the fluids, or a deficiency of bony matter in them, that I confider as the proximate caufe of the difeafe ; and which again may in fome meaf- ure depend upon a general laxity and de- bility of the moving fibres of the organs that perform the funaions of digeftion and affim- ilation. V MDCCXXVI. 320 PRACTICE MDCCXXVI. There is, however, fomething ftill wanting to explain, Why thefe circumftances difcover themfelves at a particular time of life, and hardly ever either "before or ' after a certain period ; and as to this I would offer the fol- lowing conjeaures. Nature having intended that human life fhould proceed in a certain manner, and that certain funaions Should be exercifed at a certain period of life only ; fo it has generally provided, that at that period, and not Sooner, the body fhould be fitted for the exercife of the funaions fuited to it. To apply this to our prefent fubjea, Nature feems to have intended that children fhould walk only at twelve months old ; and accord- ingly has provided, that againft that age, and no fooner, a matter fhould be prepared fit to give that firmnefs to the bones which is necef- ' fary to prevent their bending too eafily under the weight of the body. Nature, however, is not always Steady and exaa in executing her own purpoSes ; and iS therefore the prep- aration of bony matter fhall not have been made againft the time there is particular oc- cafion for it, the difeaSe of rickets, that is, of Soft and flexible bones, muft come on ; and will difcover itfelf about the particular period we have mentioned. Further, it will be equally probable, that if at the period men- tioned the bones fhall have acquired their due OF PHYSIC. 321 due firmnefs, and that nature goes on in pre- paring and fupplying the proper bony matter, it may he prefumed, that againft the time a child is two years old* fuch a quantity of bony matter will be applied, as to prevent the bones from becoming again Soft and flexible during the reft oS liSe ; unleSs it happen, as indeed it Sometimes does, that certain cauSes occur to wafh out again the bony matter from the membranes in which it had been depofited. The account I have now given of the period at which the rickets occur, feems to confirm the opinion of its proximate caufe being a deficiency of bony matter in the fluids of the body. MDCCXXVII. It has been frequently fuppofed, that a ijiphylitic taint has a fhare in producing rick- ets ; but fuch a fuppofition is altogether im- probable. If our opinion of the rickets hav- ing exifted in Europe before the fiphylis was brought into it, be well founded, it will then be certain that the diSeaSe may be occafioned without any fiphylitic acrimony having a Share in fts production. But Surther, when a fiphylitic acrimony is tranfmitted from the parent to the offspring, the Fymptoms do not appear at a particular time of life only, and commonly more early than the period of rick- ets ; the fymptoms alfo are very different from thofe of rickets, and unaccompanied with 322 PRACTICE with any appearance oS the latter ; and, laftly, the fymptoms.of fiphylis are cured by means which, in the cafe of rickets, have cither no effea, or a bad one. It may indeed poffibly happen, that fiphylis and rickets may appear in the Same perfon ; but it is to be confidered as an accidental complication : And the very few inftances oS it that have occurred, are by no means Sufficient to eftablifh any neceffary connexion between the two diFeaSes. MDCCXXVIII. With refpea to the deficiency of bony matter, which I confider as the proximate caufe of rickets, fome further conjeaures might be offered concerning its remote cauf- es : But none of them appear Jto me very fat- isfying ; and whatever they might be, it ap- pears to me they muft again be reSolved into the Suppofition of a general laxity and debil- ity of the fyftem. MDCCXXIX. - V It is upon this fuppofitioh almoft alone that the cure of rickets has entirely proceeded. The remedies have been fuch efpecially as were fuited to improve the tone of the fyftem in general, or of the ftomach in particular t And we know that the latter are not only Suited to improve the tone of the ftomach it- felf, ^ OF PHYSIC. 323 Self, but by that means to improve alfo the tone of the whole fyftem. MDCCXXX. Of tonic remedies, one of the moft prom- ifing feems to have been cold bathing; and I have Sound it the moft powerful in preventing the difeafe. For a long time pad, it has been the praaice in this country, with people of all ranks, to wain their children from the time of their birth with cold water ; and from the time that children are a month old, it has been the praaice with people of better rank to have them dipped entirely in cold water^ every morning : And wherever this praaice has been purfued, I have not met with any indance of rickets. Amongd our common people, although they wafh their children with cold water only, yet they do not fo com- monly praaice immerfion : And when a- iinongft thefe I meet with inftances of riekets, I prefcribe cold bathing; which accordingly has often checked the progrefs of the difeafe, and fometimes feems to have cured it en- tirely. MDCCXXXL The remedy of Ens Veneris, recommended by Mr. Boyle, and fince his time very uni- Verfally employed, is to be confidered as en- tirely a tonic remedy. That or fome other preparation 324 P R A C 1 l t jl preparation of iron I have almod condantly employed, though not indeed always with fuccefs. I have been perfuaded, that the ens veneris of Mr. Boyle, notwithdanding his giving it this appellation, was truly a prepa- ration of iron, and no other than what we now name the Flores Martiales: But it appears, that both Benevoli and Buchner have em- ployed a preparation of copper; and I am ready to believe it to be a more powerful to- nic than the preparations of iron. MDCCXXXII. Upon the fuppofition of tonic remedies being proper in this difeafe, I have endeav- oured to employ the Peruvian bark : But from the difficulty of adminidering it to in- fants in any ufeful quantity, I have not been able to difcover its efficacy ; but I am very ready to believe the tedimony of De Haen upon this fubjea. MDCCXXXIII. Exercife, which is one of the moft power- ful tonics, has been properly recommended for the cure of rickets; and as the exercife of geftation only can be employed, it Should al- ways be, with the child laid in a horizontal fituation ; as the carrying them, or moving them in any degree of an erea pofture, is very apt to occafion fome diftortion. It is extremely OF PHYSIC. 325 extremely probable, that, in this difeafe, fric- tion with dry flannels may be found an ufeful remedy. V MDCCXXX1V. It is alfo fufficiently probable, that the a- voiding of moidure is not only advifeable, but may likewife be of Service in the cure of tlm difeafe. There is no doubt that a certain diet may Contribute to the fame end ; but what may be the mod eligible, I dare not determine. I have no doubt that leavened bread may be more proper than unfennented farinacea ; but I cannot find any reafon to believe that ftrong beer can ever be a proper remedy. Praaitioners have been divided in opinion concerning the ufe of milk in this difeafe. Zeviani, perhaps from theory, condemns the A ufe of it; but Benevoli employed it without its impeding the cure of the difeafe. This lad I have often remarked in the courfe of my own praaice. As it is difficult to feed children entirely without milk ; fo I have commonly admitted it as a part of the diet of rickety children ; and in many indances I can affirm, that it did not prevent the cure of the difeale. In cafes, however, of any appear- ance of rickets, and particularly of a flow dentition, I have diffuaded the continuance of a child upon the bread ; becaufe the milk of women is a more watery nourishment than Vol. III. P that 3*6 PRACTICE that of cows : And I have efpecially diffuad- ed the continuing a child upon the breaft, | when I thought the nurfe gave rather too much of fuch a watery nourifhment; for, as j has been above mentioned, I have had fre- ( quent occafion to fufpea, that the milk of Such nurfes has a tendency to favour the com- ing on of rickets. . MDCCXXXV. Befides the remedies and regimen now mentioned, praaitioners have commonly em- ployed in this difeafe, both emetics and pur- gatives. When the appetite and digedion 1 are confiderably impaired, vomiting, if nei- j ther violent, nor frequently repeated, feems to be of Service $ and by a moderate agita- | tion of the abdominal vifcera, may in fome meaSure obviate the dagnation and confe- quent fwelling that ufually occur in them. As the tumid date of the abdomen, fo con- ftantly to be met with in this diSeaSe, Seems to depend very much upon a tympanitic af- Seaion of the inteftines; fo, both by obviat- ing this, and by deriving from the abdominal ; vifcera, frequent gentle purgatives may be of , Service. Zeviani, perhaps properly, recom- mends in particular rhubarb ; which, befides * its purgative quality, has thofe alSo of bitter • and aftringent, MDCCXXXVI. OF PHYSIC. 327 MDCCXXXVI. I have now mentioned moft of the reme- dies commonly employed by the praaitioners of former times ; but I muft not omit men- tioning fome others that have been lately fug- geded. The late Mr. De Haen recommends the tedacea ; and affures us of their having been employed with fuccefs : But in the few trials which I have had occafion to make; their good effeas did not appear. The late Baron Van Swieten gives us one indance oF rickets cured by the uSe oS hem- lock ; but I do not kno*r that the praaice has been repeated. T"' £/*- BOOK 328 BOOK III. of the IMPETIGINIS; or DEPRAV- ED HABIT, with AFFECTIONS OF THE SKIN. MDCCXXXVII. I FI N D it difficult to give any fufficiently correa and jrtoper chara&er of this order. The difeafes comprehended under it, depend, for the mod part, upon a depraved date of the whole of the fluids, producing tumours, eruptions, or other pre- ternatural affeaions oF the fkin. Although it be extremely difficult to find a general charaaer of the order that will apply to each of the genera and fpecies, I fhall here treat of the principal genera which have been commonly comprehended under this order, and which I have enumerated in my No- fology.^ ' " ^ C HA P. OF PHYSIC. a29 CHAP. r. of SCROPHULA, or the KING'S. EVIL. MDCCXXXVIII. 1 HE charaaer of this difeafe I have attempted in my Nofology : But it will be more properly taken from the whole of its hidory, now to be delivered. MDCCXXXIX. It is commonly, and very generally, a he- reditary difeaSe ; and although it Sometimes may, yet it rarely appears, but in children whole parents had at Some period of their lives been affeaed with it. Whether it may not Fail to appear in the children oF fcrophu- lous parents, and difcover itfelf afterwards in their offspring in the Fucceeding generation, I cannot certainly determine ; but believe that this has frequently happened. It ap- pears to me to be derived more commonly from fathers than from mothers jjDut whether this happens from there'being more fcrophu- jP 3 lous" 330 PRACTICE lous men than fcrophulous women married, I am not certain. With refpea to the influence of parents in producing this difeafe, it deferves to be re- marked, that in a family of many children, when one of the parents has been affeaed with fcrophula, and the other not; as it is ufual for fome of* the children to be in condi- tution pretty exaaiy like the one parent, and others of them like the other ; it commonly happens that thofe children who mod refem- ble the fcrophulous parent become affected with Fcrophula, while thoSe refembling the other parent entirely eScape. MDCCXL. The Scrophula generally appears at a par- ticular period of life. It feldom appears in the firlt, or even in the Second year of a child's life ; and mod commonly it occurs from the fecond, or, as fome allege, and per- haps more properly, from the third, to the Seventh year. Frequently, however, it dis- covers itfelf at a later period ; and there are indances of its fird appearance, at every pe- riod till the age of puberty ; after which, however, the fird appearance of it is vexy rare. MDCCXLI. When it does not occur very early, we can generally* didinguilhnhe habit of body pecu- liarly OF PHYSIC. 