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FIRST LINES
OF THE
PRACTICE of PHYSIC.
By WILLIAM CULLEN, m. n.
  LATE PROFESSOR OF THE PRACTICE OF 1'HYSIC IN THE
         UNIVERSITY OF EDINBURGH, &CC.


WITH PRACTICAL AND EXPLANATORY

            NOTES,

      By JOHN  ROTHERAM,  m. d.
IN TWO VOLUMES.  kvv
/
t »
       PRINTED BY L. NICHOLS & C.

J T. & J. SWORDS, E. DUYCKINCK, T. S. ARDEN, G. F. HOPKI
 W. FALCONEB, T. B. JANSEN & CO. FURMAN & LOUDON,
    S. STEPHENS, BROWN 5c STANSBURY,C. DAVIS,
       W. DURELL, & L. NICHOLS & C».
| on' 
 
    CONTENTS

            OF THE

FIRST  VOLUME.
Preface
Introduction
PAGi'
   9
 25
CHAP. I.
CHAP. II.
CHAP. III.
CHAP. IV.
CHAP. V.
CHAP. VI.
   Sect. I.
   Sect. II.
CHAP.	I.
Sect.	I.
Sect.	11.
Sect.	HI.
Sect.	IV.
Sect.	V.
CHAP.	II.
CHAP.	III.
CHAP.	IV.
CHAP.	V.
Sect.	I.
Sect.	II.
Sect.	III.
Sect.	IV.
Sect.	V.
CHAP.	VI.
CHAP.	VII.
CHAP.	VIII
CHAP.	IX.
          PART   I.

 Of Pyrexia, or Febrile Diseases

         BOOK   I.

 Of Fevers
 Of the Phenomena of Fevers
 Of the proximate cause cf Fevers     »
 Of the Difference of Fevers,  and its Causes
 Of the remote causes of Fevers
 Of the Prognosis of Fevers
 Of the Method of Cure in Fevers
 Of the Cure of Continued Fevers
 Of the Cure of Intermittent Fevers

         BOOK   II.

 Of Inflammatiojis, or Phlegmasia
 Of Inflammation in general
 Of the Phenomena of Inflammation
 Of the Proximate Cause of Inflammation
 Of the Terminations of Inflammation
 Of the Remote Causes of Inflammation
 Uf the Cure of Inflammation
 Of Inflammation, more strictly Cutaneous
 Of Ophthalmia, or Inflammation of the Eye
 Of Phrensy, or Phrenitis
 Of the Quinsy, or Cynanche
 Of the Cynanche Tonsillaris
 Of the Cynanche Maligna
 Of the Cynanche Trachealis
 Of the Cynanche Pharyngaa
 Of the Cynanche Parotidcea
 Of Pneumonic Inflammation
 Of the Peripneumonia Notka,  or Bastard Pet i-\
    pneumony
. Of the Gastritis, or Inflammaticu  of the Stomach
 Of the Enteritis, or Inflammation of the  Intestines
27
ibid
ibid
 34
 43
 50
 59
 67
ibid
 97
100
ibid
ibid
101
106
HI
112
117
119
124
127
ibid
129
13 J
136
137
ids

153
157
162 
CONTENTS.
CHAP. X.    Of the Hematitis, or Inflammation of the Liver
CHAP. XI.   Of the Nephritis, or Inflammation of the Kidneys
CHAP. XII.  Of the Rheumatism
CHAP. XIII. Of the Toothach, or Odontalgia
CHAP. XIV. Of the Gout

                     BOOK   III.
164
168
170
180
184
              Of Exanthemata, or Eruptive Fevers            214
CHAP. I.     Of the Small-pox                             ibid
CHAP. II.    Of the Chicken-pox                            231
CHAP. III.   Of the Measles                               232
CHAP. IV.   Of the Scarlet Fever                          237
CHAP. V.    Of the Plague                                242
  Sect. I.     Of the Phenomena of the Plague                ibid
  Sect. II.    Of the Prevention, of the Plague                 243
  Sect. III.   Of the Cure of the Plague                      247
CHAP. VI.   Of Erysipelas, or St. Anthony's Fire             248
CHAP. VII.  Of the Miliary Fever                          252
CHAP. VIII. Of the remaining Exanthemata : Urticaria, Pern-
                phigus,  and Aphtha                        259

                     BOOK   IV.
OfHemorrhagics                             260
Of Hemorrhagy in general                     ibid
Of the Phenomena of Hemorrhagy              261
Of the Proximate Cause of Hemorrhagy          262
Of the Remote Causes of Hemorrhagy            273
Of the Cure of Hemorrhagy                     274
Of the Epistaxis. or Hemorrhagy of the Nose    282
Of the Hemoptysis,or Hemorrhagy from the Lungs 287
Of the Phenomena and Causes of Hemoptysis     ibid
Of the Cure of Hemoptysis                      291
Of the Pthisis Pulmonalis, or Consumption of the
   Lungs                                    294
Of the Phenomena and Causes of the Pthisis Pul-
   monalis                                    ibid
Of the Cure of Pthisis                          309
Of the Hemorrhois, or of the Hemorrhoidal Swel-
   ling and Flux                              316
Of the Phenomtna and Causes of the Hemorrhois  ibid
Of the- Cure of Hemorrhoidal Affections          321
CHAP.	I.
Sect.	I.
Sect.	II.
Sect.	III.
Sect.	IV.
CHAP.	II.
CHAP.	III.
Sect.	I.
Sect.	11.
CHAP.	IV.
Sect.	I.
Sect.	II.
CHAP.	V.
Sect.	I.
* Sect.	II.
 
          THE

PRE  FACE.
 X O deliver a System of the Doctrines and Rules proper for direct-
ing the Practice of Physic, is an undertaking that appears to me to be
attended with great difficulty ; and after an experience of more than
forty years in that practice, as well as after much reading and reflec-
tion, it was with great diffidence that  I  ever entered upon such a
work.  It was, however, what seemed to be my duty  as a Professor
that induced me to make the attempt;  and Lwas engaged in it by the
same sentiments that the illustrious Dr. Boerhaave has expressed in
the following passage of the preface to his Institutions : Simtil enim
docendo admotus eram sensu, propriorum cogitatorum explicatione do-
centem plus prof cere, quam si  opus ab alio conscriptum interpretari
suscipit.   Sua quippe optime intclligit,  sua cuiqtte pra cateris placent,
wide clarior fere doctrina, atque animata plerumtfite sequitur oratio.
§hii vero  sensa alterius exponit, infelicius sapenumero eadem assequi-
lur ; quumque suo quisque sensu abundat, multa refutanda frequenter
invenit,  unde graven frustra  laborem aggvavat, minusque  incitata
dictione utitur.   It is well known, that a Text-book is not only ex-
tremely useful, but necessary to Students who are to hear Lectures ;
and from the same considerations that moved Dr. Boerhaave,  I also
wished to have one for myself;  while at the same  time, from some pe-
culiar circumstances in my situation,  I  had some additional  induce-
ments to  undertake such a work.
   Before 1 was established as Professor of the Practice of Physic in
this University, I had been employed in giving Clinical Lectures in
the Royal Infirmary ; and upon that occasion had delivered, what, in
my own opinion, seemed most just with regard to both the  nature and
the  cure of the diseases of which I had occasion to treat.  But I soon
found, that my doctrines were taken notice of, as new, and peculiar
to myself ;  and were accordingly severely criticised by  those who, ha-
ving long before  been trained up in  the system  of Boerhaave, had
continued to think that that system neither required any change, nor
admitted of any amendment.   I  found, at the  same time, that my
doctrines were frequently  criticised  by persons  who either had not
been informed of them correctly,  or  who seemed not to  understand
them fully ;  and therefore, as soon as I was employed to teach a more
coniplete  system of the Practice of Physic,  I judged it necessary to
publish a  Text-book, not only for the  benefit of my hearers, but that
I might also have an opportunity of obtaining the opinion of the pub-
lic  more at large,  and thereby be enabled either to vindicate my doc-
trines, or be taught to correct them.   These were the motives for my
attempting  the volumes I formerly published ; and now from  many-
years experience of their utility to my hea&ers, as wel^ as from the fa-
vorable reception they have  met with from  the public, I am  induced
to give a  new edition of t^iis Work, not only, as I hope, more correct
in many parts, but also more complete and"comprehensive in Us ge«
neiitl extent. 
S                      PREFACE.
   At the first publication of this work, it was intended chiefly fop the
use of those gentlemen who attended my lectures ;  altho' even then
for the reasons I have mentioned, it was rendered more full than text-
books commonly are;  and, in  the  repeated editions I have.since had
occasion to give, I have been constantly endeavoring to render it more
rfull and comprehensive.  In these respects, I hope the present edition
will appear to be rendered more fit for general use, and better  calcu-
lated to afford satisfaction to all those who think they may still re-
ceive any instruction from reading on this subject.
   While I thus  deliver my work in its now more improved state, with
the hopes that it may be of use to others as well as to those who hear
my Lectures, I must at the same time observe, that it presents  a sys-
tem which is in many respects new, and therefore I apprehend it to be
not only proper, but necessary,  that I should  explain he-re  upon what
grounds, and from what considerations, this has been attempted.
   In the first place, I apprehend that, in every branch of science with
Tespect to which  new facts are daily acquired, and these consequently
giving  occasion to new reflections, which correct the principles for-
merly adopted, it is necessary from time to time, to reform and  renew
the whole system, with all the additions and amendments which it has
received and is then capable of.   That at present this is requisite with
regard  to the Science of Medicine,  will, I believe, readily occur to
every person who at all thinks for  himself, aiid is acquainted with the
Systems which have hitherto prevailed.   While, therefore, I attempt
this, I think it may be allowable, and upon this occasion even proper,
that I should offer some  remarks on the principal Systems of  Medi-
cine which have of late prevailed in Europe,  and that I should take
notice of the present state of Physic as it is influenced by these.  Such
remarks, I  hope, may be  of some use to those who attempt to improve
their knowledge by the reading of books.
   Whether *the practice  of  Physic should admit  of reasoning, or be
entirely rested upon experience, has long been, and may still  be,  a
matter of dispute.   I shall not, however, at  present, enter upon the
discussion of this ; because I can venture to assert, that, at almost all
times, the practice has been, and still is, with every person, founded
more or less, upon certain principles established by reasoning ;  and
therefore, in attempting to offer some view of the present state of
Physic, I.must  give*an account of those systems of the principles of
science which have lately prevailed,  or may be supposed still to pre-
 vail in Europe.
   When, after many ages of darkness,  which had destroyed almost
 the whole  of ancient.literature, learning was again restored  in the
 fifteenth century ;* so from causes which are well known,  it was the

   * At this period the medical knowledge of Europe was chiefly, and indeed
 Solely, such as had been derived from, the Arabians. At the conquest of Con-
 stantinople  by the Turks,  about the middle of the fifteenth century, several
 of the Greeks fled into Italy, and the people of Europe communicating with
 them, found them to be intelligent, and  some of them even learned men; the
 Europeans were thence led to study the Greek language, in order to read the
 Valuable books which these fugitives had so much extolled ; and among other
 "Works,  those of  Galen particularly attracted the notice  of the physicians,
 which to their great astonishment, contained all the medical kaow ledge that 
PREFACE.                      ju
system of Galen alone that the Physicians of those  days became  ac-
quainted with ;  and during the course of the sixteenth century,  the
study of Physicians was almost solely employed in explaining and con-
firming that system.  Early, indeed, in the sixteenth century, the no-
ted Paracelsus * had laid the foundation of a  Chemical system which
was in direct opposition to that of Galen ; and, by the efficacy of the
medicines employed by Paracelsus and his followers, their system came
to be received by many : but the systematic Physicians continued to
be chiefly Galenists, and kept possession of the Schools till the middle
of the seventeenth century.   It is not, however, necessary here to en-
ter into any further  detail respecting  the fate of those two  opposite
sects ; for the only circumstance concerning them,  which I would at
present point out, is, that in the writings of bothy the explanations
they severally attempted to give of the phenomena of health or sick-
ness, turned entirely upon the state of the fluids of the body.
   Such was the state of the science of physic till about the middle of
the seventeenth century, when the circulation of the blood came to be
generally known and admitted ; and when this, together with the dis-
covery of the receptacle of the chyle, and of the thoracic duct, finally"
exploded the Galenic system.   About the same period a considerable
revolution  had taken place in the system o£ Natural Philosophy.   In
the course  of the seventeenth century, Galileo had introduced mathe-
matical  reasoning ;  and Lord  Bacon having  proposed the  method of
induction,  had  thereby excited a disposition to observe  facts, and to
make experiments.  These new modes of philosophizing, it might be
supposed, would soon have had some influence on the state of medi-
cine ; but the progress of this was slow.  The knowledge of the  Cir-
culation did indeed necessarily  lead to the consideration as well as to
a clearer view of the Organic  System in animal bodies ; which again
led to the application of the mechanical philosophy towards explaining

had been attributed to the Arabians.  To the Greek writers, therefore, the
physicians of those times closely applied their attention, thinking these books
the only true fountains of medical knowledge ; and thus  it was that the Ga*
lenical doctrines became prevalent all over Europe..

   * The remarkable circumstances in the life oFAureohis PSilippus Theophra--
stiis Bombastus Paracelsus de Hobeiiheim, as he called himself,  are too numer-
ous for insertion in the narrow limits allotted to these Notes.  He was  born
at the village of Einfidlen, about two German  miles from Zurick, in the  year1
1493.  At three years old he was made an eunuch by an accident.  He tra-
velled all over the continent of Europe, obtaining knowledge in chemistry
and physic, and then travelled about the country practising what he had
learned.  His chief remedies were opium and  mercury, and his great success
increased his celebrity.  He cured the  famous printer Ffobeniw of Basil of
an  inveterate disease ; this cure brought him  acquainted with Erasmus, and
made him known to the magistracy of Basil,  who elected ham professor in
1527.  He lectured two hours every day. While seated in hisVhair, he burnt
with great solemnity, the writings of Galen and Avtcenna; and declared to his-
audience, that if God would not impart the secrets of physic,  it was not on-
ly allowable, but even justifiable to consult the devil.  He soon left Basil, and
continued to ramble about the country, generally intoxicated, and never chang-
ing his clothes, or even going to bed.  He died after an illness of a few days,.
in- an inn at  Saltsbiirgh, in 1541, in his 48th year, tho' he had promised  him-
Wlf, that, by tne use of his ellxer, he should live to the age of Methusalem. 
*u
PREFACE.
the phenomena of the animal ceconomy; and it was applied accord-
ingly, and continued, till very lately,  to be the fashionable  mode of
reasoning on the subject.  Such reasoning, indeed, must still in several
respects continue to be applied : but it would be easy to show, that
it neither could, nor ever  can be, applied to any great extent in ex-
plaining  the animal  oecononay ; and we must therefore look for other
circumstances which had  a greater share in modelling the system o£
Physic.
  With this view, it maybe remarked, that till the period just now
mentioned, every Physician,  whether  Galenist or Chemist, had  been
so much accustomed to consider the *tate and condition of the fluids,
both as the cause of disease, and as the foundation for explaining the
operation of  medicines, that what we may term  an Humoral Pa-
thology still continued to make a great part of every system.   In
these circumstances, it was soon perceived, that chemistry promised
a much better explanation than the Galenic or Aristotellian  philoso-
phy had done ; and, therefore, while the latter was entirely laid aside,
a chemical reasoning was  every where received.   Lord Bacon  with
his  usual sagacity,  had early observed, that chemistry promised a
greater number of facts, and he thereby gave it  credit ; whilst the
Gorpuscularian philosophy, restored by Gassendi,  readily united with
the reasonings of  the Chemists ; and  the philosophy of  Des Cartes
readily united with both.  From all these circumstances, an Humoral,
and chiefly a Chemical Pathology, came to prevail very much till the
end of the last century ;  and has  indeed, continued to have a  great
share in our systems down to the present time.
  It is proper now, however, to observe, that about  the beginning of
the present century, when every part of science came to be on a more
improved and correct footing, there appeared in the writings of St ah l,
of Hoffman, and of Boerhaavk, three new,  and considerably dif-
ferent, Systems of Physic ; which have  ever since had a great share
in directing the practice of it.  In order, therefore, to give a nearer
view of the present state of Physic, I  shall offer some remarks upon
these different systems ; endeavoring to point out the advantages, as
well as the disadvantages of each, and how far they  still prevail ; or,
according to my judgment deserve to do so.
  I  shall begin with considering that of Dr.  Stahl, which I think
appeared first, and  for a long time after was the pre\ ailing system in
Germany.
  The chief and leading principle of this system is,  that the  rational
soul of man governs the whole  ceconomy of his body.  At all times,
Physicians have observed,  that the animal ceconomy has in itself a
power or condition, by which, in many instances, it resists the inju-
ries which t! reaten it ; and by which it also, on many occasions, cor-
rects or removes the disorders induced, or arising in it.  This power,
Physicians very anciently attributed, under  a vague  idea, to an agent
in the system, which they called nature ;  and the language of a
vis  conservatrix et medicatrix naturae,  has continued in the schools of
medicine from the most ancient times to the present.
  Dr. Stahl has explicitly founded his  system on the supposition that
the power of nature, so much talked of, is entirely in the rational soul. 
PREFACE.
2U11
He supposes, that upon many  occasions, the soul acts independently
of the state of the body ;  and that, without any physical  necessity
arising from that state, the soul, purely in consequence of its  intelli-
gence perceiving the tendency of noxious powers threatening, or of
disorders any wise arising in the system, immediately excites such mo-
tions in  the body as  are  suited to  obviate the hurtful or pernicious
eonsequences which might otherwise take place.—Manv of my rea-
ders may think  it was hardly  necessary for me  to take notice  of  a
system founded upon so fanciful an hypothesis ; but there is often so
mucfi seeming appearance of  intelligence and design in the operati-
ons of the animal ceconomy, that many eminent persons,  as Perrault
in France., Nichols and Mead  in England, Porterfield and Simson in
Scotland, and Gaubius in Holland, have very much countenanced the
same opinion, and it is therefore certainly entitled to some regard.  It
is not,  however, necessary for me here to enter into any refutation
of it.  Dr. Hoffman has done  this fully,  in his Commentarms de dif-
ferentia  inter Hoffmanni doctr'nium  medico-mtchanicam   et G. E.
Stahlii  medico-organicam ; and both Boerhaave  and Haller, though,
no favorers of materialism, have maintained a doctrine very opposite
to that of Stahl.
   In my Physiology I have offered some arguments against, the same ;
and I s*hall only add now, that whoever considers what has been said
by Dr. Nichols in his Oratio de Anima Jledica, and by Dr. Gaubius
in some  parts of his Pathology, must perceive, that the admitting of
such a capricious government of the animal oeconomy, as these authors
in some  instances suppose would at once lead us  to reject all the phy-
sical and mechanical reasoning we might employ concerning the hu-
man body.   Dr. Stahl himself seems to have been aware of  this  ; and
therefore,  in his preface to Juncker's Conspectus  Therapeia  Specialise
has'acknowledged, that his general principle was not at all necessary;
which is in effect saying that  is not compatible  with any system of
principles that ought to govern our practice.  Upon this footing,  I
might have at once rejected the Stalilion principle  ; but  it is  even
dangerous to  bring any such  principle  into view ;  for, after  all Dr,
Stahl had said in a passage just now referred to, I find, that, in the
whole of their practice, both he and his fpllowers have been very much
governed by their general principle.  Trusting much to the constant
attention and wisdom of nature, they have proposed the Art of curing
by expectation ;  have therefore, for the  most part, proposed  only very
inert and frivolous remedies ;  have zealously opposed the use of  some
of  the most efficacious,  such  as opium and  the Peruvian bark ; and
are extremely reserved in the use  of general remedies, such ai bleed-
ing, vomiting, &c.
   Although these remarks, upon  a system which may now  be consi-
dered as exploded  or neglected,  may seem superfluous ; I have  been
willing to give these strictures on the Stahlion system, that I might
carry my remarks a little farther,  and take this opportunity of obser-
ving*, that, in whatever manner we may explain what have been called
the  operations of nature,  it appears to me, that the general doctrine
of Nature curing diseases, the so  much vaunted Hippocratic method
of curing, has often had a baneful influence on the practice of physic '9 
jdv
PREFACE.
as either leading physicians into, or continuing them in, a vrez\ r.n3
feeble practice  ;  and at the same time superceding or discouraging"
all the attempts of art.   Dr.  Huxbam  has properly  observed that
even in the hands of Sydenham it had this effect.  Although it may"
sometimes avoid the mischiefs of bold and rash  practitioners, yet it
certainly produces that caution and timidity which have ever opposed
the introduction of new and efficacious remedies.  The opposition to
chemical medicines in the  sixteenth and  seventeenth centuries, and
the noted condemnation  cf Antimony by  the Medical  Faculty of Pa-
ris, are to be attributed chiefly  to those prejudices, which the physi-
cians of France did not entirely get the better of for near an hundred
years after.  We may take notice of the reserve it produced in Boer-
haave, with respect to the use of the  Peruvian  Bark.-  We have had
lately published, under the title of Constitutiones Epidemic*, notes of
the particular practice of the late  Baron Van Swieten ;  upon  which
the editor very properly observes, That the use of the bark, in ir/ter-
mitting fevers, appears  very rarely  in that practice j  and  we know
very well where Van  Swieten learned that reserve.
   1 might go farther, and show how much the attention to the Auto~
crctcia, allowed of, in one shape or other,  by every sect, has corrupted
the practice  among all physicians,  from  Hippocrates  to Stahl.   It
must, however, be sufficiently obvious, and I shall conclude  the sub-
ject  with observing, that altho' the v'.s medicatrix natura, must un-
avoidably be received as  a fact ; yet whether it is admitted, it throws
an obscurity upon our system ; and it is only where the impotence of
our art is very  manifest  and considerable, that we ought to  admit of
it in practice.
   To finish our remarks upon  the  Stahlion System,  I shall  shortly
observe, that it did not depend  entirely upon the  Autocrateia, but al-
so supposed a state of the  body and diseases, that admitted of reme-
dies ; which, under the power and  direction of the soul, acted upon
the organization  and matter of the body, so as  to cure its diseases.
Upon this footing, the Stahlion pathology turned entirely upon Ple-
thora and Cacochymy.   It was with respect to the former that they
especially applied  their doctrine of the Autocrateia in a very fanati-
cal manner ; and, with respect to the latter, they have been  involved
in a  humoral pathology as much as the systematic physicians who had
gone before them, and with a theory  so incorrect as not to merit the
smallest attention.  After all,  I ought not to dismiss  the considera-
tion  of the Stahlion system, without remarking, that as the followers
of this system were very intent upon observing the method of nature,
so they were very attentive in  observing  the phenomena of diseases,
and have  given us in  their  writings many facts not to  be found else--
where.
   While  the doctrines of Stahl were prevailing in the university of'
Halle, Dr. Hoffman,* a professor in  the  same university proposed a

  * Frederick Hoffman was born at Halle, in the year 1660.   He graduated
in 1681  ; was made professor of physic there in the year 1693 ; and hlledthat
chair till his death  in 1742.  A very remarkable circumstance of his life is,
that he never took fees from his patients, but was content with his stipend.
He was in high repute as a practitioner, and curing the Emperor Charles VI. 
PREFACE,                     xv
system that was very different.  He received into his system a great
deal of the mechanical, Cartesian, and chemical doctrines of the sys-
tems which had appeared before: but with respect to these, it is of
no  consequence to observe in what manner he modified the doctrines
of his predecessors, as his improvements in these respects were no ways
considerable, and no part of them now remain ;  and the real value of
his works, beyond what 1 am just now going to mention, rests entire-
ly on the many facts they contain.  The merit of Dr. Hoffman and
of his works is, that he made, or rather suggested, an addition to the
system, which highly deserves  our  attention.  Of this I  cannot give
a clearer account than by giving it in the author's own words.  In
his  Medicina Rationales Systematica,  Tom III. § l.chap. iv.  he has
given his Genealcgia mcrborum ex turbato solidurvm et fluidorum me-
chanismo ; and in the 47th and last paragraph of this chapter he sums
up his doctrine in the following words :  Ex hisce autcm omnibus ub^-
rius hactenus excussis,per quam dilucide apparere arbitror,  qucd solus
 spasmus et simplex A7'okia,  aquabilem, liberum, acproportionatum
sanguinis omnisque generis fluidorum  motum, quibus excretior.um sue-
cessus et integritas functionum animi  et corporisproxime nititur, tur-
bando acpervertendo, universam vitalem aconomiam subruant ac destru-
ant; atque  hinc  universa pathologia longe rectius atque facilius ex
 VltlO MOfUUM MICROCOSMICORUM IN SOLIDIS, quam EX VARUS AF-
 rECTioyjBus  yiTiosoauM  humorum,  deduci atque explicari possit,
 adeoque omnis generis agritudines intern*, ad fraeTernaTuhales
 generis nerposi affectiones sint referenda.  Etenim  lasis quo-
 cunq.ue modo,  vel nervis per corpus discurrentibus, vel membtanosis
 quibusvis nervosis partibus, illico motuum anomalia, modo letiiores,
 modo gravlores subsequuntur.   Deinde attenta observatio docet, mJus
 quoivis  morbosos principaliter sedem figere et tyrannidem exerccre in
 nervosis  corporis partibus, cujus generis prater omnes canales, qui sys-
 taltico et- diastaltico motu pollentes, contentos succos traduntj univcr-
 sum nimirum  intestinorum  et ventriculi ab asophago ad anum canalemt
 totum systema vasorum  arteriosorum, ductuum  biiiariorum, salivali-
 urn, urinariorum et subcutaneorum,  sunt  quoque membranx nerveo-
 musculares cerebri et medulla  spinalis, prasertim hac, qua dura mater
 vocatur,  organis sensoriis obducta, nee non tunica  ilia ac ligamentat
 qua ossa cingunt artusque flrmant.   Nam nullus dolor, nulla  infiam-
 tnatio, nullus spasmus, nulla motus et sensus impotentia,  nulla febris
 humoris  illius excretio,  accidit, in qua non ha partes patiantur.   Por-
 ro etiam omnes, qua morbos gignunt causa, operationem suam potissi-
 mam perficiunt in partes motu et sensu praditas, et canales  ex his co-
 ftgmentatos, eorum motum, et cum hoc fluidorum cursum, pervertendo ;
 ita tamen, ut sicuti varia indolis sunt, sic etiam varie in nerveaspar-
 tes agant, iisdemque noxam  afliricent.  Demum 'omnia quoque exim:a
 lirtutis  medicamenta, non tain in partes fluidas,  earum crasin ac in-
 temperiem  corrigenda,  quam potius in solidas et nervosas,  earundem

 and Empress, and Frederick I. of Prussia, of inveterate diseases greatly in-
 creased his reputation.  Hia works are collected into six volumes, folio, pub-
 lished at  different times from 1748 to 1754.  They abound with many useful
 practical  directions; but  at the same time,  contain many frivolous remarks,
 and an abundance of conjectural theory. 
Xvi                    P R  E  F A C  E.
 rnotus allerr.ndo  ac moderando, suam edunt  operationem : De quibus
 tameti omnibus, in vulgari usque eo recepta morborum doctrina, ahum
 est silentium.
   It  is true  that Dr. Willis  * had laid a foundation for this doctrine,
 in his Pathologia Cerebri et Nervorem;  and Baglivi had proposed a
 system of this kind in his  Specimen de flbra motrici et morbosa.   But
 in these  writers it was either not extensively  applied to diseases, or
 was still so involved in many physiological errors,  that they  had  at-
 tracted little attention; and Dr. Hoffman was the first who gave any
 tolerable simple and clear system on the^ subject, or pointed  out any
 extensive application of it to the explanation  of diseases.
   There can^e no sort of doubt that the phenomena of the animal ce-
 conomjf  in health and in sickness, can only be  explained by consider-
 ing the state and  affections of the primary  moving powers in it. It is
 to me surprising that physicians were  so long in perceiving  this, and
 I think we are particularly indebted  to Dr.  Hoffman for putting us
 into the  proper train of investigation; and it every day appears that
 Physicians perceive the necessity of entering more and more into this
 inquiry.   It was this, I  think,  which engaged Dr. Kaaw Boerhaave
 to publish his work entitled  Impetum faciens ;  as well as Dr. Gaub-
 us to  give  the Pathology of the Solidum vivum.   Even the Baron
 Van  Swieten has upon the same view thought it necessary, in at least
 one particular, to make a very considerable change in the doctrine of
 his master, as he  has done in his Commentary  upon the 755th Apho-
 rism.   Dr. Haller has advanced  this part of science very much by his
 experiments  on irritability  and sensibility.   In these and  in many
 other instances, particularly in the writings of Mr. Barthez of Mont-
 pelior, of some progress in the study of the affections in the Nervous
 System,  we must perceive how  much we  are indebted to Dr. Hoff-
 man for  his so properly  beginning \t.  The subject, however, is diffi-
 cult : the laws of the Nervous System, in the  various circumstances
 of the animal ceconomy, are by no means  ascertained ; and, from
 want  of attention and observation with the view to a system  on this
 subject,  the business appears to many  as an inexplicable  mystery.
 There is no wonder therefore, that on such a difficult subject, Dr.
 Hoffman's system was imperfect and incorrect; and has had  less in-
 fluence on the writings and practice of Physicians since his time, than
 might have  been  expected.   lie himself has not applied his funda-
 mental doctrine so extensively as he might  have done ; and he has
every where  intermixed a Humoral Pathology, as incorrect and hy-
pothetical as any  other.   Though he differed from  his colleague Dr.

  • This illustrious physician was born at great Bedwin in Wiltshire in 1621.
He took the degree of master of arts in 1642 at Oxford, where he  was made
professor  of natural philosophy in 1660 : and that same year he took the de-
gree of M. D.  His practice was extensive and successful.  He was one of
the first members of the royal society in London, whither he removed in
 1666 ; and soon made his name as  illustrious by  his writings, as he had al-
ready  done by his practice.  His works had been often printed separately ;
but they were not collected till after his death, which happened on the 1 ith
of November, 1675.   One edition was published at Geneva in  1676, and
another at Amsterdam in 1682,  both in quarto. 
PREFACE.
xvii
Stahl in the fundamental doctrines of his  system, it is but too evident
that he was very much infected with the Stahlian doctrines of Plethora
and Cacochymy, as may be observed throughout the whole course of his
work ; and particularly in his chapter De  morborum generatione ex ni-
mia sanguinis quantitate et humoruui impur it ate.
   But it is needless for  me to dwell any longer upon the system of Hoff-
man ; and I am next to offer some remarks on the system of Dr. Boer-
haave the cotemporary of both the other Systematics,and who, over all
Europe, and especially in this part of the world, gained  higher reputa-
tion than either of the others.
'   Dr. Boerhaave * was  a man of general erudition ; and, in applying to
medicine, he had carefully studied the auxiliary branches of Anatomy,
Chemistry, and Botany, so that he excelled in each.   In forming a Sys-
tem of Physic, he seems to have studied diligently all the several wri-
tings of both ancient and modern Physicians ; and, without prejudice
in favour of  any former systems, he endeavoured  to be a candid  and
genuine ecclectic.   Possessed of an excellent systematic genius, he gave
a  system superior to any that ever before appeared.   As in the great

   * Voorhoot,  a small village about two miles from Leyden,  gave birth to
this eminent physician on the last day of the year 1668.   He was educated
at Leyden, and took his first  degree  in philosophy in 1690.  His thesis on
this  occasion was a confutation of the doctrines of Epicurus, Hobbes,  and
Spinosa, in which he shewed great strength of genius and  argument.  Al-
though he was at this time well qualified to enter into the church, which was
his father's intention, yet he was difhdent of his abilities, and chose to at-
tend the  lectures of divinity longer.  His  patrimony was however now ex-
hausted, and he supported himself at the university by teaching mathema-
tics,  while  he prosecuted his theological studies.  This conduct was much
approved by the eminent men both of the University and City, and procured
for Boerhaave the friendship of Mr. Vanderburg the Burgomaster of Leyden.
Under the patronage, and at tha persuasion of this gentleman,  Boerhaave
applied himself to the study of physic with great ardor and indefatigable di-
ligence.  In  a short  time he became proficient in anatomy,  chemistry,  and
the materia medica, which indeed are  the basis of physic.   Leaving Leyden
he went to the university of Harderwick in Guelderland,  and there took his
degree of Doctor of Physic in July 1693.   On his return to Leyden he stiil
persisted in his intention of entering into the  ministry,  which luckily, for
the sake of Physic, was frustrated by the following adventure : In a passage-
boat  where Boerhaave was, a discourse was accidentally started about the
doctrines of Spinosa, as  subversive of religion ; and one of the passengers,
with  vague invectives  of blind zeal, opposed this philosopher's pretended
mathematical demonstration.  Boerhaave calmly asked him if he had read
Spinosa's work, which he had  so much derided.  The bigot was suddenly
struck dumb, and became fired with silent resentment.  As soon as he arri-
ved at Leyden, he spread abroad a rumor that Boerhaave was become a Spi-
nosist.  Boerhaave finding these prejudices to gain ground, thought it more
prudent to pursue the science of physic, than risk the refusal of a licence for
the pulpit.   He now  joined the practice of physic to  the theory.   On the
r8th of May, 1701,  he commenced his lectures  on the Institutes of physic.
In 1709 he  was created professor cf medicine and botany;  and  in 1718 he
succeeded Le Mort in the professorship of Chemistry.  In August 1722, he
was seized with the gout, and was obliged to resign his professorship of Che-
mistry and  Botany in 1729.   He  continued for some time to practice, but
was at length obliged to quit that also  j and he died on the 23d of September
1738.
   Vol.  I.                      C 
xviii                   PREFACE,
 extent, and seemingly perfect  consistency, of system, he appeared
 to improve and refine upon every thing that had before been offered ;
 and as in his Lectures he explained his doctrines with great clearness
 and elegance  ; he soon acquired a very high reputation, and his sys-
tem was more generally received than any former had been since  the
 time of Galen.   Whoever will consider the merits of Dr. Boerhaave,
 and can compare his system with that of former writers, must acknow-
 ledge that he  was very justly esteemed, and gave a system which was
 at that time deservedly valued.
   But, in the progress of an inquisitive and indrustrious age, it was
 not to be expected that any system should last so-long as Boerhaave's"
 has  done.   The elaborate -Commentary of Van Sweiten on Boerhaave'*
 system of practice, has been only finished a few years ago ; and though
 this Commentator has added'many facts, and  made seme corrections,
 he has not, except in the  particular  mentioned above,  made any  im-
 provement in  the general system.  It "rs even surprising that  Boer-
 haave himself, though he  lived near forty years after he had first  form-
 ed   his system, had hardly in all that time made any  corrections of
 it or additions to it;  the following is the most remarkable.   In Apho-
 rism 75 5, the words forte et nervosi,  tarn cerebri quam cerebelli cordi
 destinati inertia, did not appear in any edition before the fourth  ; and
 what a  difference of system this  points  at,  eveiy  physician  must
 perceive.
   When I first applied to the study of Physic, I learned only the sys-
 tem of Boerfeaave ;  and even when 1 came to take a Professor's chair
 in this university, I found that system here in its full force ; and as
 I believe it still subsists in  credit elsewhere, and that no other system
 of reputation  had been offered to the world, I think it  necessary for
 me  to point out particularly the imperfections and deficiencies of  the
 Boerhaavian system, in-order to  show the propriety and necessity of
 attempting a newone.
   To execute this,.however,  so fully as I might, would lead me  into a
 detail that can hardly be admitted of here ; and I hope it is  not  ne-
 cessary,  as I think,  that every intelligent person, who has acquired
 any tolerable  knowledge  of the  present state of our science,  must in
 many instances,  perceive its imperfections. I shall  therefore  touch
 only upon the great lines of this system ;  and from the remarks I am
 to offer, trust that both the mistakes and deficiencies which run through
 the  whole of his works will appear.
   Dr Boerhaave's treatise of the diseases of the simple solid,  has  the
 appearance of being very clear and'Consistent, and was certainly con-
 sidered by  him as a fundamental doctrine ; but, in my apprehension,
 it is neither correct nor extensively applicable.   Not to mention the
 useless, and perhaps erroneous, notion of the composition of earth and
 gluten ; nor his mistake  concerning the structure of compound  mem-
 branes ; nor his inattention to the state of the  cellular texture ;  all
 of them circumstances which render  his doctrine imperfect ;  I shall
 insist only upon the whole  being very little applicable to the  explain-
 ing the phenomena  of health or sicknes:.  The laxity or rigidity of
 the simple solid, does, indeed, take place at the different periods of life,
 and may perhaps, upon other occasions, occur as the cause ot* disease : 
P'REFAC E.
xi:!
 But I prrrjmr, that the state of the simple  solid is, upon few occasi-
 ons, either changeable or actually changed ; and that,  in ninety-nine
 cases of an hundred, the phenomena attributed to  such a change, do
 truly depend on the state of the solidum vivum ; a circumstance which
 Dr. Boerhaave lias  hardly taken notice of in any part of his works.
 How much this shows the deficiency and imperfection of his svstem, I
 need not explain.   The learned work  of Dr. Gaubius,  above  referred
 to, as well as many other treatises of  late authors,  point out suffici-
 ently the defects and imperfections of Boerhaave on this subject.
   After Dr. Boerhaave has  considered the deseases of the solids, he in
 the next place attempts to explain the more  simple diseases of the
 fluids  ;  and. there, indeed, he delivers a more correct doctrine of acid
 and alkali than had been given  before : But, after all,  he has done it
 very imperfectly.   We  have, indeed,  since his time, acquired  more
 knowledge upon the subject of digestion -y and so  much  as to know,
 that a great deal more is yet necessary to enable us to  understand in
 what manner the animal fluids are formed from the aliments taken in.
 And although Dr.  Boerhaave  has fallen into no considerable  error
 with respect to a morbid acidity in the stomach,  he could not possibly
 be compleat upon that subject ; and his  notion of the  effects of acU
 dity in the mass of blood seems to have been entirely  mistaken, andj
 is indeed not consistent  with what he himself has delivered elsewhere*
   His doctrine of alkali is somewhat better founded,, but is probably
 carried too far ;. and the state  of alkalescency and putrefaction, as
 well as all. the other changes which can take  place in the condition of
 animal fluids, are particulars yet involved in great obscurity,  and are
 therefore stilL subject of dispute.
   There is another  particular,  in which Boerhaave's  doctrine  con-
 cerningthe fluids appears to me imperfect and unsatisfactory ; and that
 is, in his doctrine de Glutinoso spontanea.  The causes  which he has
 assigned for it are by no means probable, and the actual existence of
 it is seldom to be proved.  Some of the  proofs adduced for. the exist-
 ence of a phlegma calidum, are manifestly  founded on a mistake with
 respect to what has been called the inflamatory crust, (see Van Swie-
 ten.'s Commentary, page 96.) and  the  many examples given by Boer-
 haave  of a glutinosum appearing in the human body, (Aph.. 75.) are
 all of them nothing more than instances of collections or concretions
 found out of the  course of the circulation.
   If, then, we consider the imperfections of Dr. Boerhaave's doctrine
 with respect to the state  and various condition  of the animal fluids ;
 and if at the same  time we reflect.how frequently he and his  follow-
 ers have  employed the supposition of an acrimony  or  lentor of the
 fluids,  as causes of disease,, and for directing the practice ; we must,
 as I apprehend, be satisfied, that his system  is not only deficient and
 incomplete, but fallacious, and apt to  mislead.   Although it  cannot
 be denied, that the fluids of the human body suffer various morbid
 changes ; and that upon these,  diseases may primarily  depend : yet
 I must beg leave to maintain, that the nature of these changes is sel-
dom  understood,  and more seldom still is it known when they have ta-
ken place:  that our reasonings  conceiving them have  been, for the
most part, purely hypothetical j have therefore contributed nothing  to 
XX                     PREFACE.
 improve, and have often misled, the practice of physic.   In this, par-
 ticularly, they have been hurtful, that they have  withdrawn our at-
 tention from, and prevented our study of, the motions of the animal
 system,  upon the state  of which the  phenomena of diseases do more
 certain and generally depend.   Whoever, then,  shall consider the al-
 most total neglect of the  state of the moving powers of the animal
 body, and the prevalence of an hypothetical  humoral pathology, so
'conspicuous in every part of  the Boerhaavian System,  must be con-
 vinced of its very great defects, and perceive the necessity of attempt-
 ing one more correct.
   After giving this general view, it is not requisite to enter into par-
 ticulars ; but, I believe, there are very few pages  of  his aphorisms in
 which there does not occur some error or defect;  although, perhaps,
 not to be imputed to the fault of Boerhaave, so much as to this, that
 since his time a  great collection of new facts has been  acquired  by
 observation and experiment.   This, indeed, affords the best and most
 solid reason for attempting a  new  system :  for when  many new  facts
 have been acquired, it becomes requisite that these should be incor-
 porated  into a system,  whereby not  only particular  subjects may be
 improved, but the whole maybe rendered more complete, consistent,
 and useful.   Every system, indeed, must be valued in proportion to
 the number of facts that it embraces and comprehends ; and Mons.
 Ouesney could not pay a higher compliment  to the  system of Boer-
 haave, than by saying that it exhibited La medicine collective.
    But here it will,  perhaps be suggested to me, that the only useful
 work on the subject of physic, is  the making a collection of all the
 facts that relate to the art, and therefore of all that experience has
 taught us with respect to the cure of diseases. I agree entirely in the
 opinion; but doubt if  it can ever  be properly accomplished,  with-
 out aiming at some system of principles, by  a proper induction and
 generalisation of facts  : at least I am persuaded  that it can be done
 not only very safely, but most usefully in this way.  This, however,
 must be determined by a trial.  I know that the late Mr. Lieutaud
 has attempted a  work on a plan of collecting facts without any rea-
 soning concerning their causes : And while I am endeavoring to give
 some account of  the present state of physic, I cannot dismiss the  sub-
 ject without offering some remarks upon the  promising Synopsis uni-
 versa medicina, composed by  the first physician of a  learned and in-
 genious nation.
    In thii work there are many facts  and much observation from the
 Author's own experience, which may be useful  to those who have
 otherwise some knowledge and discernment; but, throughout the whole
 work, there is such total want of  method, arrangement,  system, or
 decision, that in  my humble opinion,  it can be of little use, and  may
 prove very perplexing to those who are yet to learn.  The distinction
 of the genera of diseases,  the distinction of the species  of each, and
 often even that of the  varieties, I hold  to  be a necessary foundation
 of every plan of physic, whether dogmatical  or empirical.  But very
 little of this distinction is to be found in the work of Mr. Lieutaud ;
 and in his preface he tells us, that he meant to  neglect such arguta
 sedulitas.  And indeed his method of managing his subject must cer- 
PREFACE.
xxi
tainly interrupt and retard all methodical nocclogy.  His arrangement
of diseases is according to no affinity, but that of the slightest and un-
instructive kind, the  place of the body which they  happen to aif ct.
His  Gene: alia et incerta sedis,  have  hardly any  collection at all  ;
the titles  Rutumatisms, Hypocondriasis, Hydrops, follow one another.
When he does attempt any geneivl doctrine, itMs not till lon^ after
he has  treated of the  widely scattered particulars.  Under each par-
ticular  title  which he assumes, he has  endeavored to enumerate the
whole of the symptoms that ever appeared in a  disease under that
t'. tie ; and this without aiming at any distinction  between the essen-
tial  and accidental symptoms, or marking the  several combinations
under which these symptoms do  for the  most part steadily appear.
From the concurrence of accidental symptoms, the variety of the same
disease is frequently considerable, u circumstance necessarily perplex-
ing  and distracting to young practitioners ; but it seems "strange to
me, that an experience of thiity  years,  inconsiderable practice, could
do nothing to relieve them.
   Mr.  Lieutaud has  at the same time  increased  the confusion that
must arise from this  want of  distinction,  by his  considering as pri-
mary diseases, what appear to me to be the symptoms, effects, and se-
quels, of other  diseases only.   Of this I think the AZitus  morbjsus,
 Virum  exolutio, Dolores, Stagnatio sanguinis,  Purulentia, Tremor,
 Hervigilium, Raucedj, Su/focatio, Vomica,  Empyema, Singultus,   Vo-
 mitus,  Dolor Stomachi, Tenesmus, all treated cf under separate titles,
 are examples. A general symptomatologia may be  a very useful work,
 with a view to a System of Pathology ;  but with a view to practice
 without any System, it must have bad effects as leading only to a pal-
 liative  practice, and diverting from the proper efforts towards obtain-
 ing a radical cure.   Mr. Lieutaud, indeed, has endeavoured to exhi-
 bit the symptoms above mentioned as so many primary diseases: but
 he has  seldom succeeded in this ;  and, in delivering the practice he com-
 monly  finds  it necessary to consider them  as  symptoms, and that not
 without some theory, implied or expressed, with respect to their prox-
 imate causes.  His title of  Dolores may be tuk-rn as an example of
 this ; and from which it may be readily perceived how fir such treati-
 ses can be really useful.
   In establishing a proper pathology, there is nothing that has been
 of more service than the dissection of morbid bodies.   Mr. Lieutaud
 has been much and most commendably employed in this  way, and in
 this  Synopsis he has endeavoured no communicate his knowledge on
 the subject ; but in my humble  opinion, he has seldom  done it in  a
 manner that can be  useful.   In the same  way that he  has delivered
 the symptons of diseases without any instructive arrangement ;  so on
 the subject  of the appearances after death, he  has mentioned every
 morbid appearance that had ever been observed after the  disease  of
 which  he is  then treating : but these appearances are strangely hud-
 dled together, without, any notice taken of those which belong to one
 set of symptons or to another; and with regard  to the whole, without
 any attempt to distinguish between the causes of diseases and the cuj-
 ses of death ; although the want of such distinction is the well known
 ground of fallacy upon this subject.   I take for an  example, the ap- 
saii                   PREFACE.
  pr:.rnnc?s mentioned ss having been  observed  after  dropsy.   Here
  ni 'reed appearances, found in every part of tie  body, in. every cavity
  of it, and in every viscus contained in these cavities, are enumerated :
  but which of these morbid states are more  frequent or  more rare, and
  which has  been more particularly connected with the different causes
  or with the different state of symptoms previously recited, we are not
  informed, nor h.is he enabled us to discover.   In short, the dissection
  of morb.d bodies has been,  and may beT highly useful ; but in order
  to be so, must  be under a different  management from  what we find
  either in this Synopsis,  or even in the  Historia Anatomico medica.
    Icannotdlsmissthis subject without remarking, that the dessection
  of morbid bodies, is chiefly valuable upon account of its leading us  to
  discover the proximate causes of  diseases ;  and the great and valua-
  ble work of the illustrious Morgagni is properly intkled De sidJmsct
 cavsis.  It may well  seem surprising, then, that Lieutaud should
 find the wh< le  of proximate  causes atra calagine mersas ; and that
 he should never have thought of applying his  dissections towards the
 ascertaining at  least  some of these.
   But let me now proceed to consider the important  part of every
 practical  work, and of this Synopsis  universa medicina :   that is, the
 method of curing diseases.
   Here,  again, upon the same plan as i:i giving the  histories  of dis-
 ease,  the method of cure is delivered by enumerating the whole of the
 remedies  that have ever  been employed in a disease under the title pre-
 fixed ; without assigning the species, or the circumstances to which
 the remedies, though of a very different and sometimes opposite na-
 ture,  are particularly adapted.  O;* the subject of Asthma  he very
 justly observes  that physicians have been to blame in confounding, un-
 der this title, almost all  the species of Dyspnoea ;  and he himself very
 properly  considers Asthma  as a  disease distinct from all the other
 cases of Dyspnoea.  Still, however, he considers Asthma  zs of many
 different species, arising from many  different causes,  which till we
 understand better,  we cannot attempt to remove.  Notwithstanding
 •ill this, he proceeds to deliver a very general cure. Parum  abest, says
 he, quia specifici titulogaudeant pectoralia,  xulneraria,  et incidentia 1
 But from such  language I receive no clear idea ; nor can I  obtain
 any clear direction  from the enumeration of his  medicines.   Bacca
juniper-, gummi, tragacanteum vel ammoniacum, sapo aqua j'lcea, te-
 rcoiiii'iina,  isfc.  qua tamen hand indiscriminatim sunt usurpandar  sed
pro re nata, deluctu opus est.  Very justly indeed, deluctu opus est;
 but here,  as in  many other instances, he gives us no sort of assistance.
  , From his endeavours,  though not always successful,  to  neglect all
 system, his practice is generally delivered in a very indecisive man-
ner; or, what  has the same effect, in a way  so  conditional as will
render it always difficult, and often impossible, for a young practiti-
oner to follow him.   Let us take, for example,  his cure of Dropsy,
" The cure  may be begun by blood-letting in certain conditions ; but
in others, it cannot be employed without danger.  It gives relief in
difficult breathing;  but,  after it is practised,  the symptoms  are ag-
gravated,  and rendered more  obstinate.   It is not to be concealed that
ao:ne persons have been cured by repeated blood-lettings,  or  sponta- 
PREFACE.                   xnii
neous hErnorrhagies ;  but it is at the  same time known, that such a
remedy inopportunely employed, has in many instances hastened on the
fatal event."
   In  the  same  manner he  treats  of vomit;rig, purging,  sweating,
and the use of  mineral waters ; but  I must confess, that  he  has no
where  removed any  of my  doubts or difficulties, and indeed he has
sometimes increased them.  He says, that hepatics, or aperients, such
as the lingua" ctriir.a,  herba capillares, Isfc. deserve  commendation ;
but that when the disease has arisen  to a certain degree,  they  have
been,yi/r the  most part, found to be useless.  He observes, that the
powder of toads given in wine, to the quantity of a scruple more, has
succeeded with severals.
   Such are commonly, the methods of cure delivered by Mr. Lieu-
taud, lengiori et fortefelicissima praxi ed'jetus.
   It '.\ould be tedious to enter further into that detail, which a cri-
tic i-sm  of  this unmethodical and uninstruc-ive  work might lead me
into  ; but, if the  bounds proper for this preface did not prevent me, I
would particularly show that the work is far from  being free from those
reasonings which the  author pretends to avoid, and would affect  even
to despise.  He still holds the doctrine? of the concoction and  cri-
tical evacuation  of morbific matteu;   doctrines  depending
vpon subtile  theories, and which,  in my opinion, can in no wise be
ascertained as matters of fact.   Mr. Lieutaud likewise is  still  very
much upon the old plan  of following  nature,  and therefore gives
often what 1 consider as a feeble and inert practice.  The  hamectan-
tia,  dilueniia, demulcentia, et temperantia,  are  with him  very  uni-
versal remedies,  and often those Which alone are to be employed.
   The mention of these  medicines might lead me to take notice'of
 Mr.  Lieutaud's second volume,  in  which, ab insula  remedivrum far-
ragine alienus,  he promises a great reformation upon the subject; but
this  falls so far short of the idea of British physicians, that I  need
not make  any remarks upon it.   With respect to his list of simples,
or Emporetica, as he  is pleased to term them,  an English apothecary
would smile at it;  and with respect to his Officinal:a, I believe  they
are to be found no where but in the Codex  Medio a;nc:itarius of Paris;
and i:i  his  Magistralia his doses  are generally such as the most timid
practitioner of this country would hardly descend  to,  and such as none
of our  practitioners of experience would depend upon.  In short, the
whole of the work, both with respect to the theories with which  it  a-
bounds, and to the facts which it gives', will not, in my apprehension,
bear any serious criticism.  But 1 must conclude ; and  shall only say
further, that  such as I have represented it, is this work,  executed by a
man  of the fir t rank  in the profession.  It is indeed tor that reason I
have chosen it as the example of a work,  upon the plan of giving facts
only, and  of avoiding the study  or  even  the notice of the proximate
causes of diseases ; and with what advantage such apian is pursued, I
shall leave my readers to consider.
   In the following treatise I have followed a different course.  I have
endeavoured to collect the facts relative to the diseases of the human
body, as  fully as the nature of the work and the bound* necessarily
prescribed to it would  admit:  But I have  not been satiiiied  with  giv- 
XXIT
PREFACE.
ing the facts, without endeavouring to apply them to the investigati-
on of proximate causes, and upon these to establish a more scientific
and decided method of cure.   In aiming at this, I flatter myself that I
have avoided hypothesis, and what have been called theorie^.  1 have,
indeed, endeavoured to  establish many general doctrines, both physi-
ological and pathological ; but I trust that these are only a generalisa-
tion of facts, or conclusions from a  cautious and  full induction ; and
if'any one shall refuse to admit, or  directly shall oppose, my general
doctrines,  he must do it by showing that I have been deficient or mis-
taken in assuming and applying  facts.   I have, myself,  been jealous
of my being sometimes imperfect in these respects ;  but I have gene-
rally endeavoured to obviate the consequences of  this, by proving,
that the proximate causes which I have assigned, are true in fact,  as
well as deductions  from any  reasoning that I may seem to have em-
ployed.  Further,  to obviate any dangerous  fallacy in  proposing a
method of cure, I have always  been anxious to suggest that which,
to the best of my judgment,  appeared  to be the  method approved of
by experience, as much as it was the consequence of system.
  Upon this  general plan I have  endeavoured to  form a  system  of
physic  that should comprehend the whole of the facts relating to the
science, and  that will,  I hope,  collect  and arrange them in better
order than has been  done before, as well as point out  in particular
those which are still  wanting to establish  general  principles.  This
which I have  attemped may, like other svstems,  hereafter  suffer a
change ; but I am confident that we are at present in a better train of
investigation than physicians were in before the time of  Dr. Hoffman.
The affections of the motions and moving powers of the animal eco-
nomy,  must certainly be the leading inquiry in considering the disea-
ses of the  human body.   The inquiry  may be difficult ; but  it must
be attempted, or the subject must be deserted altogether.  I have there-
fore, assumed the general principles of Hoffman,  as laid down in the
passage which I have quoted above ;  and if I have rendered them more
correct, and more  extexisive in  their application ; and,  more particu-
larly, if I  have avoided introducing the many hypothetical doctrines
of the  Humoral Parthology which disfigured both his and all the other
systems which have hitherto prevailed ; 1 lupe 1 shall be excused  for
attempting a system, which upon the whole nu.y appear new.
Edinburgh,  Nov* 1789. 
r  25  j
       FIRST  LINES
               OF THE

PRACTICE  OF  PHYSIC.
3imtosuction*
 1. J.N teaching the Practice of  Physic, we endeavor
 to give inftru6tion for discerning, distinguishing, prevent-
 ing and curing difeafes, as they occur  in particular per-
 fons.
   2.] The  art  of  discerxing and distinguishing
 ditcafcs, may be beft attained by an accurate and complete
 obfervation of  their phenomena,  as thefe occur  in con-
 courfe and in fucceflion,  and by  constantly endeavoring
 to diitinguifh the peculiar and infeparablc concurrence of
 iymptoms, to eitablifh a Methodical  Nosolocy, or
 an arrangement  of difeafes according to their genera  and
 fpecies, founded upon obfervation alone, abftra&ed from
 all  reafoning.   Such an arrangement I have  attempted in
 another work, to which in the courfe of the prefent I mall
 frequently refer.
   3.J The  prevention of difeafes depends upon the
 knowledge of their remote caufes ;* which is partly deli-
 vered in the general Pathology, and partly to be delivered
 in this treatife.
  * Remote causes are of two kinds, viz. the predisposing'and the exciting,
 err, as it is sometimes called, the occasional.  The predisposing is that which
 renders the body liable or capable of being affected by disease when the ex-
 1 iting cause is applied.  No disease can exist without an occasional cause ;
 yet it is r.ececsarv, that at the same time, the state of the body should be such
 as to admit that cause to take effect, or act. The predisposing cause is inhe-
rent in the body ; but it may nevertheless be induced  or changed by an ex-
ternal cause still more remote.  Thuspl^hora may be the predisposing cause
cf manv diseases, yet that same plethora may be induced by various causes
p;eviou.-.ly acting on the body.   The prevention of diseases is  to  avoid the
CAt-iting cause, and to correct that state of the body, which renders, it capa-
ble cf being affected by the excising cause.
  V  u.  1.                  D 
26               PR A.C T I C E,  &c.

   4.] The Cure of difeafes  is chiefly, and almoft unavoid-
ably founded in the knowledge of their proximate cawfcs.*
This requires an acquaintance with the Inititutions of Me-
dicine ;  that is, the knowledge of the ftrutture, action, and
functions of the human body ; of  the  fevcral changes
which it may undergo ; and of the fevcral powers by which
it can be changed.   Our knowledge of  thcfe particulars,
however, is Hill incomplete, is in many refpects  doubtful,
and has often been involved in  mi (take  and  error.   The
doctrine, therefore,  of  proximate  caufes, founded upon
that knowledge, mult be IVcquently precarious and uncer-
tain.  It is, however, polfible for a judicious  phyfician to
2void what is vulgarly called theory, that is, all  reafoning
founded upon hypothecs, and thereby many  of the errors
which have formerly taken place  in  the Inlcitutions of Me-
dicine.   It is polTiblc alio for a pcrfon who has  an exten-
five knowledge of the facts  relative to the animal cecono-
my in health and in ficknefs, by a cautious and  complete
induction, to eftablifh many general principles which may
guide his reafoning with fafcty ; and while  n  the fame
time, a phyfician admits-as a foundation  of practice thole
rcafonings only  which are  fimple,  obvious  and certain,
and  for  the  molt  part admits  as proximate  caufes
thofe alone  that are eftablifhed a^  matters of fact rather
than as deductions of reafoning,  he may with  oveat advan-
tage -eftablifh a fyftem of practice chiefly founded on the
doclrine of proximate caufes.  But when this cannot  be
done with fufficient certainty,  the  judicious  and prudent
phyfician will have recourfe to  experience alone ;  al-
ways, however, aware .of the hitherto incomplete and fal-
lacious  ftate of Empiricifm.
   5.] With a ftrict attention to thefe confiderations in the
whole of the following Treatife, I proceed to treat <*f par-
ticular difeafes in the order of my Methodical Nofology.

  * Proximate causes are those which immediately produce the disease, and
v.hose removal cures the diteaie.                •
• 
     C  27 ]

PART   I.
Of Pyrexia,  or  Febrile  Diseases.
6.] JTYREXIiE,  or febrile difeafes,  are diftinguifhed
b-y the following appearances.  After beginning with fome
degree of cold ihivering, they mow fome increafe of heatx
and an increafed frequency of pulfe, with the interruption
and diforder of fcveral functions,  particularly fome dimi-
nution of (trength in the animal functions.
   7.J Of thefe Pyrexia: I have formed a clafs, and have
fubdivided it into live  orders of Fevers, In f l amm at i-
OS's,  Eruptions, Hemorrhages,  and Fluxes.—■
See Synopfis  Xofologiae Methodical, Edit. 3. 1780.
=3
BOOK  I.
               OF   FEVERS.

                      CHAP. I.

          SDf tic P&enomena of jFetoectf*

 8.]   JL  HOSE difeafes are more flricily called Fevers,
 which have the general fymptoms of Pyrexia, without ha-
 ving along with them any topical affection that is elfential
 and primary,  fuch as the other orders of the  Pyrexiae al-
 ways  have.
   9. ] Fevers,  as differing in the number and variety of
 their fymptoms, have been very properly conficlcred as of
 diltincT. genera  and  fpecies.   But we  luppofe, that there
 are certain circumftances in  common  to  all the difeafes
 comprehended under this order, which are therefore thofe
eilentially ncceffary to, and properly conftituting the na-
ture of lever.   It is our bufm<3fc efpecially, and in the lirft
place, to  inveftigate thefe; and I expect, to find them as
they occur in the parox'yfm,  or fit,  of an  intermittent fe-
ver, as this is moil commonly formed. 
28                 PRACTICE
   io.] The phenomena to be obferved in fuch a paroxyfm
are the following.   The perfon is affe&ed,  hrlt,  with a
languor or fenfe of debility, a fluggifhnefs in motion, and
fome uneafinefs in exerting it, with  frequent yawing and
ftretching.   At the fame time, the face and extremities be-
come pale ; the features Hi rink ; the bulk of every exter-
nal part isdiminifhed ; and the  fkin over the whole body,
appears conftricted, as if cold had been applied to it.   At
the coming on of thefe  fymptoms, fome coldnefs of the
extremities, though little taken notice of by the patient,
may be perceived by another perfon.   At length, the pa-
tient himfclf feels a fenfation of cold,  commonly firft in
his back, but,  from thence, palling over the whole body ;
and now his fkin feels warm to  another perfon.  The pa-
tient's fenfe of cold increafing, produces a tremor in all his
limbs, with frequent fuccefnons  or rigors of the  trunk of
the body.  When this fenfe of cold, and its effects, have
continued for  fome time, they become lefs violent, and are
alternated with warm flulhings.  By degrees, the cold goes
off entirely ; and a heat, greater than natural prevails, and
continues over the whole body.  With this heat,  the color
of the fkin returns, and a  preternatural  rednefs appears,
efpecially in the face.  Whillt the heat and rednefs comes
on, the  fkin is relaxed and fmoothed, but for fome time,
continues dry.  The features of the face, and other parts
of the body,  recover their ufual  fize,  and become even
more turgid.   When the heat, rednefs, and turgefcence
have increafed and continued for  fome  time,  a  moifture
appears upon the forehead, and by degrees becomes a fweat,
which gradually extends downwards over the whole body.
As this fweat  continues to flow,  the heat of the body  a-
bates;  the fweat,  after continuing  fome time, gradually
ceafes; the body returns  to its ufual temperature ;  and
molt of the fun6tions are reftored to their  ordinary ftate.*
   11.] This feries of appearance give occafion to divide
the paroxyfm into three different Itages; which are called
the Cold, the Hot, and the Sweating Stages or Fits.
   In the courfe of thefe,  Amhderable changes happen  in
   * This description of a paroxysm is truly5admirable.  The symptoms  are
most accurately described, and the order of their succession nco. strictly
attended to by the author. 
U F.  PHYSIC.                 29
the ftate of feveral other functions, which are now to be
mentioned.
   12] Upon the firft approach of languor,  the pulfe be-
comes foinetimes flower, and always weaker than before.
As the fenfe of cold comes on, the pulfe becomes fm.:!!cr,
very frequent and often irregular.   As the cold abates :u;d
the heat comes on, the pulfe becomes more regular,  hard,
and  full;  and in thefe  refpecls,  increafes till the  fv. cat
breaks out.   As the fweat flows,  the pulfe becomes foft-
er, and lefs  frequent, till the fweat ceafing altogether, it
returns to  its  ufual ftate.
   13.] The refpiration alfo fuffers fome changes.  During
the cold ftagc, the refpiration is fmall, frequent, and anxi-
ous,  and is fometimes attended with  a cough : as the hot
ftage  comes on,  the refpiration becomes fuller and more
free ; but continues 11 ill frequent and anxious, till the flow-
ing of the  fweat relieves the anxiety, and renders the breath-
ing lefs frequent and more free.  With the ceahug of the
fwe'at, the breathing returns to its ordinary ftate.
   14.] The natural functions alfo fuffer a change.   Upon
 the  approach of the cold ftage, the appetite for food  ceafes
and does not return till the paroxyfm be over, or the fweat
has  flowed for fome time.   Generally,  during  the  whole
of the paroxyfm,  there is not only a want of appetite, but
an averfion from all folid, and efpecially animal food. As
the  cold ftagc advances, there frequently comes on a fick-
nefs and naufea, which often ir.crcafe  to a vomiting of a
matter that is for the mod  part  bilious.  This vomiting
 commonly puts an  end to the cold  ftage, and brings on
 the  hot.   As  the hot ftage advances, the naufea and vo-
miting abate ; and when the fweat breaks out they gene-
rally ccafc altogether.
   15.] A confiderablc degree of  thirft is commonly felt
during the whole courfe of  the  paroxyfm.  During the
 cold itage, the thirft fecms to arife from the drynefs and
 clammmcfs of the mouth and fauces, but during the hot
ftage, from the heat which then prevails over the whole bo-
dy ; and as the fweat flows, the mouth become moifter, and
the thirft,  together with the heat gradually abates*
   * *The thirst in the cold and hot stac;.•. of the paroxysm seems to he a pro-
vident design of nature, and has been held i'crth as an argument for the cJi- 
3.0
PRACTICE
    16.] In the courfe of a paroxyfm, there is often a con-
 siderable change in the ftate of the fecrctions. The circum-
 ftances juft now mentioned fhow it in the fecretion of the
 faliva  and mucus of the  mouth; and  it is  ftill more re-
 markable with refpetf to the urine.  During the cold ftage,
 the urine is almoft colorlefs,and without cloud or fediment.
 In the hot ftage it becomes high colored, but is ftill with-
 out fediment.  After the fweat has flowed freely,  the urine
 depoflts a fediment, commonly lateritious,  and continues
 to  do fo for fome time after the paroxyfm is over.
    17.] Excepting in certain uncommon cafes which are at-
 tended throughout with a diarrhaa,  ftools feldom occur
 till  towards the end of a paroxyfm,  when commonly  a
 ftool happens,  which is generally of aloofe kind.*
   18. J Analogous to thefe changes in the ftate of the fecrc-
 tions, it frequently happens, that tumours fubfifting on the
 furface of the body, fuller during the cold ftage of fevers,
 a  fudden  and  conliderable detumefcence ; but generally,
 though not always, the tumours return to their former Iize
 during the fweating ftage.   In  like manner, ulcers are
 fometimes dried up during the cold ftage; and return a-
 gain to difcharge matter during the fweating ftage, or after
 the paroxyfm is oyer.
   19.] Certain changes appear alfo in fenfation and thought.
 During the cold ftage,  the fenfibility is  often greatly im-
 paired ; but when the hot ftage is formed, the fenfibility
 is  recovered, and often confiderably inereafed.
   20.] With refpecl to the intellectual functions, when the
 cold  ftagc comes on,  attention and recollection become
 difficult,  and continue mote  or lefs fo  during the whole
 istence of the vis medicatrix naturae.  The paroxysm concludes with a pro-
 fuse sweat; the production of this sweat requires  an additional quantity o£
 fluidity; and  nature, by means of the thirst, seems anxious to supply the
 quantity of fluid matter necessary lor the perspiration that is requisite to re-
 move the disease.
  *  The author's expression is here somewhat aukward; the meaning of the
 passage is, that  stools seldom occur in the  two rirst stages of a paro.w mii,
except in peculiar cases attended with diarrhoea ; and if a. stocl happens
 a'oout the end of the paroxysm, it is generally of a loose kind.
  A spontaneous  diarrhoea always inoreases  the violence of the symptoms,
and the obstinacy of the disease.   Hence the absurd practice of pix-scrihing
purges in agues, which never fail to exacerbate the paroxysms, and pVlong
their continuance.  If any uneasiness arises from accumulated i\c:cs hi '.he
colon or rectum, they may be removed by emollient clysters. 
OP  P.H Y S IC.                  31
paroxyfm.  Hence fome confufion of thought takes place,
and often arifes to a delirium, which fometimes comes on
at the beginning of the cold ftage, but more frequently not
till the hot ftage be formed.
   21.] It belongs alfo to this place to remark, that the cold
ftage fometimes comes on with a drowfinefs and  ftupor,
which often increafe to a degree that may be called coma-
tofe, or apoplectic.
 . 22.] We have ftill to add, that fometimes, early in the
cold ftage, a headach comes on;  but which, more com-
monly, is not felt till the hot ftage be formed, and  then is
ufually  attended  with a throbbing of the temples.  The
headach  continues till the fweat breaks out; but as this
flowrs more freely,  that gradually goes off.   At  the  fame
time with the headach, there are  commonly pains of the
back, and of fome of the great joints; and thefe pains have
the fame courfc with the headach.
   2-3.] Thefe are nearly the whole, and are at leaf! the
chief of  the phenomena which more conftantly  appear in
the paroxyfm of an intermittent fever ; and we have point-
ed out thvir ordinary concourfe and fucceflion.  With re-
fpecl to the whole of them, however, it is to be obferved,
that in different cafes, the feveral phenomena are in differ-
ent degrees ; that the feries of them is more or less com-
plete ; and that the feveral parts or ftages in the  time they
occupy,  are in a different proportion fo one another.
   2.{.J It  is very feldom that  a fever confifts of a^fingle
paroxyfm,  fuch as  we  have now defcribed;  and it m«re
generally happens, after a certain length of time has elapfed
from the ceafing of the paroxyfm,  that the fame feries of
phenomena again  arifes, and obferves  the fame  courfe as
before ;  and thefe ftates of  Fever and Apyrexia often
continue to alternate with one another for many times. In
fuch cafes,  the length of time from one paroxyfm  to the be-
ginning of another, is called an Intermission  ; and the
length of time from the beginning of one paroxyfm to the
beginning of another next fucceeding, is called an In ter-
val.
   25.]  When  the difeafe confifts  of a number of parox-
yfms, it is generally to be obferved, that the intervals be-
tween them are nearly equal; twit thefe intervals  are of 
32
PRACTICE
 different lengths in different cafes.   The mo ft ufual inter-
 val is that of forty-eight hours, which is named  the  Ter
 tia:\' period.  The next molt common is that of feven-
 tv-two hours, and is named the Quartan period. Some
 other intervals are alfo obferved, particularly one of twen-
 ty-four hours, named therefore, the Quotidian; and
 the appearance of this  is pretty frequent.   But all  other
 intervals longer than  that  of the  quartan  are extremely
 rare,  and probably arc only irregularities of the  tertian or
 quartan periods.*
    26.] The  paroxyfms of pure intermittent fevers are al-
 ways  finifhed in lefs than twenty-four hours :   and though
 it happens that  there  are fevers  which  confiit of repeated
 paroxyfms, without any entire mtermifnon between them ;
 yet in fuch cafes it is obferved, that though  the hot and
"fweating ftages of the paroxyfm do not entirely ceafe be-
 fore the twenty-four hours from their beginning have  ex-
 pired, they fuffer, however, hefore that time, a conhderable
 a!:;: temei it or Remission of their violence; and at the re-
 turn of the quotidian  period, a paroxyfm is in fome fhape
 renewed, which runs the fame courfc as before. This con-
 ftitutes what is called a R e m r tt e n t Fe v e r.
    27.] When in thefe remittents the remiflion is consider-
 able, and the  return of a new paroxyfm isdiftinfctly mark-
 ed by the fymptoms of a cold ftage at the beginning of it;
 fuch fevers retain fhictly the appellation of Re mitten is.
 But when it happen,  as it does in certain cafes, that the
 remiflion is not conhderable, is perhaps without fweat, and
 thit the returning paroxyfm is not marked by the molt
 ufual  Iymptoms of a  cold ftage, but chiefly by the aggra-
 vation or Exacerbation of a hot ftage, the difeafe is
 called a Continued Fever.
    28.] In fome cafes of  continued fever, the remifhons
 and exacerbations are fo inconlklerablc as not to be eafily
   * Of the quotidian, tertian, and quartan intermittents there are many va-
 ll.; es  and forms ; as the double tertian, 1-,-ja ing a ;.;iro.\-, :rn every day, with
 the alternate paroxysms similar to one another. The double tertian, with
 two paroxysms every other day.  The triple tertian, with two paroxvsms en
 one day, and another on the  next.  The double quartan, with two paroxysms
 on the  firtday,  none on the second and third, r.vd two again on the fourtii
 day.  The double quartan, with .1 paroxysm on the first day, another on the
 second, but none  on the third. The triple quartan, with three paroxysm everv
 fourth  day.  The triple quartan, with a  paroxysm every day,  eyerv fourth
 rrary.-.-yjin being similar. 
OF  PHYSIC.                 33
©bfervcd or diftinguifhed; and this has led phyficians to
imagine, that there is a fpecies of fever fubfifting for feve-
ral days together, and fcemingly, confifting of one parox-'
ylm only.  This they have called a Continent Fever ;
but, in a long courfe of  practice,  I  have not had an op-
portunity of obferviug fuch a fever.
   29.] It is, however, to be obferved here, that the fevers
of a continued form are to be diftinguifhed from one ano-
ther ;  and that, while fome  of a very continued form do
ftill belong to the fection of intermittents, there are others
which, though ftill conhlling of feparate and repeated pa-
roxyfms, yet as different from their caufes and circumftan-
ces from intermittents, are to  be  diftinguifhed from the
whole of thefe, and are more ftriflly to be called and con-
fidered as Continued.*   Such are molt of thofe which
have been commonly fuppofed to  be Continent;  and
thofe which by moft writers have been limply named Co x-
tinued ; and which  term I have employed as the title of
a fection, to be diftinguifhed from that of I n t e r m i t t e n t.
   I fliall here add the marks by which, in pra8ice, thefe
different continued fevers may be diftinguifhed from one
another.
   Thofe fevers of a continued form, which, however, ftill
belong to the fection of Intermittents, may be diftinguifh-
ed by  their  having paiTed from an intermittent or  remit-
tent form, to that of a continued ; by their fhowing fome
tendency to become intermittent, or at leaft remittent;  by
their being known to have been occafioned by marfh  mi-
afmata ; and  for the moft part,  by their having but  one
paroxyfm, or exacerbation  and remiflion, in the courfe
of twenty-four hours.
   On  the other hand, Continued Fevers, to be more ftrict-
ly fo called, may be diftinguifhed by their fhowing little
tendency to become intermittent or remittent in any part
of their courfe, and efpecially after the firft week of their
continuance ; by their being occafioned by human contagi-
on, at leaft by other caufes than the marfh miafmata;  and

  * This passage i.~ very obscure : the author's meaning is, thit some conti-
nued fevers put on the appearance of intermittents ; but being different, in
some peculiar and material circumstances, from intermittents, are n0t to be
classed with them.
  Vol.  I,                 £ 
34                  V R A C T I C E
 by their having  pretty conftantly an exacerbation and re-
 miflion twice in the courfe of every twenty-four hours.  In
 both cafes, the knowledge of the nature of the epidemic
 for the time prevailing, may have a great fhare in deter-
 mining the nature of the particular fever.
   30.] With refpeel to the form, or Type of fevers, this
 further may be obferved,  That the quartan,  while it has
 the longeft interval, has at the fame time,  the longeft and
 moft violent cold ftage ; but, upon the whole, the fhorteft
 paroxyfm: That the tertian, having a fhorter interval than
 the quartan, has at the fame time, a fhorter and lefs vio-
 lent cold ftage ;  but a longer paroxyfm :  And laftly, that
 the quotidian, with the fhorteft interval,  has the leaft of a
 cold ftage, but the longeft paroxyfm.
   31.] The type of fevers is fometimes changed in their
 courfe. When this happens, it is generally in the following
 manner :  Both tertians and quartans change into quotidi-
 ans, quotidians into  remittents, and thefe laft become often
 of the moft continued kind.  In all thefe cafes, the fever
 has its paroxyfm protracted longer than ufual,  before it
 changes into a type of more frequent repetition.
   32.] From all this a prefumption arifes, that every fever
 confifts of repeated paroxyfm, differing from others chiefly
 in the circum'ftances and repetition of the paroxyfms ; and
tlierefore, that it was allowable for us to take the paroxyfm
of a pure intermittent as  an example  and  model  of the
whole.
CHAP. II.
        ©f tlje IPvorimate Cause of jFefcer,

33.]  JL HE proximate caufe * of fever feems hitherto to
have eluded the refearch of  phyficians; and I fhall  not

  * The author, in this chapter, delivers his favorite doctrine of universal
spasm.  It is by no means new, as he himself confesses in the preface, but
borrowed from Hoffman. The author, however, greatly improved the origi-
nal idea, and brought the system to a greater degree of perfection than it had
been before.  That there are weighty objections against it, cannot indeed be
denied ;  it contains, however, much ingenuity t and Dr. Cullen (by introdu-
cing it in this university) raised his name high in the annals of medical fame. 
OF  PHYSIC.
35
pretend to afcertain it in a manner that may remove every
difficulty ; but I fhall endeavor to make an approach to-
wards it, and fuch as  I hope, may be of ufe in conducting
the pracfife in this difeafe -. while at the fame time  I hope
to avoid feveral errors  which have formerly prevailed pn
this fubjccL
   34.} As the hot ftage of fever is fo conftantly preceded
fey a cold ftage,  we prefume that the latter is the caufe of
the former ;  and therefore, that the caufe of the cold ftage
is the caufe of all that follows in the courfe of the parox-
yfm.-----See Boerh. Aph. 756.
   35 ] To difcovcr the caufe of the cold ftage  of  fevers,
we may obferve, that k is always preceded by ftrong marks
of a general debility prevailing in the fyftem.   The  finall-
nefs and wreaknefs of the pulfe, the palenefs and eoldnefs •
of the extreme parts, with the fhrinking of the whole body,
fufficiently ihow that the action of the heart and larger ar-
teries is, for the time, extremely weakened.  Together with
this, the langour, inactvity, and debility of die animal mo-
tions, the imperfect fenfations, the feeling of cold, while
the body is truly warm, and  fome other  fymptoms, all
fhew that the energy of the brain is, on this occafion, great-
ly weakened > and I  prefume, that as the weaknefs of the
acVion of the heart  can hardly be imputed to any other
caufe, this weaknefs alio is a proof of the diminifhed ener-
gy of the brain.
   36.] I  fhall hereafter endeavor to fhow,. that the moft
noted of the remote caufes of fever, as contagion, miafma-
ta, cold and fear, are of a fedative nature ;  and therefore
render  it probable that  a debility is induced.  Likewife,
when the paroxyfms of a fever have ceafed  to Be repeated,
they may again be renewed, and are moft  commonly re-
newed by the application of debilitating  powers.   And
further, the debility which fiihfifts  in the animal motions
and other fmitt ions through  die whole of fever, renders it
pretty certain that  fedative or debilitating  powers * have
been applied to the body.

  • A purge administered six cr seven days after the appearance of any pa-
roxysm, has frequently occasioned a relapse, and is a practice that ought to be
carefully avoided.  I have generally found that purges given in the be^iu.-
nin£ of th* disease, increase the di.lkulty of curing iu 
35
PRACTICE
   37.] It is therefore evident, that there are  three ftates
which always take place  in  fever: a ftate of debility, a
ftate of cold, and a ftate of heat; and ss thefe  three ftates
regularly and conftantly fucceed each other in the order we
have mentioned  them, it  is prefumed that they are in  the
feries of caufe and effect with refpeft. to one another.  This
we hold as matter of fact, even although we fhould not be
able to explain in what manner, or by what  mechanical
means thefe ftates feverally produce each other.
   38 J How the ftate of  debility produces fome of  the
fymptons of the cold ftage,  may perhaps be  readily  ex-
plained ;  but how it produces all of them,  I cannot  ex-
plain otherwife than  by referring the matter to a  general
law of the animal ceconomy, whereby it happens, tfat pow-
ers which have a tendency to hurt and deftroy the  fyftem,
often excite fuch motions as are fuited  to obviate the ef-
fects of  the noxious power.   This  is the  vis  medica-
trix nature, fo famous  in the fchools of phylic ; and
it feems  probable, that many of the motions excited in
fever are the effects of this power.
   39.] That the increafed action of the heart and arteries,
which takes place in the hot ftage of fevers, is  to be consi-
dered as  an effort of the vis medicatrix natures, has been
long a common 6pinion among phyficians;  and  I  am dif-
pofed to affert,  that  fome part of the cold ftage  may be
imputed  to the fam6 power.   I judge fo, becaufe the cold
ftage appears to be univerfally a means of producing  the
hot; becaufe cold, externally applied, has very often fi-
milar effects; and more certainly ftill, becaufe it feems to
be in proportion to the degree  of tremor in the cold ftage,
lhat the hot ftage proceeds more or lefs quickly to a  ter-
mination of the paroxyfm, and to a more compleat foluti-
on and longer intermiflion.   See 30.
   40.] It is particularly obferved, that during the cold ftage
of fever,  there feems to  be  a  fpafm  induced every where
on the extremities  of the arteries, and  more efpecially of
thofe upon the furface of the body.  This appears from
the fuppreffion of all excretions, and from the fhrinking of
the external parts; and although this may perhaps be im-
puted in part to the weaker action of the heart in prjopel-
ling the blood into the extreme veffels;  yet? as thefe fy mp- 
                  OF  PHYSIC.                  57

toms often continue after the action of the heart is reftored,
there is reafon to believe, that a fpafmoclic conftriction has
taken place ; that it fublifts for fome time,  and fupports
the hot ftage ; for this  ftagc ceafes with  the flowing of the
fweat,  and the return of other excretions, which  are marks
of the  relaxation of velfels formerly conftricted.   Hoft-
iM:i.   Med. rat. Syftem. Tom.  4.  P.  1. Sect. 1.  Cop.
 1.  art. 4.
   41.] The idea of fever, then, may  be that a fpafm of the
extreme veffels, however induced, proves an irritation to
the heart and arteries; and that this continues till the fpafm
is relaxed or overcome.  There are many appearance;
which fupport this opinion; and there is little doubt that
a fpafm docs take place, which proves  an irritation to the
heart, and therefore may be  confidcred as a principal pa it
in the  proximate caufe of fever.   It  will ftill, however, re-
main a queftion, what is the caufe of this fpafm; whether
it be directlv produced by the remote caufes of fever, or if it
 be only a part of the operation of the vis medicatrix naturae.
   42.] I am dil'pofed to be of the latter opinion,  becaufe in
 the first place, while  it remains  ftill  certain that  a  debility
 lays the foundation'of fever, it is not obvious in  what man-
ner the debility produces the fpafm, and what feems to be
its effect, the mcreafed action of the heart and arteries;
and secondly, becaufe, in almoft all the cafes, in which an
 effort is made by the vis medicatrix  natures, a cold fit aid
 a fpafm of the extreme veffels are almoft always the begin-
 nings of fuch an effort. SccGaub. Pathol. Med1cin.art.750.
    43.] It is therefore prefumed, that fuch a cold fit and
 fpafm, at the beginning of fever, is a part of the operation
 of the vis medicatrix; but, at the fame time, it feems  to
 me probable,  that during the whole courfe  of  the fever,
 there is an  atony fubfifting in the extreme veffels, and that
 the relaxation  of  the  fpafin  requires the reftoring of the
 tone and action of thefe.
    44.] This it may  be difficult to explain;  but I think it
 may  be afcertaincd as a fact, by  the confideration of the
 fymptoms which take place, with refpect to the functions
 of the ftomach in fevers,  fuch as  the  anorexia, naufea,
 arid vomiting.  (14.J 
38                 PRACTICE
   From many circumftances it is fufBciently certain, that
 there is a confent between the ftomach and furface of the
 body: and in all cafes of the confent of diftant parts, it is
 prefumed to be by the connexion of the nervous fyftcm,
 and that the confent which appears, is between the icntient
 and moving fibres of the one part witfc thofe of the other,
 is fuch, that a certain condition prevailing in the one  part,
 occafions a fimilar condition in the other.
   In die cafe of the ftomach and furface of the body, the
 confent particularly appears by the connexion which is ob-
 ferved between the ftate of the perforation, and the ftate
 of the appetite in healthy perfons; and if it may be prefum-
 ed  that the appetite depends upon the ftate  of tone in the
 mufcular fibres of the  ftomach, it  will follow, that the-
 connexion of appetite and perfpiration depends upon a
 confent between the mufcular fibres of the ftomach, and.
 the mufcular  fibres of the extreme veffels, or of the organ
 of perfpiration, on the furface of the body.
   It is further in proof of  the connexion between the ap-
 petite and perfpiration, and  at the fame time of the cir-
 cumftances on which it depends, that cold applied to the
 furface of the body, when it does not flop perfpiration,
 but proves a ftimulus to it, is always a powerful means of
exciting appetite.
   Having thus eftablifhed the connexion or  confent men-
tioned, we argue, that as the fymptoms of anorexia, nau-
fea, and vomiting, in many cafes, manifeftly depend upon
a ftate of debility or lofs of tone in the mufcular fibres  of
 the ftomach;  fb it may be prefumed, that thefe fymptoms,
in the beginning of fever, depend upon  an atony commu-
nicated to the mufcular fibres of the ftomach, from the
mufcular fibres of the extreme  veffels  on the furface  of
the body.
  That the debility  of the ftomach which produces vo-
miting in the beginning of  fevers,  actually  depends upon
an atony of the extreme veffels on the furface of the body,
appears particularly from a fact obferved by Dr. Syden-
ham.   In the attack of the plague, a vomiting happens,.
which prevents any medicine  from remaining on the fto-
mach; and Dr. Sydenham tells us, that •in fuch cafes  he
could not overcome this vomiting but by external means 
OF  PHYSIC.                39
applied to produce a fweat; that is,  to excite the action
of the veffels on the furface of the body.
   The fame connexion between  the ftate of the  ftomach
^nd that of the extreme veffels on  the furface of the body,
 appears from this alfo, that  the  vomiting, which fo fre-
 quently happens  in the cold  ftage of fevers, commonly
 ceafes upon the coming on of the hot, and very certainly
 upon any fweal's coming out (14.)  It is indeed probable,
 that the vomiting in the cold ftage of fevers, is one of the
 means employed by nature for reftoring the determination
 to the furface of the body; and it is a circumftance afford-
 ing proof, both of this, and of the general connexion be-
 tween the ftomach and furface of the body, that  emetics
 thrown into the ftomach, and operating there, in  the time
 of the cold ftage, commonly put  an end to it, and bring
 on the hot ftage.
   It  alfo affords a proof of the fame connexion, that cold
 Water, taken into the ftomach produces an increafe of heat
 on the furface of the body, and is very often a convenient
 and effectual means of producing fweat.
   From  the whole we have  now faid on this fubject, I
 think it is fufficiently probable, that the fymptoms of ano-
 rexia, naufea,  and vomiting, depend'upon, and are a
 proof of, an atony fubfifting in the extreme veffels on the
 furface of the body; and  that this atony therefore, now
 afcertained as a  matter of fact,  may be confidered as a
 principal circumftance in the proximate caufe of fever.
   45.] This atony * we fuppofe  to depend upon a dimi-
 nution of the energy of the brain;  and that this diminution
 takes place in fevers,  we conclude, not only from the de-
 bility prevailing in fo many of the funftions of the body,
 mentioned above  (35.) but  particularly from fymptoms
 which are peculiar to the  brain itfelf.  Delirium  is a fre-
 quent fymptom of fever;  and as from the phyfiology  and
 pathology we learn that this fymptom commonly depends
 upon fome inequalitv in the excitement of the brain or in-
 tellectual  organ; we  hence  conclude, that, in- fever, it
 denotes fome diminution  in the energy of the brain.  De-
 lirium, indeed,  feems often to depend upon an increafed
                «
  * The reader will perc*ive, that the whole of the doctrine delivered in thic
chapter is hypothetical. 
40
PRACTICE
impetus  of the blood,  in  the veffels of the brain,  and
therefore attends phrenitis.   It-frequently appears  alfo
in the hot fiage of fevers,  accompanied  with  a headach
and  throbbing of the temples.  But as  the impetus of
the blood in the veffels of  tire head is often coniiderably
increafed by  cxercife, external heat, pafhons, and other
caufes,   without occafioning any  delirium ;  fo,  fuppo-
fmg  that the fame impetus, in the  caufe  of fever,  pro-
duces delirium,  the reafon muft be, that at the fame time,
there is  fome caufe which diminifhes the energy of the
brain,  and prevents a free ..communication  between the
parts concerned in the intellectual functions.  Upon the
fame principles alfo, I fuppofe there is another Ipecies of
delirium, depending more entirely on  the diminifhed ener-
gy of the brain, and which may therefore arife, when there
is no unufual incrcafe of the impetus of the blood in the
veffels of the brain.   Such feems to  be the delirium oc-
curring at the beginning of the cold ftagc of fevers,  or in
the hot ftagc of fuch fevers as fhow ftrong marks of debi-
lity in thcwhole fyftem.
  46.] Upon the whole, our doctrine  of fever is explicitly
this.   The remote caufe-? (36.) are certain fedative powers
applied to the nervous fyftem, which diminifhing the ener-
gy of the brain, thereby produce a debility  in the whole of
the functions, (3^) and particularly in  the action of the ex-
treme veffels, (43. 44.) Suchy however, is, at the fame time,
the nature of the animal ceconomy, (38.) that this debility
proves an indirect ftimulus  to  the fanguifcrous fyftem ;
whence,  by the intervention of the cold ftage, and fpafm
connected with it, (39. 40.) the action  of the heart and lar-
ger arteries is increafed, (40.) and continues fo (41.)  till it
has had the effect of rcftoring the energy of the brain, of
extending this energy to the extreme  veffels, of rcftoring
therefore their action,  and thereby efpecially overcoming
the fpafm affecting them ;  upon the  removing  of which,
the excretion of fweat, and other marks of the  relaxation
of excrctories, take place.
   47.] This doctrine will, as I fuppofe, fefve  to explain
not only the nature of  fever in  general, but alfo the  vari-
ous cafes of it which occur.  Before proceeding, however,
to this, it may be proper  to point out  the opinions, and as 
                    OF  PHYSIC                41

  I apprehend, the miftakes, which have formerly prevailed
  on this fubject.
    48.] It has been fuppofed, that a lentor or vifcidity pre-
  vailing m the mafs of blood, and ftagnatingin the extreme
  veffels, is the caufe of the cold ftage of fevers and its con-
  fequences.  But there is no evidence of any fuch vifcidity
  prcvioufly fubfifting in the fluids;  and as it is very impro-
  bable that fuch a  ftate of them can  be very quickly pro-
  duced, fo the fuddennefs with which paroxyfms  come on
  renders it more likely that, the phenomena depend upon
  fome caufe aEing upon the nervous fyftem,  or the prima-
  ry  moving  powers of  the  animal  economy.   See Van
  Swieten apud Boerh. Aph.. 755.
    49.] Another opinion,  which has been almoft univer-
  fally  received,  is, that a noxious matter introduced  into,
  or generated in, the body, is the proximate caufe of fe-
  ver;  and that the increafed a&ion of the heart and arteries,
  which forms fo  great a part of  the difeafe,  is an effort of
  the vis medicatrix naturce to  expel  this morbific matter ;
  and particularly to change or concoait,  foas to render it
  either  altogether innocent, or  at leaft, fit for being more
 eafily thrown out of the body.   This doctrine,  however,
 although of as great antiquity as any of the records ofphy-
  hc now remaining, and although it has been received by
 almoft every fchool of medicine, yet appears to me to reft
 upon a very uncertain  foundation.   There are fevers pro-
 duced by cold,  fear, and other caufes, accompanied with
 all the effential circumftances of fever, and terminating by
 fweat; but,  at the fame time, without any  evidence or
 fufpicion of morbific matter.
   There have been fevers fuddenly cured by a hemorrha-
 gy,  fo moderate as  could not carry  out any confiderable
 portion of a matter diffufed over the whole mafs of blood;
 nor can we conceive how the morbific matter could becol-
 leded or determined  to pafs off by  fuch an outlet  as in
 that cafe is opened.
  Even fuppofing a morbific matter were prefent, there is
no explanation given, in what manner the concoaion of it
is performed ; nor is it fhown that any fuch change does in
fa& take place.   In certain cafes, it is indeed evident, that
a noxious matter is introduced into the body,  and proves 
42                 PRAGTIGK

the caufe of  fever; but, even  in thefe cafes, it appears
that the noxious matter is thrown out again, without hav-
ing fuffered any change;  that the  fever often terminates
before the matter is expelled; and that,  upon many occa-
fions,  without  waiting the fuppofed time of concoction,
the fever can be cured, and that by remedies which do not
feem to operate upon the fluids, or to produce  any eva-
cuation.
   50.] While  we thus reafon againft the notion of fever
heing an effort  of nature, for concoaing  and expelling a
morbific matter;  I by no means intend to deny that the
caufe of fever frequently operates upon the fluids, and par-
ticularly produces a putrelccnt ftate of them.  I acknow-
ledge that  this  is frequently the  cafe;  but,  at  the fame
time, I maintain,  that fuch a change of the fluids is  not
commonly the  caufe of fever; that  very often it  is an ef-
fea only;  and that there is no reafon to believe the termi-
nation of the fever to depend upon the expulfion of the
putrid matter.
   51.] Another opinion which has prevailed^ remains ftill to
be mentioned.   In intermittent fevers,  a great quantity of
bile is  commonly thrown out by vomiting ; and  this is fo
Frequently  the cafe, that many  have fuppofed an unufual
quantity of bile, and perhaps a peculiar quality of it, to be
the caufe of intermittent fevers.   This,  however,  does  not
appear to be well founded. Vomiting, by whatever means
excited, if too often repeated, with violent {training, feems
to be .powerful  in emulging  the biliary du6ts, and com-
monly throws out a great deal of bile.   This  will happen
efpecially in the cafe of intermittent fevers.  For as, in the
ftate of debility and cold ftagc of thefe fevers, the blood
is not propeller! in the ufual quantity into the extreme vef-
fels, and particularly into thofe on* the furface of the body,
but is accumulated in the veffels of the  internal parts,  and
particularly in the vena portarum ; fo this may occafion a
more copious fecretion of bile.
   Thefe confiderations will, in fome meafure, account for
the appearance of an unufal quantity of bile in intermittent
fevers; but the circumftance which cheifiy  occalions the
appearance of bile in thefe cafes, is the influence of warm
climates and feafons.  Thefe feldom fail to produce a ftate 
OF  PHYSIC.
*2
 of die human body, in which the bile is difpofed to pals off,
 by its fecretories, in greater quantity than ufual;  and per-
 haps alfo changed in its quality, as appears from the difeafe
 of cholera, which fo  frequently  occurs in warm feafons.
 At the fame time, this difeafe occurs often without fever;
 and we fhall hereafter render it fufticiently probable,  that
 intermittent fevers, for the moft part,  arife from another
 caufe, that is, from marfh effluvia ; while on the other hand,
 there is no evidence of their arifing  from the  ftate of the
 bile alone.   The marfh effluvia however, commonly ope-
 rate moft powerfully in the fame feafon that produce* the
 change of and redundance of the bile; and therefore confix
 dering the vomiting, and other circumftances of the intermit-
 tent fevers which here concur, it is not furprifmg that autum-
 nal intermittents are fo often attended with effufionsof bile.
   This view of the fubject does not lead us to confider the
 ftate of the bile as the caufe of intermittents, but merely as
 a circumftance accidently concurring with them, from the
 ftate of the feafon  in  which  they arife.   What attention
 this requires in the conduct, of die difeafe,  I fhali confider
 hereafter.
   52.] From this view of the principal hypothecs which
 have hitherto been maintained with refpea to the proximate
 caufe of fever, it  will appear, that fevers do not arife from
 changes in the ftate of the fluids; but that,  on the contrary,
 almoft the whole  of the phenomena of fevers lead us to be-
 lieve,  that they chiefly depend upon changes  in the ftate
 of the moving powers of the animal  fyftem.  Tho' we
 mould not be able  to  explain all the circumftances of the
 difeafe, it is at leaft of fome advantage to be led into the
proper train of inveftigation.   I have attempted to purfue
it; and fhall now endeavour to apply the dodrine already
delivered, towards explaining the diverfity  of fevers.
CHAP.  III.
  ©f tit Difference of jFeuer& ami itft'Cautfeff*
53.]  A O afcertain the difference of fevers, I think itne,
ceffary to obferve;  in the firft place;  that  every fever of 
44
PRACTICE
more than one day's duration, confifts of repeated, and in
fome meafure feparate paroxyfms; and that the difference
of fevers taken notice of above (from 25. to 30.) appears to
confift in the different ftate of paroxyfms, and in the differ-
ent circumftances of their repetition.
   54.] That fevers generally confift of diftina,and in fome
meafure feparately repeated  paroxyfms, I have alledged
above to be a matter of fact; but 1  fhall here endeavor to
confirm it, by afligning the caufe.
   55.] In every fever, in which we can diftincTly obferve
any number of feparate paroxyfms, we conftantly find that
each paroxyfm is finifhed in  lefs than twenty-four hours ;
but as I cannot perceive  any thing in the caufe of fevers
determining  to this, I muft prefume  it to depend on fome
general law * of the animal economy. Such a law feems to
be that which fubjeas the economy,  in many refpects, to a
diurnal revolution.   Whether this depends upon  the ori-
ginal conformation of the body, or upon certain powers
conftantly applied to it, and inducing a habit, I cannot pofi-
tively determine; but the returns of fleep and  watching,
of appetites and excretions, and the changes which regular-
ly occur in the  ftate of the pulfe,  fhow fufticiently, that
in the human body a diurnal revolution takes place.
    56.] It is this diurnal revolution which, I fuppofe deter-
 mines the duration of the paroxyfms of fevers; and the
 conftant and univerfal  limitation-of thefe paroxyfms, (as
 obferved in 55.) while no other caufe of it can be alligned,
 renders it fufticiently probable, that their duration  depends
 upon, and is determined by,  the  revolution mentioned.
 And that thefe paroxyfms are conneaed with that diurnal
 revolution, appears further from this, that though the in-
 tervals of paroxyfms are different in different cafes, yet the
 times of the acceftion of paroxyfms are generally fixed to
 one time of the  day; fo that  Quotidians come on in the
 morning, Tertians at noon, and Quartans in  the afternoon.
    57.] It remains to be remarked, that as  Quartans and
 Tertians are apt to become  Quotidians, thefe to pafs into
 the ftate of Remittents, and thefe laft to become Continu-

    • The reader will find entertainment in admiring the ingenuity of the au-
 thor, in contriving several articles for maintaining his doctrine.  Or.c hypo-
 thesis piled on the top of another, almost without end, 
O F P H Y S I C.                  45
eel;  and that, even  in  the  Continued  form,  daily ex-
acerbations  and remiftions are generally to be obferved ;
fo all this fhows fo much the power of diurnal revolution,
that when, in certain cafes, the daily exacerbations and re-
miifions are with difficulty diftinguifhed, we may ftill pre-
fume, that the general  tendency of  the economy prevails,
that  the difeafe ftill confifts of repeated paroxyfms,  and,
upon the whole, that there is no fuch difeafe as that which
the fchools  have called a Continent Fever.  I expea that
this  doaHne  will be confirmed  by what I fhall fay here-
after, concerning  the  periodical movements obferved  in
continued fever.
   58.] It being thus proved, that every fever, of more than
one  day's duration, confifts of repeated  paroxyfms; we,
in the next  place, remark, that the repetition of paroxyfms
depends upon the circumftances  of die paroxyfms which
have already taken place.  From what was obferved (in 30*
and 31.) it appears,  that the longer paroxyfms are  pro-
 traaed,  they  are the fooner repeated ;  and therefore, that
 the  caufe of the frequent repetition is to be fought  for in
 the  caufe of the protraction of paroxyfms.
   59.] Agreeably to what is laid down in  46.  and to the
 opinion of moft phyficians, I fuppofe, that in every  fever
 there is a power applied to the body,  which has a tenden-
 cy to hurt  and deftroy it, and produces in it certain moti-
 ons which deviate  from the natural ftate ; and at the fame
 time, in every fever which has its full courfe,  I fuppofe,
 that in confequence of the conftitution of the animal eco-
 nomy, there are certain motions excited, which  have a ten-
 dency  to obviate the effeas of the noxious power,  or to
 correa and remove them.  Both thefe kinds of motion are
 confidered as conftituting the difeafe.
   But the  former is perhaps ftriaiy the morbid ftate, while
 the latter is to be confidered as the operation of the vis me-
 dicatrix natures of falutary tendency,  and which I fhall
 hereafter call the  reaction of the fyftem.
   60.]  Upon the fuppofition  that thefe two ftates take
 place in every paroxyfm of fever, it will appear to be chief-
 ly in the time of the hot ftage that the reaaion operates in
 removing the morbid ftate; and therefore as this operation
 fucceeds more or  lefs quickly, the  hot ftage of paroxyfms 
46                 PRACTICE
 will be fhorter or longer.   But as the length of paroxyfm
 depends chiefly upon the duration of the hot ftage,  fo the
 longer duration of this and of paroxyfms, muft  be owing
 cither to the obftinacy of refiftance in the morbid ftate, or
 to the weaknefs of the falutary reaction ; and it is proba-
 ble that fometimes the one,  and fometimes the otlier of
 thefe circumftances takes place.
   61.] It feems to be only by the ftate of the fpafm,  that
 we can judge of the refiftance of the morbid ftate of fever-
 and with refpea to this fpafm I obferve,  that  either the
 caufe exciting it may  be  different in  different cafes; or,
 though the caufe fhould be the fame in different perfons,
 the different degree of irritability,  in each may give occa-
 fion to a greater or letter degree of fpafm; and therefore,
 the reaaion in fever being given,  the continuance of the
 hot ftage,  and of the whole paroxyfm, may be longer or
 fhorter, according to the  degree of fpafm  that has been
 formed.
   62.] One caufe of the obftinacy of fpafm  in fevers may
 be clearly perceived.   In inflammatory difeafes,  there is a
 diathefis phlogiftica prevailing in the body,  and this dia--
 thefis we fuppofe to confift in an increafed tone of  the
 whole arterial fyftem.   When, therefore, this diathefis ac-
 companies fever, as it fometimes does, it  may be fuppo-
 fed to give occafion to the febrile fpafm's  being formed
 more ftrongly, and thereby to produce more protraaed
 paroxyfms.  Accordingly  we find, that all inflammatory
 fevers are of the continued kind; and that all the caufes of
 the diathefis phlogiftica have a tendency to  change  inter-
 mittent into  continued  fevers.  Continued  fevers, then,
 being often attended with the diathefis phlogiftica, we con-
 clude, that, in many cafes, this is the caufe of their conti-
nued form.
   63.] In many fevers, however,  there is no evidence of
any diathefis phlogiftica being prefent,  nor  of any  other
 caufe of more conhderable fpafm; and,  in fuch  cafes,
therefore,  we  muft impute the protraction of paroxvfms
and the continued  form of  the fever,  to the weaknefs cf
reaaion.   That this  caufe  takes place,  we conclude from
hence, that, in many cafes of fever, wherein the feparate
paroxyfms are the  longeft  protraaed;  and the- moft diffi- 
OF  PHYSIC.                 47
cultly obferved, we find the moft confiderable fymptoms
of a general debility : and therefore we infer, that, in fuch
cafes, the protracted paroxyfms, and continued form, de-
pend upon a weaker reaaion;  owing either to the caufes
of debility applied having been  of a more powerful kind,
or from circumftances of the patient's conftitution favour-
ing their operation.
   64-.]-Upon thefe principles we make a ftep towards ex-
plaining in general,  with fome  probability,  the difference
of fevers; but muft own, that there is much doubt and dif-
ficulty in applying the do£trine  to particular cafes.   It ap-
plies tolerably well to explain the  different ftates of inter-
mittents, as they arc more purely  fuch, or as they ap-
proach more and more to the continued form:  But feve-
ral difficulties ftill remain with refpea to many circumftan-
ces of intermittents; and more  ftill with refpea to the dif-
ference of thofe continued  fevers, which  we have diftin-
guifhed in our Nofology as different from intermittents,
and as more efpeciallv entitled  to the appellation of Conti-
nued,  (fee Syn.  Nof. Meth. P.  V. Ch. I. Sea. II.) and
explained more fully above.
   6$.] From the view given (63 and 64.)  of the caufes of
the protraaion of paroxyfms, and therefore of the form of
Continued  fevers, ftriaiy  fo called, it feems probable,
that the remote caufes of thefe  operate by  occafioning ei-
ther a phlogiltic diathefis, or a weaker reaaion; for we can
obferve,  that the moft obvious  difference of continued fe-
vers depends upon the prevalence of one or other of thefe
ftates.
   66.] Continued fevers have been accounted of great di-
verfity ;  but phyficians have not been fuccefsful in mark-
ing thefe differences, or in reducing them to any general
heads.   The diftinaions made  by the ancients are not well
underftood; and, fo far as either they or the modern nofo-
logifts have diftinguifhed continued  fevers by a difference
of duration, their diftinaions are not well founded, and do
not apply in fuch a manner as to be of any ufe. We think
it agreeable to obfervation,  and to  the principles above
laid down, (63. 64.) to diftinguifh  continued  fevers ac-
cording as they fhow either an inflammatory irritation or a
weaker reaaion. 
48                 PRACTICE
   6y.] This diftinaion is the fame with that of fevers into
the Inflammatory and Nervous; the diftinfction  at
prefent moft generally received in Britain.  To the  firft,
as a genust I have given the name of Synochus; to the
fccond, that of Typhus; and  little ftudious whether thefe
names beauthorifed by the ancient ufe  of the fame terms,
I depend upon their being underftood by  the  charaaers *
annexed to them in our Nofology, which I apprehend  to
be founded on obfervation.
   68.] By thefe characters I think continued fevers may
in practice be diftinguifhed;  and if that be  the cafe, the
principles above laid down will be confirmed.
   69. J  Befide thefe differences of continued fever,  now
mentioned, I am not certain of having obferved any other
that can be confidered as fundamental. But the moft com-
mon form of continued fevers, in this climate, feems to  be
a combination of thefe two genera; and I have therefore
given fuch a genus a place in our Nofology,  under the  ti-
tle of Synochus. At the fame time, I think that the limits
between the Synochus and Typhus will be with difficulty
aftigned; and  I am  difpofed to believe, that the Synochus
arifes from the fame caufes as the  Typhus, and is therefore
only a variety of it.
   70.] The Typhus feems to be  a genus comprehending
feveral fpecies.  Thefe, however, are not yet well afcer-
tained by obfervation;  and in the mean  time we can per-
ceive that many of the different cafes obferved, do not im-
ply any fpecific difference, but feem to be merely varieties
arifing from a  different degree of power in the caufe, from
different circumftances  of the climate or  feafon in which
they happen, or from different circumftances in the confti-
tution of the perfons affiled.
   71.] Some of the effects arifing from thefe circumftan-
ces require to be particularly explained.
   One is,  an unufual  quantity of bile  appearing in the
courfe of the difeafe. This abundance of bile may poffibly
attend fome continued levers,  ftrictly fo called ;  but, for
the reafons above  explained,  it  more commonly attends

  * These characters are, Synocha. Calorplurimumauctus ; pulsus frequent,
validus, et durus ; urina rubra ; sensorii functiones plurimum turbats i vires
multum imminutse. 
OF PHYSIC.
43
intermittents, and we believe, it might have been enume-
rated (29.) among the marks diftinguifhingthe latter kind
of fevers from the former.   But though an unufal quantity
of bile fhould appear with continued fevers, it is confider-
ed in this cafe, as in that of intermittents, to  be a coinci-
dence only, owing to the ftate of the feafon,  and produc-
ing no different fpecies or fundamental  diftinaion,  but
merely a variety of the difeafe.   I think it proper to ob-
ferve here, that it is probable that the moft part of the con-
tinued fevers named Bilious have been truly fuch as belong
to the feaion of Intermktents.
   72.] Another effea of the circumftances occafionally va-
rying the appearance of typhus, is a putrefcent ftate of the
fluids.    The ancients, and likewife the moderns, who are
in general much difpofed to follow the  former, have  def-
tinguifhed fevers, as putrid, and non putrid : but the  noti-
ons of the ancients, on this fubject, were not fufticiently
correa to deferve much notice ; and it is only of late that
the matter has been more accurately obferved, and better
explained.
   From the diffolved ftate of the blood, as it prefents itfelf
when drawn out of the veins, or as it appears from the red
blood's being difpofed to be effufed and run off by various
outlets,  and from feveral other fymptoms to be hereafter
mentioned, IJaave now no doubt, how much  foever it has
been difputed by fome ingenious men, that a putrefcency
of the fluids, to a certain degree, does really take place in
many cafes of fever.  This  putrefcency, however, often
attends intermittent, as well as continued fevers, and of the
continued kind, both the fynochus and typhus, and all of
them in very different degrees;  fo  that whatever attention
it may deferve in praaice, there is  no fixing fuch limits to
it as to admit of eftabhfhing a fpecies under the title of
Putrid.                           '
   73.] Befide differing by the circumftances already men-
tioned, fevers differ alio by their being accompanied with
fymptoms which belong to difeafes of the other orders of
pyrexiae.  This fometimes happens in fuch a manner, as to
render it difficult to determine which of the two is the pri-
mary difeafe. Commonly, however, it may be afcertained
by the knowledge of the remote caufe. and the prevailing
  Vwj..  t.          •       G 
SO                 P~R A C T I C IE
epidemic, or by obferving the feries and  fucccflion of
fymptoms.
   74.] Moft of our fyftems of phyfi-c have  marked, as a
primary one, a fpecies of fever under the title of Hectic -;
but as it is defcribed, I have never feen it as a primary dif-
eafe.  I have conftantly found it as a fymptom of fome to-
pical affeaion, moft commonly of an internal fuppuration;
and as fuch it fhall be confidered in another place.
   75.] The diftinaion of the feveral cafes of intermittent
fever  I have not profecuted here;  both becaufe we can-
not aflign the caufes of the differences which appear ; and
becaufe  J apprehend that the differences which in fact oc-
cur may be readily understood from-what  is laid above
(25. 26. and 27.) and more  -fully from our Methodical
Nofology, Ch. I. Sea. I.
                    CHAP.  IV.


