£^\, /"ii> ■•■': .•■■•' «. Kj . •^IPM'W '.''■'V iv,-/\-;, a* 1 •Y&LH°WMUVIEi&ginrT< ■ v*,*^«^; w,vt?^ ■'. - ■ ■' | aWM^rfi^igS ::-r^:m :<<*<* ■ •■ »» S 4 \ *\ FIRST L I^E S PRACTIC nb B Y WILLIAM CULLEN, M. D. LATE PRO FE SSO R OF THE PRACTICE OF FHTSIC IN THE UNiyERSITY OF EDINBURGH, &C. &C. IN TWO VOLUMES. With PRACTICAL and EXPLANATORY NOTES, B Y JOHN ROTH ERA M, M. D. TO WHICH IS PREFIXED The LIFE of the AUTHOR. VOL. II. N E W-Y O R K: Prikted ir Samuel Campbell, Book-Seller axd St/itioxfk, No. 37, Hanover-Sqjjark. M,DCC,XCI!I. V fc£> CONTENTS OF T II E S E C O N D VOLUME. ..<.<..<•.<■.<■ .<-<..<-<..<..<(|M|, >..>..>..>,.>.>..>.). >. y. y^ PARTI. B O O K IV. CHAP. VI. Page * » Of the Menorrhagia, or the immoderate flow of the Menfcs • n CHAP. VII. Of the Leucorrhcea, Fluor Albus, or Whites 19 CHAP. VIII. Of the Amenorrheas or Interruption of the Menfes 21 CHAP. IX. Of Symptomatic Hemorrhages 30 < Sed. I. Of the Hematemqfis, or Vomiting of Blood ibid Sed II. Of the Hematuria, or the voiding of Blood ftorn the Urinary Pcffage 39 BOOK* V. Of Profuvia, or Fluxes, with Pyrexia 46 CHAP. I. Of the Catarrh 47 C H A P. II. Of the Byfentery 56 PART II. Of Neurofes, or Nervous Difeafes 65 BOOK T. Of Comataj or, of the lofs of Voluntary Motion 6tf C II A P. I. Of Apoplexy ibid C H A P. iv CONTENTS. C H A P. II. Of Palfy page 88 BOOK II. Of Adynamia*, cr Difeafes confiflin? in a weaknefs, or lofs of Motion in either the vital or natural Funclions 101 CHAP. I. Of Syncope^ cr Fainting ibid CHAP. II. Of Byfpcpfia, or Indigeftion 11 o CHAP. III. Of Hypochondrinfisy or the Hypochondriac Affec- tion, commonly called Vapcurs or Lou; Spirits 126 BOOK III. Of Spafmodic Affeclions without Fever 136 Seel. I. Of the Spafmodic Affeclions of the ani- mal Funclions , 137 C II A P. I. Of Tetanus 130 CHAP. II. Of Epilepfy I53 CHAP. III. Of the Chorea, or Dance of St. Vitus 178 Sed. II Of the Spafmodic Affeclions of the Vi- tal Functions 182 CHAP. IV. Of the Palpitation of the Heart ibid C II A P. V. OfByfpnoea, or difficult Breathing 185 C II A P. VI. OfAflhma 187 C H A P. VII. Of the Ckincough, or Hcobing Cough 198. Seel. II!. Of tbs Spafmodic AflcJisns in the * Natural Fwiclh is 2 do chap. CONTENTS. v CHAP. VIII. Of the Pyrofis, or what is named in Scotland the Water brajh CHAP. IX. Page 20 Of the Colic CHAP. X. 212 Of the Cholera r> /y *■» CHAP. XL Of Diarrhoea, or Loofenefs C ~H A P. XII. 227 Of the Diabetes 243 CHAP. XIII. Of the Hyfleria, or the Hyfleric CHAP. Bifeafe XIV. 247 . Of Canine Madnefs and Hydrophobia BOOK IV. 254 Of Vefania*, or of the Biforders of the InteJletli-al Functions, 256 CHAP. I. Of Vefanics in general CHAP. II. ibid Of Mania, or Madnefs CHAP. III. 270 Of Melancholy, and other forms PAR T of Irfanity III. 281 Of Cachexies 290 BOOK I. Of Emaciations 291 BOOK II. Of Intumefcentia?, or General Swellings CHAP. I. 3°3 Of Adipofe Swellings CHAP. II. 3°4 Of Flatulent Swellings CHAP. III. 308 Of Watery Swellings, or Bropfies 3i8 Seft. vi CONTENTS. Seft. I. Of Anafarca Page 330 Setf. II. Of the Hydroihorax, or Dropfy of the Breaft 344 Sea. III. Of the Afcites, or Dropfy of the Lower Belly 350 CHAP. IV. Of General Swellings, arifing from an increafed bulk of the whole fubfiance of particular parts 355 Of Rachitis, or Rickets ibid BOOK III. Of the Inpetignis, or depraved habit, with af- feclions of the Skin 367 CHAP. L Pf Scrophula, or the King*s Evil 368 CHAP. II. Of Siphylis, or the Venereal Bifeafe 378 CHAP. III. Of Scurvy 394 CHAP. IV. Of Jaundice 404, FIRST FI.RST LINES OF THE PRACTICE OF PHYSIC. PART I. BOOK IV. -<••<••<-< •<-<-#-<.<-<-<--->->->■>•>••►•■ >•>►••►••>■. CHAP. VI. OF THE MENORRHAGIA, » OR THE IMMODERATE FLOW OF THE MENSES. DCCCCLXVI. BLOOD difcharged from the vagina may proceed from different fources in the internal parts : but I here mean, to treat of thofe difcharges only, in which the blood may be prefumed to flow from the lame fources that the menfes in their natural ftate proceed from ; and which difcharges alone, are thofe proper- ly comprehended under the prefent title. The title of Metrorrhagia, or hcemorrhagia uteri, might compre- hend a great deal more. DCCCCLXVII. ^ The menorrhagia may be confidered as of two kinds; Vol. II. B either 10 PRACTICE either as it happens to pregnant and lying-in women,- or as it happens to women neither pregnant nor hav- ing recently born children. The firft kind, as con- nected with the circumftances of pregnancy and child- bearing, (which are not to be treated of in the prefent courfe) I am not to confider here, but mail confine myfelf to the iecond kind of menorrhagia only. DCCCCLXVIII. The flow of the menfes is confidered as immoderate, when it recurs more frequently*, when it continues longer, or when, during the ordinary continuance §, it is more abundant f than is ufual with the fame per- fon at other times. ' DCCCCLXIX. As the moft part of women are liable to fome ine- quality with refpec~t to the period, the duration, and the quantity of their menfes ; fo it is not every ine- quality in thefe refpe&s that is to be confidered as a difeafe; but only thofe deviations, which are excef- live in degree, which are permanent, and which in- duce a manifeft (late of debility. DCCCCLXX. The circumftances (dcccclxviii. dcccclxix.) are thofe which chiefly conflitute the mer.orrhagia : but it is proper to obferve, that although I allow the frequency, duration, and quantity of the menfes to be judged of by what is ufual with the fame individual at ot^er times; yet thc-rs is, in thefe particulars, fo much uniformity obfervable in the whole of the fex, that in any * The ufual period is from twenty-feven to thirty davs. § The time of it's continuance is very various in different people; it fefdom continues longer than eight days, or fhorter than two.— In general, women of a lax and delicate coiiftitution have a more copious and a longer continued difcharge than robuft people. •(• It is extremely difficult to afcertain precifely what quantity is ufually discharged; but the women themfelves can generally in- form the phyficia-.i with' fufficient e-xattnefs for regulating the prac- tice whether the difcharge be immoderate. OF FH Y S I C. n any individual in whom there occurs any considerable deviation from the common meafure, luch a deviation if conftantly recurring, may be confidered as at leaft approaching to a morbid ftate, and as requiring molt of the precautions which I fhall hereafter mention as-^ neceflary to be attended to by thofe who are actually in:? fuch a ftate. DCCCCLXXI. However we may determine with refpect to the cir- cumftances DccccLxvni. dccccjlxix. it muft ftill be allowed, that the immoderate flow of the menies is efpe,cially to be determined by thofe fymptoms affect- ing other functions of the body, which accompany and follow the difcharge. When a larger flow than ufual of the menfes has been preceded by headach, giddinefs, or difpucea, and has been ufhered in by a cold ftage, and is attended with much pain of the back and loins, ^vith a frequent pulfe, heat, and thirft, it may then be confideied as preternaturally large. ' DCCCCLXXII. When,1 in confequence of the circumftances dcccc- LXviii.—dcccclxxi. and the repetition of thefe, the face becomes.pale; the pulfe grows weak: an unufu- al debility is felt in exercile ; the breathing is hurried by moderate exercife; when, alfo, the back becomes pained from any continuance in an erect pofture ; when the extremities become frequently cold; and when in the evening the feet appear to be affected with cedematous fwelling; we may from thefe fymptoms certainly conclude, that the flow of the menfes has been immoderate, and has already induced a danger- ous ftate of debility. DCCCCLXXIII. The debility thus induced does often discover itfelf alfo by affedions of the ftomach, as anorexia and other J B 2 iymp- 12 PRACTICE fymptoms of difpepfia; by a palpitation of the heart, and frequent faintings; by a weaknefs of mind liable to ftrong emotions from flight caufes, efpecially when fuddenly prefented. DCCCCLXXIV. That flow of the menfes, which is attended with barrennefs in married women, may be generally con- fidered as immoderate and morbid. DCCCCLXXV. Generally, alfo, that flow of the menfes may be con- fidered as immoderate, which is preceded and follow- ed by a leucorrhcea. DCCCCLXXVI. I treat of menorrhagia here as an active hemorrhagy, becaufe I confider menftruation, in its natural ftate, to be always of that kind ; and although there ibould be cafes of menorrhagia which might be confidered as purely paflive, it appears to me that they cannot be fo properly treated of in any other place. DCCCCLXXVII. The menorrhagia (DccccLXXvnt. et feq.) has for its proximate caufe, either the hemorrhagic effort of the uterine veflels preternaturally increafed, or a pre- ternatural laxity of the extremities of the uterine ar- teries, the hemorrhagic effort remaining as in the na- rural ftate. DCCCCLXXVIII. The remote caufes of the hemorrhagia may be, \fl, Thofe which increafe the plethoric ftate of the uterine veffels ; fuch as a full and nourifhing diet, much ftrong liquor, and frequent intoxication, idly, Thofe which determine the-blood more copioufly and forcibly into the uterine veflels; as violent {trainings of the whole body ; violent fhocks of the whole body from falls ; violent ftrokes or contufions on the lower belly ; vio- lent exercife, particularly in dancing ; and violent paf- fions of the mind, idly, Thofe which particularly ir- ritate - OF PHYSIC. J3 ritate the veflels of the uterus;; as excefs in venery; the exercife of venery in the time of menftruation ; a coftive habit, giving occafion to violent {training' at ftool ; and cold applied to the feet*, tfbly, Thofe which have forcibly overftrained the extremities of the uterine veflels ; as frequent abortions; frequent child-bearing without nurfingf ; and difficult tedious labours, Or, lafily, Thofe which induce a general lax- ity ; as living much in warm chambers, and drinking much of warm enervating liquors, fuch as tea and coffee. DCCCCLXXIX. ♦ The effects of the menorrhagia are pointed out in dcccclxxh—DccccLxxm. where I have mentioned the feveral fymptoms accompanying the difeafc ; and from thefe the confequences to be apprehended will alfo readily appear. DCCCCLXXX. The treatment and cure of the menorrhagia muft be * It is difficult to account for the caufe of menorrhagia ; it may perhaps be owing to the circulation through the lower extremities being obftru&ed or impeded, and confequently a greater flow of blood to the uterus. The facl, however, is certain ; for experience fufficiently evinces that menorrhagia frequently follows an imprudent expofure of the feet to cold, efpecially damp cold. Sitting in wet fhoes, or in a damp eold room with a ftone floor, ought to be care- fully avoided by ladies of a delicate conftitution. ■f By nurfing, the fluids are determined to the bread, and in a peculiar manner derived from the uterus. This part of the oecono- my of nature phyfiologifts hav: not yet fufficiently explained, but the fact is well afcertained. Nurfing is not only ufeful in preventing menorrhagia, but 4s it derives the fluids from the uterus, it prevents alfo frequent child-bearing ; and confequently, which is the gieatcft advantage of all others, time is allowed to the uterus for regaining it's former tone and ftreligth : The fubfequent child-births are alfo ren- dered more eafy than they would other wife be, and the children more healthy. It would be improper to enumerate all the advan- tages of nurfing in this place, as I (hall referve the confnleration of tfietn for a future publication. «4 PRACTICE be different, according to the different caufes of the difeafe. In all cafes, the firft attention ought to be given to avoiding the remote caufes, whenever that can be done ; and by that means the difeafe may beoftenen- tirely avoided. When the remote caufes cannot be avoided, orwhen the avoiding them has been neglected, and therefore a copious menftruation has come on, it fhould be mo- derated as much as poffible, by abstaining from all ex- ercife, either at the coming on, or during the conti- nuance of the menftruation ; by avoiding even an erect pofture as much as poffible ; by manning exter- nal heat, and therefore warm chambers and foft beds 5 by ufing a light and cool diet; by taking cold drink, at lead as far^as former habits will allow : by avoiding venery; by obviating coftivenefs, or removing it by laxatives that give little ftimulus*. Th«r fex are commonly negligent, either in avoiding the remote •: auf-s, or in moderating the firft beginnings of this difeafe. I c is by fuch neglect that it fo frequent- ly becomes vi)Lnt, and of difficult cure ; and the fre- quent- repetition of a copious menftruation, may be confidt red as a caufe of great laxity in the extreme vef- fels of the uterus. DCCCCLXXXI. * The laxatives that give little ftimulus arc manna, oil, tamarinds, «affia, and fuch mild Jubilances. Aloetic and other draftic purges, mult be carefully avoided. JAhubarb, in moderate dofes, is only admiffible in cafes where there is an evident atony of the ftomach or inteflines : and in thefe cafes it ought to be given in fubltance, or in a watery infufion. The fpirituous and vinous tinctures of it arc abfolutely inadmiffible in menorrhagia. A table-fpoonfnl of the following linftus, taken occafionally, will fufficiently obviate cof- ^ivenefs, without giving much ftimulus : §, Man. opt. §ii. Ol. ricini Ji. Syr- rofar. lolut. |i. Crem. tartar §fs. M.f.Lina. OF PHYSIC. »S BCCCCLXXXI. When the coming on of the menftruation has been preceded by fome diforder in other parts of the body and is accompanied with pains of the back, refembling parturient pains, together with febrile fymptoms, and when at the fame time the flow feems to be copious, then a bleeding at the arm may be proper, but it is not often n.ceffary ; ana it will in moil cafes be fuffi- cient to employ, with great attention and dligence, thofe means for moderating the difcharge which have been mentioned in the laft paragraph. DCCCCXXXll. When the immoderate flow of the menfes fhall feem to be owing to a laxity of the vtffds of the uterus, as may be concluded from the general debility and laxity of the pe.fon's habit; from the remote caufes that have occafiuned the difeafe (dcccclxxviii ) from the ab- fence of the fymptoms which denote increafed actioa in the veflels of the uterus (dcccclxxi.) from the fre- quent recurrence of the difeafe ; and particularly from this, that in the intervals of menftruation the perfon is liable to a leucorrhcea ; then in fuch cafe the difeafe is to be treated, not only by employing all the means mentioned in dcccclxxx. for moderating the hemor- rhagy, but alfo by avoiding all irritation, every irrita- tion having the greater effect in proportion as the vef- fels have been more lax and yielding. If, in fuch a cafe of laxity, it fliall appear that fome degree of irri- tation concurs, opiates may be employed to moderate the difcharge ; but in ufmg thefe, much caution is re- quifite*. If, not with {landing thefe meafures having been ta- ken'the difcharge fhall prove very large, aftringentsf, ' both * Opiates ufed too liberally, generally increafe the difcharge, in confequence of their very great power in relaxing the whole fyftem. + The a'lringents for interna! ufe are, alum, catechu tincture ot rores &c. Ten grains of alum, and as much catechu may be gi^ea in powder, every two or three hours, with three or four fpoonful. i6 PRACTICE both external and internal, may be employed. Iri fuch cafes, may fmall dofes of emeticesbe of fervice ? DCCCCLXXXI1I. When the menorrhagia depends on the laxity of the uterine veflels, it will be proper, in the intervals of menftruation, to employ tonic remedies ; as cold bath- ing and chalybeates*. The exercifes of geftation, al- fo, maybe very ufeful, both forltrengthening the whole fyftem, and for taking off the determination of the blood to the internal parts. DCCCCLXXXIV. The remedies mentioned in thefe twolaft paragraphs, may be employed in all cafes of menorrhagia, from whatever caufe it may have proceeded, if the difeafe fhall h.tve already induced a^ confiderable degree of debility in the body. CHAP. of tinfture of rofes to wafli it down. The bark is fometimesof ufc in thefe cafes, efpecially when joined with alum. The external ap- plications are, cold clothes foiiked in vinegar and water applied to the lower region of the abdomen, or to the pudenda ; or a ftrong decoction of oak-bark, with an ounce of alum diffolved in every pint ©f it, may be applied cold to the fame parts. * The following form is very convenient. $,, Rubigin. ferri. 3H. Corr. Peruv. gi. Syr. Simpl, q. f. M. f. Eleft. The dofe of this elecluary is to be varied according to the conflitu- tion ; the fize of a nutmeg twice a day is ufually given. The bed forms of chalybeates, in thefe cafes, are the mineral wa- ters which contain iron diffolved by fixed air. Chalybeate waters fhould not, in this difeafe, be drank in fuch large quantities as to pafs off by ftool. A j 111 taken every three or four hours throughout the day, with a fpoonful of port wine, is more efficacious than a pint, or even a quart, taken at once in the morning. The dofe, however, of thefe waters, varies according to the ftrength of the particular water we ufe. Along with the chalybeate water, a fcru- ple, or half a drachm of Peruvian bark may be given twice a day.__ The following form is very agreeable, and is at the fame time Angu- larly efficacious: OF PHYSIC. *7 CHAP. VII. OF THE LEUCORRRCEA, FLUOR ALBUS, CR WHITES. DCCCCLXXXV. EVERY ferous or puriform difcharge from the va* gina, may be, and has been, comprehended un- der one or other of the appellations I have prefixed to this chapter. Such difcharges, however, may be various; and may proceed from various fources, not yet well afcertained : but I confine myfeif here to trea;; of that difcharge alone which may be prefumed to proceed from the fame veflels, which, in their natural ftate, pour out the menfts. DCCCCLXXXVI. I conclude a difcharge from the vagina to be of th;.; kind*; 1. From its happening to women who arefub- ject to an immoderate flow of the menfes, and liable to this from caufes weakening the veflels of the uterus. 2. From its appearing chiefly, and often only, a lit- tle before, as well as immediately after, the flow of the mnfes. 3. From the flow of the menfes being di- mini ftied, in proportion as the leucorrhcea is increafed. 4. From the leucorrhcea continuing after the menfes have entirely ceafed, and with fome appearance of its obferving a periodical recurrence. 5. From the leu- C coi. l-.cea &. Extraft. cort. Peruv. %\- .ExtraA. Camjxvheuf. Extract. Glycliyrrh. a a ^fa. Muci!;:;.';. Gum. Arab. q. 1. M. f. Lu-a. • , . The dofe h half a drachm or two fcruplcs twice a-^v. * Tlic y.rnn^ practitioner ought to pay great aUM/.on to tb-= diao-noilicsof the 1'tiuv.uh■ :a delivered m U-- art-'!- i8 PRACTICE corrhcea being accompained with the effects of the menorrhagia (dcccclxxii. dcccclxxim.) 6. From the difcharge having been neither preceded by, nor accompained with, fymptoms of any topical affections of the uterus. 7. From the leucorrhcea not having appeared foon after communication with a perfon who might be fufpected of communicating infection, and from the firft appearance of the difeafe not being ac- companied with any inflammatory affection of the pu- denda*. DCCCCLXXXVII. The appearance of the matter discharged in the leucorrhcea, is very various with refpect to confidence and colour; but from thefe appearances it is not al- ways poffible to determine concerning its nature, or the particular fource from whence it proceeds. DCCCCLXXXVIII. The leucorrhcea, of which I am to treat, as afcer- tained by the feveral circumftances dcccclxxxvi. feems to proceed from the fame caufes as that fpecies of me- norrhagia which I fuppofe to arife from the laxity of the extreme veflels of the uterus. It accordingly of- ten follows, or accompanies fuch a menorrhagia ; but though the leucorrhoea depends chiefly upon the laxi- ty mentioned, it may have proceeded from irritations inducing * Nothing is more frequent with ignorant practitioners than to miftake a gonorrhoea for a leucorrhoea. Women in general give the name of whites to a gonorrhoea, and therefore the unwary practi- tioner may the more eafily be mifled. The diftiaguifhing characte- riftic of gonorrhoea is, as the author fays, an inflammatory affection of the pudenda ; but, at few women will fuffer an infpe&ion of the parts, we muft pay fome attention to the concomitant fymptoms. The running in a gonorrhoea is conftant, and only in fmall quanti- ties ; in a leucorrhoea the difcharge is inconftant, and in large quantities. The other diftinguifhing marks of a gonorrhoea are, fmarting in making water, itching of the pudenda, increafed incli- nation for venery, a fwelling of the labia and of the glands about the groin. Some authors mention the c lour of the difcharged mat - ter as a diftinguifhing mark ; this, however, is inconftant. O F P H Y S I C. i9 inducing that laxity, and feems to be always increafed by any irritations applied to the uterus. DCCCCLXXXIX. Some authors have alledged that a variety of cir- cumftances. in other parts of the body may have a fhare in bringing on and in continuing this affection of the uterus now under confideration: but I cannot dif- cover the reality of thofe caufes ; and it feems to me, that this leucorrhcea, excepting in fo far as it depends upon a general debility of the fyftem, is" always prima- rily an affection of the uterus; and the affections of other parts of the body which may happen to accom- pany it, are for the raoft part to be confidered as ef- fects, rather than as caufes. DCCCCXC. The effects of the leucorrhcea are much the fame with thofe of menorrhagia ; inducing a general debi- lity, and, in particular, a debility in the functions of the ftomach. If, however, the leucorrhcea be mode- rate, and be not accompanied with any confiderable degree of menorrhagia, it may often continue long without inducing any great degree of debility,v and it is only when the difcharge has been very copious as well as conftant, that its effects in that way are very remarkable. DCCCCXCI. But, even when its effects upon the whole body are not very confiderable, it may ftill be fuppofed to weaken the genital fyftem; and it feems fufficiently probable that this difcharge may often have a fhare in occafioning barrennefs. DCCCCXCII. The matter difcharged in the leucorrhcea, is at firft generally mild : but after fome continuance of the difeafe, it fometimes becomes acrid*; and by irritat- C 2 ing * The voung practitioner muft not conclude too haftily that an to PRACTICE ing, or perhaps eroding, the furfaces over which it paffes, induces various painful diformers. DCCCCXCIII. As I have fuppofed that the leucorrhcea proceeds from the fame caufes as that fpecies of menorrhagia which is chiefly owing to a laxity of the uterine veflels, it muff be treated, and the cure attempted, by the fame means-as delivered in dcccclxxxii for the cure of menorrhagia, and with lei's relcrve in refpect of the ufeof aftringents*. DCCCCXCIV. As the leucorrhcea generally depends upon a great loft of tone in the veflels of the uterus, the difeafe has been relieved, and fometimes cured by certain flimu- lant medicines which are commonly determined to the urinary paffages, and from the vicinity of thefe are . often communic ited to the uterus. Such, for exam- ple, are canrharides, turpentine, and other balfams of a fimilar naturef. C II A I\ ulcer ex'ils in the uterus when the matter difcharged 13 :■$. id.— Practice has offered many inftances where the matter has excoriated. the pudei.la, and yet no ulcer exifledi * The electuary mentioned at the end of the raft note on Article 983, has been found very efficacious in fome cafes of leucorrhcea.— ii's dofe may be i::creufcd to a drachm thrice a-ch-.y, ehher fwallow- ed as a bolus, or diffolved in an ounce of pure water, and half an ounce of pure cinnamon-water. The chalybeate waters are ufed in this, as well in the former difeafe ; and tl.- y may be ufed in the manner above mentioned. Practitioners recommend, in thefe cafes, a nutritive but not a heating diet, as mucilaginous broths narie with rice, efpecially veal-broth, jellies cf all kinds, except thofe that a've high lealoi.cd. Port-wine muft be prefcribed in a modu- late quantity, according to the habits of the patient. f The practice here recommended is not without danger, and ivuir r.nt bt followed except with great caution and circumipediion. When the otter means fail in producing relief, we may then have recourlc to thefe balfamics, or join them to the tonic aftringents as, i'. Gum. olibar-. Terebinth, vsuct. &'iim. OF PHYSIC. 21 .,- C H A P. VIII. OF THE AMENORRHEA, OR INTERRUP- TION OF THE MENSTRUAL FLUX. DCCCCXCV. WHATEVER, in a fyiU'in of methodical nofolo- gy, may be the ficteft place for the amcncr- rhcea, it cannot be improper to treat of it l^cre as an object of practice, immediately after having confider- ed the menorrhagia. DCCCCXCVI. The interruption of the menftrual flux 13 to be con- fidered as of two different kinds ; the one being when the menfes do not Jbegin to flow at that period of life at which they ufually appear; aiul the other being that when, after they have repeatedly taken place Lr fome time, they do. from other caufes than concep- tion, ceafe to return at their ufual periods ; The form- er of thefe is named the retention, and the latter the; fupprejjion, of the menfes.- DCGCCXCVil. As the flowing of the menfes depends upon the force Term, japonic, a v.. 31. S.4, m.irtis -/s. M. f. maffu in pilulas equales. No. fio. dividend. Two or three of thefe pilli may be given twice a-dav or oftener.— ISome practitioneis have ltrongly recommended the following emul- fion : P, Balfam. copaivi. 31. Vitcl. ovi No. 1. Ttre in nuit tar. r.uumor. et addt gradatim. Aq. font. ^vii. :!v. . Simpl. %i. M.f. Emulf. The dofe of this cmulhou li two or three fpoonfuls three or four times a-day. 22 PRACTICE force of the uterine arteries impelling the blood into their extremities, and opening thefe fo as to pour out red blood; fo the interruption of the menftrual flux mult depend either upon the want of due force in the adtion of the uteiioe arteries, or upon fome preternatu- ral refiftance in their extremities. The former I fup- pofe to be the moft ufual caufe of retention, the latter the moft common caufe of fuppreflion ; and of each of thefe I mail now treat more particularly. DCCCCXCVIII. The retention of the menfes, the etnanfio menjium of Latin writers, is not to be confidered as a difeafe merely from the menfes not flowing at that period which is ufual with moft other women. This period is fo different in different women, that no time can be precifely affigned as proper to the fex in general.— In this climate^ the menfes ufually appear about the age of fourteen : but in many they appear more early, and in many not till the fixteenth year: in which laft cafe it is often without any diforder being thereby oc- cafioned. It is not therefore from the age of the perfon that the retention is to be confidered as a dif- eafe; and it is only to be confidered as fuch, when about the time the menfes ufually appear, fome difor^ ders arife in other parts of the body which may be im- puted to their retention; being fuch as, when arifing at this period, are known from experience to be re- moved by the flowing of the menfes. DCCCCXCIX. Thefe diforders are, a fluggifhnefs, and frequent fenfe of laflitude and debility, with various fymptoms of dyfpepfia ; and fometimes with a preternatural ap- petite*. At the fame time the face lofes its vivid co- lour, * This is a very extraordinary fymptom, which has not hitherto been explained. It fometimes accompanies every ceffation of the uterine difcharge, but frequently appears in the moft violent degree in pregnancy. In young women, the appetite for chalk, lime, rub- O F ^P H Y S I C. 23 lour, becomes pale, and fometimes of a yellowiih hue ; the whole body becomes pale and flaccid; and the feet, and perhaps alfo a great part of the body, become affedted with cedematous fwelling. The breathing is hurried by any quick 6r laborious motion of the body and the heart is liable to palpitation and fyncope.— A headach fometimes occurs; but more certainly pains of the back, loins, and haunches*. M. Thefe fymptoms, when occurring in a high degree, conftitute the cblorqfis of authors, hardly ever appear- ing feparate from the retention of the menfes ; and, attending to thefe fymptoms, the caufe of this reten- tion may, I think, be perceived. Thefe fymptoms manifeftly fhow a confiderable lax- ity and flaccidity of the whole fyftem ; an4 therefore give reafon to conclude, that the retention of the men- fes accompanying them, is owing to a weaker adtioa of the veflels of the uterus; which therefore do not impel the blood into their extremities with a force fufficient to open thefe, and pour out blood by them. MI. How it happens that at a certain period of life a flaccidity of the fyftem arifes in young women not originally affedted with any fuch weaknefs or-laxity, and of which but a little time before, they had given no indication, may be difficult to explain ; but I would attempt it in this way. As a certain ftate of the ovaria in females, prepares and difpofes them to the exercife of venery, about the very period at which the menfes firft appear, it is to be pre- bifh, charcoal, and various abforbents, is the moft prevalent. Stalh, and his followers, made great ufe of this circumftance in fupporting 'their favourite, opinion of the vis mcdicatrix naturae. * Thefe pains are not properly fymptoms of the difeafe, but but prognoftics of the efforts nature makes to remove the difeafe : They are fymptoms of the vis medicatrix. 24 PRACTICE prefutned, that the ftate of the ovaria and that of the uterine vefTels are in fome meafure connected toge- ther; and as generally fymptoms of a crum^e in the ftate of the former appear before thofe of the latter, it maybe inferred that the ft-ite of the ovaria has a great fhare in exciting the action of the uterine veflels and producing the menftrual flux. But analogous to what happens in the male fex, it may be prefumed, that in females a certain (late of the genitals is necef- fary to give tone and tendon to the whole fyftem ; and therefore that, if the ftimulus a:iiing from the geni- tals be wantii;;;, the whole fyftem may fajl into a tor- pid and flaccid ilate, and from thence the chlorufisand retention of the nitres may arife. MIL It appears to me, therefore, that the retention of the menfes is to be referred to a certain ftate or affec- tion of the ovaria: but what is precifely the nature of this affection, or what are the caufes of it, I will not pretend to explain ; nor can I explain in what man- ner that primary caufe of retention is to be removed. In this, therefore, as in many other cafes, where we cannot aflign the proximate caufe cf difeafes, our in- dications of cure mult be formed for obviating and removing the morbid effects or fymptoms which ap- pear. Mill. The effedts, as has be_n faid in m. confift in a ge- neral flaccidity of the fyftem, and confequently in a weaker action of the veffels of the uterus ; fo that this debility may be conlidered as the more immediate caufe of the retention. This, therefore, is to be cur- ed by reitoring the tone of the fyltem iii general, and by exciting the action of the uterine vcfilis in parti- cular. MIV. The tone cf the fyfl.em in general is to beVeftcred by OF PHYSIC. 25 by exercife, and in the beginning of the difeafe, by cold bathing. At the fame time, tonic medicines* may be employed ; and of thefe the chalybeates have been chiefly recommended. MV. The action of the veflels of the uteius may be ex- cited : ift, By determining the blood into them more co- pioufly •, which is to be done by determining the blood into the defcending aorta, by purging, by the exer- cife of walking, by fddtion, and by warm bathing of the lower extremities. It is alfo probable that the blood may be determined more copioufly into the hy- pogaftric arteries which go to the uterus, by a com- preflion of the iliacs; but the trials of this kind hi- therto made have feldom fucceeded. MVI idly, The action of the uterine veflels may be ex- cited by ftimulants applied to them. Thus thofe purgatives which particularly ftimutate the inteftinum rectum^:, may alfo prove ftimulant to the uterine vef- Vol. II. D felS * Forms of the tonic medicines have been given in fome of the preceding notes. The electuary in the note on article 983. is fre- quently ufed with fuccefs. In this cafe, we mud: not ufe aiirino-ents, but tonics, and confequently only fuch tonics as are not aflrin^ents, at lead in a high degree. 1 he frmple bitter tonics frequently an- fvver where the fymptoms are not fevere. The infufum gentian* compofitum of the new London Pharmacopoeia is a good formula. The dofe of it is two ounces twice a day, or oftener, if the flornach can bear it. Chalybeates are abfolutely neceffary if the difeafe with- ftands the ufe of bitters; they may be given in any of the forms4 mentioned in the preceding notes. f Dancing is alfo a proper exeicife in this difeafe- £ The ftimulant purges are in general the drallic refins, as Scam- tnony, Aloes, &c. Various formulae of them have been recommend- ed in thefe cafes ; the pilulae Rnfi is commonly ufed with good ef- fect. It may be given in the quantity of half a drachm, or, in llronir conftitutions, two fcruples. It ought not to be repeated abo\e twice a week j and, in the intermediate days, we may employ tl:e tonic medicines above mentioned. The Pilulae ecplnacticy; cf .the 26 PRACTICE fels connected with thofe of the rectum. The exer- cife of venery certainly proves a ftimulus to the veflels of the uterus ; and therefore may be ufeful when, with propriety, it can be emploved. The various medi- cines recommended as ftimulants of the uterine vet fels, under the title of Emmenagogues, have never appeared to me to be effectual; and I cannot perceive that any of them are poffefled of a fpecific power in this refpedt. Mercury, as an univerfal ftimulant, may adt upon the uterus, buf cannot be very fafely em- ployed in chlorotic perfons. One of the moft power- ful means of exciting the action of the veflels in every part of the fyftem is, the electrical fhock ; and it has often been employed with fuccefs for exciting the vef- lels of the u:erus. MVII. The remedies (miii----mvi.) now mentioned, are thofe adapted to the retention of the menfes; and I am I Edinburgh Pharmacopoeia is another very effectual medicine i* thefe cafes. it's dofe is half a drachm twice a week, if we intend to purge brilkly, but, by giving a fmaller quantity as ten, twelve, or fifteen grains once a-day, a conftant ftimulus is preferved, which fome practitioners prefer. The following pills arc alfo much re- co;M:iLinkd : §.. Pil. Gummof. Aloes Socotorin, a a. jii. Vin. Alcet. q. f. M. f. Maffa in pilulas 4S dividend. The dofe is 3 or 4 pills at bed time. The Tir dura facta is alfo frequently ufed as a brifk purge in thefe cafes ; it's dofe for this purpofe muit not be kfs than an ounce and a half in molt habits ; but a ftrong conftitution will require two ounces or more. Other llimulants than purges have been employed in amenorrhcea, as the tinctura fabina compofita of the new Londoa Pharmacopoeia ; its dofe is thiity or forty drops, in any fuitable ve- hicle, .,s the tinctura myrrhs of the fame Pharmacopoeia, in dofes of twenty or thirty drops, is often recommended on the authority *f Jjoeihaa-.e. or PHYSIC. *7 am next to confider the cafe of fuppreffion. In enter- ing upon this, I muft obferve, that every interruption of the flux, after it has once taken place, is not to be confidered as a cafe of fuppreflion. For the flux, up- on its firft appearance, is not always immediately efta- blifhed in its regular courfe ; and therefore, if an in- terruption happen foon after the firft appearance, or even in the courfe of the firft, or perhaps fecond year after, it may often be confidered as a cafe of reten- tion, efpecially when the difeafe appears with the fymptoms peculiar to that ftate. MVIII. Thofe which may be properly confidered as cafes of fuppreffion, are fuch as occur after the flux has been for fome time eftablifhed in its regular courfe, and in which the interruption cannot be referred to the cauf- es of retention (mii, miii.) but muft be imputed to fome refiftance in the extremities of the veflels of the uteros. Accordingly, we often find the fuppreflion induced by cold, fear, and other caufes which may produce a conftriction of thefe extreme veflels. Some phyficians have fuppofed an obftructing lentor of the fluids to occafion the refiftance now mentioned : but this is purely hypothetical, without any proper evi- dence of the fact; and it is befides, from other confi- derations, improbable. MIX. There are indeed fome cafes of fuppreflion that feem to depend upon a general debility of the fyftem, and confequently of the veflels of the uterus. But in fuch cafes, the fuppreffion always appears as fymptomatic of other affections, and is therefore not to be confidered here. MX. The idiopathic cafes of fuppreflion (mviii .) feldom continue long without being attended with various fymptoms or diforders in different parts of the bodv : D a vJrv 28' PRACTICE very commonly arifing from the blood which fhould have paffed by the uterus, being determined more co- pioufly into other parts, and very often with fuch force as to produce hemorrhagies in thefe. Hence hemorrhagies from the nofe, lungs, ftomach, and other parts, have appeared in confequence of fupprefled menfes. Befides thefe, there are commonly hyjteric and'dyfpeptic fymptoms produced by the fame caufe $ and frequently colic pains, with abound belly. MXI. In the idiopathic cafes of fuppreflion, (mvii.) the indication of cure is to remove the conftriction affect- ing the extreme veflels of the uterus; and for this pur- poi'e, the chief remedy is warm bathing applied to the region of the uterus. This, however, is not always ethdtual, and I do not know of any other remedy a- dapted to the indication. Befides this, we have per- haps no other means of removing the conftriction in fault, but that of increaflng the action and force of the veflels of the uterus f° as thereby to overcome the refinance or conitiiction of their extremities. This therefore is to be attempted by the fame remedies in the cafe of fuppreflion, as thofe prefcribed in the cafes of ret-ntion (iviiv-r-Mvi.y The tonics, however, and cold bathing (miv.) feem to be lefs properly adapted to the cafes of fuppreflion, and have appeared to me of ambiguous effedt*. MXII. * The Emenagogues enumerated in the note on article 1006, are more efficacious in thefe cafes than the tonics and chalybeates mentioned in the note on article 1004, for this reafon, that the fuppreffion of the menfes depends more on the conftridion, than on a laxity of the extreme veffcls. Some cafes indeed, occur, where a lax La'.it is the caufe of fuppreffion, but they are rare. The phy- ficians ought to be attentive in discriminating fuch cafes, becaufe a liberal ufe )f forcing emenagogues is always hurtful in them ; they can only be relieved by tonics, and efpecially by chalybeates* ' OF PHYSIO. *9 MXII. It commonly happens in the cafes of fuppreflion, that though the menfes do not flow at their ufual pe- riods, there are often at thofe periods fome marks of an effort having a tendency to produce the difcharge. It is therefore at thofe limes efpecially when the ef- forts of the fyftem are concurring, that we ought to employ the remedies for curing a fuppreflion ; and it is commonly fruitlefs to employ them at other times, unlefs they be fuch* as require fome continuance in their ufe to produce their effects. MXIIf. Nearly fimilar to the cafes of fuppreflion, are thofe cafes in which the menfes flow after longer intervals, and in leffer quantity than ufual; and when thefe c^f- es are attended with the diforders in the fyftem (mx.) they are to be cured by the fame remedies as the caf- es of entire fuppreflion. MXIV.. It may be proper in this place to take notice of the defmenorrhea, or cafes of menftruation in which the menfes feem to flow with difficulty, and are accompa- nied with much pain in the back, loins, and lower belly. We impute this diforder partly to fome weak- er action of the veflels of the uterus, and partly, per- haps more efpecially, to a fpafm of its extreme veflels. We have commonly found the difeafe relieved by em- ploying fome of the remedies of fuppreflion immedi< ately before the approach of the period, and at the fame time employing opiates. CHAP. * Viz. tonics or alterants. 3« PRACTICE CHAP. IX. OF SYMPTOMATIC HEMORRHAGIES. MXV. I HAVE thought it very improper in this work, to treat of thofe morbid affections that are almoft al- ways fymptomatic of other more primary difeafes; and this for feveral reafons, particularly becaufe it introduces a great deal of confufion in directing prac- tice, and leads phyficians to employ palliative mea- furesonly. I fhall here, however, deviate a little from my general plan, to make fome reflections upon fymptomatic hemorrhagies. MXVI. The hemorrhagies of this kind that efpecially de- ferve our notice, are the Hematemefi^, or Vomiting of Blood ; and the Hematuria, or the Voiding of Blood from the urinary paflage. Upon thefe I am here to make fome remarks ; becaufe, though they are very generally fymptomatic, it is poflible that they may be fometimes primary and idiopathic am ctions; and becaufe they have been treated of as primary dif- eafes in almoft every fyftem of the practice of phy- fic. »<"<»<..<-<-<-.<«<-.<..<^4»>.>.>.>.>.>..>..>..>.>..>„ S E C T. I. OF THE HEMATEMESIS, OR VOMITING OF BLOOD. MXVII. I HAVE faid above (in dccccxlv.) in what man- ner blood thrown out from the mouth may be known O F Ht-FI Y S I C. 3« known to proceed from the ftomaeh, and not from the lungs: but it may be proper here to fay more par- ticularly, that this may be certainly known, when the blood is brought up manifeftly by vomiting without any coughing ; when this vomiting has been preceded by fome fenfe of weight, anxiety, and pain, in the re- gion of the ftomach; when the blood brought up is of a black and grumous appearance, and when it is manifeftly mixed with other contents of the ftomach ; we can feldom have any doubt of the fource from whence the blood proceeds, and therefore of the exift- ence of the difeafe we treat of. MXVIII. We muft allow it to be poflible that a plethoric ftate of the body from general caufes may be accom- panied with caufes of a peculiar determination and afflux of blood to the ftomach, fo as to occaflon an hemorrhagy there, and thence a vomiting of blood ; and in fuch a cafe this appearance might be confider- ed as a primary difeafe. But the hiftory of difeafes in the records of phyfic, afford little foundation for fuch a fuppofition; and on the contrary, the whole of the inftances of a vomiting of blood which have been recorded, are pretty manifeftly fymptomatic of a more primary affection. Of fuch lymptomatic vomitings of blood, the chief inftances are the following. MXIX. One of the moft frequent is that which appears in confequence of a fuppreflion of an evacuation of blood which had been for fome time before eftablifhed in a- nother part of the body, particularly that of the men- ftrual flux in women. MXX. There are inftances of a vomiting of blood happen- ing from the retention of the menfes : but fuch inftances are very uncommon ; as a retention of the menfes rarely 3a PRACTICE rarely happens in confequence of, or even with, a ple- thoric ftate of the body ; and as rarely does it produce that, or the hemorrhagy in queftion. There are inftances of a vomiting of blood happen- ing to pregnant women ; that might therefore alfo be imputed to the fuppreflion of the menfes, which hap- pens to women in that ftate. There have indeed been more inftances of this than of the former cafe; but the latter are ftill very rare : for although the blood which ufed to flow monthly before impregnation, is, upon this taking place, retained, it is Commonly fo en- tirely employed in dilating the uterine veflels, and in the growth of the foetus, that it is feldom found to produce a plethoric ftate of the body, requiring a vi- carious outlet. The vomiting of blood, therefore, that is vicarious of the menftrual flux, is that which commonly and al- moft only happens upon a fuppreflion of that flux, af- ter it had been for fome time eftabliffied. MXXI. When fuch a fuppreflion happens, it may be fup- pofed to operate by inducing a plethoric ftate of the whole body, and thereby occafioning hemorrhagy from other parts of it; and hemorrhagies from many dif- ferent parts of the body have been obferved by phy- ficians as occurring in confequence of the fuppreflion we fpeak of. It is however the great variety of fuch hemorrhagies, that leads me to think, that with the plethoric ftate of the whole body there muft be always fome peculiar circumftances in the part from which the blood flows, that determine its afflux to that par- ticular, often Angularly odd, part; and therefore, that fuch hemorrhagies may from thefe circumftances occur without any confiderable plethora at the fame time pre- vailing in the whole fyftem. MXXII. O F P~H Y S I C. 33 MXXII. It is to be obferved, that if we are to expect an he- morrhagy in confequence of a fuppreflion of the menfes inducing a plethoric itate of the fyftem, we ftiould ex- pect efpecially an hemoptyfis, or hemonhagy from the Lungs, as a plethora might be expected to (howits effects efpecially there ; and accordingly, upon occafion of fupprefled menfes, that hemorrhagy occurs more fre- quently than any other : but even this, when it doe^: happen, neither in its circumftances nor its confluen- ces, leads us to fuppofe, that at the fame time any con- fiderable or dangerous plethora prevails in the body. MXXIIL Thefe conflderatlons in mxxi. mxxii. will, I ap- prehend, apply to our prefent fubject; and I would therefore alledge, that a hematemefts may perhaps depend upon particular circumftances of the ftomach determining an afflux of blood to that organ, and may therefore occur without any confiderable or dangerous plethora prevailing in the fyftem. What are the cir- cumftances of the ftomach, which upon the occafion mentioned, may determine an afflux of blood to it, I cannot certainly or clearly explain ; but prefume that it depends upon the connection and confent which we know to fubfift between the uterus and the whole of the alimentary canal, and efpecially that principal part of it the ftomach. MXXIV. From thefe reflections, we may, I think, draw the following conclufions: I. That the hematemefis we fpeak of is hardly ever a dangerous difeafe. II. That it will hardly ever require the remedies fuir- ed to the cure of active hemorrhagy ; and at leaftthat it will require thefe only in thofe unufual cafes in which there appear ftrong marks of a general plethora, Vol. II. E ai*J 34 PRACTICE and in which the vomiting of blood appears to be con- siderably active, very profufe, and frequently recurring. III. That a vomiting of blood from fupprefled menf- es, ought feldom to prevent the ufe of thefe remedies of amenorrhcei, which might be improper in the cafe of an active idiopathic hemorrhagy. MXXV. Another cafe of fymptomatic hematemefis quite analogous to that already mentioned, is the hemate- mefis following, and feemingly depending upon, the fuppreflion of an hemorrhoidal flux, which had been eftablifhed and frequent for fome time before. This may perhaps be explained by a general ple- thoric ftate induced by fuch a fuppreffion; and indeed fome degree of a plethoric ftate muft in fuch a cafe be luppofed to take place; but that fuppofition alone will not explain the whole of the cafe ; for a general plethora would lead us to expect an hemoptyfis (mxx- ii.) rather than an hematemefis; and there is there- fore fomething ftill wanting, as in the former cafe, to explain the particular determination to the ftomach. Whether fuch an explanation can be got from the connection between the different parts of the fangui- ferous veflels of the alimentary canal, or from the connection of the whole of thefe veflels with the ve- na portarum, I lfiall not venture to determine. But in the mean time I imagine that the explanation re- quired is rather to be obtained from that connection of the ftomach with the hemorrhoidal affection that I have taken notice of in dccccxlvi. MX XVI. However we may explain the hematemefis occasi- oned by a fuppreflion of the hemorrhois, the confede- rations in mxx:. mxxii. will apply here as in the ana- logous cafe of hematemefis from fupprefled menfes ; and will therefore allow us alfo to conclude here, that OF PHYSIC. 35 the difeafe we now treat of will feldom be dangerous, and will feldom require the fame remedies that idio- pathic and active hemorrhagia does. ■ MXXVII. The cafes of hematemefis already mentioned, may be properly fuppofed to be hemorrhagies of the arterial kind ; but it is probable that the ftomach is alfo liable to hemorrhagies of the venous kind, (dcclxvih.) In the records of phyfic there are many inftances of vomitings of blood, which were accompanied with a tumefied fpleen, which had compreffed the vas breve, and thereby prevented the free return of venous blood from the ftomach. How .fuch an interruption of the venous blood may occafion an hemorrhagy from cither the extremities of the veins themfelves, or from the extremities of their correfpondent arte- ries, we have explained above in dcclxix. and the hiftories of tumefied fpleens comprefiing the vafa bre- via, afford an excellent iiluftration and confirmation of our doctrine on that fubject, and render it fuffici- ently probable that vomitings of blood often arife from fuch a caufe. MXXVIII. It is alfo poflible, that an obftruction of the liver, refitting the free motion of the blood in the vena por- tarum, may fometimes interrupt the free return of the venous blood from the veflels of the ftomach, and thereby occafion a vomiting of blood; but the in- ftances of this are neither fo frequent nor fo clearly explained as thofe of the former cafe. MXXIX. Befides thefe cafes depending on the ftate of the li- ver or fpleen, it is very probable that other hemor- rhagies of the ftomach are frequently of the venous kind. The difeafe named by Sauvages Melsena, and by E 2 other 36 PRACTICE other writers commonly termed the Morbus Niger. (dcolxxh.) confiding in an evacuation either by vo- miting or ftojl, and fometimes in both ways, of a black and grumcus blood, can hardly be otherwife occafioned, than by a venous hemorrhagy from fome part of the internal furface of the alimentary canal. It is, indeed, poflible, that the bile may fometimes put on a black and vifeid appearance, and give a real foundation for the appellation of an Atra Bilis : but i> is certain, that inftances of this are very rare ; and it is highly probable that what gave occafion to the notion of atra bilis among the ancients, was truly the appearance of blood poured into the alimentary canal in the manner I have mentioned ; and which appear- ance, we know, the blood always puts on when it has ftignated therefor any length of time. I fuppofe it is now generally thought, that Boerhaave's notion of fuch a muter exifting in the mafs of blood, is without any foundation ; whiift, by diffections in modern times, it appears very clearly, that the morbus nigerprefent- ing fuch an appearance of blood, always depends up- on the eifufion and llagnation I have mentioned. MXXX. From this account of the melasna it will appear^ that vomitings of blood may arife in confequence of blood being poured out in the manner I have menti- oned, either into the cavity of the ftomach itfelf, or into the fuperior portions of the inteftines,from whence matters often pafs into the ftomach. MXXXI. Both in the cafe of the Melaena, and in the analo- gous cafes from affections of the fpleen or liver, it will appear, that the vomitings of blood occurring muft be confidered as fymptomatic affections, not at all to be treated as a primary active hemorrhagy, but by reme- dies. OF PHYSIC. 37 dies, if any fuch be known, that may refolve the pri- mary obftrudtjons*. MXXXIT. I believe I have now mentioned almoft the whole of the caufes producing a hematemefis; and certainly the caufes mentioned, are thofe which moft common- ly give occafion to that fymptom. Poflibly, however, there may be fome other caufes of it, fuch as that lin- gular one mentioned by Sauvages, of an aneurifm of the * This i • donbtlefs the moft rational practice, namely, to refolve the obftruftion which has occafioned the blood to be thrown or dtiven to the inteftine3 To difcover this primary obftru&ion is, however, extreme'y difficult; and, even v hen it is difcovered, it is frequently not eafilyref >lved ; in fuch cafes, therefore, we muft life the general remedies for removing the plethora, except laxatives, the operations of which, in general, derive the fluids to the intef- tin« s. Sweating is perhaps the bell general evacrmion for deter- mining the fluids from the interlines ; but it's ufe ought to be pre- ceded by bleeding: and it ought not, in thefe cafes, to be excited by naufeating dofes of emetics, as thefe produce the fame effett as laxatives ; we mu'l therefore have recourfe to the light aromatirs, fage, mint, balm, wine-whey, &c. Camphor and opium are alio proper fudorifics in thefe cafes. They may be given together, as in the following bolus: & Camphor, gr. vi. Spr. vini gutt. X. Opii pur. gr. i. Conf. card. ^fs. vel. q. f. M. f. b-jWis. Some practitioners have recommended large quantities of fperma- ceti in cafes of hematemefis, and not without reafon. It may be given in emulfions, with yolks of eggs, or in an eiu&uary. I fhall therefore add a formula of each. I}.. Spermat. cet. ^fs. Vilel. ovi q. f. Tere in mortar* marmoreo, et adde Aiq. font. g. Styr. fimpl. ~i. M. f. Emulf.' The dofe of this crmilfion i» two or three tabic'fpoonfulls every three hours. 3* PRACTICE the aorta burfting into the ftomach : and it is poflible that fome difeafes of other contiguous parts, which have become clofely adhering to the ftomach, may fometimes, by a rupture into the cavity of the fto- mach, pour blood into it, which is afterwards re* jc&ed §. Spermat. cet. ^i, Confcrv. roiar. ijii. Syr. fimp. £i. M. f.eled. The dofe of this eleduary is a tea-fpoonfull or two every two oy three hours. If the hematemefis be violent, we muft have recourfe to fome of the ftyptics and ailringents mentioned before in the cure of hemor- rhage in general, as alum, catechu, kino, &c. of which I fhall fub- join fome formulae. R. .Alum. uft. gr. iii. Kino 3fs. M. f. Pulvis. This powder may be repeated every two hours, and three table- fpoonfuls of the tindure of rofes may be given to warn it down. The eleduarium japonicum of the Edinburgh Pharmacopoeia is well c::kplated for thefe cafes ; it's dofe is a drachm and a half, or two drachms. The extrad of logwood is fometimes ufed in thefe dole; wlj, confiderable fuccefs. It may either be given alone in dofes of a fcruple each every three hours, or joined with alum, as in the following formula. R. Extrad. lign. Campechenf. 3fs. Alum. uft. gr. iii M, f. pulvis. This powder may be repeated every three hours ; drinking after ifc three table-fpoonfulls of the tindure of rofes : or a tea-cup full of cold water, with twenty or thirty drops of the acidum vitriolicum dilutum, or as much as is fuffkient to give an agreeable acidity. All thefe ftyptics and aftringents are apt to produce coftivenefs which muft be removed by emollient clyfters, as laxative medicine* are, fop the reafons above mentioned, generally hurtful in thefe ca- fes. The young praditioner mult not trull to thefe medicines for completely curing an hemonhage from the interlines ; they are only palliatives, and are of no other ufe than to check the violence of the difcharge until the true caufe of the difeafe be difcovered ; and the difcovery of this caufe muft be left to the fagacity cf the p'hyfi. c'an. OF PHYSIC. 39 jetted by vomiting. It is poflible, alfo, that abfcefles and ulcerations of the ftomach itfelf, may fometimes pour blood into its cavity to be thrown up by vomiting;. I did not think it necefiary among the fymptoma- tic vomitings of blood, to enumerate thofe from ex- ternal violence, nor, what is analogous to it, that which arifes from violent ftraining to vomit; «which laft, however, is much more rare than might be ex- pected. In either of thefe cafes the nature of the dif- eafe cannot be doubtful, and the management of it will be readily underftood from what has been deliver- ed above with refpect to moderating anci reftraining hemorrhagy in general. SEC T II. OF THE HEMATURIA, OR THE VOIDING OF BLOOD FROM THE URINARY PASSAGE. MXXXIII. It is alledged, than an hematuria has occurred with- out any other fymptom of an affection of the kidneys or urinary paffages being prefent at the fame time; and as this happened to plethoric perfons, and recurred at fixed periods, fuch a cafe has been fuppofed to be an inftance of idiopathic hematuria, and of the nature of thofe adive hemorrhagies I have treated of before. MXXXIV. I cannot pofitively deny the exiftence of fuch a cafe; but muft obferve, that there arc very few in- ftances of fuch upon the records of phyfic; that none have ever occurred to my obfervation, or to that of my friends ; and that the obfervations adduced may be fallacious, as I have frequently obferved an hema- turia without fymptoms of other affection of the kid- ney 4° PRACTICE ney or urinary paffages being, for the time, prrfent ; whilft, however, fits of a nephuuJa caicuh.la hav- ing, before, or foon after, happened, renucr <'< it to me fufficiently probable, that the hematuria was owing to a wound made by a ftone prefent in fome pa: t of the uri- nary paflages. MX XXV. The exiltence of an idiopathic hematuria is further improbable, as a general plethora is mo;e likely to produce an hemoptyfis (mxxii.) and as we do not well know of any circumftances which mi^ht deter- mine more particularly to the kidneys. An idiopathic hematuria, therefore, muft certainly be a r ire occur- rence ; and inftance:; oflymptomatic affections of the fame kind are very frequent. MXXXVI. One of the moft frequent is, that hematuria which attends the nephralgia calculofa, and feems manifeftly to be owing to a ftone wounding the internal furface of the pelvis of the kidney or of the ureter. In fuch cafes, the blood difcharged with the urine is fometimes, of a pretty florid colour, but for the moft part is of a dark hue : the whole of it *is fome- times diffufed or diffolved, and therefore entirely fuf- pended in the urine ; but if it is in any large quan- tity, a portion of it is depofited to the bottom of the velfel containing the voided blood and urine. On different occafions, the blood voided puts on different appearances. If the blood poured out in the kidney has happened to ftagnate for fome time in the ureters or bladder, it is fometimes coagulated, and the-coa- gulated partis afterwards broken down into a grumous mafs of a black or dark colour, and therefore gives the fame colour to the urine voided; or if the quan- tity of broken down blood is fmall, it gives only a brownifh urine refembling collce. It fometimes alfo happens, that the blood ib^nating and coagulating in OF PHYSIC. 4* in the ureters, takes the form of thefe veflels, and is therefore voided under the appearance of a worm; and if the coagulated blood happens to have, as it may fometimes have, the glutten feparated from the red globules, thefe worm-like appearances have their external furface whitifh, and the whole feemingly forming a tube containing a red liquor. I have fome- times obferved the blood which had feemingly been coagulated in the urete^ come away in an almoft dry 'ftate, refembling the half-burnt wick of a candle*. MXXXVII. Thefe are the feveral appearances of the blood void- ed in the hematuria calculofa, when it proceeds efpe- cially from the kidneys orureter; and many of the fame appearances are obferved when the blood proceeds only from the bladder when a ftone is lodged there ; but the attending fymptoms will commonly point our. the different feat of the difeafe. In one cafe, when a quantity of blood from the kid- ney or ureter is coagulated in the bladder, and is there- fore difficultly thrown out from this, the pain and un- eafinefs ou fuch an occafion may appear chiefly to be in the bladder, though it contains no ftone ; but the antecedent fymptoms will commonly difcover the na- ture of the difeafe. Vol. II. F MXXXVIIL * In general, the blood is coagulated and grurnous; hence thfe Urine depofits a dark brown fubftance fomewhat refembling coffee- grounds. As the grurnous blood is fpecifically heavier than the u- rine, it falls to the bottom of the bladder, and 13 confequently voided in greater quantity in the beginning than towards the en J of mak- ing water, the urine that comes off firft being very deep coloured and muddy, but becoming while it flows, gradually more tranfpa- rent and pure, until at latt it is perfedly of a natural appearance. The patient generally mentions this circumftance in defenbing his complaints, with this addition, that he has in the beginning fome difficulty of making water, but that this difficulty decreafrs in pro- portion as the urine becomes more tianfparent. 42 P R A C T 1 C E MXXXVIIL Irt any of the cafes of the hematuria calculofa, it will hardly be neceffary to employ the remedies fuited to an active hemorrhagy. It will be proper only to employ the regimen fit for moderating hemorrhagy in general, and particularly here to.avoid every thing or circumftance that might irritate the kidneys or ure- ters. Of fuch cafes of irritation there is none more frequent or more confiderable than the prefence of har- dened faeces in the colon ;% and thefe therefore are to be frequently removed, by the frequent ufe of gentle laxatives*. MXXXIX. The hematuria calculofaf may be properly confi- dered as a cafe of the hematuria violenta : and there- fore I fubjoin to that the other inftances of hematuria from external violence j fuch as that from external contufion on the region of the kidneyj, and that from the * Clyfters are preferable to purgatives in thefe cafes, becaufe they are lcfs ftimulating; and the emollient clyftcs are preferable to all others, for their only intention is to foften the hardened faeces. The only purgatives to be ufed are thofe of the mildeft kind, as manna, oil, caffia, &c. The intention of purgatives, in thefe cafes, is only to remove the hardened faeces; and this intention can often be fufficiently anfwered by a proper choice of food, as broths, ef- pecially thofe made of barley and young animal flefh; barley-gruel, with prunes boiled in it; ftewed endive, lettuce, and other olerace- ous difhes- f The hematuria calculofa being fymptomatic, can only be cur- ed by removing the caufe ; it may however, be greatly relieved by demulcents, as lintfeed-tea, decodions of mar mm allows, mucilage of gum Arabic, thick bariey-water, &c. j The hematuria proceeding from a contufion of the region of the kidneys, requires general and topical bleeding, with purges, and an attention to the antiphlogiftic tegimen. Some praditioners re- commend the warm ballams in thefe cafes ; but on account of their heating quality, their ufe is fomewhat doubtful. Nitre is not always admiffiblc< on account of its irritating the kidneys ; but it is a pow- erful antiphlogiftic ; and, if it is ufed iu thefe cafes, it mult be well OF PHYSIC. 43 the violent or long continued exercife of the mufcles incumbent on the kidneys. An inftance of the latter caufe occurs efpecially in riding*. MXL. It may alfo be confidered as a cafe of the hematuria violenta, when the difeafe occurs in confequence of the taking in of certain acrid fubftances, which pafs again efpecially by the urinary paflages; and, by in- flaming and fwelling the neck of the bladder, bring on a rupture of the over-diftended blood-veflels, and give occafion to a bloody urine. The moft noted inftance of this is in the effect of cantharides in a certain quan- tity, ^ny way introduced into the body. And pofli- bly fome other acrids may have the fame effectf. MXLI. Befide thefe moft frequent inftances of hematuria, which cannot be confidered as idiopathic hemorrhagies, F 2 there diluted : the mucilaginous drinks are abfolutely necefTary, and ought to be ufed plentifully. * The only method of treating this kind of hematuria is by reft. A perfon fubjed to it ought never to ride. f This fpecies of hematuria is cured by evacuating the acrid fub- fiance, and by the ufe of the mucilaginous drinks before mentioned. The acrid fubfiance may be evacuated by antiphlogillic purges, or by the milder diuretics, as nitre, decodion of parfley roots, cream of tartar whey, &c. The adion of cantharides on die urinary paf- fages is not well explained. We can fcarcely believe that any part of the cantharides is abforbed from the bliftering p'aifter ; yet its effeds are the fame with thofe produced by taking the cantharides internally. The ftrangury, and its concomitant fymptoms, may be relieved by large and plentiful dilution, and a free ufe of the mucilagi- nous drinks. Camphor has been thought to have fome fpecific qua- lity in preventing and curing the ftrangury produced by blillcrs, and experience warrants the conclufion ; efpecially if the camphor isjoin-t cd with opium as in the following formula : §,. Camphor, gr. vi. Spir. vini gutt. X. Opii puri gr. i. Conferv. rofar, 51. M. f. bolus. 44. PRACTICE there are fome other inftances of hematuria mentioned by authors, that are ftill however manifeftly fymptoma- tic; fuch as a difcharge ofblcod from the urinary paflag- es, in confequence of a fuppreflion of either the menftrual or hemorrhoidal flux. Thefe may be confidered as analogous to the hematemefis produced by the like caufes; and the feveral reflections made above on that fubject, will, I think, apply here, and particularly the concluiions formed in mxxiv. Inftances, however, of either of thefe cafes, and efpecially of the firft, have1 been extremely rare. MXLII. Of fuch fymptomatic hematuria there is however, one inftance deferving notice; and that is, whe'n a fuppreflion of the hemorrhoidal flux, either by a com- munication of veflels, or merely by the vicinity of parts, occafions a determination of the blood into the vef- fels of the neck of the bladder, which in confequence of a rixisor anaftomofis, pour out blood to be voided either with or without the urine. This cafe is what. has been named the Ilemorrhoides Veficas ; and with fome propriety, when it is manifeftly an evacuation vicarious of what had before been ufually made from the rectum. With refpedt to the management of the hemorrhoides veficae, I would apply the whole of the dcctiines that I have delivered above, with refpect to the cure of the proper hemorrhoidal affection*. MXLIII. There remains ftill to be mentioned one other in- ftance of fymptomatic hematuria, which is that which happens in the cafe of confluent and putrid fmall-pox, as well as in feveral other inftances of putrid difeaf- es. The blood, in fuch cafes, may be prefumed to come from the kidneys; and I apprehend that it comes from thence in confequence of that fluidity which is always produced in the blood approaching to a putrid ftate • Aitides 947, et frquent. OF PHYSIC, 45 Sate. Such hematuria, therefore, is not to be confi- dered as a fymptom of any affection of the kidneys, tut merely as a mark of the putrefcent ftate of the blood. MXLIV. In certain difeafes the urine is difcharged of fuch a deep red colour, as give a fufpicion of its being ting- ed by blood prefent in it; and this has given occafion to Sauvages," amongft. the other fpecies of hematuria, to mark the hematuria fpuria, and the hematuria lateri- tia; both of which, however, he fuppofes to be with- out any blood prefent in the urine. In many cafes it is of importance, in afcertaining the nature of a dif- eafe, to determine whether the red colour of urine be from blood prefent in it, or from a certain ftate of the falts and oils which are always in greater or leffer pro- portion conftituent parts of the urine ; and the quef- tion may be commonly determined by the following confiderations. It has been obferved above, that when any confi- derable quantity of blood is voided with the urine, there is always a portion of it depofited at the bot- tom of the veffel containing the voided blood and u- rine ; and in fuch a cafe there will be no doubt in at- tributing the colour of the urine floating above, to fome part of the blood diffufed in it. The queftion, therefore, with refpedt to the prefence of blood in the urine, can only occur when no fuch depofition as I have mentioned appears; and when the blood that may be fuppofed to be prefent is diffolved orciiflufed, and therefore entirely fulpended in the urine. In this cafe the prefence of the blood may be commonly known, ift, By the colour which blood gives, differ- ent from any urine without blood that I have ever" feen; and I think a little experience will enable moft perfons to make this diftinction. 2dly, By this, that the prefence of blood always diminifhes the tranfpa- 46 PRACTICE rency of the urine with which it is mixed : and it is very feldom that urine, though very high-coloured, lofes its tranfparency; at leaft this hardly ever ap- pears, if the urine is examined when recently voided. 3dly, When urine has blood mixed with it, it tinges a piece of linen dipt into it with a red colour, which the higheft-coloured urine without blood never does. 4thly, High-coloured urine without blood, upon cool- ing, and remaining at reft in a vefTel, almoft always depofites a lateritious fediment; and if upon any oc- cafion bloody u/ine mould depofite a fediment that may be of a portion of the blood formerly diffufed in it, the difference, however, may be difcerned by this, that the fediment depofited by urine without blood, upon the urine's being again heated, will be entirely re-diffolved, which will not happen to any fediment from blood. Laftly, we know no ftate of urine with- out blood, which fliews any portion of it coagulable by a heat equal to that of boiling-water ; but blood diffufed in urine is ftill coagulable by fuch a heat: and by this teft, therefore, the prefence of blood in urine may be Commonly afcertained. BOOK V. OF PROFLUVIA, OR FLUXES, WITH PYREXIA. MXLV. FORMER nofologifts have eftablifhed a clafs o"f difeafes under the title of Fluxes, or Profluvia ; but as in this clafs they have brought together a great number of difeafes, which have nothing in common, excepting o? p-*i ysia 47 excepting the fingle circumflance of an increafed dif- charge of fluids, and wh'.ch alfo are, in other refpects, very different from one another ; I have avoided fo improper an arrangement, and have diftributed moft of the difeafes comprehended in fuch a clafs by the nofologifts, into places more natural and proper for them*. I have, indeed, ftill employed here the gene- ral title; but I confine it to fuch fluxes only as are conftantly attended with pyrexia, and which therefore neceffarily belong to the clafs of difeafes of which I am now treating. Of the fluxes which maybe confidered as being ve- ry conftantly febrile difeafes, there are only two, the catarrh and dyfentery ; and of thefe therefore I now proceed to treat. •-«"*-4--4»<--4~<--<<-<--<"4i$»<$t'»">">">">">">',>"»' CHAP. I. OF THE CATARRH, MXLVI. THE catarrh is an increafed excretion of mucusr from the mucous membrane of the nofe, fauces, and bronchiae, attended with pyrexia. Practical writers and nofologifts have diftinguiihed the difeafe by different appellations, according as it happens to affect thofe different parts of the mucous membrane, the one part more or lefs than the other : But I am of opinion, that the difeafe, although affect- ing * Sauvages enumerates no lefs than thirty-fix genera effluxes, each of which is fubdivided into numerous fpecies. Vogel has for- ty-five genera, under the title of profluvia, moft of which arc ex- tremely different from each other in their effential qualities. 48 PRACTICE ing different parts, is always of the fame nature, and proceeds from the fame caufe. Very commonly, in- deed, thofe different parts are affected at the lame time; and therefore there can be little room for the diftinction mentioned. The difeafe has been frequently treated of under the title of Tuflis, or Cough; and a cough, indeed, always attends the chief form of catarrh, that is, the increaf- ed excretion from the bronchias: but a cough is fo often a fymptom of many other affections, which are very different from one another, that it is improperly employed as a generic title. MXLVII. The remote caufe of catarrh is molt commonly cold applied to the body. This application of cold pro- ducing catarrh, can in many cafes be diftinctly ob- ferved ; and I would believe it always to be fo, were men acquainted with, and attended to, the circum- ftances which determine cold to act upon the# body* See xciv—xcvi. From the fame paragraphs we may learn what in fome perfons gives a predifpofition to catarrh. MXLVIII, The difeafe, of which I am now to treat, generally begins with fome difficulty of breathing through the nofe, and with a fenfe of fome fullnefs flopping up that paflage. This is alfo often attended with fome dull pain and a fenfe of weight in the forehead, as well as fome ftiffnefs in the motion of the eyes. Thefe feel- ings, fometimes at their very firft beginning, and al- ways foon after, are attended with the diftillationfrom the nofe ; and fometimes from the eyes, of a thin fluid, which is often found to be fome what acrid, both by its tafte, and by its fretting the parts over which it paffes. MXLIX. Thefe fymptoms conftitu:e the coryza and gravrdo of me—nM SIC. 49 ✓ of medical authors, and are commonly attended with a fenfe of laflitude over the whole body. Sometimes cold fhiverings are felt, at leaft the body is more fenfi- ble than ufual to the coldnefs of the air; and with all this the pulfe becomes, efpecially in the evenings, more frequent: than ordinary. ML. Thefe fymptoms feldom continue long before they are accompanied with fome hoarfenefs, and a fenfe of roughnefs and forenefs in the trachea, and with fome difficulty of breathing, attributed to a fenfe of ftrait- nefs of the cheft, and attended with a cough, which feems to arife from fome irritation felt at the glottis. The cough is generally at firft dry, occafioning pains about the cheft, and more efpecially in the breaft. Sometimes, together with thefe fymptoms, pains re- fembling thofe of the rheumatifm are felt in feveral parts of the body, particularly about the neck and head. While thefe fymptoms take place, the appe- tite is impaired, fome thiift arifes, and a general lafli- tude is felt over all the body. MLI. Thefe fymptoms (mxlvih—ml.) mark the violence and height of the difeafe ; which, however, does not commonly continue long. By degrees the cough be- comes attended with a copious excretion of mucus ; which is at firft thin, but gradually becoming thicker, is brought up with lefs frequent and lefs laborious coughing. The hoarfenefs and forenefs of the tra- chea, likewife going off, the febrile fymptoms abating, the cough becoming lefs frequent, and with lefs ex- pectoration, the difeafe foon after ceafes altogether. MLII. Such is generally the courfe of this difeafe, which is commonly neither tedious nor dangerous; but, upon fome occafions, it is in both refpects otherwife. A perfon affected with catarrh feems to be more than u- Vol. II. G fualiy SO P R A C TTL h fually liable to be affected by cold air ; and in that condition, if expofcd to cold, the difeafe, which feem- ed to be yielding, is often brought back with greater violence than before : and is rendered not only more tedious than otherwife it would have been, but alfo more dangerous by the fupervening of other difeafes. MLIII. Some degree of the cynanche tonfillaris often ac- companies the catarrh; and when the latter is aggra- vated by a frefli application of cold, the cynanche al- fo becomes more violent and dangerous, in confe- quence of the cough which is prefent at the fame time. MLIV. When a catarrh has been occafioned by a violent caufe; when it has been aggravated by improper ma- nagement ; and efpecially when it has been render- ed more violent by frefli and repeated applications of cold, it often paffes into a pneumonic inflammation attended with the utmoft danger. MLV. Unlefs, however, fuch accidents as thofe of mlii— mliv. happen, a catarrh, in found perfons not far advanced in life, is, I think, always a flight difeafe, and attended with little danger. But, in perfons of a phthifical difpofition, a catarrh may readily produce a hemoptyfis, or perhaps form tubercles in the lungs; and more certainly, in perfons who have tubercles al- ready in the lungs, an accidental catarrh may occa- fion the inflammation of thefe tubercles, and in confe- quence produce a phthifis pulmonalis. MLVI. In elderly perfons, a catarrh fometimes proves a dangerous difeafe. Many perfons, as they advance in life, and efpecially after they arrive at old age, have the natural mucus of the lungs poured out in greater quantity, and confequently requiring a fre- quent OF PHYSIC. 5< quent expectoration. If therefore a catarrh happen to fuch perfons, and increafe the afflux of fluids to the lungs, with fome degree of inflammation, it may produce the peripneumonia notha, which in fuch caf- es is very often fatal, See ccclxxvi—ccclxxxh. MLVII. The proximate caufe of catarrh feems to be an in- creafed afflux of fluids to the mucous membrane of the ncfe, fauces, and bronchia?, along with fome de- gree of inflammation affecting thefe parts. The lat- ter circumitance is confirmed by this, that in the cafe of catarrh, the blood drawn from a vein, commonly exhibits the fame inflammatory cruft which appears in the cafe of phlegmafiae. MLVIII. The application of cold which occafions a catarrh, probably operates by diminifhing the perfpiration ufu- ally made by the fkin, and which is therefore deter- mined to the mucous membrane of the parts above mentioned. As a part of the weight which the body daily lofes by infeniib'e evacuation, is owing to an ex- halation from the lungs, there is probably a connec- tion between this exhalation and the cutaneous per- fpiration, fo that the one may be increafed in propor- tion as the other is diminilhed: and therefore we may underftand how the diminution of cutaneous per- fpiration, in confequence of the application of cold, may increafe the afflux of fluids to the lungs, andv thereby produce a catarrh. MLIX. There are fome obfervations made by Dr. James Keil which may feem to render this matter doubtful ; but there is a fallacy in his obfervations. The evident effects of cold in producing coryza, leave the matter ia general without doubt; and there are feveral other circumftances which fhow a connection between tlje lun^s and the furface of the body. G 2 MLX. $2 PRACTICE MLX. Whether, from the fuppreflion of perfpiration, a catarrh be produced merely by an increafed afflux of fluids, or whether the matter of perfpiration be at the fame time determined to the mucous glands, and there excite a particular irritation, maybe uncertain; but the latter fuppofition is fufficiently probable. MLXI. Although, in the cafe of a common catarrh, which is in many inftances fporadic, it may be doubt- Ail whether any morbific matter be applied to the mu- cous glands ; it is, however, certain, that the fymp- toms of a catarrh do frequently depend upon fuch a matter being applied to thefe glands; as appears from the cafe of the mealies, chin-cough, and efpecially from the frequent occurrence of contagious and epide- mical catarrh. MLXII. The mention of this laft leads me to obferve, that there are two fpecies of catarrh, as I have maiked in my Synopfis of Nofology. One of thefe, as I fuppofe, is produced by cold alone, as has been explained above; and the other feems manifeftly to be produced by a fpecific contagion. Of fuch contagious catarrhs*, I have pointed out in the Synopfis many inftances occurring from the 14th century down to the prefent day. In all thefe in- ftances the phenomena have been much the fame; and the difeafe has always been particularly remarka- ble in this, that it has been the moft widely and ge- nerally fpieading epidemic known. It has feldom ap- peared in any one country of Europe, without appear- ing fucceflively in every other part of it; and in fome inftances, it has been even transferred to America, and has * Thefe epidemical catarrhs have been lately termed Influenzas. OF PHYSIC. 53 has been fpread over that continent, fo far as we have had opportunities of being informed. MLXIII. The catarrh from contagion appears with nearly the fame fymptoms as thofe mentioned mxlviii.