331 Iiarly difpofed to it. It moft commonly af- feas children of foft and flaccid habits, of fair hair and blue eyes ; or at leaft affeas thofe much more frequently than thofe of an op- pofite complexion. It affeas efpecially chil- dren Of fmooth Skins and rofy cheeks ; and fuch children have frequently a tumid upper lip, with a chop in the middle of it; and this tumour is often confiderable, and extended to the columna nafi and lower part of the nof- trils. The difeafe is fometimes joined with, or follows rickets ; and although it frequently appears in children who have not had rickets in any great degree, yet it often attacks thofe who by a protuberant forehead, by tumid joints, and a tumid abdomen, Show that they had Some rachitic difpofition. In parents who, without having had the diSeaSe them- Selves, Seem to produce fcrophulous children, we can commonly perceive much of the fame habit and conditution that has been jud now defcribed. Some authors have fuppofed that the Small pox has a tendency to produce this difeaSe ; and Mr. De Haen alTerts its Sollowing the in- oculated, more Srequently than the natural, Small pox. This lad pofition, however, we can confidently affirm to be a midake ; al- though it mult be allowed, that in faa the fcrophula does often come on immediately after the fmall pox. It is, however, difficult to find any connexion between the two dif- eafe j. According to my obfervaticm^ the ac- E'4^ cident 332 PRACTICE cident only happens in children who have pretty manifedly the fcrophulous difpofition ; and I have had, feveral indances of the nat- ural fmall pox coming upon children affeaed * at the fame time with fcrophula, not only < without this difeafe being any ways aggravat- ed by the fmall pox, but even of its being for Some time after much relieved. MDCCXLII. The fcrophula generally Shows itfelf fird at a particular feafon of the year; and at fome time between the winter and Summer Sol dice; but commonly long beSore the latter period. It is to be obServed Surther, that the courSe of the difeafe is ufually conneaed with the courfe of the feafons. Whild the tumours and ul- cerations peculiar to this diSeaSe, appear firft in the Spring, the ulcers are Srequently healed up in the courSe of the fucceeding fummer,, and do not break out again till the enfuing^.jj Spring, to follow again with the feaSon the Same courSe as beSore. MDCCXLIII. Frequently the fird appearance oS the dif-,. eafe is the tumid and chopped lip above menH. tioned. Upon other occafions the fird ap-. pearance is that of fmall fpherical or oval tu-il ^ mours, moveable under the fkin. They arei foft, but- witfi-sfome^elafticity. They are; r ~" ~^ -v without OF PHYSIC. 333 without pain ; and without any change in the colour of the fkin. In this ftate they often continue for a long time ; even for a year or two, and fometimes longer. Mod commonly the}- fird appear upon the fides of the neck below the ears ; but fometimes alfo under the chin. In either cafe, they are fuppofed to affea in thefe places the conglobate or lym- phatic glands only ; and not at all the Salivary glands, till the difeafe is very greatly advanced. The difeafe frequently affeas, and even at fird appears in, other parts of the body. In particular, it affects the joints of the elbows and ankles, or thofe of the fingers and toes. The appearances about the joints are not commonly, as elfewhere, fmall moveable fwellings ; but a tumour almod uniformly furrounding the joint, and interrupting its motion. MDCCXLIV. Thefe tumours, as I have faid, remain for fome time little changed ; and, from the time they firft appeared in the Spring, they often continue in this way till the return of the fame feafon in the next,or perhaps the fecond year after.. About that time, however, or perhaps in the courfe of the feafon in which they firft appear, the tumour becomes larger and more fixed ; the fkin upon it acquires a purple, feldom a clear rednefs : But growing redder by degrees, the tuanour becomes fofter, _and Vo*.. 3. P 5 allows PRACTICE allows the fluauation of a liquid within to be perceived. All this procefs, however, takes place with very little pain attending it. At length fome part of the fkin becomes paler; and by one or more fmall apertures a liquid is poured out. MDCCXLV. The matter poured out has at firft the ap- pearance of piis, but it is ufually of a thinner kind than that from phlegmonic abfceffes; and the matter as it continues to be discharg- ed, becomes daily lefs purulent, and appears more and more a vifcid ferum, intermixed with fmall pieces of a white fubftance refem- bling the curd of milk. By degrees the tu- mour almoft entirely fubfides, while the ulcer opens more, and Spreads broader ; unequally, however, in different direaions, and therefore is without any regular circumfcription. The edges of the ulcer are commonly flat and Smooth, both on their outfide and their inner edge, which Seldom puts on a callous appear- ance. The ulcers, however, do not generally Spread much, or become deeper; but at the Same time their edges do not advance, or put on any appearance oS forming a cicatrix. MDCCXLVI. In this condition the ulcers oSten continue Sor a long time; while new tumours, with ul- ♦ cers OF PHYSIC. 335 cers fucceeding them in the manner above defcribed, make their appearance in different parts of the body. Of the firft ulcers, how- ever, Some heal up, while other tumours and ulcers appear in their vicinity, or in other parts oS the body : And in this manner the difeafe proceeds, fon'ie of the ulcers healing up, at leaft to a certain degree, in the courfe of fummer, and breaking out again in the fuc- ceeding fpring : Or it continues, by new tu- mours and ulcers fucceeding them, in the fpring SeaSon, making their appearance fuc- ceffively Sor Several years. MDCCXLVII. In this way the difeafe goes on for feveral years; but very commonly in four or five years it is Spontaneously cured, the former ulcers being healed up, and no new tumours spearing : And thus at length the difeafe (,eeafes entirely, leaving only Some indelible eSchars, pale and Smooth, but in Some parts Shrivelled; or, where it had occupied the joints, leaving the motion of thefe impaired, or entirely destroyed. MDCCXLVIII. Such is the moft favourable courfe of this difeafe ; and* with us, it is more frequently fuch, than otherwife : But it is often a more violent, and Sometimes, a iaJtal-rmalady. In P6^ thefe ?{ 336 PRACTICE thefe cafes, more parts of the body are at the fame time affeaed ; the ulcers alfo Seeming to be imbued with a peculiarly Sharp acrimo- ' ny, and thereSore becoming more deep, erod- ing, Spreading, as well as Seldomer healing up. A In Such caSes, the eyes are often particularly ] affeaed. The edges of ;he eyelids are affea- ed with tumour and fuperficial ulcerations; and thefe commonly excite obftinate inflam- mation in the adnata, which frequently pro- duces an opacity of the cornea. ; When the fcrophula efpecially affeas the { joints, it fometimes produces there confidera- ble tumours ; in the abfceffestfollowing which, the ligaments and cartilages are eroded, and the adjoining bones are affeaed with a caries of a peculiar kind. In thefe cafes, alfo, of more violent fcrophula, while every year pro- duces a number of new tumours and ulcers, their acrimony feems at length to taint ther ^ whole fluids of the body, occafioning varioue diforders ; and particularly a heaic fever, with all its fymptoms, which at length proves fatal, with fometimes the fymptoms of a phthifis pulmonalis. MDCCXLIX. The bodies of perfons who have died of | this difeafe fhow many of the vifcera in a very morbid date ; and particularly mod of the glands of the mefentery very much tumefied, and frequently in an ulcerated date. Com- r - monly j OF PHYSIC. 337 monly alSo a great number of tubercles or cyds, containing matter of various kinds, ap- pear in the lungs. MDCCL. Such is the hiftory of the difeafe; and from thence it may appear, that the nature of it is not eafily to be afcertained. It feems to be a peculiar affeaion of the lymphatic fyftem ; and this in fome meafure accounts Sor its con- nexion with a particular period oS life. Prob- ably, however, there is a peculiar acrimony of the fluids that is the proximate caufe oS the difeaSe ; although of what nature this is, has not yet been discovered. It may perhaps be generally diffufed in the fyftem, and exhaled into the feveral cavities and cellular texture of the body; and therefore, being taken up by the abforbents, may difcover itfelf eSpecially in the lymphatic fyftem. This, however, will hard- ly account for its being more confined to that fyftem, than happens in the cafe of many oth- er acrimonies which may be fuppofed to be as generally diffufed. In fhort, its appearance in particular constitutions, and at a particular period of life, and even its being a hereditary difeafe, which fo frequently depends upon the tranfmiflion of a peculiar constitution, are all of them circumftances which lead me to con- clude, upon the whole, that this di'eafe de- pends upon a peculiar conflitution of the lym- phatic fyftem. MDCCLI. 338 PRACTICE MDCCLI. It feems proper to obferve here, thatjhe fcrophula does not appear to be a contagious diSeaSe ; at leaft I have known many inftances of found children having had frequent and clofe intercourfe with fcrophulous children without being infeaed with the difeafe. This certainly Shows, that in this difeafe the pecu- liar acrimony of it is not exhaled from the furface of the body, but that it depends efpecially upon a peculiar constitution oS the Syftem. MDCCLII. Several authors have SuppoSed the fcroph- ula to have been derived Srom the venereal diSeaSe ; but upon no juft grounds that I can perceive. In very many indances; there can hardly be any SuSpicion oS the parents pro- 1 during this diSeaSe having been imbued with fiphylis, or with any fiphylitic taint; and I have known Several examples of parents con- J veying fiphylis to their offspring, in whom, M however, no Fcrophulous Symptoms at any j time afterwards appeared. Further, the | fymptoms of the two difeafes are very differ- J ent; and the difference of their natures ap- | pears particularly from hence, that while mer- cury commonly and/eadily cures the fiphy- lis, : OF PHYSIC. 