         SDf tit Eemote Cause of jFetoer,

76.] XXS fever has been held to confift chiefly in an in-
creafed aaion of the heart and arteries, phyficians have fup-
pofed its remote caufes to be certain dirc6t ftimulants fitted
to produce, this increafed attion.  In many cafes, however,
there is  no evidence of fuch ftimulants being applied ; and
in thofe in which they are applied, they either .produce on-
ly a  temporary frequency of the pulfe, which cannot be
confidered as a difeafe ;  or, if they do produce  a perma-
nent febrile ftate, it is by the intervention of a topical in-
flammation, which produces a difeafe different from what
is ftriaiy called fever.   (8.)
   77.] Thatdirea ftimulants are the remote caufes of fe-
ver,  feems farther improbable ; becaufe the fuppofition
does not account for  the phenomena attending the accefli-
on of fevers,  and becaufe other remote caufes  can with
greater certainty be affigned.
   78.] As fevers are  fo generally epidemic, it is probable,
that fome matter floating in the atmofphere, and applied to
the bodies of men, ought to be confidered as the remote
caufe of fevers : And thefe matters prefent in the atmof- 
OF  PHYSIC
51
 phere, and thus aaing upon men, may be confidered either
 as Contagions, that is, effluvia arifirfg direaiy or origi-
 nally from the body of a man under a particular difeafe,
 and  exciting the fame  kind of difeafe in the body of the
 perfon to whom they are applied;  or Miasmata, that
 is, effluvia arifing from other fubftances than the bodies of
 men, producing a difeafe in the perfon to whom  they are
 applied.
    79.]  Contagions have been fuppofed to be of great va-
 riety ; and it is  pofiible this may be the cafe ; but  that they
 truly are fo,  docs not  appear clearly from any  thing we
 know at prefent.   The genera and fpecies of contagious
 difeafes, of the  Pyrexiae at  prefent known, are in number
 not very great. They chiefly belong to the order of Fevers,
 to that of Exanthemata, or that of Profluvia.  Whether
 there be any belonging to the  order of  Phlegmafise, is
 doubtful; and  though there fhould, it will not much in-
 creafe the number of contagious pyrexiae.   Of the conta-
 gious exanthemata and profluvia, the number of fpecies is
 nearly afcertained ; and each of them is fo far of a deter-
 mined nature, that though  they  have now been obferved
 and diftinguifhed for many ages, and in many different parts
 of the world, they have been always found to retain the
 fame general  charaaer,  and to differ only irr circumftan-
 ces, that may be imputed to feafon, climate, and other ex-
 ternal caufes, or to die peculiar conftitutions of the feveral
 pcrfons affected.   It feems,  therefore, probable, that in
 each of thefe fpecies, the contagion is of one fpecific na-
 ture ; and that the number of contagious exanthemata or
 profluvia is hardly greater  than  the  number  of fpecies
 enumerated in. the fyftems of nofology.
   80.] If, while the contagious exanthemata and profluvia
 are thus limited, we fhould fuppofe the contagious pyrexia
 to be ftill of great and unlimited variety,  it muft  be with
 refpea to the genera and fpecies of continued fevers. But
 if I be right in limiting, as I have done, the genera  of thefe
 fevers (6j.—70.) it will  appear likely that  the contagions
 which produce them are not of great variety; and this will
 be much confirmed, if we can render it probable that there
is one principal, perhaps one common, fource of fuch con*
fcagior^ 
32                 PRACTICE
  81.] To thispurpofe it is how well known<fhat the efflu-
via conftantly arifmg from the living human body, if long
retained in the fame place, without being diffufed in the at-
mofphere, acquire a fingular virulence; and, in that ftate,
being applied to the bodies of men, become the caufe of a
fever which is highly contagious.
  Theexiftence of fuch a caufe is. fully proved by the late
obfervations on jail and hofpital fevers: and that the fame
virulent matter may be produced in many other places, muft
be fufticiently obvious:  and it is probable that the conta-
gion arifing in this manner, is not, like many other conta-
gions, permanent  and conftantly exifting;  but that,  in the
circumftances mentioned, it is occafionally generated. At
the fame time, the nature of the fevers  from thence,  upon
different occafions, arifing, renders it probable that the vi-
rulent ftate of human  effluvia is the comraon.caufe of them,
as they differ only in a ftate of their fymptoms; which
may be imputed  to the circumftances of feafon,  climate,
Sec.  concurring with the contagion, and modifying its force.
   82.]  With refpea to thefe contagions, though we have
fpoken of them as of a matter floating in the atmofphere,
it is  proper  to obferve, that they are  never found  to aa
but  when they are near to the fources from whence they
arife; that is, either near to the bodies of men, from  ^hich
they immediately  iffue; or near to fome fubftances which,
as having been near to the bodies  of men, are imbued with
their effluvia, and in which fubftances thefe effluvia are
fometimes retained in an aaive ftate for a very long time.
   The fubftances thus imbued with an aaive and infecti-
ous  matter, may be called,  Fomites; and it appears to me
probable, that contagions, as they arife from fomites, are
more powerful than as they  arife immediately  from the
human body.
   83 ]  Miafmata are next  to be  confidered.  Thefe may
arife from various fources,  and be of different kinds; but
we know little of their variety, or of their feveral effects.
We know with certainty only one fpecies of miafma, which
can  be confidered as  the caufe of fever; and, from the uni-
verfality of this, it may be doubted if there be any other.
   84.] The miafma, fo univerfally the caufe of  fever, is
that which arifes from marfhes or  moift ground, aaed upon 
                   OF  PHYSIC.                53.

by heat.  So many obfervations have now been made with
refpea to this,  in  fo many different regions of the earth,,
that there is neither any  dom>t of its being in general a
caufe of fevers, nor of its bein^ very univerfally the caufe
of  intermittent fevers, in all  their different forms.  The
fimilarity of the climate, feafon,  and foil,  in the different
countries in which intermittents arife,  and the fimilaritv of
the difeafes,  though arifing in different regions, concur in
proving, that there is one common caufe of thefe cufeafes,
and that this is the  marfh miafma.
   What is the particular nature of this miafma, we know
not;  nor do we certainly know whether or  not it differs in
kind; but  it is probable  that it does not; and that it varies
only  in the degree of its power, or perhaps as to its quan-
tity, in a uiven fpace.
   85.J It lias bc.c;i now rendered probable,  that the remote
caufes of fevers (8.) are  chiefly Contagions or Miafmata,
and neither of them of great variety.   Wc have fuppofed
that miafmata are the catife of intermittents,  and contagions
the caufe of continued fevers, ftridly fo named;  but we
cannot with propriety  employ  thefe general terms.  For,
as  the caufe of continued fevers may arife from fomites,
and may, in fuch cafes, be  celled a Miafma; and as other
 miafmata alfo may produce contagious difeafes; it will be
proper to  diflinguifh the caufes of  fevers, by ufmg the
terms Human or Marsh  Effluvia,  rather than the  general
ones of Contagion Miafma.
    86.] To render ourdoarine of fever confiftent and com-
 pile, it is neceffary to add here, that thofe remote caufes
 of fever, human and marfh effluvia,  feem to be of a debi-
 litating or fedative quality.   They arifc from a putrefcent
 matter.  Their produttion is favoured, and their power in-
creafed, by circumftances which  favour putrefaction;  and
they  often prove putrefactive ferments with refpect to the
 ^iimal fluids.   As putrid matter, therefore, is always with
 refpea to animal bodies, a powerful fedative, fo it can hard-
ly  be doubted,  that human and marfh effluvia are of the
 fame quality:  and it is confirmed by this, that the  debility
which is always induced, feems to be  in proportion to the
other marks that appear of the power of thofe caufes.
    87.]  Though we have endeavoured to (how that fevers 
S4
PRACTICE
  generally arife from marfh or human effluvia,  we cannot,,
  with any certainty, exclude  fome  other  remote caufes,
  which are commonly fuppofed to have at leaft a fhare in
  producing thofe difeafes.   And I proceed, therefore,  to
  enquire  concerning thefe  caufes; the firft of which that
  merits attention, is the power of cold applied to-the human
  body.
    88.] The operation of cold on a living body, is fo differ-
  ent in  different circumftances, as to be of difficult explana-
  tion; it is here, therefore, attempted with fome  diffidence.
    The power of  cold  may be confidered as  abfolute or
 relative.
    The absolute power is that by which it can diminifh the
 temperature of the body to which it is applied.  And  thus,' *
 if the natural temperature of the human body is, as we fup-
 pofe it to be, that of 98 degrees of Farenheit's thermome-
 ter;* every degree of temperature lefs.than that,  may  be
 confidered as cold with  refpea to the human body;  and,
 in proportion to its degree, will havea tendency to diminifh
 the temperature of the body. But as  the living human bo-
 dy has  in itfelf a power of generating heat,  fo it can fuftain
 its own proper heat to the degree above mentioned, though
 furrounded by air or other bodies of a lower temperature
 than itfelf; and it appears  from obfervation, that, in this
 climate, air,  or other bodies applied to the  living man, do
 not diminifh die temperature of his body,  unlefs the  tem-
 perature of the bodies applied be below 62  degrees. From
 hence it appears,  that the abfolute power  of cold in  this
 climate, does not aa upon the  living human body,  mile's
 the cold applied be below the degree juft now mentioned.
   It appears alfo that the human body's being furrounded
 by air of alower temperature than itfelf, is  neceffary to its
 being retained in its proper temperature of 98 degrees: for,
 in this climate, every temperature of the air above 62 de-
 grees, applied to the human body,  though  ftill  of a lower
 temperature than itfelf, is found to increafe the  heat of it.
 And  from all this it  appears,  that the abfolute power of
 cold with  refpea to the human body, is very different from
what it  is  with refpea to inanimate bodies.
  * In every instance of our mentioning decrees of heat or cold, we  sha.'A
roention them by the degrees in Farenheit's  scale ; and the'exp re-iion of
higher or lower shall always be according to that scale. 
OF  PHYSIC.
55
   89.] The relative power of cold with refpea to the liv-
 ing human body, is that power by which it produces a fen-
 fation of cold in it; and with refpea to this, it is agreeable
 to the general principle of fenfation, that the fenfation pro-
 duced, is not in proportion to the abfolute force of impref-
 hon, but according as  the new imprefhon is  ftronger or
 weaker than that which had been applied  immediately be-
 fore.   Accordingly, with refpect to temperature, the fen-
 fation produced by any degree  of  this,  depends  upon the
 temperature to which the body had been  immediately be-
 fore  expofed; fo that whatever is higher than  this feels
 warm, and whatever is lower than  it, feels  cold; and it will
 therefore happen that the  oppofite fenfations of heat and
 cold  may on different  occafions arife from the fame tem-
 perature, as marked by the thermometer.
   With refpea to this, however, it is to be obferved, that
 though every change of temperature gives a fenfation of
 cold  or heat as it is lower or higher than  the temperature
 applied immediately before, the fenfation produced is, in
 different cafes, of different duration.   If the temperature
 at any time applied is under 62 degrees, every increafe of
 temperature applied will  give a fenfation  of heat;  but if
 the increafe  of temperature  does  not arife to 62 degrees,
 the fenfation produced will not  continue long, but be foon
 changed to a fenfation of cold.   In like  manner,  any tem-
 perature, applied to the human body,  lower than that of
 the body itfelf, gives a  fenfation of cold;  but if the tem-
 perature applied does not go below 62  degrees, the fenfa-
 tion of cold will not continue long,  but be  foon changed to
 a fenfation of heat.
   It  will appear hereafter, that the effeas of the fenfation
 of cold will be very different, according as it is more per-
 manent or tranfitory.
   90.] Having thus explained the operation of cold, as ab-
 folute or relative, with refpea to the human body,  I pro-
 ceed to mention the general effeas of cold upon it.
   1. Cold, in certain circumftances, has manifeftly a seda-
tive power.   It can extinguifh the  vital principle entirely,
either in particular parts, or in the  whole body ; and con-
fidering how much the vital principle of animals  depend*
upon heat, it cannot be doubted that the power of cold is
always more or lefs directly fedative. 
58                 PRACTICE
   This effea may be faid to take place  from every degree
of abfolute cold ; 2nd when the heat of the body has upon
any oecafion been preternaturally increafed, every  lower
temperature may be  ufeful  in diminifhing the  aaivity  of,
the fyftem ;  but it cannot diminifh the natural vigor  of thfc
tital principle, till the cold applied  is under 62  degrees ;
nor even then will it have this ellect, unlefs the cold applied
be of an intenfe degree,  or be applied for fome length of
time to a large portion of the body.
   2. It is equally manifeft,  that in certain circumftances,
cold proves a stimulus to the living body, and particularly
to the fanguiferous fyftem.
   It is probable,  that this effea takes place in  every cafe,
in which  the temperature applied produces a fenfation  of
cold; and this, therefore, as depending entirely on the re-
lative power of cold,  will be in proportion to the change
of temperature that takes place.
   It appears to me probable, that every change .of tempe-
rature, from a higher to a lower degree, will prove more
or lefs  ftimulant; excepting when the  cold applied is {"o
intenfe, as immediately to extinguifh the vital principle in
the part.
   3. Befide the fedative and ftimulant powers of cold, it is
manifeftlv alfo a powerful astringent, caufmga contraction
of the veffels on the furface of the body, and thereby pro-
ducing a  palenefs of  the fkin, and a fuppreffion of perfpi-
ration ; and it feems  to  have funilar effeas when applied
to internal parts.  It  is like wife probable,  that this con-
ftriaion,  as it takes place efpecially in confequence of the
fenfibility of the parts to which the cold is applied, will in
fome meafure be  communicated to other parts of the  bo-
dy ;  and that thereby the application of cold proves a tonic
power  with refpea to the whole fyftem.
   Thefe  effeas of tonic and aftringent power feem to take
place both from  the abfolute and relative power of cold ;
and therefore every application of it, which gives a  fenfa-
tion of cold, is in its firft effect, both aftringent and ftimu-
luiU, though the former may be often prevented from being
cither confiderable or permanent,  when the latter immedi-
ately takes p-lace.
   01.] It will be obvious, that thefe feveral effeas of cold 
OF  P II Y'S I c.                s:
cannot all take place at the fame time, but may in fuccef-
fion be varioufly combined.  The ftimulant power taking
place obviates the effeas, at leaft the permanency  of the
effeas, that might otherwife have arifen from the fedative
power.   That the fame ftimulant power prevents thefe from
the aftringent, I have faid above ;  but the ftimulant and to-
nic powers of cold  are commonly,  perhaps always, con-
joined.
   92.] Thefe general effeas of cold now pointed out are
fometimes falutary, frequently morbid; but it is the latter
only I am to confider here, and they feem to  be chiefly
the following.
   1. A general inflammatory difpofition  of the fyftem,
which is commonly accompanied with Rheumatifm, or o-
ther Phlegmafiae.
   2. The fame inflammatory difpofition accompanied with
Catarrh.
   3. A Gangrene of particular parts.
   4.  A Palfy of a tingle member.
   5.  A Fever, or Fever ftriaiy fo called (8) which it of-
ten produces by its own power alone, but more common-
ly it is only an exciting caufe of fever by concurring with
the operation of human or marfh effluvia.
   93.] Cold is often applied to the human  body  without
producing any of thefe morbid effeas, and it is difficult to
determine in what circumftances it. efpecially operates in
producing them.  It appears to me, that the morbid effeas
of cold depend partly upon certain circumftances of the
cold itfelf, and partly on certain circumftances of the per-
fon to whom it is applied.
   94.] The circumftances of the cold applied, which feem
to give it effea, are, 1. The intenfity or degree of the cold:
2. The length of time during which it is applied ; 3. The
degree of moifture at the fame  time accompanying it; 4.
Its being applied by a wind or current of air; 5. Its be-
ing a  viciflimde, or fudden and  confiderable  change of
temperature, from heat to cold.
   95-] The circumftances of perfons rendering them more
liable to be affiled by cold, feem to be, 1.  The weaknefs
of the fyftem,  and particularly the leffened vigour of the
circulation, occafioned by faffing, by evacuations, by fa-
  Vol. I.  '               H 
53
PR A C TIC L
tigue, by a laft night's debauch, by excefs  in venery, by
long watching, by much  ftudy, by reft immediately after
great exercife, by flcep, and by preceding difeafe.   2. The
body, or its parts, being deprived of their accuftomed co-
verings.   3. One part of the body being expofed to cold,
while the reft is kept in its ufual-or a greater warmth.
  96.] The power of ihefe circumftances (95)  is demon-
ftratcd by the circumftances enabling perfons to rciift cold.
Thefe are a certain vigour of conftitution, cxercife  of the
body,  the pretence of attive paffions,  and the ufe of cor-
dials.
  Befides thefe, there are other circumftances which, by a
different operation, enable perfons to refift cold a6ting as a
fenfation ;  fuch as, paffions engaging a clofe attention  to
one object,  the ufe of narcotics,  and that ftate of the body
in which fenfibility is  greatly  diminifhed, as  in maniacs.
To all which is to be added, the  power of habit with ref-
pea to thofe parts of-the  body to which cold is more con-
ftantly applied, which both diminifhes fenfibility and in-
crcafes the power of the aaivity generating heat.
  97.]Befide  cold, there are omer powers-that feem to be
remote caufes of fever; fuch as fear,intemperance in drink-
ing, excefs in venery, and other circumftances, which evi-
dently weaken the fyftem.  But whether any of thefe feda-
tive powers be alone the remote caufe  of fever, or if they
only operate either as  concurring  with  the operation  of
marfh or human effluvia,  or as giving»an opportunity  to
the  operation  of cold, are queftions not to be pofitively
anfwered :  they may poffibly of thcmfelves produce fever,
but moft frequently they operate as concurring in one or
other of the ways above mentioned.
  98.]  Having now mentioned  the chief of the  remote
caufes of fevers, it may be further obferved, that thefe will
arife more or lefs readily, according as miafmata and con-
tagions are more or lefs prevailing or powerful, or as thefe
are  more or lefs favored  by the concurrence of coldand
other fedative powers. 
OF PHYS I-a
>y
                     CHAP.  V.


           £Df t&e prognosis of j?et)crsr.

Q9-}x\.S fevers (by 60.) confift of both morbid, and fa-
lutary motions and fymptoms, the tendency of the-difeafe
to a happy or fatal iffue,. or the prognoftic in fevers, has
been eftablifhed by marking the prevalence of the morbid
or of the falutary fymptoms ; and it might be properly  fo
eftablifhed,  if we could certainly diltinguifh between the
one and the other of thefe kind of fymptoms :  but the ope-
ration of the reaaion, or falutary efforts of nature in curing
fevers, is ftill involved in fo much obfeurity, that I cannot
explain the fevcral fymptoms of it fo clearly as to  apply
them to^ the cftabiifhing prognoftics; and this, I think,
may be  done  better, by marking the morbid  fymptoms
which fhew the tendency to  death in fevers.
   100.] This  plan of the prognoftics  in fevers muft pro-
ceed upon our knowledge of the caufes of death in general
and in fevers more particularly.
   The caufes of death, in general,,arc either direa or in-
dirca,
   The fir ft are thofe which dircaiy attack and deftroy the
vital principle, as lodged in the nervous fyftem; or deftroy
the organization of the brain immediately ncceffary to the
action of that principle.
   The fecond,. or the indirea  caufes of death, are thofe
which interrupt fuch funaions as are  ncceffary to the cir-
culation of the blood, and thereby neceffary to  the due
continuance and fupport of the  vital principle.
   101.] Of thefe general caufes, thofe which operate more
particularly in fevers feem to be, first, The violence oj re-
action ;  which either by repeated violent excitements, de-
ftroy s the  vital power itfelf; or, by its violence, .deftroy s
the organization of the brain neceffary to the aaion of that
power; or, by the fame violence, d^ftroys the organiza-
tion of the parts more immediately ncceiiary to the circu-
lation of the blood.
   Secondly, The  caufe of death in fevers may be a poison,
that i-'? a power capable of deftroying the vital principle^
                t 

PRACTICE
 and thispoifonmaybe either the miafma or contagion which
 was the remote caufe of the fever,  or it may be a putrid
 matter generated in the courfe of the fever.  In both cafes,
 the operation of fuch a power appears either as aaing
 chiefly on the nervous fyftem, inducing the fymptoms of
 debility; or  as  aaing upon the fluids of the body, indu-
 cing a putrefcent ftate in them.
    102.] From all this it appears, that the fymptoms fhow-
 ing the tendency to death in fevers, may be difcovercd by
 their being either the fymptoms
    Of violent reaction ;
    Of great debility ;
    Or, of a strong  tendency to putrefaction  in the flu,ids.
    Andupon this fuppofition,  I proceed now to mark thofe
 fymptoms  more particularly.*
    103.] The fymptoms which denote the violence of reac-
 tion, are 1. The increafed force, hardnefs and frequency,
 of the pulfe.   2. The increafed heat of the body.   3. The
 fymptoms  which are the marks of a general inflammatory
 diathefis, and more efpecially of a particular determination
 to the brain,  lungs, or other  important vifccra.   4. The
 fymptoms  which are the marks of the caufe of violent re-
 aaion;  that is of a ftrpng ftimulus applied, or of a ftrong
 fpafm formed, the latter appearing in a  confiderable fup-
 preffion of the excretions.
    104. The fymptoms which  denote  a great degree of de-
 iility, are,
    In the Animal Functions : I. The weaknefs of the
* voluntary  motions; II.  The  irregularity of the voluntary
 motions, depending on their  debility;  III. The weaknefs
 of fenfation; IV. The  weaknefs and  irregularity of  the
 intelleaual operations.
    In the Vital   Functions: I.  The weaknefs of the
 pulfe ; II. The coldnefs and  fhrinking of the extremities ;
 III.  The  tendency to a  deliquium animi in an ered  pof-
 ture; IV. The weaknefs of refpiration.
    * No part of medical knowledge is so serviceable in the practice of physic
 as prognostics.  It wonderfully assists in the cure of all diseases, but more
 especially fevers, and other acute disorders. The young reader, therefore,
 ought to be particularly attentive to this part of the work.  What the author
 advances is very different from what has gone before. We have here no hy-
 pothesis or fancies, no suppositions unsupported by facts ; but on the contra-
  ry, truths deduced from a careful cbitrvation of natui^, '.'v.fj ..>,) ,^ed in a
 distinct and perspicuous manner. 
OF  PHYSIC.
61
   In  the Natural Functions:  I. The weaknefs of
 the ftomach, as appearing in anorexia, naufea, and vomit-
 ing ;  II. Involuntary excretions,  depending upon a palfy
 of the fphinaers ;  III. Difficult deglutition, depending up^.
 on a palfy of the mufcles of the fauces.
    105.] Lastly, The fymptoms  denoting the putrescent
 state of the fluids,  are,
    I.  With refpea to the ftomach;  the loathing of animal
 food, naufea and vomiting, great thirft, and a defireof acids.
    II.  With refpea to the fluids;  1. The blood drawn out
 of the veins not coagulating as ufual; 2. Hemorrhagy from
 different parts, without marks of increafed impetus;  3. Ef-
 fufions under  the fkin or cuticle, forming patechia?,  ma-
 culae, and vibices; 4. Effufions of a  yellow ferum under
 the cuticle.
    III.  With  refpea to the ftate of the excretions; fetid
 breath, frequent loofe and fetid ftools, high coloured tur-
 bid urine,  fetid fweats,  and the fetor and lived colour of
 bliftercd places.
    IV. The cadaverous  fmell of the whole body.
    106.] Thefe feveral fymptoms have very often, each of
 them  fingly,  a fhare in determining the prognoftic; but
 more efpecially by their concurrence aiid combination with
 one another;  particularly thofe of debility  with thofe of
 putrefcency.*
    107.] On the fubjea of the prognoftic, -it is proper to
 obferve, that  many phyficians  have been of opinion there
 is fomething in the nature of fevers which  generally  deter-
 in ine  them to  be of a certain duration; and  therefore that
 their terminations, whether falutary or fatal, happen at cer-
 tain periods  of the difeafe,  rather than at others.   Thefe
 periods are  called  the Critical Days;  carefully mark-
 ed  by Hippocrates and other ancient phyficians, as well as
 by moderns of the greateft eminence in practice; whilft at
 the fame time  many other moderns, of no inconfiderable
 authority, deny their taking place  in  the fevers of thefe
 northern regions which we inhabit.
  * It may not be amiss to explain this circumstance a little more fully. Cold-
ness of the extremities may alone be sufficient to induce practitioners'to think,
the issue of the disease fatal ; yet if this symptom be combined with a weak-
ness and irregularity of the intellectual operations, and these two accompani-
ed with involuntary, loose, and foetid evacuations o;' stool, aiid •.;nr.e,  rE/.ia
rauy be pronounced to be at no great distance. 
02                 PRACTICE

   10S.] I am of opinion that the doarine of the ancients,-
and particularly that of Hippocrates, on the fubjea,  wa^
well founded; and that it is applicable to the fevers of our
climate.
   109.] I am  of  this opinion, first, Becaufe I obferve
that the animal economy, both  from its own conftitution,
and from habits which arc eafily produced in it, is readily
fubjeaed to periodical movements.   Secondly, Becaufe,
in the difeafes  or the human bpdy,  I obferve periodical
movements Lo take place with great  conftancy and exaa.
nefs;  as in the cafe of intermittent fevers,  and many other
difeafes.
   110.] Thefe confiderations render it probable,  that ex-    ^
aa periodical movements may take place in continued fe-
vers ; and I think there is evidence of fuch movements ac-    1
tually taking piace.
   111.] The critical days,  or thofe on which we fuppofe
the termination  of  continued fevers efpecially to happen,
are,  the third, fifth, seventh, ninth, eleventh, fourteenth,
seventeenth,  and twentieth.   We mark none  bevond this
laft; becaufe, though fevers are fometimes protraded be-   "
yond this period, it is, however, more rarely;  fo .that there-
are not a fufficient number of obfervations to afcertain the
courfe of  them; and  further,  becaufe it is probable that*,
in fevers long protra£ted, the movements become lefs exact
and regular, and therefore lefs eafily obferved.
   112.] That the days now mentioned are the critical days,
feems to be proved by  the particular fafts which are found
in the writings of Hippocrates.  From thefe  faas, as col-
leaed  from the feveral writings of that author by  M. do
Haen, it appears, that of one hundred and fixty three in-
fiances of the termination of fevers,  which  happened on-
one or other of the firft twenty days of the difeafe,. there arc
one hundred  and feven,  or more than two thirds of the
whole  number, which happened  on one or other of the
eight days  above mentioned; that none happened on the
fecond  or thirteenth  day;  and  upon  the  eighth, tenth,
twelfth, fifteenth, fixteenth,  eighteenth,  and nineteenth,
there  are  but eighteen inftanccs  of termination, or one
ninth of the whole.
l_  113.] As the terminations which happen on the  feven 
OF  PHYS I C.
63
"days laft mentioned, are, upon the whole, few;  and, upon
^tny one of them,  fewer than thofe which happen on any
of oUr fuppofed critical days; fo there are therefore nine
days which may be called  x ox critical; while, on the
other h?A\c], the many terminations which happened on the
feventh,  fourteenth,  and twentieth days, afford  a  proof
both of critical days in general, and that thefe are the chief
of them.   Hereafter  I fhall mention an analogy that ren-
ders the power of the other critical days fufticiently pro-
bable.
    114.]  It appears further, that  as, of the terminations
which were final and falutary, not a tenth part happened on
the noncritical days;  and of the terminations which were
final and fatal, though the greater number happened  on the
critical days,  yet above a third of them happened on. the
noncritical;  fo it would appear that tfje tendency  of the
animal economy is to obferve the critical days, and that it
is by the operation of fome violent and irregular caufe that
 the courfe of things is fometimes turned to the noncritical.
    115.]  What has been faid gives  fufficient ground for
prefuming, that it is the general tendency of the animal
economy to determine the periodical movements in fevers
to be chiefly on the critical days.   At the fame time, we
muft acknowledge it  to be a general tendency only;  and
that, in particular  cafes, many circumftances may occur to
difturb the regular courfe of it.   Thus,  though the chief
and more remarkable exacerbations in continued  fevers
happen on the critical days, there are truly exacerbations
happening every day; and thefe, from certain caufes, may
become confiderable  and critical.  Further, though inter-
mittent fevers are certainly very ftrongly determined to
obferve a tertian or quartan period, we know there are cer-
tain circumftances which  prevent them from  obferving
thefe periods exactly, and which render them either antici-
pating or poftponing fo  much, that the days of paroxyfms
come to be quite changed ;  and it is allowable to fuppofe,
that the like may happen with refpect to the exacerbations
of continued  fevers,  fo as thereby to difturb the regular
appearance of critical days.
   A particular inftancc of this occurs with refpea to the
fixfh day of fevers.  In the writings of Hippocrates, there 
$4                   PRACTICE
are many inftances of terminations happening on the fixth
day; but it is not therefore reckoned  among the critical
days; for, of the  terminations happening on that day^ there
is not one  which  proves  finally of  a falutary  kind;  the
greater  number  are fatal; and all the reft are  imperfea,
and followed with a relapfe.   All  this  fhows,  that fome
violent caufe had, in thefe cafes, produced a deviation from
the ordinary courfe of nature; that the terminations on the
fixth day are nothing more than anticipations of the feventh,
and therefore a proof of the power of this laft.*
   116.] The doctiine of critical days has been much em.
barrafled by fome diffonant accounts of it, which appear
in the writings imputed to Hippocrates.t  But this may be
juftlv accounted  for frem  thefe writings  being truly  the
worts of different perfons,  and from the moft genuine of
them having fuffered many  corruptions; fo that,  in fhort,
every thing which is inconfifteiit with the  faas above laid
down, may be afcribed to one or other of thefe caufes.
   117.] This,  further,  has efpecially difturbed the doc-
trine of critical days,  that Hippocrates himfeif attempted,
perhaps too haltily, to eftabhfh  general  rules, and to bring
the doarine to a general theory, drawn  from  Pythagorean
opinions  concerning the power of numbers.   It is  this
which feems to have produced  the  idea of odd days, and
of a quaternary and feptenary period, do&rines which ap-
   * This idea of the general tendency of nature to  preserve a regularity in
the animal motions, is a most ingenious explanation of the  apparent irregu-
larities in the termination of fevers.  It is perhaps one  of the best defences
cf the critical days that ever appeared, because  it explains in a most satisfac-
tory manner, why the termination on the sixth day should not be salutary. The
Violence of  the disturbing cause excites motions which nature has not the
power of withstanding, and which are either the immediate causes of death,
or induce such morbid affections as prove ultimately fatal.
   f To enter into a critical inquiry, whether the works handed down to us as
the writings of Hippocrates are really the productions of that great man, or
compilations from various physicians, would be foreign to the design of this
work.  The style of them is, if I may be allowed the expression, homogene*
ous ;  the same provincial dialect prevails through the whole of them ; and
they ~re extremely remarkable, especially such of them as respect the critical
da\s, for being rather a detail of observed facts, than reasonings brought to
 support a favorite hypothesis.  It is probable indeed that Hippocrates, -who
 has got the credit of the work, might have been indebted 10 many of his co-
 temporaries for some of the materials that compose them ; but the sameness
 of the style is a strong presumptive argument that they are the production of
 one person, or at least of their having been reduced to their present form by
 ene and the same hand.  Dr. Cullen's other supposition, of their having suf-
 fered many,  and, he mi^ht have added, r.uteria! corruptions seems highly
 probable. 
OF  PHYSIC.                 CS
pear fo often  in  the  writings of Hippocrates.  Thefe,
however,  are inconfiftent with the faas above laid down ;
and indeed, as Afclepiades and Celfus have obferved,  are
inconfiftent with one another.
   118.] Upon the whole,  therefore, it is apprehended,
that the critical days above affigned are truly the critical
days of Hippocrates, and may be confiftently explained in
the following manner.
   119.] From the univerfality of tertian or quartan peri-
ods in intermittent fevers, we cannot  doubt of there being,
in the animal economy, a tendency  to obferve fuch peri-
ods ;* and the critical days above mentioned are confift-
ent with this tendency of the economy, as all of them mark
either tertian or quartan periods.   Thefe periods, however,
are not promifcuoufly  mixed, but occupy conftantly their
feveral ffortions in the progrefs of the difeafe; fo that,
from the beginning to the  eleventh day,  a tertian period
takes place, and,  from the  eleventh  to the twentieth,  and
perhaps longer, a quartan period is as fteadily obferved.
   120.] What determines the periods to be changed about
the eleventh day, we have  not clearly perceived; but the
faa is certain :  for there is  no inftance of any termination
on the thirteenth,  that is, the tertian  period next following
the eleventh ;  whereas, upon the fourteenth, feventeenth,
and twentieth, which mark quartan periods, there are forty-
three inftances of  terminations, and  fix only on all the in-
termediate days between thefe.
   This prevalence of a quartan period leaves no room for
doubting that the twentieth, and not  the twenty-firft, is the
critical day marked by Hippocrates, though the laft is men-
tioned as fuch in the  common edition of the Aphorifms,
taken  from an erroneous  manufcript,  which Celfus  alfo
feems to have copied.
   121.] A confiftency with the general tendency  of the
fyftem renders the feries of critical days we have mentioned
probably  the true one; and the only remaining difficulty in
finding what  we have  delivered to be the fame with the
genuine doarine of Hippocrates, is  the frequent mentioA
of the fourth as a critical day.
  * The Author jnight have added, or periods compounded of tbe&e two.
   Vol. I.                    I 
SS                 PRA-CTJCI!

   It is true there are more inftanccs of terminations Ivap-
pening on this day, than on fome of thofe days we have af-
fcrted to be truly critical: but its inconfiftcncy with  the
more general tendency, and fome other confiderations, lead
us to deny its being naturally a critical day ; and to think
that the inftances of terminations, which have really occur-
red on the fourth day,  are to be reckoned among the other   . *
irregularities that happen in this matter.
   122.] I have thus endeavored to fupport the doarine of
critical days, chiefly upon the particular faas to be found
in the writings of Hippocrates : And although I might al-
fo produce many other  teftimonies of both ancient and mo-
dern times; yet it muft be owned, that fome of thefe tef-    ;
timonies may be fufpeacd to have arifen rather from a ve-   *
neration of  Hippocrates, than from accurate obfervation,.
   123.] With refpea  to  the opinions of many»moderns
who deny the  prevalence of critical days, they arc to be
little regarded,  for the obfervation of the courfe of conti-
nued fevers is  known  to be difficult and fallacious ; and
therefore the regularity of that courfe may have often efca-
fed inattentive and prejudiced obfervers.
   124.] Our  own obfervations amount to  this, That fe-
vers with moderate fymptoms, generally the cafes of the
fynocha, frequently terminate in nine days, or fooner, and
very conftantly upon one or other of the critical days which
fall within that period :  but it is very rare, in this climate,
that cafes of either  the typhus or fynochus terminate be-
fore the eleventh day ;  and when they do terminate on this
day, it is for the moft  part fatally.   When they are pro-
tracted beyond this  time,  I have very conftantly  founds
that their terminations  were upon the fourteenth,  feven-
teenth, or twentieth day.
   In  fuch cafes, the  falutary terminations arc fcldom at-
tended with any confiderable evacuation.   A fweating fre-
quently appears, but is feldom confiderable ;  and I have
hardly ever obferved critical and decifive terminations at-
tended with vomiting, evacuations by ftool,  or remarkable
changes in the  urine.    The folution of the difeafe is chief-
ly to  be difcerned from fome return of fleep and appetite,
the ceafing of delirium, and an abatement of the frequency
of the pulfe. By thefe fymptoms we can often mark'a crifis 
                   OF  PHYSIC.                67
                        = "■ •» "
of the difeafe : but it feldom happens fuddenly and entire.
ly ; and it is  moft commonly from ioine favorable fymp-
toms occurring upon one critical"day,that we can announce
a more entire folutionupon the next following..
   Upon the whole, I  am pcrf uaded, that  if obfervations
fhall be made with attention, and without prejudice, I fhall
be allowed to conclude, with the words of the learned and
fagacious Gaubius, "Fallor,ni Tua cenftitcrit Hippocra-
ti audoiitas, Galeno fides, Nature virtus et ordo."
             ----- '■■■ .TM»ftC3Sj*g«««- "   ----
                     CHAP.  VI.

        ©f tit 09:t6oH  of Cure in iTetwrifc.
                       Sect^  I..
             Of the Cure of Continued Fevers..

 125.] XjlS it is allowed, that in every fever which has its
full  courfe, there is an effort of nature of a  falutary tenden-
cy, it might be (ippofedthat the cure of fevers fhould be left
to the operations of nature, or that our art fhould be only
direfcted to fnpport and regulate thefe operations, and that
we fhould form  the indications accordingly.  This plan,
however, I cannot adopt, becaufe the operations of nature
are very precarious, and not fo well underftood  as to ena-
ble us to regulate them properly.   It appears to me, that
milling to thefe operations has often given  occafion to a
negligent and inert praaice; and there is reafon  to believe,
that an attention  to the operations of nature  may be often
fupcrceded by art.
   126.] The plan which to me  appears to be moft fuitable
is that which forms the indications of cure upon.the view
of obviating  the tendency to death ;  while at  the fame time
the means  of executing thefe indications are directed by a
proper attention to the proximate caufe of fevers.
   Upon this plan,  in  confequence of what  has been laid
down above on the tubject of the prognoftic, we form three
general indications in  the cure-of continued fevers ;  and
the one or other of thefe is to  be employed according as
the circumftances of the  fever (102.) fhall  direct.
   The firft therefore is} To moderate the violence of reaction. 
6*                 PRACTICE
   The fecond is, Toremovethe causes or obviate the effects
 ef debility.  And,
   The third is,  To obviate  or  correct the tendency of the
fiuids to putrefaction.
   127.]  The firft indication  may be anfwered, that is, the
 violence of reaaion may be  moderated.
   1. By  all thofe means v^ich diminifh  the aaion of the
 heart and arteries.      *
   2. By  thofe means  which take  off the fpafm of the ex-
 treme veffels, which we fuppofe to be the chief caufe of
 violent reaaion.
   128.]  The aaion of the  heart and arteries may be di-
 minifhed,
   1. By avoiding or moderating thofe irritations,  which in  • *•
 one degree or other,are almoft conftantly applied to the body.
   2. By the ufe of certain fedative powers.
   3. By diminifhing the tenfion and tone of the arterial   •
 fyftem.
   129.] The irritations (128. 1.) almoft conftantly appli-
 ed,  are the impreffions made upon our fenfes; the exercife
 of the body and mind ; and the  taking  in of  aliments.
 The avoiding thefe as much  as poffible, or the moderating
 their force, conftitute what is rightly called the Antiphlo-
 gistic Reg 1 men, proper to be employed in almoft every
 Continued fever.
   130.] The condua of the regimen is  to be direaed by
 the following rules and confiderations.
    1. Impreffions on the external fenfes,  as being ftimulant
 to die fyftem, and a chief fupport of its aaivity, fhould be
 avoided  as much as poffible; thofe  efpecially  of more
 conftant application, thofe  of a ftronger kind, and  thofe
 which give pain and uneafinefs.
    No impreflion is  to be more carefully guarded againft
 than that of external heat;  while at the  fame time,  every
 other means of increafing the heat of the body is to be fhmi-
 ned.  Both thefe precautions are to be obferved as foon as
 the hot ftage is fully formed, and to be  attended to during
 its continuance ; excepting  in certain cafes, where a deter-
 mination  to fweating is neceffary,  or where the ftimulant
 effeas of heat may be compenfated by circumftances which
 determine it to produce a relaxation and revuliion. 
OF  PHYSIC.
69
   2.  All motion of the body is to be avoided, efpecially
that whfch requires the exercife of  its own mufcles; and
that pofture  of the body is to be chofen  which employs
the feweft mufcles, and which keeps none  of them long in
a ftate of contraaion.   Speaking, as it accelerates refpira-
tion,  is particularly to be refrained from.
   3.  The exercife of the mind .alfo is a ftimulus to the bo-
dy ; fo  that  all  impreffions, fchich lead to thought, and
thofe efpecially which may excite emotion or paffion, are
to be carefully fhunned.
   With refpea to avoiding impreffions of all kinds, an ex-
ception is to  be made in the cafe of a delirium coming on,
when the prefenting of accultomed  objeas  may have the
effea of interrupting  and diverting  the  irregular  train of
ideas then arifing in the mind.
   4. The prefence of recent aliment in the ftomach proves
always a ftimulus to the fyftem, and ought therefore  to be
 as moderate  as poffible.   A total abftinence for fome time
 may be of fervice; but  as this cannot be long continued
 with fafety,  we muft  avoid  the ftimulus  of aliment,  by
 choofing that kind which gives the leaft.* We fuppofe that
 alimentary matters are more ftimulant,  according as they
 are more alkalefcent; and this leads to avoid all animal,
 and to ufe vegetable food only.
    As our drinks alfo may  prove ftimulant, fo all aromatic
 and fpirituous liquors are to be avoided; and in anfwering
 the  prefent  indication, all fermented liquors, excepting
 thofe of the loweft quality, are to be abftained from.t
    131.]  Befides thefe  ftimulant powers more conftantly
 applied, there are others which, although occafionally on-
 ly, yet,  as commonly [accompanying  fevers, muft be at-
 tended to and removed. J
   * In addition to these directions, it may be mentioned, that if the patient
 have a desire for food, which is seldom the case, he ought to make very spa-
 ring and frequent meals. Much food taken at once, proves a greater stimulus
 than the same quantity taken at several different times ; especially if suffici-
 ent quantities of diluting mucilaginous drink, such as lihtseed tea, barley-
 water, water-gruel, Sic. be taken along with it.
   f Thin liquors are the best in cases of this kind : of these we  may either
 use water alone, or weak lintseed tea, thin barley-water,  toast  and water,
 whey, currant-jelly dissolved in water, with a variety of such mucilaginous
 acesceppdrinks.  They ought to be taken in small quantities, and often.
   | Tms passage might have been more clearly expressed thus: besides the
 stimulant power* more constantly applied, others, only occasionally accompa-
nying fevers, must be attended to and removed.- 
70
PRACTICE
   One is, the fenfe of thirft, which, as a powerful ftimuTlis,
ought always, in one way or other, to be removed.'*
   Another ftimulus  frequently arifes  from  crudities,  or
corrupted humors in the ftomach ;  and it is to be removed
by vomiting, by dilution, or by the ufe of acid.f
   A third ftimulus often arifes  from the preternatural re-
tention of faeces in the interlines ;  and ought to be remo-
ved  by frequent laxative  grafters.J
   A fourth ftimulus to be conftantly fufpeacd in fevers, is
a general acrimony of the  fluids,  as produced by the in-
creafe of motion and heat, joined  with an interruption of
the excretions.  This acrimony  is to be obviated or remo-
ved  by the taking in of  large quantities of mild antifeptic
liquors.||
   132.] The avoiding of irritation in all thefe particulars,
(130. and 131.) conftitutes the  antiphlogiftic regimen ab-
solutely neceffary for moderating the violence of reaction ;
and, if I miftake not, is  proper in almoft every  circum-
ftance of continued fevers ;  becaufe the propriety and fafe-
ty of employing ftimulants is often uncertain ; and becaufe
feveral of thofe  above mentioned, befide their ftimulant
powers, have other qualities by which they may he hurtfuh
   It appears to me, that  the fuppofed utility  of ftimulants,
in certain cafes of fever, has often arifen from a miftake in
having afcribed to their  ftimulant, what really depended
upon their antifpafmodic power.
   133.] A fecond head of the means (128. 2.) for mode*
rating the violence of reaaion, comprehends certain feda-

  * The drinks mentioned  in the  former note are best adapted to this purpose.
  f The vegetable acids are the most  suitable, especially the juices of acid
fruits, as the juices of oranges, lemons, currants or apples, diluted with wa-
ter.  In some cases the mineral acids have been much extolled, especially the
nitrous, when united with the spirit of wine.  The spiritus stheris nitrosi of
the last London Pharmacopoeia is used with success in these cases.  It may-
be given in barley-water, to the quantiry of twenty ot twenty-five drops with'.
in the hour.
  + The preference of glysters to purging medicines is  obvious.—The action
even  of the most gentle laxatives is always attended with some degree of sti-
mulus, while glysters, especially the mild ones, seldom produce that effect.
The best glyster in these cases, is half a pint of milk, with as much water,
two ounces of oil, and one ounce of brown sugar, or, what is better than sv'
gar, two ounces of manna.
  || The chief of these are the acid fruits diluted  with water : to which, we
may add the decoction of malt, of radix graminis, (the Triticum repens of
Linne.) infusions of sage, mint, and other plant* ef that natural order which
X-inne calls Spirantia. 
or  PHYSIC.                  71
?ive powers, which may he employed to diminifh the aai-
vity of the whole body,  and particularly that of the fan-
guiferous fyftem.
   The first  of thefe to be mentioned is the application  of
cold.
   Heat is the chief fupport of the activity  of the  animal
fyftem ; which is therefore provided in itfelf with a power
of generating heat.   But, at the fame time we obferve, that
this would go to excefs, were it not conftantly moderated
by a cooler temperature  in  the furrounding  atmofphere.
When, therefore, that power of the fyftem generating heat
is increafed, as is commonly the cafe in fevers, it is necef-
fary not only to avoid all means of increafing  it further,
hut it feems proper alfo to apply air of a cooler tempeia-
ture ; or at  leaft to apply it more entirely and freely, than
in a ftate of health.
   Some late experiments in the fmall pox and in continu-
ed fevers, fhow that the free admiffion of cool air to the
 body is a powerful remedy in moderating the violence of
 reaaion ; but what is the mode of its operation, to what
 circumftances of fever it  is peculiarly adapted, or what li-
 mitations it requires, I fhall not venture  to determine, till
more particularly inftrutled by further experience.
    134.] A  second fedative power which may be employed
in fevers, is that of certain medicines, known, in the writ-
ings  on the Materia Medica, under the title of Refrige-
 rants.
   The chief of thefe are acids of all kinds,  when  fuffici-
ently diluted ;  and they are,  in fevcral refpeas,  remedies
adapted to continued fevers.   Thofe efpecially in ufe are,
the Vitriolic and Vegetable;  and, on many accounts, we
prefer the latter.*
   135 ] Another fet of refrigerants are, the Neutral Salts,
formed of the vitriolic, nitrous or vegetable acids; with al-
kalines, eiftier fixed or volatile.   All thefe neutrals, while
   * The vitridic acid is harsh to the taste, and frequently acts as an astrin-
gent;  it is therefore not always admissible.  The best vegetable acids for
this purpose, are as was said above,  the natural juices of acid fruits.  The
acid of tartar is the best refrigerant we have: there is an excellent formula
of it in the Swedish Pharmacopoeia, under the title  of Pulvis refrigerans,
which consists chiefly of the essential salt ; r" tartar and sugar.  The dose ct
the acid of tartar, prepared according to Scheele's prescription, is half a scru-
ple, cr fifteen grains, in th* hour, largely diluted with a mucilaginous liquor. 
72                  PRACTICE
they are'fflflblving  in  water,  generate cold; but as that
cold ceafes foon  after  the folution is fiuifhcd, and as the
falts are generally exhibited in a diflolved ftate, their refri-
gerant power in the animal body docs not at all depend up-
on their power of generating cold with water.  The neu-
tral chiefly employed as a refrigerant, is Nitre; but all the
others, "compounded as above mentioned, partake more or
lefs of the fame quality.*
  136.] Befides  thefe neutrals,  fome  metallic falts alfo
have been employed as refrigerants in fevers;  and particu-
larly the Sugar of Lead.  But the refrigerant, powers of this
are  not well afcertained; and its  deleterious qualities are
too well known to admit of its being freely ufed.
  137.] Under the third general head (128. 3.) of the
means to  be employed for moderating the violence of re-
action, are comprehended the fevcral means  of diminifh-
ing the  tenfion, tone, and activity,  of the fanguiferous fyf-
tem.  As  the aaivity  of this fyftem depends, in a great
meafure, upon the tone, and this again upon the tenfion of
the  veffels,  given to them by the  quantity of fluids they
contain, it is evident, that the diminution of the quantity of
thefe muft diminifh the aaivity of the fanguiferous fyftem.
  138.] The quantity of fluids contained in the fanguifer-
ous fyftem, may be diminifhed moft conveniently by the
evacuations of blood-letting and purging.
  139.] Nothing is more evident, than that blood-letting
is one of  the moft powerful means of diminifhing the acti-
vity of  the whole body,  efpecially of the fanguiferous fyf-
tem ; and it muft therefore be the moft effectual means of
moderating the violence of reaaion in  fevers.  Taking
this as a fact,  I omit inquiring into its mode of operation,
and fhall only confider in  what circumftances of fevers it
may be moft properly employed.
   140.] When the violence of reaaion,  and its conftant
attendant, a phlogiftic diathefis, are fufticiently manifeft ;
when thefe conftitute the principal part of the difeafe, and
may be expeaed to continue throughout the whole of it,
  *  Nitre has been leng used as a refrigerant.  In too large quantities, how-
ever, it has often done harm.  It may therefore be necessary to guard the
young practitioner against giving nitre in a larger quantity than two drachms
in the twenty-four hours, nor in do,-,£■; of above ten grains, well diluted with*
mucilaginous drinki. 
OfPHYSIC.                 *S
 as in the cafes-of synocha ;  then blood-letting is the princi-
 pal  remedy, and may be employed as far as the fymptoms
 of the difeafe may feem to require, and the conftitution of
 the  patient will  bear.   It  is,  however, to be attended to, ^
 that a greater evacuation than is neceffary, may occafion a
 flower recovery, may render the perfon more liable to are-
 lapfe, or may bring on other difeafes.
   141.] In the cafe of  synocha, therefore, thefe is  little
 doubt about the  propriety  of blood-letting: but  there are
 other fpecies of fever, as the synochus, in which  a violent
 rea6tion and phlogiftic diathefis appear, and prevail during
 fome part  of the courfe of the  difeafe ; while, at the fame
 time, thefe circumftances  do not conftitute  the  principal
 part of the difeafe,  nor are to be expeaed to continue du-
 ring the whole courfe  of it, and it is well known, that in
 many cafes, the ftate of violent reaaion is to be fucceeded,
 fooner or later, by a ftate of debility from the excefs  of
 which  the danger of the difeafe is chiefly to arife.  It  is$
 therefore,  neceffary,  that, in many  cafes,  blood-letting
 fhould be  avoided, and even although, during the inflam-
 matory ftate of the difeafe, it may be proper, it will be ne-
 ceffary to  take care that the evacuation be not fo large as
 to increafe the ftate of debility which is to follow.
   142.] From all this it muft  appear, that the  employing
 blood-letting, in certain fevers, requires much difcernment
 and fkill, and is to be governed by the confideration of the
 following circumftances;
   1. The  nature of the prevailing epedemic.
   2. The nature of the remote caufe.
   3. The  feafon and climate in which the difeafe occurs,
   4. The  degree of phlogiftic diathefis prefent.*
   5. The  period of the difeafe.
   6. The  age, vigour, and plethoric ftate of the patient.
   7. The  patient's former difeafes and habits  of blood-
 letting,                                            -j'-'
   8. The appearance of the blood drawn out.
  9. The effeas  of the blood-letting that may  have been
already praaifed.
   143.] When,  after the  confideration of thefe  circum-
ftances, blood-letting  is  determined  to  be neceffary,  it
 * The phlogistic diathesis is explained in art. 247.
  Vol. I.                   K 
74
PRACTICE
 mould be obferved, that it is more cffeaual, according as
 the blood is more  fuddenly drawn off, and as the body is
 at the fame time more free from all irritation, and confe-
 quently when in a pofture in which the feweft mufcles arc
 in aaion.
    144.] Another evacuation whereby the quantity of fluids
 contained in the body can  be confidcrably diminifhed, is
 that of Pitrging.
   145.] If we confider the quantity of fluids conftantly pre-
 fent in the cavity of the inteftines, and the  quantity which
 may be drawn from the innumerable excretories that open
 into this cavity, it will be obvious, that a very great evacu-
 ation can be made by purging;  and, if this be done by a
 ftimulus applied to the inteftines, without being at the fame
 time communicated to the reft of the body, it may, by emp-
 tying both the cavity of the inteftines, and the arteries which
 furnifh the excretions poured into it, induce a confiderable
 relaxation in the whole  fyftem; and  therefore, purging
 feems  to be a remedy fuited to moderate the violence of
 reaaion in fevers.
   146.] But it  is to  be  obferved,  that as the fluid drawn
 from  the excretories opening into the inteftines,  is not all
 drawn immediately from the arteries, as a part of it is
 drawn from the  mucous follicles only;  and as what is even
 more  immediately drawn from the arteries,  is drawn off
 flowly, fo the evacuation will not, in proportion  to  its
 quantity, occafion fuch a fudden depletion  of the red  vef-
 fels, as blood-letting does; and therefore cannot operate
 fo powerfully in taking off the phlogiftic diathefis of the
 fyftem.
   147.] At  the fame time, as this  evacuation may induce
a confiderable degree of debility; fo,  in  thofe cafes, in
which a dangerous ftate of debility is likely to occur, purg-
ing is to be  employed with  a great deal  of caution;  and
more efpecially  as  the due meafure of the evacuation is
more difficult to be applied dian in  the cafe of blood-
letting.
   148.] As we  fhall  prefently  have occafion to obferve,
that it  is of great importance, in the cure  of fevers, to  re-
ftore the  determination of the blood to  the veflels on the
iurfaceof the body; fo purging, as in fome  meafure tak- 
                     OF  PHYSIC.                  75

mg off that determination, feems to be an evacuation not
well adapted to the cure of fevers.
   149.]  If, notwithstanding thefe doubts, (146. 147. and
148.) it fhall be afferted, that purging, even from the exhi-
bition  of purgatives,  has often been ufeful  in fcv'ers;  I
would beg leave to maintain, that this  has not happened
from a large evacuation;  and therefore,  not  by moderat-
ing the violence of reaaion,  excepting in the caf*of a more
purely inflammatory fever, or of exanthemata  of an inflam-
matory nature.  In other cafes'of fever,  I have feen a large
evacuation.by purging,  of mifchievous confequence ; and
if upon occafion, a more moderate evacuation has appear-
ed to be ufeful,  it is  apprehended to have been only "by
taking off the irritation of  retained-fa*ces, or by evacuat-
ing corrupted humours,  which  happened to be prefent in
the inteftines ;  for both of which purpofes, frequent laxa-
tives may be properly employed.*
   150.] Another fet of  means  (127.2.) for moderating
 the violence of reaaion in  fevers, are thofe fuited to take
off the fpafm of the extreme veffels, which we believe to be
the irritation that chiefly fupports the reaaion.
   Though I have put here thi* indication of taking off the
fpafm of the extreme veffels, as iuborcinate to the general'
indication of moderating the violence of rea£tion;  it is,
however, to  be obferved here,  that  as  fever univerially
confifts in an increafed action of the  heart, either in fre-
quency or in force, which in cither cafe is fupported by  a
fpafm of the extreme veffels, fo the indication for  remov-
ing this is a very general one,, and applicable in almoft eve-
ry circumftance of fever,  *<r at leaf!;, with a few exceptions,
to be taken notice of hereafter.
  * Purges ought to be cautiously administered in fevers ; and such only are
to be used as operate with the least irritation.  In fevers attended with lecaf
inflammation, we may be under no.-  apprehension of danger even from i-'r.e:
brisker purges, as Glauber's sal*-, given in the quantity of an ounce, or an
ounce  and a half, or three or four ounces of the iufusum sennje, with half an
ounce of Glauber's salt, and a drachm or two of tincture cf jalnp ; but in fe-
vers where  no topical inflammation appears, the purges, if necessary, must
be of  the mildest kind, such as manna,  cassia,  &c. and they must be given
in small and often repeated doses. In most (vwrs the intestines may be suf-
ficiently evacuated by taking half an ounce of manna, and a  scruple of cream
of tartar, every hour till it operares, diluting plentifull;: at the same time y.ith
barley-wate*.  The phosphorated.soda, lately introduced into practice by the
ingeaious Dr. Pearson of London, is  well calculated for these cases. T"u$
etew t>f-itiia,n ©unce or ten div*hr..s i.i br.v,Ie;'-\Y3.:er or fcisth. 
70
FR AC 1 i u -L.
   i5i.]  For taking off the fpafm of the extreme vcfliTs,,
the means to be employed arc either internal or external.
   152.]  The internal means (151.) are,
   1. Thofe which determine the force  of the circulation
to the extreme veffels on the furface of the body, and, by
rcftoring the tone and aaivity of thefe veffels, may over-
come the fpafm on their extremities.
   2. Tho/e medicines which have the power of taking off
fpafm in any part of the fyftem,  and which arc known un-
der the title of Antispasmodics.
   153.] Thofe remedies which are fit to determine to the
furface of the body, are,
   1. Diluents.
   2. Neutral Salts,.
   3. sudorifics.
   4. Emetics.
   154.] Water enters, in a large proportion, into the coir.
pofition of all the animal  fluids,  and a large quantity of it
is always diffufed through the whole of the common mafs.
Indeed, in a found ftate, the fluidity of the whole mafs de-
pends  upon the quantity  of  water prefent in  it.   Water,
therefore, is the proper diluent of our mafs of blood; and
other fluids are diluent only in proportion to  the quantity
of water they contain.
   155.} Water may be faid to  be the vehicle of the feve-
ral matters which ought to be excerned;  and in a healthy
ftate the fulnefs of the extreme veffels, and the quantity of
excretions, are nearly in proportion to the quantity of wa-
ter prefent in the body.  In fever, however, although the
excretions are in fome  meafure  interrupted, they continue
in fuch quantity as to  exhale the more fluid parts of the
blood ;  and while a portion of them is at the  fame  time ne-
ceiTarily  retained  in the  larger veffels,  the fmallcr and the
extreme veffels, both  from  the deficiency of  fluid, and,
their own contraaed ftate, are lefs filled,  and therefore al-
lowed to remain in that condition.
   15.6/] To remedy this contraaed ftate, nothing is more
ncceffary than a large fupply of water or  watery fluids,  ta-
ken in by drinking  or otherwife; for  as  any fupcrfluous
 quantity of  water is forced  off by  the feveral excretories,
 fuch a force applied,  may be a means of dilating the ex^ 
                     OF  P H Y SIC.                   7/

treme veffels, and of overcoming the fpafm affeaing their
extremities.
   157.]  Accordingly  the throwing in of a large quantity
of watery fluids has been, at all times, a remedy.much cm-
ployed in fevers; and  in no  inftance  more  remarkably,
than by the  Spanifli and Italian  phyficians,  in the ufe of
what they call the Dioeta aquca.
   158.] This practice confifts in taking away every other
kind of aliment and drink, and in giving in divided portions
every day, for feveral days together, fix or eight pounds of
plain water,  generally cold, but fometimes warm.  AH this,
however, is to be done only after the difeafe has continued
for fome time, and, at leaft, for a week.*
   159.] A fecond  means (153  2.)  of determining to the
furface of the body, is by the ufe of neutral falts.   Thefe,
in a certain dofe taken into the itomach, produce, foon af-
ter, a fenfe of heat upon the  fuiface of the body; and,  if
 the body be  covered clofe and kept warm, a fweat is rea-
dily brought out.   The fame medicines,  taken during the
 cold  ftage of a fever,  very often  put an end to the cold
ftage,  and firing on the hot;  and they are alfo remarkable
for flopping  the vomiting- which fo frequently attends the
cold ftage of fevers.  All this fhows, that neutral falts have
a power of determining the blood  to the furface of the bo-
dy, and may  therefore be of ufe in taking off the fpafm
which in fevers fublifts there.
    160.] The neutral moft commonly employed in fevers,
 is  that formed of an alkali  with  the native acid of vegeta-
                                                      o
   * Simply as a diluent, water is undoubtedly the best drink that can be used,
but by adding a small quantity of mucilage  to it, two intentions are answered
at the same time, viz. diluting and overcoming the acrimony ;  hence the pro-
priety of  barley-water, water-gruel, lintseed tea, all made extremely weak ;
of very slight decoctions of malt, of bread-crusts, or even the gelatinous parts
of young animals,  as calf's feet, or the more solid hartshorn  shavings, &.c.
These animal substances  must however, be used in great moderation, and on-
ly in those cases where the patient requires nourishment. When this watery
regimen is carried to a great length, the patient turns anasarcous ; but this
effect may be prevented by some of the neutral salts, of which the Kali ace-
tatum of the London Pharmacopoeia is mo»i preferable, on account of its diu^
retic quality.  The dose of it may be carried as far as half an ounte or six
drachms in the day.  The same intention  may also be answered by eating
water-cresses, radishes,if in season, or a little of theouterrind oi" turnips ;.all
©f which arc diuretics. 
"73.                  PRACTICE

bles,* but all the other neutrals have more or lefs of the
fame virtue ;  and perhaps fome of them,  particularly the
ammoniacal falts, poflefs it in a ftronger degree.t
   161.] As cold water taken into the ftomach, often fhows
the fame diaphoretic effeas with the neutral falts, it is pro-
bable  that the effea of the latter depends upon their refri-
gerant powers mentioned above, (134.)   What is'the ef-
fea of the neutral falts,  given  when they are forming and
in a ftate of effervefcence ? It is probable that this circum-
ftance may increafe the  refrigerant power of thefe  falts,
and may introduce into the  body a quantity of fixed-air;
but  for thefe purpofes it would feem  proper to contrive
that the whole of the effervefcence fhould take place in the
ftomach/J"
   162.] A third means (153. 3.) of determining to the fur-
face of the body, and taking off the fpafm fubfi fling there,
is by the ufe  of fudorific medicines, and  of fweating.
   163.2 The propriety of this remedy has been much dis-
puted ; and fpecious arguments may be adduced both for
and againft this praaice.
   In favor of the praaice it may be hid,*
   1. That, in healthy perfons, in every cafe of increafed
aaion of the heart and arteries, a fweating takes place, and
is feemingly  the means  of preventing the bad effects  of
fuch increafed action.
   2. That, in fevers, their moft ufual  folution and termi-
nation is by fpontaneous fweating.
   3. That, even when excited  by art,  it has been found
manifeftly ufeful, at certain periods, and in certain fpecies-
of fever.
  • The following is the usual dose of it every three or four hours :
          R. Sal. Absinth. 9i.
             Succ Limon. §v,. vel. p. s. ad. saturationcm ;
             Addc Aq. i-'ontanx glss.
             Syrup, comrnun. 3ii.
             M. f. haust.
  t The form and dose of this is the same with the foregoing, onlv using tha
volatile alkali instead of the fixed. The aqua ammonia acetata of the London-
Pharmacopoeia is one of the ammonixal salts, and  may be given in doses oi"
two drachms every four hours, diluted with an ounce and a half of water.
  $ It is certainly extreWly useful in suppressing vomitings in fevers.  The
method of producing the effervescence in* the stomach i= as follows:- Let the
patient take the acid first, diluted with a sufficient quantity of water, and im-
mediately after let him swallow the alkali, also diluted.  The proportion of
the alkali to the acid must be learned from chemistry. If the mild fixed alkaU'
is good, it will saturate abou: twelve Ur.i^ its. weight ci' lemon juice. 
                  OF PHYSIC.                 73

   164.] Upon the other hand, it may be urged againft the
jpraaice of fweating,
   1. That as in fevers a fpontaneous fweating does not im-
mediately come on, fo  there muft be in thefe fome circum-
ftances different from thofe in a ftate of health, and which
mav therefore render it doubtful whether  the fweating can
be fafely excited by art.
   2. That,  in many cafes, the praaice has been attended
with bad confcquences. The means commonly employed
have  a tendency to produce an inflammatory diathefis;
which,  if not taken off by the fweat following their ufe,
muft be increafed with much danger.   Thus, fweating em-
ployed to prevent the acceffions of intermitting fevers, has
often changed them into a continued form, which is always
•dangerous.
   3.  The utility of the praaice is further doubtful, be-
caufe fweating, when it happens, does not always give a fi-
nal determination; as muft be manifcft in the cafe of inter-
mittents,  as well as in many continued fevers, which are
fometimes in the beginning attended with fweatings that do
not prove final;"and, on the contrary, whether fpontaneous
or excited by art, feem often to aggravate the difeafe.
   165.J From thefe confiderations, it is extremely doubt-
ful ifrhe praaice of fweating can be admitted very generally;
but at the fame time,  it is alfo doubtful,  if the failure  of
the praaice,  or the mifchiefs faid to have arifen from it,
have  not been owing to the improper condua of the prac-
titioner.  With refpe£t to this  laft, it is almoft agreed a-
mong phyficians.
   1.  That fweating has been generally hurtful, when ex-
cited by_ ftimulant, heating, and inflammatory medicines.
   2.  That it has been  hurtful, when excited by much ex-
ternal heat, and continued with a great increafe of the heat
of the body.
   3.  That it is always hurtful,  when it does not foon re-
lieve,  but rather increafes, the frequency and  hardnefs  of
the pulfe, the anxiety and difficulty of breathing, the head-
ach, and delirium.
   4.  That it is  always hurtful,  if it be  urged when the
fweat is not fluid, and when it is partial, and on the fupe-
rior parts of the body only. 
SO                 PRACTICE

   166.] In thefe cafes,  it is  probable,  that either an in-
flammatory diathefis is produced, which increafes the fpafm
on  the extreme  veffels;  or that,  from  other caufes,  the
fpafm is too much fixed to yield eafily to the increafed ac-
tion of the  heart and arteries ; and,  upon either fuppofiti-
on, it muft be obvious, that urging the fweat,  as ready to
produce a hurtful determination  to fome of the  internal
parts, may  be attended with very  great danger.
   167.] Though the doubts flarted (164.) are to be atten-
ded to;  and although the  praftices (165.) having been
found hurtful, are therefore to be rejected; it ftill  renfains
true.
   1. That fweating has certainly been often ufeful  in pre-
venting the acceffion of fevers, when the times of this have
been certainly forefeen, and a proper condua employed.
   2. That, even after fevers have in  fome meafure come
on, fweating, when properly employed,  either at the very
beginning of the  difeafe, or during its approach and gra-
dual formation,  has often prevented their further progrefs.
   3. That, even after pyrexia? have  continued for fome
time, fweating has been fuccefsfully employed in curing
them,  as particularly in the cafe of rheumatifm.
   4. That certain fevers,  produced  by a very powerful
fedative contagion, have been generally treated, lb far as
we vet know, moft fuccefsfully by fweating.
   168.] Thefe inftances (167,) are in favour of fweating,
but give no general rule; and it muft be left to further ex-
perience to determine how  far any general rule can be ef-
tablifhed in this matter.   In the mean time, if the praaice
of fweating is to be attempted, we can venture to lay down
•the following rules for the condua of it.
    1. That it fhould be excited without the ufe of ftimu-
lant inflammatory medicines.
    2. That it fhould be excited with as little external heat,-
and with as little increafe of the heat of the body,  as poffi-
ble.
    3. That when excited, it fhould be continued for a due
length of time, not lefs than twelve hours, and fometimes
 for twenty-four or forty-eight hours; always however, pro-
 viding that it proceeds without the circumftances menti-
 oned (165. 3. 4.) 
OF  PHYSIC.                   81
     4. That for  fome part of the time, and as long as the

  perfon can eafily bear, it fhould be carried on without ad-
  mitting of fleep.*

     5. That it fhould be rendered univerfal over the whole
  body;and, therefore, particularly,  that  care betaken to
  bring the  fweating to the lower extremities.

     6. That the practice fhould be rendered faferbymoderate
  purging, excited at the fame time.
     7.  That it  fhould not be fuddenly checked by cold any
  how applied to the body.
      169.J When attention is to be given to thefe rules, the
   fweating may be excited, 1.  By warm bathing, or a fomen-
  tation of  the  lower extremities.   2- By frequent draughts
  of tepid liquors chiefly water,  rendered  more grateful by
   the addition of a light aromatic,t or more powerful by that
   of a fmall quantity of wine.  3. By giving  fome  doles of
   neutral falts.*   4. Moft efFe&ually, and perhaps moft fafe-
   ly,  by a large dofe of opiate, joined with a portion of neu-
   tral falts,  and of an emetic.|j

     *  This direction is not always absolutely necessary.
     f  The light aromatics here mentioned are sage, mint, balm, &c. For the
   purpose of  sweating,  white wines answer best, especially the thin fresh
   wines ; as also Rhenish wines, particularly Hock. They must be taken warm
   and plentifully diluted.  Wine whey is also a very powerful sudorific, as are
   also wheys made with vinegar, cream of tartar, the juices of acid fruits, or
   with dulcified spirit of nitre.
     \  Neutral  salts may be given in the quantity of two scruples or a drachm :
   but the patient must nevertheless drink large quantities of warm water. The
   tartarous tartarisatus is the neutral most frequently used for producing sweats;
   its dose is generally £)i. but it may be increased to two drachms.
     ||  This is the well known Dover's powder, now called in the London Phar-
   macopoeia, pulvis ipecacuanhse compositus.  It consists of 8 parts of neutral
   salt, one of opium,  and one of ipecacuanha ;  so that 10 grains of it are an
   ordinary dose : But it has been given to the quantity of a scruple wfthout a-
   ny bad consequences, and that dose repeated every two or three hours, till
   the effect was produced.   In general, however, doses  of 12 or 15 grains are
   the most usual, and are  found by experience to be the best.  The Dover's
   powder, when given in large quantities, often nauseates, and is  rejected by
   vomit.  In the Edinburgh Pharmacopoeia, the Dover's powder consists of 9
   parts of neutral salt, one of opium,  and one of ipecacuanha. The dose of
   this, therefore, will be nearly the same as the dose of the former ; 11 grains
   of Edinburgh Dover's powder being equivalent to 10 of the London.  In ad-
  ministering this powder it  may be  necessary to observe, that the patient
$  ought to refrain from drinking for  at least an hour after taking it, because it
  nauseates more readily if much diluted }n the stomach ; and if the nausea be
  so great as to produce vomiting, its effects as a sudorific are considerably di-
  minished : when, however, a sweat is produced, thin diluting drinks may
  and  ought to be plentifully given ; for in such cases,  it is evident from the
  effect, that the medicine has passed out of the storna«h, and that no material
  ' nausea can then be produced by it.
     V»L.I.                       L 
82                  Practice
   In what cafes may cold water, thrown into the ftomach
in large quantities, be employed to excite fweating ?  See
Celsus,  Lib. III. chap, vii—ix.
   170.] The fourth means (153. 1.) of determining to the
fuiface of the body, and thereby taking off the fpafm affect-
ing the extreme veffels, is by  the ufe of emetics.
  °i7i-.] Emetics, and particularly antimonial emetics, have
been employed in the cure of fevers ever fince the intro-
du6lion of chemical medicines-:  but for a long time, they
were employed by chemifts and chemical praaitioners on-
ly ;  and although of late the ufe of them has become very
general, their eificacy is ftill difputed, and their manner of
operating is not commonly  explained*
   172.] Vomiting is, in many  refpeas, ufeful in fevers;
as it evacuates the contents of the ftomach; as it emulges
the  biiiary and pancreatic duas; as it evacuates the con-
tents of the duodenum, and perhaps, of alfo a larger porti-
on of the inteftines; as it  agitates the whole of the abdo-
minal vifcera,  expedes the circulation in them, and  pro-
motes their feveral fecretions ; and laftly, as agitating alfo
the vifcera  of the thorax,  it  has like effeas there.   AH
thefe feveral effeas are in many cafes and circumftances of
fever, procured with advantage; but do not properly fall
under our view here, where we are to confider only the ef-
fea of vomiting in determining to the  furface  of the body.
   173.]  This effea we  do not  impute to the exercife of
vomiting in agitating the whole frame; but to  the particu-
lar operation of emetics upon the mufcular fibres  of the fto-
mach, whereby they excite the action of the extreme arte-
ries on,the furface of the body, fo as thereby effeaually to
determine the blood into thefe veffels, remove the atony,
and take  of the fpafm affeaing them.
    174.] That fuch is the  power of emetics, will appear from

   *  AH the antimonial emetics are violent in their effects, and are sometimes
 attended with disagreeable consequences.  Emetic tartar is found from ex-
 perience to be the safest of them ; but it is not always of the same strength,
 unless peculiar attention be paid to the making of it.  The prescription for i*
 in the last Edinburgh'Pharmacopceia is preferable to that in the London. Some
 Chemists think that it would be better to use boiling water alone, and omit
 the alkaline salt, alledging that the alkali renders the precipitation variable
 in point of strength : But  this opinion is erroneous. The alkali is used in or-
 der to free  the precipitate more completely from any remains of the muriatic
 ■acid, making it thereby a milder powder and a more perfect calx.- 
OF PHYSIC.
the fevcral confiderations mentioned above (44) and there-
fore, that they are remedies well fuited to the cure of fevers.
   175. J Emetics, for that purpofc, arc adminiftcfed in two
different ways : that is,  either in fuch doles as may excite
full and repeated'vomitings;. or in fuch  dofes as may ex-
cite ficknefs and naufea only,.with little or no vomiting at all".
   176.3 Full vomiting is belt fuited to the feveral purpo- .
fes mentioned 172. and is alfo well fuited to  determine to
the furface of the body, fo  as thereby to obviate the atony
and fpafm which lay the foundation of fever.  Thus vomit-
ing, excited a little before die expeaed acceffion of the pa-
roxyfm of an intermittent, has been found to prevent the
paroxyfm altogether.   And it has been obferved alfo, that
when contagion Has been applied to a perfon, and firft dif-
covers its operation, a vomit given wilt prevent the fever,
which was  otherwife to have been expected.   See Lino
on Fevers and Inspection.
   177.] Thefe are advantages to be obtained by exciting
vomiting at the firft approach of fevers,  or of the parox-
yfms of fevers ; and after  fevers are  formed.;  vomiting
may alfo be employed to take off,  perhaps  entirely, the
atony and fpafm, or at leaft to moderate  thefe, fo that the
fever may proceed more gently and fafely.
   178.J It is feldom, however,  diat vomiting is found to
produce a  final' folution of fevers ; and after they are once
formed, it  is commonly neceffary to repeat the vomiting
feveral  times ; but tins is attended with inconvenience, and
fometimes with  di fad vantage..  The operation of full vo-
miting commonly foon ceafes,  and the exercife of vomit-
ing is often a debilitating power; and therefore, when the
vomiting does not remove the atony and fpafm very entire-
ly, it may give occafion to their recurring with greater force.
   179.] For thefe reafons,. after fevers are fully formed.
phyficians have thought proper  to employ emetics jii  nau-
feating dofes  only.  Thefe  are capable  of exciting the ac-
tion of the extreme veffels,  and their operation is more
permanent.   At the fame time, they often fhow their pow-
er by exciting fome degree  of fweat, and their operation is
rendered more  fafe, by their commonly producing  fome
evacuation by ftool.
   l8o.J Such are the advantages to  be procured  by  nau. 
8i                 PRACTICE
feating dofes of emetics; and it only remains to mention,
what are the medicines moft fit to be employed in that man-
ner, what are the moft proper times for exhibiting, and what
is the beft manner of adminiftering them.
   181.J The emetics at prefent chiefly in ufe, are, Ipeca.
cuanha and Antimony.
   The former may be employed for every purpofe of e-
metics,  particularly thofe mentioned (172.) It  may like-
wife be employed, either in larger or fmaller dofes for  de-
termining to  the furface of the body ;  but, even in very
fmall dofes, it fo readily excites vomiting, as to be with dif-
ficulty employed for the purpofe of nau feating only ; and
however employed  there is reafon to believe, that effeas
are lefs permanent, andlefs powerfully communicated from
the ftomach to the reft of the fyftem than thofe of Anti-
mony.
   182.] This  therefore, is generally preferred; and  its
preparations, feemingly  various, may all be referred to two
heads ;  the one comprehending thofe in which the reguline
part is in a condition to be aaed upon by acids ; and there-
fore, on meeting with acids in the ftomach becomes a£tive ;
and the  other comprehending thofe preparations in which
the reguline part is already joined with an acid, rendering
it aaive.
   183.] Of each kind there are  great numbers, but not
differing effentially from one another.   It will be enough
for us to compare the Calx Antimonii Nirrata of the Edin-
burgh Difpenfatory with the Emetic Tartar of  the fame.
The former, as I judge, is  nearly the  fame with what is
called James's Powder.*  Which of thefe is beft fuited to
the cure of fevers, as above explained,  feems doubtful;
but it appears to me, that, although the former may have
fome advantages from its flower operation, and may there-
by feem to be more certainly fudorific and purgative,  yet
the uncertainty pf its dofe renders it inconvenient, has of-
ten given occafion to the timid to be difappointed,  and to
the bold to do mifehief.   On the other hand, the  dofe of
the Emetic Tartar can be exaaiy afcertained; and I think
  * The pulvis antimonialis of the London Pharmacopoeia is intended  as a.
substitute for, or imitation of, James's powder. The dose of it is 7 or 8 grains.
It is by no means so sure in its operations as the emetic tartar; yet it has been
Kiuch extolled by several err.inea modern practitioners. 
O F  V H Y S I C.                  t5
it may he exhibited in fuch a manner as to produce all the
advantages of the other.
   184. J Whichfoever of thefe preparations be employed,
I judge the moft  proper  time for exhibiting them,  to be
the time  of acceflions;  or a little before,  when that can
be certainly  known.   In continued fevers, the exacerba-
tions are not always very  obfervable;  but there is reafon
to think,  that one commonly happens about noon, or foon
after it, and another in the evening; and that thefe, there-
fore, are the moft proper times for exhibiting emetics.
   185.]  With  refpea to  the manner  of adminiftiation,
 that of the Calx Nitrata is fimple,  as the whole of what is
judged a proper dofe is  given  at once, and no more can
 properly be given till the time of the next acceffion.*
   The adminiftration  of  the  Emetic Tartar is different.
It is to be given in fmall dofes,  not fufficient to excite vo-
miting; and thefe doles, after fhort intervals,  are  to be
repeated for feveral times, till ficknefs, naufea, and fome,
but  not much, vomiting, come  on.  The difference of
 this  adminiftration muft depend  upon the dofe,  and the
 length of the intervals at which it is given.   If it be intend-
 ed that the medicine fhould certainly operate by ftool, the
 dofes are  made fmall,  and the intervals  long.    On the
 contrary, when vomiting is proper, or when much  purg-
ing ought to be  avoided, and therefore  fome  vomiting
 muft be admitted,  the dofes are made larger and the inter-
 vals fhorter.t
    186.]  With refpea to both  kinds of preparations, the
repetition is to be made' at the  times of acceffion,  but not
  * The dose is ten or twelve grains.  This calx, however, is verv uncertain
in its operations, sometimes acting with great violence, and sometimes scarce-
ly producing any perceptible effects.
  f The dose of the Antimonium tartarisatum should never exceed three
grains.  The best method of giving it is, to dissolve three grains in six oun-
ces of water; and of this .mixture give two table spoonsful: if no vomiting
ensues within twenty minutes, repeat the dose, and continue to give a table
spoonful every ten minutes till the vomiting is excited^ which must be encou-
raged by drinking plentifully of camomile tea, or a thin water gtuel.  If the
emetie tartar be intended for a sudorific, two table spoonsful of the following
solution every two or three hours will perhaps be more proper than small
doses of the other.
             R. Antimonii tartarisati gr. ii,
               Aq. Cinnamon, simpL Jii.
               —. Font. Jvi.
               M. F. Julap, 
*6.                 PRACTICE
 very often : for if the firft exhibitions duly managed, have-
 little effea,  it is feldom  that the after  exhibitions  have
 much ; and it fometimes happens that the repeated vomit-
 ings, and efpecially repeated purges, do  harm by weaken-
 ing the patient..
   187. J The other fet of internal medicine?, (152. 2) which
 I fuppofe may be ufeful in taking off the fpafm of the ex-
 treme veffels, are thofe named Antifpafmodic.  How many
 of thefe may be properly employed, I am uncertain; and
 their mode of operation is involved  in great obfeurity. It
 is certain, however, that opium,, camphor, mufk, and per.
 haps fome others, have been employed in  fevers with ad-
 vantage;  but the  circumftances in which they are efpeci-
 ally proper and fafe, I find difficult to afeertain;  and
 therefore cannot venture here to lay down any general doc-
 trine  concerning them.
   188.] The external means (151.) fuited to take off the
 fpafm of the extreme veffels, are Blisterln g and Warm.
 BATHINCr.
   1-89.J  What are the effeas of Bliftering/fo frequently-
 employed in fevers,  is not yet agreed upon among phyfi-
 cians; and many  different opinions  have been maintained
 on this  fubjea, drawn not only from reafoning,  but alfo
 from prefumed experience.   I muft not, however, enter
 into controverfy; but fhall deliver my own opinion in a
 few words.
   190.] I am perfuaded,  that the fmall  quantity of can-
 tharides abforbed from a bliftering plafter, is not i'umcient
 to change the confiftence of the mafs of blood ;  and there-
 fore that fuch a quantity can neither do good, by refolving-
 phlogiftic  lentor,  ifitexifts; nor do harm,  by increalin^
 the diffolution of the blood arifing from a putrid tendency
 in it.  I therefore negfea entirely the effects of cantharides.
 upon the fluids.
   191.] The inflammation produced by the application of
 cantharides to the fkin. affords a certain proof of  their fti-
 mulant power; but in many perfons, the effeas of that fti-
 mulus is not confiderable; in many  it is not communicat-
 ed  to the whole  fyftem;  and even when the effect  does
take place in the whole fyftem, it feems to be taken off en-
tirely, by  the effufion and evacuation of ferum from the- 
OF  PHYSIC.                 87
flittered part.   I conclude, therefore, that neither much
good is to be expe6ted, nor much harm to be apprehended,
from the ftimulant power of bliftering; and the certainty
of this  conclufion is eftablifhed, by the great benefit arif-
ing from the proper praaice of bliftering in inflammatory
difeafes.
   192.] Much has been imputed to the evacuation occa-
 fioned  by bliftering;  but it is never fo confiderable as to
a flea the  whole f\ item;,and  therefore can neither,  by
fudden depletion, relax  the fanguiferous veffels, nor,  by
any revulfion, affea the general diftribution of the fluids.
   193.] The evacuation, however, is fo confiderable as
to affea the  neighbouring veffels;  and the manifeft utility
of  bliftering near the part affected, i 1 inflammatory dif-
eafes, leads me to believe, that bliftering, by deriving to  the
fkin, and producing an effufion there, relaxes the fpafm
of the deeper feated veffels.   I apprehend  it to be in this
manner, that the tumour of a joint, from an effufion into
 the cellular texture under the fltin, takes off the rheumatic
pain affeaing'that joint.                          -^
    194. J Analagous to this, it may be held, that thetpod
effects of bliftering in continued fevers,  arife frqpits re-
laxing the fpafm of the extreme veffels,  by a corrrMhriJca-
tion of the bliftered part with the reft of the fkin; armihis
is illuftrated by the effea of bliftering in cholic and dylen-
tery.
   195.] It appears to me, that bliftering may be employ-
ed  at any period of continued fevers; but that it will be of
moft advantage in the advanced ftate of fuch fevers, when
the reaaion being weaker, all ambiguity from the ftimu-
lant power of bliftering is removed, and when it may beft
concur with other circumftances tending to a final folulion
of the fpafm.
   196.J From the view of this matter given in (193. and
194.) it will appear, that the part of the. body  to  which
bhfters ought to be applied, is indifferent, excepting upon
the fufpicion of topical affeaion, when the bliftering ought
to be made as near as poffible to the part affeaed.
  197.J Whether Sinapisms, and other Rubef acien-
ti a, aain a manner analagous to what we have fuppofed
©f bliftering, maybe  doubtful; but their effeas in rheu. 
88                 PRACTICE

matifm, and other inflammatory difeafes render it  pro-
bable.
   198.]  The other external means of taking off the fpafm
of the extreme veffels, is  Warm Bathing.   This was fre-
quently,  and in various circumftances,  employed by the
ancients; but till very lately has been negfeaed by modern
phyficians.  As the heat of the bath ftimulates the extreme
veffels, and, with  the concurrence of moiflure, alfo re-
laxes them, it feems to be a fafe ftimulus,- and well fuited
to take off the fpafm affeaing them.
   199.]  It may be applied to the whole body by immer-
fion;  but this  is,  in many  refpe6ts, inconvenient; and
whether fome of  the inconveniences of immerfion might
not be avoided by a vapour-bath, I have  not learned  from
experience.   I know,  however, from  much experience,
that moft of the purpofes of warm bathing can be obtained
by a fomentation of the legs  and feet, if properly admi-
nistered,  and  continued for a  due length of time, which
ought not to be lefs than an hour.
   200.] The marks of the  good effeas of fuch fomentati-
on, are. the patient's bearing it eafily, its relieving deliri-
um, ana inducing fleep.
   201.] Having now confidered the feveral means of fatif-
fying  -the firft general indication in the cure of fevers, I
proceed to the fecond(i26.) which is, To  remove the cause9
or obviate the  effects of debility.
   202.]  Molt of the fedative powers inducing debility,
ceafe  to aa foon after they have been firft applied ;  and,
therefore, the removing them is not an object of our pre-
fent indication.  There is only one which may be fuppo-
fed to aa for  a long time ; and that is, the contagion ap-
plied : but we know nothing of the nature of contagion
that can lead us to any meafures for removing or correa-
ing it.  We know only its effeas as a fedative power indu-
cing debility, or as a ferment inducing a tendency to pu-
trefaaion in the fluids.   The obviating the latter will be
confidered under our third general indication, and the for-
mer alone to be confidered here.
   203.] The debility induced in fevers  by contagion, or
other caufes,  appears efpecially in the weaker energy of
the brain;  but in what this confifts, or how it may be  di- 
OF  PHYSIC
89
re&ly reftored, we do not well know.  As nature, however,
does, feemingly for this purpofe, excite the aaion of the
heart and arteries, we afcribe the continuance of debility to
the weaker reaftion of the fanguiferous fyftem; fo that the
means to be employed for obviating debility, are immedi-
ately direaed to fupport and increafe the aaion of the heart
and arteries; and the remedies ufed are Tonics or Sti-
mulants.
   204.] In contagious difeafes, both from the effeas
which appear, and from diffections,  it is known that the
tone of the heart and arteries is confiderably diminifhed;
and that tonic remedies, therefore, are properly indicated,
   Thefe are to be  confidered as of two kinds; the firft be-
ing the power of cold, the  fecond that of tonic medicines,
   205.J The power of cold, as a tonic, I have mentioned
above; (90.) and it is employed,  in fevers, in two ways;
either as the cold matter is thrown into the  ftomach, or as
it is applied to the furface of the body.
    206. j As it has been fhown above, that the tonic pow-
er of cold can be communicated from any one part to eve-
ry other part of the fyftem;  fo it will readily be allowed,
that the ftomach is a part as fit for this  communication as
any other; and that  cold  drink,  taken  into the ftomach,
may,  therefore, prove an ufeful tonic in fevers.
   207.] This the experience of all ages has  confirmed;
but, at the fame time, it  has been frequently obferved,
that, in certain circumftances, cold drink,  taken into the
ftomach, has proved very hurtful; and, therefore, that the
ufe of cold drink in  fevers requires  fome  limitations.
 What thefe limitations fhould be, and what are all the cir-
cumftances which  may forbid the ufe of cold drink, is dif-
ficult to determine;  but it feems clearly forbidden, in all
cafes where a phlogiftic diathefis prevails in the fyftem,
and more efpecially when there are topical affeaions of an
inflammatory nature.
   208.] The other method of employing cold as a tonic,
is, by applying it to the furface of the body.   The appli-
cation of cold air to  the furface of the body,  as a refrige-
rant power fit to moderate the violence of reaaion, I have
fpoken of above;  (133.) but probably it may alfo be con.
fidered here as a tonic, and ufeful in cafes of debility.
   Vol. I.                   M 
90
TII A C T 7 C E
    209.J Not only cool air, but cold water alfo,  may he
 applied to the furface  of the body,  as a refrigerant,  and
 perhaps as a tonic.  The ancients  frequently applied it
 with advantage,  to particular parts, as atonic; but it is a
 difcovery of  modern times, that in the cafe of putrid fe-
 vers, attended with much debility, the body ma}' be waffl-
 ed all over with cold water.
    210. J This was firft praaifed at Breflaw in Silcfia, as ap-
 pears from a differtation, under the title of' Epidemia ver-
 •na quae Wratiflaviam, anno 1737, afflixit, to be found in
 the appendix-to the Acta. Nat.  Curios. Vol. X.   And
 from otlier writers we find, that the practice has.paffed in-
 to  fome of  the  neighbouring  countries; although in tins
 ifland, fo far  as I know, we have hitherto had no experi-
 ence of it.
    211.] The medicines which have been employed in  fe-
 vers, as tonics,  are  various.  If the Saccharum Saturni
 has been found ufeful, it is, probably, as a tonic, rather
 than as a refrigerant; and the  Ens Veneris,  or other pre-
 parations of iron which  have  been employed, can aa as
 tonics only.   The preparations of copper,  from their ef-
 feas  in epilcpfy, are prefumed  to poffefs a tonic power;
 but,  whether  their ufe in fevers be founded upon their to-
 nic or their emetic powers, may  be uncertain.   The ufe
 of arfenic and of alum,  in intermittent fevers, feems ma-
 Jiifeftly to depend  upon their  tonic power.   And, upon
 the whole, there may occur  cafes of continued  fevers,
 which may  be cured by tonics taken from the foflil king-
 dom; but the ufe of thefe has been rare,  as well as die ef.
 feas  uncertain;  and phyficians  have  employed, more
•commonly, the vegetable tonics.
   212] A great variety  of thefe has been employed in the
 .cure of intermittent fevers; but how many of them may be
 •employed in continued fevers, or  in what circumftance*
 of thefe  fevers,  is not  well afcertained;  and  I  fhall now
 only confider the queftion with refpect to die moft celebrat-
 ed of thefe tonics, the Peruvian Bark.*

  * When or how the inhabitants of Peru first discovered the febrifuge pow-
 ers  of this  bark is involved in fable and uncertainty. They appear, however,
'to-have long known its virtue, although we have no proofs of rh«ir revealing
 it to the Europeans before the middle of the last century.  The Spaniards 
OF  PHYSIC.
?y
   213.] This bark has  been commonly confidered  as a

Specific, or as a remedy of  which the operation  was  net

imderftood.   Entitis certainly allowable to  inquire  into

this matter;  and I apprehend it may be explained..

   214.]- To this purpofe it is to be remarked,  that a?,  in

many cafes,  the effeas of the bark are perceived foon af-

ter its being taken into the ftomach, and  before it can  pofi-

fibly be conveyed to  the mafs of blood, we may conclude,

that its  effeas do not arife from its operating on the fluids;
and  muft, therefore,  depend upon  its operating on  the

nerves of  the  ftomach,  and  being thereby communicated

to  the reft of the nervous fyftem.   This operation  feems

to  be a tonic power,  the bark being  a remedy  in  many

cafes of debility, particularly in gangrene; and, as the re-
currence of the paroxyfms of intermittent fevers depends

upon a recurrence of atony,  (35. and 36.)  fo probably the

bark, by it  tonic power, prevents the recurrence of thefe
paroxyfms; and this is  greatly  confirmed by obferving,

that many other tonic medicines anfwer the fame purpofe.

*xll the tree which produces ir Palo de CalcTthirae, orfever tree.  Linne calls
it Cinchona officinalis, in memory of the Countess of  Cinchon, the  Spanish
viceroy Vlady in Peru, who was the first European thathadbeen cure! by it.
It was first brought into J.'ah by n Jesuit about the year 1649, and distributed
thnugh Europe by the fathers of that order; hence  the names Cortex and
Fuiiis Jesxtitiau, Pit his Patrviv.  By Cardinal tfe Lv;y's influence a cargo of
it was procured and.brought to Home soon after; -whence it received  the
name of Puhis Carilir.aiis de Lugo.
  As this bark io a mc.i'uine of considerable importance, it may not be im-
proper to join a short description of the external qualities of the best sort. It
is in concave pieces, scarcely ever exceeding the fourth part of a cylinder cut
longitudinally.  It breaks  short, and when broken evidently  appears  to ba
composed of  three distinct and separate coats, viz. one outer thin coat, tba<
is somewhat  rugged,  often covered with moss of different kinds, and is of a
reddish brown color like cinnamon.  The middle coat is considerably thicker,
of.a ctorer texture and deeper color than the first, and is less brittle but more
resinr us than any other part.  The third or innermost coat is woody and fi-
brous, and hi' a  brightish :td, at least considerably brighter than either of tile
ethers.  From this description of ti>e bark, great care  must be taken  in pon-
dering it, not to leav= much gross powder, but to pass  the whole of it through
tha sieve, because ths most resinous, and consequently the most effectual,
part c.f die bark is the longest and most difficult to powder,.
  With respect to *he two kinds of bark so much talked of andnoticed a few
years ago, it  mav be proper to observe, that they seem to be the production of
the same tree.  The Spaniards always selected such pieces as those above de-
scribed out of the original packages, and rejected the thin, pale, and quilled
sort, which the English preferred.  ft is certain that  both the red, pale, quil-
led, and a variety of gradation between them, all occur in the sam'e chest as
originally imported ; and it is extremely improbable, that the'bark of different
kinds of trees should be packed together. Be this matter however as it may,
e\perience gives the preference to-what is called the  red bark, and ihis sort
eight  surely to be used. 
$2                  PRACTICE
   215,] If the operation of the bark may be thus explain-
ed, from its  poffeffmg a tonic power, it is eafy to perceive
why it is improper when a phlogiftic  diathefis prevails;
and,  from the fame view, we can afeertain in what cafes
of continued fever it may be admitted.  Thefe are either
after confiderable renditions have appeared, when  it may
be employed to prevent the return of exacerbations, on the
fame  footing that it is ufed in intermittent fevers, or in the
advanced ftate of fevers,  when all fufpicion of an  inflam-
matory ftate is removed, and a general debility prevails
in the fyftem; and its being then employed is fufticiently
agreeable to  the prefent practice.
   216.]  With refpea to the ufe of the bark,  it is proper
to add, that good effects  are to be expefted from it, almoft
only  when given in fubftance and in large quantity.*
   217.]  Another fet of medicines to be employed for ob-
viating debility and  its effects, are  the  direct, ftimulants
(203.)  Thefe, in fome  meafure, increafe the tone of the
moving fibres; but  they are different from the tonics, as
more' directly  exciting and increafing the action  of the
heart and arteries.   This mode of their operation  renders
the ufe of them ambiguous; and when an inflammatory
diathefis is prefent, as  fo often  happens  in the beginning
of fevers, the effects of thefe ftimulants may be very hurt-
ful; but  it ftill remains  probable, that,  in the advanced
ftate of fevers, when debility prevails, they may be ufeful.
   218.]  What are  the ftimulants that may be moft pro-
perly employed,  I am uncertain, as  the ufe  of them  in
this age has been rare; but I am difpofed to believe that,
of all kinds, wine is the  beft.
   219.]  Wine has the advantage of being grateful to the
palate and ftomach, and of having its ftimulant parts  fo
much diluted, that it can be  conveniently given  in fmall
dofes;  fo that it maybe employed with fufficient caution;
but it is of little fervice,  unlefs taken pretty largely.t

  * The doses of the bark can only be determined from the  sta^e of the pati«
ent's stomach and the violence of the disease :  It is usual to give a drachm
of the powder at a dose, and repeat it every two or three hours, according to
the exigency of the case, or the state of the patient's bowels. It  frequently
passes off by stool when given too liberally j this inconvenience is obviated
by giving a few drops, 8 or 12 of laudanum, with each dose.
  f Wine is a valuable cordial, and is much superior to most other stimulants;
it raises the pulse, supports the  vis vitae, promotes diaphoresis, and resists
putrefaction. With respect to the medical differences of wines, it may suf- 
                   OT PHYSIC.                 93

   220.] It may he fuppofed, and on good grounds,  that
wine  has an operation analogous to that of opium, and
fome  other narcotic medicines.   It may  indeed  be faid,
that  we can diftinctly mark its ftimulant power only,
which renders its effects in the phrenitic delirium manifeftly
hurtful, and, in the mild delirium,  depending on debility,
as remarkably ufeful.   But  in all  this  the analogy  with
opium is ftill obvious; and it is probable, that both wine
and opium are more ufeful by  their fedative and antifpaf-
modic, than by their ftimulant powers.
   221.] Thefe are the means of anfwering our fecond ge*
neral indication; (126. 2.) and I now proceed to the third,
which is, To obviate or to correct the tendency of the fluids
to putrefaction.
   222.] This may be done,
   1.  By avoiding any new application of putrid or  pu-
trefcent matter.
   2.  By evacuating the putrid or putrefcent matter alrea-
 dy prefent in the body.
   3.  By correcting the putrid or putrefcent matter remain-
 ing in the body.
   4.  By fupporting the tone of the veffels, and thereby re-
 filling further putrefaction, or obviating its effects.
   223.] The further application of putrid or putrefcent
 matter may be avoided,
   1.  By removing the patient from places filled with cor-
 rupted air.
   2.  By correcting the  air from which he cannot be re-
 moved.
   3. By preventing the accumulation of the patient's own
effluvia, by a conftant ventilation, and by a frequent change
of bed-clothes and body  linen.
   4.  By the careful and fpeedy removal of all excremen-
tal matters from the patient's chamber.
   5.  By avoiding animal food or correcting it.
   224.] The putrid or putrefcent matter,  already prefent
in the body, may be  evacuated partly by evacuating  fre-
fice to  observe that the effects of full bodied wines are more lasting than those
of the  thinner.  Red wines are subastringent, and consequently possess a to-
nic virtue, and are hence more proper in fevers of all kinds where wine is at
all admissible, than white wines are.  All sweet wines are nutritive and in
general more stimulating than others ; hut they heat much and are apt to tutu
sour on the stomach. 
 $4                      P R A CTICE

 quently  the contents of the inteftines,* and  more effea ital-
 \y ftill,  by fupporting the excretions of  perfpiration  and
 urine,  by the plentiful ufe of diluents, f
    225.] The putrid or putrefcent matter, remaining in the
 body, may be rendered more mild and innocent by the ufe'
 of diluents  ; or may be corrected by the ufe of analeptics.
 Thefe  laft are of many  and various  kinds ;  but which of

 them are conveniently applicable, or more particularly fuit-
 ed  to the cafe of fevers, is not well  afcertained.   Thofe
 moft certainly applicable and ufeful, are, acefcent aliments,

 acids £ of all kinds, neutral falts || and fixed air.£

   * The evacuants to be used in these cases are, the mdder purges, s"ch as
 manna, &c.  Rhubarb and senna may also be used  ; but we must avoid the
 drastic purges, such as jalap, scammony, aloes, and similar resinous purges.
 Calomel has been found very useful in these cases:  It may be given to the
 quantity  of 8 or 10 grains, and 3 ounces of the infusum sennx,, with half an
 ounce of Glauber's salt may be given, about 10 or 12  hours after it,, to accele- ^
 rate its operation.                                                    ."m.
   f The diluents necessary in these cases must all be mixt with a little port
 wine or claret.  Warm port wine and water is the best dijuent.
   ^ Whether all kinds of" acids are to be used as antiseptics  is scmewl
 doubtful. The mineral acids, especially the  vitriolic, have been much veco
 mended; but the vegetable acids seems much more efficacious.  As  their
 mildness allows us  to give them in very large quantities, and as they r.-.crq
 easily enter into a union with the animal fluids than  the fossile acids do. they
 s«em more  suitable antiseptics  i-i these cases. Whether there is any di'I'er-
'ence between  *-he  native vegetable acids and vinegar, with respect to their
 antiseptic  qu'Jities,  was formerly much disputed hv practitioners.  Physi-
 cians, however,, have,  now settled this question: and  are generally of opinion,
 that in cases of putrescence arising from fevers, the fermented acid is most pro-
 per; but in cases if putrescence without fever, they prefer the native acidjuicc3.
   j) The  antiseptic  power of the different neutral salts is extremely various.
 According to the reasoning in the foregoing notf, those consisting of a vege-
 table acid base ought to be preferred ; and  indeed  experience confirms tlwe
 opinion.  The Sniritus Mindereri would perhaps be useful, if it could be pre-
 vented from passing two hastily olFby sweat and urine.  In dbses of a drachm
 every two hours, it is less subject to promote sweat and urine, than when gi-
 ven in theusual.dose of half an ounce. Lemon juice, saturated with volatile
 alkali, has often been successfully used in these cases ; especially vhen they
 arc taken either in the act o£ effervescence,, or separately, the one immediate-
 ly after the  other.
   § The antiseptic qualities of fixed air are  much doubted bv several eminent
 physicians.   The giving it is frequently very difficult,  avid sometimes even
 impossible.  The author might have added several other antiseptics to the
 short list he has given : What he has mentioned, however,  are  such as are
 generally used, or appioved of by practitioners.   Camphor is a considerable
 antiseptic, but it is of too heating a quality to be given in such quantities as,
 seem necessary.  The common dose of it is  from 1 to 10 grains, and it is best-
 exhibited in the form of a bolus ; in  which form it  may also be ioHed wiitL
 6ome other  antiseptic, as
             Be- Camphor, gr. viii.
                Spt. Vini. gutt. x.
                Pulv. Rad. Contrayerv. 9ii,
                Syr. Simpl. q.  s»
                M.i. bol. 
OF  PHYSIC.                 53
      £26.]  The nrOgrefs of putrefaction may be confidcra*
   bly retarded, and its effects obviated,  by  fupporting the
   tone of the veffels; and this may be  done by tonic  rcme-
   dies ;  the chief of which arc, Cold,  and Peruvian Eark,
   both fufhciently treated of above, (205. tt seq.)
      227.]  I have now finifhed the confideration of the three
   general indications to be formed in the cure of continued
   fevers; and have  mentioned moft of the remedies  which
   have been, upon any occafion, employed in this bufmefs.
   It was neceffary, in the firft place,  to confider thefe indi-
   cations and remedies feparate!}', and to explain  the ope-
   ration of the  latter more generally  ;  but  from what has
   been now delivered,  compared with what was faid above,
J^ concerning the difference of fevers,  and the fignification
   o^hekne^eral fymptoms in forming the prognoftic, I ex-
   |W it will not be difficult to affign  the indication, and to
   felect  and combine the feveral  remeflies mentioned,  fo as
   to adapt them to the fevcral fpecies and circumftances of
   contifTCeo^fe^rsY

   I think it may be ufeful for my Readers to have the whole
      of the cure of Continued Fevers brought under one
      View,  a? in the following Table.

           3|n tiz Ctue of Continues JFctie^,
                   THE INDICATIONS ARE,
             I. To moderate the violence  of reaction*
   "Which may be done by,
      1. Diminishing the action of the heart and arteries, by
   A.  Avoiding or moderating those irritations which are almost con*
          stantly applied to the body ; as,
       a.  The impressions made upon our senses, particularly,
         u. Increased heat, whether arising from
           «.«.. External heat, or,
           /8/3. The accumulation of the heat  of the body.
       b.  The exercise of the body,
       c.  The exercise of the mind,
       d.  The taking in.of, aliment,
       e.  Particular irritations arising from
         a. The sense of thirst,
   This dose maybe repeated every 6 hours, or oftener, especially if the pulse be-
   low or weak.  Iu using Camphor the practitioner ought to remember that
   this medicine, when given in large quantities, frequently occasions delirium.
   Peculiar attention must therefore be paid to that  symptom, and the doses Q§
   camphor regulated with caution. 
96
PRACTICE
       (5.  Crudities, or corrupted humors in the stomach,
       y.  The preternatural retention of faeces.
       8.  A general acrimony of the fluids.
B. Employing certain sedative powers ; as,
    a. Cold,
    b. Refrigerants ; the chief of whith are,
       a.  Acids of all kinds,
       (S.  Neutral salts,
       y.  Metallic salts.
C. Diminishing the tension and  tone of the arterial system, by
    a. Blood-letting,
    b. Purging.
  2.. Taking off the spasm of the extreme vessels, by
A.  Internal means ;  which are,
     a. Those remedies which determine to the surface, as,
       a. Diluents,
       0. Neutral salts,
       y. ■ Sudoi ifics,
       o. Emetics.
     b. Those remedies gamed antispasmodics.
 B.  External means ; as,
     a. Blistering,
     b. Warm bathing*             ...
 IT  To remove  the causts, or obviate  the eff'ects, ofdebj,
       by
   1. Supporting and increasing the action of the heart and arteries, by
 A. Tonics, as,
      a. Cold,
      b. Tonic medicines, -which are either,
        a. Eossile, as,      ,
          aa.  Saccharum saturni, Sec. or,
        0. Vegetable, as,
          ««.  Peruvian Bark.
  B. Stimulants, as,
      a.  Aromatics,  See.
      b. Wine.

  III. To obviate or correct the tendency of the f aids to putre-
          faction, by
    1. Avoiding the application of putrid or putrescent matter, by
  A.  Removing the  patient from places filled with corrupted air.
  B. Correcting the  air from which 1* cannot  be  removed.
  C. Avoiding the accumulation of the patient's own effluvia, by
       a.  A constant ventilation,
       b.  Frequently changing the bed-clothes and body-linen.
  D.  Removing carefully and speedily all excremental matters.
  E.  Avoiding animal food, or correcting it.
    2. Evacuating the  putrid or  putrescent matter already present in
              the body, by,
  A. Evacuating frequently  the intestines.
 
OF  PHYSIC.                9/
  B.  Supporting the excretions oi* perspiration and urine, by
      a. -Diluents,
      b. Neutral salts.
   ■3. Correcting the putrid or putrescent matter remaining in the bo-
         dy, by
  A.  Diluents,.
  B.  Antiseptics,
  C.  Fixed air.
   4. Resisting farther putrefaction, or obviating its effects, by
      Supporting the tcne of the vessels, by
      Tonic remedies.

                         Sect. II.

           Of the Cure  of Intermittent Fevers.
     228.]  IT ftill remains to confider the cure of intermit*
  tent%Mjrs;  and with refpecl to thefe, we form alfeuferee
  g^aera nndita ti ons-                        >*-> •
     1. In the time of intermission, to prevent the recurrence
  of paroxysms.
     z^njjie time ^paroxysms, to'cmdtttt these so as to ob-.
  taip affinal solution of the disease.
T%3|. To take off certain circumstances -which might prevent
  tWJulfilling of the two first indications.
    229.] The firft indication may be anfwered in two ways:
     1. By increafing the  adion of the heart and arteries fom#
  time before the period of acceffion, and fupporting" thatvin-
  creafed action till the period  of the acceffion be over, fo
  as thereby to prevent the recurrence of the atony and fpafm
  of  the extreme veffels which give occafion to the recurrence
  of  paroxyfms.
    2. Without increafing the action of the heart and arte-
  ries, the recurrence of paroxyfms may  be  prevented,  by
  fupporting the tone of the veffels and thereby preventing
  atony, and the confequent fpafm.
   230. J For the purpofe mentioned in 229. 1. the action
  of the heart and arteries may be increafed,
   1. By various ftimulant remedies,  internally given, or
 externally applied, and  that without exciting fweat.
   2. By the fame  remedies,  or others fo managed as to
 excite fweating, and to fupport that fweating till the period
 of acceffion be for fome time paft.
   3.  By naufeating dofes of emetics,  giv§n about an hour
   y©i. 1.                    n 
9S                 PRACTICE
 before the time of acceffron, (hereby fupporting and in-
 creafing the tone and attion of the extreme veffels.
   231. J The tone of the extreme veffels may be fupport-
 •ed without increafing the  action of the heart  and arteries
 (229. 2.) by various tonic medicines ; as,
   1. Aftringents alone.
   2. Bitters alone,
   3. Aftringents and bitters conjoined.
   4. Aftringents and aromatics conjoined,
   5. Certain metallic tonics.
   6. Opiates.
     'Laftly, an imprefiion of'horror,
   A good deal of exercife, and as full a diet as the con-
 dition of the patient's appetite and digeftion may allow of, ^
 will  be proper during the time of intermiffion, and may be ?\
 confidered as  belonging to this head.   *•*-         '•       >%
   232.] Of all the  togic remedies mentioned (231.) the   h
 THoft celebrated, and perhaps the moft certainly effectual,   ■;'
 is the Peruvian bark, the tonic power of which we ha_ve en-—.
 deavored to demonftrate above (214.) and have at the k^|fe
 time explained its ufe in continued fevers.             v^^
   The fame obfervation as made in 216. is efpecially pro-
 per in the cafe of intermittents: and further,  with rcfpe6t
 to thefe, the following obfervations or rules are offered here.
   1. That the bark may be employed with fafety  at any
 period of intermittent fevers, providing that, at the fame
time, there be neither a phlogiftic diathefis prevailing in
 the fyftem, nor any confiderable or fixed c .ngeftion pre-
 fent  in the abdominal vifcera*
   2. The proper time for exhibiting the bark in intermit-
 tent  fevers, is during the time of intermiffion; and where
 intermiflions are to be expeOed, it is to be abftained from
 in the time of paroxyfms.
   3. In remittents, though no entire apyrexia occurs, the
 bark may be given  during the remiffions;  and it fhould
be given even though the remiflion  mould be  inconfidera-
 ble,  if, from the known nature of ihe epidemic, intermiffi-
 ons or confiderable remilfions, are not to be foon  expect-
 ed,  and that  great danger is  apprehended from repeated
 exacerbations.
  4. In  the  cafe  of £fcnuine intermittents,  while a due 
                        OF  PHYSIC                     - 99


quantity  of bark  is to be employed, the exhibition of it
outfit to be brought as near to the time of acceffion as the
condition of the patient's ftomach will allow.

   5.  In ^encrat, in all cafes of intermittents, it is not fuffi-
cient that  the  recurrence of  paroxyfms  be  flopped for
once by the ufe of die bark ;  a relapfe is commonly to be

expected,  and  fhould  be prevented by  the  exhibition of
the bark, repeated at proper intervals.*

   *  The quantity of bark to be given in the intermission must be as great as
the stomach can pos'-.ibb/ bear.   It  is very common to give 2 ounces"during
the intermission, in doses of half a drachm cr two scruples every hour, espe-
cially in quartans.   But it has been found more successful  in its operations,
when we begin with small doses, viz. £)i. in the commencement of the inter-
missions, and increase thedo.ses to 51. towards the .end of it. The bark some-
times sits better on the  stomach by adding to it about an eighth or a fourth of
its weight of some aromatic antiseptic.  Virginian snake root answers this
intention very well. An ounce of red bark and 2 drachms of sna'ke root taken
during the intermission of a tertian, if the stomach  can bear it, or if no diar-
riin a comes on, generally prevents m.: next paroxysm.   In»case of diarrhoea
being produced by baric, ten or twelve drops of laudanum  are tobe given three
or four times with each dose of the bark.   The substances generally jquied
with the bark in prescription, seem calculated either to promote its eScacy or
 reduce it to the intended form,  without having regard to the agreeableness
©flfhe composition.   T-his,  however, is a point of great consequence, as the
,tmste of the bark, and the large quantity of it accessary for the cure, make th2
 patient frequently loath it before its use ought to be discontinued. When made
 into an electuary cr bolus with syrups, it sticks about the  mouth or fauces ;
whence  its taste remains »■ long while ; bur, when made into an electuary with
mucilages, it passes down freely, scarcely leaving any taste behind it.  The
ta»te of the bark is very effectually concealed by liquorice root in a decoction
or by the extract in an electuary. The  extract  of logwood also conceals the
taste of the bark, and an electuary made with it, and a sufficient quantity cf
mucilage, is a very elegant form; Decoetions, infusions, and tincture of the
bark are much less efficacious than th:- rubstance   The extract and the resin
aiv seldom employed in the cure of-intermittents,  except when other fqrms
will not  sit on the stomach.  The formula in the lz»z  London Pharmacopeia
 is the best, being a  compound of both the  extract and resin ; for the watery
extract is strong in bitterness, butwonk inastringency.and the resin is Wrong
in astriagency, .but weak in bitterness, and b<>fh qualities are necessv/\ lor
curing intermittents.  About 10 or 12 grains of the extract are equivalent to
half a drachm of powd'.-r.  Whan a paroxysm hns been stopped by the bark,
it is by no means safe  to abandon the use of this medicine altogether, as a.
relapse is alwayr. to be apprehended.   The doses are gradually to be diminish-
ed, and the intervals between the times of giving them ire to be  increased:
After tertians, we may diminish the quantity daily one half, tiU we arrive at
2 drachms ; a.id these 2 drachms ought  to bfi C*oi.tinned in do;;es of 2 scruples
3 a day for eight days ;. after which period, 2 scruples ought to be given night
and morning for a week longer : after quartans, when the dose  is reduced
to 2 drachm-, a day, it will be prud-'U to continue giving this quantity  daily
lor a fortnight, and.half a drachm night and mornirig for a fortnight longer.
In order the more effectually to  prevent a relapse, great  attention must be
paid to diet and regimen.   Patient's are genera".)'  extremely voracious after
the cure of intermittents ; and indeed they  require  considerable nutrition to
supply the waste occasioned by the fever.   Small quantities of food are tobe
taken at once and to be often repeated; and the most nutritive,  and at the
game ti.ae, cosily o^cstabic food, nuul be chosen, x> broths.with barley aal 
 ig©                  1'RACTlCE

    233. j Our fecond general indication for cor.chrcting the
 paroxyfms of intermittent fevers, fo as to obtain, a final fo-
 lution  of the difeafe, may be anfwered,
    1. By exhibiting emetics  during  the time  of  the cold
 ftage, or at the beginning of the hot.
    2. By opiates given during the time of the hot ftage.*
    234.J, The circumftances which may efpecially prevent
 the fulfilling of thofe two  indications, and therefore give
 occaiion to our third, are a phlogiftic diathefis prevailing
 in  the fyftem, and congestions  fixed m the abdominal  vif-
 cera.   The firft muft be removed by blood-letting and the
 antiphlogifticregimen; the fecond by vomiting and purging.
    Where thefe meafures are not immediately effectual, I
 hold it fafer to attempt the cure of the difeafe by the means
 pointed out in general in 229.  rather than  by thofe in  ar-
 ticle fecond of the fame paragraph.