—ml. It fejms often to come on in confequence of the ap- plication of cold. It comes on with more cold fhiver- ing than the catarrh arifing from cold alone, and foon- er fhows febrile fymptoms, and thefe likewife in a more confiderable degree. Accordingly, it more fpee- dily runs its courfe, which is commonly finifhed in a few days. It fometimes terminates by a fpontaneous fweat; and this, in fome perfons, produces a miliary eruption. It is, however, the febrile ftate of this dif- eafe efpecially, that is finifhed in a few days : for the cough, and other catarrhal fymptoms, do frequently continue longer ; and often, when they appear to be going off, they are renewed by any frefh application of cold. MLX1V. Confidering the number of perfons who are affected with catarrh, of either the one fpecies or the other, and efcape from it quickly without any hurt, it may be allowed to be a difeafe very free from danger; but it is not always 10 be confidered as fuch ; for in fome perfons it is accompanied with pneumonic inflamma- tion. In the phthifically difpofed, it often accele- rates the coming on of phthifis ; and in elderly per- fons, it frequently proves fatal in the manner explain- ed above, mliv. and mlvi. MLXV. The cure of catarrh is nearly the fame, whether it proceed from cold or contagion; with this difference, that in the latter cafe, remedies are commonly more neceffary than in the former. In the cafes of a moderate difeafe, it is commonly fufficicnt to avoid cold, and to abftain from animal food 54 PRACTICE food for fome days* ; or perhaps to lie a-bed, and by taking frequently of fome mild and diluent drink, a little warmed, to promote a very gentle fweat; and after thefe to take care to return very gradually only, tp the ufe of the free air. MLXVI. When the drfeafe is more violent, not only the anti- phlogiftic regimen muft be exactly obferved, but va- rious remedies alfo become neceflary. To take off the phlogiftic diathefis which always at- tends this difeafe, blood-letting, in a larger or fmaller quantity, and repeated according as the fymptoms fhall require, is the proper remedy. For reftoring the determination of the fluids to the furface of the body§, and at the fame time for expe- ding the fecretion of mucus in the lungs, which may take off the inflammation of its membrane, vomiting is the moft effectual means. For the latter purpofe, it has been fuppofed, that fquills, ^ * Perhaps an abfiinence from all food would accelerate the cure : The mucilaginous drinks ought to be taken in confiderable quanti- ties, and they are fomewhat nutritive. § The means of producing a gentle and continued perfpiration have been mentioned 'n a former note. In catarrh, however, the ufe of the warmer fudorifics feems more effectual. The elixir parc- goricum, diluted with whey, efpecially whey made with the dulcified fpint of nitre, is of Angular ufe ; hut it ought not to be given if there is a confiderable degieeof phlogiliic diathefis. In this cafe a fpoon- fuj of the following folution may be given every two or three hours, till a fweat breaks out : &. Tart. emet. gr. ii. Aq. font. |vi. fiyr. Ahhxx ?ii. M. It will be neceffary for the patient to chew occafionally fome muci- laginous demulcent, as Extract of Liquorice, &c. or to take a tea- fpoonful of equal parts of oil and honey, in order to prevent the fharp matter from irritating the fauces. The Elect, pedorale of the O FTTTT SIC. 56 fquills, gum ammoniac*, the volatile alkali, and fome other medicines, might be ufeful : but their efficacy has never appeared to me to be confiderable ; and, if fquills have ever been very ufeful, it feems to have been rather by their emetic, than by their expecto- rant powers. When the inflammatory affections of the lungs feem to be confiderable, it is proper, befides blood- letting, to apply blifters on fome part of the thorax. As a cough is often the moft troublefome circum- ftanceof this difeafe, fo demulcents may be employed to alicviate it. See ccclxxiii. But after the inflammatory fymptoms have much a- bated, if the cough fhould ftill continue, opiates af- ford the moft effectual means of relieving it; and in the circumftances juft now mentioned, they may be very fafely employed. See ccclxxv. After the inflammatory and febrile ftates of this difeafe are almoft entirely gone, the moft effectual means of difcufling all remains of the catarrhal af- fection, is by fome exercifeof geftation diligently em- ployed. CHAP. Edinburgh Pharmacopoeia not only relieves the tickling, but tends to produce a falutary diaphorefis ; its dofe is the fize of a nutmeg three or four times a-day. * The ammoniac and fquills may be joined together in the fol- lowing form : g,. Lac ammoniac. §iv. Syr. Scillit. %'ui. M. This mixture muft be acknowledged to be fomewhat naufeous, but it has confiderable efficacy. The dofe of it is two; or (if the ftomach can bear it) three table fpoonfuls twice a-day. 56 P R A C THE CHAP. II. OF THE DYSENTERY. MLXVII. THE dyfentery is a difeafe in which the patient ha3 frequent flools accompanied with much griping, and followed by a tenefmus. The ftools, though fre- quent, are generally in fmall quantity ; and the mat- ter voided is chiefly mucus, fometimes mixed with blood. At the fame time the natural faeces feldom ap- pear, and, when they do, it is generally in a compact and hardened form. MLXVIII. This difeafe occurs efpecially in fummer and autumn; at the fame time with autumnal intermittent and remittent fevers; and with thefe it is fometimes com- bined or complicated*. MLXIX. The difeafe comes on fometimes with cold fhiver- ings, and other fymptoms of pyrexia; but more com- monly the fymptoms of the topical affection appear firft. The belly is coftive, with an unufual flatulence in the bowels. Sometimes, though more rarely, fome degree of diarrhoea is the firft appearance. In moft cafes the difeafe begins with griping, and a frequent inclination to go to ftool. In indulging this, little is voided; but fome tenefmus attends it. By degrees* the ftools becomes more frequent, the griping more fevere, and the tenefmus more confiderable. Along with thefe fymptoms there is a lofs of appetite ; and frequently ficknefs, naufea, and vomiting, alfo affect- ing the patient. At the fame time there is always more or lefs of pyrexia prefent, which is fometimes of the * It appears more efpecially in armies encamped in low fwampy grounds, and, without proper management, is highly deftructtve. OF PHYSIC. 57 the remittent kind, and obferves a tertian period.— Sometimes the fever is manifeftly imflammatory, and very often of a putrid kind. Thefe febrile ftates con- tinue to accompany the difeafe during its whole courfe, efpecially when it.terminates foon in a fatal manner. In other cafes, the febrile ftate almoft en- tirely difappears, while the proper dyfenteric fymp- toms remain for a long time after. MLXX. In the courfe of the difeafe, whether of fliorter or longer duration, the matter voided by ftool is very va- rious. Sometimes it is merely a mucous matter, without any blood exhibiting that difeafe which Dr. Roderer has named the morbus mucofus, and others the dyfenteria alba. For the moft part, however, the mucus difcharged is more or lefs mixed with blood. This fometimes appears only in ftreaks amongft the mucus; but at other times is more copious, tinging the whole of the matter difcharged ; and upon fome occafions a pure and unmixed blood is voided in con- fiderable quantity. In other refpects, the matter voided is varioufly changed in colour and confidence, and is commonly of a ftrong and unufnaily £.-t.d odour; It is probable, that fometimes a genuine pus is voided; and frequently a putrid fanies, proceeding from gan- grenous parts. There are very often mixed with the liquid matter fome films of a membranous appearance* and frequently fome final I mafles of a feemingly feba- eeous matter. MLXXI. While the ftools confuting of thefe "anous matters are in many inftances, exceeding'}' fre;.ient., it is felJ dom that natural faeces appear in them; axid when they do appear, it is, as I have mentioned, in the form of fcybala, that is, in fomewhat hardened, fepa- rate balls. When thefe are voided, whether by the efforts of nature, or as folicited by art, they procure H a remit- 58 PRACTICE a remiflionof all the fympto ms, and more efpeci- ally of the frequent ftools, griping, and tenefmus. MLXXII. Accompanied with thefe circumftances, the difeafe proceeds for a longer or a fhortcr time. When the pyrexia attending it is of a violent inflammatory kind, and more efpecially when it is of a very putrid nature, the difeafe often terminates fatally in a very few days, with all the marks of a fupervening gangrene. When the febrile ftate is more moderate, or difappears alto- gether, the difeafe is often protracted for weeks, and even for months; but even then, after a various dura- tion, it often terminates fatally, and generally in con- fequence of a return and confiderable aggravation of the inflammatory and putrid ftates. In fome cafes, the difeafe ceafes fpontaneoufly ; the frequency of ftools, the griping, and tenefmus, gradually diminifh- es, while natural ftools return. In other cafes, the difeafe, with moderate fymptoms, continues long, and ends in a diorrhcea, fometimes accompanied with li- enteric fymptoms. MLXXIII. The remote caufes of this difeafe have been vari- oufly judged of. It generally aiifes in fummer or au- tumn, after confiderable heats have prevailed for fome time, and efpecially after very warm, and at the fame time, very dry ftates of the weather ; and the difeafe is more frequent in warm, than in cooler climates.— It happens, therefore, in the fame circumftances and feafons which coniiderabiy affect the ftate of the bile in the human body ; but as the cholera is often with- out any dyfenteric fymptoms, and copious difcharges cf bile have b< en found to relieve the fymptoms of dy- fentery, it is difficult to determine what connection the difeafe has with the ftate of the bile. MLXXIV. It has been obferved, that the effluvia from very pu- trid OF PHYSIC. 59 trid animal fubftances, readily affect the alimentary canal; and upon fome occafions they certainly pro- duce a diarrhoea; but, whether they ever produce a genuine dyfentery, I have not been able to learn with certainty. MLXXV. The dyfentery does often manifeftly ariie from the application cf cold, but the difeafe is always contagi- ous; and by the propagation of fuch contagion, inde- pendent of cold, or other exciting caufes, it becomes epidemic in camps and other places. It is, therefore, to be doubted, if the application of cold does ever produce the difeafe, unlefs where the fpecific contagi- on has been previoufly received into the body : And upon the whole, it is probable, that a fpecific contagi- on is to be confidered as always the remote caufe oi this difeafe. MLXXVI. Whether this contagion, like many others, be of a permanent nature, and only fhows its effects in certain circumftances which render it active, or if it be occa-. fionally produced, I cannot determine. Neither, if the latter fuppofition be received, can I fax by what means it may be generated. As little do we know any thing of its nature, confidered in itfelf; cr at moft this only, that in common with many other contagions, it appears to be commonly of a putrid nature, and capa- ble of inducing a putrefcent tendency in the human body. This, however, does not at all explain its pecu- liar power in inducing thofe fymptoms which proper- ly and eflentially conftitute the difeafe of dyfenteiy. (mlxvii.) MLXXVII. Of thefe fymptoms the proximate caufe is ftill ob- fcure. The common opinion has been, that the dif- eafe depends upon an acrid matter received into, or generated in, the interlines themfelves exciting their H % perif- 6e PRACTICE periftaltic motion, and thereby producing the frequenf ftools which occur in this difeafe. But this fuppofi- tion cannot be admitted : for, in all the inftances known of acrid fubftances applied to the inteftines and producing frequent ftools, they at the fame time produce copious ftools, as might be expected from acrid fubftances applied to any length of the inteftines. This, however, is not the cafe in dyfentery ; in which the ftools, however frequent, are generally in very fraall quantity, and fuch as may be fuppofed to pro- ceed from the lower parts of the rectum only. With refpect to the fuperior portions of the inteftines, and particularly thofe of the colon, it is probable they are under a preternatural and confiderable degree of con- ftriction : For as I have obferved above, the natural faeces are feldom voided ; and when they are, it is in a form which gives reafon to fuppofe, they have been long retained in the cells of the colon, and confequent-. ly that the colon had been affected with a preternatu- ral conftriction. This is confirmed by almoft all the diffections which have been made of the bodies of dy- fenteric patients, in which, when gangrene had not extirely deftroyed the texture and form of the parts, confiderable portions of the great guts have been found affected with a very confiderable conftriction. MLXXVIII. I apprehend, therefore, that the proximate caufe of dyfentery, or at leaft the chief part of the proximate caufe, confifts in a preternatural conftriction of the co- lon, occafioning at the fame time thofe fpafmodic ef- forts which are felt in fevere gripings; and which efforts, propagated downwards to the redum, occafion there the frequent mucous ftools and tenefmus.— But, whether this explanation fhall be' admitted or not, it will ftill remain certain, that hardened faeces re- tained in the colon are the caufe of the griping, fre- quent ftools and tenefmus :for the evacuation of thefe fasces, OF PHYSIC. 61 feces, -whether by nature or by art, gives relief from the fymptoms mentioned ; and it will be more fully and ufefully confirmed by this, that the moft immedi- ate and fuccefsful cure of dyfentery, is obtained by an early and conftant attention to the preventing the conftriction, and the frequent ftagnation of Leces in the colon. MLXXIX. In this manner I have endeavoured to afcertain the proximate caufe of dyfentery, and therefore to point out alfo the principal part of the cure, which from want of the proper view of the nature of the difeafe, feems to have been in feveral refpects fluctuating and undetermined among practitioners. MLXXX.' The moft eminent of our late practitioners, and of greateft experience in this difeafe, feem to be of opi- nion, that the difeafe is to be cured moft effectually by purging afliduoufly employed. The means may be various; but the moft gentle laxatives are ufually fufEcient, and as they muft be frequently repeated, the moft gentle are the moft fafe ; the more efpecially as an inflammatory ftate fo frequently accompanies the difeafe. Whatever laxatives produce £h evacua- tion of natural faeces,, and a confequent remiflion of the fymptoms, will be fufficient to effectuate the cure. But if gentle laxatives fhall not produce the evacua- tion now mentioned, fome more powerful medicines muft be employed* : and I have found nothing more proper * I fhall fubjoin fome foimulas fuitable for procuring a paffage in the dyfentery. &. Infuf. fenn. gii. Mannas opt. 2;i, M. f. haull. £. iV»aunae gi. Sal Glauber gfs. Solve in aq- bullient, |iii. et addc Tinct. Cardamomi 3L . 6z PRACTICE proper or convenient than tartar emetic, given in fmall dofes, and at fuch intervals as may determine their operation to be chiefly by ftool. Rhubarb, fo frequently employed, is in feveral refpects amongfl the moft improper purgatives. MLXXXI. Vomiting has been held a principal remedy in this difeafe; and may be ufefully employed in the begin- ning of it, with a view to both the ftate of the ftomach and of the fever : but it is not neceffary to repeat it often ; and unlefs the emetics employed operate alfo by ftool, they are of little fervice. Ipecacuanha feems to poflefs no fpecific power : and it proves only ufeful when fo managed as to operate chiefly by ftool. MLXXXII. For relieving the conftriction of the colon, and e- vacuating the retained faeces*, glyfters may fometimes be ufeful: but they are feldom fo effectual as laxatives given by the mouth ; and acrid glyfters, if they be not effectual in evacuating the colon, may prove hurtful by ftimulating the rectum too much. MLXXXIII. The frequent and fevere griping attending this dif- eafe, lead^aimoft neceffarily to the ufe of opiates, and they are very effectual for the purpofeof relieving from the gripes; but by occafioning an interruption of the ac- tion Where ftronger purgatives are requifite, &. Reftn. Jalap, gr. x. vel. xv. Tere in mortario marmoreo, cum, Armygdal. dulc. decort. No. iii. Sac'i. alb. 3L Defn adde Aq. cinnamom. fimpl. ^ifs. M. * Clyftcrsi.i thefe cafes ought to be made very large, and they ougbt alfo to be very nii!d ; as a pint and an half, or even two pints, of thin lintfeed-tea, or deco&ion of marih-mallows,, without any o- ther addition. OFPHYSIC. 63 tion of the fmall guts, they favour the conftriction of the colon, and thereby fometimes aggravate the dif- eafe : and if at the fame time the ufe ofthem fuperfede in any meafure the employing of purgatives, it com- monly does much mifchief; I believe it indeed to be only the neglect of purging, that renders the ufe of opiates very neceffary*. MLXXXIV. When the gripes are both frequent and fevere, they may fometimes be relieved by the employment of a femicupium, or by a fomentation of the abdomen, continued for fome time. In the fame cgfe, the pains may be relieved, and, as 1 think, the conftriction of the colon may be taken off, by blifters applied to the lower bellyj*. MLXXXV. At the beginning of this difeafe, when the fever is any way confiderable, Wood-letting, in patients of to- lerable vigour, may be proper and neceffary; and, when the pulfe is full and hard, with other fymptoms of an inflammatory difpofition, blood-letting ought to be repeated. But, as the fever attending dyfente- ry is often of a putrid kind, or does, in the courfe of the * The griping is much relieved, and fometimes prevented, by drinking plentifully of any mucilaginous warm liquois during the operation of the purges ; as barley-water, with bruifed prunes boil- ed in it* + Blifters applied to the abdomen, befides being exofiively ttou- blefome, muft neceffarily be extremely painful. Practitioners have probably been deceived in thinking that blifters have relieved griping in the dyfentery, for they are feldom employed alone ; a,id the cfiedts of purges and diluents have perhaps been miftaken for the effects of a blifter that might have happened to have been applied at the time when thefe other remedies were ufed. Too ftrictan ta tuition to the falfe axiom, poft hoc ergo propter hoc, has heen the l^urce of nu- merous errors in the practice of phyfic, and lus raifed the reputa- tion of the phyfician and his remedies, when the merit was u:;iy due to nature. 64 PRACTICE the difeafe, become foon of that nature, blood-letting muft be employed with great caution. MLXXXVI. From the account now given of the nature of this difeafe, it will be fufficiently obvious, that^the ufe of aftringents in the beginning of it muft be abfolutely pernicious. MLXXXVII. Whether an acrid matter be the original caufe of this difeafe, may be uncertain: but from the indigef- tion and the ftagnation of fluids in the ftomach which attend thedifeafe, it maybe prefumed, that fomeacrid matters are conftantly prefent in the ftomach and intef- tines, and therefore that demulcents may be always ufefully employed. At the fame time, from this con- federation that mild oily matters thrown into the in- teftines into confiderable quantity always prove laxa- tive, I am of opinion that the oleaginous demulcents are the moft ufeful*. MLXXXVIII. * Some forms of thefe demulcents are given in the Pharmacopoeia, The following may be added for the fake of variety, as the patient frequently loaths Linctufes. &. Mann, opt. Ol. Amygdal. recent, a a |i. Syr. e Cort. aurant. ^fs. M. &. Syr. althaea;. Ol. Amygdal. Ele£t. lenitiv. a a ?i. M. §=. Conferv. cynofbat. gi. Syr. rofar. Ol. Amygdal a a §ii. M. Two tea-fpoonfuls of any of the above tin&ures may be given every hour, or every other hour, drinking, at the fame time, bar- ley-water with bruifed prunes boiled in it. The cure of a dyfentery is briefly comprehended in keeping the belly open, and ufing mucilaginous diluents and lubricants. OF PHYSIC. 65 MLXXXVIII. As this difeafe is fo often of an inflammatory or of a putrid nature, it is evident that the diet employed in it fhould be vegetable and acefcent. Milk in its en- tire ftate is of doubtful quality in many cafes; but fome portion of the cream is often allowable, and whey is always proper. In the firft ftages of the difeafe, the fweet and fuba- cid fruits are allowable, and even proper. It is in the more advanced ftages only that any morbid acidi- ty feems to prevail in the ftomach, and to require fome referve in the ufe of accfcents. At the begin- ning of the difeafe, abforbenti feem to be fuperfluous ; and by their aftringent and feptic powers they may be hurtful. MLXXXIX. When this difeafe is complicated with an intermit- tent fever, and is protracted from that circumftance chiefly, it is to be treated as an intermittent, by ad- miniftering the Peruvian bark, which, however, in the earlier periods of the difeafe, is hardly to be ad* mitted. .<..«..«..«..«..«..«..<..< ..<^»^y">»>"K»->">-».»- PART IL O F NEUROSES, O R NERVOUS DISEASES. MXC. IN a certain view, almoft the whole of the difeafes of the human body might be called Nervous : Vol. II. I but 66 PRACTICE but there would be no ufe for fuch a general appella- tion ; and, on the other hand, it feems improper to limit the term, in the Ioofe inaccurate manner in which it has been hitherto applied, to hyfteric or hy- pochond-ical diforders, which are themfelves hardly to be defined with fufficient preciiion. MXCI. In this place I propofe to comprehend, under the title of Neuroses, all thofe preternatural affections of fenfe or motion which are without pyrexia, as a part of the primary difeafe; and all thofe which do not depend upon a topical affection of the organs, but up- on a more general affection of the nervous fyftem, and of thofe powers of the fyftem upon which fenfe and motion more efpecially depend. MXCIL Of fuch difeafes I have eftablifhed a clafs, under the title of Neuroses or Nervous Diseases. Thefe I again diftinguifh, as they confift, either in the inter- ruption and debility of the powers of fenfe and moti- on, or in the irregularity with which thefe powers are exercifed ; and have accordingly arranged them under the four orders of Comata, Adynamia, Spafmi, and Ve- fania, to be defined as we proceed to treat of them more particularly. BOOK OFPHYSIC. 67 BOOK I. OF COMA T A; OR, OF THE LOSS OF VOLUNTARY MOTION. MXCIII. UNDER this title are comprehended thofe affec- tions which have been commonly called the Soporofe difeafes; but they are moft properly diftin- guifhed by their confifting in fome interruption or fup- preflion of the powers of fenfe and voluntary motion, or of what are called the animal functions. Thefe are indeed ufually fufpended in the time of natural fleep : but of all the difeafes to be comprehended un- der our title, fleep, or even the appearance of it, is not conftantly a fymptom. Of fuch difeafes I can mark and properly explain two genera only, which come under the titles of Apoplexy and Palfy. CHAP. I. OF APOPLEXY. MXCIV. APOPLEXY is that difeafe in which the whole of the external and internal fenfes, and the whole of the voluntary motions, are in fome degree abolifh- cd ; while refpiration and the action of the heart con- I z tinue 65 PRACTICE tinue to be performed*. By its being an affection of the whole of the powers of fenfe and of voluntary motion, we diftinguifh it from Palfy ; and by its be- ing with the continuance of refpiration and the ac- tion of the heart, it is diftinguifhed from Syncope. I have further added to the ordinary definition of apo- plexy, that the abolition of the powers of fenfe and motion is in fome degree only ; meaning by this to im- ply, that, under the title of Apoplexy, are here com- prehended thofe difeafes which, as differing from it in degree only, cannot, with a view either to pathology or practice, be properly diftinguifhed from it : Such are the difeafes fometimes treated of under the names of Carus, Catapbora, Coma, and Lethargus. MXCV. Apoplexy, in all its different degrees, moft common. ly affects perfons advanced in life, and efpecially thofe above fixty years of age. It moft ufually affects perfons of large heads and fhort necksf, perfons of a corpulent habit, perfons who have paffed an indolent life and ufed a full diet, and efpecially thofe who have indulged in frequent intoxication. Men who have long laboured under a frequent and copious difcharge of blood from the * " The appearance of a profound and continual fleep," is by JSoerhaave judicioufly added to the definition of Apoplexy. To diftinguifh between a profound fleep and apoplexy, which very much refemble each other, is, however, extremely tafy. A man in a profound fleep may in general be roufed by the application 6f ftrong flimulants to the organs of fenfe which produce no effect on an apo- plectic patient. To diftinguifh between apoplexy and a fit of drunkennefs is not fo eafy ; for drunken people are fometimes incapable of being roufed by any ftimiLants, remaining totally infenfible and motionlefs. The fumes of the liquor with which they have been intoxicated may fome- times be difcovercd by fmelling : a drui.ken fit may alfo be known by the palenefs of the drunken man's face, and by his manner of living. f Different authors, one of whom is Boerhaave, have fppofed that a vertebra is wanting, the ne^k confifting only of l:x in Head ui feven vertebrae. O F P H Y S I C. 69 the hemorrhoidal veflels, upon either the fuppreflion, or fpontaneous ceafing of that difcharge, are particu- larly liable to be affected with apoplexy. MXCVI. This difeafe frequently comes on very fuddenly: but in many cafes it is preceded by various fymptoms, fuch as frequent fits of giddinefs, frequent headachs, a hemorrhagy from the nofe, fome tranfitory interrup- tions of feeing and hearing, fome falfe virion and hear- ing, fome^ tranfitory degree of numbnefs or lofs of motion in the extremities, fome faltering of the tongue in fpeaking, a lofs of memory, a frequent drow- flnefs, and frequent fits of incubus. MXCVil. An attention to thefe fymptoms, and to the predif- ponent circumftances, (mxcv.) will often enable us to forefee the more violent attacks of this difer.fe. MXCVIII. When the difeafe comes on fuddenly to a confiderable degree, it has been frequently obferved to have been immediately induced by violent exercife; by a full and long continued infpiration ; by a fit of anger; by much external heat, efpecially that arifing from a crowded affembly of people; by warm bathing ; by intoxication ; by long ftooping with the head down ; and a tight ligature about the neck. The difeafe has been remarked to make its attacks moft frequently in the fpring feafon, and efpecially when the vernal heat fuddenly fucceeds to the winter cold. MXCIX. The fymptoms denoting the prefence of this dif- eafe will be fufficiently known from the definition giv- en, mxciv. Although the whole of the body is af- iccted with the lofs of fenfe and motion, it fometimes takes place more upon one fide of the body than the other; and, in that cafe, the fide lcait affected whh palfy is fometimes affected with convullions. In this 7° PRACTICE difeafe there is often a ftcrtorous breathing; and this has been faid to be a mark of the moft violent ftate of the difeafe ; but it is not always prefent even in the moft complete form or moft violent degree of the dif- eafe. MC. The proximate caufe of this difeafe may be, in ge- neral, whatever interrupts the motion of the nervous power from the brain of the mufcles from voluntary motion ; or, in fo far as fenfe is affected, whatever interrupts the motion of the nervous power from the fentient extremities of the nerves to the brain, MCI. Such an interruption of the motions of the nervous power may be occafioned, either by fame compreffion of the origin of the nerves, or by fonts thing deylroying the mobility of the nervous power. Both thefe caufes we mult treat of more particularly ; and, firft, of that of compreffion, feemingly the moft frequent occafion of apoplexy, and perhaps the occafion of all thofe apo- plexies arifing from internal eaufes. MCII. The lefs of fenfe and motion in particular parts of the body, may be occafioned by a compreffion, either of the origin of certain nerves only, or of the fame nerves in fome part of their courfe from the brain to the organs of fer^c and motion. Such cafes of par- tial compreffion will be more properly confidered hereafter ; and the affection I am now to treat of be- ing general, it muft depend upon a very general com- preffion of the origin of the nerves, or medullary por- tion of the brain; and therefore, this more general compreffion only is to be confidered here MCIII. This compreflicn of the origin of the nerves or me. dullary portion of the brain, may be produced in dif- ferent ways; as, 1. Bv O F PH Y S I C. 7* i. By external violence fracturing and preffmg in a part of the cranium. 2. By tumours, fometimes foft, fometimes beny, formed in different parts of the brain, or in its mem- branes, and becoming of fuch a bulk as to comprefs the medullary fubftance of the brain. 3. By the blood accumulated in the blood-veffels of the brain, and diftending them to fuch a degree as to comprefs the medullary portion of the fame. 4. By fluids eflufed in different parts of the brain, or into the cavity of the cranium, and accumulated in fuch quantity as to occafion the compreffion we treat of. And, as to this laft, it is to be remarked here, that the fluids effufed may be of two kinds: that is, they may be either a portion of the common mafs of blood, poured out from red veflels; or a portion of ferum or colouilefs fluid, poured out chiefly by the exha- lants. MCIV. Of thefe feveral caufes cf compreffion, the firft is not to be confidered here, becaufe the removing it does not belong to our province; and the confederation of the fecond may be omitted, as in moft inftances it is neither to be difcerned nor cured by any means yet known. The third and fourth caufes of compreffion, as they are the moft frequent, and are alfo moft pro- perly the fubjects of our art, fo they are thofe which deierve our particular attention; and we fhall there- fore endeavour to trace them further back in the fe- ries of caufes which may produce them. MCV. Both the ftates of over-diftention and of effufion, may be produced by whatever increafes the afflux and impetus of the blood in the arteries of the head; fuch as violent exercife, a violent fit of anger, external heat applied, 72 PRACTICE applied, or any ftrong pre.Ture upon the defcending aorta. MCVI. But both thefe ftates of over-diftention and of effu- fion, may alfo and feem to be more frequently produc- ed by caufes that operate by preventing the free return of the venous blood from the veffels of the head to the right ventricle of the heai't. MCVII. The venous veflels of the brain are of a conforma- tion and diltribution fo peculiar, as lead us to believe, that Nature intended to retard the motion of the b'ood, and accumulate it in thefe veffels; and there- fore, even very fmall additional reliftances to the mo- tion of the blood from thefe towards the right ventri- cle cf the heart, may ftill more readily accumulate the blood in them. Such accumulation will moft readily happen in advanced life, when the venous fyf- tem in general is in a plethoric ftate, and when this plethora takes place efpecially in the venous veffels of the biain. It will,in like manner, be moft apt to oc- cur in perfons whofe heads are large with refpect to the reft of the body ; and in perfons of a fhort neck, which is unfavourable to the return of the venous blood from the head. The accumulation of blood in the venous veffels of the brain, will alfo be moft likely to occur in perfons of a corpulent habit, either be- caufe thefe may be confidered to be in a plethoric ftate, or becaufe obeiky, by occafioning a compreffion of the blood-veffels in other parts of the body, more readily fills thofe of the brain, which are entirely free from any fuch compreffion. MCVIII. Thefe are the circumftances in the conftitution of the body, which, producing a flower motion and re- turn of the venous blood from the veffels of the head, favour an accumulation and diftention in them ; and we OF PHYSIC. 73 we now proceed to mention the feveral o'ccafional caufes, which, in every perfon, may directly prevent the free return of the blood from the veflels of the head towards the heart. Such are, 1. Stooping down with the head, or other fttua- tions of the body in which the head is long kept in a depending ftate, and in which the gravity of the blood increafes the affiux of it by the arteries, and oppofes the return of it by the veins. 2. A tight ligature about the neck, which compreff- es the veins more ftrongly than the arteries. 3. Any obftruction of a confiderable number of the veins carrying the blood from the head, and more efpecially any confiderable obftruction of the afcend- ing vena cava. 4. Any confiderable impediment of the free paf- fage of the blood from the veins into the right ventri- cle of the heart; and it is commonly by this, and the immediately preceding circumftance, that polypous concretions in the cava, or right ventricle, are found to occafion apoplexy. 5. The return of blood from the veins of the head towards the heart, is efpecially interrupted by every circumftance that produces a more difficult tranfmif- fion of the blood through the veflels of the lungs. It is well known, that, at the end of every expiration, fome interruption is given to the free tranfmilfion of the blood through the lungs; and that this at the fame time gives an interruption to the motion of the blood from the veins into the right ventricle of the heart. This clearly appears from that regurgitation of the blood in the veins, which occafions the alternate heav- ing and fubfiding that is perceived in the brain offiv- ino- animals when the cranium is removed, and which is obferved to be fynchronous with the alternate mo- tions of refpiration. From this we readily perceive, that whatever occafions a difficulty in the tranfmiflion Vol. II. K of. 74 PRACTICE of the blood through the lungs, muft alfo interrupt the free return of the venous blood from the veflels of the head ; and muft therefore favour, and perhaps produce, an accumulation of blood, and an over-dif- tenti'/ii in thefe veflels. ft is further to be obferved, that as a very full in- fpiration, continued for any length of time, occafions fuch an interruption of the free tranfmiflion of the blood through the lungs, as produces a fuffufion of face, and a manifett turgefcence of the blood-veffels of the head and neck ; fo every full, and long-conti- nued infpiration may occafion an accumulation of blood in the veffels of the head, to a very confidera- ble degree. Thus, as every ftrong exertion of the mufcular force of the body requires, and is attended with, a very full and long-continued infpiration, we thence learn why. the violent exertions of mufcular force have been fo often the immediate or exciting caufes of apoplexy. It may alfo be remarked, that corpulency and obe- fity operate very much, by occafioning a more difficult tranfmiflion of the blood through the veflels of the lungs. It appears, that in fat perfons, from the com- preffion of the blood-veffels in many parts of the bo- dy, the veflels of the lungs are thereby kept very full; fo that, upon the leaft increafe of bodily motion, which fends the blood falter into the lungs, a more fre- quent and laborious refpiration becomes in fuch per- fons immediately neceffary. This fhows, that, in fuch perfons, the blood is not freely tranfmitted through the lungs ; a circumftance which, as in other inftances, muft give a conftant refiftance to the return of blood from the veffels of the head, and therefore favour or occafion an accumulation of blood in them. Is the motion of the blood in the veflels of the head rendered flower by ftudy, care and anxiety ? MCIX. O F P H Y S I C. 7S MCIX. It is to be obferved further, that thefe feveral cauf- es (mcv—mcviii.) of a preternatural fulnefs in the blood-veffels of the brain, may produce apoplexy in different ways, according as the fulnefs takes place in the arteries or in the veins. MCX. Accordingly,/^, the increafed afflux of blood in- to the arteries of the brain, and an increafed action in thefe, may either occafion a rupture of their extremi- ties, and thereby an effufion of red blood producing compreffion; or the fame afflux and increafed action may occafion an increafed exhalation from their ex- tremities, of a ferous fluid, which, if not as quickly re-abforbed, may foon accumulate in fuch quantity as to produce compreffion. MCXI. Secondly, The phletoric ftate of the venous veffels pf the brain, may operate in three different ways. i. The fulnefs of the veins may give fuch refiftance to the blood flowing into them from the arteries, as to determine the impetus of the blood to be f > much greater upon the extremities of the arteries as to occa- fion a rupture of thefe, and confequently an effufion of red blood, or the Hemorrhagic cerebri, which Hoffman confiders as a frequent caufe of apoplexy, and which we have before explained in dcclxxh. 2. Whilft the fame refiftance to the blood flowing from the arteries into the veins, increafes the impetus of the blood in the former, this may, without occafi- oning rupture, increafe the exhalation from their ex- halant extremities, and produce an effufion of a ferous fluid ; in the fame manner as fuch refiftance in the veins produces hydropic effufions in other parts of the body. 3. If we may fuppofe, as no lymphatics have been yet difcovered in the brain, that the ordinary abforfc- ' K1 ents 76 PRACTICE ents are not prefent there, and that the exhaled fluids are abforbed or taken up by the extremities of the veins ; this will fhow ftill more clearly that a refift- ance to the motion of the blood in the veins of the brain, may readily produce an accumulation of ferous fluid in its cavities, and confequently a compreffion producing apoplexy. MCXII. Befides thefe caufes of apoplexy from afflux in the arteries, or refiftance in the veins, an effufion of ferum may happen from two other caufes. The one is a relaxation of the exhalants, as in other cafes of hy- dropic diathefis prevailing in the body ; and it is not unufual for a general dropfy to end in apoplexy. The fecond is an over-proportion of watery parts in the mafs of blood, which is therefore ready to run off by the exhalants, as in the cafe of an ifchuria renalis; which, when it proves incurable, very commonly ter- minates in apoplexy. MCXIII. We have now mentioned the feveral caufes of apo- plexy depending upon compreffion; and from the whole it will appear, that the moft frequent of all thefe caufes is a plethoric ftate, or an accumulation and congeftion of blood in the venous veflels of the head, operating, according to its degree, in produc- ing over-^ittention or effufion. The frequent opera- tion of fuch a caufe will efpecially appear from a con- fideration of the predifponent circumftances (mxcv.) and from the antecedent fymptoms. (mxcvi.) MCXIV. From the view I have now given of the caufes of apoplexy arifing from compreffion, it will readily ap- pear that there is a foundation for the common dif- tinction of this difeafe into the two kinds of Sanguine and Serous. But this diftinction cannot be very ufe- fully applied in practice, as both kinds may often de- pend OF PHYSIC. 77 pend on the fame caufe, that is, a venous plethora, and therefore requiring very nearly the fame method of cure. ,The only diffinction that can be properly made of apoplexies from compreffion, is perhaps the dif- tinction of ferous apoplexy, into that depending on the plethora mentioned mcxui. and that depending upon hydropic diathefis, or an over-proportion of wa- ter in the blood (mcxii.) the former caufes giving a proper idiopathic, the latter only a fymptomatic, dif- eafe. MCXV. Befide the caufes now mentioned, occafioning apo- plexy by compreffion, I alledge there are other caufes producing the fame difeafe, by directly deftroying the mobility of the nervous power. Such caufes feem to be the mephtic arifing from fermenting liquors, and from many other fources ; the fumes arifing from burning charcoal, the fumes of mercury, of lead, and of fome other metallic fubftances; opium, alcohol, and many other narcotic poifons : To all which I would add the power of cold, of concuflion, of electri- citv, and of certain paflions of the mind. MCXVI. None of thefe poifons or noxious powers feem to kill by acting firft upon the organs of refpiration, or upon the fanguiferous fyftem ; and I believe their im- mediate and direct action to be upon the nervous pow- er, deftroying its mobility, becaufe the fame poifons fliovv their power in deftroying the irritability of muf- cles and of the nerves connected with them, when both thefe are entirely feparated from the reft of the body. MCXVII. It appears to me probable that the apoplectic ftate in fome degree accompanying, and almoft always fuc- ceeding, an epileptic paroxyfm, does not depend upon compreffion, but upon a certain ftate of immobility of the ;8 PRACTICE the nervous power, produced by certain circumftan- ces in the nervous fyftem itfelf, which fometimes feem to be communicated from one part of the body to ano- ther, and at length to the brain. MCXVIII. The fame obfcrvation may be made with refpect to many inftances of hyfteric paroxyfm ; and the circum- ftances, both of epileptic and hyfteric paroxyfms, end- ing in coma, or a degree of apoplexy, lead me to think, that alfo the apoplexy proceeding from retro- ceclent or atonic gout is of the fame kind, or that it depends upon an immobility of the nervous power, rather than upon compreffion. MCXIX. It may indeed happen, that as the apoplectic and gouty predifpofitions do' often concur in the fame perfon ; fo it may frequently happen, that the apo- plexy coming upon gouty perfons, may fometimes de- pend upon compreffion ; and defections may, accord- ingly, difcover that the circumftances of fuch a caufe had preceded. But, in many cafes of apoplexy fol- lowing a retrocedent, or atonic gout, no fuch antece- dent or concomitant circumftances, as commonly oc- cur in cafes of compreffion, do diftinctly or clearly ap- pear; while others prefent themfelves, which point out an affection of the nervous power alone. MCXX. With refpect, however, to the circumftances which may appear upon the diffection of perfons dead of a- poplexy, there may be fome fallacy in judging, from thofe circumftances, of the caufe of the difeafe. Whatever takes off or diminifhes the mobility of the nervous power, may very much retard the motion of the blood in the veflels of the brain ; and that perhaps to the degree of increafing exhalation, or even of oc- cafioning rupture and effufion : fo that, in fuch cafes, the marks of compreffion may appear, upon diffection, though OF PHYSIC. 79 though the difeafe had truly depended on caufes de- ftroying the mobility of the nervous power. This jfeems to be illuftrated and confirmed from what oc- curs in many cafes of epilepfy. In fome of thefe, af- ter a repetition of fits, recovered from in the ufual manner, a fatuity is induced, which commonly de- pends upon a watery inundation of the brain : And in other cafes of epilepfy, when fits have been often repeated without any permanent confequence, there happens at length a fatal paroxyfm; and upon diffection it appears, that an effufion of blood had happened. This, I think, is tobe confidered as a caufe of death, notasacaufe of the difeafe : for in fuch cafes, I fuppofe that the difeafe had diminifhed the action of the veflels of the brain, and thereby had given occafion to a ftagnation, which produced the appearances mentioned. And I apprehend the fame reafoning will apply to the cafes of retrocedent gout, which, by deftroying the energy of the brain, may occafion fuch a ftagnation as will produce rupture, effufion, and death; and in fuch a cafe, the appearances upon diffection might lead us to think that the apoplexy had depended entirely upon compreffion. MCXXL The feveral caufes mentioned in mcxv. are often of fuch power as to occafion immediate death ; and therefore have not commonly been taken notice of as affording inftances of apoplexy; but, as the operation of the whole of thefe caufes is fimilar and analogous, and as in moft inftances of the operation of thefe caufes an apoplectic ftate is manifeftly produced, there can be little doubt in confidering moft of the inftances of their effects as cafes of apoplexy, and therefore fuch as fall properly under our confideration here. MCXXII. This difeafe of apoplexy is fometimes entirely re- covered from ; but more frequently it ends in death, or 8a PRACTICE or in a hemiplegia. Even when an attack of the dif- eafe is recovered from, we generally find it difpofed to return; and the repeated attacks of it almoft al- ways, fooner or later, bring on the events we have mentioned. mcxxiti. The feveral events of this difeafe, in health, death, or another difeafe, may be expected and forefeen from a consideration of the predifponent circumftances (mxcv.); of the antecedent fymptoms (mxcvi.) ; of the exciting caufes (mxcviii.); of the violence and degree of the fymptoms when the difeafe has come on (mxciv.) ; of the duration of the difeafe ; and of the effects of the remedies employed. MCXXIV. From the great danger attending this difeafe when it has come on (mcxxii.), it will readily appear that our care fhould be chiefly directed to the prevention of it. This, I think, may be often done by avoiding the remote and exciting caufes; and how this may be accomplifhed, will be obvious from the enumeration of thofe caufes given above (mxcviii.) But it will alfo appear from what is faid above, that the prevention of this difeafe will efpecially depend upon obviating the predifponent caufe ; which, in molt cafes, feems to be a plethoric ftate of the blood-veffels of the brain. This, I think, may be obviated by different means; and, in the firft place, by a proper management of ex- ercile and diet. MCXXV. The exercife ought to be fuch as may fupport the perfpiration, without heating the body or hurrying ref- piration ; and, therefore commonly by fome mode of geftation. In perfons not liabie to frequent fits of giddinefs, and who are accuftomed to riding on horfe- back, this exercife is, of all others, the belt. Walk- ing, and fome other modes of bodily exercife, may be em- O F P H Y S I C. 81 employed with the reftrictions juft now mentioned ; but in old men, and in men of corpulent habits, bodi- ly exercife ought always to be very moderate. MCXXVI. In perfons who pretty early in life fhow the predif- pofition to apoplexy, it is probable that a low diet, with a good deal of exercife, might entirely prevent the difeafe ; but, in perfons who are advanced in life before they think of taking precautions, and are at the fame time of a corpulent habit, which generally flip- pofes their having been accuftomed to full living, it might not be fafe to put them upon a low diet: and it may be enough that their diet be rendered more moderate than ufual, efpecially with refpect to animal? food ; and that, at fupper, fuch food fhould be ab- ftained from altogether. In drinking, all heating liquors are to be abftained from, as much as former habits will allow; and the fmallefl approach to intoxication is to be carefully fliunned. For ordinary draught, fmall beer is to be preferred to plain water, as the latter is more ready to occafion coftivenefs, which in apoplectic habits is to be carefully avoided. The large ufe of tobacco in any fhape may be hurtful; and except in cafes where ic has been accuftomed to occafion a copious excretion s from the head, the interruption of which might not t be fafe, the ufe of tobacco fhould be avoided; and s, even in the circumftance mentioned, where it may be in fome meafure neceffary, the ufe of it fhould at leaft be rendered as moderate as poflible. MCXXVII. Evacuations by ftool may certainly contribute to i relieve the plethoric ftate of the veflels of the head; and, upon appearance of any unufual turgefcence in thefe, purging will be very properly employed : but, when no fuch turgefcence appears, the frequent repe- tition of large purging might weaken the bedy too Vol. II. L much; 82 PRACTICE much ; and, for preventing apoplexy, it may for the! molt part be enough to keep the belly regul.ir, and rather open, by gentle laxatives*. In the fummer feafon, it may be ufeful to drink, every morning, of a gentle laxative mineial water, but never in large quantity. MCXXVIII. In the cafe of a plethoric ftate of the fyftem, it might be fuppofed that blood-letting would be the moft effectual means of diminifhing the plethora, and of preventing its confequenccs ; and, when an attack of apoplexy is immediately threatened, blood-letting is certainly the remedy to be depended upon; and blood fhould be taken largely, if it can be done, from the jugular vein, or temporal artery.' But, when no threatening turgefcence appears, the obviating plethora is not judicioufly attempted by blood-let- ting, as we have endeavoured to demonftrate above, dcclxxxvu. In doubtful circumftances, leeches ap- plied to the temples or fcarifications of the hind-head, may be more fafe than general bleedings. MCXXIX. When there are manifeft fymptoms of a plethoric ftate in the veffels of the head, a feton, or pea-iffue, near the head, may be very ufeful in obviating any turgefcence of the blood. MCXXX. Thefe are the means to be employed for preventing the * Gentle laxatives hare been often enumerated in the preceding notes. In tnefe cafes, however, there is no danger to be apprehend- ed from the ufe of the refinous draftics, provided that they are not given in fuch yifafat may weaken the patient too much. They ought to be ule-1 tor toe purpofe of purging, but only fcr keeping tnc body moderately open ; and this effeft may be fafely produced by five or eight grains of Itufns's pills taken occafionally at bed-time, or by a tea-Ipoonful or two of the Tinft. jalap, or a tabls-fpoonful oftheel.xirfennaeui the morning. The fame end may, la r.any GAlei, be anlsvered Ly a due attention to diet. OF PHYSIC. 83 the apoplexy which might arife from a plethoric ftate of the veffels of the brain ; and if, at the fame time, great care is taken to avoid the exciting caufes (mxc- viii.), thefe means will be generally fuccefsful. In the cafes proceeding from other caufes (mcxv.), as their application is fo immediately fucceeded by the difeafe, they hardly allow any opportunity for pre- vention. MCXXXI. For the Cure of apoplexies from internal caufes, and which I fuppofe to be chiefly thofe from compref- fion, the ufual violence and fatality of it require that the proper remedies be immediately and largely em- ployed. The patient is to be kept as much as poflible in fomewhat of an erect pofture, and in cool air, and therefore neither in a warm chamber, nor covered with bed*clothes, nor furrounded with a crowd of people. 1VJCXXX1I. In all cafes of a full habit, and where the difeafe has been preceded by marks of a plethoric ftate, blood- letting is to be immediately employed, and very large- ly. In my opinion, it will be mcft effectual when the blood is taken from the jugular vein ; hut if that can- not be properly done, it may be taken from the arm. The openirjg of the temporal artery, when a large branch can be opened, fo as fuddenly to pour out a confiderable quantity of blood, may alfo be an effectu- al remedy; but, in execution, it is more uncertain, and may be inconvenient. It may be, in fome mea- fure fupplied, by cupping and fcarifyingon the tem- ples or hind-head. This, indeed, fhould feldom be omitted : and thefe fcarifications are always preferable to the application of leeches. With refpect to every mode of blood-letting, this is to be obferved, that when in any cafe of apoplexy, L 2 'it 84 PRACTICE it can be perceived that one fide of the body is more affected with the lofs of motion than the other, the blood-letting, if poflible, fhould be made on the fide oppofite to that moft affected*. MCXXXIII. Another remedy to be employed is purging, to be immediately attempted by acrid glyfters § ; and at the fame time, if any power of fwallowing remain, by draftic purgatives given by the mouth. Thefe, however, left they may excite vomiting, mould be given in divided portions at proper intervals-]-. MCXXXIV. Vomiting has been commended by fome practi- tioners and writers: but, apprehending that this might impel * DifTe&ions fhew that the congestions producing apoplexy are al- ways on the fide not affected; and hence the propriety of the direction, § Acrid clyfters are, ]},. El;d. lenitiv. ^i. Sal. cathartic, amar. S;iifs. Aq. tepid, ^xi. M. f. Enema. R. Sapon. alb. ^ifs. Solve in aq. tepid. Sjx. cui adde Syr. e fpiua cerv. §ii. M. f. Enema. R. Pidp. colocynth. ^iii. Ccque per horae quadrantem in aq. font. q. f- adcolutaroe Ixii. cui adde Ol. Olivar. gi. M. f. Enema. ■{■ The draftic purges are, in thefe cafes, to be given in draughts, rather than in pills or bolufes ; the following form may be ufed : &. Pulv. Jalap. 3i. Rad, ziiizib. 3i. Infuf. fern, lini ziii.l M. 6 ' The dofe of this mixture is two fpoonfuls every two hours till it <» perate : or we may ufe one of the formulae mentioned in the note on article 1080, efpecially the lall, repeating it every two hours till it produces an effect. or PHYSIC. 85 impel the blood with too much violence into the vef- fels of the head, I have never employed it. MCXXXV. Another remedy to be immediately employed is bliftering ; and I judge that this is more effectual when applied to the head, or near to it, than when it is ap- plied to the lower extremities. This remedy I do not confider as a ftimulant, or capable of making any confiderable revulfion; but, applied to the head, I fuppofe it ufeful in taking off the hemorrhagic difpo- fitionfo often prevailing there. MCXXXVI. It has been ufual with practitioners, together with the remedies already mentioned, to employ ftimulants of various kinds; but I am difpofed to think them generally hurtful; and they muft be fo, wherever the fulnefs of the veffels, and the impetus of the blood in thefe, is to be diminifhed. Upon this principle it is therefore agreed, that ftimulants are abfolutely impro- per in what is fuppofed to be a fanguine apoplexy ; but they are commonly fuppofed to be proper in the ferous. If, however, we be right in alledging that this alfo commonly depends upon a plethoric ftate of the blood-veffels of the brain, ftimulants muft be equally improper in the one cafe as in the other. MCXXXVII. It may be argued from the almuft univerfal employ- ment of ftimulants, and fometimes with feeming ad- vantage, that they may not be fo hurtful as my no- tions of the caufes of apoplexy lead me to fuppcfe. But this argument is, in feveral refpects, fallacious ; and particularly in this, that in a difeafe which, un- der every management, often proceeds fo quickly to a fatal termination, the effects of remedies arc not to be eafily afcertained. MCXXXVIII. I have now mentioned the feveral remedies which I think 36 PRACTICE I think adapted to the cure of apoplexy arifing f.oia compreffion, and fho ild next proceed to treat of the cure of apoplexy arifing from thofe caufes that directly dellroy the mobility of the nervDus power But many of thofe caufes are often fo powerful, and thereby fo fuddenly fatal in their ef- fects, as hardly to allow of time for the ufe of reme- dies ; and fuch cafes, therefore, have been fo feldom thefiibjccts of practice, that the proper remedies are not fo well afcertained as to enable me to fay much of them here. MCXXXIX. When, hv.v-yer, the application of the caufes, (mcxv.) is not fo powerful as immediately to kill, and induces only an apoplectic ftate, fome efforts are to be made to obviate the confequences, and to recover the patient; and even in fome cafes where the caufes re- fe red to, from theceafing of the pulfe and of refpira- tion, and from a coldnefs coming upon the body, have i ml need an appearance of death ; yet, if thefe appear- ances have not continued lone;, there may be means of recovering the perfons to life and health, I cannot, indeed, treat this fubject completely ; but for the cure of apoplexy from feveral of the caufes mentioned mcxv. malt oT.:r the following general directions. 1. When a poifon capable of producing apoplexy has been recent'y t.-iken into the ftomach, if a vomit- ing fpontaneoufly arifes, it is to be encouraged ; or, if it doe:, not fpontaneoufly come on, a vomiting is to be immediately excited by art, in order that the poifon nay be thrown out as quickly as poflible. If, howe- ver, the poifon has been taken into the ftomach long before its effects have appeared, we judge that, upon their appearance, the exciting of vomiting will be ufelefs, and may perhaps be hurtful. 2. When the poifon taken into the ftomach, or othenviie applied tu the body, has already induced an apo- O F P H Y s i c: t7 apoplectic ftate, as thofe caufes do commonly at the fame time occafion a ftagnation or flower motion of the blood in the veffels of the brain and of the lungs, ifo it will generally be proper to relieve this congcftion by taking fome blood from the jugular vein, or from the veins of the arm. 3. Upon the fame fuppofition of a congefiion in the brain or lungs, it will generally be proper to relieve it by means of acrid glyfters producing fume evacuation from the inteftines. 4. When thefe evacuations by blood-lettin^ and purging have been made, the various ftimulants which have been commonly propofed in other cafes of apo - plexy, may be employed here with more probability and fiifety*^ One of the moft effectual means of roof- ing apoplectics of this kind feems to be throwing cold water on feveral parts of the body, or wafhin-p the bo- dy all over with it. 5. Although the poifon producing apoplexy hap- pens to be fo powerful as very foon to occafion the ap- pearances of death above-mentioned ; yet if this ftate has not continued long, the patient may often be re- coverable ; and the recovery is to be attempted by the fame means that are directed to be employed for the recovery of drowned perfons, and which are now commonly known. C H A P. * The ftimulants are various according to the variou* parts of the body to which they are generally applied, as volatile and vinous fpr- rits, or vinegar, to the nofe and temples ; acrid effential oils, mixed with thrice jlhcir weight i\i hog's lard", to the brcait and back; ba- ilers, hot finapiims, and warm fomentations, with horfe-radifn, to the extremities ; frictions with warm brulrus ; the r.-'iual cautery to the foles of the feet,.and palms oi: the hands; with feveral oth 1,, which are more particularly defcribed in the notes on article 1161, et feq. 88 PRACTICE C II A P. II. O F ? A L S T. MCXL. PALSY is a difeafe confiftingin a lofs of the pow- er of voluntary; motion, but affecting certain parts of the body only', and by this it is diftinguifhed from apoplexy, (mxciv.) One of the moft freqqent forms of paify is when it affects the whole of the muf- cles on one fide of the body ; and then the difeafe is named a Hijr/.:;iple$ia. MCXLI. The lufs of the power of voluntary motion may be owin - either to a morbid affection of the mufcles or (.roans of motion, by which they are rendered unfit for motion ; or to an interruption of the influx of the nervous power into them, which is always neceffary to the motions of thofe that are under the power of the will. The difeafe, from the firit of thefe caufes, as confiftingin an organic and local affection, we refer entirely to the clafs of local difeafes. I am here to confider that difeafe only which depends upon the in- terrupted influx of the nervous power ; and it is to this difeafe alone I would give the appellation of Paify. A difeafe depending on an interrupted influx of the nervous power, may indeed often appear as merely a local affection ; but as it depends upon an affection of the moft general powers of the fyftem, it cannot be properly ieparated from the fyitematic af- fections. MCXLII. In paify, the lofs of motion is often accompanied with tiie lofs of fenfe ; but as this is not conftantly the cafe, and as therefore the lofs of ferfe is not an eflen- tial OF PHYSIC. 89 tial fymptom of paify, I have not taken it into my defi- nition (mcxl.); and I fhall not think it neceffary to take any further notice of it in this treatife ; becaufe, in fo far as it is in any cafe a part of the paralytic af- fection, it muft depend upon the fame caufes, and will be cured alfo by the very fame remedies, as the lofs of mo:ion. MCXLIII. * The paify then, or lofs of motion, which is to be treated of here, may be diftinguifhed as of two kinds ; one of them depending upon an affection of the origin of the nerves in the brain, and the other depending upon an affection of the nerves in fome part of their courfe between the brain and the organs of motion. Of the latter, as appearing in a very partial affection, I am not to fpeak particularly here ; I fhall only treat of the more general paralytic affections, and ef- pecially of the hemiplegia (mcxl.) At the fame time I expect, that what I fhall fay upon this fubject will readily apply to both the pathology and.practice in the cafes of affedions more limited. MCXLIV. The hemiplegia (mcxl.) ufually begins with, or follows, a paroxyfm of apoplexy ; and when the he- miplegia, after fubfifting for fome time, becomes fatal, it is commonly by paffing again into the ftate of apo- plexy. The relation therefore or affinity between the two difeafes, is fufficiently evident; and it is further ftrongly confirmed by this, that the hemiplegia comes upon perfons of the fame coiiftitution (mxcv.), and is preceded by the fame fymptoms (mxcviii.), that have been taken notice of with refpect to apoplexy. MCXLV. When a fit of apoplexy has gone off, and there re- mains a ftate of paify appearing as a partial affection only, it might perhaps be fuppofed that the origin of the nerves is in a. great meafure relieved; but in fo Vol. II. M far oo PRACTICE far as commonly there ftill remain the fymptoms of the lofs of memory, and of fome degree of fatuity, thefe, I think, thow, that the organ of intellect, or the common origin of the nerves, is ftill confidcrably affected. MCXLVI. Thus, the hemiplegia, from its evident connection with, and near relation to, apoplexy, may be properly confidered as depending upon like caufes ; and con- fequently, either upon a compreffion preventing the flow of the nervous power from the brain into the or- gans of motion, or upon the application of narcotic or other powers- (mcxv.) rendering the nervous power unfit to flow in the ufual and proper manner. MCXLVII. We begin with confidering the cafes depending upon compreffion. The compreffion occafioning hemiplegia may be of the fame kind, and of all the different kinds that pro- duce apoplexy; and therefore either from tumour, over-diftenfion, or effufion. The exiftence of tumour giving compreffion, may often be better difcerned in the cafe of paify than in that of apoplexy, as its effects often appear at firft in a very partial affection. MCXLVII1. The other modes of compreffion, that is, of over- diftenfion and effufion, may, and commonly do, take place, in hemiplegia : and when they do, their opera- tion here differs from that producing apoplexy, by its effects being partial, and on one fide of the body only. It may feem difficult to conceive that an over-dif- tenfion can take place in the vefHs on one fide of the brain only ; but it may be underftood : and in the cafe of a paify which is both partial and tranfitory, it is per- haps the only condition of the veffels of the brain that can be fuppofed. In a hemiplegia, indeed, which fub- fifts for any length of time, there is probably always an OF PHYSIC. 9i an effufion, either fanguine or ferous: but it is likely that even the latter muft be fupported by a remaining congeftion in the blood-veffels. MCXLIX. \ That a fanguine effufion can happen without be- coming very foon general, and thereby occafioning apoplexy and death, may alfo feem doubtful: but dif- fections prove that in fact it does happen occafioning paify only; though it is true, that this more com- monly depends upon an effufion of ferous fluid, and of this only. MCL. Can a paify, occafioned by a compreffion, remain though the compreffion be removed* ? MCLI. From what has been faid mcxliv. it will be obvious, that the hemiplegia may be prevented by all the feve- ral means propofed mcxxv. et.feq. for the prevention of apoplexy. MCLU. Upon the fame grounds, the Cure of paify muft be very much the fame with that of apoplexy (mcxxx. et.feq.) ; and when paify has begun as an apoplexy, it is prefumed, that,, before it is to be confidered as paify, all thofe feveral remedies have been employed. Indeed, even when it happens that on the firft attack of the difeafe the apoplectic ftate is not verv complete, and that the very firft appearance of the difeafe is as a hemiplegia, the affinity between the two difeafes (mcxliv.) is fuch as to lead to the fame remedies in both cafes. This is certainly proper in all Thofe cafes in which we can with much probability impute the dif- M 2 eafe * This queflion may be anfwered in the affirmative ; becaufe the ftruflure of the nerve may be dcltroyed by the compreffion, and the nerve may therefore remain impervious to the nervous in 'ucnce, after the compreffion has been removed. 9* PRACTICE eafe to compreffion ; and it is indeed feldom that a hemiplegia from internal caufes comes on but with a confiderable affection of the internal, and even of the external fenfes, together with other marks of a com- preffion of the origin of the nerves. MCLIII. Not only, however, where the difeafe can be im- puted to compreffion, but even where it can be im- puted to the application of narcotic powers, if the dif- eafe come on with the appearances mentioned at the end of laft paragraph, it is to be treated in the fame manner as an apoplexy by mcxxxi—mcxxxix. MCLIV. The cure of hemiplegia, therefore, on its firft at- tack, is the fame, or nearly the fame, with that of apo- plexy : and it feems requifite that it fhould be different only, i. When the difeafe has fubfifted for fome time; 2. When the apoplectic fymptoms, or thofe* marking a confiderable compreffion of the origin of the nerves, are removed ; and particularly, 3. When there are no evident marks of compreffion, and it is at the fame time known that narcotic powers have been applied. MCLV. In all thefe cafes, the queftion arifes, Whether fti- mulants may be employed, or- how far the cure mav be entiiely truted to fuch remedies ? Upon this quef- tion, with refpect to apoplexy, I have offered my opi- nion in mcxxxvi. And, with refped to hemiplegia, I am of opinion, that ftimulants are almoft alwavs e- quaily dangerous as in the cafes of complete "apo- plexy ; and particularly, 1. In all the cafes of hemip- legia fucceeding to a paroxyfm of complete apoplexy ; 2. In all the cafes coming upon perfons of the temper- ament * The moft infallible of thefe maiks is, the intelleaual faculties not returning. OF PHYSIC. 93 amcnt mentioned in mxcv. and after the fame antece- dents as thofe of. apoplexy, (mcxvi.) and 3. In all the cafes coming on with fymptoms of apoplexy from compreffion. MCLVI. It is, therefore, in the cafes mcliv. only, that ftimu- lants are properly admiffible: And even in the two firft of thefe cafes, in which a plethoric ftate of the blood-veffels of the brain may have brought on the difeafe, inwhicha difpofitiontothat ftate may itillconti- nue, and in which even fome degree of congestion may ftill remain, the ufe of ftimulants muft be an ambiguous remedy ; fo that perhaps it is in the third of thefe cafes only that ftimulants are clearly indicated and admiffible. MCLVII. Thefe doubts with refpect to the ufe of ftimulants, may perhaps be overlooked or difregarded by thofe whpalledge that ftimulants have been employed with advantage even in thofe cafes (mclv.) in which I have faid they ought to be avoided. MCLVII!. To compromife this contrariety of opinion, I muft obf.'i ve, that even in the caf<£«$>>•> •>■> >■■>■>• ■>•■>•>■•*" BOOK II. OF ADYNAMI/E; O R piSEASES CONSISTING IN A WEAKNESS OR LOSS OF MOTION IN EITHER THE VITAL OR NATURAL FUNCTIONS. CHAP. L OF SYNCOPE OR FAINTING. MCLXXI. THIS is a difeafe in which the adion of the heart and refpiration become coniiderabiy weaker than ufual, or in which for a certain time thefe func- tions ceafe altogether. MCLXXII. Phyficians having obferved that this affedion oc-. curs in different degrees, have endeavoured to diftin- guifh thefe by different appellations: but as it is not poffible to afcertain thefe different degrees with any precifion, tion, in which bitters, peruvian bark, and other tonics, are frequently of fome advantage. ?02 PRACTICE precifion, fo there can be no ftrid propriety in em- ploying thofe different names; and I fhall here com- prehend the whole of the affedions of this kind un- der the title of Syncope. MCLXXIII. This difeafe fometimes .cornea on fuddenly to a con- fiderable 'degree, but fometimes alfo it comes on gra- dually ; and in the latter cafe, it ufually comes on with a fenfe of langour, and of anxiety about the heart, accompanied at the fame time, or immediately after, with fome giddinefs, dimnefs of fight, and found- in^ in the ears. Together with thefe fymptoms, the pulfe and refpiration become weak; and often fo weak, that the pulfe is fcarcely to be felt, or the refpiration to be perceived ; and fometimes thefe motions, for a certain time, ceafe altogether. While thefe fymp- toms take place, the face and whole furface of the bo- dy become pale, and more or lefs cokj according to the degree and duration of the paroxyfm. Very commonly, at the beginning of this, and during its continuance, a cold fweat appears, and perhaps conti- nues, on the fore-head, as well as on fome other parts of the body. During the paroxyfms, the animal fundions, both of fenfe and motion, are always in fome degree impaired, and very often entirely fufpended. A paroxyfm of fyncope is often, after fome time, fpon- taneoufly recovered from; and this recovery is gene- rally attended with a fenfe of much anxiety about the heart. Fits of fyncope are frequently attended with, or end in, vomiting ; and fometimes with convulfions, or an epileptic fit. MCLXXIV. Thefe are the phenomena in this difeafe; and from every view of the greateft part of them, there cannot be a doubt that the proximate caufe of this difeafe is a very weak or a total ceafing of the adion of the heart. OF PHYSIC. 10$ neart. But it will be a very difficult matter to explain in what manner the feveral remote caufes operate in producing the proximate caufe. This, however, I ihaH attempt, though with that diffidence which be- comes me in attempting a fubjed that has not hither- to been treated with much fuccefs. MCLXXIVf. The remote caufe of fyncope may, in the firft place, be referred to two general heads. The one is, of thofe caufes exifting and ading in the brain, or in parts of the body remote from the heart, but ading upon it by the intervention of the brain, The other general head of the remote caufes of fyncope, is of thofe exifting in the heart itfelf, or in parts very im- mediately conneded with it, and thereby ading more diredly upon it in producing this difeafe. MCLXXV. " In entering upon the confideration of the firft fet of thofe caufes (mclxxiv.), I muft affume a propofition which I fuppofe to be fully eftablifhed in phyfiology. It is this: That, though the mufcular fibres of the heart be endowed with a certain degree of inherent power, they are ftill, for fuch adion as is neceffary to the motion of the blood, very conftantly dependent upon a nervous power fent into them from the brainj. At leaft this is evident, that there are certain powers ading primarily, and perhaps only in the brain, which influence and varioufly modify the adion of the heart. I fup- f The Paragraphs were thus numbered in the laft edition. % The author here differs fomewhat in opinion from other phyfio- logifts. He allows, indeed, that the heart poffetfes a vis infita in s certain degree, ; but he will not allow this vis infita to be fufficient- ly ftrong for carrying on the circulation ; and he thinks that fome energy muft; be imparted to the heart from the brain, in order to en- able that important mufcle to perform its office. In fupport of this opinion, we have a plain fa£t, which the author might have adduced, viz. that a ligature on the nerves going to t'i: heart immediately flops its motions. io4 PRACTICE I fuppofe, therefore, a force very conftantly during life exerted in the brain, with refped to the moving fibres of the heart, as well as of every part of the body : which force I fhall call the energy of the brain ; and which I fuppofe may be, on different occafions, ftrong^ er or weaker with refped to the heart. MCLXXVI. Admitting thefe propofitions, it will be obvious, that if I can explain in what manner the firft fet of remote caufes (mclxxiv.) diminifh the energy of the brain, I fhall at the fame time explain in what manner thefe caufes occafion a fvncope. MCLXXVII. To do this, I obferve, that one of the moft evident of the remote caufes of fyncope is a hemorrhagy, or an evacuation* of blood, whether fpontaneous or aitifij cial. And as it is very manifeft that the energy of the brain depends upon a certain fulnefs and tenfion of its blood-veffels, for which nature feems to have in- duftrioufly provided by fuch a conformation of thofe blood-veffels as retards the motion Of the blood both in the arteries and veins of the brain ; fo we can rea- dily perceive, that evacuations of blood, by taking off the fullnefs and tenfion of the blood-veffels of the brain, and thereby diminifhing its energy with refped to the heart, may occafion a fyncope. In many per- fon?, a fmall evacuation of blood will have this effed; and in fuch cafes there is often a clear proof of the manner in which the caufe operates, from this circum- ftance, that the effed can be prevented by laying the body in a horizontal pofture ; which, by favouring the afflux of the blood by the arteries, and retarding the return of it by the veins, preferves the neceffary ful- nefs of the veffels of the brain. It is farther to be remarked here, that not only an evacuation of blood occafions fyncope, but that even a change in the diftribution of the blood, whereby a larger of Physic. 105 larger portion of it flows into one part of the fyftem of blood-veffels, and confequently lefs into others, may occafion a fyncope. It is thus I explain the fyn- cope that readily occurs upon the evacuation of hy- dropic waters, which had before filled the cavities of the abdomen or thorax. It is thus alfo I explain the fyncope that fometimes happens on blood-letting, but which does not happen till the ligature which had been employed is United, and admits a larger afflux of blood into the blood-veffels of the arm. Both thefe cafes of fyncope (how, that an evacuation of blood does not always occafion the difeafe by any general effed on the whole fyftem, but often merely by taking off the requilite fulnefs of the blood-veffels of the brain. MCL XXVIII. The operation of fome others of the remote caufes of fyncope, may be explained on the following princi- ples. Whilft the energy of the brain is, upon differ- ent occafions, manifeftly ftronger or weaker, it feems to be with this condition, that aftronger exertion of it is neceffarily followed by a weakerftateof the fame. It feems to depend upon this law in the conftitution of the ner- vous power, that the ordinary contradion of a mufcle is always alternated with a relaxation of the fame ; that, unlefs a contradion proceeds to the degree of? fpafm, the contraded ftate cannot be long continued ; and it feems to depend upon the fame caufe that the voluntary motions, which always require an unufual increafe of exertion, and occafion fatigue, debility, and at length irrefiftible fleep. From this law, therefore, of the nervous power, we may underftand why a fudden and violent exertion of the energy of the brain is fometimes followeddVy fuch a diminution of it as to occafion a fyncope ; and it is thus I fuppofe that a violent fit of joy produces fyncope, and even death. It is upon the fame princi- ple alfo, I fuppofe, that an exquifite pain may fome- times excite the energy of the brain more ftronglv Vol. II. O than 106 PRACTICE than can be fupported, and is therefore followed by fuch a diminution as muft occafion fainting. But the effed of this principle appears more clearly in this, that a fainting readily happens upon the fudden remiffion of a confiderable pain ; .and thus I have feen a fainting occur upon the redudion of a painful diflo- cation. MCLXXIX. It feems to be quite analogous when a fyncope im- mediately happens on the finifhing of any great and long-continued effort, whether depending on the will, or upon a propenfity ; and in this way a fainting fometimes happens to a woman on the bearing of a child. This may be well illuftrated by obferving, that in perfons already much weakened, even a very mode- rate effort will fometimes occafion fainting. MCLXXX. To explain the operation of fome other caufes of fyncope, it may be obferved, that as the exertions of the energy of the brain are efpecially under the influ- ence of the will, fo it is well known that thofe modifi- cations of the will which are named Paffions and Emo- tions, have a powerful influence on the energy of the brain in its adions upon the heart, either in increafing or diminifhingthe force of that energy. Thus, anger has the former, and fear the latter effed ; and thence it may be underftood how terror often occafions a fyn- cope fometimes of the moft violent kind, named Af- phyxia,and fometimes death itfelf. MCLXXXI. As, from what I have juft mentioned, it appears, that the emotions of defire increafe, and thofe of aver- fion diminifh, the energy of the brain ; fo it may be underftood, how a ftrong averfion, a horror, or the feeling which arifes upon the fight of a very difagreea- ble objed, may occafion fainting. As an example of this, I have known more than one inftance of a perfon's fainting at the fight of a fore in another pcrfon. MCLXXXIL OF PHYSIC. 107 MCLXXXII. To this head of horror and difguft, I refer the ope* ration of thofe odours which in certain perfons occa- fion fyncope. It may be fuppofed, that thofe odours are endowed with a dircdiy fedative power, and may thereby occafion fyncope; but they are, many of them, with refped to other perfons, evidently of a contrary quality; and it appears to me, that thofe odours occa- sion fyncope only in thofe perfons to whom they are extremely difagreeable. MCLXXXIII. It is, however, very probable, that among the cauf- es o& fyncope, there are fome which, analogous to all thofe we have already mentioned, ad by a diredly fe- dative power: and fuch may either be diffufed in the mafs of blood, and thereby communicated to the brain; or may be only taken into the ftomach, which fo readily and frequently communicates its aifedions to the brain. MCLXXXIV. Having now enumerated, and, as I hope, explained, the moft part of the remote caufes of fyncope, that either operate immediately upon the brain, or whofe operation upon other parts of the body is communi- cated to the brain, it is proper to obferve, that the moft part of thefe caufes operate upon certain perfons more readily and more powerfully than upon others ; and this circumftance, which may be confidered as the predifponent caufe of fyncope, deferves to be inquired into. It is, in the firft place, obvious, that the operation of fome of thofe caufes depends entirely upon an idio- fyncrafy in the perfons upon whom they operate; which, however, I cannot pretend to explain. But, in the next place, with refped to the greater part of the other caufes, their effeds feem to depend upon a temperament which is in one degree or other in com- O 2 mon io8 PRACTICE mon to many perfons. This temperament feems to confift in a great degree of fenfibility and mobility, arifing from a ftate of debility, fometimes depending upon original conformation, and fometimes produced by accidental occurrences in the courfe of life. MCLXXXV. The fecond fet of the remote caufes of fyncope (mclxXiv.), or thofe ading diredly upon the heart itfelf, are certain organic aifedions of the heart itfelf, or of the parts immediately conneded with it, parti- cularly the great veffels which pour blood into or immediately receive it from the cavities, of the heart. Thus a dilatation or aneurifm of the heart, a potypusj in its cavities, abfceffes or ulcerations in its fubfiance, a clofe.adherence of the pericardium to the furface of the heart, aneurifms of the great veffels near to the heart, polypus in thefe, and offifications in thefe or in the valves of the heart, are one or other of them condi- tions which, upon difledion, have been difcovered in thofe perfons who had before laboured under frequent fyncope. MCLXXXVI. It is obvious, that thefe conditions are all of them, either fuch as may, upon occafion, difturb the free and regular influx into, or the free egrefs of the bloooj from, the cavities of the heart; or fuch as may other- wife difturb its regular adion, by fometimes interrupt- ing it, or fometimes exciting it to more violent and convulfive action. The latter is what is named the Palpitation of the Heart, and it commonly occurs in the fame perfons who are liable to fyncope. MCjLXXXVII. It is this, as I judge, that leads us to perceive in what manner thefe organic affedions of the heart and great veffels may occafion fyncope: for it may be fuppofed, that the violent exertions made in palpita- tions may either give occafion to an alternate great relax- OF PHYSIC. 