339 lis, it does no fervice in fcrophula, and very often rather aggravates the difeafe. MDCCLIII. For the cure of fcrophula, we have not yet learned any praaice that is certainly or even generally fuccefsful. The remedy which feems to be the moft SucceSsful, and which our practitioners efpec- ially truft to and employ, is the uSe of mineral waters ; and indeed the wafhing out, by means of thefe, the lymphatic fydem, would feem to be a meafure promising SucceSs : But in very many indances oSthe uSe oS theSe waters, I have not been well Satisfied that they had fhortened the duration of the difeafe more than had often* happened when no fuch rem- edy had been employed. MDCCLIV. With regard to the choice of the mineral waters moft fit for the purpofe, I cannot with any confidence give an opinion. Almoft all kinds of mineral waters, whether chalybeate, fulphureous, or faline, have been employed for the cure of fcrophula, and feemingly with equal fuccefs and reputation : A circumftance which leads me to think, that, if they are ever fuccefsful, it is the elementary water that is the chief part of the remedy. Of 340 PRACTICE Of late, fea water has been efpecially rec- ommended and employed; but after nume- rous trials, I cannot yet difcover its fuperior efficacy. MDCCLV. The other remedies propofed by practical writers are very numerous ; but, upon that very account, I apprehend they are little to ]be truded ; and as I cannot perceive any juft reafon for expeaing fuccefs from them, I have very feldom employed them. Of late, the Peruvian bark has been much recommended : And as in fcrophulous per- fons there are generally fome marks of laxity and flaccidity, this tonic may poffibly be of fervice ; but in a great variety of trials, I have never Seen it produce any immediate cure of the difeaSe. In Several indances, the leaves of coltsfoots have appeared to me to be fuccefsful. I haye ufed it frequently in a drong decoction, and even then with advantage ; but have found more benefit from the expreffed juice„ when the plant could be had in fbmewhat of a Suc- culent date, foon after its fird appearance in the fpring. MDCCLVI. I have alfo frequently employed the hem- lock, and have Sometimes found it ufeful in di feu (ling OF PHYSIC. 341 difcufling obdinate fwellings : But in this, it has alfo often difappointed me ; and I have not at any time obferved that it difpofed fcrophulous ulcers to heal. I cannot conclude the fubjea of internal medicines without remarking, that I have never found, either mercury or antimony, in any Shape, of ufe in this difeafe ; and when any''degree of a feverifh date had come on, the ufe of mercury proved manifedly hurtful. MDCCLVII. In the progrefs of fcrophula, feveral exter- nal medicines are requisite. • Several applica- tions have been uSed for difcufling the tu- mours upon their firft coming on ; but hith- erto my own praaice, in theSe reSpeas, has been .attended with very little SucceSs. The Solution of faccharum faturni has Seemed to be ufeful; but it has more frequently failed : And I have had no better fuccefs with the fpiritus Mindereri. Fomentations of every kind have been frequently found to do harm ; and poultices feem only to hurry on a Sup- puration. I am doubtful if this laft be ever praaifed with advantage j Sor fcrophulous tumours Sometimes Spontaneously diSappear, but never aSter any degree of inflammation has come upon them ; and therefore poul- tices, which commonly induce inflammation, prevent that difcuffion of tumours, which might otherwife have happened. ~ ~•• - 342 PRACTICE Even when fcrophulous tumours have ad- vanced towards fuppuration, I am unwilling to had en the fpontaneous opening, or to make it by the lancet; becaufe I apprehend the fcrophulous matter is liable to be rendered more acrid by communication with the air, and to become more eroding and Spreading than when in its inclofed date. MDCCLVIII. The management of fcrophulous ulcers has, fo far as I know, been as little SucceSsful as that of the tumours. Efcharotfc prepara- tions, of either mercury or copper, have been fometimes ufeful in bringing on a proper fup*. puration, 3nd thereby difpofing the ulcer to heal ; but they have feldom Succeeded, and more commonly they have caufed the ulcer to fpread more. The efcharotic from which I have received moft benefit is burnt alum ; and a portion of that mixed with a mild oint- ment, has been as ufeful an application as any I have tried. The application, however, that I have found moft Serviceable, and very uni- verfally admiffible, is that of linen cloths wetted with cold water, and frequently chang- ed when they are becoming dry, it being in- convenient to let them be glued to the fore. They are therefore to be changed frequently during the day ; and a cloth fpread with a mild ointment or plafter may be applied for the^nighC^Itrthis praaice I have fometimes S >- -^ employed OF PHYSIC. 343 employed fea water : But generally it proved too irritating ; and neither that nor any min- eral water has appeared to be of more fervice than common water. MDCCLIX. To conclude what I have to offer upon the cure of fcrophula, I muft obferve, that cold bathing feems to have been of more benefit than any other remedy that I have had occa- fion to lee employed. CHAP. PRACTICE CHAP. II. of SIPHYLIS, or the VENEREAL DISEASE. MDCCLX. A.FTER praaitioners have had fo much experience in treating this dif- eafe, and after fo many books have been pub- lifhed upon the Subject, it does not feem uec- effary, or even proper, For me to attempt any | full treatiFe concerning it; and I Shall there- < fore confine myfelf to fuch general remarks, ] as may Serve to illuftrate fome parts of the pathology or of the praaice. MDCCLXI. It is fufficiently probable, that, anciently,, in certain parts of Alia, where the leproSy, prevailed, and in Europe after that difeafe1 had been introduced into it, a difeafe of the genitals, refembling that which now common- ■ ly arifes from fiphylis, had Srequently appearl ed : But it is equally probable, that a new difeafe, and what we at prefent term Siphylis, wag fijiKbrought into Europe about the end I OF PHYSIC. 345 of the fifteenth century ; and that the diftem- per now So frequently occurring, has been very entirely derived from that which was imported from America at the period men- tioned. MDCCLXII. This difeafe, at leaft in its principal circum- ftances, never arifes in any perSon but Srom Some communication with a perSon already affeaed with it. It is moft commonly con- traaed in conSequence oF coition with an in- fefted perfon; but in what manner the in- Seaion is* communicated, is not clearly ex- plained. I am.perfuaded, that in coition, it is communicated without there being any Open ulcer either in the perSon communicat- ing or in the perSon receiving the inSeaion ; but in all other caSes, I believe it is never communicated in any other way than by a contaa of ulcer, either in the perfon com- municating, or in the perfon receiving the infeaion. MDCCLXIIL As it thus arifes from the Contaa of partic- ular parts, fo it always appears firft* in the neighbourhood of the parts to which the in- Feaing matter had been immediately applied j and therefore, as moft commonly coutraaed by 346 PRACTICE by coition, it generally appears firft in the genitals. MDCCLXIV. After its firft appearance in particular parts, more efpecially when thefe are the genitals qf either fex, its effeas for fome time Seem to be confined to theSe parts; and in- deed, in many caSes, never extends Surther. In other caSes, however, the inSeaing mat- ter paffes From the parts firft affeaed, and From the genitals therefore, into the bloodvef- Sels ; and being there diffuSed, produces dis- orders in many other parts oS the body. From this view oS the circumdances, phy- ficians have very properly didinguifhed the different ftates oF the difeaSe, according as they are local or are more univerSal. To the former, they have adapted appellations fuited to the manner in which the diSeaSe appears; and to the other the general affeaion, they have almod totally confined the appellations oF Siphylis, Lues Venerea, or Pox. In the re- marks I am now to offer, I fhall begin with considering the local affection. MDCCLXV. This local affeaion appears chiefly in the j form of gonorrhoea or chancre. The phenomena oF gonorrhoea either upon its fird coming on or in its aFter progreFs, or the OF PHYSIC. 347 the fymptoms of ardor urinae, chordee, or others attending it, it is not neceffary For me to deferibe. I fhall only here obFerve, that the chieF circumdance to be taken notice oF, is the inflamed date oF the urethra, which I take to be infeparable from the difeafe. MDCCLXVI. In thefe well known circumdances, the gonorrhoea continues for a time longer or fliorter, according to the conditution of the patient ; it ufually remaining longeft in the moft vigorous and robuft, or according to the patient's regimen, and the care taken to re- lieve or cure the diSeaSe. In many caSes, if by a proper regimen the irritation of the in- flamed date is careSully avoided, the gonor- rhcea"*Spontaneoufly ceaf'es, the Symptoms of inflammation gradually abating, the matter discharged becoming of a thicker and more vifcid confidence, as well as of a whiter col- our ; till at length, the flow of it ceafes alto- gether ; and whether it be thus cured Spon- taneously, or by art, the diSeaSe often exifls without communicating any infeaion to the other parts of the body. MDCCLXVII. In other cafes, however, the difeafe having been negleaed, or by an improper regimen •aggravated, it continues with all its fymptoms for •*> 348 PRACTICE « for a long time ; and produces various other diforders in the genital parts, which, as com- monly taken notice of by authors, need not be defcribed here. I fhall only obferve, that the inflammation of the urethra, which at firft feems to be feated chiefly, or only, in its an- terior parts, is in fuch negleaed and aggravat- ed cafes fpread upwards along the urethra, even to the neck of the bladder. In thefe circumdances, a more confiderable inflam- mation is occafioned in certain parts of the urethra ; and confequently, fuppuration and ulcer are produced, by which the venereal poifon is Sometimes communicated to the fyf- tem, and gives rife to a general fiphylis. MDCCLXVIII. It was fome time ago a pretty general fup- pofition, that the gonorrhoea depended al- ways upon ulcers of the urethra, producing a difcharge of purulent matter ; and fuch ul- cers do indeed fometimes occur in the manner that has been jud now mentioned. We are now affured, however, From many diffeaions > of perSons who had died when labouring un- der a gonorrhoea, that the difeafe may exid, - and from many confiderations it is probable that it commonly does exid, without any ulceration of the urethra ; fo that the dis- charge which appears, is entirely that of a vitiated mucus from the mucous follicles of the urethra. *'■ MDCCLXIX. OF PHYSIC. 349 MDCCLXIX. Although moft of the fymptoms of gonor- rhoea fhould be removed, yet it often happens that a mucous fluid continues to be discharg- ed from the urethra for a long time after, and fometimes for a great part of a perfon's life. This difcharge is what is commonly called a Gleet. With refpea to this, it is proper to obferve, that in fome cafes, when it is certain that the matter difcharged contains no venereal poifon, the matter may, and often does put on that puriform appearance, and that yellow and greenifh colour, which appears in the difcharge at the beginning and during the courfe of a virulent gonorrhoea. Thefe appearances in the matter of a gleet which before had been of a lefs coloured kind, have frequently given occafion to fuppofe that a frefh infeaion had been received : But I am certain that fuch appearances may be brought on by, perhaps various other caufes ; and particularly, by in- temperance in venery and drinking concur- ring together. I believe, indeed, that this feldom happens to any but thofe who had'be- fore frequently laboured under a virulent gonorrhoea, and have more or lefs of gleet remaining with them : But I mud alfo ob- ferve, that in perfons who at no period of their life had ever laboured under a virulent gon- orrhoea, or any other fymptom of fiphylitic Vol. III. Q affeaion, PRACTICE affeaion, I have met with indances of dif- charges from the urethra refembling thofe of a virulent gonorrhoea. > The purpofe of thefe obfervations is, to fuggeft to praaitioners what I have not found them always aware of, that in perfons labour- ing under a gleet, fuch a return of the appear- ances of a virulent gonorrhoea may happen without any new infeaion having been re- ceived, and confequently not requiring the treatment which a new infeaion might per- haps demand. When in the cure of gonor- rhoea it was the praaice to employ purgatives very frequently, and fometimes thofe of the draftic kind, I have known the gleet, or Spu- rious gonorrhoea, by fuch a praaice much in- creafed, and long continued, and the patient's constitution very much hurt. Nay, in order more certainly further to prevent midakes, it is to be obferved, that the fpurious gonorrhoea is Sometimes attended with heat of urine, and fome degree of inflammation • but thefe Symptoms are feldom confiderable, and, mere* ly by the affiftance oF a cool regimen, com* monly diFappear in a Few days. MDCCLXX, With refpea to the cure of a virulent gon« orrhoea, I have only to remark, that if itbe true, as I have mentioned above, that the difeafe will often, under a proper regimen, be fpontaneoufly cured ; and that the whole- of OF PHYSIC. 