  *"*<.            BOOK    II.

       Of Inflammations,  or  Phlegmasia:*

                        CHAP. I.

            ©f inflammation in  general*
                         Sect.  I.
         Of the Phenomena of Inflammation.

 235]  VV HEN any part upon the furface of the body-
 is affeckd with unufual rednefs, heat, pain and tumour,  we
 name the difeafe an Inflammation or Phlegmafia.  Thefe
 white flesh meat, roast lav.-b, veal, chickens, new laid egg«, broiled fresh  fish,
 Stc.  Acrid, acescent, and irritating aliment., and acids are to be carefully
 avoided.  The drink ought to be in moderate quantity, but rich and strong ;
 as mild ale, Port wine and water.   With respect to the regimen proper for
 convalescents from intermittents, it may sufnee to observe, that sleep may be
 indulged in.  Exercise without fatigue is of great use, either bv walking, by
 riding on horseback, or in a carriage, according to the strength cf the pati-
 ent.  But above all, cold must be carefully avoided ; lor nothing more effec-
 tually produces a relapse than an imprudent exposure to cold damp air,  or a
 neglect in keeping the bedy properly clothed.  The practice of giving purges
after the cure of intermittents is highly blameable, and is frequently the <}ause
 of a rehp-e.  Should costive*ness be troublesome, it may be removed by very
 mild emollient glysters.
  *  This practic of giving vomits in the end of the rold rtage and an opiate
after their, operation,:.: eld.  It is mentioned by Sydenham, Booerhaave, Van 
BF  PHYSIC.                10]
fymptoms of inflammation are never confiderable, without
the whole fyftem being, at the fame time, affected with py-
rexia.
   236.] As the external, fo likewife  the internal parts'
may be affected with inflammation;  and we judge them to
be fo, when, together with pyrexia,  there is  a fixed pain
in any internal part, attended with fome interruption in the
exercife of its functions.
   237.}  We judge of the prefence of inflammation alfo
from the  ftate of the blood drawn out of the veins.  When
the blood, after cooling and concreting, fhows a portion
of the gluten feparated from the reft of the mafs, and lying
on the  furface of the craffamentum; as  fuch feparation
happens in  all cafes of more evident phlegmafia; fo,  in
ambiguous cafes,  we, from this  appearance,  joined with
other fymptoms, infer  the prefence of inflammation.   U
the fame time, it muft be obferved, that  as  feveral cir-
cumftances in blood-letting, may prevent  this feparation
of gluten from Liking place in blood otherwife difpofed to
it; fo,  from the abfence  of fuch appearance, wc cannot
always conclude againft the prefence  of inflammation.
   238.J  I cannot eafily give any other general hiftory of
the phenomena of inflammation than what  is  contained in
the three  preceding  paragraphs;  and the variations which
may take place in its circumftances,  will occur to be more
properly taken notice of  under  the feveral heads of the
particular genera and fpecies to  be hereafter  mentioned.
I proceed,  therefore, to inquire  into the proximate caufe
of inflammation in general.

                       Sect.  II.

        Of the Proximate  Cause of Inflammation.
   239.] The phenomena of inflammation (235.) all con-
cur in fhowing,  that there is  an  increafed impetus of the
blood in the  veffels of the part affected;  and as, at the fame
time, the a£tion of the heart is  not always evidently in-
creafed* there is reafon to prefume, that the increafed im-
Swieten, and most practical writers.  It must not, however, be indiscrimi-
nately used.  It i; seldom attended with any salutary effect, except in vernal
intermittents, and in the earlier period of the disease ;  and it is constantly
attended with disadvantage when the disease, has been of ion^ continuance. 
102                PRACTICE
petu > of the blood in the particular part is owing efpecially
to the increafed action of the veffels of that part itfelf.
   240.] The caufe of this increafed action in the  veffels
of a particular part is,  therefore, what we are  to confider
as the proximate  caufe of inflammation.
   In many cafes, we can mjmifeftiy perceive, that inflam-
mation arifes from the application of ftimulant fubftances
to  the part.  When the application of  fuch  ftimulaniSj
dierefore, is evident, we feek for no other caufe of inflam-
mation;, but as,  in many  cafes, fuch application  is nei-
ther evident, nor, widi any probability, to be fuppofed,
we muft,  in fuch cafes,  feek for fome other caufe  of die
increafed impetus of the blood in the veffels of the part.
   241.] Many phyficians have  fuppofed^ that  an obftruc-
tion of the extreme veffels, any how produced, may prove
a caufe of inflammation ; and particularly, that this may
arife from an obftruction formed by a matter flopping up
thefe veffels.  But many difficulties attend this doctrine*
   1.  The opinion feems chiefly to have arifen frcm the
appearance of the blood defcribed in (2.37.) when the fepa-
rated gluten was confidered as a preternatural and morbid
matter;  but we now know very certainly,  that this gluten.
is conftantly a conftituent part of the human blood; and
that it is "only a  peculiar feparation of the parts of the blood
that happens in confequence of inflammation and fome
other circumftances, which gives occafion to the appear-
ance that was falfely confidered asa mark of a morbid
lentor in the blood.
   2.  There are no experiments  directly in proof of a pre-
ternatural lentor  prevailing in  the mafs of blood;  nor is
there any evidence of certain parts of the blood oceafion-
ally acquiring a greater denlity and force of cohefion than
ordinary; neither is there any p.-oof of the denier or more
coherent parts being prefent in the mafs of blood,  in fuch
greater proportion than ufual, as to occafion *a dangerous
fpiflitude.   The experiments of Dr. Browne Langiifh on
this fubjeft afford no conclufion, having been made on
certain parts of the blood feparated  from the reft, without
  *  This is the Boerhaavian doctrine which the author, here refa'ts, manv
objections might be made against several parts of this refutation; but to ex-
amine it minutely, is foreign to my purpose, and would require i.icic rocja
than the narrow limits of these notes can possibly allow. 
Or  PHYSIC.                103
  attending to the circumftances of blood-letting, which very
  much alter the ftate of the feparation and concretion of
  the blood drawn out of the veins.
     3. The fuppofition of a preternatural lentor or vifcidity
  of the blood, is not well founded ;  for it is probahle, that
  nature has fpecially provided againft a ftate of the fluids, fo
  incompatible with the exercife of the moft important func-
  tions of the animal economy.   While motion continues to
  prevent any feparation of parts, and heat continues to pre-
  ferve the fluidity of the mo*e  vifeid,  there feems to  be al-
  ways fo  large a pfoportion of water prefent as to give a
  fufficient fluidity  to  the  whole.  I muft own that this is
  not abfolutely conclufive; but I ftill repeat it, as giving
  a probability to the general argument.
     4. In the particular cafe of inflammation, there are fe-
  veral circumftances which render it probable that the blood
  is then more  fluid than ufual.
     5. I prefume that no fuch general lentor,  as Boerhaave
  and his difciples have fuppofed, does  ever take place; be-
  caufe if it did, it muft mow more confiderable effects than
k  commonly appear.
     6. Befides  the fuppofition of an obftrucfing lentor, phy-
  ficians have fuppofed, that an obftruction may be formed
  by an impermeable matter of  another kind, and that fuch
  anobftruftionmay alfo be the caufe of inflammation.  This
  fuppofition is what is well known in the fchools under the
  title of an error loci ; but it is an opinion that  I cannot
  find to be at  all probable : for the motion of the blood in
  the" extreme veffels is fo weak and flow, as readily to admit
  a retrograde courfe of it; and therefore, if a particle of
  blood fhould happen to enter a vcffel whofe branches will
  not allow of its paflage, it will be moved backwards,  till it
  meet with a vefTel fit for  tranfmittingit;  and the frequent
  ramifications  and anaftomofes  of the extreme arteries are
  very favourable to this.   I muft own indeed, that this ar-
  gument is not abfolutely  conclufive  ; becaufe I allow it
  to bg pretty certain that-an error loci, does actually  upon
  occafion  happen ;  but for, the reafons I  have given, it is
  probable that it feldom happens, and is therefore rarely the
  caufe of in.Manimation \ orif it be3 that it is not merely by 
104                ? R AC i'lCE
 the obftru&ion that it produces;  as, among other reafons,
 I conclude particularly from the  following argument.
    7. Though an obftruftion fhould be fuppofed to take
 place, it will not be fufficient for producing the effects, and
. exhibiting the phenomena, that appear in inflammation. The
 theory that has been commonly employed on this occafion
 is by no means  fatisfying ; and, in  fact, it appears,  from
 many obfervations and experiments, that confiderable ob-
 ftruttions may be formed, and may fubfift, without produc-
 ing the fymptoms of inflammation.
    242.J Obftruction, therefore, from  a matter flopping
 up the veffels, Gaub.  Pathol. 249.  1.  is not to be confi-
 dered as the primary caufe of inflammation ; but at the fame
 time, it is  fuificicntly probable,  that fome  degree of ob-
 ftrufction does take place in every  cafe of inflammation.
 The di (tenfion, pain, rednefs and tumour, attending in flam*
 mation, are to be explained only by  fuppoting, that the ex-
 tremities of the arteries do not readily tranfmit the unufu-
 al quantity  of blood impelled into  them by  the increafed
 action in the courfe of thefe veffels.   Such an obftru6tion
 may be fuppofed to happen in every  cafe 'of an  increafed
 impetus of the blood  ; but it is probable, that in the cafe '
 of inflammation, there is alfo a preternatural refiftance to
 the free paffage of the fluids.
    243.] From thedoBrine of fever, we  are led to believe,
 that an increafed action   of the  heart and  arteries is not
 fupported for any length of time'by any other  means than
 a;fpafm affecting the extreme veffels; and that the fpafm
 takes place in inflammation feems likely, becaufe that eve-
 ry confiderable inflammation is introduced by a cold ftage,
 and is accompanied with that and other circumftances  of
 pyrexia.   It feems alfo  probable,  that fomething analo-
 gous to this occurs even in the cafe of thofe inflammations
 which appear lefs confiderable, and to be purely topical.
    244.] From all this, the nature of inflammation may in
 many cafes be explained in the following manner.   Some
 caufes of inequality in the diftribution of the  blood may
 throw an unufual quantity of it upon particular veffels,  to
 which itmuftneceffarily  prove a  ftimulus.   But, further,
 it is probable, that, to relieve the congeltion, the vis me-
 dicatrix naturae increafes ftill more the aclion of thefe vcf- 
0 F  P H Y S I C.                105
  f Is;  and which, as  in all other febrile difeafes, it effeas
  by the formation of a fpafm on their extremities.
    245.]  A fpafm  of the extreme arteries, fupporting an
  increafed action in the courfe of them, may therefore be
  confidered as the proximate caufe of inflammation; at leaft,
  in all  cafes not arifing from direct ftimuli applied;  and
  even  in this cafe the  ftimuli may be fuppofed to produce
  a fpafm of the extreme veffels.
    246. j  That, in inflammation, there is the concurrence
  of a conftriction of the exlfeme veffels, with an increafed
  a6tion in the other parts of them, feems probable, from the
  confideration of Rheumatifm.   This is a fpecies of inflam-
  mation which is often manifeftly produced,  either by cold
  applied to over diftended  veffels, or by caufes of 'an in-
  creafed impetus, and over diftention in veffels previoufly
  conftncled.   Hence the difeafe efpecially appears  at fea-
  fons liable to frequent and confiderable viciflitudes of heat
  and cold.
    To this we may add,  that the parts of the body moft
  frequently affefted with inflammation, are  thofe expofed,
  both to over diftention,  from a change in the diftribution
  of the fluids,  and, at the fame time, to the immediate ac-
  tion of cold.  Hence, quinfies, and pneumonic inflamma-
  tions, are more frequent than any others.
    247. j  That a fpafm of the extreme veffels takes place
  m inflammation, is to be further prefumed from what is at
  the fame  time the ftate of the whole arterial fyftem.   In
 every confiderable  inflammation, though arifing in one
 part only,  an affeaion is communicated to the whole  fyf-
 tem, mconfcquenceofwhichan inflammation is readily
 produced in.other parts befide  that firft affeaed.   This'
 general affeaion  is  well known among phyficians,  under
 the name of the Diathesis Phlogis*ica.  It appears
 moft commonly in perfons of the moft rigid fibres: is of-
 ten manifeftly induced by the tonic or aftringent powers
 0. cold ; is increafed by all tonic and ftimulant powers ap-
 plied to the body ; is always attended with  a hardnefs of
 the pulfe;  and is moft effeaually taken off  by the relat-
ing power of blood-letting.   From thefe circumftances, it
feems probable, that the diathefis phlogiftica  confifts in an
increafed tone, or contraaility, and perhaps  in an increa-
  V 0 L« 1%                  r\ 
1&5               -P R AG T I C E
fed-contraction of the mufcular fibres of the whole arteri-
al fyftem.  Such a ftate of the fyftem feems often to arife,
and fubfift for lomc time, without the apparent inflamma-
tion of any particular part;  but fuch a Jlate of the fyftem
renders it likely, that a fpafm may arife in any of the ex-
treme veffels, and a particular inflammation be there pro-
duced.   It does,  however, appear alfo, that the general
diathefis frequently arifes from  inflammation begun in a
particular part.
  248.] I have thus endeavored, in the cafe of inflamma-
tion, to explain the ftate of the whole fyftem, as well as that
of-the part more particularly affeaed.  The latter I have
confidered as when in its firft formation ;  but  after it has
fubfifted for fome time, various changes take  place in the
part affeaed; and of thefe  I muft now take notice.
          Of the Terminations of Inflammation.
   249.] IF an inflammation be cured while the ftate and
texture of the  part remain entire, the difeafe is faid to be
terminated by Resolution.
   This happens v.7hen the previous congeftion  and fpafm
have been in a moderate degree, and the increafed impetus
of the blood has been fufficient to overcome the fpafm, to
dilate the  veffels and to remove the congeftion  fo that the
part is reftored to its ordinary and healthy ftate,
   A refolution takes place alfo when the increafed impe-
tus of the  fluids has  produced an increafed exhalation into
the adjoining cellular texture, or an increafed excretion iri
fome neighbouring part, and has thereby relaxed the fpafm,
and relieved the congeftion, in the veffels of the part'more
particularly affeaed.
   Laftly, A refolution may take place, when the increaf-
ed impetus of the  blood in the whole fyftem occafions an
evacuation, which, though in a diflant part, may prove fuf-
ficient to take off the phlogiftic diathefis  of the  whole fyf-
tem, and thereby  relieve  the congeftion  and fpafm of the
particular part affeaed by inflammation.
   250.] The tumour which appears in inflammation may
be imputed in part to the congeftion of fluids in their proper 
OF  physic.                ior
vefTels; but is owinq; chieflv to an effufion of matter into
the adjoining cellular texture ; and. accordingly, tumours
feldoni  appear but in parts  adjoining to  a lax  cellular
texture.   If, in  this cafe, the matter effufed be  only a
larger quantity of the ordinary exhaling f!aid.  this, when
the free circulation in the veffels is reftored, will be  readily
abforbed, and the ftate  of the part will become  the fame
as before.   But,  if the increafed impetus of the  blood in
an inflamed part, dilate  the exhalent vc'ifels to fuch a de-
gree, that they pour  out aa entire ferum, this will  not be
fo readily reabfbrbed : ana, from the  experiments of Sir
 John Pringle, and  efpecially from thofe of Mr.  Gaber,
Miscell. Taurin. Vol. II. we learn, that the ferum, under
ftagnation, may  fuffer a particular change, by having the
gluten prefent in it changed into a white opaque, moderate-
ly vifeid,  mild liqour, which  we name Pus.   When this
change takes place in the inflamed part, as it is at the fame
time attended with an abatement  of the-rednefs, heat, and
pain, which before diftinguifhed the inflammation,  fo the
difeafe i-s faid to be terminated by £u p?u rat ton ; and an
inflamed part, containing a colfeaion of pus is called an
Abscess.
   251.J In inflammation, the tendency of it to fu ppurati-
on may be difcovered by the long continuance of  the in-
flammation,  without the fymptoms of refolution ; by fome
remiflion of the pain of diftention;  by the pain becoming
a  throbbing kind, more diftinaiy connected with the pui-
fation of the arteries; by the pulfe of the arteries being ful-
ler and fofter;  and often by the patient's  being frequently
affeaed with cold fhiverings.  The period at which this
takes place is not determined,  but may fometimes  fooner,
fbmctimes later.  When the  tendency  is determined, the
time neceffary to complete fuppuration is different in dif-
fer en.: cafes.
   When pus is completely formed, the pain in the part en-
tirely ceafes, and a weight is felt in it.  If the collection
be formed immediately under the (kin,the tumour becomes
pointed, the part becomes foft, and the fluci nation of the
fluid within can commonly be perceived; while at the fame
time, for  the moft par.t, the  rednefs of the fkin formerly
prevailing is  very much gone, 
 108                 PRACTICE

   252.] In abceffes, while the pus is formed of one part
 of die matter which had been effuied,the other and thinner
 parts are reabforbed, fo that in the abfcefs, when opened,
 a pus alone appears.  Thus pus, however, is not the  con-
 verted gluten alone : for the  converfion of this being the
 effea of a particular fermentation, which  may  affea the
 folid fubftance of the part, and perhaps every folid of ani-
 mal bodies; fo it moft readily, and particularly,  affeas
 the cellular texture, eroding much of it, which thereby be-
 comes a part of the pus.   It  generally happens  alfo,  that
 fome of the fmaller red veffels are eroded,  and thereby
 fome red blood often appears  mixed with the pus in abfeef-
 fes.   Upon the whole, the internal fuiface of an abfcefs
 is  to be confidered as an ulcerated part.
   253-] This account of fuppuration explains, why an ab-
 fcefs,  when  formed, may either fpread into the cellular
 texture of the neighboring parts; or by eroding the incum-
 bent teguments, he poured out upon the furface of the bo-
 dy, and produce an open ulcer.
   254«] We have here given the idea of an abfcefs as a col-
 leftion  of  matter  following  inflammation; but the term
 has been applied to every colfeaion of matter effufed, and
 changed by ftagnatiou in an enclofed cavity.           ,
   The  matter  of abfeeffes,  and of the ulcers  following
 them is various, according to the nature of what is effufed,
 and which may be,
   1.  A matter thinner  than ferum.
   2.  An entire and pure ferum.
   3.  A quantity of red globules.
   4.  A matter furnifhed by  particular glands  feated in
the part.
   5. A mixture of matters from different fources, changed
by peculiar fermentation.
   It is the fecond only which  affords a proper pus; the ef-
fufion whereof, whether in fuppurating parts or ulcers,
feems to be the peculiar effea of an inflammatory ftate of
the veffels; and for this reafon it is, that, when ulcers do
not produce a proper pus, a circumftance always abfolute.
iy  neceffary to their healing,  we in many cafes, bring the
ulcers to a  ftate of fuppuration, by the application of ftir 
© F P H Y S I C.                109
mulants exciting inflammation, fuch as balfams,.mercury,
copper, Sec.
   255-J When the  matter  effufed in the cellular texture
of an inflamed part,  is tainted with a putrid ferment, this
produces in the effufed  matter, a ftate approaching more
or lefs to that of putrefaaion.  When this is in a moderate
degree, and affects only  the fluids effufed, with the fub-
ftance of the cellular texture, the part is faid to be affeaed
with  Gangrene ; but  if the putrefa6tion affea alfo the
veffels and mufcles of the part, the difeafe is  faid to be a
Sphacelus.
   256-j A gangrene, and its confequences, may arife from
 a putrid ferment diffufed in the mafs of blood, and poured
out with the ferum effufed,  which it operates upon  more
powerfully while the ferum is ftagnant,  and retained in the
heat of the body : but it may alfo arife from the peculiar
nature of the matter effufed being difpofed to putrefaaion ;
as particularly feems to be the cafe of the red globules of the
blood effufed in a large quantity.  In a third manner alfo,
a gangrene feems frequently to arife from the violent  ex-
citement of the inflammation deftroying the tone  of the
veffels ;  whereby the whole fluids ftagnate and run into
putrefaaion, which taking place in any degree, deftroysftill
further the tone of the veffels, and fpreads the gangrene.
   257.} In inflammation, the tendency to gangrene may
be apprehended from an extreme violence of pain and heat
in the inflamed part, and from a great degree of pyrexia
attending the inflammation.
   The aaual  coming on  of gangrene may be perceived by
the color of the inflamed-part  changing from a  clear to a
dark  red;  by blifters arifing  upon the  part;  by the part
becoming foft, flaccid, and infenfible ; and by the ceafing
of all pain while thefe appearances take place.
   As the gangrene proceeds, the color of the part becomes
livid, and by degrees quite black;  the heat of the part en-
tirely ceafes; the foftnefs and flaccidityof the part increafe;
it lofes its confiftence, exhales a cadaverous frriell,and may-
then be confidered as affected with fphacelus.
   258.]  Gangrene is thus a third manner in which inflam-
mation terminates; and the fchools have commonly mark-
ed a fourth termination of inflammation; which is, by a 
no                PRACTICE
fcirrhus, or an indolent hardncfs of the part formerly ai-
feaed with inflammation.   This however, is a rare occur-
rence, and does not feem to depend fo much upon the na-
ture of inflammation, as upon the circumftances of the part
affected.  It is in glandular parts chiefly that feirrhofity is
obferved ; and it is probably owing tothe parts readily ad-
mitting  aftagnation of the fluids.   I have obferved, that
inflammation feldom induces fcirrhus ;  but that this lnore
commonly arifes from'other caufes;  and when inflamma-
tion fupervenes, which it is fooner or later apt to do, it
does not fo commonly increafe, as change the feirrhofity
into fome kind of abfcefs.   From thefe confederations it
does not feem  ncceffary to take any further notice of fcirr-
hus as a termination of inflammation.
   259.] There are,  however,  fome other terminations of
inflammation,  not commonly taken notice of, but now to
be mentioned.
   One is, by the effufion of a portion of the entire mafs of
blood, either by means of rupture  cr of anaflomofis, into
the adjoining cellular texture.   This happens efpecially in
inflammations of the lungs,  where the effufed matter, by
compreffmg the veffels and flopping the circulation, oc-
cafions a fatal  fuffocation ; and this is perhaps the manner
in which pneumonic inflammation  moft  commonly proves
fatal.
   260.] Another kind of termination is, that of certain
inflammations  on the furface of the body, when there h
poured out under the cuticle a fluid,  which being too grofs
to pafs through its pores,  therefore feparates it from the
fkin,  and raifes it up into the form of a veficle'containing
the effufed fluid ; and by which effufion  the previous in-
flammation is taken off.
   261.] Befide thefe already  mentioned, I believe there
is ftill another  manner in  which inflammation  terminates.
When the internal parts are affeaed with inflammation^
there feems to  have been almoft always upon their furface,
an exudation,  which appears partly asavifeid concretion
upon their furface;  and partly as a  thin ferous fluid effufed
into the cavities in which the inflamed vifcera are placed.
Though we have become acquainted with thefe appearand
ces only, as very conftantly accompanying  thofe iidlaai- 
Oh  PHYSIC.                Ill
Tnations which have proved fatal,  it is however probable,
that like circumftances may have attended thofe which were
terminated by refolution, and may have contributed to that
event.  It is in favour of this fuppofition that there are
inftances of pneumonic inflammation terminating in a hy-
drothorax.

                      Sect. IV.

         Of the Remote Causes  of Inflammation.
   262.J THE remote caufes of inflammation may be re-
 duced to five heads.
   l. The application of ftimulant fubftances;  among
 which are to be reckoned the afction of fire, or burning.
   2.  External violence operating mechanically in  wound-
 ing, bruiting, compreifing, or ovcrftretching the parts.
   3.  Extraneous fubftances, lodged in any part of the bo-
 dy,  irritating  by their chemical acrimony or mechanical
 form, or compreifing by their bulk or gravity.
   4. Cold, in a certain degree, not fufficient immediately
 to produce gangrene.
   5. An increafed impetus of the blood determined to a
 particular part.
   It  will not be difficult to underftand how thefe remote
 caufes, fingly,  or in concurrence,  produce the proximate
 caufe of inflammation.
   263.] It does not appear, that in different cafes of in-
 flammation, there is any difference in the ftate of the prox-
 imate caufe, except in the degree of it;  and though fome
 difference  of inflammation may arife from the difference
 of the remote caufes,  yet this is not ncceffary to be taken
 notice of here; becaufe the different appearances which
 attend different inflammations may be referred, for the moft
 part,  to the difference of the part affeaed; as will appear
 when we fhall confider the feveral genera  and fpecies mark-
 ed in the Nofology.  When I  come to treat of  thefe, I
 fhall  find a more proper occafion for taking notice of the
 different ftates of the proximate,  or of  the differences of
the remote caufe,  than  by treating of them in  general
 here. 
112                 PRACTICE
                       Sect.V.

              Of the Cure of Inflammation.
   264.] THE indications of cure in inflammation are dik
ferent, according as it may ftill be  capable of refolution,
or may have taken a tendency to the feveral other termi-
nations above mentioned.  As the  tendency  to thefe ter-
minations is not  always immediately  evident, it is always
proper, upon the firft appearance of inflammation,  to at-
tempt the cure of it by refolution.   For this purpofe,-  the
indications of cure are,
   1.  To remove the remote  caufes, when they  are  evi-
dent, and continue to operate.
   2.  To take off  the phlogiftic diathefis  affeaing  either
the whole fyftem, or the particular  part.
   3.  To take off the fpafm  of the  particular part, by re-
medies applied either to  the whole  fyft.em, or to the part
itfelf.
   265.] The means of removing  the remote caufes will
readily occur, from confidering the particular nature and
circumftances of the different kinds.  Acrid matters muft
be removed, or  their aaion  muft be prevented, by the ap-
plication of correctors or demulcents.*   Compreifing and
overftretching powers muft  be  taken away ;  and,  from
their feveral circumftances,  the means of doing  fo will be
obvious.
   266.]  The means of taking off the phlogiftic diathefis
of the fyftem, arc the fame with thofe;for moderating the
violence of reaBion in  fever, which are mentioned and
treated of from  (127 to  159) and therefore need not be re-
peated here.   I  only obferve, diat in the ufe of thofe  re-
medies, there is lefs occafion for any referve than in many
cafes of fever ;  and  more particularly,  that topical bleed-
ingst are here particularly indicated and proper.

   * If the matter causing the inflammation be an acid, thenthe application
of an alkaline substance will be proper: If, on the contrary, the inflammati-
on be produced by an alkali, then an acid must be applied. In many cases,
however, the acrid substances causing inflammation are neither allialine nor
acid ;  and, in such cases, or when we cannot  find a proper corrector, we must
use demulcents, which by their obtunding quality,  sheath the acrimony, or
defend the parts to which they are applied from being irritated or corroded.
   f The advantages  of topical bleedings, in most cases of local inflammation
are very great.  They may be performed by cupping, or what is in many ca-
 ses more preferable, by leeches.  Cupping acts sometimes  <u a stimulus, espe- 
OF  PHYSIC                     113
   267.] The means of taking off the fpafm of the particu-
lar part are nearly the fame as  thofe mentioned above,  for

taking off the fpafm of the extreme veffels in the cafe of fe-

ver,  and which are  treated of from  150. to 200. Only it is

obferved here, that fome of thefe are  here  efpecially indi-
cated, and that  fome of them arc to be direaed more par-

ticularly to the  part efpecially   affeaed :  the management
of which will be more properly confidered when we  fhall
treat of particular inflammations*.

   268.J When a tendency to fuppuration(251.)is diftina-

cially on parts that are tendinous  or fleshy, cr  where the cellular substance
Is thin, and thus frequently increases the inflammation which we would wiih
to resolve.
   *The resolution of an inflamed part is considerably assisted by the applicati-
on of discutients; and in most cases, when the general system is not affected,
these discutients alone frequently succeed in dissolving an incipient phlegm-
on.  Solutions of lead in vinegar are the applications which the best modern
practitioners generally approve.  Goulard's extract was supposed by the vul-
gar to be* a new remedy  ; and his panegyric on it, tended in a considerable
degree to render the use of lead ir.ore universal than it had been before his
time.  There are, however,  many weighty objections against  the formula
used by that gentleman; the chief one is, that on acccuntofthe different strength
of the vinegar employed,  and of the degree of heat used in the process, we can
never accurately ascertain the quantity of lead dissolved' in the acid ; and con-
sequently the efficacy of this preparation  must be uncertain. The Saccharum
Saturni, which is always of the same strength, is therefore preferable to Gou-
lard's extract: and as vinegar is a powerful discutient itself", it has been usual
to add a quantity of vinegar to the solution of the sugar of lead in distilled
water. The following proportions have been found in general to be the best ;
               R.  Sacchar. Saturn'. B'i.
                   Acet. Gallic, opt. §iv.
                   Ac,, font, distillate §xxxii.
                   M."
In the application of thfcsnlution, it is of great consequence that the parts af-
fected should be continually moistened wuh it. Poultices made of iVe^h brc ad
crumb, and as much  o£.the above solucion as is necessary, are in general  pre-
ferable to any other mode of appl\ ing it ; but it  sometimes happens that the
inflamed pan is so extremely painful  and tender,  as not  to bear the great
weight of a poultice; and in such cases we must have recourse to pieces of
soft linen, moirtencd with the solution.  Both these applications, viz. poul-
tices, or wet pledgets, must always be applied cold, and be frequently renew-
ed when  they become warm, hard or stiff.  This is the most approved me-
thod of apph ing lead for the purpose of resolving inflammations'; yet it  fre-
quently happens that practitioners meet with patients whose prepossessions
f.n- a popular remedy are so great that there is no persuading them from using
it.  The method of making Goulard's extract and Vegato-Mineral Water are
therefore subjoined,
            Take Litharge of Gold, one pound,
            French White-Wine Vinegar, a quart,
Boil them in an earthen vessel, on a slow fire, f r an hour and an half, con-
stantly stirring them with a wooden spatula, and when cold, pour off the cleaf
liquor, which must be kept in well stopped glass phials.  The  Vegeto-Mine-
ral water is made by adding a hundred drops of the above extract to a quart
»f water, and four tea-spoonsful of French Brandy.
   \ 9L.  1.                        P 
114                   PRACTICE
ly  perceived, as we  fuppofe it  to depend upon  the effu-
fion of a fluid which cannot be eafily reab forked, fo it be-
comes neceffary that this fluid be converted  into pus,  as

the only natural means of obtaining its evacuation : and  as
the effufion is, perhaps,  feldom made without fome rup-
ture of the veffels, to the healing of which a pus is abfolute-
ly neceffary;  fo in the cafe  of a tendency to  fuppuration,
the indication of cure always is, to promote  the produai-

on of aperfea pus as  quickly as poffible.
   269.] For this purpofe, various  remedies, fuppofed to

poffefs a fpecific power, have been propofed; I can per-

ceive  no fuch power in  any of  them;  and  in my  opini-
on, all that can  be  done is,  to favour  the fuppuration by

fuch applications as may fupport a proper heat in the part,
as by   fome tenacity,  may  confine the  perfpiration of the

part, and as, by an emollient quality, may weaken the  co-
hefion of the  teguments, and favour their erofion.* •

    270. J  As,  in the cafe of certain cffufions, a fuppura-

tion is not only  unavoidable, but defirable, it may  be fup-

  * Poultices of various  kinds have been  recommend for this purpose.  It is
however, of little consequence what  their ingredients are, provided they be
emollient, and applied warm.   The  white bread poultice is in common use,
and answers in general very well ; the addition of a little oil keeps it from
becoming hard, as is at the same time serviceable as an emollient.  A poul-
tice of  bruised lintseed well boiled with milk and  water is strongly recom-
mended by some writers, and indeed not without  reason, on account of its
very great emollient quality.
  As heat is absolutely necessary for the production of matter in tumours, it
is of great consequence that the poultices should not be suffered to cool en the
part, and that they should be often renewed.  Mr. Bell has given excellent
directions for applying poultices, with the intention of promoting suppuration.
  " Warm fomentations and poultices, (says that  rational practitioner) are
the means usually employed for the application of heat to an inflamed part ;
and when these are regularly and frequently renewed, nothing, it is probable
can more effectually answer the purpose. But in the ordinary manner in which
they are appliedj and as the cataplasms are renewed only once, or at most
twice a day, they must always,  it is imagined, do more harm than good  For
as soon as the degree of heat they at first possessed is dissipated,  the moisture
kept up by them, with the consequent evaporation that ensues, must always
render  the part much colder than if it had been merely wrapped up in flannel,
ivithout the use of any such application.
   " In order to receive all the  advantage of such remedies, the part affected
should  be well fomented with flannels, pressed out of any warm emollient de-
coction, applied as  warm as the patient can easily bear them, continued at
least half an hour at once, and  repeated four or five times a day.
   " Immediately after  the fomentation is over, a large emollient poultice
should likewise be applied warm, and renewed  every second or third hour
at farthest.   Of all the forms recommended for emollient cataplasms, a com-
mon bread and milk poultice, with a due  proportion of butter or oil, is per-
haps the most eligible ; as it not only possesses  all the advantages of the
others, but can at all times he m0^ easily procured."——Treause onUjcers,
Edition of 1787, p. 67, 
OF  PITY SIC.                115
pofed,  that moft of the means of refolution formerly men-
tioned fliould be avoided; and accordingly our pradice is
commonly fo direaed.  But as  we obferve,  on  the one
hand, that a certain degree of increafed impetus,,  or of the
original circumftances of inflammation, is requifiteto pro-
duce a  proper fuppuration ;  fo it is  then efpecially necef-
fary to  avoid thofe means of refolution that may  diminifh
too much the force of  the circulation.  And as, on  the
other hand,  the impetus of the  blood, when  violent, is
found to prevent the  proper fuppuration;  fo, in  fuch ca-
fes,  although a  tendency to fuppuration may have begun,
it may be proper to continue thofe means of refolution
which moderate die force of the circulation.
   With refpefct  to the opening of abfeeffes, when com-
pletely  formed,  I refer to the writings on furgery.*
   271.] When an inflammation  has taken a tendency to
gangrene,  that event is  to be prevented by every pofhble
means; and thefe muft be different, according to the na-
ture of the feveral caufes occafioning that tendency, as may
be underftood from  what  has been already faid  of them.
After a gangrene has, in fome degree, taken place, it can
be currd only by the feparation of the dead from the living
parts.   This, in  certain circumftances, can be performed
by the  knife,  and  aluiays  moft properly,  when it can  be
fo done.
   In other cafes, it can De done by exciting a fuppuratory
inflammation on  the verge of the. living part,  whereby its
cohefion with the dead may be every where broken off, fo
that the latter may  fall  off by itfelf.   While this  is doing,
it is proper to prevent the further putrefaaion of  the part,
and  its  fpread ing  wider.   For this purpofe,  various anti-
feptic applications have been propofed r  But if appears to
me,  that, while the teguments are entire, thefe applications
can hardly have  any effea;  and,  therefore,  that the fun-
damental procedure muft be to  fearify the. part fo as to
reach the living fubftance, and,  by the wounds made theie,
to excite the fuppuration required.  By the fame incihons
alfo, we give  accefs to analeptics, which  may both  pre-
vent the pgrogrefs of the putrefaaion  in the dead, and ex-
  * For a  particular account of knowing when abscesses are completely f>vm«
ed, at what period they oughtto be opened, and the manner of opening the:ii|
ths> reader can consult no author preferable- to Mr. Bell. 
JI5                    PRACTICE


cite the inflammation neceffary on the verge of the living

part.*
   272.] When the gangrene proceeds from  a lofs of tone ;
a,nd when  this,  communicated to the neighboring  parts,

pi events that inflammation which, as I have faid, is nccef-
fary to  the feparation of  the dead part from the living; it
will be proper to obviate this'lofs of  tone by tonic  medi-
cines given internally;  and,  for this purpofe,  the Peruvi-

an bark has been found to be  efpecially  effectual.   That

this medicine  operates  by  a  tonic  power, I have endea-     I

voured to prove above,  (214.) and  from what is  faid in

 215. the limitations to  be obferved in employing it may al-
fo be learned.    When the gangrene arifes from  the  vio-

lence of inflammation, the bark may not only fail of prov-
 ing a remedy, but may do harm: and its power as atonic

is efpecially  fuited to  thofe cafes of  grmgrcne  which pro-

ceed from an original lofs of tone,  as in the cafe of palfy
and oedema;  or to  thofe cafes of  inflammation  where a
lofs of tone takes place,  while the  original inflammatory

fymptoms are removed.t

   * The author mentioned in  the preceding note treats this subject in his vi-
 sual ralional  manner, and with n■, -less perspicuity than judgment.  Contrary
 to the cpinion of all former writers on gangrene, he disapproves of scarifica-
tions,, and the subsequent replication of antiseptics and stimulants. Mr. Bell's.
 reasoning against this practice is to the following purport: The degree of in-
 flaminaion requisite, and  indeed necessary, for the separation of the dead
 parts, is only very flight, and  when too violent, it fails to produce ,the desired
 erlect.  Scarifications,  and the subsequent application of stimul-nts, which
 increase  the  inflammation too much, are therefore hurtful.  Again,  in scari-
 fying, there is a considerable risk of wounding large bk>od vessels, nerves,
 or tendons ; bet-ides the disadvantage of allowing the putrescent fluids of the
 gangrene to enter more freely  the sound parts, by increasing'the surface of the
 wound.   With respect to the application of antiseptics.it is justly remarked,
 thai although these medicines have the quality  of preserving dead animal sub-
 stances  from corruption, they by no means .produce the same effect on living
 animal substances.  But the concluding argument is of much greater weight,
 \\z. that, in  a long course of extensive practice, no advantages ever accrued    t
 from scariiication.
   These ohjectiens against promiscuous scarification were first proposed by
 Mr. Bell in his Treatise on Ulcers, about  12 years a.^o ; and the novelty of*
 the opinion excited the attention of almost every practitioner.   At  present,
 however, it is universally adopted,  and would  of itself, independent of the
 many improvements  Mr. Bell has made in surgery, perpetuate his justly ac-
 quired fame.
   f The bark must be given  ir> these cases in large quantities ; and as the
 pulse is  in general very small, Port wine mut-t be used along with it.  Beside
 the us.e  of those remedies, a good nourishing diet is absolutely requisii.e,with
 such a quantity of strong generous wine as is fully sufficient  to keep up the
 pulse, and induce the necessary slight degree of inflammation. When indeed
 the patient is extremely languid, and much reduced, the warm stimulating   '
 cordials, as  camphor,  confectio cardiacs, spin'-us ui'jmaticv.i volatilis, SiC.
 ni.'.y be used with «,dvaritage. 
OF  PHYSIC.               117
   573.]  The other terminations of inflammation either do
not admit of any treatment, except that of preventing them
by the means of refolution ; or they belong to a treatife of
furgery,  rather than to this place.
   Having thus, therefore, delivered the general doarine,
I proceed now to confider the particular genera and fpe--
cies of inflammation.
   It has  been hinted above (263.) that the difference of
inflammation arifes chiefly from the difference of the part
affeaed : I have therefore arranged them, as they are cu-
taneous, visceral,  or articular; and  in this or-
der they  are now to be confidered.
                    CHAP.  II.

   ©f 3inflamniattcn, more sttfctlg Cutaneous

274.] V>tUTANEOUS inflammations are of two kinds,
commonly diftinguifhed by the names of Phlegmon and
Erysipelas.
   Of the latter there are two cafes, which ought to be dif-
tinguifhed by different appellations.  When the difeafe is
an affeaion of the fkin alone, and very little of the whole
fyftem, or when the affeaion of the fyftem is only fympto-
matical of the external inflammation,  I fhall give  the dif-
eafe the name of Erythema; but when the external in-
flammation is an exanthema,  and fymptomatical of an af-
fection of the whole fyftem,  I  fhall then name the difeafe
Erysipelas.*
   275.] It is the erythema only that I am to'confiderhere.
   For the di'ftinttion between Erythema and Phlegmon, I
have formerly referred to the characters given of them in
our Nofology.   See Synops. Nosolog. Meth, Vol. II. p. 5.
gen. vii. fpec. 1. and 2.   But I think it proper now to de-
liver the characters  of them more fully and exaaiy here,
as follows.
   A phlegmon is an inflammatory affeaion of the fkin,
with a fwelling,  riling generally to a  more  confiderable
eminence in the middle of it; of a bright red colour; both

  * The Erysipelas is particularly described in article 6c6, et se^. 
M*                PRACTICE
 the fwelling and color being prettv exaaiy circumfcribed;
 the whole being attended with a pain of diftention, often
 of a ftounding or throbbing kind, and frequently  ending
 in fuppuration.
   An Erythema, Rofe, or St. Anthony's fire, is an inflam-
 matory affe6tion of the fkin, with hardly any evident fwel-
 ling; of a mixed and not very bright red color, readily
 difappearing upon preffurc, but quickly returning again;
 the rednefs of no regular circumfeription, but fpreading
 unequally and continuing almoft conftantly to fpr.ead upon
 the neighboring part;  with a pain like to that from burn-
 ing; producing bliftcrs,  fometimes of a fmall,. fometimes
 of a larger fize; and always ending in a  defquamation  of
 the fearff-fkin,  fometimes in gangrene.
   This fubjeCt I am not to profecute here, as properly be-
 longing to furgery, the bufinefs of which I am feldom  to*
 enter upon in this.work;  and fhall  therefore obferve only
 as neceffary here, that the difference of thefe appearances
 feems to depend on the different feat of the inflammation.
 In the phlegmon, the  inflammation feems to affea efpecial-
 ly the veffels on the internal furface of the fkin communi-
 cating with the lax fubjacent cellular texture;  whence a
 more copious effufion, and that of ferum  convertible into
 pus, takes place. In the erythema, the inflammation  feems
 to have its feat in the veffels on the external furface of the
 Ik in, communicating with the rete mucofum, which does
 not admit  of  any effufion, but what  feparates the cuticle,
 and gives  occafion to the  formation of a bliftcr, while the
 fmaller fize of the veffels admits only of the effufion of a
 thin fluid, very feldom  convertible into pus.
  Befides thefe differences in the circumftances of thefe
 two kinds of inflammation, it is probable  that they alfo dif-
 fer  with refpea to their caufes.   Erythema is the effect  ®f
 all kinds  of acrids externally  applied to the fkin; and,
 when arifing from an internal caufe,  it is from, an acrimo-
 ny, poured out on the furface of the fkin under the cuticle.
 In the phlegmon an acrimony is not commonly evident.
  276  j  Thefe  differences in the feat and caufes of the
phlegmon and erythema being admitted, it will be evident,
that when an erythema affefts any internal part, it can take
place in thofe only whofe  furfaces are  covered with an epU
thelion, or membrane analagous to the cuticle.

                                                      * 
OF  PHY S'lC,
111
   277.] The fame diftinciion between the feat and caufes
of the two difeafes will, as I judge, readily explain what
has been delivered by praaical writers, with refpea to the
cure* of thefe different cutaneous inflammations.   But I
fliall  not,  however, profecute  this here,  for the  reafon
given above; (275.) and, for the  fame reafon, fhall not
fay anything of the variety of external inflammation, that
might otherwife be confidered herc.t


                      chap.  in.


  fl)f Dp&tfjalmia, or  Jnflammation  of tU  Gpe."

278.]  JL  HE inflammation  of the eye may be confider-
ed as of two kinds; according as it has its feat in the mem-
branes of the ball of the eye,  when I would name it Oph-
thalmia Mem bran arum ; or as it has  its feat in the
febaccous glands placed in the tarfus,  or edges of the eve-
lids,   in  which  cafe  it  may be  termed  Ophthalmia
Tarsi.
   Thefe two kinds are very frequently combined together,
as the one may readily excite the other;  but they  are ftill
to be diftinguifhed according  as one or the other may hap-
pen to be the primary affection, and properly as they often
arife from different caufes.
   279.] The inflammation of the membranes of the eye,
affect* efpecially, and moft frequently, the adnata, appear-
ing in a turgefcence of its veffels;  fo  that  the  red veffels
which are naturally there, become not only increafed in
fize,  but there  appear many more than did in a  natural
ftate. •  This turgefeence of the veffels is attended with pain,
efpecially upon the motion of the ball of the eye ;  and this
like every other  irritation applied to the furface of the eye,
produces an effufion of tears from the lachrymal gland.

  * The method of curing an erysipelas is delivered in article 708, et sequent.
  t The cure of erythema is chiefly effected by the antiphlogistic regimen al-
ready sufficiently described. Although bleeding,  purging, and the general
remedies for resolving an inflammation, will in most cases, cure an erythema,
yet as ii is a disease frequently depending on a peculiar acrimony, we shall
always find great advantage from the external use of emollients applied cold,
•r mucilaginous dilueirs taken internally.  Ths disease, however, is scldoai
dangerous, and generally terminates favorably, 
    120                 T> R A C T I C b

     This inflammation commonly, and chiefly, affeBs  the
   adnata fpread on the anterior part of the bulb of the  eye ;
   but ufually fpreads  alfo  along  the  continuation  of  that
   membrane on the infide of the palpebral; and, as that is
   extended on the tarfus palpebrarum, the excretories of the
   febaceous glands opening there are alfo frequently affeaed,
   When the affeaion of the adnata is confiderable,  it is fre-
   quently communicated to the fubjacent membranes of the
   eye, and even to the  retina itfelf,  which thereby acquires
   fo great a fenfibility,  that the flighteft imprefhon of light
   becomes  painful.                                          J
     280.] The inflammation  of the membranes of the eye is
   in different degrees, according as the adnata is more or lefs
   affeaed, or according as the inflammation  is cither of the
   adnata alone, or of the fubjacent membranes alfo; and upon
   thefe differences,  different  fpecies  have been eftablifhed)
   and different appellations given to them.   But I fhall not,
   however, profecute the confideration  of thefe,  being of
   opinion, that all the cafes of the Ophthalmia membranarum   |
   differ only in degree, and. are to be cured by remedies of
   the  fame kind,  more or lefs employed.
     The remote  caufes of Ophthalmia are many and vari-
   ous ;  as,
     1. External violence, by blows, contufions, and woundsj
   applied to the eyes; and even very flight impulfes appliedj  t
   whilft the eyelids are  open, to the  ball of  the eye itfelfj. •
   are  fometimes  fufficient for the purpofe.
     2.  Extraneous bodies introduced under the eyelids, ei-
   ther of an acrid quality, as fmokeand other acrid vapours,*
   or of a bulk  fufficient to  impede the free  motion of the
   eyelids upon the furface of the eyeball.
     3.  The application of ftrong light, or even of a mode-
   rate light long  continued.
     4.  The  application of much heat,  and  particularly of
   that with moifture.
     5.  Much exercife of the eyes  in viewing minute ob-
   jeBs.
     6.  Frequent intoxication.
     7. Irritation from other and various difeafes of the eyes.
     * Hence chemists, when much.employed in processes where copious noxi-
   ous vapour* arise, ought to he extremely careful to avoid ihcm as much aa
   possible.                                                -

____________________'_________________________ 
OF  PHYSIC.
121
   8.  An aciimony prevailing  in the mafs of blood,  anq*
dcpofited in the fcbaccous glands on the  edges of the eye-
lids.
   9.  A change in the distribution of the blood,  whereby
cither a more than ufual quantity of blood, and with more
than ufual force, is  impelled  into the veffels of the head,
or whereby the free return of the venous blood from the vef-
fels of the head is interrupted.
   to. A certain confent of the eyes with the other parts
of the fyftem, whereby from a certain ftate of thefe parts,
either a fimultaneous,or an alternating affeaion of the eyes,
is produced.
   281. J The proximate  caufe  of Ophthalmia, is not dif-
ferent from that of inflammation in general; and the  dif-
ferent circumftances of Ophthalmia  may he explained by
the difference of its  remote caufes, and  by the  different
parts of the eye which it happens to  affea.   This may be
underftood from what has been  already faid;-and  I  fhall
now therefore proceed to confider the Cure.
   282.J In the cure of Ophthalmia, the firft attention will
 be always due  to the removing of the remote caufes,  and
 the various means neceffary for this purpofe will be direa-
ed by the confideration of thefe caufes enumerated above.
   The Ophthalmia membranarum requires the remedies
proper for inflammation in general; and  when the deeper
 feated membranes are affected, and efpecially when a  py-
 rexia is prefent, large general bleedings may be neceffary.
 But this is feldom the cafe; as the Ophthalmia, for the molt
part, is an affeaion purely local, accompanied with little
or no pyrexia.   General bleedings,  therefore, from the
arm or foot, have  little effea  upon it; and the cure is
chiefly to be obtained by topical bleedings,  that is, blood
drawn from  veffels near the inflamed part;  and opening
the jugular vein or the  temporal artery,  may be confider-
ed as in fome meafure of this kind.   It  is commonly fuf-
ficient to apply a number of leeches* round the eye;  and
it is  perhaps better ftill to draw blood from the temples,

  * Ten or twelve may be applied at onee, and when many are employed to-
gether, they generally produce a better effect, than if fewer be employed re-
peatedly : That is twelve at once are more efficacious than three at a thue re«
peated four times a day.
  Vol. I.                    Q 
122
P R  A C T i CTE
by cupping and  fcarifying.*  In  many cafes, a very effec-
tual remedy is, that of fcarifying  the internal furface of the
inferior eyelid;  and more fo ftill, is cutting the turgid vef-
fels upon the adnata itfelf.t
   283.] Befidcs blood-letting, purging, as a remedy fuit-
ed to inflammation in general, has been confidered as pe-
culiarly  adapted to inflammations in any of the parts of
the head, and therefore to Ophthalmia; and it is fometimes
ufeful;  but, for the reafons  given before  with refpea to
general  bleeding, purging in the cafe  of Ophthalmia does
not prove ufeful in  any degree in proportion to the evacu-
ation excited.
   284.] For the relaxing the  fpafm in the part,  and tak-
ing off the determination of the fluids to it,  bliftering near
the part has commonly been  found ufeful.J
   285.] Efearical fparks  taken from the eye will  often
fuddenly difeufs the  inflammation of the adnata:  but the
effea is feldom permanent, and even a frequent repetition
feldom gives an entire cure.
   286. j Ophthalmia, as an external inflammation, admits
of topical applications.   All thofe, however, that increafe
the heat and relax the veffels of the part, prove commonly
hurtful; and the admiflion of cool air to the eye,  the pro-
per application of cold  water immediately  to the ball of
ihe eye,  and the application of various cooling and aftrin-

   * Cupping and fcarifying the temples ought to be performed with very
great caution, becaufe of the numerous ramifications of conhderable branches
of arteries in thofe places.
  f Thefe operations require great nicety.  For the particular method of per-
forming them, the reader is referred to the writers on Surgery-
  Much harm enfues  from thefe operations  when injudicioiulv performed ;
they ought therefore to be refrained from, except when a very fkilful and ex-
pert furgeon can be procured.  They are feldom ferviceable, except they be
repeated feveral times.  Cutting the veffels of the adnata is perhaps the beft
preventive of an opacity of the Cornea that we know : and wherever there
is the leaft tendency to an opacity, the  praflice fliould be  put in execution.
The operation ought to be repeated daily for two, three, or four weeks, or
even longer, if a cure is not accompliflied fooner.
  | The part where blilters are ufually applied in ophthalmia are behind the
ear, or the nape of the neck.  The blilters ought to be kept open by the fub-
fequent application of the mild bliftering ointment, if they affume appearances
of healing.
  Setons in the neck are  fometimes  recommended ; but  when fpeedy relief
is required, they are of little fervice, becaufe they feldom begin  to difcharge
till the expiration of a few days ; befides they are extremely troublefome  to
the patient; and if the phlogiftic diathefis be confiderable, they'fometimes
become fo exceedingly inflamed as to produce many difagreeable circumftan-
ces that might have been avoided. 
OF  PHY SIC.
123
gent medicines, which at the  fame time do not  produce

much irritation, prove generally  ufeful; even fpirituons

liquors, employed in moderate quantity, have often been

of fervicc*
   287.]  In the cure of Ophthalmia, much care is requr-

fitc to avoid  all  irritation,  particularly  that of light;  and

the only fafe  and certain means of doing this,  is by confi-

ning the patient to a very dark chamber.
   288.] Thefe are the remedies of the Ophthalmia mem-

branarum; and in the  Ophthalmia tarfi, for  as it is pro-

duced  by Ophthalmia membranarum, the  fame remedies

may be neceffary.   As, however, the  Ophthalmia  tarfi
may often depend upon an acrimony depofited in the fe-

baceous glands of the part,  fo it may require  various in-

ternal remedies according to  the nature of the  acrimony in

fault;  for which I muft refer  to the confideration of fero-
phula, fyphilis,  or other difeafes with which this Ophthal-
 mia may  be  conncaed; and when the nature of the acri-

 mony  is not afcertained,  certain remedies,  more generally

 adapted to the evacuation of acrimony,  fuch,  for inftance,

as mercury,  may be employed.t
   289. J In the Ophthalmia tarfi,  it almoft conftantly hap-
pens,   that fome  ulcerations  are  formed on the  tarfus.

 Thefe require the application of mercury or copper, ei-

 ther of which  may by itfelf  fometimes entirely cure the

  * A folution of a fcruple of fugar of lead in four ounces of diftilled water,
is a very effectual application ; fome authors recommend equal parts of white
vitriol and fugar of lead diffolved in diftilled water.  Thefe ccllyria, as they
are called, do infinite mifehief if they are too flrong.
  If, therefore, the patient complains of the leaft fmarting on their applicati-
on, it will be neceffary to dilute  them with the addition of more diftilled wa-
ter.  They ought  to be applied cold, and pledgets moiftened  with them ought
tobe frequently renewed when they grow hot or dry.  An additional direfti-
011 may  be added,  viz. that the folution of faccharum faturni be always made
with diftillcd water, efpecially when it is to  be ufed as a collyrium, becaufe
the leaft impregnation of any mineral  acid, however combined, decompcfes
the fu-^ar of lead.
  CoLI pouUices of rafped raw potatoes or turnips are fometimes very efEca-
ci'ius.  They may be applied in  a .fine muflin hag, and ought to be renewed
whenever they grow warm.
  t If the ophthalmia be veneral, mercury is the only remedy, and external
applications have little effect.  If fcrophula is the caufe, relief is often fpeedi-
1 v procured by an application of the Coagulum a luminis, or the unguentum
cirrinum, now called unguentum hydrargyri nhratum in the London Pharma-
copeia.   The unguentum tutix has been ufed in many cafes with advantage,
as has alfo the unguentum ceruiTjc acetatre. But thefe topical applications ne»
xcr cilefl apermr.:iont ciire.                            % 
124                PRACTICE

affeaion; and thefe may even be ufeful when  the  difeafe
depends upon a fault of the whole fyftem.
   290. J  Both in Ophthalmia mc c.branarum,  and in the
Ophthalmia tarfi, it is neceffary to obviate that gluting or
flicking together of the eye-lids which commonly happens
in fleep; and this may be done  by inlinuating a little of
any mild unauous medicines, of fome tenacity, between
the eye-lids before the patient fhall go to fleep.*
                     CHAP.  IV.



291.]  JL HIS difeafe is an inflammation of the parts con-
tained in the cavity of the cranium ; a$d may effea either
the membranes of the brain, or the fobftance of the brain
itfelf.  Nofblogifts have apprehended, that thefe two ca-
fes might be diftinguifhed by different fymptoms, and there-
fore  by different appellations :  but this  does not feem to
be confirmed by obfervation and  diflectiori; and therefore
I fhall treat of both  cafes under the title of Phrenzy, or
Phrenitis.
   292.]  An  idiopathic phrenzy  is a rare occurrence, a
fympathic more frequent ;  and the afcertaining either one
or the other is, upon many  occafions,  difficult.   Many of
the fymptoms by which the  difeafe is moft commonlyjudg-
ed to be  prefent have appeared, w hen from  certain conii-
derations, it was prefumed, and even from diffection it ap-
peared, that  there had been no internal inflammation; and
on the .other hand, diffe6tions  have fhown, that the brain
had been inflamed, when few of the peculiar fymptoms of
phrenzy  had  before appeared.t
   293.] The fymptoms by  which this difeafe may be moft
certainly known,  are  a vehement pyrexia, a violent deep-
feated headach, a rednefs and turgefcence of the face and
eyes, an impatience of light and noiic, a conftant watching
  * Hog's lard, frefh .preffed lintfeed-oil, or oil of almonds, anfwer this inten-
tion very Well, or the unguentum fpermatis  ce'ti, of the  London Pharmaco-
poeia.
  t This fentence is very obscure;  the Author meant to fay, that  the diag-
nostic fymptoms of this difeafe are uncertain. 
OF  PHYSIC.
125
and a delirium impetuous and furious.   Some nofologifts
have thought thefe fymptoms peculiar to an inflammation
of the membranes, and that the inflammation of the  fub-
ftance of the brain was to be diftinguifhed by fome degree
of coma attending it. It was for this reafon that in the No-
fology I added  the Typhomania to the charaaerof Phre-
nitis;  but  upon further reflection,  I find no proper foun-
dation for  this; and, if we pafs from the characters  above
delivered,  there will be no means of fixing the variety that
occurs.
   I am here, as in other  analogous Cafes, of opinion, that
the fymptoms above mentioned of an acute  inflammation,
always mark inflammations of membranous parts; and that
an inflammation of the paronchyma or fubltance of vifce-
ra, exhibits, at leaft commonly, a more  chronic  affeaion.
   294.] The remote caufet>f phrenzy, are all thofe which
directly ttimulate the membranes or fubftance of the brain;
and particularly all thofe which increafe the impetus of the
blood in the veffels of the brain.   Among thefe the expo-
fure of the naked head to the direa rays of a very warm
fun, is a frequent caufe.  The paffions of the mind, and cer-
tain poifons,  are  amongft the remote caufes of phrenzy ;
but in what manner they  operate is not well  underttood.
   295.] The cure of phrenzy is the fame with that of in-
flammation in general; but in phrenzy  the moft powerful
remedies are to be immediately employed.  Large and re-
peated blood-letting is efpecially neceflary ;  and the blood
fhould be  drawn from veffels as near as poffible to the part
affeaed.   The opening  of the temporal artery has been
recommended, and with fome reafon :  but the practice is
attended with inconvenience ; and I apprehend that open-
ing the jugular veins may prove more cffeaual; but at the
fame time, it will be generally proper to draw blood from
the temples by cupping and fcarifying.*

  * Prafti doners have in general admitted two kinds of phrexzv, viz. the
idiopathic or true phrenzy, and the f> mptomatic.  The former is what the
Author defcribes in the text; and as he has  omitted to defcribe the latter.
which in article 292, he acknowledges to be the more frequent of the two, I
fhall enumerate its fymptoms.
  The i'ymptomatic phrenzy is conftantly preceded by feme very acute inflam-
matory fever.   Its approach may be fufpecled by a fuppreluon of the excreti-
ons, by coloilefs ftools, by a black, dry and rough tongue,'by pale and watery
urine, which fometimes has black ord'ark brown clouds floating in it, by a de-
fire but inability to lleep, by picking the bed clothes, by the eyes appearing 
 126   *                 PRACTICE

   296.]  It is probable, that purging, as it may operate by

revulfion, may  be of more ufe than  in  fome other inflam-

matory affections.
   For the fame purpofe of revulfion,  warm pediluvia are
a remedy ;  but, at the  fame time fomewhat ambiguous

The taking off the force of the blood in the veffels  of the

head by an creel pofture, is  generally ufeful.
   297.] Shaving of the head is always proper and ncceffa-

ry for the admiflion of other remedies.   Bliftering is com-

monly ufed in this difeafe, but chiefly  when applied near

the part affeaed.*
   298.]  Every part of the antiphl otitic regimen is here

neceflary, and particularly the admiflion of cold air.   E-

ven cold  fubftances, applied clofe to the head,  have been
found fafe and  highly ufeful; and the  application of fuch

refrigerants as vinegar,  is certainly proper.t
   299.]  It appears to me certain, that  opiates are hurtful

in every  inflammatory ftate of the brain; and  it is  to be

obferved,  that,  from the ambiguity mentioned in (292.)
the accounts of prattitioners, with regard to thejuvantia

fierce, and the veffels of the albuginea becoming turgid, and by a few drops of
blood dialling from the nofe.
  When moft of thefe fvmptoms appear in inflammatory fever-., we juftly ap-
prehend an attack of the phrenzy, and ought to have immediate recourfe to
Inch remedies as willleffen its violence, or altogether prevent itsaccefs. Large
bleedings, if the pulfe permits muft be made on the lower extremities, cmfl'.i-
ent glyfters are to be frequently injefled,  laxatives administered, fometimes
applied to the feet and legs, cupping glades  applied 10 the thighs, and the pa-
tient muft be forced to drink plentifully, for he  is feldom thirlly in thefe ca-
fes, although his tongue be parched.  Befide thefe general remedies,  peculiar
attention muft be paid to the primary difeafe ; and the treatment of the fymp-
tomatic phrenzy will  vary according to the nature of the difeafe by which it
is produced.
  No part of the practice of phyfic requires more judgment and fagacity in
the practitioner, than afcertaining the proper mode of treating the fymptoma-
tic phrenzy in different fevers.  To enter fully into the fubject, would require
more room than thefe notes will allow.  I can only therefore recommend the
young pratfitioner to pay great attention to  it. He will find many ufeful prac-
tical direftions for the treatment of thefe cafes, in moft of the medical wri-
ters, both ancient and modern, efpecially Sydenham and Van Swieten.
  *  It has been ufual to apply a large bliftering pl'arfter over the whole head,
and fuffer it to remain on for eight and forty hours.  This, Ivvever, hinders
the application of other very powerful remedies. Shaving the head cf a fran-
tic patient is always a troublefome operation ; but the very great benefit ari-
fing from it, renders it abfolutely neceffary in all  cafes;  and the phyfician
ought therefore to advife it on the firft fufpicion of an approachingphrenzy.
  f Many eminent practitioners have diffuaded the ufe of thefe refrigerant
applications to the newly (haven head; the immediate relief which the mere (ha-
ving 2 :..r. lly procures feems to indicate the propriety of the pra&ice : and
experience has not difcovered any material  difadvantages attending it, but on
the contrary, much benefit accruing from it. 
OF  PHYSIC.                127
and la^dentia in this difeafe,  are of very uncertain applica-
tion.
                     CHAP. V.

           £>f t&c £tum02, ot Qnanc&e*

300.]   X  If IS name is applied to every inflammation of
the internal fauces; but thefe inflammations are different,
according to the part of the fauces which may be affeaed,
and according to the nature of the inflammation.   In the
Nofology,  therefore, after giving the charaacr of the Cy-
nanche as a genus,  I have  diftinguifhed five different fpe-
cies, which muft here hkewife be feparately confidered.

                       Sect. I.

              Of the Cynanche Tonsillaris.
   301.J THIS is an inflammation of the mucous mem-
brane of the fauces, affecting efpecially that congeries  of
mucous follicles which forms the tonfils,andfpreadingfrom
thence clou; the velum and uvula, foas frequently to affect
every part of the  mucous membrane.
   302. J The difeafe appears by fome tumour,  fometimes
confiderable, and by a rednefs  of the parts; is attended with
a painful and .difficult deglutition; with a  pain fometimes
fhooting into the  ear; with a troublefome clamminefsof the
mouth and throat;  with  a frequent, but difficult,  excre-
tion of mucous;  and the whole is accompanied with a py-
rexia.
   303.] This fpecies of quinfy is never contagious.   It
terminates frequently by refolution,* fometimes by  fup-
puration,  but hardly ever by gangrene; although in difs
difeafe fome floughy fpots  commonly fuppofed to be fore-
runners of gangrene, fometimes appear upon the fauces.
   304. J This difeafe is commonly occafioned by cold ex-
ternally applied,  particularly about the neck.   It  affects
efpecially the young and fan^uir.e, and a difpofition to it
is often acquired by habit;  fo that from every confiderable

  * As the moft frequent termination of this difeafe is by refolution, this mode
ef cur« mult always be attempted, and will feldom fail of proving fuccefsful. 
128
PRACTICE
application of cold to any part of the body, this difeafe is
readily induced. It occurs efpecially in fpiing and autumn,
when viciflitudes of heat and cold  frequently  take place.
The inflammation and tumour are commonly at firft moft
confiderable in one tonfil;  and afterwards, abating in that,
increafe in the other.
   395.]  In the  cure of this inflammation,  fome bleeding
may be proper:  but large general bleedings will feldom be
neceffary.  The opening of the  ranular veins feems to be
an infignificant remedy; and leeches fet upon the external
fauces arc of more efficacy.
   306.] At the beginning of the difeafe, full vomiting has
been frequently found to be of great fervice.*
   307.J This  inflammation may be often relieved by mo-
derate aftringents, and particularly by acids applied to the
inflamed parts.t In many cafes, however,  nothing has been
found to give more relief than the vapor of warm water re-
ceived into the fauces by a proper apparatus.
   308.]  The other remedies of this  difeafe are rubefaci-
ent or bliftering medicines, applied externally to the neck;
and with thefe,  the employment  of antiphlogiftic  purga-
tives,J as well as every  part of the antiphlogiftic regimen,
excepting the application of cold.
   309. J This  difeafe, as we have faid, often terminates by
refolution, frequently accompanied  with fweating ; which
is therefore to be prudently favored and encouraged.|J (
  * The formula of an emetic may be feen in the note on art. 185.
  f Various have been the opinions of phyficians refpecling the kind of gar*
gles proper in thefe cafes. A pint of tincture of roles, with two drachms of
honey, has often been found ferviceable. The following gargle is frequently
ufed with fuccefs.  Boil an ounce of oak-bark, bruifed in a quart of water,
till half is evaporated, and to the ftrained liquor add an ounce of honey of rc~
fes, and a drachm of allum.  Sage tea, with honey, is in common ufe, and
frequently anfwers every purpofe.
 _ | Glauber's Salts anfwer the end of purges in thefe cafes very well, efpe-
cially if the patient drinks copioufly during the operation.
  || Dover's powder is an excellent fudorific in thefe cafes.  The method of
giving it has been defcribed in a former note, on art. 169.  Many other fudo-
rifics, however, are found to anfwer tolerably well, as wine-whey, whey made
with dulcified fpirit of nitre, vinegar-whey, fage tea, with feveral other drinks
ofafimilar kind.  The following bolus is often  very  efficacious, efpecially
when the patient drinks largely of fage or balm tea.
          R. Camphor, gr. viii.
              Opii pur. gr. i.
              Tart.  Vitriolat. 9i.
              Tere in mortario marmoreo ; et addc
              Confeet. cardiac 3"i, vel. 9. s. ut fiat bolus. 
                    G F  P H Y S I C.                 129

   310.] When this difeafe fhall have taken a tendency to
fuppuration, nothing will be more ufeful, than the frequent
taking into the fauces the fleams of warm water.*  When
the abfcefs is attended with much fwelling, if it break not
fpontaneoufiy, it fhould be opened by a lancet; and this
does not require much caution, as even the inflammatory
ftate may be relieved by  fome  fearification  of the tonfils.
   I have never had occafion  to  fee any cafe requiring
bronchotomy.
                Of the Cynanche  Maligna.
   311.]  THIS is a contagious  difeafe, feldom fporadic,
and commonly epidemic.  It attacks  perfons of all ages
but more commonly thofe in a young and infant ftate.  It
attacks perfons of every  conftitution when expofed to the
contagion, but moft read ily the weak and infirm.
   312.] This difeafe is ufually attended with  a confidera-
ble pyrexia ; and the fymptons of the acceffion of this, fuch
as frequent cold fhiverings, ficknefs,  anxiety, and vomit-
ing, are often the firft appearances of the difeafe.   About
the fame time, a ftiffnefs is felt m the neck, with fome unea-
finefs  in the internal  fauces,  and fome hoarfenefs  of the
voice.  The  internal fauces, when viewed, appear of a deep
red colour, with fome tumour ; but this laft is feldom con-
fiderable, and deglution is feldom difficult orpainful. Very
foon a number of white or afh coloured fpots appear upon
the inflamed parts.   Thefe fpots fpread and unite, cover-
ing almoft the whole fauces with thick  floughs;  which
falling  off,  difcover ulcerations.  While thefe fymptoms
proceed in  the fauces, they  are generally attended  with a

  Small dofes of tartar emetic taken in fuch quantities as to produce a flight
naufea without vomiting, are alfo good fudorifics. Two table-fpoonsful of the
following julep may be taken every half hour, till the effeS be produced,
drinking, at the fame time, plentifully of fome warm diluent.
          R. Tartar, emetic, gr. iii.
             Aq. font. Bvii.
             Syr. Papavcris rubri, |i.
             M. f. julap.
  *  Very convenient apparatus for this purpofe are made by moft tin-work-
ers.  Befide the fteam of warm water here recommended, externat applicatU
ons to the throat and fides of the neck have a confiderable effect in forward-
ing the fuppuration, as warm poultices, fomentations, &c.
  Vox.. J.                     R 
130
PRACTICE
cpryza which pours out a thin acrid and fetid matter, exco-
riating the noftrils and lips.  There is  often alfo efpecially
in infants, a frequent purging; and a thin'acrid matter flows
from the anus excoriating this and the neighboring parts.
   313. J With thefe fymptoms, the pyrexia proceeds with a
fmall, frequent, and irregular pulfe; and  there occurs a
manifeft exacerbation  every evening, and fome  r  miffion
in the mornings-  A great debility appears in the  animal
funaions ; and the fenforium is affeaed with delirium, fre-
quently  with coma.
   314.J On the fecond  day, or fometimes later, effloref-
cences appear upon the fkin, which are fometimes in fmall
points hardly eminent;  but, for the moft part, in patches
of red colour, fpreading and uniting fo as to cover the whole
fkin.  The) appear firft about the face  and neck, and  in
the courfe of fome days fpread by degrees to the lower ex-
tremities.  The fcarlet rednefs  is often confiderable on
the hands and extremities of the fingers, which feel ftiff
and  fwelled.  This eruption is  often irregular,  as  to the
time of its appearance,  as to its  fteadinef s, and as to the
time of its duration.   It ufually continues four days, and
goes off by fome defquamation of the cuticle ; but neither
on its appearance, nor on its  difquamation, does  it  always
produce a remiflion of the pyrexia, or of* the other fymptoms.
   315.] The progrefs of the difeafe depends on the ftate
of the fauces and of the pyrexia.   \\ nen the ulcers on the
fauces, by their livid and black colour, by the fetor of the
breath, and by many marks of acrimony in the fluids, fhow
a tendency to gangrene, this takes place to a confiderable de-
gree ; and the fymptoms of  a putrid fever conftantly in-
creafing, the patient dies, often on the third day, fometimes
later, but fV the moft part before the feventh. '  The acri-
mony poured out from the difeafed fauces muft ncceffari-
ly, in part, pafs into the pharynx,  and there fpread the in-
feaion  into the cefophagus, and  fometimes through the
whole of the alimentary'canal, propagating the putrefaai-
on, and ofignexhaufting the patient by a frequent diarrhoea.
   The dfrSjj matter poured out in the fauces  being again
abforbed^#equently occafions  large  fwellings of the lym-
phatic glands about the neck, and fometimes to fuch a de-
gree as to occafion fuffocation. 
0 F  P H Y S ft?.                 iVf
   It is feldom that the organs of refpiration efcape entire-
ly unhurt, and very often the inflammatory affeaion iscorir-
municated to them.   From diffeaions it appears, that, in
the Cynanche maligna the laryax.and trachea are often'a A
feaed  in the fame manner as"i4ttl4jpynanche tracheal!*;
and it  is probable,  that,  irwcoiMBMfe'of that  affeaion,
the Cynanche maligna oftcyi proTe!3al hy fuch a fudden
fuffocation as happens fyi the proper 6fnanche trachealis;
but there is reafon to-fu|pect, that upip^fthis fubjea diffec-
tors have not always'  diftin^tuifhefl'.jA'operly  between the
two difeafes.   ||, ■                 -
   316.] Tfiffc are fifec feveral'fatat terminations of the .C/n>
anche  maligna./and they do not always take place.  : Some- >
times  the ufelT4%f*lne\fauccsvare °f'a milder nature ; ana
the fever is mptkmbderate, as }wcjl as of a lefs putrid kind.
 And when, uapirme aajpearan^c of the effforefcence on the
fkin, the fever j£ufik&\i ren^ffion ; when  tile  efflorefeence
 continues for firce  or fouildays, till' ]tn$$''fpread over the
 whole body, aMJ|luk^$as by a defquamation, giving a
 further  remiffioirof* the fever ; this-often  entirely termi-
nates, by gentle fweats,  on or before the feventh day  ; and
the reft of the  difeafe terminates in a few days more, by an
excretion of Houghs from the fauces ; while fleep, appatitjifr
and the other marks of health  return.
   From what  is faid in this and the preceding paragfaph,
tlie prognostics in this difeafe may be readily learneQjjtj
    317.]  In the cure of this difeafe,  its feptic tendenqrfe
cheifly to  be  kept in view.   The debility,  with which it
is attended, renders all evacuations  by bleeding and purg-
ing improper,  except in a few  inflanccs where the debility
is lefs, and the inflammatory fymptoms more confiderable.
The fauces are to be prcferud from the effeas of the acrid
matter poured out upon them, and are therefore  to be fre-
quently waffled out by ami feptic  gargles * or injeaions;
  * When the violence of the iymptoms is moderate, and when the ulceration
is (light, fage tea, or tea made of role leaves, or both together, may be fuffi-
cient.   A gargle made of a pint of fage and rofe tea, three fpoonsful of vine-
gar, and one fpoonful of honey,  has been fuund as efficacious as any of the
fharpcr  autifeptics with the mineral acids.  Dr.  FothergilPs gargle is,
           R. Decoct, pectoral. 5xii. cui inter cocju.er.dura, addc
              Rad. contrayerv. contus. 3ss,
              Liquori coluto admisce,
             Actu viu. alb. iii. 
132
PRACTICE
andthefeptic tendency of the whole fyftem fhould be guard-
ed againft and corrected by internal antifeptics, efpecially
by the Peruvian bark given in fub fiance,  from the begin-
ning and  continued  through the courfe of the  difeafe.  *
Emetics, both  by vomiting and naufeating, prove ufeful,
efpecially when emplqQral early in the difeafe.   When any
confiderable  tumour "Juts,  blifters applied  externally

will be of fervice, ani, in any cafe, may  be fit to moderate

the internal  inflammation.t

               Tinct. myrrh,  %'u
               Mel. opt. 5vi.
But he often ufed it with a drachm of the  Mel Egyptiacum cUfiblved in two
ounces of it.
  The Mel Egyptiacum is a very harfh application, and ought to be cautious-
ly ufed.  If the Houghs caft off fo flowly as to require a powerful application,
it is better practice to touch them with Mel Egyptiacum by means of an arm-
ed probe,  than to ufe gargles of which it  is an .i.yf^^wt.  In this difeafe,
ftrict attention muft be giyen to the ufe of gargles avii mjl-'lipns for the tliroar,
becaufe the cure feems to depend in part on procuring a difcharge from the
glands cf the fauces which  thefe gargles induce, and alio becaufe they are
the only means of retarding the progrefs rjf the ulcers.
  * The quantity  of bark given ought to be very confiderable, viz. as much
as the ftomach and inteftines can poflibly bear.; half a drachm or two fcrupU-s
every hour, with a glafs of good Port wine.  A fcfiJpIe of confeftio cardiaca,
joined with each dofe of the bark, has a double effect of making the bark lefs
naufeous, and of preventing in fome meafure, a tendency to a diarrhoea, but
opium is afovereign remedy fcr removing  this fymptom when it  is actually
prefent.
  Mjfcdminiftering the bark, great care muft be taken  to avoid a diarrhoea,
which is a very dangerous fymptom in any period of the difeafe, but efpeci-
ally after the third or fourth day, when the patient is in a confiderable ftate
of debility.
  Children are more frequently attacked with this difeafe than adults ; and
it is fometimes extremely difficult to prevail on them to  take a fufficient quan-
tity cf this neceffary and valuable, though  naufeous medicine.  In thefe ca-
fes glyfters with powdered bark have been ufed with very great fuccefs. Two
drachms of the fine powder may  be given in five or fix ounces of barley-wa-
ter, every 3 or 4 hours to very young children, and half an ounce or 6 drachms
to children of 8 or  10 years old, in three quarters of a  pint of I iilej -water.
If the firft glyfter comes away too fpeedily, two or three grains cf opium may
be added to the fubfequent glyfters.
  t In addition to the method of cure here delivered, it may be proper to ob-
ferve, that as the cure depends much on the removal of every thing  putrid
frcm the patient, it is abfolutely  neceffary to have the room well ventilated,
but not with cold air.  The reafon for this precaution is, that the patient al-.
wavs^complains  of the  leaft admiffion of cold air, becoming fick and oppreff-
edfprobably in confequence of the fudden  difappearance of the efllorcfcence
which always accompanies the difeafe.  The linen ought  frequently  to be
Changed, the patient kept clean, the mouth  and throat frequently waflied, and
great plenty of liquid vegetable nutriment mutt be given, with generous wine.
  A hemorrage from the nofe, mouth, or ears, very frequently occurs  in the
later ftages of a malignant fore throat.  This difcharge is by no means criti-
cal, but always a dangerous fymptom,  and muft be flopped with  the  utmoft
expedition.  It is the confequence cf fome  arterial branch being corroded by
the mortification. If the hemorrhage withftands the ufual means of tents dip- 
OF  PHYSIC.
is*
                       Sect. III.

               Of the Cynanche Trackballs.
  318.] THIS* name has been given to an inflammation
of the glottis, larynx, or upper part of the trachea,  whe-
ther it affect the  membranes of thefe parts,  or the mufcles
adjoining.   It may arife firft in thefe  parts, and continue
to fubfift in them alone; or it  may come to affea  thefe
parts from  the Cynanche tonlillaris or maligna fprcading
into them.
   319.]  In either way it has been a rare occurrence, and
few inftances of it have been marked and recorded by phy-
ficians.   It is to be known by a peculiar ringing found of
the voice, by difficult refpiration, with a fe de of ftraiten-
ing about the larynx,  ahd by a pyrexia attending it.
   320. J  From the nature of thefe fymptoms, and from the
diflection of the  bodies of perfons who had died of this dif-
eafe, there is no doubt of its being of an inflammatory na-
ture.   It does not, however,  always run the courfe of  in-
flammatory affeaions, but frequently produces fuch an
obftruaion of the paffage  of the  air, as fuffocates,  and
thereby proves fuddenly fatal.
   321.J  If we judge rightly of the nature of this  difeaft^
it will be obvious, that the cure of it requires the moft pow-
erful remedies of inflammation, to be employed upon the
very firft appearance of the fymptoms.—When a fuffoca-
 tion is threatened,  whether any remedies can be employed
 to prevent it, we have not had experience to determine.
    32 2. J The accounts which books have hitherto given us
of  inffammation of  the larynx,  and the parts conneaed
 with it, amount to what we have now  faid; and the inftaa-
ces recorded have almoft all of them happened in adult
perfons; but there is a peculiar affection of this kind hap-
ped in vinegar, or a folution of alum, 8tc. recourfe muft be had to opium and
bark j and the Part wine muft be given fparingly.
  I;i the advanced ftages, a diarrhcea frequently  appears, efpeciallv in chil-
dren; it proceeds from the putrid and acrid matter of the ulcers being recei-
ved into the inteftines.  It can only be prevented, or effectually removed, by
a careful attention to keep the mouth as clean as poffible.
  * This difeafe has been fuppofed to be new, and confined chiefly to infants.
It is, however,  defcribed by many of both the ancient and modern  writers.
Boerhaave defcribes it in his 801ft and 8o2d Aphorifin. It is, indeed, uncom-
mon in adults, and moft frequent in infants.  It was never 1 i0!itly underftood,
however, till Dr. Home, the profeffor of the Materia Medha in this Univer-
fity, inveftigated its nature, and pointed out the only effectual method of cure. 
\Zi             «  PRACIRt
 pening efpecially to infants, which till lately has been little
 taken notice of.  Dr. Home is the firft who has given any
 diftina account of it; but, fince he wrote, feveral other
 authors have taken notice  of it, (fee Mien a e i. i s  De an-
 gina polyposa sive membranacea,  Argcntorati 1778) and
 have given different opinions with regard to it.   Concern-
ing this diverfity of opinions I  fhall not at prefent inquire;
 but fhall deliver the hiftory and cure  of this difeafe, in fo
 far as thefe  have  arifen from my own  obfervation, from
 that of  Dr. Home, and of other  fkilful  perfons in this,
 neighborhood.
   323.] This difeafe feldom attacks infants till after they
 have been weaned.  After this period, the younger drey
 are, the more they are liable to it. The frequency of it be-    ^
 comes lefs as children become  more advanced; and there
 are no inftances of children above twelve years of age being
 affeaed with it.   It attacks children of the midland coun-
 tries, as wTell as thofe who live near the lea.  It docs not ap-
 pear to be contagious, and its  attacks are frequently re-
 peated in the fame child. It is often manifeftly the effea of
 cold applied to the body;  and therefore appears  moft fre-
 quently in the winter and fpring feafons. It very common-
 ly comes on with the ordinary fymptoms of a catarrh; but
 fometimes the peculiar fymptoms of the difeafe fhow die in-
 felves at the very firft.
 *. 324.] Thefe peculiar  fymptoms are the following; A
 hoarfenefs, with fome fhrillnefs and ringing found, both in.
 fpeaking and in coughing, as if the noife came from a bra-
 zen tube. At the fame time, there  is a fenfe of pain about
 the larynx,  fome  difficulty of refpiration, with a whizzing
 found in infpiration, as if the paffage of the air was ftrait-
 ened.  The cough w hich attends it, is commonly dry; and
 if .rany thing be fpit up,  it is a matter  of purulent appear-
 ance, and fometimes films refembling portions of a mem-
 brane.  Together with thefe fymptoms, there is a frequen-
 cy of pulfe, a reftleffnefs, and an uneafy  fenfe of heat.
   When the internal fauces are viewed, they are fometimes
 without  any appearance of inflammation: but frequently
 a rednefs and even fwelling, appear ; and fometimes in the
 fauces there is an  appearance of matter like to that rejeaed   t
 by coughing.  With the  fymptoms now  defcribcd and'4* 
CfF PHYSIC.                135
particularly with great difficulty of breathing,  and a fenfe
of ftrangling in the fauces, the patient is fometimes fuddenly
taken off.
   325.] There  have been many diffeaions made of in-
fants who had died of this difeafe ; and almoft conftantly
there has appeared  a preternatural  membrane  lining  the
whole internal Surface of the upper part of the trachea,  and'
extending in the  fame manner downwards into fome of its
ramifications.  This preternatural membrane may be eafily
feparated, and fometimes has been found  feparated in part,
from die fubjacent proper membrane of the trachea. This
laft is commonly found entire, that is, without any  ap-
pearance of erofionor ulceration; but it frequently (hows
the vcftiges of inflammation, and is covered by a matter
refembling pus,  like to that  rejected  by coughing;  and
very often a matter of the fame kind is found in the bron-
enhe.  fometimes in confiderable quantity.
   326. J From the remote caufes of this  difeafe; from the
catarrhal fymptoms commonly attending it; from the  py-
rexia conftantly  prefent withit; from the fame kind of pre-
ternatural  membrane being found in the  trachea when the
cynanche maligna is communicated to it;  and, from lhe
veftiges of inflammation on the  trachea difcovered upon
diffection ; we muft conclude, that the difeafe confifts in
an inflammatory affeaion of the mucous membrane of the
larynx and trachea, producing an exudation analogous to
that found on  the furface of inflamed vifcera, and appear-
ing partly in a membranous cruft, and partly in a fluid re-
fembling pus.
   327.] Though this difeafe manifeftly confifts in an  in-
flammatory affection, it does not commonly end either in
fuppuration or gangrene.   The peculiar  and troublefomc
circumftances  of the difeafe feems to confift in a fpafm of
the mufcles of the glottis, which by inducing a fuffocation,
prevents the common confcquences of inflammation.
  328.j When this difeafe terminates in  health, it  is by a
refolution of an inflammation, by ceafing of the fpafm of
the glottis, by  an expeaoration of the matter exuding from
the trachea, and  of the crufts formed here ; and frequent-
ly it ends without any expeaoration, or at leaft with fuch
only as attends an_ordinary catarrh. 
   13$                  PRACTICE

      329.]  When the difeafe ends fatally, it is by a feffoca-
   tion ;  feemingly, as we have faid, depending upon a fpafm
*  affeaing  the glottis;  but fometimes, probably, depending
   upon a quantity of matter filling the bronchiae.
      330.]  As we fuppofe the difeafe to be an inflammatory
   affedion, fo we attempt to cure it by the ufual remedies of
   inflammation,  and which for the moft part  I have found
   effeaual.   Bleeding, both general  and topical,*  has often
   given immediate relief; and by being repeated, has entirely
   cured the difeafe.  Bliftering alfo,  near the part  affeaed,
   has been  found ufeful. Upon the firft attack of the difeafe,  .
   vomiting, immediately after bleeding, feems  to be of con-
   fiderable ufe, and fometimes fuddenly removes the difeafe.
   In every ftage of the difeafe, the antiphlogiftic regimen is
   neceffary,  and particularly the  frequent ufe of laxative
   glyfters.t  Though we fuppofe that a fpafm affeaing the   '
   glottis is  often  fatal in this difeafe, I have  not found antif-   1
   pafmodic medicines to be of any ufe.

                           Sect. IV.

                   Of the  Cynanche Pharyngcea.
      331.] IN the Cynanche tonfillatis,  the  inflammation of
    the mucous membrane often fprcadsupon the pharynx, and
    into the  beginning of the cefophagus, and thereby renders
    deglutition more difficult and uneafy : but fuch a cafe does
    not require to be diftinguifhed as  a different fpecies from
    the common Cynanche tonfillaris; and only requires that
    blood-letting and other remedies fhould be employed with

      * The topical bleeding is beft performed by leeches. Three or four may
    he applied  at once on each fide of the trachea, or on the trachea itfelf.  Not-
    ■withftanding this recommendation of topical bleeding, previous general bleed-
    ing is abfolutely neceffary in every cafe, and ought never to he omitted.  It
    frequently  produces relief even while the blood is flowing from  the vein; but
    in thefe cafes, it is imprudent to ftop the evacuation, even on the total removal
    ©f the fymptoms.  As much blood muft be drawn as the  infant can bear to
    lofe, and leeches ought moreover to be applied, as above directed ; for it fre-
    quently happens, that when all the fymptoms fuddenly difappear, the difeafe
    returns in  a few hours with redoubled violence, and fpeedily puts an end t«
    the child's life.                                               ^i.
      f Laxative glyfters are tobe carefully diftinguifhed from purging glyfters^jjB
    ■which generally irritate too violently, and thus increafe the inflammatory dWBH
    athefis. It is of little confequence what the compofitions of glyfters be, pro-^H
    vided they contain fome Glauber's or Epfom fait, and are fufficiently large.  *
    The common glyfter with milk and water, and a little Epfom fait, anfwersf
    fufficiently well. 
OF  P H Y S I C.                137
 greater diligence than in ordinary cafes.   We have never
 feci any cafe in which the inflammation began in the pha-
 rynx,  or in which this part alone was inflamed ; but prac-
 tical writers have taken notice of fuch a cafe ; and to them
 therefore,  I muft refer, both for the appearances which dif-
 tinguifh it, and for the method of cure.

                       Sect. V.

               Of the  Cynanche  Parotideza.
   332.] Tins is a difeafe known to the vulgar, and among
 them  has  got a peculiar appellation, in every country of
 Europe *  ; but has been little taken notice of by medical
 writers.  It is  often epidemic,  and manfeftly contagious.
 It comes on with the ufual fymptoms of pyrexia, which is
 foon after attended with a confiderable tumour of the ex-
 ternal  fauces  and neck.—This  tumour appears firft as a
 glandular moveable tumour at the corner of the lower jaw  ;
 but the fwelling foon  becomes uniformly  diffufed over a
 great  part of  the neck, fometimes on one fide only, but
 more  commonly on both.   The fwelling continues to in-
 creafe till  the fourth day ;^ut from that period it declines,
 and iii a few days more panes off entirely.   As the fwclliiw,
 of the  fauces recedes, fome  tumour  affects the  tefticlcs in
 the male fex, or the brcafts in the female.   Thefe tumours
 are fometimes large, hard,  and fomewhat painful; but in
 this climate are feldom either very painful or of long con
 tinuance.  The pyrexia attending this difeafe is common-
 ly flight, and recedes with the fwelling of the  fauces ;  but
 fometimes, when the fwelling of the telticles does not fuc-
 cced to that of the fauces, or when the other has been fud-
 denly  repreffed, the pyrexia, becomes more confiderable,
 is often attended with delirium, and has fometimes proved
 fatal.
   333.] As this difeafe commonly runs its courfe without
 either  dangerous ortroublefome  fymptoms, foit hardly re-
 quires  any  remedies.   An antiphlogiftic regimen and avoid-
 ing cold, arc all that  will  be commonly  neceffary.  But
 when,  upon the receding of the  fwelling of the telticles in
 males, of of the brcafts in females, the pyrexia comes to be
* * It is called here, and in many parts »f Great-Britain, the Mii:!"(>
   Vol. 1.                    S 
133                PRACTIC i:

confiderable, and threatens an affeaion of the brain, it will
be proper, by  warm fomentations, to bring back the fwel-
ling ;  and by vomiting, bleeding, or bliftering, to obviate
the confequences of itsabfence.
                     CHAP.  VI.

 flDf Pneumonia, or Pneumonic inflammation.

334-]  UNDER  this title I  mean to comprehend the
whole of the inflammations affeaing either the vifcera of
the thorax, or the membrane lining the interior furface of
that cavity : for neither do  our  diagnostics ferve to  afeer-
tain exaaiy the feat of the difeafe ; nor does the difference
in the feat of the difeafe exhibit any confiderable variation
in the ftate of the fymptons, nor lead to any difference in
the method of cure.
   335.] Pneumonic inflammation, however various in its
feat, feems to me to be always known and diftinguifhed by "* J
the followingfymptoms: pyrexia, difficult breathing, cough
and pain in fome parts of  the thorax.   But thefe  fymp-
toms are,  on different occasion^ varioufly modified.
   336.] The difeafe almoft always comes on with  a  cold
ftage, and is accompanied with  ether fymptoms of pyrex-
ia ; though, in a few inftanccs, the  pulfe may not be more
frequent, nor the heat of the body increafed bevond what
is natural.-  Sometimes the pyrexia is  from the beginning
accompanied with the  other fymptoms ; but frequently it
is formed  for fome hours  before the  other  fymptoms be-
come confiderable,  and particularly before the pain be felt.
For the moft part, the pulfe is frequent,* full, ftrong, hard,
and quick ;t  but in  a few inftances, efpecially in the advan-
ced ftate of the difeafe, the pulfe is weak and foft,  and at
the fame time irregular.
   337.] The difficulty -of breathing is always prefent, and
tnoft confiderable in infpiration; both becaufe the lungs do
  *  A frequent pulfe is when there is a great number of ftrokes in a given  ^B
time.                                                    J|
  f A quick pulfe is when the ftrokc itfelf is quick, although the number in   5
a given time be not very great.  It  is therefore no tautology to mention both  V
frequent and quick, as  they are really diftincl, and may be both^refent at  %
once ; but, if the pulfe be above an hundred in a minute, the phyfician muft   *
•have a very nice fenfe of feeling to diftinguiih between a quick and a flo-w
beat. 
OF  PHYSIC.                139
 not eafil) admit of a full  dilatation, and becaufe the dila-
 tation aggravates the pain attending the  difeafe.   The
 difficulty of breathing is alfo greater when the patient is in
 one pofture of his body rather than another.   It is generally
 greater when he lies upon the  fide affected; but fometimes
 the  contrary happens.  Very often the patient cannot lie
 eafy upon either fide, finding  cafe only vhen lying on his
 back; and fometimes he cannot breathe eafily, except when
 in fomewhat of an erea pofture.
   338. ] A cough always attends this difeafe; but in differ-
 ent cafes, is more or  lefs urgent and painful.   It is fome-
 times dey, that is without any expeaoration, efpecially in
 the beginning of the difeafe : but  more commonly it i:g even
 from the firft, moift, and the matter fpit up various both in
 conhftence and colour; and frequently it is ftreaked with
 blood.*
   339-J The pain attending this  difeafe, is in different cafes,
 felt in different parts of the thorax, but moft frequently in
 one  fide.   It  has.been faid to  affea  the right fide more
 frequently than the left; but this" is not  certain ; while on
 the other hand, it is certain that the left lias been very often
 affeaed.  Tire pain is felt  fometimes as if it were under the
 fternum ;  fometimes in the back between the fhoulders ;
 and when in the fides, its place  has been  higher or lower,.
 more forward or backward :  but the place of all others
 moft frequently affeaed,  is about the fixth or feventh rib,
 near the middle of its length, or a little  more forward.  The
 pain is often f'evere and pungent;, but fometimes more dull
 and  obtufe, with a fenfe of weight rather than of pain.  It
 is moft efpecially fevere and pungent when occupying the
 place  laft mentioned.   For the  moft part it continues fix-
 ed in one place ; but fometimes fhoots from the fide to the
 fcapula on one hand, or to the fternum and clavicle on the
 other.
   340.] The  varying ftate of fymptoms now  mentioned
docs not always a {'certain precifely the  feat of the  difeafe:*
To me it feems prohable, that the difeafe is always feated,
ar at leaft  begins, in fome part  of the  pleura ;  taking that
  * Young pradlitioners fliould not be alarmed at this fymptom; nor  fliould
they fuppofe it a dangerous one :  it is  on the contrary a falutary fymptom,
and ought not to be rcftrained, c itlier by too rigorous an adherence to tha Jin*
tiphlogiftic regimen, sr by ihe ufe of ftvptics au.i c-tlv;r aftringeuts. 
 140                PRACTICE

membrane in its greateft extent, as now commonly under-
stood ;  that is, as covering not only the internal luvfacc ot
the cavity of the thorax, but alfo as forming the mediafti-
num, and as extended over the pericardium, and over the
whole furface of the lungs.
   341.] There  is, therefore, little foundation for diftin-
guilhing this difeafe by different  appellations taken from
the part which may be fuppofed to be chcifly affected.  The
term  Plcurify, might v/ith propriety be applied to every cafe
 of the difeafe ; and has been very improperly limited to
that inflammation which begins in, and cheifiy affects the
pleura costalis.   I have no doubt that fuch a cafe does truly
 occur : but, at the fame time, I apprehend it to be a rare
 occurrence; and that  the difeafe much  more frequently
 begins in, and chiefly affc&s, the pleura inventing the lungs,
 producing all the fymptoms fuppofed to  belong to  what
 has been called the Pleuritis vera.
   342.] Some phyficians have imagined, that there is a cafe
 of pneumonic inflammation  particularly  entitled to the
 apellation  of Peripneumony ; and that is, the cafe  of an
 inflammation beginning in the parenchyma or cellular tex-
 ture of the lungs,  and having its feat chiefly there.   But
 it feems to me very doubtful, if any acute  inflammation of
 the lungs or any difeafe which has been called Peripneumony
 be of that kind.   It feems probable, that every acute in-
 flammation  begins in  membranous  parts;  and, in  every
 diffie£tion of perfons dead of peripneumony, the external
 membrane  of the lungs, or  fome part of the  pleura, has
 appeared to have been confidcrably affeaed-
    343.] An inflammation ofthe pleura covering the upper
 furface of the diaphragm, has been  diftinguifhed  by the
 appellation of Paraphrenias, as fuppofed to  be attended
 with the peculiar fymptoms of delirium, rilus fardonicus,
 and  other convulfive motions: but  it is  certain, that an
 inflammation of that portion of the pleura, -and affecting
'•alfo even the mufcular fubftance ofthe diaphragm, has of-
 ten taken place  without any of thefe fymptoms; and I have
 not met with either diffedions, or any accounts of di flections,
 which  fupport the opinion, that an inflammation of the pleu-
 ra covering the diaphragm, is attended with delirium more
 commonly than any other pneumonic inflammation. 
or  PHYSIC  :               141
   3 4 4. J  With refpea to the feat of pneumonic inflamma-
tion, I muft obferve further, that although it may arife and
fubfiit chiefly in one part of the pleura onlv. it is however
frequently communicated to other, parts ofthe fame, and
commonly communicates a morbid  affeaion through  its
whole extent,
   345.J  The remote caufe of pneumonic inflammation, is
commonly cold applied to the. body,  obftructing perfpira-
tion, and  determining to the lungs ;  while at the fame time
the lungs  themfelvcs arc expofed to the aaion of the cold.
Thefe circumftances operate efpecially, when an inflamma-
tory diathefis prevails i \  the  fyftem ;  and,  confequently,
upon perfons of the greater! vigor; in cold climates; in the
winter feafon ; and particularly in the fpring, when vicifli-
tudes of heat and cold are frequent. The difeafe, however,
may arife in any feafon when fuch viciflitudes occur.
   Oihcr  remote caufes alfo may have a  fhare in this mat-
ter ; fuch as  every means of obllruaing, {training,* or o-
therwife injuring,t the pneumonic organs.
   Pneumonic inflammation may happen to perfons of any
age. but rarely to thofe under the age of puberty:  and moll
commonly it affeas perfons fomewhat advanced in life, as
thofe between forty-five and fixty years ; thofe two, efpe-
cially of a robuft aiid full habit.
   The pneumonic inflammation has been fometimes  £0
much  an  epidemic, as to occafion a fufpicion of its depend-
ing upon a {'pacific contagion ; but I have  not met  with
any evidence in proof of this.—See Morgagni  de can sis
et sedibus  morborum, epift. xxi. art.  26.
   346. J  The pneumonic,  like other inflammations,  may
terminate by refolution, fuppuration,  or gangrene; but it
has alfo a termination peculiar to itfelf, as has been hinted
above (259J ; a:id  that is, when it is attended with an effu-
fion of blood into the cellular texture of the lungs, which
foon interrupting the circulation of the blood through this
vifeus, produced a fatal fu [location.   This, indeed, feems
  * Violent excraons, in  fpeaking, finging, playing on wind inftruments, ruu-
ni'i',- up hill,  or in fliort any exercifs that iuci-eafes the action of the lungs.
  f Receiving nnxious vapors into the lungs is fometimes the caufe ot pneu-
monic inflammation ; efpecially coiTiiive qp other acrid poifonous vapors, as
the fumes of ari'enic, of  fulphur, ofthe muriatic acid, and iimilar cauilic and
definitive exhalations. Chemiiis,  th.-ref(;re,  in making experiments, or. ar-
tifts who work on fubftances yielding inch vapors, ihoi.kl be careful io avoid
thni. 
142
PRACTICE
to be the moft common termination of pneumonic inflam-
mation, When it ends fatally ; for, upon the diffeBion of al-
moft every perf6n dead of the difeafe, it has appeared that
fuch an effufion had happened.
   347.] From thefe diffeaions alfo we learn, that pneumo-
nic inflammation commonly produces an exudation from
the internal furface of the pleura; which appears  partly as
a foftvifcid cruft, often of a compaa, membranous form
covering every where the furface of the pleura, and parti-
culary thofe parts where the lungs adhere to the pleura cof-
talis, or mediaftinum ; and this cruft feems always to be
the cement of fuch adhefions.
   The fame exudation fhows itfelf, alfo, by a quantity of
a ferous whitifh fluid, commonly found i:r the cavity ofthe
thorax; and fome  exudation or effufion  is  ufuallv found
to have been made likewife into the  cavity  of the pericar-
dium.
   348.] It feems probable, too, that a like effufion is fome-
times made into the cavity of the bronchiae : for, in fome
perfons who have died after labouring under a pneumonic
inflammation for a few days only, the bronchiae have been
found  filled with a confiderable quantity of a ferous and
thickifh fluid; which, I think, muft be confidered rather
as the effufion  mentioned, having had its thinner parts tak-
en off by refpiration, than as a pus fo fuddenly formed in
the inflamed part.
   349.] It is, however, not improbable, that this effufion,
as well as  that made into the cavities ofthe thorax and pe-
ricardium, may be a matter of the  lame kind with that
which, in  other inflammations is poured into the cellular
texture of the parts inflamed, and there converted into pus :
but, in the thorax  and pericardium, it does not always af-
fume that  appearance, becaufe the cruft covering the fur-
face prevents the abforption of the the thinner part.  This
abforption, however, may be compenfated in the bronchiae
by the drying power of the air ; and therefore the effufion
into them may put on a more perulent appearance.
   In many cafes of pneumonic inllammation, when the
Sputa are very copious, it is difficult to fuppofe that the
whole of them proceed from the mucus follicles ofthe bron-
chiae.  It feems  more probable that a great part of them 
OF  PHYSI C.               US
may proceed from the effufed ferous fluid we have been
mentioning ; and this too will account for*thc fputa beiiig
fo often of a pcrulent appearance.  Perhaps the fame thing
may account for  that pcrulent  expeaoration^ as well as
that pcrulent matter found in the bronchiae, which the learn-
ed Mr. de Hacn fays he had often obferved, when there
was no ulceration ofthe lungs: and this explanation is at
leaft more probable than Mr. de  Haen's  fuppofition of a
pus formed in the circulating blood.
   350.] To conclude this fubjett, it would appear, that
the effufion into the bronchiae which we have mentioned,
often occurs with the effufion of red blood in occafiomeg
the fuffocation, which fatally terminates pneumonic inflam-
mation ; that the effufion of ferum alone may have this ef-
fea; and that the ferum poured out in a certain quantity,
rather than any debility in the powers of ?xpecloration,  is
the caufe of that ceafing of expeaoration which very con-
flantiy pre^edej the fatal event.    For, in  many cafes, the
expectoration  has ceafed, when no other fymptoms of de-
bility have appeared,  and when  upon diffenion, the bron-
chiae have been found full of liquid matter.   Nay, it is
even probable, that  in fome cafes, fuch an effufion may
take place, without any fymptoms of violent inflamma-
tion ; and in other cafes,  the effufion taking place, may
feem to remove the fymptoms of inflammation which had
appeared before,  and thus account for thofe unexpeaed
fatal terminations which have fometimes happened.  Poffi-
 bly this effufion may  account alfo for many of the pheno-
mena of the Peripneumonia Notha.
   351.]  Pneumonic  inflammation feldom terminates by
refolution, without being attended with fome evident eva-
 cuation.   An haemorrhagy from the nbfe  happening upon
fome of the firft days ofthe difeafe, has fometimes put an
end to it; and it is  faid that an evacuation from the hemor-
rhoidal veins,  a bilious evacuation by ftool, and an evacu-
ation of urine  with a copious fediment, have feverally had
the fame effea : but fuch occurrences have been rare and
unufual.
   The evacuation moft frequently attending, and feeming
to have the greateft effett in promoting refolution, is an
expeaoration  of a thick, white, oryellowifh  matter, a little 
H4r                P R A C 1 l t: L
 ftreaked with blood, copious, and brought up  without
 either much or violent couohin?".
   Very frequently the refolution of this difeafe is attended
 with, and perhaps produced  by a  fweat,  which is warm,
 fluid, copious over the whole body, and attended with an
 abatement of the frequency of the pulfe, ofthe heat ofthe
 body, and ofthe other febrile fympioms.
   352.] The prognostics in  this difeafe are formed from
 obferving the ftate of the principal fymptoms.
   A violent pyrexia is always dangerous.
   The danger, however, is chiefly  denoted by the difficul-
 ty of breathing. When the patient can lie on one fide on-
 ly ;  when he can lie on  neither fide, but upon his back on-
 ly ; when he cannot breathe  with  tolerable cafe, except
 the trunk of his body be ereCt; when even in this pofture
 the breathing is very  difficult, and  attended with a turgef-
 cence and flufhing of the face, together with partial fweats
 about the head and  neck,  and an irregular pulfe :  thefe
 circumftances mark the difficulty of breathing in progreff-
 ive degrees, and confequently, in proportion, the danger
 ofthe difeafe.
   A frequent violent cough aggravating the pain, is always
 the fymptom of an obftinate difeafe.
   As I apprehend that the difeafe is hardly ever rcfolvcd,
 without fome expeaoration ; fo a dry cough muft be al-
 ways an unfavorable fymptom.
   As the expectoration formerly defcribed, marks that the
 difeafe is proceeding to a refolution ; fo an expectoration
 which has not the conditions there  mentioned, muft denote
 at leaft a doubtful ftate of the difeafe ;  but the marks taken
 from the colour ofthe matter  are for  the moft part  falla-
 cious.
  An acute pain, very much interrupting infpiration is al-
 ways the mark of a violent difeafe;  though not of one more
dangerous, than an obtufe pain, attended with very diffi-
cult refpiration.
  When the pains, which at firft had affeaed one fide only,
have afterwards fpread into the other ;  or when leaving the
fide firft affeaed,  they entirely pafs into the other : thefe
are always marks of an increafing, and therefore of a dan-
gerous difeafe. 
Or:  P H Y SIC.                   US
   A deliiium coming on during a pneumonic  inflammati-
on, is conftantly a fymptom denoting much danger.
   353-J When the termination of this difeafe proves fatal,
it is on one or other of the days ofthe firft week, from the
third to  the fevcnth.   This is the moft common cafe ;  but,
i:i a few inftanccs, death has happened at a later period of
the difeafe.
   When the difeafe is violent,  but admitting of refolution,
this alfo happens frequently in the courfe of the firft week;
but,  in a more moderate ftate ofthe difeafe, the refolution
is often delayed to the fecond week.
   The  difeafe, on  fome of the days from the  third to the
feventh, generally  fuffers a  remiffion ;  which, however,
may  be often fallacious, as the  difeafe does fometimes re-
turn  again with  as much violence as  before, and then with
great danger.
   Sometimes the difeafe difappears  on the fecond or third
day, while an.eryfipelas makes  its appearance on fome ex-
ternal part : and if this continue fixed,  the pneumonic in-
flammation does not recur.
   354-J Pneumonia, like  other inflammations, often ends
in fuppuration  or gangrene.*
   355. J When a pneumonia, with fymptoms neither very
violent nor very flight, have continued for many days, it is
to be feared it will end in a  fuppuration.   This, however,
is not to be determined precifcly by the number of days:
for, not only after  the fourth, but even after the tenth day,
   * As this termination of Pneumonia is always fatal, it is highly" neceffary
that the phyfician (hould be able to knew when  a gangrene is to be fufpeaed,
that lie may take the proper means for preventing it:  or, when it is abfolute*
ly formed, that he may favc his reputation, by informing the patient's relati-
ons of the impending danger, and the fatal confcquences with which fuch a
termination is attended : I fhall therefore add fome of the moft remarkable
diagnoftics of an incipient gangrene in  this difeafe.  A  purulent fpitting,
ftreakedwith deep colored blood, or wiA a blackiih matter; a fetid breath ;
a rattling  in the throat; a dejected conwenance ; a dim eye ; a languid quick
pulfe ; the blood drawn from a vein  void of the inflammatory cruft; fetid
green ftools in abundance ; urine of a bright flame color, or depofiting a black
fediment of a fcaly appearance. More  fymptoms of this fatal termination
are unneceffary ; for, if moft of the above mentioned be prefent, the phyfician
has no other duty to  perform than warn the friends of the patient that death
may Ije foon expected.  It may be farther remarked, that when a gangrene is
begun, the patient is  confiderably freed from pain, and both himfelf and his
attendants have great hopes of his recovering ;  a few hours, however, foon
undecieves them, and raifes the reputation of the phyfician, who has pro-
nounced, a true prognofis.  See fome other diagnoftics of gangrene $1 the
notes on article 359.
   Vol. I.                      T 
146                 T R A C T I C £

there have been examples of a pneumonia ending by a re-
folution ; and if the difeafe has  fuffered fome intermiffion
and again recurred, there may be in fiances of a refolution
happening at a much  later period  from the beginning  of
the difeafe, than that juft now mentioned.
   356.] But if a moderate difeafe, in fpite of proper re-
medics employed, be protraaed  to the fourteenth day with-
out any confiderable remiflion, a fuppuration is pretty cer-
tainly to be expcaed  ; and it will  be ftill more certain, if
no figns of refolution  have appeared, or if an expectorati-
on which had appeared fhall have again ceafed, and the dif-
ficulty of breathing has continued or  increafed, \\ bile the
other fymptoms have  rather abated.
   357.J That in a pneumonia, the effufion is made, which
may  lay the foundation of  a  fuppuration, we conclude
from the difficulty of breathing becoming greater when the
patient is in  a horizontal pofture,* or when he can lie more
eafily upon the affeaed fide.
   358.J That in fuch cafes, a fuppuration has aft-uaHy be-
gun,  may be concluded from the patient's be in 3 frequently
affeaed with flight cold fhiveiings, and v. ith a fenfe of cold
fometimes in one,  and  fometimes in another part of the
body. We form the fame conclufion alfo from the Rate of
the pulfe,  which is commonly lefs  frequent and lbftcr, but
fometimes quicker and fuller than before.
   359.] That a  fuppuration is already formed,  mav  he
inferred from there being a confiderable remiflion r of the   ,
pain  which   had before fubfifted, while along  with this,   1
the cough, and efpecially the dyfpnoca, continue, and arc
rather augmented.  At the fame time, the frequency of the
pulfe is rather increafed ; J the  feverifh ftate fuffers consi-
derable exacerbations  every  evening, and bv degrees, a
heaic in all its circumftancfKs comes to be formed.
   * In all pneumonic affections, the breathing is generally mere difficult when
 the patient lies  in an horizontal pofture,  it cannot therefore be admitted as ^
 diagnoitic of an effufion.
   f The young phyfician muft be on his guaid with refptft to this fymptom:-  I
 for it is alfo a fvmptcm of an incipient,  or an already formed gangrene: he
 ought therefore to be peculiarly attentive to the concomitant Iymptoms v. hie a  j
the author enumerates, viz. the continuance or augmentation oT the d'nT.cul'y J
 of breathing and the cough, both of which cither totally difr.ppcar, crate m
 confiderably leffened on the fupervention of gangrene.                  ™
   \ The-increafed frequency cf the pulfe is alfo a fymptcra cf a rar.frene be-
 ii'ii formed, but if that increafed frequency he attended with febrile esae'erba- 
of  physic.                nr
   300.]  The termination of  Pneumonia by gangrene, is
much more rare than has been,  imagined ;  and when it does
occur, it is ufually joined with the termination by effufion
(346.) and the fymptoms ofthe one  arc hardly to be dif-
tinguilhed from thofe of the o.her.
   361.]  The cure of pneumonic inflammation, muft pro-
ceed upon the general plan (264.) but the importance of
the part affeaed, and the danger to which  it is expofed, re-
quire that the remedies be fully, as well as early employed.
   362.] The remedy chiefly to he depended upon, is that
of bleeding at the arm ;  which will be performed with mo ft
advantage in the arm of the fide moft affeaed, but mav be
done in either arm, as may be moft  convenient for the pa-
tient or the furgeon.  The quantity drawn muft be fuited
to the violence of the difeafe, and to the vigour of the pa-
tient ; and generally ought tobe as large as this laft circum-
ftance will allow.  The rcmiffion of pain, and the relief of
refpiration, during the flowing ofthe  blood, may limit the
quantity to be then c|rawn ;  but  if thefe fymptoms of relief
do not appear, the  bleeding fhould be continued  till the
fymptoms of a beginning fyncope come on.  It is feldom
that one bleeding however large, will prove a cure of this
difeafe; and although the pain and  difficulty of breathing
may  be  much relieved  by the firft bleeding, thefe fjmp-
toms commonly, and after no long  interval,  recur, often
with as much violence as before.   In the event o^fuch re- "
currence the bleeding is  to be  repeated, even in the 'courfe
of the fame day,  and perhaps  to  the fame  quantity as
before.
   Sometimes the fecond bleeding may be larger than the
firft.   There are pei fens who, by their conftitution, are
ready  to fei it even upon a  fmall bleeding; and in  fuch
perfons this may prevent the drawing  fo much  blood at
firft as a pneumonic inflammation might require ; but, as
the fame perfons are frequently found to bear after-bfeed-
ings better than the firft, this allows the fecond  and fubfe-
cjucnt bleedings to be laigeiv and to fuch a quantity as the
fymptoms ofthe difeafe may feern to demand.
   363. J  It is according to the ftate ofthe fymptoms,  that

tions ift the evenings, then, and then-only can tho. phyfician be fure that th«
dilcafs '..as •.ermiuaii.i in fuppuration, and .:i£ in cftngrenc. 
148                  PRACTICE
bleedings are to be repeated; and they will be more effec-
tual when praaifed in the courfe of the firft three days, than
afterwards;  but they are not to be omitted, although four
days may have already clapfed.   If the phyfician fhall not
have  been called in fooner; or if the bleedings praaifed
during the firft days fhall  not have been  large enough, or
even  although thefe bleedings fhall have procured fome re-
miflion ;  yet upon the recurrence of the urgent  fymptoms,
the bleeding  fhould be repeated  at  any period of the dii-
cafe,  efpecially within the firft fortnight ; and  even after-
wards, if a tendency  to  fuppuration be not  evident, or if,
after a feeming folution, the difeafe fhall have again returned.
   364. J With refpea to the quantity of b'lood which ought,
or which with fafety may be taken  away, no general rules
can be delivered,  as it muft be very different,  according
to the ftate of the  difeafe and  conftitution of the  patient.
   In an adult male of tolerable ftrength, a pound of blood,
avoirdupois, is a full bleeding.  Any quantity abo ve twen-
ty ounces, is a large, and any quantity below twelve a fmall
bleeding.   A quantity of from four to  five pounds, in the
courfe of two or three  days, is generally  as much  as fuch
patients will fafely bear;  but, if the intervals between  the
bleedings and the whole of the time during which the bleed-
ings  have been employed have  been long,  the quantity
taken upon the whole may be greater.*
   365. J  When a large quantity of blood has been  ahcady
taken from the arm, and  when it is doubtful  if more  can
with  fafety  be drawn in that manner, fome blood may  ftill
be  taken by cupping and fcarifying.  Such a meafure will
be  more particularly proper, when the continuance or
  *  Bleedings produce the bell effect, when  the blood is drawn off as quicl.ly
as poffible in a large full ftream : and in order to prevent fyncope, the patient
ought to be laid horizontally, or even with his head low* r than his trunk.
  With refpecl; to the quantity of blood to be drawn at once,  or in the whole
courfe 6f the difeafe, no general directions  can be given : it muft depend en-
tirely on the circumftances of the difeafe and the patient. In general, it is ufual
to continue the difcharge until the patient can  either breathe more freely,  or
feels a  confiderable abatement of the pain.  If, however,  th? pain does not
abate while the blood continues to flow, but figns of fainting appear, the blood
muft then be-immediately {topped.  If the pain and other fymptoms continue
violent, or return after the firft bleeding, it will then  be neceffary to have re-
courfe to the operation : and it muft be repeated frequently through  the courfe
nf the  difeafe : avoiding, however, fo large an evacuation at  once as may in-
duce fainting.  The reafon of this precaution is evident, viz. that while the
motion of the heart is fufp£nded  during fainting, the bleed Magnate* in the
right fide of the heart, a*d jjpaftenvavds  thrown with greuicr impetucfity
through the lungs.    * *\fcj|^^.                       it 
O F  P H Y S I C.                149
   recurrence of pain, rather than the difficulty of breathing,
   becomes  the urgent fymptom;  and then the cupping and
   fcarifying fhould be made as near to the pained part as can
   conveniently be done.
      366.] An expeaoration takes place fometimes very early
   in  this  difeafe; but if, notwithflanding that,  the  urgent
   fymptoms fhould ftill continue, the expeaoration muft not
   fuperfede the bleedings  mentioned;  and during the firft
v  days of the difeafe, its folution is not to be trufted to the
   expeaoration alone.   It is in a more advanced ftage only,
   when the  proper remedies have been before employed, and
   when the  fymptoms have fuffered a confiderable remiflion,
   that the entire cure may  be trufted to a copious and free
   expe6toration.
      367.J  During the firft days of the difeafe,  I  have not
   found that bleeding (tops expeaoration.   On the contrary,
   I have often obferved bleeding promote it; and it is in a
   more advanced  ftage of the difeafe only when  the patient,
   by large evacuation and the continuance of the difeafe, has
   been already exhaufted,  that bleeding feems to  flop expec-
   toration.   It appears  to me, that even then bleeding does
   not ftop expeaoration fo much by weakening the powers
   of expectoration, as by favouring the ferous effufion into
   the bronchiae, (348) and thereby preventing it.
      368. J  While the bleedings we have mentioned fhall  be
   employed,  it will  be neceffary to employ alfo every part
   of the antiphlogiftic regimen, (130—132) and  particularly
   to prevent the irritation which might arife from any increafe
   of heat.  For this purpofe, it will be proper  to keep the
   patient out of bed, while he can bear it eafily ; and when
   he cannot, to cover him very lightly  while he  lies in bed.
    The temperature of his chamber ought not to exceed fixty
   degrees of Farenheit's thermometer ;  and whether it  may
   be at any time colder, I am uncertain.
       369. j  Mild and diluent drinks, moderately tepid, at leaft
    never cold, given by fmall portions at a time,  ought to  be
   adminiftered plentifully.  Thefe drinks may be impregnated
   with vegetable  acids.* They  may be properly accompani-
   ed alio with nitre, or fome other neutrals;? but thefe falts
   fhould be given feparately from the drinks.J
     * See the Note on Art. 131. aci>U.   f See the Note on Art. 160.
     J Thefe falls generally render the drink naufeous : and as plentiful diluti- 
150                  PRACTICE
   It has  been alledged, that both acids and nine arc ready
to excite coughing, and in fome perfons they certainly have
this effect; but except in perfons of a peculiar habit, I have
not found their effects  in exciting coue,h lb confiderable or
troublefeme as to prevent our fee king the advantages other-
wife to be obtained from thefe medicines.
   37°-J  Some praaitioners have  doubted,  if purgatives
can be fafety employed in this difeafe;  and indeed a fpon-
taneous  diarrhoea occurring in the beginning  of the  dif-
eafe has feldom proved ufeful:  but I have found the mo-
derate ufe of cooling  laxatives* generally fafe, and have
always found it ufeful  to keep the  belly open by frequent
emollient glyfters.
   371.]  To excite full vomiting by emetics, I judge to
be a dangerous praaice in this difeafe :  but I have found
it  ufeful to .exhibit naufeating dofes ; and in a  fomewhat
advanced ftate ofthe difeafe, I have found fuch dofes prove
the belt means of promoting expeaoration.t
   372.]  Fomentations and poultices applied to the pain-
ed part have been recommended, and may be ufeful;  but
the application of them is often inconvenient, and may be
enthcly omitted for the fake of the more effectual remedy,
bliftering.J
   Very early in the  difeafe, a blifter  fhould  be applied as
near the pained part as poffible.   But as, when the irrita-
tion of a  blifter is prefent, it renders  bleeding lefs effettu-
al; fo the application  of the blifter fhould be delayed till
on is abfelutely neceffary in thefe cafCs, fo far from rendering the patient's
common dri.ik naufeous, by impregnating it with ill flavored medicines, wc
ooghr by every poffible means, to endeavor to make it as agreeable as we can,
that he may be the more eafily prevailed on to take it plentifully.
  * The cooling laxaiives are, falts, manna, See. but in thefe cafes, 3 or 4
ounces of infufum femise, wiih half aa ounce of Glauber's fait may be given
with*«t danger-
 * f The tartar emet;c is the  medicine generally  employed for this- purpofe.
The dofe of it in thefe cafes, mull Le very fmall, and well diluted,  ab in. the
following formula :
           R. Antlmon.  tartar'. ;at, gr ii.
              Aq. font. 5viis.:.
              Svr. papa\eris rubr. §ss.
              M.
  The dofe  of this mixture ought not to exceed three  table-fpoonsful, when
jivc.i with this intention.
  $ The application of a blifter to the part affeded, ought to be the firft pre-
fcription in  all complaints  of the thorax,  e :cc;.: fome'remarkable or urcnt
caufe forbid the praaice, becaufC it is a moil  ^cud -U; remedy a-.d is as\u-
ceffary as bleeding..'   •• 
0 F  P II.Y SIC.                  151
a bleeding fhall  have been employed.   If the difeafe Le
moderate, the blifter may be applied immediately after the
firft bleeding; but if the difeafe be violent, and it is prefum-
ed  that a fecond bleeding may be neceffary foon after the
firft, it will then be proper to delay the firft blifter till alter
the fecond bleeding, when it may be fuppofed that any fur-
ther bleeding may be  poftponed till the irritation arifing
from the blifter fhall have ceafed.   It may be frequently
neceffary in this difeafe to repeat the bliftering: and in that
 cafe the plaifters fhould always be applied fomewhere  on
 the thorax ; * for, when applied to more diftant parts, they
 have little effea.   The keeping the bliftered parts open,
 and making what is called a perpetual blifter,  has much
 lefs effea than a frefh bliftering.
    373.] As this difeafe often terminates by an expeaora-
 tion, fo various means of promoting this have been propo-
 fed :  but none  of them appear to be very cffeaual; and
 fome of them being acrid ftimulant fubftances, cannot be
 very  fafe.
    The gums ufually  employed feem too heating :  fquills
 feem to be lefs fo; but they are not very powerful, and
 fometimes inconvenient by the conftant naufea they induce, t
    The volatile alkali may be of ferviceas an expeaorant;
 but it fliould be referved for an advanced ftate of thedifeafe.
    Mucilaginous  and oily demulcents appear to be ufeful,
 by allaying  that acrimony of the  mucus which  becafions
 too frequent coughing ;  and which coughing prevents the
 ftagnation and thickening of the mucus, and thereby its be-
 coming mild.
    The receiving into the lungs the fleams of warm  water

    v They ought, however, to be  applied 2s near to the pained part as poffible.
    t All the liquid forms of fquills which we have in the fliops arenaufeadu;.;.
 Pills made ofthe dry powder, with an ele&uary or conferve, or honey, is the
 form in which fquills affea  the ftomach leaft.  The dofe is 4 or 5 grains  of
 ihe dry powder: 10 grains generally, if not conftantly produce vomitings. To
 prevent the naufeating effeas of fquills, the addition cf fome grateful aroma-
 tic is of material ufe.  The pilulx lilitierc of the Edinburgh Pharmacopoeia
 is a good formula, except that the dofe of it muft be large,  in order to take a
 fufficientquantity*!' the  fquills, 10 grains of it containing only 1 grain of dry
 fquills, fuppofing no fyrup to be ufed in making the mafs.  One convenience
 indeed, attends this formula, viz. that we can give fmall dofes with more pre-
 ciliun than if we ufed the powder alone.  The gum ammoniac is an expecto-
 rant;  and therefore, when  given along with the fquills in.thefe pills, may
 render a k-fs dole ofthe  fquills neceffary.  If the extraft of liquorice be omit*
 ted, the p. .portion of thefquir*  to the whole will be iiKrj;U;d. 
152
PRACTICE
impregnated with vinegar, has often proved ufeful in pro-
moting expeaoration.*
   But, of all other remedies the moft powerful for this
purpofe, are antimonial medicines, given in naufeating do-
fes, as  in (179).   Of thefe, however, I have not found the
kermes mineral more efficacious than  emetic tartar, or an.
limonial  wine ; and the dofe ofthe kermes is much more
uncertain than that of the others.
   374.]  Though a fpontaneous fweating often proves the
crifis of this difeafe, it ought not to be excited by art, un-
lefs with  much caution.   At leaft I have  not yet found it
either  fo e.ffcaual or fafe, as fome writers have  alledged.
When, after fome remiffion ofthe fymptoms, fpontaneous
fweats  of a proper kind  arife.  they  may be  encouraged ;
but it ought to be without much heat, and without ftimu-
lant medicines.   If, however, the fweats be  partial  and
clammy only,  and a great difficulty of breathing ftill re-
main, it will be very dangerous to encourage them.
   375. J  Phyficians have differed much in opinion with re-
gard to the ufe of opiates in pneumonic inflammation.  To
me it appears, that, in the beginning of the  difeafe, and be-
fore bleeding and bliftering have produced fome  remiffion
ofthe pain and of the difficulty of breathing, opiates have a
very bad effect, by their increafing the difheuiy of breath-
ing, and other inflammatory fymptoms.   But in a more
advanced ftate ofthe difeafe, when the difheuiy of breath-
ing has abated, and when the urgent fymptom is a cough,
proving the chief caufe ofthe continuance ofthe  pain and
of the want of fleep, opiates may be employed with great
advantage  and fafety.   The interruption of  the expec-
toration, which they  feem to occafion, is for a fhort time
only; and they feem  often to promote it, as they  occafion
a ftagnation of what was by frepuent coughing diffipated
infenfibly,  and therefore give the  appearance  of what
phyficians have called Concoaed Matter.