109 relaxation, (mclxxviu.) or to a fpafmodic contrac- tion ; and in either way fufpend the adion of the heart, and occafion fyncope. it feems to me probable, rhat it is a fpaf/nodic contradion of the heart that oc- cafions the intermilfion of the pulfe fo frequently ac- companying palpitation and fyncope. MCLXXXVIU. Though it frequently happens that palpitation and fyncope arife, as we have faid, from the organic affec- tions above mentioned, it is proper to obferve, that difeafes even when in a violent degree, do not always depend oh fuch caufes ading directly on the heart, but are often dependent on fome of thofe caufes which we have mentioned, above as ading primarily on the brain. MCLXXXIX. I have thus endeavoured to give the pathology of fyncope ; and of the cure I can treat very fhortly. The cafes of fyncope depending on the fecond fet of caufes, (mclxxiv.) and fully recited in mclxxxv. I fuppofe to be generally incurable ; as our ait, fo far as I know, has not yet taught us to cure any of thofe feveral caufes of fyncope (mclxxxv.) The cafes of fyncope depending on the firft fet of caufes, (MCLxxtv.) and whole operation I have endea- youred to explain in mclxxv^. et feq. I hold to be generally curable, either by avoiding the feveral occa- sional caufes there pointed out, or by correding the predifponent caufes (mclxxxiv.) The latter, I think, may generally be done by correding the debility or mobility of the fyftem, by the means which 1 have al- ready had occafion to point out in another place*. CHAP. *•• See Aiticle 217, Sec. no PRACTICE CHAP. II. OF DYSPEPSIA, OR INDIGESTION. MCXC. AW ANT of appetite, a fqueamifhnefs, fometimes a vomiting, fudden andtranfient diftentionsof the ftomach,erudationsof various kinds, heartburns, p*aii1% intheregionsofthe ftomach, and a bound belly, are fymp- toms which frequently concur in the fame perfon, and therefore may be prefumed to depend upon one and the fame proximate caufe. In both views, therefore, they may be confidered as forming one and the fame difeafe, to which we have given the appellation of Bvfpepfia, fet at the head of this chapter. MCXCI. But as this difeafe is alfo frequently a fecondary and fympathic affedion, fo the fymptoms above-mentioned are often joined with many others ; and this has given occafion to a very confufed and undetermined defcrip- tion of it, under the general title of Nervous Difeafes, or under that of Chronic Weaknefs. It is proper, however, to diftinguifh ; and I apprehend the fymp- toms enumerated above are thofe effential to the idio- pathic affedion I am now to treat of. MCXCII. It is indeed to be particularly obferved, that thefe fymptoms are often truly accompanied with a certain ftate of mind which may be confidered as a part of the idiopathic affedion: but I fhall take no further notice of this fymptom in the prefent chapter, as it will be fully and more properly confidered in the next, under the title of Hypochondriafis. MCXCIII. That there is a diftind difeafe attended always .with a greater O F P H Y S I C. in a greater part of the above fymptoms, is rendered very probable by this, that all thefe feveral fymp- toms may arife from one and the fame caufe; that is, from an imbecility, lofs of tone, and weaker adion in the mufcular fibres of the ftomach : and I conclude therefore, that this imbecility may be confidered as the proximate caufe of the difeafe I am to treat of under the name of Dyfpepfia. MCXCIV. The imbecility of the ftomach, and the confequent fymptoms (mcxc.) may, however, frequently depend topon fome organic affedion of the ftomach itfelf, as tumour, ulcer, or fcirrhofity ; or upon fome affedion of other parts of the body communicated to the fto- mach, as in gout, amenorrhcea, and fome others. In all thefe cafes, however, the dyfpeptic fymptoms are to be confidered as fecondary or fympathic affedions, to be cured only by curing the primary difeafe.— Such fecondary and fympathic cafes cannot, indeed, be treated of here; but as I prefume that the imbeci- lity of the ftomach may often take place without ei- ther any organic affedion of this part, or any more primary affedion in any other part of the body ; fo I fuppofe and exped it will appear, from the confidera- tion of the remote caufes, that the dyfpepfia may be often an idiopathic affedion, and that it is therefore properly taken into the fyftem of methodical Ncfology, and becomes the fubjed cf our confideration here. MCXCV. There can be little doubt, that in moft cafes, the weaker adion of the mufcular fibres of the ftomach, is the moft frequent and chief caufe of the fymptoms mentioned in mcxc. ; but I dare not maintain it to be the only caufe of idiopathic dyfpepfia. There is, pretty certainly, a peculiar fluid in the ftomach of ani- mals, or at leaft a peculiar quality in the fluids, that we know to be there, upon which the folution of the 112 PRACTICE aliments taken into the ftomach chiefly depends:' and it is at the fame time probable, that the peculiar quali- ty of the diffolving or digefting fluids may be variouf- ly changed, or that their quantity may be, upon occa- fion, diminifhed. It is therefore fufficiently probable, that a change in the quality or quantity of thefe fluids may produce a confiderable difference in the pheno- mena of digeftion, and particularly may give occafion to many of the morbid appearances mentioned in mcxc. MCXCVI. This feems to be very well founded, and points out another proximate caufe of dyfpepfia befide that we have already afiigned: But, notwithftanding this, as the peculiar nature of the digeftive fluid, the changes which it may undergo, or the caufes by which it may be changed, are all matters fo little known, that I can- not found any pradical dodrine upon any fuppolition with refped to them ; and as, at the fame time, the im- becility of the ftomach, either as caufing the change in the digeftive fluid, or as being induced by that change, feems always to be prefent, and to have a great fhare in occafioning the fymptoms of indigeftion; fol fhallftill confider the imbecility of the ftomach as the proximate and almoft fole caufe of dyfpepfia. And I more rea- dily admit of this manner of proceeding ; as, in my opinion, the dodrine applies very fully and clearly to the explaining the whole of the pradice which expe- rience has eftablifhed as the moft fuccefsful in this difeafe. MCXCVil. Confidering this, then, as the proximate caufe of dyfpepfia, I proceed to mention the feveral remote caufes of this difeafe ; as they are fuch, as, on differ- ent occafions, feem to produce a lofs of tone in the mufcular fibres of the ftomach. They may, I think, be confidered under two heads. The firfl is, of thofe which OF PHYSIC. IX3 which ad diredly and immediately upan the ftomach itfelf: The fecond is, of thofe which ad upon the whole body, or particular parts of it, but in confe- quence of which^the ftomach is chiefly or almoft only affeded. MCXCVIII. Of the firft kind are, i. Certain fedative or narcotic fubftances taken into the ftomach; fuch as tea, coffee, tobacco, ar- dent fpirits, opium, bitters, aromatics, putrids, and acefcents. 2. The large and frequent drinking of warm water, or of warm watery liquids. 3. Frequent furfeit, or immoderate repletion of the ftomach. 4. Frequent vomiting whether fpontaneoufly arif- ing, or excited by art. 5. Very frequent fpitting, or rejedion of faliva. MCXCIX. Thofe caufes vwhich ad upon the whole body, or upon particular parts andfundions of it, are, 1. An indolent and fedentary life. 2. Vexation of mind, and diforderly paffions of any kind. 3. Intenfe ftudy, or clofe application to bufinefs too long continued. 4. Excefs in venery. 5. Frequent intoxication; which partly belongs to this hea'd, partly to the former. 6. The being much expofed to moift and cold air when without exercife. MCC. Though the difeafe, as proceeding from the laft fet of eaufes, may be confidered as a fymptomatic affec- tion only; yet as the affedion of the ftomach is gene- rally the firft, always the chief, and often the only ef- fed which thefe caufes produce or difcover, I think the affedion of the ftomach may be confidered as the Vol. II. P difeafe ii4 PRACTICE difeafe to be attended to in pradice; and the more properly fo, as in many cafes the general debility is only to be cured by reftoring the tone of the ftomach, and by remedies firft applied to this organ. MCCI. For the cure of this difeafe, we form three feveral indications; a prefervativc, a palliative, and a curative. The jirfl is, to avoid or remove the remote caufes juft now enumerated. The fecond is, to remove thofe fymptoms which efpecially contribute to aggravate and continue the difeafe. And, The third is, to reftore the tone of the ftomach; that is, to cor red or remove the proximate caufe of the difeafe. MCCII. The propriety and neccffity of the firft indicatioif is fufficiently evident, as the continued application, or frequent repetition of thofe caufes, muft continue the difeafe ; may defeat the ufe of the remedies ; or, in fpite of thefe, may occafion the recurrence of the difeafe. It is commonly the neg^ed of this indication which renders this difeafe fo frequently obftinate.— How the indication is to be executed, will be fuffici- ently obvious from the confideration of the feveral caufes : but it is proper for the praditioner to attend to this, that the execution is often exceedingly diffi- cult, becaufe it is not eafy to engage men to break in upon eftablifhed habits, or to renounce the purfuit of pleafure; and particularly, to perfuade men that thefe pradices are truly hurtful which they have often pradifed with feeming impunity. MCCIII. The fymptoms of this difeafe which efpecially con- tribute to aggravate and continue it, and therefore require to be more immediately correded or removed, are, firft, the crudities of the ftomach already produc- ed O F P H Y S I C. 115 sd by the difeafe, and difcovered by a lofs of appetite, by a fenfe of weight and uneafinefs in the ftomach, and particularly by the erudation of imperfedly digefted matters. Another fymptom to be immediately correded, is an unufual quantity, or a higher degree than ufual, of acidity prefent in the ftomach, difcovered by various diforders in digeftion, and by other effeds to be menti- oned afterwards. The third fymptom aggravating the difeafe, and othprwife in itfelf urgent, is ooftivenefs, and therefore conftantly requiring to be relieved. MCCIV. T\\QfirJl of thefe fymptoms is to be relieved by ex citing vomiting; and the ufe of this remedy, therefore, ufually and properly begins the cure of this difeafe. The vomiting may be excited by various means, more gentle or more violent. The former may anfwer the purpofe of evacuating the contents of the ftomach : but emetics, and vomiting, may alfo excite the ordi- nary adion of the ftomach ; and both, by varioufly agitating the fyftem, and particularly by determining to the furface of the body, may contribute to remove the caufes of the difeafe. But thefe latter effeds can only be obtained by the ufe of emetics of the more powerful kind, fuch as the antimonial emetics efpeci- ally are*. MCCV. The fecond fymptom to be palliated, is an excefs of acidity, either in quantity or quality, in the contents of the ftomach. In man there is a quantity of acefcent aliments almoft commonly taken in, and, Nas I think, always undergoes an acetous fermentation in the fto- mach ; and it is therefore that, in the human ftomach, p % and * The formulae and dofes of antimonial emetics have been defer ibjr cd in a note on Article 185. n6 PRACTICE and in the ftomachs of all animals ufing vegetable food, there is always found an acid prefent. 1 he a- cid, however, is generally innocent, and occafions no diforder, unlefs either the quantity of it is large, or the acidity proceeds to a higher degree than ufual. But, in either of thefe cafes, the acid occafions various dif- orders, as flatulency, erudation, heartburn, gnawing pains of the ftomach, irregular appetites and cravings, loofenefs, griping, emaciation, and debility. To ob- viate or remove thefe effeds aggravating and continu- ing the difeafe, it is not only neceffary to corred the acid prefent in the ftomach ; but, efpecially as this a» cid proves a ferment determining and increafing the acefcency of the aliments afterwards taken in, it is pro- per alfo, as foon as poffible, to corred the difpofition to exceffive acidity. MCCVI. The acidity prefent in the ftomach may be corred- ed by the ufe of alkaline falts, or abforbent earths*; or * No part of the practice of phyfic requires more caution than the adminiftering alkaline falts, and abforbent earths. The alkaline falts, by their cauftic quality, corrode the ftomach, and blunt its ac- tion, when taken in too large quantities ; and efpecially if, from a miftaken diagnofis, no acid is in the ftomach. Lime-water is certainly preferable to the alkaline falts ; its dofe may vary from two to four ounces twice a-day, according to the ur- gency of the cafe. The abforbent earths, as chalk, crabs eyes, &c. if they do not meet with an acid, are apt to concrete into a hard indiffoluble mafs, by the mucus of the ftomach. Magneha is doubtlefs, in many cafes, preferable to the calcareous earth ; when, on account of its purgative quality, we cannot conti- nue its ufe. Chalk is preferable to the teftaceous powders, becaufe it is free from that glutinous fubftance with which teftaceous powders abound, and which the more readily difpofes them to concrete in the ftomach. The dofe of magnefia is from 9i. to 3i. twice or thrice a-day; and its purgative quality may, in many cafes, be prevented, by adding to each dofe of it ten or fifteen grains of rhubarb, and five or fix drops of ofl of anife-feed. OF PHYSIC. "7 or by fuch fubftances, containing thefe, as can be de- compofed by the acid of the ftomach. Of the alka- line?, the cauftic is more effedual than the mild; and this accounts for the effeds of lime-water. By em- ploying abforbents, we avoid the excefs of alkali, which might fometimes take place. The abforbents are different, as they form a neutral more or lefs laxa- tive ; and hence the difference between magnefia alba and other abforbents. It is to be obferved, that alka- Jines and abforbents may be employed to excefs • as when employed in la;ge quantity, they may deprive the animal fluids of the acid neceffary to their proper compofition. MCCVII. The difpofition to acidity may be obviated by a- voiding acefcent aliments, and ufing animal-food little capable of acefcency. This, however, cannot be long continued without corrupting the ftate of our blood • and as vegetable food cannot be entirely avoided, the excefs of their acefcency may in fome meafure be a- voided, by choofing vegetable food the leaft difpofed to a vinous fermentation, fuch as leavened bread and well fermented liquors, and, inftead of frefh native acids, employing vinegar. MCCVIII. The acid arifing from acefcent matters in a found ftate of the ftomach, does not proceed to any high de- gree, or is again foon involved and made to difappear: but The Decoftum cretaceum of the Edinburgh Pharmacopoeia is a good form for the exhibition of chalk. But chalk may be given with ihubarb and oil of anife-feeds, like magnefia. The Trochifci e creta is a convenient form for giving the chalk, had the crabs eyes been omitted. The following antacid troches are both effectual and pleafant: 3». Magnef. alb. vi. Sacch. alb. ^iii. Nuc. mofch. 9ii. M. f. trochifci cum mucilagin. gum tragacanth. q. f. n8 PRACTICE but this does not always happen ; and a more copious acidity, or a higher degree of it, may be produced, either from a change in the digeftive fluids, become lefs fit to moderate fermentation and to cover acidi- ty, or from their not being fupplied in due quantity. How the former may be occafioned, we do not well underftand ; but we can readily perceive that the lat- ter, perhaps the former alfo, may proceed from a weaker adion of the mufcular fibres of the ftomach. In certain cafes, fedative paffions, immediately after they arife, occafion the appearance of acidity in the ftomach which did not appear before; and the life of ftimulants often correds or obviates an acidity that would otherwife have appeared. From thefe con- fiderations, we conclude, that the production and fub- fiftence of acidity in the ftomach, is to be efpecial- ly prevented by reftoring and exciting the proper ac- tion of it, by the feveral means to be mentioned here- after. MCCIX. But it is alfo to be further obferved, that though there are certain powers in the ftomach for preventing a too copious acidity, or a high degree of it, they are not however always fufficient for preventing acefcen- cy, or for covering the acidity produced ; and there- fore, as long as vegetable fubftances remain in'the fto- mach, their acefcency may go on and increafe. From hence we perceive, that a fpecial caufe of the excefs of acidity may be, the too long retention of the acef- cent matters in the ftomach ; whether this may be from thefe matters being of more difficult folution, or from the weaknefs of the ftomach more flowly dif- chargingits contents into the duodenum, orfromfome impediment to the free evacuation of the ftomach by the pylorus. The latter of thefe caufes we are well acquainted with, in the cafe of a fcirrhous pylorus, producing commonly the higheft degree cf acidity. la OF PHYSIC. nj In all the inftances of this fcirrhofity I have met with, I have found it incurable: but the firft of thefe caufes is to be obviated by avoiding fuch aliments as are of difficult folution; and the fecond is zo be mended by the feverai remedies for exciting the adion of the ftomach, to be mentioned afterwards. MCCX. The third fymptom commonly accompanying dyf- pepfia, w hich requires to be immediately removed, i9 coftivenefs. There is fo much connedion between the feveral portions of the alimentary canal with re- fped to the periftaltic motion, that, if accelerated or retarded in any one *part, the other parts of it are commonly affeded in the fame manner. Thus, as the brifker adion of the ftomach muft accelerate the adi- on of the inteftines, fo the flower adion of the intef- tines muft in fome meafure retard that of the fto- mach. It is therefore of confequence to the proper adion of the ftomach, that the periftaltic motion of the inteftines determining their contents downwards, be regularly continued; and that all coftivenefs, cr interruption of that determination, be avoided. This may be done by the various means of exciting the adion of the inteftines : but it is to be obferved here, that as every confiderable evacuation of the inteftines weakens their adion, and is ready therefore to induce coftivenefs when the evacuation is over ; fo thofe pur- gatives which produce alai'ge evacuation, are unfit for correding the habit of coftivenefs. This, therefore, fhould be attempted by medicines, which do no more than folicit the inteftines to a more ready difcharge of their prefent contents, without either hurrying their adion, or increafing the excretions made into their cavity ; either of which effeds might produce a purg- ing. There are, I think, certain medicines peculiarly proper on this occafion, as they feem to ftimulate efpc- 120 PRACTICE cially the great guts, and to ad little on the higher parts of the inteftinal canal*. MCCXI. We have thus mentioned the feveral means of exe- cuting our fecond indication ; and I proceed to the third, which is, as we have faid, the proper curative; :.nd it is to reftore the tone of the ftomach, the lofs of which we confider as the proximate caufe of the dif- eafe, or at leaft as the chief part of it. The means of fatisfying this indication we refer to two heads. One is, of thofe means which operate diredly and chiefly on the ftomach itfelf; and the other is, of thofe means which, operating upon the whole fyftem, have their tonic effeds thereby communicated to the ftomach. MCCX1I. The medicines, which operate diredly on the fto- mach, are either ftimulants or tonics. The ftimulants are faline or aromatic. The faline are acids or neutral*. Acids of all kinds feem to have the power of ftimu- lating the ftomach, and therefore often increafe appe- tite : but the native acids, as liable to fermentation, may otherwife do harm, and are therefore of ambigu- ous ufe. The acids, therefore, chiefly and fuccefsful- ly employed, are the vitriolic§, muriaticf, and the dif- tilled acid of vegetables, as it is found in tar water, which are all of them antizymics {:. The * Ten or fifteen grains of Pil. Ruf. anfwer this purpofe fufficiently well. It is to be regretted that the Author did not mention thofe certain medicines to which he alludes. § The dofe of the vitriolic acid ought not to exceed ten drops, and it fhould be well diluted with water. f The Tindura Martis of the Edinburgh College powerfully fti- mulates the ftomach, and acts at the fame time as a tonic ; its dofe is from ten to twenty drops thrice a-day, in a fufficient quantity of any proper liquid, and it is a very agreeable medicine. J I. e. refiit fermentation. OF PHYSIC. 121 The neutral falts anfwering this intention, are efpe- cially thofe which have the muriatic acid in their compofition, though it is prefumed that neutrals of all kinds have more or lefs of the fame virtue*. MCCXIII. The aromatics, and perhaps fome other acrids, cer- tainly ftimulate the ftomach, as they obviate the acef- cency and flatulency of vegetable food : but their fti- mulus is tranfitory; and if frequently repeated, and taken in large quantities, they may hurt the tone of the ftomachf. MCCXIV. The tonics employed to ftrengthen the ftdmach are bitters, bitters and aftringents combined, and chaly- * beates. Bitters are undoubtedly tonic medicines, both with refped to the ftomach and the whole fyftem : but their long-continued ufe has been found to deftroy the tone of the ftomach and of the whole fyftem ; and, whether this is from the mere repetition of their to- nic operation, or from fome narcotic power joined with the tonic in them, I am uncertain. MCCXV. Bitters and aftringents combined, are, probably, more effedual tonics than either of them taken fin- gly ; and we fuppofe fuch a combination to take place, in the Peruvian bark ; which therefore proves a pow- Vol. II. Q^ erful * The, Sal digeftivus, i. e. the muriatic acid faturated with vege- table fixed alkali, was thought to be preferable to common fait in promoting digeftion. Hence its old name of Sal digeftivus. Its fuperiority over common fait is however doubtful. f This caUtion againft the too free ufe of aromatics ought to be peculiarly attended to by the young practitioner. The fpcedy re- lief which they procure tempts the patient to have frequent recourfq to them, which, as the Author juftly obferves, may materially hurt the tone of the ftomach, and confequently increafe the difeafe which they were intended to remove. W PRACTICE erful tonic, both with refped to the ftomach and to the whole fyftem. But I have fome ground to fuf. ped, that the long-continued ufe of this bark may, like bitters, deftroy both the tone of the ftomach and of the whole fyftem*. MCCXVI. Chalybeates may be employed as tonics in various formsf, and in confideraole quantities, with fafety. They have been often employed in the form of mine- ral waters, and feemingly with fuccefs: but whether this is owing to the chalybeate in the compofition of thefe waters, or to fome other crrcumftances at- tending their ufe, I dare not pofitively determine; but the latter opinion feems to me the more probable. MCCXVII. The remedies which ftrengthen the ftomach, by be- ing applied to the whole body, are, exercife and the application of cold. As exercife ftrengthens the whole body, it muft al- fo ftrengthen the ftomach ; but it does this alfo in a particular manner, by promoting perfpiration, and exciting the adion of the veffels on the furface of the body, which have a particular confent with the muf- cular fibres of the ftomach.. This particularly ex- plains why the exercifes of geftation, though not the moft powerful in ftrengthening the whole fyftem, are, however, very powerful in ftrengthening the ftomach; of which we have a remarkable proof in the effeds of failing. * Forms of thefe tonics may be feen in the preceding notes on Articles 982, 983, 993. f See the notes on Articles 982, 983, 993. ^ In thefe cafes the Tinftura Mar:is, mentioned in the note on Ar- ticle 1212, is as proper a form of chalybeates as any we can ufe. Its dofe is from ten to twenty drops in any proper vehicle. A glafs of cold fpring-water, acidulated with a few drops of this tin&ure, is agreeable and refrcfhir.T, and may be ufed as the patient's common dcink ; its agreeablencfs may be confidcrably increafed by adding to each half-pint glaf;; a tablc-fpoonful of fimpft cinnamon-water. OF PHYSIC. 123 failing. In ftrengthening the general fyftem, as fa- tigue muft be avoided, fo bodily exercife is of ambi- guous ufe ; and perhaps it is thereby, that riding on horfeback has been fo often found to be one of the inoft powerful means of ftrengthening the ftomach, and thereby of curing dyfpepfia. MCCXVIll. The other general remedy of dyfpepfia is the appli- cation of cold : which may be in two ways ; that is, either by the application of cold air, or of cold water. It is probable, that, in the atmofphere conftantly fur- rounding our bodies, a certain degree of cold, confider- ably lefs than the temperature of our bodies them- felves, is neceffary to the health of the human body. Such a degree of cold feems to ftrengthen the veffels on the furface of the body, and therefore the mufcular fibres of the ftomach. But, further, it is well known, that if the body is in exercife fufficient to fupport fuch a determination to the furface, as to prevent the cold from producing an entire conftridion of the pores; a certain degree of cold in the atmofphere, with fuch exercife, will render the perfpiration more confiderable. From the fharp appetite that in fuch circumftances is commonly produced, we can have no doubt, that, by the application of fuch cold,, the ton£ of the ftomach is confiderably ftrengthened. Cold air, therefore, applied with exercife, is a moft powerful tonic with refped to the ftomach : and this explains why, for that purpofe, no exercifes within doors, or in dofe carriages, are fo ufeful as thofe in the open air. MCCXIX. From the fame reafoning, we can perceive, that the application of cold water, or cold bathing, while it is a tonic with refped to the fyftem in general, and e- fpecially as exciting the adion of the extreme veffels, Q^2 muft X24 PRACTICE muft in both refpeds be a powerful means of ftrength- ening the tone of the ftomach. MCCXX. Thefe are the remedies to be employed towards a radical cure of idiopathic dyfpepfia ; and it might be, perhaps, expedcd here, that I fhould treat alfo of the various cafes of the fympathic difeafe. But it will be obvious that this cannot be properly done without treating of all thr difeafes of which the dyfpepfia is a fymptom, which cannot be proper in this place. It has been partly done already, and will be further treated of in the courfe of this work. In the mean time, it may be proper to obferve, that there is not fo much occafion for diftinguifhing between the idi- opathic and fympathic dyfpepfia, as there is in many other cafes of idiopathic and fympathic difeafes. For, as the fympathic cafes of dyfpepfia are'owing to a lofs of tone in fome other part of the fyftem, which is from thence- communicated to the ftomach; fo the tone of the ftomach reftored, may be communicated to the part primarily affeded ; and therefore the reme- dies of the idiopathic may be often ufefully employ- ed, and are often the remedies chiefly employed, in fympathic dyfpepfia. *' Mccxxr. Another part of our bufinefs here might be to fav, how fome other of the urgent fymptoms, befides thofe above-mentioned, are to be palliated. On this fubjed, I think it is enough to fay, that the fymptoms chiefly requiring to be immediately relieved, areflatu? lency, heartburn, other kinds of pain in the region of the ftomach, and vomiting: The dyfpeptic are ready to fuppofe that the whole of their difeafe confifts in a flatulency. In this it will be obvious that they are miftaken ; but, although the flatulency' is not to be entirely cured, but by mending tile imbecility of the ftomach by the means above- OF PHYSIC *25 above-mentioned ; yet the flatulent diftention of the ftomach may be relieved by carminitives, as they are called, or medicines that produce a difcharge of wind from the ftomach ; fuch are the various antifpafmo- dics, of which the moft effedual is the vitriolic as the r. The her.tbum may be relieved by abforbents*, an- tifpafm^dics^ or demulrentsf. The other p.H.'.ns.of the ftomach may be fometimes relieved by carminitives||, but moft certainly by opi- ates Vomiting is to be cured rnofr effedually by opiates thrown by injedion into the anus. CHAP. * The abforbents have been defcribed above, fee note on Article 1206. § It may be doubtful whether antifpafmodics are effectual in re- moving heartburn. Opium undoubtedly often gives relief in dofes of twenty or thirty drops of laudanum. f Ext raft of liquorice is as good a demulcent in thefe cafes as any in the lilt of the Materia Medica. Sucking a little piece of it, and drinkiug a cup or two of weak lintfeed-tea after it, feldom fail of giving relief. || Carminatives fuitable in thefe cafes are the effential oils of the feeds of fome aromatic umbiliferous plants, as Ol. Anifi. tlie dofe of which is fifteen or twenty drops on a piece of fugar, though com- mon praftice feldom goes half that length. The Oleum Carvi is another excellent carminative, but it is very hot, and its dofe mu't never exceed five drops ; two drops are a moderate dofe. The O- lcum Mentha: is another good carminative ; its dofe is two or three drops on a piece of fugar. Two grains of the Extraft of opium, or forty drops of the lauda- num, are ufually given in half a cupful of lintfeed tea. The dofe may be increafed to 100 drops of laudanum, in the fame quantityof vehicle, efpecially if the pain of the ftomach be accompanied with Tomitings. >, . 126* PRACTICE CHAP. HI- OF HYPOCHONDRIASIS. OR THE HYPOCHONDRIAC AFFECTION, COMMONLY CABLED ■ * VAPOURS'OR LOW SPIRITS. MCCXXII. IN certain perfons there is a ftate of mind diftin- guifhed by a concurrence of the following cir- cumftances : A langour, liftleffnefs, or want of refolu- tion and adivity with refped to all undertakings; a difpofition to ferioufnefs, fadnefs, and timidity ; as to all future events, an apprehenfion of the worft or moft unhappy ftate of them ; and therefore, often upotj flight grounds, an apprehenfion of great evil. Such perfons are particularly attentive to the ftate of their own health, to even the fmalleft change of feeling in their bodies; and from any unufual feeling, perhaps of the flighteft kind, they apprehend great danger, and even death itfelf. In refped to all thefe feelings 'and apprehenfions, there is commonly the moft obfti- nate belief and perfuafion. MCCXXIII. This ftate of mind is the Hypochondriafis of medi- cal writers. See Linnaei Genera Morborum, Gen. j6. et Sagaii Syftema Symptomaticum, Clafs XIII. Gen. 5. The fame ftate of mind is what has been commonly called Vapours and Low Spirits. Though the term Vapours may be founded on a falfe theory, and therefore improper, I beg leave, for a purpofe that t)T'P it r sic. 127 that will immediately appear, to employ it for a little here. MCCXXIV. Vapours, then, or the ftate of mind defcribed above, is, like t^ery other ftate of mind, conneded with a a certain ftate of the body, which muft be inquired in- to in order to its being treated as a difeafe by the art of phyfic. MCCXXV. This ftate of the body, however, is not very eafily afcertained : for we can perceive, that on different oc- cafions it is very different; vapours being combined fometimes with dyfpepfia, fometimes with hyfteria, and fometimes with melancholia, which are difeafes feem- ingly depending on very different ftates of the body. MCCXXVI. The combination of vapours with dyfpepfia is very % frequent, and in feemingly very different circumftan- ces. It is, efpecially, thefe different circumftances that I would wifh to afcertain; and I remark, that they are manifeftly of two different kinds. Firft, as the difeafe occurs in young perfons of both fexes, in per- fons of a fanguine temperament, and of a lax and flac- cid habit. Secondly, as it occurs in elderly perfons of both fexes, of a melancholic temperament, and of a firm and rigid habit. MCCXXVII. Thefe two different cafes of the combination of the vapours and dyfpepfia, I confider as two diftind dif- eafes, to be diftinguifhed chiefly by the temperament prevailing in the perfons affcded. As the dyfpepfia of fmguine temperaments is often without vapours; and as the vapours when joined with dyfpepfia in fuch temperaments, may be confi- dered as, perhaps, always a fymptom of the affedion of the ftomach; fo to this combination of dyfpepfia and vapours, I would ftill apply the appellation of Byfpepfia, 128 PRACTICE Byfpepfia, and confider it as ftridly the difeafe treated of in the preceding chapter. But the combination of dyfpepfia and vapours in melancholic temperaments, as the vapours or the turn of mind peculiar to the temperament, nearly that defcribed above in mccxxii. are effential circumftan- ces of the difeafe ; and as this turn of mind is often with few, or only flight fymptoms of dyfpepfia; and, even though the latter be amending, as they feem to be rather the effeds of the general temperament, than of any primary or topical affedion of the ftomach ; I confider this combination as a very different difeafe from the former, and would apply to it ftridly the ap- pellation of Hypochondria/is. MCCXXVIII. Having thus pointed out a diftindion between Dyf- pepfia and Kypochondriafis, I fhall now, ufing thefe terms in the ftrid fenfe above mentioned, make fome obfervations which may, I think, illuftrate the fubjed, and more clearly and fully eftablifh the diftindion propofed. MCCXXIX. The dyfpepfia often appears early in life, and is frequently much mended as life advances: but the hypochondnafis feldom appears early in life, and more ufually in more advanced years only ; and more cer- tainly ftill, when it has once taken place, it goes on increafing as life advances to old age. This feems to be particularly well illuftrated, by our obferving the changes in the ftate of the mind which ufually take place in the courfe of life. In youth, the mind is chearful, adive, rafh, and movea- ble : but as life advances, the mind by degrees be- comes more fenous, flow, cautious, and fteady ; till at length, in old age, the gloomy, timid, diltruftful, and obftinate ftate of melancholic temperaments, is more e;:quifitely formed. In producing thefe changes, it is true, OF PHYSIC. 129 true, that moral caufes have a fhare ; but it is at the fame time obvious, that the temperament of the body determines the operation of thefe moral caufes, fooner or later, and in a greater or Jeffer degree, to have their effeds. The fanguine temperament retains longer the charader of youth, while the melancholic tempera- ment brings on more early the manners of old age. MCCXXX. Upon the whole, it appears, that the ftate of the mind which attends, and efpecially diltinguifhes hy- pochondriafis, is the effed of that fame iigidity of the folio's, torpor of the nervous power, and peculiar ba- lance between the arterial and venous fyftems which occur in advanced life, and which at all times take place more or lefs in melancholic temperaments. If therefore there be alfo fomewhatof a likeftute of mind attending the dyfpepfia which occurs early in life in fanguine temperaments and lax habits, it muft depend upon a different ftate of the body, and probably up- on a weak and moveable ftate of the nervous power. MCCXXXI. Agreeable to all this, in dyfpepfia, there is more of fpafmodic affedion, and the affedion of the mind (m- ccxxii.) is often abfent, and, when prefent, is perhaps always of a flighter kind : while, in hypochondriafis, the affedion of the mind is more conftant, and the fymptoms of dyfpepfia, or the affedions of the fto- mach, are often abfent, or, when prefent, are in a flighter degree. I believe the affedion of the mind is commonly dif- ferent in the two difeafes. In dyfpepfia, it is often languor and timidity only, eafily difpelled ; while in hypochondriafis, it is generally the gloomy and ri- vetted apprehenfion of evil. The two difeafes are alfo diftinguifhed by fome o- ther circumftances. Dyfpepfia, as I have faid, is oft- en a fymptomatic affedion ; while hypochondriaf s Vol. II. R is, 130 PRACTICE is, perhaps, always a primary and idiopathic difeafe; As debility may be induced by many different cauf- es, dyfpepfia is a frequent difeafe ; while hypochondii- afi>, depending upon a peculiar temperament, is more rare. MCCXXXII. Having thus endeavoured to diftinguiih the twodik eafes, i fuppofe the peculiar nature and proximate caufe of Hypochondriafis will be underftood; and I proceed therefore to treat of its cure. So far as the affedions of the body, and particular- ly of the ftomach, are the fame here as in the cafe of dyfpepfia, the method of cure might be fuppofed to be alio the fame; and accordingly the pradice has been carried on with little diftindion : but I am perfuaded that a diftindion is often neceffary. MCCXXXI1I. There may be a foundation here for the fame pre- fervative indication as firft laid down in the cure of dyfpepfia; (mccii.) but I cannot treat this fubjed fo clearly or fully as I could with, becaufe I have not yet had fo much opportunity of obfervation as I think neceffary to afcertain the remote caufes ; and 1 can hardly make ufe of the obfervations of others, who have feldom or never diftinguifhed between the two difeafes. What, indeed, has been faid with refped to the remote caufes of melancholia, will often apply to the hypochondriafis, which I now treat of; but the fubjed of the former has been fo much involved in a doubtful theory, that I find it difficult to feled the fads that might properly and ftridly apply to the latter. I delay this fubjed, therefore, till another oc- cafion ; but in the mean time truft, that what I have faid regarding the nature of the difeafe, and fome re- marks 1 fhall have occafion to offer in confidering the method of cure, may in fome meafure fupply my defi- ciency on this fubjed of the remote caufes. MCCXXXIV. OF P H Y S i C. o* MCCXXXIV. The fecond indication laid down in the cure of dyf- pepfia (^mcci.) has properly a place here: but it is ftil} to be executed with fome diftindion. MCCXXXV. An anorexia, and accumulation of crudities in the ftomach, does not fo commonly occur in hypochon- driafis as in dyfpepfia; and therefore vomiting (m- cciv.) is not fo often neceffary in the former as in the latter. MCCXXXVI. The fymptom of excefs of acidity, from the flow evacuation of the ftomach in melancholic tempera- ments, often arifes to a very high degree in hypochon- driafis ; and therefore, for the fame reafon as in mccv. it is to be obviated*and correded with the utmoft care. It is upon this account that the feveral anta- cids, and the other means of obviating acidity, are to be employed in hypochondriafis, and with the fame attentions and confederations as in mccvi. and follow- ing ; with this reflection, however, that the exciting the adion of the ftomach there mentioned, is to be a little differently underftood, as fhall be hereafter explained. MCCXXXVII. As coftivenefs, and that commonly to a confiderable degree, is a very conftant attendant of hypochondria- fis, fo it is equally hurtful as in dyfpepfia. It may be remedied by the fame means in the former as in the latter, and they are to be employed with the fame re- ftridions as in mccx. MCCXXXVIU. It is efpecially with refped to the third indication laid down in the cure of dyfpepfia (mcci.) that there is a difference of pradice to be obferved in the cure of hypochondriafis; and that often one diredly op- R 2 pofite, 132 PRACTICE pofite to that in the cafe of dyfpepfia, is to be fol- lowed.. MCXXXIX. In dyfpepfia, the chief remedies are the tonic medi- cines, which to me feem neither neceffary nor fafe in hypochondriafis; for in this there is not a lofs of tone, but a want of adivity that is to be remedied. Chalybeate mineral waters have commonly been employed in hypochondriafis, and feemingly with fuc- cefs. But this is probably to be imputed to the amufe- ment and exercife ufually accompanying the ufe of thefe waters, rather than to the tonic power of the fmall quantity of iron which they contain. Perhaps the elementary water, by favouring the excretions, may have a fhare in relieving the difeafe. MCCXL. Cold bathing is often highly ufeful to the dyfpeptic, and, as a general ftimulant, may fometimes fee'm ufeful to the hypochondriac; but it is not commonly fo to the latter ; while, on the other hand, warm bathing, hurtful to the dyfpeptic, is often extremely ufeful to the hypochondriac. MCCXLI. Another inftance of a contrary pradice neceffary in the two difeafes, and illuftrating their refpedive na- tures, is, that the drinking tea and coffee is always hurtful to the dyfpeptic, but is commonly extremely ufeful to the hypochondriac. MCCXLII. Exercife, as it ftrengthens the fyftem, and thereby the ftomach,'and more efpecially, as by increafing the perfpiration, it excites the :adion of the ftomach, it proves one of the moft ufeful remedies in dyfpepfia ; and further, as, by increafing the perfpiration, it ex- cites the adivity of the ftomach, it likewife proves an ufeful remedy in the hypochondriafis. However, in the latter cafe, as I fhall explain prefently, it is fti'll a more OF PHYSIC. l33 more ufeful remedy by its operation upon the mind than by that upon the body. MCCXLIII.' It is now proper that we proceed to confider the moft important article of our pradice in this difeafe, and which is, to confider the treatment of the mind ; an affedion of which fometimes attends dyfpepfia, but is always the chief circumftance in hypochondriafis. What 1 am to fuggeft here^will apply to both difeafes; but it is the hypochondriafis that 1 am to keep moft conftantly in view. MCCXLIV. The management of the mind in hypochondriacs, is often nice and difficult. The firm pe. fuafion that generally prevails in fuch patients, does not allow their feelings to be treated as ima ;inary, nor their appre- henfion of danger to be confidered as groundlefs, though the phyfician may be p^rfuaded thai it is the cafe in both relpeds. Such patients, therefore, are not to be treated either by raillery or by reafoning. It is faid to be the manner of hypochondriacs to change cften their phyfician ; and indeed they often do it confiltently ; for a phyfician who does not admit the,rea'ity of the difeafe, cannot be fuppofed to take much pains to cure it, or to avert the danger of which he entertains no apprehenfion. If in any cafe the pious fraud of a placebo be al- lowable, it feems to be in treating hypochondriacs : who, anxious for relief, are fond of medicines, and, though often difappointed, will ftill tafte every new drug that can be propofed to them. MCCXLV. As it is the nature of man to indulge every prefent motion, fo the hypochondriac cheriflies his fears, and, attentive to every feeling, finds in trifles light as air a ftrong confirmation of his apprehenfions. His cure therefore depends efpecially upon the interruption of h:s 134 PRACTICE his attention, or upon its being diverted to other ob- jeds than his own feelings. MXXLVI. Whatever averfion to application of any kind may appear in hypochondriacs, there is nothing more per. nicious to them than abfolute idlenefs, or a vacancy from all earneft purfuix. Jt is owing to wealth admit- ting of indolence, and leading to the purfuit of tranfi- tory and unfatisfying amufements, or to that of cx- haufting pleafures only, that the prefent times exhibit to us fo many inftances of hypochondriacifm. The occupations of bufinefs fuitable to their cir- cumftances and fituation in life, if neither attended with emotion, anxiety, nor fatigue, are always to be admitted, and p rfilted in by hyponchondriacs. But occupations upon which a man's fortune depends, and which are always, therefore, objeds of anxiety to me- lanch lie men ; and more particularly where fuch oc- cupations are expofed to accidental interruptions, dif- appointments, and failures, it is from thefe that the hypochondriac is certainly to be withdrawn. MCCXLVII. The hypochondriac, who is not neceffarily, by cir- cumftances or habits, engaged in bufinefs, is to be drawn from his attetion to his own feelings by fome amufement. The various kinds of fport and hunting, as purfued with fome ardour, and attended with exercife, if not too violent, are amongft the moft ufeful. All thofe amufements which are in the open air, joined with moderate exercife, and requiring fome dexterity, are generally of ufe. Within doors, company which engages attention, which is willingly yielded to, and is at the fame time of a chearful kind, wiil be always found of great fervice. Play, in which fome fkjll is required, and where the OF PHYSIC. *3S the ftake is not an objed of much anxiety, if not too longproiraded, may often be admitted. In dyfpeptics, however, gaming, liable to fudden and conhuerable emotions, is dangerous, and the long continuance of it, with night-watching, is violently debilitating. But in melancholies, who commonly excel in fkill, and are lefs fufceptible of violent emo- tions, it is more admiflible, and is often the only a- mufement that can engage them. Mufic, to a nice ear, is a hazardous amufement, as long attention to it is very fatiguing. MCCXLVUI. It frequently happens, that amufements of every kind are rejeded by hypochondriacs ; and in that cafe, mechanical means of interrupting thought are the re- medies to be fought for. Such is to be found in brifk exercife, which requires fome attention in the condud of it. Walking is feldom of this kind ; though, as grati- fying to the reftleffnefs of hypochondriacs, it has fome- times been found ufeful. The required interruption of thought is beft obtain- ed by riding on horfeback, or in driving a carriage of any kind. The exercife of failing, except it be in an open boat, engaging fome attention, does very little fer- vice. Exercife in an eafy carriage, in the diredion of which the traveller takes no part, unlefs it be upon rough roads, or driven pretty quickly, and with long continuance, is of little advantage. MCGXLIX. Whatever exercife may be employed, it will be moft effedual when employed in the purfuit of a jour- ney ; firft, becaufe it withdraws a perfon from many objeds of uneafinefs and care which might prefent themfelves at home ; fecondly, as it engages in more con- 136 PRACTICE conftant exercife, and in a greater degree of it than is commonly taken in airings about home; and, laftly, as it is conftantly prefenting new objeds which call forth a perfon's attention. MCCL. In our fyftem of Nofology we have, next to Hypo- chondriafis, placed the Chlorofis, becaufe I once thought it might be confidered as a genus comprehend- ing, befides the Chlorofis of Amenorrhcea, fome fpe- cies of Cachexy : but, as I cannot find this to be well founded, and cannot diftindly point out any fuch dif- eafe, I now omit confidering Chlorofis as a genus here; and, as a fymptom of Amenorrhcea, I have endeavoured before to explain it under that title. BOOK III. O F SPASMODIC AFFECTIONS, WITHOUT FEVER. MCCLI. UNDEJ£ this title I am to comprehend all the difeafes which confift in motu abnonni ; that is, in a preternatural ftate of the contradion and motion of the mufcular or moving fibres in any part of the body. 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 fpafmi, or that Linnaeus has done under the title of Motorii. But OF PHYSIC. *37 But I exped it will be obvious, that, upon this occa- fion, it would not be proper to confine our view to the affedions of the voluntary motion only; and if thofe Nofologifts have introduced into the clafs of Spafmi, Palpitatio and Hyfteria, it will be with equal propriety that Afthma/Colica, and many other difeafes, are admitted. MCCLIII. It has been hitherto the method of our Nofologifts to divide the Spafmi into the two orders of Tonici and Clonici, Spaftici and AgitatOrii ; or, as many at pre- fent uf<- the terms, into Spafms ftridly fo called, and convulfions. I find, however, that many, and indeed moft >f t! c difeafes to be confidered under our title of Spafmodic affedions, in refped of tonic or Cloric con- tiadions, are of a mixed kind : and, therefore, I can- not f How the ufual general divifion ; but have at- tempted another, by arranging the feveral Spafmodic difeaf-s according as they affed the feveral fundions, Animal, Vital, or Natural. SECT. I. OF THE SPASMODIC AFFECTIONS OF THE ANIMAL FUNCTIONS. MCCLIV. Agreeable to the language of the ancients, the whole of the cifeafes to be treated of in this fedion might be termed fpajm; and many of the moderns continue to apply the term in the fame manner : but I think it convenient to diftinguifh the terms of Spafm and Convulfion, by applying the former, ftridly to Vol. II. S what i3S PRACTICE what has been called tie Tonic ; and the latter, to what has been called the Cloni Spafm. There is cer- tainly a foundation for the uic f thofe different terms, as there is a remarkable difference in the ftate pf the c< ntr.idion of moving fibres up »n different occafions. This I have indeed pointed out before in my treatife of Phyfijlogy, but muft alfo repeat L here. MCCLV. In the exercife of the feveral fundions of the animal ceconcmy, the contradions of the moving fibres arc excited by the will, or by certain other caufes fpecially appointed by nature for exciting thofe contradions; and thefe other caufes I name the natural caufes. In a ftate of health, the moving fibres are contraded by the power of the will, and by the natural caufes only. At the fame time the contradions ufed are in force and velocity regulated by the will, or by the circum- ftances of the natural caufes; and the contradions, whether produced by the one or the other, are always foon fucceeded by a ftate of relaxation, and are not repeated but when the power of the will or of the na- tural caufes is again applied. MCCLVI. Such are the conditions of the adion of the moving fibres in a ftate of health ; but in a morbid ftate the contradions of the mufcles and moving fibres ordina- rily depending upon the will are excited without the concurrence of the will, or contrary to what the will intends; and in the other fundions they are excited by the adion of unufual and unnatural caufes. In both cafes, the contradidions produced may be in two different ftates. The one is, when the contradidions are to a more violent degree than is ufual in health, and are neither fucceeded by a fpontaneous relaxa- tion, nor even readily yield to an extenfion either from the adion of antagonift mufcles, or from other extending powers applied. The ftate of contradions is OF PHYSIC. 139 is what has been called a tonic fpafm, and is what I fhall name fimply and ftridly a fpafm. The other morbid ftate of contradion is, when they art fucceed- ed by a relaxation, but are immediately again repeated withuiit the concurrence of the will or of the repeti- tion of muural caufe?, and are at the fame time com- monly, with refped to velocity and force, more vio- lent than in a healthy ftate. This ftate of morbid contradion is what has been named a clonic fpafm, and what I mul name fimply and ftridly a convulfion. In this fedion i fhall follow nearly the ufual divifion of the fpafmodic difeafes into th fe confift ing in Spafm, and thofe confifting in convulfion; but it may not perhaps be in my power to follow fuch divifion ex- adiy. CHAP. I. OF TETANUS. MCCLVII. BOTH Nofologifts and Pradical writers have dif- tinguifhed Tetanic complaints into the feveral fpecies of Tetanus, Opifthotonos, and Emprofthoto- nos ; and I have in my Nofology put the Trifmus, or Locked Jaw, as a genus dittind from the Tetanus.— All this, however, I now judge to be improper ; and am of opinion, that ail the feveral terms mentioned, denote, and are applicable only to, different degrees of one and the fame difeafe; the hiftory and cure of which I fhall endeavour to deliver in this chapter. MCCLVIII. Tetanic complaints may, from certain caufes, occur S 2 in 140 PRACTICE in every climate that we are acquainted with; but they occur moft frequently in the warmeft climates, and moft commonly in the warmeft feafons of fuch cli- mates. Thefe complaints affed all ages, fexes, tem- peraments, and complexions. The caufes from va hence they commonly proceed, are cold and moifture appli- ed to the body while it is very warm, and efpecially the fudden viciffitudes of heat and cold. Or, the dif- eafe is produced by punduie, lacerations, or other le- fions of nerves in any part of the body. There are, probably, fome other caufes of this difeafe ; but they are neither diftindly known, nor well afcertained. Though the caufes mentioned do, upon occafion, affed all forts of perfons, they feem however to attack per- fons of middle age more frequently than the older or younger, the male fex more frequently than the female,, and the robult and vigorous more frequently than the weaker. MCCLIX. If the difeafe proceed from cold, it commonly comes on in a few days after the application of fuch cold ; but, if it arife f:o:n a pundure 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 frequently when the wound has been entirely healed up. MCCLX. The difeafe fometimes comes on fuddenly to a vio- lent degree, but more generally it approaches by flow degrees to its violent ftate. In this cafe it comes on with a fenfe of ftiffnefs in the back-part of the neck, which, gradually increafing, renders the motion of the head difficult and painful, r.s the rigidity of the neck comes on and increafes, there is commonly at the lame dme a fenfe of uneafinefs felt about the root of the tongue ; which by degrees, becomes a difficul- ty OF PHYSIC. 141 ry of fwallowing, and at length an entire interruption of it. While the rigidity of the neck goes on increaf- ing, there arifes a pain, often violent, at the lower end of the fternum, and from thence lhooting into the back. When this pain arifes, all the mufcles of the neck, and particularly thofe of the back part of it, are immediately affeded with fpafm, pulling the head ftrongly backwards. At the fame time, the mufcles that pull up the lower jaw, which upon the firft ap- proaches of the difeafe were affeded with fome fpaftic rigidity, are now generally affeded with more violent fpafm, and fet 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 difeafe. When the difeafe has advanced thus far, the pain at the bottom of the iternum returns very frequently, and with it the fpafms of the hind-neck and lower-jaw are renewed with violence and much pain. As the difeafe thus proceeds, a greater number of mufcles come to be af- feded with fpafms. After thofe of the neck, th ic along the whole of the fpine become affeded, bending the trunk of the body ftrongly backwards; and this id what has been named the Opifihotoncs. In the lower extremities, both the flexor and ex- tenfor mufcles are commonly at the fame time affeded, and keep the limbs rigidly extended. Though the extenfors of the head and back are ufually the molt ftrongly affeded, yet the flexors, or thofe mufcles of the neck that pUll the head forward, and the mufcles that fhould pull down the lower jaw, are often at the fame time ftrongly affected with fpafm. Dufng the whole of the difeafe, the abdominal i.-.ufcles are vio- lently affeded with fpafm, fo that the belly is ftrongly retracted, and feels hard as a piece of board. At length the flexors of the head and trunk become fj ftrongly affeded as to balance the extenfors, and to / keep 142 PRACTICE keep the head and trunk,ftraight, and rigidly extendr ed, incapable of being moved in any way ; and it is to this ftate the term Tetanus has been ftridly applied. At the fame time, the arms, little affeded before, arc now rigidly extended ; the whole of the mufcles be- longing to them being affeded with fpafms, except thofe that move the fingers, which often to the laft retain fome mobility. The tongue alfo long retains its mobility ; but at length it alfo becomes affeded with fpafms, which, attacking certain of its mufcles only, often thruft it violently out between the teeth. At the height of the difeafe, every organ of volun- tary motion feems to be affeded ; and amongft the reft, the mufcles of the face. The forehead is drawn up into furrows, the eyes fometimes diftorted, are com- monly rigid, and immoveable in their fockets; the nofe is drawn up, and the cheeks arc drawn backwards to- wards the ears, fo that the whole countenance expreff- es the moft violent grinning. Under thefe univerfal fpafms, a violent convulfion commonly comes on, and puts an end to life. MCCLXI. Thefe fpafms are every where attended with moft violent pain". The utmoft violence of fpafm is, how- ever, not conftant; but, after fubfifting for a minute or two, the mufcles admit of fome remiffion of their contradion, although of no fuch relaxation as can al- low the adion of their antagonifts. This remiffion of contradion gives alfo fome remiffion of pain; but neither is of long duration. From time to time, the violent contradions and pains are renewed fometimes evrry ten or fifteen minutes, and that often without any evident exciting caufe. But fuch exciting caufes frequently occur; for almoft every attempt to motion, as attempting a change of pofture, endeavouring to fwallow, and even to fpeak, fometimes gives occafion to a renewal of the fpafms over the whole bodv. MCCLXII, OF PHYSIC. i43 MCCLXII. The attacks of this difeafj are feldom attended with any fever. When the fpafms are general and violent, the pulfe is contraded, hurried, and irregu- lar ; and the refpiration is affeded in like manner: but, during the remiffion, both the pulfe and refpira- tion ufually return to their natural ftate. The heat of the body is commonly no: increafed ; frequently tho face is pale, with a cold fweat upon it; and very often the extremities are cold, with a cold fweat over the whole bodv. When, however, the fpafms are fre- quent and violent, the pulfe is fometimes more full and frequent than natural; the face is flufhed,and a warm fweat is forced out over the whole body. MCCLXIII. Although fever be not a conftant attendant of this difeafe, efpecially when arifing from a lefion of nerves ; yet, in thofe cafes proceeding from cold, a fever fome- times has fupervened, and is faid to have been at- tended with inflammatory fymptoms. Blood has been ofren drawn in this difeafe, but it never exhibits any inflammatory emit; and all accounts feem to agree, that the blood drawn feems to be of a loofer texture than ordinary, and that it does not coagulate in the uliial manner. MCCLXIV. In this difeafe the head is feldom affeded with deli- rium or even contufion of thought, till the laft ftage of it; when, by the repeated fhocks of a violent diftemper, every fundion of the fyftem is greatly dif- ordered. MCCLXV. It is no lefs extraordinary, that, in this violent dif- eafe, the natural fundions are not either immediately or confiderably affeded. Vomitings fometimes ap- pear early in the difeafe, but commonly they are not continued ; and it is ufual enough for the appetite of hunger 144 PRACTICE hunger to remain through the whole courfe of the dif- eafe ; and what food happens to be taken down, feems to be regularly enough digefted. The excretions are fometimes affeded, but not always.^ The urine is fometimes fupprefled, 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 effed of the opiates or of the difeafe. In feveral inftances of this- difeafe, a mi- liary eruption has appeared upon the fkin ; but whe- ther this be a fymptom of the difeafe, or the effed of a certain treatment of it, is undetermined. In the mean while, it has not been obferved to denote either fafety or danger, or to have any effed in changing the courfe of the diftcmper. MCCLXVI. This difeafe has generally proved fatal; and this indeed may be juftly fuppofed to be the confequence of its nature: but, as we know, that, till very lately, phyficians were not well acquainted with a proper me- thod of cure ; and that fince a more proper method has been known and pradifed, many have recovered from this difeafe ; it may be therefore concluded, that the fatal tendency of it is not fo unavoidable as has been imagined. In judging of the tendency of this difeafe, in parti- cular cafes, we may remark, that, when arifing from lefions of the nerves, it is commonly 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 always more dangerous than that which is flower in its progrefs. Accordingly, the difeafe often proves fatal before the fourth day ; and, when a patient has paffed this peri- od, he may be fuppofed to be in greater fafety, and in general the difeafe is the fafer the longer it has con- tinued. OF PHYSIC. HS tinued. It is however, to be particularly obferved, that, even for many days after the fourth, the difeafe continues to be dangerous ; and, even after fome con- fiderable 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 recedes by degrees only, and it is often very long before the whole of the fymptoms difappear. MCCLXVIF, From the hiftory of the difeafe now defcribed, it will be evident, that there is no room for diftir.gLiifh- ing the tetanus, opi/lhotonos, and trifmus or locked jaw, as different fpecies of this difeafe, fince they all arife from the fame caufes, and are almoft conftantly con- joined in the fame perfon, I have no doubt that the emprofihotonos belongs alfo to the fame genus; and as the ancients have frequently mentioned it, we can have no doubt of its having occurred; but, at the fame time, it is certainly in thefe days a rare occurrence ; and, as 1 have never feen it, nor find any hiftories in which this particular ftate of the fpafms is faid to have prevailed, I cannot mention the other circumftances which particularly attend it, and may diftinguifh it from the other varieties of tetanic complaints. MCCLXVIII. This difeafe has put on ftill a different form from any of thofe above mentioned. The fpafms have been fometimes confined to one fide of the body only, and which bend it ftrongly to that fide. This is what has been named by Sauvages the Tetanus Lateralis, and by fome late writers the Pleurofthotonos, This form of the difeafe has certainly appeared very feldom ; ;md, in any of the accounts given of it, I cannot find any eircurnftances that would lead me to confider it as any other than a variety of the fpecies already menti- oned, or to take further notice of it here. Vol. II. T MCCLXIX 146* PRACTICE MCCLXIX. The pathology of this difeafe I cannot in any mea- fure attempt; as the ftrudure of moving fibres, the ftate of them under different degrees of contradion, and particularly the ftate of the fenforium, as varioufly determining the motion of the nervous power, are all matters very imperfedly, or not at all, known to me. In fuch a fituation, therefore, the endeavouring to give any rules of pradice, upon a fcientific plan, appears to me va:n and fruitlefs; and towards direding the cure of this difeafe, we muft be fatisfied with having learned fomething ufeful from analogy, confirmed by experience. MCCLXX. When the difeafe is known to arife from the lefion of a nerve in any part of the body, the firft, and, as I judge, the moft important fteo to be taken towards the cure, is, by every poflible means, to cut off that part from all communication with the fenforium, either by cutting through the nerves in their courfe, or perhaps by deftroying, to a certain length, their affeded part or extremity. MCCLXXI. When the cure of the difeafe is to be attempted by medicine, experience has taught us that opium has often proved an effedual remedy; but that, to render it fuch, it muft 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 fa'ely than the body has been known to bear in any other condition. The pradice 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, frequently repeated, at the interval of one, two, three or more hours, as the violence of the fymptoms feems to require*. Even when large quantities have been given * Though the exhibition of opium in Tetanus has been the moft O F~P H Y S I C. 147 given in this way, it appears that the opium does not operate here in the fame manner as in moft other ca- fes; for, though it procures fome remiffion of the fpafms and pains, it hardly induces any fleep, or occafions that ftupor, intoxication, or delirium, which it often does in other circumftances, when much fmaller quantities only have been given. It is therefore very properly obferved, that, in tetanic affedions, as the opium fhows none of thofe affedions by which it may endan- ger life, there is little or no reafon fur being fparing in the exhibition of it; and it may be given, probably ihould be given, as largely and as fall as the fymptoms 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 fymptoms, yet.the e'ffeds of opium do not long continue in the fyftem; and this T 2 difeafe univerfal pradice, it muft nevertheless be acknowledged, that, in ma- ny, if not in moft cafes, it has been ineffectual. The difeafe, indeed is in.general fatal; but, in molt of the cafes that terminated happi- ly, opium has been given, as the Author defcribes, cither in large dofes, or frequently repeated fmall dofes, we muft neceffarily conclude that the practice ought to be followed. I have feen only one cafe of Tetanus ; it proceeded from a wound which a carpenter received iit the wrill of his left arm with a faw. The inflammation was violent: the ftiffnefs of the neck at firft ap- peared on the third day, when the inflammation began 10 abate after bleeding, and the application of emollient poultices ; the pulfe was weak and fmall ; thirty drops of laudanum were given ; the fymp- toms increafed ; and, on the day following, the jaw became tuGd, Thirty drops of laudanum were repeated ; and the fymptoms abat- ing within two hour3 after its exhibition, indicated a repetition of the dofe, which, from its good effects, was a fouith time repeated the fame day. The wound fuppurated ; and the day following, with two dofes of forty drops of laudanum, the fymptoms of Tetanus wholly difappeared, but left the patient in a moll debilitated ltate. A co:tive:itfs fupervened, that was removed with the ufe of manna and Glauber's falts occafionally : The patient was nourifhed with rich broths and wine ; but he did not recover his former ftrength till after fix ,.veel:sJ although the wound was healed in half that time- 148 PRACTICE difeafe being for fome time ready to recur, it is com- monly very neceffary, by the time that the effeds of the opium given may be fuppofed to be wearing off, and efpecially upon the lealt appearance of a return of the fpafms, to repeat the exhibition of the opium in the fame quantities as before. This pradice is to be continued while the difeafe continues to (how anv dif- pofition to return; and it is only after the difeafe lias already fubfifted for fome time, and when confiderable and long-continued len.ifiions have taken place, that the dofes of the opium may be diminilhed, and the intervals of exhibhi >g them be more confiderable. MCCIA'XII, The adminifteving of opium iii this manner, basin many cafes been fuccefsful; and probably would hav« been equally fo in many others, if the opium had noc been too fparingly employed, either from the timidity of practitioners, or from its exhibition being prevent- ed by that interruption of deglutition which fo ofren attends this d;f,:aJe. This hitter circumftance direds, that the medicine fhould be immediately and largely r-.mployed upon the firft approach of the difeafe, be- fore the deglutition becomes difficult; or that, if this opportunity be loft, the medicine, in fumYient quan* tity, and with due frequency, ftiould be thrown into the body by go viler ; which, however, dries not feem to have been hitherto often practifed. MCCLXXIII. It is highly probable, that, in this difeafe, the intef. tines are affected with the fpafm that prevails fo much in oilier parts of the fyftem ; and therefore, that coftive- ii is occurs here as a fymptom of the difeafe*. It is probably alfo increafed by the opium, which is here fo largely employed; and, from whichever±>f thefe caufes . * This fymptom occurred in the cafe mentioned in the preceding OF PHYSIC. 149 caufes it arifes, it certainly muft be held to aggravate the difeafe, and that a relaxation of the inteftinal ca- nal will contribute to a relaxation of the fpafms elfe- where. This confideration direds the frequent exhi- bition of laxatives while the power of deglutition re- mains, or the frequent exhibition of glyfters when it does not; and the good effeds of both have been fre- quently obferved. MCCLXXIV. It has been with fome probability fuppofed, that the operation of opium in this difeafe, may be much affifted by joining with it fome other of the moft pow- erful antifpafmodics. The moft promifing are mufk and camphire ; and fome praditioners have been of opinion, that the former has proved very ufeful in te- tanic complaints. But, whether it be from its not having been employed of a genuine kind, or in fuffi- cient quantity, the great advantage and propriety of its ufe are not yet clearly afcertained. It appear* to me probable, that analogous to what happens with re- fped to opium, both mufk and camphire might be em- ployed in this difeafe, in much larger quantities than they commonly have been in other cafes. MCCLXXV. Warm bathing has been commonly employed as a remedy in this difeafe, and often with advantage ; but, fo far as I know, it has not alone proved a cure ; ai-d, in fome cafes, whether it be from the motion of the body here required, exciting the fpafms, or from the fear of the bath, which fome perfons were feized with, I cannot determine ; but it is allowed, that the warm bath hath in fome cafes done harm, and even occafi- oned death. Partial fomentations have been much commended, and, I believe, upon good grounds : And I have no doubt but that fomentations of the feet and legs, as wc now ufiially apply thorn in fevers, might, without *5« PRACTICE without much flirting of the patient, be very affidu* oufty employed with advantage. MCCLXXVI. Unduous applications were very frequently employ- ed in this difeafe by the ancients : and fome modern praditioners have confidered them as very ufeful. Their effeds, however, have not appeared to be con- fiderable ; and, as a weak auxiliary only, attended with fome inconvenience, they have been very much negleded by the Britifh praditioners. MCCLXXVIl. Bleeding has been formerly employed in this dif- eafe ; but of late it has been found prejudicial, except- ing in a few cafes, where, in plethoric habits, a fever has fupervened. In general, the ftate of men's bodies in warm climates is unfavou-.iblc to blood-letting: and, if we may form indications from the ftate of the blood drawn out of the veins, the ftate of this in teta- nic difeafes would forbid bleeding in them. MCCLXXVIII. Bliftering alio has been formerly employed in this difeafe ; but feveral praditioners affert, that Llifters are conftantly hurtful, and they are now generally omitted. MCCLXXIX, Thefe are the pradices thaf hitherto have been ge- nerally employed ; but of late we are informed by fe- veral Weft India praditioners, that in many inftances they have employed mercury with advantage. We are told, that it muft be employed early in the dif- eafe ; that it is moft conveniently adminiftered by undion, 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 bo generally fufficient for the cure of this difeafe, or if it may hz afiiitcd by the uf- of opium, and require this in OF PHYSIC. 151 in a certain meafure to be joined with it, I have not yet certainly learned. MCCLXXX. I have been further informed, that the tetanus, in all its different degrees, has been cured by giving in- ternally the Piffelaeum Barbadenfe, or, as it is vulgar- ly called, the Barbadoes Tar. I think it proper to take notice of this here, although I am not exadJy in- formed what quantities of this medicine are to be giv- en, or in what circumftances of the difeafe it is moft properly to be employed. MCCLXXX.* In the former edition of this work, among the reme- dies of tetanus I did not mention the ufe of cold ba- thing ; becaufe, though I had heard of this, I was not informed of fuch frequent employment of it as might confirm my opinion of its general efficacy : nor was I fufficiently informed of the ordinary and proper ad- miniftration of it. But now, from the information of many judicious praditioners who have frequently em- ployed it, I can fay, that it is a remedy which in nu- merous trials has been found to be of great fervice in this difeafe; and that, while the ufe of the ambiguous remedy of warm bathing is entirely laid afide, the ufe of cold bathing is over the whole of the Weft Indies commonly employed. The adminiftration of it is fometimes by bathing the perfon in the fea, or more frequently 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 a-bed, and at the fame time a large dofe of an opiate is given. By thefe means a confiderable remiffion of the fymptoms is ob- tained ; but this remiffion, at firft, does not common- ly remain long, but returning again in a few hours, the * The Paragraphs were thus numbered in the lad edition. 15-2 PRACTICE the repetition both of the bathing and the opiate be- comes neceffary. By thefe repetitions, however, longer intervals of eafe are obtained, and at length the difeafe is entirely cured ; and this even happens fome- times very quickly. I have only to add, that it does not appear to me, from any accounts that I have yet had, that the cold bathing has been fo frequently em- ployed, 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 teta- nus, or trifmus, which attacks certain infants foon af- ter their birth, and has been properly enough named the Trifmus Nafcentium. From the fubjeds it af- feds, it feems to be a peculiar difeafe : for thefe are infants not above two weeks, and commonly before they are nine days, old ; infomuch that, in countries where the difeafe is frequent, if children pafs the peri- od now mentioned, they are confidered as fecure a- gainft its attacks. The fymptom of it chiefly taken notice of, is the trifmus, or locked jaw, which is by the vulgar improperly named the Falling of the Jaw. But this is not the only fymptom, as, for the moft part, it has all the fame fymptoms as the Opifthotonos and Tetanus ftridly fo called, and which occur in the o- ther varieties of the tetanic complaints above defcrib- ed. Like the other varieties of tetanus, this is moft frequent in warm climates, but it is not, like thole a- rifing from the application of cold, entirely confined to fuch warm climates, as inftances of it have occur- red in moft of the northern countries of Europe. In thefe latter it feems to be more frequent in certain dif- trids than in others; but in what manner limited, [ pan not determine. It feems to be more frequent in Switzerland than in France. I am informed of its frequently O F P H Y S I C. i33 frequently occurring in the Highlands of Scotland ; but I have never met with any inftance of it in the low country. The particular caufes of it are not well known; and various conjedures have been offer- ed ; but none of them are Satisfying. It is a difeafe that has been almoft conftantly fatal; and this, alfo, commonly in the courfe of a few days. The women are fo much perfuaded of its inevitable fatality, that they feldom or never call for the affiftance of our art. This has occafioned our being little acquainted with the hiftory of the difeafe, or with the efteds of reme- dies in it. Analogy, however, would lead us to em- ploy the fame remedies that have proved ufeful in the other cafes of tetanus : and the few experiments that are yet recorded, feem to approve of fuch a pradice. ..<..<..<..<..<..«..«.<..«..<..<,$»>■■»■•>•*••*■•>••>■*•■►■■>■•>•• CHAP. II. OF EPILEPSY. MCCLXXXII. IN what fenfe I ufe the term Convulfion, I have ex- plained above in mcclvi. The convulfions that affed the human body are in feveral refpeds 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 Epilepfy. 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 ending in a ftate of infenfibility and feeming fleep. MCCLXXXIII. The general form or principal circumftances of this Vol. II. U difeafe, i54 PRACTICE difeafe, are much the fame in all the different perfons whom it affeds. It comes by fits, which often attacks perfons feemingly in perfed health ; and, after lafting for fome time, pafs off, and leave the perfons again in their ufual ftate. Thefe fits are fometimes preceded by certain fymptoms, which to perfons who have be- fore experienced fuch a fit, may give notice of its ap- proach, as we fhall hereafter explain ; but even thefe preludes do not commonly occur long before the for- mal attack, v/hich 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 imme- diately, or perhaps, with convulfions, is thrown to the ground. In that fituation he is agitated with vi- olent 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 coniider- abiy agitated than thofe upon the other. In all cafes the mufcles of the face and eyes are much affeded, exhibiting various and violent diftortions of the coun- tenance. The tongue is often affeded, and thruft out of the mouth ; while the mufcles of the lower jaw are alfo affeded ; and, fhutting the mouth with vio- lence while the tongue is thruft out between the teeth, that is often grievoufly wounded. While thefe convulfions continue, there is common- ly at the fame time a frothy moifture iffuing from the mouth. Thefe convulfions have for fome moments fome remiflions, but are fuddenly again renewed with great violence. Generally, after no long time, the convulfionsceafe altogether; and the perfon for fome time remains without motion, but in a ftate of abfo- lute infenfibility, and under the appearance of a pro- found fleep. After fome continuance of this feeming fleep, the perfon fometimes fuddenly, but for the moft part by degrees only, recovers his fenfes and power of OF PHYSIC. l5S of motion ; but without any memory of what had paff- ed from his being firft 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 ftate. This is the general form of the diieafe; and it va- ries only in different perfons, or on different occafions in the fame perfon, by the phenomena mentioned be- ing more or lefs violent, or by their being of longer or fhorter duration. MCCLXXXIV. With refped to the proximate caufe of this difeafe, I might fay, that it is an affedion of the energy of the brain, which, ordinarily under the diredion of the will, is here, without any concurrence of it, impelled by preternatural caufes. But I could go no farther : For, as to what is the mechanical condition of the brain in the ordinary exertions of the will, I have no diftind knowledge ; and therefore muft be alfo igno- rant of the preternatural ftate of the fame energy of the brain under the irregular motions here produced. To form, therefore, the indications of a cure, from a knowledge of the proximate caufe of this difeafe, I muft not attempt, but, from a diligent attention to the remote caufes which firft induce and occafionally excite the difeafe, I think we may often obtain fome ufeful diredions for its cure. It fhall therefore be my bufinefs now, to point out and enumerate thefe re- mote caufes as well as I can. MCCLXXXV. The remote caufes of epilepfy may be confidered as occafional or predifponent. There are, indeed, cer- tain remote caufes which ad 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. U % MCCLXXXVI. 156 PRACTICE MCCLXXXVI. The occafional caufes, may, 1 think, be properly re- ferred to two general heads ; the firfl being of thofe which feem to ad by diredly ftimulating and exciting the energy of the brain ; and the fecond, of thofe which feem to ad by weakening the fame. With refped to both, for the brevity of expreffing a fad, without meaning to explain the manner in which it is brought abour, I fhall ufe the terms of Excitement and Collapfe. And though it be true, that with re- fped to fome of the caufes I am to mention, it may be a little uncertain whether they ad in the one way or the other, that does not render it improper for us to mark, with refpect toothers, the mode of their operat- ing wherever we can do it clearly, as the doing fo may often be of ufe in direding our pradice. MCCLXXXVII. Firft, then, of the occafional caufes ading by excite- ment : They are either fuch as ad immediately and diredly upon the brain itfelf; or thofe which are firft applied to the other parte of the body, and are from tlience communicated to the brain. MCCLXXXV1II. The caufes of excitement immediately and diredly applied to the brain, may be referred to the four heads of, i. Mechanical Stimulants ; 2. Chemical Stimu- lants; 3. Mental Stimulants; and 4. The peculiar Stimulus of Over-diftention. MCCLXXXIX. The mechanical ftimulants may be, wounding in- ftruments penetrating the cranium, and entering the fubftance of the brain ; or fplinters of a fradured cra- nium, operating in the fame manner; or iharp-point- ed offifications, either arifing from the internal furface of the cranium, or formed in the membranes of the brain. MCCXC. OF PHYSIC. *57 . MCCXC. The chemical ftimulants (mcclxxxviii.) may be fluids from various caufes lodged in certain puns of the brain, and become acrid by ita^imcmn or other; - wifc. MCCXCI. The mental irritations acting by excitement, are, all violent emotions of the active kind, fuch as joy and anger. The firft or thole is manifeitiy an excit- ing power, ading ftrongly. and immediately, on the energy of the brain. The f»:co.id is manifeftly, alfo, a power ading in the fame maimer. But it mail be remarked, that it is not in this manner alone aii^cr produces its effeds : for it ads, alio, ftrongly on the fanguiferous fyftem, and may be a means of giving the ftimulus of over-diltention; as, under a fit of an- ger, the blood is impelled into the veffels of the head with violence, and in a larger quantity. MCCXClf. Under the head of Mental Irritations, is to be mentioned, the fight of perfons in a fit of epilepfy, which has often produced a fit of the like kind in the fpedator. It may, indeed, be a queition, Whether this effed be imputable to the Horror produced by a fight of the feemingly painful agitations of the limby, and of the diftortions in the countenance of the epi- leptic peifon; or if it may be afaibed to the force of imitation merely ? It is poflible, that horror may lome- times produce the effed : but cerr inly much m.iy b^ imputed to that propenlity to imitation, at ail times fo powerful and prevalent in human nature : and fo often operating in othm- cafes of convuliive d.ioraeis, which do not prefent any f,*cdaele of howm. iVJ OV-iAOi.il. Under the fame head of Mental Irritation. I think proper to mention as an inftance of it, the Epilepiia Simulata, or the i^ci^ned Epilepfy, io ukwi l.