35.1 the virulent matter may be thus entirely dis- charged without the affiftance of art; it would feem that there is nothing required of prac- • J titioners, but to moderate and remove that inflammation which continues the diSeaSe, and Occafions all the troubleSome Symptoms that ever attend it. The Sole bufinefs therefore of our art in the cure of gonorrhoea, is to take off the inflammation accompanying it; And this I think may commonly be done, b^ avoiding exercife, by ufing a low and cool diet, by abstaining entirely from fermented and fpirituous liquors, and by taking plenti- fully of mild diluent drinks. s MDCCLXXL The heat of urine, which is fo troublefome in this difeaSe; as it arifes from the increafed j fenfibility of the urethra in its inflamed ftate ; ' fo, on the other hand, the irritation of. the ' urine has the effea of increafing the inflam- - mation, and is therefore to be removed as foon as poffible. This can be done moft effeau*. ally by taking in a large quantity of mild watery liquors. Demulcents may be em- ployed ; but unlefs they be accompanied with a large quantity of water, they will have little «ffea. % Nitre has been commonly employed as a Fuppofed refrigerant : But, from much obfervation, I am convinced, that in a fmall quantity it is ufelefs, and in a large quan- tity certainly hurtful; and, for this rea- Q 2 fon, 352 PRACTICE fon, that every faline matter palling with the urine generally gives fome irritation to the urethra. To prevent the irritation of the urethra arifing from- its increafed fenfibility, the injeaion of mucilage-or of mild oil into it has been praaifed ; but I have feldom found this of much fervice. MDCCLXXII. In gonorrhoea, as coftiveneSs may be hurt- ful, both by an irritation oS the Sydem in gen- eral, and of the urethra in particular, as this is occafioned always by the voiding oS hardr ened faeces; So codiveneSs is to be carefully avoided or removed ; and the frequent ufe of large glyders of water and oil, I have found of remarkable benefit in this difeaSe. If . glyders, however, do notentirely obviate cof- tiveneSs, it will be neceffary to give laxatives by the mouth : Which, however, fhould be of the milded kind, and fhould do no more than keep the belly regular and a little loofe, without much purging. The praaice of frequent purging, which ; was formerly fo much in ufe, and is not yet entirely laid afide, has always appeared to me to be generally Superfluous, and often very j hurtful. Even what are fuppofed to be cool- ing purgatives, fuch as Glauber's fait, Soluble tartar, and cry dais of tartar, in fo far as any part of them pafs by urine, they, in the Same manner as we have Said of nitre, may be hurt- ful ; OF PHYSIC. 853 ful ; and So Sar as they produce very liquid ftools, the matter oS which is generally acrid, they irritate the reaum, and consequently the urethra. This laft effea, however, the acrid, and in any degree draftic purgatives, more certainly produce. MDCCLXXIII. In cafes of a gonorrhoea attended with vi- olent inflammation, bloodletting may be of fervice; and in the cafe of perfons of a robuft and vigorous habit, in whom .the difeafe is commonly the moft violent, bloodletting may be very properly employed. As general bleedings, however, when there is no phlo- gistic diathefis in the fyftem, have little effea in removing topical inflammation -, fo in gon- orrhoea, when the inflammation is confidera-, ble, topical bleeding applied to the urethra by leeches, is generally more effedlual in re- lieving the inflammation, MDCCLXXIV. When there is any phymofis attending a gonorrhoea, emollient fomentations applied to the whole penis are often of fervice. In fuch cafes it is neceffary, and in all others ufeful, to keep the penis laid up to the belly, when the patient either walks about or is fitting. Q3 MDCCLXXV. 354 PRACTICE MDCCLXXV. Upon occafion of frequent pirapiSm and chordee, it has been Found uSeSul to apply to the whole of the penis a poultice of crumb of bread moiftened with a drong Solution of fugar of lead. I have, however, been often difappointed in this praaice, perhaps by the poultice keeping the penis too warm, and thereby exciting the very fymptoms I wifhed to prevent. Whether lotions of the external urethra with a Solution of the fugar of lead, might be ufeful in this cafe, I have not prop- erly tried. MDCCLXXVI. With refpea to the uSe of injeaions, fo - frequently employed in gonorrhoea, I am perfuaded, that the early uie of adringent in- jeaions is pernicious ; not by occafioning a fiphylis, as has been commonly imagined; but by increafing and giving occafion to all the conSequences of the inflammation, partic- ularly to the very troublefome fymptoms of fwelled tedicles. When, however, the diSeaSe has continued for fome time, and the inflam- matory fymptoms have very much abated, I am of opinion, that by injeaions of moderate adringency, or at lead of this gradually in- creafed, an end may be fooner put to the dif- eaSe than would otherwife have happened ; OF PHYSIC. 355 and that a gleet, fo readily occurring, may be generally prevented. MDCCLXXVII. Befides the ufe of aftringent injeaions, it- has been common enough to employ tjjjofe of a mercurial kind. With refpea to thefe, al- though I am convinced that the infeaion producing gonorrhoea and that producing chancres and fiphylis, are one and the fame ; yet I apprehend, that in gonorrhoea mercury cannot be of ufe by correaing the virulence of the infeaion ; and therefore that it is not univerfally neceffary in this difeafe. I am perfuaded, however, that mercury applied to the internal furface of the urethra, may be of ufe in promoting the more full and free dis- charge of virulent matter from the mucous glands of it. Upon this fuppofition, I have frequently employed mercurial injeaions; and, as I judge, with advantage ; thofe injec- tions often bringing on fuch a ftate of the confiftence and colour of the matter discharg- ed, as we know uSually to precede its Spon- taneous, ceafing. I avoid theSe injeaions, however, in recent caSes, or while much in- flammation is ftill preSent; but when that in- flammation has Somewhat abated, and the discharge notwithstanding ftill continues in a virulent form, I employ mercurial injeaions freely. I employ thofe only that contain mercury entirely in a liquid form, and avoid Q 4 thofe 356 PRACTICE thofe which may depofite an acrid powder in the urethra. That which I have found moft ufeful is a Solution of the corrofive Sublimate in water ; fo much diluted as not to occafion any violent Smarting, but not So much diluted as to give no Smarting at all. It is Scarce neceffary to add, that when there is reaSon to Sufpea there are ulcerations already Sormed in the.. urethra, mercurial injeaions are not only proper, but the only effeaual remedy that can be employed. MDCCLXXVIII. With regard to the cure oF gonorrhoea, I have only one other remark to offer. As moft of the fymptoms arife from the irritation of a Stimulus applied, the effeas of this irri- tation may be often leffened by diminishing. the irritability of the fyftem ; and it is well f known, that the moft certain means of accom- plishing this is by employing opium. For that reaSon, I confider the praaice both of applying opium direaiy to the urethra, and of exhibiting it by the mouth, to be extremely*'*. uSeSul in moft cafes of gonorrhoea. MDCCLXXIX. After thus offering fome remarks with red- pea to gonorrhoea in general, I might pro- ceed to cOUfider particularly the various fymp- toms which fo frequently attend it j but it does OF PHYSIC. 357 does not feem neceffary for me to attempt this after the late publications of Dr. Foart Simmons, and of Dr. Schwediaur, who have treated the fubjea fo fully, and with fo much difcernment and flrill. MDCCLXXX. . The other form of the local affeaion of fiphylis, is that of chancre. The ordinary appearance of this I need not defcribe, it hav- ing been already So often done. Of the few- remarks I have to offer, the firft is, that I be- lieve chancres never appear in any degree without immediately communicating to the blood more or lefs of the venereal poifon : For I have conftantly,. whenever chancres had appeared, found, that unlefs mercury was immediately given internally, fome fymptoms of a general fiphylis did certainly come on afterwards; and though the internal ufe of mercury fhould prevent any fuch appearance, it is dill to be prefumed that the poifon had been communicated, becaufe mercury could aa upon it in no other manner than as dif- fufed in the fluids. MDCCLXXXI. It has been a queftion among praaitionew, upon the fubjea of chancres, Whether they Vol. 3. Q5 maf 358 PRACTICE may be immediately healed up by applications * made to the chancres, or if they fhould be left open for Some time without any Such appli- cation ? It has been SuppoSed, that the Sud- den healing up of chancres might immediate- ly force into the blood a poifon which might have been excluded by being difcharged from the chancre. This, however, is a fuppofition that is very doubtful ; and, upon the other hand, I am certain, that the longer a chancre is kept open, the more poifon it perhaps gen- erates, and certainly Supplies it more copioufly to the blood. And although the above men- tioned Suppofition were true, it will be of little con Sequence, iS the internal uSe oS mercury, which I judge neceffary in every caSe oF chan- cre, be immediately employed. I have often Seen very troubleSome conSequenees follow ] from allowing chancres to remain unhealed; J and the fymptoms of general fiphylis have j always Seemed to me to be more confiderable • and violent in proportion as chancres had J been Suffered to remain longer unhealed. 1 They fhould always, therefore, be healed as j foon as poffible j and that, by the only very | effeaual means, the application of mercurials 1 to the chancre itfelf. Thofe that are recent, J and have not yet formed any confiderable ul- I cer, may often be healed by the common mer- 1 curial ointment; but themoff powerful means 1 of healing them has appeared to me, to be the 1 application of red precipitate in dry a powder. ] MDCCLXXXII. OF PHYSIC. 