  * Some praaitioners propofethe fteam of vinegar alone : but it proves in
general too irritating.  The fame objeftion may be made  againft ufing the
fteam of wine, which fome praaitioners have recommended inftead of the
fteam of vinegar.  Plain water  is the beft, as the warm vapor only a&s br
relaxing the internal furface of the lungs. 
OF  PHiSIC.               153
                    CHAP. VII.

   fl)f t&e Peripneumonia jftot&a, oi* 15agta#
                 peripneumony*

376.] XJL DISXASE under this  name is mentioned in
fome medical writings of the fixtcenth century; but it is
very doubtful if the name was then applied  to the fame dif-
eafe to  which we now apply it.  It appears to me,  that
unlets fome. of the cafes detcribed under the title of Ca-
tarrhus Suffocative be fuppofed'to have been of the kind
I am now to treat of, there was no defcription  of this dif-
eafe given before that by Sydenham, under the title  I have
employed here.
   37-7.] After Sydenham, Boerhaave was the firft who in a
fyftem took notice of it as a diftina difeafe; and he has
defcribed  it in his aphorifms, although with fome circum-
ftances different from thofe in the defcription of Sydenham.
Of late, Mr.  Lieutaud has with great confidence afferted,
that Sydenham and Boerhaave had,  under the fame title,
defer.!bed  different difeafes ; and that, perhaps,  neither of
them had on this fubjea delivered any thing but hypothefis.
   378.] Notwithflanding this bold affertion, I am humbly
of opinion, and the Baron Van Swieten feems to have been
of the fame, that Sydenham and Boerhaave did defcribe
under the  fame title, one and the fame difeafe.   Nay, I am
further of opinion,   that  the  difeafe  defcribed by  Mr.
Lieutaud  himfelf, is  not effcntially different from that def-
cribed by both the other authors.   Nor will the doubts of
the very  learned, but modeft Morgagni,  on this fubjea,
difturb us, if we confider, that while very few defcribers of
difeafes either  have  it  in  their power,'  or have  been
fufticiently attentive in diftinguifhing between the effential
a;id accidental fymptoms of difeafe; fo, in  a difeafe which
may have  not  only  different, but a greater number of
fymptoms, in one perfon than it has in another, we need not
wonder that the defcriptions of the fame difeafe by  differ-
ent perfons fliould come out in fome refpeas different.  I
fhall,  however, enter  no further into this controverfy ; but
endeavour to defcribe the difeafe as it has appeared to myr
  Vol. I.                U 
1*4                PRACTICE

felf; and, as I judge, in the effential fymptoms, much the
fame as it has appeared to all the other authors mentioned,
   379-] This difeafe appears at the fame feafons that other
pneumonic and catarrhal affeaions commonly do ;  that is,
in autumn and  fpring. Like thefe difeafes alfo, it is feem-
ingly occafioned by fudden changes of the weather from
heat to  cold.  It appears, alfo, during  the prevalence of
contagious catarrhs.; and it is frequently under the form
ofthe Peripneumonia Notha that thefe catarrhs prove fa-
tal to elderly perfons.
   This  difeafe attacks moft commonly perfons fomewhat
advanced in life, efpecially thofe of a full phlegmatic habit;
thofe who have  before been frequently liable to catarrhal
affeaions;  and thofe who have been much addiaed to the
large ufe of fermented and fpiritous liquors.
  The difeafe commonly comes on with the fame fymp-
toms as other febrile difeafes; that is, with alternate chills
and heats;  and the fymptoms of pyrexia are fometimes
fufficiently evident;  but in moft cafes thefe are very mode-
rate, and in fome hardly at all appear. With the firft attack
ofthe difeafe, a cough comes on; ufuafly accompanied with
fome expeaoration, and in many cafes, there is a frequent
throwing up of a confiderable quantity of vifcid opaque ma-
cus.   The cough often becomes frequent and violent; is
fometimes accompanied with a rending head-ach ;  and, as
in other cafes of cough, a vomiting is fometimes excited by
it.  The face is fometimes flufhed, and fome giddinefsor
drowfinefs often attends the difeafe. A difficulty of'breath-
ing, with a fenfe of  oppreffion, or ftraitening in the cheft,
with fome obfeure pains there, and a fenfe of laffitude over
the whole body, very conftantly attends this difeafe. The
fclood drawn in this difeafe,  ihows a buffy furface, as in
other inflammatory affeaions.
   The difeafe has often the appearance only of a more vu
olent catarrh, and after the employment of fome remedies
is entirely relieved  by a free and copious expeaoration.
In other cafes,  however, the feverifh and catarrhal  fymp.
toms are very moderate, and even flight; but after a feW/j
days, thefe fymptoms fuddenly become confiderable,  and'
put an end to the patient's life when the indications  of dan-
ger were before very little evident. 
OF  PHYSIC.                  155
    380.] From the different circumftances in which this dif-
 eafe appears, the pathology of it is difficult.   It is certain-
 ly often no other at firft than a  catarrhal  affeaion, which,.
 in elderly perfons,  is  frequently attended  with a  large
 afflux  of mucus to the lungs;. and. it  was on this footing
 that Sydenham confidered it as  only differing  in degree
 from his Febris Hyemalis.   A catarrh* however, is ftri&ly
 an affection  of the  mucus membrane and follicles of the
 bronchia? alone :  but it  may readily have, and frequently
 has, a degree  of pneumonic  inflammation joined to it;
 and in that cafe may prove more properly the peculiar dif-
 eafe we treat of here.   But, further,, as pneumonic inflam-
 mation very often produces an  effufion of ferum into the
 bronchia; (348.) fo this, in elderly perfons, may occur in
 confequence of a flight degree of inflammation ; and when
 it does happen, will give the exquifite and fatal cafes ofthe
 peripneumonia notha.
    381.] After this attempt to eftablifh the pathology, the
 method of cure in the different circumftances of the dif-
 eafe will not be difficult.
    In cafe the fever, catarrhal  and pneumonic fymptoms,
 are immediately confiderable, a blood-letting, will certain-
 ly be proper and neceffary : but, where thefe fymptoms are
 moderate, a blood-letting will hardly be requisite;  and,
 when an effufion is  to be feared, the repetition of blood-
 letting  may prove extremely hurtful*.
    In all cafes the  remedies chiefly to be  depended upon,
 arc vomitingt and bliftering. J
    Full vomiting may be frequently repeated, and naufea-
 ting dofes  |[ ought to be conftantly employed.
  * The intention of bleeding in this difeafe is merety to facilitate the circu-
 lation through the lungs, and to relieve the oppreflion in the breaft, when this
 intention is therefore anfwtred, and when the fhortnefsof breath and oppref-
 fion about the breaft are removed, there is no farther need of the lancet. As
 this difeafe chiefly attacks elderly perfons, and fuch as are of a phlegmatic
 habit, much harm may be dyne by repeated, bleedings, which alwajs increafe
 debility and retard the cure.
  t Vomiting, in this difeafe, has been thought by many praaitioners to be
 a doubtful remedy.  The aftion of vomiting always oppreftes the breaft, and
 fometimes even increafes the fymptoms ofthe difeafe.
  t This is the chief remedy :  and the blifters ought  to be applied as near
 the part affecled as pofTible.
  |j In feveral of the former Jfotes we have- fully defcribed the methed of giv-
 ing the emetic tartar in naufeating doft s. Their principal effect, is to procure
 a perfpiration: and, when  this effect is produced, the patient muft drink
largely of any diluent or attenuating liquor,  as thin barley water, with ths 
 15$                  PRACTICE

   Purging may perhaps be ufeful; but as it is feldom fo
 in pneumonic affeaions, nothing but gentle laxatives are
 here neceffary.*
   In all the circumftances of this difeafe, the antiphlogif-
 tic regimen is proper ; cold is to be guarded againft ; but
 much external heat is to be  as carefully avoided.
   382.] If a perfon fweats eafily,  and it can be  brought
 out by the ufe of mild tepidliquors only, the praaice may
 in  fuch  perfons be tried.   See Morgagni  de  Sed.  et
 Caus. Epift. xiii. Art. 4.
   383.] I might here, perhaps  give a feparate feaion on
 the  Carditis and  Pericarditis, or the inflammation of the
'Heart and Pericardium; but they hardly require a particu-
 lar confideration.  An acute inflammation of the pericardi-
 um is almoft  always a part of  the fame pneumonic affec-
 tion I have been  treating of;  and is not  always diftin-
 guifhed by any different fymptoms: or, if  it be, does not
 require any different treatment.   The  fame may be faid
 of an acute inflammation of the heart  itfelf; and  when
 it happens that the  one or other  is difcovered by the fymp-
 toms of palpitation or fyncope, no more will  be  implied
 than that the remedies of pneumonic inflammation fhould
 be employed  with  greater diligence.
   From diffeaions, which fhew the heart and pericardium
 affeaed with erofions, ulcerations, and abfeeffes, we difco-
 ver, that thefe parts had been before affeaed with inflam-
 mation ; and that  in cafes where no fymptoms  of pneumo-
 addition ofthe juice of fome of the acid fruits,  or infulions of feme of the
 gentle aromatics,  as fage.Jjalm, mint, &c. or even a thin wine whey.
   *  Purging is furely hurtful in this difeafe, by inducing too great a ftate of
 debility: the inteftines,  however, are tobe emptied in the beginning ofthe
 difeafe, which is  beft done by a purging glyfter, and kept open by the fubfe-
 quent ufe of gentle laxatives, or by repetitions of mild emollient glyfters. The
 purging glyfter mav be made as follows :                        ^
            ft.  Aq. font. lb. 1.
               Fol. Senn. ^ss.
               Coqne leniter, et colaturae acute.
              ^>al. Cathart. ama. Bi.
               Mel.  511.
               M. t". Enema.
 The fubfequent glyfters ought to confift  of nothing more than fimple barleyJ
 water, or milk and water.  The laxatives, if they are ufed, fhould be very1
 gentle and mild ; as cream of tartar, whey, manna, tamarinds, &.c.  Half ari'
 ounce of manna diffolved in half a pint of cream of tartar whev, makes an a-
 greeable opening mixture ; half a tea-cupful of it may be taken three or four
 times a day, fo as to procure at leaft two or threeftools in the twenty-four hours. 
O F P H Y S I C.                157
nic inflammation had appeared: it may therefore be alledged
that thofe inflammations ofthe heart and pericardium fhould
be confidered as difeafes independent of the pneumonic.
This indeed is juft : but the hiftory of fuch  cafes proves,
that thofe inflammations  had been of a  chronic kind, and
hardly difcovering themfelves  by any peculiar fymptoms ;
or, if attended with fymptoms marking an affection of the
heart, thefe were,  however, fuch as have been known fre-
quently  to  arife from  other caufes  than inflammation.
There is therefore, upon the whole, no room for our treat-
ing particularly of the inflammation of the heart or peri-
cardium.

                    CHAP. VIII.

    2)f tfjc ®a$trftis, or 31nflammation of tU
                     ^tomacf),

 384.] ilMONG the inflammations of the abdominal
region, I have given a place in our Nofology to the Perito-
nitis; comprehending under that title, not only the inflam-
mations affeaing the peritonaeum lining  the cavity of the
abdomen,  but alfo thofe  affeaing the  extentions of this
membrane in the omentum and mefentery. It is not, how-
ever, propofed to treat of them here, becaufe it is very dif-
ficult to fay by what fymptoms they are always to be known;
 and farther, becaufe when known, they do not require any
 remedies befide thofe  of inflammation in general.  I pro-
 ceed therefore, to treat of thofe inflammations, which af-
 feaing vifcera of peculiar funaions; both give occafion to
 peculiar fymptoms, and require fome peculiarities in the
 method of cure;  and I  fhall begin with the  inflammation
 of the ftomach.
   385.J The inflammation ofthe ftomach is of two kinds,
 Phlegmonic, or Erythcmatic*  The firft may  be  feated
in what is  called the  Nervous Coat of the ftomach, or in
 the peritonaeum inverting it.  The fecond is always feated
 in the  villous coat  and cellular  texture   immediately
 fubjacent.
   * This is a new term : but whoever confiders what is laid in 274, will I
 expect., perceive the propriety, and even neccifity, of it.
4 
158                PRACTICE
   38S.] The phlegmonic inflammation of the ftomach, or
 what has been commonly treated of under the title of Ga-
 ftritis, is known by an acute pain in fome part of the region.
 ofthe ftomach, attended with pyrexia, with frequent vom-
 iting,  efpecially upon occafion of any thing being taken
 down into the ftomach, and frequently with hickup.  The
 pulfe is commonly fmall  and hard; and there is a greater
 lofs of ftrengthin all the funaions of the body, than in the
 cafe of almoft any other inflammation.
   387.J This inflammation may be produced by various
 caufes; as,  by external contufion ; by  acrids of various
 kinds taken into the ftomach; frequently by very cold drink.
 taken into it while the body is very warm-; and fometimes
 by over-diftenfion,from the having taken in a large quantity
 of food of difficult digeftion. All thefe may be confidered
 as external   caufes;.  but the difeafe fometimes arifes alfo
 from internal caufes  not  fo well underftood.   It may
 arife from inflammations  ofthe neighbouring parts com-
 municated to the ftomach,  and is then to be confidered as
 asymptomatic affeaion only.   It may arife alfo from  va-
 rious acrimonies generated within the body, either in  the
 ftomach itfelf, or in other parts,  and poured into the  ca-
 vity ofthe ftomach.   Thefe are caufes more direaiy ap-
 plied to the ftomach; but there are perhaps others origin-
 ating elfewhere, and affeaing the ftomach only fympathe-
 tically.   Such may  be fuppofed to  have a£ted in the cafe
 of putrid fevers and exanthematic pyrexia;  in which, up-
 on diffeaion, it has been difcovered that the ftomach had
 been affeaed with inflammation.
  388.J  From the fenfibility of the ftomach, and its com-
 munication with the  reft of the fyftem, it will be obvious,
 that the inflammation of this organ, by whatever  caufes
 produced, may be attended with fatal confequences.   In
 particular, by the great debility which fuch an inflammati- ^
 on fuddenly  produces, it may quickly prove fatal, without i
 running the common courfe of inflammations.              ■
  When it lafts long enough to follow the ordinary courfe  •;
 of other  inflammations, it may terminate  by refolution,
 gangrene, or fuppuration.   The feirrhofities which are of-
 ten difcovered affeaing  the ftomach, are feldom  known
to be the confequences of inflammation. 
                  OF PHYSIC.                159

   389.] The tendency of this difeafe to admit of refolu-
tion, may be known by its having arifen from no violent
caufe;  by the moderate ftate of the fymptoms; and by a
gradual rcmiffion of thefe, efpecially in confequence of re-
medies employed in the courfe of the firft, or  at fartheft,
the fecond week of the difeafe.
   390.J The tendency to fuppuration may be known by
the fymptoms continuing, in a moderate  degree, for more
than one,or two weeks; and likewife by a confiderable re-
miffion of the pain, while a fenfe of weight and an anxiety
ftill remain.
   When an abfcefs has been formed, the frequency of the
pulfe is at firft abated; but foon after, it is again increafed,
with frequent cold fhiverings, and with marked exacerba-
tions in the afternoon and evening, followed by night fweat-
ings, and other fymptoms of hectic fever.  Thefe at length
prove fatal, unlefs  the abfcefs  opened into  the cavity  of
the ftomach, the pus be evacuated  by vomiting,  and the
 ulcer foon heal.
    391. J The tendency to gangrene may be fufpeaed from
the violence of the fymptoms not yielding  to the  remedies
 employed during the firft days of the difeafe : and that a
 gangrene has already begun, may be known from the  hid-
den remiffion ofthe pain, while the frequency ofthe pulfe
 continues, and at the fame time becomes weaker, accom-
 panied with other marks* of an increafing debility in the
 whole fyftem.
    39fc.] From the diffeaion of dead bodies  it  appears,
 that the ftomach very often has been affeaed with inflam-
 mation, when the charaaeriftic fymptoms  of it (386.) had
 not appeared ; and therefore it is very difficult to lay down
 any general rules for the cure of this difeafe.
    393.] It is only in the cafe of phlegmonic inflammati-
 on, charaaerifed in (386.) that we can advife the cure  or
 refolution to be attempted by large and repeated bleedings
 employed early in the difeafe :  and we are  not to be deter-
 cd from thefe by the fmallnefs ofthe pulfe; for after bleed-
 ing, it commonly becomes fuller and fofter.  After bleed-
 ing, a blifter ought to be applied to the region of the fto-

   * A delirium js one of the moft general concomitants of the increafing dc«
 bility of tfce fyftem, aud may be confidered as % diagnoftic. 
160
PRACTICE
mach ;  and the cure will be afiiftcd by fomentations ofthe
whole abdomen, as well as by frequent emollient and lax-
ative glyfters.
   394.] In this difeafe, the irritability ofthe ftomach will
not admit of  any medicines being thrown into it; and  if
any  internal medicines  can be fuppofed  ncceffary,  they
muft be exhibited in glyfters.  The giving of drink may
be tried; but it ought to be of the very mildeft  kind, and
in very  fmall quantities at  a time.*
  395.] Opiates, in whatever manner exhibited, are very
hurtful  during  the  firft  days of the difeafe;  but when its
violence fhall have abated,  and when the violenee of the
pain and vomiting recur at intervals  only, opiates  given
in glyfters  may be  cautioufly  tried, and  fometimes have
been employed with advantage.
  396.] A tendency to fuppuration,  in this difeafe,  is to
be obviated by the means juft now  propofed.   After a
certain duration of the difeafe,  it cannot be prevented by
any  means whatever;  and  when  actually  begun muft
jje left to nature;  die bufinefs of the phyfician being only
to avoid all irritation.
  397. J A tendency to gangrene  can be obviated in no
other way  than by  the means fuggefted (393.) employed
early in the difeafe;  and,  when it does aaually fupervene,
admits of no remedy.
  398.] Erythematic inflammations of the ftomach, are
more frequent than thofe of thephlemonic kind.  It appears
at leaft, from diffeaions,  that the ftomach has often been
affeaed with inflammation, when neither pain nor pyrexia
had  before given any notice of it; and fuch inflammation
I apprehend to have been  chiefly of the erythematic kind.
ThisTpecies of inflammation alfo, is efpecially to  be ex-
peaed from acrimony of any kind thrown into the ftomach;
and  would certainly occur more  frequently  from  fuch a
caufe, were not the interior furface of this organ common-
ly defended by mucus exuding in large quantities from the
numerous follicles placed  immediately under the  villous

  * Chicken  broth is extremely mild ; it may be taken in fmall quantities,
with  about 8 or 10 grains of nitre in every pint of it.  Lintfeed tea is
alfo a very mild drink; and if the inflammation be owing to the prefence of
any acrid matter initating the ftomach, it is of great fervice by its fheathing
quality 
OF  PHYSIC.                161
 coat.   Upon many  occafions,  hov/ever, the exudation of
 mucus is prevented, or the liquid poured out is of a lefs
 vifcid kind, fo as to be  lefs fitted to defend the fubjacent
 nerves; and it is in  fuch cafes that matters even of mode-
 rate acrimony, may produce  an erythematic affeaion of
 the ftomach.
    399.] From what has been  faid,  it muft appear that an
 erythematic inflammation ofthe ftomach may frequently
 occur;  but will not always difcover itfelf, as it fometimes
 takes places without pyrexia, pain,  or vomiting.
    400. J There are cafes, however, in which it may be dif-
 covered.   The affeaion ofthe ftomach fometimes fpreads
 into the oefophagus, and appears in the pharynx, as well
 as on the whole  internal furface of the mouth.   When,
 therefore, an erythematic inflammation affe&s the mouth
 and fauces,  and when at the fame time  there fhall be in the
 ftomach an  unufual fenfibility to all acrids, with a frequent
 vomiting, there  can be little doubt of the ftomach being
 affeaed with the fame inflammation  that  has appeared in
 the fauces.   Even when  no inflammation appears in the
 fauces yet it if fome  degree of pain be felt in the ftomach,
 if there  be a want of appetite, an  anxiety, frequent vom-
 iting, an  unufual  fenfibility with refpea to acrids, fome
 thirft, and frequency of pulfe, there  will  then be room  to
 fufpea an erythematic inflammation of the ftomach; and
 we have known fuch fymptoms, after fome time, difcover
 their caufe   more clearly by  the appearance of the in-
 flammation  in the  fauces or mouth.  Erythematic in-
 flammation  is often difpofed to fpread from one place to
 another on the  fame furface; and, in doing fo, to leave the
 place it had firft occupied.  Thus, fuch an  inflammation
 has been  known to  fpread fucceffively along  the whole
 courfe of the  alimentary canal,  occafioning  in  the in-
 teftines diarrhoea, and in the ftomach  vomitings; thediarr-
 hcea ceafing when the  vomitings came on, or the vomit-
 ings upon the coming on of the diarrhoea.
  401.]  When an erythematic  inflammation of  the fto-
mach fhall be difcovered,  it is to be treated differently, ac-
cording to the difference of its caufes and fymptoms.
  When it is owing to acrid matters taken in by the mouth,
and when thefe may be fuppofed ftill prefent in the ftomach,
  Vol.  I.                X 
Ifi                PRACTICE

they are to be wafhed out by throwing  in a large quantity
of warm and mild liquids, and by exciting vomiting.   At
the fame time, if the nature ofthe acrimony and its proper
correaor be known, this fhould be thrown in ;  or if a fpe-
cific correaor be not  known,  fome general demulcents
fhould be employed.
  402. J Thefe meafures, however, arc more fuited to pre-
vent the  inflammation, than to cure it after it  has taken
place.   When this laft may be  fuppofed to be the cafe, if
it be attended with a fenfe of heat, with pain and pyrexia,
according to the  degree  of thefe  fymptoms the meafures
propofed in (393.) are to be more or lefs employed.
   403.] When an erythematic. inflammation of theftomach
has arifen from internal caufes, if pain and pyrexia accom-
pany the difeafe, fome bleeding, in perfons not otherwife
weakened, may be employed: but, as  the  affeaion often
arifes in putrid difeafes, and in  convalefcents from fever^
fo in thefe cafes,  bleeding is inadmiffible ;  all  that can be
done being to avoid irritation,  and to  throw into the fto-
mach what quantity of acids, and ofafecfeent aliments, it
fhall be found to bear.
   In fome conditions ofthe body  in which this  difeafe ari-
fes, the Peruvian  bark and bitters may  feem to be indica-
ted ; but an erythematic ftate of the ftomach does not com-
monly allow of them.

                    CHAP.  IX.

     SDf t&e <£nte?itte,  or 3|nflammation  of tfee
                    3[ntcstine^

404.]  1 HE inflammation of the inteftines,  like that of
theftomach,  may be either phlegmonic or  erythematic;
but, on the fubjeft of the latter, I have nothing to add to
what has been faid in the laft chapter; and fhall here there-
fore treat ofthe phlegmonic inflammation only.
   405.] This inflammation may be known to  be prefent,
by a fixed pain in the abdomen, attended with pyrexia, cof-
tivenefs, and vomiting.   Praaical writers mention the pain
in this cafe as felt in different parts of the abdomen, accord-
ing to the different feat ofthe inflammation3  and fo, indeed, 
                      OF  PHYSIC.                   163


it-irtfbmctirncs  happens; but very often the pain fpreaas

over the whole belly, and is felt more efpecially about the

navel.
   406.] The Enteritis and Gaftritis arife from like caufes;

but the former more readily than the latter, proceeds from

cold applied to the lower extremities,  or to the belly itfelf.

The enteritis has likewife its own peculiar  caufes, as fuper-

vening upon the fpafmodic cholic, incarcerated hernia, and,

volvulus.
   407.] Inflammations ofthe inteftines have the fame ter-

minations  as thofe ofthe ftomach ;  and, in both cafes, the

fevcral tendencies are to be difcovered by the fame fymp-

toms (389. 391.).

   408. j The  cure of  the interitis is, in general, the fame

with that of the gaftritis ; (393. and fcq.)  but  in the inte-

rnes, there is  commonly ♦more accefs to  the introduaion
of liquids, of  acids, acefcent, and  other cooling remedies,

and even of laxatives.* As, however, a   vomiting fo fre-

quently attends this difeafe, care muft be taken not to ex-

cite that vomiting by either the quantity  or the quality, of

any thing thrown into the ftomach.

  * I 1 this difeafv,', we ought to be extremely cautious  in the adminiftration
either of the medicines or diluents.   The reafon  is evident from the follow-
ing confiderations.  In every cafe of inflammation of a  canal, the bore of that
canal is diminilhed, and frequently quite fhut.  A quantity of any kind of in-
gefta being forced againft this obilrucYion, muft neceflarily increafe the irrita-
tion, and coiifrequently aggravate all the fymptoms.  The fame reafon may
be given for the caution neceffary in prefcribing laxatives, which always ir-
ritate ; f r their action generally depends upon the irritation they produce.
Large bleedings,  emcllient glyfters  frequently repeated,  fomentations, the
v/arm bath, and fmall anodyne glyfters occan\;nally injected, are the moft ef-
fectual remedies in the firft ftage of this violent difeafe.  When the pain re-
mits, and the violence of the fymptoms abates, n ild diluents may then be ad-
mitted, as chicken-broth, thin lintfecd tea, 8cc.  and if fuch liquors be retain-
ed without aggravating the fymptom";, \vu may then venture to give an ounce-
of manna every three or four hours, till it procures a paffage.
  The internal ufe of opium has been extolled by feveral practitioners in.,thcfe
cafes; but experience {hews that it generally does harm in every cafe cf in-
flammation, efpecially in the early ftages of it.
  The anodyne glyfter is the lafeft method of  ufing opium ;  but glyfter3 of
this kind are faid to obllruct:  This objection is,  however, ill founded ;  for.
by diminifhing the irritation, they evidently tend to refolve the inflammation.
The following formula of an anodyne glyfter is generally ufed :„
           JRc. Decoct, hord. 5-ir.  .
              Opii puri gr. iv.
              M.
In thefe  glyRers, particular care muft be taken to avoid every thing that has
the lealt  tendency to irritae.  If a gangrene be formed before the phyfician.
be c;;l'cd, as is too frequently the ca,ic, then all remedies are in vain. 
164
PRACTICE
   The fame obfervation with refpea to the ufe of opiat'es
is to be made here as in the cafe of gaftritis.
   409.]  Under the title of Enteritis, it has been ufual with
praaical writers to treat ofthe remedies proper for the cho-
lic* and its higher degree named Ileus : but, although it
be true that the ententes and cholic do frequently accom-
pany each other, I ftill hold them to be diftintt difeafes, to
be often occurring feparately, and accordingly to require
and admit of different  remedies.   I fhall therefore delay
fpcaking ofthe remedies proper  for the cholic, till  I fhall
come to treat of this difeafe in its proper place.
   410.] What might be mentioned with refpea to the fup-
puration or gangrene occurring in the enteritis, may  be fuf-
ficiently underftood from  what has been faid on the fame
fubjea with refpea to the gaftritis.


                      CHAP. X.

£Df  ifte hepatitis, or inflammation cf tfcc Litter*

411.]  JL HE inflammation of the liver feems to  be of
two  kinds; the one acute, the other chronic.
   412.J  The acute is attended with pungent pain;  confi-
derable pyrexia; a frequent, ftrong,  and hard pulfe; and
high colored urine.
   413.]  The chronic hepatitis very often does not exhibit
any  of thefe fymptoms; and it is only difcovered to have
happened,  by our finding in the liver,  upon diffeaion,
large abffceffes, which are prefumed to be the effea of fome
decree of previous inflammation.  As this chronic  inflam-
mation is feldom  to be certainly  known, and therefore
"does not lead  to any determined  pra6tice, we omit treating
of ifhere, and fhall only treat of what relates  to the acute
fpecies of the hepatitis.t
   414. J The acute hepatitis maybe known by a pain more
or lefs acute  in the  right hypochondrium,  increafed by
preffihg upon the part.  The pain is very often in fuch a
part of the fide as to make it appear like that of a pleurify;
and frequently, like that too, is increafed on refpiraiioc,
  * See art. 435.
  t It is doubtful whether this chronic hepatitis ever exifts. 
0 1'  PHYSIC.                16S
The difeafe is, in fome inftances, alfo attended with a cougb
which is commonly dry, but fometimes humid :  and whea
the pain thus refembles that of a pleurify,  the patient can-
not lie eafily except upon the fide affeaed.
   In every kind of acute hepatitis, the pain is often ex-
tended to the clavicle, and to the top of the fhoulder. The
difeafe is attended fometimes with hickup, and fometimes
with vomiting.  Many praaical writers have  mentioned
the jaundice, or a yellow color of the fkin and eyes, as a
very  conftant fymptom of the hepatitis;  but experience
has fhown, that it may often occur without any fuch fymp-
tom.*
   415.] The remote  caufes of hepatitis are not always to
be dilcerned, and many have been amgned on a very un-
certain foundation.   The following feem to be frequently
evident. 1. External violence from contufions orfalls,and
efpecially thofe which have occafioned  a fraaute of the
cranium.   2.  Certain paffions of  the mind.  3.  Violent
fummerheats.   4. Violent exercife.   5.  Intermittent and
remittent fevers. 6. Cold applied externally, and internal-
ly ; and therefore in  many cafes the fame caufes which
produce pneumonic inflammation, produce hepatitis; and
whence alfo the two difeafes are fometimes joined together.
7.  Various folid concretions or colfeaions of liquid mat-
ter, in the fubftance of the liver,  produced by unknown
caufes.  Laftly, The acute is often induced by a chronic
inflammation  of this vifcus.
    416.]  It has been fuppofed, that the hepatitis may^be an
affection either of the extremities ofthe hepatic artery,  or
of thofe ofthe vena potarum; but of the laft fuppofition
there is* neither evidence nor probability.
   417.]  It feems probable,  that the acute hepatitis is ah
ways an affeaion ofthe external membrane of tire liver _;
and that the parenchymatic is of the chronic kind.   The
acute difeafe may be feated either on the convex or on ths
concave furface of the liver.  In the former cafe, a more
pungent pain and hickup may be produced, and the ref-
piration is more confiderably affeaed.  In the latter, the e
occurs lefs pain; and a vomitting is produced, commonly
  * This fymptom generally appears, however, after tl* difeafe has continu-
ed for three or four days ; perhaps, indeed, it might have been prefent in the
beginning, for it is fre<}nemlv fo flight as to cfcape obfervatioJl. 
166
PRACTICE
by fome inflammation communicated to the ftomach.  The
inflammation of the concave furface of the liver, may  be-
readily communicated to the gall bladder and biliary duas;,
and this perhaps is the only cafe of idiopathic hepatitis at-
tended with jaundice.
  418.]  The hepatitis, like other inflammation:, may end
by refolution, fuppuration,  or gangrene;  and the tenden-
cy to the one or the other of thefe events, may be known
from  what has been delivered above.
  419.]  The refolution of hepatitis is  often the confe-
quence of, or is attended with, evacuations of different
kinds.  A hemorrhagy, fometimes from the * right nofh il,.
and fometimes frorruhe hemorrhoidal veffels, gives a  fo-
lution of the  difeafe.  Sometimes a bilious diarrhoea con-
tributes to the fame event; and the refolution ofthe hepa-
titis,  as of other inflammations, is attended with fweating,
and with an  evacuation of urine, depofiting  a copious fe-
diment.  Can this difeafe be refolved by expeaoration r"
It would feem to be  fometimes cared by  an eryfipelas ap-
pearing in fome external part.
  420. J  When this difeafe has ended in  fuppuration, the
puscolfeaed may  be difcharged by the biliary duels; or,
if the Tuppurated part docs not any where adhere  clofely
to the neighbouring parts, the pus may be difcharged into
the cavity of the abdomen; but if, during the firft ftate of
inflammation, the  affeaed part of the  liver fhall  have
formed a clofe adhefion to fome of the neighboring parts,.
the difcharge of the pus after fuppuration may be various,
according to the different feat of the abfcefs.  When feat-
ed on the convex part of the  liver, if the adhefion be to
the peritonaeum  lining the common  teguments, the  pus.
may make its way  through thefe, and be  difcharged out-
wardly ; or, if the adhefion fhould have been to the dia-
phram,  the pus  may penetrate through this,  and into the
cavity of  the thorax, or of  the  lungs;  and through the
latter may be difcharged by coughing.   When the abfcefs
of the liver is  feated on its concave part, then,  in confe-
quence'of adhefions, the  pus may be difcharged into the
  * And the left alfo.  It was a fancy of Galen's that inflammatory fevefs
were only refolved by fuch  hemorrhagies as flowed from the fide  affected :
Thus, an hemorrhage from  the right noftril, refolved an inflammatorv of the
liver ; but a difcharge from the left, an inflammavion of the fpleca. 
OF  PHYSIC*
167
ftomach or the  inteftines; and  into thefe laft, either di-
re6tly, or by the intervention of the biliary duels.
  421. J The prognoftics h\ this difeafe are. eftablifhed up-
on the general principles relating to inflammation, upon the
particular  circumftances of the liver, and upon the parti-
cular ftate of its inflammation.
  The cure of  this difeafe muft proced upon the general
plan ; by bleeding, more or lefs, according to the urgency
of pain and pyrexia ; by the application of blifters ; by fo-
mentations, ofthe external par t> in the ufual manner, and
ofthe internal parts by frequent emollient glyfters;  by fre-
quently opening the belly by means of gentle laxatives, and
by diluent and refrigerant remedies.,
   4 2 2. J Although, in many cafes the chronic hepatitis does
not clearly difcover itfelf; yet upon many occafions, it may
perhaps be difcovered,  or at leaft fufpeaed, from  thofe
caufes which might affea the  liver  (316.)  having  been
applied; from feme fulnefs and fome tenfenefs of weight in
the righ t hypochondrium ; from fome fhooting pains at times
felt in that region; from fome  uneafinefs or pain felt upon
preffure in that part;  from fome uneafinefs  from  lying
upon the left fide; and laftly, from  fome degree of pyrexia,
combined with more  or fewer of thefe  fymptoms.  When
from feme of  thefe  circumftances a chronic inflammation
is to be fufpeaed, it  is to be treated by the fame remedies
as in the laft paragraph, employ more or lefs, as the degree
ofthe feveral fymptoms fhall more diftinftly indicate.
   423.] When from either kind  of inflammation a fup-
puration of the liver has been formed,  and the  abfcefs
points outwardly, the  part muft  be  opened, the pus e-
vacuated, and the ulcer healed  according to the ordinary
rules for clcanfine and healing  fuch abfeeffes and ulcers.
   424.] I might here confider the Splenitis, or inflamma-
tion ofthe fpleen ; but it does not feem neceffary, becaufe
the difeafe very feldom occurs.  When it does,  it may
be readily known  by the chapter given in our Nofology;
and its various  termination, as well as the pra&ice which
it requires, may be undeiflood from what has been already
faid with refpea to  the inflammations of the other abdo-
minal vifcera. 
168              PRACTICE
                    CHAP.  XI.

 4bi tfje JScpfeititf, or tfee  Jnflammaticn of t&t t
                     fcitmegs*

425.]  1  HIS difeafe, like other internal inflammations,
is always attended with pyrexia;  and is efpecially known
from the region of the kidney being affeaed by pain, com-
monly obtufe, fometimes pungent.  This pain is not in-
creafed  by  the motion  of the trunk of the  body,  .fo
much as  a  pain of  the rheumatic  kind affeaing  the
fame region.   The pain ofthe nephritis may be often dif-
tinguifhed by its fhooting along the courfe of the ureter;
and is frequently attended with a drawing up of the tefticle,
and with a numbnefs of the limb on the fide affeaed; al-
though, indeed, thefe fymptoms moft commonly accom-
pany the inflammation arifing from a calculus in the  kid-
ney or in the ureter.   The  nephritis is almoft conftantly
attended with  frequent vomiting, and alfo with coftive-
nefs  and cholic pains.  Ufually the ftate of  the urine is
changed; it is moft commonly of a  deep red  color, is
voided frequently, and in  fmall  quantity at  a time.   In
more violent cafes, the urine is  fometimes colorlefs.
  426.] The  remote caufes of this difeafe may be various;
as^"external contufion; violent or long continued riding;
{trains of 'the mufcles of the back incumbent on the kid- •
neys; various acrids in the courfe of the circulation con-
veyed  to the  kidneys; and perhaps fome other internal
c3ufes not yet well known.   The moft frequent is that of
calculous matter obftru6ting the tubuli uriniferi, or calculi
formed  in the pelvis of  the  kidneys, and either flicking
there, or fallen into the ureter.
  427.] The various event of  this difeafe may be  under-
itood from what has been delivered on the fubjea of other
inflammations.
  428.] Writers, in treating ofthe cure of nephritis, have
commonly at the  fame time treated of the cure of the Cal-
culus renalis; but, though  this may often  produce  ne-
phritis,  it is to be confidered as a diltina and feparate dif-
eafe ; and what I  have to offer  as  to the mode of treating 
                       OF   PHYSIC.                    16jj


it,  muft  be referved  to its  proper place.   Here I fhall

treat only  of  the cure of  the  Nephritis Vera or  Idiopa-

thica.                                 '
   429.]  The cure of this proceeds  upon  the general plan,
by  bleeding,   external  fomentation,  frequent emollient

glyfters, antiphlogiftic purgatives, and the free ufe  of mild
and  demulcent  liquids*.   The application of blifters  is
hardly  admiffible; or,  at leaft, will  require great  care, to
avoid any confiderable  abforption of ihe cantharides t

   430.J The  Cyftitis,  or inflammation of the  bladder, is

  * Thefe have all been enumerated in fome of,the preceding notes.
  f This is a very neceffary caution.  Blifters  generally  affect, the urinary
organs and veffels,  occafloning  much irritation, and confequently increafing
the inflammation.   As the author is rather fnort in his directions for the cure
of this very troubhfome inflammation, it maybe proper to add fome particu-
lar direclions for regulating our  praftice in thefe cafes.
  An ulcer in the  kidneys is extremely difficult to heal ; we ought therefor*
always to attempt the cure of nephritis by refolution.  The general remedies
for anfwering this  intention have been frequently enumerated, efpecially in
the notes on art. 130—131.—The particular remedies more peculiarly adapt-
ed to this difeafe arc demulcent drinks of the fofteft nature,  and fuch as are^
leaft apt  to irritate the parts  ;  as lintfeed-tea,  decoclion of marih-mallows,
&C.   Nitre  has been recommended among the  general antiphlogiftic reme-
dies ; but, in nephritis its ufe is doubtful, on account of its paffing quickly by
the kidneys, and irritating them.
   A difficulty of making water is one of the fymptoms of this difeafe, and
fome practitioners recommend heating diuretics.  This praftice, however, is  «
extremely hurtful,  and ought to be carefully avoided, becaufe thefe warm
medicines, as turpentinesjhalfams, &c. always increafe the irritation, efpeci-
ally in the urinary paffages.                                          ^.  ■
   As the colon preffes immediately on the kidneys,  efpecially on the right
one, we  fliould be  careful to  keep it  empty, which js beft done by glyfters.-
.Befide the ufe of glyfters in evacuating the contents flf the colon, they ail aa
 a fomentation to the inflamed part ; we  ought  therefore, in thefe cafes,  to
 prefcribe them larger than ufual, and repeat them often.  They ought to  be
 extremely emollient, and void of every ingredient that  is any way ftimulating.
   A quart of thin  barley-wi.ter or liaifted tea anfwers the purpofe as com-
pletely as any ofthe more compound emollient glyfters of the Pharmacopoeias.
With refpecl to diet  and regimen, we may obferve that lenient nourishment
is highly proper; for every thing acrid naturally forces itfelf off by the mine,
and consequently increaftse the irritation.  A total abftinence from food is by
no means advifaBle,  becaufe, from abftinence, little urine is fecreted, and
the fmaller the quantity fecreted  it is generally the  more acrid,  and confe-
quently noxious.  The patient ought  to be made to fit  up as much as poffible.
Warm foft beds, which are always improper in all  inflammatory  difeafes,
are peculiarly hurtful in nephritis,  if the patient lies on his back ; for in this
pofition the kidneys are kept very warm, and are at the fame time prefledby
the fuperincumbent weight ofthe abdominal  vifcera,  all which  will contri-
bute to increafe the inflammation.  Although  lying much ia bed be dif.p-
proved,  the patient ought by  no means to be  overfatigued with  fitting too
long.  The room fliould be moderately cool, and the bed fpringy, but notfofc.
In addition to what was faid  above refpecling blifters in this difeafe, it may
be neceffary to obferve, that other vificants befides cantharides may be ufed,
fuch  as  muilard poultices, commonly called fuiapifms, a poultice of frelh
leaves of the ranuntlus acris, and otlier acrid plants.
   Vol. I.                      Y 
J7U                -PRACTICE

feldom a primary difeafe ;  and therefore is not tobe treat-
ed of here.  The treatment of it, fo far as neceffary to be
explained, may be readily underftood from what has been
already delivered.
   431.]  Of the  vifceral  inflammations, there remains to
be confidered the inflammation of the  Uterus;  but I omit
it here, becaufe the confideration of it cannot be feparated
from that of the difeafes of child-bearing women.
      CHAP. XII.

©f tf)e iRfrcumatimtt,
 432.] V|/F this difeafe there are two fpecies, the one na-
 med  the Acute, the other the Chronic rheumatifm.
   433.] It is the acute Rheumatifm which efpecially be-
 longs to this place, a? from ifls caufes, fymptoms, and me-
 thods of cure, it will appear to be a fpecies of phlegmatic
 or inflammation.                         ^
   434.] This difeafe is frequent mcedd", a,nd more uncom-
 mon  in warm climates.  It appears moft frequently in au-
 tumn and fpring, lefs frequently in winter when the cold is
 confiderable and conftant, and very feld^Vi during the heat
jof fummer.  It may occur, howevfci, at any feafon, if vi-
 ciflitudes of heat and cold be for the time frequent.
   435.] The a£i|^»rheumatifm generally arifes from the
 application of cold  to the body when any way  unufually
 warm ;  or when one part ofthe body is expofed to cold
 whilft the other parts are kept warm ; or, laftly, when the
 application of the cold is long continued, as it is when wet
 or moift clothes are applied to any part of the body.
   436.] Thefe caufes may affea perfons of all ages; but
 the rhpumatifm feldom appears  in either very young or el-
 derly' jierfons, and moft commonly occurs from  the age of
 puberty to  that of thirty-five years.
   437.] Thefe caufes  (435.) may alfo  affea perfons of
 any conftitution -, but they moft commonly affeet thofe of
 a fanguine temperament.
   438.] This difeafe is particularly diftinguifhed by pains
 affecting the joints, for the moft part the joints alone, but
 fometimes affeaing alfo the mufcular parts.  Very often 
OF  PHYSIC.               ttt
the pains fhoot alone; the courfe ofthe mufcles, from one
joint  to  another,  and are always much increafed by the
aaion ofthe mufcles belonging to the joint or joints affeaed.
   439.] The larger joints are moft frequently affeaed;
fuch as the hip-joint and knees ofthe lower, and the fhoul-
ders and elbows ofthe upperextremities.   The ankles and
wrifts are  alfo frequently affeaed ; but  the fmaller joints,
fuch as thofe ofthe toes or fingers, feldom fuffer.
   440.] This difeafe although  confined to one part ofthe
body only, yet very  often affeas many  parts of it ; and
then it comes on with a cold ftage, which is immediately
fucceeded by the other Iymptoms of pyrexia and  particu-
larly  by a frequent, full, and hard pulfe.  Sometimes the
pyrexia is formed before any pains are perceived; but more
commonly pains are felt in particular parts, before any
fymptoms of pyrexia appear.
   441.] When no pyrexia is prefent, the pain is fometime3
confined to one joint only ; but,-when any confiderable py-
rexia is prefent, although the pain may be chiefly in one
joint, yet it feldom happens-but that the pains affea feve-
ral joints  often at the very fame time, but for the moft part ^
fhifting their place, and having abated in onejoint,  become ,
more violent in another.  They do not commonly remain
long in the fame joint, but frequently fhift from one to a-
nother, and fometimes return to joints formerly affeaed ;
and in this manner the difeafe often  continues., for a long
time.
   442.] The pyrexia attending this difeafe has an  exacer-
bation every  evening, and is moft confiderable during the
night, when the pains alfo become more violent; and it is
at the. fame time that the  pains fhift their place from one
joint to another. The pains feem tobe alfo increafed during
the night,  by the body being covered more  clofely, and
kept warmer.
   443-] A joint, after having been for forne time affeaed
with pain, commonly  becomes affeaed alfo  with fome
rednefs and fwelling, which is painful to the touch. It fel-
dom happens, that a fwelling coming on does not alleviate
the pain of the joint; but the fwelling does not always take
off the pain entirely, nor fecure the joint againft a return of it.
   44i]   The  difeafe is commonly attended with fome
* 
m
PRACTICE
fweating, which  occurs early in the courfe ofthe difeafe ;
but it is feldom free or copious, and feldom either relieves
the pains or proves critical.
   445.] In the courfe of this difeafe the urine is high co-
loured, and in the beginning without fediment; but as the
difeafe advances, and the pyrexia has more  confiderable
remiffions, the urine depofits a lateritious fediment.  This,
however, does not  prove entirely critical; for the difeafe
often continues long after fuch a fediment has appeared in
the urine.
   446.] When blood is drawn is this difeafe it always ex-
hibits the appearance mentioned 237.
   447.] The acute rheumatifm, though it has fo much
ofthe nature ofthe other phlegmafia?, differs from all thofe
hitherto mentioned, in this,  that it is not apt to terminate
in fuppuration. This almoft never happens in rheumatifm;
but the difeafe fometimes produces eifufions of a tranfpa-
rent gelatinous fluid into the fheaths of the tendons.  If
we may be allowed to fuppofe that fuch eifufions are fre-
quent, it muft alfo happen,  that the effufed  fluid is com-
monly reabforbed;  for it has feldom  happened, and never
indeed to my obfervation, that  confiderable  or permanent
tumours have been produced, or fuch as required to be o-
pened, and to have the contained fluid evacuated.   Such
 tumours, however,  have occurred to others, and the open-
 ing made in  them has produced ulcers difficult to heal.
Vide Storck. Ann. Med. II.
    448.] With the circumftances mentioned from (438. to
 447.) the difeafe often continues for feveral wreeks.  It fel-
 dom, however, proves fatal ;  and it rarely happens that the
 pyrexia continues to be confiderable  for more than two or
 three weeks. While the pyrexia abates in its violence, if
 the pains of the joints continue, they are lefs violent, more
 limited in their place, being confined commonly to one or
 a few joints only, and are lefs ready  to change their place.
    449.] When the pyrexia attending rheumatifm has en-
 tirely ceafed; when the fwelling, and particularly the red-
 nefs ofthe joints, are  entirely gone ;  but when pains ftill
 continue to  affea certain joints, which remain ftiff, which
 feel uneafy upon motion, or upon change of weather; the dif-
 eafe is named the  Chronic  Rheumatifm? as it very often 
O F  P H Y S I C.                173
continues for a long time.  As the chronic is  commonly
the fequel of the acute rheumatifm, I think it  proper to
treat of the former alfo in this place.
   450.] The limits between the acute and chronic rheuma-
tifm are not always exaaiy marked.
   When the pains are ftill ready to fhift their place ; when
they are efpecially  fevere in the night-time ; when, at the,
fame time, they are attended with fome degree of pyrexia,
and with fome fwelling, and efpecially with fome rednefs
of the joints;  the difeafe is to be confidered as ftill partak-
ing the nature of the acute rheumatifm.
   But when there is no degree of pyrexia remaining; when
the pained joints are without rednefs; when they are cold
and ftiff; when they cannot eafily be made to fweat;  or
when while a free and  warm  fweat is brought out on the
reft of the body,  it is only clammy and cold on  the pained
joints ;  and when, efpecially the pains of thefe joints are
increafed by cold,  and relieved by heat applied to them;
the cafe is  to be confidered as that of a purely chronic
rheumatifm.
   451.] The chronic rheumatifm may affea different joints;
 but is efpecially ready to affea thofe joints which are fur-
rounded with many mufcles, and thofe of which themufeles
are employed in the moft conftant and vigorous exertions.
 Such is the cafe of the vertebrae of the loins, the affeaion
 of which is named Lumbago; or that of the hip-joint, when
 the difeafe is named lfchias, or Sciatica.
    452.] Violent ftrains and fpafms occurring on  fudden
 and fomewhat violent  exertions,  bring on rheumatic af-
 feaions, which at firft  partake ofthe acute, but very foon
 change into the nature of the chronic rheumatifm.
    453. J I have thus delivered the hiftory of rheumatifm;
 and fuppofe,  that, from what has been faid, the  remote
 caufes,  the diagnofis,  and prognofis of the difeafe, may
 be underftood.   The diftinction of the  rheumatic pains
 from thofe refembling them, which occur in the  fyphilis
and feurvy, will  be obvious, either from the feat of thofe
 pains,  or  from  the concomitant fymptoms peculiar to
 thefe difeafes.*   The diftinttion of rheumatifm from gout
   * To diftinguifh the chronic rheumatifm from venereal or fcorbuticpains,
is, however, in fome cafes, extremely difficult, tr.J cfien requires the uunuft 
174                 PRACTICE

will be more fully underftood from what is to be delivered
in the following chapter.
   454.] Withrefpea to the proximate caufe of rheumatifm,
there have been various opinions.  It has  been imputed to
a* peculiar  acrimony; of which, however,  in ordinary
cafes, I can find no evidence; and from the confideration
ofthe remote caufes, the fymptoms,  and cure of  the dif-
eafe,  I  think the fuppofition very improbable.
   The caufe of  an  Ifchias Nervofa affigned by Cotux-
nius, appears to me hypothetical, and is not fupportcd
by either  the phenomena or method of cure.   That, how-
ever, a difeafe of a rheumatic nature may be occafioned
by an acrid  matter applied to the nerves, is evident from
the toothach, a rheumatic affeaion generally arifing from
a carious tooth.
   That pains  refembling thofe of rheumatifm may  arife
from dcep-feated fuppurations, we know  from fome cafes
depending on fuch a caufe, and which,  in their fymptoms,
refcmble  the lumbago or ifchias.  I  believe,  however,
that by  a  proper attention, thefe cafes  depending  on fup-
puration,  may be commonly diftinguifhed from  the genu-
ine cafes of lumbago and ifchias ; and, from what is faid
in (447.) I judge it to be at leaft improbable,  that a genu-
ine lumbago or ifchias does ever end in fuppuration.
   455.] The proximate caufe of rheumatifm  has been by
many fuppofed to be a lentor of  the fluids obftruaing the
veffels of  the part;  but the fame confideration as in (241.
*5 2, 3,  4, and 5)  will apply equally here for rejeaing
the fuppofition of a lentor.      *
   456. J While I cannot,  therefore,  find either evidence
or reafon  for fuppofing that the rheumatifm depends upon
any change in the ftate of the fluids,  I muft conclude, that
the proximate caufe of acute rheumatifm,  is commonly thg
fame with that  of other inflammations not depending upon
a dirett ftimulus.
   457.J In the cafe of rheumatifm, I fuppofe,  that the
fagacity of the pracliticner.  A due attention to the caufes of  rheumatifm,
recited in the foregoing articles, and a ftriclexamination whether the patient
has been fubjefted  to thefe  caufes, will fometimes determine the difeafe;
but it oftign happens, that the fame caufes  which produce rheumatifm, alfo
exacerbate venereal and foorbutic pains.  No general rules can be delivered
on this fubject;  and the practitioner muft truft to his own fagacity fur direc-
tion in this difficult diagnofis. 
OF  PHYSIC.
175
moft  common remote caufe of it, that is, cold applied,
operates efpecially on the veffels of joints,  from thefe be-
ing lefs covered by a cellular texture than thofe of the in-
termediate parts of the limbs.   I fuppofe further, that the
application of cold produces a con(tri6tion ofthe extreme
veffels on the furface, and at the fame time an increafe  of
tone or phlogiftic diathefis in  the  courfe of them, from
which arifes an  increafed impetus of the blood, and,  at
the fame  time, a refiftance to  the * free paffage  of it, and
confequently inflammation and pain.  Further, I fuppofe,
that the refiftance formed  excites the vis medicatrix to a
further increafe of the impetus ofthe blood;  and, to fup-
port  this,  a cold  ftage arifes, a fpafm  is formed,  and a
pyrexia and phlogiftic diathefis are produced in the whole
fyftem.
   458.]  According to this explanation, the caufe of acute
rheumatifm appears to be exactly analogous to that of the
inflammations depending on an increafed afflux of  blood
■to a part while it is expofed to the aaion of cold.
   But there feems to be alfo, in the cafe  of rheumatifm, a
peculiar affection ofthe fibres ofthe mufcles.
   Thefe fibres feem to be under fome degree of rigidity,
and  therefore lefs eafily admit of motion; and are pained
upon the exertions of it.
   It is alfo an affeaion of thefe fibres which gives an op-
portunity to the  propagation  of pajns from one joint to
another, along the courfe of the mufcles, and which pains
are more feverely felt in the extremities of the mufcles ter-
minating in the  joints, becaufe,  beyond thefe,  the ofcil-
lations are not propagated.
   This  affection of the mufcular fibres attending  rheu-
matifm,  feems to explain why  ftrains  and fpafms produce
rheumatic affections; and, upon the  whole,  fhows,  that,
with an inflammatory affeaion of the  fanguiferous fyftem,
there is alfo in rheumatifm a peculiar affection of the muf-
cular fibres, which has a  confiderable fhare in producing
the phenomena of the difeafe.
   4 59-J  Having thus given my opinion  ofthe proximate
caufe of rheumatifm,  I proceed to treat ofthe cure.
   460. J  Whatever difficulty may occur with refpea to die
explanation given, (457. and 458.) this  remains certain; 
If 6                 PRACTICE
 that in acute rheumatifm, at leaft in all thofe cafes which
 do not arife from direa ftimuli, there  is an inflammatory
 affeaion of the parts, and a phlogiftic diathefis in the whole
 fyftem ;  and upon thefe  is founded  the method of cure,
 which frequent experience has approved of.
   461.]  The cure therefore requires, in the firft place, an
 antiphlogiftic regimen, and particularly a total abftinence
 from animal food, and from all fermented or fpirituous li-
 quors ; fubftituting a vegetable or milk diet, and the plen-
 tiful ufe of bland diluent drinks.
   462.]  Upon the fame principle  (449) at  leaft with per-
 haps the fame exception as above, blood-letting is the chief
 remedy of  acute rheumatifm.   The  blood ought to be
 drawn in large quantity, and the bleeding is to be repeated
 in proportion to the frequency,  fullnefs, and hardnefs of
 the pulfe, and to the violence  of the pain.   For the moft
 part,  large  and repeated  bleedings,  during the  firft days
 of the difeafe, feem to be neceffary, and accordingly have
 been very much employed: but to this fome bounds are
 to be fet; for very profufe bleedings  occafion a  flow re-
 covery, and, if not abfolutely effectual, are ready to pro-
 duce a chronic  rheumatifm.
   463.]  To avoid that debility of the  fyftem, which ge-
 neral bleedings arc ready to occafion,  the urgent fymptom
 of pain  may be often relieved  by topical bleedings; and
^efpecially when  any,  fwelling  and rednefs   have come
 upon a joint, the pain of it may be very certainly relieved
 by fuch bleedings; but,  as the continuance of the difeafe
 feems to depend  more upon the phlogiftic diathefis of the
 whole fyftem, than  upon the affeaion of particular parts,
 fo topical bleedings will not always fupply the place ofthe
 general bleedings propofed above.*

  •Thefe topical bleedings, however, have by repeated experience been found
 of effential advantage, efpecially when the partial inflammation has been very
 violent   They are beft performed by leeches, many of which ou^ht to be ap-
 plied all over the inflamed part. Cupping has been long the favorite praftice
 of many phyficians, bnt it generally irritates more than the leeches ; vet in
 cafes that require immediate relief, it is preferable to them.  The Glauber,
 or Eplom falts, are  the moft convenient purges hi all cafer. of acute rheuma-
 tilm.  Either of them  may be given feparately, or  join«d with  the infufum
 iennx, as m the following formula :
           jRc« Intus. Senna ^iii.
  *          Sal.  Glauber. §ss.
              Tinct. Jalap. 3i« 
OF  PHYSIC.                 177
   464.] To take off the phlogiftic diathefis prevailing in
this difeafe. purging may be ufeful, if procured by medi-
cines which do not ftimuhte  the whole fyftem, fuch as neu-
tral falts, and which have, in  fome meafure, a refrigerant
power.  Purging, however,  is not fo powerful as bleeding,
in removing  phlogiftic diathefis; and when the difeafe has
become general and violent,  frequent ftools are inconveni-
ent, and even hurtful, by the motion and pain which they
occafion.
   465. J In acute rheumatifm,  applications to the p:,inful
parts are of little  fervice.   Fomentations, in the beginning
of the difeafe  rather  aggravate,  than relieve the pains.
The rubefacients  and camphire are  more effeaual in  re-
lieving the pains;  but generally they only fhift  the pain
from one part into  another,  and do little towards  the cure
of the general affection.  Bliftering, applied to the pained
part, may  alfo be very effeaual in removing the pain from
it;  but will be  of little ufe, except where the  pains  are
much confined to one part.
   466.] The feveral remedies  mentioned  from  (450. to
 454.) moderate the violence ofthe difeafe, and fometimes
remove it entirely; but  they fometimes fail  in this, and
leave the cure imperfea.   The attempting a cure by large
and repeated bleedings, is attended with many inconvenien-
ces, (fee 140.) and the moft effeaual and  fafe method of
 curing this difeafe, is, after fome general bleedings for tak-
 ing off, or at leaft diminifhing,  the  phlogiftic  diathefis, to
 employ fweating, conducted by  the rules laid down (168.
 and  169.)*
    467.j Opiates, except where they are direaed to pro-
 cure fweat, always prove hurtful in every ftage of this  dif-
 eafe. t
              Tinct. Aromat. ^ss.
              M. f. haus%
 The more fuddenly purges operate in acute rheumatifms, the more efficacious
 are they generally found ; and as large dilu.ing warm thin liquors confidera-
 bly accelerate the operation cf all purges, fuch practice is never to be neglect-
 ed in thefe cafes.  Cream of tartar whey, mixed with twice its quantity of
warm water, is a very proper drink to alfift the operation of purges.
   * Sweating is moft effectual in this difeafe,  when produced  by Dover's
powder.  The dofe of it is 12 or 15 grains, repeated at intervals, of two
or three hours, till a fweat be produced.  Diluent drinks are to be ufed with
 it : and it may be ncceffary to obferve, that they ought to be fuch as areJjand
and by no means ftimulating; viz. barley-water, lintfeed-tea, thinwater-^uel.
   t Notwithftanding this caution, many practitioners ufe opiates, efpeci^ly
   Vol.  I.                   Z                        A
• 
178
P R A C TICE
   468.] The peruvian bark  has  been fuppofed a remedy
in fome cafes of this difeafe ; but we have feldom found
it ufeful, and in fome cafes hurtful.   It appears to me to
be fit in thofe cafes only, in which the phlogiftic diathefis
is already much abated, and where, at the fame  time, the
exacerbations ofthe difeafe are manifeftly periodical, with
'confiderable remiffions interpofed.*
   469. J Calomel and fome other preparations of mercury,
have been recommended it  the acute rheumatifm  ;  but I
believe they are ufeful only in  cafes of the chronic  kind,
or at leaft  in cafes approaching to the nature of thefe.
   470.] Having now  treated fully ofthe  cure of the acute
rheumatifm, I proceed to treat ofthe cure of the chronic,
which  is fo frequently a fequel ofthe former.
   471. J The phenomena ofthe purely chronic rheumatifm,
mentioned in (438. and 439.) lead me to conclude,  that its
proximate caufe is an atony, both of the blood-veffels and
of the mufcular fibres ofthe part affeaed, together with a
degree of  rigidity  and contraaion in the latter,  fuch as
-frequently attends them in a ftate of atony.
   472. J Upon this view ofthe proximate caufe  the  gene-
ral indication of cure  muft be, to reftore the aaivity and
vigour ofthe vital principle in the part;  and the remedies
for this difeafe, which experience has approved of, are  chief-
ly fuch as are manifeftly fuited to the indication propofed.
   473.] Thefe remedies are either external or internal.
   The external are, the fupporting the heat ofthe part, by
keeping it conftantly covered with flannel; the increafing
the heat ofthe part by external heat, applied either  in a dry
-or in a humid form ;  the diligent ufe ofthe flefh-brufh, or

when joined with camphor,  to procure fweats in acute rheumatifm. This
compound never fails to increafe  the phlogiftic diarhelis, and confequently
muft be  hurtful. In the chronic rheumatifm, indeed, camphor and opium to-
gether form a valuable medicine.  The dofe is the following bolus  :
           R. Camphor,  gr. vi.
             Sp. Vini. gutt. x.
             Opii gr. i.
             Tart. Vitriol gr. xv.
             Syr. q. s.  M. f. bolus.             !*
  * Bark is always an amb'iguous remedy in rheumatifm, and on its  firft in-
troduction into practice it was thought to occafion  or induce the  difeafe.
Vtiterever an inflammatory diathefis prevails, the Peruvian barkis always an
irrr^oper medicine,  and  it  has been found by experience to be  manifeftly
feurtful  in the beginning, or inflammatory ftate of the  rhemnatifm.
  t 
                      OF  phytic.                   m


other means of  friction ; the  application of efearicity in
fparks or Ihocks ;  the application of cold * water by  affu-
hon or immerfion ; the applica-tion of effential oils of the
moft warm and  penetrating kind;  the application of fait
brine; and, laltly, the  employment of cxercife,  either of
the part  itfelf fo far as it can eafily bear it, or of the whole
body bv riding  or other mode of geftation.
   474. J  The interred remedies are,. 1.  Large dofes  of ef-
fential oil drawn from refinous fubftances,  fuch as turpen-
tine ;J  2.  Subftanees containing  fuch oils, as guaiac ;,t  3.
Volatile  alkaline falts ; 4.  Thefe,  or other  medicines di-
reaed to procure fweat, (169.)  and,  laftly,  Calomel,|[ or
other preparation  of mercury, in  fmall  dofes, continued

for fome time.

   475-] Thefe  (462,  463.) are the remedies fuccefsfully
employed in the purely chronic rheumatifm ; and there are
ftill  others  recommended.   As bleeding, general and to-
pical, burning, bliftering,  and iffues : but  thefe appear to
me to be chiefly,  perhaps  only,  ufeful  when  the  difeafe
ftill partakes ofthe nature of acute rheumatifm 4.

   * This,  when compared with art. 457 and others, feems to be a typogra-
phical error, and  the author meant warm.   Pra&ice affords many inftances
of chronic rheumatifm being occafioned by cold bathing.
   f Turpentine is an extremely healing oil, as indeed are all the effential oils ;
its ufe therefore requires the greateft caution.  The dofe is from 8 to 15 drops
on a piece of  fugar.  Venice turpentine may be more conveniently given in
 the form of an emulfion, by diffolving it in water by means-of.yoiks of eggs.
 Two fcruples of turpentine is the ordinary dofe ; and when  given in this  li-
 quid and diluted llate, is much preferable to the oil.
   \ The officinal preparations of guaicum, are an extract of the wood* a folu-
 tion of the gum in rectified fpirit,. another in volatile  alkali, and an empyreu-
 matical oil.  The gum may be given in the quantity of  15 or 20 grains for a
 dofe, either in a belas, or made into an emulfion  with yolk of egg and  an
 ounce or two of water : In larger quantities it is too purgative.  The volatile
 tlixer of the Edinburgh Pharmacopoeia is  an excellent form, as the volatile
fpirit promotes the medicinal virtue ofthe guaiacum.  The dofe  of it is from
a drachm to half an  ounce, morning and evening, in any convenient vehicle ;
a tea-cupful of milk is the beft, as it (heaths in forne meafure  the pungency of
the medicine;  Guaiacum is very conveniently joined with rhubarb and mag-
nefia, when we find that(fuch a dofe of it, a.-, is neceffary for procuring a fuf-
ficient opening, would be. too heating.   A formula of this kind is defcribed
in the note on article 558.
   |j Calomel, perhaps, has only beenferviceable in venereal cafes.
   | The diet in the cure of chronic rheumatifm ought tobe generous and full.
In many cafes, efpecially among people in poor circumftances,  good living,
with two or three glaffcs of fherry in the day, has cured the difeafe without
any medicines. One material circumftance ought not to be omitted: viz. that
the cure is much impeded by coftivenefs :  if, therefore, the guiacum does not
procure two motions in the day, it will be neceffary to give along with it'iome
warm laxative.  The tiniftura facra is a proper medicine in thefe cafes :  its
dole is fi• jiu one to two ounces ' As is alfo the elixer facrum of the Edinburg; 
180                PRACTICE
                   CHAP. XIII.

        ©f t&e €Toot&ac&,  or SDEontnlgia,

476.] i HAVE formerly confidered this difeafe as a fpe-
cies of Rheumatifm, to be treated upon the lame principles
as thofe delivered  in  the  preceding  chapter;  but  now,
from more attentive confideration, I am led to confider the
toothach as a diflinct difeafe. Whilft the moft of what has
been delivered in the laft chapter proceeds upon the fup-
pofition that the rheumatifm depends upon a certain  ftate
ofthe blood veffels and of the motion of the blood in them,
without this being produced by the  irritation of any acrid
matter applied ; I judge,  that in the toothach, though there
are often the fame  circumftances in the ftate of the blood
veffels as in the cafes of  rheumatifm, thefe circumftances
in toothach  always arife  from the application of an acrid
matter to the nerves of the teeth.    1
   477. J This difeafe  is often no other than a pain felt in
a particular  tooth, without any inflammatory affeaion be-
ing at the fame time  communicated  to  the  neighboring
parts.  This, however, is rarely the cafe ;  and for the moft
part, together with the pain of the tooth, there is fome de-
gree of pain and of inflammatory affeaion communicated
to the neighboring parts, fometimes to the whole of thofe
on the fame fide of the head with the affeaed tooth.
   478. J This inflammatory affeaion feems to me to be al-
ways an affeaion of the mufcles and of the membranous
parts conneaed with thefe,  without any tendency to fup-
puration; and fuch an affeaion, as  is excited by cold in
fimilar parts elfewhere. It is from thefe circumftances that
I conclude the affeaion to be of the rheumatic  kind.
   479. J It is poffible  that the mufcles and membranes of
the jaw may be affeaed by the fame caufes which produce
the rheumatifm in other parts;  and it is alfo poffible, that
a rheumatic diathefis at  firft produced by irritation, may
fubfift in the mufcles  and  membranes of the jaw, fo that
the inflammatory affeaion may be renewed by certain cau-
fes without any new application of acrid matter: But I am
College Pharmacopccia, its dofe may be fror  a drachm to half an ounce, ss
eccafion may require. 
OF  PHYSIC.
181
pcrfuaded that either  of thefe occurrences are very rare,
and I have never been able to afcertain ahy cafes of tooth-
ach to be of thefe kinds.  I confider it, therefore, as high-
ly probable that this rheumatic affection of the jaws winch
we name toothach,  is always dependent upon fome imme-
diate application of acrid matter to the nerves ofthe teeth.
   480.J It is  however to be obferved,  that  this applica-
tion of acrid matter does not always excite  a pain in the
tooth itfelf, or an inflammatory affeQion of the  neighbor-
ing parts; but that  it v*ery often operates by  producing  a
diatheiis only;  fo that cold applied to  the neighboring
parts does excite both a pain in the tooth, and an  inflam-
matory affeaion of the neighboring parts  which did  not
appear before.
   There feems to be alfo certain ftates of the body, which
operate upon the fame diathefis fo  as to produce toothach.
 Such feems to be the cafe of pregnant women, who are
 more  liable to  toothach than other  women.  There are
 probably alfo fome cafes  of increafed irritability which
 render perfons more  fubjea to toothach.    Thus  women
are more liable to the difeafe than men, and particularly
 women liable  to hyfteric affeaions.
   481.]  The acrid matter producing this difeafe feems to
 be generated firft in the hard fubftances of the teeth;  and
 as it often appears firft upon the external  furface of thefe,
 it might be fufpeaed  to arife from the application of exter-
 nal  matters to the teeth:   But as  the  production  of this
 acrimony is often begun in the internal cavity of the teeth,
 where the operation of external matters cannot be fufpefct-
 ed,  and as even when it begins upon the external parts of
 the teeth, the operation of the  caufe is at firft in a fmall
 portion ofthe teeth only,  that it is difficult to fuppofe that
 any matter externally applied could  a£t in  fuch a partial
 manner;  fo it is prefumed that the acrid matter occafion-
 ing the toothach is produced by fome vice originating in
 the fubflance of the tooth itfelf.  When it begins upon the
 external furface, it is on the enamel; but upon  the inter-
 nal  furface, it  muft  be in the bony part.  From  what
 caufes it  arifes  in  either of thefe fubftances, I do not at
 all know;  but I fufpea diat it often arifes from fome more
 general fault in  the  fluids of the body.  The frequent ufe 
182
PRACTICE
of mercury, efpecially when thrown much upon the mouthy
and the ftate ofthe fluids in feurvy, feem both of them to-
give a difpofition to a caries in the teeth; and it is poffi-
ble that fome other  acrimonious ftates of the fluids may
have the fame effea.
   482.] A caries in fome'part ofthe teeth, whether arif-
ing upon their internal furface or upon their external, pro.
ceedingfo far as to reach the nerves in the cavity of the
teeth,  is pretty manifeftly  the caufe of  toothach, and of
the firft attacks of it; but when  the cavity of (he teeth has
been opened,  fo that the external air  or other matters can
reach that  cavity, thefe are often the exciting caufes of
toothach,  and ferve to prove in general,  that acrid mat.
ters applied to the nerves occafion the difeafe.
   483. J What is the nature of the matter produced in the
caries  ofthe teeth, I do not uhderftand,  nor have I found
any proper correaor of it; but  I prefume it to  be ofthe
putrid kind, as it often taints the  breath with a fetid odo%
   484.] In the cure of this difeafe, a long experience has
fhown, that the extraaion of the carious tooth proves the
moft effeaual, and very often the only effeaual, remedy
of the  difeafe.   But as in fome cafes this  extraaion is not
proper, and as in many cafes it is obttinately avoided, other
means of curing the difeafe, or at leaft of relieving the pain,
have been fought for and much  praaifed.
   485.] Among thefe remedies, thofe arc likely to be the
moft effectual which entirely deftroy the affeaed nerve, or
at leaft fo much of it as is expofed to the aaion ofthe acrid
matter in the tooth.   Wnen an  opening  is made into the
cavity of the tooth, the nerve of it may be deftroyed moft
certainly by the aaual cautery ;  and  it may alfo poffibly
be done by  the application of potential cauftics,  either of
the alkaline or acid kind.
   486.] When thefe remedies  cannot be rendered  effec-
tual, relief may often be obtained by dimini thing the fen-
fibility ofthe nerve affeaed, by die application of opium,
or of  the more acrid aromatic oils,* and direaiy to the
nerve in the tooth.   It appears alfo, that the fenfibility of
the affeaed nerve may often be  for fome time diminiihed
  * The Oleum Origani is the oil generally ufed for this purpofe. Great care
muft be taken in ufing either thefe acrid effential oils, or the vr.riolic or other
mineral acids, that n.opart of them touch the gums. 
U 1?  PIT Y SIC.                183
by the external application of opium to the extremities of
thofe nerves  in  the fkin, which are branches ofthe fame
fifth pair of nerves with thofe of the teeth.
   487.] When the difeafe confifts entirely in a pain ofthe
nerve of the tooth, without any confiderable affeaion com-    •
municated  to the neighboring parts, the remedies  already
mentioned  are thofe efpecially to be employed; but when
the difeafe confifts very much in an inflammatory affeaion
of the mufcles and  membranes of the jaw,  and when at
the  fame time there is little or no accefs for the abovemen-
tioncd remedies to the affeaed nerve, other  meafures are
to be employed for relieving the difeafe.
   488. |  If the difeafe he attended with any general phlo-
giftic diathefis of the fyftem, or with any confiderable de-
gree of pyrexia, a general bleeding may be ufeful in reliev-
ing the dileafe; but  thefe circumftances occur very rarely,
and the difeafe is for the molt part a purely topical affec-
tion; in which,  as  I obferved before, a  general bleeding
is of very little fervice.   As this difeafe,  however, is a to-
pical inflammation, it might be  fuppofed  that  topical
bleedings would be very ufeful,  and fometimes they are
fo;  but  it in  feldom that their effeas are either confider-
able or permanent.  The reafons of this I take to be that
the difeafe docs  not confift in an affeaion of the  blood-
vefiels alone, as in  the ordinary cafes of rheumatifm;  but
in a peculiar affeaion of the fibres both of the mufcles and
ofthe veffels ofthe part induced by irritation.   The inef-
ficacy of Lopical bleedings is with me a proof of the difeafe
being of the latter kind.
   489.]  The remedies therefore neceffary to give relief
in this difeafe, are thofe which take off the fpafm  of  the
veffels, and efpecially of the mufcles and membranes affect-   ,
ed.   Such are bliftering, brought as near to the part affea-
ed as can be conveniently done ;* and fuch are alfo increaf-
  * Blifters  are applied moft fuccefsfully behind the ears, fuch applications,
however, are always tfoublefome ; and their effects are often doubtful, other
milder ftimulants frequently anfwer all the intention of blifters, and by' many
praaitioners are thought to be equallv efficacious.  The applications general-
ly ufed are camphorated fpirit, or * ol'atile alkali. This laft, either alone or
mixed with an equal quantity  of oil of almonds rubbed on the jaw, the part
being kept warm by apiece of flannel, has often been found extremely ufeful
Warmth, any how produced on the part, always gives relief; while on  the
contrary, cold always ejiafperates the fymptoms ; hence the propriety of co-
vering tlie jaws with flannel, and ayoiding a cold, ftreajn of air.         J 
184                 PRACTICE
ed excretions excited in the neighbouring parts, as of the
faliva and mucus of the mouth by the ufe of acrid mafti-
catories *  It is often fufficient to excite a ftrong fenfation
in the  neighboring parts ; -as  by can de luce,  fpirit of la-
vender, or Hungary  water fnuffed  up the noftrils;  or by
the vitriolic aether properly applied  to  the cheek.   It is
upon the fame footing  that I  fuppofe brandy or other ar-
dent fpirit held in the mouth is often of fervice.
   490. J There are cafes of toothach in  which it does not
appear that the difeafe arifes  from  an acrid matter imme-
diately applied to the nerve ofthe tooth ;  but from the ex-
ternal application of cold,  or  fome other  caufes immedi-
ately applied to  the mufcles and membraircs of the jaw;
and which therefore feem to require fome remedies differ-
ent from thofe above mentioned.  But in all  fuch  cafes,
it is  to be  fufpecled. that  the effects of cold  or of feme
other fuch caufes are owing to a diathefis produced  by an
acrid matter  applied to the nerve of  a tooth,  ana conti-
nuing in fome meafure  to aa  there ; and we have accord-
ingly often found,  that the aaion of thofe external caufes
were to be obviated only by the extraaion  of the-tooth
from which the diathefis had arifen.
                     CHAP.  XIV.

                    fiDf t&e mut
491-]  A HE Gout, not only  as it occurs  in different
rri
perfons, but even as it occurs in the fame perfon at differ-
ent times, is a difeafe of inch  various appearance,  that it
is difficult to  render the hiftory of it complete and exact,
or to give a eharaclcr of  it that  will  univerfally apply.
   Thefe arc horfe-radifh, fcurvy-grafs, the greater celandine, with fome
others ; but the radix pyrethri is the beft.  In feme Pharmacopoeia, but I do
not recollect which, there is a formula, called Trcchifci Sialagcgi, to the beft
oi my remembrance as follows :
          R. Pulv. Had. Tyr'-hri, §i.
             Gum. Mastich.  Bss.
             01. Caryophyll. Aromat.
             01. Marjoranae  a a §i.
             Cerx Alb. g;. •.;. ut. f. Trochisci.
One of thefe held in the mouth, cr chewed, promotes a COpiowdifcharg* of
ialvia, by warming and ilimujating the falivary glands.     • 
OF  PHYSIC.                   185
However,  I  fliall  endeavor  to  defcribe the  difeafe as  it
moft commonly appears,  and to mark the varieties of it as
well as I can.    From fuch a hiftory I expect that a general
charaaer mav be given ; and fuch I think is the following,

as given in the laft edition of our Nofology:
   Gen.  XXIII.  PODAGRA.    Morbus hsereditarius,

oriens fine can la externa evidente,  fed praeeunte plerum-
que ventriculi affeclione infolita;  pyrexia ; dojor ad arti-
culum et plerumque pedis pollici, certe pedum et manuum
junauris, potiffimum infeftus;  per  intervalla revertens, et

faepe cum ventriculi et internarum partium affeaionibus al-

ternans.
   492.]  The  Gout  is generally a hereditary difeafe: but
fome perfons, without hereditary difpofition, feem to acquire
it;  and, in fome a  hereditary  difpofition  maybe coun-
teracted  by  various caufes.  Thefe circumftances  may
feem to give exceptions to our general  pofition;  but the

facts direaiy fupporting it are very numeroas.
    493.] This  difeafe attacks efpecially the male fex: but
it fometimes, though more rarely, attacks alfo the female.*

   *  Hippocrates fays, that women feldom have the gout, and  never before
 the  disappearance of the catamenia.  In his time and country,perhaps the la-
 dies were more temperate than they were in other ages and in other places.
We  find the gout a familiar difeafe among the Roman ladies ; which Seneca
 in his 95th epiftle, jullly afcribes to the  luxurious living and debaucheries,
 in which they iniulged without controul.  As the whole of that epiftle is an
 excellent account of the direful effects of high living and debauchery, it may
 not  be unacceptable to the young praditioner, who perhaps, might otherwife
 be unacquainted with fo jutt a deicription df luxurious living, and its concom-
 itant evils.  Independent of its containing a minute relation of Roman cuf-
 toms, which makes it a valuable morfel for antiquaries,  it may be read with
 peculiar advantage by the young phyfician.   As an apology for giving it iu
 the original, I fliall fay of Seneca, what an elegant Englifh writer fays of Ci-
 cero ; That any tranflation of his nervous language, is like the faint glimmer-
 ings of a taper compared with the blazinglight of the meridian fun.
   "  Medicina quondam paucarum fuit fcientiaherbarum,  quibus iifteretur fan-
 guis flueas, vulnera coierent paulatim. Ueinde  in hanc pervenit tam multi-
 plicem varietatem.   Nee  mirum eft  ; tunc illam minus  negotii habuifle, fir-
 mis  adhuc.jfolidifque corporibus, et facili cibo, nee per artem voluptatemque
 corrupto.  Qui poftquam cocpit, non  ad tollendam, fed ad irritandam famen
 quieri, et inventae funt mille conditurx, quibus aviditas excitr.retur^ qux de-
 fiderantibus alimcnta erant, onera funt plenis.  Inde pallors et nervorum vi>
no madentium tremor, et rniferabilior ex cruditatibus quam ex fame macies.
Inde incerti labantium pedes, et Temper qualis in ipia ebrietate titubatio. In-
de in t tam cutem humor admifrus.difrentusque venter, dum male affuefcitplus
capere, quam poterat.  Inde fuffufioluridae bilis,  et decolar vultus, tabefquo
in ie putrcfcentium, et retorti digiti articulis obrigefcentibus, nervorum fine
fiinfu jacentiu n, torpor aut palpitatio line intermiflione vibrantium.   Quid
capitis vt*»|giues dicam 'Quid oeulorum aairiumquetormenta, et cerebri aftu-
 antis verminati«ne?, et omnia per quae exoneiaoiw intends ulceribus affefta i
   V»». I.                    A. a 
186
PRACTICE
  The  females  liable to it are thofe ofthe more robuft and
  full habits;  and it very often happens to fuch long hefore
  the menftrual evacuation has ceafed.   I have found it oc-

  curring in  feveral females,   whole  menftrual evacuations
  were more-abundant than  ufual.
     494.]  This difeafe  feldom attacks eunuchs, and when it

 does, they feem to  be  thofe  who happen to be  of a robuft
 habit, to lead an indolent  life, and live very  full.

  Innumerabiliapraeierea febrium genera, aliarum irapetu fubeuntium, aliarura
 tenui pefte repentium, -aliarum cum horrore et multa membrorum quaffatione
 venientium ?  Quid alios referam  innumerabilos morbos,  fupplicia luxuriz I
 Immunes erant ab iftis malis qui nondum  fe deliciis folverant, qui fibi impe-
 rabant, fibi miniftrabant.  Corpora opera ac vero labore durabant, aut curia
 ■clefatigati,  aut tellure verfata.  Excipiebat illos cibus qui nifi efurieiuibus
 piacere non poterat. Itaque nihil  opus erat tarn magna medicorum fupellec-
 tile, nee tot ferramentis atque pyxidibus.  Simplex erat ex fimplice caufa va-
 letudo.  Moltos morbox multa "fercula fecerunt.  Vide quancum rerum per
 unam gulam tranfiturarum permifecat luxuria, terrarum marifque vaftatrix.
 Neceffe eft itaque  inter fe tarn diverfa diflideant,  et haufta mali  digerantur,
 aliis alio nitenMbus.  Nee mirum.quod inconftans variufque ex difcordioibo
 morbus eft, et ilia ex contrariis naturae partibus in eundem compulfa redundant.
 Inde tarn nullo jegrotamus .genere quam vivimus.  Maximus ille  medicorunij
 •et hujus fcientix conditor,-feminis nee capilios dufluere  dixit, nee pedes labo-
 raxe.  Atqui hae jam et capillis deftiunnrur, et pedibus  aegrae funt.  Non mu<
 tata feminarum narnra, fed vita eft.   Nam cum virorum licentiam aequave-
 rint, corporum quoque virilium vitia  aequaverunt.  Non minus per vigilant,
 non minus potant, et oleo et mero  viros provocant. jEque itwitis ingefta vif-
 ceribus per os reddunt, et vinum omne vomitu remetiuntur; aeque nivem ro-
 'dunt, folatiunvftemachi jeftuantis.  Libidini vero necmaribus quidem cedunt,
 pati natae Dii illas deaeque male perdant:  adeo perverfum comments genus
 impudicitiae viros ineunt.   Quid ergo  mirandum eft, maximum medicorum ac
 naturae peritiffimum, in mendacio prehendi, cum tot femina podagricx calve-
 que  fint.  Beneficium fexus fui vitiis perdiderunt; et quiafeminam exerunt,
 damnatae funt morbis virilibus.  Antiqui medici nefciebant dare cibum faepi-
 us, et vino fulciri venas cadentes;  nefciebant faniem emittere, et diutinam
 segrotationem balneo fiidoribufqu?  larare ;  nefciebant  ciurum vinculo, bra«
 chiorumque, latentem vim, et in medio fedentem, ad extrema revocare.  Noa
 erat hecefle circumfpicere  multa auxiliorum genera cum effent periculorum
 pauciffima. Nuncautem quam longe procefferunt mala veletudinis  ? Has ufu«
 ras voluptatum pendimus, ultra modum fafque conctipitarum.  InnumerabUea
 effe  morbos miraris ? Coquos numera.  Ceflat omne ftuidum : et Iiberalia, pro-
 feffi, fine ulla frequentia, defertis angulis praefident.  In  rhetorum ac philofo-
 phorum fcholis folitudo eft.  At quam celebres culinae funt ? Quanta nepotun
 focos juventus premit ? Tranfeo puerum infelicium greges ; quos  polt tranf-
 afla convivia alix cubiculi contumeliae expectant. Tranfeo agmina exoletorum
 per nationes  colorefque defcripta ;  et  eadem omnibus levitas fit, eadem pri-
 mae  menfura languinis, eadem fpecies  capillorum, ne quis cui redYior fitcomai
 Crifpulis fnifcatur.   Tranfeo piftorum turbam, tranfeo miniftratorum, perquos
 fignio dato ad inferendam coenam difcurritur.  Dii boni quantum hominum
 unus venter exercet! Quid tu illios boletos, voluptarium venemum, nihil oc-
 ulti operis judicas facere, etiamfi praefentanei non furant ? Quid tu illam aefti-
 vam nivem non putas callum jeci noribus obducere ? Quid ilia oftrea, inertiffi-
 mam carnem,  coeno faginatam, nihil  exiftimas limofae gravitatis inferre ?
<^uid illud fociorum garum, pretiofam pifcium faniem,  non credis  urere falfa
 tape praecordia ? Quid ilia ponilenta,  et quae tantum non ab ipfo vifceribus
*xtingui ?  Quam fcedi atque peftilentesruihis funt, quantum faftidiom fui, ex«
tiaUntibus crapuUm vttesem I 
Of  PHYSIC.               IS/
   495.] The gout  attacks efpecially  men of robuft and
large bodies, men of large heads, of full and corpulent ha.
bits, and men whofe fkin is covered with a thicker reie mu-
iosum, which gives a coarfer furface.
   496. ] I f with the ancients, we might afcertaih, by certain
terms, the temperaments of men, I would fay, that the gout
attacks efpecially men of a choleric-sanguine temperament,
and that it very feldom attacks the purely fanguine or me-
lancholic.   It is however^ very difficult to treat this mat-
ter with due precifion.
   497.] The gout feldom attacks perfons employed in con-
ftant bodily labour, or perfons who live much upon vege-
table aliment.  It is alfo faid to be lefs frequent among
thofe people who make no ufe of wine or other fermented
liquors.
   498. J The gout does not commonly attack men, till af-
ter the age of five and thirty >  and generally not till a ftill
later period.   There are indeed inftances of the gout oc-
curring more early  ; but  thefe are.few in eomparifon of
the  numbers which  agree with what  we  have  given
as the general rule.   When the difeafe does appear early
in life, it feems to be in thofe in whom the hereditary dif-
pofition is very ftrong, and to whom the remote caufes to
be hereafter  mentioned have been applied in a coofider-
able degree.
   499.] As the gout is a hereditary difeafe, and affects ef-
pecially men of a particular habit, its remote caufes may
be confidered as predifponent and occafional.
   500. J The predifponent caufe, fo far asexpreffed by ex-
ternal  appearances  or by the  general temperament  we
have already  marked ; and phyficians have been very can-
fident in affigning the occafional caufes: but, in a difeafe
depending fo much upon a predifpofition, the afftgning the
occafional caufes  muft be uncertain ; as in the predifpo-
fed, the occafional caufes may not always- appear, and in
perfons not  predifpofed, they may appear without effea.
This uncertainty  muft particularly affea  the cafe of the
gout;  but I fliall offer what appears to me moft probable
on the fubjea.
   501.]  The occafional caufes of the gout feem to be of
two kinds.   Firft, thofe  which induce a plethoric ftate of 
ISS                    PRACTICE
the body.   Secondly, thofe which, in plethoric habit?, in-

duce a ftate of debility.
   502.] Of the firft kind are a fedentary indolent manner
of life, a full  diet of animal food, and the large ufe of wine
or of other fermented liquors.   Thefe ciicumftances com-
monly precede the  difeafe;  and  if there  fhould be  any

doubt of their power of  producing it,  the faa,  however,
will be rendered fufticiently probable  by what  has been

obferved in 497.
   503.] Of the fecond kind of  occafional caufes which
induce debility are,  execis  in  venery;*  intemperance  in
the  ufe  of intoxicating  liquors ;t indigcttion,   produced
either by  the quantity or quality of aliments;J  much ap-
plication to ft udy or bufinefs ;|| night-watching:** execf-

five evacuations ;tt the ceafing of ufual labom ;J+ the fud-
den  change  from a very full to  a very fpare diet;|||| the
large ufe of acids and acefcents ;(*) and, laftly, cold(t) ap-

plied, to the lower extremities.