^cu no- tice i3S PRACTICE tice of. Alrhough this, at the firft, may be entirely feigned, I have no doubt but that the repetition ren- ders it at length real. The hiftory of vioietifm and of Exorcifms leads me to this opinion: and which receives a confirmation from what we know of the power of imagination, in renewing epileptic and hyf- teric fits. MCCXCIV. I come now to the fourth head of the irritations applied immediately to the brain, and which I appre. hend to be that of the over-diftenfion of the blood- veffels in that organ. That fuch a caufe operates in producing epilepfy, is probable from this, that the diffedion of perfons dead of epilepfy, has commonly dilcovered the marks of a previous congeftion in the blood-veffels of the brain. This, perhaps, may be fiippofed the effect of the fit which proved fatal: but that the congeftion was previous thereto, is probable from the epilepfy being fo often joined with headach, mania, paify, and apoplexy ; all of them difeafes de- pending upon a congeftion in the veffels of the brain. The general opinion receives alfo confirmation from this circumftance, 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 depend on the compref- fion of a cjnfiderable portion of the brain, may, how- ever, have been fufficient to comprefs fo many veffels as to render the others upon any occafion of a more than ufual mrgefcence, or impulfe of the blood into the veffeis of the brain more liable to an over-diften- tion. MCCXCV. Thefe confiderations alone might afford foundation for a probable conjcdure with refped to the clfeds of over-diftention. But the opinion does not reft upon conjedure alone. That it is alfo founded in fad, ap- pears OF PHYSIC. lS9 pears from hence, that a plethoric ftate is favourable to epilepfy ; and that every occafional 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 immediate exciting caufes of epileptic fits. ' MCCXCVI. I venture to remark further, that a piece of theory may be admitted as a confirmation of this dodrine. As I have formerly maintained, that a certain fulnefs and tenfion of the veffels of the brain is neceffary to the fupport of its ordinary and conftant energy, in the diftribution of the nervous power; fo it muft be fufficiently probable, that an over-diftenfion of thefe blood-veffels may be a caufe of violent excitement. MCCXCVII. We have now enumerated the feveral remote or oc- cafional caufes of epilepfy, ading by excitement, and ading immediately upon the brain itfelf. Of the caufes ading by excitement, but ading upon other parts of the body, and from thence communicated to the brain, they are all of them impreffions producing an exquifite or high degree either of pleafure or pain. Impreffions which produce neither the one nor the other, have hardly any fuch effeds, unlefs when fuch impreffions are in a violent degree ; and then their operation may be confidered as a mode of pain. It is, however, to be remarked, that all ftrong impreffions which are fudden and furprifing, or, in other words, unforefeen and unexpeded, have frequently the effect of bringing on epileptic fits. MCCXCVIII. There are certain impreffions made upon different parts of the body, which as they often operate with- out producing any fenfation, fo it is uncertain to what head they belong ; but it is probable that the greater part i6o P R A c-ri l; ■*, pan of them ad by exciterr.en-, and therefore fall, to be mentioned here. The chief inftances are, The teething of infants; worms; acidity or other acrimo- ny in the alimentary canal; calculi in the kidneys ; acrid matter in abfceff-s or ulcers; or acrimony dif- fufed in the mats of blood, as in the cafe of fome con- tn^i; ns. ° XT^nVriV Phvficians have found no difficulty in comprehend- ing how dired ftimulants, of a certain force, may ex- cite the action of the brain, and occafion epilepfy : but they have hitherto taken little notice of certain caufes which manifeftly weaken the energy of the brain, and ad, as 1 fpeak, by collapfe. Thefe, how- ever, have the effed of exciting the adion of the brain in fuch a manner as to occafion epilepfy. ^ I might upon this fubjed, fpeak of the vis medicatrix natural; and there is a foundation for the term ; but^ as I do not admit the Stahlian dodrine of adminiftering foul, I make ufe of the term only as expreffing a fad, and would not employ it with the view of conveying an explanation of the manner in which the powers of collapfe mechanically produce their effeds. In the mean time, however, I maintain, that there are certain powers of collapfe, which in effed prove ftimulants, and produce epilepfy. iYl^v^O. That there are fuch powers, which may be termed Indirect Stimulants, I conclude from hence, that feve- ral of the caufes of epilepfy are fuch as frequently produce fyncope, which we fuppofe always to depend upon caufes weakening the energy of the brain, (mc- lxxvi.) It may give fome difficulty to explain, why The fame caufe fometimes occafion fyncope, and fome- times occafion the readion that appears in epilepfy ; and I fhr.ll not attempt to explain it: but this, I think, does net prevent my fuppofing that the operation of thefe OF P H Y S I C. 161 thefe caufes is by collapfe. That there are fuch caufes producing epilepfy, will, I think, appear very clearly from die particular examples of them I am now to mention. MCCCI. The firft to be mentioned, which I fuppofe to be of this kind, is hemorrhagy, whether fpontaneous or artificial. That the fame hemorrhagy which produc- es fyncope, often at the fame time produces epilepfy, is well known; and from many experiments and ob- fervations it appears, that hemorrhagies occurring to fuch a degree as to prove mortal, feldom do fo with- out firft producing epilepfy. MCCCII. Another caufe ading, I fuppofe, by collapfe, and therefore fometimes producing fyncope, and fumetimes epilepfy, is terror ; that is, the fear of fome great evil fuddenly prefented. As this produces at the fame time a fudden and confiderable emotion, (mclxxx.) fo it more frequently produces epilepfy than fyncope. MCCCI1I. A third caufe ading by collapfe, and producing epilepfy, is horror; or a ftrong averfion fuddenly raif- ed by a very difagreeable fenfation, and frequently arifing from a fympathy with the pain or danger of another perfon. As horror is often a caufe of fyncope, there can be.no doubt of its manner of operating in producing epilepfy ; and it may perhaps be explain- ed upon this general principle, That as defire excites adion and gives adivity, fo averfion reftrains from adion, that is, weakens the energy of the brain; and, therefore, that the higher degrees of averfion may have the effeds of producing fyncope or epilepfy. MCCCIV. A fourth fet of the caufes of epilepfy, which I fup- pofe alfo to ad by collapfe, are certain odours, which occafion either fyncope or epilepfy ; and, with refped Vol. II. X to 162 PRACTICE to the former, I have given my reafons (mclxxxii.) for fuppofing odours in that cafe to ad rather as difa- greeable than as fedative. Thefe reafons will, I think, alfo apply here ; and perhaps the whole affair of odours might be confidered as inftances of the effed of hor- ror, and therefore belonging to the laft head. MLCCV. A htth head of (he caufes producing epilepfy by collapfe, is the operation of many fubftances confi- dered. and for the moft part properly confidered, as poifons. Many of thefe, before they prove mortal, occafion epilepfy. This effed, indeed, may in fome cafes be referred to the inflammatory operation 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 ftrongly fedative power, it is probably by this power that they produce epilepfy, and therefore belong to this head of the caufes ading by collapfe. MCCCVI. Under the head of the remote caufes producing epilepfy, we muft 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 bo- dy, and from thence creeping upwards to the head; and when it arrives there, the perfon is immediately deprived ol fenfe, and falls into an epileptic fit. This motion is defcribed by the perfons feeling it fome- times as a cold vapour, fometimes as a fluid gliding, and fometimes as the fenfe of a fmall infed creeping along their body ; and very often they can give no diftind idea of their fenfation, otherwife than as in general of fomething moving along. This fenfation might be fuppofed to ai ife from one affedion of the extremity or other part of a nerve aded upon by fome irritating matter ; and that the fenfation, therefore, fol- O F P H Y S I C. 163 followed the courfe of luch a nerve : but I have neve? found it following diftindly the courfe of any nerve ; and it generally feems to pafs along the teguments. It has been found in fome inftances to arife from fomething prefung upon cr irritating a particular nerve, and that fometimes in confequence of contufi- on or wound: but inftances of thefe are more rare ; and the more common confequences of contufions-and wounds is a tetanus. This latter effed wounds pro- duce, without giving any fenfation of an aura or other kind of motion .proceeding from the wounded part to the head ; while, on the other hand, the aura produ- cing epilepfy often arifes from a part which never had been affeded with wound or contufion, and in jS' which part the nature of the irritation can feldom t*e difcovered. It is natural to imagine that this aura epileptica is an evidence of fome irritation or dired ftimulus ading in the part, and from thence communicated to the brain, and fhould therefore have been mentioned a- mong the caufes ading by excitement; but the re- markable difference that occurs in feemingly like caufes producing tetanus, gives fome doubt on this fubjed. MCCCVII. Having now enumerated the occafional caufes of epilepfy, I proceed to confider the predifponent. As fo many of the above-mentioned caufes ad upon cer- tain perfons, and not at all upon others, there muft be fuppofed in thofe perfons a predifpofition to this dif- eafe : But in what this predifpofition confifts, is not to be eafily afcertained. MCCCVIII. As many of the occafional caufes are weak impref- fions, and are applied to moft perfons with little or no, effed, I conclude, that the perfons affeded by thofe caufes are more eafily moved than others; and there- X 2 fore 164 PRACTICE fore that,.in this cafe, a certain mobility gives the preoifpofition. It will, perhaps, make this matter clearer, to fhow, in the firft place, that there is a greater mobility of conftitution in fome perfons than in others. MCCC1X. This mobility appears moft clearly in the ftate of the mind. If a perfon is readily elated by hope, and as readily depreffed by fear, and paffes eafily and quickly from one ftate 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 imprcifions, to ftrong emotions, but tenacious of none ; this is the boyifh temperament qui colligit ac ponit iram temere, et mutatur in horas ; this is the varium et mutabile fcemina /and, both in the boy and woman, every cne perceives and acknowledges a mobility of mind. But this is neceffarily conceded with an an- alogous ftate of the brain; that is, with a mobility, in refped of every impreffion, and therefore liable to a ready alteration of excitement and collapfe, and or" both to a confiderable degree. MCCCX. There is, therefore, in certain perfons, a mobility of conftitution, generally derived from the ftate of o- riginal itamina, and more exquifite at a certain period of life than at others ; but fometimes arifing from, and particularly modified by, occurrences in the courfe of life. MCCCXI. This mobility confifts in a greater degree of either fenfibility or irrirabihty. Thefe conditions, indeed, phyficiam confider ;:s fo neceffarily conneded, that the conftitution with refpect to thcrri, may be confider- ed 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 fometim es on O F P H Y S I C. 165 on that of the other. If an adion excited, is, by re- petition rendered more eafily excited, and more vigo- roufly performed, I confider this as an increafe of irri- tability only. I go no farther on this fubjed here, as it was only neceffary to take notice of the cafe juft now mentioned, for the purpofe of explaining why epilepfy, and convulfions of all kinds, by being repeat- ed, are more eafily excited, readily become habitual, and are therefore of more difficult cure. MCCCX1I. However we may apply the diftindion of fenfibili- ty and irritability, it appears that the mobility, which is the predifponent caufe of epilepfy, depends more particularly upon debility, or upon a plethoric ftate of the body. MCCCXIII. What fhare debility, perhaps by inducing fenfibi- lity, has in this matter, appears clearly from hence, that children, women, and other perfons of manifeft debility, are the moft frequent fubjeds of this difeafe. MCCCXIV. The effeds of a plethoric ftate in difpofing to this difeafe appears from hence, that plethoric perfons are frequently the fubjeds of it : that it is commonly ex- cited, as I have faid above, by the caufes of any uou- fual turgefcence of the blood; and that it has been frequently cured by diminifhing the plethoric ftate of the body. That a plethoric ftate of the body fhould difpofe to this difeafe, we may underftand from feveral con- fiderations. \fl, Becaufe a plethoric ftate implies, for the moft part a laxity of the folids, and therefore fome debility in the moving fibres. 2u'ly, Becaufe, in a plethoric ftate, the tone of the moving fibres de- pends more upon their tenfion, than upon their inhe- rent power: and as their tenfion depends upon the quantity and impetus of the fluid in the blood-veffe I;, which 166 PRACTICE which are very changeable, and by many caufes frc quently changed, fo thefe frequent changes muft give a mobility to the fyftem. y^y-, Becaufe a plethoric ftate is favourable to a congeftion of 4>lood in the veffels of the brain, it muft render thefe more readily affeded by every general turgefcence of blood in the fyltem, and therefore more efpecially difpofe to this difeafe. MCCCXV. There is another circumftance of the body difpof- ing to epilepfy, which I cannot fo well account for : and that is, the ftate of fleep : but whether I can ac- count for it or not, it appears, in fad, that this ftate gives the difpofition I fpeak of; for, in many perfons li- able to this difeafe, the fits happen only in the time of fleep, or immediately upon the perfon's coming out of it. In a cafe related by De Haen, it appeared clear- ly, that the difpoficion to epilepfy depended entirely upon the ftate of the body in fleep*. MCCCXVI. Having thus confidered the whole of the remote caufes of epilepfy, I proceed to treat of its cure, as I have faid it is from the confideration of thofe remote caufes only that we can obtain any diredions for our pradice in the difeafe f. I be- * This was a very fingular cafe. The chief circumftances in it were, that the boy was more liable to the paroxyfms when lying and afleep, than when fitting up and awake. This peculiarity was not obferved till the difeafe had been of fome Handing, and, on a more rr.arate attention, the paroxyfms were found to be more frequent when the patient was in a peculiar ftate of deeping, namely, when he was dro-.vfy, or when he fnored in his deep, than when he enjoy- ed an eafy and quiet fleep. A natural, quiet, and eafy fleep, was procured by the ufe of opium ; and in a Ihort time, the difeafe was peiftftly cured ; but the boy died afterwards in confequence of a tumor in his groin. f Other caufes of Epilepfy are enumerated by medical writers, which the author, for the fake of brevity, left unnoticed. 'OTTH Y S I C. 167 I begin with obferving, that as the difeafe may be confidered as fympathic or idiopathic, I muft treat of thefe feparately, and judge it proper to begin with the former. MCCCXVII. When this difeafe is truly fympathic, and depend- ing upon a primary affedion in fome other part of the body, fuch as acidity or worms in the alimentary ca- nal, teething, or other fimilar caufes, it is obvious that fuch primary affcdions muft be removed for the cure of the epilepfy ; but it is not our bufinefs here to fay how thefe primary difeafes are to be treated. MCCCXVIII. There is, however, a peculiar cafe of fympathic epilepfy; that is, the cafe accompanied with the au- ra Cafes have occurred in whfcn the epilepfy feems to have proceed- ed from an hereditary taint. Quickfilver, cither accidentally or intentionally applied, h.is been frequently found to produce epilepfy. Perfons employed in gilding of metals are often feized with tremblings of the hands, with paify, and with epilepfy, which can be attributed to nothing elfe than the abforption of the vapours of mercury ufed in the operation, wkich is as follows : the piece of metal to be gilt is firlt well cleaned and po- liflied ; fome mercury fhaken with aqua fortis is fpiead upon it, till ttie furface appears all over as white as filver : being then heated and le-touched in thofe parts that have efcaped the mixture, an amalga- rna of mercury and gold is laid on it; the heat foftening the amal- gania, makes it fpread more uniformly ; and the intervention of the mercury and aqua fortis makes it adhere more firmly. The piece thus covered with the amalgama is placed on a convenient fupport, over a charcoal fire ; and examined, from time to time, as the mer- cury evaporates, that, if any deficiencies appear, they may be fuppli- ed with a little more of the amalgama before the operation is com- pleted. This procefs neceffarily expofes the artiit to the fumes of the mercury. fr Van Swicten fays that he has feen fkulls, in the dipploe of which. globules of mercury manifeftly appeared ; and he thinks it probable that the mercury may poffibly be thrown out into the cavities of the brain itfelf, and produce much mifchief. Venery, when exceffive, has been enumerated among the caufes of epilepfy by Boerhaave, but on what authority feems uncertain. 168 PRACTICE ra epileptica, asdefcribedin mcccvi, in which, though we can perceive by the aura epileptica arifing from a particular part, that there is fome affedion in that part; yet, as in many fuch cafes we cannot perceive of what nature the affedion is, I can only offer the fol- lowing general diredions. i/2. When the part can with fafety be entirely de- ftroyed, we fhould endeavour to do fo by cutting it out, or by deftroying it by the application of an adual or potential cautery. idly, When the part cannot properly be deftroyed, that we fhould endeavour to corred the morbid affec- tion in it by bliftering, or by eftablifhing an iffue up- on the part. $diy, When thefe meafures cannot be executed, or do not fucceed, if the difeafe feems to proceed from the extremity of a particular nerve which we can eafi- ly come at in its courfe, it will be proper to cut through that nerve, as before propofcd on the fubjed of teta- nus. 4thly, When it cannot be perceived that the aura arifes from any precife place or point, fo as to dired to the above-mentioned operations ; but, at the fame time, we can perceive its progrefs along the limb ; it frequently happens that the epilepfy can be prevented 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 hfs fit to propagate the aura. MCCCXIX. The cure of idiopathic^epilepfy, as I have faid a- bove, is to be direded by our knowledge of the remote caufes. There are therefore two general indications to be formed : The firft is, to avoid the occafional cauf- es ; and the fecond is, to remove or corred the pre- difponent. This OF PHYSIC- 169 This^method, however, is not always purely palli- ative ; as in many cafes the predifponent may be confidered as the only proximate caufe, fo our fecond indication may be often confidered as properly cura- tive. MCCCXX. From the enumeration given above, it will be mani- feft, that for the moft part the occafional caufes, fo far as they are in our power, need only to be known, in order to be avoided ; and the means of doing this will be fufficiently obvious. I fhall here, therefore, offer only a few remarks. MCCCXXI. One of the moft frequent of the occafional caufes is that of over-diftenfion, (mcccxiv.) which, fo far as it depends upon a plethoric ftate of the fyftem, I fhall fay hereafter how it is to be avoided. But as, not only in the plethoric, but in every moveable conftitu- tion, occafional turgefcence is a frequent means of ex- citing epilepfy, the avoiding therefore of fuch turgef- cence is what ought to be moft conftantly the objed of attention to perfons liable to epilepfy. MCCCXXII. Another of the moft frequent exciting caufes of this difeafe are, all ftrong impreffions fuddenly made upon the fenfes; for as fuch impreffions, in moveable confti- tutions, break in upon the ufual force, velocity, and order of the motions of the nervous fyftem, they there- by readily produce epilepfy. Such impreffions, there- fore, and efpecially thofe which are fuited to excite any emotion or pafiion of the mind, are to be moft carefully guarded againft by perfons liable to epilep- MCCCXXIII. In many cafes of epilepfy, where the predifponent caufe cannot be correded or removed, the recurrence of the difeafe can only be prevented by theftrideft at- Vol. II. Y tention i;o .PRACTICE tention to avoid the occafional; and as the difeafe is of- ten confirmed by repetition and habit, fo the avoiding the frequent recurrence of it is of the utmoft import- ance towards its cure. Thefe are the few remarks I have to offer with re- fped to the occafional caufes ; and 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 correding 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 certain ftate of debility in it. MCCCXXV. How the plethoric ftate of the fyftem is to be co% reded, I have treated of fully above in dcclxxxiii. etfeq. and I need not repeat it here. It will be enough to fay, that it is chiefly to be done by a proper ma- nagement of exercife and diet; and, with refped to the latter, it is particularly to be obferved here, that an abftemious courfe has been frequently found to be the moft certain means of curing epilepfy. MCCCXXVI. Confidering the nature of the matter poured out by iffues, thefe may be fuppofed to be a conftant means of obviating the plethoric ftate of the fyftem; and it is, perhaps, therefore, that they have been fo oft- en found ufeful in epilepfy. Poffibly, alfo, as an open iffue maybe a means of determining occafional tur- gefcences to fuch places, and therefore of diverting them in fome meafure from their adion on the brain • fo alfo, in this manner, iffues may be ufeful in epi- lepfy. MCCCXXVII. It might be fuppofed that blood-letting would be the moft effedual means of correding the plethoric ftate OF PHYSIC, 171 ftate of the fyftem ; and fuch it certainly proves when the plethoric ftate has become confiderable, and imme- diately threatens morbid effeds. It is therefore, in fuch circumftances, proper and neceffary : but as we have faid above, that blood-letting is not the proper means of obviating a recurrence of the plethoric ftate, and, on the contrary, is often the means of favouring it; fo it is not a remedy advifable in every circumftance 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 fyftem, gi iug occafion to a recurrence of the difeafe. In fuch cafes, when the means of preventing plethora have been negleded, or may have proved ineffedual, it is abfolutely neceffary for the praditioner to watch the returns of thefe turgefcences, and to obviate their effeds by the only certain means of doing it, that is, by a large blood-letting. MCCCXXVIII. The fecond caufe of mobility which we have affign- ed, is a ftate of debility. If this is owing, as it fre-. quently is, to original conformation, it is perhaps not poffible to cure it; but when it has been brought on in the courfe of life, it poffibiy may admit of being mended ; and, in either cafe, much may be done to.' obviate and prevent its effeds. MCCCXXIX. The means of correding debility, fo far as it can be done, arc, The perfon's being much in cool air ; the frequent ufe of cold bathing; the ufe of exercife, a- dapted to the ftrength and habits of the perfon ; and, perhaps, the ufe of aftringent and tonic medicines. Thefe remedies are fuited to ftrengthen the inherent power of the folids or moving fibres: but as the ftrength of thefe depends alfo upon their tention, fo when debility has proceeded from inanition, the ftrength may be reftored, by reftoring the fulnefs and Y 2 tenfion *7a PRACTICE tenfion of the veffels by a nourifhing diet ; and we have had inftances of the propriety and fuccefs of fuch a pradice. MCCCXXX. The means of obviating the effeds of debility, and of the mobility depending upon it, are the ufe of to- nic and antifpafmodic remedies. The tonics are, Fear, or fome danger of terror ; af- tringents ; 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-houfc at Haerlem. See Kauu Boer- haave's treatife, intitled Impetum Fociens, \ 406. And we have met with feveral other inftances of the fame. As the operation of horror is in many refpeds an- alogous to that of terror, feveral feemingly fuperftiti- ous remedies have been employed for the cure of e- pilepfy; and, if they have ever been fuccefsful, I think it muft be imputed to the horror they had in- fpired*. MCCCXXXII. Of the aftringent medicines ufed for the cure of er pilepfy, the moft celebrated is the vifcus quercinus, which, when given in large quantities, may poffibly be ufeful; but I believe it was more efpecially fo in ancient times, when it was an objed of fuperftition. In * Drinking a draught of the blood of a gladiator juft killed ; drinking a draught of water with a toad at the bottom of the juo- ; eating a piece of human liver, or the marrow of the bones of the leg of a malefactor ; powder of the human flcull, or the mofs that grows on it ; with a variety of fuch abominable remedies, were formerly in great repute ; and indeed fome of them are ftill retained in feverd foreign Pharmacopoeias. OF PHYSIC. 173 In the few inftances in which I have feen it employed, it did not prove of any effed*. MCCCXXXIII. Among the vegetable tonics, the bitters are to be reckoned ; and it is by this quality that I fuppofe the orange-tree leaves to have been ufeful: but they are not always fo. MCCCXXXIV. The vegetable tonic, which from its ufe in analogous cafes is the moft promifing, is the Peruvian bark; this, upon occafion, has been ufeful, but has alfo often failed. It is efpecially 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 peri- odical cafes, if the bark is employed fome time before the expeded recurrence, it may be ufeful; bur. it muft be given in large quantity, and as near to the time of the expeded return as poffible. MCCCXXXV. The metallic tonics feem to be more powerful than the vegetable, and a great variety of the former have been employed. Even arfenic has been employed in the cure of epi- lepfy ; and its ufe in intermittent fevers gives an analo- gy in its favour. Preparations of tin have been formerly recommend- ed in the cure of epilepfy, and in the cure of the ana- logous difeafe of hyfteria; and feveral confederations renders the virtues of tin, with refped to thefe difeaf- es, probable : but I have had no experience of its ufe in fuch cafes. A much fafer metallic tonic is to be found in the preparations of iron ; and we have feen fome of them employed * The dofe of it was from half a drachm td"a drachm in powder, an ounee in infufion. 174 PRACTICE employed in the cure of epilepfy, but have never found them to be effedual. This, however, I think, may be imputed to their not having been always em- ployed in the circumftances of the difeafe, and in the quantities of the medicine, that were proper and ne- ceffary*. 1 MCCCXXXVI. Of the metallic tonics, the moft celebrated and the moft frequently employed is copper, under vaiious preparation. What preparation of it may be the moft effedual, I dare not determine; but of late the cuprum ammonUcwn has been frequently found fuccefs- fulf. MCCCXXXVII. Lately the flowers of zinc have been recommended by a great authority as ufeful in all convulfive difor- ders ; but in cafes of epilepfy, I have not hifierto found that medicine 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 reme- dy are confirmed, it will allow us to think that the fame may be adapted alfo to the cure of certain cafes of epilepfy. MCCCXXXIX. * The method of ufing iron, was defcribed in a note on article 577- f This was a favourite remedy of the Author's. He firft intro- duced it into praftice in this country, and the preparation of it was inferted in the Edinburgh Pharmacopoeia. It is employed by beginning with fmall dofes of half a grain, and increafing them gradually to as much as the ftomach will bear. It is, however, like all preparations of copper, a very dangerous medi- cine, and ought to be ufed with caution. t The great authority by which the flowers of zinc were recom- mended was Gnubius It is as dangerous a medicine as the cuprum immcniacum, and muft be ufed with the fame caution. OF PHYSIC. l75 MCCCXXXIX. With refped to the employment of any of the a- bove mentioned tonics in this difeafe, it muft be ob- ferved, that in all cafes where the difeafe depends up- on a conftant or occafional plethoric ftate of the fyf- tem, thefe remedies are likely to be ineffedual; and if fufficient evacuations are not made at the fame time, thefe medicines are likely to be very hurtful. MCCCXL. The other fet of medicines which we have mention- ed as fuited to obviate the effeds of the too great mo- bility of the fyftem, are the medicines named antifi pafmodics. Of thefe there is a long lift in the writers on the Materia Medica, and by thefe authors re- commended for the cure of epilepfy. The greater part, however, of thofe taken from the vegetable king- dom, are manifeftly inert and infignifieant*. Even the root of the wild valerian hardly fupports its cre- dit. MCCCXLI, , Certain fubftances taken from the animal kingdom feem to be much more powerful: .and of thefe the chief, and feemingly the moft powerful, is mufk ; which, employed inks genuine ftate, and in due quan- tity, has often been an •effedual remedyf. It * This is certainly true ; but it muft be acknowledged that fome of them are manifeftly active and ufeful, as the affafcetida, fagapenum, and other foetid gums. Thepilulaegummofae of the Pharmacopoeias, are good formulae for thefe naufcous medicines ; and their being re- puted inefficacious and infignifieant feems to have arifen from theLr not having been given in fufficiently large dofes. .They may be given with fafety to the quantity of two drachms in a day in repeated dofes of twenty or thirty grains each ; and, if they fhould happen to purge, this inconvenience may be prevented, by adding a quarter or half a grain of opium to each dofe of the pills, or taking ten drops of laudanum after each dofe, as occafion may require. f iViuflc is more effectual when given in fubftance, than in any preparation that has been attempted j it is given in dofes of from ten 176 PRACTICE It is probable alfo, that the oleum animale, as it has been named, when in its pureft ftate, and exhibited at a proper time, may bean effedual remedy*. MCCCXLII. In many difeafes, the moft powerful antifpafmodic is certainly opium; but the propriety of its ufe in epi- lepfy has been difputed among phyficians* When the difeafe depends upon a plethoric ftate in which bleeding may be necelfary, the employment of opium is likely to be very hurtful : but, when there is no plethoiic or inflammatory ftate prefent, and the difeafe feems to depend upon irritation or upon increafed irri- tability, opium is likely to prove the moft certain re- medy-)-. Whatever effeds in this and other convul- five diforders have been attributed to the hyofcyamus, ' muft probably be attributed to its poffeffing a narcotic power fimilar to that of opium. MCCCXLIII. With refped to the ufe of antifpamodics, it is to be obferved, that they are always moft ufeful, and per- haps only ufeful, when employed at a time when epi- leptic fits are frequently recurring, or near to the times to thirty grains, and frequently repeated. It may be made into a bolus, as in the formula : &. Mofch. gr. xv. Tere in mortar, marmor. cum Sacch. alb. 3i. et adde Confeft. cardiac. 3fs. • M. f. bolus. This bolus may be repeated three or four times a day. * The dofe of this oil k from twenty to thirty drops j it is, how- ever, feldom ufed. f In thofe cafes, in which fome peculiar fymptoms indicate the approach of the fit, opium taken in a large dofe has fometimes pre- vented it altogether ; but moft commonly, however, fuch a dofe greatly leffens its violence. Two grains of opium in fubftance, oi» fixty or feventy drops of laudanum, are large dofes. OF PHYSIC. 177 times of the acceflion of fits which recur after confi- derable intervals. . MCCCXLIV. On the fubjed 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 habic has a great fhare in increafing mobility, and therefore in continuing this difeafe ; fo the breaking in upon fuch habit, and changing the whole habits of the fyf- tem, is likely to be a powerful remedy in epilepfy. Accordingly, a confiderable change of climate, diet, and other circumftances 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 diftinguifhed from epilepfy by their, being more partial: that is, affeding certain parts of the body only, and by their not being attended with a lofs of fenfe, nor ending in fuch a comatofe ftate as epilepfy always does. MCCCXLVI.. Of fuch convulfive affe&ions many different inftan-i ces have been obferved and recorded by phyficians. But many of thefe have been manifeftly fympathic af- Vol. II. Z fedions, * After all that has been faid on this difeafe, we muft acknow- ledge that we know but little of its true nature, and confequently no certain method of cure can be given. It has baffled the fkill of phy- ficians from the earlieft ages of phyfic, and ftill remains to be one of thofe many difeafes which we cannot certainly cure. ; Some fpecies of it, indeed, are certainly curable ; but thefe artf few, and fuch only as are fymptomatic, or arife from peculiar ms- chanical irritations. Experience has moreover fhewn us, that the difeafe often exifts withoiltany apparent irritation, and without any caufe obfervable ou diffection. ■ Much room is therefore left for future invefligations on th it dark fubje& ; and we muft at prefent content ourftlves with the hopesthat time will unfold whj>t human ingenuity has not been capa- ble of effecting. 178 PRACTICE fedions, to be cured only by curing the primary dif- eafe upon 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, how- ever, have not any fpecific charader with which they occur in different perfons, 1 muft therefore leave them to be treated upon the general principles I have laid down with refped to epilepfy, or fhall lay down with refped to the following convulfive diforder ; which as having very conftantly in different perfons a peculiar charader, I think neceffary to treat of more particu- larly. CHAP. III. OF THE CHOREA OR DANCE OF St. VITUS; MCCCXLVII. THIS difeafe affeds both fexes, and-almoft only young perfons. It generally happens from the age of ten to that of fourteen years*. It comes on al- ways before the age of puberty, and rarely continues beyond that period. MCCCXLVI1I. It is chiefly marked by convulfive motions, fome- what varied in different perfons, but nearly of one kind in all; affeding the leg and arm on the fame fide, and generally on one fide only. MCCCXL1X. Thefe convulfive motions commonly firft affed the leg * I have feen it in a robuft man of forty-two. This patient, after various ineffectual remedies had been ufed, was cured by ftrong elec- trical fhocks directed through the whole body. • OF PHYSIC. 179 kg and foot. Though the limb be at reft, the foot is often agitated by convulfive motions, turning it al- ternately outwards and inwards. When walking is attempted, the affeded leg is feldom lifted as ufual in walking, 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 becom- ing atritated by irregular convulfive motions. 88 7 MCCCL. The arm of the fame fide is generally affeded at the fame time ; and, even when no voluntary motion is attempted, the arm is frequently agitated with vari- ous convulfive motions. But efpecially when volun- tary motions are attempted, thefe are not properly ex- ecuted, but are varioufly hurried or interrupted by convulfive motions in a diredion contrary to that in- tended. The moft common inftance of this is in the perfon's attempting to carry a cup of liquor to his mouth, when it is only after repeated efforts, interrupt- ed by frequent convulfive retradions and deviati- ons, that the cup can be carried to the mouth. MCCCL I. It appears to me, that the will often yields to thefe convulfive motions, as to a propenfity, and thereby they are often increafed, while the perfon affeded feems pleafed with increafing the furprife and amufe- ment which his motions occafion in the byftanders. MCC'CLII. In this difeafe the mind is often affeded with fome degree of fatuity ; and often fhows the fame varied, defultory, and caufelefs emotions which occur in hy- fteria. MCCCLIII. Thefe are the moft common circumftances of this difeafe; but at times, and in different perfons, it is varied by fome difference in the- convulfive motions, particularly by thefe affeding the head and trunk of Z 2 the i8o PRACTICE the body. As in this difeafe there feem to be pro- penfities to motion, fo various fits of leaping arid run- ning occur in the perfons affeded ; and there have been inftances of this difeafe, confifting of fuch con- vulfive motions, appearing as an epidemic in a certain corner of the country. In fuch inftances, perfons of different ages are affeded, and may feem to make an exception to the general rule above laid down; but ftill the perfons arc, for the moft part, the young of both fexes, and of the more manifeftly moveable con- ftitutions. MCCCLIV. The method of curing this difeafe has been variouf- ly propofed. Dr. Sydenham propofed to cure it by alternate bleeding and purging. In fome plethoric habits I have found fome bleeding ufeful; but in ma- ny 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 readily yield to tonic remedies, fuch as the Peruvian bark, and chalybeates. The late Dr. De Haen found feveral perfons labour- ing under this difeafe cured by the application of elec- tricity. * 14.. . SECT. OF PHYSIC. 182 SECT. II. OF THE SPASMODIC AFFECTIONS OF THE VITAL FUNCTIONS. CHAP. IV{. OF THE PALPITATION OF THE HEART. MCCCLV. THE motion thus named is a contradion or fyf- tole of the heart, that is performed with more rapidity, and generally alfo with more force than ufu- al ; and when at the fame time the heart ftrikcs 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 with great pains by Mr. Senac and others ; whom however, I cannot follow in all the particulars with fufficient dif- cernment, and therefore fhall here only attempt to re- fer all the feveral cafes of this difeafe to a few general heads. MCCCLVII. The firft is of thofe arifing from the application of the ufual ftimulus to the heart's contradion ; 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 bead of the cafes of palpitation, is of thofe arifing from any refiftance given to the free and entire evacuation of the ventricles of the heart. Thus a li- gature f Though I have thought it proper to divide this book into fcc- tions, I think it neceffary, for the convenience of references, to num- ber the chapters from the beginning. 183 PRACTICE gature made upon the aorta occafions palpitations of the moft violent kind. Similar refiftances, either in the aorta or pulmonary artery, may be readily imagin- ed ; and fuch have been often found in dead bodies^ of perfons who, during life, had been much affeded with palpitations. To this head are to be referred all thofe cafes of palpitation arifing from c tufes producing an accumu- lation of blood in the great veffels near to the heart. MCCCL IX. A third head of the cafes of palpitation, is of thofe arifing from a more violent and rapid influx of the ner- vous power into the mufcular fibres of the heart. It is in this manner that I fuppofe various caufes ading in the brain, and particularly certain emotions 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 adi- on of the heart, by diminifhing the energy of the brain with refped to it. That fuch cafes operate in producing palpitation, I prefume from hence, that all the feveral caufes mentioned above (mclxxvii. et feq.) as in this manner producing fyncope, do often pro- duce palpitation. It is on this ground that thefe two difeafes are affedions 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 mobili- ty of the perfon aded upon. It feems to be a law of human ceconomy, that a degree of debility occurring in any iundion, often produces a more vigorous exer- tion of the fame, or at leaft an effort towards it, and that commonly in a convulfive manner. I apprehend it to be the convulfive adion, frequent- ly ending in fome degice of a fpafm, that gives occa- fion to the intermittent pulfe fo frequently accompa- nying palpitation. MCCCLXI. OF PHYSIC 184 MCCCLXI. A fifth head of the caufes of palpitation may per- haps be of thofe arifing fiom a peculiar irritability or mobility of the heart. This, indeed, may be confi- dered as a predifponent caufe only, giving occafion to the adion of the greater part of the caufes recited a- bove. But it is proper to obferve, this predifpofition h often the chief part of the remote caufe ; infomuch that many of the caufes producing palpitation would not have this effed but in perfons peculiarly predif- pofed. This head, therefore, of the caiVs of palpita- tion, often requires to be diftinguifhed from all the reft. MCCCLXII. After thus marking the f-vcral 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 reduced to two heads. The firft is, of thofe confifting in, or depending upon, certain organic aifedions of the heart itfelf, or of the great veffels immediately cenneded with it. The fecond is, of thofe confifting in, or depending upon, certain affedions fubfifting and ading in other parts of the body, and ading either by the force of the caufe, or in confequenee of the mobility of the heart. MCCCLXI1I. With refped to the cafes depending upon the firft fet of caufes, I muft repeat here what I faid with re- fped to the like cafes of fyncope, that I do not know any means of curing them. They, inik.d, admit of fome palliation^r/?, by avoiding every circumftance that may hurry the circulation of the blood ; and, fe- condly, by every means of avoiding a plethoric ftate of the fyftem, or any occafional turgefcence of the blood. In many of thefe cafes, blood-letting may give a temporary relief: but in fo far as debility and mobi- i§5 PRACTICE lity are concerned, in fuch cafes this remedy is likely to do harm. MCCCLXIV. With refped to the cafes depending upon the other fet of caufes, they may be various, and require very different meafures : but I can here fay in gene- ral, that thefe cafes may be confidered as of two kinds : one depending upon primary aifedions in o- ther parts of the body, and ading by the force of the jparticular 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 affedion :• which is not to be treated of here. In the fecond, the cure muft be obtained, partly by diligently avoiding the oc- cafional caufes, partly and chiefly by correding the mobility of the fyftem, and of the heart in particular; for doing which we have treated of the proper means clfewhere. CHAP. V. OF DYSPNOEA, OR DIFFICULT BREATH- ING. MCCCLXV. THE exercife of refpiration, and the organs of it, have fo conftant and confiderable a connedion with almoft the whole of the other fundions and parts of the human body, that upon almoft every occafion of difeafe, refpiration muft be affeded. Accordingly fome difficulty and diforder in this fundion, are in fad fymptoms very generally accompanying difeafe. MCCCLXVI. O F P H Y S I C. 185 MCCCLXVI. Upon this account, the fymptom of difficult breath- ing deferves a chief place and an ample confideration in the general fyftem of Pathology; but what ihare of confideration it ought to have in a treatife of Prac- tice, I find it difficult to determine. MCCCLXVII. . On this fubjed, it is, in the firft place, neceffary to diftinguifh between the fymptomatic and idiopathic aifedions: that is, between thofe difficulties of breath- ing which are fymptoms only of a more general af- fedion, or of a difeafe fubfifting primarily in other parts than the organs of refpiration, and that difficul- ty of breathing which depends uport a primary affec- tion of the lungs themfelves. The various cafes of fymptomatic dyfpnoea I have taken pains to enume- rate in my Methodical Nofology, and it will be obvi- ous 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 leaft the greater part of the proper, idiopathic cafes of dyfpnoea; but from that enumeration it will, I think, readily ap- pear, that few, and indeed hardly any, of thefe cafes , will admit or require much of our notice in this place. MCCCLXIX. . The Dyfpnoea Sicca*, fpecies 2d, the Dyfpnoea Ac- rea\,fp. 3c/, the Dyfpnoea 7errea\,fp. /\th, and Dyf- Vojl. II. A a pncea * The definition, which the author gives of this fpecies in his No- fology is Dyfpnoea cum tuffi plerumque ficca. It ar|ifes from vari- ous caufes, fome of which are extremely difficult, if not impoffible, to be difcovered. § The definition of this fpecies is, Dyfpnoea a minima quavis tempeftatum mutatione au£ta. + It is defined Dyfpnoea cum tuffi materiam terream vel cakulo- fa'm ejiciente. This is fometimes the expulfion of a gouty matter. 186 PRACTICE pnoea Tboracica*,fp. yth, are fome of them with diffi- culty 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 the plethoric ftate of the lungs§, and every circumftance that may hurry refpiration. MCCCLXX, Of the Dyfpnoea Extrinfeca\, fp. Stb, I can fay no more, but that thefe external caufes marked in the Nofology, and perhaps fome others that might have like effeds, are to be carefully avoided ; or, when they have been applied, and their effeds have taken place, the difeafe is to be palliated by the means mentioned in the laft paragraph. MCCCLXXI. The other fpecies, though enumerated as idiopathic, can hardly be confidered as fuch, or as requiring to be treated of here. ' The Dyfpnoea Catarrhalis\,fp. \fly may be confi- dered as a fpecies of catarrh, and is pretty certainly to be cured by the fame remedies as that fpecies of ca- tarrh which depends rather upon the increafed affiux of mucus to the bronchise, than upon any inflammato- ry ftate of them ||. The * The definition of this fpecies is, Dyfpnoea a partibusthoracem cingentibus laefis, vel male conformatis. $ This intention is moft fpeedily obtained by occafional bleeding. -f- It is defined Dyfpnoea a caufis externis manifeltis. Thefe cauf- es arc various, as expofure to dud of different kinds, to metallic fumes, to vitiated air, to vaponrs of different kinds, &c. £ It is defined, Dyfpnoea cum tuffi frequentc mucum vifcidem copiofum ejiciente. || The remedies for this purpofe are, emetics, fudorifics, and ex- pectorants ; formulae of which may be feen in the notes on article iq66, OF PHYSIC, 18; The Dyfpnoea 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 dif- eafe. The Dyfpnoea Pinguedinofa-f, fp. 6th, is in like manner to be confidered as a fymptom or local effed of the Polyfarcia, and is only to be cured by corred- ing the general fault of the fyftem |. MCCCLXXII. From this view of thofe idiopathic cafes of dyf- pnoea, which are perhaps all I could properly arrange under this title, it will readily appear that there is lit- tle room for treating of them here: but there is ftill one cafe of difficult breathing, which has been proper- ly diftinguiftied from every other under the title of Ajlh'.na ; and as it deferves our particular attention, I (hall here feparatcly confider it. CHAP. VI. OF ASTHMA. MCCCLXXIII. THE term of Afthma has been commonly applied by the vulgar, and even by many writers on the Pradice of Phyfic, to every cafe of difficult breathing, A a 2 that * It is dcfiued, Dyfpnoea cum urina parca, et oedemate, pedum, fine fluftuatione in peflorc, vel aliis charaderifticis hydrothoracis- fignis. \ It is defined, Dyfpnoea in hominibus valde obefis. \ A low diet, fufficient exercife, fweating, and brifk purges, will foon have the derived effc£t ; and the difeafe may be prevented by abftcmious living. i88 PRACTICE that is, to every fpecies of Dyfpnoea. The Methodi- cal Nofologifts, alfo, have diftinguifhed Afthma from Dyfpnoea chiefly, and almoft folely, by the former be- ing the fame affedion with the latter, but in a higher degree. Neither of thefe applications of the term feems to have been corred or proper. I am of opini- on, that the term Afthma may be moft properly ap- plied, and fhould be confined, to a cafe of difficult breathing that has peculiar fymptoms, and depends upon a peculiar proximate caufe, which I hopeto af- fign with fufficient certainty. It is this difeafe I am now to treat of, and it is nearly whatPradical Writers have * generally diftinguifhed from the other cafes of diffi- cult breathing, by the title of Spafmodic Afthma, or of Afihma convulfivum ; altho' by not diftinguifiling it with fufficient accuracy from the other cafes of Dyf- pnoea, they have introduced a great deal of confufiou into their treatifes on this fubjed. DCCCLXXIV. The difeafe I am to treat of, or the Afthma to be ftridly fo called, is often a hereditary difeafe. It* fjldoin appears very early in life, and hardly till the time of puberty, or after it. It affeds both fexes, but moft frequently the male. I have not obferved it td be more frequent in one kind of temperament than in another ; and it does not feem to depend upon any general temperament of the whole body, but upon a particular conftitution of the lungs alone. It frequent- ly at tucks perfons of a full habit; but it hardly ever continues to be repeated for fome length of time with- out occafioning an emaciation of the whole body. MCCCL XXV. 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 * This defcription of the difeafe under confideration is excellent. O F P H Y S I C. 189 the courfe of the day. At whatever time they come on, it is for the moft part fuddenly, with a fenfe of tightnefs and ftridure acrofs the breaft, and a fenfe of ftraitnefs in the lungs impeding infpiration. The per- fon thus attacked, if in a horizontal fituation, is imme- diately obliged to get into fomewhat of an ered pof- ture, and requires a free and cool air. The difficulty of breathing goes on for fome time increafing; ancl both infpiration and exfpiration are performed'flowly, and with a wheezing noife. In violent fits, fpeaking js difficult and uneafy. There is often fome propen^ fity to coughing, but it can hardly be executed MCCCLXXVI. Thefe fymptoms often continue for many hours to- gether, and particularly from midnight till the morn- ing is far advanced. Then commonly a remiffion takes place by degrees ; the breathing becomes lefs la- borious and more full, fo that the peifon can fpc.i^ and cough with more eafe; and, if the cough brings up fome mucus, the remiffion becomes irnrnediately^more confiderable, and the peifon falls into a much wifhecl- for fleep. MCCCLXXVII. During thefe fits the pulfe often continues in its na- tural ftate; but in fome perfons the fits are attended with a frequency of pulfe, and with fome heat and thirff, as marks of fome degree of fever. If urine be voided at the beginning of a fit, it is commonlv in confiderable quantity, ancl with little colour or odour - but, after the fit is over, the urine voided is in the or- dinary quantity of a high colour, and fometimes depo- fites a fediment. In lome perfons, during the fit, the face is a little flufhcd and turgid ; but more common- ly it is fomewhat pale and fhrunk. MCCCLXXVIII. After fome fleep in the morning, the patient, for the reft of the day, continues to have more free and eafy jao PRACTICE eafy breathing, but it is feldom 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 his breathing rendered more difficult and uneafy. In the afternoon he has an unufual flatulency of his ftomach, and an unufual drowfinefs; and, very frequently, thefe fvmptoms precede the firft attacks of the difeafe. But, whether thefe fymptoms appear or not, the diffi- culty cf breathing returns towards the evening ; and then fometimes gradually increafes, till it becomes as violent as in the night before: or if, during the day, the difficulty of breathing has been moderate, and the perfon got fome fleep in the firft part of the night, he is, however, waked about midnight, or at fome time between midnight and two o'clock in the morn- ing ; and is then fuddenly feized with a fit of difficult breathing, which runs the fame courfe as the night before. MCCCLXXIX. In this manner fits return for feveral nights fuccef- fively : but generally, after fome nights paffed in this way, the fits fuffer more confiderable remiffions. This efpecidlly happens when the remiffions are attended with a more copious expedoration 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 en- joy alfo nights of entire fleep, without the recurrence of the difeafe. MCCCLXXX. When this difeafe, however, has once 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 dif- ferent perfons. MCCCLXXXI. OF PHYSIC. *9< MCCCLXXXI. In fome perfons the fits are readily excited by exter- nal heat, whether of the weather or of a warm cham- ber, and particularly by warm bathing. In fuch per- fons fits are more frequent in fummer, and particular- 4y during the dog-days, than at other colder feafons. The fame perfons are alfo readily affeded by changes of the weather; efpecially by fudden changes made from a colder to a warmer, or, what is commonly the fame thing, from a heavier to a lighter atmofphere. The fame perfons are alfo affeded by every circum- ftance threatening the capacity of the thorax, as by any ligature made, or even by a plafter laid, upon it; and a like effed happens from any increafed bulk of the ftomach, either by a full meat, or by air colleded in it. They are likewife much affeded by exercife, or whatever elfe can hurry the circulation of the blood. MCCCLXXXII. As afthmatic fits feem thus to depend upon fome fulnefs of the veffels of the lungs, it is probable that an obftrudion of perfpiration, and.the blood being lefs determined to the furface of the body, may fa- vour an accumulation in the lungs, and thereby be a means of exciting afthma. This feems to be the cafe of thofe afthmatics who have fits moft frequently in the winter-feafon, and who have commonly more of a catarrhal affedion accompanying the afthma; which therefore occurs 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 excit- ed by powers applied to the nervous fyftem ; as by paffions of the mind, by particular odours, and by ir- ritations of fmoke and duft. That this difeafe is an affedion of the nervous fyf- tem, and depending upon a mobility of the moving fi- bres iq* PRACTICE bres of the lungs, appears pretty clearly from its be- ing frequently attended with other fpafmodic affedi- ons depending upon mobility ; fuch as hyfteria, hy- pochondriafis, dyfpepfia, and atonic gout. MCCCLXXXIV. From the whole of the hiftory of afthma now deliver- ed,! think it will readily appear, that the proximate caufe of this difeafe is a preternatural, and in fome meafure a fpafmodic, conftridion of the mufcular fibres of the bronchiae ; which not only prevents the dilata- tion of the bronchiae neceffary to a free and full in- fpiration, but gives alfo a rigidity which prevents a full and free expiration. This preternatural conftric- tion, like many other convulfive and fpafmodic af- fcdions, is readily excited by a turgefcence of the blood, or other caufe of any unufual fulnefs and diftention of the veflels of the lungs. MCCCLXXXV. This difeafe, as coming by fits, may be generally diftinguifhed from moft other fpecies of dyfpnoea, whole caufes being more conftantly applied, produce there- fore a more conftant difficulty of breathing. There may, however, be fome fallacy in this matter, as fome of thefe caufes may be liable to have abatements and intenfities, whereby the dyfpncea 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 afthmatic fits defcribed above. Perhaps, however, there is ftill another cafe that may give more difficulty; and that is, when feveral of the caufes, which we have affigned as caufes of feveral of the fpecies of difficult breathing referred to the genius of Dyfpnoea, may have the effect of exciting a genuine afthmatic fit. Whe- ther this can happen to any but the peculiarly predif- pofed to afthma, I am uncertain; and therefore, whe- ther, in any fuch cafes, the afthma may be confider- ci as fymptomatic; or if, in all fuch cafes, the afthma may O F P H Y S I C. 193 x\ rnay not ftill be confidered and treated as an idiopa- thic difeafe. MCCCLXXXVI. The afthma, though often threatening immediate (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 per- haps always at length. In fome young perfons it has ended foon, by occafioning a phthifis pulmonalis. Af- ter a long continuance, it often ends in a hydrothorax; and commonly, by occafioning fome aneurifm of the heart or great veffels, it thereby proves fatal. MCCCLXXXVII. As it is feldom that an afthma has been entirely ou> ed; I therefore cannot propofe any method of cure which experience has approved as generally fuccefsful, But the difeafe admits of alleviation in feveral refpeds 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 em- ployed in cafes of afthma. MCCCLXXXVIII. As the danger of an afthmatic fit arifes chiefly from the difficult tranfmiflion of the blood through the vef- fels of the lungs, threatening fuffocation; fo the moft: probable means of obviating this feems to be blood- letting : and therefore, in all violent fits, praditioners have had recourfe to this remedy. In firft attacks, and efpecially in young and plethoric perfons, blood- letting maybe very neceffary, and is commonly allow- able. But it is alfo evident, that, under the frequent recurrence of fits, blood-letting cannot be frequently repeated without exhaufting and weakening the pati- ent too much. It is further to be obferved, that blood- letting is not fo neceffary ?s might be imagined, as the paffage of the blood through the lungs is not fo Vol. II. B b much 194 PRACTICE interrupted as has been commonly fuppofed. This I particularly conclude from hence, that, inftead of the fuffufion of face, which is the ufual effed of fuch inter- ruption, the face, in afthmatics fits, is often fhrunk and pale. I conclude the fame alfo from this, that, in afthmatic fits, blood-letting does not commonly give fo much relief as, upon the contrary fuppofition, might be expeded. MCCCLXXXIX. As I have alledged above, that a turgefcence of the blood is frequently the exciting caufe of afthmatic fits, fo it might be fuppofed, that a plethoric ftate of the fyftem might have a great fhare in producing a tur- gefcence of the blood In the lungs ; and efpecially, therefore, that blood-letting might be a proper reme- dy in afthma: I allow it to be fo in the firft attacks of the difeafe : but as the difeafe, by continuing, gene- rally takes off the plethoric ftate of the fyftem ; fo, af- ter the difeafe has continued for fome time, I alledge that blood-letting becomes lefs and lefs neceffary. MCCCXC. Upon the fuppofition of afthmatics being in a ple- thoric ftate, purging might be fuppofed to prove a re- medy in this difeafe : but, both becaufe the fuppofi- tion is not commonly well founded, and becaufe purg- ing is feldom found to relieve the veffels of the thorax, this remedy has not appeared to be well fuited to afth- matics ; and large purging has always been found to do much harm. But as afthmatics are always hurt by the ftagnation and accumulation of matters in the ali- mentary canal, fo coftivenefs muft be avoided, and an open belly proves ufeful. In the time of fits, the em- ployment of emollient and moderately laxative glyf- ters* has been found to give confiderable relief. MCCCXCI. * A clyfterof milk, with a little fait, is generally fufficient. The coftivcocft may be removed by mucilaginous laxatives of the OF PHYSIC. «9S MCCCXCI. As a flatulency of the ftomach, and other fymp- toms of indigeftion, are frequently attendants of afth- ma, and very troublefome to afthmatics; fo, both for removing thefe fymptoms, and for taking off all deterr mination to the lungs, the frequent ufe of gentle vo- mits* is proper in this difeafe. In certain cafes, where a fit was expeded to come on in the courfe of the night, a vomit given in the evening has frequently fecmed to prevent it. MCCCXCII. Bliftering between the fhoulders, or upon the breaft, has been frequently employed to relieve afth- matics ; but in the pure fpafmodic afthma we treat of here, I have rarely found blifters ufeful, either in pre- venting or relieving fits. MCCCXCIII. Iffues are certainly ufeful in obviating plethora; but as fuch indications feldom arife in cafes of afthma, fo iffues have been feldom found ufeful in this difeafe. MCCCXCIV. As afthmatic fits are fo frequently excited by a tur- gefcence of the blood, fo the obviating and allaying of this by acids and neutral fairs, feems to have been at all times the objed of praditioners. See Floyer on the Afthma. MCCCXCV. Although a plethoric ftate of the fyftem may feem to difpofe to afthma, and the occafional turgefcence of the blood may feem to be frequently the exciting caufe of the fits; yet it is evident, that the difeafe muft have arifen chiefly from a peculiar cpnftitution B b 1 in milder kind, as manna, eaffia, Sec. or by a proper attention to diet, efpecially by ufiag tbw pulps of particular fruits, as prunes or raifins boiled in barley-water ; roalted apples eaten with brown fugar, &c. * Vomits ought, in thefe cafes, to be mild. Some formulae cf them are given in one of the notes on article 185. 196 PRACTICE in the moving fibres of the bronchia?, difpofing them upon various occafions to fall into a fpafmodic con- ftridion ; and therefore, that the entire cure of the difeafe can only be expeded from the correding of that predifpofition, or from correding the preterna- tural mobility or irritability of the lungs in that re- fped. MCCCXCVI. In cafes wherein this predifpofition depends upon original conformation, the cure muft be difficult, and perhaps impoffible; but it may perhaps be moderated by the ufe of antifpafmodics. Upon this footing, va- rious remedies of that kind have been commonly em- ployed, and particularly the fetid gums ; but we have not found them of any confiderable efficacy, and have obferved them to be fometimes hurtful by their heat- ing 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 effeds are not lafting. MCCCXCVII. As in other fpafmodic affedions, fo in this, the moft certain and powerful antifpafmodic is opium*. I have often found it effedual, and generally fafe 5 and if there have arifen doubts with refped to its fafety, I believe they have arifen from not diftinguifhing be- tween certain plethoric and inflammatory cafes of dyf- pnoea, improperly named Afthma, and the genuine fpafmodic afthma we treat of here. MCCCXCVIII. * The great efficacy of opium, in cafes of fpafmodic afthma, is fally confirmed by experience. It ought to begiven in large dofes, out not often repeated ,n the day. It feems to be moft ufeful when given occafionally to allay the violence of the fit, or to prevent its. acceffion. Ihus, forty drops of laudanum have been frequently found to relieve the fymptoms when the fit is violent; or when tak- en at the approach of the fit, to have wholly fuppreffed it', or at leaft. to have coniiderabiy blunted its violence. OF PHYSIC. ?97 MCCCXCVIII. As in many cafes this difeafe depends upon a pre- difpofition which cannot be correded by our art, fo in fuch cafes the patient can only efcape the difeafe by a- Voiding the occafional or exciting caufes, which I have endeavoured to point out above. It is, however, dif- ficult to give any general rules here, as different afth- matics have their different idiofyncrafies with refped to externals. Thus, one afthmatic finds himfelf eafieft: living in the midft of a great city, while another can- not breathe but in the free air of the country. In the latter cafe, however, moft afthmatics bear the air of a low ground, if tolerable free and dry, better than that of the mountain. MCCCXCIX. In diet, alfo, there is fome difference to be made with refped to different afthmatics. None of them bear a large or full meal, or any food that is of flow and difficult folution in the ftomach ; but many of them bear animal-food of the lighter kinds, and in moderate quantity. The ufe of vegetables which rea- dily prove flatulent, are always very hurtful. In re- cent afthma, and efpecially in the young and pletho- iic, a fpare, light, and cool diet is proper, and com- monly neceffary; but, after the difeafe has continued for yeais. afthmatics commonly bear, and even require, a tolerably full diet, though in all cafes a very full diet is very hurtful. MCCCC. In drinking, water, or cool watery liquors, is the only fafe and fit drinks for afthmatics ; and all liquors ready to ferment and become flatulent, are hurtful to them. Few afthmatics can bear any kind of ftrong drink ; and any excefs in fuch is always very hurtful to them. As afthmatics are commonly hurt by taking warm or tepid drink; fo, both upon that account, and Upon account of the liquors weakening the nerves of ! r the E98 PRACTICE the ftomach, neither tea nor coffee is proper in this difeafe. MCCCCI. Afthmatics commonly bear no bodily motion eafi- ly but that of the moft gentle kind. Riding, howe- ver, on horfeback, or going in a carriage, and efpeci- ally failing, are very often ufeful to afthmatics. CHAP. VII. OF THE CHINCOUGH, OR HOOPING- COUGH. MCCCCII. THIS difeafe is commonly epidemic, and manifeft- ly contagious. It feems to proceed from a con- tagion of a fpecific nature, and of a lingular quality. It does not like moft other contagions, neceffarily pro- duce a fever; nor does it, like moft others, occafion any eruption, or produce otherwife any evident change in the ftate of the human fluids. It has, in common with the catarrhal contagion, and with tfiat of the meafles, a peculiar determination to the lungs; but with particular effeds there, very different from thofe of the other two; as will appear from the hiftory of this difeafe now to be delivered. MCCCCIII. This contagion, like feveral others, affeds perfons but once in the courfe of their lives ; and therefore, neceffarily, children are moft commonly the fubjeds of this difeafe : but there are many inftances of it occur- ring in perfons confiderably advanced in life ; though it is probable, that the further that perfons are advanc- ed OF PHYSIC. 199 ed in life, they are the lefs liable to be affeded 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 entirely to that appearance; and I have had inftances of a difeafe which though evi- dently arifing from the chincough contagion, never put on any other form than that of a common ca- tarrh. . This, however, feldom happens; for, generally, in the fecond, and at fartheft in the third, week after the attack, the difeafe puts on its peculiar and charac- teriftic 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 circumftances, however, in different inftances of coughing, are in very different degrees; fo no exad limits can be put to determine when the cough can be ftridly faid to be convulfive ; and it is therefore efpecially by ano- ther circumftance that the chincough is diftinguifhed from every other form of cough. This circumftance is, when many exfpiratory motions have been convul- fively made, and thereby the air is in great quantity thrown out from the lungs, a full infpiration is necef- farily and fuddenly made; which, by the air rufhing in through the glottis with unufual velocity, gives a peculiar found. This found-is fomewhat different in different cafes, but is in general called a Hoop ; and from it the whole of the uifeafe is called the Hooping Cough. When this fonorous infpiration has happen- ed, the convulfive coughing is again renewed, and con- tinues in the fame manner as before, till a quantity of mucus is thrown up from the lungs, or the contents of the ftomach are thrown up by vomiting. Either of thefe evacuations commonly puts an end to the coughing, 200 PRACTICE coughing, and the patient remains free from it foif fome time after. Sometimes it is only after feveral alternate fits of coughing and hooping that expedora- tion or vomiting takes place; but it is commonly af- ter the fecond coughing that thefe happen, and put an end to the fit. MCCCCV. When the difeafe, in this manner, has taken its proper form, it generally continues for a long time af- ter, and generally from one month to three ; but fometimes much longer, and that with very various circumftances. MCCCCVI. The fits of coughing return at various intervals, rarely obferving any exad period. They happen fre^ quently in the courfe of the day, and more frequently ftill in the courfe of the night. The patient has com- monly fome warning of their coming on ; and, to a- void that violent and painful concuffion which the coughing gives to the whole body, he clings faft to any thing that is near to him, or demands to be held faft by any perfon that he can come at. When the fit is over, the patient fometimes breathes faft, and feems fatigued for a little after: but in many this appears very little ; and children are commonly fo entirely relieved, that they immediately return to their play, or what elfe they were occupied in before. MCCCCVII. If it happens that the fit of coughing ends in vo- miting up the contents of the ftomach, the patient is commonly immediately after feized with a ftrong craving and demand for food, and takes it in very greedily. MCCCCVIII. At the firft coming on of this difeafe, the expedo- ration is fometimes none at all, or of a thin mucus only; and while this continues to be the cafe, the-fits of OF PHYSIC. 201 of coughing are more violent, and continue longer; but commonly the expedoration foon becomes con- fiderable, and a very thick mucus, often in great quantity, is thrown up; and as this is more readily brought up, the fits of coughing are of fhorter dura- tion. MCCCCIX. The violent fits of coughing frequently interrupt the free tranfmiflion of the blood through the lungs, and thereby the free return of blood from the veffels of the head. This occafions that turgefcence and fuf- fufion 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 manner we have now defcribed, without any pyrexia attending it; but, though Sydenham had feldom obferved it, we have found the difeafe very frequently accompani- ed with pyrexia, fometimes from the very beginning, but more frequently only after the difeafe had conti- nued for fome time. When it does accompany the difeafe, we have not found it appearing under any re- gular intermittent form. It is conftantly in fome de- gree prefent; but with evident exacerbations towards evening, continuing till next morning. MCCCCXI. Another fymptom v ery frequently attending the chin- cough, is a difficulty of breathing; and that not onlv immediately before and after fits of coughing, but as conftantly prefent, though in different degrees in dif- ferent perfons. I have hardly ever feen an inftance of a fatal chincough, in which a confiderable degree of pyrexia and dylpncea had not been for fome time con- ftantly prefent. Vol. II. C c MCCCCXII. 204 PRACTICE mccccxil When by the power of the contagion this difeafe has once taken place, the fits of coughing are often re- peated, without any evident exciting caufe : but, in many cafes, the contagion may be confidered as giv- ing a predifpofition only ; and the frequency of fits depends in fome meafure upon various exciting cau- fes ; fuch as, violent exercife; a full meal; the having taken in food of difficult folution ; irritations of the lungs by dull, fmoke, or difagreeable odours of a ftrong kind ; and, efpecially any confiderable emotion of the mind. MCCCCXIII. Such are the chief circumftances of this difeafe, and it is of various event; which, however, may be commonly forefeen by attending to the following confiderations. The younger that children are, they are in the greater clanger from this difeafe; 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 fe- cure againft an unhappy event; and this I hold to be a very general rule, though I own there are many ex- ceptions to it. Children born of phthifical and afthmatic parents are in the greateit danger from this difeafe. When the difeafe, beginning in the form of a ca- tarrh, is attended with fever and difficult breathing, and with little expectoration, it often proves fatal, without taking on the form of the hooping cough ; but, in moft of fuch cafes, the coming on of the con- vulfive cough and hooping, bringing on at the fame time a more frequent expedoration, generally removes the danger. When the difeafe is fully formed, if the fits are nei- ther frequent nor violent, with moderate expectora- tion, OF PHYSIC. 203 tion, and the patient, during the intervals of the fits, is eafy, keeps his appetite, gets fleep, and is without fever or difficult breathing, the difeafe is attended with no danger; and thefe circumftances becoming daily more favourable, the difeafe very foon fpontaneoufly terminates. An expedoration, either very fcanty or very copi- ous, is attended with danger; efpecially if the latter circumftance is attended with great difficulty of breath- ing. Thofe cafes in which the fits terminate by a vomit- ing, are immediately followed by a craving of food, are generally without danger. A moderate hemorrhagy from the nofe often proves falutary; but very large hemorrhagic* are generally very hurtful. This difeafe coming upon perfons under a ftate of much debility, has very generally an unhappy event. The danger of this difeafe fometimes arifes from the violence of the fits of coughing, occafioning apo- plexy, 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 dyfpnoea 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 violent, or merely to fhorten the courfe of it when it is mild. When the contagion it recent, and continues to ad, we neither know how to corred, nor how to expel it; and therefore the dif- eafe neceffarily continues for fome time: but it is pro- bable, that the contagion in this as in other inftances ceafes at length to ad ; and that then the difeafe con- tinues, as in other convulfive affedions, by the power of habit alone. C c 2 MCCCCXV, 204 PRACTICE MCCCCXV. From this view of the matter I maintain, that the pradife muft be different, and adapted to two differ- ent indications, according to the period of the difeafei At the beginning of the difeafe, and for fome time af- ter, the remedies to be employed muft be fuch as may obviate the violent effeds of the difeafe, and the fatal tendency of it; but, after the difeafe has continued for fome time, and is without any violent fymptoms, the only remedies which can be required are thoffe which may interrupt its courfe, and put an entire flop to it fooner than it would have fpontaneoufly ceafed. ^MCCCCXVI. For anfwering the firft indication. In plethoric fub- jeds, or in others, when from the circumftances of the. cough and fits it appears that the blood is diffiH cuitly tranfmitted through the lungs, blood-letting* is a neceffary remedy; and it may be even neceffary to repeat it, efpeoally in the beginning of the difeafe : but, as fpafmodic affedions do not commonly admit of much bleeding, fo it is feldom proper in the chin- cuugh to repeat this remedy often. * . MCCCCXVII. As coftivenefs frequently ittends this difeafe, fo it is neceffary to obviate or remove it by laxatives em- ployed ; and keeping an open belly is generally ufe- ful : bu: large evacuations in this way are commonly hurtful f. MCCCCXVIII. To obviate or remove the inflammatory determin- ation * Bleeding, in thefe cafes, isbeft performed by leeches ; and they feem to give greater relief when applied about the neck than on any other part. f In genera!, the belly may be kept open by a proper attention to diet : roafted apples, eaten with brown fugar, itewed prunes, and other fimil.ir food, which children generally devour with avidity, fuf- ficiently anfwer the purpofe of removing or preventing coftivenef:. OF PHYSIC. ation to the lungs that fometimes occurs in this dif- eafe, bliftering is often ufeful, and even repeated blif- tering has been of fervice; but iffues have not fo much effed, and fhould by no means fuperfede the re- peated bliftering that may be indicated. When blif- ters are proper, they are more effedual when applied to the thorax, than when applied to any diftant parts. MCCCCXIX Of all other remedies, emetics are the moft ufeul in this difeafe; both in general by interrupting the re- turn of fpafmodic affections, and in particular by de- termining very powerfully to the furface of the body, and thereby taking off determinations to the lungs. For thefe purpofes, I think, full vomiting is frequently to be employed ; and, in the intervals neceffary to be left between the times of full vomiting, naufeating do- fes of the antimonial 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, em- ployed in the manner direded by the late Dr. Fother- gill, has appeared to be more ufeful. MCCCCXX. * The method of giving tartar emetic in naufeating dofes has been frequently mentioned in preceding notes ; but in cafes of chin- cough, where children are generally our patients, we are under the neceffity of varying the dofes to the age and conftitution. When the child is under a year old, we ought to nfe the weak folution of tartar emetic, fpecified in the end of the laft note on article 185, in repeated dofes of a table-fpoonfgl every ten or fifteen minutes, till it operates. Large dofes, efpecially to youug children, are frequent- ly attended with dangerous confequences, of which the following cafe is a fufficient proof. To a child not ten months old, that laboured under the chincough, half a grain of tartar emetic was giveu in a little cinnamon-water. A violent vomiting was produced, and the child died fuddenly, dur ing the action of the medicine : on infpefting the body after death, we found the ftomach burft, there being in it a laceration that ad- mitted two fingers. The infpection of tlv's body has always made me extremely cautious in adininiftering emetics to young children. 2©<5 PRACTICE 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 ftage, when I fuppofe the contagion has ceafed to ad, and that the difeafe continues merely by the power of habit, a different indication arifes, and different re- medies are to be employed. mccccxxt. 1 his 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 re- maining in the body, and continuing to ad in it. That the difeafe does often continue long after the contagion has ceafed to ad, and that too by the pow- er of habit alone, appears to me probable from hence, that terror has frequently cured the difeafe ; that any confiderable change in the 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 to- nic medicines ; whilft none of all thefe means of cure can be fuppofed either to corred or to expel a mor- bific matter, though they are evidently fuited to change the ftate and habits of the nervous fyftem. MCCCCXXIL From this view we are direded to the indication that may be formed, and in a great meafure to the re- medics which may be employed in what we fuppofe to be the fecond ftage of the difeafe. It may perhaps be alledged, that this indication of fhortening the courfe of the difeafe is not very important or neceffary, as it fuppofes that the danger or violence is over, and, in confequence, that the difeafe will foon fpontaneoufly ceafe. The laft fuppofition, however, is not well founded; as the difeafe, like many other convulfive and fpafmodic affedions, may continue for a long time by the power of habit alone, and by the repeti- tion OF PHYSIC. 207 tion of paroxyfms may have hurtful effeds; more efpe- cially as the violence of paroxyfms, and therefore their hurtful effeds, may be much aggravated by va- rious external caufes that may be accidentally applied. Our indication, therefore, is proper; and we proceed to confider the feveral remedies which may be employ- ed to anfwer it: MCCCCXXIII. Terror may poffibly be a powerful remedy, but it is difficult to meafure the degree of it that fhall be pro- duced ; and, as a flight degree of it may be ineffedual, and a high degree of it dangerous, I cannot propofe to employ it. MCCCCXXIV. The other remedies which we fuppofe fuited to our fecond indication, and which indeed have been fre- quently employed in this difeafe, are antifpafmodics or tonics. Of the antifpafmodics, caftor has been particularly recommended by Dr. Morris; but in many trials we have not found it effedual. With more probability mufk has been employed : but whether it be from our not having it of a genuine kind, or not employing it in fufficiently large dofes, I cannot determine; but we have not found it common- ly fuccefsful. Of antifpafmodics, the moft certainly powerful is opium : and when there is no confidera- ble 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 entirely to cure the difeafe. 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 an- tifpafmodic. 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, 2c8 PftACTICi 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, formerly ce- lebrated, as of this kind ; as alfo the bark of the mif- letoe ; but I have had no experience of either, as I have always trufted to the Peruvian bark. I confider the ufe of this medicine as the moft certain means of curing the difeafe in its fecond ftage ; and when there has been little fever prefent, and a fufficient quantity of the bark has been given, it has feldom failed of foon putting an end to the difeafe. MCCCCXXVI. When convulfive diforders may be fuppofed to con- tinue by the force of habit alone, it has been found that a confiderable change in the whole of the cir- cumftances and manner of life has proved a cure of fuch difeafes ; and analogy has applied this in the cafe of the chincough fo far, that a change of air has been employed, and fuppofed to be ufeful. In feve- ral inftances I have obferved it to be fo ; but I have never found the effeds of it durable, or fufficient to put an entire ftop to the difeafe. BOOK * Experience has not found that any of the antifpafmodics have ever been employed with much advantage in this difeafe. All of them are extremely naufeous, and confequently difficultly given to children who cannot well fwallow pills. OF PHYSIC. 