359 MDCCLXXXII. When, in confequence of chancres, or of the other circumdances above mentioned, by which it may happen the venereal poifon has been communicated to the blood, it produces many different Fymptoms in different parts of the body, not neceffary to be enumerated and defcribed here, that having been already done by many authors with great accuracy. MDCCLXXXIII. Whenever any of thofe fymptoms do in any degree appear, or as foon as it is known that the circumdances-which give occafion to the communication of the venereal poifon have taken place, I hold the internal ufe of mercu- ry to be immediately neceffary ; and I am well perfuaded, that mercury employed with- out delay, and in fufficient quantity, will pret- ty certainly prevent the fymptoms which would otherwife have foon appeared, or will remove thofe that may have already difcover- ed themfelves. In both cafes, it will fecure the perSon Srom any future confequences of fiphylis from that infeaion. MDCCLXXXIV. This advice for the early and full ufe of mercury, I take to be the mod important that O 6 can 360 PRACTICE can be given with refpea to the venereal dif- eafe : And although I mud admit that the virulence of the poifon may be greater in one cafe than in another, and even that one con-, ftitution may be more favourable than anoth- er to the violence of the difeafe ; yet I am thoroughly convinced, that moft of the in- ftances which have occurred of the violence and obftinacy of fiphylis have been owing very entirely to the neglea of the early ap- plication of mercury. MDCCLXXXV. Whatever other remedies of fiphylis may be known, or may hereafter be found out, 1 cannot pretend to determine; but I am well perfuaded, that in mod cafes mercury prop- erly employed will prove a very certain and effeaual remedy. With refpea to others that have been propofed, I Shall offer this re- mark only, that I have Found the decoaion of the mezereon contribute to the healing of ulcers which feemed to have refided the pow- er oS mercury. MDCCLXXXVI. With regard to the many and various prep- arations of mercury, I do not think it necef- fary to give any enumeration of them here, as they are commonly very well known, and i ave been lately well enumerated by Dr. Schwediaur. OF P H Y S I C. 361 Schwediaur. The choice of them feems to be for the moft part a matter of indifference ; as I believe cures have been, and ftill may be, effeaed by mahy different preparations, if properly administered. The proper admin- istration Seems to confider/?, In the choofing thoSe preparations which are the lead ready to run off by dool; and therefore the appli- cations externally by' unaion, are in many cafes the mod convenient, idly, In employ- ing the unaion, or in giving a preparation of mercury internally, in Such quantity as may fhow its Senfible effeas in the mouth. And, $dly, without carrying thefe effeas to a great- er length, In the continuing the employment of mercury for feveral weeks, or till the fymp- toms of the difeaSe fhall have Sor Some time entirely disappeared. I Say nothing oS the regimen proper and neceffary For patients dur- ing the employment oF mercury, becauSe I prefume it to be very well known. MDCCLXXXVII. Amongd the other preparations of mercu- ry, I believe the corrofive Sublimate has often been employed with advantage : But I believe alfo, that it requires being continued for a longer time than is neceffary in the employ- ment of other preparations in the manner above propofed ; and I fufpea it has often failed in making a cure, becaufe employed * while 362 PRACTICE while perfons were at the fame time expoSed to the free air. MDCCLXXXVIII. Upon thefe points, and others relative to the adminidration of mercury, and the cure of this difeafe, I might offer Fome particular remarks : But I believe they are generally underdood ; and it is enough For me to Say here, that iF praaitioners will attend, and pa- tients will Submit, to the general rules given above, they will Seldom Fail oF obtaining a certain and Speedy cure of the difeaSe. CHAP. OF PHYSIC. 363 CHAP. III. of SCURVY. MDCCLXXXIX. 1 HIS diSeaSe appears fo fre- quently, and the effeas of it are fo often fatal, in fleets and armies, that it has very properly engaged the particular attention of phyficians. It is indeed furprifing that it had not Sooner attraaed the efpecial notice both of flatefmen and phyficians, fo as to have produced thofe meafures and regulations that might prevent the havock which it fo often occafions. Within theSe lad fiSty years, however, it has been So much attended to and dudied, that we might SuppoSe every circumdance relating to it So fully and exaaiy afcertained, as to render all further labour upon the fubjea fuperfluous. This perhaps may be true ; but it appears to me, that there are flill feveral circumdances regarding the difeaSe not agreed upon among phyficians, as well as different opinions form- ed, fome of which may have a bad effea upon the praaice : And this feems to me to be fo much the cafe, that I hope I fhall be ex- cuSed in endeavouring here to ftate the Saas as 364 PRACTICE as they appear to me from the beft authorities, and to offer remarks upon opinions which may influence the praaice in the prevention and cure of this difeafe. **► MDCCXC. With refpea to the phenomena of the dif- eafe, they have now been fo fully obferved, and fo accurately deScribed, that there is no longer any doubt in diScemang the diSeaSe when it is prefent, or in diftinguifhing it Srom almoft every other ailment. In particular, it feems now to be fully determined, that there is one diSeaSe only, intitled to the appellation of Scurvy ; that it is the Same upon the land as upon the fea; that it is the Same in all climates and SeaSons, as depending every where upon nearly the fame cauSes ; and that it is not at all diverfified, either in its phenomena or its cauSes, as had been imagined Some time ago. MDCCXCI. The phenomena of fcurvy, therefore, are not to be deScribed here, as it has been So fully and accurately done elfewhere; and I fhall only endeavour to afcertain thofe facts with refpea to the prevention and cure of the dif- eafe which Seem not yet to be exaaiy agreed upon. And, firft, with refpea to the ante- cedents OF PHYSIC. 3% cedents that may be confidered as the remote cauSes of the difeafe. MDCCXCII. The moft remarkable circumftance amongft the antecedents of this difeafe is, that it has moft commonly happened to men living very much on Salted meats ; and whether it ever ariSe in any other circumftances, is extremely doubtful. Thefe meats are often in a putres- cent ftate; and to the circumftance of the long continued ufe of animal food in a pu- trescent and Somewhat indigestible date, the difeafe has been efpecially attributed. Wheth- er the circumdance of the meat's being fail- ed, has any effea in producing the difeafe, otherwife than by being rendered more indi- gedible, is a queftion that remains ftill in diS- pute. MDCCXCIII. It Seems to me, that the Salt concurs in pro- ducing the effea ; Sor there is hardly any in- stance of the difeafe appearing unlefs where falted meats had been employed, and Scarcely an example where the long continued ufe of thefe did not produce it: Befides all which, there are fome inftances where, by avoiding falted meats, or by diminifhing the propor- tion of them in diet, while other circumftances remained much the fame, the difeaSe was pre- vented t g66 PRACTICE vented from appearing. Further, if it may be admitted as an argument upon this fubje&,'i> I fhall hereafter endeavour to Show, that the large ufe of fait has a tendency to aggfivate and increafe the proximate caufe of fcurvy. MDCCXCIV. It muft however be allowed, that the prin- cipal circumftance in caufing Scurvy, is the living very much and very long upon animal food, eSpecially when in a putreScent ftate; and the clear proof of this is, that a quantity of frefh vegetable food will always certainly' prevent the difeaSe. MDCCXCV. j While it has been held, that, in thofe cir- | cumftances in which fcurvy is produced, the animal Sood employed was eSpecially hurtful j by its being of difficult digeftion, this opinion j has been attempted to be confirmed, by ob- ferving, that the reft of the food employed in J the fame circumftances was.alSo of difficult 1 digeftion. This is fuppofed to be efpecially I the cafe of unfermented farinacea which fo I commonly makes a part of the fea diet. But I apprehend this opinion to be very ill found- ed ; for the unfermented farinacea, which are in a great proportion the food of infants, of women, and of the greater part of mankind, can hardly be SuppoSed to be food of difficult I digeftion : OF PHYSIC. 367 digeftion : And with refpea to the production of fcurvy, there are faas which Show, that unfermented farinacea, employed in large proportion, have had a confiderable effea in preventing the difeafe. MDCCXCVL It has been imagined, that a certain im- pregnation of the air upon the Sea had an ef- fea in producing Scurvy. But it is altogeth- er improbable : For the only impregnations which could be SuSpeaed, are thoSe of inflam- mable or mephitic air; and it is now well known, that thefe impregnations are much lefs in the air upon the fea than in that upon the land ; befides, there are otherwife many proofs of the Salubrity of the fea air. If, therefore, fea air have any effea in producing fcurvy, it muft be by its fenfible qualities of cold or moifture. MDCCXCV1I. That cold has an effea in favouring the produaion of fcurvy, is manifeft from hence, that the diSeaSe is more Srequent and more confiderable in cold than in warm climates and SeaSons; and that even warm clothing has a confiderable effea in preventing it. MDCCXCVIIL 3$8 PRACTICE MDCCXCVIII. Moifture may in general have an effe*a in favouring the produaion of fcurvy, where that of the atmofphere in which men are placed is very confiderable : But the ordinary moifture of the Sea air is far from being fuch. Probably it is never confiderable, except in the cafe of unufual rains; and even then, it is perhaps by the application of moifture to the bodies of men in damp clothing only that it has any fhare in the produaion of fcurvy. At the fame time, I believe there is no inftance of either cold or moidure produc- ing fcurvy, without the concurrence of the; faulty Sea diet. MDCCXCIX. Under thoSe circumdances which produce fcurvy, it commonly Seems to occur mofl readily in the perSons who are the leaft exer- ciSed ; and it is thereSore probable, that con- finement and want of exercife may have a great fhare in producing the difeafe. MDCCC. It appears that weaknefs, in whatever man- ner occafioned, is favourable to the produc- tion of fcurvy. It is therefore probable, that unufual labour and fatigue may often have fome OF PiH Y S I C. 369 fome fhare in bringing it on : And upon the Same account, it is probable, that SadneSs and deSpondency may induce a weaknefs of the circulation ; and thereby, as has been remarked, favourable to the produaion of fcurvy. MDCCCI. It has alfo been obferved, that perfons neg- ligent in keeping their fkin clean by wafhing and change of clothing, are more liable than others to be affected with Fcurvy. MDCCCII. Several of thefe caufes, now mentioned, concurring together, feem to produce Scurvy ; but there is- no proper evidence that any one of them alone will produce it, or that all the Others uniting together will do it, without the particular concurrence of the fea diet. A- longd with this, however, feveral of the other circumdances mentioned, have a great effea in producing it Sooner, and in a more confid- erable degree, than would otherwife have hap- pened from the diet alone. MDCCCIII. From this view of the remote caufes, it will readily appear, that the prevention of the dif- eafe may in fome meafure depend upon the avoiding 370 PRACTICE avoiding of thofe circumdances which wfi have enumerated as contributing to bring on the difeaSe fooner than it would otherwife come on. At the fame time, the only effeau- al means will be, by avoiding the diet of falt- ed meats ; at lead by leffening the proportion of thefe, and ufing meat preServed otherwife than by Salt; by ufing in diet any kind of ef- culent vegetable matter that can be obtained; and efpecially by ufing vegetable matters the mod difpofed to aceScenCy, Such as malt; and by drinking' a large quantity oS pure water. MDCCCIV. The cure of fcurvy Feems now to be Very, well afcertained ; and when, the neceffary means can be obtained, the difeafe is com- monly removed very quickly. The chief means is a food of frefti and Succulent vegeta- bles, and thofe almod of any kind that are at all efculent. Thofe mod immediately ef- feaual are the acid fruits, and, as being of the fame nature, all fort of fermented liquor. MDCCCV. The plants named alkalefeent, fuch as thole of the garlic tribe and of the tetradynamiae, are alfo particularly ufeful in the cure of this difeafe; for, notwithdanding their appellation, they in the fird part of their fermentation un- dergo f OF PHYSIC. 