   * Why excefs of venery fhould be caufe of gout, has much engaged the at-
tention of medical writers, and various rcafous have been given why it fhould
produce fuch  an effect. There is not the leaft doubt of the-fact., though fome
authors have  ventured to deny it,  and  have  excluded the excefs of venery
from being a  caufe of gout.  It produces gout not primarily, but fecondarily,
if I may be allowed the expreflion, by inducing a general ftae of debility, and
by weakening the power  of digeftion, both of which circumftances are caufes
of the gout.      f  By intemperate drinking, the action of the  ftomach and
bowels becomes extremely feeble and languid, if it be not wholly deftroyed :
hence continual  indigeftions, to which the origin of the gout is attributed.
   J Both the quantity and the quality of the aliments may produce  indigefti-
on ; and hence the indulging in too great a-quantity  of aliment, as well as in
that which is of an indigeftible nature, are fecondary caufes of the gout:  viz.
caufes which induce a ftate of debility.
   || Much application to ftudy  may d< ubtlefs induce Indigeftion, and thus
increafe the general ftate of debility: it is not, however, by intenfe, or deep
thinking merely, that men grow pale amid their books, but by the fedentary
life which men generally lead, and the untimely lucubrations in  which they
inconfiderately indulge.  Much application to bufinefs can ci.l.  be an occafi-
onal caufe of the gout,  when the bufinefs requires a fedentary and inactive
life ; but as moft bufinefs requires activity, attention to bufinefs is feldom the
caufe of the  gout.
   ** The want of fleep is always a caufe of indigeftion, and increafes debili-
ty more perhaps when carried to excefs, than any other of the circumftances
mentioned by the author.
   ft  That large evacuations induce debility is fuftjciently evident.
   \\ Nothing more effecrually promotes digeftion than proper exercife ;  the
leaving off accuftomed labor muft therefore necefiarily induce indigeftion and
confequently debility.
   ||||  Why this induces debility is evident.  See note on article 548.  ,
   (*)  That acids, by impairing the digeftive powers of the ftomach, may pro-
 duce debility, is what every practitioner allows.
   (f)  How cojd thus applied, can produce a ftate of debility, is not very evi- 
OF  PHYSIC.               189
   504 j The firft (502.) feem to aa by increafing the pre-
difpofition.   The  laft (503.) are commonly the exciting
caufes,  both of the firft attacks, and of the repititions of
the difeafe.
   505.] It is an inflammatory  affeaion of fome of the
joints, which efpecially conftitutes what we call a parox-
yfm of  the gout.  This  fometimes comes on  fuddenly
withont any warning, but is is generally preceded by fev-
eral fymptoms; fuch as the ceafing of a fweating which
the feet had been commonly affected with before; an un-
ufual coldnefs ofthe feet and legs;  a frequent nuinbnefs,
alternating with a fenfe of prickling along  the whole ofthe
lower extremities; frequent cramps ofthe mufcles of the
legs; and an unufual turgefcence of the veins.
   506.J While thefe  fymptoms take place in  the lower
extremities, the whole body is affeaed with fome degree of
torpor and languor,  and the funaions of the ftomach in
particular are more or lefs difturbed.  The appetite isdi-
minifhed, and flatulency,  or other fymptoms of indigefti-
on, are felt,   Thefe fymptoms, and thofe of (505.) take
place for feveral days, fometimes for a week or two, be-
fore a  paroxyfm  comes  on:   but commonly,  upon the
day immediately preceding it, the appetite becomes great-
er than  ufual.
   507.] The circumftanees of  paroxyfms are the follow-
ing.  They come on moft commonly  in  the fpring, and
 fooner or later according as the vernal heat fucceeds iooner
 or later to the winter's cold; and perhaps fooner or later
alfo according as the body  may happen to be more or lefs
expofed to viciffitudes of heat and cold.
   508.J  The attacks are fometimes felt firft in  the even-
ing,  but more  commonly about  two  or  three o'clock of
the morning.   The paroxyfm begins with a pain affeaing
one foot, moft commonly  in the ball or  firft joint of the
great toe, but fometimes in other parts of the foot.   With
the coming on of this pain, there is commonly more or
lefs of cold fhivering,  which, as the pain increafes, gradu-
ally ceafes, and is fucceeded by a hot ftage  of pyrexia,
which continues  for  the fame  time with the pain  ftfelk
dent.  It is, however, one of the occafional caufes of gout, as experie»ce fuf-
ficientlv teftitlcs. 
Htf  190
PR......v.-
 From the firft  attack, the pain becomes by degrees more
 violent, and continues in this ftate with great reftleffnefs
 of the whole body, till next midnight,  after which it gra-
 dually remits;  and, after it has continued for  twenty-four
 hours from the firft attack, it commonly ceafes very en-
 tirely, and with the coming on  of a gentle fweat, allows
 the patient to fall afleep.   The patient,  upon  coining out
 of this fleep in the morning, finds the pained part affected
 with  fome rednefs and fwelling, which, after  having con-
 tinued for fome days,  gradually abate.
   509.] When a  paroxyfm has thus conae on,  although
 the violent pain after  twenty-four hours be confiderably
 abated, the patient is not entirely  relieved from it.  For
 fome days he has every  evening a return of more confi-
 derable pain and pyrexia, and which  continue with more
 or fefs  violence till morning.   After continuing  in this
 manner for feveral days, the difeafe fometimes goes entire-
 ly .off, not to return till after a long interval.
   5 to.] When the difeafe, after having thus remained for
 fome time in a joint; ceafes very entirely, it generally
 leaves the perfon  in very perfea health, enjoying greater
 eafe and alacrity in the funaions of both body and mind,
 than he had for a long time before  experienced.
   511.] At the beginning of the difeafe,  the returns of it
 are fometimes only once in three^or four years : but, ^fter
 fome time, the intervals become fhorter, and  the attacks
 become annual;  afterwards they  come  twice each year,
 and at length recur  feveral times during the whole courfe
 of autumn, winter, and fpring;  and as it happens that,
 when  the fits are frequent, the paroxyfms become alfo
 longer, fo, in the  advanced ftate of the difeafe,  the pati-
 ent is hardly ever tolerably free from it,  except perhaps
 for two or three months in fummer.
   512.] The progrefs ofthe difeafe is alfo marked by the
 parts which it affeas.  At firft,  it  commonly  affeas one
 foot only; afterwards every paroxyfm affeas both feet,
 the one after the other; and, as the difeafe continues to
recur, it not only affeas both feet at once, but after hav-
 ing ceafed in the foot which was fecondly attacked, returns
again into the foot firft affeaed, and perhaps a fecond time
alfo into the other.  Its  changes of place are not only from. 
OF  PHYSIC.                191
one foot to the other,  but alfo from the feet into other
joints, efpecially thofe of the upper and lower extremities;
fo that there is liardly a joint of the body that is not, on
one occafion or other, affeaed.  It fometimes affects two
different joints at the fame time;  but more commonly it
is fevere  in  a fmgle joint only, and paffes fucceflively
from one joint to another;  fo that the  patient's affliction is
often protraaed for a long time.
   513.] When the difeafe has-often returned,  and the pa-
roxyfms have become very frequent,  the pains are com-
monly  lefs violent  than they were at firft; but the patient
is more affeaed with ficknefs,  and the other  fymptoms of
the atonic  gout, which fhall be hereafter mentioned.
   514.] After the firft paroxyfms of the difeafe, the joints
which have been affeaed are entirely reftored to their form-
er fupplenefs and ftrength; but after the difeafe has  recurr-
ed very often,  the joints affeaed  do neither fo  fuddenly
nor  fo entirely recover their  former  ftate,  but  continue
weak and ftiff; and thefe effeas at length proceed to fuch a
degree, that the joints lofe  their motion  altogether.
   515.] In many perfons, but not in all, after the difeafe
has frequently recurred, concretions of a chalky  nature
are formed upon the outride of the joints, and for the moft
part immediately under the fkin.   The matter  feems to be
depofited at firft in a fluid  form, but  afterwards  becomes
dry and firm.   In their dry ftate,  thefe concretions are a
friable  earthy fubftance, very entirely foluble  in acids.
After they have been formed,  they contribute, with other
circumftances, to deftroy the motion of the joint.
   516.] In moft perfons who have laboured under the gout
for many years, a nephritic affection comes on, and difca-
vcrs itfelf by all the fymptoms which ufually attend calcu-
lous concretions in  the kidneys, and which we fhall have
occafion to defcribe in another  place.  All that is neceffary
to be obferved here is, that the nephritic affeaion alternates
with paroxyfms of the gout; and that the two affeaions,
the nephritic and the gouty, are hardly ever prefent at the
fame time.  This alfo may be obferved, that children of
gouty or nephritic parents, commonly  inherit one or other
of thefe difeafes; but whichever may have been the prin-
cipal xiifeafe of the parent, fome of the  children  have the 
152
PRACTICE
one, and fome the other.   In fome of them, the nephritic
affeaion occurs  alone, without  any  gout fupervcning;
and this happens to be frequently the cafe ofthe female off-
fpring of gouty parents.
   5y.] In the whole ofthe hiftory already given I have
defcribed the moft common form ofthe difeafe; and which
therefore, however divcrfified in the manner I have faid,
may be ftill called the regular ftate of the gout.  Upon oc-
ca! on,  however, the difeafe affumes different appearan-
ces;^ but, as I fuppofe the difeafe  to depend always upon
a  certain  diathefis or difpofition  ofthe  fyftem;  fo every
appearance which  we  can perceive to depend upon that
fair.e difpofitionj 1  fliall confider as a fymptom and cafe of
the <*out.   The  principal circumftance in what  we  term
the Regular gout,  is the  inflammatory affeaion  of the
joints;;  and, whatever fymptoms we  can perceive tobe
conneaed with, or to depend upon, the difpofition which
produces  that inflammatory affeaion,  but without its tak-
ing place,  or being prefent at the fame time, we name the
Irregular gout.
   518.] Of  fuch irregular gout there are three different
ftates, which I name the atonic, the  retrccedent, and the
miyplaced gout.
   519.]  The atonic ftate is when  the gouty diathefis pre-
vails m the fyftem, but, from certain caufes. does not pro-
duce the inflammatory affeaion ofthe joints.  In this cafe,
the morbid fymptoms which appear are chiefly affeaions
of the ftomach;  fuch as lofs of appetite, indigeftion, and
its various circumftances of ficknefs, naufea, vomiting,
 flatulency, acrid ertfetations,. and pains in the  region of
the ftomach.   Thefe fymptoms are frequently accompa-
nied with pains and cramps  in feveral parts of the trunk,
and the upper extremities of the body, which are relieved
 by the difcharge of wind from the ftomach.  Together
with thefe affeaions  of the  ftomach there  commonly oc-
 curs a coftivenefs; but fometimes  a loofenefs with cholic
   * Thefe different appearances which the gout affumes, are extremely unlike
 the regular gout above defcribed; the young praftitioiier ought therefore to
 pay peculiar attention to them, that when he obferves them in patients, he
 mav not think them fymptoms of other difeafes, or even miftake them for
 primary difeafes.  Errors of this kind are frequently committed by ignorant
 praditioners, to their own difevedit and the danger of their patient's life. 
e F  P H Y S I C.                193
pains.   Thefe affeaions  of the alimentary canal arc often
attended with all the fymptoms of hypochondriafis; asde-
jedion of mind, a conftant and anxious attention to the
llighteft feelings, an imaginary aggravation of thefe, and an
apprehenfion of danger from them.
   In the fame atonic gout, the vifcera of the thorax alfo
are fometimes affected, and palpitations, faintings,and afth-
ma, occur.
   In the head alfo occur, headachs, giddinefs, apopfeaic
and paralytic affeaions.
   5'iO.] When the feveral fymptoms now mentioned occur
in habits having the maiks of a gouty difpofition, this may
be fufpected to have laid the foundation of them, and efpe-
cially when  either, in fuch habits, a manifeft tendency to
the inflammatory affeaion has formerly appeared ;  or when
the fymptoms mentioned  are intermixed  with, and are re-
lieved by, fome degree ofthe inflammatory gout.   In fuch
cafes there can be no doubt of confidering the whole as a
 ftate of the gout.
   521.] Another ftate ofthe difeafe I name the retrocedent
gout. This occurs when an inflammatory ftate ofthe joints
has, in  the ufual manner, come on, but which, without a-
rifing to the  ordinary degree of pain and inflammation, or,
at leaft, without thefe continuing for the ufual time, and re-
 ceding  gradually in the ufual manner, they fuddenly and
entirely ceafe, while  fome internal part becomes affeaed.
 The internal part moft commonly affeaed is the ftomach,
 which is then affeaed with anxiety, ficknefs, vomiting, or
 violent pain ; but fometimes the internal part is the heart,
 which gives occafion to afyncope ;  fometimes it is the lungs
 which is affeaed with afthma ; and fometimes it is the head,
 giving occafion to apoplexy or palfy.  In all thefe cafes,
 there can be  no doubt ofthe fymptoms being all  a part of
the fame difeafe, however different the affeaion may  feem
 to be in the parts which it attacks.
   522.] The third ftate of irregular gout, which we name
the misplaced, is  when  the gouty diathefis, inftead of pro-
ducing  the inflammatory  affeaion  of the joints, produces
an inflammatory affeaion of fome internal part, and which
appears from the fame  fymptoms  that attend the inflam-
mation of thofe parts arifing from other caufes.
   Vsii..  I.                  B b 
19i                PRACTICE
    Whether the gouty diathefis does ever produce fuch in-
  flammation of thcintcrnal parts without having firft produc-
  ed it  in the joints, or if the inflammation ofthe internal
•  part bealwaysa tranflation from the joints previoufly affect-
  eel, I  dare not determine ; but, even  fuppofnv* the latter
  to be  always the cafe, I thank the difference of tire affection
  ofthe internal part muft ftill diftinguifh the mifplaced from
  what  I have named the Retrocedent Gout.
     523.] What internal  parts may  be affetted by the mif-
  pkeed gout I cannot precifely fay, becaufe I have never
  met with any cafes of the mifplaced gout in my practice ;
  and I  find no cafes of "It diitinttly marked  by praaical wri-
  ters, except that of a pneumonic inflammation.
     524.] There are two cafes of a tranflatedgout;  the one
  of which is an affection of the neck of the bladder,  pro-
  ducing pain, ftrangury, and a catarrhus  veficae : The other
  is an  affection of the rectum, fometimes  by pain alone 111
  that part,  and fometimes by hemorrhoidal  fwelling there.
  In gouty perfons, I have known fuch  affeaions alternate
  with inflammatory affeaions ofthe joints : But whether to
  refer  thofe affections to  the retrocedent, or  to themifplac-
  •ed gout, I will not prefume to determine.
     525.] From the hi'tory which I  have now delivered  of
  the gout,  I-think it may be difeerned under all its various
  appearances.   It is, however, commonly fuppofed, that
  there  are cafes in which it may be  difficult to diftinguifh
  gout  from rheumatifm,  and it is poffible there may be fuch
  cafes  : but, for the moft part, the two difeafes may be dif-
  tinguifhed with great certainty by obferving the predifpo-
  fition, the antecedents, the parts affeaed, the recurrences of
  the difeafe, and its connection with the other parts ofthe
  fyftem ; which circumftances, for the  moft part,  appear
  very  differently in the two difeafes.
     526.]  With refpea to the gout, our next bufinefs is to
  inveftigate its proximate caufe;  which  muft be a  difficult
  tafk,  and I attempt it with fome diffidence.
     527.]  Upon  this fubjea, the opinion which has gene-
  rally  prevailed is, that  the gout depends upon  a certain
  morbific matter,  always prefent in  the body;  and that this
  matter, by certain caufes, thrown  upon the joints or other
  parts, produces the feveral phenomena of the difeafe. 
OF  PHYSIC.                1SS
   528.] This doarine, however ancient and general, ap-
 pears to me very doubtful; for,
   Firft, There  is no direct evidence of any morbific mat-
 ter being prefent in  perfons difpofed to the gout.  There
 are no experiments  or obfervations  which mow  that the
 blood,  or other humours of gouty perfons, are in any ref-
 pect different from thofe of other perfons.   Previous to
 attacks of the gout,  there appear no marks of any morbid
 ftate of the  fluids;  for the difeafe generally  attacks  thofe
 perfons who have enjoyed the moft perfect health, and.ap-
 pear to be in that ftate when the difeafe comes on.   At as-
 certain period of the difeafe,  a peculiar matter indeed ap-
 pears  in ;,outy  perfons; (515.) but this,, which  does not
 appear in every inftar.ee, and which appears only  after the
 difeafe  has fubfifted for a long  time, feems manifeftly to
 be the effect,  not the caufe, of the  difeafe.   Further,
 though there be certain acrids  which, taken into the body,.
 feem to excite the gout, (503.)  it is probable that thefe
 acrids operate otherwife in exciting the difeafe, than by af-'
 fording the  material caufe of it.  In general, therefore^
 there is no proof of any morbific matter being the  caufe of
 the gout.
   Secondly, The fuppofitions  concerning the particular
 nature ofthe matter  producing the gout, have been fo va-
 rious and fo  contradictory to each other,  as to allow us to
 conclude,  that there is truly no proof of the cxiftence of
 any of them..  With refpefct to many of thefe fuppofitions,
 they are fo inconfiftent  with  chemical philcfbphv. and
 with the laws of the animal.economy, that they  muft be
 entirely rejected.
   Thirdly, The fuppofition of  a morbific matter being
 the caufe ofthe gout, is n.uconfiitent with the phenomena
 of ihe difeafe, par;ici:Iaily, with  its frequent and fudden
 trauflations from one part to another.
   Fourthly,  The fuppofition  is further rendered impro-
 bable by thw, that, if a morbific matter did cxift, ir.(v--_
ration  fhould be fimilar in the feveral pints which it at-
tacks;  whereas  it feems to be very dilfeent,  being |hn .-
lant, and exciting inflammation in the lointr,  but  fecauve
and dellroying the tone in the ftomach:  Whicn, coon -the
fuppofition of particular matter aaing in both cafes, is no^.
to be explained by any  difference- in the part affeaed. 
196                PRACTICE

   Fifthly,  Some  faas, alledged in proof of a morbific
matter, are not fufficiently confirmed, fuch as thofe which
would prove the difeafe to be contagious.  There is, how-
ever, no proper evidence  of this, the  faas given being
not only few, but exceptionable;  and the negative obfer-
vations are  innumerable.
   Sixthly,  Some arguments brought in  favour  of a mor-
bific matter, are founded  upon  a miftaken explanation.
The difeafe has been fuppofed to depend upon  a morbific
matter, becaufe it is hereditary: But the inference- is not
juft;  for moft hereditary difeafes do not depend upon any
morbific matter, but upon a particular conformation of
the ftruaure of the body,  tranfmitted  from the parent to
the offspring;  and this laft appears to be  particularly the
cafe in the gout.  It may be alfo obferved,  that heredita-
ry difeafes, depending upon a morbific matter,  always ap-
pear much more early in life than the gout commonly
does.
   Seventhly, The fuppofition of a morbific matter being
the caufe of the gout, has been hitherto ufelefs,  as it has
not fuggefted any fuccefsful  method of cure.   Particular
fuppofitions have  often corrupted  the pra6licc, and have  •
frequently  led from thofe  views  which might be ufeful,
and from that praaice which  experience  had  approved."
Further, though the fuppofition of a morbific  matter has
been generally received, it has been as generally negfeaed
in praaice.  When the gout has affeaed the ftomach, no-
body thinks of correaing the matter  fuppofed to be pre-
fent there,  but merely of reftoring the tone of the moving
fibres.
   Eighthly, The fuppofition of a morbific matter is quite
fuperfluous;  for  it explains nothing,  without fuppofing
that matter to produce a change in the ftate of the moving
powers; and a change in  the ftate of the moving powers,
produced by other caufes, explains every circumftance,   J
without the fuppofition of a morbific matter; and, to this   .
purpofe, it may  be obferved,  that many  of the caufes
(503.) exciting the gout,  do not operate upon the ftate of
the fluids,  but directly and  folely upon that of the mov-  |
ing powers.
   Laftly, The fuppofition of a morbific matter is alfo fu- 
                   U h  PHASIC.                19*
                          ■
 perfluous; becaufe, without any fuch fuppofition, I think
 the difeafe can be explained in a  manner more confiftent
 with its phenomena, with the laws of the animal economy,
 and with the method of cure which experience has approv-
 ed.
   I now proceed to give this explanation; but, before en-
 terim^ upon it,  I muft prfemife fome general obfervations.
   529.]  The firft obfervation is,  that the gout is a difeafe
 of the whole fyftem, or  depends upon  a certain  general
 conformation and ftate of the body;  which manifeftly ap-
 pears  from the faas mentioned from (493. to 496.)  But
 the general ftate of the  fyftem depends chiefly upon the
 ftate  of its primary moving  powers; and  therefore  the
 gout may be fuppofed to be chiefly an affeaion of thefe.
   530.] My fecond obfervation is, that the gout is manifeftly
 an affection of the nervous fyftem;* in which the  primary
 moving powers of the whole fyftem are lodged.   The oc-
 cafional or exciting caufes (503.) are almoft all fuch as ad
 direaiy upon the nerves and nervous  fyftem; and  the
 greater part of the fymptoms of the atonic or retrocedent
 gout are manifeftly affeaions of the fame fyftem (519. and
 521.J   This leads  us to  feek for an explanation of the
 whole ofthe difeafe in the laws of the nervous fyftem, and
 particularly the changes  which may happen in  the ba-
 lance of its feveral parts.
   531.] My third obfervation is, that the ftomach, which
 has fo univerfal a confent with the  reft ofthe fyftem, is the
 internal part that is the moft  frequently, and often very
 confiderably affeaed by the gout.   The paroxyfms of the
 difeafe are commonly preceded by an affeaion ofthe ftom-
 ach ; (506.) many ofthe exciting caufes (503.) aa firft up-
 on the ftomach; and the fymptoms of the atonic and retro-
 cedent gout (519. 521.) are moft commonly and chiefly af-
 feaions ofthe fame organ.   This obfervation leads us to
 remark, that there is a ballance fubfifting between the ftate
 ofthe internal and that  of the external parts ; and, in par-
 ticular, that the ftate ofthe ftomach is conneaed with that

  • Boerhaave after defcribing the difeafe, fays, Aphorifm, 1262.  '<■ From
all which it appears that the proximate caufe of the gout is a vitiated ftate
ofthe moft minute, and confequently nervous veffelj of the budv; and aU'o
of that fluid which flows through the nerves." 
198                PRACTICE
  ofthe external  parts (44.) fothat the  ftate of tone in the
  one may be communicated to the other.
    53-.] Thefe  obfervations being premifed, I  fhall now
  oner the following pathology of the gout. .
    In fome perfons there is a certain vigorous and  pletho-
  ric ftate ofthe fyftem (495.) which, at a certain period of
  life, is liable to a lofs  ol tone in the extremities. (498.)
  (505.) This is in fome meafure communicated to the wr.ole
  fyftem, but appears more efpecially in the functions ofthe
  ftomach.  (506.) When  this lofs of tone occurs  while the
  energy of the brain ftill retains its  vigour, the vis medica-
  trix naturay| excited to reftore the tone ofthe parts ; and
  accomplifrW it  by exciting an inflammatory affection in
  fome part cf the extremities.   When thi^ has fubfifted for
  forne days,  the tone of the extremities, and of  the whole
  fyftem, are reftored, and the patient returns to his  ordina-
  nary ftate of health. (510.)
    533-] This is the courfe of things, in the ordinary form
  of the difeafe, which we name the regular gout;  but there
  are circumftances ofthe body, in which  this  courfe is in-
  terrupted or  varied.   Thus when the  atony (505. 506.)
  has taken place,  if the reaction (508.) do not  fuccecd,  the
  atony continues  in the ftomach, or perhaps in other inter-
  nal parts,  and produces that ftate which we have, for rea-
  fons now obvious, named the atonic gout.
    534-]  A  fecond cafe of variation in  the courfe ofthe
  gout is,  when, to the atony, the reaction and mtiammation
  have to a certain degree  fuccecded; but, from caufes ci-
  ther  internal or external, the tone of the  extremities, and
  perhaps of the whole fyftem, is  weakened;  fo that  the in-.
.  flammatory ftate, before it had either proceeded to  the de-
 gree,  or continued for the time, requifite for  rcftoring the
  tone ofthe fyftem, fuddenly and entirely ceafes.   Hence
 the ftomach,  and  other internal  pans,  rclapfc into the
 ftate of atony; and perhaps  have this increafed bv the ato-
 ny communicated from the extremities:  All which appear*
 in  what we have termed the retrocedent gout.
    535-] A third cafe of variation from the ordinary- coiirfe
 of the gout,  is, when, to the atony ufually preceding, an
 inflammatory reaaion fully fuccceds; but has its ufual deter-
 mination to thejoints by fome circumf bailees prevented- and- 
                  OF  PHYSIC.                199

is therefore direaed to an internal part, where it produces
an inflammatory  affection, and that ftate of things which
we have named the misplaced go it.
  536.]  WTc have thus offered an explanation of the cir-
cumitances of the fyftem in the feveral ftates of the  gout;
and this explanation we fuppofe to be confiftent  with the
phenomena ofthe difeafe,  and with the laws of the animal
economy.  There are  indeed, with refpea to the theory
of the  difeafe,  feveral  queftions which might be put, to
winch we have not given any-anf.ver.   But,  though per-
haps we could give an anfwer to many of thefe queftions,
it does not here appear neceffary; as at prefent we intend
only to eftablifh fuch general facts with regard to this dif-
eafe, as may  lay a foundation for the cure  of it,  fo far as
experience has enabled us to  profecute it.   Proceeding,
therefore, upon the feveral parts  of the pathology given,
as fo many matters of faa, I fhall now confider what may
be attempted towards the cure  of the difeafe.
   537].  In entering upon this, I muft obferve, in the firft
place, that a cure has been commonly thought impoffible;
and we acknowledge it to be very probable, that  the gout
as a difeafe of the whole habit, and very often depending
upon original conformation, cannot be cured by medicines,
the effects of which arc always  very tranfitory, and feldom
extend to  the producing any  confiderable change of the
whole  habit.
   538.]  It would perhaps have been happy for gouty per-
fons, if this opinion had been implicitly received by them ;
as it would have prevented their  having been fo often the
dupes of felf-interefted  pretenders, who have either am uf-
ed them with inert medicines or  haverafhly employed thofe .
of the  moft pernicious tendency. I am much difpofed to
believe theimpoffibility of a cure of the gout by medicines;
and more cvrtainly ftill  incline to think, that whatever may
be the poffible power of medicines yet no medicine for cu-
ring the  gout has hitherto been found.  Although almoft
every age has prefented a new remedy, yet all hitherto of-
fered have very foon been either  neglected as ufelefs, or
condemned as pernicious.
  539-J  Though unwilling to admit the power of medi-
cines, yet I contend  that a great deal can be done towards 
200
PRACTICE
 th« cure  of the gout by a regimen :  And from what has
 been obferved (497.) 1 am firmly perfuaded, that any man
 who. early in life, will enter upon the conftant practice of
 bodily  labour,  and of abftinence from  animal food, will
 be preferved entirely from difeafe.
    Whether there be any  other means of radically curing
 the gout  I am not ready to determine.   There are hifto-
 ries of  cafes of the gout, in which it is faid,  that by great
 emotions of mind, by wounds, and by other accidents, the
 fymptoms have been  fuddenly relieved, and never again
 returned ; but how far thefe accidental cures might be imi-
 tated by  art,  or would fucceed in other cafes, is at leaft
 extremely uncertain.
    540.]  The praaices proper and neceffary in the  treat-
 ment of the gout, are to be confidered under two heads;
 first, As they are to be employed in the intervals  of pa-
 roxyfms; or, secondly,  As during the time of thefe.
    541.]  In the intervals  of paroxyfms, the indications
 are, to prevent the return of paroxyfms, or at leaft to ren-
 der them lefs frequent,  and more moderate.  During the
 time of paroxyfms, the indications  are, to moderate the
 violence, and fhortcn the duration of them as much as can
 be done with fafety.
    542.]  It has  been already obferved,  thatthe gout may
 be entirely prevented by conftant bodily exercife,  and by
 a low diet;  and I am of opinion, that this prevention may
 take place even in  perfons who have a hereditary  difpofi-
  tion to the  difeafe.  I muft add here, that, even when
  the difpofition  has  difcovered itfelf  by feveral paroxyfnw
  of inflammatory gout,  1   am perfuaded that labour and
.  abftinence will  abfolutely prevent  any returns of it for
  the reft of life.*  Thefe,  therefore, are the means of an-
  fwering the firft indication to be purfued in the  intervals
  of paroxyfms;  and I muft here offer fome remarks upon
  the proper ufe  of thefe remedies.
    * Several cafes are to be met with in practical authors, which confirm this
  Obfervation. Van Swieten relates the cafe of a prieft, who enjoyed a jich  i
  living, ahd had been long an old and conftant fufferer in the gout ; but hap-
  pening at laft to be taken by the pirates of Barbary, was detained there in a
  ftate of flavery fot the fpace of two years, and kept conftantly at work in the
  galleys, with only a very fpare diet.  The regimen he there underwent had
  this good effeft, that after he was ranfomed from his captivity, having loft
  his troublefome and monftrous fatnefs, he never once had a fit of the gout,
  though he lived feveral years af.er the event happened.
                       •                                   1 
OF  PIPY SIC.               201
   543.]  Exercife, in perfons difpofed to the gout,  is di-
 reaed to  two purpofes:  Que  of thefe is the  lengthen-
 ing of the tone of the extreme  veffels; and the other,
 the guarding againft a plethoric ftate.   For  the  former,
 if exercife be employed early in  life, and before intem-
 perance has weakened  the  body, a very  moderate degree
 of it will anfwer the purpofe; and for the latter, if abfti-
 nence be  at the fame time obferved,  little exercife will be
 neceffary.
   544. j With  refpea to exercife, this in general is to be
 obferved, that it fhould never be violent;  for if violent, it
 it cannot be long continued, and muft always endanger the
 bringing on an atony in proportion to the violence of the
 preceding exercife;
   545.] It is alfo to be obferved, that the exercife of gefta-
 tion though confiderable and conftant, if it be entirely with-
 out bodily exercife, will not anfwer the purpofe in prevent-
 ing the gout.  For this end, therefore, the exercife muft be
 in fome meafure,  that of the body, and muft be moderate,
 but at the fame time conftant and continued through life.
   546.]  In  eveiy cafe and circumftance of  the'gout in
 which the patient retains  the ufe of his limbs,  bodily ex-
 ercife, in the intervals  of paroxyfms, will always be ufe-
 ful; and, in the beginning of the difeafe, when the difpo-'
 fition to it is not yet ftrong, cxercife may  prevent  a pa-
 roxyfm which otherwife might  have come on.   In  more
 advanced ftates  of the difeafe, however, when  there is
 fome difpofition to a paroxyfm, much walking will bring
 it on; cither as it weakens the  tone  of the lower extremi-
 ties, or as it excites an inflammatory difpofition in them ;
 and it is probable, that in the fame manner ftrains or con-
 tufions often bring on a paroxyfm ofthe  gout.
   547.]  Abftinence, the other part of our regimen (539 )
 for preventing the gout,  is of more difficult application.
 If an abftinence from animal food be entered upon early
 in hfe, while the vigour of the fvftcm is yet  entire, we
have no doubt  of its being both'fafe and effeaual; but
 if the motive for this diet fhall  not  have occurred till the
conftitution  fhall  have been broken by intemperarreej or
 by the decline of life,  a low diet may then endanger the
 bringing on an atonic ftate.
  Vol, I.                 C c   - 
se:                "Practice
   548 ] Further, if a low  diet be entered upon only in
the decline of life,  and be at the fame time a very  great
change in the former manner of living, the withdrawing
of  an accuftomed  ftimulus  of  the  fyftem  may readily
throw this into an atonic  ftate.*
   549.] The fafety of an abftemious courfe may be great-
er or lefs according to the management of it.   It is ani-
mal food which efpecially difpofes to the plethoric and in-
flammatory ftate, and that  food  is to be therefore efpe-
cially avoided; but, on  the  other  hand,  it is vegetable
aliment of the loweft quality that is in danger of weaken-   ,
ing the  fyftem too much, by not affording fufficient nou-
rifhment; and more particularly  of weakening  the tone
of  the ftomach by its acefeency.   It is therefore a diet of
a middle nature that is to be  chofen; and milk is precifely
of  this kind,  as containing both animal and vegetable
matter.
   As approaching to the nature of milk,  and as being a
vegetable matter containing  the greateft portion of nou-
rifhment, the farinaceous feeds are next to be chofen, and
are the food moft proper to  be joined with milk.
   550.] With refpea to drink, fermented  liquors are ufe-
ful only when they  are joined with animal  food,  and that
by  their acefeency; and  their ftimulus is  only  neceffary
from cuftom.   When,  therefore,  animal  food  is to be
avoided, fermented liquors  arc unneceffary; and, by in-
creafing the acefeency of  vegetables, thefe liquors may be
hurtful.  The ftimulus of fermented or fpirituous liquors, '
is not neceffary  to the  young and vigorous ;  and,  when
much employed,  impairs the tone  of the fyftem.  Thefe
liquors,  therefore,  are to be avoided, except fo far as
cuftom  and the declining ftate of the fyftem may have
rendered them neceffary.  For preventing or moderating
the regular gout, water is the only proper  drink.         ;
   551.] With refpea to an  abftemious courfe, it has been ^
fuppofed that an abftinence from animal food and ferment- i
ed liquors, or the living upon milk and farinacea alone for
the fpace of one year might  be fufficient for a radical cure  I
of the gout; and it is poffible that,  at a certain period of  j
  •  A fudden change from a full to a fpare diet was juftjy enumerated among J
the occaficnai caufes of the gout in Art. 503.                      £■ 
& F  P H Y S I C.                2C5
life, in certain circumftances of the conftitution,  fuch x
meafure might anfwer the purpofe.  But this is very doubt-
ful ; and it  is more probable that the abftinence muft, in
a great meafure, be continued, and the milk diet be perfift-
ed in, for the reft of life.  It is well known, that feveral
perfons who had entered on an abftemious courfe, and had.
been thereby delivered from the gout, have, however, upon
returning to their former manner of full living,  had  the
difeafe  return upon them with as much violence as before,
or in a more irregular and more dangerous form.
   552.]  It  has  been alledged, that,  for  preventing  the-
return of the gout,  bloodletting, or  fcarifications of  the
feet, frequently repeated,.and at ftated times, may be prac-
tifed with advantage; but of this I have had no experience.
   553.]  Exercife and abftinence are the means of avoid-
ing the plethoric  ftate which gives the  difpofition to the
gout; and arc-therefore  the means propofed for  prevent-
ing paroxyfms, or at leaft for rendering them lefs frequent,
and more moderate.  But many  circumftances  prevent
the ftcadinefs ncceffary  in pur filing, thefe meafures; and
therefore, in fuch  cafes,, unlefs great care be  taken  to
avoid the exciting caufes, the  difeafe may  frequently re-
turn ; and  in many cafes, the  preventing of paroxyfms is
chiefly to be obtained by avoiding thole exciting caufes
enumerated in (503.)   The  condua neceffary for avoid-
ing them, will be fufffciently obvious to perfons acquaint-
ed with die do8trincs of the Hygicinc, which I fuppofe to
have been delivered in another place
   554.]  A due attcn:ion in avoiding thofe  feveral caufes
(502. 503.) will  certainly prevent fits of the gout; and
the taking care that the exciting caufes be never applied in
a great degree, will certainly render fits more  moderate
when they do come on.   But,  upon the whole, it will ap-
pear, that a ftria attention to the  whole condua of lifcr
is in  this  matter neceffary ;* and therefore,  when  the pre-
  * The  phyfician has more difficulty in perfuading his patients to a proper
regimen in the gout than in any other difeafe ; and.if he would gain reputa-
tion, he ou^ht to pay peculiar attention to this part of pra&ice, and ufe his
utmeft arc in convincing his patient of the necelfity of au abftemious  diet,.
and a regular conduct..
  Gouty patients are generally the genuine oiTspring of jolly Bacchus, and;
prefer the traniient indulgence of their jovial inclinations to the r&nfom of
whole year-, of torment at the eafy price of a life of fobriety and temper-
ance, until the  invincible Ou<?en °f tortures, as Lucian calls .her, fullj coi>- 
204                   PRACTICE
difpofitio!! has taken place,  it will be extremely difficult

to avoid the difeafe.                                 **
   555.] I  am indeed firmly perfuaded,  that, by obviat-
ing the predifpofition, and by avoiding the exciting caufes,
the gout may be entirely prevented:  But as the meafures
neceffary for this purpofe,  will in  moft cafes,  be purfued
with difficulty, and even with reluttance, men have been

very defirous  to find a medicine which might  anfwer the
purpofe without any reftraint on  their manner of living.

To gratify this defire, phyficians have propofed,  and, to
take advantage of  it, empirics have  feigned,  many  reme-
dies,  as we have already obferved.   Of what nature feve-

ral of thefe remedies have  been,  I cannot  certainly fay;
but,  of thofe  which  are unknown,  we  conclude, from

their having been  only of temporary fame,  and from their
having foon fallen into negfea,  that they have been either
inert or pernicious,  and  therefore I  make no inquiry after

 them ;  and fhall now remark only  upon one or two known
 remedies for the gout,  which have been lately in vogue.

    556.] One of  thefe is what  has  been  named in Eng-
 land the Portland Powder * This is not a  new medicine,

 vinces them of their errors.  They are then anxious for medical advice, and
 after confulting the phyfician, they are willing implicitly to obey his ftridhdt
 injundions.   They feldom, however, then  find  much relief ; and remain
 living proofs  of the truth cf the adage :
              --------fero medicina paratur,
          Cum mala per longas invalueie moras.
   * This medicine was fo called from one of the Dukes of Portland being
 cured by it, cf an hereditary and very inveterate gout.  It confifts of  equal
 parts of the follow ing bitter aromatics : viz.  Rad. ariftolochiaerotundx, Rad.
 gentianae, Summitat.  chamedryos, Summitat. chamzepityos, Summitat. cen-
 taur, min. A drachm of this powder is ordered to be taken, in any convenient
 vehicle, as a little wine, broth, tea, &c.  in a morning,  fafting, the patient
 tailing nothing for an  hear and an half after it; it muft  be ufed in this dofe
 for three months without the leaft interruption : Forty-five grains are to be
 taken daily in the fame manner, for the fucceeding three months: half a
 drachm  every day, for the next fix months;  and half a drachm every  other
 day, during the fecond year.   It it. fometimes two years complete before any
 change be produced, but the patient muft  not therefore  abandon the  medi-
 cine, but continue its  ufe.
    Thefe aromatic bitters have been long in ufe as remedies for the gout.
 We find Galen  prefcribing in this difeafe the feeds and tops cf wild rue,
 birth-wort, lefler centaury, gentian, &.c.  either fingiy, or  mixed in certain
 proportions.  Trallian defcribes fimilar antidotes, which he fays, muft be
 continued for a great length of time, viz. iix or feven months, or even ffcr a
 year and upwards. The tetra-pharmacon of  Aetius, compofed cf gentian,
 birth-wort, bay-berries, and myrrh, is a rimilar remedy, and is alfo directed
  to be ufed for a great length of time. Carlius Aurelianus likewife mentions
  the bitters to be long  ufed in the gout, and  he gives  them the appofite epi-
  thet of annalia.   The Diatefferon, which  has not been long throw ;i out of 
OF  PHYSIC.
205
 but is mentioned by Galen-, and,  with fome little varia-
 tion  in- its compofition, has been mentioned by the writers
 of almoft every age fince that time.   It appears to have
 been at  times in fafhion,  and to have  again fallen  into
 neglect;  and I think that  this laft has  been  owing to its
 having  been found to be,  in  many inftances, pernicious.
 In every inftance which I have  known  of its  exhibition
 for the  fengih  of time prefcribed,  the  perfons  who  had
 taken it were indeed afterwards  free  from  any  inflamma-
 tory affection of the joints;  but they were affected with
 many fymptoms of  the atonic gout;  and  all, foon after
 finifhing their courfe of the medicine, have been attacked
 with apoplexy,  afthma, or dropfy, which proved fatal.
   557.J  Another remedy  which  has had  the appearance
 of preventing the gout, is an alkali in various forms, fuch
 as the fixed alkali both mild and cauftic, lime  water, foap
 and abforbent earths.  Since it became common to' exhi-
 bit thefe medicines in nephritic and calculous cafes,  it has
 often happened that they  were given to thofe who were at
 the fame time fubjea to the gout; and it has been obferv
 ed,  that under the ufe of thefe medicines,  gouty perfons
 have been longer free from the fits of their difeafe.* That,

 Z &kh£ " ftiU retahied " f°me °f thC h^ P^macopcias, is of
 rwLUf\ 'f^^ medi.cines h*s doubtlefs in many cafes completed cured
 the gout;  but m many cafes, even in thofe that have been cured K?
 eales have lupervened. The ancient, were well aware of the danger of^
 mdifcrimmate ufe of thefe medicines : « Many," fays Galen  » 3 I   f
 Sf-dl SW °/ hC% l"ve bfl their ,ifc S^u^of drlks cot'
 pofed  of thefe kinds of remedies  their blood being dried up.  The mime?
 ous arthritic cafes cured by thefe medicines, encouraged goutypeople to W
 recourfe to them nulifcriminately,  and without reneiing*h£Toff who harl
 been cured by them,  were of a humid and phlegmatic habit  tnwL     v
 c.nes of this fort might be adminiftered wifh  faf«y »  1'ineta  ha^f  •"
 ar paflage.  "Thofe," fays he, - who endeavour to renfov   he" dif afe "a"
 t.rely by med.c.nes, to be r.ied through the whole year, w ill doubdef d» S"
 vice to fuch patients as arciufeitcd with pituitous and e«remenS«!'I
mours ,„ their joints, but they will haftenan tint i me  de'atnTnZrZ  f""
patient is encouraged to  perfeve e in i - 7',    r        *'' hm the
femova, of fome o/the m£^C^^^™ °< * *"*T
  I ue method of making it is defcribed by' feveral authors ; but, for the fak. 
206
PR
 however,  the ufe  of thefe medicines has entirely prevent-
 ed the returns  of  gout,  I  do not know; becaufe  I "never

 pufhed  the ufe of thofe medicines  for a long time,  being

 apprehenfivc  that  the long continued ufe of them might

 produce a hurtful change in the ftate of  the fluids.

   558.]  With refpea to preventing the  gout,  I have on-
 ly one other remark to offer.   As the preventing the gout

 depends very much on fupporting the tone of the ftomach,

 and avtfjding  indigeftion;  fo  coitivenefs,  by  occafioning

 this, is very hurtful to gouty perfons.   It is therefore ne-

 ceffary for fuch perfons to prevent or remove coftivenefs,

 and by a laxative medicine,  when   needful; but  it is at

 the  fame time proper,  that the medicine  employed fhould

 be  fuch  as may  keep the  belly regular,  without much

 purging.   Aloetics,  rhubarb, magnefia  alba,  or  flowers

 of fulphur, may  be employed,  as  the  one  or the other
 may happen to be beft fuited to  particular perfons.*

 of thofe readers who are unacquainted with the procefs, I fliall give an ab«
 ftraa of it.
  Difiblve three ounces, Troy weight, of good fait of' Tartar in a gallon and
 a half of rain water, or good foft fpring water  ; fibre the folution, and put
 as much of it  into the middle glafs of Parker's machine as will completely
 fill the veffel, referving the remainder for a fubfequent making.  The effer-
 vefcing materials muft then be put into the lower veflel, and a gentle ftream of
 fixed airmuftbe made to pafs through the liquor, till it taftes evidently acidu-
 lous, which will probably require forty-eight or fixty hours, or infummer more.
  The method of managing the effervefcence is  of confiderable confequence:
 for, if it is too  violent at iirft, much air efcapes through the veffels without
 effect.  Afcertain, by previous experiment,  how much of the vitriolic acid,,
 which you have procured, for it is of very  different  ftrengths in  the fhops,
 will faturate a drachm of the chalk.  Put four ounces of dry powdered chalk
 into the lower  veffel, and (hake it to one fide :  under that fide put a wedge,
 fo as to raife it above an inch and an half from the table.  With a long fun-
nel, which reaches to the bottom of the veffel,  pour in the quantity of vit-
riolic acid neceffary for the faturation, which will run down to the other fide
of the veffel, and not come into contarl with the chalk: through the  fame
funnel,  pour very (lowly as much water as will be fufficient to cover about a
 fourth part of the chalk as it then lies.   The veffel being gently fhaken occa-
 fionally,  the effervefcence will go on very fiowly,. and the alkaline liqur.r will
 be fooner and more effedually faturated, than if the effervefcence  had been
 too violent.  If the materials are not fufficient  for giving an acidulous taile
to the liquor, the lower veffel muft be wafhed, and frefh chalk and acid again.
 put into it.
  The dofe of this water is half a pint about noon, and another in the even-
 ing.  In urgent cafes half a pint has been given morning,  noon, and night,
for a confiderable time together,  without difagreeing  with the ftomach, or
 injuring the appetite or general health of the patient.  If it proves  flatulent,
a tea-fpoonful or two, but not more, of fpirituous cinnamon  water may be
taken in each  dofe.  If it inflames or  too violently irritates the urinary
paffages, five or ten, or in urgent cafes, twenty drops of laudanum mav be
 taken with each dofe of the'water.
  * The following formula may b; ufed in particular cafco : 
0 F  P H Y S I C.                207
    559-1  Thefc  ar^ the feveral  meafures (from 541. to
  558.) to be purfued in the  intervals of  the paroxyfms;
  and we are next to mention the meafures proper durino-
  the time of them.
    560.]  As during the times of paroxyfms the body is in
  a fevenfh ftate,  no irritation fhould then  be added  to it;
  and ever)- part,  therefore, of the antiphlogiftic regimen',
  (130. to 133.) except the application of cold,  ought to
  be ftriaiy obferved.
    Another exception to the general rule mav occur when
  the tone of the ftomach is weak,  and when the patient has
  been before much accuftomed to the ufe of ftron^ drink •
  for it then may be allowable, and even neceffary,°to give
  feme animal food, and a little wine.*
    561.]  That no irritation is to be added to the fyftem
  during  the paroxyfms of gout,  except  in  the cafes men-
  tioned,  is entirely agreed upon among phyficians: But it
  is a more difficult matter to determine whether, during the
  time of paroxyfms, any meafures may be  purfued to mo-
     R.  Aloes Socotorin. jii.
         Gum. Guaiac. $\i\.
         Tnidt. Sacrx, q. s.
         M. f. mafia,  in pilulas equates xv. dividend*;  quarura Hi,
           mat m. vel iv. pro re nata.
     R.  Pulv. Rad.  Rhei, 3iii.
         Magnef. alb.  g £.
         Gum. Guaiac. 3ii.
         Confcct. Aromat.  5ii.
         Syrup, comra. q. s.



 ^z%^i~&™:OT -<»—- *.«»*» ^ „
 PuS:Eit 2Sr* 'X"i.a fctiM,r1,ere we -tv* *"ic
 >vhich,hef„llo,,i„KforPm1^v"/ctve„?em!!','<> " """ "*  t"^m- °f
    R. hlor. Sulphuris, 3'ii.
       Eleft. Lenitivi, |ii.
       Pulv. Rad. Jalap. 3':i.
                 Zinzib. 3'h
       Syr* Sirnpl. q. s.



are equally improper.      *   * Wines and lhs auftere thin acid vices 
208
P R .1 b 1 l Ku X.
derate the violence of reaaion and of inflammation.   Dr.
Sydenham has given it as his opinion,  that the more vio-
lent the inflammation and pain, the paroxyfms will be the
fhorter, as well as the interval between  the prefent  and
next paroxyfm longer;  and,  if this  opinion be admitted
as juft,  it will forbid the ufe of any remedies which  might
moderate the inflammation; which is, to  a certain degree,
undoubtedly neceffary  for the health of the body.   On
the other hand, acute pain preffes for relief;  and, although
a certain degree of  inflammation  may feem  abfolutely ne-
ceffary, it is not certain but  that a moderate degree of it
may anfwer the  purpofe :  And it is even probable, that,
in many cafes, the violence of inflammation may weaken
the tone  of the parts, and thereby invite a return of pa-
roxyfms.   It feems to me to be in this way,  that,  as the
difeafe advances, the paroxyfms become more frequent.
   562.] From thefe laft confiderations, it feems probable,
that, during the time of  paroxyfms, fome  meafures may
be taken to moderate  the violence  of the  inflammation
and pain; and particularly,  that  in firft paroxyfms, and
in the young and vigorous, blood-letting at the arm may
be praaifed with  advantage.  But I am perfuaded,  that
this praaice cannot be repeated often with fafety ; becaufe
blood-letting not only weakens the tone of the fyftem, but
may alfo contribute to produce plethora.  I believe, how-
ever, that bleeding by leeches on the  foot,  and upon the
inflamed part, may be praaifed, and repeated with greater
fafety ; and I have known inftances of its having been prac-
tifed with fafety, to moderate and fhorten paroxyfms , but
how far it may be  carried, we have not had  experience
enough to determine.
   563.]  Befides blood-letting, and the  antiphlogiftic re-
gimen, it has been propofed to employ remedies for mo-
derating the inflammatory fpafm of the part affeaed, fuch
as warm  bathing and emollient  poultices,-  Thefe have
fometimes been employed with advantage and fafety ;  but
at other times, have been found to give occafion to  a re-
troceffion of the gout.*
  __ * On this account thefe topic?l remedies ought to be ufed with great oau"
tion : thejiemporary relief which they afford, by procuring an intermiffion of
the pain, is agreeable to the patient, but it is frequently the occafion of an
cxac erb^tion of all the fymptoms. 
OF  PHYSIC.                 209
   564.]  Bliftering  is a very  effeaual means of relieving
and difcuffing a paroxyfm of the gout; but  has alfo  fre-
quently had the effea of rendering it retrocedent.*
   565.]  The flinging with nettles I confider as analogous
to bliftering;  and  I think it probable that it  would be at-
tended with the fame danger.
   566.]  The burning with moxa,t or  other fubftances, I
confider as a remedy of the fame kind.   I have had indeed
no evidence of this proving  hurtful; but neither have I
had any proper evidence of its having proved a  radical
cure.
   567.] Camphire, and fome aromatic oils,  have  the
power of allaying the  pain, and of removing the  inflam-
mation from  the part affeaed; but thefe remedies com-
monly make the inflammation only fhift from one  part to
another, and therefore with the hazard of its falling  upon a
part where it may be more  dangerous:  and they have
fometimes rendered the gout retrocedent.
    568.]  From  thefe reffeaions (563.  et feq.) it will ap-
 pear, that fome danger muft  attend every external appli-
 cation to the  parts affeaed during a paroxyfm;  and that!
 therefore the  common practice of  committing the perfon
 to patience and  flannel alone, is eftablifhed upon the bell
 foundation.
    569.]  Opiates give the moft certain relief from pain;
 but, when  given in the  beginning  of  gouty paroxyfms,
 occafion  thefe  to  return with greater  violence.   When,
   * This is a very dangerous pra&ice.  Blifters are however extremely ufe-
 ful, in bringing back the retrocedent gout to the part originally affe&ed; but,
 the violent degree of pain that  accompanies the gout,  when brought to a
 part already irritated by the blifters, frequently prevents a patient who has
 t.nce  differed it, from allowing it a fecond time.  It is, however,  fo impor-
 tant and neceffary a practice, that it ought not to be  omitted. As foon as the
 gout has been brought back to its original place, the blifters muft be immedi-
 ately removed, a piece of foft linen dipped in frefh oil, applied to the part,
 and the whole well wrapt up in foft flannel: a moderate degree of heat muft
 be preferved in the  flannel, and the patient muft be encouraged to bear withi
 patience the violent pain which he fuffers.
   f Moxa is a foft Januginous fubftance prepared in Japan, from  the young
 leaves of a fpecies of Artemifia, by beating them when thoroughly dried,
 and rubbing them between the ringers till nothing but the fineft fibres remairi.
   A little cone of this cottony fubftance is laid upon the Ik in, which is pre-
 viously moiftened to prevent the cone from hiding off: Fire is fet to the apex
 of the cdrie, and it is fuffered to burn till it extinguilhes itfelf. A fmall ef-
 char is produced and the ulcer either healed or kept open as occafion requires.
   Cotton impregnated with a fin all quantity of a folution of nitre, and af-
 terwards dried, ai.fwers the end'Is effectually as the Japenefe moxa.
   Vol. I.                   D  d  ' 
210                 PRACTICE
 however, the  paroxyfms fliall  have abated in  their vio-
 lence, but ftill continue  to return, fo as to occafion pain-
 ful and reftlefs nights, opiates may be then given with fafe-
 ty and advantage, efpecially in the cafe of perfons  advan-
 ced in life, and who have been often affected with the  dif-
 eafe.*
    570.] When, after paroxyfms have ceafed, fome fwel-
 ling and  ftiffnefs fhall remain in  the joints,  thefe fymp-
 toms are to be difcuffed by  the diligent ufe of the flefh-
 brufh.
    571.]  Purging, immediately after a paroxyfm,  will be
 always employed with the hazard of bringing it  on again.
    572.]  I have now finifhed what has occurred  to  be faid
 upon  the means of preventing and curing the regular gout;
 and fhall now confider its management when it has become
 irregular ; of which, as I have obferved above, there are
 three  different cafes.
    573.]  In the firft cafe, which I have named the  Atonic
 Gout, the cure is to be accomplifhed  by carefully  avoid-
 ing all debilitating caufes ; and  by employing, at the fame
 time,  the means of ftrengthening the fyftem in general, and
 the ftomach in particular.
    574.]  For thcavoiding debilitating caufes, I  muft re-
 fer to the doarines of the Hygieine, as in 553.
    575-J  For  ftrengthening the fyftem in general,  I muft
 recommend frequent exercife on horfeback, and moderate
 walking.   Cold  bathing alfo may anfwer the  purpofe,
 and may be eafily employed, if it appear to be powerful in
 ftimulating the  fyftem, and be not applied when the extre-
 mities are threatened with any pain.t
    For fupporting the tone of the fyftem in general, when
 threatened with atonic gout, fome animal fopd+ ought  to
  * The beft form  for exhibiting opium in thefe cafes, is the Confeclio Opi-
 ata of the London Pharmacopoeia,  or the ElecTarium Thebaicum of the
 Edinburgh.  The dofe of the former is half a drachm, but  of the latter a
 drachm  and an half.
  As opiates ought never to be adminiftercd where the inflammation is vio-
 lent, but only in fuch cafes as are attended with little or no inflammation,
 thefe warm opiates cannot be improper.  If however the praclitioner fliould
 think either of the above formula too hot, he can have recourfe to the T::;c-
 tura Thebaica.
  t Cold bathing is a doubtful remedy, and ought to be ufed with caution.
 If it does not prove a tonic, it ought to be abandoned; and we  know by ex-
perience that it frequently debilitates.
  J The ufe of animal food is abfolutely neceffary, and fuch ought to be cho- 
OF   PHYSIC.                 2H
be employed, and the more accfeent vegetables ought to

be avoided.   In the fame cafe, fome  wine* alfo may  be

neceffary ; but  it fhould be in moderate quantity, and of

the leaft accfeent kinds; and, if  every kind of wine fliall

be found to increafe the acidity of the ftomach, ardent fpi-

rits and water muft be employed.t
   576.]  For ftrengthening the  ftomach, bitters and the

Peruvian bark may be employed; but care muft be taken

that they be not conftantly employed for any great length

of time.   Compare 556.
   The  moft  effectual  medicine for  ftrengthening  the

ftomach  is  iron, which may  be  employed under various

preparations; but, to me, the beft appears to be the  ruft

in fine powder, which may be given in  very large dofes.J
   For fupporting the tone of the ftomach, aromatics may

be employed ; but fliould be ufed with caution, as the fre-  ,

quent and large ufe of them may have an oppofite effea ;

and they fhould therefore be given only in  compliance
with former habits, or for palliating prefent fymptoms.

   When the ftomach happens to be  liable to  indigeftion,

gentle vomits may be frequently given ;  and proper laxa-

tivesj| fhould be always employed to  obviate, or  to  re-

move coftivenefs.

fen as is moft nutritive.  Beef or mutton have been with propriety preferred
to all other animal food, and fome eminent pra&itioners have recommended
fteaks to every other mode of drefiing beef and mutton. Stews, hafhes, p} es>
and all high feafoned difhes, ought to be avoided.
  * The wine which a gouty perfon  ufes, ought to be generous and good,
 as Madeira, Sherry, &c. the thin acefcent wines, as hock, claret, &c. always
 do mifehief.
   ■fin order the more effectually to guard againft acefeency, the fpirits and
water ought, if pofiiUe, to be taken without fugar, and cold.  No drink is
perhaps more prejudicial for gouty patients, than what is called rich punch,
viz. with a large quantity of fugar and lemon, efpecially when taken warm.
  ^ The dofe muft be very fmall at firft, not exceeding four or five grains in
the day ; the dofes may be daily increafed two grains, till we arrive at ten or
twelve, and after two or three days, ten grains may be given twice  a day.
Aromatics always make it fit eafier on the ftomach than it would do if takca
alone ;  the  moft convenient form therefore is the following:
       R.  Rubigv Martis,  gr. 10.
           Confeci. Card. 3 lb*
           Syr. Croci, q. s.
           M. i.  bolus.
  After the patient has taken two of thefa bolufes for three or four days, he
may proceed to take three of them; and after a few more days, if the ltom-
ach is nut difordered, each bolus may be daily increafed till we arrive at.24,
or even 30 grains thrice a day.
  || The proper laxatives for gouty conftitutions, are mentioned in a note on,
Article 558. 
512
PRACTICE
   577.] In the atonic gout, or  in perfons liable to it, to
guard againft cold is efpecially nccefTary ;  and the moft
certain means of doing this is, by repairing to a warm cli-
mate during the winter feafon.
   578.] In  the more violent cafes  of the atonic gout,
bliftering the lower extremities may  be ufeful; but that
remedy fhould be  avoided when any pain threatens  the
extremities.   In perfons liable to  the atonic  gout, ilfues
may be eftablifhed in the extremities,  as, in fome meafure,
a fupplement to the difeafe.
  '■679'] A fecoiid cafe ofthe irregular gout, is that which
I have  named the  Retrocedent.  When  this affeas the
ftomach and inteftines, relief is to be inftantly  attempted
by the free ufe of ftrong wines, joined with aromatics, and
given warm ;  or if thefe fhall not prove powerful enough,
ardent fpirits muft be employed, and are to be given in a
large dofe.   In moderate attacks,  ardent fpirit impreg-
nated with garlic,  or  with afafcetida, may be employed;
or, even without the ardent fpirits, a folution of afafcetida
with the volatile  alkali may anfwer the purpofe.  Opiates
are  often  an effeaual remedy, and  may be  joined with
aromatics, as in the  Efeauarium Thebaicum  * or they
may be ufefully joined with volatile alkali and camphire.t
Mufk has likewife  proved ufeful in this difeafe.
   When the affeaion of the ftomach  is accompanied with
vomiting, this may  be encouraged, by taking draughts of
warm wine, at firft with water, and afterwards without it;
having at length recourfe if neceffary, to fome  of  the re-
medies  above mentioned, and particularly the opiates.
  * The following form is extremely efficacious, and at the fame time plea-
fant to the tafte : it may be repeated three or four times, if the firft does not
procure relief,
      ft. Eled. Thebaic. 3?.
         Aq. Cinnamom. fpirituofae, §i. |^.
         Syr.  Croci,  3ii«
         M. f. hauft.
  t The beft way of giving thefe medicines is in the following form.
      ft. Opii purificati, gr. i.
         Camphor, gr. xii.
         Spt. Vini,  q. s.
         Confect. Cardiac. 3'h
         M. f. bolus.
  Or the camphor may be made into a bolus with  a drachm of the Elefl.
Thebaic, and  forty drops of the Spiritus Aromaticus, in a glafs  of ftrong
wine, as Madeira or Sherry, may be drank after it. 
«F  PHYSIC.                 213
    In like manner, if the  inteftines be affeaed  with diar-
  rhoea, this is to be at firft encouraged, by taking plentiful-
  ly of weak broth; and when this fhall have been done fuf-
  ficiently, the tumult is to be quieted  by opiates.
    580.]  When the retrocedent gout fliall affea the lungs,
  and produce aflhma, this is to  be cured by opiates, by an-
  tifpafmodics,* and, perhaps, by bliftering on  the breaft or
  back.
    581.]  When the  gout, leaving the extremities, fhall
  affea the head, and produce pain, vertigo, apoplexy, or
  palfy, our refources are very precarious.  The moft pro-
  bable means  of relief is, bliftering the  head; and if the
  gout fliall have receded very entirely from the extremities,
  blifters may be applied to thefe alfo.   Together with thefe
  blifterings,  aromatics,  and  the  volatile alkali, may  be
  thrown into the ftomach.t
    582.]  The third  cafe of the irregular gout is what  I
  have named the  Mifplaced; that is,  when the inflamma-
  tory affeaion of the gout, inftead of falling upon the ex-
  tremities, falls upon fome internal part. In this  cafe, the
  difeafe is to be  treated by  bloodletting, and by fuch oV.'I
  remedies  as would be proper  in  an idiopathic inflamix^
  tion of the fame parts.
    583.]  Whether the tranflation fo frequently made from
  the extremities  to the kidneys,  is  to  be confidered  l> c 1
  mftance of the mifplaced gout,  feems,  as we have faid  h
  fore, uncertain; but I am difpofed to think it fornethi i<?
  diftcrent; and therefore am of opinion, that, in the N-pfT
  ralgia Calculofa produced upon  this occafion, the  re n-
 dies of inflammation are to be employed no farther than

 in thS aF^T^feiy?ri°11CUS h * medic!ne Ufcd with m"ch  fuccer»
 Th*l\t   1 r •  • • 7.     fr0m twenty t0 thirt7 droPS in a Hals cf wi-
 The ethereal fpirit is fo very volatile, that it will wholly evaporate   f i '£
 A.fteredtoftandiu the wine for a few.minutes; it muft SffiSbe d ».*
 fP eddy: and the dofe may be repeated every tw0 hours, in  cafes of emer.
 £; y   In moft  cafes laudanum will anfwer every purpofe.  Ammonk
  '- 1.. en much recommended, and its powers in cafes of routy aflhma W
a ef  Two T Tr>' C°fPiCU°US = U ™* * ?iven inck^p. nde ftly of The  ni!
ates.  Two drachms of it may be made into an emulfion with L oimces'ef
^o^ntVourf °f ^P00^ of this emulfion may be"^
dietsLiLar^Iae^iia%errCbeen °bt*'ined in ther««fes from internal reme-
ciallv the feet „■.;     r     efle^of blifters  on the esiram t es, efpe-
With a iklU bruQi, impregnated with plenty of dry  flow of muilut     W 
214
PRACTICE
 they may be otherwife fometimes ncceffary in that difeafe,
 arifing from other caufes than the gout.


               BOOK   III.

        Of Exanthemata, or Eruptive Fevers.

 584.]   X  HE difeafes comprehended under  this title,
 which make the third Order of Pyrexiae in our Nofology,
 are in general fuch as do not arife but upon  occafion of a
 fpecific contagion applied, which firft produces fever, and
 afterwards an eruption upon the furface  of the body ; and
 which difeafes, for the  moft part, affea perfons but once
 in the courfe of their lives.
   585.] Whether the charaaer ofthe Order may be thus
 limited, or  if the Order may be allowed to comprehend al-
 fo the eruptive fevers produced by a  matter generated in
 the body itfelf, and likewife thofe cafes of eruption which
 do not depend upon contagion, or upon a matter generat-
 ed before the  fever, but upon a matter generated in  the
 courfe of the fever, I  am not ready to determine.   Of
 the difeafes enumerated by the Nofologifts as Exanthema-
 ta, there are certainly three different kinds, which may be
 diftinguifhed by the circumftances mentioned in  this and
 the preceding paragraph.   Of the firft kind are the Small
 Pox,  the Chicken Pox, the Meafles, the Scarlet Fever,
 and the Plague.  Of the  fecond kind  feems  to be  the
 Eryfipelas; and  of the third kind I  judge the Miliaria
 and  Petechia to  be.  But as I am no't fufficiently con-
 fident in the faas  which fliould fupport  thefe diftinaions,
 or which would enable us to apply them  in all cafes; I go
 on in this book to treat of almoft all the  exanthemata enu-
 merated by preceding Nofologifts, with  only fome differ-
 ence in  the arrangement from what it was in my former
 editions.

                      CHAP. I.

               £Dftfje§maUP)r*

 586.]  1 HE fmall pox is a  difeafe arifing from a con-
tagion of a fpecific nature, which firft produces a fever; 
O F  PHY SIC.              "215
and on the third or fourth day thereof, produces an erup-
tion of fmall red pimples.   Thefe are afterwards formed
into puftulcs, containing a matter, which, in the courfe of
eight days from the time of the eruption, is changed into
pus.   After this, the matter dries, and falls off in crufts.
   587.] This i.> a general idea  ofthe difeafe; but there
are two particular forms or varieties of it, well known un-
der the appellation!* of the Distinct and Confluent,  which
requires to be fpccially defcribcd.
   588.J In the former, or the  diftina  finall pox, the
eruptive fever is moderate, and appears to be evidently of
the inflammatory kind,  or what we name a Synocha.  It
generally comes on about mid-day, with fome fymptoms
of a cold ftage,  and commonly with a confiderable lan-
guor  and drowfinefs.   A  hot ftage is-foon formed,  and
becomes more confiderable on the fecond and third days.
During  this courfe, children are liable to frequent ftart-
ings for their {lumbers;  and adults, if they are kept  abed,
are difpofed to much  fweating.   On the third day, chil-
dren are fometimes affeaed with one  or two epileptic fits.
Towards the end of the third day, the eruption common-
ly appears, and  gradually increafes during  the fourth;
appearing firft upon the face, "and fucceflively on the in-
ferior parts, fo as to be completed over the whole body on
the fifth day.
   From the third day the  fever abates;  and againft the
fifth it entirely ceafes.   The eruption appears firft in fmall
red fpots, hardly eminent, but by degrees riling into pim-
ples.   Thefe are  generally upon the face in fmall num-
ber ;  but even  when  more numerous, they are feparate
and diftina from one another.   On the fifth or fixth day,
a  finall vcficle, containing an almoft  colourlefs or  whey-
coloured fluid,  appears upon  the top  of each pimple.
For two days, thefe vcficles increafes  in breadth only, and
there is a fmall hollow pit in their middle;  fo that it is on-
ly againft the eighth day that they are raifed into fpheroidi-
cal puftulcs.
   Thefe vcficles or puftulcs, from their firft formation,
continue to be furrounded with an exaaiy circular inflam-
ed margin, which, when the puftules are numerous,  diffu-
fes fome inflammation over the neighbouring fkin, fo as
to give fomewhat of a damafk rofe-colour to the fpaces be-
1 
5 IS         |£     PRACTICE

tween the pufiufes.   As the puftulcs increafe in fize, if
they be numerous on the face, againft the eighth day the
whole of the face becomes confiderably fwelled ;  and,  in
particular, the eye-lids are fo much fwelled as entirely  to
ftiut the eyes.
   As the difeafe thus proceeds, the matter in the puftulcs
becomes  by de'grees more opaque and white, and at length
of a yellowifh colour.  On the eleventh day, the fwelling
of the face  is abated,  and  the puftulcs  feem quite full.
On the top of each a darker fpot appeafs;  and at this place
the puftule,  on the eleventh day, or foon after,  is fpon-
taneoufly broken, and a portion of the matter oozes out;
in confequence of which, the puftule  is  fhrivelled, and
fubfides ; while the matter oozing out dries, and  forms a
cruft  upon its  furface.  Sometimes a little  only of the
matter oozes  out;  and what remains in  the  puftule be-
comes thick and even hard.  After fome days,  both the
crufts and the hardened puftulcs fall  off,  leaving the fkin
which they covered of a brown red colour; and it is only
after  many days that the  fkin. in thefe places refumes its
natural colour.    In fome cafes, where the matter of.the
puftulcs has been more liquid, the crufts formed  by  it are
later in falling off, and the part they  covered fuffers fome
defquamation, which leaves in it a fmall pit or hollow.
   This is the courfe of things on the face;  and fucceflivcly,
the puftules on the reft  of the body take  the fame.  The
matter of the puftules, on the arms and hands, is frequently
abforbed; fo that, at the height ofthe difeafe, thefe puftules
appear empty veficles.   On the tenth and eleventh days,
as the fwelling of the face fubfides, a fwelling arifes in the
hands and feet;  but which, again, fubfides, as  the puftules
come to maturity.
   When the puftules on the face are numerous,  fome de-
 gree of pyrexia  appears  on the tenth  and eleventh days,
 but difappears again  after the puftules are fully ripened; or
perhaps remains in a very flight degree till the puftules on
 the feet have finifhed their courfe.  It is feldom that in the
 diftina fmall-pox the fever continues longer.
   When the puftules  on the  face  are  numerous, fome
 uneafinefs in the throat, with  ahoarfenefs of the voice comes
 on upon the fixth or feventh day, and a thin liquid is pour-
 ed out from the  mouth.   Thefe fymptoms increafe with 
                     OF  PHYSIC.                $1*

  the fwelling ofthe face ;  and the liquids ofthe mouth and
  throat becoming thicker,  are more  difficultly thrown out.
  There, is, at the fame time, fome difficulty of fwallowing;
  fo that liquids taken in  to be fwallowed are frequently re-
 jected, or thrown out by the note.  But all  thefe affections
  of the fauces abate as the fwelling ofthe face fubfides.*
    589.]  In the Other form of fmall-pox, or what is called
  the Confluent, the courfe of the difeafe is, in general, the
  fame with that we have defcribed; but  the fymptoms  of
  every ftage are more  violent,  and feveral of  the circum-
  ftances are different.
    In particular,  the  eruptive fever  is more violent.  The
  pulfe is more frequent and more contraaed,  approaching
  to that ftate of pulfe which is found in the typhus.  The
  coma is mare confiderable, and there is frequently  a de-
  lirium.   Vomiting, alfo,  is a common fymptom, efpeci-
 ally at the coming on of the difeafe.   In very young in-
  fants, epileptic fits are fometimes frequent on the firft days,
  of the difeafe, and fometimes proves fatal before any erup-
  tion  appears •  or they ufher in a very confluent and putrid
 fmall pox.
   590.]  The eruption appears more  early on  the  third
 day, and it  is frequently preceded  or accompanied with
 an eryfipelatous  afflorefcence.  Sometimes the eruption
 appears in clufters,  like that of the meafies.   When the
 eruption is completed,  the pimples are always more nu-
 merous upon  the face,  at  the fame time fmaller and lefs
 eminent.   After the eruption,  the  fever  fuffers  fome re-
 miffiort, but never goes  off  entirely;  and, after the fifth
 or fixth day,  it again increafes, and continues confiderable
 through the remaining courfe of the difeafe.
   The vcficles formed on the tops of the pimples appear
 fooner; and while they increafe in breadth, do not retain
 a circular, but arc every way of an irregular figure.  Many
 of them run into  one another, infomuch that° very often

  * The difcharge of faliva is always falutarv, and ought to Be moderately
 encourajre.1.   It is probably owing to the morbific matter attacking  the fall.
 vary glands, and through them making its exit out of the body.
  A I the affeftions of  the fauces, and  the falivation, gradually abate as the
fwe lm^ot the face iubf.de. ; but if thefe iymptoms difappear suddenly,  or are
not lucoied.d by a fwelling of the extremities, danger is to be apprehended
  rim remark,, fojely the refult of experience, and the ttpuStion ofS
l-.-ems to be involved 111 conhderable difficulty.            r
  Vol. I.                  E  K  Y 
31*                PRACTICE
the face is covered rather with one veficlc than with a num-
ber of puftules.   The veficles, fo far as they are any-wife
feparated, do not arife  to a fpheroidical form, but remain
flat, and fometimes the  whole ofthe face is of an even fur-
face.   When the puftules are in any meafure  feparated,
their circumference is not bounded with an inflamed mar-
gin, and the part of  the fkin that is free from puftules  is
commonly pale and flaccid.
   The  liquor that is in the puftules changes  from a clear
to an opaque appearance,  and becomes whitifh or brown-
ifh, but never acquires the yellow colour and thick con-
iiftence that appear in the diftina fmall-pox.
   591.3 The fwelling ofthe face which attends the diftina
fmall-pox, when they are numerous, and almoft then only,
always attends the confluent, comes on more  early, and
arifes..to a greater degree; but abates on the tenth day, and
on the  eleventh ftill more.  At this time  the puftules or
veficles break,  and  lhrivelling pour out a liquor that  is
formed into brown-or black crufts, which do not fall off
for many days after.  Thofe of the face, in falling off, leave
the parts they  cover fubjea to  a defquamation, which
pretty certainly produce .pittings.
   On the other parts of the body, the puftules of the con-
fluent fmall-pox are more  diftina than upon the face, but
never acquire the fame  maturity  -and conftftence of pus'as
in the properly diftina  kind.
   The falivation which only fometimes attends the diftinct
{mall-pox,  very  conftantly attends the  confluent:  and
both  the falivation and the affeaion of the fauces above-
mentioned are, efpecially in adults, in a higher degree. In
infants, a diarrhoea comes frequently  in place of the  fali-
vation.
   In the confluent fmall-pox, there is often a confiderable
putrefcency of the fluids, as appears from petechia?, from
ferous veficles, under which the fkin fhows a difpofition to
gangrene, and  from bloody urine or other haemorhargy,
all which fymptoms frequently accompany this elifeafe.
   In the confluent fmall-pox, the fever, which had only
fuffered a remiflion from the time  of eruption  to that of
maturation, is often, at or immediately after this pteriod,
renewed with confiderable violence.    This is what has 
OF  PHYSIC.
21*
been called the Secondary Fever;  and is, in different ca-
fes, of various duration and event.
   592] We have thus endeavoured to defcribe the vari-
ous circumftances of the fmall-pox ; and from the differ-
ence of thefe circumftances, the event of the difeafe  may
be determined.  The whole of the prognofis may be near-
ly comprifed in the  following propofitions.
   The more exaaiy the difeafe retains  the form of  the
diftina kind, it is the fafer;  and the more completely  the
difeafe takes the form of the confluent kind, it is the more
dangerous.
   It is only when the diftina kind fhows a great number
of puftulcs on the face, or otherwife, by fever or putref-
cency, approaches to the circumftances of the confluent,
that it is attended with  any danger.
   In the confluent fmall-pox there is always danger ; and
this is always more confiderable and certain, according as
the fever is more violent and permanent, and efpecially as
the marks and fymptoms of putrefcency are more evident.
   When the putrid difpofition is  very great, the difeafe
fometimes proves fatal  before the eighth day; but itvmoft
cafes it is on the eleventh that death happens,  and fome-
times it is put off till the fourteenth or feventeenih day.
   Though the fmall-pox fliould not be immediately fatal,
the more  violent kinds arc often  followed  by a morbid
ftate ofthe body, of various kind and event.   Thefe con-
fequences, as I judge, may be  imputed fometimes to an
acrid  matter produced by  the preceding difeafe, and de-
pofited indifferent parts; and fometimes to an inflamma-
tory diathefis produced, and determined to particular parts
of the body.
   593.] It is, I  think, agreed among praaitioners, that,
in the different cafes of  fmall-pox, the difference chiefly
depends  upon  the  appearance of  diftina or confluent';
and, from the above defcription  of thefe kinds, it will ap-
pear, that they chiefly differ in the period ofthe eruption,
in the  number of puftules  produced, in  the form of the
puftules, in the ftate of the  matter contained in them, in
the continuance  of the fever, and laftly in the danger of
the difeafe.
   594-]  Upon inquiring into the caufes of thefe differen-
ces, we might readily fufpea, that they depended upon a 
220                 PRACTICE'
difference of the contagion producing the difeafe.   This,
however, is not probable:  for there are innumerable in-
ftances of the contagion, arifing from  a  perfon  labouring
under the  fmall-pox of  the diftina kind, producing ths
confluent;  and on the contrary.   Since the  practice  of
inoculation became frequent, we have  known the fame
variolous matter produce in one perfon the. diftina, and
in another the confluent fmall-pox.   It is therefore high-
ly probable, that the difference  of the fmall-pox does not
depend  upon any  difference of  the contagion, but upon
fome difference in the ftate of the perfon to  whom it j$
applied, or in the  ftate of certain circumftances  concur-
ring with the application of the contagion.
   595.] To find out wherein the difference in the ftate of
the perfons to whom the contagion ofthe fmall-pox is ap-
plied confifts, I obferve,  that the difference between the
diftina and confluent  fmall-pox  confifts  efpecially in the
number of puftules produced;  which, in the diftina, are
generally few, in the confluent, always' many.   If, there-
fore, we fhall be able  to difcover what, in the ftate of dif-
ferent perfons, can give  occafion to more or fewer puf-
tules, we fhall probably  be able to account  for all the
other differences of the diftina and confluent fmall-pox,
   596.] It is evident,  that the contagion of the fmall-pox
is a  ferment with refpea to the human fluids, and  affimi-
lates a great part of them to its own nature ;* and it is pro-
bable, that the quandty thus affimilated, is,  in  proportion
to the bulk of their feveral bodies,  nearly the fame in dif:
ferent perfons.  This quantity paffes again out of the bo-
dy, partly by infenfible perfpiration, and partly by being
depofited in puftules; but  if the quantities generated be
nearly equal,  the quantities pafting out of the body by the
two  ways mentioned are very unequal in different perfons;
and, therefore, if we can  explain the  caufes which deter-
mine more to pafs by the  one way  than by the other, we
  * This opinion is moft probably true, but it  is by no means (as the author
fays,) evident.  His reafoning however, is ingenious, and deferves atten-
tion.  The expulfion, or rather evacuation ofthe morbific matter is admitted
as a cure ofthe difeafe, and  the difference of the  difeafe to the different
manner in which this evacuation is made:  But the author  has not prowl
either of the premiffes he has advanced, viz. that the quantity of hum**
fluids which the ferment affimilates, is nearly the fame in different perfons',
nor that any part of the morbihc matter, or the morbid affimilated fluids pafs
off by perfpiration. 
                  OF PHYSIC.                ?2J

may thereby difcover the caufes which give  occafion to
more puftules in one perfon than in another.
   597.] The caufes which determine more of the variol-
ous matter to pafs by perfpiration, or to form puftules, are
probably certain circumftances of the fkin, that determine
more or lefs of the  variolous matter to flick in it, or to
pals freely through it.
   598.] The circumftance of  the ikin,  which feems to
determine the variolous matter  to ftick in it, is a certain
ftate of inflammation depending, much upon  the heat of
it.   Thus  we have many inftances of parts ofthe body,
from being  more heated, having a grc&tcr number of puf-
tules than other parts.   In the prefent praaice of inocu-
lation, in which few puftules are produced, much feems to
be owing  to the care  that is taken to keep the fkin cool.
Parts covered with platters, efpecially with thofe of a fti-
mulant kind, have more puftules than other parts.   Fur*
ther, certain circum Stances, fuch as  adult age,  full  living,
determining to a'phlogiftic diathefis, feem to produce a
.greater: number of puftules ;  while the contrary circum-
 ftances have contrary effects.
   599 ] It is therefore  probable, that an inflammatory
 ftate of the whole  fyftem, and more particular!)' of the
 fkin, gives occafion to a greater number of puftules : and
 the caufes of this may likewife produce moft ofthe other
 circumftances  ofthe confluent fmalkpox; fuch as the pe-
 riod of eruption; the continuance of the fever ; the effu-
 fion of a more putrefcent matter, and lefs fit to he convert-
 ed into pus ; and,  what arifes  from thence, the form and
 other circumftances of the puftules.
    600.] Having thus attempted to account for the  chief
 difference which occurs  in the  ftate of the fmall-pox, we
 fliall now try the truth of our doarine, by its  application
 to praaice.
    601.] In confidering the praaice, we view it  firft, in
 general, as fuited to render the difeafe more generally be*-
 nign and fafe,  and this by the praaice of inoculation.
    602.] It is not neceffary here to defcribe the operation
 of inoculating; and what we name the pTaaice of inocula-
 tion,  comprehends all the feveral meafures which precede
 or follow that  operation,  and are fuppofed  to  produce its
 falutary effeas.                          , 
222
PRACTICE
   Thefe meafures are chiefly the following.
   1.  The choofing for the fubjea of inoculation perfons
otherwife free from difeafe, and not liable,  from their age
or other circumftances,  to any incidental difeafe.
   2.  The choofing a perfon at the time of life moft favour-
able to a mild difeafe.
   3.  The choofing for the praaice a feafon the moft con-
ducive to the mildnefs ofthe difeafe.
   4.  The preparing the perfon to be inoculated, by abfti-
nence from animal food for fome time before inoculation.
   5.  The preparing the perfon by courfes of mercurial
and antimonial medicines.*
   6.  The taking care, at the time of inoculation, to avoid
cold, intemperance, fear, or  other circumftances  which
might aggravate the future difeafe.
   7.  After thefe preparations and precautions, the choof-
ing a fit matter to be  employed in inoculation, by taking
it from a perfon of a found conftitution, and free from any
difeafe or fufpicion of it;  by taking it from a perfon who
has had the fmall pox  of the moft benign kind;  and,  laftly,
by taking tile matter from fuch perfons, as  foon as it has
appeared in the puftules, cither in the part inoculated, or
on other parts of the body.
   8.  The introducing, by inoculation, but a fmall portioit
of the contagious matter.
   9.  After inoculation, the continuing the vegetable diet,
as well as the employment of  mercurial and  antimonial
medicines ; and, at the  fame time, frequently employing
purgatives.
   10. Both before and  after inoculation,  taking care to
avoid external heat,  either from the fun,  artificial  fires,
warm  chambers, much  clothing,  or  being  much in bed;
and, on the  contrary, expofing the perfon to a free and
cool air.
   11. Upon the appearance of the eruptive fever, the ren-
dering that moderate by the employment of purgatives; by
the ufe of cooling and antifeptic acids;  and efpecially by
expofing the perfon frequently to a cool and even a  cold
air, at the fame time giving freely of cold drink.
   12. After the eruption,  the  continuing the application
* Comgarethis paragraph with what follows in article 608. 
OF  PHYSIC.
.223
of cold air,  and the  ufe  of purgatives, during the courfe
of the difeafe, till the puftules are fully ripened.
   603.]  Thefe are the meafures propofed and praaifed in
the latelt and moft improved ftate of inoculation ; and the
advantages obtained by the whole of the praaice, or at leaft
by moft of the meafures above mentioned,  are now afcer-
tained by a  long experience to amount to this, That, in
iiinety  nine  cafes of the hundred,  inoculation gives a  dif-
tina fmall pox only, and that alfo very generally of the
mildeft form ; but it will ftill  be ufeful, for the proper
condua  of  inoculation,  to confider the importance  and
utility  of  the  feveral meafures above  mentioned, that we
may thereby more exaaiy determine upon what the advan-
tages of inoculation more certainly depend.
   604.] As  the common  infc£tion may often feize perfons
labouring under another difeafe,  which  may render the
fmall pox more violent, it is obvious that inoculatirvmuft
have a great advantage, by avoiding fuch  concurrence.
But as the  avoiding fuch concurrence may often,  in the
mean while, leave perfons expofed to the common infec-
tion, it merits inquiry,  whether every difeafed ftate fhould
rcftrain from the praaice of  inoculation, or what are the
particular difeafes that fhould do fo.   This is not yet fuf-
ficiently  afcertained by  obfervation; and we have fre-
quently remarked,  that the fmall pox have often occurred
with a  difeafed  ftate of the body,  without  being thereby
rendered more violent.   In particular, we have obferved,
that a ferophulous habit, or even the<prefence of ferophula,
did not render the fmall  pox  more violent;  and we have
obferved alfo, that feveral difeafes of the fkin are equally
innocent.   I am of opinion,  that they are difeafes of the
febrile  kind, or ailments  ready to induce  or aggravate a
febrile  ftate, that efpecially give the concurrence which is
moft dangerous with the fmall pox.  I dare not attempt any
general rules; but I am difpofed to maintain, that though a
perfon  be in  a difeafed ftate, if that ftate be of uncertain na-
ture and effea, and at the fame time the fmall pox be ex-
ceedingly rife, fo as to render it extremely difficult to guard
againft the common infeaion, it will always be fafer to give
the fmall pox by inoculation,  than to  leave the perfon to
take them by the common infeaion.
   605.] Though inoculation has been praftifed with fafety. 
   324                PRACTICE

 .  upon perfons of all ages; yet from what has aaually oc-
   curred in the cafes of common infection, and from feveral
   other confiderations, there is reafon to conclude, that adults
   are more liable to a violent difeafe than perfons of younger
   years.   At the fame time, it is obferved, that children, in
   the thane of their  firft dentition, are liable,  from this irri-
   tation, to have the fmall-pox rendered more violent; and
   that infants,  before the time of dentition, upon receiving
   the contagion of the fmall-pox, are liable  to be affected
   with epileptic fits,  which frequently  prove fatal.   It is,
5^therefore,  upon  the whole, evident, that, though circum-
   ftances may admit, and even render inoculation at any age
   proper; yet, for the moft part,  it will be ftill more ad-
   vifable to choofe perfons at an age, after the firft dentition
   is over, and  before the  time of puberty.
     606.] Though inoculation has been praaifed with fafe-
   ty at v-'ery feafon of the year;  yet, as it is certain that the
   cold of the winter may  increafe the inflammatory, and the
   heats of fummer increafe the putrefcent ftate of the fmall-
   pox, it is highly probable that inoculation may have fome
   advantage, from avoiding the extremes, either of heat of
   cold.
      607.] Although  the original temperament and contti-
   tutions of men  are not to be readily  changed ;  it is fuffi-
   ciently certain, that the conditions ofthe human body may,
   by various caufes, in many refpeas be occafionally very
   much changed :  and therefore, as the ufe of animal food
   may increafe both the inflammatory and putrefcent ftate
   of the human body, fo  it muft render perfons, on receiv-
   ing the  contagion of the fmall-pox,  lefs fecure againft a
   violent difeafe;  and, therefore,  inoculation  may  derive
   •fome  advantage from  abftinence from animal  food, for
   fome time before the inoculation is performed :  but I am
   of opinion, that a longer time than that ufually prefcribed
   may be often neceffary ;  and I am  perfuaded, that the
   Scottifh mothers who  avoid giving their children animal
   food till they are paft the fmall pox, render  this  difeafe in
   them of a milder kind.
      608.] I cannot deny that mercurial and antimonial me«
   dicmes may  have fome  effea in determining to a more free
   perfpiration, and therefore  may  be  of fome ufe in pre-
   paring a perfon for the final! pox; but there are  many 
OF  PHYSIC.                225
 obfervations which render me doubtful as to their effea.
 The quantity of both thefe medicines, particularly of the*
 antimony, commonly employed, is too inconfiderable to
 produce any effea.   It is  true, that  the  mercurials have
 often been employed more freely; but their  falutary ef-
 feas have not been evident, and their nrifchievous effeas,
 have fometimes appeared.  I doubt,  therefore, upon the
 whole, if inoculation derives any  advantage  from  thefe
 pretended preparatory courfes of medicines.
   609.]  As it has been often obferved, in the cafe of al-
 moft  all  contagions,  that cold, intemperance, fear,  and
 fome other circumftances, concurring with the application
 of the contagion, have greatly aggravated the future  dif-
 eafe, fo it muft be the fame in the  cafe of the  fmall-pox ;
 and it is undoubted, that inoculation muft derive a great,
 and perhaps its principal,  advantage, from  avoiding the
 concurrences abovementianed.
   610.]  It  has been commonly fuppofed, that inocula-
 tion has derived fome advantage from the choice  of the
 matter employed in it; but, from what has been obferved
 in 594, it muft appear very doubtful if any choice be ne-
 ceffary, or can be of any benefit in determining the ftate
 of the difeafe.*
   611.]  It has been fuppofed by fome,  that inoculation
 has an advantage, introducing a  fmall portion only of the
 contagious matter: But this refts upon an  uncertain foun-
 dation.   It is  not known what quantity is introduced by
 the common infeaion, and it  may be a fmall quantity on-
 ly.  Although it wers larger than  that thrown in by  ino-
 culation,  it  is not afcertained that the circumftance of
 quantity  would have any effea.   A  certain quantity of
 ferment may  be neceffary to  excite  fermentation  in a
 given  mafs : but that  quantity  given,  the  fermentation
 and  affimilation are  extended to  the whole  mafs;  and
 we do not find that a greater quantity than is juft necefla-
 ry, either increafes the aaivity of the fermentation, or
 more certainly  fecures the affimilation of the whole.   In
 the cafe of the fmall-pox, a confiderable difference in the

   To remove all fufpicion, however, it is doubtlefs better toincculat* with
m.un-r tukfn  from a mild Hate ofthe difeafe.
  Vc.i.1.                 Ff 
226                   PRACTICE
 quantity of contagious matter introduced,  has not difco-
 vered any effea in modifying the difeafe.

   612.]  Purging has the effea of diminifhing the aaivity

 ofthe fanguiferous fyftem,  and of obviating its inflamma-

 tory ftate. .  It is therefore probable, that the frequent ufe

 of cooling purgatives is  a  praaice attending inoculation

 which may be of confiderable advantage; and, probably,

 it is  alfo ufeful  by  diminifhing  the determination to the

 fkin.   It appears to me,  that mercurials and antimonials,

 as they  are  commonly managed, are ufeful  only as they

 make a part ofthe purging  courfe.*

   613.]  It is probable,  that the ftate of the fmall pox de-

 pends very much upon the  ftate ofthe  eruptive fever, and

 particularly upon moderating the inflammatory ftate of the

 fkin;  and,  therefore,  it  is  probable,  that  the  meafures
 taken for moderating the eruptive fever and inflammatory

 ftate of the fkin, afford the greateft  improvement which

 has  been made in the praaice of inoculation.   The ten-
 dency of purging, and the ufe of acids for this purpofe,  is

 fufficiently obvious; and upon the fame ground, we fhould

 fuppofe, that bloodletting might be ufefrfl; but probably

 this has been omitted,  for the fame reafon that might per-

 haps have  led to  the  omiffion  of other remedies alfo,

  * All purgatives are extremely naufeous to children ; and as it is of little
 confequence what purgative we ufe, if we  only avoid the hot draftic ftimu-
 lants, we ought to pay attention to the agreeablenefs of the form. Children
 may in general be deceived by the following device : Put half an ounce  of
 fenna leaves (after the ftatks are all picked out) into a tea-pot, with a quar-
 ter of an ounce of green tea ;  pour on it a quart of boiling water.  Let the
 child fee it poured out into a tea-cup, fweetened with plenty of moift fugar,
 and cream put to it.  The child will drink it with avidity.  A tea-cupful may
 be given every hour till it began to operate.
 •m1{ this device fhould fail a fecond time, another may be ufed in its ftead.
 Two drachms of fenna leaves, powdered, may be added  to half a pound  of
 ginger-bread pafte;  the mafs may be divided into  fifteen fmall cakes to  he
 baked : give the child one of thefe cakes every half hour till it begins to ope-
 rate,  or till  he has taken a fufficient dofe for his  age.   A drachm of jalap
 may be ufed inftead of the fenna.
  If  neither of thefe artifices fucceed, a dofe of powdered fenna, with  or
 without a little ginger, may be given in orange marmalade.
  Children will fometimes eat as many tamarinds as will fufticiently anfwer
 all the intentions of a formal purge.   A little Caflia-purp,  added to the tama-
rinds, will increafe their activity, and will not be eafily perceivedby the child.
  The empirics have committed many ftrange chemical blunders in com-
 pounding their .purges for inoculation.  Dimfdale's powder, may ferve as  an
 example :  it confifts of tartar emetic and crabs claws. The  calcareous earth
 deprives the tartar emetic of its acid; in confequence of which, the antimony
 will be inert,  except it accidentally meets with an acid in the ftomach ; and
 even then the acid muft be in fuch a quantity to faturate the crabs claws, hfl-
 forc it can a<ft on the antimonial calx. 
0 F  P H Y S I C.                 227
 which is, that we have found  a more powerful and effec-
 tual one in the application of cold air, and'the ufe of cold
 drink.   Whatever doubts or difficulties our theory might
 prefent to us on this fubjea, they may be entirely neglect-
 ed, as the praaice of Indoltan had long ago, and the prac-
 tice of this country has lately,  by a large  and repeated ex-
 perience,  afcertained  the fafety and efficacy of this reme-
 dy :  and as it may and can be  more  certainly employed
 with the praaice of inoculation, than it can be in cafes of
 common infeaion,  it  muft give a  fingular advantage to
 the former.*
    614.] After the eruption, when a few pimples only have
 appeared on the face, the continuing the application of cold
 air, and the employment of purgatives,  has indeed been
 the practice of many inoculators : but I think, thefe prac-
 tices cannot be faid to give any peculiar advantages to ino-
 culation ; for when the  ftate of eruption is  determined,
 when the number of puftulcs is very fmall,  and  die fever
 has entirely ceafed,  I hold the fafety of  the difeafe to be
 abfolutely afcertained, and the further ufe of remedies en-
 tirely fupcrfluous.   In fuch cafes,  I judge the ufe of pur-
 gatives to be  not only unneceffary,  but that they may be
 often hurtful.
   615.] I have  thus confidered the fevcral circumftances
 and praaices accompanying inoculation,  and  have endea-
 voured to  afeertain the utility and importance  of each.
 Upon the whole, I hope I have fufficiently afcertained the
 general utility and great advantage of this  practice, efpe-
 cially confifting in this, that if certain precautions,  prepa-
 rations, and remedies, arc of importance, all  of them can
 be employed with more certainty in the praaice of inocu-
 lation,  than in the cafe of common infection, t
  * Notwithftanding the juftnefs of this remark, bleeding ought not to be
 employed, except in cafes where the phlogiftic diathefis and fymptoms are
 violent:  the fright which children fuffer in  confequence of the operation,
 may be productive of much mifehief; and purgatives,, when properly admini-
 ftered, fuperfede the neceflity of bleeding, efpecially when the cold regimen
 is employed at the fame time.
  f The author feems to have forgotten a frequent confequence of inoculati-
 on, that demands fome attention, viz. an inflammation  of the axillary glands,
 that often terminates in fuppuration.  Many cafes of this kind occurred to
 me in practice, and I attempted feveral methods of preventing the fuppura-
tion ; of which I found the  following the moft efficacious :  If only one arm
 had been punctured, the gland of that arm, when fuch an accident happened,
and not ofthe other, was inflamed   In attempting the  refolution, which per-
haps fome practitioners may think improper, I applied cold  compreffes, ini- 
92t                 PRACTICE
  It remains now that I fhould offer fome remarks on the
condua of the fmall pox, as received by infeaion, or even
when, after inoculation, the fymptoms fhall prove violent.
The latter fometimes happens, although every precaution
and remedy  have been employed.   The caufe of this is
not  well  known; but  it appears to me to be commonly
owing to a difpofition of the fluids to putrefcency.  But,
however this may be, it will appear, that, not only in the
cafe of common infeaion, but even in that for inoculation,
there may be occafion for ftudying the condua of this dif-
eafe, in all its poffible varying circumftances.
   616.]  When, from the prevailing of fmall pox as an
epidemic, and more efpecially when it is known that a per-
fon  not formerly affected with the difeafe has been expofed
to the infeaion, if  fuch perfon  fliould  be feized with the
fymptoms of fever, there can be little doubt of its being
an attack of the  fmall pox; and  therefore he is to be treat-
ed in every  refpea as  if the difeafe had been  received by
inoculation.   He is to be freely expofed to  a  cool air, to
be purged, and to have cooling  acids given  liberally.*
   617.]  If thefe  meafures moderate  the fever,  nothing
 more is neceffary :  But if the nature of the fever attacking
 a perfon be uncertain; or if, with  fufpicions  of the fmall
pox, the  fymptoms  of the  fever be violent; or even if,
 knowing the difeafe to be  fmall pox,  the  meafures men-
 tioned (596.) fhall  not moderate the fever  fufficiently;  it
 will be proper to let fome blood:  and this will be more ef-
 pecially proper,  if the perfon be an adult,  of a plethoric
 habit, and accuftomed to full living.t
    618.]  In the fame circumftances,  we judge it will he
 always proper to give a vomit, as ufeful in the commence-
 ment of all fevers,  and more  efpecially in this, where a

 pregnated with a folution of Saccharum Saturni, to the inflamed gland, and
 a warm poultice to the  ulcer of the punfture. The confequence was an in-
 creafed difcharge from the puncture, and a diminution of the axillary fwelled
 gland. No ill confequences attended any of thofe cafes where the tumcur
 v/as thus refolved :  but when thefe tumours fuppurate,  they are apt to pro-
 duce finous ulcers, very difficult to heal.
   * The cooling acids have been defcribed in former notes, (Art. 131. and
 134.)  Whey made  with cream of tartar is very ufeful in the fmall-pox, as
 it is a cooling drink, and at the fame time laxative-  It is made by throwing
 into a quart of boiling milk half an ounce or fix drachms  of powdered cieam
 of tartar.
   f This practice is moft judicious, and ought to be firictly followed. 
OF  PHYSIC.
229
determination to the ftomach appears from pain  and fpon-
taneous vomiting.
   619.]  It frequently happens, efpecially in infants,  that,
during me eruptive fever  of the fmall pox, convulfioiu
occur.  Of  thefe, if  only one or two fits appear on the
evening preceding the eruption,  they  give a favourable
prognofLc of a mild difeafe, and  require no remedy ;  but
if they occur more early, and be violent and frequently
repeated,  they are very dangerous, and require a  fpecdy
remedy.   For this purpofe, bleeding is hardly ever of fer-
vice; bliftering always comes too late ;  and the only re-
medy I have found effeaual,  is an opiate given inalaroe
dole.*                                               °
   620.] Thefe are the  remedies neceffary  during the e-
ruptive fever;  and if, upon the eruption, the pimple's upon
the face be very few and diftina,  the difeafe is no further
of any danger, requires no remedies,  and the purgatives,
which, as has been faid before, are by fome praaitioners
continued, prove  often hurtful.
   But when,  upon the eruption,  the pimples on the face
are very numerous; when they are not diftina;  and efpe,
cially when,  upon the fifth day, the fever docs not fuffer
a  conhderable remifiion,t the difeafe  will ftill require  a
great deal of attention.
   621.]  If,  after the eruption, the  fever fliall continue;
the avoiding  heat, and the continuing to expofe  the body
to a  cool  air,  will ftill be proper.   If the fever be confi-
derable,  with a full and hard pulfe, in  an  adult perfon,  a
bleeding will be neceffary;  and, more certainly, a cooling
purgative.  It is,  however, feldom that a  repetition ofthe
bleeding will be proper, as a lofs of ftrength  does ufually
come on very foon ; but the repetition of a purgative, or
the frequent ufe of laxative glyfters, is commonly ufeful +
  • The dofes for children in thefe cafes arc as follow -• A child of half a
year, hvc drops of laudanum : From half a vear to a vear, fix drops : From
one to  two years,  feven or eight : From two to three, nine or ten: Five years.
twelve, or at  moft fifteen.  Thefe are large dofes, and  are fuch as are onlr
to be given to robuft children.
  f The practitioner ought tobe particularlv attentive to the fymptoms which
appear on the fifth day.  The fubfequent paragraphs render anv farther re-
marks  needlefs.
  f Laxative  glyfters are preferable to repeated purgatives, on account of
their not debilitating the patient fo much  as pui-aiivea.  The foliowv»
ljrm has been found very effedual :                 ,            *
          Be Fol. Senna-, g f^. 
230                   PRACTICE
   622.] When a lofs of ftrength, with  other marks of a
putrefcent tendency  of the fluids, appears, it will be ne-
ceffary to exhibit the  Peruvian bark in fubftance,  and  in
large quantity.*  In the fame cafe, the  free ufe of acids,
and of nitre,t  is ufeful;  and it is  commonly  proper alfo
to give wine very freely.+
   623.] From the fifth day of the difeafe, onward through
the whole courfe of it, it is proper to  give  an  opiate once
or twice a day; taking care, at  the fame time,  to obviate
coftivenefs, by purgatives,  or laxative glyfters.
   624.] In  a violent difeafe, from the  eighth to the ele-
venth day, it is proper to lay on blifters fucceffively on dif-
ferent parts of the body; and that without regard  to the
parts being covered with puftulcs.
   625.] If, in  this difeafe, the tumour of  the fauces be con-
fiderable;  the  deglutition difficult; the faliva  and  mucus
vifcid, and with difficulty thrown out;  it will be proper to
apply blifters  to the external  fauces,  and to employ dili-
gently detergent gargles, jj
   626.] During the whole courfe ofthe difeafe, when any
confiderable fever is prefent,  the frequent exhibition   of
antimonial medicines, in naufeating dofes, has been found
ufeful;** and thefe, for the moft part, fufficiently anfwer
the purpofe  of purgatives.

              Sal. cathartic, amar. |i.
              Aq. bullient. lb. i.
              Colaturse frigidae adde.
              Syr. e Spin. Cervin.  B'u
              01. Olivar. § ft.
              M.
  Or even a fimple folution of Epfom fait in warm water.
  * The method of giving the bark in the  fmall pox, is the fame with that
mentioned in the note on article 317.  For children, the glyfter there men-
tioned, is extremely convenient, and proves wonderfully efficacious.
  f The Spiritus Nitri dulcis is the beft form in which nitre can be given to
children.  See the  notes on article 131.
  \ The wine beft  fuited to thefe cafes is Port wine : but as children fome-
times loath it, good claret may be fubftituted in its place.
  || 1'he beft detergent gargles in this cafe are the tincture of rofes with ho-
ney ; or the gargle of fage and rofe-tea, with vinegar and honey, mentioned
in the note on article 317; or Dr. Fothergill's gargle defcribed in that note.
  ** A folution  of two grains of emetic tartar in  eight ounces of water an-
fwers this intention very effectually.  The dofe is to be determined by the
naufeating effect, produced :  a table-fpoonful of the folution may be given
occafionally every two or three hours.  Care, however, muft be taken, that
vomiting is not produced; and, at the fame time, a fufficient quantity muft
be given/o produce a naufea.  Both thefe circumftances depend on the age,
ftrength, and conftitution of the patient and on the violence of the difeafe. 
OF   PHYSIC.                 231
  627.]   The remedies mentioned from 621.  to  625.
are thofe frequently neceffary, from the fifth day, till the
fuppuration is finifhed. But as, after that period, the fever
is  fometimes continued and increafed; or, as fometimes,
when after there has been little or no fever before, a fever
now arifes,  and continues with confiderable danger; this
is what is called the Secondary Fever,  and requires par-
ticular treatment.
   628.]  When the  fecondary fever  follows the diftina
fmall pox, the pulfe is full and hard, the cafe is to be treat-
ed as an inflammatory affeaion, by bleeding and purging.
But, if the fecondary fever follow the confluent fmall pox,
and be a  continuance  or exacerbation of  the fever which
had fubfifted before,  it-is  tobe confidered  as of the pu-
trid kind; and in that  cafe, bleeding is improper-   Some
purging may be neceffary;  but the remedies to be chiefly
depended on,  are  the  Peruvian bark and acids.*
   When the fecondary fever firft appears, whether it is af-
ter a diftina or confluent fmall-pox,  it will be ufeful  to
exhibit an antimonial emetic in naufeating dofes,  but in
fuch a  manner as to produce fome vomiting.
   629.]  For avoiding the pits which frequently follow the
fmall-pox, many different meafures have been propofed :
but none of them appear to be fufficiently  certain.t

                       CHAP. II.
                ©f t&e  C&icfccn4Por.

 630.]  X HIS difeafe feems  to depend upon a fpecific
 contagion, and to  affea perfons but once in.their  lives.

  * The fecondary fever is always the worft, and moft dangerous ftage ofthe
 difeafe.  In  the diltindt fmall pox  it feldom occurs; but it is a conftant at-
 tendant on the confluent kind,'  It feems to be owing to the abforption ofthe
 matter : for it never appears, evidently at leaft, till after the fuppuration :
 and, ceteris paribus, it is always more violent in proportion to the quantity
 of puftules.  Some authors recommend opening the puftules, in order to eva-
 cuate the matter, as a preventative againft the fecondary fever ; and when
 the eruption is large, this praaice is advifable.
  The Peruvian bark muft be given in thefe cafes in the largeft quantities
 that the ftomach can bear, and alfo in glyfters as formerly mentioned.  Some
 practitioners,  belidesthe internal ufe of bark, and given in glyfters, have ad-
 vifed it to be  applied externally by throwing the dry powder on thofe parts
 of the body that are the moft exulcerated.
  *  The moft effectual means of preventing pits, are to avoid much expofurc
to the cold air, to anoint the face with oil, Sec. 
452                 PkACTICE

It is hardly ever attended with any danger;  but as it feems
frequently  to have given occafion to the fuppofition of a
perfon's having the  fmall-pox twice, it is proper to ftudy
this difeafe, and to diftinguifh it from the  genuine fmall-
pox.*
   631.] This may be generally done by attending to the
following circumftances.
   The eruption of  the chicken-pox comes on with very
little fever preceding it, or with  fever of  no determined
duration.                                          ^
   The  pimples of the chicken-pox, more quickly than
thofe of the fmall-pox, are  formed into  little veficles or
puftules.
   The matter in thefe puftules remains  fluid, and  never
acquires the colour  or confiftence of the  pus which ap-
pears in the puftules  of the fmall-pox.
   The puftules of the chicken-pox are always in three or
four days from the firft appearance, formed into crufts.
   See Dr.  Heberden in Med. Tranfatt. Vol. I.  art. xvii.

                     CHAP. III.



632.]  X  HIS difeafe alfo depends upon a fpecific conta-
gion, and affeas perfons but once in their lives.
   633J It occurs moft frequently in children; but no age
is exempted from it, if the perfons have not been fubjecf-
ed to it before.
   634.] It commonly appears as an epidemic, firft in the
month of January,  and ceafes foon after  the fummer fol-
ftice; but  various  accidents, introducing   the contagion,
may produce the difeafe at other times ofthe year.
   635.] The difeafe always begins with a cold ftage, which
is foon followed by  a hot, with the ordinary fymptoms of
thirft, heat, anorexia,  anxiety,  ficknefs,  and vomiting;
and  thefe are more or lefs confiderable in  different  cafes.
Sometimes from the beginning,  the fever is fharp and vio-

  * As this difeafe is generally mild, and fcarcely ever requires the affiftance
cf art in the cure, the author very properly paffes it over in a curfory manner.
It fometimes, however, very much refembles the mild fmall pox ; and in fuch
cafes may require the treatment which has been recommended a& feiviceabhj
in that difeafe. 
                    O F  PHYSIC.  /            233

 lent;  often, for the firft two days, it is obfcure and incon-
 fiderable, but always becomes violent before the eruption,
 which ufually happens upon the fourth day.
    636.] This eruptive fever from its commencemcut,  is
 always attended with hoarfenefs, with a frequent hoarfe dry
 cough,  and frequently with fome difficulty of breathing.
 At the fame time,  the eye-lids are fomewhat fwelled, the
 eyes are a little inflamed, and pour out tears;  and, toge-
 ther with thefe  fymptoms, there is a coryza,  and frequent
 fneezing.  For the moft  part, a conftant  drowfinefs at-
 tends the beginning of this difeafe.
    637.] The eruption,  as we have faid, commonly ap-
 pears upon the  fourth day, firft on the face, and fucceflive-
 \y on the lower parts of the body.  It difeovers itfelf firft
 in finall red points; but,  foon after a number of thefe ap-
 pear in clufters, which do not arife into vifible pimples,
 but by the  touch are found to be a little prominent. This
 is the cafe on the face; but on other parts of the body, the
 prominence, or roughnefs, is hardly to be perceived. On
 the face the eruption retains  its rednefs, or has that in-
 creafed for two days: but,  on the third,  the vivid rednefs
 is changed to a  brownifh red : and, in a day  or  two more,
 the eruption entirely difappears, while a meally defqua-
 mation takes place.  During the whole time ofthe erup-
 tion, the face is  fomewhat turgid, but feldom confiderably
 fwelled.
   638.]  Sometimes, after the eruption has appeared, the
 fever  ceafes entirely: but this is feldom the cafe;  and
 more commonly the fever  continues, or is increafed after
 the eruption, and does not ceafe till after the defquamation.
 E\( n  then the fever does not always ceafe, but continues
 with various duration and effea.
   639. ]  Though the fever happen to ceafe upon the erup-
 tions taking place, it is common for the cough to continue
 till after the  defquamation, and fometime much longer.
   In all cafes, while the fever continues, the  cough alfo
continues, generally with an increafe  of the difficulty of
 breathing ; and both of thefe fymptoms fometimes arifes to a
degree that  denotes  a  pneumonic affeaion.   This may
arife at any period of the difeafe ;  but very often it docs
not come ou till after the defquamation of the eruption
  Vci. I.                 G G 
*34                 PRACTICE
   After the fame period, alfo, a diarrhoea frequently comes
 on, and continues for fome time.
   640.] It is common for the meafies, even when they
 have not been of a  violent kind,  to be fuccecded by in-
 flammatory affeaions, particularly ophthalmia and phthifis.
   641.] If the blood  be drawn from  a vein during the
 meafies, with the circumftances neceffary to favour the
 feparation  of the gluten, this always  appears feparated,
 and lying  on the furface of the craffamentum, as in in-
 flammatory difeafes.
   642.] For the moft part, the  meafies, even when vio-
 lent, are without any putrid tendency ; but in fome cafes
 fuch a tendency appears, both in the courfe of the difeafe,
 and efpecially after the  ordinary courfe of it is  finifhed.
 See  Dr. Watfon, in London Med. Obfervations,  Vol.
 IV. art. xi.
   €43.] From  what is delivered, from  636, to 641, it
 will appear, that the meafies are diftinguifhed by a catarr-
 hal affeaion, and by an inflammatory diathefis to a con-
 fiderable degree,  and therefore the danger attending them
 arifes chiefly from the coming on  of a pneumonic inflam-
 mation,
   644.] From this confideration it will be obvious, that
 the remedies efpecially neceffary, are thofe which  may ob-
rviate and diminifh the  inflammatory diathefis; and there-
 fore, in a particular manner, blood-letting.  This remedy
 may be employed at any time in the courfe of the difeafe,
 or after its ordinary courfe is  finifhed.  It is to be em-
 ployed more'or lefs according  to the urgency ofthe fymp-
 toms of fever, cough,  and dyfpnaea; and generally may
 be employed very  freely.*   But, as the  fymptoms of
 pneumonic inflammation feldom come on during the erup-
 tive fever; and, as this fever  is fometimes violent imme-
 diately before the eruption, though a fufficiently  mild dif-
 eafe be to  follow; fo  bleeding  is  feldom very neceffary
 during the eruptive fever,  and may often be referved for
 the periods of greater  danger which are perhaps to enfue.
   645.] In all cafes of meafies, where  there are no marks
 of putrefcency, and where  there  is no reafon, from the
   * Bleeding ought to be ufed where it is abfolutely neceffary ; but,  too free
 a, ufe of it has been attended with a long continued weaknefs, and a very flow
 .recovery. 
OF  PHYSIC.                 23*
known nature of the epidemic, to apprehend putrefcency,
bleeding is the remedy to be depended upon : but affift-
ance may  alfo be obtained from cooling purgatives;  and
particularly from bliftering on the fides,  or between the
fhoulders.
   646.] The dry cough may  be alleviated by the large
ufe of demulcent peaorals, mucilaginous, oily,  or fweet.*
It may,  however, be obferved, with refpea to thefe demul-
cents, that they are not fo powerful in involving and  cor-
reaing the acrimony  of the mafs of blood as has  been
imagined ; and that their chief operation is by befmearing
the  fauces, and thereby defending them from the irrita-
tion of acrids, either arifing  from  the  lungs, or diftilling
from the head'.
   647.] For  moderating and  qufeting the cough in this
difeafe, opiates certainly prove the moft effeaual means,
whenever  they can be fafely  employed.   In the  meafies,
in which an inflammatory ftate prevails in a confiderable
degree,  opiates may be fuppofed to  be inadmiflibte;  and,
in thofe cafes in  which a high degree of pyrexia and dyfp-
ncea fhew either the prefence,  or at leaft the danger, of
pneumonic  inflammation,  I think that opiates might be
very hurtful.  In cafes, however, in which the dyfpnoea is
not confiderable, and where bleeding, to obviate or abate
the inflammatory ftate, has been duly employed,  and where
  * Two ounces of pearl barley, and four ounces of dried figs, cut, boiled iix.
a gallon of  water to three quarts, is a good drink in  thefe cafes.  If the pati-
ent loaths this drink, lintfeed tea, or a flight infufion of Orrice root in boil-
nig water; may be fubftituted in its phice, or a folution of an ounce of gum a-
rabic in a pint of water.
  Oily emulfions are alfo recommended; the moft- ufual is the following  :
           R. OI.  Amygdal. Jiu
             Aq. Font. §.vi.
             Alkali Caustic, q. s. ut flat Elmus. cui adde
             Syrup. Althxse, §ii.
  The patient may take half a tea-cupful of this  emulfion occafionally, when
the cough is moft troublefome.  The cough may  alfo be relieved, by taking
now and then  a tea-fpoonful ofthe following Lin&us"i
           R. OU Amygdal.
             Syrup. Altluea?.
             Conserv. Cynosbat. aa. §ii*
             M. £. Linct.
        Or  the following :
           R. Mel. anglic.
             01. Amygdal. aa. §ii.
             Succ. Limon. §i,
             M+  £» Linct*. 
236                   PRACTICE
the cough and watchfulncfs  are the  urgent  fymptoms,  I
think diat opiates may be fafely exhibited, and with git at
advantage*   I think, further, that, in all  the exanthema-
ta, there is  an acrimony diffufed over the  fyftem, which
gives a confiderable irritation ;  and, for obviating the ef-
fed.s of this, opiates are ufeful, and  always  proper, when
no particular  contra-indication prevails.
   648.] When the difquamation of the meafies  is finifh-
ed,  though there  fhould  then be no diforder  remaining,
phyficians have thought  it neceffary to  purge the patient
feveral times, with a view to draw off the dregs of this dif-
eafe, that is, a portion of the morbific matter which is fup-
pofed  to remain  long in the body.   I cannot reject this
fuppofition;  but,  at  the fame time, cannot believe,  that
the remains ofthe morbific matter, diffufed over the whole
mafs of blood, can be entirely drawn off by purging ;  and
it appears to  me, that, to avoid the confequences of the
mealies,  it is not the drawing oft the morbific matter which
we need to ftudy,  fo much as the obviating  and removing
the inflammatory ftate of the fyftem which had  been in-
duced by the  difeafe.   With this  laft view-, indeed, purg-
ing  may ftill  be a  proper remedy ;  but bleeding, in pro-
portion to the fymptoms of inflammatory  difpofition, is
yet more fo.t                             >
  * Opiates, in all inflammatory cafes,  ought to be cautioufly ufed.   The
danger arifing from them is confiderably obviated, by ufing only the gummy
part of the opium, and therefore the watery folution of opium, ib in thefe
cafes preferable to any other form.
  The Syrupus papaveris albi, is an opiate peculiarly adapted to this difeafe;
the dofe of it is immaterial,  provided we do not exceed  four ounces in the
foftr and twenty hours ;  a table-fpoonful may  be taken  when the cough is
iroublefome, and may be repeated every two or  three hours according to the
urgency of the fymptoms.
  t The complaints wl.ich the  meafies leave are chiefly pneumonic.  The
cough is the moft troubiefome fymptom, and to relieve the patient from it,
not only bleeding and purging muft be ufed, but  expectorants ought alfo tobe
adminiftered.   The Lac Ammoniacum, formerly mentioned, has often prcv-
eJ beneficial.
  On the fuppofition, that the cough  and pneumonic affeclion remaining after
the meafies are owing to a peculiar acrimony, fome pra&itiouers have recom-
mended alteratives and demulcents :  Experience, however, has found  little
advantage from their ufe.  I once faw a body opened, that had died 32 dajs
after the eruption ; the  internal furface of the hronchise was covered  with
fmall furfuraceous fcales, fomewhat  like thofe that appear on the fkin when
the eruption goes off.  Hence I have been induced to fuppofe, that expecto-
rants are the belt remedies in thefe cafes, and  indeed, experience cc minus
the practice. Bleeding and purging are only to be occafionally ufed, in order
to prevent the inflammation.  The beft method of avoiding the ill confcquen-
ces that follow the difeafe, is a free ufe of demulcent drinks during the eiup- 
OF   PHYSIC.                 237
   649.]  From our late experience ofthe benefit of  cold
air in the eruptive fever of the fmall-pox, fome phyficians
have been of opinion, that the practice might be transfer-
red  to the mealies;  but we have not yet had trials fuffi-
cient to  a {certain this.
  There is no doubt that external heat may be very hurtful
in the meafies,  as in moft other inflammatory  difeafes;
and therefore the body ought to be kept in a moderate tem-
perature during the whole courfe of the meafies; but how
far, at any period of the difeafe, cold air  may be applied
with fafety,  we are yet uncertain.   Analogy, though fo
 often the refource of phyficians, is, in geneial, fallacious;
and further, though the analogy with the  fmall-pox lead to  »
the application of cold air during the eruptive fever ofthe
meailes, the analogy with catarrh feems  to  be againft the
practice.  After the eruption had appeared upon the fkin,
we have  had  many  inftances of cold air  making  it difap-
pear, and thereby producing much diforder in the fyftem ; '
and have alfo had frequent examples of  fuch diforder be-
ing  removed by rcftoring the heat ofthe body, and there-
by again bringing forth the eruption.*

                       CHAP.  IV.