209 BOOK III. SECT. III. OF THE SPASMODIC AFFECTIONS IN TEE NATURAL FUNCTIONS. CHAP. VIII. OF THE PYROSIS, OR WHAT IS NAMED IN SCOTLAND THE WATER-BRASH. MCCCCXXVII, THE painful fenfations referred to the ftomach, and which are probably occafioned by real affediohs of this organ, are of different kinds. Probably they proceed from affedions of different natures, and fhould therefore be diftinguifhed by different appellations ; but I muft own that the utmoft precifion in this mat- ter will be difficulti In my effay towards a methodi- cal Nofology, I havcj however, attempted it. For thofe pains that are either acute and pungent, or ac- companied with a fenfe of diftenficn, or with a fenfe of conftridion, if they are at the fame time not attended with any fenfe of acrimony or heat, I employ the ap- pellation of Gaftrodynia. 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 externally or internally applied, often gives, I employ the term of Cardialgia; and by this I particularly mean to tic- note thofe feelmgs which are expreffed by the term Heartburn in the Englifh language. I think the term Soda has been commonly employed by pradical wri- ters, to exprefs an affedion attended with feelings of the latter kind. Vol. II. D d MCCCCXXVIII. no PRACTICE MCCCCmFVIU. Befide the pains denoted by the terms Gaftrodinia, 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 account 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 Pyrofis Suecica, are all of them fpecies of the Gaftrodynia or of the Cardialgia; and if there is a genus to be formed under the title of Pyrofis, it can in my opinion comprehend only the fpe- cies 1 have mentioned. In this cafe, indeed, I own that the term is not very proper ; but my averfion to introduce new names has made me continue to employ the term of Mr. Sauvages. MCCCCXXIX. The Gaftrodynia and Cardialgia I judge to be for the moft part fymptomatic afffedions ; and therefore have given them no place in this work : but the Py- rofis, as an. idiopathic difeafe, and never before treat- ed of in any fyftem, I propofe to treat of here. MCCCCXXX. It is a difeafe frequent among people in lower life, but occurs alfo, though more rarely, in people of better condition. Though frequent in Scotland, it is by no means fo frequent as Linnaeus reports it to be in Lapland. It appears moft 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 occafionally for a long time after; but it feldom appears in perfons confiderably advanc- ed in life. - It affeds both fexes, but more fre- quently the female. It fometimes attacks pregnant women, and fome women only when they are in that condition. Of other women, it more frequently af- feds OF PHYSIC. 211 feds the unmarried; and of the married, moft fre- quently the barren. I have had many inftances of its occurring in women labouring under a fluor albus. MCCCCXXXI. The fits of this difeafe ufually come on in the morn- ing and forenoon, when the ftomach is empty. The firft fymptom of it is a pain at the pit of the ftomach, with a fenfe of conftridion, as if the ftomach was drawn towards the back ; the pain is increafed by raifing the body into an ered pofture, and therefore the body is bended forward. This pain is often very fevere ; and, after continuing for fome time, it brings on an erudation of a thin watery fluid in confiderable quantity. This fluid has fometimes an acrid tafte, but is very often abfolutely infipid. The erudation is for fome time frequently repeated ; 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 difeafe commonly come on without any evident exciting caufe ; and I; have not found it fteadily conneded with any particular diet. It at- tacks perfons ufing animal food, but I think more fre- quently thofe living on milk and farinacea. It feems often to be excited by cold applied to the lower ex- tremeties : and is readily excited by any confiderable emotion of mind. It is often without any fymptoms. of dyfpepfia. MCCCCXXXI1I. The nature of this affedion is not very obvious; but I think it may be explained in this manner : It feems to begin by a fpafm of the mufcular fibres of the ftomach ; which is afterwards., in a certain man- ner, communicated to the blood-veffels and exhalants, fo as to increafe the impetus of the fluids in thefe vef- fels, while a conftriction takes place on their extremi- ties. While therefore the increafed impetus deter-, D d i mine^ 212 PRACTICE mines a greater quantity thari ufual of fluids into thofil veffels, the conftridion upon their cxtremeties allows only the pure watery parts to be poured out, analogous, as I judge, in every refped, to what happens in the diabetes hyftericus. MCCCCXXXIV. The pradice in this difeafe is as difficult as the the- ory. The paroxyfm is only to be certainly relieved by opium. Other antifpafmodics, as vitriolic ether and volatile alkali, are fometimes of fervice, but not conftantly fo. Although opium and other antifpaf- modics relieve the fits, they have no effed in prevent- ing their recurrence. For this purpofe, the whole of the remedies of dyfpepfia have been employed without fuccefs. Of the ufe of the nux vomica, mentioned a£ a remedy by Linnaeus, I have had no experience. „<■.<..<..<..<..«..<../..<..«....>..>.■>••>•> ■>••>•> v- C H A P. IX. OF THE COLIC, MCCCCXXXV. THE principal fymptom in this difeafe is a pah\ felt in the lower belly. It is feldom fixed and pungent in one part, but is a painful diftention in fomemerfure fpieading over the whole of the belly ; and particulaily with a fenfe of twilling or wringing round the navel. At the fame time, with this pain, the navel and Teguments of the be]Iy are frequently diT'wn inwards, and often the mufcles of the belly are fpafmodically contracted, and this in feparate portions, giving the appearance of a bag full of round balls. MCCCCXXXVI. OF PHYSIC. 213 MCCCCXXXVI. Such pains, in a certain degree, fometimes occur in cafes of diarrhoea and cholera ; but thefe are lefs vio- lent and more tranfitory, and are named Gripings. It is only when more violent and permanent, and at- tended with coftivenefs, that they conftitute colic. This is alfo commonly attended with vomiting, 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 alfo the contents of the duodenum and therefore frequently a quantity of bile. MCCCCXXXVII. In fome cafes of colic, the periftaltic motion is in- verted through the whole length of the alimentary canal, in fuch a manner that the contents of the great guts, and therefore ftercoracecus matter, is thrown up by vomiting ; and the fame inverfion appears ftill more clearly from this, that what is thrown into the redum by glyfter is again thrown out by the mouth- In thefe circumftances of inverfion the difeafe has been named Ileus, or the Iliac Paffion ; and this has been fuppofed to be a peculiar difeafe diftind from colic ; but to me it appears that the two difeafes are owing to the fame proximate caufe, and have the fame fymp- toms, only in a different degree. MCCCCXXXVIII. The colic is often without any pyrexia attending it. Sometimes, however, an inflammation comes upon the part of the inreftine efpecially affeded ; and this inflaramation aggravates all the fymptoms of the dif- eafe, being probably what brings on the moft confi- derable inverfion of the periftaltic motion ; and, as5 the ftercoraceous vomiting is what efpecially diftin- guifhes the ileus, this has been confidered as always depending on an inflammation of the inteftines. How- ever, I can affirm, that as there are inflammations of . the 2J4 PRACTICE the inteftines without ftercoraceous vomiting, fo I have feen inftances of ftercoraceous vomiting without in- flammation ; and there is therefore no ground for dif- tinguifhing ileus from colic, but as a higher degree of the fame affedion. MCCCCXXXIX. The fymptoms of the colic, and the diffedions of bodies dead of this difeafe, fhow very clearly, that it depends upon a fpafmodic conftridion of a pait of the inteftines; and that this therefore is to be confidered as the proximate caufe of the difeafe. In fome of the diffedions of perfons dead of this difeafe, an intus-fuf- ception has been remarked to have happened; but whether this be conftantly the cafe in all the appear- ances of ileus, fs not certainly determined. MCCCCXL. The colic has commonly been confidered as being of different fpecies, but I cannot follow the writers on this fubjed in the diftindions they have eftablifhed. So far, however, as a difference of the remote caufe conftitutes a difference of fpecies, a diftindion may per- haps be admitted; and accordingly in my Nofology I have marked feven different fpecies: but I am well perfuaded, that in all thefe different fpecies the prox- imate caufe is the fame, that is, a fpafmodic conftridion of a part of the inteftines; and confequently, that in all thefe cafes the indication of cure is the fame, that is, to remove the conftridion mentioned. Even in, the feveral fpecies named Stercorea, Callofa, and Cal- culofa, in which the difeafe depends upon an obftruc- tion of interline, I am perfuaded that thefe obftrudi- ons do not produce the fymptoms of colic, excepting in fo far as they produce fpafmodic conftridions of the inteftines; and therefore, that the means of cure in thefe cafes, fo far as they admit of cure, muft be ob- tained by the fame means which the general indica- tion above mentioned fuggefts. MCCCCXLI. OF PHYSIC. 215 MCCCCXLI. The cure, then, of the colic univerfally, is to be ob- tained by removing the fpafmodic conftridions of the inteftines; and the remedies fuited to this purpofe may be referred to three generajl heads : 1. The taking off the fpafm by various antifpafmo- dic powers. 2. The exciting the adion of the inteftines by pur- gatives. 3. The employing mechanical dilatation. MCCCCXLII. Before entering upon a more particular account of thefe remedies, it will be proper to obferve, that in all cafes of violent colic, it is advifable to pradife blood- letting ; but as it may be ufeful in obviating the in- flammation which is commonly to be apprehended, and even as it may be a means of relaxing the fpafm of the inteftine. This remedy may perhaps be im- proper 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 leaft fufpicion of an inflammation adually coming on, it will be abfo- lutely neceffary. Nay, it will be even proper to re- peat it perhaps feveral times, if, with a full and hard pulfe, the appearance of the blood drawn, and the re- lief obtained by the firft bleeding, fhall authorife fuch repetition. MCCCCXLIII. The antifpafmodic powers that may be employed, are, tfre application of heat in a dry or humid form, the application of blifters, the ufe of opium, and the ufe of mild oils. 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, or bags of fubftances which long retain their heat; and all thefe have fometimes been applied with fuccefs ; 2i6 PRACTICE but none of them feem to me fo powerful as the appli- cation of heat in a humid form. This may be employed either by the immerfion of a great part of the body in warm water, or by fo- menting the belly with cloths wrung out of hot watef. 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 pradifed, and fomentation may have" the advantage of being longer 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. From confidering that the teguments of the lower belly have fuch a conncdion with the inteftines, as at the fame time to be affeded with fpafmodic contrac- tions, we perceive that blifters applied to the belly may have the effed of taking off the fpafms both from the mufcles of the belly and from the inteftines; and accordingly, bliftering has often been employed in the colic with advantage* Analogous to this, rubefaci- ents applied to the belly have been frequently found ufeful. MCCCCXLV. The ufe of opium in colic may feem to be an ambi- guous remedy. Very certainly it may for fome time relieve the pain, which is often fo violent and urgent, that it is difficult to abftain from the ufe of fuch a re- medy. At the fame time, the ufe of opium retards or fufpends the periftaltic motion fo much, as to allow the inteftines to fall into conftridions; and may there- fore, while it relieves the pain, render the caufe of the difeafe more obftinate. On this account, and further as opium prevents the operation of purga- tives fo often neceffary in this difeafe, many praditi- oners are averfe to the ufe of it, and lome entirely re- ject OF PHYSIC. 217 jed the ufe of it as hurtful. There are, however, o- thers who think they can employ opium in this difeafe with much advantage. In all cafes where the colic comes on without any previous coftivenefs, and arifes from cold, from paffi- ons of the mind, or other caufes which operate efpeci- ally on the nervous fyftem, opium proves a fafe and certain remedy ; but in cafes which have been preced- ed by long coftivenefs, or where the colic, though not preceded by coftivenefs, has however continued for fome days without a ftool, fo that a ftagnation of faeces in the colon is to be fufpeded, the ufe of opium is of doubtful effed. In fuch cafes, unlefs a ftool has been firft procured by medicine, opium cannot be employ- ed but with fome hazard of aggravating the difeafe. However, even in thofe circumftances of coftivenefs, when, without inflammation, the violence of the fpafm is to be fufpeded, when vomiting prevents the exhibi- tion of purgatives, and when with all this the pain is extremely urgent, opium is to be employed, not only as an anodyne, but alfo as an antifpafmodic, neceffary to favour the operation of purgatives; and may befo employed, when, either at the fame time with the opi* ate, 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 dif- eafe than opium ? MCCCCXLVI. It is feemingly on good grounds that feveral prac- titioners have recommended the large ufe of mild oils in this difeafe, both as antifpafmodics and as laxatives; and, where the palate and ftomach could admit them, I have, found them very ufeful. But as there are few Scottifh ftomachs that can admit a large ufe of oils, I have had few opportunities of employing them. MCCCCXLVII. The fecond fet of remedies adapted to the cure of Vol. II. E e colic, 218 PRACTICE colic, are purgatives; which, by exciting the adion of the inteftines, either above or below the obftrudcd place, may remove the conftridion ; and therefore thefe purgatives may be given either by the mouth, or thrown by glyilcr into the anus. As the difeafe is often feated "in°the great guts ; as glyfters, by having a more fudden operation, may give more immediate re- lief; and as purgatives given by the mouth are ready to be rejrded by vomiting; fo it is common, and in- deed proper, to attempt curing the colic in the firft place by glyfters. Thefe may at firft be of the mildeft kind, confifting of a large bulk of water, with fome ouantiry of a mild oil; and fuch are fometimes fuffi- ciently efficacious : 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 powerful is the common or marine fait. If thefe faline glyfters, as fometimes happens, are rendered again too quickly, and on thisaccount or other- wife are found ineffedual, it may be proper, inftead of thefe falts, to add to the glyfters an infufion of fen- na, or of fome other purgative that can be extraded by water. The antimonhl wine* may be fometimes employed in glyfters with advantage. Hardly any glyfters are more effedual than thofe made of turpen- tine properly § prepared. When all other injedions are * Tartar Emetic is furer than the antimonial wine ; but it is it \o;-y violent remedy, and ought to be ufed with caution even in cly- itus. Five or iix grains is the ufual quantity given in clyfters. § The proper maimer of preparing tuipcntine clyfters is as follows: I>. Tereb. Venet. 5vi. Vitel. Gv. No. ii. Tue iu uiortario mannor^u donee pcuitu. fjlvetur Tuidiiuthina ; dcin add; ^r.idatim, Aq. font- fri»i ing the farces. § In the early ftages of this difeafe, the bc'.ly is-to be* kept 07 -n by the mildeit laxatives, and a milk diet ftri&ly ufed. The f< Uo+- iao' formula anfwers extremely \ve!i ; H22 PRACTICE in the form of a colic, my want of experience concern- in? it doetnot allow me to fpeak with any confidence on~the fubjed; but, fo far as I can learn from others, it appears to me, that it is to be treated by all the fe- veral means that I have propofed above for the cure of colic in general. How far the peculiar effeds of this difeafe are to be certainlv forefeen and obviated, I have not properly learned"; and I muft leave the matter to be determin- ed by thofe 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 matter rejeded both upwards and downwards appears manifeftly to confift chiefiy of bile. MCCCCL1V. From this laft circumftance I conclude, that the difeafe depends upon an increafed fecretion of the bile, and its copious effufion into the alimentary ca- nal ; and, as in this it irritates and excites the mo- tions 5. Mannas. OL olivar. I a ^i. M. f. Lin&us. This quantity is a proper dofe, and it may be repeated every day with ihirty or forty drops of laudanum at bed-time. If the fymp- toms, however, do not a'aate, we may (at the fame time,) give large emollient clyfters. Of physic. 223 tfons above mentioned, I infer, that the bile thus ef* fufed in larger quantity is at the fame time alfo of a more acrid quality. Tt.is appears likewife from the violent and very painful.gripings that attend the dif- eafe, and which we can impute only to the violent fpafmodic contradions of the inteftines that take place here. Thefe fpafms are commonly communicated to the abdominal mufcles, and very frequently to thofe of the extremities. MCCCCLV. In the manner now defcribed, the difeafe frequent- ly 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, fometimes in the courfe of one day. In other cafes the difeafe is lefs violent, continues for a day or two, and then ceafes by degrees; though fuch reco- veries feldom happen without the affiftanceof reme- dies. MCCCCLVI. The attacks of this difeafe are feldom accompanied with any fymptoms cf pyrexia: and though, during the courfe of it, both the pulfe and refpiration are hurried and irregular, yet thefe fymptoms are gene- rally fo entirely removed by the remedies that quiet the fpafmodic affcdions peculiar to the difeafe, as to leave no ground for fuppofing that it had been accom- panied by any proper pyrexia. MCCCCLVIl. This is a difeafe attending a very warm ftate of the air; and in very warm climates, it may perhaps ap- pear at any time of the year: but even in fuch cli- mates it is moft frequent during their warmeft feafons 5 and in temperate climates, it appears only in the warm feafons. Dr. Sydenham confidered the appear- ances of this difeafe in England to be confined to the month K4 PRACTICE month of Anguft ; but he himfelf obfe.ved it to ap- pear fometimes towards the end of iummer, when the feafon was unufually warm ; and that, in proportion to the heat, the violence of the uifeafc was greater.— Others have obferved that it appeared more early in fummer, an J aLvays fooner or later, according as the great heats fooner or later fet in. MCCCCLVilL From all thefe circumftances, it is, I think, very evident that this difeafe is the effed of a warm atmof- phere, producing fome change in the ftate of the bile in the human body ; and the change may confift, ei- ther in the matter of the bile being tendered more acrid, and thereby fitted to excite a more copious fe- cretion ; or, in the fame matter, its being prepared to pafseff in larger quantity than ufual. MCCCCLIX. It has been remarked, that in warm climates and feafons, after extremely hot and dry weather, a fall of rain cooling the atmofphere feems efpecially to biing on this difeafe ; and it is very probable that an ob- ftruded perfpiration may have a'io a fhare in this, though it is alfo certain that the difeafe does appear when no change in the temperature of the air, nor any application of ccid, has been obferved. MCCCCLX. It is poffible, that, in fome cafes, the heat of the feafon may ^ive only a predifpofition, and that the difeafe may be excited by certain ingefta or other cauf- es ; but it is equally certain, that the difeafe has occur- red without any previous change or error, either in diet, or in the manner cf life, that could be obferved. MCCCCLXI. The Nofologifts have coaitituted a Genus under the title of Cholera, and under this have arranged as fpecies, e^.ery affedion in which a vomiting and purg- ing of any.kind hsppentd lo concur. Innfanyof thefe OF PHYSIC. 225 thefe fpecies, however, the matter evacuated is not bi- lious ; nor does the evacuation proceed from any caufe in the ftate of the atmofphere. Further, in ma- ny of thefe fpecies alfo, the vomiting which occurs is not an effential, but merely an accidental, fymptom from the particular violence of the difeafe. The ap- pellation of Cholera therefore fhould, in my opinion, be confined to the difeafe I have d fcrihed above ; which by its peculiar caufe, and peroaps alfo by its fymptoms, is very different from all the other fpecies that have been affociated with it. I believe that all the other fpecies arranged under the title of Cho^ lera by Sauvages or Sagar, may be properly enough referred to the genus of Diarrhoea ; which we are to treat of in the next chapter. The diftindion I have endeavoured to eftablifh be- tween the proper Cholera, and the other difeafes that have fometimes got the fame appellation, will, as I judge, fuperfede the queftion, Whether tfie Cholera, in temperate climates, happens at any other feafon than that above affigned ? MCCCCLXII. In the cafe of a genuine cholera, the cure of it has been long eftablifhed by experience. In the heginning of the difeafe, the evacuation of the redundant bile is to be favoured by the plentiful exhibition of mild diluents*, both given by the mouth, andinjeded by the anus; and all evacuant medicines, employed in either way, are not only fuperfluous, but commonlv hurtful. MCCCCLXIII. When the redundant bile appears to be fufficiently wafhed out, and even before that, if the fpafmodic af- Vol. II. F f fedions * Thin rice-gruel is as proper a mild diluent as any we can ufe ; as is alio water in which a cruft of bread is boiled. A very fmall quantity of port wine may be added to thefe diluents if the pulfe h<3 fmall or weak, \ 226 PRACTICE fedions of the alimentary canal become very violent', and are communicated in a confiderable decree to other parts of the body, or when a dangerous debility feem3 to be induced, the irritation is to be immediately obviated by opiates in fufficiently large dofes, but in fmall bulk, "and given either by the mouth, or by glyftir*. MCCCCLXIV. Though the patient be in this manner relieved, it frequently happens, that when the operation of the opi- um is over, the difeafe fhows a tendency to return ; and, for at leaft fome days after the firft attack, the ir- ritability of the inteftines, and their difpofition to fall into painful fpafmodic contradions, feem to continue. Inthisfituation,the repetition of the opiates, for perhaps feveral days, may come to be neceffary ; and as the debility commonly induced by the difeafe fav-mrs the difpofition to fpafmodic affedions, it is often ufeful and neceffary, together with the opiates, to employ the to- nic powers of the Peruvian bark§. CHAP: * A pill confiding of a grain of opium may be given every two hours, and if it does not relieve the fymptoms after the third or fourth repetition, we may inject the following glyfter : &. Decoa. Hord.Jx. Ti'nft. Thebaic. 5i'« M. f. Enema. This clyfter may be repeated twice, or thrice if there be occafioru. § The bark in thefe cafes, is often fuccefsfully given along with. rhuh;>rb, as in the following formula : £,. Pulv. Cort. Peruv. |fs. RiK.. Rhei. -^i. M. f. Pulv. in part, aequal. xii. dividend. One of thefe pow,].;rs may be given three times a day with t glafs of port wine. OF PHYSIC. 227 C II A P. XF. OF DIARRHOEA OR LOOSENESS. xMCCCCLXV. * THIS difeafe confifts in evacuation by ftool, more frequ-nt and of more liquid matter than ufual. This leading and charaderiftic fymptom is fo diverfi- fied in its degree, in its caufes, and in the variety of matter evacuated, that it is almoft impoffible to give any general hiftory of the difeafe. MCCCCLXV1. It is to be diftinguifhed from dyfentery, by not be- ing contagious; by being generally without fever; and by being with the evacuation of the natural ex- crements, which are, at leaft for fome time, retained in dyfentery. The two difeafes have been commonly diftinguifhed by the gripings being more violent in the dyfentery ; and they are commonly lefs violent and lefs frequent in diarrhoea : but as they frequently do occur in this alfo, and fometimes to a confiderable degree, fo they do not afford any proper diftindion*. MCCCCLXVII. A diarrhoea is to be diftinguifhed from cholera chiefly by the difference of their caufes ; which, in cholera, is of one peculiar kind ; but in diarrhoea is prodigioufly divcrfified, as we (hall fee pvefently. It has been common to diftinguifh choleia by the eva- cuation downwards being of bilious matter, and by this being always accompanied with a vomiting of the fame kind ; but it does not univerfally apply, as a diar- F f 2 rhcea * Tenefmus is a diliinguifhing fymptom of dyfentery, but it is fometimes ptefent in diarrhoea alfo; efpecially thofe diarrhoeas which proceed from acri 1 or putrid fubftances in the inteftines. £2$ PRACTICE rhcea is fometimes attended with vomiting, and even of bilious matter. MCCCCLXVIII. The difeafe of diarrhoea, thus diftinguifhed, is very greatly diverfitied ; but in all cafes, the frequency of ftools is to be imputed to a preternatural increafe of the periftaltic motion in the whole, or at leaft in a confi- derable portion, of the inteftinal canal. This increaf- ed adion is in different degrees, is often convulfive and fpafmodic, and at any rate is a motus abnormis: for which reafon, in the Methodical Nofology, I have re- ferred it to the order of Spafmi, and accordingly treat of it in this place. MCCCCLXIX. Upon the fame ground, as 1 confider the difeafe named Lientcry to be an increaLd periftaltic motion over the whole of the inteftinal canal, arifing from a peculiar irritability, 1 have confidered it as merely a fpecies of diarrhoea. The idea of a laxity of the in- teftinal canal being the caufe either of lientery, or other fpecies of diarrhoea, appears to me without foun- dation, except in the finale cafe of frequent liquid ftools from a paify of'the fphintler ani. MCCCCLXX. The increafed action of the periftaltic motion, I con- fider as always the chief part of the proximate caufe of diarrhoea: but the difeafe is further, and indeed chi .fly, di-er(iiied by the different caufes of this in- creafed adion ; which we are now to inquire into MCCCCLXXI. The feveral caoLs of the increafe* adion ofthein- telines may be referred, I think, in the firft place, to two general heads. Tiie firft is, of the difeafes of certain parts of the body which, either from a content of the inteftines with thefe parts, or from the relation which the intef- tines have to the whole fyftem, occafion an increafed adion OF PHYSIC. 229 adion in the inteftines, without the transference of any ftimulant matter from the primary difeafed part to them. 'The fecond head of the caufes of the increafed ac- tion of the inteitines is the ftimuli of various kinds, which are applied diredly to the inteftines themfelves. MCCCCLXX1I. That affedions of other parts of the fyftem may affed the inteftines without the transference or ap- plication of any ftimulant matter, we learn from hence that the paffions of the mind do in fome perfons excite diarrhoea. MCCCCLXXIII. That difeafes in other parts may in like manner af- fed the inteitines, appears from the dentition of in- fants frequently exciting diarrhoea. I believe that the gout often affords another inftance of the fame kind ; and probably there are others alfo, though not well afcertained. MCCCCLXXIV. The ftimuli Cmcccclxx'i.) which may be applied to the inteftines are of very various kinds'; and are ei- ther, i. Matters introduced by the mouth. 2. Matters poured into the inteftines by the feveral excretofies opening into them. 3. Matters poured from certain preter-natural open- ings made into them in certain difeafes. MCCCCLXXV. Of thofe (mcccclxxiv, j.) introduced by 'he mouth, the firft to be mentioned ;.re the alilnenrs commonly taken in. Too great a quantity-of thefe taken in, often prevents their due digeftion in the ito mach ; and by being thus fent in their crude, and pro- bably acrid, ftate to the inteftines, they frequently ex- cite diarrhoea. The fame aliments, though in proper qmntity, yet having *3° PRACTICE having too great a proportion, as frequently happens, of faline or faccharine matter along with them, p^ove ftimulant to the inteftines, and excite diarrhoea. - But our aliments prove efpeciaUy the caufes of di- arrhoea, according as they, from their own nature, or from the weaknefs of the ftomach, are difpofed to un- dergo an undue degree of fermentation there, and thereby become ftimulant to the inteftines. Thus acefcent aliments are ready to produce diarrhoea; but whether from their having any diredly purgative qua- lity, or only as mixed in an over proportion with the bile, is not well determined. MCCCCLXXVI. Not only the acefcent, but alfo the putrefcent dif- pofition of the aliments, feems to occafion a diarrhoea; and it appears that even the effluvia of putrid bodies, taken in any wav in large quantity, have the fame ef- fed. 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* f ^ MCCCCLXXVII. The other matters introduced by the mouth, which may be caufes of diarrhoea, are thofe thrown in either as medicines, or poifons that have the faculty of flimu- lating the alimentary canal. Thus, in the lift of the Materia Medica, we have a long catalogue of thofe named purgatives ; and in the lift of poifons, we have many pofteffed of the fame quality. The former, riven in a certain quantity, occafion a temporary di- arrhceD ; and given in very large dofes, may occafion it in excefs, and continue it longer than ufual, produ- cing that fpecies of diarrhoea named aHypercatharfis. MCCCCLXXV1II. * Rancid oils and r-.-.ts certaialy irritate the inteftines; and may therjr.rc produce Diarrhoea. OF P II T S I C. 251 MCCCCLXXVIII. The matters (mcccclxxiv, 2.) poured into the cavi- ty of the inteftines from the cxcretories opening into them, and which may occafion diarrhoea, are either thofe from the pancreatic or biliary dud, or thofe from the excretories in the coats of the inteftines themfelves. MCCCCLXXIX. What changes may happen in the pancreatic juice, I do not exactly know ; but I fuppofe that an acrid fluid may iffue from the pancreas, even while ftill en- tire in its ftrudure ; but more efpecially when it is in a fuppcrated, fcirrhous, or cancerous ftate, that a very acrid matter may be poured out by the pancreatic dud, and occafion diarrhoea. MCCCCLXXX. We know well, that from the biliary dud the bile may be poured out in greater quantity than ufual; and there is little doubt of its being alfo fometimes pour- ed out of a more than ordinary quality. It is very probable, that in both ways the bile is frequently a caufe of diarrhoea. Though I have faid above that diarrhoea may be commonly diftinguifhed from cholera I muft admit here, that as the caufes producing that ftate of the bile which occafions cholera, may occur in all the dif- ferent poffible degrees of force, fo as, on one occafion, to produce the moft violent and diltindly marked cholera ; but, upon another, to produce only the gen- tleft diarrhoea: which, however, will be the fame dif- eafe, only varying in degree: So I think it probable, that in warm climates, and in warm feafons, a diar- rhoea biliofa of this kind may frequently occur, not to be always certainly diftinguifhed from cholera. However this may be, it is fufficiently probable, that, in fome cafes, the bile, without having been ad- ed upon by the heat of the climate or feafon, may be redundant 232 PRACTICK redundant and acrid, and prove therefore a particular caufe of diarrhoea. MCCCCLXXXI. Befide bile from the feveral caufes and in the con- ditions mentioned, the biliary dud may pour out pus; or other matter from abfceffes in the liver, which may be the caufe of diarrhoea. Pradical writers take notice of a diarrhoea wherein a thin and bloody liquid is difcharged ; which they fuppofe to have proceeded from the liver, and have therefore given the difeafe the name of Hepatirrhcea : but we have not met with any inftance of this kind; and therefore cannot properly fay any tiding concern- ing it. MCCCCLXXXH. A fecond fet of excretories, from which matter is poured into the cavity of the inteftines, are thofe from the coats of the inteftines themfelves ; and are ei- ther the exhalants proceeding diredly from the extre- mities of arteries, or the excretories from the mucous follicles: and both thefe fources occur in prodigious number over the internal furface of the whole intefti- nal canal. It is probuble that it is chiefly the effufion from thefe fources which, in moft inftances, gives the x matter of the liquid ftools occurring in diarrhoea. MCCCCLXXXIII. The matter from both fources may be poured out in larger quantity than ufual, merely by the increafed adion of the inteftines, whether that be excited by the paffions of the mind (mccccxxii.) by difeafes irt other parts of the fyftem (mcccclxxi, i.) or by the various ftimulants mentioned mcccclxxv. and follow- ing; or the quantity of matter poured out may be in- creafed, not lb much by the increafed adion of the in- teftines, as .by an increafed afflux of fluids from other parts of the fyftem. Thus, cold app'ied to the furface of the body, and fuppreffing or j? ri y s i c. 223 urppreffirig perfpiration, may determine a greater quantity of fluids to the inteftines. Thus, in the ifchuria renatis, the urine taken into the blood-veffels is fometimes determined to pafs off again by the inteftines. In like manner, pus or ferum may be abforbed from the cavities in which they have b>en ftagnant, and be again poured out into the iiiteftines, as frequently happens, in particular with refped to the water of drop ties. 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 fyftem, but likewife by the mere determination of various acrid matte] s from themafsof blood into the cavity of the inteftines. Thus it is fup- pofed that the morbific matter of fevers is fometimes thrown out into the cavity of the inteftines, and gives a critical diarrhoea : and whether I do or do not admit the dodrine of ciitical evacuations, I think it is probable that the morbific matter of the exanthe- mata is frequently thrown upon the inteftines, and occafions diairhcea. MCCCCLXXXV. It is to me further probable, that the putrefcent matter diffufed in the mafs of blood in putrid difeafes, is frequently poured out by the exhalants into the in- teftines, and proves there the caufe, at leaft in part, of the diarrhoea fo commonly attended with thefe dif- eafes. MCCCCLXXXVI. Upon this fubjed of the matters poured into the ca- vity of the inteftines, I have chiefly confidered them as poured out in unufual quantity, but it is pVobable that, for the moft part, they are alfo changed in their quality, and become of a more acrid and ftimulant na- Vol. II. G g ture; 234 P R A C T I C E ture ; upon which account efpecially it i-> that tluy excite, or at leaft increafe, a diarrhoea. MCCCCLXXXVIl. How far, and in what manner, the exhahnt fluid may be changed in its nature and qualiy, we do not certainly know : but with refped to the fluid from the mucous excretories, we know, that, when poured out in unufual quantity, it is commonly, at the fame time, in a more 1-quid and acrid form ; and may prove,. therefore, coniiderabiy initating IvICOCCLXXXVIII. Though the copious effufion of a more liquid and aciid matter from the mucous excretories, be proba* blv owing to ths matter being p/.ured out immediate- ly as it is fee re ted from the blood in o the mucous fol- licles, without being allowed to ftagnate in the latter, fo as to acquire that milder quality and thicker con- fidence we commonly find in the mucus in its natural ftate; and although we might fuppofe that the excre- tions of a thin and acrid fluid ftiould always be the ef- fed of every determination to the mucous follicles, and of every ftimulant applied to them : yet it is cer- tain, that the reverie is fometimes the cafe; and trut, from the mucous follicles, there is frequently an in- creafed excretion of a mucus, which appears in it$ proper form of a mild viicid, and thickiih matter. This commonly occurs in the cafe of dyfentery ; and it has been oLfcrved to give a fpecies of diarrhoea, which has been properly named the Biarrhcea Mucofa. MCCCCLXXXIX. A third fierce of matter poured into the cavity of the .inteftines, and occafioning diarrhoea (mcccc- lxxiv, 3.) is from thofe preternatural openings re- duced by difeafes in the intcftin-s cr neighbouring pans. Thus the blood-veffels on the internal furface of the inteftines may be opened by erofion, rupture, cr anaftomofis, and pour into the cavity their blood, which, OF PHYSIC. 235 * which, either by its quantity or by its acrimony, whe- ther inherent, or acquired by ftagnation, may fome- times give a diarrhoea evacuating bloody matter. This is what I think happens in that difeafe which has called the Melcena or Morbus Niger. MCCCCXC. Another preternatural fource of matter pou-ed in- to the cavity of the inteftines, is the rupture of abfcef- fes feated either in the.coats of the inteftines them- felves, or in any of the contiguous vifcera, which, du- ring 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 each of thefe ftates may be a caufe of diarrhoea. MCCCCXCI. Amongft the ftimuli that may be diredly applied to the inteftines, and which, by increafing their periftal- tic motion, may occafion diarrhoea, I muft not omit to mention worms, as having frequently that effed. MCCCCXCil. I muft alfo mention here a ftate of the inteftines, wherein their periftaltic rpotion is preternaturally in- creafed, and a diarrhoea produced; and that is, when they are affeded with an erythematic inflammation. With refped to the exiftence of fuch a ftate, and its occafioning diarrhoea, fee what is faid above in ccc- xcvm. and following. Whether it is to be confider- ed as a particular and diftind cafe of diarrhoea, or is always the fame with fome of thofe produced by one or other of the caufes above mentioned, 1 have not been able to determine. MCCCCXC1II. Laftly, by an accumulation of alimentary or of o- ther matter poured in the cavity of the inteitines from feveral of the fources above mentioned, a diarrhoea G g 2 may 236 PRACTICE may be efpecially occafioned when the abforption of the ladeals, or of other abforbents, is pi evented, ei- ther by an obftrudion of their orifices, or by an ob- ftrudion of the mefenteric glands, through which alone the abforbed fluids can be tranf fitted. In one inftance of this kind, when the chyle pre- pared Jn the ftomach and duodenum is not abforbed in the courfe of the inteftines, but pafles off in confidera- ble quantity by the anus, the difeafe has been named morbus Cceiiaca, or fimply and more properly Cceliaca; which accordingly I have confidered as a fpecies of diarrhoea. MCCCCXCIV. I have thus endeavoured to point out the various fpecies of difeafe that may come under the general appellation of Diarrhoea; and from that enumeration it will appear, that many, and indeed the greater part of the cafe of diarrhoea, are to be confidered as fympa- thetic affedions, and to be cured only by curing the primary difeafe upon which they depend ; of which, however, I cannot properly treat here. From our enumeration it will alfo appear, that many of the ca- fes of diarrhoea which may be confidered as idiopa- thic, will not require my faying much of them here. In many inftances, the: difeale is afcertained, and alfo roe caufe aifigued, by the condition of the matter e- vacuated ; fo that what is neceffiiry to corred or re- move it wiil be fufficiently obvious to praditioners of any knowledge. In fhort, I do not find that I can of- fer any general plan for the cure of diarrhoea ; and all that I can propofe to do on this fubjed, is to give fome general remarks on the pradice that has been commonly followed in the cure of this difeafe MCCCCXCV. The pradice in this difeafe has chiefly proceeded upon the fuppofition of an acrimony in the fluids or of a laxity in the fimple and moving fibres of the'in- teftines; OF PHYSIC. 237 feftines; and the remedies employed have according- ly been Corredors of particular acrimony, general demulcents, evacuants by vomi ing or purging, af- tringents, or opiates. Upon eav h of thefe kinds of remedy 1 fhall now offer fome remarks. MCCCCXCVI. An acid acrimony is, upon feveral occafions, the caufe of diarrhoea, particularly in children; and in fuch cafes the abforbent earths have been very proper- ly employed. The common, however, and pr mif- cuous ufe of thefe has been very injudicious; and where there is any putrefcencv, they muft be hurtful. MCCCCXCVII. The cafes in which there is a putrid or putrefcent acrimony prevailing, have been, I think, too feldom taken notice of; and, therefore, the ufe of acids too feldom admitted. The acrimony to be fufpeded in bilious cafes, is probably of the putrefcent kind. MCCCCXCVIII. The general corredors 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 veiy much increafe the effeds of the latter: and although the demulcents, both mucilaginous and oily, mny by themfelves be ufeful, yet without the afliftance of diluents they can hardly be introduced in fuch quantity as to anfwer the purpofe*. MCCCCXCIX. * Lintleed-teaisboth diluent and demulcent ; but as the patient lometimc; loaths it, we may in its place nfe a decoction of marfh- nrdllows root, or of quince feed. Thefe infufions and decoctions ouglit to be extremely thin. An ounce of bruifed quince-feed will make three pints of water as thick and ropy as the white of an egg ; hence a drachm is fufficient for a pint of the decoction. We have another inilance of a diluent and demulert in the al- mond emulhon, which is an exceedingly elegant imdicine. The formula: in both the London and Edinburgh Pharmacopoeias arc net ".x'l adapted to cafes of diarrhoea : for the former contains fugar, / 223 PRACTICE MGCCCXCIX. As indigeftion and crudities prefent in the ftomach are fo often the caufe of diarrhoea, vomiting muft therefore be frequently very ufeful in this difeaie. In like manner, when the difeafe proceeds, as it oft- en does, from obftruded perfpiration, and increafed afflux of fluids to the inteftines, vomiting is perhaps the moft effedual means of reftoring the determina- tion of the fluids to the furface^ of the body. It is poffible alfo, that vomiting may give fome in- verfion of the periftaltic motion which is determined too much downwards in diarrhoea ; fo that upon the whole it is a remedy which may be very generally ufe- ful in this difeafe*, ' MD. Purging has been fuppofed to be more univerfally neceffary, and has been more generally pradifed. This however, in my opinion, proceeds upon very mif- taken notions with refped to the difeafe ; and fuch a pradice feems to me for the moft part fuperfluous, and in many cafes very hurtful.. It goes upon the fuppo- fition of an acrimony prefent in the inteftines, that ouojn to be carried out by purging : but, if that acii- mony has either been introduced by the mouth, or brought into the inteftines from other parts of the bodv, purging can neither be a means of correding nor of exhaufting it; and muft rather have the effed iA increafing its afflux, and of aggravating its effeds. From and the Liter bitter almonds ; both of which increafe tha irritation. •In thefe cafes, therefore, an emulfion made with fweet almonds and £ii-.ii arabic, is preferable to either of the others : as, IJ,. Amygdal. dulc. decorticat. J\. Gum Arabic. 31. Tere in mortario marmoreo, et adde gradatim. Aq. font. lb. i. M.f. Lmtdf. * Tie methods of giving the tartar emetic, for producing either voiMiii'g or fweating, may be ften in the notes on article 185. OF PHYSIC. 259 From whatever fource the acrimony which can excite a diarrhoea proceeds, it may be fuppofed fufficient to evacuate itfelf, fofaras that can be done by purging ; and as in cholera, fo in the fame kind of diarihoes, :c will be more proper to affift the evacuation by diluents and demulcents, 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 fu- perfluous, there are many other cafes in which it may be extremely hurtful. If the irritability of the intef- tines fhall, from affedion', in other parts of the fyftem, or other caufes, have been already very much, increaf- ed, purgatives muft neceffarily aggravate the difeale. In thecafe of lientery, nobody thinks of giving a pur- gative; and in many cafes of diarrhoea approaching to that, they muft be equally improper. I have al- ready obferved, that when diarrhoea proceeds from an afflux of fluids to the inteftines, whether in too great quantity, or of an acrid quality, purgatives may be hurtful; and whoever, therefore, conliders the nu- merous and various fources from which acrid matter may be poured into the cavity of the inteftines, will readily perceive, that, in many cafes of dial rhcea, pur- gatives 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 ferous fluids run off too copionfly into the cavity of the inteftines, and excite that diarrhoea which attends the advanced ftate of hedic fever, and is properly called a Colliquative Diarrhoea ; I have, in fuch cafes, often feen purgatives given with the moft baneful effeds. There is ftill another cafe of diarrhoea in which purgatives are pernicious ; and that is, when the o-i- eafe depends, as we have alledged it fometimes may upon an erythematic inflammation cfthe inrefir.ee. i need 240 PRACTICE I need hardly add, that if there be a cafe of diarrhoea depending upon a laxity of the folids, purgatives can- not there be of any fervice, 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 the promifcuous ufe of them, which has been fo com- mon, is injudicious, and often pernicious. I believe the pradice has been chiefly owing to the ufe of purgatives in d\fenteric eafes, in which they are truly ufeful ; becaufe, contrary to the cafe of diarrhoea, there is in dyfentery a confiderable conftridion of the intef- tines*. MDII. Another fet of remedies employed in diarrhoea are aftringents. There has been fome h fitation about the employment of thefe in recent cafes, upon the fuppofition that they might occafion the retention of an acrid matter that fhould be thrown out. I cannot, however, well underftand or alfign the cafes in which fuch caution is neceffary ; and I think that the power of aftringents is feldom fo great as to render their ufe very * Notwithstanding all the author advances concerning the danger of purgatives in a dianhoea, there are fome c fes in which they are of lingular utility. His arguments in tin's article are doubtlefs juft ; and, in the fpecies of diarrhoea which he here enumerates, pur- gatives are certainly hurtful : but many inftances of diarrhoea occur, which proceed from an acrimony that is extremely tenacious, and that adheres clofely to the internal furface of the interlines, or is re- tained in their folds. In fuch cafes, purgatives are the only re- medies for removing the dileafe, and oughr. therefore to be ufed. In ail other cafes, (as the author juftly obferves,) thty are certainly pernicious. Having afcertained when purgatives are proper, the next confi- deration is, what purgatives ought to be ufed ? The anfv.er is obvi- ous :—Neutral falts, particularly Soda phofphorata, Ruchel Salt, Glaubers falts, and Epfom lalt, which are enumerated in the order of their being agreeable, but in a contrary order to their degree of efficacy ; the Epror:i fall bt-in-j the leaft agreeable, but tht inoll t_lli.;u:"ous. OF PHYSIC. 241 very dangerous. The only difficulty which has occur- red to me, with refped to their ufe, has been to judge of the circumftances to which they are efpecially adapt- ed. It appears to me to be only in thufe where the irritability of the inteftines depends upon a lofs of tone: and this, I think, may occur either from the debility of the whole fyftem, or from caufes ading on the inteftines alone. All violent or lon^-continued fpafmodic and convulfive aifedions of the intefiinal canal neceffarily induce a debility there; and fuch caufes often take place, from violent irritation, in co- lic, dyfentery, cholera, and diarrhoea*. MDIII. The laft of the remedies of diarrhoea that remain to Vol. II. H h be * The aftringents to be ufed when they are proper, are various : as Alum, Logwood, Catechu, Rhubarb, &c. The author jultly remarks, that aftringents are only ufeful in cafes of debility, and therefore the tonic aftringents are undoubtedly preferable to any other. Rhubarb and Peruvian bark, each poffeffing both thefe qua- lities, may therefore be advantageoufly ufed conjointly, as in the following formula : JJ,. Pulv. Cort. Peruv. ^i. Rad. Rhei, §fs. M. f. Pulv. The dofe of this powder may be varied according to circumftances, from a fcruple to a dram, twice a-day, with a glafs of port wine after it. It may not be improper to obferve, that in diarrhoeas in general peculiar attention muft be paid to diet. The oleraccous and acef- cent vegetables muft be carefully avoided; as muft alfo all fermented liquors except port wine ; of the farinaceous vegetables, rice is the bell; and rice-water., with a little cinnamon and port wine, is the moft proper drink for patients in thefe cales. Roafted meats are preferable to boiled ; and veal, lamb, or chicken?, preferable to beef or mutton. Pork is very improper, as are alfo all kinds of fifh. Puddings of all kinds without fruit are very proper food for, fuch patients, efpecially rice-puddings made without eggs, but with milk and cinnamon; and alfo rice-milk, fago with port wine, blanc mang.-, &c. 242 PRACTICE be mentioned are opia e?. The fame objections have been made to the ufe of thefe, in recent cafes of diar- rhoea, as to that cf aftringents ; but on no good grounds : for t!.e effed of opiates, as attringenf, U ne- ver very permanent ; and an evacuation depending upom i.ritatioii, though it may be for fome timefuf- pend-.d 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 irritation is cc rreded or exhausted, opiates are the molt ufeful and certain remedy. And thoughopiates are not fuited to corred or remove an irritation applied, they are often of great b.-.nefit in fufpending the effeds of that irritation whenever thefe are violent : and, upon the whole, it will appear, that opiates may be very frequently, and with great propriety, employed in the cure of diarrhoea. CHAP. XII. OF THE DIABETES. MD1V. THIS difeafe confifts in the voiding of an unufually large quantity of urine. As hardly any fecretion can be increafed without an increafed action of the veffels concerned in it, and as fome inftances of this difeafe are attended with'affec- tions manifeftly fpafmodic, I have had ho doubt of arranging the diabetes under the order of Spafmi MDV. This difeafe is always accompanied with a great de- gree OF PHYSIC. 243 gree of thirft, and therefore with the taking in of a great quantity of drink. This in fome meafure ac- counts for the very extraordinary quantities of urine voided: but ftill, independent of this, peculiar dif- eafe certainly takes place; as the quantity of urine voided does almoft always exceed the whole of the liquids, and fometimes the whole of both folids and li- quids, taken in. MDVI. The urine voided in this difeafe is always very clear, and at firft fight appears entirely without any colour : but, viewed in a cert:.in light, it generally appears to be flightly tinged with a yellouilh green, and in this refped has been very properly compared to a folution of honey in a large proportion of water. Examined by the talte, it is very generally found to be more or lefs fweet; and many experiments that have now been made in different inftances of the dif- eafe, fhow clearly that fuch urine contains, in confider- able quantity, a faccharine matter which appears to b^ very exadly of the nature r,f common fugar. MDVII. Dodor Willis feems to me to have been the firfy who took notice of the fweetnefs of the urine in dia- betes, and almoft every phyfician of England has fince taken notice of 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 an- cients, nor, in the other countries of Europe, the mo- derns, till the latter were direded 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 myfeif, indeed, think I have met with one iuftance of diabetes in which the urine was perfedly infipid ; and it would feem that a like obfervation had occur- red to Dr. Martin Lifter. I am perfuaded, however, H h 2 that 244 PRACTICE that fuch inftances are very rare; and that the other. is by much the more common, and perhaps the al- moft univerfal occurrence. I judge, therefore, that the prefence of fuch a faccharine matter may be con- fidered as the principal circumftance in idiopathic di- abetes ; and it gives at leaft the only cafe of that dif- eafe 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 confequently the remote caufes of it, have not been well afcertain- ed. It may be true that it frequently happens to men who, for a long time before, had been intemperate in drinking ; that it happens to perfons of a broken con- ftitution, or who, as we often exprefs it, are in a cachedic ftate ; that it fometimes follows intermit- tent fevers ; and that it has often occurred from excels in the drinking of mineral waters. But none of thefe caufes apply very generally to the cafes that occur: fuch cafes are not always, nor even frequently, fol- lowed by a diabetes; and there are many inftances of diabetes which could not be referred to any of them. In moft of the cafes of this difeafe v/hich I have met with, I could not refer it to anv particular caufe MD1X. This difeafe commonly comes on flowly, and almoft imperceptibly, without any previous diforder. It of- ten rifes to a confiderable degree, and fubfifts long without being accompanied with evident diforder in any particular part of the fyftem. The great thirft which always, and the voracious appetite which fre- quently occurs in it, are often the only remarkable fymptoms. Under the continuance of the difeafe, the body is often greatly emaciated ; and a great weak- nefs alfo prevails. The pulfe is commonly frequent ; and an obfeure fever is for the moft part prefent.__ When the difeafe proves fatal, it generally ends with a fever O F P H Y s I e. fl4- a fever, in many circumftances, particularly thofe of emaciation and debility, refembling a hedic MDX. The proximate caufe of this difeafe is not certainly or clearly known. It feems to have been fometimes conneded with calculous aifedions of the kidneys ; and it is poffible, that an initation applied there may in- creafe 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 certainly o'ten happens, that cal- culous matters are long pr.efci.t in the urinary paffages, without having any fuch effed as that of "producing diabetes in any fhape. Some have fuppofed that the difeafe occur? from a relaxed ftate of the fecretory veffels of the kidneys ; and indeed the diffedions of perfons who had died of this difeafe have fhown the kidneys in a very flaccid ftate. This, however, is probably to be confidered as rather the effed than the caufe of the difeafe. That no topical iffedion of the kidneys has a fhare in producing this difeafe, and that a fault in the affi- mulation of the fluids is rather to be blamed, i con- clude from hence, that even the folid food taken in, increafes the quantity of the urine voided, at the fame time with an increafe of tfie faccharine matter above- mentioned. MDXL The diabetes has been fuppofed to be owing to a certain ftate of the bile ; and it is true, that this difeafe has fometimes occurred in perfons who were at tie fame time affeded with difeafes of the liver : but th;\ occurrence does not often take place; and the di an- tes frequently occurs feparately from any afTedion of the liver. In twenty inllar.ces of diabetes which I have feen, there was not m any on: of them any evi- dent affedion of the liver. The 246 PRACTICE The explanation that has been offered of the nature and operation of the bile, in producing diabetes, h ve- ry hypothetical, and nowife fatisfying. MDXII. As I have already faid, 1 think it probable, that in moft cafes the proximate caufe of this difeafe is fome fault in the affimilatory powers or in thofe employed in converting alimentary matters into the proper ani- mal rl aids. This I formerly hinted to Dr. Dobfon, and it has been profecuted and publifhed by him ; but 1 muft own that it is a theory embarraffed with fome difficulties which I cannot at prefent very well remove. MDXJII. 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 believe that the difeafe has been cured: but I believe alfo, that this has feldom happen- ed ; and when the difeafe has been cured, I doubt much if it was effeded by the feveral remedies to which thefe cures have been afcribed. In all the in- ftances of this difeafe which I myfeif have feen, and in feveral * The difeafe is happily not very common ; but, when a phyfici- an is called, he is under the neceffity of doing fomething, and not remaining inaftive. bome general ilire&ions may therefore be ac ceotabk to the young pradt.itioner. The cure will principally confift in avoiding whatever may relax the renal vefTels, efpecially by avoiding ftrong drink. As the quan- tity of urine is always lefs in proportion as the perfpiration is in- creafed, it feems advifable to keep the furface of the fkin lax and perfpirable ; and, if the patient's llrength allows him, he ought fre- quently to ufe bodily exercife to promote fweat. For a fimilar rea- icn, external cold mult be avoided, becaufe by diminifhing perfpiia- ti jh, a larger quantity of fluids is derived to the kidneys. In fome cafes, the difeafe may be probably owing to a lax or weak (late of the kidneys : hence the indication of tonic, as Peru- vian bark, and other tonic bitters. OF PHYSIC. 247 feveral others of which I have been informed, no cure of it has ever been made in Scotland, though many inftances of it have occuired, and in moft of them the remedies recommended by authors have been diligent- ly employed. I cannot, therefore, with any advan- tage, enter into a detail of thefe remedies; and as the difeafe, together with its feveral circumftances, when they fhall hereafter occur, is likely to become the fub- jed of diligent inveftigation, I avoid going farther at prefent, and judge it prudent to fufpend my opinion till I -hall have more obfervations and experiments up- on which I can form it more clearly. • < <•<■«■< < < < <-<•■« <>$>>• >•>■>•>■>■>•>>•> *■*•■ CHAP. XIII. OF THE HYSTERIA, OR THE HYSTERIC DISEASE. MDXIV. THE many and various fymptoms which have been fuppofed to belong to a difeafe under this appella- tion, render it extremely difficult to give a general charader or definition of it. It is, however, proper in all cafes to attempt fome general idea ; and there- fore, by taking the moft common form, and that con- currence of fymptoms by which it is principally dif- tinguifhed, I have formed a charader in my fyltem of Methodical Nofology, and fhall here endeavour to il- luftrate it by giving a more full hiftory of the pheno- mena. MDXV. The difeafe attacks in p^roxyf ns or fits. Thefe commonly begin by fome pain and fulnefs felt :n the lei: 243 PRACTICE left fide cf the beliy. From this a ball* feems to move with a grumbling noife into the other parts of the bel- ly ; and, making as it were various convolutions there, feems to move into the ftomach ; and more diftindly ftill riles up to the top of the gullet, where it remains for fome time and by its preffurc upon the larynx gives a fenfe of fufibcation. By the time that the difeafe has proceeded thus far, the patient is af- feded with a ftupor and infer.Ability, 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 varioufiy agitated ; commonly the con- vulfive motion of one arm and hand, is that of beating with the clofed fid, upon the breaft very violently and repeatedly. This ftate continues for fome time, and has during that time fome remiffions and renew- als of the convulfive motions ; but they at length ceafe, leaving the patient in a ftupid and feemingly fleeping ftate. More or lefs fuddenly, 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 with- out any recolledion of the feveral circumftances that had taken place during the fit. \ n\ VTTT lti jl> -t\. v I. This is the form of what is called an hyfteric parox- yfm, and is the moft common form ; but its parox- yfms are coniiderabiy varied in different perfons, and even in the fame perfon at different times. It differs, by having more or fewer of the circumftances above- mentioned : by thefe circumftances being more or lefs violent; and by the difierent duration of the whole fit. Before the fit there is fometimes a fudden and unu- fually large flow of limpid urine. At the coming on cf Commonly called Gkbus hyftcricus by authors. U F PHYSIC. 249 of the fit, the ftomach is fometimes affected with vo- miting, the lungs with confiderable difficulty of breath- ing, and the heart with palpitations. During the fit, the whole of the belly, and particularly the navel, is drawn ftrongly inwards; the fphinder and ani is fome- times fo firmly conftrided as not to admit a fmall glyfter-pipe, and there is at the fame time an entire fuppreffion of urine. Such fits are, from time to time, ready to recur; and during the intervals, the patients are liable to involuntary motions, to fits of laughing and crying, with fudden tranfition from the one to the other; while fometimes falfe imaginations, and fome degree of delirium, alfo occur. MDXVII. Thefe affedions have been fuppofed peculiar to the female fex; and indeed they moft commonly appear in females : but they fometimes, though rarely, at- tack the male fex; never, however, that I have ob- ferved, in the fame exquifite degree. In the female fex, the difeafe occurs efpecially from the age of puberty to that of thirty-five years ; and though it does fometimes, yet very feldom ap- pears before the former or after the latter of thefe pe- riods. At all ages, the time at which it moft readily occurs is that of the menftrual period. The difeafe more efpecially affeds the females of the moft exquifitely fanguine and plethoric habits, and frequently tffeds thofe of the moft robuft and maf- culine conftitutions. It affeds the barren more thnn breeding women, and therefore frequently young widows. It occurs efpecially in thofe females who are liable to the Nymphomania ; and the Nofologifts have pro- perly enough marked one of the varieties of this dif- eafe by the title of Hyfleria Libidinofa. In the: perfon,s liable to the fits of this difeafe, it h Vol. II. 1 i readily 25° PRACTICE readily excited by the paffions 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 ftrongly affeded by every impreffion that comes upon them by furprife. MDXVIII. In this hiftory, there appears to be a concurrence of fymptoms and circumftances properly marking a very particular difeafe, which I think may be diftin- guifhed from all others. It feems to me to have been improperly confidered by phyficians as the fame with fome other difeafes, and particularly with hypochon- driafis. I he two difeafes may have fome fymptoir::, in common, but for the moil part are confiderably dif- ferent. Spafmodic affedions occur in both difeafes; but neither fo frequently nor to fo great a degree, in hy- pochondriafis as in hyfteria. Perfons liable to hyfteria are fometimes affeded at the fame time with dyfpepfia. They are often, how- ever, entirely free from it; but I believe this never happens to perfons affeded with hypochondriafis. Thefe difierent circumftances mark fome difference in the two difeafes; but they are ftill more certainly diftinguifhed by the temperament* they attack, and by the time§ of life at which they appear to be molt ex- quifitely formed. It has been generally fuppofed, that the two difeaf- es differ only in refped of their appearing in different fexes. But this is not well founded : for although the hyfteria appears moft commonly in females, the male fex * Hyfteria attacks the fanguine and plethoric, but Hypochondri- afis the melancholic. § Hypochondriafis fcarcely ever appears early in life, nor Hyfte- ria late ; and Hypochondriafis becomes aggravated, but Hvlteria re- lieved by advancing age. OF PHYSIC. 251 (ex is not abfolutely free from it, as I have obferved above; and although the hypochondriafis may be moft frequent in men, the inftances of it in the female fex are very common*. MDXIX. From all thefe confiderations, it muft I think, ap- pear, that the hyfteria may be very well, and properly, diftinguifhed from hypochondriafis. Further, it feems to me to have been with great im- propriety, that almoft every degree of the irregular motions of the nervous fyftem has been referred to the one cr the other of thefe two difeafes. Both are marked by a peculiarity of temperament, as well as by certain fymptoms commonly accompanying that; but fome of thefe, and many others ufually marked by the name of nervous fymptoms, may, from various caufes, arife in temperaments different from that which is peculiar to either hyfteria or hypochondriafis, and without being joined with the peculiar fymptoms of either the one or the other difeafe : fivthat the appel- lations of Hyfteric and Hypochondriac are very inac- curately applied to them. Under what view thefe fymptoms are otherwife to be confidered, I am not ready to determine ; but muft remark, that the appel- lation of Nervous Difeafes is too vague and undefined to be of any ufeful application. MDXX. Having thus endeavoured to diftinguifh hyfteria from every other difeafe, I fhall now attempt its pecu- liar pathology. With refped to this, I think it will, in the firft place, be obvious, that its paroxyfms be- gin by aconvuifive and fpafmodic affedion cf the ali- mentary canal, which is afterwards communicated to the brain, and to a great part 9!'the nervous fyftem. I i 2 Although * The Hypochondriafis in women has frequently been miiiaken for Hylteria. 252 PRACTICE Although the difeafe appears to begin in the alimen- tary canal, yet the connedion which the paroxyfms fo often have with the menflrual flux, and with the dif- eafes that depend on the ftate of the genitals, fhows, that the phyficians have at all times judged rightly in confidering this difeafe as an affedion of the uterus and other parts of the genital fyftem. MDXXl. With regard to thi-j, however, I can go no farther. In what manner the uterus, and particularly the ova- ria, are affeded in this difeafe ; how the. atfedion of thefe is communicated, with particular circuml'ances, to the alimentary canal; or how the affedion of tl-ii, riling upwards, affeds the brain, fo as to occafion the particular convulfions which occur in this difeafe, I cannot pretend to explain. But although I cannot.trace this difeafe to its fjrft caufes, or explain the whole of the phenomena, I hope, that wiih refped to the general nature of the dif- eafe, I may form fome general conciufions, which may ft rve to dired our condud in the cure of i:. MDXX1I Thus, from a cenfideration of the predifponent and occafional canfes, it v/i:l, I think, appear, that the chief parr of the proximate caufe is a mobility of the fvftem, depending- generr.v.v upon its plethoric ftate. MDXXlif, Whether this difeafe ever uriles from a mobility of the fyltem, independent of any plethoric ftate of it, I cannot pofitively deteimiue ; but in many cafes that have fubliitod for iome time, it is evident that a fen-» froility, and confequently a mobilfy, are acquired, which often appear when neither a general plethora c :n be fuppofed to fubfift, nor an occafional turgef- cence to have happened. However, as we have ihown above, tlut a dlftenfhm .of the veffels of the brain feems to occafion epilepfy, and that a turgef- cence OF PHYSIC. 253 cence of the blood in the veffels of the lungs feems to produce afthma ; fo analogy leads me to fuppofe, that a turgefcence of blood in the uterus, or in other parts of the genital fyftem, may occafion the fpafmodic and convulfive motions wfiich appear in hyfteria. It will, at the fame time, be evident, that this affedion of the genitals muft efpecially occur in plethoric habits; and every circumftance mentioned in the hiftory of the difeafe ferves to confirm this opinion with refped to its proximate caufe. MDXXIV. From this view of the fubjed, the analogy of hyf- teria and epilepfy will readily appear ; and why, therefore, I am to fay that the indication* of cure are the fame in both. As the indications, fo the feveral means of answer- ing them are fo much the fame in both difeafes, that the fame obfervations and diredions, with regard to the choice and employment of thefe remedies, that have been delivered above on the fubjed of epi- itpfy, will apply pretty exadly to hyfteiia ; and there- fore need not to be repeated here*. C H A P. * Although the indications of cure maybe the fa:qe in both dif- eafe?, yet in hylteria we are more iiu'jsrialy under the nccefiitv of relieving the violence of the fymptoms than in epilepfy; a:d for this purpofe vvc mult hive rccju.fe to a variety of antifpufmoJics. Atafcetiua, in various forms, is ufually employed; as are a!;'.> volatile fpirits: but both thefe joined, prove inure eliicu^iuus thin either of them finely. There are excellent formulae of thin kind in the London and Edinburgh pharmacopoeias, under the title of Jpi- ritus A-.noniae foetidus. It's dofe is twenty or thirty drops, re- peated accoidiug to the urgency of the cafe, feveral times a-day. The 1 inftura CaHorei compolita of the Edinburgh I'liannaco- poeia is another excellent foimula of the fame kind ; it is a remedy of real (.ificacy. The dofe of it is thirty or forty drops r.peated pccafionally. The Tindtura Valerianae volatilis of both the pharmacopoeias is idfo ficquently ufed, lt'o dofe li a tea-fpoouful or iwu. Few of the compofitions of the fhops are found to be more effi- cacious antifpafmodics than the Spiritus iEdieiis Vitriolicus corn- poiltus of the London Phi.imucup'Ja. It's dofe is from thirty to ^54 PRACTICE CHAT. XIV. OF CANINE MADNESS AND HYDROPHOBIA. MDSXV. TTIIS difeafe has been fo exactly and fully defcrib. ed in books that are in every body's hands, that it is on no account neceffary to give any hiftory of it here ; and with refpect to the pathology of it, I find that I cen fay nothing fatisfying to myfeif, or that I can e;;pcd to prove fo to others. I find alfo, with re- fped to the cure of this difeafe, that there is no fub- jed in which the fallacy cf experience appears more ftrongly than in this. From the moft ancient to the prefent times, many remedies for preventing and cur- ing fifty drops in two or three fpoonfulls of cold water ;'and it muft be fwallowed immediately on pouring out of the vial. Thefe and other antifpalmodics may be ufed promifcuoufly ; for, in different cafes and conltitutions, they prove differently efficacious. Sometimes they may be varioufiy combined with one another, and with opium'. Opium, however, ought not to be ufed, except where other antilpafmociics fail, as it always leaves the patient lemarkably low, and liable to returns of the paroxyfms. Befides the ufe of thefe remedies internally, fome of them may be ufefuily employed externally; as ftiong volatile fpirits to the nofe,» the vitriolic aether to the temples, Sec. Thefe remedies are chiefly defigned for occafiona'ly removing the violence of the fymptoms ; but the fetid gums, in fubftance, mult he ufed, when we willi to procure permanent effects. The formu- lae of them are in both our Pharmacopoeias, under the title of gum- pills; but they will be found much more efficacious by adding to them a little caftor, as in the following formula : Eo. Pilul. Gummof. Edinb. =fsf. Caftor Rufiic. Si. Syr. fimpl. q. f. M. f. in air. in pilulas lxxv\ equates dividend. Fire of tlx'fe pills ra„y be taken twice a-day v.odl'ing them down with a tea-cvpfid r f coid water w ith a tea-fpoonful of volatile tinc- ture of valeriai) in it. The Filnlar fctidse of the Sweedifh Pharmacopoeia, in which caf- tor ib one of the ingredients, is preferable to either rS our gum-pills. OF PHYSIC. *55 ing this difeafe have been recommended under the fandion of pretended experience, and have perhaps alfo kept their credit for fome time: but fuccecding times have generally, upon the fame ground of expe- rience, deftroyed that credit entirely ; and moft of the remedies formerly employed are now fallen into abso- lute negled. In the prefent age, fome new remedies have been propofed, and have experience alledged to vouch for their efficacy ; but many doubts ftill remain with refped to this : and though I cannot determine in this matter from my own experience, I think it in- cumbent on me to give the beft judgment I can form with refped to the choice of the remedies at prefent recommended. MDXXVI. I am, in the firft place, firmly perfuaded, that the moft certain means of preventing the confequences of the bite, is to cut out, or otherwife deftroy, the part in which the bile has been made. In this every body agrees ; but with this difference, that fome are of opi- nion that it can only be effedual when it is done very foon after the wound has been made, and they there- fore negled it when this opportunity 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 fyftem; and there- fore, that this meafure of deftroying the part may be pradifed with advantage, even many days after the bite has been given. MDXXVII. Whilft the ftate of our experience, with refped to feveral remedies now in ufe, is uncertain, I cannot venture to aifert that any of thefe is abfolutely inef- fedual ; but I can give it as my opinion, that the e^d- cacy of mercury, given very largely, and perfilted in for a long time, both as a means of preventing the 256 PRACTICE difeafe, and of curing it when it has adually come on, is better fupported by experience than that of any other remedy now propolod or commonly employed. BOO K IV. O F V E S A N I JE, Q. R OF THE DISORDERS OF THE INTELLECTUAL FUNCTIONS. i CHAP. I. OF VESANIJE IN GENERAL. MDXXVIII. THE Nofologifts, Sauvages and Sagar, in a clafs of difeafes under the title of Vesani^e, have com- prehended the two orders, of Hallucinationes or Falfe Perceptions, and of Morojitates or Erroneous Appe- tites and Paffions; and, in like manner, Linnaeus in his clafs of Mentales, cotrefpondmg to the Vefaniae of Sauvages, has comprehended the two orders of Ima<- ginarii and Pathetici, nearly the fame with the Hallu- cinationes and Morojitates of that author. This, how- ever, from feveral confederations, appears to me im- proper ; and I have therefore formed a clafs of Vefa- nia; nearly the fame with the Paranoic of Vogel, ex- cluding O F P H Y S I C. 257 binding from it the Hallucinationes and Ivlorofitates, which I have referred to the Morbi Locales. Mr. Vogel has done the like, in feparating from the Para- noiac the falfe perceptions and erroneous appetites ; and has thrown thefe into another clafs, to which he has given the title of Hvperaeftefes. MDXXIX. It is indeed true, that certain hallucinationes and. morofitates are frequently combined with what I propofe to confider as ftridly a vefania or an errone- ous judgment ; and fometimes the hallucinationes feem to lay the foundation of, and to form almoft en- tirely, the vefania. But as moft part of the halluci- nationes enumerated by the Nofologifts are affedions purely topical, and induce no other error of judgment befide that which relates to the fingle objed of the fenfe or particular organ affeded ; fo thefe are certain- ly to be feparated Jjjfom the difeafes which confift in a more general affedion of the judgment. Even when the hallucinationes conftantly accompany or feem to ipduce the vefania, yet being fuch as arife from inter- nal caufes, and may be prefumed to arife from the fame caufe as the more general affedion of the judg- ment, they are therefore to be confidered as fymptoms of this only. In like manner I judge with refped to tfie morofi- tates, or erroneous paffions, that accompany vefania ; which, as confequences of a falfe judgment, muft be conlidered as arifing from the fame caufes, and as fymptoms only, of the more general affedion. There is?, indeed, one cafe of a morofitas which feems to induce a vefania, or more general affection 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 com- prehending the morofitates in general uuder the vefa- niac, confidered as primary difeafes. Vol. 11. K k The 258 PRACTICE The limitation, therefore, of the clafs of VUaniie to the lefions of our judging faculry, feems from every confideration to be proper. The particular difeafes to be comprehended under this clafs, may be diftinguifhed according as they af- fed perfons in the time of waking or fleeping. Thofe which affed men awake, may again be confidered, as they confift in an erroneous judgment, to which I fhall give the appellation of Belirium ; or as they confift in a weaknefs or imperfedion of judgment, which I fhall name Fatuity. I begin with the confideration of De- lirium. 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 imperfedion of our judg- ing faculty is to be confidered as morbid, and to ad- mit of the appellations of Delirium and fatuity. In doing this, I fhall firft confider the morbid errors of judgment under the general appellation of Delirium, wrhich has been commonly employed to denote every mode of fuch error. MDXXXI. As our judgment is chiefly exerciled in difcerning and judging of the feveral relations of things, I ap- prehend that delirium may be defined to be,—In a perfon awake, a falfe or miftaken judgment of thofe relations of things, which as occurring moft frequent- ly 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 miftaken judgment of relations there ia frequently joined fome falfe perception of external ob- jeds, without any evident fault in the organs of fenfe, and which feems therefore to depend upon the imagi- nation OF PHYSIC. 