371 dergo an aceScency, and Seem to contain a great deal of acefcent matter. At the fame time,|hey have generally in their composition an acrid matter that readily paffes by urine, probably by perFpiration ; and by promoting both excretions, are ufeSul in the diSeaSe. It is probable, that Some plants of the coniferous tribe, fuch as the fpruce fir, and others poffeff- ed of a diuretic power, may likewife be of Some uSe. * MDCCCVI. It is Sufficiently probable, that milk of every kind, and particularly its produaions whey and butter milk, mangrove a cure of this diSeaSe. ^ MDCCCVIL It has been common in this diSeafe to em- ploy the foffil acids ; but there is reaSon to doubt if they be of any fervice, and it is cer- tain they are not effectual remedies. They can hardly be thrown in in Fuch quantity as to be ufeful antiFeptics ; and as they do not .feem to enter into the composition of the an- imal fluids, and probably pafs off unchanged by the excretions, Fo they can do little in changing the date of the fluids. MDCCCVIIL PRACTICE MDCCCVIII. The great debility which condantly attends fcurvy, has naturally led phyficians to employ tonic and drengthening medicines, particular- ly the Peruvian bark; but the efficacy of it feems to me very doubtful. It is furprifi$g how foon the ufe, of a vegetable diet redores the drength of Scorbutic |(%fons ; which Seems to mow that the preceding debility had depended upon the date oS the fluids; and consequently, till the Sound date oS theSe can be redored, no tonic remedy can have much effea : But as the Peruvian bark has little power in changing the date of the fluids, fo ^t eanliave little effea in fcurvy. MDCCCIX. I fhall conclude my observations upon the medicines employed in Scurvy, with remark- ing, that the uSe of mercury is always mani- festly hurtSul. MDCCCX. v After having obferved that both the pre- vention and cure of this difeafe are now very well known, it may feem unneceffary to enter into much difcuffion concerning its proximate cauSe : But as Such difcuffions can hardly be avoided, and as falfe opinions may in fome meafure OF PHYSIC. 373 meafure corrupt the praaice, I fhall venture to fugged here what appears to me mod prob- able upon the fubjea. MDCCCXI. Notwithdanding what has been aiTerted by fome eminent perfons, I trud to the concur- ring tedimony of the mod part of the authors upon the fubjfea, that in Scurvy the fluids Suffer a confiderable change. From thefe authors we learn, that in the blood drawn Srom the veins oF perSons la- bouring under the Scurvy, the craffamentum is different both in colour and confidence from what it is in healthy perfons ; and that at the Same time the Serum is commonly changed both in colour and tade. The ex- cretions alfo, in Scorbutic perfons, fhow a change in the date of the fluids. The breath is fetid ; the urine is always high coloured, and more acrid than ufual; and if that acrid exfudation from the feet, which Dr. Hulme takes notice of, happens efpecially in Scorbutic perfons, it will be a remarkable proof to the fame purpofe. But however this may .be, there is evidence enough that in fcurvy the natural date of the fluids is confiderably changed. Further, I apprehend it may be confidently prefumed from this, that the dif- eafe is brought on by a particular nourifhment introduced into the body, and is as certainly cured by the taking in of a different diet. In Vol. III. R the 374 PRACTICE the latter cafe, the diet ufed has no other evi- dent operation, than that of giving a particu- lar date and condition to the fluids. ,t # MDCCCXII. Prefuming, therefore, that the difeafe de- pends upon a particular condition of the fluids of the body, the next fuftjea of inquiry is, What that condition may be ? With this view, I mud obferve, that the an- imal economy has a lingular power of chang- ing acefcent aliments, in fuch a manner, as to render them much more difpofed to putre- faaion ; and although, in a living date, they hardly ever proceed to an aaually putrid date ; yet in man, whofe aliment is of a mixed kind, it is pretty certain, that if he were to live entirely upon animal food, without a fre- quent Supply oS vegetable aliment, his fluids would advance further towards putrefaaion than is confident with health. This advance towards putrefaaion feems to confid in the produaion and evolution of a faline matter which did not appear in the vegetable ali- ment, and could not be produced or evolved in it, but by carrying on its fermentation to a putrefaaive date. That this faline date is condantly in fome meafure produced and evolved by the animal procefs, appears from this, that certain excretions of faline matter are conftantly made from the human body, OF PHYSIC. 375 and are therefore prefumed neceffary to its health. % From all this, it may be readily understood, how the continual ufe of animal food, efpec- ially when already in a putrefcent ftate, with- out a mixture of vegetable, may have the ef- fea of carrying the animal procefs too far, and particularly of producing and evolving a larger proportion of faline matter. That fuch a preternaturar^uantity of faline matter does exift in the blood of fcorbutic perfons, appears from the State of the fluids above mentioned. It will be a confirmation of all this to obferve, that every interruption of perfpiration, that is, the retention of faline matter, contributes to the produaion of fcurvy; and this inter- ruption is efpecially owing to the application of cold, or to whatever elfe weakens the force of the circulation, fuch as the neglea or want of exercife, fatigue, and defpondency of the mind. It deferves indeed to be remarked here, that one of the firft effeas of the fcurvy once induced, is very foon to occafion a great debility of the fyftem, which occafions of courfe a more rapid progrefs of the difeafe. How the ftate of the fluids may induce fuch a debility is not well understood ; but that it does depend upon Such a date of the fluids, is rendered fufficiently prefumable from what has been faid above with regard to both the caufes and the cure of fcurvy. R 2 MDCCCXIII. 376 PRACTICE MDCCCXIII. It is poffible, that this debility may haVe a great fhare in producing feveral of the phea nomena of fcurvy j but a preternaturally Sa^ line/ and consequently diffolved State of the blood, will account for them with more profil ability; and I do not think' it neceffary to perfons who are at all accultomed to reafon upon the animal economy, to explain this matter more Sully. I have only to add, that if my opinion in fuppofihg the proximate CauSe oS Scurvy to be a preternaturally Saline State of the blood, be at all founded, it will be Sufficiently Obvious, that the throwing into the body along with the aliment an unufual quantity of faltj may haye a great fhare in pro- ducing the diSeaSe^ Even Suppofing Such Salt to Suffer no change in the animal body, the effea of it may be confiderable ; and this will be rendered Still more probable, if it may be prefumed, that all neutral falts, confifting of a fixed alkali, are changed in the animal body > into an ammoniacal fait; which I apprehend to be that efpecially prevailing in fcurvy. If I be at all right in concluding, that meatsj from being i'alted, contribute to the produc- tion of fcurvy, it will readily appear, how dan- gerous it may be to admit the conclufion Srom another theory, that they are perfeaiy innocent; MDCCCXIV. OF PHYSIC. 377 MDCCCXIV. Having thus endeavoured to explain what relates to the cure of fcurvy in general, I judge it proper to leave to other authors, what relates to the'management of thofe fymptoms which require a particular treat- ment. *3 CHAP. 378 PRACTICE CHAP. IV. of JAUNDICE. MDCCCXV. I HAVE here paffed over Sev- eral oS the titles in my nofology, becauSe they are difeafes not of this Ifland. In thefe, therefore, I have no experience ; and with- out that, the compiling from other writers is always extremely fallacious. For thefe rea- fons I omit them ; and fhall now only offer fome remarks upon the fubjea of jaundice, the laft in order that I can poffibly introduce in my courfe of Leaures. MDCCCXVI. The jaundice confifts in a yellow colour of the fkin over the whole body, and particular- ly of the adnata of the eyes. This yellow colour may occur from different caufes : But in the jaundice, hereafter to be more exaaiy charaaerifed, I judge it to depend upon a quantity of bile prefent in the mafs of blood; and which, thrown out upon the furface, gives its own proper colour to the fkin and rvcs. MDCCCXVII. OF PHYSIC. 379 MDCCCXV1I. That the diSeaSe depends upon this, we know particularly and certainly Srom the caufes by which it is produced. In order to explain thefe, I muft obferve, that bile does not exift in its proper Sorm in the mafs of blood, and cannot appear in this form till it has paffed the Fecretory organ oF the liver. The bile thereFore cannot appear in the mafs of blood, or upon the furface of the body,. that is, produce jaundice from any interrup- tion of its fecretion ; and accordingly, if jaun- dice does appear, it mud be in confequence of the bile, after it had been Secerned, being again taken into the bloodveffels. This may happen in two ways j either by an interruption oF its excretion, that is, of its paffage into the duodenum, which by accu- mulating it in the biliary veffels, may give oc- cafion to its palling again into the bloodvef- fels ; or it may pafs into thefe, by its being abforbed from the alimentary canal when it happens to be accumulated there in an un- ufual quantity. How far the latter caufe can take place, or in what circumdances it does occur, I cannot clearly afcertain, and I ap- prehend that jaundice is Seldom produced in that manner. MDCCCXVIII. The former caufe of dopped excretion may be underdood more clearly j and we R 4 have 380 PRACTICE have very certain proof of its being the ordi- nary, and indeed almod the univerfal caufe of this difeafe. Upon this fubjea it will be obvious, that the interrupted excretion of the bile mud depend upon an obdruaion of the dutlus communis choledochus ; the mod com- mon caufe of which is a biliary concretion formed in the gall bladder, and from thence fallen down into the duaus communis, it be- ing at the fame time of fuch a fize as not to paSs readily through that dua into the duo- denum. This dua may likewife be obftrua- ed by a SpaSmodic condriaion affeaing it : And Fuch Fpafm may happen, either in the dua itfelf, which we fuppofe to be contraaile; or in the duodenum preffing the fides of the dua clofe together ; or, ladly, the dua may be obdruaed by a tumour compreffing it, and that arifing either in the coats of the duct it- felf, or in any of the neighbouring parts that are, or may come to be, contiguous to it. MDCCCXIX. When fuch obdruaion happens, the Se- creted bile mud be accumulated in the biliary duas ; and from thence it may either be ab- forbed and carried by the lymphatics into the bloodveffels, or it may regurgitate in the duas themfelves, and pafs from them direaiy into the afcending cava. In either way, it comes to be diffufed in the mafs of blood ; and from thence OF PHYSIC. 