                SDft&e  <®tailzt Sfztob

650.] J.T may be doubted if the fearlct  fever be a difeafe
fpecifically different from the cynanche maligna above def-
 cribed.   The latter is almoft always attended  with a fcar-
fet eruption ; and, in all the inftances  I have feen of what
may be  called the fearlet fever,  the difeafe, in almoft eve-
ry perfon affeaed, has been attended with an ulcerous fore
throat.
   651. This  view ofthe matter may create fome doubt;
tion, and of expectorants immediately after it.  The decoaum hordei compo-
fitum, ofthe London Pharmacopoeia is peculiarly adapted to thefe cafes, but
it is much improved by adding half an ounce of Orrice  root, when it is nearly
boiled enough ; if the Orrice be added too foon, the efficacious part of it eva-
porates. The Lac Ammoniacum above mentioned, is  averv pr~j;;i «::;;i.mig-
rant, but if it fliould prove  too naufeous, through ufe,  and be loathed by the
patient, recourfe may be had tb the weak  folution of the Tartar Einetic, fo
oiten mentioned in thefe notes.
  * Though the  application of cold air be dangerous, yet ventilation is of
confiderable ufe in the meafies; as is alio a frequent  change of linen, and
clcanhnefs. 
238                PRACTICE
 bin I am ftill of opinion, that there is a fcarlet fever which
 is a difeafe fpecifically different from the Cynanche Maligna.
    Dr. Sydenham has defcibed a fcarlet fever, which he had
 feen prevailing as  an epidemic, with all the circumftances
 of the fever and eruption, without its being accompanied
 with any affeaion of the throat; at leaft he does not take
 notice of any fuch affeaion,  which fuch an accurate  ob-
 ferver could not fail to have done,  if any fuch fymptom, as
 we have commonly feen making a principal part of the dif-
 eafe, had attended thofe cafes which he had obferved.  Se-
 veral other writers  have defcribed the fcarlet fever in the
 fame manner, and I know phyficians who have feen the dif-
 eafe in that form ; fo that  there can be no doubt of there
 being a fcarlet fever not neceffarily conneaed with an ulce^
 rous fore throat, and therefore a difeafe different from the
 Cynanche Maligna.
   652.] But, further, although in all the inftances of fcar-
 let fever which I have feen, (and in the courfe of forty years
 I have feen it fix or feven times prevailing as an epedemic
 in Scotland) the difeafe, in almoft all the perfons affe6ted,
 was attended with an  ulcerous fore throat, or was what Sau-
 vages names the  Scarlatina Anginofa;  and although,  in
 fome  inftances the ulcers of the throat were of a putrid
 and gangrenous kind, and at the fame time the  difeafe in
 all its fymptoms refembled very exaaiy the Cynanche Ma-
 ligna ; yet I am ftill  perfuaded, that not only the Scarla-
 tina of Sydenham, but that even the Scarlatina Anginofa
 of  Sauvages,  is a  different difeafe from the Cynanche
 Maligna  ; and I have formed this opinion from the follow-
 ing confiderations.
  653.]  1st, There is a fcarletfever entirely free from any
 affeaion ofthe throat, which fometimes prevails as an epi-
 demic; and therefore there is a fpecific contagion produc-
 ing a fcarlet eruption without any determination to the throat.
  2dly, The Scarlatina, which, from its matter being ge-
nerally determined to the throat, may be properly termed
Anginofa, has, in many cafes  of the fame  epidemic, been
without any affeaion ofthe throat;  and therefore the con-
tagion may be fuppofed to be more efpecially determined
to produce the eruption only.
  %dly, Though in all the epidemics that I could alledge
to be  thofe of the Scarlatina  Anginofa, there have been 
                  OF  PHYSIC.                239

fome cafes, which, in the nature of the ulcers, and in other
circumftances, exaaiy refembled  the  cafes of the Cy-
nanche Maligna;  yet I have as conftantly remarked, that
thefe cafes have not been above one or two in a hundred,
while the  reft have all  of  them been with ulcers of a be-
nign kind, and with circumftances hereafter to be defcrib-
ed, fomewhat different from thofe of  the cynanche ma-
ligna.
   qthly, On the other hand, as I have  two or three times
feen the  cynanche  maligna epidemically prevailing; fo,
among the perfons affeaed, I have  feen inftances of cafes
as mild as thofe of the fearlatina anginofa ufually are : but
here the proportion was reverfed;  and thefe mild cafes
were not one fifth of the whole, while the reft were of the
putrid and malignant kind.
   Lastly, It applies to the fame purpofe to obferve,  that,
of the cynanche maligna,  moft of  the inftances terminate
fatally; while, on the other hand, that is the event of very
few ofthe cafes ofthe fearlatina anginofa.
   654.] From thefe confiderations, though it may appear
that there is fome affinity between the  cynanche maligna
and fearlatina anginofa, it  will ftill remain  probable that
the two difeafes are fpecifically different.   I have been at
fome pains to eftablifh this opinion : for,  from all my ex-
perience, I find,  that thofe two difeafes require a different
treatment; and I therefore now proceed to mention more
particularly the circumftances ofthe fearlatina anginofa.
   655.]  This difeafe commonly appears about the begin-
ning of winter, and continues throughout that feafon.   It
comes on with fome cold  fhivering,  and other fymptoms
of the fever which ufually  introduces the other exanthe-
mata.   But here  there is no cough, nor  the other catarrhal
fymptoms which attend the meafies; nor is there that anx-
iety and vomiting which commonly introduce the conflu-
ent fmall-pox, and which  more certainly  introduce the
Cynanche Maligna.
   Early in the difeafe, fome uneafinefs is felt in the throat;
and frequently the deglutition is difficult, gericrally more fo
than in  the  Cynanche Maligna.   Upon looking into the
fauces, a rednefs and fwelling appear in  color and bulk ap-
proaching to the ftate of thefe  fymptoms in the Cynanche
Tonfllaris •  but in the Scarlatina, there is always more or 
840                 PRACTICE
lefs  of fioughs, which feldom  appear  in the Cynanche
Tonfillaris;  and the fioughs* are commonly whiter  than
thofe in the Cynanche maligna.
   While  thefe appearances are difcovered  in  the fauces,
upon the third or fourth day a fcarlet eruption appears on
the fkin in the fame form as defcribed  in  (314.)    This
eruption is commonly  more  confiderable  and univerfal
than in the Cynanche;  but it feldom produces a remiflion
ofthe fever.   The eruption for  the moft part remains till
the third or fourth day  after its firft appearance;  but then
goes off, ending in ameally defquamation.   At this  time
the fever ufually fubfides; and generally, at,the fame time,
fome degree  >f fweat comes on.
  ,Tbe fioughs on the fauces, which appeared early  in the
difeafe, continue for fome days; but then falling off, dif-
cover the fwelling abated, and an ulcer formed on one or
both  tonfils fhowing a  laudable pus; and foon  after the
fever has fubfided,  thefe ulcers heal up entirely.  For the
moft  part this difeafe has much lefs of coryza attending it
than the Cynanche maligna; and,  when there is a coryza
attending the Scarlatina, the matter difcharged is lefs acrid,
and has not the fetid fmell which  it has in the other difeafe.
   In  the Scarlatina, when the eruption  has entirely difap- _
peared, it frequently happens, that, in  a few days after,
the whole body is affeaed with an anafarcous fwelling;
which, however, in a few days more, gradually fubfides-
   We have thus defcribed the moft common circumftan-
ces of the Scarlatina Anginofa; and have only to add, that
during the time of its being epidemic, and efpecially upon
its firft fetting in, there are always a few7 cafes in which the
circumftances of the difeafe approach' very nearly to thofe
ofthe Cynanche Maligna;  s#& it is only in thefe inftances
that the difeafe is attended with any danger.*
   656.]  With refpea to the cure of this difeafe, when the
fymptoms of  it are nearly the fame with thofe of the Cy-
nanche Maligna, it requires exaaiy the fame treatment as
direaed in (317.)                                 •
  * "Jne e cafes in which the difeafe is attended with danger,  are, however,
v£ry few,, and are only the effect of art. Teazing the patient by doing too
Koch";  tormenting him with a clofe confinement to his bed,  well furnifhed
wjjjfyilankets ; and adding fuel to the flame, by forcing him to fwallow large
qcBj^Jllies cf cordials and alexipnarmics, are the fure methods of ii creating*
ihf.d-feafe : and the patient, diftreffed by Ui* exceflive efficioufnefs of hi& fage
decior,4s obliged to take refuge in the arras of Death.           % 
OF  PHYSIC.                 241
    657.] When the fcarlet fever appears,  without any af-
 feaion ofthe throat,  the treatment of it is very fimple, and
 is delivered  by  Dr.  Sydenham.   An  antiphlogiftic regi-
 men * is commonly all that is  requifite; avoiding, on one
 hand, the application of cold air;  and, on the other, any
 increafe of external heat.
    658.] In the ordinary ftate ofthe Scarlatina Anginofa,
 the fame treatment is, in moft cafes, fufficient; but as here
 the  fever is  commonly more  confiderable,  and there is
 likewife an affeaion ofthe throat,  fome remedies may be
 often neceffary.
    659.] When there is a pretty high degree of fever, with
 a full pulfe, and a confiderable fwelling  of the  tonfils,
 bleeding is very proper, efpecially in adults; and it has
 been frequently practifed with advantage :  but as,  even
 in the Cynanche Tonfillaris,  much bleeding is feldom ne-
 ceffary ;  (305.) fo, in the Scarlatina, when the ftate ofthe
 fever and the appearances of the fauces render the nature
 of the difeafe ambiguous, bleeding may be omitted ; and,
 if not altogether avoided, it fhould at  leaft  not be large,
 and ought not to be repeated.
    65o.] Vomiting,  and  efpecially naufeating  dofes  of
 emetics,t notwithflanding the.inflamed ftate ofthe fauces,
 have been found very ufeful in this difeafe. An open belly
 is proper in every form of this difeafe; and when the nau-
 feating dofes  of emetics operate a  little downwards, they
 are more ferviceable.
   661.] In every form ofthe Scarlatina Anginofa, through
 the whole courfe of it, detergent gargles J fhould be em-
 ployed, and more or lefs as the quantity of fioughs and the
 vifcid mucus  in the faucus may feem to require.
   662.]  Even  in the  milder ftates of the Scarlatina Angi-
 nofa, it has been common with practitioners to'exhibit the
 Peruvian bark through  the whole courfe of the  difeafe;
 but we are affured,  by much experience,  that in fuch ca-

  * The«ntiphlogiftic regimen muft not however be carried too far, left we
 induce a ftate of debility that may prove hurtfuL
  t Thefe have been mentioned in former notes.
  f The detergent gargles were defcribed in the note on article 317.-  Thac-
i.ire of rofes is generally ufed, and in moft cafes anfwerevery intention. IT,
h.-,\vever, the ulceration is confiderable, and t,he fioughs do not eafily caftofF,
itourfe muft be had to Dr. Fothergill's gargle, defcribed in article 317.
  Vol.. I.                 -H H 
242                PRACTICE
fes it may be fafety omitted, though in cafes any ways am-
biguous it may not be prudent to negle6t this remedy.
  663.] The anafareous fwelling, which frequently follows
the Scarlatina Anginofa, feldom requires any remedy; and,
at leaft, the purgatives, fo much inculcated, fo commonly
exhibited, foon take off the anafarca.
                     CHAP. V.


                 ©f  tbz Plague*
                      Sect. I.
           Ofthe Phenomena of the Plague.

664.]  X HE Plague is a difeafe which always arifes from
contagion ; which affeas many perfons about  the fame
time; proves fatal to great numbers,  generally  produces
fever; and, in moft perfons,  is attended with buboes  or
carbuncles.
   665.] Thefe are the circumftances which, taken toge-
ther,  give the chara6ler ofthe difeafe;  but it is  accompa-
nied with many  fymptoms almoft peculiar to itfelf, that,
in different perfons, are greatly diverfified in number and
degree, and fhould be particularly ftudied.   I would with
to lay the foundation for this; but think it unfit  for a per-
fon who has never feen the difeafe to attempt its  particular
hiftory.   For this,  therefore,  I muft refer to the authors
who have written on the fubjea; but allowing thofe only
to be confulted,  who have themfelves feen and treated the
difeafe in all  its different forms.
   666.]  From the accounts of fuch authors,  it appears to
me, that the circumftances which particularly  diftinguifh
this difeafe, and  efpecially the  more violent and danger-
ous ftates of it, are
   15*,  The  great lofs  of ftrength in the animal  fun&ions,
which often appears early in the difeafe.
   2dly, The ftupor, giddinefs,  and confequent ftaggering,
which refembles drunkennefs, or the head-ach and various
delirium; which are  all of them  fymptoms denoting a
great diforder in the funaioris of the brain.
   %dly^ The anxiety, palpitation, fyncope, and efoccially 
OF  PHYSIC.               S42
 the weaknefs and irregularity of the pulfe, which denotes
 a confiderable difturbance in the aaion of the heart.
    4-thly,  The  naufea  and vomiting,  particularly the vo-
 miting of bile,  which  fhows  an accumulation of vitiated
 bile in the gall-bladder and biliary ducts, and from thence
 derived into the inteftines and ftomach; all of which fymp-
 toms  I fuppofe to denote a confiderable fpafm, and lofs of
 tone,  in the  extreme veffels on the furface ofthe body.
    $thly,  The buboes or carbuncles, which denote an acri-
 mony prevailing in the fluids.  And,
    Lastly, The petechia?, hemorrhagies,  and colliquative
 diarrhoea, which denote  a putrefcent tendency prevailing
 to a great degree in the mafs of blood.
    667.] From the confideration of all thefe  fymptoms, it
 appears, that the plague is efpecially diftinguifhed by a fpe-
 cific contagion, often fuddenly producing the moft confi-
 derable fymptoms of debility in the  nervous fyftem or
 moving powers, as well as of a general putrefcency in the
j fluids;  and it is from the confideration  of thefe circum-
 ftances as the proximate caufe, that I think  both' the pre-
 vention and cure of the plague muft be direaed.
    668.]  If this difeafe fliould revifit the nothern parts of
 Europe, it is probable, that, at the time, there will be no
 phyficians th.cn alive, who,  at the firft appearance of the
 difeafe, can be guided by his former experience, but muft
 be inftrucfed by his ftudy ofthe writers  on this fuhjea,
 and by analogy.  It is, therefore, I hope, allowable for
 me, upon the fame grounds, to offer here my opinion  with
 refpecl to both the prevention and cure of this difeafe.
    This paragraph was written before  I had any notice of,
the plague of Mofeow  anno 1771; but I  think'it will ftill
apply' to  the cafe of  Great  Britain and of many othe| N
northern ftates.

                      Sect. II.

           Of the Prevention of the  Plagut.
   669.]  WITH refpea to the prevention:  As we are
firmly  perfuaded that the  difeafe never arifes in the north-
ern parts of Europe, but in confequence of  its being im-
ported from fome other country;  fo the firft meafure ne-
ceffary, is the magiftrate's  taking care  to prevent the  em- 
444                PRACTICE
portation : and  this may generally be done by  a due at-
tention to bills of health, and to the performance of qua-
rantines.
   670.] With refpea to the latter, we are perfuaded, that
the quarantine of perfons may fafely  be much lefs than
forty days; and, if this were allowed,  the execution of the
quarantine would be more  exaa and certain, as the temp-
tation to break it would be  in a great meafure removed.
   671.] With refpea to the quarantine of  goods, it can-
not be perfea, unlefs the fufpected goods be unpacked and
duly  ventilated,  as well as  the  other means employed for
correcting  the infeaion they may  cany;  and,  if all this
were properly done, it is probable that the time common-
ly prefcribed  for the quarantine of goods might alfo be
fhortened.
   672.] A fecond meafure, in the way of prevention, be-
comes requifite, when an  infeaion  has reached and  pre-
vailed in any place, to prevent that infeaion from fprcad-
ing into other places.   This can be done only by prevent,
ing the inhabitants, or the goods of  any infected place,
from going out of it, till they have undergone a proper
quarantine.
   673.] The third meafure for prevention, to be employ-
ed with great care, is to hinder the infection from  fprcading
among the inhabitants  of the place in which it has arifen.
The meafures neceffary for this, are  to be direaed by the
doarine laid down in (82.)  and  from that doarine we infer,
that all perfons  who can avoid any  near communication   ,
with infeaed perfons, or goods, may efcape the infection.
   674.] For avoiding fuch communication, a great deal
'jaay be done by the magifjtrate: 1. By allowing as many
jpf the inhabitants as are free from the  infeaion, and cot
neceffary to the  fervice of the place, to go out of it.  2. By
prohibiting all  affemblies, or  unnecelfary intercourfe of
the people.  3.  By taking care that neceffary  communi-
cations be formed without contaa.   4. By making fuch
arrangements and provifions as  may render it eafy for the
families remaining,  to fhut themfelves up  in   their own
houfes.  5.  By allowing perfons to quit houles in which
an infeaion appears, upon condition that they go  into la-
zarettoes.   6. By ventilating and purifying, or deftroying
at the public expence, all  affeaed goods.  LatUy, by a- 
OF  PHYSIC.               24S
voiding hofpitals, and providing  feparate apartments for
infected perfons.
   The execution of thefe meafures will require great au-
thority, and much vigilance and attention, on the part of
the magiftrate; but it is not our province to enter into any
detail on this fubject of the public police.
   675.] The fourth and laft part ofthe bufinefs  of pre-
vention, refpeas the condua of perfons neceffarily remain-
ing in infeaed places, efpecially  of thofe obliged to have
fome communication with perfons infeaed.
   676.] Of thofe obliged to remain in infeaed places, but
not obliged to have any  near communication with the fick,
 they may be preferved from the contagion by avoiding all
near communication with other perfons, or their goods;
and  it is  probable, that a fmall diftance will anfwer  the
purpofe, if, at the fame time,  there be no ftream of air to
carry the effluvia of perfons, or goods, to fome diftance.
   677.] For thofe who are neceffarily obliged to have a
near communication with the fick, it is proper to let them
know, that fome of the  moft powerful contagions do  not
operate, but when the bodies of men expofed to the con-
tagion are  in  certain circumftances which  render them
more liable to be affeaed by it;  and therefore,  by avoid-
ing thefe circumftances and caufes, they may often efcape
infection.
   678.] The bodies of men are efpecially liable to be af-
feaed  by contagions, when they are any ways confiderably
weakened by want of food,  and even by a feanty diet, or
one  of little nourifhment;  by intemperance in drinking,
which  when the ftupor  of intoxication is over, leaves  the
body in a weakened ftate;  by excefs in venery; by great
fatigue; or  by any confiderable evacuation.
   679.]  The  caufes  which, concurring with  contagion,
render it more  certainly aaive, arc cold,  fear, and  full
living.
   The feveral means, therefore, of avoiding or guarding
againft the action  of cold (94, to 96.) are to be carefully
ftudied.
   680.]  Againft fear the mind is to be fortified as well as
poffible,  by infpiring a favorable idea of the power of pre-
servative means; by deftroying the opinion of the incura-
ble nature of the difeafe; by occupying mens  minds with 
2iG
P n A C T I c ?.
 bufinefs or labour; and by avoiding all ohjefis of fear,  ai
 funerals, pa'fing bells, and any notice of the death o.( par-
 ticular friends.
   681.] A full diet of animal food increafes the irritabi-
 lity ofthe body, and favors the operation of contagion ;
 and in digeftion, whether from  the quantity or quality of
 food, has the fame effea.
   682. J Befides giving attention to obviate the feveral cir-
 cumftances (009, 678, to 681.)  which favor the operation
 of contagion,  it is probable that fome  means may be em-
 ployed for ftrengthening the bodies of men,  and thereby
 enabling them to refift contagion.
   For this purpofe,  it is probahle, that the moderate ufe
 of wine, or of fpirituous liquors, may have a good effea.
   It is  probable alfo, that exercife,  when  it can be em-
 ployed, if fo moderate asto.be neither heating nor fatiguing
 to the body, may be employed with advantage-
   Perfons who have tried  cold bathing, and commonly
 feel invigorating effects from it, if they are any ways fe-
 cure againft having already received infection, may polfibly
 be enabled to refift it by the ufe of the cold bath.
   It is probable,  that fome medicines alfo may be ufeful
 in enabling men to refift infection :  but amongft thefe  I can
 hardly admit the numerous  alexipharmics formerly pro-
 pofed; or, at  leaft, very few of them, and thofe only of
 tonic power.  Amongft thefe laft we reckon the Peruvian
 bjik; ami it is perhaps the moft effeaual.  If any  thing
 is to be expeaed from antifeptics, I think camphire, whe-
 ther internally or externally employed,  is one of the moft
 promiimg.
   Every perfon is  to be indulged in the ufe of any means
 of prefervation of which he has conceived a good opinion,
 whether it be a charm or a medicine,  if the latter be not
directly hurtful.
  Whether iffues be ufeful in preferving from, or in mo-
derating the effeas of contagion, I  cannot determine from
the obfervations I have yet read.
  683.] As neither the atmofphere in  general, nor anv
confiderable portion of it, is tainted or impregnated with
the matter of contagions; fo the  lighting of fires over a
great part of the infected city, or  other  general fumigati- 
OF  PHYSIC-
5i7
ons in the open air,  are of no ufe for preventing the dif-
eafe, and may perhaps be hurtful.
   684.] It would probably contribute much to check the
progrefs of infection, if the poor were enjoined to make a
frequent change  of clothing, and were fuitably provided
for that purpofe; and if they were, at the fame time, in-
duced to make a frequent ventilation of their houfes and
furniture.

                      Sect. III.

              Of the Cure ofthe Plague.
 ■  685.] IX the cure of the plague,  the  indications arc
the fame as thofe of fever in general,  (126.) but here they
are not all  equally ncceffary and important.
.   686.] The meafures for moderating the violence of re-
action,  which operate by diminifhing  the aaion of the
heart and arteries (i28.)'have feldom any place here, ex-
cepting fo far as the  antiphlogiftic regimen  is -proper.
Some phyficians, indeed, have  recommended bleeding;
and there may occur cafes in which bleeding may be  ufe-
ful ; but, for the moft part, it is unneceffary, and  in many
cafes it might be  very hurtful.
   Purging has alfo been recommended ; and, in fome de-
gree, it may be ufeful in drawing off the bile, or other pu-
trefcent matters  frequently prefent  in the inteftines;  but
a large evacuation this way may certainly be hurtful.'
   687.] The moderating the violence of reaction, fo far
as it can be done by taking off the fpafm of the extreme
veffels  (151.) is a meafure ofthe utmoft neceftity in the
cure of the plague; and  the whole ofthe means (152, to
200.) fuited to this indication are extremely proper.
   688.] The giving an emetic at the very firft approach
of the difeafe, would probably be of great fervice; and it .
is likely, that at  fome other periods of the difeafe emetics '
might be ufeful,  both by evacuating bile abundant in the
alimentary  canal, and by taking off the fpafm of the ex-
treme veffels.
   689.] From fome  principles with refpea to fever in
general, and with refpecl to the plague in particular, I am
of opinion, that,  after the exhibition of the firft vomit, the
body fiioulu be difpofed ty fweat; which ought to be raif- 
2«                 PRACTICE
 ed to a  moderate degree only,  but continued  for at leaft
 twenty-four hours, or longer if the patient bear  it eafily.
   690.] This  fweating fhould  be excited and conduaed
 agreeably to the rules laid down in 168.   It is to be pro-
 moted by the plentiful  ufe of diluents,  rendered more
 grateful  by vegetable  acids, or more powerful  by being
 impregnated with fome portion of neutral falts.
   691.]  To fupport the patient under the continuance of
 the  fweat, a little weak broth,  acidulated  with juice of
 lemons, may be given frequently ;  and fometimes a little
 wine, if the heat of the body be not confiderable.
   692.J  If fudorific medicines are judged to be neceffary,
 opiates are the  moft effeaual and fafe :  but they fhould
 not  be combined with  aromatics;  and probably  may be
 more effectual,  if joined with a portion of emetics, and of
 neutral falts.
   693.]  If, notwithflanding the  ufe of emetics and  fudo-
 rifics, the difeafe fhould  ftill continue, the cure muft de-
 pends upon the employment of means  for obviating debi-
 lity  and putrefcency; and for this purpofe, the various re-
 medies propofed above (from 201, to 227.) may be ad-
 miniftered, but efpecially  the   tonics;  and of thefe the
 chief are cold drink and the  Peruvian bark.
   694.] In the cure ofthe  plague, fome attention is due
 to the management of buboes and carbuncles :  but we do
 not touch this, as it belongs  to the province of furgery.*

                      CHAP. VI.

      ©f GE^gipelatf, 01 <&t.  ant&onp's jFire.

 695.] XN 273,1 mentioned the diftinaion  which I pro-
 pofed to make between the difeafes to be named the Ery-
 thema and the Eryfipelas; and from thence it will appear,
 that  Eryfipelas,  as an Erythema following fever, may have
 its place here.
  * The reader might poflibly expect a detail of the medicines ufed in the
plague, with their dofes, and the manner of adminiftering them ; but I thought
it better to refer to the authors who have either feen the difeafe, or whe
have exprefsly written on it.
  On confulting different authors, it appears, that every particular epidemic
requires a different treatment, in fome part  of the cure at leaft.  Should any
young practitioner be  unfortunate enough to have occafion to exercife his art
in the cure of the plague, he mult chiefly be dire&ed by the general indica-
tions of the cure of fevers. 
                     Of  PHYSIC                249

     696.*] I fuppofe the eryfipelas to depend on a matter
   generated within the body, and which,  analogous to fhe
   Other cafes  of exanthefitata, is, in confequence of fever,
   thrown out upon the furface ofthe body.  I own it may
   be difficult to apply this to every particular cafe  of eryfi-
   pelas :  but I take the cafe in which it is generally fuppofed
   to apply, that of the eryfipelas of the face ; which I fhall
   therefore confider here.
     697.] The Eryfipelas of the face comes on with a cold
- ,  fhivering, and other fymptoms of pyrexia. The hot ftage
   of this is frequently attended with a confufion of head, and
   Come degree of delirium; and almoft always with drowfi-
   nefs, or perhaps coma.   The pulfe is always frequent, and
   commonly full and  hard.
     698.] When  thefe fymptoms have continued for one,
   two, or at moft  three days,  there appears, on fome part
   of the  face,  a rednefs,  fuch as that defcribed in (275.) as
   the appearance of Erythema.  This rednefs,  at firft, is of
   no great extent; but gradually  fpreads from the part it
   firft occupied to the other parts of the face, commonly
   till it has affeaed the whole; and frequently from the face
   it fpreads over the hairy fcalp, or defcends on fome part of
   the neck.  As the rednefs fpreads, it commonly difappears,
   or  at leaft decreafes, in the parts it had  before occupied.
   All the parts upon  which the rednefs appears are,  at the
   fame time, affeaed with  fome fwelling, which continues
   for fome time after the rednefs has abated.   The  whole
   face becomes confiderably turgid;  and the eye-lids are
   often fo much fwelled as entirely to fhut the eyes.
     $99-] When the rednefs and fwelling have proceeded
   for fome time, there commonly arife, fooner or later, blif-
   ters of a larger or fmaller fize, on feveral parts, of the face.
   Thefe contain a thin yellowifh or almoft colourlefs liquor,
   which fooner or  later runs out.   The furface of the  fkin,
   in the bliftered places, fometimes becomes livid and black-
   ifh ; but this livor feldom goes deeper than the furface, or
   difeovers any degree of gangrene affeaing the fkin.   On
   the parts of  the face not affeaed with blifters, the cuticle
   fuffers, towards the  end of the difeafe, a confiderable def-
   quamation.   Sometimes the tumour of the eye-lids ends in
  a fuppuration,
    Vu:.  I.                 1, 
250                PR Ai; 1  tuh
  700.]  The  inflammation  coming  upon the face does
not produce any remiflion ofthe fever which  had before
prevailed ; and fometimes the fever increafes  with the in-
creafing and fpreading inflammation.
  701.]  The inflammation  ufually continues for eight or
ten days; and for the fame  time, the fever and fymptoms
attending it alfo continue.
  702.]  In the progrefs of the inflammation the delirium
and coma attending it fometimes go on increafing, and the
patient dies apopfeaic on the feventh,  ninth, or eleventh
day ofthe difeafe.   In fuch cafes it has  been commonly
fuppofed that the difeafe is tranflated from the  external to
the internal parts.  But I have not feen any  inftance  in
which  it did not appear to  me, that  the affeaion of the    1
brain was merely a  communication of the external affec-
tion, as this continued increafing at the fame time with the
internal.
  703.]  When the fatal event does not take place, the in-
flammation, after having affe6ted  a part, commonly  the
whole of the face, and perhaps the other external parts of
the head, ceafes.  With the inflammation, the fever alfo
ceafes; and, without any evident crifis, the patient returns
to his ordinary ftate of health.
   704.]  This difeafe is not  commonly contagious;  but as
it may arife from an acrid matter externally applied, fo it
is poffible that the difeafe may fometimes be communicat-
ed from one perfon to another.
   Perfons who have  once laboured under this difeafe are
liable to returns of it.
   705.]  The event  of this difeafe may be forefeen from
the ftate ofthe fymptoms which denote more or lefs affec-
tion of the brain.  If neither delirium nor coma come on,
the difeafe is feldom attended with any danger;  but when
thefe fymptoms appear early in the difeafe, and are in a con-
fiderable degree, the  utmoft danger is  to be apprehended.     1
   706.] As this difeafe often arifes in the part, at the fame
time with the coming on ofthe pyrexia;  as I have know*   i
it with all its fymptoms, arife from an acrimony applied to
the part; as it is commonly attended with a full, and fre-
quently  a hard pulfe; as the blood  drawn in this difeafe
fhows the fame cruft  upon its furface, that appears  in the
phlegmafiae; and, laftly; as the fwelling ofthe eye-lids, in 
0 F  P'H Y S I C.
251
this difeafe,  frequently ends  in  a  fuppuration;  fo, from
thefe confiderations, it  feems doubtful  if this difeafe  be
properly,  in  Nofology,  feparated from the Phlegmafiae.
At any rate, I take the difeafe I have defcribed to be what
phyficians have named the  Eryfipelas Phlegmonodes, and
that it partakes a great deal of the nature ofthe Phlegmafiae.
   707.]  Upon this conclufion,  the Eryfipelas of the.face
is to be cured very much in the fame manner as phlegmonic
inflammations, by blood-letting,cooling purgatives, and by
employing every  part of the antiphlogiftic regimen ;* and
our experience has confirmed the fitnefs  of this method of
cure.
   708.]  The evacuations of blood-letting and  purging,
are to be employed more or  lefs according to the urgency
of fymptoms, particularly thofe  of  the pyrexia, and  of
thofe which mark an affeaion ©f the brain.  As the pyrexia
continues, and often increafes with the inflammation of the
face ; fo the evacuations mentioned may be employed at
any time in the courfe of the difeafe.
   709.]  In this,  as in other difeafes ofthe head,  it  is pro-
per  to put the patient, as often as he carve afily bear  it, into
fomewhat of an erea pofture.
   710.]  As in this difeafe there is always an external  af-
feaion, and as in  many inftances there is no other;  fo  va-
rious external applications to the  part affeaed have been
propofed; but almoft all of them are of doubtful effea.
The  narcotist refrigerant, and aftringent^ applications,
are  fufpeaed of difpofing to gangrene; fpirituous|| appli-
cations feem to increafe the inflammation ;  and all oily or
watery** applications feem to oecafion its fpreading. The
application that feems moft fafe, and  which is now moft
commonly employed, is that of a dry mealy powder fre-
quently fprinkled  upon the  inflamed parts.tt

  * The antiphlogiftic rVgimen, &c. have been defcribed iii former notes.
See Art. 120. et  feq.
  t The leaves of folanum, of hemlock, of henbane, and other fimilar plants
applied as fomentations.
  J Solutions of Saccharurn Saturni, or Vitriolum album, applied cold.
  || Efpecially if they are fuch as are compounded with aromatics or volatile
falts, as camphorated fpirit of wine,  Hungary water, volatile liniment, &e^
  ** The reafon is evident, becaufe they confine the acrimonious liquor dif-
charged from the part affected.
  f \ Wheat flour is apt to run into hard lumps by the thin acrimonious Hqttor-
vrhicu always exhales from parts affected with erjfipelas.  Oatmeal not be> 
252                 PRACTICE

   711.] An Eryfipelas Phlegmonodes frequently appears
on the other parts of the body, befide the face ;  and fuch
other eryfipelatous inflammations  frequently end in  fup-
puration.  Thefe cafes are feldom dangerous.   At  com-
ing on, they are fometimes' attended  with drowfinefs, and
even with  fome  delirium; hut this rarely happens; and
thefe fymptoms do not continue after the inflammation is
formed.  I have never feen an inftance of the tranflation
of  this inflammation from  the limbs  to an internal part;
and though thefe inflammations of the  limbs be  attended
with pyrexia, they feldom require the fame evacuations  as
the eryfipelas ofthe face.   At firft they  are to  be treated
by dry mealy applications only;  and all humid applica-
tions, as fomentations, or poultices, are  not to be applied,
till, by the continuance of the difeafe, by the  increafe of
fwelling, or by a throbbing felt in the  part, it appears that
the difeafe is proceeding to fuppuration.
   712.] We have hitherto confidered  -eryfipelas as in a
great meafure of a phlegmonic nature;  and agreeably to
that opinion, we have propofed our method of cure.  But
it is probable, that an eryfipelas is fometimes attended with,
or is a fymptom of, a putrid fever; and, in fuch cafes, the
evacuations propofed above may be improper,  and the ufe
of the Peruvian bark may be neceffary ; but I  cannot  be
explicit upon this fubjea, as fuch putrid  cafes have not
come under my obfervation.


                     CHAP. VII.

               ©f t&e 9Mtfa# jFe&o:,

713.]  1  HIS difeafe is faid to have  been  unknown to
the ancients, and that it appeared, for the firft time, in Sax-
ony, about the mid4.le.0f the laft century.*  It  is faid to
ing fo liable to this  inconvenience, is therefore preferable :  it  ought to be"
wiped off, and a frefh quantity applied twice or thrice a day.
  Many practitioners recommend the application of cabbage leaves to  ery-
fipelatous fwellings, and their efficacy has been frequently approved.  They
ought to be removed as foon as they groW warm or uneafy,  and frefh cold
ones applied.
  * Hoffman, Welfch, and feveral other writers, fix the firft appearance of
this difeafe at Leipfic in the years 1651 and 1652.   This, opinion, however,
is falfe ; for defcriptions of miliary eruptions are to  be found  in the writings
of the ancients, and among the moderns we find Riverius defcribing it in 
OF   PHYSIC.
253
 have fpread from thence into all the other parts of Europe;*
 and,  fincc the period mentioned, to have appeared in ma-

 ny countries in which it had never appeared before.

   714.]  From the time of its having been firft particular-
 ly obferved, it has been defcribed and  treated of by many

 different  writers ;  and by all of them,  till very lately, has
 been confidered as a peculiar idiopathic difeafe.

    It is faid to have been conftantly attended with peculiar
 fymptoms.   It  comes on with a cold ftage, which is often

 confiderable.   The hot ftage which fucceeds,  is attended
 with great anxiety, and frequent fighing.   The heat of the

 body becomes great, and foon produces  profufe fweating;

 preceded, however, by a fenfe of pricking, as of pin-points
 in the fkin; and the fweat is  of a peculiar rank and dif-

 agreeable odour.   The eruption appears  fooner or  later
 in different perfons, but at no determined period ofthe dif-
 eafe.  It feldom or never  appears on the face ;  but dif-
 eovers itfelf firft upon the neck and breaft, and from thence
 often fpreads over  the whole bodv.

   715. J  The eruption named Miliary is faid to be of two
 kinds, the one named the Red, the other the  White Milia-

 ry.  The former which in Englifh is ftriaiy named the Rath,

 is commonly allowed to be a  fy mptomatic affeaion ; and
 as the latter is the only one  that has any  pretenfions 'tobe

 confidered as an idiopathic difeafe, it is this alone that I fhall

-more paiticularly defcribe and treat of in the prefent chapter.
   716.]  What  then is called the  White Miliary eruption

 France, juft after the appearance of the comet in the year 1618 ; to which
 phenomena  that author afcribes the fatal  epidemic, as well as the bloody
 wars that were at that time making horrid devaftations in Europe.
 <   We meet with feveral accounts of the appearance of the miliary eruption
 in different  parts of Europe foon after the middle of the laft century, not on-
 ly by medical writers, bur by general hiftorians • among the latter'of whom
 we may mention Robert  Sibbald, who takes notice of it in his Scotia illuf-
trata, pubhmed at Edinburgh in the  year 1684. (Sibbald, however, was a
 phyiician.)  To enumerate the medical writers who have defcribed the dif-
eafe in the different parts of Europe, would take,more room than the (hort
compafs of thefe notes admit, the chief of them are Welfch, Hoffman Lan-
 gius  Reyger, Bonetus, Grinwald, Sydenham, Ramizini,  Fuchfius, &c. &c
   1 he authors above mentioned, and feveral others about the end of the laft
and beginning of this century, entertained various opinions conceminff the
nature of the miliary eruption, fome of them fuppofing it to be a critical
termination of a peculiar fever, and others on the contrary ftrenuoullv infill-
ing that it was only accidental or fymptomatic, and never critical or falutary
1 he controverfy, which was carried on with fome warmth, is now terminat-
ed  as will appear by what follows ; but the inquifitive young phyfician will
find both entertainment and inftruaion in perufing it.  A very good abftraft
of  it occurs in De ilaen's treatife on the divifion of Fevers 
954
PRACTICE
 appears at firft like the red, in very fmall red pimples, for
 the moft part  diftina, but fometimes cluftered together.
 Their flight prominence is diftinguifhed better by the fin-
 ger than by the eye.   Soon after the appearance of this
 eruption, and at leaft on the fecond day, a fmall veficle ap-
 pears upon the top of each pimpk^   At firft the veiicle is
 whey colored ; but foon becomes white, and. Hands out
 like a tittle globule on the top ofthe pimple.   In two or
 three days, thefe globules break, or are rubbed off ; and
 are fucceeded by fmall crufts,  which foon after fall off in
 fmall fcales.   While one fet of pimples takes this courfe,
 another  fet fucceeds; fo that the difeafe often  continues
 upon the fkin  for many  days together.   Sometimes  when
 one crop of this eruption has appeared, another, after fome    •
 interval, is produced.   And it has been further obferved,
 that in fome perfons there  is -fuch a tendency to this dif-
 eafe,  that they have been affected w ith it feveral times in
 the courfe of their lives.
   717.] This difeafe is faid to affea both fexes, and per-
 fons of all ages and conftitutions; but it has been obferved,
 at all  times, to affea efpecially,  and moft frequently, ly-
 ing-in women.
   718.] This difeafe is often accompanied with  violent
 fymptoms, and has frequently proved fatal.  The fymp-
 toms attending it are,  however, very various.   They are,
 in one or other inftances, all the feveral fymptoms attend-
 ing febrile difeafes; but I  cannot find  that  any fymptom
 or concourfe  of fymptoms  are fteadily the fame in differ-
 ent perfons, fo as to furnifh any  fpecific character to the
 difeafe.   When the difeafe is violent, the moft common
 fymptoms are phrenitic,  comatofe, and convulfive affec-
 tions, which are alfo fymptoms of all fevers treated by a
 very warm regimen.
   719.]  While there is  fuch a variety of  fymptoms ap-
pearing  in this difeafe, it is  not to be expeaed that any one
particular method of cure  can be propofed: and accord-
ingly  we find, in different writers, different methods and
remedies prefcribed;  frequent difputes  about the  moft
 proper; and  thofe received and praaifed by fome, op-
pofed and rejeaed by others.
   720.]  I have thus  given an account of what I  have
found delivered by authors who have confidered the white 
OF  PHYSIC.               255
miliary  fever  as  an idiopathic difeafe: but, now, "after
having often obferved the difeafe,  I muft fay that I doubt
much if it ever be fuch an idiopathic as has been fuppofed,
and I fufpca that  there is much fallacy in what has been
written on the fubjea.                        ^
   721.] It feems to me very improbable, that thfe1 fhould
have been really a new difeafe when it was firft ccfcifidered
as fuch.  There appear to me very clear traces of it in au-
thors who wrote long before  that period; "and,  though
there were not, we know that the defcriptions of the anci-
ents were inaccurate and imperfea, particularly with ref-
pea  to  cutaneous affeaions; whilft we know alfo  very
well, that thofe affections which ufually appeared as fymp-
tomatic only,  were commonly negfeaed, or  confounded
together under a general appellation.
   722.]  The antecedent  fymptoms of anxiety,  fighing,
and pricking of the fkin, which have been fpoken of as pe-
 culiar to this difeafe, are, however, common to many
 others;  and,  perhaps  to all thofe  in which  fweatings are
 forced out by a warm regimen.
   Of the fymptoms faid to be concomitant of  this  erup-
 tion, there are none which can be conftant  and peculiar
 but that of fweating.   This, indeed,  always precedes and
 accompanies the eruption ; and, while the miliary eruption
 attends  many different difeafes, it  never, however, ap-
 pears in any of thefe, but after fweating; and,  in perfons
 labouring under thefe difeafes, it does not appear, if fweat-
 ing be avoided.   It is therefore probable,  that the erupti-
 on is the effea of fweating; and that it is the produce of a
 matter,  not before prevailing in  the mafs of blood, but
 generated, under  particular circumftances, in the fkin  it-
 felf.  That it depends upon particular circumftances ofthe
 fkin, appears further from hence, that the eruption fel-
 dom or never appears upon the face, although it affeas
 the whole ofthe body befides; that it comes upon thofe
 places efpecially which are more clofely covered;  and that
 it can be brought  out upon particular parts by external
 applications.
   723.] It is to be obferved, that this eruptive difeafe dif-
 fers from the other exanthemata in many circumftances;
 in its not being contagious, and therefore never  epidemic;
 that the  eruption appears at no determined period of the 
256                PRACTICE
difeafe; that the eruption  has no determined duration;
that fucceffive eruptions frequently appear in the courfe
ofthe fame fever; and that fuch eruptions frequently oc-
cur in the courfe of the fame perfon's life.
   All  thefe circumftances  render it extremely probable,
that, inMe miliary fever, the morbific matter is not a fub-
fifting contagion communicated to the blood, and  thence,
in confequence of fever and affimilation, thrown out upon
the furface ofthe body ; but a matter occafionally pro-
duced in the fkin itfelf, by fweating.
   724.] This  conclufion  is further  rendered  probable
from hence, that, while the miliary eruption has  no pecu-
liar fymptoms, or concourfeof fymptoms, belonging to it;
yet upon occafion,  it accompanies almoft all febrile dif-
eafes, whether inflammatory or putrid, if thefe  happen to
be  attended with fweating; and  from thence it mav be
prefumed, that the miliary eruption is a fymptomatic affec-
tion only, produced in the manner we have faid.
   725.] But, as this fymptomatic affeaion does  not al-
waysac.company every inflance of fweating, it may be pro-
perlo inquire what are the circumftances which efpecially
determines  this eruption to appear ? To this, however, I
can give no full and proper anfwer.  I cannot fay that
there is  any one circumftance which in all  cafes gives oc-
cafion to the eruption; nor can I fay what different caufes
may, in different cafes, give occafion to it.   There is on-
ly one obfervation I  can offer to the purpofe of this in-
quiry ; and it is, that, of the perfons, fweating under feb-
rile difeafes, thofe are efpecially liable to miliary eruption,
who have been previoufly weakened by large evacuations,
particularly of blood.  This will explain why it happens
to lying-in women more frequently than to any  other per-
fons ; and to confirm this explanation, I have remarked,
that the  eruption happened to women not in  child-bed,
but who had been much fubjeaed to a frequent and copi-
ous menftruation;  and to an almoft conftant fluor albus.
I have alfo had occafion to obferve it happen to men in
fevers, after wounds from which they had fuffered great
lofs of blood.
   Further, that this eruption is produced by a certain ftate
of debility, will appear probable, from its often occurring
in fevers of the  putrid. kind7 which are always attended 
OF  PHYSIC.                 257
  with great debility.   It is  true, that it alfo  fometimes  at-
  tends inflammatory difeafes, when it cannot be accounted
  for in the Tame manner ;  but I believe it will be  found to
  attend efpecially  thofe inflammatory difeafes in which the
  fweats have been long protrafcfed or frequently repeated,
  and which have thereby produced a debility, and perhaps
  a debilitating putrid diathefis.
    726.] It  appears fo cleaily to me  that this eruption is
  always a fymptomatic* and  faaitious affeaion, that I am
  perfuaded it may  be in moft cafes prevented merely by
  avoiding fweats.   Spontaneous  fweatings,  in  the  begin-
  ning of difeafes, are very rarely critical; all fweatings, not
  evidently critical, fliould be  prevented ; and the promot-
  ing them, by increafing external heat, is commonly very
  pernicious.   Even critical fweats  fliould  hardly be  en-
  couraged by fuch means. If, therefore, fpontaneous fweats
 -arife, they are to  be checked by the coolnefs of the cham-
  ber ;  by the  lightnefs  and coolnefs of  the bed-clothes; by
  the pcrfon's laying out their hands and arms, and by their
  taking cold drink:  and, by  thefe precautions,  I think  I
  have frequently prevented  miliary eruptions, which  were
  otherwife likely to have appeared, particularly in lying-in
  women.
    727.] But it may happen, when thefe precautions have
 been neglected, or from other circumftances, that a milia-
 ry eruption does  aaually  appear;  and the  queftion will
 then be put, how the cafe is to be treated ?  It is a queftion
  of confequence, becaufe I  believe that the matter here ge-
 nerated is often of a virulent kind; it is frequently the off-
 fpring of putrefcency ;  and, when treated by increafing the
 external heat of the body,  it feems to  acquire a virulence
 which produces  thofe  fymptoms mentioned in 718. and
 proves certainly fatal.
  * As this difeafe is always fymptomatic and never idiopathic, the method of
 curing muft neceffarily vary in different cafes ; the chief attention of the phy-
 fician muft therefore be turned to the primary difeafe, and to the meaus of
 preventing this fymptom from appearing in thofe difeafes \fhich it accom-
 panies.
  The author judicioufly begins his method of cure by giving dire&ions for
 preventing the eruption, which he properly fuppofes to be entirely faaitious,
 and to depend on the application of too much heat.  With a proper atten-
 tion to the direftions given in the teyt, we may. in  general prevent the erup-
tion.  I f, however, the eruption is prefent before the phyfician is called, thofe
remedies muft be ufed for i<* removal that are enumerated in the fubfecruent
 articles.
  \ CM.. I.                   K  K  . 
958                  PRACTICE
     It has been an unhappy  opinion with  moft phyficians,
  that eruptive difeafes were  ready to be hurt by cold ;  and
  that it was therefore neceffary to cover up  the  Dody very
  clofely, fo  as thereby to increafe the external heat-.  We
  now know that this is a miftaken opinion;  that increafing
  the external heat of the body is very  generally mifehiev-
  ous; and that feveral eruptions not only admit, but require
  the application of cold air.  We are  now* perfuaded, that
  the praaice which formerly prevailed, in the cafe of mi-
  liary eruptions, of covering up the body  clofe, and both
fc  by  external  means, and  internal remedies, encouraging
  the fweatings which accompany this eruption, was highly
  pernicious,  and commonly fatal.   I  am therefore of opi-
  nion, even when a miliary eruption has appeared, that in
  all cafes where the fweating is  not manifeftly critical, we
   fhould employ all the feveral means  of flopping it that are
  mentioned above ;  and I have fometimes had occafion to
   obferve, that even  the admiflion of  cool air was  fafe and
  ufeful.
     728.] This is,  in general, the treatment of miliary e-
   ruptions; but,  at the fame time, the  remedies fuited  to
   the primary  difeafe, are to  be employed;  and therefore,
   when the eruption happens to accompany  inflammatory
   affeaions, and when the fulnefs and hardnefs of  the pulfe
   or other fymptoms fhow an inflammatory ftate prefent, the
   cafe is to be treated by blood-letting,  purging,  and  other
   antiphlogiftic remedies.
      Upon the other hand, when the miliary eruption attends
   difeafes in which debility and putrefcency prevail, it will be
   proper to  avoid  all evacuations,  and employ tonic and
     * The  prefent rational pra&ice  has entirely akered the regimen in fevers;
   and  inftead of macerating the patient in a hot bed, and obliging him to
   breathe the corrupt air of a confined  chamber, we now cover him with light
   bed-clothes, and ventilate his room.
     It may, however, be neceffary to guard the young phyfician againft the ex-
   cefs of this praftice.  The precept, Omne nimium nocet, fhould always b«
   attended to.  If the patient feels any difagreeabte effeas, or if he fhould fuf-
   fer rigors, or trembles from the admiffion of cold air, it is certainly prejudi-
   cial, and its admiffion ought to be regulated.
     It may not be improper to mention another caution, viz. That the young
   praftitioner muft not, by the means here recommended, check fweats that irt
   really critical.  To determine what fweats are, and what are not, critical, is
   perhaps, in fome cafes, attended with confiderable difficulty.  In general how-
   ever, critical fweats may be known by their happening on the  critical days
   before mentioned in articles 107. et feq. and by their always being  immediately
   followed by an abatement of all, or at leaft the greateft part of tbt; fymptcitrt. 
QF  PHYSIC.                259
 antifeptic  remedies, particularly the Peruvian bark, cold
 drink, and cold air.
   I fhall conclude  this fubjea with  mentioning,  that the
 venerable  octogenarian praaitioncr,  de  Fifcher,  when
 treating of this fubjea,  in laying down the indications of
 cure,  has given this as one of them: " Excretionis peri-
 phericae non primariam habere rationem."

                     CHAP. VIII.

         SDf  t&eEemaining <ZErant&emata*
     URTICARIA,  PEMPHIGUS,  AND  APHTHA.

 729.]  X HE Nettle  Rafh is a name applied  to  two dif-
 ferent difeafes. The one is the chronic eruption defcribed
 by  Dr. Heber'den  in the Medical Tranfaaions, Vol. I.
 art. xvii. which,  as not being a febrile diforder,  does not
 belong  to  this place.  The  other is the Urticaria of our
 Synopfis, which, as taken into every fyftem of Nofology
 as one ofthe  Exanthemata Febrilia, is properly to be treat-
 ed of here.
   730.] I have never  obferved this  difeafe as contagious
 and epidemic; and the few fporadic cafes of it  which have
 occurred to me, have feldom taken the regular courfe def-
 cribed by authors.   At the fame time, as the accounts of
 different authors are not  very uniform, and hardly  con-
 fiftent, I cannot enter further into the confideration of this
 fubjea: and I hope it is not very neceffary, as on all hands
 it is agreed to be a mild  difeafe, and  fuch as feldom re-
 quires the ufe of remedies.  It is generally  fufficient to
 qbferve an antiphlogiftic regimen, and to keep the patient
 in a temperature that is neither hot nor cold.
   731.]  The Pemphigus, or Vificular fever, isarareand
 uncommon difeafe,  and very few inftances of it  are record-
 ed in the writings of phyficians.   As I have never had oc-
 cafion to fee  it, it  would be improper for me to treat of
 it ;* and I do not choofe to repeat after others, while the
  * It appears from the following paffage in the author's Synopfis, that he
had afterwards feen it : " Colleganofter eximius Francifcus Home, mihi ho-
 " minem leviter febricitentem oftendit, cui, primum, in brachiis, et fucceffive
 " demum in toto corpore,  veficulx magnitudine avellanae obortae funt, et poll
 " duos trefve dies effufo humoris feroli pauxillo, collapfse funt.  H<ec febris
«' autem nullam indolem vel typuni pecuiiarem monltrabat, et cito difparuit-
" neq.uaq.uam contagjofa."                               g . 
260                   PRACTICE
difeafe has yet been little obferved,  and its character does
not feem tobe exaaiy afcertained.   Vid. Aaa Helvetica,
vol, ii. p. 260. Synopf. Xofolog. vol. ii. p. 149.
   732.] The Aphtha,or Thrufh, is a difeafe bett rknown;
and,  as it commonly appears in infants,  it is  fo well  un-
derftood, as not to need our treating of it here.   As an
idiopathic  difeafe,  affeaing  adults,  I have not feen it in
this country :  but it feems to be more frequent in Holland;
and, therefore, for the ftudy of it,  I refer to  Dr. Boer-
haave, and his commentator Van Swieten, whofe works
are in every body's hands.*
   733. j The  Petechia  has  been,  by all our Nofologifts,
enumerated  amongft the exanthemata;  but as,  according
to the opinion of moft phyficians,  it is very juftly held to
be always a fymptomatic affeaion only,  I cannot  give it a
place here.
                  BOOK   IV.


            Of HEMORRHAGES.



                        CHAP.  I.

             S)f ^emorrfjagp  in genial.

734.] IN  eftabhfhing a clafs or order of  difeafes under
the title of Hemorrhagies,  Nofologifts have employed the

fmgle circumftance of an effufion of red blood,  as the cha-

  * Boerhaave only faw aphthae twice without, and preceding, fever, and
Van Swieten  only onc« ; but Ketelaer fays he has frequently feen them.
They fometimes accompany inflammations ofthe vifcera, and other inflam-
matory fevers, and are often difficult to remrve.  They are to be treated in
the fame manner  as the ulcerations in the Cynanche maligna, by gargles of
the deterfive kind, until the aphthous truft fepaiates and falls off; but when
that cruft has fallen off, the painfulnefs cf the nakedly expofed feniible parts
requires emollient applications ;  of which  kind a decoction of Rad. Alth. or
an infufion of lintfeed, are proper gargles alone : if honey be added, the pa-
tient complains of its making the parts fmart. The patient's diet ought to
be ofthe mildeft kind, that it may be fwallowed without  caufing much pain.
  The aphthous cruft frequently appears at the anus, which  fymptom gener,-
ally leads us to conclude, as is really the cafe, that  aphthae ccvers the whole
inteftinal canal.  Hence confiderable danger arifes.  The abforbents are co-
vered, and refufe admittance to all nourifhment; hence an increafed debility,
with all its evil confequences.  In thefe cafes, a nutritive, liquid, and deter-
five diet, muft be ufed. For this purpofe a decoction of bread, with wine and
honey, is the propereft drink. Such a decoftion is extremely nutritive, and alfo
avcrfe to putreiacvion, and therefore well adapted to the exigency of the cafe. 
OF  PHYSIC.
26"!
Taacr of fuch a clafs or order.   By this  means they have
affociatcd difeafes which in their nature are very different;
but, in every methodical ciftribution, fuch arbitrary and
unnatural b donations fhould be avoided  as much as poffi-
ble.   Further,  by that management Nofologifts have fur>-
prelfed or loft fight of an eftablifhed and  well-founded dif-
tinaion of hemorrhagies into Aaive and  Paffive.
   735-] It is my defign to reftore this diftinction ; and I
fliall therefore here, under the title of Hemorrhagies, com-
prehend thofe only which have been commonly called Ac-
tive,  that is, thofe attended with fome degree of pyrexia-
which feem always to depend upon an increafed  impetus
of the blood in the veffels pouring it out,  and which'chiefly
arife  from an internal caufe.   In this I follow Dr. Hoff-
man, who joins the aaive hemorrhagies with the febrile
difeafes; and have accordingly  eftablifhed thefe  hemorr-
hagies as an order in the clafs of Pyrexiae.  From this or-
der I exclude all thofe eifufions of  red blood that are ow-
ing entirely to external violence; and  all thofe which,
though arifing from internal caufes, are,  however, not au
tended with pyrexia, and which feem to  be owing to a pu-
trid fluidity of the blood, to the weaknefs or to the erolioii
ofthe veffels,  rather than to any increafed impetus ofthe
blood in them.
   736.] Before proceeding to treat  of thofe proper he-
morrhagies^which form an order in our Nofology, I fhall
treat  of aaive  hemorrhagy in  general;  and indeed the fe-
veral genera and fpecies, to be treated of particularly af-
terwards,  have fo many  circumftances in common with
one another, that the  general confideration to be now of-
fered will prove both proper and ufeful.

                       Sect. I.               ,,
                          =                 <\
          Of the  Phenomena  of Hemorrhagy.
   737.] THE phenomena of hemorrhagy are generally
the following.
   Hemorrhagies happen efpecially  in plethoric habits, and
to perfons of a  fanguine temperament.   They appear moft
commonly in the fpring, or in the beginning of fummer.
   For fome time,  longer or fhorter in different cafes, be-
fore the blood flows,  there are  fome fymptoms of fulnefs 
£63                PRACTICE
and tenfion about the parts from whence the blood is  to
iffue.   In fuch parts as fall under our view, there are fome
rednefs fwelling,  and fenfe of heat or of itching;  and in
the internal parts  from which blood  is to flow, there is a
fenfe of weight and heat; and, in both cafes, various pains
are often felt in the neighbouring parts.
   738.] When thefe fymptoms have  fubfifted  for fome
time, fome degree  of a cold ftage of pyrexia comes on, and
a hot ftage is formed;  during which, the blood flows of a
florid color,  in a greater or leffer quantity,  and continues
to flow for a longer or a fhorter time ; but commonly, af-
ter fome time, the effufion fpontaneoufly ceafes, and to-
gether with it the pyrexia alfo.
   739-] During the hot ftage which precedes  an hemorr-
hagy,  the pulfe is  frequent, quick,*  full, and  often hard;
but, as the blood flows, the pulfe  becomes fofter and left
frequent.
   740.] In hemorrhagies, blood drawn from a vein, does,
upon its concreting,  commonly fhow the gluten feparated,
or a cruft formed,  as in the cafes of Phlegmafiae.
   741.] Hemorrhagies from  internal caufes, having once
happened,  are apt, after a certain interval, to return;  in
fome cafes very often, and frequently at ftated periods.
   742.] Thefe are, in general, the  phenomena of hemorr-
hagy;  and if in fome cafes  all of them be  not exquifkely
marked, or if perhaps fome of them do not at all appear,
it imports only, that, in different cafes the  fyftem is more
or lefs  generally  affeaed; and that,  in fome cafes, there
are purely topical hemorrhagies, as there are purely topi-
cal inflammations.

                      Sect. II.

        Of the Proximate Cause ef Hemorrhagy.
   743.] THE pathology of hemorrhagy feems to be fuf-
ficiently obvious.   Some inequality  in the diftribution of
the blood,  occafions  a congeftion in particular parts of the
fanguiferous fyftem;  that is, a greater quantity of  blood
is poured into certain veffels than their natural  capacity is
fuited to receive.   Thefe veffels become thereby, preter-
 * The difference between a frequent and quick pulfe was mentioned in a
note on article 336. 
OF  PHYSIC
563
naturally diftended; and this diftention, proving a ftimulus
to them, excites their afction to a greater degree than ufual,
which pufhing the  blood with unufual force into  the  ex-
tremities of thefe veffels,  opens them  by  anaftomofis, or
rupture; and, if thefe extremities be loofely fituated on
external furfaces,  or on the internal furfaces of certain ca-
vities that open outwardly, a  quantity of blood flows out
of the body.
   744.] This reafoning will,  in fome meafure, explain the
produaion of hemorrhagy.   But it appears to me,  that,
in moft cafes, there are other circumftances that occur to
produce it; for it is probable, that, in confequence of con<-
geftion,  a fenfe of refiftance  arifes,  and excites the aaion
of the Vis Medicatrix Naturae,  the exertions of which are
ufually made by the formation of a cold ftage of  pyrexia,
inducing a more vigorous action  of the veffels;  and  the
concurrence  of this  exertion more effeaually opens the
extremeties, and occafions the flowing out of the blood.
   745.]  What has been delivered in the two preceding
paragraphs,  feems to explain the whole phenomena of he-
morrhagy, except the circumftance of its  frequent recur-
rence,  which I apprehend may be explained in the follow-
ing  manner.  The congeftion  and confequent irritation
being taken off by the flowing of the blood; this, therefore,
foon after, fpontaneoufly ceafes; but, at the fame  time,
the  internal caufes which had before produced the unequal
 diftribution  of  the  blood, commonly remain, and muft
 now operate the  more readily, as the over-ftretched and
 relaxed veffels of the part will more eafily admit of a con-
 geftion of blood in them, and,  confequently, produce the
 fame feries of phenomena as  before.
   746.]  This may fufficiently explain the ordinary return
 of  hemorrhagy:  but there  is  ftill another circumftance,
 which, as commonly concurring, is to be taken notice of;
and that is, the general plethoric ftate of the fyftem, which
 renders every caufe of unequal diftribution of more confi-
derable effea.  Though hemorrhagy may often depend
 upon the ftate of  the veffels of a particular part being fa-
 vourable to  a congeftion's being formed in them; yet, in
order to  that ftate's producing its effea, it is neceffary that
 the  whole fyftem  fliould be at leaft in its natural plethork
 condition; and,  if this fhould be in any  degree increafed 
264                PRACTICE
 beyond what is  natural, it \* ill ftill more certainly deter-
 mine the effeas of topical  confoimation to  take place.
 The  return of hemorrhagy, therefore, will  be more cer-
 tainly occafioned, if the fyftem  becomes preternaturally
 plethoric;  but hemorrhagy has  always a tendency to in-
 creafe the plethoric ftate ofthe fyftem, and,  confequently,
 to occafion its owrn return.
   747.] To  fhow that hemorrhagy does contribute to
 produce or increafe the plethoric ftate of the fyftem,  it is
 only  neceffary to obferve. that the quantity of ferous fluids
 being given, the  ftate  of the excretions depends upon a
 certain  balance between the force of the larger arteries pro-
 pelling  the  blood, and the refiftance of the excretories:
 but the  force ofthe arteries depends upon their fulnefs and
 diftenfion,  chiefly given to them by the quantity of red
 globules and gluten, which are, for the greateft part con-
 fined to the red arteries;  and therefore, the spoliation made
 by an hemorrhagy, being chiefly of red globules and glu-
 ten,  the effufion of blood muft leave the red arteries more
 empty and weak.   In confequence of  the weaker aaion
 of the red arteries, the excretions are in proportion dimi-
 nifhed ; and,  therefore,  the  ingefta  continuing the fame,
 more fluids will be accumulated  in the  larger veffels.  It
 is by this means that the lofs of blood by hemorrhagies,
 whether artificial or fpontaneous, if within certain bounds,
 is commonly fo foon recovered :  but as the diminution of
 the excretions, from a lefs quantity of fluid being impelled
 into  the excretories, gives occafion to thefe veffels to fall
 into  a contraaed ftate;  fo, if this fhall  continue long,
 thefe veffels will become more rigid, and will not yield to
 the fame impelling force as before.  Although the arte-
 ries,  therefore, by new blood colfeaed in them, fhall have
 recovered their former  fulnefs, tenfion, and force; yet
 this force will  not be in balance with the refiftance of the
more rigid excretories, fo as to reftore the former ftate of
excretion;  and, confequently, a further accumulation will
 take  place in the arteries, and  an increafe of  their pletho-
ric ftale be thereby induced.  In this manner,  we perceive
moreclearly,  that hemorrhagy, as producing a more ple-
thoric ftate of the fyftem, has a tendency to  occafion its
own recurrence with greater violence; and, as the  renewal
and further accumulation of blood require a determinate 
                   OF  PHYSIC.                265

 time, fo, in the feveral repetitions of hemorrhagy, that time
 will be nearly the fame; and therefore the returns of he-
 morrhagy will be commonly atftated periods, as has been
 obferved frequently to happen.
   748.] I have thus  explained the nature of hemorrhagy
 in general, as depending upon fome inequality in the diftri-
 bution of the blood, occasioning a congeftion of it in par^
 ticular parts of the fanguiferous fy ftem.   It is indeed pro-
 bable,  that,  in moft perfons, the feveral parts  of the fan-
 guiferous fyftem, are in  balance with one  another;  and
 that the denfity, and  confequently the refiftance,  in  the
 fevcral veffels, is in proportion to the quantity of blood
 which each  fliould receive; from whence it frequently
 happens, that no inequality in the diftribution of the blood
 takes place in the courfe of a lor.5 life.   If, however, we
 confider that the fanguiferous fyftem is conftantly in a ple-
 thoric ftate, that is, that the veffels are conftantly diftend-
 ed beyond that fize which they would be of, if free from
 any di{tending force, we fliall be fatisfied that this ftate
 may be readily changed.   For as, on the  one hand, the
 veffels are elaftic, fo as to be under a conftant tendency to
 contraa upon the withdrawing of any part of the defend-
 ing force;  and,  on the other hand, are not fo rigid but
 that, by an  increafe ofthe impetus of the blood in them,
 they may be  more than ordinarily  diftended;   fo we can
 eafily underftand how, in moft perfons,  caufes of an in-
 creafed contraaion or diftenfion may arife  in one part or
 other ofthe fyftem, or that an  unequal diftribution may
 take place ;  and how, in an exquifitely diftended or  ple-
 thoric  fyftem, a fmall  inequality  in the diftribution ofthe
 blood may form thofe congeftions  which give occafion to
 hemorrhagy.
   749.] In this manner I endeavour to explain how he-
 morrhagy may  be occafioned at any period of life, or in
any part of the body :  but hemorrhagies happen in cer-
tain parts more frequently than in others,  and at certain
periods of life more readily than at others;  and therefore,
in delivering  the  general  doarine of hemorrhagy, it may
be required that I fhould explain thofe circumftances which
produce the fpccialities mentioned ;  and I fliall now at-
tempt it.                                 •
  Vor. I.                 I. 1. 
266                PRACTICE
  75°-]  The human body, from being of a finall bulk at
its firft formation, grows afterwards to a confiderable fize.
This increafe of bulk confifts, in a great meafure, in the
increafe  of the  quantity of fluids and a proportional en-
largement of the containing veffels.  But at the fame time,
the  quantity of folid matter is alfo gradually increafed;
and, in whatever manner we may fuppofe-this to be done,
it is probable  that the  progrefs,  in  the whole  growth of
animal bodies, depends upon  the extenfion of the arterial
fyftem ;  and fuch  is the  conftitution of the fanguiferous
fyftem, that the motion  of the blood in the arteries has  a
conftant tendency to extend them in  every dimenfion.
  751.]  As the ftate of the animal folid is, at the firft form-
ation of the body, very  lax and yielding ; fo the extenfion
of the  fyftem proceeds, at firft, very fait:  but, as  the ex-
tenfion gives occafion to the appofition of more matter to
the folid  parts, thefe are, in proportion to their extenfion,
conftantly acquiring a greater denlity, and therefore giving
more refiftance to their  further extenfion and growth. Ac-
cordingly, we obferve, that as the growth of the body ad-
vances,  its  increafe, in  any given time, becomes propor-
tionally  lefs, till at length it ceafes altogether.
   752.]  This is the general idea of the growth ofthe hu-
man body,  till it attain the utmoft bulk which it is capable
of acquiring :  but,  it is to be remarked, that this  growth
does not proceed equally  in every part of the body, it be-
ing requifite for the ceconomy of the fyftem, that certain
parte fhould be firft evolved, and fhould alfo acquire their
full bulk fooner than others.   This  appears particularly
with refpea to the head, the  parts of which appear to  be
firft evolved, and fooneft to acquire their full fizes.
   753.] To favour this  unequal growth, it is prefumed,
 that the  dimenfions or the laxity of the veffels of the head,
 or that the  direaion of the force of the blood, are adapted
 to the purpofe; and from what  has been faid in  751.  it
 will alfo certainly  follow, that as the veffels of the head .
 grow  fafteft, and fooneft acquire their full fize, fo they will
 fooneft alfo acquire that  denfity which  will prevent their
 further  extenfion.    While, however, the force of the
 heart, and  the quantity of the fluids, with  refpea to the
 whole fyfteim, remain the fame, the diftending and extend-
 ing powers will be  direaed to fuch parts as have  not yet 
O F  P H Y S I C.                267
 acquired  the  fame denfity  and dimenfions of thofe firft
 evolved;   and the diftending  and extending powers will
 proceed to operate till every part ofthe fyftem, in refpea
 of denfity and refiftance, fhall have been brought to be in
 balance with every other, and till the whole be in  balance
 with the force of the heart,  fo that there can be no further
 growth in  any particular part,  unlefs fome preternatural
 circumftance fhall happen to arife.
   754.]  In this procefs ofthe growth ofthe  body, as it
 feems in general to depend upon a certain balance  between
 the force of the heart, or diftending power, and the refift-
 ance of the folids; fo it will appear, that, while the folids
 remain very lax and yielding, fome occafional increafe  of
 the diftending power may arife without producing any very
 perceptible diforder in the  fyftem.   But, it will  alfo ap-
 pear, that, in proportion as the diftending power  and re-
 fiftance ofthe folids come to be more nearly in equal bal-
 ance with one another, fo any increafe of the diftending
 power  will more readily produce a  rupture of veffels,
 which do not eafily yield to extenfion.
   755-]  from all this, it muft follow, that the effeas of
 any unufual plethoric ftate ofthe fyftem, will be different
 according as  this fliall occur at different periods of the
 growth of the body.   Accordingly, it is  evident, that if
 the plethoric ftate arifes while the head is yet growing, and
 while the determination  of the  blood is  ftill more to the
 head than to the other parts, the increafed quantity of the
 blood will be efpecially determined to the head; and as
 there alfo, at the fame time, the balance between the dif-
 tending and extending power is moft  nearly adjufted,  fo
 the determination of  the blood will moft readily produce
 in that part a rupture of the veffels, or an hemorrhagy.
 Hence it  is, that hemorrhagies of the nofe fo frequently
 happen to young perfons;  and in thefe more readily,  as
 they approach nearer to their acme, or full growth; or,
if it may be faid, perhaps more properly, as they approach
nearer to the age of puberty, when, perhaps, in both fexes,
but efpecially in the female, a new determination arifes  in
the fyftem.
  756.] The determination of a greater quantity of blood
to the veffels of  the head, might be fuppofed to occafion
a rupture of veffels in otlier parts of the head; as- well as in 
26S                PRACTICE
the nofe : but fuch a rupture does not commonly happen;
becaufe in  the nofe there is,  for the purpofe of fenfe, a
confiderable net work  of blood-\ cffels  expanded on the
internal furface of the noftrils, and covered only with thin
and weak  teguments.   From this circumftance  it is, that
upon any increafed impetus of the blood in  the veffels of
the head, thofe of the nofe are moft eafily  broken; and
the effufion from the nofe taking place, it not only relieves
the other extremities of the external carotid,  to which the
arteries of  the nofe chiefly  belong, but  relieves alfo, in a
great meafure, the fyftem of the  internal carotid.   For,
from the internal carotid, certain branches are fent to the
nofe, are fpread out on  its'internal furface,  and probably1
inofculated with the extremities of the external carotid: fo
that, whichfoever  of  the extremities  are broken, the vii
derivation^ of Haller will take place; the effufion will re-
lieve the whole fanguiferous fyftem of the head; and the
fame effufion  will alfo commonly prevent an hemorrhagy
happening  at the fame time in any other part  of the body.
   757.] From thefe principles,  it will appear why he-
morrhaies  of  the nofe, fo frequent before  the period of
puberty, or of the acme, feldom happen after  thefe peri-
ods: and I muft obferve further, that although they fliould
occur, they would not afford any objeaion to my doarine,
as fuch hemorrhagies might be imputed  to a  peculiar lax-
ity of the veffels of the nofe, and  perhaps   to a habit ac-
quired  with refpea to thefe veffels,  while the balance  of
the fyftem might be otherwife adjuftcd.
   758.] When the procefs ofthe growth ofthe body goes
on regularly,  and the balance of the fyftem is properly ad-
jufted to the gradual growth of  the whole,  as well  as to
the fucceffive growth of the feveral parts, even a plethoric
ftate does not produce any  hemorrhagy, or at leaft any af-
ter that of the nofe :  but if, while the plethoric ftate con-
tinues, any inequality fliall alfo fubfift in any ofthe parts
of the fyftem, congeftions, hemorrhagic or inflammatory,  «
may be ftill readily formed.
   759-] Jn geneiai? ft ixiay be obferved, that, when the
feveral parts of the fyftem  of the aorta have  attained their
full growth, and are duly balanced with one another, if then
any confiderable  degree of plethora remain or arife, the
nicety of the  balance will  be between the fy Items  ofthe 
OF  PHYSIC.               269
 aorta and pulmonary artery, or between the veffels of the
 lungs and thofe of all the reft of the body.   And although
 the leffer capacity of the veffels of the lungs is commonly
 compenfated by the greater velocity ofthe blood in them ;
 yet, if this velocity be not always adjufted to the neceffary
 compenfation, it is probable that a plethoric ftate ofthe
 whole body  will always be efpecially  felt in the lungs;
 and, therefore, that an hemorrhagy, as the effea of a ge-
 neral plethora, may be frequently occafioned in the lungs,
 even though there be no fault in their conformation.
   760.]  In fome cafes, perhaps, an hemorrhagy from the
 lungs, or an hemoptyfis, does  arife from the  general  ple-
 thoric ftate of the body ; but an hemoptyfis more frequent-
 ly does, and may be expeaed to happen, from  a faulty
 proportion between the capacity of the lungs  and that of
 the reft of the body.
   761.] When fuch a difproportion takes place, it will be
 evident, that an  hemoptyfis will efpecially happen about
 the time that the  body is approaching to its acme ; that is,
 when the fyftem  of the aorta has arrived at its utmoft ex-
 tenfion and  refiftance, and when, therefore, the plethoric
 ftate of the whole muft efpecially affea the lungs.
   762.] Accordingly,  it has  been conftantly obferved,
 that the hemoptyfis efpecially occurs about the time ofthe
 body's arriving at its acme ; but I muft remark alfo,  that
 the hemorrhagy may occur fooner or  later, according as
 the balance between the veffels of the lungs, and thofe of
 the fyftem of the aorta, happen to be more or lefs exa6tly
 adjufted to one another ; and it may, therefore often occur
 much later than  the period mentioned, when that balance,
 though not quite  even, is however not  fo ill adjufted,  but
 that fome other concurring caufes are  neceffary to give  it
 effea.
   763.] It was anciently remarked by Hippocrates,  and
 has been confirmed by  modern obfervation,  that the he-
 moptyfis  generally occurs in perfons  between the age of
 fifteen and that of five and thirty;  that it may happen at
any time between thefe two periods;  but that it  feldom
happens before the former, or after the latter;  and it may
be proper here to inquire into the reafon of thefe  two li-
mitations. 
•- *sro
PRACTICE
   764.] With refpea to  the firft, the reafon of it has
been already explained in 761, and 762.
   With refpea to the fecond  limitation, I expea that the
reafon of it will be underftood from the following conli-
derations.
   It has been  already  obferved,  that  the extenfion and
growth of the  body require the plethoric ftate of  the ar-
terial fyftem ;  and nature has  provided for this, partly by
the conftitution of the blood being fuch, that a great por.
tion of it is unfit to pafs into  the  exhalents and excreto-
ries ; partly by giving a certain denfity and refiftance to
the feveral exhalents  and excretories through which the
fluids might pafs out of the red arteries ; and partly, but
efpecially, by a refiftance in the veins to the  free  paffage
of the blood into them from the arteries.
   765.] With refpea to this laft and chief circumftance,
it appears from rhe experiments of Sir Clifton Wintring-
ham, in his Experimental Inquiry, that the proportional
denfity ofthe coats ofthe veins to  that of the coats of the
arteries, is greater in young than  in old animals:  From
which it may be prefumed,  that the refiftance to the paf-
fage of the blood from the arteries into the  veins, is great-
er in young animals than in old; and, while this refiftance
continues, the  plethoric ftate of the arteries muft be con-
ftantly continued and  fupported.   As however the denfity
of the coats of the veffels confifting chiefly  of a cellular
texture, is increafed by preffure ; fo, in  proportion as the
coats of the arteries are more expofed to preffure by dif-
tenfion than thofe ofthe veins, the  former, in the progrefs
of the growth  of the  body, muft increafe much  more in
denfity than the latter; and, therefore, the coats of the ar-
teries, in refpea of denfity and refiftance,  muft come, in
time, not  only to he  in balance with thofe of the veins,
but to prevail over them :  a faa which is fufficiently prov-
ed by  the experiments of the  abovementioned ingenious
author.
   By thefe means, the proportional quantities of blood in
the arteries and veins muft change in the courfe of life.  In
younger animals, the quantity of blood in the arteries muft
be proportionally greater than in old ones;  but by the in-
creafing denfity of the arteries, the quantity  of blood in,
them muft be continually diminifhing, and that in the veins 
OF  PHYSIC.
271
be proportionally increafing, fo as at length to be in a pro-
portionally greater quantity than that in the arteries.  When
this change  happens in the proportional  quantities of the
blood in the arteries and veins, it muft be evident that the
plethoric  ftate of the arteries will be in  a great meafure
taken off; and, therefore, that the arterial  hemorrhagy is
no longer likely to happen ;  but that, if  a general pletho-
ric ftate afterwards takes place in the fyftem, it muft efpe-
cially appear in the veins.
   766.] The change I have .mentioned to happen in the
 ftate  of the  arterial and venous fyftems, is properly fup-
pofed to take place in the human body about  the a-e of
 thirty-five, when it is manifeft that the vigour of the body,
 which depends fo much upon the fulnefs and tenfion ofthe
arterial fyftem,  no longer increafes; and therefore it is,
that the fame age is the period, after which the arterial he-
morrhagy, hemoptyfis, hardly ever  appears.    It is *^iic,
there are inftances of the hemoptyfis happening at a later
 period; but it is for the  reafons given (757.) which fhow
 that an  hemorrhagy may happen at any period of life, from
accidental caufes forming congeftions,  independent of the
ftate of the balance ofthe fyftem at that particular period.
   767.] I have faid (765.) that if, after  the age of thirty-
five,  a  general and preternatural plethoric ftate occur, it
muft  efpecially  appear in the venous fyftem; and  I muft
now obferve,  that this venous plethora may alfo give oc-
cafion to hemorrhagy.
   768.] If a plethoric ftate of the venous fyftem take place,
it is to  be prefumed, that it will efpecially and in the  firft
place affect, the fyftem of the vena portaru'ra, in which the
motion  of the venous blood is more flow than elfewhere;
in which the motion ofthe blood is little  affifted by exter-
nal  compreffion; and in which, from the want  of  valves
in the veins that form the vena portarum,  the motion of
the blood is little affifted by the compreffion that is appli-
ed; while, from the fame want of valves in  thofe veins,
the blood is more ready to regurgitate in  them.  Whether
any regurgitation of the blood can produce an aaion in the
veins, and which inverted, or directed towards their ex-
tremities,  can  force thefe, and occafion hemorrhagy. may
perhaps be difputed :  but it appears to me that an hemorr-
hagy,  produced by a  plethoric ftate of the veins, may be 
 272               PRACTICE

 explained in another and more probable manner.  If the
 blood be accumulated in the veins, from an eruption of
 its proper courfe,  that accumulation muft  refift the free
 paffage of the blood from the arteries into the veins.  This
 again muft produce fome congeftions in the extremities of
 the red arteries, and therefore feme increafed aaion in
 them,  which muft be determined  with more  than ufual
 force,  both upon the  extremities of the arteries, and upon
 the exhalants proceeding from them ;  and this force may
 occafion an effufion of  blood, either  by anaftomofis or
 rupture.
   769.] In this manner I apprehend the hemorrhoidal flux
 is to be explained, fo far as it depends  upon  the  ftate of
 the whole fyftem.   It appears moft commonly to proceed
 from the extremities of  the  hemorrhoidal veffels, which,
 being the moft dependent and diftant branches of thofe
 vernsf that form the vena portarum, are  therefore the molt
 readily affeaed by every accumulation  of blood in that
 fyftem of veins, and confequently by any general plethora
 in the venous fyftem.
   770.] It is  here to be obferved,  that I have fpoken of
 this hemorrhagy as proceeding from  the hemorrhoidal vef-
 fels only, as indeed it moft commonly does;  but ii will be
 readily underftood, that the fame accumulation and refift-
 ance to the  venous blood may, from  various caufes,  affea
 many of the extremities  of  the vena portarum, which lie
 very fupcrficially upon the internal furface of the  alimen-
 tary canal,  and give occafion to what has been called the
 Morbus Niger or Mclcena.
   771.] Another part in which  an unufually plethoric
 ftate of the veins may  have particular effeas, and occafion
 hemorrhagy, is the head.  In this, the venous fyftem is of
 a peculiar conformation,  and  fuch  as feems  intended by
 nature to give there a  flower motion to  the venous blood.
 If, therefore, the plethoric ftate of the  venous  fyftem in
general, which feems  to increafe as life  advances, fhould
at length increafe to a  great degree,  it  may very  readily
affea the venous veffels  of  the  head,  and produce there
fuch a refiftance to the  arterial  blood, as to determine this
to be poured out from the nofe,  or in  the cavity of  the
cranium.   The fpecial effea of the latter effufion will be,
to produce the difeafe termed Apoplexy;  and which, 
OF PHYSIC.
273
 therefore, is properly named by Do&or Hoffman, He-
 morrhage  Cerebri:  and the explanation of its caufe,
 which I have now given, explains well why it happens ef-
 pecially to men of large heads and fhort necks, and to men
 in the decline of life, when the powers promoting the mo-
 tion of the blood are much weakened.
    772.] I have thus attempted to give the hiftory of the
 plethoric and hemorrhagic ftates  of the  human body,  as
 they occur at the different periods of life ; and hope I have
 thereby explained, not only the  nature of  hemorrhagy in
 general, but alfo ofthe particular hemorrhagies which moft
 commonly appear, and as they occur fucceflively at the
 different periods of life.

                      Sect. III.

           Ofthe Remote Causes of Hemorrhagy.
    773.]  IN the explanation hitherto given, I have efpe-
 cially confidered the predifpofition to hemorrhagy; but it
 is proper alfo, and even neceffary; to take notice of the
 occafional caufes, which  not only concur with the predif-
 ponent, in exciting hemorrhagy,  but may alfo fometimes
 be the  fole caufes of it.
    774.] Thefe occafional caufes are,
    1. External heat, which, by  rarefying the blood, pro-
 duces or increafes the plethoric ftate of the body; and the
 fame heat, as giving a ftimulus to the whole fyftem,  muft
 urge any particular determinations before eftablifhed, ftill
 further, or may urge to excefs any inequality,  otherwife
 innocent;  fo that, in either way, external heat may im-
 mediately excite hemorrhagies, to which there was a pre-
 difpofition,  or  may  form congeftions  where there  were
 none before,  and thereby occafion hemorrhagy.
   2.  A confiderable and fudden diminution of the weight
 ofthe atmofphere, which feems to occafion the fame effeas
 as heat, by producing alfo an  cxpanfion of the blood.
   3.  Whatever increafes the force of the circulation, and
 thereby the velocity of the blood,  may operate in the fame
 manner as heat, in urging not only previous determina-
 tions wj,th violence, but  alfo in urging to  excefs inequali-
ties, otherwife innocent.   All violent exercife; thereforej
  Vor. 1.                 M  si 
274                PRACTICE
and  efpecially all violent  efforts, which,  not  only by a
Jarger and longer infpiration, but alfo by the fimultancous
aaion of many mufcles interrupting the free motion of the
blood, impel it with unufual force into the extreme veffels
more generally, and, according to the different poftures of.
the body, and mode of the effort, into certain veffels more
particularly.
   Among the caufes increafing the force ofthe circulation,
anger* and other violent aaive paffions are to be reckoned.
   4. The violent exercife of particular parts of the body.
If thefe are already affeaed with congeftions,  or liable to
them, fuch  exercife may be  confidered as a ftimulus ap-
plied to  the veffels of that particular part.   Thus, any
violent exercife of refpirationt may excite hemoptyfis, or
occafion its return.
   5, The poftures of the body increafing determinations,
or ligatures occafioning accumulations of the blood in par-
ticular parts of the body.
   6. A determination  into certain veffels rendered habitual
by the frequent repetition of hemorrhagy from them.
   7. Cold, externally applied, as changing the diftribu-
tion of the  blood, and determining  it in greater quantity
into the  internal parts.

                     ~~sIcV. IV.

             Of the Cure  cf Hemorrhagy.
   775.] HAVING thus confidered the proximate and
remote caufes of hemorrhagy in general, our next bufinefs
is, to treat of the cure of the  difeafe in the fame manner.
   In entering upon this fubjeel, the firft queftion which
prefents  itfelf, is, Whether the cure of hemorrhagies ought
to be attempted by art, or if they fhould be left to the con-
dua of nature ?
   776.] The latter opinion was the favourite doarine of
the  celebrated  Dr. Stahl, and  his  followers.   They
maintained, that the human body  is much difpofed to a
plethoric ftate; and, confequently, to many diforders which
  * Paffionate children frequently bring on a bleeding of the nofe; and wben
/uch an.accident happens, the child's face, before the blood breaks out, be-
comes red, and all the veffels of the head and neck feem diftended and full.
  f A.s playing on the German flute, or any other wind inllrument that K'
«uires a great force to blow it. 
OF  PHYSIC.                in
 nature endeavours  to obviate and  relieve by  exciting he-   *
 morrhagy :  that this,  therefore, is often neceffary to the
 balance and health of the fyftem : that it is accordingly to
 be generally encouraged, fometimes  folicited, and is not
 to be fuppreffed, unlefs  when it goes to great excefs, or
 happens in parts in which it may be dangerous.
   777.] Much of  this doarine may be admitted.   The
 human body, upon many occafions, becomes preternatu-
 rally plethoric; and  the dangerous confequences which
 might from  thence be apprehended, feem to  be obviated
 by an hemorrhagy taking place: and, further, the neceffity
 of hemorrhagy often  appears  from hence, that the fup-
 preffion of it feems to occafion many diforders.
   All this feems to  be juft;  but, in the conclufion drawn
 from it, there is a fallacy.
   778.] It appears to me certain, that hemorrhagy, either
 upon its firft attack, or upon its after recurrence, is never
 neceffary  to the health of the body, excepting upon the
 fnppofition,  that the plethoric ftate which feems to require
 the evacuation, cannot be otherwife prevented or removed;
 and as I imagine it poffible by other means to prevent or
 remove a plethoric ftate,  fo I do not think that hemorrha-
 gy is,, in all cafes, ncceffary.  In general,  I am of opini-
 on,  that hemorrhagy is to be avoided.
   1. Becaufe  it does not always happen in parts where it
 is fafe.
   2. Becaufe often, while it does relieve a plethoric ftate,
 it may, at the fame time, induce a very dangerous difeafe.
   3. Becaufe it may often go to excefs, and either endan-
 ger life, or induce a dangerous infirmity.
   And, laftly, Becaufe it has a tendency to increafe the
 plethoric ftate it was meant to relieve; to occafion its own
 recurrence,  (720.) and thereby  to induce a habit,  which,
 if left to the  precarious and unequal operation of nature,
 may, from the frequent errors  of  this, be attended with
 much danger.
   779.] It is further tobe confidered, that hemorrhagies
 do not always arife from the neceflities of the fyftem,  but
often proceed from  incidental caufes.  It appears  to me,
 that all hemorrhagies of the latter kind may be immediately
fuppreffed,  and the repetition of thcm; as it induces a pie. 
275                PRACTICE
thora, and a habit  not otherwife  neceffary  may be pre-
vented with great advantage.
  780.]  Upon the whole of  this fubjea I conclude, that
every preternatural hemorrhagy, or, in other words, every
one except that of the menfes in females,  is to be avoided,
and efpecially the returns of it prevented ; and I therefore
now proceed to mention, how hemorrhagy,  and its recur-    j
rences, may, and fliould be prevented.
  781.]  From the principles delivered  above, it will im-
mediately appear,  that the prevention,  either of the firft
attacks, or the returns of hemorrhagy, will chiefly,  and    '
in the firft place, depend upon the preventing or removing,
any confiderable degree  of a  plethoric ftate which may
happen to prevail in the body.   It is true, that, where the
hemorrhagy depends upon the  particular conformation of
certain parts, rather than upon the general plethoric ftate
of the whole;  the meafures for removing or preventing the
latter,  may not always be fufficient for preventing  he-
morrhagy : but at the fame time it  muft be evident,  that
determinations, in confequence of  the  conformation of
particular parts, will always be urged more or lefs, in pro-
portion to the greater or leffer degree of the  plethoric ftate
of the whole fyftem; and therefore, that, even in the cafes
depending upon particular conformation,  the preventing
or removing an unufually plethoric ftate, will always be a
chief means of preventing hemorrhagy.  It is further to
be attended  to, that there may be  feveral  inequalities in
the balance ofthe fyftem, which may have little or no ef-
fea unlefs when the fyftem becomes prctcrnaturally  ple-
thoric;  and therefore, that,  in all cafes, the  preventing or
removing of the plethoric ftate of  the fyftem, will be a
chief means of preventing the firft attacks,   or the returns
of hemorrhagy.   It now, therefore, remains to explain,
how the plethoric ftate of the fyftem is  to be prevented or
removed.
   782.]  The fluids of the human  body are in continual  1
wafte -by the excretions,  but are commonly replaced by   '
the aliments taken in; and if the quantity  of aliments in
any meafure exceed that of  the excretions,  an increafe of
the quantity of the fluids of the body,  or, in other words,
a plethoric ftate, muft neceffarily arife.  This, to a  cer-
tain degree, is requifite for the growth of the body, but, j'i 
O F  P H Y S I C.                277
-even then, if the proportion of the aliments to the excre-
tions,  be greater than is fuited to the growth of the body,
and more certainly ftill,  if,  after the  growth is completed,
when an equality between the ihgesta and the excreta fhould
be eftablifhed, the difproportion ftill  continue, a preterna-
turally plethoric ftate muft arife.   In both cafes,  it is evi-
dent,  that the plethora muft be prevented or correaed by
adjufting the ingefta and excreta to each other; which ge-
nerally may be done, either by diminifhing the ingefta, or
by increafing the excreta.*  The  former may be effected
by the management of the diet,  the latter by the manage-
ment of exercife.
    783.] The ingefta may be diminifhed, either by giving
aliment in lefs quantity than ufual, or by giving  aliments
of a lefs nutritious quality;  that is, aliments of a fubftance
which, under  the fame bulk and  weight,  contain lefs of a
matter capable of being converted into animal fluids, and
more of a  matter ready to  pafs off by the excretions, and
confequently lefs of a matter to be retained and accumu-
lated in the veffels.
    The choice of aliments fuited to thefe purpofes muft he
left to be direaed by the doarines ofthe  Materia Medica.
    784.] The increafing of the excreta, and thereby dimi-
nifhing the plethoric ftate of  the fyftem,  is  to be obtained
 by increafing  the exercife of the body;  and generally for
adjufting the balance between the ingefta and excreta, and
 thereby  obviating the plethoric ftate, it  is  neceffary that
exercife, in a due meafure, be very conftantly employed.t
    785.] The obferving  abftinence,  and the employment
of exercife, for obviating or removing the plethoric ftate
of the body, were formerly confidered pretty fully, when
treating ofthe gout, (547, to 551.) fo that the lefs is ne-
ceffary to be faid here :  and it is now only requifite to ob-
 ferve, that the fame doubts, as in cafe of the gout, do  not
 occur here with regard  to the fafety  of thofe meafures,
   * This effeft may furely be more  fpeedily produced by ufeing both thefe
means  at once.
   t The exercife bell adapted to thefe cafes is fuch as does not heat the body
 or increafe the force of the blood. Hence  riding- moderately, travelling iu a
 carriage, or failing, are preferable to walking.  Young people may nfe fuch
 gentle exercife as may amufe the mind, and at the^fame time conduce to bo-
 dily health, as gardening, feveral agricultural labours, or mechanical opera-
 tions ; or fome of the fports that require a gentle bodilv exertion, as bow lii^g,
 archer/, Stc. 
27*                 PRACTICE
 which, in a  plethoric  ftate of the body difpofing to he-
 morrhagy, are always admiflible and proper.   Flere, how-
 ever, it is to  be obferved, that fome choice in the mode of
 exercife is neceffary,  and  that it  fhould be  different ac-
 cording to the particular determinations which may  hap-
 pen to  prevail in the  fyftem.   In general,  in the cafe of
 plethora difpofing  to hemorrhagy, bodily exercife will al-
 ways  be hazardous, and geftation more commonly fafe.
   786.]  Artificial  evacuations may  be employed to di-
 minifh the plethoric ftate of the body: and when,  at  any
 time,  it has become confiderable,  and immediately threat-
 ens a difeafe,  thefe evacuations fhould be  made to  the
 quantity that the fymptoms  feem to  require.   But it is
 conftantly to be attended to,  that blood-lettings are impro^
 perly  employed to  prevent  a  plethora, as they have a ten-
 dency to increafe it (720.) and as they  require to be often
 repeated, and are thereby apt to induce a habit which may
 be attended with much danger.*
   787.] While a plethora, and thereby the predifpofition
 to hemorrhagy, is  avoided, or removed, the other mea-
 fures neceffary for  preventing the  occurrence of this,  are
 thofe for avoiding  the  remote caufes.   Thefe have been
 enumerated in 774, and  the means of avoiding  them, fo
 far as  within our  power, are fufficiently obvious.
  * Brilk purges are perhaps preferable to every other mode of evacuating
 the ingefta; and in thefe  cafes we may have recourfe to draftics without any
 apprehenfion of danger.  I'he following formal*: may ferve as fpecimens of
 the purges ufeful in thefe cafes.
           R.  Pulv. Rack  Jalap.  I ft.
                  Aromat. 3i«
              Sal. Tart. 5 ft.
              Syr. Simp. q.  s.
              M. f. Eleft.
  This elerlnary may be divided into fonr dofes, one of which may be taken
 early in the morning, as occafion may require.
           R.  Pilul. Ruh\  3 ft.
              Calomel, gr. vu
              Syr. Simpl.  q. s.
              M. f. Mafia in pilulas equalas sex dividend.
  Two of thefe pills may be taken  in the evening, and the remaining four
 the following morning.
          R. Reiin. Jalap. 3i.
             Tere in mortar, cum Sacch. alb. 3 ft.
             Amygdal. dulc. decorticat. No. ii.
             Add* gradatim Aq. Cinnamon, fimpl. 31.
             M. f. hauft. mane sumend.
  This is a very elegant purge, and  has the peculiar advantage of operating
powerfully without griping or occauoning much inconvenience. 
0 F  P H Y S I C.                  Z79
   788.]  Having thus mentioned the means of preventing
either the firft attacks, or the recurrence of hemorrhagy ;
I muft next fay how it is to be managed when it has aaual-
ly come  on.
   789.]  When an hemorrhagy has  come on which ap-
pears to have arifen from a prctematurally plethoric ftatef^
or from fome change in the  balance of the fanguiferous
fyftem, no meafures are to be immediately taken for fup-
preffing it; as we may expea, that, when  the quantity of
blood neceffary for the relief of the fyftem is poured out,
the effufion will fpontaneoufly ceafe.*
   790.]  In many cafes however,  it may be fufpeaed,
that the  quantity of blood poured out, is not exaaiy in
proportion to the neceflities of the fyftem, either for reliev-
ing a general plethora or a particular  congeftion, but that
it is often to a greater quantity than thefe require.  This
we fuppofe to happen in confequence of an inflammatory
diathefis  prevailing, and of a febrile fpafm being  formed;
and therefore it is in many cafes proper, as well as for the
moft part  fafe, to moderate the evacuation, and, when it
threatens to go to excefs,  to  fupprefs it altogether.
   791.]  An hemorrhagy may be moderated by avoiding
any irritation that might  concur to increafe it;  fo that
every part ofthe antiphlogiftic regimen is to be obferved;
particularly external  heat, both as it rarefies  the fluids,
and ftimulates the folids, is to be carefully avoided:  and,
it is probable, than in all cafes an hemorrhagy may be fafely
moderated by cool air applied, and cold drink exhibited.
   792.]  A fecond means for the fame purpofe. is, the ufe
of refrigerant medicines, and particularly of acids and nitre.t
  • The doctrine here delivered, and the practice founded on it, is pure Stah-
lianifm ; and is, doubtlefs, in thefe cafes the beft practice. A patient, how-
ever, is not always fatisfied when the phyfician is inailive, which often ob-
liges him to prelcribe fome of the medicamenta inertiora, and the choice of
them mult be left to the practitioner's own fagacity.
  •f The refrigerant medicines have been enumerated in former notes, arti-
cles 134, and 135.  The Tinetura rofarum is a very proper acid refrigerant in
rauft hemorrhagies.  The dofe of it muft be proportioned to the exigency of
the cafe ; it ought never to exceed four ounces in the fpace of an hour; an
ounce every half hour is generally fufficient, and a greater quantity at a time
frequently occafions gripes, and by its irritation increafes the difeafe; efpe-
cially if it dots not produce a diarrhoea which is feldom the cafe.  With ref-
pecl to nitre, the precautions, mentioned in the note on article J35,  muft be
obferved.  The dulcified fpirit of vitriol or of nitre are npt always fafe me-
dicines in thefe  cafes as they heat and irritate.  The acid of tartar, in the
form defcribed in the note on urtLU 134. anfwers very well in molt cafts. 
+ SO                PRACTICE
     793.]  A third means which has been frequently em-
   ployed, is that of blood-letting.    The propriety of this
   practice may be doubtful, as the quantity of blood pour-
   ed out by the hemorrhagy, may be fuppofed to anfwer the
   purpofe  of an evacuation in  any other way; and  I am
•pready to allow, that the practice has been often fuperflu-
-  ous,  and  fometimes hurtful, by making a greater evacua-
   tion than  was neceffary or fafe.  At the fame time, I ap-
   prehend it is not for the mere purpofe of evacuating,  that
   blood-letting is to be praaifed in the cure of hemorrhagy;
   but that it is further ncceffary for taking off the inflamma-
   tory  diathefis  which prevails, and the  febrile fpafm  that
   has been formed.   Accordingly, in the  cafe of hemorrha-
   gy, when  the pulfe is not frequent, but quick and full, and
   does  not become foftcr or flower upon the flowing of the
   blood, and that the  effufion is  profufe, and threatens to
   continue fo, it appears to me, that blood-letting  may be
   neceffary, and I have often found it ufeful.   It feems pro-
   bable alfo, that the particular circumftances of venefettion
   may render it more powerful for taking off the tenfion and
   inflammatory  irritation  of the fyftem,  than any  gradual
   flow  from an artery.
     794.]  That a fpafm ofthe extreme veffels has a  fhare
   in fupporting hemorrhagy,  appears to  me probable from
   hence, that bliftering has  been often found  ufeful in mo-
   derating and fupprcfling the difeafe.
     795.]  Do emetics and vomiting  contribute  to the  cure
   of h|mprrhagy ? See Dr. Bryan Robinson on the vir-
   tues and power of medicines.
     796.]  When an hemorrhagy is very profufe, and feems
   to endanger life, or even threatens to induce a dangerous
   infirmity,  it is agreed on all hands, that  it is to be imme-
   diately fuppreffed  by every means in our power, and par-
   ticularly that, befides the means above-mentioned for mo-
   derating the difeafes, aftringents,  internal  or external,
   where the latter can be applied, are to be employed for
   fuppreffing it.
     797.] The internal aftringents are either  vegetable or
   foflil.
     The vegetable aftringents are feldom very powerful  in
   the cure of any hemorrhagies, except thofe of the alimen-
   tary canal. 
OF  PH Y SIC.                 23i
    The foffil aftringents  arc more  powerful;  but fome
 choice amongft the different kinds may be proper.
    The chalybeats, fo frequently employed, do not appear
 to me to he very powerful.                    -.:);..       ;
    The preparations of lead are certainly more fo, tmr are
 other.vife of fo pernicious a quality,  that they flifirrlH  not % "*
 be employed except  in cafes of  the mm oft danger.  The«^
 Thfetura Saturnina, or Antiphthifica, as  it has been called,^V'
 appears  to be of little efficacy;*  but  whether from  the
 finall portion of lead which  it contains,  or from die ftate
 in which the lead is in it,  I am uncertain.
    The foffil  aftringent that appears to me the moft  pow-
 erful, and at the fame time the moft fafe, is alum.t
    798.]  External aftringents,  when they can be applied,
 are more effeaual  than the internal.   The choice of thefe
 is left to the furgcons.
    799.]  The moft powerful of all the aftringents appears
 to me  to be cold,  which may be employed,  either by  ap-
 plying cold water to the furface of the body, or by thfefw-
 ing it into the internal parts.^                   rr#j-"
    8oq.J  For fuppreffmg hemorrhagies, many fupfrftitious
 remedies and charms || have  been recommended, and pre-
 tended to have been employed with  fuccefs.  The feeming
 fuccefs of thefe,  however, has been generally owing to the
 by-ftanders miftaking a fpontaneous ceafing of the hemorr-
 hagy for  the  effea of  the  remedy.   At  the fame  time,
 I believe, that thofe  remedies may have been fometimes
 ufeful, by impreffing the mind with horror, awe, or dread.

   * It is a very dangerous medicine, and  ought to be ufed with the  uttnoft,
 caution.  But fince its efficacy is doubtful, we had better abandon it altoge-
 ther, except  when every other remedy Fails.
  f Alum frequently  irritates if given in too large dofes at firft, p>o*ing
 fometimes a purgative and fometimes an emetic.  In cafes of great  danger,,
 however, it mult be given in large quantities by frequently repeating fmall
 dofes. Five grains is a fufficient dofe to begin with ; but it may be repeated
 every hour,  or every  half hour.  Some authors have given it in dofes  of a
 fcruple feveral times a day ; but that is certainly too great a quantity at once.
  f Van Swieten relates a cafe of a bleeding at the  nofe  being ltopped by
 the application of pledgets, dipped in cold wine and water, to the fcrotum *
 a lhivering was produced, and the bleeding Hopped.
  || It is ait'>nii1ring that thefe charms iliouf I continue in ufe in this enlight-
ened age.  They are nraftifed among the country people frequently.  Some
 of them,  however, aa mechanically, as the application  ofthe great key of
the church-door to the nape of the neck, in bleedings at the nofe ; drinking
large draughts of cold water out of a human fcull, &c.  The cold iron  and
 the cold water were in fail proper remedies.
   Vol.  i,                   N n 
?8U
PRACTICE
   801.] Upon occafion of the profufe hemorrhagies, opi-
 ates hav*e been employed with advantage; and,  when the
 fulnefs and inflammatory  diathefis ofthe fyftem have.been
 previoufly taken off by the hemorrhagy itfelf, or by blood-
 letting, I think opiates may be employed with fafety.*
   802.] For reftraining hemorrhagy, ligatures have been
 applied upon the limbs, in the view of retarding the return
 of the venous blood from the extremities ;   but they ap-
 pear to me to be of uncertain and ambiguous ufe.
   803.] In the cafe of profufe hemorrhagies, no pains are
 to be taken to prevent a Deliquium Animi, or fainting, as
 the happening of this is often the moft  certain means of
 flopping the  hemorrhagy.t
   804.] Having thus delivered the general doarine of he-
 morrhagy, I  proceed to confider the particular cafes of it.
 It may perhaps be remarked, that I have marked fewer of
 thefe than are commonly enumerated by the  nofologifts;
 but my reafons for differing from thefe authors, muft be
 left to a nofological difcuffion, to be entered into elfewhcre
more properly than here.
                      CHAP.  II.

 €>f tfre (JEpigtans, or ©emorr&agp of tit Bose,

 805.]  JL  HE ftate of the veffels upon the internal furface
of the nofe being fuch as already mentioned (756.) renders
hemorrhagy from that more frequent than from any other
part ofthe body.
   806.] The blood commonly flows from one noftril only;
and probably becaufe an hemorrhagy from one veffel re-
lieves the congeftion in all the neighbouring veffels.
   The  blood flowing from both noftrils at the fame time,
fhows commonly a  more confiderable difeafe.
   807.] This hemorrhagy happens to perfons of every
conftitution and temperament, but moft frequently to thofe

  * Opium, however, ought to be cautioufly employed in aaive hemorrha-
gies, which are frequently accompanied with a phlogiftic diathofis ; opium is
generally, if not  univerfally, hurtful. But, as the author  observes, when
the hemorrhagy has reduced the inflammatory  diathefis, we may then give
opium freely:  and for this purpofe large dofes  are preferable to fmaller ones."
  f Attention, however,  is neceffary in this cafe, as fainting is frequently
tJw forerunner of death. 
0 F P H Y S I C.                283
of a plethoric habit and fanguine temperament.   It hap-
pens to both fexes, but moft frequently to the male.
   808. J  This hemorrhagy may occur at any time of life ;
but moft commonly happens to young perfons, owing to
the ftate  ofthe ballance of die fyftem peculiar to that age,
as mentioned in (755.)
   809. j Although generally it happens to  perfons before
they have arrived at their full growth, and more rarely af-
terwards ;  yet fometimes it happens to perfons after  their
acme, and  during the ftate of manhood : And it muft then
be  imputed to an unufually plethoric ftate of the fyftem ;
to an habitual determination of the blood to the veffels of
the nofe; or to the particular weaknefs of thefe.
   810.] In all thefe cafes the difeafe may  be confidered
as an hennorrhagy purely arterial, and depending upon an
arterial plethora ;  but it fometimes occurs in the decline
of life, when probably it depends upon, and may be confi-
dered as  a  mark of a venous plethora of the veffels of the
head.  See (771.)
   811.]  This hemorrhagy happens alfo at  any period of
life, in certain febrile difeafes, which are altogether or part-
ly of an inflammatory nature, and which fhow a particular
determination of  the blood to the veffels  of the head.
Thefe difeafes. often admit of a folution by this hemorrha-
gy, when it may be properly termed critical.
   812.]  The difeafe fometimes comes on without any pre-
vious  fymptoms;  particularly, when fome  external  vio-
lence has a fhare in producing it.   But, when it proceeds
entirely from an internal caufe, it is commonly preceded
by  hcadachs, rednefs of the eyes, a florid  colour of the
face,  an  unufual pulfation in  the temples, a fenfe of ful-
nefs about the nofe, an an itching of the noftnls..  A
round belly, pale urine, coldnefs of the feet, and cold fhi-
veringover the whole body, are alfo fometimes among the
fymptoms that precede  the difeafe
   813. J  From the weaknefs of the veffels of the nofe, the
blood often flows from them without any confiderable ef-
fort of the whole fyftem,  and therefore without any ob-
fervable febrile diforder; which, however, in many cafes,
is, iu all its circumftances,  very difcernable.
   814.]  An hemorrhagy of the  nofe happening to young
perfons,  b; and may generally be confidered  as a flight 
584                PRACTICE
difeafe of little confequence, and hardly requiring any  re-
medy.  But, even in young perfons, when it recurs wry
frequently, and is very copious,  it will require particular
attention, as it  is tobe confidered as a mark of arierial
plethora; and, as frequently returning, it may increafe the
plethoric itate ; which, in a  more advanced 11 age of  life,
may give the blood a determination  to parts  from which
the hemorrhagy would be more dangerous.  All this will
more particularly require attention, according as the marks
of plethoi a, and of a particular congeftion, preceding  the
hemorrhagy, are more confiderable;  and as the flowing of
the blood is attended with a  more confiderable degree of
febrile diforder.
   815.] When the epiftaxis happens to perfons after their
acme, returning frequently, and flowing copioufly, it is ah
ways to be confidered as a dangerous difeafe, and as more
certainly  threatening  the confcquences mentioned  in  the
laft paragraph.
    816.] When this hemorrhagy happens in the decline of
life, it may he confidered as in itfelf very falutary: but at
the fame time,  it is to  be confidered as a mark of a  very
dangerous ftate of the  fyftem ; that  is, as a mark of a  very
ftrong tendency to a venous plethora in  the veffels of the
head: and I have accordingly obferved  it often  followed
by apoplexy, palfy, or fuch like difeafes.
    817.] When an hemorrhagy from the nofe happens in
febrile difeafes, as mentioned in 811, and is in pretty large
quantity, it may be confidered as critical and falutary;  but
his very apt to be profufe, and even in this way dangerous.
    It upon fome occafions occurs during the eruptive fever
of feveral  exanthemata, and in fuch cafes fometimes  falu-
tary; but, if thefe exanthemata be accompanied with  any
putrid tendency, this hemorrhagy, like artificial blood-let-
 tings, may have very  bad effeas.
    818.] Having thus explained the feveral circumftances of
epiftaxis, I proceed to confider the management and cure
of it.  I ufe the exprefiion  of management, becaufe it has
been ufually thought to  require no cure,  but that nature
fhould be allowed to throw out blood in this way  very
frequently; and as often as  it appears to arife from inter-
nal caufes, that is, from  a ftate of the fyftem fuppofed to
require fuch evacuation. 
OF  PHYSIC.                285
   819.] I am however,  of opinion, for the reafons given
in (778.) that this difeafe is very feldom to be left to the
conduct of nature;  and that in all cafes it  fliould be mo-
derated by keeping  the patient in cool air;  by giving cold
drink;  by  keeping the body and head crea; by  avoiding
any  blowing  of the nofe, fpeaking,  or other  irritation:
And, when the blood  has  flowed for fome time,  without
frK)\ving any tendency to ceafe, a profufe bleeding is to be
prevented by meafures  employed to flop it, fuch  as pref-
fing the noftril  from which the blood flows, waffling the
face with cold water, or applying this to other parts of the
body.
   820.] Even in the cafe of young perfons, where the dif-
eafe is leaft hazardous, and even in the firft attaas, I judge
fuch meafures  to be proper;  but  they will be ftill more
proper if the difeafe frequently recurs without any external
violence;  if the returns fhall hsquen to perfons of a habit
difpofed to be plethoric; andniore»rticularly, if the marks
of a plethoric ftate appear in the-pwrcedent fymptoms (812)
   8ii.] Even in  young perfons, if the bleeding  be  very
profufe and long continued, and more efpecially if the pulfe
become weak and the face pale, I apprehend it will be pro-
per to fupprefs the hemorrhagy by every means in  our pow-
er.   See (796.) and following paragraphs.*
   822.] Further, in the fame cafe of young perfons, when
the returns of this hemorrhagy become frequent, and ef-
pecially with the marks of a plethoA habit, I think it ne-
ceffay to employ fuch a regimen as may prevent-a pletho-
ric ftate, (782.  786.)   At the fame time,  care fhould be
taken to avoid all circumftances which may determine the
blood more fully to the veffels ofthe head, or  prevent its
free return from them ;  and,  by keeping an open belly to
make fome derivation from them.t
   8 2 3. J In adult perfons, liable to frequent returns ofthe
epiftaxis, the whole of the meafures  propofed  (822.) are
  * Befides the general dire<ftions referred to above, plugs of lint or cotton,
impregnated with vinegar and a folution of alum,  are recommended.   Thick
cotton threads, impregnated with thefe fhptic folutions,  have  been palfed
through the noftril, and brought out by the mouth by means of a bent probe,
with great fuccefs.
  t For this purpofe Glauber's fait feems peculiarly adapted.  It operates
fpeedily,  and without too much irritation ; evacuating, at the fame Lime, not
only the contents of  the inteitinal canal, but the fuperfluities of the fanguife-
rous fyllem. 
2S6                PRACTICE
 more certainly and freely to be  employed.   When, with
 the circumftances mentioned in 812, the tendency to pro-
 fufe hemorrhagy appears, a bleeding at the  arm may be
 proper, in young perfons;  but 1:1 the cafe of adults,  it will
 be ftill  more allowable, and  even ncceffary.
    824.]  In perfons of any age  liable to frequent returns
 of this  hemorrhagy, when  the meafures  propofed in 816,
 et. seq.  fhall have been negfeaed, or from peculiar circum-
 ftances in the balance of the fyftem, fliall have proved in-
 effectual, and the fymptoms threatening hemorrhagy (817.)
 fliall appear, it will then be proper, by blood-letting, cool-
 ing purgatives, and every part of the antiphlogiftic regimen,
 to prevent the hemorrhagy, or at leaft to prevent its  being
 profufe when it does happen.
   825.]  In the circumftances juft now  mentioned (824.)
 the meafures propofed are proper, and even neceffary; hut
 it fliould at the fame time be obferved, that thefe are prac-
 tifed with much lefs actyantage than thofe pointed out in
 (823.) becaufe, though thofe fuggefted here may prevent
 the  coming  on of the hemorrhagy for  the prefent,  they
 certainly however difpofe to the return of that plethoric
 ftate which  required their being ufed;   and  there can be
 no proper fecurity againft returns of the difeafe, but by
 purfuing the means propofed in (822.)
   826.] When the hemorrhagy  of*the nofe  happens to
 perfons approachinokheir full growth,  and when its re-
 turns have been preened by the  fymptoms (812.) it may
 be fuppofed, that, if the returns can  be  prevented by the
 meafures propofed in (824.) thefe may be fafely employed;
 as the plethoric ftate induced will be rendered fafe, by the
 change  which is foon  to take  place in  the balance of the
 fyftem.   This, however, cannot be admitted; as the eva-
 cuations praftifed upon this plan will have all the confe-
 quences which I have already obferved, may follow  the
 recurrence of the hemorrhagy itfelf.
   827. J When the hemorrhagy of the nofe fhall be found
 to make its returns at nearly  ftated periods, the  meafures
for preventing it (824.) may  be practifed with great cer-
tainty ;  and, upon every repetition of blood-letting, by di-
minifhing the quantity taken away, its tendency  to induce
a plethora may be in fome meafure avoided.  ' When  in-
deed, the repetition of evacuations is truly unavoidable, 
OF  PHYSIC.               287
the diminifhing them upon every repetition is properly prac-
tifed; But it is a praaice of nice and precarious manage-
ment, and fhould by no means be trufted to, fo far as to
fuperfede the meafures propofed in (824.) wherever thefe
can be admitted.
   828.] When  the hemorrhagy  of the nofe happens in
confequence of a venous plethora in the veffels of the head,
as in (771.)  the flowing ofthe blood pretty largely may
be allowed, efpecially when it happens  after the fuppref-
 fion or ceafing  of the menftrual  or hemorrhoidal flux.
But though  the flowing of the blood is,  on its  firft occur-
ring,  to be allowed, there is nothing  more proper than
guarding againft its returns. This is to be done not only by the
meafures propofed in (732.  et. seq.) but, as the  effefcts of
a  plethoric ftate of the veffels of the head are very uncer-
tain; fo, upon any appearance of it, and efpecially  upon
any threatening of hemorrhagy, the plethora is to be re-
moved, and the  hemorrhagy to be obviated immediately
by proper evacuations,  as blood-letting, purging, and il-
fues ; or by reftoring  fuppreffed evacuations, where this
can be done.