259 nation arifing from a condition in the brain preferr- ing objeds which are not adually prefent. Such falfe perceptions muft neceffarily occafion a delirium, or an erroneous judgment, which is to be confidered as the difeafe. MDXXX1II. Another circumftance, commonly attending deliri- um, is a very unufual affociation of ideas. As, with refped to moft of the affairs of common life, the ideas laid up in the memory are, in moft men, affociated in the fame manner ; fo a very unufual affociation, in any individual, muft prevent his forming the ordinary judgment of thofe relations which are the moft com- mon foundation of affociation in the memory : and therefore this unufual and commonly hurried affocia- tion of ideas, ufually is, and may be confidered as, a part of delirium. In particular it may be confidered as a certain mark of a general morbid affedion of the intelledual organs, it being an interruption or perver- iion of the ordinary opo«£tions of memory, the com- mon and neceffary foundation of the exercife of judg- ment. MDXXXIV. A third'circumftance attending delirium, as in emo- tion or paffion, fometimes of the angry, fometimes of the timid kind } from.whatever caufe in the percep- tion or judgment, it is proportioned to fuch caufe, ei- ther in the manner formerly cuftomary to the perfon fiimfelf, or in the manner ufual with the generality of other men. MDXXXV. Delirium, then, may be more fhortly defined,—In a perfon awake, a falfe judgment arifing from percepti- ons of imagination, or from falfe recoiledion, and commonly producing difpropnrtionate emotions. Such delirium is of two kinds ; as it is combined with pyrexia and comatofe ailldions; or, as it is en- K k 2 tirely 260 PRACTICE tirely without any fuch combination. It is the latter cafe that we name Infinity ; and it is this kind of de- lirium only that I am to treat of here. MDXXXVI. Infanity may perhaps be properly confidered as a genus comprehending many different fpecies, each of which may deferve our attention; but before proceed- ing to the confideration of particular fpecies, I think it proper to attempt an inveftigation of the caufe of jnfanitv in general. MDXXXVIf. In doing this, I fhall take it for granted, as demon. firated elfevvhere, that although this difeafe feems to be chiefly, and fometimes folely, an affection of the mind ; yet the connedion between the mind and bo- dy in this ca!e is fuch, that thefe affcdions of the mind rnuit be confidered as depending upon a certain ftate of our corporeal part. See Halleri Prim. Lin. Phy- fio. log. § dlxx. See Boerhaavii Lift. Med, § DLXXXI. DCXCVl. MDXXXVI1I. Admitting this propotition, I muft in the next place affume another, which I likewife fuppofe to be demon- ■ it rated elfewhere. This is, that the part of our body more immediately conneded with the mind, and therefore more efpecially concerned in every affedion of the intelledual fundions, is the common oroan of the nerves; which I fhall, in what follows, fpeak of under the appellation of the Brain. MDXXXIX. Here, however, in affuming this Lift propofition, a very great difficulty immediately prefents itfelf. Al- though we cannot doubt that the operations of our in- telied always depend upon certain motions taking place in the brain, (fee Gaub. Path. Med. § 523;) yet thefe motions have never been the objeds of our fenfes, nor have we been able to perceive that any par- ticular O F P H Y S I C. 261 ticular part of the brain has more concern in the ope- rations of our intelled than any other. Neither have we attained any knowledge of what fhare the feveral parts of the brain have in that operation; and there- fore, in thisfituaticn of our fcience, it muft be a verv difficult matter to difcover thofe ftates of the brain that may give occafion to the various ftate of our intel- ledual fundions. MDXL. It may be obferved, that the different ftate of the motion of the blood in the veffels of the brain has fome fhare in affeding the operations of the intelled : andphyficians, in feeking for the caufes of the differ- ent ftates of our intelledual fundions, have hardly looked further than into the ftate of the blood, or into the condition of the blood itfelf: but it. is evident that the operations of the intelledual fundions ordinarily go on, and are often confidembly varied, without our being able to perceive any difference either in the mo- tions or in the condition of the blood. MDXLL Upon the other hand, it is very probable that the ftate of the intelledual fundions depends chiefly upon the ftate and condition of what is termed the Nervous Power, or, as we fuppofe, of a fubtile very moveable fluid, included or inherent, in a manner we do not clearly understand, in every part of the medullary fub- ftance of the brain and nerves, and which in a living and healthy man is capable of being moved from eve- ry one part to every other of the nervous fyftem. MDXL1I. With refped to this power, we have pretty clear proof that it frequently has a motion from the fentient extremities of the nerves towards the brain, and there- by produces fenfation ; and we have the fame proof, that in confequence or" volition the nervous power has a motion from the brain into the neole'es or organs of 262 PRACTICE of motion. Accordingly, as fenfation excites our in- telledual operations, and volition is the effed of thefe, and as the connedion between fenfation and volition is always by the intervention of the brain and of intelledual operations; fo we can hardly doubt, that thefe latter depend upon certain motions, and the various modification of thefe motions, in the brain. MDXLIII. To afcertain the different ftates of thefe motions may be very difficult; and phyficians have commonly confidered it to be fo very myfterious, that they have generally defpaired of attaining any knowledge with regard to it; but I confider fuch abfolute defpair, and the negligence it infpires, to be always very blamea- ble ; and 1 fhall now venture to go fome length in the inquiry, hoping that fome fteps made with tolerable firmnefs may enable us to go ftill further. MDXLIV. To this purpofe, I think it evident, that the nervous power, in the whole as well as in the nervous fyftem, and particularly in the brain, is at different times in difierent degrees of mobility and force. To thefe dif- ferent ftates, I beg leave to apply the terms of Excite- ment and Collapfe. To that ftate in which the mobili- ty and force are fufficient for the exercife of the func- tions, or when thefe ftates are any way preternatural- ly increafed, I give the name of Excitement ; and to that ftate in which the mobility and force are not fuf- ficient for the ordinary exercife of the fundions, or when they are diminifhed from the ftate in which they had been before, I give the name of Collapfe. I beg, however, it may be obferved, that by thefe terms I mean to exprefs matters of fad only ; and without in- tending, by thefe terms, to explain the circumftance or condition, mechanical, of the nervous power or flu- id in thefe difierent ftates. MDXLV. OF PHYSIC. 263 MDXLV. That thefe different ftates of excitement and collapfe take place on different occafions, muft, I think, be manifeft from numberlefs phenomena of the animal oeconomy : but it is efpecially to our prefent purpofe to obferve, that the different ftates of excitement and collapfe, are in no inftance more remarkable, than in the different ftates of waking and fleeping. In the latter, when quite complete, the motion and mobili- ty of the nervous power, with refped to the whole of what are called the Animal Fundions, entirely ceafe, or, as I would exprefs it, are in a ftate of collapfe; 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 ftates of the nervous power in fleeping and waking being admitted, I muft in, the next place obferve, that when thefe ftates are changed from the one into the other, as commonly happens every day, the change is hardly ever made inftantane- oufly, but almoft always by degrees, and in fome length of time only : and this may be obferved with refped to both fenfe and motion. Thus when a per- fon is falling afleep, the fenfibility is gradually dimi- nifhed: fo that, although fome degree of fleep has come on, flight impreffions will excite fenfation, and bring back excitement; which the fame, or even ftronger impreffions, will be infufficient to produce when the ftate of fleep has continued longer, and i-, as we may fay, more complete. In like manner, tlu power of voluntary motion is gradually diminifhed. In fome members it fails former than in others ; and it is fome time before it becomes general and confiderable over the whole. The fame gradual progrefs may be remarked in a perfon's coming out of fleep : The ears in this cafe are - often 264 PRACTICE 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 cuiious to obferve, that, in fome cafes, fenfations may be excited without producing the ordinary affociation of ideas. See xMem. de Berlin. it^~. MDXLVII. From all this, I think it will clea.ly appear, that not only the difierent ftates of excitement and collapfe can . take place in difierent degrees, but that they can take place in different parts of the brain, or at leaft, with refped to the different fundions, in different de- grees. As I prefume that almoft every perfon has perceived the gradual approach of fleeping and waking, 1 like- wile fuppofe every perfon has obferved, that, in fuch intermediate ftate of unequal excitement, there almoft always occurs more or lefs of delirium, or dreaming, if any body choofes to call it fo. There are in this ftate falfe perceptions, falfe affociations, falfe judg- ments, and difproportionate emotions ; in fhort, all the circumftances by which I have above defined deli- rium. This clearly fhows that delirium may depend, and I fnall hereafter endeavour to prove that it commonly does depend upon fome inequality in the excitemenE of the brain ; and that both thefe aifertions are found- ed on thi?, that, in order to the proper exercife of our intelledual fundions, the exekement muft be complete, and equal in every part of the brain. For though we eaniu-t fay that the veftiges of ideas are laid up in different parts of the brain, or that they are in fome meafure diffufed ever the whole, it will follow upon either fuppofition, that as our leifoning cur in- telledual opeiatioos always require the orderly and ex- ad recolledion or memory of afiociated ideas; fo, if any part of the brain is not excited, or not excitable, that OF PHYSIC. 265 that recolledion cannot properly take place, while at the fame time ofher parts of the brain, more excited and excitable, may give falfe perceptions, affociaticns, and judgments. MDXLVIII. It will ferve to illuftrate this, that the collapfe 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 confiderable decree, yet certain impreffions do ftill take effed, and excite motions, or, if you will, fenfations in the brain; but which fenfations, upon account of the collapfed ftate of fo great a part of the brain, are generally of the delirious kind, or dreams, confifting of falfe perceptions, affociations, and judg- ments, that would have been correded if the brain had been entirely excited. Every one, I believe, has obferved, that the mofl imperfed fleeps, are thofe chiefly attended with dream- ing ; that dreams, therefore, moft commonly occur towards morning, when the complete ftate of fleep is paffing away ; and further, that dreams are moft com- monly excited by ftrong and uneafy impreffions made upon the body. I apprehend it may alfo be an illuftration of the fame thing, that, even in waking hours, we have an inftance of an unequal ftate of excitement in the brain producing delirium. Such, 1 think, occurs in the cafe of fever. In this it is manifeft, that the energy of the brain, or its excitement, is coniiderabiy dimi- niflied with refped to the animal fundions: and it is accordingly upon this ground that I have explained above, in xlv. rhe delirium which fo commonly at- tends fever. To what 1 have there faid I fhall here only add, that it may ferve to confirm my dodrine, that the delirium in fever comes on at a certain period of the difeafe only, and that we can commonly -difcern Vol. II. L 1 its i65 PRACTICE its approach by a more than ufual degree of it appear- ing in the time cf the patient's falling into or coming out of fleep. It appears, therefore, that delirium, when it fir;t comes on in fever, depends upon an ine- quality of excitement; and it can hardly be doubted, that the delirium which comes at length to prevail in the entirely weakened ftate of fevers, depends upon the fame caufe pie\ ailing in a more confiderable de- gree. > IdDXLIX, From whnt has been now delivered, I hope it will be fufficiently evident, that delirium may be, and fre- quently is, occafioned by an inequality in the excite- ment of the brain. How the different portions of the brain may at the fame time be excited orcoilanfed in different decrees or howtheenergv of the brain may be in different de- grees of force, wifh refped to the ieveral animal, vital, and natural fundions, I cannot pretend to explain ; but it is fufficiently evident in fad, that the brain may be at one and the fame time in different conditi- ons with refped to thefe fundions. Thus in inflam- matory difeafes, when by a ftimulus applied to the brain the force of the vital fundions is preternaturally increafed, that of the animal is either little changed, or confiderable diminiihed. On the contrary, in ma- ny cafes of mania, the force of the animal fundions depending always on the brain, is prodigioufly increaf- ed, while the ftate of the vital fundion in the he;o t is very little or n„t at all changed. I muft therefore fay again, that how difficult focver it may be to explain the mechanical or phyfical condition of the brain in fuch cafes, the fads are fufficient toifiow that there is fuch an inequality as may difturb our intelledual operations. MDL. I have thus endeavoured to explain the general caufe O F P H Y S I C. 267 caufe of Delirium ; which is of two kinds: according as it is with, or without, pyrexia. Of the firft 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 pro- perly belongs to the clafs of Vefaniae, and which I fhall treat of under the general title of Infinity. MDLI. In entering upon this fubjed, it immediately occurs, that in many inftances of infanity, we find, upon dif- fection after death, that peculiar circumitanees had taken place in the general condition of the brain. In many cafes, it has been found of a drier, harder, and firmer confidence, than what it is ufually of in per- fons who had not been affeded with that difeafe. In other cities, it has been found in a more humid, foft, and flaccid fttte; and in the obfervations of the late Mr. Meckel*', it has been found confidcrably changed in its denfity or fpecific gravity. Whether thefe different ftates have been obferved to be uni- formly the fame over .the whole of the brain, I cannot certainly learn ; and I fufped the diffedors have not always accurately inquired into this circumftance : but in feveral inftances, it appears that thefe ftates had been different in different parrs of the brain ; and in- ftances of this inequality will afford a confirmation of our general dodrin?. The accurate Moiyapafi has obferved, that in mani- acal perfons the medullary portion of the brain is un- ufuxlly dry, hard, and firm : And this he had fo fre- quently obferved, that he was cifpofed to confider it as generally the cafe. Hut in molt of the particular inftances which he has given, it appears, that, for the moft pan, while the cerebrum'was of an unufually hard and firm confidence, the cerebellum was of iii L 1 2 ufual '* Memoir, de Berlin pour 1'annec 1764. It Appeared in many inftances of infant pa h\;i„, that the medullary fubftance of the ceie- brum was drier, and of a lefs fpecific gravity, than in perfons uho luj been always of a foundjudgment. 268 PRACTICE ufual foftnefs : and in many cf the cafes it was unfu- aliy foft and flaccid. In fome other cafes, Morgagni obferves, that while a part of the cerebrum was hard- er and firmer than ordinary, other parfs of it were pre:ernaturally foft. MDLII. Thefe obfrvations tend to confirm our general doc- trine : and toere aie others which I think wiif apply to *he fame purpfe. Upon the diifedion of the bodies of perfons who had laboured under infanity, various organic affedions had been difcove.ed in particular parts of the brain ; ad it is furliciently probable, that luch organic af- fed; o i> might have produced a different degree of ex no i.eiv in the free and affeded parts, and mult ha\c inter, up'ed iii lome meafure the free communi- cation between the feveral parts of the brain, and in either way ha e occafioned infanity. The e have occurred fo many inftances of this kind, that i believe phyficians are generally difpofed to luf- fped organic lefions of the brain to exilt in almoft every cafe of infanity. MDLIII. This, however, is probably a miftake : for we know that there have been inftances of infanity from which the perfons have entirely recovered; and it is difficult to fuppofe that any organic lefions of the brain had in fuch cafe taken place. Such ttanfitory cafes, indeed, render it probable, that a date of excitement, change- able by various caufes, had been the caufe of fuch in- ftances of infanity. MDLIV, It is indeed further afferted, that in many inftances of in fane peifons, their brain had been examined after death, without fhowing that any organic lefions had btioie fubfifted in the brain, or finding that any mor- bid ftate of the brain then appeared. This, no doubt, may t O F P H Y S I C. 26g may ferve to fhow, that organic lefions had not been the cauft^ of the difeafe ; but it does not affure us that no morbid change had taken place in the brain : for it is probable, that the diffedors were not always aware of its being the general condition of hardnefs and den- fity, as different in different parts of the brain, that was to be attended to, in order to difcover the caufe of the preceding difeafe ; and therefore many of them had not with this view examined the ftate of the brain, as Morgagni feems carefully to have done. MDLV. Having thus endeavoured to inveftigate the caufe of infanity in general, it were to be wifhed that I could apply the dodrine to the diftingui filing the feveral fpecies of it, according as they depend upon the differ- ent ftate and circumftances of the brain, and thereby to the eftablifhing of a fcientific ar.d accurate!/ adapted method of cure. Thefe parpofes, however, appear to me to be extremely difficult to be attained ; and I can- not hope to execute them here. All I can do is to make lbme attempts, and offer fome reficdions which further obfervation and greater fagacity, may hereaf- ter render more ufeful. MDLVI. The ingenious Dr. Arnold has been commendably employed in diftinguifhing the different fpecies of in- finity as they appear with refped to the mind ; and his labours may hereafter prove ufeful, when we fhall c :me to know fomething more of the different ftates of tliebain correfponding to thefe different ftates of the mind ; but at prefent I can make little application of his numerous diftindions. It appears to me that he has chiefly pointed out and enumerated diftindions, that are merely varieties, which can lead to little or no vanetvof pradice : 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 a;o PRACTICE qhanged into one another, in the fame perfon ; in whom we muft therefore fuppofe a general^caufe of the difeafe, which, fo far as it can be known, muft eilubiifh the pathology, and efpecially diredthe prac- tice. MDLVIL In my limited views of the different ftates ofinfani- tv, I muft go on to confider them under the tv/o heads of Mania and Melancholia: ancl though I am fenfible that thefe two genera do not comprehend the whole of the fpecies of infanity, I am not clear in affigning theoiher fpecies which may not be comprelvended under thofe titles. I fhall, however, endeavour, on proper occafions, as I go along, to point them out as well as I can. C K A P. II. OF MANIA, OR MADNESS. MDLVIII. T'HE circumftances which I have mentioned above in mdxxxv. as conftituting delirium in general, do more efpecially belong to that kind of 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 con- ftant^ nor ever, a frequent, attendant of the difeafe. The falfe judgment, is of relations long before laid up in the memory. k very ofren turns upon one fingle fubjed ; but more commonly the mind rambles from one fubjed to another with an equally falfe judgment con- OF PHYSIC. 271 concerning the moft part of them ; and as at the fame time there is commonly a falfe affociation, this increaf- es theconfufion of ideas, and therefore the falfe judg- ments. What for the moft part more efpecially dif- tinguifhes the difeafe is a huny of mind, in purfuing any thing like a train of thought, and in runnino- from one train of thought to another. Maniacal perfons are in general vety irafcible; but what more particu- larly produces their angry emotions is, that their falfe judgments lead to fome adion which is always pufned with impetuofity and violence ; when this is interrupted or reftrained, they break out into violent anger and furious violence againft every perfon near them, and upon every thing that ftands in the way of their impetuous will. The falfe judgment often turns upon a miftaken opinion of fome injury fuppofed to have been formerly received, or now fuppofed to be intended : and it is remarkable, that fuch an opinion is often with refped to their former deareft friends and relations ; and therefore their refentment and anger are particularly direded towards thefe. And although this fhould not be the cafe, they commonly foen lofe that refped and regard which they formerly had for their friends and relations. With all thefe circum- ftances, if will be readily perceived, that the difeafe muft be attended very conftantly with that incoherent and abfurd fpeech we call raving. Further, with the circumftances mentioned, there is commonly joined an unufual force in all the voluntary motions ; and an infenfibility or refiftance of the force of all impreffi- ons, and particularly a refiftance of the powers of fleep, of cold, and even of hunger ; though indeed in ma- ny inftances a voracious appetite takes place. MDLIX. It appears to me that the whole of thefe circum- ftances and fymptoms point out a confiderable and un- ufual excefs in the excitement of the brain, efpecially with 272 PRACTICE with refped to the animal fundions ; and it appears at the fame time to be maoifeftly in fome meafure un- equal, as it very often takes place with refped to thefe fundions alone, while at the fame time the vital and natural are commonly very little changed from their ordinary healthv ftate. MDLX. How this excefs of excitement is produced, it may be difficult to explain. In the various inftances of what Sauvages has named the Mania Metafilatica, and in all the inftances I have mentioned in my Nofology under the title of the Mania Corpcrca, it may be fuppof- ed that a morbid organic affedion is produced in .ome part of the brain; find how that rmiy produce an in- creafed or unequal excitement in certain parts of it, I have endeavoured to explain above in mdi.ii. But I muft at the fame time acknowledge, that fuch remote caufes of mania have very rarely occurred ; and that therefore fome ether caufes of the difeafe muft be fought for. The effeds of violent emotions or paffions of the mind have more frequently occured as the remote caufes of mania; and it is fufficiently probable, that fuch violent emotions, as they do often immediately produce a temporary increafe of excitement, fo they may, upon feme occafions of their permanent inhe- rence or frequent repetition, pioduce a more confi- derable and more permanent excitement, that is, a mania. With refped to thofe caufes cf mania which arife in confequence of a melancholia which had previoufly long fubfifted ; whether we confider that melancholia as a partial infanitv,or as a long perfifting attachment to one train of thinking, it will be readily perceived, that in either cafe fuch an increafe of excitement may fake place in fo confiderable a degree, and in fo large a portion w 1 t iri I S I C, 273 portion of the brain, as may give occafion to a complete mania. MDLXI. Thefe confiderations with regard to the remote caufes appear to me to confirm fuliiciently our general dodrine of increafed and unequal excitement in the mania which I have defcribed above ; but I muft own that I have not exhaufted the fubjed, and that there are cafes of mania of which I cannot affign the remote caufes: but although i cannot in all cafes explain in what manner the mania is produced, I prefume, from the explanation given,'and efpecially from the fymp- toms enumerated above, to conclude, that the dif- eafe defcribed above depends upon an increafed ex- citement of the brain ; an opinion in which 1 am the more confirmed, as I think it will point out the proper method of cure. Ac leaft I think it will moft 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 moft fuccefsful in this difeafe ; and, to illuftrate this, I now enter upon the confidera- tion of thefe remedies, and to make fome remarks upon the proper manner of employing them. MDLXII. Reftraining the anger and violence of madmen is always neceffary for preventing their hurting them- felves or others : but this reftraint is alfo to be confi- dered as a remedy. Angry paffions are always ren- dered more violent by the indulgence of the impetu- ous motions they produce ; and even in madmen the feeling of reftraint will forrfetimes prevent the efforis which their paffion would otherwife occafion. Re- ftraint, therefore, is ufeful, and ought to be complete ; but it fhould be executed in the eafieft manner pofli- ble for the patient, and the ftrait waiftcoat anfwers eve- ry purpofe better than any other that has yet been thought of. The reftraining madmen by the force of Vol. II. M m other 274 PRACTICE other men. as occafioning a conftant ftrugglc and vio- lent aairari.m, is often hurtful. Although, on many occafions, it may not be fafe to allow maniacs to be upon their legs or to walk about, it is never delirable to confine them to a horizontal filuation ; and whene- ver it can be admitted, they mould be more or lefs in an erect poilure. Although there may be no fymp- toms of any preternatural fulnefs or increafed impetus of blood in the veffels of the brain, a horizontal pof- ture always ir.creafes the fuineis and tenfion of thefe veffels, and may thereby increafe the excitement of the brain. MDLXIII. The reftraint mentioned requires confinement with- in doors, and it ftiould be in a place which prefents as few objeds of fight and hearing as poflible; and par- ticularly, it fhould be removed from the objeds that the patient was formerly acquainted with, as thefe would more readily call up ideas and their various affo- ciations. It is for this reafon that the confinement of madmen fhould hardly ever be in their ufual habita- tion ; or if they are, that their apartment fhould be ftripped of all its former furniture. It is alfo for the moft part proper, that maniacs fhould be without the company of any of their former acquaintance ; the ap- pearance of whom commonly excites emotions that increafe the difeafe. Strangers may at firft be offen- five ; but in a little time they come to be objeds either of indifference or of fear, and they fhould not be fre- quently changed. MDLXIV. Fear being a paffion that diminifhes excitement, may therefore be cppofed to the excefs of it; and particularly to the angry and irafcible excitement of maniacs. Thefe being more fufceptible of fear than might be expeded, it appears to me to have been commonly ufeful. In moft cafes it has appeared to be UP l1 11T S I C. 275 be neceffary to employ a very conftant impreffion of fear; and therefore to infpire them with the awe and dread of fome particular perfons, efpecially of thofe who are to be conftantly near them. This awe and dread is therefore, by one means or ether, to be ac- quired ; in the firft place, by their being the authors of all the reftraints that may be occasionally proper ; but fometimes it may be neceffary to acquire it even by ftripes and blows. The former, although having the appearance of more fcverity, are much filter than ftrokes or blows about the head. Neither of them, however, fhould be employed further than feems ve- ry neceffary, and fhould be trufted only to thofe whofe difcretion can be depended upon. There is one cafe in which they are fuperfluous; that is, when the ma- niacal rage is either not fufceptible of fear, or incapa- ble of remembering the objeds of it; for in fuch in- ftances, ftripes and blows would be wanton barbarity. In many cafes of a moderate difeafe, it is of advantage that the perfons who are the authors of reftraint and punifhmenn ftiould be upon other occafions the be* flowers of indulgence and gratification that is admif- fible ; never, however, needing to employ their awe when their indulgence fhall have led to any abufe. MDLXV. Although in mania, no particular irritation nor ful- nefs of the fyftem feem to be prefent, it is plain, that the avoiding all irritation and means of iulnelsL p;o- ner; and therefore, that a diet neither ftimulating nor nourishing is commonly to be employed. As it may even be ufeful to diminifh the fulnefs of the fyf- tem fo both a low and afparc diet is likely in moft ca- fes to be of fervice. MDLXVI. Upon the.fame principle, although m unufual ful-- ncf- of the body be prefent, it may be of advantage Ik r.i 2 to 2-6 PRACTICE to diminifli even its ordinary fulnefs by different eva- cuations. Blood-letting, in particular, might be fuppofed ufe- ful ; and in all recent cafes of mania it has been com- monly pradifed, and I think wiljfc advantage; but when the difeafe has fubfifted for fome time, I have feldom found blood-letting of fervice. 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, blood-letting is a pro- per and even a neceffary remedy. Some praditioners, in fuch cafes, have preferred to a particular manner of blood-ierting, recommending arteriotomy, fcarifying the hind-head, or opening the jugular vein ; and where any fulnefs or inflammatory difpofition in the veffels of the brain is to be fufpeded, the opening of the veiled neareft to them is likely to be of the great- eft fervice. The opening, however, of either the temp vai a:tery or the jugular vein in maniacal per- fons is very often inconvenient; and it may generally be fufficient to open a vein in the arm, while'the body is kept in fomewhat of an ered poiture, and fuch a quantity of blood drawn as nearly brings on a deliqui- um ammi, which is always a pretty certain mark of fome diminution of the fulnefs and tenfkm of the vef- fels of the brain. - MDLXVIL For the^ fam#purpofe of taking off the fulnefs and tenfion of thefe veffels of the brain, purging may be employed ; and I can in no other view underftand the celebrated ufe of hellebqre among the ancients. I cannot, however, fuppofe any fpecific power in helle- bore ; and can by no means find that, at leaft the black hellebore, is fo efficacious with us as it is faid to have been at Anticyra, As coftivenefs, however, is commonly a very conftant and hurtful attendant of mania, purgatives come to be fometimes very necef- fary; OF PHYSIC. 277 fary ; and I have known fome benefit obtained from the frequent ufe of pretty draftic purgatives. In this, however, I have been frequently difappointed ; and I have found more advantage from the frequent ufe of cooling purgatives, particularly foluble tartar, than from more draftic medicines. MDLXVIII. Vomiting has alfo been frequently employed in ma- nia; and by determining powerfully to the furface of the body, it may poflibly diminifh the fulnefs and tenfion of the veflels, and thereby the excitement of the brain ; but I have never carried the ufe of this re- medy fo far as might enable me to judge pre periy of its effeds. Whether it may do harm by impelling the blood too forcibly into the veflels of the brain, or whether by its general agitation of the whole fvf- tem it may remove that inequality of excitement which prevails in mania, I have not had experience enough to determine. MDLXIX. Frequent {having of the head has been found offer- vice in mania, and by promoting perfpiraticai it pro- bably takes off from the excitement of internal parts. This, however, it is likely, may be more effectually clone by bliftering, which more certainly takes off the excitement of fubjaccnt parts. In recent cafes it 1 as been found ufeful by inducing fleep ; and when it has that elTecl, the repetition of it mav be proper : but in maniacal cafes that have lafted for fome time, blifter- ing has not appeared to me to be of any fervice : and in fuch cafes alio I have not found perpetual blifters, or any other form of iffue, prove ufeful. MDLXX. As heat is the principal means of firft exciting the nervous fyftem, and eilablifhing the nervous power and vital principle in animals; fo, in cafe of preterna- tural excitement, the application cf cold might bt- fuppofed 273 P R A C T I C E fuppofed a proper remedy : but there are many inftan- ces of maniacs who have been expofed for a great icogth of time to a confiderable degree of cold with- out having their fymptoms any wife relieved. This may render in general the application of cold a doubt- ful remedy ; but it is at the fame time certain, that maniacs have often been relieved, and fometimes en- tirely cured, by the ufe cf cold bathing, efpecially when adminiftered in a certain manner. This feems to confift, in throwing the madman in the cold wa- ter by furprife ; by detaining him in it for fome length of time ; and pouring water frequently upon the head, while the whole of the body e^ieept the head is im- merfed in the' water ; and thus mana ting the whole proccfg fo as that, with the affiftance of fome fear, a refrigerant effed mav be produced. This, I can af- firm, h.;;s been often ufeful; and that the external ap- plication of cold mav be of fervice, we know further from the benefit which has been received in fome ma- niacal cau-'S from the application of ice and fnow to the naked head, and from the application of the not- ed Clay Clap. V/arm bathing alfo has been recommended by fome pradical writers ; and in fome rigid melancholic habits it may poftibly be ufeful, or as employed in the manner prefcribed by fome, of immerfing the low- er parts of the body in warm water, while cold water is poured upon the head and upper part..:. Of this pradice, however, I have had no experience, and in the common manner of employing warm bathing I have found it ra.fier hurtful to maniacs. MDLXXI. According to my fuppofition that the difeafe de- pends upon an increafed excitement of the brain, e- fpecially with refped to the animal fundions, opium, fo commonly po.er'a! in inducing fleep, or a confi- derable coiiapfe as to ttKie /unctions, ihculd be a powerful OF PHYSIC. 2/9 powerful remedy of mania. That it has truly proved fuch, I believe from the teitimony of Bernard Huet, whofe pradice is nanated at the end of Wepferi Llif- toria Apopledicorum. I leave to my readers te ftudy this in the work I have referred to, where every part of the pradice is fuliy, and it appears to me, very ju- dicioufly delivered. I have never indeed carried the trial fo far as feems to be requifite to an entire cure : but I have frequently employed in fome maniacal caf- es large doles of opium ; and when they had tlie effed of inducing fleep, it was manifeftly with advantage. At the fame time, in fome cafes, f.:om doubts, whe- ther the difeafe might not depend upon fome organic lefions of the brain, when the opium would be fuper- fluous ; and in other cafes, from doubts, whether there might not be fome-inflammatory affedion 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 remedy cf mania, and there are inftances alledged of its having performed an entire cure. As it appears from the ex- periments of Beccaria that this fubftance is poffeffed of a fedative and narcotic virtue, thefe cures are not altogether improbable : but in feveral trials, and even in large dofes, I have found no benefit from it; and excepting thofe in the PhilosophicalTranfadions, N°. 400. I have hardly met with any other teiUmonies in its favour. MDLXXIII. I have been informed that fome maniacs have been cured by being compelled to conftant and even hard labour ; and as a forced attention to the condud of any bodily exercife is a very certain means of divert- ing the mind from purfuing any train of thought, it is highly 280 P R A U I I C £ highly probable that fuch exercife may be ufeful in many cafes of reania. I mud conclude this fubjed with obferving, that e- ven in feveral cafes of complete mania I have known a cure take place in the courfe of a journey carried on for lbme length of time. MDLXXIV. There are the remedies which have ^been chiefly empkned in the mania that has been above defcrib- ed, and I believe they have been employed promifcu- oufty without fuppofing that the mania was to be dif- lincudftied into different fpecies. Indeed I am not readv to fay how far it is to be fo diftinguifhed, but I fhall'off r one obfervation which may poifibly merit attention. It appears to me that there are two different cafes of rm nia that are efpecially different according to the ori- ginal temperament of the perfons whom the difeafe affects. It perhaps occurs moft frequently in perfons of a melancholic or atrabilarian temperament; but it certainly does alfo often occur in perfons of that very oppoi'te temperament which phylicians have named the Sanguine. According as the difeafe happens to occur in perfons of the one or other of thefe tempera- ments I apprehend it may be confidered as of a differ- ent nature; and i b-ftieve, that accurate obfervation, employed upon a fufficient number of cafes, would dif- cern fome pretty conftant difference, either of the fymptoms, or at leaft of the ftate of fymptoms, in the two cafes. I imagine that falfe imaginations, particu- lar averfions and refentments, are more fixed and ftea- dy in the melancholic than in the fanguine ; and that fomewhat inflammatory is more commonly joined with mania in the fanguine than in the melancholic. If fuch difference, however, does truly take place, it will be obvious, chat it may be proper to make fome difference alfo in the practice. I am opinion, that in the O F P H Y S I C. 281 the mania of fanguine perfons, blood-letting and other antiphlogiftic meafures are more proper, and have been more ufeful, than in the melancholic. I likewife ap- prehend that cold bathing is more ufeful in the fan- guine than in the melancholic : but I have not had ex- perience enough to afcertain thefe points with fuffici- ent confidence. I have only to add this other obfervation, that ma- niacs of the fanguine temperament recover more fre- quently and more entirely than thofe of the melancho- lic. ■-«■■< «■•<••« ■«•■« '<-<"4--<4»4''$>$>">">">">->">">>">">-->' CHAP. III. OF MELANCHOLY AND OTHER FORMS OF INSANITY. MDLXXV. MELANCHOLY has -been commonly confidered as a partial-infanity ; and as fuch it is defined in my Nofology: but I now entertain doubts if this be altogether proper. By a partial infanity, I underftand a falfe and miftaken judgment upon one particular fub- jed, and what relates to it; whilft, on every other fubjed, the perfon affeded judges as the generality of other men do. Such cafes have certainly occurred ; but, I believe, few in which the partial infanity is ftrid- ly limited. In many cafes of general infanity, there is one fubjed of anger or fear, upon which the falfe judgment more particularly turns, or which is at leaft more frequently than any other the prevailing objed of delirium : and though, from the inconfiftency which this principal objed of delirium muft produce, there Vol. II. N n is 282 PRACTICE is therefore alfo a great deal of infanity with regard to moft other objeds; yet this laft is in very different degrees, both in difierent perfons, and in the fame per- fon at difierent times. Thus perfons confidered as ge- nerally infane, will, however, at times, and in fome cafes, pretty conftantly judge properly enough of pre- fent circumftances and incidental occurrences; though, when thefe objeds engaging attention are not pre- fented, the operations of imagination may readily bring back a general confufion, or recal the particular objed of the delirium. From thefe confederations, I am inclined to conclude, that the limits between ge- neral and partial infanity cannot always be fo exactly affigned, as to determine when the partial affedion is to be confidered as giving a peculiar fpecies of difeafe, different from a more general infanity. MDLXXVI. When infanity, neither ftridly partial, nor entirely nor conftantly general, occurs in perfons of a fanguine temperament, and is attended 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 partial, mult be held as different from the proper Melancholia to be mentioned hereafter. MDLXXVII. Such a difeafe, as difierent from thofe defcribed m- dliv. requires, in my opinion, a different adminiftra- tion of remedies; and it will be proper for me to take particular notice of this here. Although it may be neceffary to reft rain fuch infane perfons as we have mentioned mdlxxvi. from purfu- ing the objeds of their falfe imagination or judgment, it will hardly be requilite to employ the fame force of reftraint that is neceffary in the impetuous and an- gry mania. It will be generally fu'licient to acquire fome awe over them, t'.e.t may be employed, and font .dims O F P H Y S I C. 283 fometimes even be neceffary, to check the rambling of their imagination, and incoherency of judgment. MDLXXV1II. The reftraint juft now mentioned as neceffary will generally require the patient's being confined to one place, for the fake of excluding the objeds, and more particularly the perfons, that might excite ideas con- neded with the chief objeds of their delirium. At the fame time, however, if it can be perceived there are objeds or perfons that can call off their attention from the purfuit of their own difordered imagination, and fix it a little upon fome others, thefe laft may be frequently prefented to them: and for this reafon, a journey, both by its having the effed of interrupting all train of thought, and by prefenting objeds engag- ing attention, may often be ufeful. In fuch cafes al- fo, when the infanity, though more efpecially fixed upon one miftaken fubjed, is not confined to this alone, but is further apt to ramble over other fubjeds, with incoherent ideas, I apprehend the confining or forcing fuch perfons to fome conftant uniform labour, may prove an ufeful remedy. MDLXXIX. When fuch cafes as in mdlvi. occur in fanguine temperaments, and may therefore approach more nearly to Phrenitic Delirium ; fo, in proportion as the fymptoms of this tendency are more evident and con- fiderable, blood-letting and purging will be the more proper and nece.farv. 'MDLXXX. To this fpecies of infanity, when occurring in fan- guine temperaments, whether it be more or lefs parti- al, I apprehend that cold bathing is particularly a- dapted; while, in the partial infanity of melancholic perfons, as I fhall fhow hereafter, it is hardly admifii- ble. N n 2 MDLXXXI. 234 PRACTICE MDLXXXL Having thus treated of a fpecies of infanity, differ- ent, in my apprehenfion, from both the Mania and Melancholia, I proceed to confider what feems more properly to belong to this laft. MDLXXXII. The difeafe which I name Melancholia is very oft- en a partial infanity only. But as in many inftances, though the falfe imagination of judgment feems to be with refped to one fubjed only ; yet it feldom happens that this does not produce much inconfiftency in the other intelledual operations: And as, between a ve- ry general and a very partial infanity, there are all the poffible intermediate degrees; fo it will be often diffi- cult, or perhaps improper, to diftinguifh melancholia by the character of Partial Infanity alone. If I mil- take not, it muft be chiefly diftinguifhed by its occur- ring in perfons of a melancholic temperament, and by its being always attended with fome feemingly ground- lefs, but very anxious, fear. MDLXXX1II. To explain the caufe of this, I muft obferve, that perfons of a melancholic temperament are for the moft part of a ferious thoughtful difpofition, and difpofed to fear and caution, rather than to hope and temerity. Perfons of this caft are lefs moveable than others by any impreffions ; and are therefore capable of a clofer or more continued attention to one particular objed, or train of thinking. They are even ready to be en- gaged in a conftant application to one fubjed ; and are remarkably tenacious of whatever emotions they happen to be affeded with. MDLXXXIV. Thefe circumftances of the melancholic charader, feem clearly to fhew, that perfons ftrongly affeded with it may be readily feized with an anxious fear ; and that this, when much indulged, as is natural to fuch OF PHYSIC. 285 fuch perfons, may eafily grow into a partial infinity. MDLXXXV. Fear and dejedion of mind, or a timid and defpond- ing difpofition, may arife in certain ftates, or upon cer- tain occafions of mere debility : and it is upon this footing, that I fuppofe it fometimes to attend dvfpep- fia. But in thefe cafes, I believe the d.fpondent dif- pofition hardly ever arifes to a confiderable degree, or proves fo obftinately fixed as when it occurs in per- fons of a melancholic temperament. In thefe laft, al- though the fear proceeds from the fame dyfpeptic feelings as in the other cafe, yet it will be obvious, that the emotion may arife to a more confiderable de- gree ; that it may be more anxious, more fixed, and more attentive ; and therefore may exhibit all the va- rious circumftances which I have mentioned in mcc- xxii. to take place in the dfeafe named Hypochon- driasis. MDLXXXVI. In confidering this fubjed formerly in diftinguifhing Dyfpepfia from Hypochondriafis, although the fymp- toms affeding the body be very much the fame in both, and even thofe affeding the mind be fomewhat fimilar, I found no difficulty in diftinguifhing the lat- ter difeafe, merely from its occurring in perfons of a melancholic temperament, But I muft now acknow- ledge, that I am at a lofs how to determine in ali caf- es hypochondriafis and melancholia may be diftin- guifhed from one another, whilft the fame tempera- ment is common to both. MDLXXXVII. I apprehend, however, that the diftindion may be generally afcertained in the following manner. The hypochondriafis I would confider being al- ways attended with dyfpeptic fymptoms : and though there may be, at the fame time, an anxious melancho- lic fear arifing from the feeling of thefe fymptoms; 286 PRACTICE yet while this fear is only a miftaken judgment with refped to the ftate of the perfon's own health, and to the danger to be from thence apprehended, I would ftill confider the difeafe as hypochondriafis, and as dif- tind from the proper melancholia. But when an anx- ious fear and defpondency arifes from miftaken judg- ment with refped to other circumftances* than thofefof health, and more efpecially when the perfon is at the fame time without any dyfpeptic fymptoms, every one will readily allow this to be a difeafe widely dif- ferent from both dyfpepfia and hypochondriafis ; and it is, what I would ftridly name Melancholia. MDLXXXVfil. In this there feems little difficulty ; but as an exqui- sitely melancholic temperament may induce a torpor and flownofs in the adion of the ftomach, fo it gene- rally produces fome dyfpeptic fymptoms; and from thence there may be fome difficulty in diftinguifhing fuch a cafe from hypochondriafis. But I would main- tain, however, that when the charaders of the tem- perament are ftrongly marked ; and more particularly when the falfe imagination turns upon other fubjeds than that of health, or when, though relative to the perfon's own body, it is of a groundlefs and abfurd kind ; then, notwithftanding the appearance of fome dyfpeptic fymptoms, the cafe is ftill to be confidered as that of a melancholia, rather than a hypochondri- afis. MDLXXXIX. The difeafe of melancholia, therefore manifeftly depends upon the general temperament of the body: and although, in many perfons, this temperament is not attended with any morbid affedion either of mind or body ; yet when it becomes exquifiteiy formed, and is in a high degree, it may become a difeafe affed- ing both, and particularly the mind. It will therefore be proper to confider in what this melancholic tempe- rament OF PHYSIC. 287 rament efpecially confifts; and to this purpofe, it may be obferved, that in it there is a degree of torpor in the motion of the nervous power, both with refped to fenfation and volition ; that there is a general rigidity of the fimple folids; and that the balance of the fan- guiferous fyftem, is upon the fide of the veins. But all thefe circumftances are the diredly oppofite of thofe of the fimguine temperament; and muft therefore alfo produce an oppofite ftate of mind. MDXC. It is this ftate of the mind, and the ftate of the brain correfponding to it, that is the chief objed of our pre- fent confideration. But what that ftate of the brain is, will be fuppofed to be difficult to explain ; and it may perhaps feem rafh in me to attempt it. I will, however,"*venture to fay, that it is probable the melancholic temperament of mind depends upon a drier and firmer texture in the medullary fubftance of the brain ; and that this perhaps proceeds from a certain want of fluid in that fubftance, which appears from its being of a lcffer fpecific graviiv than ufual. That this ftate of the brain in melancholia does adu- ally exift, I conclude, firft, from the general rigidity of the whole habit; and, fccondly, from diffedions, fliowing fuch a ftate of the brain to have taken pka-.e in mania, which is often no other than a higher decree of melancholia: It does not appear to me anvwife difficult to fuppofe, that the fame ftate of the brain may in a moderate degree give mehu.cholia ; ana hi a higher, that mania which melancholia fo cftee. uaftes into ; efpecially if I Oral! be allowed further to*fJ,--.v> .fo, that either a qreater degree o ' ;hm.::e:a in the iV......:.cj of the brain may render it fufceptibie of a h'edier de- cree of excitement, or that one ponmn oi the brft.n may be liable to acquire a greater ilimnel's than n of his chapter, ,c After " having confidered the various caufes of emaciations, 1 fliould per- " haps treat of their cure : but it will readily appear, that the " greater part of the cafes above mentioned are purely fymptomatic, " and confequently that the cute of them mult be that of the pri- " mary difeafes upon which they depend. Of thofe cafes that can " any wife be confidered as idiopathic, it will appear that they " arc to be cured, entirely by removing the temote caufes;" It n ay not be improper to treat of the cure as we proceed. The fpecies of emaciation may be obvioufly cured by a rich and nutritious ditt. ,. r§ This fpecies may be cored by preventing the vomi'dng by an- £94 PRACTICE Another caufe, frequently interrupting the conveyance of the alimentary matter into the blood-veffels, is an obftrudion of the conglobate lymphatic glands of the niefentery, through which the chyle muft neceffarily pafs to the thoracic dud. Many inftances of emacia- tion, feemingly depending upon this caufe, have been obferved by phyficians, in perfons of all ages, but efpe- cially in the young. It has been remarked, that fuch cafes have moft frequently occurred in fcrophulous perfons, in whom the mefenteric glands are commonly affeded with tumour or obftrudion, and in whom. generally at the fame time, fcrophula appears exter- nally. Hence the Tabes fcrophulofa Synop, Nofolog. vol. ii. p. 266.: And under thefe 1 have put as fynonimes Tabes glandularis, fp. 10.; Tabes mefenterica. fp. 9.; Scrophuta mefenterica, fp. 4. ; Atrophia infantilis, fp. 1 3.; Atrophia rachitica, fp. 8 ; Tabes rachialgica, fp. 16. At the fame time, I have frequently found the cafe occurring in perfons' who did not fhow any exter- nal appearance of fcrophula, but in whom the mefen- teric obftrudion was afterwards difcovered by differ tion. Such alfo I fuppofe to have been the cafe in the difeafe frequently mentioned by authors under the title of the Atrophia infantum. This has received its name from the time of life at which it generally ap- pears; but I have met with inftances of it at fourteen years of age afcertained by diffedion. In feveral fuch cafes which I have feen, the patients were without fcrophulous appearances at the time, or at any period of their lives before*. In iifpafmodics, efpecially opium, and by the ufe of gentle laxatives occafionally. A nutricious diet will alfo be neceffarv in thefe ca- fes. * Thefe cafes are generally incurable ; if, however, there be no fufpicion of fcrophula we may attempt a cure, by endeavouring to remove the obstruction, cither by invigorating the habit, or by ac\- i.e expcrie.ts. Open «nd pure air, with exercife fuited to the OF PHYSIC. «dife3fe. § If a particular abominable practice be the caufe, it muft be a- bandoned before the cure can be attempted, z9S PRACTICE the cafe of paralytic limbs, in which the arteries are affeded as well as the mufcles. The Atrophia latera- lis, 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 be a deficiency of oil. The extent and quantity of the cellular texture in every part of the body, and therefore how confidera- ble part it makes in the bulk of the whole, is now well known. But this fubftance, in different circumftan- ces, 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 fubftance is more or lefs filled in that manner. The deficiency of the fluids, for a reafon to be imme- diately explained, is generally accompanied with a deficiency of oil: but phyficians have commonly at- tended more to the latter caufe of emaciation than to the other, that being ufually the moft evident; and I fhall now endeavour to affign the feveral caufes of the deficiency of oil as it occurs upon different occa- fions, MDCXIII. The bufinefs of fecretion in the human body is in general little underftood, and in no inftance lefs fo than that of the fecretion of oil from blood which does not appear previoully to have contained it. It is poffible, therefore, that cur theory of the deficiency of oil may be in feveral refpeds imperfed; but there are certain fads that may in the mean time apply to the prefent purpofe. MDCXIV. Firft, it is probable, that a deficiency of oil may be owing to a ftate of the blood in animal bodies lefs fit- ted * This is one of the incurable fpecies of emaciation, and it can ' :.ly be itii.ved by a very nutritious and invigorating diet. OF PHYSIC. 299 ted to afford a fecretion of oil, and confequently to fupply the wafte of it that is conftantly made." This ftate of the blood muft efpecially depend upon the ftate of the aliments taken in, as containing lefs of oil or oily matter. From many obfervations made, both with refped to the human body and to that of other animals, it appears pretty clearly, that the aliments taken in by men and domeftic animals, according as they contain more of oil, are in general more nutriti- ous, and in particular are better fitted to fill the cellu- lar texture of their bodies with oil. I might illuftrate this, by a minute and particular confideration of the difference of alimentary matters employed ; but it will be enough to give two inftances. The one is, that the herbaceous part of vegetables, does not fatten a- nimals, fo much as the feeds of vegetables, which ma- nifeftly contain in any given weight a greater propor- tion of oil; and a fecond inftance is, that in general vegetable aliments do not fatten men fo much as ani- mal food, which generally contains a larger propor- tion 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 deficiency of fluids (mdciv.) but muft alfo afford lefs oil, to be poured into the cel- lular texture. In fuch cafes, therefore, the emacia- tion produced, is to be attributed to both thefe general caufis*. MDCXV. A fecond cafe of the deficiency of oil may be ex- plained in this manner. It is pretty manifeft, that the oil of the blood is fecreted and depofited in the cellular texture in greater or leffer quantity, according as the circulation of the blood is falter or flower ; and P p 2 therefore * The cure of this fpecies of em:ic;atio:i will be bed citlcLa by a rich diet of animal food. 3co PRACTICE therefore that exercife, which haftens the circula- tion of the blood, is a frequent caufe of emaciation. Exercife produces this effed in two ways, ift, By in- creafing the perfpiration, and thereby carrying off a greater quantity 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 faid above, caufing a general deficiency of thefe, which muft alfo caufe a deficiency of oil in the cellu- lar texture. 2dly, It is well known, that the oil de- pofited in the cellular texture is upon many occafions, and for various purpofes of the ceconomy, again ab- forbed, and mixed or diffufed in the mafs of blood, to be from thence perhaps carried entirely out of the bo- dy by the feveral excretions. Now, among other pur- pofes of the accumulation and re-abforption of oil, this feems to be one, that the oil is requifite to the pro- per adion of the moving fibres in every part of the body ; and therefore that nature has provided for an abforption of oil to be made according as the adion of the moving fibres may demand it. It will thus be obvious, that the exercife of the mufcular and moving fibres every where, muft occafion an abforption of oil; and confequently that fuch exercife noc only pre- vents the fecretion of oil, as has been already faid, but may alfo caufe a deficiency of it by occafioning an abforption of what had been depofited; and in this way, perhaps efpecially, does it produce emacia-. tion*. MDCXVI. A third cafe of the deficiency of oil may occur from the following caufe. It is probable, that one purpofe of the accumulation of oil in the cellular tex- ture of animals is, that it may, upon occafion, be again abforbed * Abftinence from too fevere exercife ii the only cure for this fpecies of the iifeafe. O F P II Y S I C. 301 abforbed from thence, and carried into the mafs of blood, for the purpofe of enveloping and correding any unufual acrimony arifing and exifting in the ftate of the fluids. Thus, in moft inftances in which we can difcern an acrid ftate of the fluids, as in fcurvy, cancer, fyphilis, poifons, and feveral other difeafes, we find at the fame time a deficiency of oil and an emaciation take place; which, in my apprehenfion, muft be attributed to the abforption of oil, which the prefence of acrimony m the body excites. It is not unlikely that certain poifons introduced in- to the body, may fubfift there ; and, giving occafion to an abforption of oil, may lay a foundation for the Tabes a vcneno*, Sauv. fp. 17. MDCXVII. A fourth caufe of emaciation, and which I would attribute to fudden and confiderable abforption of oil from the cellular texture, is that of feve-, which fo generally produces emaciation. This nny perhaps be in part attributed to the increafed perfpiration, and therefore to the general deficiency of fluids that may be fuppofed to take place: but whatever fhare that may have in producing the effed, we cm, from the evident fhrinking and diminution of the cellular fubftance, wherever it falls under our obfervation, certainly conclude, that there has been a very confi- derable abforption of the oil which had been before depofited in that fubftance. This explanation is ren- dered the more probable from this, that I fuppofe the ; abforption * As this kind of emaciation proceeds from various caufes, the practitioner, muft, (after having afcercained the true caufe) endea- vour to remove it: and this mill be left entirely to his own fagacity. It may however be proper to obferve, that feveral of thefe emacia- tions proceed from incurable difeafes ; as from Cancer, Scrophula, Sec and confequently admit of no cure : And thofe emaciations which proceed from fcurvy, fyphilis, or thofe difeafes which we can care, arconly to be cured by curing the primary difeafe. 302 PRACTICE abforption mentioned is neceffarily made for the pur. pofe of enveloping or correding an acrimony, which manifeftly does in many, and may be fufpeded to arife in all cafes of fever. The moft remarkable in- ftance of emaciation occurring in fevers, is that which appears in the cafe of hedic fevers. Here the emaci- ation may be attributed to profufe fweatings that com. monly attend the difeafe: but there is much reafon to believe, that an acrimony is prefent in the blood ; which, even in the beginning of the difeafe, prevents the fecretion and accumulation of oil ; and in the more advanced ftates of it, muft occafion a more con- fiderable abforption of it; which, from the fhrinking of the cellular fubftance, feems to go farther than in almoft any other inftance*. Upon the fubjed of emaciations from a deficiency of fluids, it may be obferved, that every increafed evacuation excites an abforption from other parts, and particularly from the cellular texture; and it is therefore probable, that a deficiency of fluids, from increafed evacuations, produces an emaciation, not only by the wafte of the fluids in the vafcular fyltem, but alio by occafioning a confiderable abforption from the cellular texture. MDCXVIII. I have thus endeavoured to explain the feveral cafes and caufes of emaciation ; but I could not pr-ofecufe the confideration of thefe here in the order they are fet down in the Methodical Nofology. In that work I was engaged chiefly in arranging the fpecies of Sau- vages ; but it is my opinion now, that the arrange- ment there given is erroneous, in both combining and feparating fpecies improperly: and it feems to me more * This emaciation is purely fymptomatic, and confequently can- not be cured but by removing the primary difeafe, and a fubfeqnent very nutritious diet, confifting chiefly of animal food. OF PHYSIC. 303 more proper here to take notice of difeafes, and put them together, according to the affinity of their na- ture, rather than by that of their external appearances. I doubt, if even the diftindion of the Tabes and Atro- phia, attempted in the Nofology, will properly apply ; as I think there are certain difeafes of the fame nature, which fometimes appear with, and fometimei with- out, fever. MDCXIX. After having confidered the various cafes of ema- ciations, I fhould perhaps treat of their cure: but ir will readily appear, that the greater part of the cafes above-mentioned are purely fymptomatic, and confe- quently that the cure of them muft be that of the pri- mary difeafes upon which they depend. Of thofe ca- fes that can anywife be confidered as idiopathic, it will appear that they are to be cured, entirely by re- moving the remote caufes; the means of accomplifh- ing which muft be fufficiently obvious. _<..«..«..<..««<..<..<..<..«...>. >••>.>.> >.»..>■ BOOK II. O F INTUMESCENTI^, O R GENERAL SWELLINGS. MDLXX. THE fwellings to be treated of in this place are thofe which extendeiity never happens to a confiderable degree without producing a plethora ad fpatium in a great part of the fyftem of the aorta, and therefore a pletho- ra ad molcm in the lungs, and in the veffels of the brain. MDCXXIII. r In attempting the cure of polyfarcia, I am of opi- nion that the conjundion of plethora and obefity, in- the manner juft now mentioned, fhould be conitantly attended to ; and when the morbid effeds of the ple- thoric habit are threatened, either in the head or lungs, that blood-letting is to be pradifed: but at the fame time it is to be obferved, that perfons of much obefi- ty do not bear blood-letting well ; and when the cir- cumftances I have mentioned do not immediately re- quire it, the pradice upon account of obefity alone, is hardly ever to be employed. The fame remark is to be made with refped to any other evacuations that may be p opof.d for the cure of corpulency : for with- out ihe other means i ao to mention, they can give but a very lrnperfed relief; and, in fo far as they ei- ther empty or we-ken the fyftem, they may favour the return of plethora, and the increafe of obefity. MDCXXIV. Polyfarcia, or corpulency, whether it depend upon plethora or obefity, whenever it either can be confi- dered as a difeafe, or threatens to induce one, is to be cured, or the efieds of it are to be obviated, by diet and exercife. The diet muft be fparing; or rather, vvnat is more admiffible, it muft be fuch as affords lit- tle nutritious matter. It muft therefore be chiefly, or almoft only, of vegetable matter, and at the very ut- moft of milk. -Such a diet fhould be employed, and generally O F P II Y S I C. 3*7 generally ought to precede exercife : for obefity doe* not eafily admit of bodily exercife ; which is, howe- ver, the only mode that can be very effedual. Such, indeed, in many cafes, may feem difficult to be admit- ted ; but I am of opinion, that even the molt corpu- lent may be brought to bear it, by at firlt attempting it very moderately, and increafing it by degrees very ilowly, but at the fame time perfifling in fuch at- tempts with great conftancy*. MDCXXV. As thefe, though the only effedual meafures, ar.e often difficult to be admitted or carried into execu- tion, fome oth^r means have been thought of and em- ployed for reducing corpulency. Thefe, if I miftake not, have all been certain methods of inducing a faline ftate in the mafs of blood ; for fuch I fuppofe to be the effects of vinegar and of foap, which have been propofed. The latter, 1 believe, hardly panes into the blood-veffels, without being refoLved and formed into a neutral fait, with the acid which it meets with in the ftomach. How well acrid and faline fubftanc- es are fitted to diminifh obefity, may appear from what lias been faid above in mdcxv. What effeds vinegar, foap, or other fubftances employed, have had "in reducing corpulency, there have not proper opportunities of obferving occurred to me : but I am well perfuaded, that the inducing a faline and acrid ftate of the blood, may have worfe comequences than the corpulency it was intended to corred ; and that no perfon ftiould hazard thefe, while we may have rer courfe to the more fafe and ce.rtain means of abfti- nence and exercife. Q^q % CHAP. * Befides the means mentioned by the author, evacuations of diffe ent kinds ought to be oceafionally made, efpcgially by purging and fweating. 3o3 PRACTICE CHAP. II., QF FLATULENT SWELLINGS, MDCXXVI. THE cellular texture of the human body very rea- dily admits of air, and allows the fame to pafs from any one to every other part of it. Hence Em- phyfemata have often appeared from air colleded in the cellular texture under the fkin, and in feveral other parts of the body. The flatulent fwellings un- der the fkin, have indeed moft commonly appeared in confequence of air immediately introduced from with- out : but in fome inftances of flatulent fwellings, efpe- cially thofe of the internal parts not communicating with the alimentary canal, fuch an introdudion can- not be perceived or fuppofed ; and therefore, in thefe cafes, fome other caufe of the produdion and collec-, tion of air muft be looked for, though it is often not to be clearly afcertained. In every folid as well as every fluid fubftance which makes a part of the human body, there is a confidera- ble quantity of air in a fixed ftate, which may be again reftored to its elaftic ftate, and feparated from thoje fubftances, by the power of heat, putrefadion, and perhaps other caufes : but which of thefe may have produced the feveral inftances of pneumatofis and fla- tulent fwellings that have been recorded by authors, I cannot pretend to ascertain. Indeed upon account of thefe difficulties, I cannot proceed with any clear- nefs on the general lubjed 01 pneumatofis; and there- fore, with regard to flatulent fwellings, I find it ne- ceffary to confine myfeif to the confideration of thofe of the abdominal region alone; which I fhall now treat of under the general name of Tympanites. MEjCXXVIL OF PHYSIC. 3G9 MDCXXVII. The tympanites is a fwelling of the abdomen ; in which the teguments appear to be much ftretched by fome diftending power within, and equally ftrctched in every poftur■. 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 ftruck, it gives a found like a drum, or other ftretched animal membranes. No fluduation within is to be perceived ; and the whole, feels lefs weighty than might be expeded from its bulk. The uneafinefs of the diftention is commonly relieved by the difcharge of air from the alimentary canal, either upwards or downwards. MDCXXVIII. Thefe are the charaders by which the tympanites may be diftinguifhed from afcites or phyfconia ; and many experiments fhow, that the tympanites always depends upon a preternatural colledion of air, fome- where within the teguments of the abdomen; but the feat of the air is in different cafes fomewhat dif- ferent ; and this produces the different fpecies of the difeafe. One fpecies is, when the air colleded is entirely confined within the cavity of the alimentary canal, and chiefly in that of the inteftines. This fpecies, there- fore, is named the Tympanites inteftinalis, Sauv. fp. i. It is, of all others, the moft common; and to it efpe- cially belong the charaders given above. A fecond fpecies is, when the air colleded is not entirely confined to the cavity of the inteftines, but is alfo prefent between their coats ; and fuch is that which is named by Sauvages Tympanites enterophyfodes', Sauv. fp. 3. This has certainly been a rate occur- rence; and has probably occurred only in confe- quence of the tympanites inteftinalis, by the air efcap- jng from the cavity of the inteftines into the inter - ftices 3i© PRACTICE fticcs of the coats. It is, however, poffible that an erofion of the internal coat of the inteftines may give occafion to the air, fo conftantly prefent in their cavi- ty, to efcape into the interfticcs of their coats though in the whole their cavity there has been no previous accumulation. A third fpecies is, when the air is colleded in the f ic of the peritonaeum, or what is commonly called the cavity of the abdomen, that is, the fpace between the peritenreum and vifcera ; and then the difeafe is named tympanites abdominalis, Sauv. fp. 2. The ex- iftence of fuch a tympanites, without any tympanites inteftinalis, has been difputed ; and it certainly- has been a rare occurrence ; but from feveral difledions, it is unqueftionable that fuch a difeafe has fometimes truly occurred. A-fourth fpecies of tympanites is, when the tympa- nites inteftinalis and abdominalis are joined together, or take place at the fame time. With refped to this, it is probable that the tympanites inteftinalis is the pri- mary difeafe ; and the oiher, only a confequence of the air efciping, by an erofion or rupture of the coaa of the inteftines, from the cavity of thefe into that of the abdomen. It is indeed poffible, that in confe- quence of erofion or rupture, the air which is fo con- ftantly prefent in the inteftinal canal, may efcape from thence in fuch quantity into thex:avity of the ab- domen, as to give a tympanites abdominalis, whilft there was no previous confiderable accumulation of air in the inteftinal cavity itfelf; but I have not fads to af- certain this matter properly. A fifth fpecies has alfo been enumerated. It is when a tympanites abdominalis happens to be joined with the hydrops afci/es ; and fuch a difeafe therefore is named by Sauvages tympanites afciticus, Sauv. fp. 4* In moft cafes of tympanites, indeed, fome quantity of ferum has, upon diffedion, been found in the fac of the OF PHYSIC. 3" the peritonaeum ; but that is not enough to conftitutd the fpecies now mentioned, and when the colledion of ferum is more confiderable, it is commonly where, both from the caufes which havepreceded, 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 laft 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 diftin- guifhed, nor, as confidered in themfelves, admitting of any cure, I fhall here take no further notice of them ; confining myfeif in what follows, to the con- fideration of the moft frequent cafe, and almoft the only objed of pradice, the tympanites inteftinalis. MDCXXX. With refped to this, I cannot perceive that it arifas in any peculiar temperament, or depends upon any •predifpofition, which can be difcerned. It occurs in either fex, at every age, and frequently in young per- fons. MDGXXXI. „ Various remote caufes of it have been affigned ; but many of thefe have not commonly the effed of pro- ducing this difeafe ; and although fome of them have been truly antecedents of it, I can in few inftances difcover the manner in which they produce the difeafe, and therefore cannot certainly afcertain them to have been caufes of it. MDCXXXII. The phenomena of this difeafe in its feveral ftages" are the following. The tumor of the belly fometimes grows very quickly to a confiderable degree, and feldom in the flow manner the afcites commonly comes on. In fome cafes, 5u PRACTICE, cafes, however, the tympanites comes on gradually^ and is introduced by an unufual flatulency of the fto- mach and inteftines, with frequent borborygmi, and an uncommonly frequent expulfion of air upwards and downwards. This ftate is alfo frequently aLtended with colic pains, efpecially felt about the navel, and upon the fides towards the back ; but generally as the difeafe advances, thefe pains becomes lefs confi- derable. As the difeafe advances, there is a pretty conftant defire to difcharge air, but it is accomplifhed with difficulty ; and when obtained, and although it gives fome relief from the fenfe of diftenfion, this re- lief is commonly tranfient and of fhort duration.— While the difeafe is coming on, fome inequality of tu- mour and tenfion may be perceived in.different parts of the belly ; but the diftenfion foon becomes equal over the whole, and exhibits the phenomena mention- ed in the charader. Upon the firft coming on of the difeafe, as well as during its progrefs, the belly is bound, and the fixces difcharged are commonly hard and dry. The urine, at the beginning, is ufually ve- ry little changed in quantity or quality from its natu- ral ftate : but as the difeafe continues, it is commonly changed in both refpeds ; and at length fometimes a ftranguary, and even an ifchuria, comes on. The difeafe has feldom advanced far, before the appetite is much impaired, and digeftion ill performed ; and the whole body, except the belly, becomes coniiderabiy emaciated. Together with thefe fymptoms, a thirft and uneafy fenfe of heat at length comes on, and a confiderably frequency of pulfe occurs, which conti- nues throughout the courfe of the difeafe. When the tumor 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, fometimes proba- bly OF PHYSIC. 313 bly in confequence of a gangrene coming upon the inteftines. MDCXXXIII. The tympanites is commonly of fome duration, and to be reckoned a chronic difeafe. It is very feldom quickly fatal, except where fuch an affedion fudden- ly arifes in fevers. To this Sauvages has properly given a different appellation, that of Meteorifmus ; and I judge it may always be confidered as a fymptomatic affedion, entirely diftind from the tympanites we a;e now confidering. MDCXXXIV. The tympanites is generally a fatal difeafe, feldom admitting of cure; but what may be attempted in this way, I fhall try to point out, after I fhall have endea- voured to explain the proximate caufe, which alone can Jay the foundation of what may be rationally at- tempted towards its cure. MDCXXXV. To afcertain the proximate caufe of tympanites, is fomewhat difficult. It has been fuppofed in many cafes, to be merely an uncommon quantity of air pre- fent in the alimentary canal, owing to the extrication and detachment of a greater quantity of air than ufu- al from the alimentary matters taken in. Our vegeta- ble aliments, I believe, always undergo fome degree of fermentation ; and in confequence, a quantity of ai\ is extricated and detached from them in the ftomach and inteftines 5 but it appears that the mixture of the animal Auto's which our aliments meet with in the ali- mentary canal, prevents the fame quantity of air from being detached from them that would have been in their fermentation without fuch mixture ; and it is probable that the fame mixture contributes alfo to the reabforption of the air that had been before in fome meafure detached. The extrication, therefore, of an unufual quantity of air from the aliments, may, in cer- Vol. II. R r tai» 3H PRACTICE tain circumftances, be fuch, perhaps, as to produce a tympanites: fo that this difeafe may depend upon a fault of the digeftive fluids, whereby they are unfit to prevent the too copious extrication of air, and unfit al- fo to occafion that reabfirption of air which in found perfons commonly happens. An unufual quantity of ur in the alimentary canal, whether owing to the na- ture of the aliments taken in, or to the fault of the digeftive fluid, does certainly fometimes take place; and may poffibly have, and in fome meafure certainly has, a fhare in producing certain flatulent diforders of the alimentary canal; but cannot be fuppofed to pro- duce the tyn p.mites, which often occurs when no previous diforder had appeared in the fvftem. Even in thofe cafes f tympanites which are attended at their beginning with fiotukr.t cf'orrfeis ii; the whole of the alimentary canal, as we know that a firm tone of the inteftines both moderates the extrication of air and contributes to its reabforption or icady cxpulfion, fo the flatulent fymptoms which happen to appear at the coming on of a tympanites are, in my opinion, to be referred to a lofs of tone in the mufcular fibres of the inteftines, rather than to any fault in the digeftive fluids. MDCXXXVI. Thefe, and other confederations, lead me to con- clude, that the chief part of the proximate caufe of tympanites, is a lofs of tone in the mufcular fibres of the inteftines. Eat further, as air of any kind accu- mulated in rhe cavity of the inteftines fhould, even by its ownelaiticity, find its way either upwards or down- wards, and fhould alfo, by the affiftance of infpira- tion, be entirely thrown out of the body; fo, when neither the reabforption nor the expuifion takes place, and the air is accumulated fo as to produce tympan- ites, it is probable that the paffage of the air along the courfe of th~ inteftines is in fome places of thefe inter- O F P H Y S I C. 315 interrupted. This interruption, however, can hardly be fuppofed to proceed from any other caufe than fpafmodic conftridions in certain parts of the canal; and I conclude, therefore, that fuch conftridions con- cur as part in the proximate caufe of tympanites.— Whether thefe fpafmodic conftridions are to be attri- buted to the remote caufe of the difeafe, 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. Ha'ving thus endeavoured to afcertain the proxi- mate caufe of tympanites, I proceed to tieat of its cure ; which indeed has feldom fucceeded, and al- moft never but in a recent difeafe. I muft, however, endeavour to fay what may be reafonably attempted; what has commonly been attempted ; and what at- tempt have fometimes fucceeded in the cure of this difeafe. MDCXXXVIII. It muft be a firft indication to evacuate the air ac- cumulated in the inteftines : and for this purpofe it is neceffary that thofe conftridions, which had efpecially occafioned its accumulation, and continue to inter- rupt its paffage along the courfe of the inteftines fhould be removed. As thefe, however, can hardly be removed but by exciting the periftaltic motion in the adjoining portions of the inteftines, purgatives have been commonly employed ; but it is at the fame lime agreed, that the more gentle laxatives only ought to be employed, as the more draftic, in the overftretch- ed and tenfe ftate of the inteftines, are in danger of bringing on inflammation. It is for this reafon, alfo, that glyfters have been frequently employed ; and they are the more neceffa- ry, as the faeces colleded are generally found to be in a hard and dry ftate. Not only upon account of this 11 r 2 ftate 31b PRACTICE ftate of the faeces, but, farther, when glyfters produce a confiderable evacuation of air, and thus fhow that they have fome effed in relaxing the fpafms of the inteftines, they ought to be repeated very frequently. MDCXXXIX. In order to take off the conftridions of the intef- tines, and with fome view alfo to the carminative ef- feds of the medicines, various antifpafmodics have been propofed, and commonly employed ; but their effeds are feldom confiderable, and it is alledged that their heating and inflammatory powers have fome- times been hurtful. It it, however, always proper to join fome of the milder kinds with both the purgatives and glyfters that are employed* ; and it has been ve- ry properly advifed to give always the chief of antif- pafmodics, that is, an opiate, after the operation of purgatives is finifhed. MDCXL. In confideration of the overftretched tenfe, and dry ftate of the inteftines, and efpecially of the fpafmodic conftridions that prevail, fomentations and warm bathing have been propofed as a remedy ; and arc 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 continued. MD£XL1 Upon the fuppofition that this difeafe depends efpe- cially upon an atony of the alimentary canal, tonic re- medies * The antifpafmodics that are to be joined with purgatives ought to be effential oil?, efpec ally the effential oils of umbelliferous plan s, as oil of anifeed, oil ofcarui, &c. and their dofe ought to be moderate. In many caffs they may be ufed in repeated fmall dqfes by themfelves on a piece of fugar. The dofe of the ol anWi ouglit Jiot to exceed ten or twelve drops, nor of the ol. carui five drops; larger dofes are too heating. It may be proper alfo to obferve, that the effential oils of the verticellated plants, as mint, marjoram, thyme, &c. are much too heating, and much more fo thofe of the aromatics, as cloves, cinnamon, &c. OF PHYSIC. 317 mcdies feem to be properly indicated. Accordingly chalybeates, and various bitters, have been employed ; and, if any atonic*, the Peruvian bark might probably be ufeful. MDCXLII. But as no tonic remedy is more powerful than coldt applied to the furface of the body, and cold drink thrown into the ftomach ; fo fuch a remedy has been thought of in this difeafe. Cold drink has been con- ftantly preleribed, and cold bathing has been employed with advantage ; and there have been feveral in- ftances of the difeafe being fuddenly and entirely cur- ed by the repeated application of fnow to the lower belly. MDCXLIN. It is hardly neceffary to remark, that, in the diet of tympanitic perfons, all forts of food ready to become flatulent in the ftomach are to be avoided ; and it is probable, that the foflil acids and neutral falts, as an- tizymics, may be ufeful§. MDCXLIV. In obftinate and defperate cafes' of tympanites, the operation of the paracentesis has been propofed : but it is a very doubtful remedy, and there is hardly any teftimony of its having been pradifed with fuccefs. It muft be obvious, that this operation is a remedy fuited efpecially, and almoft only, to the tympanites abdominalis ; the exiftence of which, feparately from the inteftinalis, is very doubtful, at leaft not eafily af- certained. Even if its exiftence could be afcertained, vet it is not very likely to be cured by this remedy; and * The author here furely meant to fay tonic ; and atonic feems to be a typographical error ; but it was fp printed in the lalt edition publilhed before bis death. § Thefoffil acids are undoubtedly very powerful in refilling fer- mentation ; and if the air in the inteftines is produced by fermenta- tion, they are confequently highly ufeful, 318 PRACTICE and how far the operation might be fafe in xheiympan* ites inteftinalis, is not yet determined by any proper experience. ..«..< .< .< .«..< < <..< .< ^hJ»>-V->->->- >■•>•• CHAP. III. OF WATERY SWELLINGS, OR DROPSIES. MDCXLV. A PRETERNATURAL colledion of ferous or watery fluids, is often formed in different parts <>1" the human body ; and although the difeafe thence arifing he diftinguifhed according to the different parts which it occupies, yet the whole of fuch collec- tions come under the general appellation of Dropfies. At the fame time, although the particular inftances of fuch colledion are to be diftinguifhed from each other according to the parts they occupy, as well as by other circumftances attending them; yet all of them feem to depend upon fome general caufes, very much in common to the whole. Before proceeding, therefore, to confider the feveral fpecies, it may be proper to endeavour to affign the general caufes of dropfy. MDCXLVI. In perfons in health, a ferous or watery fluid feems to be conftantly poured out, or exhaled in vapour, in- to every cavity and intcrftice of the human body ca- pable of receiving it; and the fame fluid, without re- maining long or being accumulated in thefe fpaces, feems conftantly to be foon again abforbed from thence by veffels adapted to the purpofe. From this view OF PHYSIC. 