381 thence may pafs by every exhalant veflel, and produce the difeafe in queftion. MDCCCXX. I have thus Shortly explained the ordinary produaion of jaundice : But it muft be ob- Served Surther, that it is at all times accompa*. nied with certain other Symptoms, Such as a whiteneSs of the faces alvina, which we read- ily account for from the abfence oS bile in the inteftines ; and generally, alSo, with a certain confidence of the faeces, the caufe of which it is not fo eafy to explain. The difeafe is al- ways accompanied alfo with urine of a yellow colour, or at lead with urine that tinges a linen cloth with a ydlow colour. Thefe are condantly attending fymptoms ; and though not always, yet there is commonly a pain felt in the epigadrium, correfponding, as we fup- pofe, to the feat of the duaus communis.. This pain is often accompanied with vomit- ing ; and even when the pain is not confid- erable, a vomiting fometimes occurs. In fome cafes,_when the pain is confiderable, the pulfe becomes frequent, full, and hard, and fome other fymptoms of pyrexia* appear. ' MDCCCXXI. When the jaundice is occafioned by tu- mours of the neighbouring parts compreffing the biliary du£l, I believe the difeafe can very Vol. 3. R 5 ■ feldom 382 PRACTICE Seldom be cured. . That fuch is the caufe of jaundice, may with fome probability be fup- pofed, when it has come on in confequence of other difeafes which had fubfided long before, and more efpecially fuch as had been attend- ed with fymptoms of obdruaed vifcera. Even when the jaundice has fubfided long without any intermiffion, and without any pain in the epigadrium, an external compreffion is to be fufpeaed. MDCCCXXII. In fuch circumdances, I confider the dif- eafe as incurable ; and it is almod only when the diSeaSe is occafioned by biliary concretions obdruaing the biliary dua, that we may com- monly expea relieS, and that our art may contribute to the obtaining it. Such caSes may be generally known, by the difeaSe fre- quently disappearing and returning again ; by our finding, after the former accident, biliary concretions amongd the faeces ; and by the difeafe being frequently accompanied with pain of the epigadrium, and with vomitings arifing from fuch pain. MDCCCXXIII. In thefe cafes, we know of no certain and immediate means of expediting the paffage of the biliary concretions. This is generally a work of time, depending upon the gradual dilatation OF P H i S 1 C. 383 dilatation of the biliary dua ; and it is fur- prifing to obferve, from the Size of the dones which fometimes pafs through, what dilata- tion the dua will admit of. It proceeds, however, Fader or flower upon different occa- sions ; and therefore the jaundice, aFter a va- rious duration, oSten ceaSes Suddenly and Spontaneously. It is this which has given rife to the belieS, that the jaundice has been cured by Such a number and Such a variety of dif- ferent remedies. Many of thefe, however, are perfeaiy inert, and many others of them fuch as cannot be fuppofed to have any effea in ex- peding the paltage oFa biliary concretion. I fhall here, therefore, take no notice of the nu- merous remedies of jaundice mentioned by the writers on the Materia Medica, or even of> thofe to be found in praaical authors ; but fhall confine myfelf to the mention of thofe that may with probability be fuppofed to fa- vour the paffage of the concretion, or remove the obdacles to it which may occur. MDCCCXXIV. In the treatment of this difeafe, it is, in the fird place to be attended to, that as the dif- tention of the biliary dua, by a hard mafs that does not eafily pafs through it, may ex- cite inflammation there ; fo, in perfons of tol- erable vigour, bloodletting may be an ufeful precaution ; and when much pain, together with any degree of pyrexia occurs, it becomes R 6 an ■'""■'■ -V *} * 384 P K. A U T 1 1; E San abfolutely neceffary remedy. In Some in- ftances of jaundice accompanied with thefe fymptoms, I have Found the blood drawn covered with an inflammatory cruft as thick as in caFes of pneumonia. \ MDCCCXXV. There is no means of pufhing forward a biliary concretion that is more probable than the aaion of vomiting ; which, by compref- * fing the whole abdominal vifcera, and partic- ularly the full and didended gall bladder and biliary veffels, may contribute, Fometimes gently enough, to the dilatation oF the biliary dua. Accordingly vomiting has oFten been found uSeSul Sor this purpoSe : But at the | fame time it is poffible, that the Sorce exerted t in the aa of vomjting may be too violent, I and thereSore gentle vomits ought only to be I employed. And either when, by the long ' continuance oS the jaundice, it may be fuf- peaed that the fize of the concretion then pafling is large ; or more eSpecially when pain attending the diSeaSe gives apprehenfion oF inflammation, it may be prudent to avoid vomiting altogether. MDCCCXXVI. It has been uSual in the jaundice to em- ploy purgatives ; and it is poffible that the aaion of the intedines may excite the aaion of OF PHYSIC. 385 of the biliary duas, and thus favour the ex- pulfion of the biliary concretion : But this, I think, cannot be of much effea, and the at- tempting it by the frequent ufe of purgatives, may otherwife hurt the patient. For this reafon I apprehend, that purgatives can never be proper, excepting when there is a flow and bound belly. MDCCCXXVII. As the relaxation oS the Skin contributes to relax the whole Sydem, and particularly to relieve the condriaion of •fubjacent parts ; fo, when the jaundice is attended with pain, fomentations of the epigadrium may be of fervice. MDCCCXXVIII. As the Solids of the living body are very flexible and yielding ; fo it is probable, that biliary concretions would in many cafes find the biliary dua readily admit of fuch dilata- tion as to render their paffage through it eafy, were it not that the didention occafions a preternatural Spafm.odic contraaion oF the parts below. Upon this account, opium is often of great benefit in jaundice ; and the benefit refulting from its ufe, proves fufficient- ly the truth of the theory upon which the ufing of it has been founded. MDCCCXXIX. 386 PRACTICE, Sec. MDCCCXXIX. It were much to be wifhed, that a folvent of biliary concretions, which might be ap- plied to them in the gall bladder or biliary duas, was difcovered : But none fuch, fo far as I know, has yet been found ; and the em- ployment of foap in this difeafe, I confider as a frivolous attempt. Dr. White of York has found a folvent of biliary concretions when thefe are out of the body; but there is not the lead probability that it could reach them while lodged within. INDEX INDEX TO THE THREE VOLUM E S. N. B. The Ciphers refer to the number of the Paragraphs, Abscess, 2$0 Abscesses and ulcers, the caufes of their different ' Hates, 254 Acids employed in fever, 134 refrigerant in fever, 134 Action ot the heart and arteries, how increafed for preventing the recurrence of the paioxyfms of Jnter- mitting fever, 230 Adynamic, ,,-j Amenorrhoea, 995 from retention, 996 when occurring, 998 lymptoms of, 999 caufes of, 1000 -2 cure of, 1002-6 from fuppreflion, 996 when occurring, 1008 fymptoms of, ioio caufes of, 1008 - 9 cine of 1011-ia Amentia, 1598 Anasarca, 1668 the characler of, 1668 phenomena of, 1668 73 cure of, 1674 96 diitinguifhed from Leucophlegmatia, 1669 St. 388 I N D E X St. Anthony's Fire. See Erythema. Antimonial emetics, employed in feredifponent caufes of, 1410 ympathic, 1316 cure of, 1317 idiopathic, 1316 cure of, 13'9 EPISTAXIS, »o6 the caufes of it, 808 the various circumftances of, 807—818 the management and cure of, 819—829 E&YSIFELAS, 274 of fhe face, 708 fymproms of, 705—708 prognosis of, 7ofi proximate caufe of, 697 cure of, 708—711 phlegmonodfis in different parts of the body, 712 Erysipelas, INDEX. 393 Erysipelas, attending putrid fever, 7*3 Erythema, »74 Exanthemata, ( $8$ Exercise, ufeful in intermittent fevers, *3* « F. Fainting. See Syncope. 1171 Fatuity, J529 Fear, a remote caufe of fever, 97 Fever, * ftri&ly fo called, the character of, 8—32 phenomena of, 8 remote caufes of, are of a fedative nature, 36 proximate caufe of, 33 atony of the extreme veflels, a principal cir- cumftance in the proximate caufe of it, 43—44 fpafm, a principal part in the proximate caufe of it, 40 general doctrine of, tfi the caufes of death in it, 101 the prognosis of, 99 indications of cure in, i»6 differences of, 53 continent, 28 continued, 37 Inflammatory, #7 miliary. See Miliary ftvtr. nervous, 67 bilious, 71 fear let. See Scarlet Fever. Eutrid, 72 amed fynocha, 67 fynochus, 69 typhus, 67 hecYic, 74 intermittent, the paroxyfms of, defcribed, 10 the cold Stage of, 11 the hot Stage of, 11 the fweating Stage of, i'\ of a tertian period, 25 of a quartan period, 25 of a quotidian period, 25 caufed by maim effluvia, 84 bile not the caule of it, $1 cure of, 228 its paroxyfms, how prevented, 229 attended with phlogiltic diethefis, 234 attended with congeflton in the abdominal ulcer a, 234 remittent, 26 Fluxes, 394 INDEX, Fluxes, without f<*rer. See Profluvia. Fluor albus. See Leucorrhcea. Fomentation of the lower extremities, its ufe in fevers, 199 Fomites of contagion, , 82 Functions intellectual, diforders of, 1528—29 Gangrene of inflamed parts, the caufe of, 255—256 marks of the tendency to, 257 < marks of its having come on, 257 Gastritis, 384 phlegmonic or erythematic, 385 phlegmonic, the feat of, 385 the fymptoms of, 386 the caufes of, 387 the cure of, 393—397 erythematic, how difcovered, 400 the feat of, 385 the cure of, 401 Gastrodynia, 1427 Gleet, 1769 Gonorrhoea, 1765 phenomena of, 1767—69 cure of, 1770—78 Gout, the character of, 492 a hereditary difeafe, 500 distinguished from rhe-umatifm, 526 predifponent caufes of, 493—500 occafional catiles of, 502—505 proximate caufe of, 517 — 533 ,not a morbific matter, 529 Regular, defcribed, 506—518 pathology of, 533 cure of, 537—573 no effectual or fafe remedy yet found for the cure of it, 539 medicines employed for it, 556 whether it can be radically cured, 540 treatment in the intervals ef p irox- ■ yfms, 542 treatment in the time of paroxyfms, 560 regimen during the paroxyfms, 561 . external applications, how far fafe, 568—569 bloodletting in the intervals of paroxyfms, 553 ----------in the time of parox- yfms, 563 coftiveiiefs hurtful, 559 Gout, 1 N D E X. 39s Gout, Regular, laxatives to be employed, 559 effects of alkalines, 558 effects of Portland powder, ce7 Irregular, y^ Atonic, S74—&9 pathology of, 534 cure of, 580-5F» Retrocedent, .22 pathology of, 535 n..r , . Cl,re °f» 58°— 5«2 Mfplaced, > pathology of, 536 cure of, 583—584 Tranjlated, two particular cafes of, 525 H. H.«MATEMESI3, jot? arterial and venous, 1027 from obstructed menftruation, 1020 from fuppreSIion of the hemorrhoidal flux, ,02S from compreSlion of the vafa brevia, by the Spleen, 1017 from obstruction of the liver, 1028 Hematuria, iojj idiopathic, improbable, 1033—34 calculofa, 1037 cure of, 1038 violcnta, 1039 from fuppreflion of accuftomed dif- charges, I04, putrida, 1043 fpuria et lateritia, 1044 HEMIPLEGIA, ., n40 caufes of, 114I frequently occafioned by apoplexy, 114a frequently alternates with apoplexy, 1144 cure of, ,I52 Stimulants, of ambimous ufe in, 1160 Stimulants, external, in, 1161 HiEMOPTYSia, the fymptoms of, 838—840 thecaulesof, 760—63—830—836 how distinguished from other fpittiags of blood, 841—45 Mire of, 846-52 H^emorrhagia uteri, 966 Hemorrhagy, active or paflive, 735 character of, 736 Hemorrhagy, 396 INDEX. Hemorrhagy, arterial, 744 venous, 768 the caufes of the different fpecies appearing at different periods of life, 750—773 the general phenomena of, 738—743 the remote caufes of, 774 ' cure of, 77$ 1----- whether to be attempted by art, 776—81 prevention of the firft attacks, or of the recurrence of, 782—789 treatment of when prefent, 789—805 fymptomatic, 1015 H^morrhoides vesica, 1042 He.morrhois, external and internal, 925 phenomena of, 925—93' nature of the tumours, 932 caufes of, 933—943 acquire a connexion with the fyf- tem, 943—944 particularly with the ftomach, 946 cure of, 947—96J HepatirrHoea, 1481 Hepatitis, 41a acute and chronic, 412 acute, the fymptoms of, 413—415 combined with pneumonic inflam- mation, 416 remote caufeS ©f it, 416 feat of, 4'8 various exit of pus produced in, 421 cure of, 422 chronic, the feat of, 4'8 how difcovered, 423 HOOPINGCOUGH. See Chincough. 