                     CHAP. III.

      ©fibe^emoptgsiisf, or $emorr&ag;g
                 from t&e Lung**
                      Sect. I.
     Of the  Phenomena  and Cause of Hemoptysis.

829.] VV  HEN, after fome affeaion of the breaft,
blood is thrown  out  from the mouth, and is brought out
with more or Ids  of coughing,  there can be no doubt that
it comes from the lungs; and this  generally afcertains the
difeafe of which I am now to treat.  But there are cafes in
which the fource  of  the blood fpit out  is uncertain; and
therefore, fome  other  confederations to be  mentioned
hereafter,  are often neceffary to afcertain the exiftence of
an hemoptyfis.
   830.]  The  blood-veffels  of the  lungs are more numer-
ous than thofe of any other part of the  body of the fame
bulk.   Thefe vcffclsj of die largeft fize3  as they arife from 
38ft
PRACTICE
the heart, are  more immediately than  in  any other part
fubdivided into veffels of the fmallcft fize;  and thefe fmall
veffels fpread out near to the internal  furfaces of the bron-
chial cavities,  are fituated in a loofc cellular texture, and
covered by a tender membrane only :  fo that, confidering
how readily and  frequently thefe veffels are gorged with
blood, we may underftand why an hemorrhagy from them
is, next to that of the nofe,  the moft frequent of any; and
particularly, why any violent fhock  given  to the  whole
body fo readily occafions an hemoptyfis.
   831.]  An hemoptyfis  may be  occafioned by external
violence, at any period of life; audi have  explained a-
bove (759.) why, in adult perfons, while the arterial ple-
thora ftill prevails in the fyftem, that is, from the age of
fixteen to that of five-and-thirty,  an  hemoptyfis may at
any time be produced,  merely by a plethoric ftate of the
lungs.                     'V
   832.]  But it has been alfo obferved above, (760.) that
an hemoptyfis more frequently arifes from a faulty propor-
tion between the capacity of the  veffels of the lungs and
that of thofe of the reft of the  body.  Accordingly it  i$
often a hereditary difeafe, which implies a  peculiar and
faulty conformation.  And the difeafe alfo happens efpe-
cially to perfons who difcover the fmallcr capacity of their
lungs,  by the narrownefs of their  cheft, and by the pro-
minency  of their fhoulders; which laft is a mark of their
having been long liable to a difficult refpiration.
   833.] With thefe circumftances alfo the difeafe happens
efpecially to perfons of a fanguine temperament; in whom,
particularly, the  arterial plethora  prevails.   It happens
likewife to perfons of a flendcr delicate make,  of which a
long neck is a  mark; to perfons of much fenfibility  and ir-
ritability, and therefore of quick parts,  whofc bodies are
generally of a delicate ftru6ture; to perfons who have been
formerly liable to frequent hemorrhagies of  the nofe; to
perfons who have fuffered a fuppreffion of any hemorrhagy
they had  formerly been liable to, the moft frequent inftance
of which is in  females who  have  fuffered a fuppreffion of
their menftrual flux; and, laftly,  to perfons who have fuf-
fered the  amputation of any confiderable limb.
   834.]  In moft of thefe cafes (833.) the difeafe happens
efpecially to  perfons about the time of their coming to 
OF  PHYSIC.               289
 their full growth, or foon after it, and this for the reafons
 fully let forth above.
   835.] From all that has been faid from (830, to 834.)
 the predifponent caufe of hemoptyfis will be  fufficiently
 underftood,  and the  difeafe may  happen from the mere
 circumftance of the predifponent caufe arifing to a confi-
 deiable degree.  In the predifpofed, however, it is often
 brought on by the recurrence of various occafional and ex-
 citing caufes.   One of thefe, and perhaps a frequent one,
 is external  heat; which, even iu no great degree, will bring
 on the difeafe in fpring,  and  the  beginning of fummer,
 while the heat rarefies the blood more than it relaxes the
 folids which  had  been before contraaed by  the  cold of
 winter.  Another exciting caufe is a fudden diminution of
 the weight of the atmofphere,  efpecially when concurring
 with  any effort in bodily exercife.  The effort, too, alone,
 m;-:y  often, in the predifpofed, be the exciting  caufe; and,
 more particularly,  any violent exercife of refpiration.  In
 fliort, in the predifpofed,  any degree of external violence
 alfo.may bring on the difeafe.
   836.] Occafioned by one or other of thefe caufes (835.)
 the difeafe comes on with  a fenfe of weight and anxiety in
 the cheft, fome  uneafinefs in breathing,  fome pain of the
 breaft or other parts of the thorax,  and fome fenfe of heat
 under the fternum ; and very often,  before the difeafe ap-
 pears, a faltifh-taftc is perceived in the mouth.
   837.] Immediately before the appearance  of blood,  a
 degree of irritation is felt at the top of the larynx.   To re-
 lieve this,  a hawking is  made,  which  brings up  a  little
 blood,  of a florid colour,  and fomewhat frothy.   The ir-
 ritation returns; and, in the fame manner, more blood of
 a like kind is brought up, with fome noife in the windpipe,
 as of air palling through a  fluid.
   838.] This is commonly the manner in which  the he-
 moptyfis begins; but fometimes at the very firft the blood
 comes up by  coughing, or at leaft fomewhat of coughing
accompanies the hawking juft now mentioned.
   839. J The blood iffuing  is fometimes at firft in  very
fmall quantity, and foon  difappears altogether:  but,  in
other cafes,  efpecially when it repeatedly occurs,  it is in
greater  quantity, and frequently continues to appear at
  Vol. I.                 0 0 
290
PRACTICE
 times for feveral days together.  It is fometimes profufe;
 but rarely in fuch quantity as either bf its  excefs, or by
 its fudden fuffocation, to prove  immediately mortal.   It
 commonly either  ceafes fpontancoufly, or is flopped by
 the remedies employed.
   840.]  When blood is thrown out from the mouth, it is
 not always eafy to  determine from what  internal part it
 proceeds; whether from the internal furface ofthe mouth
 itfelf, from the fauces,  or adjoining cavities ofthe nofe,
 from the ftomach, or from the lungs.  It is, however, very
 neceffary to diftinguifh  the  different cafes;  and, in moft
 inftances, it may be  done  by attending to the following
 conliderations.
   841.]  When the  blood  fpit out, proceeds from fome
 part of the internal  furface ofthe  mouth itfelf,  it comes
 out without any hawking or coughing; and generally, up-
 on infpeaion, the particular fource  of it becomes evident.
   842.]  When blood  proceeds from the fauces,  or ad-
 joining cavities of the  nofe, it may be brought out by
 hawking, and fometimes by coughing, in the manner we
 have defcribed in (836,  and 838.)  fo that, in this way, a
 doubt may arife concerning its real fource.   A patient of-
 ten lays hold of thefe circumftances to pleafe himfelf with
 the opinion of its coming from the  fauces, and  he may be
 allowed to do fo:  but a phyfician cannot readily be deceiv-
 ed, if he confider, that a bleeding from the fauces is more
•rare than  one from the lungs; that  the  former feldom hap-
 pens but to perfons who have been before liable either to an
 hemorrhagy ofthe nofe,  or to fome evident caufe of erofi-
on; and, in moft cafes, by looking into the fauces, the diftil-
Jation ofthe blood, if it comes from thence, will be perceived.
   843.] When blood proceeds from the lungs, the manner
 in which it is brought  up will commonly fhow from whence
 it comes:  but, independent of that, there are many  cir-
cumftances which may occur to point  it out, fuch as the
 period of life, the habit of body, and other marks of a pre-
 difpofition (832.—834.) and together with thefe, the occa-
 fional caufes (835.) having been immediately before applied.
   844.] When vomiting accompanies  the throwing out
 of blood from the mouth, as vomiting and coughim* often
 mutually  excite each other;  fo they may be frequently
joined, and render it doubtful whether the  blood thrown 
OF  PHYSIC.                i$V
 out proceeds from the lungs or from the ftomach.  We
 may however generally decide, by confidering, that blood
 does not fo frequently proceed from the ftomach as from
 the lungs:  that  blood proceeding from the ftomach com-
 monly appears in  greater quantity, thin when it proceeds
 from the lungs: that the blood proceeding from the lungs
 is ufually of a florid colour, and mixed with a little frothy*
 mucus only; whereas the blood from the ftomach  is com-
 monly of a darker colour, more grumous, and mixed with
 the other contents of the ftomach:  That the coughing  or
 vomiting, according as the one or the other firft arifes in
 the cafes in which they are afterwards joined, may fome-
 times point out  the fource ofthe blood; and, laftly, that
 much may be learned  from the circumftances and fymp-
 toms which have preceded the hemorrhagy.
    Thofe which precede the hemoptyfis, enumerated in
 (836.) are moft of them evident marks of an affeaion of
 the lungs.   And,  on the other hand,  the hematemefis,  or
 iffuing of blood  from the ftomach,  has alfo its peculiar
 fymptoms and circumftances preceding it; as,for inftance,
 fome morbid affeaion of this organ, or at leaft fome pain,
 anxiety, and fenfe of weight, referred diflinttly to the re-
 gion of the ftomach.  To all this may  be added, that the
 vomiting of blood happens more frequently to females than
 to  males ; and to the former, in confequence of a fuppref-
 fion of their menftrual flux: and, by attending to all thefe
 confiderations (841.—854.) the prefence ofthe hemopty-
 fis  may commonly be fufficiently afcertained.


                       Sect. II.

               Of the Cure of Hemoptysis.
   845.] THIS difeafe is fometimes attended with little
 danger;  as when it happens to females in confequence of a
 fuppreffion ofthe menfes.;* when, without any marks of a
 predifpofition, it arifes  from external violence;  or when,
 from whatever caufe arifing, it leaves behind it no cough^
 dyfpncea, or other affeaion of  the lungs.   Even in fuch
'cafes, however, a danger may arife from too large a wound
 being made in the veffels of the  lungs;  from a quantity of
  •  The author might have added, " And when no fymptom of phthiiis hawk
 preceded «r accompanies the hemorrhage." 
29-                  PRACTICE

red  blood being left to ftagnatc In the cavity of the bron-
chia?; and particularly,  from  any  determination  of the
blood being made into the veffels of the lungs, which,  by
renewing  the hemorrhagy,  may have dangerous  confe-
quences.  In every inftance therefore of hemoptyfis, the
effufion is to be moderated by the feveral means mention-
ed (791, to 794.)
   846.] Thefe meafures are efpecially neceffary when the
hemoptyfis arifes  in confequence of a prediipolition; and
in ail cafes where there is the appearance of a large effufi-
on, or where the hemorrhagy frequently returns, the effu-
fion is not only to  be moderated,  but to be entirely flop-
ped, and the returns of it prevented by every means in our
power.   See (796.) and following.*
   847.] To flop  an hemoptyfis, or prevent the returns of
it, two medicines have been frequently employed ;  neither
of which I can approve of.   Thefe are, chalybeates, and
the Peruvian bark.   As both of them contribute  to in-
creafe the phlogiftic diathefis of the fyftem, they can hardly
be fafe in any cafe of aaive hemorrhagy,  and I have fre-
quently found them hurtful.
    848.]  As the hemoptyfis which happens in confequence
of predifpofition, is always attended with a phlogiftic dia-
   * The tincture of rofes  has been frequently employed with fuccefs in thefe
cafes :  alum, however, is the principal aftringent.  It may be given, either
 by itfelf in finall and often repeated dofes, or combined with terra Japonic*.
 The following formula is very convenient:
           ft. Alumin.
              Terr. Japonic, a a 3l«
              Conserv.  Rosar. §i.
              M. f. Elcft. cum. syr. commun. q. s.
 The dofe ought to be proportioned  to the exigency of  the  cafe :  in general,
 the above prefcribed mafs maybe divided into ten equal parts ; one of which
 may be given every two hours,  or in urgent cafes, every hour.  In ufing this
 medicine, it will be neceffary. to keep the belly  open;  but  for this purpffe
 purgatives are ill adapted,  as they carry off with them the medicine that is
 employed : glyllers are therefore preferable, and in order that they be the
 more effectual, they ought to be fomewhat of a ftimulating nature  : as,
           ft. Infus.  Senna: 5vi.
              Sal. Cathartic. Amar. §i.
              Decoct. Hordei. §viii.
              M.
Or,
R. Pulp. Tamarind. §ii.
   Crem. Tart. §.;s.
   Coque in Aq. font. q. s, ad. colaturx §xii.
   Adde Mann. §ii,
   M. 
                     OF  PHYSIC.                 393,

thefis: and,  as the bad confequences ofthe difeafe are ef-
pecially  to be apprehended from^ke-otetinuance of that
diatheiis; fo this is tobe induftrioufly taken off by blood-
letting,  in greater  or finaller quantity,  and more or lefs
frequently repeated, according  as  the fymptoms fliall di-
rect.  At the fame time, cooling purgatives are to be em-
ployed,  and every-part of the antiphlogiftic regimen is  to
be ftrictly enjoined.  The refrigerants may alfo be admi-
niftered;  taking care,  however, that the acids,  and  more
efpecially the nitre,*  do not excite coughing.
    849.] From what was obferved in (794.) it will appear
that bliftering  upon the breaft or  back may be a remedy
of hemoptyfis, when  it  is prefent;  and that iffues in the
fame places may be ufeful in preventing the recurrence  of
it when it has ceafed.
    85°-] The avoiding of motion is generally a proper part
of the antiphlogiftic regimen ;  and in the hemoptyfis, no-
thing isjnore neceffary than avoiding bodily exercife  : But
fome kinds of geftation, as failing,f and travelling in an eafy
carriage on fmooth roads, have often proved a remedy.
    851.] Such is the treatment  I can  propofe for  the he- '
moptyfis, confidered merely as an hemorrhagy : But when,
in fpite of all our precautions, it continues to recur, it is of-
ten followed by an ulceration of the lungs, and a  phthyfis
pulmonalis.   This, therefore, I muft now proceed to con-
fider ; but, as it arifes alfo from other caufes  befides the
hemoptyfis, it muft be treated of with a more general view. J
  * Nitre ought to be cautioully ufed in all complaints of the lungs, on  ac-
count of the irritation which it produces,  and the fubfequent cough which it
exekes.
  t A fea-voyage has often been prefcribed for hemoptyfis: it is, ncverthe-
lefs, a very dangerous practice, on account of the  violent agitation produced
by the fea-licknefs in the ailion of vomiting.  The violence of the Teachings
iufea-ficknel'.i, efpecially after the  contents of the ftomach  are thoroughly
evacuated, has be en known to caufe hemoptyfis, by a  rupture of fome confi-
derable veflel.—The hemorrhagy indeed, hence proceeding,  is not an a<ftive
hemorrhagy; but, neverthelefs, in a phlogiftic diathefis,  which predifpofes
to an aflive hemorrhagy, we ought always to be cautious how we employ  re-
medies, which, although they do not immediately increafe the predifpofing
diathefis, produce the leaft irritation, or give any violent ihuck in iheir action.
  Speaking loud, finging, playing  on wind-inftruments, and  whatever  re-
quires any exertion of the lungs ought carefully to be avoided.
  $ In the cure ofthe hemoptyfis, the patient's drink ought to be ofthe aci-
dulous kind, or ofthe acidulous and aftringent kinds conjoined.  The vitrio-
lic acid is therefore the moft eligible, but'it ought to be well diluted. A plea-
faut drink may be compofed of one part of the tinaure of rofes, and  four of
cold water; or the tinfture of  roles mav- be prefcribed with five times the
quantity of water that is ordered in  the pharmacopoeia.   The acid of tartat- 
294                 PRACTICE           .^
                      CHAP. IV.

£>f m 1H>UWi$ Pulmonale,  or Consumption
                    of  tbe lungs*
                        Sect. I.
 Ofthe Phenomena and Cause of the Phthisis Pulmonalis.

852.]  JL  HE  Phthifis Pulmonalis I would define to be,
an expeaoration of pus or purulent matter from the lungs,
attended with a fever.
   As this is the principal fpecies  of  phthifis,  I  fhall fre-
quently in this chapter employ the general term of phthifis,
though ftrictly meaning the phthifis pulmonalis.
   853.] I have met with fome inftances of an expeaorati-
on of purulent matter, continuing for many years, accom-
panied with very few fymptoms of he6tic, and at leaft with-
out any heaic exquifitely formed : But, in none of thefe
inftances, were the perfons fo entirely free from fymptoms
of hectic, as to form any exception to the general definiti-
on.
   854.] In every inftance of an expeaoration of  pus,  I
prefume there is an ulceration of the lungs.   The late Mr.
Haen is the only author that I know of, who has advanced
another opinion, and has fuppofed, that pus may be form-
ed  in the blood-veffels,  and be from thence poured into
the bronchiae.   Admitting  his faa,  I have  attempted an
explanation ofthe appearance of pus without ulceration in
(349.) but, after all,  I  cannot help fufpeaing the accura-
cy of his obfervations; muft entirely reject his explanation
of  them;  muft however allow,  that  we  ftill want faas to
dill .lived in twenty times it's weight of water, and fweetened with a little
fyrup of rofes, is alio a fuitable drink.  A deco&ion either of  the frelh fruit
of quinces, fweetened with fugar,  or an  infufion of quince marmalade, is
another e*cellent acid aftringent.  In addition to what has been faid, it may
be proper to  obferve, that cpium is admiffible only in very few cafes of he-
moptyfis; viz. when the hemoptyfis is the cenfequence of coughing. Thefe
cafes are very difficultly diftinguifhed.  If the blood  be thrown out into the
lungs, a cough is excited for its difcharge, and then the hemoptyfis is the
primary difeafe ; in this cafe opium does more harm than good.—But if a
cough.arifing from any other irritating caufe, than extravafated blood in the
lungs fliould by its violence and long continuance, produce an hemoptyfis,
then opium, joined with fuch remedies as are fuitable to remove the peculiar
irritation, is the onlv medicine  on which we can have any reliance ; and in
thefe cafes we muftuie it in largedqfes, fuch as forty or fifty drops of laudanum. 
O b  t ft Y S I C.
295
fupport the explanation I have offered; and doubt much
if it will apply to any cafe of phthifis.   For thefe realbns I
ftill conclude,  agreeably  to the faith of all other diffeai-
ons, and the opinions of all phyficians,  that the fymptoms
mentioned in our definition depend always upon an ulcera-
tion formed in the lungs.
   855.] It  has  fometimes happened,  that a catarrh was
attended with  an expectoration of a matter fo much refem-
bling pus, that phyficians have been often uncertain  whe-
ther the difeafe was mucus or pus, and therefore whether
the difeafe was a catarrh or a phthifis.  It is often of con-
fequence to  determine thefe queftions;  and it appears to
me that it may be generally done, with fufficient certainty,
from the following confederations,  of which each particu-
lar is not  always fingly decifive, but when they are taken
together can hardly deceive us.
   1.  From  the colour pFtheorffter; as mucus is natural-
ly tranfparent, ancj^pus alwifr^sopaque.  When mucus be-
comes opaque,  as it fometimes does,  it becomes white,
yellow, or gre>nifh;  but the laft mentioned colour is hard-
ly ever fo remarkable in mucus as  in pus.
   2.  From  the confidence;  as mucus is more vifcid and
coherent, and  py»s lefs fo, and may be more friable. When
mucus is thrown into water, it is  not readily diffufed, but
remains united in uniform and circular maffes : but pus,
in  the fame circumftances,  though not readily diffufed,
does not remain fo uniformly united, and by  a little agita-
tion is broken  into ragged fragments.
   3.  From the odour; which is feldom perceived in mu-
cus, but frequently in pus.  It has been propofed to try
the odour of the matter expectorated, by throwing it upon
live coals; but in fuch a trial both mucus and pus give out
a difagrecable fmell,  and it is»not eafy to diftinguifh be-
tween them.
   4.  From  the fpecific gravity compared with water; and
indeed, it is ufual for the mucus ofthe lungs to fwim on
the furface of water,  and for ufus to fink in it. But in this
we may fometimes be deceives; as pus which has entangled
a great deal of air may fwim, and mucus that is free from
air may fink.
   5.  From the mixture which is difcernable in the matter
brought up;  for if a yellow or gujeftifh matter appears fur- 
«S                PRACTICE "

rounded with a quantity of tranfparent or lefs opaque and
lefs  coloured matter,  the more ftrongly coloured matter
may be generally confidered  as pus; as it is not  eafy to
undcrftand how one portion ofthe mucus of the lungs can
be very confiderably changed, while the reft of it  is very
little fo, or remains in its ordinary ftate.
   6.  From the admixture of certain  fubftances with the
matter thrown out from the lungs.   To this purpofe we
are informed by the experiments ofthe late Mr.  Charles
Darwin: a. That the  vitriolic acid diflolves both mucus
and pus, but moft readily  the former:  That, if water be
added'Jo fuch a folution of mucus, this is feparated, and
either fwims on the furface, or,  divided  into flocculi, is
fufpended in the liquor; whereas, when water is  added to
a like folution of pus, this falls to the bottom, or by agita-
tion is diffufed fo as to exhibit a uniformly turpid liquor.
b. That a folution ofthe qiuftic fixed  alkali, after feme
time, diflolves mucus, and generally pus; and, if water be
added to fuch  folutions, the  pus is precipitated,  but the
mucus is not.   From fuch experiments it is.fuppofed, that
pus and mucus may be certainly diftinguifhed from each
other.
   7.  From the expeaoration's being attended with a hec-
tic fever.   A catarrh,  or expeaoration of mucus,  is often
attended with fever: but never, fo far as I have obferved,
with fuch a fever as I  am prefently to defcribe as a heaic.
This, in my opinion, is  the moft certain mark of a puru-
lent  ftate  in fome part of the body;   and if others have
thought differently, I am perfuaded that it has been owing
to this, that, prefuming  upon the mortal nature  of a con-
firmed or purulent phthifis,  they have confidered every
cafe in which a recovery happened, as a  catarrh onlv: but,
that  they may  have been miftaken in this, fhall be fhown
hereafter.
   856.] Having thus  confidered the firft part of the cha-
raaer of the phthifis pulmonalis as a mark of an ulcerati-
on ofthe  lungs ;  and  having juft now faid,  that the other
part of the character,  that is, the heaic fever, is  a mark
or indication ofthe fame thing; it is proper now to confi-
der this here,  as I had with  that view omitted  it before
(74.)
   857.] A heaic fever has the form of a remittent, which 
                    OF  PHYSIC.                S9f
                         —i—■-=           •       -hA
  has exacerbations twice every day.   The firft of thefe oc-
  curs about noon, fometimes a little fooner or later; and a
  flight rcmiffion of it happens about five afternoon.  '"*This
  laft is foon fucceeded by another exacerbation,  gradually
  increafing till after midnight:  But after two o'clock of the
  morning, a remiffion takes place, which  becomes more
  and  more confiderable  as the morning advances.   The
  exacerbations are frequently attended with  fome degree of
  cold fhivering; or at leaft,  the patient is exceedingly fen-
  fiblc to any coolnefs of the air, feeks external  heat,  and
  often complains of a fenfe of cold, when,  to the thermo-
  meter, his fkin is preternaturally warm.  Of thefe exacer-
  bations, that ofthe evening is always the moft confiderable.
    858. j It has commonly been given as a part ofthe chai
  raaer of a heaic fever, that  an exacerbation  of it com-
  monly appears after the taking food; and it  is true  that
  dinner,  which is  taken at noon or after it, does feem to
  occafion fome exacerbation,   But this muft not make us
 judge the mid-day  exacerbation to be the effea  of eating
  only; for I have often obferved it to  come on an hour be-
  fore noon, and often fome hours before dinner;  which, in
 this country at prefent, is not taken till fome  time  after-
 noon.   It is indeed to  be obferved,  that in almoft every
 perfon,  the taking food occafions fome degree of fever:
 but I am perfuaded this would not appear fo confiderable
 in a heaic, were it not that an exacerbation of fever is
 prefent from another caufe; and accordingly,  the taking
 food in the morning has hardly any fenfible effea.
   859. ]  I have thus defcribed the general form of heaic
 fever; but many circumftances attending it, are further to
 be taken notice of.
   The  fever I have defcribed does not commonly fubfift
 long, till the evening exacerbations become attended with
 fweatings; which continue to  recur, and to prove more
 and more profufe, through the whole courfe ofthe difeafe.
  Almoft from the firft appearance of theheaic, the urine
is high-coloured, and  depofites a copious branny red fe-
diment, which hardly ever falls clofe to the bottom of the
 veffel.
  In the heftic, the appetite for food is generally  lefs im-
paired than in any other kind of fever.
  Y<.u  I.                 pf 
23*
PRACTICE
   The^Jjirftis  feldom confiderable; the mouth is  com-
monly mdift; and as the difeafe advances,  the tongue be-
comes free from fur, appears very clean; and in the ad-
vanced flages of the difeafe,  the tongue and fauces appear
to be fomewhat inflamed, and become more or lefs cover-
ed with aphthae.
   As the difeafe advances,  the red vfeffels  of the adnata
of the eye difappear, and the whole of the adnata becomes
of a pearly white.
   The face is commonly pale; but, during the exacerba-
tions, a florid red, and  an almoft circumfcribed fpot, ap-
pear on each  cheek.
   For fome  time, in the courfe of a heaic, the belly is
bound; but,  in the advanced ftages of it,  a  diarrhoea al-
moft always comes on, and continues to recur frequently
during the reft of the difeafe, alternating in fome meafurq
with the fweatings mentioned above.
   The difeafe is  always attended with a debility, which
gradually increafes during the courfe of it.
   During the fame courfe an emaciation takes place, and
goes to a greater degree than in almoft any other cafe.
   The falling off of the hairs, and the adunque form of
the nails,  are alfo fymptoms of the want of nourifhment.
   Towards the end of the difeafe, the feet are often affea-
ed with cedematous fwellings.
   The exacerbations of  the fever are feldom attended with
any headach,  and fcarcely ever with delirium.
   The fenfes and judgment commonly  remain entire to
the very  end  of the difeafe; and the mind, for the  moll
part, is confident and full of hope.
   Some days before death, a delirium comes on, and conw
monly continues to the end.
   860.]  The heaic fever  now  defcribed (857, 858.) as
accompanying a purulent ftate of the lungs,  is  perhaps the
cafe in which it moft frequently appears:  but I have never
feen it in any cafe, when there was not evidently, or  when
I had not ground to fuppofe, there was a permanent puru-
lency or ulceration in fome external or internal part.  It
was for this  reafon that in (74.) I concluded it to  be a
fymptomatic  fever only.  Indeed, it appears to me to be
always the effeft of an acrimony abforbed from abfeeffes
or tilcersj althoughitis not equally the effeft of every fort 
OF  PHYSIC.               29*
 of acrimony;, for the fcofbutic and cancerous kinds often
 fubfift long in the body without producing a heaic.  What
 is theprecife ftate of the acrimony producing this I cannot
 determine, but it feGms to be chiefly that of a vitiated puru-
 lency.
    861.]  However this may be, it appears, that the heaic's
 depending in general upon an acrimony, explains ks pecu-
 liar circumftances.   The febrile ftate  feems  to be chiefly
 an exacerbation of that frequency ofthe pulfe, which oc-
 curs twice every  day to perfons in health, and may be pro-
 duced by acrimony alone.   Thefe exacerbations, indeed,
 do not happen without  the proper circumftances of py-
 rexia ; but the fpafm ofthe extreme veffels in a heaic does
 not feem to be fo  confiderable  as in  other fevers: and
 hence the ftate of fweat and urine which  appears fo early
 and fo conftantly in heaics.  Upon the fame fuppofition
 of an acrimony corrupting the fluids, and debilitating the
 moving powers,  I  think  that moft of the other fymptoms
 may alfo be explained.
   86-2.]  Having thus confidered the charaaeriftical fymp-
 toms and chkf part of the proximate caufe of the phthifis
 pulmonalis, I  proceed to obferve, that  an ulcer of the
 lungs, and ks concomitant circumftance  of heaic fever,
 may arife from different previous affeaions ofthe lungs:
 all of which however may,  in my opinion, be referred to
 five heads; that is,  1. To an hemoptyfis; 2. To a fuppu-
 ration of the lungs  in confequence of pneumonia; 3. To
 catarrh; 4. Toafthma; or,  5. To a tubercle.  Thefe fe-
 veral affections,  as  caufes of ulcers, fhall now be confi-
 dered in the order mentioned.
   863.] It has been commonly fuppofed, that an hemop-
 tyfis was naturally,  and almoft neceffarily, followed by an
 ulcer ofthe lungs:.  but I will prefume to fay, that, in ge-
 neral, this is a miftake; for there have been many inftan-
 ces of hemoptyfis occafioned by external violence* without
 being followed by any ulcer of the lungs;  and there have
 alfo been many inftances of  hemoptyfis  from an internal
 caufe, without any  confequem ulceration.  And this too
 has been the cafe, not only when the hemoptyfis happen-
ed to young perfons, and recurred for feveral times,  but
wheri it has often recurred during the courfe of a long life.
It is indeed eafy to conceive, that a rupture of the veffel* 
30c                PRACTICE

of the lungs like that of  the veffels  of the nofe, may be
often healed,  as  the furgeons fpeak,  by the firft intention.
It is probable therefore, that it is an  hemoptyfis in parti-
cular circumftances only,  which is neceffarily followed by
an ulcer; but what thefe circumftances are, it is difficult to
determine.   It is poffible, that merely the degree of rup-
ture, or frequently repeated rupture preventing the wound
from healing by the firft intention, may occafion an ulcer;-
or it is poffible that red blood effufed,  and not brought up
entirely by coughing, may, by ftagnating in the bronchiae,
become acrid, and  erode the parts.   Thefe however are
but fuppofitions,  not fupported by any clear  evidence.
And, if we confider that thofe cafes of hemoptyfis which
follow the predifpofition  (831.—834.) are thofe efpecially
which end in phthifis, we fhall be led to lufpea  that there
are fome other circumftances which concur  here to deter-
mine the confequence of hemoptyfis,  as I fhall hereafter
endeavour to fliow.
   864.] Any fuppofition,however,which we canmakewith
 refpc6t to the innocence of an hemoptyfis, muft not fuper-
fede the meafures propofed aboye for its cure ; both be-
caufe we cannot certainly forefee what may be the confe-
quence of fuch an accident, and becaufe the meafures above
fuggeftedare fafe ;  for, upon every fuppofition, it is a di-
athefis phlogiftica that may urge on every bad confequence
to be  apprehended.
   865.] The fecond caufe of an ulceration ofthe lungs, to
be confidered, is a fuppuration formed in confequence of
pneumonia.
   866.] From the fymptoms mentioned  in  ("857.—85S.)
 it may with reafon be concluded, that an abfcefs, or, as it
is called, a vomica, is formed in fome part ofthe pleura, and
moft  frequently in that portion of  it invefting the lungs.
Here purulent matter frequently remains for  fome time,
 as if enclofed in a cyft:  but commonly it is not long be-
fore it comes to be either abforbed, and  transferred to
 fome  other part of the body; or that it breaks through in-.
 to the cavity of the lungs, or into that of the thorax.  In
 the latter  cafe, it produces the  difeafe called empyema ;
 but It is only when the matter is poured into the cavity of
 the bronchiae, that it properly  conftitutes the phthifi.s pul-
 monalis.  Jn the cafe of empyema, the chief circumftances 
                 *0F PHYSIC.               301

of the'phthifis are alfo prefer.r; but I fhall here confider
that cafe only in which the abfcefs of the lungs gives occa-
fion to a purulent expeaoration.
   867.] An abfcefs of the lungs, in confequence of pneu-
monia,  is not always followed by a phthifis: for fome-
times a hectic fever is not formed; the matter poured into
the bronchia i> a proper and benign  pus, which is fre-
quently coughed up very readily, and fpitout: and, though
this purulent expeaoration fhould continue for fome time,
yet if a  heaic does  not  come on, the ulcer foon heals,
and every morbid fymptom difappears. This  has happen-
ed to frequently,  that we may conclude,  that neither the
accefs of the air, nor the  conftant motion of the lungs,
will  prevent an ulcer of thefe parts from  healing, if the
matter of it be well-conditioned.   An abfcefs ofthe lungs,
therefore, does not neceffarily produce the phthifis pul-
monalis;  and if it be followed by fuch a difeafe, it muft
be in confequence of  particular circumftances which cor-
rupt the purulent matter produced, render it unfuitable to
the healing of the ulcer, and at the fame time make it af-
ford  an acrimony,  which, being abforbed,  produces  a
heaic and its confequences.
   868.]  The corruption of the matter of fuch abfeeffes
may  be owing to feveral caufes,  as, 1.  That the matter
effufed during the inflammation,  had not been a pure fe-
rum fit to be converted into a  laudable pus, but had been
united with other matters which prevented that,  and gave
a  confiderable acrimony to the whole:  Or,  2. That the
matter effufed, and converted into pus,  either merely by
a  long  ftagnation in a vomica, or by its  conneaion with
an empyema, had been fo corrupted, as  to'become unfit
for the purpofe of pus in the healing of the ulcer.  Thefe
feem to be poffible caufes of the corruption  of matter in
abfeeffes, fo as to make it the occafion of phthifis in per-
fons otherwife found;  but it is probable, that a pneumonic
abfcefs does efpecially produce phthifis when it happens to
perfons previoufly difpofed to that difeafe, and therefore
only  as it concurs with fome other caufes of it.
   869.]  The third caufe fuppofed to produce phthifis,  is
a  catarrh; which in many cafes feems in length of time to
have the expectoration  of mucus proper to it,  gradually
changed into an expedoration of pus; and at the fame time, 
302                PRACTICE
 by the addition of a heaic fever, the difeafe, which was
 at firft a pure catarrh, is converted into a phthifis.  Thitf
 fuppofition, however, is not eafily to be admitted.   The
 catarrh is properly an affeaion of the mucus  glands  of
 the trachea and bronchize, analogous to the coryza, and lefe
 violent kinds of cynanche toniillaris, which  very feldom
 terminate in fuppuration.   And although a catarrh fhould
 be difpofed to  fuch  termination, yet the ulcer produced
 might readily heal up, as it does in the cafe of a cynanche
 tonfillaris ;  and therefore fhould not produce a phthifis.
    870]  Further,  the catarrh, as purely the effea of cold,
 is generally a mild difeafe,  as well  as of fhort  duration;
 and ofthe numerous inftances of it,  there are at moft but
 very few cafes which  can be faid to have ended in phthifis.
 In all thofe cafes in which this feems to have happened, it
 is to me probable, that the perfons affeaed were pe'cufc
 arly predifpofed to phthifis.  And the beginning of phthifis
 fo often refembles a catarrh, that the  former  may  have
 been miftaken for the latter.  Befides,  to increafe the fal-
 lacy, it often happens that the application of cold, which
 is the  moft frequent caufe of catarrh, is alfo  frequently
 the exciting caufe of  the cough which proves the begin*
 ning of phthifis.
   871.] It is  tome, therefore, probable, that a catarrh
 is very feldom the foundation of phthifis; but I would not
 pofitively affiert that it never is  fo; for it is  poffible that
 the cafes of a more violent  catarrh may have joined with
 them a pneumonic 1ffeaion,  which may end in a fuppura-
 tion; or it may happen that a long continued catarrh, by
 the violent agitation ofthe lungs  in coughing will produce
 fome of thofe tubercles which are prefently to  be menti-
 oned as the  moft frequent caufe of phthifis.
   872.] It  muft be particularly obferved here, that no-
 thing faid in (871.) fhould allow us to negfea any appear-
 ance of catarrh, as is too frequently done; for it may be
either the beginning of a phthifis, which is miftaken for a
genuine catarrh, or that even as a catarrh continuing long*
it may prdduee a phthifis, as in (871.)
   873.] Many phyficians have  fuppofed an acrimony of
the fluids eroding fome ofthe veffels of the lungs, to be a
frequent caufe  of  ulceration and phthifis.  But this ap-
pears to me to be a mere fuppofition: for in any of the in- 
OF  PHYSIC.                303
 Hances ofthe produ&ion of phthifis which I  have feen,
 there was no evidence of any acrimony of the blood capa-
 ble of eroding the veffels.  It is true, indeed,  that in ma-
 ny cafes an acrimony fubfifting in fome part of the fluids,
 is the caufe of the difeafe; but it is at the fame time pro-
 bable,  that this acrimony operates by producing tubercles,
 rather than by any direct erofion.
    874.]  It has been mentioned in  (862.) that an afthma
 may be confidered  as one ofthe caufes of phthifis; and
 by  afthma I mean, that fpecies of it which has been
 commonly named the Spafmodic.   This difeafe frequent-
 ly fubfifts very long without producing any other, and may
 have its own peculiar fatal termination, as fhall  be explain-
 ed hereafter.  But I have feen it frequently end in phthi-
 fis; and in fuch cafes I  fuppofe it to operate in the man-
 ner above alledged of catarrh,  that  is, by producing tu-
 bercles, and their confequences, which fliall be prefently
 mentioned.
   875.]  I  come  now  to confider  the fifth head of the
 caufe of phthifis,  and which I apprehend to be the moft
 frequent of any.   This I have faid,  in general, to  be tu-
 bercles; by which terms arc meant, certain fmall tumours,
 which have the appearance of indurated glands.   Diffec-
 tions have frequently fhown fuch tubercles formed in the
 lungs;  and although at firft indolent, yet  at length they
 become inflamed,  and are thereby changed into little ab-
 feeffes, or vomica?, which breaking, and pouring  their
 matter  into the bronchia?, give a purulent expeaoration,
and thus lay the foundation of phthifis.
   876.] Though the matter expeaorated upon thefe oc-
cafions  has the appearance of pus, it is feldom that of a
 laudable kind; and,  as the ulcers do not readily heal, but
are attended with a heaic fever, for the moft part  ending
fatally,  I prefume that the matter of the ulcers  is imbued
with a  peculiarly  obnoxious acrimony, which prevents
their healing, and  produces a phthifis in aH its circum-
ftances, as mentioned above.
   877.] It is very probable that the  acrimony which thus
difeovers itfelf in the ulcers, exifted before, and produced
the tubercles themfelvcs; and it is to this acrimony that
we muft trace up the caufe of the phthifis following thefe
tubercles.   This acrimony is probably,  in different cafe»> 
3? 4
PRACTICE
 of different kinds; and it will not be eafy to determine its
 varieties: but to a certain length I fhall attempt it.
   878.] In one cafe, and that,  too, a very frequent one,
 of phthifis, it appears, that the noxious acrimony is of the
 feme kind with that which prevails in the fcrophula. This
 may be concluded from obferving,  that a phthifis, at its
 ufual periods, frequently attacks perfons born of feropbu-
 lous parents; that is, of parents who had been affeaed with
 fcorphula in their younger years: that very often, when the
 phthifis appears, there occur at the  fame time  fome lym-
 phatic tumours in the internal parts; and very often I have
 found the tabes mefenterica, which is a ferophulous affec-
 tion,  joined with the phthifis pulmonalis.   To all this I
 would add, that,  even when no ferophulous affeaion has
 either manifeftly preceded or accompanied a phthifis, this
 laft however moft commonly affeas  perfons of a  habit re-
 fembling the  ferophulous;  that is, perfons of a fanguine,
 or of a fanguineo-melancholic temperament, who have very
 fine fkins, rofy complexions, large veins,  foft flefh, and
 thick upper lip: and further, that in fuch perfons the phthi-
 fis comes on in the  fame manner  that it does  in perfons
 having tubercles, as  fliall be immediately explained.
   879.]  Another fpecies of acrimony producing tubercles
 of the lungs, and thereby phthifis, may be faid to be the
 exanthematic.   Il is  well known, that the fmall-pox fome-
 times, and more frequently  meafies,  lay the foundation of
 phthifis. It is probable alfo, that other exanthemata have the
 fame  effea; and from the phenomena of the difeafe, and
 the diffeaions of perfons who have died of it, it is pro-
 bable, that all the exanthemata may occafion  a  phthifis,
 by affording  a matter which in the  firft place produces
 tubercles.
   880.]  Another acrimony, which  feems fometimes  to
 produce  phthifis,  is the  fiphyiitic;  but whether fuch an
acrimony produces phthifis  in any other perfons than the ,,
previoufly difpofed, does not appear to me certain.
   881 ]  What other fpecies of acrimony, fuch as from *
 fcurvy, from pus abforbed  from other parts ofthe body,
from  fuppreffed eruptions, or from other fources,  may
alfo produce tubercles and phthifis,  I cannot now decide,
 but muft leave  to be determined by  thofe who have had
experience of fuch cafes. 
0FPHYS1C.
3C5
    882.] There is one peculiar cafe of phthifis, which from
  my own experience I can take notice of.  This is the cafe
  of phthifis from a calcareous matter formed  in the lungs,
  and couched up, frequently with a little blood, fometimes
  with mucus only, and  fometimes  with pus. . How this
  matter is generated,  or in what precife part of the  lungs it
  is feated, I acknowledge myfelf ignorant.  In three cafes
  of this kind which have  occurred to me, there' was at the
  fame time no appearance of ftony or earthy concretions iri
  any other part of; he body.  In one of thefe cafes, an cxqui-
  fittly formed phthfis came on, and proved mortal: While
  in the other two, the fymptoms of phthifis were never fully
  formed^ andafter fome time, merely by a milk diet and
  avoiding irritation,  the  patients entirely recovered.
    883] Another foundation for phthifis, analogous, as I
  judge, to that of tubercles,  is that which occurs to certain
  artificers whofe employment keep them almoft  conftantly
  expofed to dull; fuch as ftone-cutters, millers, flax-dreffers,
  and fome others.   I have not obferved in this country ma-
  ny inftances of phthifis which could be referred to^this
\ caufe;  but, from Ramazzini, Morgagni, and  fome
  other writers, we muft conclude fuch cafes to be more fre-
  quent in the fouthern parts of Europe.
    884.] Befides thefe now mentioned, there are probably
  fome other caufes producing tubercles, which have not yet
  been afcertained by obfervations; and it is likely, that in
  the ftate of tubercles there is a variety not yet accounted for;
  but all this muft be left to future obfervation and inquiry.
    885.J It has been frequently fuppofed by phyficians,
  that the phthifis is a contagious difeafe;  and I dare not af-
  fert that it  never is fuch: but in many  hundred inftances
 of the difeafe which I have feen, there has been hardly one
  which to me could appear to have arifen from contagion.
  It is poffible, that in warmer climates the effeas of conta-
 gion may be more difeernible.
    After having faid that a phthifis arifes from tubercles
 more frequently than from any other caufe, and after hav-
 ing attempted to affign the variety of thefe, I now  proceed
 to mention the'peculiar circumftances and fymptoms which
 ufually accompany the coming on of the difeafe from tu-,
 bcrcles.
   Vol. I,                 Q <^ 
 3Q6                 PRACTICE

   886.]  A tuberculous and  purulent ftate. of tne mng'
 has  been obferved  in very young children, and in fome
 others at feveral different periods before the age of puber-
 ty and full growth; but inftances of this kind  are rare:
 and the attack of phthifis, which we have reafon to impute
to tubercles, ufually happens at the fame period which I
 have afiigned for the coming on of the hemoptyfis.
   887.] The phthifis from tubercles does alfo generally
 affea the fame habits as the hemoptyfis, that is, perfons of
 a flender make, long necks, narrow chefts, and prominent
 fhoulders; but very frequently the perfons liable to tuber-
 cles have lefs of a florid countenance, and of the other
 marks of an exquifitely fanguinc temperament,  than  the
 perfons liable  to hemoptyfis.                        ,n
   888.] This difeafe,  arifing from  the tubercles, ufualjy
 commences with a flight and fhort cough, which, becoiaes
 habitual, is often little remarked by  thofe affeaed, and
 fometimes fo  little  as  to  be  abfolutely denied by them.
 At the fame time their breathing becomes eafily hurried by
 any bodily motion, their body grows leaner, and they be-
 come  languid and indolent.   This ftate fometimes con-
 tinues for a year, or even for  two years,  without the per-
 fons  making any complaint of it, excepting only that they
 are affeaed by cold more readily than ufual, which fre-
 quently increafes their cough, and produces fome catarrh.
 This, again, however, is fometimes relieved;  is fuppofed
 to have arifen  from cold alone; and therefore gives no
alarm either to the patient or to his friends, nor leads them
 to take any'precautions.
  889.] Upon one or other of thefe occafions of catching
cold, as we commonly fpeak, the cough becomes more con-
fiderable; is particularly troublefome upon the patient's
Jying down at night,  and in this ftate continues longer than
is ufual in the cafe of a fimple catarrh.  This is more efpe-
cially to call for attention, if the increafe and continuance^
of cough come on during the fummer feafon.
  890.J The cough which comes on as in (888.) is very^
often for a long time without any expeaoration,; but when,
from repeatedly catching cold, it becomes fiibre  conftant,
it is then at the fame time attended with fome expectora-
tion, which is  moft  confiderable in  the mornings.  The
matter of this expeaoration becomes by degrees more co- 
OF  PHYSlt                507
  pious, more vifcid, and more opaque;  at length of a yel-
  low or greenifh colour, and of a purulent appearance.
  The whole ofthe  fitter, however, is not  always at once
  entirely changed in this manner; but, while one part of it
  retains the ufual form of mucus, another  fuffers the changes
  now defcribed.
    891.]  When the cough increafes,  and continues  very
  frequent through the night, and when the matter expeao-
  ratcd undergoes the changes I have mentioned, ihe breath:
  ing  at the fame time becomes more difficult, and the ema-
  ciation and weaknefs go on alfo increafing.   In the female
  fex, as the difeafe advances, and fometimes  early  in  its
  progrefs,  the menfes ceafes to flow; and this circumftance
  is to be confidered as commonly the effea, although the fex
  themfelves are ready to believe it the fole caufe  of the dif-
  eafe.
    892.] When the cough comes on as in (888.) the pulfe
  is often natural, and for fome  time after continues to be
  fo;  but the fymptoms  have feldom fubfifted long before
  the pulfe becomes frequent, .and fometimes to a considera-
  ble degree, without much ofthe other fymptoms of fever.
  At length, however,  evening  exacerbations become re-
  markable; and by  degrees the fever affumes the exquisite
  form of heaic, as'defcribed in (847—859.)
    893.]  It is feldom that the cough, expeaoration, and
 fever,  go  on increasing,  in the manner now defcribed,
 without fome pain being  felt in fome part  of the thorax.
 It is  ufually and moft frequently felt at firft under the fter-
 num, and that efpecially, or almoft only, upon occasion
 of coughing; but very  oaen, and that too, early  in the
 courfe ofthe difeafe, a pain is felt on one side, fometimes
 very  conftantly, and fo as to prevent the>crfon from lying
 easily upon that side:  but at other  times the pain is'felt
 only upon a full infpiration, or upon coughing.   Even
 when no pain is felt, it generally happens that phthisical
 perfons cannot lie easily on ft^ne one of their fides, with-
 out having^their difficulty of breathing increafed, and  their
 cough excited.
   894.] The phthisis begins, and fometimes proceeds to
 its fatal iffuc, in  the manner defcribed from (888, to 894.)
 without any appearance of hemoptyfis.   Such  cafe> are
indeed rare; bur it is very common for the  difeafe to ad. 
*<>«                PRACTICE
vance far, and even to an evident purulcncy aad heaic ftate,
without any appearance of blood in the fpitting : fo that it
may be affirmed, the difeafe is frequency not founded in he-
moptysis.  At the fame time, we muff allow, not only that
it fometimes begins with an hemoptysis, as it is faid in (863.)
but further, that it feldom happens that in the progrefs of
the difeafe more or lefs of an hemoptysis does not appear.
Some degree of blood-fpitting does, indeed, appear fome-
times in  the ftate mentioned (888.  892.) but more com-
monly in the more advanced ftages of the difeafe only, and
particularly upon the firft appearance of purulency.  How-
ever this may be,  it is feldom, in the phthisis from tuber-
cles, that the hemoptysis is considerable, or requires any re-
medies different from  thofe which are otherwife neceffary
for the ftate of the tubercles.
   895.] I  have now defcribed a fucceflion of fymptoms
which, in  different cafes, occupy more or lefs time.   In
this climate they'very often take up fome year*, the fymp-  ;
toms appearing efpecially in the winter and fpring, com-
monly becoming  eafier, and  fometimes almoft difappear-
ing, during the fummer: but returning  again in winter,
they at length  after  two or three years, prove fatal,  to-% '
waids the end of fpring or the beginning of fummer.
   896.] In this difeafe, the prognofis is for the moft part
unfavourable.  Of thofe affeaed with it, the greater num-
ber die; but there are alfo many of them  who recover en-
tirely, after having been in very unpromifing circumftan-
ces.  What are, however, the circumftances more certain-
ly determining to a happy or to a  fatal event, I have not
yet been able to afcertain.
   897.] The following aphorifms are the refult of my ob-
fervations.
   A phthifis  pulmonalis from hemoptyfis, is more fre-
quently  recovered than one from tubercles.
   An hemoptyfis not only  is  not always followed by a
phthifis, as we have faid above (863.) but even when fol- -T
lowed by an ulceration, the ulceration is fometimes attend-  .
ed with little of heaic, and frequently admits of being foon
healed.  Even when hemoptyfis and ulceration have hap-
pened to be repeated, there are inftances  of perfons reco-  •
vering entirely after feveral fuch repetitions!
   A phthifis from a fuppuration in confequence  of pneu-

__________________________________■________*lr;____________ 
OF PHY SIC                £09
monic  inflammation, is that which moft rarely occurs in
this climate;  and a phthifis does not always follow fuch
fuppuration, when the abfcefs formed foon breaks and dif-
charges a laudable pus; but, if the abfcefs continues long
lhut up, and till after a confiderable degree of heaic has
been formed,  a phthifis is then produced, equally danger-
ou . as that from other caufes.
  A phthifis from tubercles has, I think, been recovered:
but it isof all others the moft dangerous; and, when arifing
from a hereditary taint almoft certainly fatal.
  The danger of a phthifis, from whatever  caufe it may
have  arifen, is moft certainly to be judged of by the de-
gree to which the he£tic and its confcquences have arrived.
From  a certain  degree of emaciation, debility, profufe
fweatiiv,, and diarrhcea, no perfon recovers.
   A mania coming on, has been found to remove all the
fymptoms, and fometimes has entirely cured the  difeafe;
but, in other cafes, upon going off of the mania, the phthi-
fis has recurred, and proved fatal.
   The pregnancy of women has often retarded the progrefs
of a phthifis;  but commonly it is only till after delivery,
when  the fymptoms of phthifis return with violence3  and
foon prove fatal.


                      Sect. II.

                Of the Cure of Phthisis.
   898.] FROM what has been juft now faid, it will readily
appear, that the  cure ofthe phthifis  pulmonalis muft be
exceedingly difficult; and  that even the utmoft care and
attention in the  employment of remedies,  have feldom
fucceeded.  It may be doubtful whether this failure is to
be imputed to the imperfeaion of our art, or to the abfo-i
lutely incurable  nature of  the difeafe.   I  am extremely
averfe in any cafe to admit of the  latter fuppofition,  and
can always readily allow of the former; but, in the mean
time, mull mention here, what has been attempted towards
either curing or moderating the violence of the difeafe.
   899.]  It muft be obvious, that according to the differ-
ent circumftances of'this difeafe, the method of cure muft
be different.   Our firft attention  ihould  be employed in 
Sid                PRACTICE
 watching the approach of the  difeafe,  and preventing its
 proceeding to an incurable ftate.
   In all perfons of a phthifical habit,  and efpecially in
 thofe born of phthifical parents, the fiighteft  fymptoms of
 the approach of phthifis, at the phthifical period of life,
 ought to be attended to.*
   900.] When an hemoptyfis  occurs,  though it  be not
 always followed  with ulceration and phthifis, thefe how-
 ever are always to be apprehended; and every precaution
 is to be taken a.gainft them.   This is efpecially to be done
 by employing every means of moderating the hemorrhagy,
 and of preventing its return, direaed in  (891.) et seq. and
 thefe precautions ought to be continued  for feveral years
 after the occurrence ofthe hemoptyfis.
   901.] The phthifis which follows a fuppuration from
 pneumonic  inflammation, can only be prevented with cer-
 tainty,  by  obtaining a refolution  of fuch inflammation.
 What may be attempted towards the cure of an abfcefs and
 ulcer which have taken place,  I  fhall fpeak of hereafter.
   902.] I have  faid, it is doubtful if a genuine catarrh
 ever produces a phthifis;  but have allowed that it poffibly
 may: and both upon  this account,  and upon  account of
 the ambiguity which may arife, whether the appearing ca-
 tarrh  be a primary difeafe, or the effea  of  a tubercle, I
 confider it as of confequence  to cure a catarrh as foon as
*poffible after its firft appearance.   More efpecially when
 it fhall linger, and continue for fome time, or fhall, after
 fome  intermiffion, frequently return, the cure of it fhould
 be diligently attempted.   The meafures requifite for this
 purpofe fhall be mentioned afterwards, when we come to
 treat  of catarrh as  a primary difeafe; but,  in  the mean
 time,  the means neceffary for preventing its producing a
 phthifis fhall be mentioned immediately, as  they are the
 fame with thofe I fhall point out as neceffary for preventing
a phthifis from tubercles.
   903.] The preventing of a phthifis from afthma muft:
be by curing, if poffible, the afthma, or at leaftVby  mode-
rating it as much as may be done:  and as it is probable that
afthma occafions phthifis, by producing tubercles, the mea-
  * This early attention to the nrft fymptoms ofthe difeafe is ofthe mmoftcon-*
fequence, for it is only in the early ftage that any remedies can be employed
with fuccefs, as experience has fufficiently taught.  Sec Article 905. et fe^. 
OF  PHY SIC.                 3H
fures neceffary for preventing phthifis from afthma, will be
the fame  with  thofe neceffary in the  cafe  of tubercles,
which I am now about to mention.               r
   904.] I confider tubercles as by much the moft frequent
caufe of phthifis; and even in many cafes where this feems
to depend upon hemoptyfis,  catarrh,  or afthma,  it does
however truly arife from tubercles.   It is upon this fub-
jea, therefore,  that I  fhall have occafion to treat of the
meafures  moft commonly requifite for curing phthifis.
   905.]  When, in a perfon born of phthifical parents, of
a phthifical habit, at the phthifical period of life, the fympr
toins (888.) in the fpring, or the beginning of fummer,'
fhall appear in  the  fiighteft degree, we may prefume that
a tubercle, or tubercles, either have been  formed, or are
forming in the lungs; and therefore, that every means  we
can devife for preventing their formation, or for procuring
their refolution,  fliould be employed immediately, even
ahhough the patient himfelf fhould overlook or negfea
the fymptoms,  as imputing them to accidental cold.
    906.]  This is certainly the general indication; but how
it may  be executed, I cannot readily fay.    I do not know
that, at any time, phyficians have propofed any  remedy
capable of preventing  the formation ofthe tubercles, or of
rcfolving them  when formed.  The analogy of fcrophula,
gives no aflifiance in this matter.  In fcrophula the reme-
dies that are feemingly of moft power, are, fea-water, or
certain  mineral waters;  but thefe have generally proved
hurtful in the cafe of tubercles of the lungs.  I  have known
feveral  inftances of mercury very fully employed for cer-
tain difeafes, in perfons who were fuppofed  at the time to
have tubercles  formed, or forming,  in their lungs; but
though the mercury proved a cure for thofe other difeafes,
it  was  of no fervice in preventing phthifis, and in fome
cafes feemed to hurry it on.
    907.]  Such  appears to me to be the prefent ftate of our
art, with refpea to tlie cure of tubercles; but I do not def-
pair of a remedy for the  purpofe being found hereafter.
In the mean time, all that at prefent feems to be within the
reach of our art, is to take the meafures proper for avoidr
ing the inflammation  of tubercles.  It is probable that tu-
bercles may fublift long without producing any diforder;
and I am difpofed to think, that nature fometimes refolyes 
3!2                PRACTICE
and difeuffes tubercles which have been formed; and that
nature does this only when the tubercles remain in  an un-
inflamed ftate;  and therefore, that the meafures neceffary
to be taken, are chiefly thofe for avoiding  the inflamma-
tion of the tubercles.
   908] The inflammation of a tubercle ofthe lungs is to
be avoided upon the  general plan of avoiding inflamma-
tion, by blood-letting, and by an antiphlogiftic regimen;
the chief part of which, in this cafe, is the ufe of a low diet.
This fuppofes a total abftinence from animal food, and the
ufing of vegetable food  almoft alone:  but it  has  been
found, that it is not neceffary for the patient to be confin-
ed to vegetables of the weakeft nourifhment, it being fuffi-
cient  that the farinacea be employed, and  together with
thefe, milk.
   909.J Milk  has been generally confidered as the chief
remedy in the phthifis, and in the cafe of every tendency
to it; but whether from its peculiar qualities, or from  its
being of a lower  quality, with refpea to nourifhment,
than any food entirely animal,  is not certainly determined.
The choice and adminiftration of milk will be properly di-
rected,  by considering the nature ofthe milk of the feve-
ral animals from which it may be taken, and the particular
ftate of the patient with refpea to the period and circum-
ftances ofthe difeafe, and to the habits of his ftomach with
refpea to milk.
   910.] A fecond means of preventing the inflammation
ofthe tubercles ofthe lungs,  is,  by avoiding any particu-
lar irritation ofthe affeaed part, which may arife from any
violent exercife of refpiration; from any  confiderable de-
gree of bodily  exercife;  from any pofition of  the  body,
which ftraitens the capacity of the thorax; and laftly, from
cold applied to  the furface of the body, which determines
the blood in greater quantity to the internal parts, and par-
ticularly to the lungs.
   911.] From the laft-mentioned confideration,  the ap-
plication of cold in general,  and therefore  the winter-fea-
fon, in cold climates, as diminifhing the cutaneous per-
fpiration, is to be avoided; but more particularly, that ap-
plication of cold is to be fhunned that may fupprefs per-
fpiration, to the degree of occafioning  a catarrh,   which
confifts in an inflammatory determination to the lungs? and 
O F  P H Y 3 I C.                313
 may therefore m^ft certainly produce an inflammation of
 the t ubercles there.
    By confidering, that the avoiding heat is a part of the
 antiphlogiftic regimen above recommended, and by compar-
 ing  this  with what  has been juft now  laid refpeaing the
 avoiding cold, the proper choice of climates  and feafons
 for phthifical patients will be readily underftood.
    912.] A third means of avoiding the inflammation  of
 the tubercles ofthe  lungs confifts, in diminifhing the de-
 termination of the blood to the lungs, by fupporting and
 increafing the determination  to the  furface of the  body;
 which is to be chiefly and moft fafely done by warm cloth-
 ing,* and the frequent ufe of the exercifes of geftation.
    913.]  Every  mode of geftation has been found of ufe
 in the  phthifical cafes;  but  riding on horfeback,  as being
 accompanied with a  great deal  of bodily exercife, is lefs
 fafe in perfons liable to an hemoptyfis.   Travelling in a
 carriage  unlefs upon very  fmooth roads may alfo be of
 doubtful effea;  and all the modes of geftation that are em-
 ployed on  land,  may fall fhort of the effeas expeaed from
 them, becaufe they cannot be  rendered fufficiently con-
 ftant ; and  therefore it is that failing, of all other modes of
 geftation, is  the moft effeaual in pneumonic cafes, as be-
 ing both the fmoothefl and moft conftant.
   It has  been imagined, that fome benefit is  derived from
 the ftate of the atmofphere upon the fea; but I  cannot find
 that  any  impregnation of this which can be fuppofed  to
 take place,  can be of fervice to phthifical perfons.   It is
 however  piobable, that frequently fome  benefit may be
 derived from the more moderate temperature and greater
 purity of the air upon the fea.
   914.]  In order to take off any inflammatory determi-
 nation of the blood into the veffels of the lungs, blifters ap-
 plied to fome part of the thorax may often  be of feFvice;
 and for the  fame purpofe, as  well  as  for moderating the
 general inflammatory ftate ofthe body,  iffues  of  various
 kinds may be employed with advantage.
  • This is a moft effential part in the cure of phthifis, and many other defea-
 ts prevalent in cold climates.
  The warm clothing that is moft effe&ual is flannel fliirts next the fkin.  It
 frels a little difagrecable at firft to a perfon unaccuftomed to it; but the great
relief it affords, and the comfortable fenfation it produces, are fo ftrong in-
ducements for continuing its ufe, that few people who have once experienced
its beneficial effects have any defire torelinquiih it.
  Vol. I.                  R r 
311                PRACTICE
   915.] The feveral meafures to be  purfued in  the cafe
of what is properly called an Incipient Phthisis, have now
been mentioned; but they have feldom been employed in
fuch cafes in due  time,  and  have  therefore, perhaps,
feldom proved effectual. It has more commonly  happen-
ed, that after fome time, an inflammation has come upon
the tubercles, and an abfcefs has been formed, which open-
ing into the cavity ofthe bronchiae, has produced an ulcer,
and a confirmed phthisis.
   916.] In this ftate of matters, fome new indications dif-
ferent  from the former  may be fuppofed to arife, and in-
dications for preventing abforption, for preventing the ef-
feas of the abforbed matter upon the blood, and for heal-
ing the ulcer, have  been aaually propofed.  I cannot find,
however,  that any   of the  means propofed  for executing
thefe indications, are either probable or have proved effec-
tual.   If, upon fome occasions, they  have appeared to be
ufeful,'it-has been  probably by anfwering  fome other in-
-tention.
   While no antidote againft the poifon  which efpecially
operates here, feems to have been as yet  found out, it ap-
pears to me, that too great a degree of inflammation  has a
great fliare in preventing the healing of the ulcers  which
occurs; and fuch inflammation is certainly what has a great
fhare in urging on  its fatal confcquences. The only prac-
tice, therefore, which I  can venture to propofe, is the fame
in the ulcerated as in the crude ftate of a tubercle; that is,
the employment of means for  moderating  inflammation,
which  have been already mentioned (908. et seq.)
  917. J The bal famics whether natural or artificial, which
have been  fo commonly advifed in cafes of phthisis, ap-
pear to me to have been  propofed  upon no fufficient
grounds, and to have'proved commonly hurtful.  The re-
sinous and acrid fubftance of myrrh, lately recommended,
has not appeared to me to be of any fervice, and  in  fome
cafes to have proved hurtful.*
   918.] Mercury, fo often ufeful in healing ulcers, has
been fpecioufly enough propofed in this difeafe; but whe-
ther that it be not adapted to the particular nature of the
  *  From the preceeding account of the difeafe, it is fufliciently evident that
all acrid and hot fubftances mull be hurtful in phthifis.  The balfamics have
been long recommended in thefe cafes, even by the beft authorhks  but  oa
What principle is not eafv to determine. 
                   OF  PHY SLC.                3.15

itlcers of the lungs occurring in phthifis,  or that it proved
hurtful  becaufe  it cannot have  effea, without exciting
(uch an inflammatory  ftate  of the whole fyftem, as, in a
heaic ftate, muft prove very hurtful, I cannot determine.
Upon many trials which  I have feen made, it has proved
of no fervice, and commonly has appeared to be manifeft-
ly pernicious.
  919.] The Peruvian bark has been recommended for fe-i
veral purpofes in phthifical cafes;  and it is faid, upon fome
occafions  to   have  been  ufeful ;  but I have feldom
found it to be  fo ; and as by its tonic power  it increafes
the phlogiftic  diathefis of the fyftem,  I have frequently
found  it hurtful.  In fome cafes, where the morning re-
miffions ofthe fever were confiderable, and the noon exa-
cerbations well marked, I have obferved the Peruvian bark
given in large quantities,  have the effect of flopping thefe
exacerbations, and at the fame time of relieving the whole
ofthe phthifical fymptoms :  but in the cafes in which I ob-
ferved this, the fever fliowed a conftant tendency to recur;
and at length the phthifical  fymptoms  alfo  returned, and
proved (juickly fatal.
  920.] Acids of all kinds, as antifeptic  and  refrigerant,
are ufeful in cafes of phthisis ; but the native acid, of vege-
tables*  is more ufeful than the foffil acids, as  it.can be gi-
ven in much larger quantities, and may  alfo be given more
fafely than  vinegar, being lefs liable to excite coughing.
•  921.] Though our art can-do fo little towards the cure
of this difeafe, we muft, however, palliate the uneafy fymp-
toms of it as well as we  can.  The fymptoms efpecially
urgent arc the cough and diarrhoea.  The cough may be in
fome meafure relieved by demulcents, (872.)  but the re-
lief obtained by thefe is imperfea and transitory, and very
often the ftomach is difturbed by the quantity  of oily, mu-
cilaginous,  and fweeU fubftances, which are on thefe occa-
sions taken into it.
  922.] The only certain means of relieving the cough,
is by employing  opiates.   Thefe, indeed, certainly in-
creafe the phlogiftic diathefis of the fyftem; butcommonly
they do not fo much harm in this way, as they do fervice
by quieting the cough, and  giving fleep.   They are fup-
  * The acid fruits, acid of tartar, acid of forrel, and other plants yielding an
acid but not an acrid, juice. The eating of oranges is thercfojre ferviceable. 
316                PRACTICE

pofed to be  hurtful by checking expeaoration : hut they
do it for a fhort time only;  and, altera found fleep, the
expeaoration in the morning is more eafy than ufual.   In
the advanced ftate of the  difeafe, opiates feem to increafe
the fweatings that occur;  but they compenfate this, by the
 eafe they afford in a difeafe which cannot be cured.
   923.]  The diarrhoea which happens  in  the  advanced
ftate of this difeafe, is to be palliated by moderate aftrin-
gents, mucilages, and opiates.
   Rhubarb, fo commonly  prefcribed in every diarrhoea,
and all other purgatives, are extremely dangerous  in the
colliquative diarrhoea of hettics.
   Frefh fubacid fruits, fuppofed to be always  laxative,
are often in the diarrhoea of  hectics, by their antifeptic
 quality, very ufeful.
                    CHAP. V.

  £Df tbe IJ)emotri)oi£;  or cf tbe JjKmorr&oitml
               Startling ans Stlux*
                      Sect. I.
   Ofthe Phenomena and Causes of the Hemorrhois.

924.] XX DISCHARGE of blood from fmall tumours
on the verge of the anus, is the fymptom  which generally
conftitutes the Hemorrhois;  or, as it is vulgaily  called,
the Hemorrhoidal Flux.  But a difcharge of  blood from
within the anus, when the blood is of a florid colour, fhow-
ing it to have come from no great diftance, is alfo  confi.
deredasthe  fame difeafe;  and phyficians have agreed in
making two  cafes or varieties of it, under the names of
External and Internal Hemorrhois.
   926.] In both cafes it is fuppofed that the flow of blood
is from tumours previously formed, which are named He-
morrhoids,  or piles ; and it frequently happens, that the
tumours exift without  any difcharge of blood; in which
cafe,however, they are  fuppofed to be a part  of the fame
difeafe, and are named Hemorrhoides Caecae,6r Blind Piles.
   926.] Thefe tumours, as they appear without the anus,
are fometimes feparate, round, and prominent, on the verge
of the anus; but frequently the tumour is only one tumid
ring, forming, as it were, the anus pufhed without the body. 
OF  PHY SIC.               31T
  927.] Thefe tumours, and  the difcharge of blood from
them, fometimes  come on  as an affeaion purely topical,
and without any previous diforder .in other parts ofthe bo-
dy : but  it frequently happens, even  before the tumours
are formed, and more efpecially  before the blood flows,
that various diforders are felt in different parts ofthe body,
as headach, vertigo, ftupor,  difficulty of breathing, fick-
nefs, cholic-pains, pain of the back and loins; and often,
together with more or fewer of thefe fymptoms, there oc-
curs a confiderable degree of pyrexia.
   The coming on  of the difeafe with  thefe fymptoms, is
ufually attended with a fenfe of fullnefs, heat, itching, and
pain in and about the anus.
   Sometimes the difeafe is preceded by a difcharge of fe-
rous matter from the anus: and fometimes  this ferous dif-
charge, accompanied with  fome fwelling,  feems  to be in
place of the difcharge of blood, and  to relieve thole dif-
 orders of the fyftem which we have mentioned.   This fe-
rous difcharge, therefore, has been named the Hemorr-
 hois Alba.
    928.] In the hemorrhois, the quantity of blood difcharg-
 ed is different upon different occafions.   Sometimes the
 blood flows only upon the perfons going to ftool; and com-
 monly, in larger or lelfer quantity, follows the difcharge
 of the faeces.   In other cafes, the blood flows widiout any
 difcharge o^ fasces; and then, generally,  it  is after havmg
 been preceedcd by the diforders above  mentioned, when
 it is alfo commonly in larger quantity.  This difcharge of
 blood is often very confiderable; and, by the repetition, it
 is often fo  great, as we could hardly  fuppofe the body to
 bear but with the hazard of life.   Indeed, though rarely, it
 has been fo great as to prove fuddenly fatal.  Thefe con-
 fiderable difcharges occur efpecially  to perfons who have
 been frequently liable to the difeafe.   They often induce
 great debility ; and frequently a leucophlegmatia,  or drop-
 fy, which proves fatal.
    The  tumours and difcharges of blood in tljis difeafe, .
 often recur at exaaiy ftated periods.
    929.]  It often happens, in the decline of life, that the
 hemorrhoidal flux, formerly frequent, ceafes to flow; and,.
 upon that event, it generally happens that  the perfons are
 affeaed with apoplexy or palfy. 
318
PRACTICE
    930.] Sometimes hemorrhoidal tumours are affeaed*
 with confiderable inflammation; which, ending in fuppu-
 ration, gives occafion to the formation of hftulous ulcers
 in thofe parts.
    931.] The hemorrhoidal tumours have been often con-
 fidered as varicous  tumours, or dilatations of veins; and
 it is true, that in fome cafes varicous dilatations have ap-
 peared upon  diffettion.   Thefe, however, do not always
 appear; and I prefume it is not the ordinary cafe, but that
 the tumours are formed by an  effufion of blood into the
 cellular texture of  the  inteftine  near to its extremity.
 Thefe tumours, efpecially when recently formed, frequent*.
 ly contain fluid blood;  but, after they have remained for
 fome time,  they are commonly of a firmer fubftance.
   932.]  From a confideration of their caufes, to be here-
 after mentioned, it is fufficiently probable, that hemorrhoi-
 dal  tumours are produced by fome  interruption of the free
 return of blood  from the veins  of the  lower extremity of
 the reaum; and it is poffible, that a confiderable accumu-
 lation  of blood in thofe veins, may occafion  a rupture of
 their extremities, and thus produce the hemorrhagy or tu-
 mours I have  mentioned.  But, confidering that the he-
 morrhagy occurring here is often  preceded  by pain, in-
 flammation, and a febrile ftate, as well as by many other
 fymptoms which fhow a connection  between the topical af-
 feaion and the ftate of the whole fyftem, it feems probable
 that the interruption of the venous  blood, which we have
 fuppofed to take place, operates in  the manner explained
 in (768.) and therefore, that the difcharge of blood here is
 commonly from arteries.
   933-] Some phyficians have been  of opinion, that a
 difference in the nature of the hemorrhois, and of its effeas
 upon the fyftem, might arife from the difference of the he-
 morrhoidal  veffels from which the  blood iffued.   But it
 appears to me, that hardly in any cafe we can diftinguifh
 the veffels from w7hich the blood flows; and that the fre-
 quent inofculations,  of both the arteries and veins which
 belong to the lower extremity of the reaum, will  render
 the effeas of the hemorrhagy nearly  the fame, from which-
foever of thefe veffels the blood  proceed.
   934-] In (768.) * have endeavoured to explain the man-
ner in which a certain ftate of the fanguiferous fyftem mi<dit 
0 F P H Y S IC.                 519
give occafion to an hemorrhoidal flux;  and I have no
doubt, that this flux may be produced in that manner.   I
cannot, however, by any means admit that the difeafe is fo
often produced in that manner, or that, on its firft appear-
ance, it is fo frequently a fyftematic  affeaion, as the Stah-
lians have imagined, and would have us to believe.  It
occurs in many perfons  before the period of life at which
the venous plethora takes place;  it happens to females, in
whom a venous plethora, determined to the hemorrhoidal
veffels, cannot be fuppofed; and it happens to both fexes,
and to perfons of all ages, from caufes which do not affea
the fyftem, and are manifeftly  fuited to produce a topical
affection only.
   935. J  Thefe caufes of a topical affeaion are, in the firft
 place, the frequent voiding of hard and bulky faeces, which,
 not only by their long  ftagnation in the reaum, but efpe-
 cially when avoided, muft prefs upon the veins of the anus,
 and interrupt the courfe of the blood in  them.   It  is for
 this reafon that the difeafe happens fo often to perfons of a
 flow and bound belly.
    936.] From the caufes juft now  mentioned, the difeafe
 happens  efpecially to  perfons liable to  fome degree of a
 prolapfus ani.   Almoft every perfon in voiding faeces has
 the internal  coat  of the reaum more or  lefs protruded
 without the body; and this will be  to a greater or leffer
 degree,  according as the hardnefs  and bulk of the faeces
 occafion a greater or leffer effortor preffure upon the anus.
 While the gut is thus pufhed out, it often happens that the
 fphinaer ani is contracted before the gut is replaced; and,
 in confequence thereof, a ftrongconftriaion is made, which
 preventing the fallen-out gut from being replaced;  and at
 the fame time preventing the return of blood from it, oc-
 cafions its being confiderablv  fwelled, and its forming a
 tumid ring round the anus.
    937.] Upon  the fphinaer's being a little relaxed, as it
 is immediately  after its ftrong contraaion, the fallen-out
 portion ofthe gut is commonly again taken within the bo-
 dy; but by the frequent repetition of fuch an accident  the
 fize and fullnefs of the ring formed by the  fallen-out gut,
 is much increafed.   It is therefore  more flowly and diffi-
 cultly replaced; and in this confifts the chief uneafinefs of
 hemorrhoidal perfons. 
X2G                PRACTICE
   938.] As the internal edge ofthe ring mentioned, is ne-
 ceffarily divided by clefts, the whole often affumes the ap-
 pearance of a number of diftina fwellings ; and it alfo fre*
 quently happens, that fome portions of it, more confider*
 ably  fwelled than others,  become more protuberant, and  ,
 form thofe fmall  tumours more ftrictly called Hemorr-  J
 hoids, or Piles.       .
   939.] From confidering that the preffure of faeces, and  1
 Other caufes interrupting the return of venous blood from  .
 the lower extremity of  the  reaum,  may operate a good  *
 deal higher up in the gut than that extremity, it  may be
 eafih underftood that tumours  may be formed withm the
 anus; and probably,  it alfo happens, that fome of the tu-
 mours formed without the anus, as in (938.) may continue
 when taken within the body, and even be increafed by the
 caufes juft now mentioned. It is thus that I would explain
 theproduaion of internal piles, which, on account of their
 fituation and bulk, are not protruded on the perfon's go-
 ing to ftool,  and are often, therefore, more painful.   The
 fame  internal piles are more efpecially painful, when af-
 feaed by the hemorrhagic effort defcribed in (744. and

   940.] The produaion of piles is particularly illuftrated
 by^thi,, that pregnant women are frequently affeaed with
 them.   This is to be accounted for, partly from the pref-
 fure of  the uterus upon the reaum,  and partly from-the
 coftive habit to which pregnant women are ufually liable.
 I  have  known many  inftances of  piles  occurring for the .  l
 firft time during the ftate of pregnancy; and there are few
 women  that  have  borne children who are afterwards en-  '
 tirely free from piles.   The  Stahlians have commonly af-
 ferted, that the male fex is more  frequently  affeaed with  J
this difeafe than the female;   but in this country I  have  I
conftantly found it otherwife.                             ^
   941.] It is commonly fuppofed, that  the frequent ufe  i
of purgatives, efpecially of thofirof the more acrid kind, J
and more particularly of aloetics, is apt to produce the he,'j|
morrhoidal affeaion; and as thefe purgatives ftimulatftJR
chiefly the  great guts, it feems fufficiently probable  thaM
they may excite this difeafe.                              *
   942.]  I have now mentioned feveral caufes which may  <
produce the hemorrhoidal  tumours and  flux as a  topical  j 
OF  PHYSIC.               321
 aflfeaion only; but muft obferve farther, that although the
 difeafe appears firft as a purely topical affeaion, it may, by
 frequent repetition, become habitual, and therefore may be-
 come conneaed with the whole fyftem, in the manner alrea*
 dy explained, withrefpeato hemorrhagy in general, in 747.
   943.] The doarine now referred to, will, it is appre-
 hended, apply very fully to the cafe ofthe hemorrhoidal
 flux; and will the more readily apply, from the perfon who-
 has been once affeaed being much expofed to a renewal
 ofthe caufes which firft occafioned the difeafe;  and from
 many perfons being much expofed to a congeftion in the
 hemorrhoidal veffels, in confequence of their being often
 in an erea pofition of the body, and in an exercife which
 pufhes the blood into the depending, veffels, while  at the
 fame time  the effeas  of thefe circumftances are much fa-
 voured by the abundance and laxity of the cellular texturj-
 about the reaum.
   944.] It is thus that the hemorrhoidal flux is fo often ar-
 tificially rendered an habitual and fyftematic affeaion; and I
 am perfuaded, that it is this which has given occafion to the
 Stahlians to confider the difeafe as almoft univerfally fuch.
   945.] It is to be particularly obferved here, that when
 the hemorrhoidal difeafe  has either been originally, or has
 become, in the manner juft now  explained, a  fyftematic
 affeaion, it then acquires a particular conneaion with the
 ftomach, fo that certain affeaions there excite the hemor-
 rhoidal difeafe, and certain ftates ofthe hemorrhoidal af-
 feaion excite diforders of the ftomach.
   It is perhaps owing to this conneaion,  that the gout
 fometimes affeas the reaum.   See (524.)'


                      Sect. II.

       Of the  Cure  of Hemorrhoidal Affections.
   946.]  ALMOST at all times it has been been an opi-
nion amongfti phyficians,  and from  them fpread amorigfti
 the people, that the hemorrhoidal  flux  is a falutary eva-
cuation,  which prevents many difeafes  that would othef-
wife have happened;  and that it even contributes t6 give*
long life.  This opinion,  in later times, lias been efpecial-
ly maintained by Dr. Stahl, and his folio-weft; and has had
  Vol, L                ^ s 
322                PRACTICE

a great deal of influence upon the practice of phyfic in
Germany.
   947.]  The queftion arifes with refpeft to hemorrhagy in
general,  and indeed it  has  been extended fo far by the
Stahlians.  I have accordingly confidered it  as a general
queftion  (766—779.) but it has been more efpecially agi-
tated with regard to the difeafe now under our confidera-
tion: And as to this, although I am clearly of opinion that
the hemorrhois may take place in confequence of the  ge-
neral ftate ofthe fyftem (768.) or, what is. ftill more  fre-
quent, that by  repetition it may become conneaed with
that general ftate (942.) and in either cafe cannot be fup-  •
preffed with great caution; I muft beg leave, notwithfland-
ing this, to maintain, that the  firft is a rare cafe; that ge-
nerally the difeafe  firft appears as an affeaion purely topi-
cal (934—941.) and that the allowing it to become habi-
tual is never proper.  It is a nafty difagreeable difeafe,
ready to go to excefs, and to be thereby very hurtful, as
well as fometimes  fatal.  At beft it is  liable  to accidents,
and thereby to unhappy confequences.  I am therefore of
opinion, that not  only  the firft approaches of the difeafe
are to be guarded  againft, but even that, when it  has taken
place for fome time,  from  whatever caufes  it may have
proceeded, the flux is always to be moderated, and thene-
■ceflity of it, if poffible, fuperfeded.
   948.] Having delivered  thefe general rules, I proceed  y
to mention more  particularly,  how  the  difeafe is to be
treated,  according to the different circumftances under
which it may appear.                                   J
   When we can manifeftly  difcern the firft appearance of
the difeafe to arife from caufes aaing upon the part only,
the ftriaeft attention fhould be  employed in guarding a-
gainft the renewal  of thefe caufes.                         3
   949-3 One of the moft frequent of the remote caufes of  J
 the hemorrhoidal affeaion, is a flow and bound belly (935.) ■
 and this is to be  conftantly obviated by a  proper diet,*JB
 which each  individual's own experience muft dired; or, ■
 if the management of diet be not effeaual, the belly muft M
 be  kept regular by fuch medicines as may  prove gently.
   * Broths of all kinds are proper in thefe oafes : barley broth is preferably '
 to that which is made with rice.  Barley gruel, with prunes, is an excellent
 laxative broth. 
OF  PKYSTG.                 3*3
  laxative, without irritating the reaum.*   In moft cafes it
  will be of advantage to acquire a habit with refpea to time,
  and to obferve it exaaiy.
     950.]  Another caufe of hemorrhois to be efpecially at-
  tended to, is the prolapfus or protufion of the anus, which
  is apt to happen on a perfon's having a ftool, (936.)   If it
  fhall  occur  to any confiderable degree, and at the fame
  time be not eafily and immediately  replaced, it moft cer-
  tainly produce piles, or increafes them when otherwife pro-
  duced.   Perfons therefore liable to  this prolapfus, fliould,
  upon their having been at ftool, take great  pains to have
  the gut immediately replaced, by lying down in a horizon^
  tal pofture, and preffing gently upon the anus, till the re-
  du6tion  fhall be completely obtained.
  •   951']  When the prolapfus of which I fpeak, is  occa-
  fioned only by voiding hard  and bulky faeces, it fhould be
  obviated by the means mentioned  in (949.) and may be
  thereby avoided..  But in fome perfons it  is owing to a
  laxity ofthe reaum;  in which cafe it is often moft confi-
  derable upon occafion of a  loofe ftool;; and then the dif-
  eafe is to be treated by aftringent,t as well as by proper
  artifices for preventing the falling dow7n of the gut.
     952.] Thefe are the means to be employed upon the
  firft ao.uoaehes of the hemorrhoidal affeaion;  and when
  from negfea it fhall have frequently occurred, and hasbe-
  .come in fome meafure eftablifhed, they are no lefs proper.
  In the latter cafe, however, fome other means are alfo ne-
  ceffary.   It is particularly proper to guard againft a ple-
  thoric ftate of the body; confequently, to avoid a feden-
  tary life, a full diet, and  particularly intemperance in the
  ufe of ftrong liquor, which,  as  I fhould have obferved be-
  fore, is, in all cafes of hemorrhagy, ofthe greateft influence
  in increafing the difpofition to the difeafe.

    * The lenitive eleiluary alone may in many cafes be fufficient, when given
  inthe quantity of half an ounce or fix drachms.  The following formula may
1  be ufed where greater colli venefs prevails ;
*             R. Sal. Nitri  SiL
               Pulv. Jalap. 3'*
               Ele£k. Lenitiva. §i.
               M. f. Ele&. cujus sumat q„n. m. pro re nata..
    t Aftringents may be ufed both internally and externally.  The internal
  aftringents are Alum, Kino, Terra, Japonica, &c. But in cafes of hemorrhoids
  from laxity, nothing produces a betrer effedt than the frequent application c£
  pfedjets dipped ii; a tircng iatuuon of galls, or oak bark; 
324                T R A C T I C E

  953 JI needhardly repeat here,  that exercife of all kinds
mutt be a cheif means of obviating and removing a pletho-
ric ftate of the body :  but upon  occafion of the hemorr-
hoidal flux immediately approaching, both walking and rid-
ing, as increafing the determination of the blood  into the
hemorrhoidal veffels, are to be avoided.   At other times,
when no fuch determination has been already formed, thofe
modes of exercife may be very properly employed. *
   954.] Cold bathing is another remedy that may be em-
ployed to obviate plethora, and prevent  hemorrhagy ; but
it is  to be  ufed with caution.  When  the  hemorrhoidal
flux is approaching, it may  be dangerous to turn it fud-
denly  alide by cold bathing: but during the  intervals of
the difeafe, this remedy may be employed with advantage;
and in perfons liable to a prolapfus ani,  the frequent waffl-
ing of the  anus with cold water  may be very ufeful.
   955-] Thefe are the means for preventing the recur-
rence  of the hemorrhoidal flux;  and in all cafes, when it
is not immediately approaching, they are to be employed.
When it has aaually come on, means are to be employed
for moderating it as much as poffible, by tjie perfon's lying
in  a horizontal pofition  upon a hard bed;  by  avoiding
 exercife in  an ere£t pofture;  by  ufing a cool diet;  by
 avoiding external heat;  and by obviating the irritation  of
 hardened  faeces  by me  ufe of  proper laxatives, (949-)
 From what has been  laid above, as to the being careful £'
 not to increafe the determination ofthe blood into the he-.
 morrhoidal  veffels, the propriety of thefe meafures muftm
 fufficiently appear; and if they were not fo generally neg- M
 ieded, many perfons would  efcape the great  trouble, and
 various bad confequences, which  fo frequently refult from  I
 this difeafe.                                           J
   956.]  With refpea to the further cure of this difeafe, j
 it is almoft in two cafes only  that hemorrhoidal perfons J
 call for the  affiftance of the phyfician.   The  one is wh^pfl
 the affeaion is accompanied with much  pain; and of thisM
 there are  two cafes, according as the pain happens to at- ■
 tend the external or the internal piles.                   \
    957.]  The pain ofthe external piles arifes efpecially-
           r
   *  It is doubtful whether riding is ever advifible in any period of the dif-
  eafe.  Riding frequently produces Piles, in perfons not in the leaft p:-jdifpo-
  fed to then. 
0 F PHYTIC.                Z25
  when a confiderable protnafion ofthe reQum has happened;
  and  when, continuing unreduced, it  is ftrangled by  the
  conftriaion of the fphinaer;  while, at the fame time, no
  bleeding happens, to take off the fwelling ofthe protruded
  portion of the inteftine.  Sometimes an inflammation fu-
  pervenes, and greatly aggravates the pain. To relieve the
  pain in this cafe,  emollient fomentations and poultices are
  fometimes of fervice; but a more  effeaual relief is to be
  obtained by applying leeches  to the tumid parts.
     958.] The other cafe in  which hemorrhoidal perlbas
  feek affiftance,  is that  of exceflive bleeding.  Upon the
  opinion fo generally received of this difcharge being falu-
  tary, and from the obfervation that upon the difcharge oc-
  curring perfons have fometimes found relief from various'
  diforders, the moft part of perfons liable to it are readyito
  let it go too far;  and indeed  the Stahlians will not allow it
  to be a difeafe, unlefs when it has aaually gone to excefs.
  I am, however,  well perfuaded,  that  this  flux ought al-
  ways to be cured as foon as poffible.
     959.]  When  the difeafe occurs as a purely topical af-
  feaion, there can be no doubt ofthe propriety of this rule;
  and, even when it has occurred as a  critical difcharge in
  the cafe of a particular difeafe, yet when this difeafe fhall
  have been entirely cured and  removed, the preventing any
  return ofthe hemorrhois, feems tobe both fafe and proper.
     960.] It is only when the difeafe arifes from a plethoric
-' nftate ofthe body, and from a flagnation of blood in the hy-
  pochondriac region, or when, though originally topical,
  the  difeafe, by  frequent repetition, has become  habitual,
  and has thereby acquired a conneaion with the whole  fyf-
  tem, that any doubt can arife as to ihe fafety of curing it
  entirely.   Even  in thefe cafes,  however,  I apprehend it
  will be always proper to moderate the bleeding;  left by
  its continuance or repetition, the plethoric ftate of the body,
  and the particular determination of the blood into the he-
[  morrhoidal veffels, be increafed, and the recurrence of the
f  difeafe, with all its inconveniences and danger, be too much
   favoured.
     961.]  Further, even in the cafes ftated (960.) in fo far
   as the plethoric ftate of the body, and the tendency to that
   ftate, can be obviated and removed,  this is always to be 
326                PRACTICE
  diligently attempted; and if it can be executed with fuc-
  cefs, the flux may be entirely fuppreffed.
    962.] The Stahlian opinion, that the hemorrhoidal flux
  is only in excefs when it occafions great debility, or a leu-
  cophlegmatia, is  by no means juft; and it appears to me,
  that the fmalleft approach towards producing either of thefe,
  mould be confidered as an excefs, which ought to be pre-
  vented from going farther.
    963.] In all cafes,  therefore, of excefs, or of any ap-
  proach towards it, and particularly when the difeafe de-
  pends upon a prolapfus ani, (950.) I  am of opinion, that
  aftringents,  both internal, and external, may be fafely and
  properly employed; not indeed to induce an immediate
• and total fuppreffion, but  to moderate the hemorrhagy,
  and by degrees to fupprefs it altogether, while at the  fame
  time meafures are taken for removing the neceffity of  its
  recurrence.
    964.} When the circumftances (945.) marking a con-
  nexion between the hemorrhoidal affeaion and the ftate of
  the ftomach occur,  the meafures neceffary are the fame as
  in the cafe of atonic gout.
END OF VOLUME L
 
FIRST LINES
OF THE
PRACTICE of PHYSIC,
By WILLIAM CULLEN, m. d.
I.ATK PROFESSOR OF THE PRACTICE OF THYSIC IN THfi

      UNIVERSITY OF EDINBURGH, Sec.
WITH PRACTICAL AND EXPLANATORY

            NOTES,

      By JOHN ROTHERAM,v m. d.
IN TWO VOLUMES.
        PRINTED BY L. NICHOLS 8c C*.

70K T. & J. SWORDS, E. DUYCKINCK, T. S. AROEN, G. F. HOPKINS,
   W. FALCONER, T. U. JANSEN & CO. FURMAN & LOUDON,
     S. STEPHENS, BROWN Sc STANSBURY, C. DAVIS,
         W. DURELL, & L. NICHOLS & CO.
1801. 
#■ 
CONTENTS.
SECOND   VOLUME.
                      BOOK   IV.
                                                          Pace.
%JF the Menorrhagia, or the immoderatejlo'tv cf the Menses        5
CHAP.  VII.  Ofthe  Leucorrhcta, Fluor Albus, or Whites        10
CHAP.  VIII. Of the Amenorrhea, or Interruption of the Menses  13
CHAP.  IX.   Of Symptomatic Hemorrhagies                 fc 19
   Sect. I.     Of the Hematcmasis, or Vomiting-of Blood       '*^l0
   Sect.  II.    Ofthe Hematuria, or the voiding of Blood from
                  the Urinary Passage                        26

                       BOOK  V..
               Of Profluvia, or Fluxes, with Pyrexia           .32
 CHAP. I.     Of the  Catarrh                               ibid
 CHAP. II.    Of the  Dysentery                              33

                        PART   II.
               Of Neuroses, or Nervous Diseases                45

                        BOOK   I.
               Of Comata, or  the Lgss of Voluntary Motion      46
 CHAP. I.     Of Apoplexy                                   47
 CHAP. II.    Of Palsy   jB.                                  €2

                        BOOK  II.
               Of Adynamia, or Diseases consisting in a weakness
                 or loss of Motion in either the vital or natural
                 Functions                                   ,72
 CHAP. I.     Of Syncope or Fainting                        ibid
 CHAP. II.    Of Dyspepsia,  or Indigestion                    78
 CHAP. II J.  Of Hypochondriasis, or the Hypochondriac Affec-
                 tion, commonly called Vapors or Low Spirits    90

                      BOOK   III.
               Of Spasmodic Affections without Fever            97
 ., Sect.  I.     OftH^Spasmodic Affections ofthe Animal Functions 93
 CHAP. I.     Off Tetanus                                   99
 CHAP. II.    Of Epilepsy                                  110
 CHAP. III.  Of the Chorea, or Dance of St. Vitus            128
   Sect. II.    Of the  Spasmodic Affections of the Vital Functions 130
 CHAP. 1V.   Of the  Palpitation of the Heart                 ibid
 CHAP. V.    Of Dyspnoea, or Difficult  Breathing            132 
CONTENTS,
	Page.
CHAP. VI.	Of Asthma 134
CHAP. VII.	Of the Chincough, or Hooping Cough \ 42
Sect. III.	Of the Spasmodic Affections in the Natural Func-
	tions 149
CHAP. VIII	, Of the Pyrosis, or what is named in Scotland, the
	Water-Brash ibid
CHAP. IX.	Of the Colic 152
CHAP. X.	Of the Cholera 159
CHAP. XI.	Of Diarrhoea, or Looseness 162
CHAP. XII.	Ofthe Diabetes 173
CHAP. XIII	. Of the Hysteria, or the Hysteric Disease 176
CHAP. XIV	, Of Canine Madness and Hydrophobia 181
                      BOOK   IV.
              Of Vesanix, or of the Disorders of the Intellectual
                 Functions                                   183
CHAP. I.    Of Vesanite ingeneral                          ibid
CHAP. II.    Of Mania, or Madness                         193
CHAP. III.  Of Melancholy', and other forms of Insanity       201
            PART   III.
     Of Cachexies

             BOOK   I.
Of Emaciations
208
209
                      BOOK.   II.
              Of Intumescentit, or General Swellings          217
CHAP. I.    Of Adipose Swellings                          218
CHAP. II.   Of Flatulent Swellings                          220
CHAP. III.  Of Watery Swellings, or Dropsies                228
  Sect. I.     Of Anasarca                                   237
  Seet. II.    Ofthe Hydrothorax, or Dropsy ofthe Baeast     248
  Sect. III.   Ofthe Ascites, or Dropsy of the Lower Belly     252
CHAP. IV.  Of General Swellings,  arising from an increased
                 bulk of the whole substance of particular parts  255
              Of Rachitis, or Rickets                        ibid

                     BOOK   III.
              Of the Impetigines,  or depraved habit, with Af-
                 fections of the Skin                          264
CHAP. I.    Of Scrophula, or the King's Evil                 ibid
CHAP. II.   OfSiphylis, or the Venereal Disease            273
CHAP. III.  Of Scurvy.                                    283
CHAP. IV.  Of Jaundice                                   290 
                         [  5  J.

                 FIRST  LINES
                         OF THE
          PRACTICE  OF  PHYSIC.


                  BOOK   IV.
                      CHAP. VI.

     £Df tbe a^enouimgia, or tfje 3fmmotiecate
                jTloto of t&e  ^crises,

965.] JDLOOD 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 fame fources that the
menfes in their natural ftate proceed from ; and which dif-
charges alone, are thofe  properly comprehended under the
prefent title.   The title of Metrorrhagia, or  hcemorrhagia
uteri, might comprehend a great deal more.
   966.J  The  menorrhagia may be confidered as of two
kinds;  either  as  it happens to  pregnant and lying-in wo-
men, or as it happens to women neither pregnant nor hav-
ing  recently born children.   The firft kind,  as connected
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 fhall Sonfine my felf to  the fecond
kind of menorrhagia only.
   96 7. J  The flow ofthe menfes is confidered as immoder-
ate,  when it recurs more frequently,*  when it continues
longer, or when, during the ordinary continuance,t it is
more abundant* than is ufual with the fame perfon at other
times.
   968. J  As the  moft part of women are liable  to fome in-
equality with  refpecl: to  the period, the duration, and the
  * The ufual period is from twenty-feven to thirty days.
  f The time of its continuance is very various in differentpeople ; it feldom
continues longer than eight days, or (hotter than two.—In general, women
of a lax and delicate conftitution have a* move copious and a longer continued
difcharge than robuft people.
  \ It is extrcmefy difficult to afcertain precifely what quantity is ufually dif-
charged ; but the women themfelves can generally inform the phyfician with
iufheient exaclnefs for regulating the praftlce whether  the  difcharge be im-
moderate.
  Vol. II.                   A 
«5                   P R A C T I C K

quantity of their menfes;  fo it is  not  every inequality in
thefe refpc8s that is  to be confidered as a difeafe;  but on-
ly thofe deviations, which are cxceflive  in decree, which
are permanent, and which induce a manifect ftate of debility.
   969.J The circumftances (967. 968.) are thofe which
chiefly conftitute the menorrhagia:  but it is proper to ob-
ferve, 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 other times;  yet there is, in   '
thefe particulars,  fo much  uniformity obfervable  in the   *
whole of the fex,  that in any individual in  whom there oc-
curs  any confiderable deviation  from the common  mca-  , j
fure,  fuch a deviation if conftantly recurring, msy be con-   J
fidered as at leaft approaching to a morbid ftate, and as
requiring moft of the precautions which I fliall hereafter
mention as neceffary to be attended  to by thofe who are
actually in fuch a ftate.
   970. J However wc  may determine with refpect to the
circumftances (967. 968.) it muft ftill be allowed, that the
immoderate  flow  of the menfes is efpecially to be deter-
mined by thofe fymptoms affecf 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 dyfpncea, and has been
ufhered in by a cold ftage, and is  attended with much pain
ofthe back and loins, with a frequent pulfe, heat, and thirft,
it may then be  confidered&s preternaturally large.
   971. J When, in confequence of the circumftances (967;
—970.) and the repetition of thefe, the face becomes pale;   ;
the pulfe grows weak: an unufual debility is felt in  cxer-
cife ; when, alfo,  the back becomes pained from any con-   ,
tinuance in an erect pofture j 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   J-
menfes  has been  immoderate, and has  already induced a   <
■dangerous ftate of debility.
   972.] The  debility  thus induced does often difcover
itfelf" alfo by affections of the ftomach,  as anorexia and
other fymptoms of difpepfia; by a palpitation ofthe heart,
and frequent faintings; by a weaknefs of  mind liable to 
OF  PHYSIC.
ftrong emotions from flight  caufes,  efpecially when fud-
denly prefented.
   973-] Tnat flow of themenfes,  which is attended with
barrennefs in married women,  may be generally confider-
ed as immoderate and morbid.
   974.] Generally, alfo,  that flow of the menfes may be
confidered as immoderate, which is preceded and followed
by a leucorrhcea.
   975.]  I  treat of menorrhagia here as an active hemorr-
hagy, becaufc I confider menftruation, in its natural ftate,
to  be  always  of that  kind;  and  although  there fhould
be cafes of  menorrhagia  which  roi^ht be  confidered as
purely  paffive, it appears to rae that they cannot be fo pro-
perly treated of in any other place.
   976.] The menorrhagia (967. et sea) has for its  proxi-
mate caufe, either  the  hemorrhagic effort  of the uterine
veffels preternaturally increafed, or a preternatural laxity
of the extremities of the uterine arteries, the hemorrhagic
effort remaining as in the natural ftate.
   977.} The remote caufes of  the hemorrhagia  may be,
 1st, Thofe which increafe the plethoric ftate of the uterine
veffels; fuch as a full and  nourifhing diet,  much ftrong li-
quor, and frequent intoxication,   zdly, Thofe which de-
termine the  blood more  copioufly and forcibly  into the
uterine veffels; as violent ftrainings of the whole  body;
violent fliocks ofthe whole body from falls; violent ftrokes-
or contufions on the lower belry; violent exercife, parti-
cularly  in  dancing;  and violent  paffions  of  the mind.
Zdly, Thofe which particularly irritate the veffels of the
uterus;  as  excels in venery ; the cxercife of venery in the
time of menftruation ;  a coftive habit, giving occafion to
violent ft raining at ftool; and cold applied  to the feet.*
4M/1', Thofe which have forcibly ovcrftrained  the extremi-
ties  ofthe uterine veffels;  as frequent abortions; frequent
child-bearing without nurfingt;  and difficult tedious la-
  * It is difficult to account for the caufe of menorrhagia; it may perhaps be
owing to the circulation, through  the lower extremities being cbftruiled or
impeded, and confcquen'.l/ a greater flew of blood to the uterus.   The fatit,
however, is certain;  for experience, fufficiently  evinces that menorrhagia.
frequently foll3fc*,an imprudent expo fure ofthe feet to cold, efpecially damp
cold.   Sitting in wet fhoes,  or in a damp cold room with a ftone floor, ought
to be carefully avoided by lad^s of a deljcate conftitution.
  f By nurfing, the fluids are determined to the breaft, and in  a  peculiar
manner dciivcd from the uterus.  This part ofthe ceconomy of nature phyfip
ologias hav-« not y.-i fufficiently explained, but the fait i» well afcertained. 
a
PRACTICE
bours, Or, lastly, Thofe which induce a general laxity ;  as
living much in warm chambers, and drinking much of warm
enervating liquors, fuch as tea arjd coffee.
   978. j The effecls  ofthe  menorrhagia are pointed out
in (971—972.)  where I have mentioned the feveral Iymp-
toms accompanying the difeafe ;  and  from  thefe the con-
fequences to be apprehended will alfo  readily appear.
   979.] The treatment and cure ofthe menorrhagia  muft,
be different, according to the different caufes of the difeafe.
   In all cafes, the firft attention ought to be given to avoid-
ing the remote caufes, whenever that can be done ; and  by
that means the difeafe may be often entirely  avoided.
   When the remote  caufes cannot  be avoided,  or when
the avoiding them has been  neglected, and therefore  a co-
pious menftruation  has come on, it fhould be moderated
as much as poffible,  by abftaining from all exercife, cither
at the coming on, or during the continuance of the  men-
ftruation ; by avoiding even  an  ere£t  pofture as much as
poffible; by fhunning external heat,  and therefore warm
chambers and foft beds; by ufing a light and cool  diet; by
taking cold drink, at leaft as far as former habits will allow:
by avoiding venery;  by obviating coftivenefs, or remov-
ing it by laxatives  that give little ftimulus.*
   The fex are commonly negligent, either in avoiding  the
remote caufes,  or  in moderating the firft beginnings of this
difeafe.   It  is by fuch neglecf that it fo  frequently becomes-
violent,  and of difficult cure; and  the frequent repetition
Nurfing is not only  ufeful m preventing menorrhagia, bat as it derive* the
fluids from the uterus, it prevents  alfo frequent  child-bearing; and confe-
quently, which is the greateft advantage of all others, time is allowed to the
uterus for regaining  its former tone and ftrength: The fubfequent child-births
are alfo rendered more eafy than they would otherwife be, and the children
more healthy.  It would be improper to  enumerate all the advantages of
nurfing in this place, as I (hall referve the confideration of them for a future
publication.
   * The laxatives that give little ftimulus are  manna, oil, tamarind;;, caflia,
and fuch mild fubftances.  Aloetic%nd other draftic purges, muft be careful-
ly avoided.  Rhubarb, in moderate dofes, is  only a4miflible in cafes where
there is an evident atony ofthe ftomach or  inteftines : and in thefe cafes it
ought to be given in fubftance, or in a watery  infufion. The fpirituous  and
vinous tinctures of  it a-re abfolutely inadmiflible  in menorrhagia. A table-
fpoonful of the  following linclus, taken occafionally, will fuiiciently obviate
coftivenefs, without  giving much ftimulus :
           R. Man,.opt. gii.
              01. ricini fi.
              Syr. rosar. solut. |ir
              Crem. tartar. §S5.
              M. f. Li net. 
OF  PHYSIC                    «
of a copious menftruation, may be confidered as a caufe
of great laxity in the extreme veffels ofthe uterus.
  980.]  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 ne-
ceffary ;  and it  will in moft cafes be  fufficient to employ,
with great attention and  diligence, thofe means for mode-
rating the difcharge which have been mentioned in the laft
paragraph.
   9^1.] When the immodeitate flow of  the menfes fliall
 feem to be owing to a laxity of  the veffels of  the uterus,
as may be concluded from the general debility and laxity
of the perfon's habit;  from the remote caufes  that have oc-
 cafioned the difeafe (977.) fr°ra me abfence-of the fymp-
toms which  denote  increafed  a&ion in the veffels of the
 uterus (970.) from the frequent recurrence of  the difeafe,
 and particularly from this, that in the intervals of menftru-
ation  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  (979.) for moderating the hemorrha-
 gy, but alfo by  avoiding all irritation, every irritation hav-
 ing the greater effect in proportion as the veffels have been
 more  lax and yielding.  If, in  fuch a cafe of laxity, it fhall
 appear that feme degree of irritation concurs, opiates may
 be employed to  moderate the difcharge;  but in ufing thefe,
much caution is requifite.*
   If,  notwithflanding thefe meafures having been  taken,
the difcharge fhall prove  very  large,  .aftriugents,t  both
 external and internal, may be employed.  In  fuch cafes",
may fmall dofes of emetics be of fervice ?
   982.] WThen the menorrhagia depends on the laxity of
 the uterine veffels, it will be proper, in the intervals of men.
  * Opiates ufed too liberally, generally increafe the difcharge,  in confe-
quence  of their very great power in relaxing the whole fyftem.
  f The aftringents  for internal ufe are, alum, catechu, tiniture of rofes, &c.
Ten grains of alum,  and as much catechu may be given in powder, every two
or three hours, with  three or four fpoousful of tinfuire of rofcs,. to warn it
 down.  The bark is fometimes of ufe in thefe cafes, efpecially when Joined
 with alum. The external applications are, cold clothes foaked 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 of it, may be applied cold to the fame parta. 
10                   PRACTICE
  ftruation, to employ tonic remedies; as cold bathing and
  chalybeates.*  The  exercifes  of geftation,  alio,  may be
  very ufeful,  both for ftrcngthcnipg the whole fyftem, and
  for taking off the determination of the blood to the inter-
  nal parts.
    983.J The remedies mentioned in thefe two laft para-
  graphs, may be employed in all cafes  of menorrhagia, from
  whatever caufe it may  have proceeded, if the difeafe fnall
  have already induced a confiderable  degree of  debility in
  the body.

                       CHAP. VII.
                            —>«»—
   £Df t&e Leucorr&oea, jFiuor $ftu3, cr eobite*.