3*9 view of the animal ceconomy, 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 ferous fluid *will be made in fuch parts; or though the quantity poured out be not more than ufual, yet if the abforp- tion be any wife interrupted or diminifhed, from this caufe alfo an unufual colledion of fluids may be occa- fioned. Thus, in general, dropfy may be imputed to an increafed effufion, or to a diminifhed abforption ; and I therefore proceed to inquire 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 carrying, or of facs con- taining, ferous or watery fluids. MDCXLVIII. The ordinary exhalation may be increafed by vari- ous caufes, and particularly by an interruption given to the free return of the venous blood from the ex- treme veffels of the body to the right ventricle of the heart. This interruption feems to operate by refitting the free paffage of the blood from the arteries into trie veins, thereby increafing the force of the arterial flu- ids in the exhalants, and confequently 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 to cer- tain circumftances affeding the courfe of the venous blood ; very frequently, 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 obftrudions in the veffels of theiur.e,s; re- venting the entire evacuation cf the right ventre!o. 3*s PRACTICE and thereby hindering its receiving the ufual quari- tity of blood from the cava. Thus, a polypus in tha right ventricle of the heart, and the offification of its valves, as well as all confiderable and permanent ob- ftrudions of the lungs, have been found fo be caufes of dropfy. MDCL. It may ferve as an illuftration of the operation of thefe general caufes, to remark, that the return of the venous blood is in fome meafure refifted 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 effed when the force of the circu- lation is weak ; and from whence it is that an upright pofture of the body produces or increafes ferous fwell- ings in the lower extremities. MDCLL Not only thofe caufes interrupting the motion of the venous blood more generally, but, farther, the in- terruption of it in particular veins, may likewife have the effed of increafing exhalation, and producing dropfy. The moft remarkable inftance of this is, when confiderable obftrudions of the liver prevent the blood from flowing freely into it from the vena portarum and its numerous branches ;and hence thefe obftrudions 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 difeafe, I do not perceive, except it may be where they happen to be near fome confider- able vein, by the compreffion of which they may oc- cafion fome degree of afcites ; or, by compreffing the vena cava, may produce an anafarca of the lower ex- tremities. It is indeed true, that fcirrhofiiies of the fpleen and other \i:cera, have been frequently difco- vered OF PHYSIC. 3?.£ vered in the bodies of hydropic perfons : but I be- lieve they have been feldom found unlefs when fcir- rhofities of the liver were alfo prefent; and I am in- clined to'think, that the former have been the effeds of the latter, rather than the caufe of the dropfy ; or, that, if fcirrhofiiies of the other vifcera have appeared in hydropic bodies when that of the liver was not pre- fent, they muft have been the effeds of fome of thofe caufes of dropfy to be hereafter mentioned ; and con- fequently to be the accidental attendants, rather than the caufes, of fuch dropfies, MDCLIII. Even in fmaller portions of the venous fyftem, the interruption of the motion of the blood in particular veins has had the fame effed. Thus a polypus form- ed in the cavity of a vein, or tumours formed in u coats, preventing the free paffage of the blood through it, have had the effed of producing dropfy in parts to- wards the extremity of fuch veins. MDCLIV. . But the caufe moft frequently interrupting the mo- tion of the blood through the veins is, the compreffi- on-of tumours exifting near to-them; fuch as aneu- rifms in the arteries, abfceffes, and fcirrhous or fteato- matous tumours in the adjoining parts. To this head may be referred the compreffiort of the defcending cava by the bulk of the uterus in preg- nant women, and the compreffion of the fame by the bulk of water in the afcites; both of which compreffi- ons frequently produce ferous fwellings in the lower extremities. MDCLV. It may be fuppofed, that a general preternatural plethora of the venous fyftem may have the effed of increafing exhalation; and that this plethora may happen from the fuppreffion of fluxes, or evacuations of blood, which had for fome time taken place in the Vol. II. S s body, 322 P R A C T I C E body, fuch as the menftrual and hem'orrhoidal fluxes. A dropfy, however, from fuch a caufe, has been a"t leaft a rare occurrence; and when it feems to have happened, I fhould fuppofe it owing to the fame cauf- es as the fuppreffion itfelf, rather than to the pletho- ra produced by it. MDCLVI. One of the moft frequent caufes of an increafed ex- halation, I apprehend to be the laxity of the exhalant veffels. That fuch a caufe may operate, appears pro- bable from this, that paralytic limbs, in which fuch a laxity is to be fufpeded, are frequently affeded with ferous, or, as they are called, cedematous fwellings. But a much more remarkable and frequent exam- ple of its operation occurs in the cafe of a general de- bility of the fyftem, which is fo often attended with dropfy. That a general debility does induce dropfy, appears fufficiently from its being fo commonly the confequence of powerfully debilitating caufes; fuch as fevers, either of the continued or intermittent kindj which have lafted long; long-continued and fome- what exceffive evacuations of any kinds ; and in fhort, almoft all difeafes thac have been of long continu- ance, and have at the fame time induced the other fymptoms of a general debility. Among other caufes inducing a general debility of the fyftem, and thereby dropfy, there is one to be mentioned as frequently occurring, and that is, in- temperance in the ufe of intoxicating liquors ; from whence it is that drunkards of all kinds, and efpeci- ally dram-drinkers, are fo affeded with this difeafe. MDCLVII. That a general debility may produce a laxity of the exhalants, will be readily allowed : and that by this efpecially it occafions dropfy, I judge from thence, that while moft of the caufes already mentioned are fuited to produce dropfies of particular parts only, the ftate © F f H Y S I C. 323 ftate of general debility gives-rife to increafed exhala- tion into every cavity and interftice of the body, and therefore brings on a general difeafe. Thus, we have feen effufions 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 tex- ture almoft over the whole of the body. In fuch caf- es, the operation of a general caufe difcovered itfelf, by thefe feveral dropfies. increafing in one part as they diminifhed in another, and this alternately in the dif- ferent parts. This combination, therefore, of the dif- ferent fpecies of dropfy, or rather, as it may be term- ed, this univerfal dropfy, muft, I think, be referred to , a general caufe; and in moft inftances, hardly any o- ther can be thought of, but a general laxity of the ex- halants. It is this, therefore, that I call the hydropic diathefis; which frequently operates by itfelf; and frequently, in fome* meafure, concurring with other caufes, is efpecially that which gives them their full effed. This ftate of the fyftem, in its firft appearance, feems to be what has been confidered as a particular difeafe under the name of Cachexy ; but in every in- ftance of it that has occurred to me, I have always confidered, and have always found, it to be the be- ginning of general dropfy. MDCLVIIL The feveral caufes of dropfy already mentioned mny produce the difeafe, although there be no preternatu- ral abundance of ferous or watery fluid in the blood- veffels ; but it is now to be remarked, that a preterna- tural abundance of that kind may often give occafion to the difeafe, and more efpecially when fuch aouu- dance concurs with the caufes above enumerated. One caufe of fuch preternatural abundance may be an unufual quantity of water taken into the body Thus an unufual quantity of water taken in by drink- S s 2 ing, 324 PRACTICE ing, has fometimes occafioned a dropfy. Large quan: titics of water, it is tiue, are upon many occafions taken in; and being as readily thrown out again by ftool, urine, or perfpiration, have not produced any difeafe. But it i^ alfo certain, that upon fome occa- Jions, an unufual quantity of watery liquors taken in has run otf by the feveral internal exhalants, and pro- duced a dropfy. This feems to have happened, ei- ther from the excretories not being fitted to throw out the fluid fo faft as it had been taken in, or from the excretories having been obftruded by accidentally concurring caufes. Accordingly it is faid, that the fudden taking in of a large quantity of very cold wa- ter, has produced dropfy, probably from the cold pro- ducing a conftridion of the excretories. The proportion of watery fluid in the blood may be increafed, npt only by the taking in a large quantity of water by drinking, as now mentioned, but it is poffible that it may be increafed alfo by water taken in from the atmofphere by the fkin in an abforbing or imbibing ftate. It is well known that the fkin may be, at leaft, occasionally in fuch a ftate ; and it is pro- bable, that it many cafes of beginning dropfy, when the circulation of the blood on the furface of the bo- dy is very languid, that the fkin may be changed from a perfpiring to an imbibing ftate; and thus, at leaft, the difeafe may be very much increafed. MDCLIX. A fecond caufe of a preternatural abundance of wa- tery fluids in the blood-veffels, may be, an interrup- fi n of the ordinary watery excretions ; and according- ly it is alledged, that perfons much expofed to a cold and moiil air are liable to dropfy. It is alfo faid, that an inter/uption, or confiderable diminution, of the urinary fecretion, has produced the difeafe : and it is certain, that in the cafe of an ifchuria rcnalis, the fe- rofity retained in the blood-veffels has been poured OF PHYSIC. 3*j out into fome internal cavities, and has occafioned diopfy. MDCLX. A third caufe, of an over-proportion of ferous fluid in the blood ready to run off by the exhalants, has been very large evacuations of blood, either fpontane- ous or artificial. Thefe evacuations, by abftrading a large proportiqn of red globules and gluten, winch are the principal means of retaining ferum in the red vef- fels, allow the feruni to run off more readily by the exhalants: and hence dropfies have been frequently the confequence of fuch evacuations. It is poffible alfo, that large and long-continued if- fues, by abftrading a large proportion of gluten, may Jiave the fame effecf. An over-proportion of the ferous parts of the blood, may not only be owing to the fpoliation juft now men- tioned, but may, I apprehend, be likewife owing to a fault in the digesting and affimilating 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, ftill continuing to fupply the watery parts, occafion thefe to be in an o- ver-proportion, and confequently ready to run off in too large quantity by the exhalants. It is in this manner that we explain the dropfy, fo often attending chlorofis : which appears always at firft by a pale co- lour of the whole body, fhowing a manifeft deficien- cy of red blood ; which in that difeafe can onjy be attributed to an imperfed digeftion and affimiiaiion. Whether a like imperfedion 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 general caufes of debility above mention- ed : and it being probable that the general debility mav affed the organs of digeftion and aflimilation ; fo the 320 PRACTICE the imperfed ftate of thefe fundions, occafioning a deficiency of red globules and gluten, may often con- cur with the laxity of the exhalants in producing dropfy. MDCLXI. Thefe are the feveral caufes of increafed exhalation, which I have mentioned as the chief caufe of the ef- fufion producing dropfy ; but I have likewife obferv- ed in mdcxlvii: that with the fame effed, an effu- fion may alfo be made by the rupture of veffels carry. ing watery fluids. In this way, a rupture of the thoracic dud, has giv- en occafion to an effufion of chyle and lymph into the cavity of the thorax : and a rupture of the lade- als has occafioned a like effufion into the cavity of the abdomen ; and in either cafe, a dropfy has been pro- duced. It is fufficiently probable, that a rupture of lympha- tics, in confequence of ftrains, or the violent com- preffion of neighbouring mufcles, has occafioned an effufion ; which, being diffufed in the cellular texture, ■lias produced 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 urine ; whereby the urine has been poured into the cavity of the abdomen, and produced an afcites. MDCLXII. Upon this fubjed, of the rupture of veffels carrying, or of veficles containing, watery fluids, I muft obferve, that the diffedion of dead bodies has often fhov/n ve- ficles formed upon the furface of many of the inter- nal 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 OF PHYSIC. 3*7 Uie poflibility of fuch a caufe, but fufped the matter muft be explained in a different manner. There have been frequently found, in almoft every different part ot animal bodies, colledions of fpherical veficles, containing a watery fluid ; and in many cafes of fuppofed dropfy, particularly in ih ofe called the preternatural encyfted dropfies, the fwelling has been entirely owing to a colledion of fuch hydatides. Ma- ny conjedures have been formed with regard to the nature and produdion of thefe veficles ; but the mat- ter at laft feems to be afcertained. It feems to be cer- tain, that each of thefe veficles has within it, or an- nexed 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 ceconomy, 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 Taenia hydatigena. The origin and ceconomy of this animal, or an account cf the feveral parts of the human body which it occupies, I cannot profecute further here ; but it was proper for me, in delivering the caufes of dropfy, to fay thus much of hydatides : and I muft conclude with obferving, 1 am well perfuaded, that moft of the inftances of preterna- tural encyfted dropfies which have appeared in many different parts of the human body, have been truly colledions of fuch hydatides ; but how the fwellings occafioned by thefe are to be diftinguifhed from other fpecies of dropfy, or how they are to be treated in pradice, I cannot at prefent determine. MDCLXIII. After haying 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 abforption that fhould take up the exhaled flu- ids from the feveral cavities and interfaces'of the bo- 328 PRACTICE dy ; the cau^s of which interruption, howeverj aid not eafily afcertained. MDCLXIV. It feems probable, that abforption may be diminifh- ed, and even ceafe altogether, from a lofs of tone in the abforbent extremities of the lymphatics. I can- not indeed ddubt that a certain degree of tone or act- ive power is neceffary in thefe abforbent extremities ; and it appears probable, that the fame general debili- ty which produces that laxity of the exhalant veflels, wherein I have fuppofed the hydropic diathefis to con- fift, will at the fame time occafion a lofs of tone in the abforbents ; and therefore that a laxity of the exha- lants will generally be accompanied with a lofs of tone in the abforbents; and that this will have a fhare in the produdion of dropfy. Indeed it is probable that the diminution of abforption has a confiderable fhare in the matter : as dropfies are often cured by medicines which feem to operate by exciting the adU on of the abforbents^ MDCLXV, It has been fuppofed, that the abforption performed by- the extremities of lymphatics may be interrupted by an obftrudion of thefe veffels, or at leaft of the conglobate glands through which thefe veflels pafs. This, however, is very doubtful. As the lymphatics have branches frequently communicating with one another, it is not probable that the obftrudion of any one, or even feveral of thefe, can have any confidera- ble effed in interrupting the abforption of their extre- mities. And for the fame reafon it is as little probable that the obftrudion of conglobate glands can have fuch an effed : at leaft it is only an obftrudion of the glands, of the mefentery, through which fo confiderable a por- tion of the lymph paffes, that can poflibly have the efc fed of interrupting abforption. Bu: evsn this we fhould OF PHYSIC. 325} mould not readily fuppofe, there being reafon to he- Sieve that thefe glands, even in a coniiderabiy tume- fied ftate, are not entirely obftruded : And according- ly i have knoWn feveral inftances of the moft part of the mefenteric glands being confiderably tumefied, without either interrupting the tranfmiflion of fluids to the blood-veffels, or occafioning any dropfy. An hydropic fwelling, indeed, Teems often to affed the arm from a tumour of the axillary gland : but it feems to me doubtful, whether the tumour of the arm may not be owing to fome compreffion of the axilla- ry vein, rather than to an obftrudion of the lympha- tics. • MDCLXVI. A particular interruption of abforption may be fup- pofed to take place in the brain. As no lymphatic veffels have yet very certainly been difcovered in that organ, it may be thought, that the abforption, which certainly takes place there, is performed by the extre- mities of veins, of by veffels that carry the fluid di- redly into the veins ; fo that any impediment to the free motion of the blood in the veins or tlie brain, may interrupt the abforption there, arid occafion that accumulation of ferous fluid which fo frequently oc- curs from a congeftion of blood in thefe veins. But I give ail this as a matter of conjedure only* MDCLXVII. Having thus explained the general caufes of drop- fy,! fhould proceed, in the next place, to mention the feveral parts of the body in which ferous colledions take place, and fo to mark the different fpecies of dropfy : but I do not think it neceffary for me to en-< ter into any minute detail upon this fubjed. In ma- ny cafes thefe colledions arc not to be afcertained by any external fymptoms, and therefore cannot be the objeds of pradice ; and many of them, though in fome meafure difcerniblej do not feem to be curable Vol. IL T t by S30 PRACTICE by our art. I ihe more efpecially avoid mentioning very particularly the fpecies, becaufe that has already been fufficiently done by Dr. D. Monro, and other writers, in every body's hands. I muft confine my- feif here to the confideration of thofe fpecies which are the moft frequently occurring and the moft common objeds of our pradice ; which are, the Anafarca, Hydrothorax, and Afcites ; and each of thefe I fhall treat in fo many feparate fedions. SECT. I. OF ANASARCA- MDCLXVIII. The Anafarca is a fwelling upon the furface of the body, at firft commonly appearing in particular parts only, but at length frequently appearing over the whole. So far as it extends, it is an uniform fwelling over the whole member, at firft always foft, and rea- dily 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, firft, upon the lower extremities; and there too only in the evening, difappearing again in the morning. It is ufually more confiderable as the perfon has been more in an ered pofture during the day; but there are many inftances of the exercife of walking prevent- ing altogether its otherwife ufual coming on. Al- though this fwelling appears at firft only upon the feet and about the ankles ; yet if the caufes producing it continue to ad, it gradually extends upwards, occu- pying OF PHYSIC. 33i pying the legs, thighs, and trunk of the body, and fometimes even the head. Commonly the fwelling of the lower extremities diminifhes during the night; and in the morning, the fwelling of the face is moft confiderable, wdiich again generally difappears almoft entirely in the courfe of the day. MDCLX1X. * The terms of Anafarca and Leucophlegmatia have been commonly confidered as fynonimous ; but fome authors have propofed to confider them as denoting diftind difeafes. The authors who are of this lalt opinion employ 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 defcribed ; while they term Leucophleg- matia, that in which the fame kind of fwelling appears even at firft very generally over the whole body. They feem to think alio, that the two difeafes proceed from different caufes; and that, while the anafarca may arife from the feveral caufes in mdcxlviu.—?,i- dclix. the leucophlegmatia proceeds efpecially from a deficiency of red blood, as we have mentioned in m- dclx. et feq. I cannot, however, find any proper foundation for this diftindion. For although in drop- fies proceeding from the caufes mentioned in mdclx, et feq. the difeafe appears in fome cafes more immedi- ately affeding the whole body ; yet that does not efta- blifh a difference from the common cafe of anafarca: for the difeafe, in all its circumftances, comes at length to be entirely the fame ; and in cafes occafioned by a deficiency of red blood, 1 have frequently obferved it to come on exadly in the manner of an an.ifarca, as above defcribed. MDCLXX. An anafarca is evidently a preternatural colledion of ferous fluid in the cellular texture immediately un- der the fkin. Sometimes pervading the fkin itfelf, it T t 2 oozes 332 PRACTICE oozes out through the pores of the cuticle ; and fome^ times, too grofs to pafs by thefe, it raifes the cuticle in blifters. Sometimes the fkin, not allowing the water to pervade it, is compreffed and hardened, and at the. fame time fo much diftended, or to give anafarcous tu- mours an unufual firmnefs. It is in thefe laft circum- ftances alfo that an erythematic inflammation is ready to come upon anafarcous fwellings. MDCLXXI. An anafarca may immediately arife from any of the feveral caufes of dropfy which ad more generally up- on the fyftem : and even when other fpecies of dropfy from particular circumftances, appear firft ; yet when- ever thefe proceed from any caufes more generally af- feding the fyftem, an anarfaca fooner or later comes always to be joined with them. MDCLXXII. The manner in which this difeafe commonly firft appears, will be readily explained by what I have faid in mdcl. refpeding the effeds of the pofture of the body. Its gradual progrefs, and its affeding, after fome time, not only the cellular texture under the fkin, but probably alfo much of the fame texture in the in- ternal parts, will be underftood partly from the com- munication that is readily made between the fevenil parts of the cellular texture ; but efpecially from the fame general caufes of the difeafe producing their ef-. feds 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. MDCLXXIU. An anafarca is almoft always attended with a fcarci- ty of urine ; and the urine voided, is, from its fcarci- ty always of a high colour; and from the fame caufe, after cooling, readily lets fall a copious reddifh fedir ment, OF PHYSIC. 333 ment. This fcarcity of urine may fometimes be ow-. ing to an obftrudion of the kidneys ; but probably is generally occafioned by the watery parts of the blood running off into the cellular texture, and being thereby prevented from paffing in the ufual quantity to the kidneys. The difeafe is alfo generally attended with an unu- fual degree of thirft ; a circumftance I would attribute to a like abftradion of fluid from the tongue and fauces, xvhich are extremely fenfible to every diminution of the fluids in thefe parts. MDCLXXIV. The cure of anafarca is to be attempted upon three general indications. i. The removing the remote caufes of the diieafc. i. The evacuation of the ferous fluid already col- leded in the cellular texture. 3. The reftoring the tone of the fyftem, the lofs of which may be confidered in many cafes as the proxi- mate caufe of the difeafe. MDCLXXV. The remote caufes are very often fuch as had not only been applied, but had been removed* long be- fore the difeafe came on. Although, therefore, their eifeds remain, the caufes themfelves cannot be the objeds of practice ; but if the caufes ftill continue to be applied, fuch as intemperance, indolence, and fome others, they muft be removed. For the molt part, tlie remote caufes are certain difeafes previous to the dropfy, which are to be cured by the remedies parti- cularly adapted to them, and cannot be treated of here. The curing of thefe, indeed, may be often dif- ficult ; but it was proper to lay down the prefent in- dication, in order to 'fhow, that when thefe remote caufes * Th^fe are Lirge evacuations of different kinds, b')t efpecially hemorrhagies, which have ceafed before the dropfy came on. 334 PRACTICE caufes cannot be removed, the cure of the dropfy mult be difficult, or perhaps impoflible. In many cafes, therefore, the following indications will be to. little purpofe; and particularly, that often the execu- tion of the fecond will not only give the patient a great deal of fruitlefs trouble, but commonly alfo hur- ry on his fate. MDCLXXVI. The fecond indication for evacuating the colleded ferum, may be fometimes executed with advantage, and often, at leaft, with temporary relief. It maybe performed in two ways. Firft, by drawing off the water diredly from the dropfical part, by openings made into it for that purpofe : Or, feconuly, by ex- citing certain ferous excretions; in con<; quence of which, an abforption maybe excited in the dropfical parts, and thereby the ferum abforbed and carried into the blood-veffels may afterwards be direded to run out, or may fpontaneoufly pafs out, by one or other of the common excretions. MDCLXXVII. In an anafarca, the openings into the dropfical part are commonly to be made in fome part of the lower extremeties; and will be moft properly made by ma- ny fmall pundures reaching the cellular texture. For- merly, confiderable incifions were employed for this purpofe : but as any' wound made in dropfical parts, which, in order to their healing, muft neceffarily in- flame and fuppurate, are liable* to become gangre- nous ; fo it is found to be much fafer to make the open- ings by fmall punctures only, which may heal up by the firft intention. At the fame time, even "with re- fped to thefe pundures, it is proper to obferve, that they ftiould be made at fome diftance from»one another, and * Peculiarly liable in this difeafe on account of the diminnhed tone and confequently the diminifhed ftrength of the parts. OF PHYSIC. 335. and that care fhould be taken to avoid making them in the moft depending parts. MDCLXXVIII. The water of anafarcous limbs may be fometimes drawn off by pea-ifiues, made by cauftic a little below the knees : for as the great fwelling of the lower ex- tremities is chiefly occafioned by the ferous fluid ex- haled into the upper parts conftantly falling down to the lower; fo the iffues now mentioned, by evacuating the water from thefeUpper parts, may very much relieve the whole of the difeafe. Unlets, however, the iflues be put in before the difeafe is far advanced, and before the parts have very much loft their tone, the places of the iffues are ready to become affeded with gan- grene. Some pradical writers have advifed the employ- ment of fetans, for the fame purpofe that I have propofed iffues; but I apprehend, that fetons will be more liable than iffues to the accident juft now mentioned. MDCLXXIX. For the purpofe of drawing out ferum from anafar- cous limbs, blifters have been applied to them, and fometimes with great fuccefs; but the bliftered parts are ready to have a gangrene come upon them. Bliftering is therefore to be employed with great caution; and perhaps only in the circumftances that I have mention- ed above to be fit for the employment of iffues. MDCLXXX. Colewort-leaves applied to the fkin, readily occafion a watery exfudation from its furface; and applied to the feet and legs affeded with anafarca, have fome^ times drawn off the water very copioufly, and with great advantage. Analogous, as I judge, to this, oiled filk-hofe put upon the feet and legs, fo as to fliut out all communi- cation with the external air, have been found fome- times to draw a quantity of water from the pores of the 336 PRACTICE the fkin, and are faid in this way to have relieved aha; farcous fwellings; but in feveral trials made, I have never found either the application of thefe hofe, or that of the colewort-leaves, of much fervice. MDCLXXXI. The fecond means propofed in mdclxxvi. for draw- ing off the water from dropfical places, may be the employment of emetics, purgatives, diuretics, or fu- dorifics*. MDCLXXXII. As fpontaneous vomiting has fometimes excited an abforption in hydropic parts, and thereby drawn off ihe waters lodged in them1, it is reafonable to fuppofe that vomiting excited by art may have the fame effed; and accordingly it has been often pradifed with ad- vantage. The pradice, however, requires that the ftrong antimonial emetics be employed, and that they be repeated frequently after fhort intervals. MDCLXXXII1. Patients fubmit more readily to the ufe of purga- tives, than to that of emetics; and indeed they com- monly bear the former more eafily than the latter. At the fame time, there are no means we can employ to procure 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 moft frequently, and perhaps with* moft fuccefs, employed in dropfy. It has been gene- rally found neceffary to employ purgatives of the more draftic kind ; which are commonly known, and need not be enumerated here*. I believe, indeed, that the * How does this lad agree with the firll fentence of this ariticle? § The Draftic purgatives are Jalap, Colocynth, Gamboge, Scammony, &e. Their Draftic quality however depends very much on the dole in which they are given, fmall dofes being gently laxa- tive, while large ones are very violent in their operation. They ought leldom to be given alone, but in conjunction with fome aro- matic, which greatly increaf:s their adtion, and at the fame time DF PHYSIC, 33? the more draftic purgatives are the moft effectual forex- citing abforption, as their ftimulus is moft readily com- municated to the other parts of the fyftem; but of late an opinion has prevailed, that fome milder purgatives may be employed with advantage. This opinion has prevailed particularly with regard to the cryftals vul- garly called the Cream of Tartar, which in large dof- es, frequently repeated, have fometimes anfwered the purpofe of exciting large evacuations both by ftool and urine, and has thereby cured dropfies. This medi- cine, however, has frequently failed, boih in its opera- Vol. II. U u tion prevents the uneafinefs of griping, with which their operation is fre- quently attended: moft of thefe drallies being refinous fubftances, they are difficultly foluble in the alimentary canal, or if reduced to a powder they are liable to concrete ; in either cafe their action is impeded. To remedy theie inconveniencies, it is ufual to add to them fome fait, which both divides the refin and prevents k's con- cretion ; and confequently incieafes it's aftion. For thefe reafons, we find in the (hops many formulae, in which the draftic lefins are mixed with either falts or aromatics, or both : As, the Pulvis Aloe- ticus, Pulvis e Scammonio compofitus, Pulvis e Scammonio cum A- lce, Pulvis e fenna compofitus, and Electuarium e Scammonio of the London Pharmacopoeia; and, the Pulvis e Jalappa compofitus,Pulvis e Scammonio compofitus Pilulae Aleeticse, Pilule ex colocynthide cum Aloe, Pilulae, e Jalappa, and Pilulae Rufi of the Edinburgh. Pharmacopoeia. Any of the foregoing compofitions, if given in fufficient dofes, are very a&ive and bnfk purges. Many more might be contrived, and on fome occafions may be neceffary. For procuring a brifk difcharge of fluids, an addition of Calomel is remarkably efficacio»» as in the following formula : g,. Scammon. Calomel. Crem. Tart. Zinzib a- a« p, ar. M. f. Pulv. The dofe of this powder is two fcruples or a drachm, it is extremely active and ought to be ufed with care, the patients being kept mo- derately warm, and drinking fome thin mucilaginous liquor during it's operation. 35S PRACTICE tion and effects, when the draftic purgatives have been more fuccefsful. Praditioners have long ago obferved, that, in the employment of purgatives, it is requifite they be re- peated after as fliort 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 fyftem, and thereby in* creafes the affiux of fluids to the hydropic parts. MDCLXXX1V. The kidneys afford a natural outlet for a great part of the watery fluids contained in the blood-veffels; and the increafing the excretion by the kidneys to a confi- derable degree, is a means as likely as any other of exciting an abforption in dropfical parts. It is upon this account that diuretic medicines have been al- ways properly employed in the cure of dropfy. The various diuretics that may be employed, are enumerat- ed in every treatife of the Materia Medica and of the Pradice 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 fometimes fucceed, and why they fo often fail; nor why one medicine fhould prove of fer- vice when another does not. It has been generally the fault of writers upon the Pradice of Phyfic, that they give us inftances of cafes in which certain medi- cines have proved very efficacious, but negled to tell us in how many other inftances the fame have failed. MDCLXXXV. It deferves to be particularly obferved here, that there is hardly any diuretic more certainly powerful than a large quantity of common water taken in by drinking. I have indeed obferved above, in mdclvih. that a large quantity of water, or of' watery liquors, taken in by drinking, has fometimes proved a caufe of dropfy; OF PHYSIC. 339 dropfy; and praditioners have been formerly fo much afraid that watery liquors taken in by drinking might run off into the dropfical places and increafe the dif- eafe, that they have generally enjoined the abftaining, as much as poffible, from fuch liquors. Nay, it has been further afferted, that by avoiding this fupply of exhalation, and by a total apftinence ftom drink, dropfies have been entirely cured. What conclufion is to be drawn from thefe fads, is however, very doubtful. A dropfy arifing from a large quantity of liquids taken into the body, has been a very rare occurrence; and there are, on the other hand, innumerable inftances of very large quantities of water having been taken in and running off again very quickly by ftool and urine, without producing any degree of dropfy. With refped to the tot'al abftinence from drink, it is a pradice of the moft difficult execution ; and therefore has been fo feldom pradifed, that we cannot poflibly know how far it might prove effedual. The pradice of giv- ing drink very fparingly, has indeed been often em- ployed :, but in a hundred inftances I have feen it car- ried to a great length without any manifeft advantage; while, on the contrary, the pradice of giving drink very largely has been found not only fafe, but very of- ten effedual in curing the difeafe. The ingenious and learned Dr. Millman has, in my opinion, been com- mendably employed in rel\oling the pradice of giv- ing large quantities of watery liquors for the cure of dropfy. Not only from the inftances he mentions from his own pradice, and from that of feveral eminent phyficians in other parts of Europe, but alfo from many inftances in the records of phyfic, of the good •effeds of drinking large quantities of mineral waters in the cure of dropfy, I can have no doubt of the pradice recommended by Dr. Millman being very of-. ten extremely proper. 1 apprehend it to be efpecial- ly adapted to thofe cafes in which the cure is chiefly U u 2 at- 343 PRACTICE attempted by diuretics. It is very probable that thefe medicines can hardly be carried in any quantity to the kidneys without being accompanied with a large portion of water; and the late frequent employment of the cryftals of tartar has often fhown, that the diu- retic effeds of that medicine are almoft only remarka- ble when accompanied with a large quantity of water; and that without this, the diuretic effeds of the medi- cine feldom appear. I fhall conclude this fubjed with obferving, that as there are fo many cafes of dropfy abfoluf ely incurable, the pradice now under confide- ration may often fail, yet in moft cafes it may befitfe- ly tried; and if it appear that the water taken in paffcs readily by the urinary fecretion, and efpecially that it increafes the urine beyond the quantity of drink taken in, the pradice 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 employed for exciting a ferous excretion, and thereby curing dropfy, is that of fudoiifics. Such remedies, indeed, have been fometimes employed; but however ufeful they may have been thought, there are few accounts of their having effeded a cure ; and although I have had fome examples of their fuccefs, in moft inftances of their t.ial they have been ineffedual. Upon this fubjed it is proper to take notice of the feveral means that have been propofed and employed for diffipatmg the humidity of the body ; and parti- cularly that of beat externally applied to the furface of it. Of fuch applications I have had no experience; and then propriety and utility muft reft upon the cre^ dit of the «.uriiors who relate them. I fhall offer only this OF PHYSIC. 34i this conjedure upon the fubjed : That if fuch mea- fures have been truly ufeful, as it has feldom been by the drawing out of any fenfible humidity, it has pro- bably been by their reftoring the perfpiration, which is fo often greatly diminifhed in this difeafe ; or, per- haps, by changing the ftate of the fkin, from the im- bibing condition which is alledged to take place, into that of perfpiring. MDCLXXXVIL When, by. the feveral means now mentioned, we fhall have fucceeded in evacuating the water of drop- fies, there will then efpecially be occafion for our third indication ; which is, to reftore 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 cer- tain meafures adapted to this purpofe may, upon fuch firft appearance, be employed with advantage. In many cafes of a moderate difeafe, I am perfuaded that they may obviate any future increafe of it. MDCLXXXVIII. Thus, upon what is commonly the firft fymptoms of anafarca, that is, upon the appearance of what are called Oedematous Swellings of the feet and legs, the three remedies of bandaging, friction, and exercife, have often been ufed with advantage. MDCLXXXIX. That fome degree of external compreffion is fuited to fupport the tone of the veffels, and particularly to prevent the effeds of the weight of the blood in dilat- ing thofe of the lower extremities, muft be fufficiently evident; and the giving that compreffion by a bandage properly applied, has been often ufeful. In apply- ing fuch a bandage, care is to be taken that the com- preffion may never be greater on the up^er than on (he lower part of the limb ; and this, i think, c?nhard- 342 PRACTICE ly ever be fo certainly avoided, as by employing a properly conftruded laced flocking. MDCXC. Fridion is another means by which the adion of the blood-veffels may be promoted, and thereby the ftagnation of fluids in their extremities prevented. Accordingly, the ufe of the flefti-brufh has often con- tributed to difcufs cedematous fwellings. It appears to me, that fridion, for the purpofes now mentioned, is more properly employed in the morning, when the fwelling is very much gone off, than in the evening, when any confiderable degree of it has already come on. I apprehend alfo, that fridion being made from below upwards only, is more ufeful than when made alternately upwards and downwards. It has been. common, inftead of employing the flefti-brufh, to make rhe fridion by warm and dry flannels; and this may in fome cafes be the moft convenient: but I can- not perceive that the impregnation of thefe flannels with certain dry fumes is of any benefit. MDCXCI. With refped to exercife, I muft obferve, that al- though perfons being much in an ered pofture during the day, may feem to increafe the fwelling which comes on at night; yet as the adion of the mufcles has a great fhare in promoting the motion of the ve- nous blood, fo I am certain, that as much exercife in walking as the patient can eafily bear, will often pr§- vent that cedematous fwelling, which much ftanding% and even fitting, would have brought on. MDCXC1I. 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; which may be employed both during the courfe OF PHYSIC. 343 courfe of the difeafe and efpecially after the water has been evacuated. MDCXCIII. Exercife is fuited to aflift inevtryfundionofthe ani- mal ceconomy, particularly to promote perfpiration, and thereby prevent the accumulation of watery flu- ids in the body. I apprehend alfo, that it may be the moft effedual means for preventing the fkin from be- ing in an imbibing ftate; and, as has been hinted a- bove on the fubjed of Emaciation (mdcvii.) I am per- fuaded, that a full and large perfpiration will always be a means of exciting abforption in every part of the fyftem. Exercife, therefore, promifes to be highly ufeful in dropfy ; and any mode of it may be employ- ed that the patient can moft conveniently admit of. It ftiould, however, always'be as much as he can eafily bear : and in anafarca, the ffiare which the exercife of mufcles has in promoting the motion of the venous blood, induces me to think that bodily exercife, to whatever degree the patient can bear it, will always be the moft ufeful. From fome experience alfo, I am perfuaded, that by exercife alone, employed early in the difeafe, many dropfies may be cured. MDCXCIV. Befides exercife, various tonic remedies are properly employed to reftore the tone of the fyftem. The chief of thefe are, chalybeates, the Peruvian bark, and various bitters. Thefe are not only fuited to reftore the tone of the fyftem in general, but are particularly ufeful in ftrengthening the organs of digeftion, 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 moft pow- erful tonic "we can employ ; but at the beginning of dropfy, when the debility of the fyftem is confiderable, it 344 PRACTICE ic can hardly be attempted with fafety. After, how* ever, the v. ater of dropfies has beenvery fully evacuat- ed, and the indication is to ftrengthen the fyftem for preventing a relapfe, cold bathing may perhaps have a place. It is, at the fame time, to be admitted with caution ; and can fcarcely be employed till the fvftem has othervvife recovered a good deal of vigour. When that indeed has happened, cold bathing may be very ufeful in confirming and completing it. MDCXCVI. In perfons recovering from dropfy, while the feve- ral means now mentioned for ftrengthening the fyftem are employed, it will be proper at the fame time to keep conftantly in view the fupport of the watery ex- cretions ; and confequently the keeping up the per- fpiration by a great deal of exercife, and continuing the full flow of the urinary excretion by the frequent ufe of diuretics. SECT. II. OF THE HYDROTHORAX OR DROPSY OF THE BREAST. MDCXCVII. The preternatural colledion of ferous fluid in the thorax, to which we give the appellation*of Hydrotbo- rax, occurs more frequently than has been imagined. Its prefence, however, is not always to be very cer- tainly known ; and it often takes place to a confidera- ble degree before it be difcovered. MDCXCVIU. Thefe colledions of watery fluids in the thorax, are found bf PHYSIC. 345 found in different fituations. Very often the water is found at the fame time in both facs of the pleura, but frequently 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 collec- tion is prefent in one or both cavities of the thorax. In fome inftances, the colledion is found to be only in that cellular texture of the lungs which furrounds the brcnchiae, without there being at the fame time any effufion into the cavity of the thorax. Pretty frequently the water colleded confifts chief- ly of a great number of hydatides in different fituati- ons ; fometimes feemingly floating into the cavity, but frequently conneded with and attached to particular parts of ehe internal furface of the pleura. MDCXC1X. From the colledion of water being thus in various fituations and circumftances, fymptoms arife which are different in different cafes ; and from thence it be- comes often difficult to afcertain the prefence and na- ture of the affedion. I fhall, however, endeavour here to point out the moft common fymptoms, and efpecially thofe of that principal and moft frequent form of the difeafe, when the ferous fluid is prefent in both facs of the pleura, or, as we ufually fpeak, in both cavities of the thorax; MDCC. The difeafe frequently comes on with a fenfe of anx- iety about the lower part of the ftcrnum. This, be- fore it has fubfifted long, conies to be joined with fome difficulty of breathing ; which at firft appears on- ly upon the perfon's moving a little fatter than ufual, upon his walking up an activity, or upon his afcend- ing a ftair-cafe : but after fome time, this difficulty of breathing becomes more conftant and confiderable, efpecially during the night, when the body is in a horizontal fituation. Commonly, at the fame time, Vol. II. X x lying 346 PRACTICE lyiiig upon one fide is more eafy than upon the other* or perhaps lving upon the back more eafy than upon either fide. Thefe circumftances are ufually attended with a frequent cough, that is at firft dry; but which, after fome time, is accompanied with an expectoration of thin mucus. With all thefe fymptoms, the hydrothorax is not certainly difcovered, as the fame fymptoms often at- tend other difeafes of the breaft. When, however, along with thefe fymptoms, there is at the fame time an cedematous fwelling of the feet and legs, a leuco- phlegmatic palenefs of the face, and a fcarcity of urine, the exiftence of a hydrothorax can be no longer doubtful. Some writers have told us, that fometimes in this difeafe, before the fwelling of the feet comes on, a watery fwelling of the fcrotum appears : but I have never met any inftance of this. MDCOI. Whilft the prefence of the difeafe is fomewhat un- certain, there is a fymptom which fometimes takes place, and has been thought to be a certain charadef- iftic 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 feelings immediately require an ered pofture ; and very often the difficulty of breathing continues 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 other difeafe of the thorax ; and therefore, when it attends a difficulty cf breathinsr, arcompajiied with any the fmalleft fyftem of dropfy, I have had no doubt in concluding the prefence of water in the cheft, and have OF PHYSIC. 317 have always had my judgment confirmed by the fymp- toms which afterwards appeared. MDCU1. The hydrothorax often occurs with very few, or almoft none, of the fymptoms above mentioned ; and is.not, therefore, very certainly difcovered till fome others appear. The moft decifive fymptom is a fluc- tuation of water in the cheft, perceived by the pati- ent himfelf, or by the phyfician, upon certain motions of the body. How far the method propofed by Alien.- b.rugger will apply to afcertain the prefence of water and the quantity (fit in the cheft, I have not had oc- cafion or opportunity to obferve. It has been faid, that in this difeafe fome tumour ap- pears upon the fides or upon the back ; but I have not met with any inftance of this. In one inftance of the dilVafe, I found ope fide of the thorax coniiderabiy en- . larged, the ribs ft an ding, out farther on that fide than upon the other. A numbnefs. and a degree of paify in one or both arms, has been frequently obferved to attend a hydro- thorax. Soon after this difeafe has made fome progrefs, the pulfe commonly becomes irregular, and frequently intermitting: but this happens in fo many other dif- eafes of the breaft, that, unlefs when it is attended with fome other of the above mentioned fymptoms, it can- not be confidered as denoting the hydrothorax. 1VIDCCIII. This difeafe, as other dropfies, is commonly attend- ed with thirfiVand a fcarcity of u>ine,xto be explained in the fame manner as in the cafe of anafarca (mdc- Lxxii i.) .-/The hydrothorax, however, is -fometimes without thirft, or any other febrile fymptom ; although I beliive this happens in the cafe of partial affeclions onlv, or when a more general affedion is yet but in a ifiiht degree. In both cafes, however, and more efpe- 34S PRACTICE cially when the difeafe is confidcrably advanced, fome degree of fever is generally prefent: and I apprehend it to be in fuch cafe, that the perfons affeded are more than ufually fenfible to cold, and complain of the coldnefs of the air when that is. not perceived by other perfons. MDCCIV. The hydrothorax fometimes appears alone, with- out any other fpecies of dropfy being prefent at the fame time: and in this cafe the difeafe, for the moft part, is a partial affedion, as being either of one fide of the thorax only, or being a colledion of hydatides in one part of the cheft. The hydrothorax, ho'wever, is very often a part of more univerfal dropfy, and when at the fame titne there is water in all the three princi- pal cavities and in the cellular texture of a great part of the body. I have met with feveral inftances, in which fuch univerfal dropfy began firft by an effufion into the thorax. The hydrothorax, however, more frequently comes on from an anafarca gradually in- creafing ; and, as I have faid above, the general dia- thefis feems often to affed the thorax fooner than it does either the head or the abdomen. MDCCV: This difeafe feldom admits of a cure, or even of alle- viation, from remedies. It commonly proceeds to give more and more difficulty of breathing, till the adion of the lungs be entirely interrupted by the quantity of water effufed ; and the fatal event fre- quently happens more fuddenly than was expeded.— In many cf the inftances of a fatal hydrothorax, I have remarked a fpittmg of blood to come on feveral days before the patient died. MDCCVL The ( aure of hydrothorax is often manifeftfy one or other of the general caufes of dropfy pointed out a- jpove: but what it is that determines thefe general caufes OF PHYSIC. 345 caufes to ad more efpecially in the thorax, and parti- cularly what it is that produces the partial colledions that occur there, I do not find to be eafily afcertained MDCCVTI. From what has been faid above, it will be evident that the cure of hydrothorax muft be very much the fame with that of anafarca ; and when the former is joined with the latter as an effed 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 particular caufes ading in the thorax only, there can hardly be any other meafures employed, than the general "ones propofed above. There is only one particular mea- fure adapted to 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 moft properly adapted, I find it difficult to determine. That it may be executed with fafety, there is no doubt; and that it has been fometimes pradifed with fuccefs, feems to be very well vouched*. When the difeafe depends upon * In the memoirs of the Academy of Sciences at Paris, for 1703. M. IJu Vcrney relates the cafe of a woman who had'both an Af- cites and Hydrothorax. He firft emptied the abdomen by tap- ping, and a few days afterwards, he pierced the thorax with a tro- char, near to the fpine, between the fecond and third faife ribs ; by which opening he drew off a confiderable quantity of water ; the o- peration gave immediate relief to the patient, and fhe was able to return to her ordinary employments in about a month's time. Bianchi alfo relates a fuccefsful operation of tapping; the thorax ; but he feems to be timid in his practice, and confeffes th.it he has feldom ventured on the operation. The piactice of evacuating water contained in the thorax by an incifion is very old. We find it recommended by Hippocrates, with particular directions for performing the operation, in his fecond book on difeafes, See the Geneva edition of Fpefius'a Hippocrates, pag. 483. 35o PRACTICE upon a general hydropic diathefis, it cannot alone prove a cure, but may give a temporary relief; and when other remedies feem to be employed with advan- tage, the drawing off the water may very much fa- vour a complete cure. I have not, however, been fo fortunate as to fee it pradifed with any fuccefs ; and even where it was moft promifing, that is, in cafes of partial affedion, my expedations have been difappoint* ed from jt. SECT. III. OF ASCITES, OR DROPSY OF THE LOWE$ BELLY. MDCCIX. The name of Afcites is given to every colledion of waters caufing a general fwelling and diftenfion of the lower belly : and fuch colledions are more frequent than thofe which happen in the thorax. MDCCX, The colledions in the lower belly, like thofe of the thorax, are found in different fituations. Moft com- monly they are in thefac of the peritonaeum, or gene- ral cavity of the abdomen : but they often begin by facs formed upon, and conneded'with, one or other of That the practice was frequently attended with fuccefs, in thofe early ages, is fufficiently evident by the context; for Hippocrates. after defcribi-.g the operation, and the fubfequent management of the patient fays, " If pus appear on the plaiiter covering the wound, '* on the fifth day after the operation, the patient generally rcca- *' vers; if not, ke is feized with a cough and thirft, and dies." OF PHYSIC. 35 * of the vifcera; and perhaps the moft frequent in- ftances of this kind occur in the ovaria of females^ Sometimes the water of afcites is found entirely with- out the peritonaeum, and between this and the abdomi- nal mufcles, MDCCXI. Thefe colledions conneded with particular vifcera* and thofe formed without the peritonaeum, form that difeafe which authors have termed the encyfted dropfy, or hydrops faccatus. Their precife feat, and even their exiftence, is very often difficult to be afcertain- ed. 1 hey are generally formed by colledions of hy- datides. MDCCXII. In the moft ordinary cafe, that of abdominal drop- fy, the fwelling at firft is in fome meafure over the whole belly, but generally appears moft confiderable in the epigaftrium. As the difeafe, however, advanc- es, the fwelling becomes more uniform over the whole. The diftenfion and fenfe of weight, though confider- able, vary a little according as the pofture of the bodv 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 diftenfion becomes fomewhat lefs. In almoft all the inftances of afcites, the fludu- ation of the water within, may be perceived by the praditioner's feeling, and fometimes by his hearing. This perception of fluduation does not certainly dif- tinguifh the different ftates of dropfy ; but ferve? very well to diftinguifh dropfy from tympanites, from cafes of phyfeonia, and from the ftate of pregnancy i:i women. MDCCXIII. As afcites frequently occurs when no other fprri s of dropfy does at the fame time appear; but fo:i;> times the afcites is a part only of univerfal dreply. In this cafe, it ufually comes on in confequence of an ana- 352 PRACTICE anafarca, gradually increafing; but its beingjouled with anafarca, does not always denote any general dia- thefis, as for the moft part an afcites fooner or later oc- cafions cedematous fwellings of the lower extremities. When the colledion of water in the abdomen, from whatever caufe, becomes confiderable, it is always at- endfd with a difficulty of breathing ; but this fymp- rom occurs often when, at the fame time, there is no water in the thorax. The afcites is fometimes unac- companied with any fever ; but frequently there is more or lefs of fever prefent with it. The difeafe is never confiderable, without being attended with thirft and fcarcity, of urine. MDCCXIV. In the diagnofls of afcites, the greareft difficulty that occurs, is in difcerning when the 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 certain means of afcertaining this in all cafes; but in many we may attempt to form fome judgment with regard to it. When the antecedent circumftances give fufpicion of a general hydropic diathefis; when at the fame time fome degree of dropfy appears in other parts of the body ; and when, from its firft appearance, the fwelling has been equally over the whole belly, we may generally prefume that the water is in the cavity of the abdomen. But when an afcites has not been pre- ceded by any remarkable cachedic ftate of the fyftem, and when at its beginning the tumour and tenfion had appeared in one part of the belly more than ano- ther, there U reafon to fufped 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 general appear to be little affeded; if the patient's ftrength be little impaired ; if the appetite continue pietty en*ire. and the natural fleep OF PHYSIC. "pi fteep be little interrupted ; if t,he menfes in females continue to flow as ufual; if there be yet no anafarca; or, though it may have already taken place, if it be ftill confined to the lower extremities, and there be no leucophlegmatic palenefs or fallow colour in the coun- tenance ; if there be no fever, nor fo much thirft, or fcarcity of urine, as occur in a more general affedion; then, according as more of thefe different circumftanc- es take place, there will be the ftronger ground for fuppofing the afcites to be of the encyfted kind. The chief exception to be made from this as a gene- ral rule, will, in my opinion, be when the afcites may with much probability, be prefumed to have come on in confequence of a fcirrhous liver; which, I appre- hend, may occafion a colledion of water in the cavity of the abdomen, while the general fyftem of the body may not be otherwife much affeded. MDCCXV. With refped to the cure of afcites when of the en- cyfted kind, it does not, fo far as I know, admit of any. When the colledion of water is in the abdomi- nal 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 of the liver, or other confi- derable affedion of the abdominal vifcera, which I conceive to be of very difficult, cure, and therefore the afcites depending upon them. At the fame time, fuch cafes may often admit of a temporary relief by the paracentefis. MDCCXVI When the afcites is a part of univerfal dropfy, it may, as far as other cafes of that kind can, admit of a cure; and it will be obvious, that fuch a cure muft be obtained by the fame means as above propofed for the cure of general anafarca*. It frequently happens that the afoites is attended Vol. II. Y y with * See .the notes on Article 1683. 354 PRACTICE with a diarrhoea; and,-in that cafe, does not admit of the ufe of purgatives fo freely as cafes of anafarca commonly do. It is therefore often to be treated by diuretics almoft 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 fridion of the fkin over the whole of the abdomen, by the fingers dipped in oil. This has fometimes been ufeful in exciting an increafed flow of urrne ; but in moft of the trials of it which I have known made, it has failed in producing that effed. MDCCXVII. The afcites admits ot a particular means for imme- diately drawing off the colleded waters : and that is the well-known operation of the paracentefis of the abdomen. In what circumftances of afcites this ope- ration can moft properly be propofed, it is difficult to determine ; but, fo far as I can judge, it muft be re- gulated by very much the fame confiderationsas 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 refpect to it, are now fo commonly known, and delivered in fo many books, that it is altogether unneceffary for me to offer any directions upon that fubjed here; efpecially after the full and judicious information and diredions given by Mr. Bell, in the fecond volume of his Sjftcm cf Surgery. OF P H Y s i g. 355 CHAP. IV. OF GENERAL SWELLINGS, ARISING FROM AN INCREASED BULK OF THE WHOLE SUBSTANCE OF PARTICULAR PARTS. MDCCXVIII. UPON the fubjeds of this chapter, feveral nofolo- gical difficulties occur, and particularly with re- fped to admitting the Phyfconia into the order of Ge- neral Swellings. At prefent, however, it is not necef- fary for me to difcufs this point, as lam here to omit entirely the confideration of Phyfconia ; both becaufe it can feldom admit of any fuccefsful pradice, and becaufe I cannot deliver any thing ufeful either with regard to the pathology or pradice in fuch a dif- MDCCXIX. The only other genus of difeafe comprehended un- der the title of the prefent chapter, is the Rachitis; and this being both a proper example of the clafs of Cachexy, and of the 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. This opinion, notwithftanding it has beem maintained by perfons of the moft refpedable authori- ty*, appears to me, from many confederations, impro- bable; but it is a point of too little confequence to Y y 2 detain * Boerhaave was of this opinion, fee Van S.vieten's commentary n of bony matter fhall not have been made againft the time there is particular occafi- on ;or it, the difeafe of rickets, that is, of foft and flex- ible 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 menti- oned the bones lhall have acquired their due firmnefs, and that nature goes on in preparing and fupplying the proper bony matter, it may be 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 foft and flexible during the reft of life ; unlefs it happens, as indeed it fometimes does, that certain caufes occur to wafh out again the bony matter from the membranes in which it had been de- pofited. The account 1 have now given of the period at which the rickets occur, feems to confirm the opi- nion of its proximate caufe being a deficiency of bo- ny matter in the fluids of the body, MDCCXXVfl. It has been frequently fuppofed, that a fiphylitie taint has a fhare in producing rickets ; but fuch a fuppofition is altogether improbable. If our opinion of the rickets having exifted in Europe before the fi- > phyiis was brought into it, be well founded, it will then be certain that the difeafe may be occafioned without any fiphylitie actimony having a fhare in its produdion. But further, when a fiphylitie acrimony is tranfmitted from the parent to the offspring, the fymptoms do not appear at a particular time of life on- ly, and commoniy moie early than the period of rick- ets; O F P H Y S I C. 363 ets; the fymptoms alfo are very different from thofe of rickets, and unaccompanied with any appearance of the latter : and, laftly, the fymptoms of liphylis are cured by means which, in the cafe of rickets, have ei- ther no effed, or a bad one. It may indeed poffibly happen, that fiphylis ancl rickets may appear in the fame perfon ; but it is to be confidered as an accident- al complication : and the very few inftances of it that have occurred, are by no means fufficient to efta- blifli any neceffary connedion between the two dif- eafes. MDCCXXVIII. With refped to the deficiency of bony matter, which I confider as the proximate caufe of rickets, fome further conjedures might be offered concerning its remote caufes ; but none of them appear to me ve- ry fatisfying; and whatever they might be, it appears to me they muft again be refolved into the .fuppofition of a general laxity and debility of the fyftem. MDCCXXIX. It is upon this fuppofition 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: and we know that the latter are m.t only fuited to improve the tone of the ftomach itfelf, but by that means to improve aifo the tone of the whote fyftem. MDCCXXX. Of tonic remedies, one of the moft promifing feems to have been cold bathing; and I have found it the moft powerful in preventing the difeafe. lor a long time pail, it has been the pradice in this country, with people of all ranks, to wafh their children from the time of their birth with cold water ; and from the time that children are a month old, it hus been the pradice with people of better rank to have them It z 2 i pped 3. Extr. Cort. P ruv. dur. gr. viii. Pulv. Rad. Riui. gr. x. Sacch. alb. jjr. xv. M. f. pulv. 366 PRACTICE Practitioners have been divided in opinion concern-. ing the ufe of milk in this difeafe. Zeviani, perhaps from theory, condemns the ufe of it; but Benevoli employed it without its impeding the cure of the dif- eafe. This laft I have often remarked in the courfe of my own practice. 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 ma- ny inftances I can affirm, that it did not prevent the cure of the difeafe. 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 breaft; becaufe the milk of women is a more watery nourifhment than that of cows: and I have efpecially diffuaded the continuing a child upon the breaft, when I thought the nurfe gave rather too much of fuch a watery nourifhment; for, as has been above mentioned, I have had frequent occafion to fufpect, that the milk of fuch nurfes has a tendency to favour the coming on of rickets*. MDCCXXXV. Befides the remedies and regimen now mentioned, praditioners have commonly employed in this difeafe, both emetics and purgatives. When the appetite and digeftion are coniiderabiy impaired, vomiting, if' nei- ther violent nor frequently repeated, feems to be of fervice ; and, by a moderate agitation of the abdomi- nal vifcera, may in fome meafure obviate the ftagna- tion and confequent fwelling that ufually occur in them. As the tumid ftate of the abdomen, fo conftantly to be met with in this difeafe, feems to depend very much upon a tympanitic affection of the inteftines : fo, both by obviating this, and by deiiving from the abdomi- nal vifcera, frequent gentle purgatives may be of fer- vice * How ones to's accord with the laft fentence of art'eoe 17Z2. O F P H Y S I C. 367 vice. Zeviani, perhaps propel ly, recommends in par- ticular rhubarb ; which, befides its purgative quality, has thofe alfo of bitter and aftringent. MDCCXXXVI. I have now mentioned moft of the remedies com- monly employed by the praditioners of former times ; but I muft not omit mentioning fome others that have been lately fuggefted. The late Mr. De Haen re- commends the teftacea; and affures of their having been employed with fuccefs; but in the few trials which I have had occafion to make, their good effects did not appear. The late Baron Van Swieten gives us one inftance of rickets cured by the ufe of hemlock ; but I do not know that the practice has been repeated. BOOK III. OF THE IMPETIGINIS; O R. DEPRAVED HABIT, WITH AFFECTIONS OF THE SKIN. MDCCXXXVII. I FIND it diificult to give any fufficiently correct and proper character of this order. The difeaic* comprehended under it, depend, for the moft part, up- on a depraved ftate of the whole of the fluids, produc- 68 PRACTICE ing tumours, eruptions, or other preternatural affec- tions of the fkin. Although it be extremely difficult to find a general character of the order that will ap- ply to each of the genera and fpecies, I fhall here treat of the piincipal genera which have been commonly comprehended under this order, and which I have enumerated in my Nofology. CHAP. I. OF SCROPHULA, OR THE KING's EVIL. MDCCXXXVIII. THE character of this difeafe I have attempted in my Nofology : but it will be more properly taken from the whole of its hiftory, now to be deliver- ed. MDCCXXXIX. It is commonly, and very generally, a hereditary difeafe; and although it fometimes may, yet it rarely appears, but in children whofe parents had at fome period of their lives been affected 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 cer- tainly determine; but believe that this has frequently happened. It appears to me to be derived more com- monly from fathers than from mothers; but whether this happens from there being more fcrophulous men than fcrophulous women married, I am not certain. With refpect to the influence of parents in produc- ing this difeafe, it deferves to be remarked, that in a family of many children, when one cf the parents has been OF PHYSIC. 56$ been affected with fcrophula, and the other not; as it is ufual f >r fome of the children to be in con- ftitution pretty exactly like the one parent, and others of them like the other; it commonly happens, that thofe children who moft refemble the fcrophulous pa- rent become affected with fcrophula, while thofe..re- fembling the other parent entirely efcape. MDCCXL. The fcrophula generally appears at a particular pe- riod of life. It feldom appears in the firft, or even in the fecond year of a child's life ; and moft commonly it occurs from thefecondj or, as fome alledgc, and per- haps more properly, from the third, to the feventh year. Frequently, however, it difcovers itfelf at a later period ; and there are inftances of its firft appear- ance, at every period till the age of puberty; after which, however, the firft appearance of it is very rare. MDCCXLI. Whert it does not occur very early, we can general- ly diftinguifh the habit of body peculiarly difpofed to it. It moft commonly affects children of foft and flaccid habits, of fair hair and blue eyes ; or at leaft affects thofe much more frequently than thofe of an oppofite complexion. It affects efpecially children of fmooth fkins and rofy cheeks; and fuch children have frequently a tumid upper lip, with a chop in the mid- dle of it; and this tumour is often confiderable, and extended to the columna nafi and lower part of the hoftrilsi 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 fore- head, by tumid joints, and a tumid abdomen, fhow that they had fome rachitic difpofition. In parents who, without having had tt>e difeafe themfelves, feem to produce fcrophulous children, we can commonly Vol. II. 3 A per- 370 PRACTICE perceive much of the fame habit and conftitution that has been juft now defcribed. Some authors have fuppofed that the fmall-pox has a tendency to produce this difeafe ; and Mr. DeHaen afterts its following the inoculated, more frequently tharr'the natural fmall-pox. This laft pofition, how- ever, we can confidently affirm to be a miftake; al- though it muft be allowed, that in fact the fcrophula does often come on immediately after the fmall-pox. It is, however, difficult to find any connection between the two difeafes. According to my obfervation, the accident only happens in children who have pretty manifeftly the fcrophulous difpofition ; and I have had feveral inftances of the natural fmall-pox coming up- on children affected 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 fome time after much relieved. MDCCXLII. The fcrophula generally fhows itfelf firft at a par- ticular feafon of the year; and at fome time between the winter and fummer folftice ; but commonly long before the latter period. It is to be obferved further, that the courfe of the difeafe is ufually connected with the courfe of the feafons. Whilft the tumours and ulcerations peculiar to this difeafe, appear firft in the fpring, the ulcers are frequently healed up in the courfe of the fucceeding fummer, and do not break out again till the enfuing fpring, to follow again with the feafon the fame courfe as before. MDCCXLIII. Frequently the firft appearance of the difeafe is the tumid and chopped lip above mentioned. Upon other occafions, the firft appearance is that of fmall fpheri- cal or oval tumours, moveable under the fkin. They ate foft, but with fome elafticity. They are without pain; and without any change in the colour of the fkin. OF PHYSIC. 37» fkin; In this ftate they often continue for a. long time; even for a year or two, and fometimes longer. - Moft commonly they firft appear upon the fides of the neck below the ears; but fometimes alfo under the chin. In either cafe, they are fuppofed to affect in thefe places the conglobate or lymphatic glands only : and not at all the falivary glands, till the dif- eafe is very greatly advanced. The difeafe frequently affects, and even at firft 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 ap- pearances about the joints are not commonly, as elfe- where, fmall moveable fwellings; but a tumour almoft 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 appear in the fpring, they often continue in this way till the return of the fame feafon in the next, cr perhaps the fecond year after. About that time, however, cr per- haps in the courfe of the feafon in which they firft ap- pear, the tumour becomes larger and more fixed ; the fkin upon it requires a purple, feldom a clear rednefs : but growing redder by degrees, the tumour becomes fofter, and allows the fluctuation 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 appearance of pus, but it is ufually of a thinner kind than that from pblegmonic abfeeffes ; and the matter as it continues to be difcharged, becomes daily ltfs purulent, and ap- pears more and more a vifcid ferum, intermixed with fmall pieces of a white fubftance refembling the curd of milk. By degrees the tumour almoft entirely fub- 3 A 2 fides 372 PRACTICE fides while the ulcer opens more, and fpreads broad-. er : unequally, however, in different directions, and therefore is without any regular circumfcription.—■ The edges of the ulcer are commonly flat and fmooth, both on their outfide and their inner edge, which fel- dom puts on a callous appearance. The ulcers, how- ever, dd not generally fpread much, or become deep- er ; but at the time their edges do not advance, or puij pn any appearance of forming a cicatrix. MDCCXLVI. In this condition the ulcers often continue for a long time; while new tumours, with ulcers fucceed- ing them in the manner above defcribed, make their appearance in different parts of the body. Of the firft ulcers, however, fome heal up, while other tu- mours and ulcers appear in their vicinity, or in other parts of the body ; and in this manner the difeafe proceeds, fome of the ulcers healing up, at leaft to a certain degree, in the courfe of fummer, and breaking out again in the fucceeding fpring ; or it continues, by new tumours and ulcers fucceeding them, in the fpring feafon, making their appearance fucceffively for. feveral years. MDCCXLVII. In this way the difeafe goes on for feveral years;. but very commonly in four or five years it is fpontane- oufly cured, the former ulcers being healed up, and no new tumours appearing ; and thus at length the difeafe ceafes entirely, leaving only fome indelible efchars, pale and fmooth, but in fome parts fhriyelled; or, where it had occupied the joints, leaving the mo- tion of thefe impaired, or entirelv deftroved. MnCCXLVIH. Such is the moft favourable courfe of this difeafe ; and with us, it is more frequently fuch, than other- wife : but it is often a more violent, and fometimes a fatal malady. In thefe cafes, more parts of the body are f OF PHYSIC. 3'>3 • $re at the fame time affected ; the ulcers alfo feeming ;o be imbued with a peculiar fharp acrimony, and therefore becoming more deep, eroding, fpreading, as well as feldomer healing up. In fuch cafes, the eyes are often particularly affected. The edges of the eye- lids are affected with tumour and fuperficial ulcera- tions ; and thefe commonly excite obftinate inflamma- tion in the adnata, wftich frequently produces an opa- city of the cornea. When the fcrophula efpecially affects the joints, it fometimes produces there confiderable tumours ; in the abfceffes following which, the ligaments and car- tilages are' eroded, and the adjoining bones are affect- ed 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 acri- mony feems at length to taint the whole fluids of the body, occafioning various diforders; and particularly a hectic fever, with all its fymptoms, which at length proves fatal, with fometimes the fymptoms of phthiiis pulmonalis. MDCCXLIX. The bodies of perfons who have died of this difeafe {how many of the vifcera in a very morbid ftate ; and particularly moft of the glands of the menfentery very much tumefied, and frequently in an ulcerated ftate. Commonly alfo a great number of tubercles or cyfts, containing matter ofvarrouskinds, appear 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 affection of the lymphatic fyftem ; and this in fome meafure accounts for its connection with a particular period of life. Probably, however, there is a peculiar acrimony of the fluids that is in the proximate caufe of the difeafe; al- though 374 PRACTICE (hough of what nature this is, has not yet been difco^ vered. It may perhaps be generally diffufed in the fyftem, and exhaled into the feveral cavities and cellu- lar texture of the body : and therefore, being taken up by the abforbents, may difcover itfelf efpecially in the lymphatic fyftem. This, however, will hardly account for its being more confined to that fyftem, than happens in the cafe of mauy other acrimonies which maybe fuppofed to be as generally diffufed.— In fhort, its appearance in particular conftitutions, and at a particular period of life, and even its being a hereditary difeafe, which fo frequently depends upon the tranfmiflion of a peculiar conftitution, are air of them circumftances which lead me to conclude, upon the whole, that this difeafe depends upon a peculiar cotiftitution of the lymphatic fyflem. MDCCLL It feems proper to obferve here, that the fcrophula, docs not appear to be a contagious difeafe; at leaft I have known many inftances of found children having had frequent and clofe intercourfe with fcrophulous, chiidren'without being infected with the difeafe. This, certainly fhows, that in this difeafe the peculiar acri- mony of it is not exhaled from the furface of the body\ but that it depends efpecially upon a peculiar confti- tution of the fyftem. MDCCLII. Several authors have fuppofed the fcrophula to have been derived from the venereal difeafe ; but upon no juft grounds that I can perceive. In very many in- itances, there can hardly be any fufpicion of the pa- rents producing this difeafe having been imbued with fiphylis ro their offspring, in whom, however, no fcro- phulous fymptoms at any time afterwards appeared. Further, the fymptoms of the two difeafes are very dif- ferent ; and the difference of their natures appear par^ ticularly from hence, that while mercury commonly and Of physic. 375 and readily cures the fiphylis, it does no fervice irt fcrophula, and very often rather aggravates the dif- eaf:. MDCCLIII. For the cure of fcrophula, we have not yet learned any practice that is certainly or even generally fuccefs* ful. The remedy which feems to be the moft fuccefsful, and which our practitioners efpecially truft to and employ, is the ufe of mineral waters; and indeed the wafhing out, by means of thefe, the lymphatic fyftem, Would feem to be a meafure promifing fuccefs : but in very many inftances of the ufe of thefe waters, I have not been well fatisfied that they had fhortened the du- ration of the difeafe more than had often happened when no fuch remedy had been employed. MDCCL1V. 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 chaly- beate, fulphureous, or faline, have been employed for the cure of fcrophula, and feemingly with equal fuc- cefs and reputation : a circumftance which leads me to think, that, if they are ever fuccefsful, it is the ele- mentary water that is the chief part of the remedy. Of late, fea-water has been efpecially recommend- ed and employed; but after numerous trials, 1 cannot yet difcover its fuperior efficacv. MDCCLV The other remedies propofed by practical writers are very numerous; but, upon that very account, I apprehend they are little to be trufted: and as 1 can- not perceive any juft reafon for expecting fuccefs from them, I have very feldom employed them. Of late, the Peruvian bark has. been much recom- mended : and as in fcrophulous perfons there are ge- nerally 3?G PRACTICE nerally fome marks of laxity and flaccidity, this toaie may poffibly be of fervice; but in a great variety of trials, I have never feen it produce any immediate cure of the difeafe. In feveral inftances, the leaves of Colts-foot have appeared to me to be fuccefsful. I have ufed it fre- quently in a ftrong decoction, and even then with ad- vantage : but have found more benefit from the ex- preffed juice, when the plant could be had in fomewhat of afucculent ftate, foon after its firft appearance in the fpring. MDCCLVI. I have alfo frequently employed the hemlock, and have fometimes found it ufeful in difcuffing obftinate fwelhngs: but in this* it has alfo often difappointed me : and I have not at any time obferved that it dif- pofed fcrophulous ulcers to heal. I cannot conclude the fubjed of internal medicines without remarking, that I have never found either mercury or antimony, in any fhape, of ufe in this dif- eafe; and when any degree of a feverifh ftate had come on, the ufe of mercury proved manifeftiy hurtful MDCCLVII- In the progrefs of icropnula, feveral external medi- cines are requifite. Soveral applications have been ufed for difcuffing the tumours upon their firft com- ing on; but hitherto my own practice, in thefe re- fpeds, has been attended with very little fuccefs.