1402 Horror, impreffion of, employed in intermittent fevers, . *3' Human effluvia, the caufe of fever, 81 body, its temperature, 88 body has a power of generating heat, 88 Hydrophobia, . i525 Hydrothorax, 1697 where feated, 169S fymptoms of, 1701—c*j often combined with univerfal dropfy, 1704 proximate caufe of, 1706 cure of, 1707—08 paracentefis in if, when proper, 1708 Hypercatharsis, INDEX. 397 Hypercatharsis, 1477 Hypochondriasis, 1222 phenomena of, 1222 distinguished from dyfpepfia, 1226 proximate caufe of, 1230 cure of, ,232 treatment of the mind in, 1244 Hysteria, ,5I4 fymptoms of, 1515—16 paroxySm or fit defcribed, 1515—16 rarely appears in males, 1517 how distinguished from hypochondri- afis, 151S—19 proximate caufe of, 1522 analogy between and epilepfy, 1523 cure of, 1524 libidinofa, ici7 •Hysteric difeafe. See Hyfteria. I. James's powder, its ufe in fever, i«j Jaundice, 1815-16 caufes of, 1816—21 cure of, 1823—20 Icterus.. See Jaundice. .Iliac paffion. See Ileus. Ileus, i437 Impetiginis, i737 character of the order, 1737 Indigestion. See Dyfpepfia. Inflammation, the phenomena of, 235 internal, the mirks of, 236 the ftate of the blood in, 237 the proximate cauie of, 239 not depending upon a lentor of the blood, 241 lpalm the proximate caufe of. 243—248 terminated by refolution, 249 by fuppuration, 350 by gangrene, 255 by fcirrhus, 258 by effufion, 259 by blisters, 260 by exfudation, 26c the remote caufes of, 262 the cure of in general, 264 by refolution, 264 Vol. III. S Inflammation, 398 INDEX. Inflammation, the cure of, when tending to Sup- puration, , 268—70 when tending to gan- its general drvifions, 273 more Strictly cutaneous, 274 of the bladder. See Cyflitis. of the brain. See Phrenitis. of the heart. See Carditis. of the inteftines. See Enteritis. of the kidneys. See Nephritis. of the liver. See Hepatitis. of the lungs. See Pneumonia. of the pericardium. See Pericarditis. of the peritonaeum. See Perittnitis. of the fpleen. See Splenitis. of the ftomach. See Gaftritis. of the uterus, 432 Insanity, i535 caufes of, 1550- 57 of different fpecies, 1557 partial and general, difference of, 1575 Intemperance in drinking, a remote caufe of fever, 97 Intermission of fever, 24 Interval of fever, 24 Intumescenti^:, t6io character of the order, »6» K. King's evil. See Scrophula. L. Leucophlegmatia, m 1669 Leucorrhoea, 98$ character of, 98* appearance of the matter difcharg- ed in, 987—99* the caufes of, 988 the effects of, 99° the cure of, 99J Lethargus, 1094 Lientery, M*9 Looseness. See Diarrhcea. M. Madness. See Mania. canine. SzeCanint. Mania, IN D t. a. 399 Mania, ijj8 the fymptoms of, 1558 the remote caufes of, 1559—61 the treatment of, 1562 —74 occurring in fanguine temperaments! 1576 in fanguine temperaments, cure of, 1.577 Marcores, ,6oo Marsh effluvia, a caufe of fever, 84 Measles, 633 the Symptoms of, 637—642 the nature of, 644 the cure of, 645—650 of a. putrid kind, 643 Medicine, the institutions of, 4 Mbl^ena, 1017 Melancholia, 1575 how distinguished from hypochon- driafis, 1587—88 the character of, 1582—89 the proximate caufe of, - 1590 the treatment of, 1592—97 Melancholic temperament, 1230 Melancholy. See Melancholia. Menorrhagia, 966 active or paftive, 966 when a difeafe, 968—75 effects of, 972 proximate caufe of, 977 remote caufes of, 978 cure of, 980 Menses, immoderate flow of them. See Menorrhagia. Metallic tonics, employed in intermittent fevers, 231 salts, refrigerant, 136 Meteorismus, ' *<>33 Miasmata, 78' Miliary fever, the general hiftory of, 714—715 of two kinds, red and white, 716 white, the fymptoms of, 717—769 the cure of, 720 Morbus coeliacus, 1493 mucosus, 1070 NIGER, IO29 N. Nephritis, 4*6 the fymproras of, 426 the remote caufes of, 427 the cure of, 43° ^ Nervous 400 INDEX. Nervous Diseases. See Neurofet. Neuroses, io§b Neutral Salts, diaphoretic in fevers, 159—161 refrigerant in fevers, 135 Nosology, Methodical, a O. Obesity, when a difeafe,. 1621 Oneirodynia, 1598 Ophthalmia, 278 membranarum, 278 its different de- grees, 279—280 its remote caufes, 280 the cure of, 288—290 tarfi, 278 the cure of, 288—290 Opiates, employed in the hot Stage of intermittent fevers, 233 in the interval of intermittent fevers, 231 Opisthotonos. See Tetanus. P. Palpitatisn of the heart, 1355 the phenomena of, 1355 the caufes of, 1356 the cure of, 1363 Palsy, 1140 diftinguifhed from apoplexy, 1094 caufes of, n41 Paracentesis in afcites, when to be attempted, 1717 in hydrothorax, when proper, 1708 Paraphrenias, 343 Paroxysm of intermittent fevers, the recurrence, how to be prevented, 229 Pemphigus, 732 Pericarditis,, T 3$3 Peripneumonia notha, 376 •" ' fymptoms of, 379 \ pathology of, 380 the cure of, 381—382 fome of the fymptoms ex- v plained,. 350 Peripneumony, 342 Peritonitis, 384 Peruvian Bark, not a fpecific, 213 its tonic power, 214 when proper in fever, 215 how moft effectually employed, 216 Peruvian N D X. 40t 232 232 734 235 274 291 293 294 295—299 Peruvian Bark, the administration of, in inter- mittent fevers, the tonic chiefly employed in inter- mittent fevers, Petechia, Phlegmasia, Phlegmon, Phrenitis, the character of, the remote cauSes of, the cure of, PHRENSY. See Phren'itis. Physic, the practice of, how taught, r the theory of, how to be employed, 4 Physconia, *1l% Phthisis pulmonalis, the general character of, 853 always with an ulceration of the lungs, the pus coughed up in, how clilhnguifhed from mucus, accompanied with hectic fever, the various caufes of it, from hxinoptyfis, from pneumonia, from catarrh, from afthma, from tubercles, from calcareous matter in the lungs, if contagious, from tubercles, fymptoms of, its different duration, the prognofis in, the cure of, the treatment of when arifing from tuber- cles, the palliation of fymp- toms, 855 856 »57 863 864—865 866-869 870-873 875 876—882 884 886 889 896 897 899-924 906—921 922 —924 Plague, „ /, the general character of, phenomena of, principal Symptoms of, proximate caufe of, prevention of, cure of, Pleurisy, Pleurosthotonos. See Tetanus. Vol. 3. S. a 665 665 667 66S 670—685 686—695 . 34i Pneumonia* 402 I N D ^E X. Pneumonia, or pneumonic inflammation, 334 general fymptoms of, 335~339 feat of, 340—344 prognofis of, 352—369 cure of, ^6r the management of bloodletting in the cure of, 362—367 the ufe of purgatives in, 370 the ufe of emcics in, ^1 the ule of blisters in, 3?2 the means ot promoting expectoration ,,n> 373 the ufe of fweating in, 374 the ufe of opiates m, -j7? Polysarcia, when a difeafe, 1621 cure of, 16*3-25 Profluvia, |04j character of the clafs, 1045 Puls.e, the ftate ot the, during the paroxyfm ©fan intermittent fever, 12 Purging, its ufe in continued fevers, 144 intermittent fevers, 234 Pus, how produced, 250 Putrescency of the fluids in fever, the fymp- toms of, l05 the tendency to in fever, how to be corrected, 222-226 Pylorus, scirrhous. See Dyfpepfia. Pyrexia, 6 character of the clafs, 6 orders ot the clafs, 7 Pyrosis, 1427 fymptoms of, 1431 proximate C3iife of, 1433 remote caufes of, 1432 cure of, 1434 Suecica of Sauvages, 1428 Qjjinsy. SeeCynanche. R. Rachitis, 1719 its origin, 1720 remute caufes of, 1721- 23 phenomena of, 1724 proximate caufe of, 1725-28 cure of, 1729—36 Reaction I N D E X. 405 Reaction of the fyftem, 59 violent in fever, fymptoms of, 103 violence of, how moderated, 127 Refrigerants, the ufe of them in fever, 134 Remedies, table of thofe employed in continued fevers, 22- Remission of fever, 26 Resolution of inflammation, how produced, 249 Respiration, the changes of, during the paroxyfm of an intermittent, 13 Revolution, diurnal, in the human body, 55 Rheumatism, acute or chronic, 433 Acute, the remote caufes of, 436' the proximate caufe of, 455—460 the fymptoms of, 439—447 cure of, 461—470 Chronic, fymptoms of, 4.50 how diftinguifhed from the acute, 451 proximate caufe of, * 472 cure of, 473—.476 how distinguished from gout, 526. Rickets. See Rachitis. Rose. See Erythema. Rubefacients, the effects of them. S. Scarlet fever, 651 the fymptoms of, 656 different from cynanche ma- ligna, f>Sl~~-^S5 the cure of, 657—664 Scrophula, 1738 the phenomena of, 1738 -1749 the proximate caufe of, 1750 not contagious, 1751 not arifing from the lues venerea, 1752 the cure of, '753 59 Mefenterica, 1606 Scurvy, 1789 remote caufes of, 1792 — 1802 cure of, 1804- 09 proximate caufe of, 1811—14 Sinapisms, the effects of them, 197 Skin, affections of. See Impetiginis. Small Pox, cet.eral character of, 587 fymptoms of the distinct kind, 589 ot the confluent kind, 59^—593 general differences between diftinct and confluent, 594 Small 4°4 N D E X. Small Pox, caufes of thefe differences, 595—600 prognofis in, 593 cure of, 601—630 inoculation of, 602 the feveral practices of which it confifts, 603 the importance of the feveral practices be- longing to, 604—615 management of fmall pox received by infection, 616—630 Soda, 1427 Spasm, internal, means of removing in fevers, 152—187 the proximate caule of inflamma- tion, 243—248 Spasmodic affections without fever, 1251 of the animal functions, 1254 of the vital functions, 1355 ot the natural functions, 1427 Sphacelus, 255 Splenitis, 425 Stimulants, when to be employed in fevers, 217 their ufe in intermittent fevers, 230 Stomach, its confent with the veffels on the furface of the body, 44 Sudorifics, arguments for their ufe in fevers, 163-167 againft their ufe in fevers, 164 Suppuration of inflamed parts, the caufes of, 251 the marks of a tendency to, 251 formed, the marks ot, 251 Surface of the body, its confent with the ftomach, 44 Swellings, general. See Intumefcent'ine. adipofe, 1621 flatulent, 1626 watery. See Dropfies. Sweating, when hurtful in continued fevers, 165 rules tor the conduct of in continued fevers, 168 ufe of in intermittent fevers, 230 Syncope, "71 phenomena of, "7* remote caufes of, 1174—1178 predifpofition to, 1184 cure of, 1189 distinguished from apoplexy, 1094 Synocha. See Fe-jer. Synochus. See Fever. Syphilis, '76° originally from America, .1761 how propagated, 1762 and gonorrhoea, how ■distinguished, 17^4 SVPKIUS, INDEX. 405 Syphilis, cure of, 1783—88 Tabes a hydrope, 1609 a fanguifluxu, 1608 dorfalis, 1610 glandularis, 1606 mefenterica, 1606 nutricum, 1608 ischialgia, 1606 fcrophulofa, 1606 Tartar emetic, its ufe in fevers, '85 Tetanus, "57 remote caufes of, J268 cure of, '27° piflilcum Barbadenfe, or Baibadoes tar.ln, 1280 lateralis, 1268 Tonic medicines employed in continued fevers, 211 intermittent fevers, 231 Toothach, how far different from rheumatilm, 477—480 fymptoms of, 47^ predifpofition to, 48' remote caufes of, 48'—48a proximate caufe of, 483 cure of, 485—49' Trismus. See Tetanus. NASCENTIUM, la&* Tussis. See Catarrh. Tympanites, the character of, 1627 the different fpecies of, 1628—30 inteftinahs, 1628 enterophyfodes, '628 abdominalis, '628 afciticus, '628 phenomena of, l63* proximate caufe of, 1635—36 cure of, '637—44 Typhus. See Fever. the fpecies of, 7© V. Vapours,, or low fpirits. See Hypochondriafis. Venereal disease. See Syphilis. Venery, excels in, a remote caufe of fever, 97 VESANI.S, in general, '52X VlS MEDICATRIX NATURE, 38 St. Vitus's dance. See Chorea, VOMITING 406 INDEX. Vomiting of blood. See Heematemefis. effects of in continued fevers, 172, 173 the ufe of in intermitting fevers, 230—34 Urine, bloody. See Hamaturia. Urticaria, the hiltory and treatment of, 730 W. Water brash. See Pyrofis. Whites. See Leucorrhoea. Warm bathing, the effects of in fever, the adminiftration of in fevers, the marks of the good effects, Wine, the mofl proper ftimulant in fevers, its convenient ufe in fevers, when hurtful or ufeful in fevers, 198 199 200 218 219 220