— The folution of the faccharum faturni has feemed 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 fuppuration. I am doubtful if this laft be ever pradifed with advantage; for fcrophulous tumours fometimes fpontaneoufly difappear, but never after a- ny degree of inflammation has come upon them ; and therefore poultices, which commonly induce in- • flam mat ion OF P H Y S I t 377 ftammation, prevent that difcuffion of tumours, which might otherwife have happened. Even when fcrophulous tumours have advanced to- wards fuppuration, I am unwilling to haften the fpon- taneous opening, or to make it by the lancet; becaufe I apprehend the fcrophulous matter is liable to be ren- dered more acrid by communication with the air, and to become more eroding and fpreading than when in its inclofed ftate; MDCCLVIIL The management of fcrophulous ulcers has, fo far as I know, been as little fuccefsful as that of the tu- mours. Efcharotic preparations, of either mercury'or copper have been fometimes ufeful in bringing on a proper fuppuration, and thereby difpofing the ulcer to heal; but they have feldom fucceeded, and more com- monly 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 ointment, has been as ufeful an application as a- ny I have tried. The application, however, that I have found moft ferviceable and very univerfally sd- miffiblej is that of linen cloths wetted with cold water, and frequently changed when they are becoming dry, it being inconvenient to let them begliied to the fore. They are therefore to be changed frequently during the day ; and a cloth fpread with a mild ointment or plaifter may be applied for the night. In this prac- tice I have fometimes employed fea-water; but gene- rally it proved too irritating; and neither that nor any mineral water has appeared to be of mire 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 occafion to fee employed. Vol. H. 3 B c A A r- 373 PRACTICE CHAP. II. OF S1PHILIS, OR THE VENEREAL DISEASE, MDCCLX. AFTER praditioners have had fo much experi- ence in treating this difeafe, and after fo many books have been publifhed upon the fubjed, it does not fesm neceffary, or even proper, for me to attempt any full treatife concerning it; and I fhall therefore confine myfeif to fuch general remarks, as may ferve to illuftrate fome parts of the pathology or of the pradice. MDCCLXI. It is fufficiently probable, that, anciently, in certain parts of Afia, where the leprofy prevailed, and in Eu- rope after that difeafe had been introduced into it, a difeafe of the genitals, refembling that which now commonly arifes from fiphylis, had frequently appear- ed : but it is equally probable, that a new difeafe, and what we at prefent term Siphylis, was firft brought in- to Europe about the end of the fifteenth century; and that the diftemper now fo frequently occurring, has been very entirely derived from that which was im- ported from America at the period mentioned*. MDCCLXII. * Various opinions have been held by different phyficians about the origin of this difeafe ; fome fuppofing it to have exiited in the old world, while otliers think it was imported from the new world, difcovered by Columbus. Thedifpute produced many controverfial traces, from the perufal of which, the young prac-titiqner can gain little advantageous knowledge. All that we certainly know about the origin of the difeafe is, that it was firft obferved among the French, when they were at Napferin the year 1493, and that it was brought into France by the French who returned thither with Charles. Co- lumbus landed at Palos on the 15th of March in the fame year, on his return from his firft voyage. The difeafe therefore, if imported by Columbus's trew m«ft have fpread rapidly through Europe. OF PHYSIC. 379 MDCCLXII. This difeafe, at leaft in its principal circumftances, never arifes in any perfon but from fome communi- cation with a perfon already affeded with it. It is moft commonly contraded in confequence of coition with an infeded perfon ; but in what manner the in- fedjon is communicated, is not clearly explained. I am perfuaded, that in coition, it is communicated without there being any open ulcer either in the per- fon receiving the infedion; but in all other cafes, I believe it is never communicated in any other way than by a contad of ulcer, either in the perfon com- municating, or in the perfon receiving the infedion. MDCCLXIII. As it thus arifes from the contad of particular parts, fo it always appears firft in the neighbourhood of the parts to which the infeding matter had been immedi- diately applied; and therefore, as moft commonly contraded by coition, it generally appears firft in the genitals. MDCCLXIV. After its firft appearance in particular parts, more efpecially when thefe are the genitals of either fex, iis effeds for fome time feem to be confined to thefe parts; and indeed, in many cafes, never extends fur- ther. In other cafes, however, the infeding matter paffes from the parts firft affeded, and from the geni- tal, therefore, into the blood-veffels ; and being there diffufed, produces diforders in many other parts of the body. From this view of the circumftances, phyfi fans have very properly diftinguifhed the different ftates ot the difeafe, according as they are local or are more univerfal. To the former, they have adapted appella- tions fuited to the manner in which the difeafe ap- pears; and to the other the general affection, they' have almoft totally confined the appellations of Sifhy- 3 B 2 lis, k o-*J PRACTICE lis, Lues Venerea, or Pox. In the remarks I am now to offer, I fhall begin with confidering the local affec- tion. MDCCLXV. This local affedion appears chiefly in the form of gonorrhoea or chancre. The phenomena or gonorrhoea, either upon its firft coming on or in its after progrefs, or the fymptom^ of ardor urinse, chordee, or others attending it, it is not neceffary for me to defcribe. I fhall only here obferve, that the chief circumftance to be taken notice of, is the inflamed ftate of the urethr^, which I tak? to be infeparable from the difeafe. MDCCLXVL In thefe well-known circumftances, the gonorrhoea continues for a time longer or fhortcr, according to the conftitution of the patient; it ufually remaining Iongeft in the irtoft vigorous and robuft, or according to the patient's regimen, and the care taken to relieve or cure the difeafe. In many cafes, if by a proper re- gimen the irritation of the inflamed ftate is carefully avoided, the gonorrhoea fpontaneoufly. ceafes, the fymptoms of inflammation gradually abating, the mat- ter difcharged becoming of a thicker and more vifcid confiftence, as well as of a whiter colour ; till at length, the flow of it ceafes altogether ; and whether it be thus cured fpontaneoufly, or by art, the difeafe. often exifts without communicating any infedion to, the other parts of the body. MDCCLXVII. In other cafes, however, the difeafe having been neglcdcd, or by an improper regimen aggravated, it continues with all its fymptoms for a long time; and produces various other diforders in the genital parts, which, as commonly taken notice of by authors, need not be defcribed heie. I ftiail only obferve, that the inflammation of the urethie, which at firft feems to be OF PHYSIC. 381 fee feated chiefly, or only, in its anterior parts, is in fuch negleded and aggravated cafes fpread upwards along the urethra, even to the neck of the bladder. In thefe circumftances, a more confiderable inflam- mation is occafioned in certain parts of the urethra; and confequently, fuppuration and ulcer are produc- ed, by which the venereal poifon is fometimes com- municated to the fyftem, and gives rife to a general fiphylis. MDCCLXVIil. It was fome time ago a pretty general fuppofition, that the gonorrhoea depended always upon ulcers of the urethra, producing a difcharge of purulent mat- ter; and fuch ulcers do indeed fome times occur in the manner that has been juft now mentioned. We are now affured, however, from many diffedions of perfons who had died when labouring under a goncr- ihcea, that the difeafe may exift, ancl from many con- federations it is probable that it commonly does exift, without any ulceration of the urethra ; fo that the dif- charge which appears, is entirely that of a vitiated mu- cus from the mucous follicles of the urethra. MDCCLXIX, Although moft of the fymptoms of gonorrhoea ftiould be removed, yet it often happens that a mu- cous fluid continues to be difcharged from the urethra for a long time after, and fometimes for a great parr. of a perfon's life. This cjifcharge is what is common- ly called a Gleet. With refped to this, it is proper to obferve, that in fome cafes, when it is certain that the matter difcharg- ed 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 dif- charge at the beginning and during the courfe of vi- rulent gonorrhoea. Thefe appearances in the matter cf a gleet, which before had been of a lefs coloured 3S2 PRACTICE kind, have frequently given occafion to fuppofe that a frefh infedion had been received : but I am certain that fuch appearances may be brought on by, per- haps, various other caufes; and particularly, by in- temperance in venery and drinking concurring toge* ther. I believe, indeed, that this feldom happens to any but thofe who had before frequently laboured under a virulent gonorrhoea, and have more or lefs of gleet remaining with them: but I muft alfo obferve, that in perfons who at no period of their life had ever laboured under a virulent gonorrhoea, or any other fymptom of fiphylitie affedion, I have met with in- ftances of difcharges from the urethra refembling thofe ofa virulent gonorrhoea. The purpofe of thefe obfervations is, fo fuggeft to praditioners what I have not found them always aware of, that in perfons labouring under a gleet, fuch a re- turn of the appearances of a virulent gonorrhoea may happen without any new infedion having been receiv- ed, and confequently not requiring the treatment which a new infedion might perhaps demand. When, in the cure of gonorrhoea, it was the pradice to em- ploy purgatives very frequently, and fometimes thofe of the draftic kind, I have known the gleet, or fpuri- ous gonorrhoea, by fuch a pradice much increafed and long continued, and the patient's conftitution ve- ry much hurt. Nay in order more certainly further to prevent miftakes, it is to be obferved, that the fpu- rious gonorrhoea is fometimes attended with heat of urine, and fome degree of inflammation ; but thefe fymptoms are feldom confiderable, and, merely by the affiftance of a cool regimen, commonly difappear in a few days. MDCCLXX. With refped to the cure ofa virulent gonorrhoea* I have only to remark, that if it be true, as I have men- tioned above, that the difeafe will often, under a pro- per OF P H Y S I C. 38J per regimen, be fpontaneoufly cured; and that the whole of the virulent matter may be thus entirely difcharged without the affiftance of art; it would feem that there is nothing required of praditioners, but to moderate and remove that inflammation which continues the difeafe, and occafions all the trouble- fomc fymptoms that ever attend it. The fole bu- finefs 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, by avoiding ex- ercife, by ufing a low and cool diet, by abftaining en- tirely from fermented and fpirituous liquors, and by taking plentifully of mild diluent drinks.* MDCCLXXL * This fimple method of curing a gonorrhoea is, in many cafes, fufficient, but it can only be depended on- when the difeafe is flight and the patient ofa healthy conftitution. As every virulent gonor- rhoea is evidently produced by the action of the venereal poifon, the judicious practitioner will feldom truft to this method without the ufe of mercurials after the inflammatory fymptoms have been fome what fubdued. They ought to be given in fuch cafes in very fmall quantities, fo as to produce onty a flight effect on the mouth ; and their ufe ought to be continued till every fymptom difappeats. Mercury may be ufed internally or externally as occailon may re- quire; if it does not affect the bowels nor purge, the eommon mer- curial pill of the Edenburgh pharmacopcea is as good a formula as any we have in the fhops. It's dofe muft be regulated by the effect^ it produces. In general, we begin with a four grain pill every night,. and continue that quantity till the gums be flight ly affeded, or a coppeiy tafte be perceived in the mouth. When either of thefe fymptoms appear, we are certain that the mercury is received, in p: fufficient quantity, into the general mafs of the blood, for deftroying the venereal virus, and then a pill may be given once in two or three days, fo as to keep up the fame flight affection of the mouth, but without increafing it. If the pill purges, we then are to have re- courfe to the ftrong mercurial ointment, half a dram of which mult be rubbed into the hams night and morning, till the mouth be af- fected in the manner above defcribed. The patient ought to wear flannel drawers during the whole time of the continuing the rubbing, which ought to be regulated by the degree of affection perceived in the mouth. The ufe titlier of the pill or of friction mult be continued eight or ten day? after every fymptom of the difeafe ha3 difappeared. 384 $ R A C T I t E MDCCLXXI. The heat of urine, which is fo troubleforhe in this* difeafe*, as it arifes from the increafed fenfibility of the urethra in its inflamed ftate ; fo} on the other hand, the irritation of the urine has the effed of increafing the inflammation, and is therefore to be removed as foon as poffible. This can be done moft effedually by tak- ing in a large quantity of mild watery liquors. De- mulcents may be employed; but unlefs they be ac- companied with a large quantity of water, they will- have little effed.* Nitre has been commonly employ- ed as a fuppofed refrigerant: but, from much obfer- vation, I am convinced, that in a fmall quantity it Is ufeleis, and in a large quantity certainly hurtful*; and for this reafon, that every faline matter paffing with the urine generally gives fome irritation to the urethra. To prevent the irritation of the urethra arifing from its increafed fenfibility, the injedion of mucilage or of mild oil into it has been pradifed ; but I have feldom found this of much fervice. MDCCLXXIt. In gonorrhoea, as conftivenefs may be hurtful, both by an irritation of the fyftem in general, and of the urethra in particular, as this is occafioned always by the avoiding of hardened faeces ; fo conftivenefs is to be carefully avoided or removed ; and the frequent ufe of large glyfters of water and oil, I have found of remar- kable benefit in this difeafe. If glyfter9, however, (jlo hot * Lintfeed-tea, a very thin decoction of marfh-mallow root, or thin barley-vvater, will, in moft cafes, anfwer the intention fufficient- ly well. The common almond emulfion has been recommended in thefe cafes, and when taken in large quantities is certainly very effica- cious. It may be ufed as the patient's common drink. -f The ufe of nitre has been ltrongly recommended by many practi- cal writers, in cafes of fimple gonorrhoea accompained with th's fymp- tom ; but it muft be acknowledged, (as the authorjuftly obfeives,) to be hurtful by it's irritating quality. It is certainly a ichingrran*. OF PHYSIC. 5S5 not entirely obviate coftivenefs, it will be neceffary to give laxatives by the rnouth : which, however, ftiould be of the mildeft kind, and Humid do no more than keep the belly regulac and a little loofe, without much purging*. The piadiee of frequent purging, v/hich was for- merly fo much in ufe, and is not yet entirely laid afide, has always appeared to me to be generally fuperfluous, and often very hurtful. Even what are fuppofed to be cooling purgatives, fuch as Glauber's fait, foluble tartar, and cryftals of tartar, in fo fur as any part of them pafs by urine, they, in the fame manner as we have faid of nitre, may be hurtful; and fo far as they produce very li- quid ftools, the matter of which isgenerally acrid, they ir- ritate the redum, and confequently the urethra. This laft effed, however, the acrid, and in any degree draf- tic, purgatives, more certainly produce. MDCCLXXIII. In cafes ofa gonorrhoea attended with violent inflam- mation, blood-letting may be of fervice; and iii the cafe of perfons of a robuft and vigorous habit, in whom the difeafe is commonly the moft violent, blood-letting may be very properly employed. As general bleed- ings, however, when there is no phlogiftic diathefis in the fyftem, have little effed in removing topical in- flammation ; fo in gonorrhoea, when the inflammation is confiderable, topical bleeding applied to the urethra Vol. II. 3 c by and as fuch is allaying ^he inflammatory fymptoms; but it is ir.ad- miflible in cafes where the ardor Uiirne is violent. * A tea-fpoonful of the following electuary taken cccafionJly will keep the belly fufficiently open. &. Pulv. Jalap. 3i. Nitri. |ii. Elect. Lenitiv. gi. Syr. Simpl. q, f. M. f. LLct. 386 PRACTICE by leeches, is generally more effedual in relieving the inflammation*. MDCCLXXIV. When there is any phymofis attending a gonorrhoea, emolient 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 bel- ly, when the patient either walks about or is fitting}. MDCCLXXV. Upon occafion of frequent priapiftn and chordee, it has been found ufeful to apply to the whole of the pe- nis a poultice of crumb of bread moiftened with a ftrong folution of fugar of lead. I have, however, been often difappointed in this pradice, 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 folution of the fugar of lead, might be ufeful in this cafe, I have not properly triedf. MCCCLXXVI. With refped to the ufe of injedions, fo frequently employed in gonorrhoea, I am perfuaded that the early ufe of aftringent injedions is pernicious ; not by oc- cafioning * The good effe&s of leeches in thefe cafes arc confirmed by ex- perience. They may be applied on the under fide of the penis, and rjiree or four thus applied have frequently produced amazing effects. The operation, however, is extremely painful, and is feldom fub- mitted to a fecond time by a patient who has once experienced it. § In all cafes of inflammation of the urethra thefe emollient ap- plications give great relief. The common white bread poultice may be ufed during the night time or while the patient is in bed; and, warm flannels impregnated with lintfeed-tea while he is fitting up. f The fugar of lead folution may perhaps be objected againft on account of it's flopping the difcharge, and inducing a fwelled tefticle, which has fometimes followed it's application. Wrapping the penis up in linen rags wet with cold water, frequently anfwers the purpofe of preventing the violence of the fymptoms, as well as any more complicated application. The cold wet rags ought to be renewed v/henever thsy grow warm. O F P H Y S I C. 387 cafioning a fiphylis, as has been commonly imagined; but by increafing and giving occafion to all the confe- quences of the inflammation, particularly to the very troublefome fymptoms of fwelled tefticles. When, however, the difeafe has continued for fome time, and the inflammatory fymptoms have very much abated, I am of opinion, that by injedions of moderate aftrin- gency, or at leaft of this gradually increafed, an end may be fooner put to the difeafe than would other- wife have happened ; and that a gleet, fo readily oc- curring, may be generally prevented*. MDCCLXXVII. Befides the ufe of aftringent injedions, it has been common enough to employ thofe of a mercurial kind. With refped to thefe, although I am convinced that 3 C 2 the * The practice of ufing aftringent injections is extremely com- mon ; but, fas the author juftly obferves,) their ufe is frequently at- tended with difagreeable confequences. In general they do harm when ufed during the continuance of the inflammatory fymptoms, or even too foon after thefe fymptoms have difappeared. If, how- ever, (after the inflammatory fymptoms are overcome, and mercury has been ufed for fix weeks or two months in the manner defcribed in the note on article 1770,) the iunning ftill continues, we may then have recourfe to thefe aftringent injections. They may be made of fugar of lead and white vitriol well diluted with water as in the following: &. Sacch. Saturn, Vitriol, alb. a a 5fs. Aq. font, |;viii. M. et cola per chartam. Half an ounce of this injection flightly warmed may be thrown up in the urethra twice a-day ; but if it produce any fmarting, it ouo-ht to be diluted with more water, Solutions of copper have alfo been ufed with advantage in thefe cafes, but they are of fo corrofive a nature, as frequently to do harm, if not verv much diluted. An imprudent or too frequent ufe of any thefe injections, efpecially if they are too ftrong or not fufficiently diluted, fometimes inflames or even excoriates the urethra, and hence much mifchief arifes. The cautious practitioner muft therefore never ufe them fo flrong as to produce much fmai ting. 3S8 PRACTICE the infedion producing gonorrhoea, and that produc- ing chancres and fiphylis, are one and the fame ; yet I apprehend, that in gonorrhoea mercury cannot be of ufe by correding the virulence of the infedion ; and therefore that it is not univerfally neceflary in this difeafe. I am perfuaded, however, that mercury ap- plied to the internal furface of the urethra, may be of ufe in promoting the more full and free difcharge of virulent matter from the mucous,glands of it. Upon this fuppofition, I have frequently employed mercu- rial injedions ; and, as 1 judge, with advantage ; thofe injedions often bringing on fuch a ftate of the confiftence and colour of the matter difcharged, as we know ufually to precede its fpontaneous ceafing. I avoid thefe injedions, however, in recent cafes, or while much inflammation is ftill prefent ; but when that inflammation has fomewhat abated, and the dif- charge notwithftanding ftill continues in a virulent form, I employ mercurial injedions freely. I employ thofe only that contain mercury entirely in a liquid form, and avoid thofe which may depofite an acrid poweder in the urethra. That which I have found' moft ufeful is a folution of the corrofive fublimate in water; fo much diluted as not to occafion any violent fmarting, but not fo much diluted as to give no fmart- ing at all. It is fcarce neceffary to add, that when there is reafon to fufped there are ulcerations already formed in the urethra, mercurial injedions are not only proper, but the only effedual remedy that can be employed. MDOCLXXVIU. • With regard to the cure of gonorrhoea, I have only one other remark to offer. As moft of the fymptoms arife from the irritation ofa ftimulus applied, the ef- feds of this irritation mav be often leflened by dimi- nifhing the irritability of the fyijem ; and it is well known, that the moft certain means of accomplilhing OF PHYSIC. 389 this is by employing opium For that reafon, I con- fider the practice both of applying opium di'-edlv to the urethra*, and of exhibiting it by the mouthj to be extremely ufeful in moft cafes of gonorrhoea. MDCCLXXIX. After thus offering fome remarks with refped to go- norrhoea in general, I might proceed to confider par- ticularly the various fymptoms which fo frequently at- tend it; but it does n )t feem neceffiirv for me to at- tempt this after the late publications of Dr. Foart Simmons, and of Dr. Schwediaur, who have treated the fubjed fo fully, and with fo much difeeinmcnt andfkill§. , MDCCLXXXI. * Opium may be very conveniently applied to the urethra by in- jection ; and for this purpofe a diluted folution of opium in water is preferable to a fpirituous or vinous folution. A grain of opinni diffolved in an ounce of water, and the folution drained, may be in- jected twice or thrice a-day ; and thiity or forty drops of laudanum may be given every night at bed-time. (J Asa fwelled tefticle frequently attends a funpreffeu gonorrhoea, it may be proper to give the young practitioner iome uirectiuns con- cerning the management of it. Sometimes without any other preceding fvrr.ptom, but genevnliv pi a premature flopping ofa gonorrhoea, a pain is felt in the fper- matic veffels and epididymis. The pair, continuing, the veffels an J epididymis begin to fwcll. and the pain and fwelling are foon com- municated to the tefticle. In thefe cafes, we mull confine the patient to his bed, bleeding him if the inflammatory diathefis appears to* be univerfp! ; but, if not, three or four leeches may be applied to the inilamed patt. A briflv purge muft be given, for which purpofe an ounce of Glauber's Salt, with a large quantity of water, anfwers fufficiently well Gold pledgets foaked in a folution of Sugar of Lead, defcribed in the note on article 267. mult be applied to the Scrotum, and their place fupplied with frefli cold ones, as often as they grow warm by lyin<; on the parts. A warm poultice of bread and milk, muft be alfo ap- plied to the glans penis or to the whole penis. The patient mu:l be ki'nt on a ver\. fpare diet, ufnig (or his drink cold water with a fcru- j le of nitre in each pint of it. This regimen generally allays the violence of the fymptoms, within twenty four hours ; but, it will be neceffary to continue the ufe of the cold pLdgets *nd warm poul- 38a PRACTICE MDCCLXXX. . The other form of the local affedion of fiphylis, is that of chancre. The ordinary appearance of this I need not defcribe, it having been already fo often done. Of the few remarks I have to offer, the firft is, that 1 believe chancres never appear in any degree without immediately communicating to the blood more or lefs of the venereal poifon ; for I have conftantly, when- ever chancres has appeared, found, that unlefs mer- cury was immediately given internally, fome fymp- toms ofa general fiphylis did certainly come on after- wards ; and though the internal ufe of mercury fhould prevent any fuch appearance, it is ftill to be prefumed that the poifon had been communicated, becaufe mer- cury could ad upon it in no other manner than as dif- fufed in the fluids. MDCCLXXXI. It has been a queition among praditioners, upon the fubjed of chancres, Whether they may be imme- diately healed up by applications made to the chancres, or if they fhould be left open for fome time without any fuch application ? It has been fuppofed, that the fudden tice for three or four days or longer, and to repeat the purge. After the pain and fwelling have been completely removed, the patient may fit up, but it will be prudent for him to ufe a fufpenfory bandage for the fcrotum, as the weight of the tefticles, by ftretching fpermatics cords will be apt to occafion the return of all the fymptoms. Sometimes the gonorrhoea,if it has preceded the fwellings of the epididymis and tefticles, will be a-jain brought on ; but, it likewife fometimes happens that, on difcuffinfr the tumor in the fcrotnm the glands of the groin begin to be painful and to fvvell. • In thefe cafes we muft apply cold p'edgets to thefe glands as well as to the fcro- tum ; and rub, at the fame time, fome ftrong mercurialointment on the infide of the thighs, in the courfe of the lymphatics going to thefe glands ; and, if the penis be not inflamed, half a dram or a fcruple of mercurial ointment ought to be rubbed on the bafe of the glans penis in the infide of the prepuce. Such is the general method of treating cafes of this>kind, and a pru- dent continuance of it feldom fail of fuccefs. O F P H Y S I C. 301 fudden healing up of chancres might immediately 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 long- er a chancre is kept open, the more poifon it perhaps generates, and certainly fupplies it more copioufly to the blood. And although the above-mentioned fup- pofition were true, it will be of little confequence, if the internal ufe of mercury, which I judge neceffary in every cafe of chancre, be immediately employed. I have often feen very troublefome confequences fol- low from allowing chancres to remain unhealed ; and the fymptoms of general fiphylis have always feemed to me to be more confiderable and violent in propor- tion as chancres, had been fuffered to remain longer unhealed : They fhould always, therefore, be healed as foon as poffible ; and that by the only very effedu- al means, the application of mercurials to the chancre itfelf. Thofe that are recent, and have not yet form- ed any confiderable ulcer, may often be healed by the common mercurial ointment; but the moft powerful means of healing them has appeared to me, to be the application of red precipitate in a dry powder*. MDCCLXXXII. * Although chancres may be very fpeedily healed by red preci- pitate alone, yet it will be neceffary fometimes to ufe an ointment made of the red precipitate and twice or thrice it's weight offreffi hogs lard. The precipitate will by this means be more conftantly kept oa the part. The practitioner, however, muft be cautious left he ufe too great a quantity of precipitate, which, by it's corrofive quality, fometimes increafes the ulcer it was meant to heal. During the ufe of this application, it will be neceffity alfo to ufe mercury either internally or externaiiy, in the manner defcribed in the note on article J 770. , The application ot the laps infernalis to chancres, comes recom- mended to us on the authority of fome eminent practitioners. It is however a dangerous application, and frequently produces ulcers that are extremely difficult to l\;zl. 392 PRACTICE RIDCCLXXXII. "When, in confequence of chancres, or of the other circumftances above mentioned, by which it may hap- pen the venereal poifon has been communicated to the blood, it produces many different fymptoms in differ- ent 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 circumftan- ces which give occafion to the communication of the venereal poifon has taken place, I hold the internal ufe of mercurv to be immediately neceffary; and I am well perfuaded, that mercury employed without delay, and in fufficient quantity, will pretty certainly prevent the fymptoms which would otherwife have foon appeared, or will remove thofe that may have already difcovered themfelves. In both cafes, it will fecure the perfon from any future confequences of fiphylis from that in- fedion. MDCCLXXXIV. This advice for the early and full ufe of mercury, I take to be the moft important that can be given with refped to the venereal difeafe; And although I muft admit that the virulence of the poifon may be greater in one cafe than in another, and even that one confti- tution may be more favourable than another to the -violence of the difeafe ; yet I am thoroughly con- vinced, that moft of the inftances which have occurred of the violence and obltinacy of fiphylis have been owing very entirely to the negled of the early appli- cation of mercury*. MDCCLXXXV. * In a word, mercury is a certain fpecific for fiphylis, and a furc antidote againft the venereal poifon. If it be properly ufed, it fel- dom fails of producing a cure ; and this cure will always be more OF PHYSIC. m MDCCLXXXV. Whatever other remedies * of fiphylis may be known, or may hereafter be found out, I cannot pre- tend to determine; but I am well perfuaded, that in moft cafes mercury properly employed will prove a very certain and effedual remedy. With refped to others that have been propofed, I fhall offerthis remark only, that I have found the decodion of -the meze- reon contribute to the healing of ulcers which feem- ed to have refifted the power of mercury* M DC CL XXXVI. With regard to the many and various preparations of mercury, I do not think it neceffary to give any enumeration of them here, as they are commonly ve- ry well known, and have been lately well enumerated by Dr. 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, effeded by many different preparations, if properly adminiftered. The proper adminiftration§ feems to confift, lft, In the choofing thofe preparations which are the leaft ready to run off by ftool; and therefore the applications ex- ternally by undion are in many cafes the moft conve* nient. 2dly, In employing the undion, or in giving a preparation of mercury internally;, in fuch quantity as may fhow its fenfible effeds in the mouth* And $dly, without carrying thefe effeds to a greater length, In the continuing the employment of mercury for fe- veral weeks, or till the fymptoms of the difeafe fhall have for fome time entirely difappeared. 1 fay no- Vol. II. 3 D thing fpeedy, in proportion, as mercury has been ufed in the earlier ftage of the difeafe. * We have no occafion to feek for other remedies than mercury : and the practitioner who rifks his patient's health, and his own re- putation, on the uncertain effects of other remedies, furely dsfervcg reprchenfion. § See the notes on Article I77> 394 PRACTICE thing of the regimen proper and neceffary for patients during the employment of mercury, becaufe I prefume it to be very well known. MDCCLXXXV1I. Amongft the other preparations of mercury, I be- lieve the corrofive fublimate has often been employed with advantage: but I believe alfo, that it requires be- ing continued for a longer time than is neceffary in the employment of other preparations in the manner above propofed ; and I fufped it has often failed in making a cure, becaufe employed while perfons were at the fame time expofed to the free air. MDCCLXXXVIII. Upon thefe points, and others relative to the admi- niftration of mercury, and the cure of this difeafe, I might offer fome particular remarks: but I believe they are generally underftood ; and it is enough for me to fay here, that if praditioners will attend, and patients will fubmit, to the general rules giVen above, they will feldom fail of obtaining a certain and fpeedy cure of the difeafe. CHAP. III. OF SCURVY. MDCCLXXXIX. THIS difeafe appears fo frequently, and the effeds of it ar£ 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 fooner attraded the efpecial notice both of ftatefmen and phyficians, fo as to have produced thofe meafures and OF, PHYSIC. 3S and regulations that might prevent the havock which it fo often occafions. Within thefe laft fifty years, however, it has been fo much attended to and ftudied, that we might fuppofe every circumftance relating to it fo fully and exactly afcertained, as to render all fur- ther labour upon the fubjed fuperfluous. This per- haps may be true ; but it appears to me, that there are ftill feveral circumftances regarding the difeafe not agreed upon among phyficians, as well as different opi- nions formed, fome of which may have a bad effed upon the pradice ; and this feems to me to be fo much the cafe, that I hope I fhall be excufed in endea- vouring here to ftate the fads as they appear to me from the befl authorities, and to offer remarks upon opinions which may influence the pradice in the pre- vention and cure of this difeafe. MDCCXC, With refped to the phenomena of the difeafe, they have now been fo fully obferved, and fo accurately defcribed, that there is no longer any doubt in difcern- ing the difeafe when it is prefent, or in diftinguifhing it from almoft every other aliment. In particular, it feems now to be fully determined, that there is one difeafe only, intitled to the appellation of Scurvy ; that it is the fame upon the land as upon the fea ; that it is the fame in all climates and feafons, as de- pending every where upon nearly the fame caufes; and that it is not at all diverfified, either in its pheno- mena or its caufes, as had been imagined fome time ago. MDCCXCL The phenomena of fcurvy, therefore, are not to be defcribed here, as it has been fo fully and accurately done elfevvhere ; and I fhall only endeavour to ascer- tain thofe fads with refped to the prevention and cuie of the difeafe which feem not yet to be exadly a- greed upon. And, firft, with refped to the antece- 3 D 2 dents 39e> PRACTICE dents that may be confidered as the remote caufes of the difeafe. MDCCXCII. The moft remarkable circumftances amongft the antecedents of this difeafe is, that it has molt common, ly happened to men living very much on falted meats; and whether it ever arife in any other circumftances, is extremely doubtful. Thefe meats are often in a putrefcent ftate ; and to the circumftance of the long continued ufe of animal food in a putrefcent and fomewhat indigeftive ftate, the difeafe has been efpe- cially attributed. Whether the circumftances of the meat's being falted, has any effed in producing the difeafe, otherwife than by being rendered more mdigeftible, is a queftion that remains ftill in difpute. MDCCXCI1I. It feems to me, that the fait concurs in producing the effed ; for there is hardly any inftance of the dif- eafe appearing unlefs where fait meats had been em, ployed, and fcarcely an example where the long conti- nued ufe of thefe did not produce it; befides all which, there are fome inftances where, by avoiding falted meats, or by diminifhing the proportion of them in di- et, while other circumftances remained much the fame, the difeafe was prevented from appearing. Fur- ther, if it may be admitted as an argument upon this fubjed, I fhall hereafter endeavour to fnow, that the large ufe of fait has a tendency to aggravate and in- creafe the proximate caufe of fcurvy. MDCCXC1V. It muft, however, be allowed, that the principal circumftance in caufing fcurvy, is the living very much and very long upon animal food, efpecially when in a putrefcent ftate ; and the clear proof of this is, that a quantity of frefli vegetable food will always certainly prevent the difeafe. MDCCXC V, OF PHYSIC. 397 MDCCXCV. While it has been held, that, in thofe circumftances in which fcurvy is produced, the animal food employ- ed was efpecially hurtful by its being of difficult digef- tion, this opinion has been attempted to be confirm- ed, by obferving, that the reft of the food employed in the fame circumftances was alfo of difficult digefti- on. This is fuppofed to be efpecially the cafe of unfermented farinacea which fo commonly makes a part of the fea-diet. But I apprehend this opinion to be very ill-founded ; for the unfermented farinacea, which are in a great proportion the food of infants, of women, and of the greater part of mankind, can hard- ly be fuppofed to be food of difficult digeftion : and with refped to the produdion of fcurvy, there are fads which fhow, that unfermented farinacea, em- ployed in large proportion, have had a confiderable effed in preventing the difeafe. MDCCXCVI. It has been imagined, that a certain impregnation of the air upon the fea had an effed in producing fcurvy. But it is altogether improbable : for the onlyimpreg- nations which could be fufpeded, are thofe 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 falubrity of the fea-air. If, therefore, fea-air have any effed in producing fcurvy, it muft be by its fenfible qualities of cold or moifture. MDCCXCVII. That cold has an effed in favouring the produdion of fcurvy, is manifeft from hence, that the difeafe is more frequent and more confiderable in cold than in warm climates and feafons ; and that even warm cloathing has a confiderable effed in preventing it. MDCCXCVUI. Moifture may in general have an effed in favouring the- 39« PRACTICE the produdion of fcurvy, where that of the atmofphere in which men are placed is very confiderable: but the ordinary moifture of the fea-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 cloathing only that it has any fhare in the produc- tion of fcurvy. At the fame time, I believe, there is no inftance of either cold or moifture producing fcurvy, without the concurrence of the faulty fea- diet. MDCCXCIX. Under thofe circumftances which produce fcurvy, it commonly feems to occur moft readily in the perfons who are the leaft exercifed ; and it is therefore proba- ble, that confinement and want of exercife may have a great fhare in producing the difeafe. MDCCC. It appears that weaknefs, in whatever manner occa- fioned, is favourable to the produdion of fcurvy. It is therefore probable, that unufual labour and fatigue may often have fome fhare in bringing it on : and upon the fame account, it is probable, that fadnefs and defpondency may induce a weaknefs of the circula- tion ; and thereby, as has been remarked, favourable to the produdion of fcurvy. MDCCCI. It has alfo been obferved, that perfons negligent in keeping their fkin clean by wafhing and change of cloathing, are more liable than others to be affeded with fcurvy. MDCCCII. Several of thefe caufes, now mentioned, concurring together, feem to produce fcurvy ; but there is no pro- per 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. Along with this, however, feveral of the, other circum- ftances O F P PI Y S I C. 399 ftances mentioned have a great effed in producing it fooner, and in a more confiderable degree, than would otherwife have happened from the diet alone. MDCCCIII. From this view of the remote caufes, it will readily appear, that the prevention of the difeafe may in fome meafure depend upon the avoiding of thofe cir- cumftances which we have enumerated as contributing to bring on the difeafe fooner than it would otherwife come on. At the fame time, the only effedual means will be, by avoiding the diet of falted meats; at leaft by leffening the proportion of thefe, and ufing meat prcferved otherwife than by fait; by ufing in diet any kind of efculent vegetable matter that can be ob- tained ; and efpecially by ufing vegetable matters the moft difpofed to acefcency, fuch as malt; and by drinking a large quantity of pure water. MDCCCIV. The cure of fcurvy feems now to be very well af- certained ; and when the neceffary means can be ob- tained, the difeafe is commonly removed very quick- ly. The chief means is a food of frefh and fucculent vegetables, and thofe almoft of any kind that are at all efculent. Thofe moft immediately effedual are the acid fruits, and, as being of the fame nature, all fort of fermented liquor. MDCCCV. The plants named alkahfcent, fuch as thofe of the garlic tribe and of the tetradynamiae*, are alfo parti- cularly * The plants of this clafs ought to be tifed in large quantities, and raw. The more active fpecies are, Horfe-radifh, Muftard, Water- crefs, gar den-crefs, Scurvy grafs : The milder fpecies are, Radifhes, Turnips, Cabbages, Cauliflowers, Brocoli, &c. To the above lift, may be added fome other antifcorbutics of dif- ferent claffes ; as Malt, Spinach, Beet, Carrots, Celery, Endive, Lettuce, Afparagus, the young fhoots of Hops, Purflain, with fe- veral others. All thefe frefh vegetables muft be eaten in large quan- tities ; they ought indeed to couftitute the patient's chief food, and his drink may be a frefh infufion of malt. 403 PRACTICE cularly ufeful in the cure of this difeafe; for, notwith- ftanding their appellation, they in the firft part of their fermentation undergo an afcency, and feem to contain a great deal of acefcent matter. At the fame time, they have generally in their compofition an acrid matter that readily pafles by urine, probably by perfpiration ; and by promoting both excretions, are ufeful in the difeafe. It is probable, that fome plants of the coniferous tribe, fuch as the fpruce fir, and other poffefled ofa diuretic power, may likewife be of fome ufe. MDCCCVI. It is fufficiently probable, that milk of every kind* and particularly its produdions whey and butter-milk, may prove a cure of this difeafe. MDCCCVII. It has been common in this difeafe to employ the foflil acids; but there is reafon to doubt if they be of any fervice, and it is certain they are not effedual re- medies. They can hardly be thrown in fuch quan- tity as to be ufeful in antifeptics ; and as they do not feem to enter into the compofition of the animal flu- ids, and probably pafs off unchanged by the excreti- ons, fo they can do little in changing the ftate of the fluids. MDCCCVIII. The great debility which conftantly attends fcurvy, has naturally led phyficians to employ tonic and ftrengthening medicines, particularly the Peruvian bark ; but the efficacy of it feems to me very doubt- ful. It is furprifing how foon the ufe ofa vegetable diet reftores the ftrength of fcorbutic perfons; which feems to fhow that the preceding debility had depend- ed upon the ftate of the fluids; and confequently, till the found ftate of thefe can be reftored, no tonic re- medy can have much effect: but as the Peruvian bark' ha* OF PHYSIC. 401 ha6 little power in changing the ftate of the fluids, fo it can have little effed in fcurvv. MDCCCIX. I fhall conclude my obfervations upon the medi- cines employed in fcurvy, with remarking, that the ufe of mercury is always manifeftly hurtful. MDCCCX. After having obferved that both the prevention and cure of this difeafe are now very well known, it may feem unneceffary to enter into much difcuffion con- cerning its proximate caufe : but as fuch difcuffions can hardly be avoided, and as falfe opinions may in fome meafure corrupt the pradice, I fhall venture to fuggeft here what appears to me moft probable upon the fubjed. MDCCCXl. Notwithftanding what has be^n afferted by fome eminent perfons, I truft to the concurring teftimony t)f the moft part of the authors upon the fubjed, that in fcurvy the fluids fuffer a confiderable change. From thefe authors we learn, that in the blood drawn from the veins of perfons labouring under the fcurvy, the craffamentum is different both in colour and confiftence from what it is in healthy perfons; and that at the fame time the ferum is commonly changed both in colour and tafte. The excretions al» fo, in fcorbutic perfons, fhow a change in the ftate 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 fcorbutic 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 ftate of the fluids is coniiderabiy changed. Further, I apprehend it may be confidently prefume I from this, that the difeafe is brought on by a particular nourifhment introduced into the body, and Vol. II. 3E ij 402 PRACTICE is as certainly cured by the taking in ofa different di- et. In the latter cafe, the diet ufed has no other evi- dent operation, than that of giving a particular ftate and condition to the fluids. MDCCCXII. Prefuming therefore, that the difeafe depends upon a particular condition of the fluids of the body, the next fubjed of inquiry is, What that condition may be? With this view I muft obferve, that the animal ceconomy has a lingular power of changing acefcent aliments, in fuch a manner, as to render them much more difpofed to putrefadion; and although, in a living ftate, they hardly ever proceed to an adually putrid ftate ; yet in man, whole aliment is ofa mixed kind, it is pretty certain, that if he were to live entire- ly up m animal food, without a frequent fupply of ve- getable aliment, his fluids would advance further to- wards putrefadion than is confiftent with health.---- This advance towards putrefadion feems to confift in the produdion and evolution of a faline matter which did not appear in the vegetable aliment, and could not be produced or evolved in it, but by carrying on its fermentation to a putrefadive ftate. That this faline ftate is conftantly in fome meafure produced and evolv- ed by the animal procefs, appears from this, that cer- tain excretions of faline matter are conftantly made from the human body, and are therefore prefumed ne- ceffary to its health. From all this, it may be readily underftood, how the continual ufe of animal food, efpecially when al- ready in a putrefcent ftate, without a mixture of vege- table, may have the effed of carrying the animal procefs too far, and particularly of producing and evolving a larger proportion of faline matter. That fuch a preternatural quantity of faline matter does ex- ift in the blood of fcorbutic perfons, appears from the OF PHYSIC. 403 the ftate of the fluids above-mentioned. It will be a confirmation of all this to obferve, that every interrup- tion of perfpiration, that is, the retention of faline. matter, contributes to the produdion of fcurvy ; and this interruption is efpecially owing to the application of cold, or to whatever elfe weakens the force of the circulation, fuch as the negled or want of exercife, fatigue, and defpondency of the mind. It deferves in- deed to be remarked here, that one of the firft effeds 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 un- derftood ; but that it does depend upon fuch a ftate of the fluids, is rendered fufficiently prefumable from what has been faid above with regard to both the caufes and the cure of fcurvy. MDCCCXIII. It is poffible that this debility may have a great fhare in producing feveral of the phenomena of fcurvy ; but a preternaturally faline, and confequently diffolved, ftate of the blood, will account for them with more probability; and I do not think it neceffary to perfons who are at all accuftomed to reafon upon the animal ceconomy, to explain this matter more fully. I have' only to add, that if my opinion in fuppofing the prox- imate caufe of fcurvy to be a preternaturally faline ftate of the blood, be at all founded, it- will be fuffi-r ciently obvious, that the throwing into the body along with the aliment an unufual quantity of fait, may have a great fhare in producing the difeafe. Even fuppof- ing fuch fait to fuffer no change in the animal body, the effed of it may be confiderable ; and this will be rendered ftill 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 4°4 PRACTICE fcurvy. If I be at all right in concluding, that meats, from being falted, contribute to the produdion of fcur- vy, it will readily appear, how dangerous it may be to admit the conclufion from another theory, that they are perfedly innocent. MDCCCXIV. Having thus endeavoured to explain what relates to the cure of fcurvy in general, 1 judge it proper to leave to other authors, what relates to the manage- ment of thofe fymptoms which require a partic star treatment. CHAP. IV. OF J A U N D I C 1.. MDCCCXV. I HAVE here paffed over feveral of the titles in my nofology, becaufe they are difeafes not of this ifland. In thefe, therefore, I have no experience ; and withi out that, the compiling from other writers is always extremely fallacious. I4 or thefe reafons I omit them ; and fhall now only offer fume remarks upon the fubjed of jaundice, the laft in order that I can poffibly intro- duce in my courfe of Ledures. MDCCCXVI. The jaundice confifts in a yellow colour of the fkin over the whSle body, and particularly of the adnata of the eyes. This yellow colour may occur from differ- ent caufes : but in the jaundice, hereafter to be more exadly charaderifed, I judge it to depend upon a quantity of bile prefent in the mafs of blood ; and which, OF PHYSIC. 405 which, thrown out upon the furface, gives its own pro- per colour to the fkin and eyes. MDCCCXVII. That the difeafe depends upon this we know parti- cularly and certainly from the caufes by which it is produced. In order to explain thefe^ I muft obferve, that bile does not exift in its proper form in the mafs of blood, and cannot appear in this form till it has paff- ed the fecretory organ of the liver. The bile, there- fore, cannot appear in the mafs of blood, or upon the furface of the body, that is, produce jaundice from any interruption of its fecretion; and accordingly, if jaun- dice does appear, it muft be in confequence or" the bile, after it had been fecerned, being again taken into the blood-vefkls. This may happen in two ways; either by an inter- ruption of its excretion, that is, of its paffage into the duodenum, which by accumulating it in the biliary veffels, may give occafion to its paffing again into the blood-vefiels; or it may pafs into thefe, by its being abforbed from the alimentary canal, when it happens to be accumulated there in an unufual quantity. How far the latter caufe can take place, or in what circum- ftances it does occur,, I cannot clearly afcertain, and I apprehend that jaundice is feldom produced in that manner. MDCCCXVII r. The former caufe of flopped excretion may be un- derftood more clearly ; and we have very certain proof oftts being the ordinary, and indeed the almoft univer- fal, caufe of this difeafe. Upon this fubjed it wiil be ohvious, that the interrupted excretion of the bile muft depend upon an obftrudion of the ductus com- munis cboledochus; the moft common caufe of which is a biliary concretion formed in the gall-bladder, and from thence fallen down into the dudus communis, it being at the fame time of fuch a fize as not to paft readily 4o5 PRACTICE readily through that dud into the duodenum. This dud may likewife be obftruded by a fpafmodic con- ftridion affeding it : and fuch fpafm may happen, ei- ther in the dud itfelf, which we fuppofe to be contrac- tile ; or in the duodenum prefling the fides of the dud clofe together; or, laftly, the dud may be obftruded by a tumour compreffing it, and that arifing either in the coats of the dud itfelf, or in any of the neighbour- ing parts that are, or may come to be, contiguous to it. MDCCCXIX. When fuch obftrudion happens, th? fecreted bile muft be accumulated in the biliary duds; and from thence it may either be abforbed and carried by the 1; rnpoatics in:o the blood-veffels, or it may regurgitate. in the duds themfelves, and pafs from them diredly into the afcending cava. In either way, it comes to be diffufed in the mafs of blood ; and from thence may. pafs by every exhalant veflel, and produce the difeafe in queition. MDCCCXX. I have thus fhortly explained the ordinary produc*. tion of jaundice : but it muft be obferved further, that it is at all limes accompanied with certain other fymptoms, fuch as a whitenefs of the faces alvinar, which we readily account for from the abfence of bile. in the inteftines; and generally, alfo, with a certain confiftence of the feces, the caufe of which is not fo eafy to explain. The difeafe is always accompanied alfo with urine of a yellow colour, or at leaft with urine that tinges a linen cloth with a yellow colour. Thefe are conftantly attending fymptoms; and though not always, yet there is commonly, a pain felt in theepiga- ftrium, correfponding, as we fuppofe, to the feat of the dudus communis. This pain is often accompanied with vomiting; and even when the pain is not confi- derable, a voniiting fometimes occurs. In fome cafes, when OF PHYSIC. 407 When the pain is confiderable, the pulfe becomes fre- quent, full, and hard, and fome other fymptoms of py- rexia appear. MDCCCXXI. When the jaundice is occafioned by tumours of the neighbouring parts compreffing the biliary dud, f be- lieve the difeafe can very feldom be cured. That fuch is. the caufe of jaundice, may with fome probability be fuppofed, when it has come on in confequence of other difeafes which had fubfifted long before, and more efpe- cially fuch as had been attended with fymptoms of ob- ftruded vifcera. Even when the jaundice has fubfift- ed long without any intermiflion, and without any pain in the epigaftrium, an external compreffion is to be fufpeded. MDCCCXXII. In fuch circumftances, I confider the difeafe as in- curable ; and it is almoft only when the difeafe is oc- cafioned by biliary concretions obftruding the biliary dud, that we may commonly exped relief, and that our art may contribute to the obtaining it. Such cafes may be generally known by the difeafe frequent- ly difappearing and returning again ; by our finding, after the former accident, biliary concretions amongft the faeces; and by the difeafe being frequently accom- panied with pain of the epigaftrium, and with vomit- ings arifing from fuch pain. MDCCCXXIII. In thefe cafes, we know of no certain and immedi- ate means of expediting the paffage of the biliary con- cretions. This is generally a work of lime depending upon the gradual dilatation of the biliary dud; and it is furprifing to obferve, from the fize of the ftones which fometimes pafs through, what dilatation the dud will admit of. It proceeds, however, falter or flower upon different occafions; and therefore the jaundice, after a various duration, often ceafes fudden- 4cB PRACTICE ly and fpontaneoufly. It is this which has given rife to the belief, that the jaundice has been cured by fuch a number and fuch a variety of different reme- dies. Many of thefe, however, are perfedly inert, and many ol hers of them fuch as cannot be fuppofed to have any effed in expediting the paffage ofa biliary concretion. I fhall here, therefore, take no notice of the numerous remedies of jaundice mentioned by the writers on the Materia Medica, or even of thofe to be found in pradical authors; but fliall confine myfeif to the mention of thofe that may with probability be fup- pofed to favour the paffage of the concretion, or re- move the obftacles to it which may occur; MDCCCXXIV. In the treatment of this difeafe, it is in the firft place, to be attended to, that as the diftenfion of the biliary dud, by a hard mafs that does not eafily pafs through it, may excite inflammation there ; fo, in perfons of tolerable vigour, blood-letting may be an ufeful pre- caution ; and when much pain, together with any degree of pyrexia, occurs, it becomes an abfolutely neceffary remedy. In fome inftances of jaundice ac- companied 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 biliarv corr- cretion that is more probable than the adion of vo- •fniting ; which, by compreffing the whole abdominal vifcera, and particularly the full and diftended gall- bladder and biliary veffels, may contribute, fometimes gently enough, to the dilatation of the biliary dud. Accordingly vomiting has often been found ufeful for this purpofc ; but at the fame time it is poffible, that the force exerted in the ad of vomiting may be too violent, and therefore gentle vomits ought only to be employed. And either when, by the long continu- ance OFPHtSlC. 40$ ance of the jaundice, it may be fufpeded that the fize of the concretion then paffing is large; or more efpe- cially when pain attending the difeafe gives apprehen- fion of inflammation, it may be prudent to avoid vo- miting altogether. MDCCCXXVI. . It has been ufual in the jaundice to employ purga- tives ; and it is poflible that the adion of the intef- tines may excite the adion of the biliary duds, and thus favour the expuliion of the biliary concretion : but this, I think, cannot be of much effed; and the attempting it by the frequent ufe of purgatives, may otherwife hurt the patient. For this reafon I appre- hend, that purgatives can never be proper, excepting when there is a flow and bound belly*. MDCCCXXVI1. As the relaxation of the fkin contributes to relax the whole fyftem, and particularly to relieve the con- ftridion of fubjacent parts ; fo, when the jaundice is attended with pain, fomentations of the epigaftrium may be of fervice. MDCCCXXVIII. As the folids of the living body are very flexible and yielding; fo it is probable, that biliary concretions would in many cafes find the biliary dud readily ad- mit of fuch dilatation as to render their paffage through it eafy, were it not that the diftenfion occa- fions a preternatural fpafmodic contradion of the parts below. Upon this account, opium is often of great benefit in jaund\ce; and the benefit refulting from its Vol. II. 3 F ufe, * The good effects of purgatives, in removing biliary concre- tions in the duct, are fufficiently apparent by daily experience. It is true, indeed, that all purgatives have not this effect, efpeciallv fuch as are, of a gentle and flow operation. The draftic purges, how- ever, whofe action is both brifk, and of long continuance, have fre- quently been attended with good effects. Some formulas of thtfe brifk draftics have been defcribed in the Botes on article 16S3. 4io PRACTICE ufe, proves fufficiently the truth of the theory upon which th# ufing of it has been founded. MDCCCXX1X. / It were much to be wifhed, that atblvent of biliary concretions, which might be applied to them in the gall-bladder or biliary duds, was difcovered; but none fuch, fo far as I know, has yet been found ; and the employment of foap in this difeafe, I confider as a frivolous attempt. Dr. White of York has found a folvcnt of biliary concretions when thefe are out of the body; but there is not the leaft probability that it could reach them while lodged within. INDEX, INDEX TO THE TWO VOLUMES. N. B. The Figures refer to the number of Paragraphs. ABSCESS, 2co Abscesses and Ulcers, the caufes of their dif- ferent ftates 254 Acids, employed in fever 134 refrigerant in fever ib. Action of the heart and arteries, how increafed for pre- venting the recurrences of the paroxyfms of in- termitting fever 330 ^.DYNAMJE 1171 Amenorrhoea, 995 from retention, 996 when occurring 998 fymptoms of 999 caufes of 1000—2 cure of 1002—6 a Ame- INDEX. Amenorrhoea from fuppreffion, 996 when occurring 1008 fymptoms of 101Q caufes of 1008—9 cure of 1011—12 Amentia , 1598 Anasarca, 1668 the charader of ib. phenomena of 1668—73 cure of 1674—96 diftinguifhed frorn. Leucophlegmatia 1665 St. Anthony's Fire. Sse Erythema. Antimonial emetics, employed in fevers 181 their different kinds ib. the adminiftration of them in fevers X83-—6" Antiphlogistic Regimen, 129 how conduded 130 when employed in inter- mittent fevers 234 Antispasmodics employed in fevers 152—187 Aphtha ?33 Apoplexy, 1094 diftinguifhed from paify ib. diftinguifhed from fyncope ib, predifponent caufes of *°9,5 exciting caufes of 1098—1115—16. proximate caufe of iiqo—21 serosa, proximate caufe of 1114 prognoftic J122—23 frequently ending in hemiplegia 11*2 prevention of 1124 whether fanguine or ferous, ftimulants hurtful in it 1136—37 from powers that deftroy the mobility of the nervous power- JI3° cure of 1131—39 Apyrexia 24 Ascites, 17°9 charader of ib. its various feat 1710—11 the phenomena of 1712—13 Ascites, INDEX. iii Ascites, its particular feat difficultly afcertained . 1714 the cure of 1715—x~ Asthma, ^37^ phenomena of *37J exciting caufes of 1381 proximate caufe of *384 diftinguifhed from other kinds of dyfpnoea 1385 Asthma, fometimes occafions the phthifis pulmonalis 1386 frequently ends in hydrothorax ib. feldom entirely cured ib* Astringents, employed in intermittent fevers 231 joined with aromatics, employed in in- termittent fevers ib. joined with bitters, employed in inter- mittent fevers. ib. AtR-abilts ic j Atrophia, ab alvi fluxu 1(07 debilium i6cf$ inanitoruru 1607 infantilis l^°5 la£tantium ib. lateralis 1606—n a leucorrhoea, 6cj neryofa, _ 606 nutricum, C07 a ptyalifma, ib. yachitica, 605 fenilis, 1606—11 Aura Epileptica, J3°6 B. Pitters employed in intermittent fevers, 231 .joined with aftringents, employed in intermittents, ib. Blistering, its effects, ^ _ 189—197 its mode of operation in the cure of fevers, 190—194 when to be employed in fevers, 19,5 where to be applied in fevers, 196 Blood-letting, the employment of it in fevers, 138—143 the circumftances directing its ufe in fevers, 142 the adminiftration of it in fevers, 143 when employed in intermittent fevers, 234 C. Cachexies character of the elate, 1599 Cachexy, \r INDEX. CachexT, the term, how applied by authors, Coo Calculus renalis, 429 Calx kitrata antimonii, its ufe in fevers, 183—185 Canine madness, 1525 thecureof, 1525—1527 Cardialgia, 1427 Carditis, 383 of the chronic kind, ib. Carus, 1094 Cataphora, ib. Catarrh, I04g predifpofition to, I04~ fymptoms of, ,048 remote caufes of, i©47 proximate caufe of, i°57 cure of, 1065 produces phthifis, ioa5 paffes into pneumonia, 10,54 produces a peripneumonia notha* 1056 contagious, 1062 Catarrhus stjffocativus, 376 Chancre, method of treating, 4781 Chicken-pox, 631 how diftinguifhed from fmall-pox, 632 Chincough, I4oz contagious, jb frequently accompained with fever, 1410 phenomena, 1404 prognoftic in, ,4,3 cure of, 14,4 Chlorosis, 99jj Cholera, i4pq fymptoms of, HoZ— 5& remote caufes of, 1458—60 proximate caufes of, 1454 cure of, 1462—£4 Chorea, 1347 phenomena, *347—53 cure of, ^354 Chronic weaknefs, 1191 Coeliaca, 1493 Cold, INDEX. Y Cold, its operations, 88 abfolute, •» relative, « its general effects on the human body, 90—«t its morbid effects, p2 moderates the violsnce of reaction in fever, i?a its tonic power, how to be employed in fevers, 205 Cold drink, an ufeful tonic in fevers, 206 the limitation of its ufe in fevers, 207 air applied in fevers, 208 water applied to the furface of the body in fevers, 205—209 Colic, i435 the fymptoms of, 1435—38 proximate caufe of, '439 cure of, <•• 1441 Devonfhire. See Colic ofPoitou. Colic, of Poitou, 1451 cure of, 1452 Coma, ,09£ Comat a, io93 Contagion*, 78 their fuppofed variety, 79 Convulsions, 1253 Corpulency, 1621 Cynanche, 300 MALIGNA, 311 parotidea, 232 ; pharyngea, 331 tonsillaris, 301 TRACilEALIS, 3 I 8 as affecting infants, 322—329 the cure of ir, 330 Cystitis, 431 D. Days critical, in fevers, 107—124 non-critical, lxi Death, the caures of, in general, -too the r\ii-'j£t caufes of, ib. the i )d:reft caufes of, ib. the caufes of it in fever, lot Dibility, infevers, the fymptoms of, 104 Debility, vi INDEX. DlBILlTY, how obviated, 20a Delirium, in general, explained, 15"9—,50 in fever, of two kinds, 4^ or insanity without fever, 1,'jo—57 Diabetes, 1,504 fymptoms of, 15°4—9 remote caufe of, IJ08 proximate caufe of* 151°—1& cure of, 1,513 Di;eta Aquea, 157 Diarrhoea, i4°5 Diarrhoea, diftinguifhed from dyfentery, M0^ diftinguifhed from cholera, M°7 proximate caufe of, 14°8 remote caufes of, 1471__93 cure of, 2494—1503 biliosa, 1480 colliquative, IcOl mucosa, " I488 Diathesis phlogistica, 62—247 how removed, 260 Diluents, their ufe in fevers, 154—158 Diseases, the diftinguifhing of them, how attained, 2 the prevention of them, on what founded, 3 the cure of them, on what founded, 4 Dropsies, 1645 V in general, the caufe of them, 1646 of the breaft. See Hydrothorax. of the lower belly. See Afcites. Dysentery, 1067 contagious, 1075 remote caufes of, 1072 , proximate caufe of, 1077 cure of, 1080 ufe of mild cathartics to be frequently repeat- ed in it, ib. rhubarb improper in it, ib. Dysenteria alba, JOj0 Dysmenorhoea, 1014 Dyspepsia, uo0 remote caufes cf. 1198 Dyspasia, INDEX. vii DispEpsia, proximate caufe of ll93 cure of 1201 flatulence in it, cure of I22t heart-burn in it, cure of ib. pains of ftomach in it, cure of ib. vomiting in it, cure of ib. Dyspnoea, *36S E. Effluvia, human 85 from marfhes ib. Emaciations, 1600 caufes of 1602—18 cure of 1619 Emansio mensium 99* Emetics, fuited to the cure of fevers 174 their, effecls 176—180 a means of removing fpafm 170 the adminiftration of, in fevers 175 their ufe in intermittent fevers ?3°—233 Emprosthotonos, 1267 Enteritis, i 404 phlegmonic or erythematic ib. caufes of 407 cure of 409 Epilepsy, 281 phenomena of 1283 proximate caufes of 1284 remote caufes of 1285 predifponent caufes of 13*0 fympathic, *3:6 cure of J3i7 idiopathic, 1316 cure of < x3i9 Epistaxes, 806 the caufes of it 808 the various circumftances of 807—818 the management and cure of 819—829 Erysipelas, 274 of the face 708 fymptoms of 705—708 prognofis of 706 b Erysipelas, viii INDEX. Erysipelas, proximate caufe of 697 cure of 7°8—711 phlegmonodes in different parte of the body 712 attending putrid fever 7*3 Erythema, • 274 Exanthemata, $85 Exercise, ufeful in intermittent fevers 231 F. Fainting See Syncope. 1171 Fatuity, 1529 Fear, a remote caufe of fever 97 Fever, 8 ftrictly fo called, the character of 8—32 phenomena of 8 remote caufes of, are ofa fedative nature 36 proximate caufe of 33 atony of the extreme veffels, a principal circum- ilance in the proximate caufe of it 43—44 fpafm, a principal part in the proximate caufe of it 40 general doctrine of 46 the caufes of death in it 101 the prognofis of 99 indications of cure in 126 differences of ro continent 28 continued Zy inflammatory 67 miliary. See Miliary Fever. nervous Qj bilious 71 fcarlet. See Scarlet Fever. putrid 72 named fynccha 67 fynochus 6g typhus 67 hectic, 74 intermittent, the paroxyfms of, defcribed 10 the cold ftage of II Fever, INDEX. IX k Ever, intermittent, the hot ftage of It the fweating ftage of ib. ofa tertian period 25 of a quartan period ib. of a quotidian period ib. caufed by marfh effluvia 84 bile not the caufe of it rj. cure of - '228 its paroxyfms, how prevented 229 attended withphlogiftic diathefis 214 intermittent, attended with congeftion in the abdominial vifcera 234 remittent, 26 Fluxes, without fever. See Profiuvia. Fluo» AlbuS. See Leucorrhcea. Fomentation of the lower extremities, its ufe in fevers 199 Fo mites of contagion 3 a Functions intellectual, diforders of 1528—29 G. Gangrene of inflamed parts, the caufe of 255—256 marks of the tendency "to 257 marks of its having come on ib. Gastritis, ib. phlegmonic or ery thematic ^r phlegmonic, the feat of ib# the fymptoms of ogg the caufes of og7 the cure of 393—397 erythematic, how difcovered 4o0 the feat of ob r the cure of 401 Gastrodynia, 427 Gleet, 1769 Gonorrhoea, 1765 phenomena of 65—69 cure of 1770—78 Gout, the character of 492 a hereditary difeafe 300 diftinguifhed from rheumatifm 526 b 2 Gout, X INDEX. Gout, predifponent caufes of 495—joo occafional caufes of 502—505 proximate caufe of 527—^33 not a morbific matter 329 Regular, defcribed ,506—^18 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 of paroxyfms ^42 treatment in the time of paroxyfms 560 regimen during the paroxyfms ,561 external applications, how far fafe 56*—^69 blood-letting in the intervals of paroxyfms 553 <--------in the time of paroxyfms ,563 coftivenefs hurtful ,559 laxatives to be employed ib. effects of alkalines 553 effe&s of Portland powder ^7 •Irregular ^I^ Atonic, 574—£99 pathology of ,534 cure of 580—582 Retro cedent, £22 pathology of 535 cure of 580—582 Gout, Mifplaced, 523 pathology of 536 cui'e of 583—,584 Tranjlaied, t;vo particular cafes of 525 H. ILematemesis, 1017 arterial and venous 1027 from obilructed menftruation 1020 from fuppreffion of the hemorrhoidal flux 1025 from comprefnon of the vafa b re via by the fpleen 1027 from obftruction of the liver 1028 Hematuria, INDEX. Si 038 °39 041 043 044 140 141 142 144 *52 160 161 Hematuria, , idiopathic, improbable 1033—34 calculofa -,Jlz cure of violenta from fuppreffion of accuftomed difcharges putrida fpuria et lateritia HEMIPLEGIA, caufes of frequently occafioned by apoplexy frequently alternates with apoplexy cure of ftimulants, of ambiguous ufe in ftimulants, external in HAEMOPTYSIS, the fymptoms of 838—840 the caufes of 760—763—830—836. how diftinguifhed from other fpiltings of blood 841—45 cure of 846—52 Htemorrhagia uteri, 966 Hemorrhagy, active or paffive 73c charadter of 705 arterial 744 venous 768 the caufes of the different fpecies appearing at different periods of life 750__jy? the general phenomena of 738—743 the remote caufes of 774 cure of 776 ----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 101,5 Hemorrhoides vesicae 1042 H.emorrhois, external and internal 925 phenomena of 925—931 nature of the tumours 932 HiEMORRJIOIS, kii INDEX. Hjemorrhois, caufes of 933—943 acquire a connection with the fyftem 943—944 particularly with the ftomach 946 cure of 947—965 Hepatirrhoea, 1481 Hepatitis, 412 acute and chronic ib. acute, the fymptoms of 413—41^ combined with pneumonic inflammation , 416 remote caufes of it ib. feat of 418 various exit of pus produced in 421 cure of 423 chronic, the feat of 418 how difcovered 423 Hooping-cough. See Chincough. 1402 Horror, impreffion of, employed in intermittent fevers 231 Human effluvia the caufe of fever hi body, its temperature 88 body has a generating heat ib. Hydrophobia, 1525 Hydrothorax, 1697 where feated 1698 fymptoms of 1701—03 often combined with univerfal dropfy 1704 proximate caufe of 1706 cure of 1707—c8 paracentefis in it, when proper 1708 Hypercatharsis, 1477 Hypochondrasis, 1222 phenomena of ib. diftinguifhed from dyfpepfia 1226 proximate caufe of 1230 cure of 1232 treatment of the mind in. 1244 Hysteria, 1514 fymptoms of 1SI5—x^ paroxyfm cr fit defcribed ib. rarely appears in males i5J7 how diftinguifhed from hypochondriafis 1518—19 proximate caufe of 1522 analogy between and epilepfy 1523 Hysteria? INDEX. Xlll Hysteria, cure of 2524 libidinofa 1 ?17 Hysteric difeafe. See Hyfteria. I. James's powder, its ufe in fever jgn Jaundice, 1815—16 x caufes of 1816—21 cure of ^23—29 Icterus. See Jaundice. Iliac paffion. See Ileus. Ileus, 1437 Impetigines, I737 character of the order ib. Indigestion. See Dyfpepfia. Inflammation, the phenomena of 3-_ internal the marks of ^26 the ftate of the blood in * 2q- the "proximate caufe of 230 not depending upon a lentor of the blood 241 fpafm the proximate caufe of 243—248 terminated by refolution 240 by fuppuration 250 by gangrene 2^ by fcirrhus 2rg by effufion 259 by blifters 20o by exfudations ofo the remote caufes of 262 the cure of in geneial 264 by refolution ib. when tending to fuppuration 268—70 when tending to gangrene 271 its general divifions 27,, more ftricHy cutaneous 274 of the bladder. See Cyfiitis. 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. Inflammation, xiv INDEX. Inflammation, of the lungs. See Pneumonia of the pericardium. See Pericarditis, of the peritonaeum. See Peritonitis. of the fpleen. See Splenitis. of the ftomach. See Gafiritis. of the uterus 43s Insanity, 1535 caufes of IS5°—57 of different fpecies l557 partial and general difference of I57S Intemperance in drinking, a remote caufe of fever 97 Intermission of fever, 24 Interval of fever, 124 Intumescentije, 1620 character of the order ib, K. King's Evil. See Scroph\ula Leucophlegmatia. 1669 Leucorrhoea, 985 character of 986 appearance of the matter difcharged in 987—992 the caufes of 988 the effefts of 990 the cure of 993 Lethargus, 1094 Lientery, 1469 Looseness. See Diarrhoea. M. Madness. See Mania. canine. See Canine. Mania, 15,58 the fymptoms of ib. the remote caufes of *559—61 the treatment of 1562—74 Mania, INDEX. xv Mania, occurring in fanguine tempo "amenta 1576 in fanguine temperaments, cure ot" lS17 Marcores, 1600 Marsh effluvia, a caufe of fever 8u Measles, 633 the fymptoms of 637—642 the nature of 644 cure of 64<5—()S° of a putrid kind 634 Medicine, the inflitution of 4 Mel^na, 101'' Melancholia, *575 how diftinguifhed from hypocl lon- driafis, 1587—88 the character of 1582—89 the proximate caufe of l59° the treatment of *592—97 Melancholic temperament, 1230 Melancholy. See Melancholia. MENORRHAGIA, 966 active or paffive ib. when a difeafe 968—75 effects of 972 proximate caufe of 977 remote caufes of 97* cure of 980 Menses, immoderate flow of them. See Menorrhagia. Metallic tonics, employed in intermittent fevers 2 -J 1 salts, refrigerant ,36 Meteorismus, 1633 Miasmata, 7« Miliary Fever, the general hiftory of 714—715 [Miliary Fever, of two kinds, red and white 71O white, the fymptoms of 717—719 ihe cure of 720 Morbus coeliacus, M93 mucosus, 1070 NIGER, 1029 N. Nephritis, 426 the fymptoms of ib. c Nephritis, xvi INDEX. Nephritis, the. remote caufes of 427 the cure of 430 Nervous Diseases. See Neurofes. Neuroses, 1090 Neutral Salts, diaphoretic in fevers 159—161 refrigerant in fevers 135 Nosology, Methodical 2 O. Obesity, when a difeafe 1621 Oneirodynia, 1598 Ophthalmia, 278 membranarum ib. its different degrees 279—280 its remote caufes ib. the cure of 288—290 tarfi 278 the cure of 288—290 Opiates, employed in the hot ftage of intermittent fevers 233 in the interval of intermittent fevers 231 Opisthotonos. See Tetanus. P. Palpitation of the heart 1355 . \ the phenomena of ib. the caufes of 13^6 the cure of 1363 Palsy, i140 diftinguifhed from apoplexy l094 caufes of 1141 Paracentesis in afcites, when to be attempted 1717 in. hydrothorax, when proper 1708 Paraphrenias, 040 Paroxysm of intermittent fever, the recurrence, how to be prevented 732 Pemphigus, 229 Pericarditis, 383 Peripneumonia Notha, 376 fymptoms of 379 pathology of 380 thecureof 381—382 fome of the fymptoms explained 350 Peritneumoxy, 242 Peritonitis, INDEX. Peritonitis, 3§4 Peruvian bark, not a fpecific 213 its tonic power 214 when proper in fever 2*5 how moft effectually employed 216 the adminiftration of, in intermittent fevers 232 the tonic chiefly employed in intermittent fevers ib. Petechia, 734 Phlegmasia 235 Phlegmon, 274 Phrenitis, 291 the character of 293 the remote caufes of 294 the cure of 295- -299 Phrensy. See Phrenitis. Physic, the practice of, how taught 1 the theory of, how to be employed 4 Physconia, 1718 Phthisis pulmonalis, the general character of 8<53 always with an ulceration of the lungs 8^5 the pus coughed up, how diftinguifhed from mucus 856 accompanied with, hectic fever 8.57 the various caufes of it 862 from haemoptyfis 864- -865 from pneumonia 866- -869 from catarrh, 870- -87* from afthma 875 from tubercles 876- -882 from calcareous matter in the lungs 884 if contagious 8S6 from tubercles, fymptoms of 889 its different duration 896 the prognofis in §97 the cure of 899- -924 the treatment of when arifing from tu- bercles 906- -921 the palliation of fymptoms 922- -924 Plague, the general character of 665 phenomena of ib. principal fymptoms of C 2 bt>7 Plague, xvii INDEX. Plague, proximate caufe of 668 prevention of 670—685 cure of 686—695 Pleurisy, 341 Pleurosthotonos. See Tetanus. Pneumonia, or pneumonic inflammation, 334 general fymptoms of ^>3S—339 feat of 34c—344 prognofis of 352—360 cure of 361 the management of blood-letting in the cure of 362—367 the ufe of purgatives in 370 the ufe of emetics in 371 the ufe of blifters in 372 the means of promoting expectoration in 373 the ufe of fweating in 374 the ufe of opiates in 375 Tolysarca, when a difeafe 1621 cure of 1623—25 Profluvia, 1045 character of the clafs ib. Pulse, the ftate of the, during the paroxyfm of an in- termittent fever 12 Purging, its ufe in continued fevers 144 intermi'tent fevers 234 Pus, how produced 250 Putrescency of the fluids in fever, the fymptoms of 105 the tendency to in fever, how to be corrected 222—226 Pylorus, scirrhous. See Dyfpepfia. Pyrexia, 6 character of the clafs 7 orders of the clafs ib. Pyrosis, ,427 fymptoms of 1431 proximate caufe of 1433 remote caufes of *432 cure of 14,4 Suecica of Sauvages 1428 Quincy. See Cynanche. PvACHITIS, INDEX, xviii R. Rachitis, I7,9 its origin 172o remote caufes of 1721__23 phenomena of 1724 proximate caufe of *72 5—28 cure of 1729—36 Reaction of the fyftem 59 violent in fever, fymptoms of 102 violence of, how moderated 127 Refrigerants, the ufe of them in fever 134 Remedies, table of thofe employed in continued fevers 227 Remission of fever 26 Resolution of inflammation, how produced 240 Respiration, the changes of, during the paroxyfm of an intermittent T „ Revolution, diurnal, in the human body rr Rheum atism, acute or chronic .~~ Acute, the remote caufes of *q0 the proximate caufe of 44 c__460 the fymptoms of 439—447 cure of 461—470 Chronic, fymptoms of 4?0 bow diftinguifhed from the acute 451 proximate caufe of 4^2 cure of 473—476 how diftinguifhed from gout 526 Rickets. See Rachitis. Rose. See Erythema. Rubefacients, the effects of them. S. Scarlet Fever, the fymptoms of different from cynanche maligna the cure of SCROPHULA, the phenomena of the proximate caufe of not contagious not arifing from the lues venerea the cure of Mefen1 erica Scurv 651 6,6 651 -6,55 6S7 —664 173^ \3«- -1749 175° *75l i75^ x7< 3—59 i6c6 xix INDEX. Scurvy, > 1789 remote caufe of 1792—1808 cure of 1804—09 proximate caufe of l8n— '4 Sinapisms, the effects of them 197 Skin, affections of. Seelmpetigines. Small-pox, general character of 587 fymptoms of the diftinct kind 589 of the confluent kind 590—593 general differences between diftinct and confluent 5)4 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 belonging to 604—615 management of fmall-pox received by in- fection 616—630 Soda, M*7 Spasm, internal, means of recovering in fevers 152—187 the proximate caufe of inflammation ;243—248 Spasmodic affection without fever 1251 of the animal functions x42<5 of the vital functions 1355 of the natural functions 1427 Sfacelus, 255 Splenitis, 425 Stimulants, when to be employed in fevers 217 their ufe in intermittent fevers 230. Stomach, its content 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 ib. formed, the the marks of ib. Surface of the body, its confent with the ftomach 44 Swellings, general. See Intumefcentia. adipofe 1621 Spellings, INDEX. xx Swellings, flatulent 1626 watery. See Dropfies. Sweating, wheu hurtful in continued fevers 16j rules for the conduct of in continued fevers 168 ufe of in intermittent fevers 230 Syncope, h^ phenomena of ib. remote caufes of 1]t74—1178 predifpofition to 1184 cure of 1189 diftinguifhed from apoplexy 1°91 Synocha. See Fever. Synochus. See Fever. Siphylis, 1760 originally from America 1761 how propagated 1762 and gonorrhoea, how diftinguifhed 17^^ the cure of 1783—88 T. Tabes a hydrope 1609 a fanguifluxu 1608 dorfalis 1610 glandularis 1606 mefenterica ib. nutricum 1608 rachialgia 1606 fcrophulofa ib. Tartar emetic, its ufe in fevers 183 Tetanus, 1257 remote caufes of 1268 cure of 1270 piffileum Barbadenfe, or Barbadoes tar, in 1280 LATERALIS, 1268 Tonic medicines employed in continued fevers 211 intermittent fevers 231 Tootiiach, how far different from rheumatifm 477—480 , fymptoms of 478 predifpofition to 481 remote caufes of 481—482 proximate caufe of 483 cure of 485—491 Trismus, xxi INDEX. Trismus. See Tetanus. nascentium, 1281 Tussis. See Catarrh. Tympanites, the character of 1627 the different fpecies of, 1628—30 inteftinalis 1628 enterophyfodes ib. abdominalis ib. afciticus *b. phenomena of 1632 proximate caufe of 1635—36 cure of J637—44 Typhus. See Fever. the fpecies of 7° V. Vapours, or low fpirits. See Hypochrondriafis,. Venereal disease. See Siphylis. Venery, excefs in, a remote caufe of fever 97 Vesani^e, in general i528 Vis medicatrix naturje, 38 St. Vitus's Dance. See Chorea. Vomiting of blood. See Hamatemefis. effects of in continued fever 172—173 the ufe of intermitting fevers 230—34 U. Urine, bloody. See Hematuria. Urticaria, the hiftory and treatment of 730 W. Water-brash. See Pyrofis. Whites. See Leucorrhcea. Warm-bathing, the effects of in fever 198 the adminiftration of in fever 199 the marks of the good effects 300 Wine, the moft proper ftimulant iu fevers 218 its convenient ufe in fevers 219 when hurtful or ufeful in fevers 220 THE END. \ ^mmm ■ M Rotheram, John, Cullen, William, First lines of the practice of physics... WZ 270 C967f 1793,2 vol. Condition when received: The 2 volume set was extensively conserved at some time in the past to include new casings that consisted of linen cloth spines attached to original leather covers. The leather was weak, abraded and powdering. The front and back covers were loosely attached and the inside paper hinges were broken. Volume 2 covers had been attached at hinges using thick, linen cloth. The gutters of fly pages, title pages and various other outer pages had been guarded at some time in the past using thick support papers adhered with an insoluble adhesive. As a result, several pages in each volume were breaking at the gutters. With exception of the above described pages, the text blocks remained intact. Acid migration from the frontice piece in volume 1 caused dark brown discoloration on the title page. Volume 2 held a loose historic bookplate. Conservation treatment: Because only minimal treatment was carried out, numerous old mends were allowed to remain. Some areas of adhesive buildup at the gutter were removed in dry condition using a micro spatula. The inner hinges of covers were reinforced using strips of acrylic-toned Japanese paper (usumino. all papers from Japanese Paper Place) adhered using wheat starch paste (zin shofu. Conservation Materials, Ltd.) Various fly pages, title pages and other "outer" pages were mended at the gutter using same. The spine leather was consolidated using 2% hydroxypropyl cellulose (Klucel G, BookMakers) in ethanol (Nasco). In volume 1, a barrier sheet of gampi tissue was inserted between the frontice piece and the title page. In volume 2, a loose bookplate was encapsulated in clear archival plastic of polyethylene terephthalate (2 mil, Light Impressions) and placed in a hinged archival pocket at the inside back cover. Conservation carried out by Rachel-Ray Cleveland NLM Paper Conservator 06 / 2006 TO iMamaMMBOMr C'\ /%% :*H- -o ;>^ " .o* - ;■' • V **. 3 ■§ n i ^*