 984.] JtLiVERY ferous or puriform difcharge  from the
 vagina, may be, and has been comprehended under one or
 other of the appellations I have  prefixed to this chapter.
 Such difcharges, however may be various; and  may pro-
 ceed from various fources, not yet well afcertained; but I
 confine my felf here to treat of that difcharge alone  which
 may be prefumed to proceed from the fame vcflels, which,
 in their natural ftate, pour out the menfes.
    985.J I conclude a difcharge from the vagina to be  of
 this kind;*  1. From its happening to  women who are fub-
   * The following form is very convenient.
           R. Rubigin.  lerri. 3ii«
              Corr. Peruv. 51.
              Syr.  Simpl. q. s.
              M. f. Eleft.
 The dofe of this electuary is to be varied according to the conftitution; the
 fize of a nurmeg twice a day is ufually given.
  The beft forms of chalybeate-, in thefe cafes, are the mineral waters which
 contain iron difiblved  by* fixed air.  Chalybeate waters fhould not, in this
 difeafe, be drank in fuch large quantities as to pafs off by ftool.  A gill 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 ofthe
 particular water we ufe.  Along with the chalybeae water, afcruple,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 finguLarly efficacious:
           R. Extra ft. cort. Peruv. §i.
              Extract. Campechens.                         "•
              Extract. Glychyrrh* a a 5 «;.
              Mucilag. Gum. Arab. q. s.
              M. f.  Elect.
 The dofe is half a drachm or two fcruples twice a-dav.
  *  The young practitioner ought to pay great attention to the diagnoftics of
the lencorrhoea delivered in this article. 
OF  PHYSIC.                  II
je£t to an immoderate flow of the menfes, and liable to this
from caufes weakening the veffels of the uterus.   2. From
its appearing chiefly, and often only, a little before, as well
as  immediately after, the  flow of the menfes.   3. From
the flow of the menfes being diminifhed, in "proportion as
the lcucorrheca is increafed.   4. From the leucorrhcea con-
tinuing after the menfes have entirely ceafed, and with  fome
appearance of its obferving a periodical  recurrence.  5.
From the leucorrhcea being accompanied  with the effects
of the  menorrhagia (971—972 )   6.  From the difcharge
having been neither preceded by, nor accompanied  with,
fymptoms of any topical affections ofthe uterus.  7. From
the leucorrhcea not having appeared foon after  communi-
cation with  a  perfon who might be fufpected of communi-
cating infection, and  from  the firft appearance of the dif-
eafe  not  being accompanied with any inflammatory  affec-
tion  of the pudenda.*
    986.]  The appearance  of the matter difcharged in the
 leucorrhcea, is very various with refpect to confiitence and
 colour;  but from  thefe appearances, it is not always  poflt-
 ble to determine concerning its nature, or the particular
 fource from whence it proceeds.
    987. J  The leucorrhcea, of which I am to treat, as  afcer-
 tained by the feveral circumftances (985.) feems to proceed
 from the  fame caufes as that Ipecies of menorrhagia which
 I fuppofe to  arife  from the laxity of the extreme veffels
 of the  uterus.  It  accordingly often follows or accompa-
 nies fuch a menorrhagia;  but though the leucorrhcea de-
 pends  chiefly upon the laxity mentioned, it may have pro-
 ceeded from irritations inducing that laxity, and feems to be
 always increafed by any irritations applied to the uterus.
    988. J  Some authors have alleged, that a variety of cir-
 cumftances in other parts of the body may have a  fliare in

   * Nothing is more frequent with ignorant practitioners than to miftake a
 gonorrhea for a leucorrhcea.  Women in general give the name of whites to
 a gonorrhoea, and therefore the unwary practitioner may the more eafily be
 milled.  The diilinguifiiing character! (lie of gonorrhoea is, as the author fays,
 an inflammatory  affection ofthe pudenda; but, as few  women willfuiTer an
 i.ifpcdtion of the parts, we muft pay fome attention to the concomitant fymp-
 toms.  The running in a gonorrhoea \?, conftant, and only in fmall quantities ;
 in a leucorrhcea the difcharge is inccnftant, and in large quantities. The other
 diftinguifiiing marks of a gonorrh ia are, fmarting in making water, itching
 of the pndrnda, increafed inclination for venery, a fwelling of the labia and
 ofthe glands about th«  groin.  Some  anthers mention the color of  the dif-
 charged matter as a dilunguifhing mark; thii, however, is inconftant. 
IS                  PRACTICE
 bringing on  and in continuing this affection of the uterus
 now under confideration; but I cannot difcover the reali-
 ty of thofe caufes; and it feems  to me, that this leucor-
 rhcea, excepting in fo far as it depends  upon a general de-
 bility ofthe fyftem, is always primarily an afftclion ofthe
 uterus; and the affections  of other parts of the body which
 may happen to accompany it, are for the moft part to  be
 confidered as effects, rather than as caufes.
    989.]  The effects of the leucorrhcea arc much the fame
 with  thofe of menorrhagia :  inducing a general debility,    *
 and in particular, a debility in the functions ofthe ftomach.
 If, however,  the leucorrhcea  be moderate, and be not ac-
 companied with  any confiderable degree of menorrhagia,
 it may often continue long without inducing any great de-
 gree of debility, and  it is only when the difcharge has been
 very copious as wrell  as conftant, that its effects in that way    1
 are very remarkable. •
    990.] 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.
    991. J The matter difcharged  in  the leucorrhcea, is at
 firft generally mild; but after fome continuance of the dif-
 eafe, it  fometimes becomes acrid;* and by irritating,  or
 perhaps eroding, the  furfaces over which it pafies,  induces
 various painful diforders.
   992.] 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 veffels,  it muft
 be treated, and the cure attempted, by  the fame means  as
 delivered in (981.) for the cure of menorrhagia, and  with    '
 lefs referve in  refpect of the ufe of aftringents.t
  * The young practitioner  muft not conclude toohaftily that an ulcer exifts ^
 in the uterus when the matter difcharged is acrid.—Practice has offered ma-
 ny inftances where the matter has excoriated the pudenda, and yet no ulcer   a
 cxifted.
  f The electuary  mentioned at the end of the laft note on Article 982, hat   JJ
 been found very efficacious in fome cafes of leucorrhoea.—Its dofe may be j J
 increafed to a drachm tfirice a-day, either fwallowed as a bolus, or diffolved IkVl
 in an ounce of pure water, and half an ounce of pure cinnamon-water.  The
rhalybeate waters are ufed in this, as well as in the former difeafe ; and they    i
 may he ufed in the manner  above mentioned.  Practitioners recommend, in
 thefe cafes, a nutritive  but not a heating diet, as mucilaginous broths made   J
 i\ithrice,  efpecially veal-broth, jellies  of all kinds, except thofe that are    „
 high feafoned. Port-wine muft be prefcribed in a moderate quantity, accord-
 ing to the habits of the patient. 
6 F  PHYSIC.
13
   993-] A-s trie  leucorrhcea generally  depends upon a
great lofs of tone in the veflels of the  uterus, the difeafe
has been relieved, and fometimes cured by certain ftimu-
lant medicines, which are commonly determinecTto the uri-
nary paffages, and from the vicinity of thefe are often com-
municated to the uterus.   Such, for example, are cantha-
rides, turpentine, and other balfams of a fimilar nature.*

                     CHAP. VIII.

©f t&e 3menorr!)Oca,  or  interruption  of  t&c
                  menstrual jflur,

99 4-J W HAT EVER, in a fyftem of methodical no-
fology, may be the fitteft place for the amenorrhoea, it can-
not be improper to treat of it here as an object of practice,
immediately after having confidered the menorrhagia.
   995-J The interruption of the menftrual flux is to be
confidered as of two different kinds; the one being when
die menfes do not begin to flow at that period of life at
which they ufually appear; and the other being that when,
after they have repeatedly taken place for fome time, they
do, from other caufes than conception, ceafe  to  return  at
their ufual  periods:  The former of thefe cafes  is named
the retention, and the latter the suppression, of the menfes.
   996.J As the flowing  ofthe menfes depends  upon the
  * The practice here recommended is not  without danger, and muft not be
followed except with great caution  and circumfoe&ion.  When the other
means fail in producing relief, we may then havewceurfe to thefebalfat&ic*,
or join them to the tonic aftringents, as,
          ft. Gum. oliban.
             Terebinth, venet.
             Alum.
             Terr. Japonic, a a $i>
             Sal. martis 3»s.
             M. f. massa. in pilulas seqiaales No. 60, dividend.
  Two- or three of thefe pills may be given twice a day or ofteneK
  Some practitioners have ftrongly recommended the following eraulfien.
          R. Balsam, copaivi. 3»«
             Nitd, ovi No. 1.
             Tere in mortar, marnaor. et adde gradatim,
             Aq. font. Svii.
             Svr. Simpl. Ji.
             M. f. Emuls.
  The dofe of this f niuliion is two or three fpoonsftd three OT four times a-d***;
  Vol. Ii,                    |; 
M
PRACTICE
force of the uterine arteries impelling the blood into their
extremities, and opening thefe fo as to pour out red bloodj
fo the interruption ofthe menftrual flux muft depend, ci-
ther upon the want of due force in the action of the uterine
arteries, or upon fome preternatural refiftance in their ex-
tremities.   The  former I fuppofe to be the moft ufual
caufe of retention,  the latter  the  moft common  caufe of
fuppreffion; and of each of thefe I fhall now treat more par-
ticularly.
   997-J The retention ofthe menfes, the emansio emensium
of Latin writers, is not  to be confidered as a difeafe mere-
ly from the menfes not flowing at that period which is ufual
w7ith molt-other women. •  This period is fo different in dif-
ferent women, that no time  can be  precifely afligned 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 be-
ing thereby occafioned.  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 diforders arife
in other rJarts of the body which may be imputed to their
retention;  being fuch as, when arifing at this period,  are
known from experience to be removed by the  flowing of
the menfes.
   998.] Thefe diforders are, a fluggifhnefs,  and  frequent
fenfe of laffitude and debility, with various fymptoms of
dyfpepfia; and fometimes with a preternatural appetite.*
At the fame time the face lofes  its vivid colour,  becomes
pale, and fometimes of a yellowifh hue;  the  whole body
becomes pale and flaccid; and the feet, and perhaps alfo a
great part of the body, become affected with cedematous
fwelling.   The breathing is hurried by any quick or labo-
rious motion of the  body and the heart is liable to palpita-
tion and fyncope.—A  headach fometimes   occurs;   but
more certainly pains of the back, loins, and haunches.t
  * This is a very extraordinary fymptom, which  has not hitherto been ex«
plained.   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, rubbim, charcoal, and various abforbents,
is the moft prevalent.  Stahl,  and his followers, made great ufe of this cir-
Ctimftance in fupporting their favourite opinion of the vis medicatrix naturx.
  \ Thefe pains are not properly fymptoms of the difeafe, but prognoftic* of 
                   OF  PHYSIC.                 15

   999-] Thefe fymptoms, when occurring in a high  de-
gree, conftitute the chlorosis of authors,  hardly ever  ap-
pearing  feparate from  the retention of the menfes;  and,
attending to thefe fymptoms,  the  caufe of this retention
may, I think, be perceived.
   Thefe fymptoms manifeftly fhow a confiderable laxity
and flaccidity ofthe whole fyftem; and therefore give rea-
fon to conclude, that the retention of the  menfes accom-
panying them,  is owing to a weaker action of the veffels 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.
   1000.J How it happens that at a certain period of life
a flaccidity of the  fyftem  arifes  in young women not ori-
ginally affected 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 prefum-
ed, that the ftate of the ovaria and that of the uterine vef-
fels  are in fome meafure connected together; an<5 as gener-
ally fymptoms of a change in the ftate of the former appear
before thofe of the latter, it may be inferred that the  ftate
of the ovaria has a great fhare in exciting the aftion of the
uterine veffels  and  producing the menftrual  flux.   But
analogous to what happens in the male fex, it may be pre-
fumed, that in females a certain  ftate of the genitals is ne-
ceffary to gire  tone and tenfion to the whole  fyftem; and
therefore that, if the ftimulus.arifing from the genitals be
wanting, the whole fyftem may fall into a torpid and flac-
cid  ftate, and from thence the chlorofis and  retention  o£
the menfes may arife.
   1001.J It appears to me, therefore, that the retention1
of the menfes is to be referred to a certain itate or affection
of the ovaria:  but what is precifely the nature of this af-
fection, or what are the caufes of it, I will not pretend to
explain;  nor can I explain in what manner that primary
caufe of rctentipn  is to be removed.   In this,  therefore,.
the efforts nature male;; to remove, the difeafe.;  They are fymptoms ofthe
vis medicatrix. 
u
PRACTICE
as in many other cafes, where we cannot affign the proxi-
mate caufe of  difeafes,  our indications of  cure muft be
formed for obviating and removing the morbid effects or
fymptoms which appear.
   1002.]  The effects, as has been faid in (999.) confift in
a general flaccidity of the fyftem,  and confequently  in  a
weaker  action  of the veffels of the uterus; fo that this de-
bility may be confidered as the more immediate caufe of
the retention.   This therefore, is to be cured by reftoring
the tone of the fyftem  in general, and by exciting the ac-
tion of the uterine veffels in particular.
   1003.]  The tone of the  fyftem in general is to be reftor-
ed by exercife, and in the beginning ofthe difeafe, by cold
bathing.   At the fame  time, tonic medicines* may be em-
ployed; and of  thefe  the  chalybeates  have been chiefly
recommended.
   1004.] The action of the veffels ofthe uterus may be
excited :
   ill,  By determining the  blood into them  more copiouf-
ly ; which is to be done  by determining the blood into the
defcending aorta, by purging, by the  exercife of walking,t
by friction, and by warm bathing ofthe  lower extremities.
It is alfo probable that the blood may be determined more
copioufly into the hypogastric arteries which go to the ute-
rus, by  a compreffion of the iliacs ;  but  the trials of this
kind hitherto made have  feldom fucceeded.
    1005.]  2^y? The action of the  uterine veffels may  he
excited by ftimulants applied to them.  Thus thofe purga-
tives which particularly ftimulate the inteftinum rectum,*
   * Forms of the tonic medicines have been given in fome of the preceding
notes.  The electuary in the note on article 9S2. is frequently ufed with fuc-
cefs.-  In this cafe, we muft not ufe aftringents, but tonics, and confequently
only fuch tonics as are not aftringents, at leaft in a high degree.  The fimple
bitter tonics frequently anfwer where the fymptoms are not fevere.  The in-
fufum gentianae compofitum of the new London Pharmacopoeia is a good for-
mula. The  dofe of it is two  ounces twice a day, or oftener, if the ftomadl
can bear it.   Chalybeates are abfolutely neceffary if the difeafe withftands
the ufe of bitters ; they may be given in any of the forms mentioned in the
preceding notes.
   t Dancing is alfo a proper exercife in  this difeafe.
   | The ftimulant purges are in general the drafticrefins, as Scammony, Aloes.
&c.  Various formulx of them have been recommended in thefe cafes ;  the
pilul* Rufi is commonly ufed with good effect.   It may be given in the quan-
tity of half a drachm, or, in ftrong conftitutions, two fcruples.  It ought not
tobe repeated above twice a week; and, in the intermediate days, we may
employ the tonic medicines above mentioned.  The Filulaeecphraeticae ofthe,
Edinburgh Pharmacopoeia is another very effectual medicine iu thefe cafes, 
                    O F  ft H Y S I C.                  17

may alfo prove  ftimulant  to the uterine veffels connected
with  thofe  of the rectum.   The exercife of venery cer-
tainly proves a ftimulus to the veffels  of the uterus; and
therefore may  be ufeful when,  with propriety,  it can be
employed.  The  various  medicines recommended as fti-
mulants of the uterine veffels, under the title of Emmena-
gogues, have never appeared to me to be effectual; and I
cannot perceive that any of them are poffefled of a fpecific
power in  this refpe6t.  Mercury, as an univerfal ftimulant,
may act upon the uterus,  but cannot be very lately em-
ployed  in chloiotic perfons.  One of  the  moft powerful
means of exciting the action of the veffels in every part of
 the fyftem is,  the electrical  fhock; and it  has often been
employed with fuccefs for  exciting the veflels ofthe uterus.
    1006.J  The remedies (1002—1005.) now mentioned,
are thofe adapted to the retention of the menfes;  and I am
next to confider the cafe of suppression.   In entering upoa
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 fuppreffion.   For the flux,  upon its firft appear-
 ance, is  not  always immediately eftablifhed in its regular
 courfe; and therefore, if an interruption 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 retention, efpecially when the difeafe appears with
 the fymptoms peculiar to that ftate.
    1007.] 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
 Its dofe is half a drachm twice a week, if we intend to purge brifkly, but, 07
 giving a fmaller quantity, as ten,  twelve, or fifteen grains Once a-day, a com-
 ftant ftimulus is preferved, which fome practitioners prefer.  The following
 pills are alfo much recommended:
            R. Pil. Gummos.
              Aloes Socotorin,  a a. 3'i-
              Vin. Aloet. q. s.
              M. f. Mafia in pllulas 41 dividend.
    The dofe is 3 or 4 pills at bed time.
   The Tinctura facra is alfo frequently ufed as a brifk purge In thefe cafes:
 its dofe for this purpofe mutt not be lefs than an ounce and a half in moft ha-
 bits ; but a ftrong conftitution will  require two ounces or more. Other fti-
 mulants than purges have been employed in amenorrhoea, as the tinctura fabi-
 na compofua of the new London  Pharmacopoeia;  its dofe is thirty or forty
 drops, 'm any fuitable vehicle, as the tinctura myrrh <e ofthe fame Pharmaco-
 poeia, in dofes of twenty or thirty drops, is often recommended on the aatho»
 rity of Boerhaave. 
I
  U                 PRACTICE

  which the interruption cannot be referred  to the caufes of
  retention (1001, 1002.) but muft be imputed to fome re-
  fiftance in the extremities of the veffels of the uterus.  Ac-
  cordingly, we often find  the fuppreffion induced by cold,
  fear,  and other  caufes which may  produce a conftriction
  of thefe extreme veffels.  Some phyficians have fuppofed
  an obftructing lentor ofthe fluids to occafion the refiftance
  now mentioned:  but this is purely hypothetical,  without
  any proper  evidence of the fact;  and it is befides, from
  other confiderations, improbable.
    1008.] There are indeed fome cafes of fuppreffion that
  feem to depend upon a general debility of the fyftem, and
  confequently of the veffels of the uterus.   But in fuch
  cafes, the fuppreffion always appears ai> fymptomatic of other
 affections, and is therefore not to be confidered here.
    1009.]  The idiopathic cafes of fuppreffion (1007.) ^
 dom continue long  without  being  attended with  various
 fymptoms or diforders in different parts of the body; very
 commonly arifing from the blood which fhould  have paff.
 ed by the uterus, being determined more  copioufly  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 confe-
 quence of fuppreffed menfes.  Befides thefe,  there are
 commonly hyfteric and dyfpeptic  fymptoms produced by
 the fame caufe;  and frequently cholic pains, with a bound
 belly.
   1010.] In the idiopathic cafes  of fuppreffion, (1007.)
 the indication of cure is to remove the conftriction affect.
 ing the extreme veffels ofthe uterus ; and for this purpofe
 the chief remedy is warm bathing applied to the  region of
 the uterus.   This, however, is not alwavs effeaual, and I
 do not know of any other remedy adapted to the indication.
 Befides this, we have perhaps no other means of  removing
 the conftriBion in fault, but that of increafing the  action
 and force ofthe veffels ofthe uterus,  fo as thereby to over-
 come the refiftance or conftriction of the extremities. This
therefore is to be attempted by the  fame remedies in the
ca.fe of fuppreffion, as thofe prefcribed in the cafes of re-
tention (1003. 1005.)  The tonics,  however, and cold-
bathing (1003.) feem  to be lefs properly adapted to the 
t> F  P H Y S I C.                  19
cafes of fuppreffion, and have appeared to me of ambigu-
ous effect.*
   1011.] It commonly happens in the cafes of.fuppreffion,
that though the menfes do not flow at their ufual periods,
there are  often at  thofe periods fome marks of an effort
having a tendency  to produce the difcharge,   It is there-
fore at thofe  times efpecially when the efforts ofthe fyf-
tem are concurring, that we ought to employ the remedies
for curing a fuppreffion; and it is commonly fruitlefs to
employ them  at other times, unlefs they  be  fucht as re-
quire fome continuance in their ufe to produce their effects.
   1012. J Nearly  fimilar to the cafes  of fuppreffion, are
thofe cafes in  which the menfes  flow  after long  intervals,
and in lcffer quantity than ufual;  and when thefe cafes are
attended with  the diforders in the fyftem (1009.) they are
to be cured by the fame remedies as the cafes of entire fup-
preffion.
   1013.] It  may be proper in  this place to take noticraf
the defmenorrhea,  or cafes  of menftruation  in which the
menfes feem to  flow with difficulty, and are accompanied
with much pain in  the back, loins, and lower belly.   We
impute  this diforder partly'to fome  weaker aaion  ofthe
veflels ofthe  uterus, and partly, perhaps more efpecially,
to a  fpafm of its extreme veffels.   We have commonly
found the difeafe relieved by employing fome of the reme-
dies of fuppreffion immediately before the approach ofthe
period, and at the  fame time employing opiates.

                      CHAP.  IX.

         £)f  ^mptomatic ^emorrbagieau

 1014.] J_ HAVE thought it very improper,  in this work,
to treat  of thofe morbid affeaions that are almoft always
fymptomatic of other more primary  difeafes; and this for
  * The Emenagogues enumerated in the note on article 1006, are more effi-
cacious in thefe cafes than the tonics and chalybeates mentioned in the note
on article 1003, for this reafon, that the fuppreffion of the menfes depends
more on the conftriction,  than on a laxity of the extreme veffels. Some cafes
indeed, occur, where a lax habit is the caufe of fuppreffion, but they are rare.
The phyfician ought to be attentive in difcriminating fuch cafes, becaufe a
liberal ufe of forcing emenagogues is always hurtful in them ; they can only
be relieved by tonics, and Efpecially by chalybeates.
  t Vu. tonics or alterants. 
JO                 PRACTICE
feveral reafons, particularly becaufe it  introduces a gffcat
deal of confufion in  direBing praaice,  and  leads phyfici-
ans to employ palliative meafures only.  I fliall here, how-
ever,  deviate a little from my general plan, to make fome
refleaions upon fymptomatic hemorrhagies.
   1015.]  The hemorrhagies of this kind that efpecially
deferve our notice, are the Hematemefis, or Vomiting of
Blood; and the Hematuria, or the Voiding of Blood from
the urinary paffage.   Upon thefe I am here to make fome
remarks;  becaufe, though they are very  generally fymp-
tomatic, it is poffible they may be fometimes primary and
idiopathic  affections; and becaufe they have been treated
of as primary difeafes in almoft every fyftem of the prac-
tice of phyfie.

                      Sect. I.

  %    Ofthe Hematemesis, or Vomiting  of Blood.
   ioi 6.J  I HAVE faid above in  (944.) in what manner
blood thrown out from the mouth  may be known to pro*
cced from the ftomach,  and not from  the  lungs;  but
it  may be proper here to  fay more  particularly,   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 region of the ftomach;
when the blood brought up is of a black and grumous ap-
pearance,  and when it is manifeftly mixed with other con-
tents of the ftomach;  we can feldom have  any doubt of
the fource  from whence the blood proceeds, and therefore
pf the exiftence of the difeafe we treat of.
   1017.]  We muft allow it to be poffible that a plethoric
ftate of the body from general caufes may be accompani-
ed with caufes of a  peculiar determination and  afflux of
blood to the  ftomach, fo as to occafion an hemorrhagy
there, and  thence a vomiting of blood; and in fuch a cafe
this appearance might be confidered as a  primary difeafe.
But the hiftory of difeafes in the records of phyfie, afford
little foundation for fuch  a fuppofition;  and on the  con-
trary, the  whole ofthe inftances of a vomiting  of blood
which have been recorded, are pretty \panifeftly fymptom*
atic of a more  primary affection.     • 
OF PHYSIC.                 21
   Of fuch fymptomatic vomitings of blood, the chief in- -,
 ftanccs are the following.
   1018.] One ofthe moft frequent is that which appears
 in confequence of a fuppreffion of an evacuation of blood
 which had been for fome time before eftablifhed in another
 part of the body, particularly that of  the menftrual flux in
 women.                      •
   1019.]  There are inftances of a vomiting of blood hap-
 pening from the retention ofthe menfes : but fuch inftances
 are  very uncommon ; as  retention of the menfes rare.ly
 happens in confequence of, or even with a plethoric ftate of
 the body; and as rarely does it produce that, or the hemorr-
 hagy in queftion.
   There are  inftances of  a vomiting  of blood happening
 to pregnant women ;  that might therefore alfo be impu-
 ted to the fuppreffion of the menfes, which happens to wo-
 men in that ftate.  There  have  indeed been more inftan-
 ces of this than ofthe former cafe ; but the latter are ftill
 very rare: for although the blood which ufed to flow month-
 ly before impregnation, is, upon this taking place, retained,
 it is  commonly fo entirely employed in dilating the uterine
 veffels, and in the growth of the foetus that it is feldom
 found to produce a plethoric ftate of the  body, requiring
 a vicarious outlet.
 v. The vomiting of blood, therefore, that is vicarious of
 the menftrual flux, is that which  commonly and almoft on-
 ly happens upon a fuppreffion of that flux, after it had been
 for fome time eftablifhed.
  1020.] When fuch a fuppreffion happens, it maybe fup-
 pofed to operate by inducing a plethoric ftate of the whole
 body, and thereby occafioning hemorrhagy  from othes
 parts of it; and hemorrhagies from many  different parts
 of the body have been obferved by  phyficians as occur-
 ring in confequence of the fuppreffion we  fpeak of.  It is
 however the great variety of fuch hemorrhagies, that leads
 me to think, that with the plethoric ftate ofthe whole body
 there muft be  always  fome peculiar circumftances  in the
 part from which  die blood flows, that determine its afflux
to that particular, often Angularly odd, part;  and diere-
forc, that fuch hemorrhagies may from thefe circumftances
occur without  any confiderable  plethora at the fame time
prevaling in the whole fyftem.
  Vol. IJ.                  G 
22
PRACT ICE
   1021.}  It is tobe obferved,  that if we arc to expect an
hemorrhagy in confequence of a fuppreffion of the menfe'l
inducing a plethoric ftate of the fyftem, we fliould expea
efpecially an hemoptyfis,  or hemorrhagy from the lungs,
as a  plethora might be expected to fhow its effeas efpeci-
ally there; and accordingly, upon occafion of fuppreffed
menfes, that hemorrhagy occurs more  frequently than
any other : but even this, when it does happen, neither in
its circumftances nor its confequences, leads us to fuppofe,|
that at the fame time  any confiderable  or  dangerous ple-
thora prevails in the body.
 .  3 02 2.J Thefe confiderations in (1020. 1021.) will, I ap-
prehend, apply to our prefent fubjea;  and I would there^
fore  alledgc, that a hematemefis may perhaps depend up-
on particular circumftances of the ftomach determining an
afflux of blood to that  organ, and may therefore occur
without any confiderable or dangerous  plethora  prevail-
ing in the fyftem.  What are the circumftances of the fto-
mach, which upon the occafion mentioned, may determin©
an afflux of bipod to it, I cannot  certainly or clearly ex-
plain ; 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.
   1023.] From thefe refteaions, we may, I think draw
the following conclufions:
   I. That the hematemefis we fpeak  of is hardly ever a
dangerous difeafe.
   I;I. That it will hardly ever require the remedies fuit-
ed to the cure of aaive hemorrhagy ;  and at leaft that it
w;ll  require thefe only in thofe unufual cafes in which there
appear ftrong  marks of a general plethora, and  in which
the vomiting of blood appears to be confiderably aaive,,
very profufe, and frequently recurring.
   III. That a vomiting of blood from fuppreffed menfes,
 ought feldom to prevent the ufe of thefe remedies of ame-
 norrhea, which might be improper in the  cafe of an aaive
 idiopathic hemorrhagy.
   1034,] Another cafe of fymptomatic hematemefis quite
 analagous to that already,  mentioned,  is.the hematemefis
 following, and feemingly depending upon,-the fuppreffion 
0 rF  P H Y S I C.
gff
  of an hemorrhoidal flux, which had been eftablifhed and
  frequent for fome time before.                         '
    This may perhaps be explained by a general plethoric,
  ftate induced by fuch a fuppreffion; and indeed fome de-
  gree of a plethoric ftate muft in filch a cafe be fuppofed to-
  take place; but that fuppofition alone will not explain the?
  whole of the cafe; for a general plethora would lead us ta
  txpeaan hemoptyfis (i02i.) rather than an hematemefis^
  and there is therefore  fomething ftill wanting, as in the
  former cafe} to explain the particular determination to the
  ftomach.
  -  Whether fuch an explanation can be gdt'from the con-
  nexion between the different parts of the fahguiferous vef-
  fefs of the alimentary canal, Or from the connexion of the
  whole of thefe veffels with the vena portarum,  I mall  not
  venture to determine.   But in the  meah tiine I imagine,
  that  the explanation required is rather to be detained from-
  #»at  connexion of the ftomach with the hemorrhoidal af-
  feaion that I have taken notice of in (945J
    1625. J H6w we may explain  the hematemefis Occafi-
  oned by a fuppreflion of the hemorrhois, the confiderations
  in (load,  1021.) will apply here as in the  analogous cafe1
 of hematemefis from fuppreffed menfes; and will'therefore
 allow us alfo to conclude here, that the difeafe we now treat
 Ofwillferdoni  be  dangerous,  and will feldom require the
 feme remedies  that idiopathic and active hemorrhagy does.-
    10267.]  The cafes of hematemefis already mentioned*
 may be properly fuppofed to be hemorrhagies of the arte-'
 rial kind;  but it is probable that the ftomach is alfo liable
 to hemorrhagies of the Venous kind (767.)
   In the records of phyfie therefcre many inftances of vo-
 miting  blood,  which were accompahied  with a tumefied
 fpleen,  which had eomprcfTed the vas breve, and thereby
 fVre-ventcdthe free return of venousblood from tfiLftomacrv
 How  fuch an interruption of the venous blooTmay occa-
 fion-an hemorrhagy from either the extremities of the veins
 trvemferves, or from the extremities of their correfponderit
 arteries, we have explained above in (76&.J and the hifto-'
 nes of tumefied fitfeerrs compreffing the vafa brevia, afford
 ah excellent illuftration and confirmation of our doarine'
0V1 that fubject, and  render it fufficiently  jWbable  that
vomitings of Wood often arife from fuch a caufe, 
Vk                 PRACTICE
   1027.]  It is alfo poffible,  that an obftruction of the li-
ver refifting the free motion of the blood in the vena por-
tarum, may fometimes interrupt free return of the venous
blood from the veffels of the ftomach, and thereby  occafi-
on a vomiting of blood;  but the inftances  of this are nei-
ther fo frequent nor  fo clearly explained as thofe  of the
former cafe.
   1028.J  Befides thefe cafes depending on  the ftate of the
liver or fpleen, it is very probable that other hemorrhagies
of the ftomach are frequently of the venous kind.
   The difeafe named  by Sauvages  Melaena, and by other
writers commonly termed the Morbus Niger (771.] con-
lifting in an evacuation either by vomiting or by ftool, and
fometimes in both ways, of a  black and grumous blood can
hardly be  otherwife occafioned, than by a venous hemorr-
hagy from fome pfert of the internal furface of the alimen-
tary canal.
   It is, indeed, poffible, that the bile may fometimes put
on a black and vifcid appearance and give  a real founda-
tion for the appellation of an Atra  Bilis : but it is certain,
that inftances of this are very  rare  ;  and it is highly pro-
bable that what gave occafion to the notion  of atra  bilis
among the ancients, was truly the appearance of blood pour-
ed into the alimentary canal in the  manner I have menti-
oned ; and which appearance, we know, the blood always
puts on when it has ftagnated there for any length of time.
I  fuppofe it is now generally thought, that Boerhaave's no-
tion of fuch a matter exifting in the mafs of blood, is with-
out any foundation;  whilft, by diffeaions in modern times,
it appears very clearly, that the morbus niger prefenting
fuch an appearance of blood, always depends upon the e f-
fufion and ftagnation  I have  mentioned.
   1029.3 From this account ofthe melaena it will appear
that vomiting of blood may arife in confequence of blood
being poured out in the manner I  have mentioned, either
into the cavity of the ftomach itfelf, or into the fuperior
portions of the inteftines, from whence matters often pafs
into the ftomach.
    1030.] Both in the cafe ofthe melaena, and in the ana-
logous cafes from affeaions of the fpleen  or liver, it will
appear, that the vomitings  of blood occurring muft he
confidered as fymptomatic affections, not at all to be treat- 
OF  PHYSIC.
25
cd as a primary aaive  hemorrhagy, but  by remedies, If

any  fuch be known,  that may refolve the primary  obflruv.-

tions.*

  * This is doubtlefs the moft rational practice, namely, to rcf Ive the ob-
ftrufVion which has occafioned the blood to be thrown or drive;, to the intef-
tines.  To  difcover this primary obftruction is, however, extremely dillicult ;
and, even when it is difcovered, it is frequently  not eafily refolved ; in fuch
cafes, therefore, we muft ufe the general remedies for removing the plethora,
except laxatives, the operations of which, in general, derive the fluids  fo the
inteltines.  Sweating is perhaps the beft general evacuation for determinir.g
the fluids from the inteftines ; but its ufe ought  to be preceded by bleeding :
and icought not, in thefe cafes, to be excited by naufeating dofes of emetics,
as thefe produce the fame effect as  laxatives ;  we muft therefore have re-
courfe to the light aromatics, fage, mint, balm, white-whey, &c.   Camphor
and opium  are alfo proper fudorincs in thefe cafts.   They may be given to-
gether, as in the f>,llowing b~iur. :
             ft. Camphor,  gr. vi.
                 Spr.  vnii gutt.  x.
                 Opii pur. gr. i.
                Conf. card. 3 s. vel.  q. s.
                M. f. bolus.                •  ■
 Bot.c practitioners  have recommended large quantities of fpermaceti in caTes
 of hematemefis, and not without reafon.  It may be given  in emulnons, witlj
 j >!ks of eggs, or in an electuary.  1 fliall therefore add a formula of each.
              ft. Spermat. cet. |ss.
                 Vitcl. ovi. q. s.
                 Tere in  mortar, marniorco, et adde
                 Aq. font.  3vii.
               .. Syr. simpl. 3ji.
                 II. f. EmuJs.
 The dofe of this emulfion is two or  three tablc-fpocmsful every three hours.
              ft. Spermat. cet. B'»
                 Conserv. rosar.  %\u
                 Syr. simp. 3i.
                 M. f. elect.
   The dofe of this electuary is a tea-fpoonful or two every two or three hours.
    If the hematemefis be violent, we muft have recourfe to fome of the ftyptics
 and aftringents mentioned before in the cure of the hemorrhagy in general, as
 alum, caiechu, kino, &c. of which I fhall fubjoin fome formula.
              ft. Alum. ust. gr.  iii.
                 Kino 9js.
                 M. f. Pulvis.
   This powder may be repeated every two hours, and three  table fpoonsful
 of the tincture of rofes may.be given to wafh it down.
    The eleciuarium  japonicum of the Edinburgh Pharmacopoeia is well calcu-
 lated for thefe cafes ; its dole is a drachm and a half or two drachms.  The
 extract of  logwood is fometimes ufed in thefe cafes with confiderable fuccefs.
 It may either be given alone in d^ fes of a fcruple each every three hours,  or
 joined with alum, as in the following formula;
              ft. Extract, lign. Campcchcns. 9ss.
                 Alum. ust. gr.  iii.
                 M. f. pulxis.
   This powder may be  repeated every  three hours; drinking after it three
 table-fpoonsful of the tincture of rofes; or a tea-cup full ci cold water,  wik
 twenty or  thirty drops of the acidum vitriolicum dilutum, or as much as i\:\.-
 cient to give an agreeable acidity.   AU thefe ityptics  and aftringeiftTarc xv\ 
25
PRACTICE
    1031.] I believe I have now mentioned almoft the whole
 ofthe caufes producing an hematemefis;  and certainly the
 caufes mentioned, are thofe which moft commonly  give
 occafion to that fymptom.   Poffibly, however, there may
 be fome other caufes of it,  fuch as that fingular one men-
 tioned by Sauvage of an aneurifm of the  aorta burfting in-
 to the ftomach; and it is poffible,  that  fome  difeafes of
 other contiguous parts,  which have become clofely. ad-
 hering to the ftomach,  may fometimes, by a rupture  into
 the cavity of the ftomach, pour blood into it,  which is af-
 terwards rejected  by vomiting.  It is poffible alfo,  that
 abfeeffes and ulcerations of the  ftomach itfelf, may fome-
 times pour  blood into its cavity  to be thrown up by vo-
 miting.
   I did not think it neceffary, among the  fymptomatic vo-
 mitings  of blood, to enumerate thofe from external  vio-
 lence, nor, what is analogous to it,  that which arifes from
 violent ftraining to vomit;  which laft, however,  is much
 more rare than might be expected.  In either of thefe cafes
 the nature of the difeafe cannot be doubtful, and the  ma-
 nagement of it will  be readily  underftood from what  has
 been delivered above with  refpect to moderating and  ref-
 training hemorrhagy in general.

                       Sect. II.

 Of the Hematuria, or the Voiding of Blood from the Uri-
                     nary Passage.
   1032.J IT is alleged, that an  hematuria has occurred
 without 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 inltance of
idiopathic hematuria, and of the nature of thofe active he-
morrhagies I have treated of before.
   1033-J I  cannot pofitively deny the exiftence of fuch a
cafe; but muft obferve, that there are very few inftances of
to produce coftivenefs, which muft be removed by  emollient glyfters as lax-
ative medicines are, for the reafons above mentioned, generally hurtful in
thefe cafes.  The young practitioner muft not truft. to tftefe medicines for
completely curing a hemorrhage frorrtfhe inteftines; they are only palliatives,
and are of no other ufe than to check the violence of the difeharge until the?
true cauf^of the difeafe be drfcovered; and the difeoyery ef this caufe mull
be Jeft to the fagaeity of the phyfician. 
OF  PHYSIC.                2*
fuch upon the records of phytic ;  that none  have ever ocl
curred to  my  obfervation, or to  that of my friends; and
that the obfervations adduced may be fallacious, as I have
frequently obferved  an  hematuria  without  fymptoms of
other affection ofthe kidney or urinary paflages being, for
the time, prefent; whilit, however, fits of a nephralgia cal-
culofa having, before, or foon after, happened, rendered
it to me fufticiently probable, that the hematuria was owin*
to a wound  made by  a ftone prefent in fome part of the
urinary paflages.
   1034-J The exiftence of an idiopathic hematuria is fur-
ther improbable, as  a general plethora is more likely to
produce an hemoptyfis  (1021.) and as we do not well
know of any circumftances  which might  determine more
particularly to the kidneys.  An idiopathic hematuria, there-
fore, mult certainly be a rare occurrence; and inftances of
fymptomatic affections of the fame kind are  very frequent.
   *°35-] O*16 of  the mofl frequent is, that hematuria
which attends the nephralgia calculofa, and feems mani-
feftly 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 pret-
ty florid colour, but for the moft part isof a dark hue: the
whole of it is fometimes diffufed or diffolved, and therefore
entirely fufpended  in the urine;  but if it is in any large
quantity, a portion  of it is depofited to the bottom of the
veffel containing the voided blood and urine.   On differ-
ent occafions, the blood voided puts  on different appear-
ances.  If the blood poured out in the kidney has happen-
ed to ftagnate for fome time in the ureters or bladder, it is
fometimes coagulated,  and the coagulated  part is after-
wards 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  quantity of  broken down blood
is finall, it gives only a browniIn urine refembling coffee.
It fometimes alfo happens, that  the  blood  ftagnating and
coagulating in the ureters,  takes the form "of thefe veffels,
and  is therefore voided under the appearance of a  worm:
and  if  the coagulated blood happens to have, as  it may
fometimes have, the gluten feparated from the globules,
thefe worm-like  appearances have their external furface
whitifh, and the whole feemingly forming a tube contain- 
28                   PRACTICE
 ing a red liquor.   I have fometimes  obferved the blood
 which  had  feemingly been coagulated in the ureter,  come
 away in an almoft dry ftate, refembling the half burnt wick

 of a candle.*
    1036.]  Thefe are the feveral appearances  of the blood
 voided in the hematuria calculofa, when it proceeds efpe-
 cially from the  kidneys or ureter; 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 out the different

 feat of the difeafe.
    In one cafe,  when  a  quantity of blood from the kidney
 or ureter is coagulated in the bladder, and is therefore dif-
 ficultly thrown  out from  this,  the pain and uneafinefs on
 fuch an  occafion may appear chiefly to be in the bladder,
 though it contains no  ftone;  but the antecedent fymptoms
 will commonly  difcover the nature of the difeafe.

    1037.]  *n an)' °f  tne ca^es °f me hematuria calculofa,
 it will  hardly be neceffary to employ the remedies fuited
 to an active hemorrhagy.   It will  be proper only to em.
 ploy the regimen fit for  moderating hemorrhagy in general,
 and particularly here  to avoid every thing or circumftance
 that might irritate the kidneys or ureters.  Of  fuch cafes
 of irritation there is none more frequent or more confider*
 able than the  prefence of hardened fa?ces in  the colon;
 and thefe therefore  are to be  frequently  removed  by  the

 frequent ufe of  gentle laxatives.t
   1038. J The  hematuria  calculofa J may  be  properly

  • In general, the blood is coagulated and grumous ; hence the urine depoflts
 a dark brown fubftance fomewhat refembling coffee-grounds.  As the grum-
 ous blood is fpecifically heavier than the urine, it falls to the bottom of the
 bladder, and is confequently voided in greater quantity in the beginning than
 towards the end of making water,  the urine that  comes off firft being very
 deep coloured and muddy, but becoming, while it flows, gradually more tranf-
 parent and pure, until at laft it  is perfectly of a natural appearance.  The pa-
 tient generally mentions this circumftance in defcribing his complaints, with
this addition, that he has in t\.e  beginning fome difficulty of making water, but
that this difficulty decreafes in proportion as the urine becomes more tranfparent.
  f Glyfters are preferable to purgatives in thefe cafes, becaufe they are lefi
ftimulating; and the emollient  glyfters are preferable to all others, for their
only  intention is to foften the  hardened faeces. The  only purgatives to be
tifedr are thofe ofthe  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, efpecially thofe made with barley and young animal flefti; barley gruel,
 with prunes boiled in it; fiewed endive, lettuce, and otheroleraceousdimes.
  J The hematuria calculofa  being fymptomatic, can only be cured by remov-
 ing the caufe; it may, however, be greatly relieved by demulcents, as lint- 
OF  PHYSIC  ■                  89
confidered  as a cafe ofthe hematuria violenta:  and there-

fore I fubjoin to that the other inftances of hematuria from
external violence; fuch as that from  external  contufion
on the region of the kidney,* and that from the violent or
long continued exercife of the  mufcles incumbent on the

kidneys.   An inltance of the latter caufe occurs efpecially

in riding.t
    1039.]  It may alfo be confidered as a cafe of the hema-
turia 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 inflaming and

fwelling the neck of the bladder, bring on a rupture ofthe
over diftended blood-veffels, and give occafion to a bloody
urine.   The moft noted  inftance of this is  in the effect of
cantharides in a certain quantity, any way introduced into
the body.   And poffibly fome  other acrids  may have the
fame effect. J
    1040. J Befide  thefe moft frequent inftances of hematu-
ria, which cannot  be confidered as idiopathic hemorrhagies,
there are fome other inftances of hematuria mentioned by

feed tea, decoction of marfli-mallows, mucilage of gum Arabic, thick barley-
water, he.
  * The hematuria proceeding from a contufien of the region of the kidneys
requires general  and topical bleeding, with purges, and an attention to the
antiphlogiftic regimen.   Some practitioners recommend the warm balfams in
■thtjle cafes; but, on account of their heating  quality, their ufe is fomewhat
doubtful.  Nitre is not  always  admiffible, on account of its irritating the kid-
neys ; but it is a powerful antiphlogiftic ;  and, if it is ufed in thefe cafes, rt
muft be well diluted : the mucilaginous drinks are abfolutely neceffary, and
ought to be ufed plentifully.
  f The only method of treating this kind of hematuria is by reft.   A perfon
ful>ject to it ought never to ride
  |  This fpecies of hematuria is cured by evacuating the acrid fubftance, and
by the ufe of the mucilaginous drinks before mentioned.  The acrid fubftance
may be evacuated by antiphlogiftic purges, or by the milder diuretics, as nitre,
decoctions of parlley roots, cream of tartar, whey, &c.  The action of can-
tharides on the urinary  paflages is not well explained.  We can fcarcely be-
lieve that any part of the cantharides is abforbed from the bliftering plaifter;
yet its effects are the fame with thofe produced by taking the cantharides in-
ternally.  The  llrjingury, and .its concomitant  fymptoms, may be relieved by
large and plentiful dilution, and a free ufe ofthe mucilaginous drinks.  Cam-
phor has been thought to have  fpecific quality in preventing and curing the
ftrangury produced by blifters,  and experience warrants the eonclufion:  efpe*
dull; if the camphor is  joined with opium, >u  in the following foruiida >
           ft.  Camphor, gr. vi.
               Spir.  vini gutt. x.
               Opii puri gr. i.
               Cunserv. rosar. %i,
               M. 1', bolus.
  Vol. II.                     D 
 36                  PRACTICE

 authors, that are ftill however  manifeftly fymptomatic ;
 fuch as a difcharge of blood from the urinary palfages, in
 confequence of a fuppreffion of either the menftrual or he-
 morrhoidal 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  conclufions formed in
 (1023.)  Inftances, however, of either of  thefe cafes, and
 efpecially ofthe firft, have been extremely rare.
   1041. J Of fuch fymptomatic  hematuria there is howe-
 ver  one inftance deferving notice; and that is, when a fup-
 preffion ofthe hemorrhoidal flux, either by a communica-
 tion of veffels,  or merely by the vicinity of parts, occa-
 fions a determination of the blood into the veffels of the
 neck of the bladder, which in confequence  of a rixis or
 anaftomofis, pour out  blood  to be voided either with or
 without  urine.    This  caufe is what has been named the
 Hemorrhoides  Veficae; and with fome propriety, when it
ris manifeftly an evacuation vicarious of what  had  before
 been ufually made from the rectum.   With refpect to the
 management of the hemorrhoides veficae, I  would apply
 the whole ofthe doctrines that I have delivered above, with
 refpect to the cure of the proper hemorrhoidal affedion.*
   1042.] There  remains ftill to be mentioned one other  ,
 inftance of fymptomatic  hematuria, which  is that  which   j
 happens in the cafe of confluent  and putrid fmall-pox, as
 well as in feveral other inftances  of putrid difeafes.    The  1
 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.   Such hematuria,
 therefore, is not to be confidered as a fymptom of any af-
 fection ofthe kidneys, but merely as a mark of the putref-
 cent ftate of the blood.
   1043.] *n certam difeafes the urine is difcharged of fuch  <
 a deep red colour, as to 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 lateritia ; both of
 which, however, he fuppofes to be without any blood pre-
 fent in the urine.  In many cafes  it is of importance, in
                 * Articles 846. et fequent. 
OF  FH Y SIC.
afccrtaining the nature ofthe difeafe, 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 proportion conftituent parts of the
urine; and the queftion may be commonly determined by
the following confidcrations.
   It has been obferved above, that when any confiderable
quantity of blood is voided with the urine, there is always
a portion of it depofited at the bottom of the veffel  con-
taining the voided blood and urine: and in fuch a cafe there
will be no doubt in attributing the colour of the urine float-
ing above to fome part of the blood diffufed in it.   The
q ueftion, therefore, with refpect 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 or diffufed, and there-
fore entirely  fufpended in the urine.  In this cafe the pre-
fence ofthe blood  may be commonly known, ift, By the
colour, which blood gives, different from any urine w ithout
blood that I  have ever feen; and I think a little experience
will enable molt perfons to make this diftinction..  2dly, By
this, that the prefence of blood always diminifhes the trans-
parency ofthe 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 appears, if the urine
is examined when  recently voided.   3dly, When urine
has blood mixed with it, it tinges a piece of linen dipped
into it with a red colour, which the higheft coloured urine
without blood, never does..  4thly, High coloured  urine
without blood, upon  cooling, and remaining at reft in a
veflel, almoft always depofites a lateritious fediment;  and
if upon any occafion bloody urine  fhould depofit a fedi-
ment  that may be of a portion ofthe blood formerly dif-
fufed in it, the difference, however, may  be difcerned by
this, that the fediment depofited by urine without blood,
upon the ..rincs being again heated, will be entirely  redif-
folved, which will not happen to any fediment from blood..
Laftly, we know no ftate of urine  without blood, which
fhews any portion of it,  coagulated by a  heat equal to that
of boiling water; but blood diffufed in urine is ftill coagu.
lable by fuch a heat;  and  by this  teft, therefore, the pro*
fence  of blood in urine  may be commonly afcertained^ 
t 'S2   ]
                 BOOK    V.

      Of Profluvia, or Fluxes, with Pyrexia.

1044.] JL ORMER nofologifts  have eftablifhed a clafs
of 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 the
fingle circumftance of an increafed difcharge of fluids, and
which alfo are,  in other refpeefs,  very different from one
another; I have avoided fo improper an arrangement, and
have diftributed moft ofthe difeafes comprehended in fuch
a clafs by the nofologifts, into places  more  natural  and
proper for them.*   I have, indeed, ftill employed here the
general title; but  I  confine it to fuch fluxes only as are
conftantly attended with pyrexia, and which therefore ne-
ceffarily belong to  the clafs of difeafes of which I am now
treating.
   Of the fluxes which may  be  confidered as being very
conftantly febrile difeafes, there are only two,  the catarrh
and dysentery;  and  of thefe therefore I now proceed to
treat.

                       CHAP. I.

                   £)f t{je Catarrh

 1045.]  X HE catarrh is an increafed excretion of mu-
cus from the mucous membrane of the nofe, fauces, and
 bronchia?, attended with pyrexia.
    Practical writers and nofologifts have diftinguifhed the
difeafe by different appellations,  according as it happens
to affect thofe different parts ofthe mucous membrane, the
 one part more or lefs than the other: But I am  of opinion,
 that the difeafe, although affecting different  parts,  is al-
 ways of the fame  nature, and  proceeds from the fame
 caufe.   Very commonly, indeed, thofe different parts are
 affected at the fame time; and therefore there can  be little
 room for the diftinction mentioned.
   * Sausages enumerates no  lefs than thirty-fix genera of fluxes, each  of
 which are fubdivided into numerous fpecies.  Vogel has forty-five ger.era,
 under the title of Profliivia, moft of which are extremely different frcm each
 other in their effential qualities. 
OF  PHYSIC.                 S3
  The difeafe has been frequently treated of under the ti-
tle of Tuffis, or Cough; and a cough, indeed, always at-
tends the chief form of catarrh,  that is, the increafed ex-
cretion from the bronchiae: but a cough is fo often a fymp-
tom of many other affections, which  are  very different
from one  another, that  it is improperly employed  as a
generic title.
   1046.]  The remote caufe of catarrh is moft commonly
cold applied to the body.   This application of cold pro-
ducing catarrh, can in many cafes be  diflinctly obferved;
and I would believe it always to be fo, were men acquaint-
ed  with, and attended to,  the circumftances which deter-
mine cold to act upon the body.  See (94—96.)
   From the fame  paragraphs we may learn what in fome
perfons gives a prediipolition to  catarrh.
    i<*47-]  The difeafe,  of which I am now to treat, ge-
nerally begins with fome  difficulty  of breathing through
the nofe, and with  a fenfe of fome fullnefs flopping up that
paffage.  This is  alfo often attended with fome dull pain
and a fenfe of weight in the forehead, as well as fome itiff-
nefis in the motion  of the eyes.   Thefe feelings, fometimes
at their very firft beginning, and always foon after, are at-
tended with the diftillation from  the nofe; and fometimes
from the  eyes, of a thin fluid, which is often  found  to be
 fomewhat acrid,  both by  its tafte, and by  its fretting the
parts over which it pafles.
    1048. J Thefe fymptoms conftitute the coryza and^nz-
 vedo of medical authors, and are commonly attended with
 a fenfe of laffitude over the whole body.  Sometimes cold
 fhiverings are felt, at leaft the body is more fenfible than
 ufual to the coldnefs  ofthe air;  and with all this the pulfe
becomes,  efpecially in  the evenings, more frequent than
ordinary.
    1049.J 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 dif-
 ficulty  of breathing,  attributed to a fenfe of  ftraitnefs of
 thecheft, and attended with a cough,  which feems to arife
 from fome irritation felt at the glottis.  The cough  is ge-
 nerally at firft dry, occafioning pains about the cheft, and
 more efpecially in the breaft.   Sometimes, together with
 thefe fymptoms, pains refembling thofe of the rheumatifm 
34                 PRACTICE
are felt in fevcral parts of the body,  particularly about the
neck and head.  While thefe Iymptoms take place, the
appetite is impaired, fome  thirft arifes, and a general laf-
fitudc is  felt over all the body.
   1050. j Thefe fymptoms (1047.—1°49-] mark the vio-
lence and height ofthe difeafe; which, however, docs not
commonly continue long.   By degrees the cough becomes
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 hoarle-
nefs and  forencis of the trachea likewife going off, the fe-
brile fymptoms abating, the cough becoming lefs frequent,
and with lefs expectoration, the  difeafe foon after ceafes
altogether. •
   1051.] 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 ufually
liable to be affected by cold air;  and in that condition, if
expofed  to cold, the difeafe, which feemed to be yielding,
is often brought back with greater  violence than before;
and is  rendered not only more tedious than  otherwife in
would have been, but alfo more  dangerous by the fuper-
vening of other difeafes.
   1052.J Some degree of the cynanche tonfillaris often
accompanies the catarrh; and, when the latter is aggravat-
ed by a  frefh application  of cold, the cynanche alfo be-
comes more violent and dangerous, in confequence of the
cough  which is prefent at the fame time.
   1053. J When a catarrh has been occafioned by a violent
caufe;  when it has been aggravated by improper manage-
ment;  and efpecially when it has been rendered more vio-
lent by frefh  and repeated  applications of cold,  it often
paifes into a pneumonic inflammation attended with the
utmolt danger.
   1054.] Unlefs,  however,  fuch accidents  as thofe  of
(1051.—1053.) 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 phthi-
fical difpofition, a catarrh may readily produce an hemop-
tyfis, or  perhaps form tubercles in  the  lungs;  and more
certainly, in perfons who have tubercles already formed 111 
OF  PHYSIC                35
the lungs, an accidental catarrh may occafion the inflam-
mation of thefe tubercles, and in confequence  produce a
phthifis pulmonalis.
   1055. J *n ^derly perfons, a catarrh fometimes proves
a dangerous difeafe.   Many  perfons, as they advance in
life, and efpecially after they have arrived at old age, have
the natural mucus of the lungs poured out in greater quan-
tity, and confequently requiring a frequent expectoration.
If tlierefore a catarrh happen to fuch perfons, and increafe
the influx of  fluids to the lungs, with fome degree of in-
flammation, it may produce the peripneumonia notha, which
in fuch cafes is very often fatal.   See (376.  382.)
   1056.] The  proximate caufe of catarrh feems to be an
increafed afflux of fluids  to the mucus membrane of the
nofe, fauces, and  bronchiae, along with fome degree of in-
flammation affecting thefe parts.  The latter circumftance
is confirmed by this, that in the cafe of catarrh,  the blood
drawn from a vein commonly exhibits the fame inflamma-
matory cruft which appears in the cafe of phlegmafiae.
   1057.J The application of cold which occafions  a ca-
tarrh, probably operates by  diminifhing the perfpiration
ufually made by the fkin, and which is therefore determin-
ed to Ute mucus membrane of the  parts above mentioned.
Asa part of the weight which the body daily lofes by infen-
fible evacuation, is owing to an exhalation from  the lungs,
there is probably a connection between this exhalation and
the cutaneous perfpiration, fo that the one may be increafed
in proportion as  the other is diminifhed:  And therefore
we may undcrftand how the diminution of cutaneous  per^
fpiration, in confequence of the application  of cold,  may
increafe the afflux of fluids to the  lungs, and thereby pro-
duce a catarrh.
   1058.] There  are fome  obfervations made by  Dr.
James Keil which may feem to render this  matter doubt-
ful;  but there is a fallacy in  his obfervations.   The  evi-
dent effects of cold in producing coryza, leave the matter
in general without doubt; and there are feveral other cir-
cumftances which fhow a connection between the lungs and
the furface ofthe body.
   1059.] Whether,  from the fuppreffion of perfpiration,
a catarrh be produced merely by  an increafed afflux of
fluids,  or whether the matter of perfpiration  be at the fame 
86
PRACTICE
time determined to the mucous glands, and there excite a
particular irritation,  may be uncertain; but the latter fup-
pofition is fufficiently probable.
   ic6o.] Although, in the cafe of a common catarrh,
which is in many inftances fporadic, it may be doubtful
whether any morbific matter be applied  to the mucous
glands;  it is,  however, certain, that  the fymptoms  of a
catarrh do frequently depend upon fuch a matter being ap-
plied to thefe glands; as appears from the cafe ofthe mea-
fies, chin-cough, and efpecially from the frequent occur-
rence of contagious and epidemical catarrh.
   1061. J The mention of this laft leads  me to obferve,
that there are two fpecies of catarrh, as I have marked  in
my Synopfis  of Nofology.   One of thefe,  as I fuppofe,
is produced bv cold  alone,  as has been explained above;
and the other feems manifeftly to be produced by a fpeci-
fic 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 inftances the pheno-
mena have been much the fame ; and the difeafe has always
been particularly remarkable in this, that it had been the
moft  widely  and  generally fpreading epedemic known.
It has  feldom appeared in any one country of Europe,
without appearing fucceffively  in every other part  of it;
and in fome inftances, it has been even transferred to Ame-
rica, and has been fpread over  that continent, fo far as we
have had opportunities of being informed.
   1062.J The catarrh from contagion appears with nearly
the fame fymptoms as thofe mentioned (1047—1049-)  *'
feems often to come on in confequence of  the application
of cold.   It comes on with more cold fhivering than the
catarrh arifing from cold alone, and fooner fhows febrile
fymptoms, and thefe likewife in a more confiderable degree.
Accordingly, it more  fpeedilyruns its courfe, which is com-
monly 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
difeafe efpecially,  that is finiflied in a  few days ;  for the
cough, and other catarrhal fymptoms,  do frequently  con-

    • Thefe epidemical catarrh* hav« twen lately termed Influenzas. 
■OF  PHYSIC.                 -37
tlnue longer; and often, when they appear to be going off,
they are renewed by any frefh application of cold.
   1063.]  Confidering the number of perfons who are af-
fected with catarrh, of either the  one fpecies or the other,
andefcape from it quickly without any hurt, it may be al-
lowed to be a difeafe very free from danger : but it is not
always to  be  confidered as fuch ;  for in fome perfons it  is
accompanied with pneumonic inflammation.  In the phthi-
fically difpofed, itoften accelerates the camming on of phthi-
fis ; and in elderly perfons, it frequently proves fatal in the
manner explained above, (1053. and 1055.)
   1064.]  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 necef-
fary than in the former.
   In the cafes  of a moderate difeafe, it is commonly fuf-
ficient to avoid cold, and to abftain  from  animal food for
fome  days ;* or perhaps to lie a-bed, and,  by  taking fre-
quently of fome mild and dilueru drink a little warmed, to
promote a very gentle fweat; and after thefe to take car6
to return very gradually only, to the ufe ofthe free air.
   1065.]  When the difeafe is  more violent, not only the
antiphlogiftic  regimen muft be exactly obferved, but va-
rious remedies alfo become neceffary.
   To take off the phlogiftic diathefis which always attends
this difeafe, bloodletting, in a larger or fmaller quantity,
and repeated  according as  the fymptoms fliall require,  is
the proper remedy.
   For reftoring the determination of the fluids to the fur-
face ofthe body,t and at the fame  time for expeding the
  * Perhaps an abftinence from all food would accelerate the cure > The mu-
cilaginous drinks  ought to be taken in conilderable quantities, and they are
fomewhat nutritive.
  t The means of producing a gentle and continued perfpiration have been
mentioned in  a former note.  In catarrh, however, the ufe of the warmer fu-
ctorifics feems moft effectual.  The elixir paregoricum, diluted with whey, ef-
pecially whey made with the dulcified fpirit of nitre, is of finguiar ufe ; but
it ought not to be  given if there is a confiderable degree of phlogiftic diathe-
fis.  In this cafe,  a fpoonful of the following folution may be given every two
or three hours, till a fweat break out:
           ft.  Tart. emet. gr. ii.
             Aq. font. Bv>«
             ?vr.  Althsex  5ii.
             M.
  It will be neceflary for the patient to chew occafionally feme nmcilaginoufl
  Vol. II.                    £ 
5S
. PRACTICE
fecretion of mucus in the lungs,  which may take off the
inflammation of its membrane, vomiting is the moft effec-
tual means.
   For the latter purpofe, it has been fuppofed, that fquills,
gum ammoniac,* the volatile alkali, and fome other me-
dicines, might be ufeful: But their efficacy has never ap-
peared to me to be confiderable ;  and, if fquills have ever
been very ufeful, it feems to have been rather by their eme-
tic,  than by their expectorant powers.
   When the inflammatory affections of the lungs feem to
be confiderable, it is proper, befides blood-letting, to ap-
ply  blifters on fome  part ofthe thorax.
   As a cough is often the  moft troublefome circumftance
of this difeafe,  fo demulcents may be employed to allevi-
ate it.  See (373.)
   But after the  inflammatory fymptoms have much abat-
ed,  if the cough fhould ftill  continue, opiates afford the
moft effectual means of relieving it; and in the circumftan-
ces juft now mentioned, they may be very  fafety employ-
ed.   See (375.)
   After the inflammatory  and febrile ftates of this difeafe
are almoft entirely gone, the moft effectual means of dif-
cufling all remains of the catarrhal affection, is by fome
•exercife of geftation  diligently employed.

                       CHAP.  II.



1066.]  X HE dyfentery  is a difeafe in which the patient
has frequent ftools accompanied with much griping, and
followed by a tenefmus.  The ftools, though  frequent, are
generally in fmall quantity; and the matter voided is cheif-
demulcent, as Extra& of liquorice, &c. or to take a tea-fpoonful of equal parti
of oil and honey, in order to prevent the (harp matter from irritating the fau-
ces.  The Ele&. Peflorale of the 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 following form:
          R. Lac ammoniac §iv.
             Syr. scillit. Siii.
             M.
  This mixture muft be acknowledged to be fomewhat naufeous, but it has
confiderable efficacy.. The dofe of it is two, or, if the ftOBiach can bear it.
three *able-fpoonsful twice a-day. 
OF PHYSIC.
3»:
ly mucus, fometimes mixed with blood.   At the fame time •
the natural faeces feldom appear, and, when they do, it is-
generally in a compact; and hardened form.
   1067.]  This difeafe occurs efpecially in fummer and au-
tumn, at the fame time with autumnal intermittent and re-
mittent fevers; and with thefe it is fometimes combined or
eomplicatedi*
   1068.J The difeafe comes on fometimes with cold fni-
verings, 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 w7ith griping, arid  a frequent inclination to go to-
ftool.   In indulging this, little is voided ; but fome tenef-
mus attends it.  By degrees, the ftools become more fre-
quent,  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 affecting  the patient.  At the fame time there is  always
more or lefs of pyrexia prefent,  which is fometimes ofthe
 remittent  kind,  and obferves a tertian period.—Some-
times the  fever is manifeftly inflammatory, and very often
of a putrid kind..  Thefe febrile ftates continue to accom-
pany the difeafe during its whole courfe,  efpecially when it
terminates foon in a fatal manner.  In other cafes,  the fe-
brile ftate almoft  entirely  difappears,  while  the proper
dyfenteric fymptoms remain for a long time after.
    1069. J  In  the courfe of the difeafe, whether of fhorter
or longer  duration, the matter voided by ftool is very vari-
ous.   Sometimes it is merely a  mucous matter, without
any blood exhibiting that  difeafe which  Dr. Roderer has
named  the morbus mucosus, and others the dy sent aria 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  confiderable  quantity.  In other refpects,  the  matter
voided is  varioufiy changed in colour and confiftence, and
  • It appears more efpecially in armies encamped in low fwampy ground^
and, without proper management, is highly deftructive« 
4*
PRACTICE
is commonly of a ftrong and unufually fetid odour.  It 19
probable, that  fometimes a genuine pus is  voided; and
frequently a  putrid  fanies,  proceeding  from gangrenous
parts.  There are very often mixed with the liquid matter
fome films  of membranous appearance, and frequently
fome fmall maffes of a feemingly febacious matter.
   1070.] While the ftools confifting of thefe various mat-,
ters are in many inftances,  exceedingly  frequent, it is  fel-
dom that natural faeces appear in them;  and when they do
appear, it is,  as I have mentioned, in the form oi fcybala,
that is,  in  fomewhat hardened, feparate  balls.  When
thefe are voided, whether  by the  efforts of nature, or as
folicited  by art, they procure a  remiffion of all the fymp-
toms,  and more efpecially of the frequent ftools, griping-,
and tenefmus.
   1071. J Accompanied with thefe circumftances, the dif-
eafe proceeds for a longer or a  fhorter time.   When the
pyrexia attending it is of a violent inflammatory kind, and
more efpecially when it is of a very putrid nature, thedif,
eafe 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 altogether, the dif-
eafe is often protracted for weeks, and  even  for months;
but even then,  after  a various duration,  it often terminates
fatally, and generally in confequence of a return and con-
fiderable aggravation ofthe inflammatory and putrid ftates.
In fome cafes the difeafe ceafes fpontaneoufly; the frequen-
cy of ftools, the griping, and tenefmus, gradually diminifh-
es, while natural ftools return.   In other cafes, the difeafe
with moderate fymptoms, continue long, and ends in a di-
arrhcea,  fometimes accompanied with lienteric fymptoms.
   1072.] The remote caufe of this difeafe have been vari-
oufly judged of.  It generally arifes in fummer or autumn
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 confiderablv af-
fect the  ftate of the  bile in the  human body ; but as the
cholera is often without any dyfenteric  fymptoms, and co-
pious  difcharges of bile have been found to  relieve the 
0 F  P H Y S I C.                41
fymptoms of dyfentery, it is difficult  to determine what
connection the difeafe has with the ftate of the bile.
   1073.] It has been obferved, that the effluvia from very
putrid animal fubftances, readily affect the alimentary ca,
nal; and  upon  fome occafions  they certainly produce a
diarrhoea;  but, whether they ever produce a genuine dy-
fentery, I have not been able to learn with certainty.
   1074.] The dyfentery does often manifeftly arife from
the application of cold, but the difeafe is always contagi-
ous :  and, by the propagation of fuch contagion, indepen*
dent of cold, or other exciting caufes, it becomes epidemic
in camps and other places.    It is, therefore, to be doubt-
ed, if the application of cold does ever produce the difeafe*
unlefs where the fpecific contagion has been previoufly re-
ceived into the body: And upon the whole, it is probable*
that a fpecific contagion is to be confidered as always the
remote caufe of this difeafe.
   1075.]  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 occafion-
 ally produced, I cannot determine.  Neither, if the latter
 fuppofition be received, can I fay by what means it may
 be generated.   As little do we know any thing of its na-
ture, confidered in  itfelf;  or  at moft this only,  that, in
common with many other contagions, it appears to be com-
monly  of a putrid nature,  and capable of inducing a pu-
trefcent  tendency  in the human  body.  This, however,
 does not at all explain its peculiar power in inducing thofe
 fymptoms which  properly  and effentiaUy conftitute the
difeafe of dyfentery.   (1066.)
   1076.]  Of thefe  fymptoms the proximate caufe is ftill
 obfeure.   The  common opinion has been, that the difeafe
 depends upon an  acrid matter received into, or generated
 in the inteftines themfelves, exciting their periftaltic mo-
 tion, and thereby producing the  frequent ftools which oc*
 cur in this difeafe.   But this fuppofition cannot be admit-
ted ;  for in all  the inftances known of acrid fubftances ap-
 plied to the inteftines and producing frequent ftools,  they
 at the fame time produce copious  ftools, as might be ex-
 pected 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 
42                 PRACTICE
fmall quantity, and fuch as may be  fuppofed to proceed
from the lower parts of the rectum only.  With refpect to
the fuperior portions  ofthe inteftines, and  particularly
thofe ofthe colon,  it is probable they arc under a preter-
natural and confiderable degree of conftriction: For, as I
have obferved above,  the natural fa?ces are feldom void-
ed;  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 confequently  that the colon had been  affected
with a preternatural conftriction.    This  is confirmed  by
almoft all the defections which  have been made of the bo-
dies of dyfenteric patients,  in which, when gangrene had
not entirely deftroyed  the  texture and form  of the parts,
confiderable portions of the great guts have been found  af-
fected with a very confiderable conftriction.
   1077.]  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 colon,
occafioning at the fame time thofe fpafmodic efforts which
are felt in fevere gripings, and which efforts,  propagated
downwards to the rectum, occafion there the. frequent mu-
cous ftools and tenefmus.   But, whether this explanation
(hall be admitted  or not,  it will  ftill remain certain, that
hardened faeces retained in the colon are the caufe of the
griping, frequent ftools, and tenefmus; for the evacuation
of thefe faeces, 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 immediate
and  fuccefsful cure of dyfentery is  obtained by an early
and conftant attention to  the preventing the  conftriction,
and the frequent ftagnation of faeces in the  colon.
   1078.] In this manner I have endeavoured  to afcertain
the proximate caufe of dyfentery, and therefore to point
out alfo the principal part ofthe 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.
   1079-J The moft eminent of our late practitioners, and
of the greateft experience in this difeafe, feem to be of opi-
nion, that the difeafe is to be cured  moft effectually  by
purging affiduoufly employed.   The means mav be vari-
ous;  but the moft gentle  laxatives are ufually fufficient; 
OF  PHYSIC.
42
and as they muft be frequently repeated, the  moft gentle
are the molt fafe; the more efpecially as an inflammatory
ftate  fo  frequently'accompanies the difeafe.   Whatever
laxatives  produce an evacuation of natural faeces, and a
confequent remiffion of the fymptoms,  will be fufficient
to effectuate the cure.  But if gentle  laxatives fhall not
produce the evacuation now mentioned, fome more pow-
erful medicines muft be employed;* and I have found no-
thing more 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 amongft the moft improper
purgatives.
   1080. J  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 ofthe 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  poffefs
no fpecific power ; and it proves only ufeful when fo ma-
naged as to  operate chiefly by ftool.
   1081.]  For relieving the  conftriction of the colon, and
evacuating the retained fseces,t 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.
 " I Hull fubjoin fome formulas fuitable for procuring a paflage in the dyfentery.
           R. Infus. semi. 3'ii.
              Manna; opt. %'r»
              M. f. hauft.
          R. Manns §i.
              Sal. glauber.  *ss.
              Solve in aq. bullient. %'m.; et adde
             Tinct. Cardamomi $\.
    Where ftronger purgatives are requifite,
          R. Refin. Jalap,  gr. x. vel xv.
             Tere in mortario marmoreo, cum
             Amygdal. dulc. decort. No. iii.
             Sacch. alb. 3i;
             Dcin adde
             A. cinnamom. fimpl. §iss.
             M.
  t Glyfters in thefe cafes ought to be made very large, and they  ought alia
to be very mild; as a pint and a half, or even two pirns, of thin lint-feed tea,
or decoction of m^rty allows, without any other addition. 
44                   PRACTICE
   1082.] The frequent and  fevere  griping attending this
 difeafe, leads almoft neceffarily to the ufe  of opiates, and
 they are very effectual for the purpofe of relieving from the
 gripes ;  but by occafioning an interruption ofthe atlion of
 the fmall guts, they favour the conftriction of the colon,
 and thereby fometimes aggravate the difeafe ; and if at the
 fame time the ufe of them fuperfede in any meafure the em-
 ploying of purgatives, it commonly does much mifehief;  I
 believe it indeed to be only the neglect of purging that ren-
 ders the ufe of opiates very neceffary.*
   1083.] When the gripes are both frequent and fevere,
 they may  fometimes be relieved by the employment of a
 femicupium, or by a fomentation ofthe abdomen, continu-
 ed for fome time.   In the fame cafe, the pains may be re-
 lieved, and, as I  think, the conftritlion ofthe colon may be
 taken oft, by blifters applied to the lower belly.t
   1084.] At the beginning of this difeafe, when the fever is
 any way  confiderable, biood-letting, in  patients of tolera-
 ble vigour, may be proper and neceffary ;  and, when the
 pulfe is full and  hard, with other fymytoms of an inflam-
 matory  difpofition, blood-letting ought to be repeated.
 But,  as the fever attending dyfentery  is  often of a  putrid
 kind, or does, in the courfe of the difeafe, become foon of
 that nature,  blood-letting muft be  employed with great
 caution.
   1085.] 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 perni-
 cious.
   1086.] Whether an  acrid  matter be the original caufe
 of this difeafe may be uncertain ; but from  the indigeftion
 and the ftagnation of fluids in the ftomach which attend the
 difeafe,  it may be prefumed, that fome acrid  matters are
  * The griping is much relieved, and fometimes prevented, by drinking
 plentifully  of any mucilaginous warm  liquors during the operation  of the
 purges ; as barley water, with bruifed prunes boiled in it.
  f Blifters applied to the abdomen, befides being exceflivcly troublefome,
 muft neceffarily be extremely painful.
  Pra&itioners have probably been deceived in thinking that blifters have re-
 lieved gripings in the dyfentery, for they are feldom employed alone ; and the
 effefts of purges and diluents have perhaps been miftaken for the effe&s cf a*
 blifter that might have happened to have been applied at the time when thefe
 other remedies were ufed.  Too ftriet an attention to the falfe axiom, poft
 hoc ergo propter hoc, has been the fource of numerous errors in the pradice
 •f phyfie, and has raifed the reputation of the phyfician and his remedieSj
when the merit was only due to nature. 
OF  PHYSIC.
4j
 conftantly prefent in the ftomach and inteftines, and there-
 fore that demulcents may  be always ufefully  employed.
 At the fame time,  from this confideration that mild  oily
 matters thrown into the inteftines in confiderable quantity
 always prove Iaxatire, I  am of opinion that the oleaginous
 demulcents arc the moft ufeful.*
   1087. J  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. Iviiik in its entire ftate is
 of doubful  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 fubacid
 fruits are  allowable,  and even proper.  It is in the more
 advanced ftages  only  that  any morbid acidity feems to
 prevail in the ftomach, and to require fome referve in the
 ufe of acefcents.  At the beginning of the  difeafe,  abfor-
 bents feem to  be fuperfluous;  and by  their aftringent
and feptic powers they may be hurtful.
   1088.] When this  difeafe is complicated with an inter-
mittent fever, and is protraBcd from that circumftance chief-
ly, it is to be treated as an intermittent, by adminiftering
the Peruvian bark, which, however, in the earlier periods
of the difeafe, is hardly to be admitted.
                  PART   II.

         Of Neuroses,  or Nervous Diseases.

 1089.] IN a certain view, almoft the whole ofthe difeafes
 ofthe human body might be called Nervous: But there
 would be no ufe for fuch a general appellation; and on the
 other hand, it feems improper to limit the term, in the loofe
  * Some forms of thefe demulcents are given in the Pharmapopoeias.  The
following may be added, for the fake of variety, as the patient frequently
loaths Lincuifes.                                     *   *
          R. Mann. rpt.
             01. amygdal. recent, aa. §i.
             Syr. e Cort. aurant. §ss.
             M.
          R. Syr. althxx.
             OI. amygdal.
             Elenitiv. aa, 3?.
             M.
  Vol. II.                  F 
 "46               '  PRACTICE

 inaccurate manner in which  it has been hitherto applied, ton
 hyfteric or hypochondriacal diforders, which are themfelvcs
 hardly  to be defined with fufficient precifion.
   1090.] In this place I propofe to comprehend under the
 title of Neuroses, all  thole preternatural  affections  of
 fenfe or motion which are w ithout pyrexia, as a part ofthe
 primary difeafe ; and all thofe which do not depend upon
 a topical affe6tion ofthe organs, but upon a more general
 affeclion ofthe nervous fyftem, and of thofe powers ofthe
 fyftem upon which fenfe and motion more efpecially depend.
   1091.J Of fuch difeafes I have eftablifhed a clafs, under
 the title of Neuroses, or Nervous Diseases.   Thefe
 1 again diftinguifh, as they confift, either in the interrupti-
 on and  debility ofthe powers of fenfe and motion, or in the
irregularity with which thefe powers are exercifed; and have
accordingly arranged them under the four orders of Coma-
ta, Adynamia:, Spasmi, and  Vesanice, to be denned as we
proceed to treat of. them more particularly.
                  BOOK   L

    VfComata, or the Loss of Voluntary Motion.

 1092.] LJ NDER  this title are comprehended thofe af-
fections which have been commonly  called  the Soporofe
difeafes ;  but they are moft properly diftinguifhed by their
confifting in fome interruption or fuppreffion of the pow-
ers 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 com-
prehended under 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 Palsy.

          R. Conserv. cynofbat.  5:.
             Syr. rosar.
             01. amygdal. aa. §ii.
             M.
  Two tea-fpoonsful of any of the above tinftures may be given every hour,
or every other hour, drinking, at the fame time barley-water with bruifed
prunes boiled in it.  The  cure of the dyfentery  is briefly comprehended i*
Keeping the beily open, and ufing mucilaginous diluents and lubricants. 
                    OT  PHYSIC.                  *?


                       CHAP.  I.

                     ©fapopler?.

1093.] APOPLEXY is that difeafe in which the whole
of the external and internal fenfes, and the whole of the vo-
luntary motions,  are in fome degree abolifhed ; while ref-
piration and the action of the heart continue to be perform-
ed.*  By its being an affection ofthe whole of the powers
of fenfe and  of voluntary motion, we diftinguifh it from
Palsy;  and by its being with the continuance of refpirati-
on  and the action of the heart, it  is diftinguifhed from  Syn-
cope.   I have further  added to  the ordinary definition  of
apoplexy, that the abolition ofthe powers of fenfe and mo-
tion is in some degree only ; meaning by this  to imply, that
under the title of Apoplexy, are here comprehended thofe
difeafes  which, as differing from  it in degree  only,  cannot,
with  a  view either to pathology or pradice, be properly
diftinguifhed from  it: Such  are the difeafes  fometimes
treated of under the names  of Cams, Cataphora,  Coma,
and Lethargus.
   1094. J Apoplexy, in all its different degrees, moft com-
monly aifects perfons advanced in life, and efpecially thofe
above fixty years of age.    It moft ufually affe£ts perfons
of targe heads and  fhort necks,f  perfons of a corpulent
habit, perfons who have  palfed an indolent life and ufed  a
full diet, and efpecially thofe who have indulged infrequent
intoxication. Men who have long labored under a frequent
and copious difcharge of blood from the  hemorrhoidal vef-
fels, upon either the fuppreffion  or fpontaneous ceafing  of
that difcharge,  are  particularly  liable to be affected  with
apoplexy.
  • " The appearance of a profound and continual fleep," is by Boerhaave
judicioufly added to the definition of Apcptexy. To diftinguifh between a pro-
found fleep and apoplexy, which verv much reu-mble each other, is, however,
extremely eafy. A man in a profound lleep may in general be roufed by the
application of ftrong ftimulants to the organs of fenfe which produce no effeit
on an apopledtic patient.  To diftinguifh between apoplexy and a fit of drunk-
ennefs is not fo eafy ;  for  drunken people arc fometimes  incapable of being
roufed  by any ftimulants, remaining totally, infeniible and  motionlefs.  The
fumes ofthe liquor with which they have been intoxicated may fometimes be
difcovered by fmelling : a drunken fit may alfo be Known by the palenels  of the
drunken man's face, and by his manner of living.
  t Different authors, one of whom is Boerhaave, have fuppofed that a v\?r.
tcbra is fometimes wanting, the neck conufting only of lix inftcaa cf  feven
vertebra:. 
48
PRACTICE
   1095.] 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 hemorrha-
gy from the nofe, fome tranfitory interruption ol leein^ and
hearing, fome falie vilion and hearing, fome tranfitory de-
gree of numbnefs or lofs of motion in the cxticmitics. fome
faltering  of the tongue in fpeaking,  a lofi. of memory, a
frequent  cirowfinefs, and frequent fits of incubus.
   1096.] An attention to thefe fymptoms, and to the pre-
difponcnt circumftances  (1094.)  will often enable  us  to
fore fee the more violent attacks of this difeafe.
   1097.] When the difeafe comes on fuddenly to a confi-
derable decree, 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 crowed affembly of peo-
ple; by warm bathing; by intoxication;  by long ftooping
with the head down; and by 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 ver-
nal heat fuddenly fucceeds to the winter  cold.
   1098.J The fymptoms denoting  the prefence of this dif-
eafe will be fufficiently  known  from  the definition given
(1093.)  Although the whole ofthe body is affected 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 leaft affected with palfy  is fometimes affected with
convulfions.   In this difeafe there  is often  a  ftertorous
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 difeafe.
   1099. J The proximate caufe of this difeafe may be, in
general,  whatever interrupts the motion of the nervous pow-
er from the brain to the mufcles, from voluntary motion ;
or, in fo far as fenfe is affected, whatever interrups the mo-
tion ofthe nervous power  from the fentient extremities of
the nerves ofthe brain.
   1100.J Such  an interruption of the motions of the ner-
vous power may be occafioned, either by some compression
ofthe origin of the nerves, or by something  destroying the
mobility  of the nervous power.  Both thefe caufes we muft 
OFPHYSIC.           *    49
treat of more particularly; and, firft, of that of compref-
fion, feemingly the moft frequent occafion of apoplexy, and
perhaps the  occafion of all thofe  apoplexi.es acting from
internal caufes.
   not.J The lofs of fenfe and motion in particular parts
of the body, may be obcafioned by a compreffion, either
of tie origin of certain nerves  only, or ofthe fame nerves
in foinc part of their courfe from the brain to the organs of
fenfe and motion.   Such cafes of partial compreffion will
be more properly confidered hereafter ; and the affection
I am now to treat of being general, it mult depend upon a
very general compreffion ofthe  origin of the nerves, or me-
dullary portion of the brain ; and therefore this more gen-
eral compreffion only is to be confidered here.
   1102. J This compreffion of the origin ofthe nerves, or
medullary portion of the brain, may be produced in diftjjy:-
ent ways ; as,
   l. By external violence fracturing and preffing in a part
of the cranium.
   2. By tumors, fometimes foft, fometimes bony, formed
in different parts of the brain, or in its membranes,  and
becoming of fuch a  bulk as  to comprefs the medullary
fubftance of the  brain.
   3. By the blood being 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 effufed in different parts of the brain, or in-
to the cavity  of the cranium, and accumulated in fuch
quantity as to occafion the compreffion we treat of.
   An<^ 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 veffels ; or a portion of ferum or colorlefs fluid,
poured out chiefly by  exhalants.
   1103.]  Of thefe feveral caufes of compreffion, the firft
is not to be confidered here, becaufe the removing it does
not  belong to our province ; and the confideration 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 properly the fubjects of our air,
fo they are thofe which deferve our particular attention : 
SO                 PRACTICE
and we fliall therefore endeavor to trace them further back
in the feries of caufes  which mav produce them.
   1104.] f>otn me ftates of over diftention and of effufion
may be produced by  whateveHnereafes the afflux and im-
petus of the blood in the arteries of the head ;  fuch as vi-
olent exercife, a violent fit of anger, external heat applied,
or any ftrong preffure upon the defcending aorta.
   1105.J But both thefe ftates of over diftention and of
effufion, may  alfo and feem to be more frequently produ-
ced 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 heart.
   1106. j The venous veffels of the brain are of a confor-
mation ar.d diftribution fo peculiar, as to lead us to believe,
that Nature intended  to retard the motion of the: blood,
ana"accumulate it in thefe veffels; and therefore, even very
fmall additional refiftances to the motion of the blood from
thefe  towards the right ventricle of the heart, may  ftill more
readily accumulate the blood in them.  Such accumulation
■will moft readily happen in advanced life, when the venous
fyftem in general is in a plethoric ftate, and when this ple-
thora takes  place efpecially  in the  venous  veffels of the
brain.  It  will,  in like  manner,  be moft apt to occur in
perfons whofe heads are large with refpect to  the reft of
the body; and  in perfons of a fhort neck, which is un-
favorable to i'he  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 becaufe thefe may be confidered to
be in  a plethoric ftate, or becaufe obefity, by1 occafioning
a compreffion of the blood veffels in other parts  of the
body, more readily fills thofe of the brain, which are en-
tirely free from any fuch compreffion.
   1107. J Thefe are the circumftances in the conftitution
ofthe body, which, producing a {lower motion and return
of the venous  blood from the veffels of the head, favor an
accumulation and diftention in them;  and we now proceed
to mention the feveral occafional caufes, which, in every
perfon, may directly prevent the free return ofthe blood
from the veffels of the head towards the heart.   Such are,
   1.  Stooping down  with the head, or other fituations of
the body in which the head is long kept in a depending ftate, 
O F  P H Y S I C.                 51
and in which the gravity of the blood increafes the aRIux
of it by the arteries, and oppofes the return of it by the veins.
  2.  A  tight ligature about the neck, which compreffes
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 ofthe afcending vena cava.
  4.  Any confiderable impediment of the free paffage of
the fjlood from the veins  into the right ventricle  of the
heart; and it is  commonly by  this, and the immediately
preceding circumftances, that polypous concrotk>n:> in the
cava, or right ventricle, are  found to occafiontapoplexy..
   5.  The return of blood from  the veins of the head to-
wards the heart, is efpecially interrupted by every circum-
ftance that  produces a  more difficult tranfmiffion of the
blood through the veffels of the lungs.  It is well  known,
that, at the end of every expiration, fome  interruption is
given to the  free  tranfmiffion of the blood  through the
lungs;  and that this at the fame  time gives an interruption
to  the motion ofthe blood from the veins into the  right
ventricle ofthe heart.  This clearly appears from that re-
gurgitation ofthe blood in the veins, which occafions the
alternate heaving and fubfiding  that  is perceived in the
brain of living 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 tranfmiffion ofthe blood
through the lungs, muft alfo interrupt the free return ofthe
venous blood from the veffels of the head ;  and muft there-
fore favour, and perhaps produce, an accumulation of blood,
and an over-diftcntion in thefe veffels.
   It is further to be obferved, that as a very  full infpira-
tion,  continued for any length of time,  occafions fuch an
interruption of the free tranfmiffion of the blood through
the lungs, as produces a fuffufion of face, and a manifeft
turgefcence of the blood-vcffels  of the head and neck ; fo
every  full and long continued infpiration may occafion an
accumulation of blood  in  the  veffels of  the  head, to a
very confiderable degree.   Thus, as every ftrong exertion
of the mufcular force ofthe  body requires, and* is attended
with, a very full and long continued infpiration, we thence 
53                 PRACTICE
learn why the violent exertions of mufcular force have been
fo often the immediate or exciting caufes of apopicxy.
   It may alfo be remarked,  that corpulency and obelity
feem to operate very much, by occafioning a more diffi-
cult tranfmiffion of  the blood  through the  veffels  of the
lungs.   It appears that in fat perfon,-, from the compref-
fion of the blood veflels in many parts ofthe  body, the vef-
fels ofthe 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 frequent and laborious refpira-
tion becomes in fuch pcrlons immediately neceflary.  This
fhows, tlS| in fuch perfons, the blood is not freely transmit-
ted through the lungs;.a circumftance \vhich, as in other
inftances, muft give a conftant refiftance  to the return of
blood from the veffels ofthe head, and therefore favour or
occafion an accumulation  of blood in them.
   Is the  motion of the blood in the veffels of the head ren-
dered flower by ftudy,  care, and anxiety?
   1108.] It is to be obferved further, that thefe feveral
caufes (1104.—1107.) of a preternatural  fulnefs  in  the
blood veffels of the brain, may produce apoplexy in dif-
ferent ways, according  as the fulnefs takes place in the ar-
teries or  in the veins.
   1109.] Accordingly, firfl, the increafed afflux of blood
into the  arteries of the brain, and an increafed action in
thefe,  may either occafion a  rupture in their extremities,
and thereby an effufion of red blood producing compref-
fion;  or  the fame  aiilux and increafed action may  occa-
fion an increafed exhalation from  their extremities,  of a
ferous fluid, which, if not as quickly re-abforbed, may foon
accumulate in fuch quantity as to produce compreffion.
   1110.] Secondly, The plethoric ftate of the venous vef-
fels of the brain, may operate in three different ways.
   1.  The fulnefs of the veins may give fuch refiftance to
the blood flowing into them from the arteries, as to deter-
mine the impetus of the blood to be fo much greater upon
the extremities of the arteries as to occafion a rupture of
thefe, and confequently an effufion of red  blood,  or the
Hazmorrhagia cerebri, which Hoffman  confiders as a
frequent  caufe of apoplexy, and which we have before ex-
plained in (771.J
   2.  Whilit the fame refiftance to the blood flowing from 
                   OF  P FI Y S I C.   -ft*-         53

the arteries into the veins,  increafes the impetus of the
blood  to the former, this may, without occafioning rup-
ture, increafe the exhalation  from their  exhalant extremi-
ties, 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 abforbents 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 refiftance to the motion ^he blood
in the  veins of the brain, may readily produce aMccurnu-
lation  of ferous fluid in its cavities, and  confequently a
compreffion producing apoplexy.
   111 x.J 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
ofthe  exhalants, as in the other cafes of hydropic diathefis
prevaling in the  body ; and it is not unufual for a general
dropfy to end in apoplexy.  The fecond  is an over pro-
portion of watery parts in the mafs of blood, which is there-i
fore ready to run off by the exhalants, as in the cafe of an
ifchuriarenalis; which, when it proves incurable, very com-
monly terminates in apoplexy.
   1112.J We have now mentioned  the feveral caufes of
apoplexy depending upon compreffion; and from the whole
it will appear, that tha moft frequent  of all thefe caufes is a
plethoric ftate, or an accumulation and congeftion of blood
in the venous veffels of the head, operating, according to
its degree, in producing  over-diitention or effufion.  The
frequent operation of fuch a  caufe  will efpecially appear
from a  confideration of the  predifponent circumftances 1
(1094.) and from the antecedent  fymptoms. (1095.)
   1113. J From the view I have now given ofthe caufes of
apoplexy arifing from compreffion,   it will readily appear
that there is a foundation for the common diftinction of
this difeafe into  the  two kinds  of  Sanguine and Serous.
But this diftinction cannot be very ufefully applied in prac-
tice, as both  kinds may often depend on the fame caufe,
that is, a venous plethora, and therefore requiring very
Dearly  the fame  method of cure.  The only diftinction
  Vol. II.                 G- 
  54           ^k-  ** R#A C T T C E
  that can dc pioperly made of apoplexies from comprcffiot:,
  is perhaps the diftinction of ferous apoplexv, into that de-
  pending on  the plethora  mentioned (1112.) and  that de-
  pending on  hydropic diathefis or an over proportion of
  water in the blood (1111,) the former caufes giving a pro-
  per idiopathic, the latter only a fymptomatic difeafe.
    ix 14.J Befide the caufes  now mentioned, occasioning
  apoplexy by compreffion, I al ledge there are other caufes
  producing the fame difeafe,  bv directly deftroying the mo-
  bility of the nervous power.   iSuch caufes feem tobe the
  mephitiJkrifing from fermenting liquors,  and from manv
  other foffl^cs;  the fumes arifing from burning charcoal;
  the  fumes of mercury,  of lead, and of fome other metal-
  lic  fubftances;  opium, alcohol, and many other narcotic
  poifbns: To all which 1 would add the power of  cold, of
  concuffion,  of electricity, and of certain paffions'of the
  mind.
    1115.J None of thefe poifons or noxious powers feem
  to kill by acting firft upon the organs of refpiration,  or up-
  on the fanguiferous fyflem ;  and I believe their immediate
  .'md direct atlion to be upon the nervous power, deftroying
  its mobility, becaufe the fame poifons fhow their power in
  deftroying the irritability  of mufcles and ofthe nerves con-
  nected with  them,  when both thefe arc  entirely icperated
  from the reft ofthe body.
    1116. J It appears tome probable, that the apoplectic
  ftate in fome degree accompanying, and almoflPalways Suc-
  ceeding, an epileptic paroxyfm, does not depend upon com-
  preffion, but upon a certain ftate of immobility of the ner-
  vous power, produced by certain circumftances in the ner-
  vous fyftem itfelf,  which fometimes feem to be  commit
~ nicated from one part of the body to another, and at length
  to the brain.
    1117.3 The fame obfervation may be made with refpect
  •to many inftances  of hyfteric paroxyfm ;  and the circum-
  ftances, both of epileptic and hyfteric paroxyfms, ending
  in coma, or a degree of apoplexy lead me to think, that al-
  fo the apoplexy proceeding  from retrocedent or  atonic
  gout is ofthe fame kind,  or that it depends upon an immo-
  bility of the nervous power, rather than upon compreffion.
    1118. J If may indeed  happen, that as theapoplectic and
  gouty predifpofitions do often concur in die fame perfon; 
                   OF  PHYSIC.    <•"          55

fo it may confequently happen, that the apoplexy coming
upon gouty perfons, may fometimes depend  u]*>n com-
preffion; and diffe6tions may,  accordingly,*lifcover that
the circumftances of fuch a cafes had preceded.  But, in
many cafes of apoplexy following a retrocedent, or atonic
gout, no  fuch antecedent or concomitant circumftances,
as commonly occur in cafes of compreffion, do diftinctly
or clearly appear; while others prefent themfelves, which
point out an affection ofthe nervous power alone.
   1119.]  With refpect,   however, to  the  circumftances
which may  appear  upon  the diffection of perfijs dead of
apoplexy, there may  be fome  fallacy in  jui^ig, from
thofe circumftances, of the caufe of the difeafe.  What-
ever takes off or diminifhes the mobility of the nervous
power, may very much retard the motion of the blood in
the veffels ofthe brain; and that perhaps to the degree of
increafing exhalation, or  even of occafioning rupture and
effufion :  fo that, in fuch cafes, the marks of compreffion
may appear, upon diffection, though the difeafe had truly
depended on caufes deftroying the mobility ofthe nervous
power.   This feems to be illuitrated and confirmed from
what occurs in many cafes of epilepfy.   In  fome of thefe,
after a repetition of fits, recovered from in the ufual man-
ner, a fatuity is induced,  which commonly depends  upon
a  watery inundation ofthe brain:  And in other cafes of
epilepfy, when fits have been often repeated without any
permanent confequence,  there  happens at length a fatal
paroxvfm; and upon difle£tion it appears, that an effufion
of blood had happened.   This,-1 think, is to be confider-
ed as a caufe of death,  not as a caufe of the difeafe: for in
fuch cafes, I fuppofe that the difeafe -had diminifiVd the
action of the veffels of the brain, and  thereby  given  oc-
cafion  to  a ftagnation, which produced the appearances
mentioned.  And I apprehend the fame reading will ap-
ply to the cafes of retrocedent  gout, which^1  deftroying
the energy ofthe 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.
   1120.J  The fevcral  caufes mentioned in (1114.) are of-
ten of fuch power as to  occafionimmediate deatjp and
tlierefore have not commonly bcenflken notice of as afford- 
56
PRACTICE
ing inftmces of apoplexy ?-but, as  the operation of the
whole %f thefe caufes is  fimilar and analogous, and as in
moft inftanc«o of the operation of thefe caufes an apoplectic
ftate is manifeftly produced, there can be little doubt in
confidering molt of the inftances of their effects as cafes of
apoplexy, and therefore fuch as fall  properly under  our
confideration here.
   1121. J This difeafe of apoplexy is fometimes entirely
recovered from; but more.frequently it ends  in death, or
in a hemiplegia.   Even when an attack of the difeafe is re-
coveredAom, we generally find it difpofed to return;  and
the repei^d attacks of it almoft always, fooner or later,
bring on the events we have mentioned.
   ii22.J The  feveral events of  this difeafe, in  health,
death, or another difeafe, may be expected and forefeen
from a confideration  of  the predifponent  circumftances
(1094.) of the antecedent fymptoms (1095.) of theexciting
caufes (1097.) of the violence  and  degree of the fymp-
toms when the difeafe has come on (1093.) of the duration
of the difeafe; and of the effects of the remedies employed.
   1123. J From the great danger attending  this difeafe
when  it has come on  (1121.) it  will readily appear,  that
our care fliould 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 ihe enumeration  of thofe caufes given
above  (1097.)  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
moft cafes, feems to be a plethoric ftate of the blood-vef-
fels of the brain.  This,  I think, may be obviated by dif-
ferent means; and, in the firft place,  by a proper manage-
ment of exercife and diet.
   1124. J ^e exercife ought to  be  fuch as may fupport
the perfpin^n, without heating the  body  or hurrying
refpiration;  and,  therefore, commonly by fome mode of
geftation.  In perfons not liable  to frequent fits of giddi-
nefs, and who are accuftomed to riding on horfeback,  this
exercife is, of all others, the beft.   Walking,  and fome
other modes of bodily exercife, may be  employed with
the reftrictions juft now mentioned; but in  old men,  and 
OF  PHYSIC.
ST
in men of  corpulent habits,  bodily exercife ougnt always
to be very moderate.                           •
   1125.J  In perfons who pretty early in lifeihow the pre-
difpofition 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 cor-
pulent habit, which generally fuppofes 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 \ykh refpect
to animal fooci|  and that,  at fuppcr,  fuch food mould be
abftained from altogether.
   In drinking, all heating liquors are  to be abftained from,
as much as former habits will allow;  and the fmalleft  ap-
proach to intoxication is to be  carefully  fhunned.  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 it has been accuftomed to occafion a
copious excretion from the head, the interruption of which
might not  be fafe, the  ufe of tobacco fhould be avoided;
and  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 poffible.
   1126.J  Evacuations by ftool may certainly contribute
to relieve the plethoric ftate of the veffels of the head; and,
upon an appearance of any unufual  turgefcence in thefe,
purging will be very properly employed: But,  when  no
fuch turgefcence appears,  the frequent  repetition  of large
purging might weaken the body too much;  and,  for pre-
venting apoplexy, it may  for the moft part be  enough to
keep the belly  regular, and rather  open, by^ gentle laxa-
tives.*  In the fummer feafon,  it may  be ufeful to drink,
  * Gentle laxatives have been often enumerated in the preceding notes. In
thefe cafes, however, there is no danger to be apprehended from the ufe of
the relinous draftics, provided that they are not given in fuch dofes as may
■weaken the patient too much.  They ought not to be ufed for the purpofe of
purging, but only for keeping the body moderately open; and this effeft ma/
be fafely produced by live or eight grains of Rufus's pills taken occafionally
at bed-time, or by a tea-fpoonful or two of the Tinft. jalap, or a table-fpoon-
ful of the elixir fenna: in the morning.  The fame end may, in many cafe:,, bo
anfwered by a due ittcutionto diet. 
53                 PRACTICE
every morning, of a gcntjp  laxative mineral water, but
never iff'large quantity.
   1127. J In the cafe of a plethoric ftate of the fyftem,  it   ^
might be  fuppofed that bl^tfcl-letting worild be the moft    |
effectual means of diminifhing  the  plethora, and of pre-
venting its  confequences; and, when an  attack of apo-
plexy is immediately threatened, bldod-lctting is certainly
the remedy  to be depended  upon;  and blood fliould be
taken largely, if it can be done, from  the jugular  vein,
or temporal artery.  But,  when no threatening turgefcence     \
appears,^he obviating plethora is not judicioufly attempt-
ed by blood-letting, as we have endeavoured  to demon-
ftrate above, (786.)  In doubtful circumftances,  leeches
applied to the temples or fcarificatious  of the  hind-head,
may be more fafe than general bleedings.                    f
   1128. J When there arc manifeft fymptoms of a pletho-     j
ric ftate in  the veffels of  the head,  a fe.ton, or pca-iffue,
near tire head, may be very ufeful in obviating any turgef-    J
cence of the blood.                                        j
   1129. J Thefe are the means to  be employed for pre-    1
venting the apoplexy which might arile from a plethoric
ftate ofthe veffels of the brain;  and if, at  the fame  time,
great care is taken to avoid the excitingcauies (1097.) I hefe
means will be generally fuccefsful.
   In the cafes  proceeding from  other caufes  (1114.) a-.
their application is fo immediately fucceeded by the dif-    A
cafe, they hardly allow any opportunity for prevention.
   1130.J For the Cure of apoplexies from internal cau-    I
fes, and which I fuppofe to be chiefly thole from comprel-    1
lion, the ufual violence and fatality of it require that the    J
proper remedies be immediately and largely employed.
   The patient is to be kept as much as  poffible in fome-
what 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.
   1131. J 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 largely.
In my opinion, it will be moft effectual  when the blood is
taken from the jugular vein;  but, if that  cannot be  pro-
perly done,  it may be taken from the arm.   The opening    •*
of the temporal artery, when a large branch can be opened, 
OF  PHYSIC.                  5*
fo as fuddenly to pour out a confiderable quantity of blood,
may alio be an  effectual remedy; but, in execution, it is
more uncertain, and may be inconvenient.   It may be in
fome meafure fiipplied, by cupping and  fcarifying on  the
temples  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  cafh of apoplexy, 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 pof-
fible,  fliould be made  on the fide  oppofite to that moft
affected.*
   1132.J Another remedy to be employed is purging, to
be immediately attempted by acrid glyfters;t 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  fliould be given in divided por-
tions at  proper intervals. +
   1133. J Vomiting has been commended by fome prac-
titioners  and writers:  But, apprehending  that this might

  * Diffe&ions fhew that the congeftions producing apoplexy are always on,
tlie fide not affeded; and hence the propriety ofthe dire&ion.
  f 'Acrid glyfters are,
           R. Elect, lenitiv. §i.
              Sal. catharic. amar. 3'iiss.
              Aq. tepid. §xi.
              M. f. Enema.
           R. *apon. alb. Biss.
              Solve in aq. tepid. §x. cui adde
              Syr. e spina cerv. §ii.
              M. 1". Enema.
           R, Pulp, colocynth. S'tii.
              Coque per horx quadranfm in aq. font.
                     ij. :,. ad colutara: §xii. cui adde
              01. Olivar.  §i.
              M. i". Enema.
  \ The draftic purges are, in thefe cafes, to be given in draughts, rather than
Jn pills or bolides.  The following form may be ufed :
           R. Pulv. Jalap. 5 .
              Rad. zinzih. ►")!.
              In!'u?. scm.  lini |iii.
              M.
  The dofe of this mixture is two fpoonsful every two hours till  it open?.
♦r we may ufe one of the formula mentioned in the note on arcicle 1070. efpe-
cially the laft, repeating it every two hours till it produces an effcA. 
60
PRACTICE'
impel jhe blood with too much violence into the vcifcis of
the head!, I have never employed it.
   1134.] 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 applied
to the  lower extremities.   This remedy I do not confider
as a ftimulant, or capable of  making any confiderable re-
vulfion; but, applied to the head, I fuppofe it  ufeful in
taking off the hemorrhagic difpofition fo often prevailing
there.
   ii35.]#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 gene-
rally 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 arc abfolutely improper in what is fuppofed
tobe a fanguine apoplexy; but  they are commonly fup-
pofed to be proper in the ferous.   If, however,  we be
right in allcdging that this alfo commonly depends upon a
plethoric ftate of the blood-veflels of the brain,  ftimulants
muft be equally improper in the one cafe as in the other.
   1136. J It may be argued from the almoft univerfal emr
ployment of ftimulants, and  fometimes with feeming ad-
vantage, that they may not be fo hurtful as my notions of
the caufes  of apoplexy lead me to fuppofe.  But this ar-
gument is,  in feveral refpects, fallacious;  and particularly
in this, that in a difeafe which, under every management,
often proceeds fo quickly to a fatal termination, the effects
of remedies are  not to be eafily afcertained.
   1137.] I have now  mentioned  the  feveral remedies
which  I think adapted to the cure of apoplexy arifing from
compreffion,  and fliould next proceed to treat ofthe cure
of apoplexy arifing from thofe caufes that directly deftroy
the mobility of  the nervous  power.  But many of thofe
caufes are often fo powerful, and thereby fo fuddenly fatal
in their effects,  as hardly to allow of time for the ufe of
remedies; and fuch cafes,  therefore, have been fo feldom-
the fubjects of  practice, that the proper remedies are not
fo well afcertained as  to enable me to fay much of them
here.
   1138.] When,  however, the application of the  caufes, 
O F  PH Y SIC                  61
(1114.) is not fo powerful as immediately to kill^and in-
duces 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 referred to, from the
ceafing of the pulfe and of  refpiration, and from a cold-
nefs coming  upon the body,  have  induced an appearance
of death; yet,  if thefe appearances  have  not continued'^
long, there may be means of recovering the perfons to life
and health.    I  cannot, indeed, treat  this  fubject com-
pletely;  but for the cure  of  apoplexy  from feveral of the
caufes mentioned (1114.)  fhall  offer the following general
directions.
   1. When  a poifon capable of producing apoplexy has
been recently taken into the ftomach, if a vomiting fpon-
taneoufly arifes, it is to be encouraged; or, if it does not
fpontaneoufly come on, a vomiting is  to be immediately
excited by art, in order that  the poifon may be thrown out
as quickly as poffible.  If, however, the poifon has been
taken into the ftomach long before its effects have appear-
ed,  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 other-
wife applied to the body, has already induced an apoplec-
tic  ftate, as thofe caufes do commonly at the fame time oc-
cafion a ftagnation or flower motion ofthe blood in the
veffels ofthe brain and ofthe lungs, fo it will generally be
proper to relieve this congeftion by taking fome blood from
the jugular vein, or from the veins of the arm :
   3. Upon the fame fuppofition of a congeftion in the brain
or lungs, it will  generally be  proper to relieve it by means
of acrid glyfters producing fome evacuation from the in-
teftines.
   4. When thefe evacuations  by  blood-letting and purg-
ing have been made, the various ftimulants which have been
commonly  propofed in other  cafes of apoplexy, may be
employed here with more  probability and  fafety *   One
  *  The ftimulants are various according to the various parts of the body to
which thevare generally applied, as volatile and vinous fpirits, or vinegar, to
the nofe and temples; acrid eflential oils, mixed with thrice their weight of
hog's lard, to the breaft and back ; blifters, hot finapifms, and warm fomen-
tations,  with horfe-radifti, to the extremities; friftions with warm bruiries;
the aftual cautery to the foles of the feet, and palms of the hands ; with fe-
veral others, which are more particularly defcribed in the notes on article
; 160, et feq.
  Vol. IU                    H 
6?                 PRACTICE
of thegioft effectual means of roufing apoplectics of this
kind feems to  be throwing cold water on feveral parts oi
the body, or wafhing the body all over with it.
   5. Although the poifon producing  apoplexy happens
to be fo powerful as very foon to occafion the appearances
of death above-mentioned; yet if this  ftate has not con-
tinued long, the patient may often  be recoverable; and
the recovery is to be attempted by the fame means that are
directed to be employed, for the recovery of drowned per-
fons, and which are now commonly known.

                     CHAP. II.



1139.] X ALSY is  a difeafe  confiffing in a lofs of the
power of voluntary motion, but affecting certain parts of the
body only, and by this it is diftinguifhed from apoplexy.
(1093.)   One ofthe moft frequent forms of palfy is when
it affects the whole of  the mufcles on one fide of the body;
and then the difeafe is named a. Hemiplegia.
   1140.] The lofs ofthe power of voluntary motion may
be owing either to a morbid affection ofthe mufcles or or-
gans of motion, by which they are rendered unfit for mo-
tion ;  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 firft of thefe caufes, as confifting in an organic
and local affection, we refer entirely to the clafs of local dif-
eafes..  I am here to confider that difeafe only which de-
pends upon the interrupted influx of the nervous power;
and it is to this difeafe alone I would give the appellation
of Palsy.   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
feparated from the fyftematic affections.
   1141.] In palfy, the lofs of motion is often accompanied
with  the lofs of fenfe;  but as this is not  conftantly the cafej
and as therefore the lofs of fenfe is not an effential fymp-
tom of palfy,  I have not ta|<Len it into my definition (1139.),
 and I fhall not think  it neceffary to take any further notice;
\ 
OF  PHYSIC.
63
of it in  this treatife ;  becaufe, in fo far as it is in any cafe
a part ofthe paralytic affection, it muft depend upon the
fame caufes,  and will be cured alfo by the very  fame re-
medies, as the lofs of motion.
   1142.] The palfy 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 af-
fection of the nerves in fome part of their courfe  between
the brain and the organs of motion.   Of .the latter, as ap-
pearing in a very partial affection,  I am not to fpeak parti-
cularly here ;  I fhall only treat of the more general para-
lytic affections, and efpecially of the  hemiplegia (1139.)
At the fame time I expect, that what I fhall fay upon this
fiibject will readily apply to  both  the pathology and prac-
tice in-the cafes of affections more limited.
   1143. The  hemiplegia (1139.) ufually .begins with, or
follows, a paroxyfm of apoplexy ; and when the hemiple-
gia, after fubfifting for fome  time becomes fatal, it is com-
monly by palling again into the ftate  of apoplexy.  The
relation therefore or affinity  between  the two  difeafes, is
fufficiently eviderit; and is further ftrongly confirmed by
this, that the hemiplegia comes upon perfons  of the fame
conftitution (1094.) and  is  preceded by the fame fymp-
toms (1097.) that have heen taken notice of with refpect:
to apoplexy.
   1144. J When a "fit of apoplexy has gone off, and there
remains a ftate of palfy appearing as a partial affection on-
ly, it might perhaps be fuppofed that the origin ofthe nerves
is in a great meafure relieved;  but in fo far as common-
ly there ftill remain the fymptoms of the lofs of memory,
and of fome degree of fatuity, thefe, I think, fhow that the
organ of intellect, or the common origin  of the nerves, is
ftill confiderably affected.,
   1145.J Thus, the hemiplegia, from its  evident connec-
tion with, and near relation to apoplexy, may be properly
confidered as depending upon like caufes; and confequently
either upon a compreffion preventing  the  flow of the ner-
vous power from the brain into  the organs of motion, or
upon the  application of narcotic or other  powers (1114.)
rendering the nervous power unfit to flow in the ufual and
proper manner. 
64                 PRACTICE
   1146.} 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 produce
apoplexy ;  and therefore either from tumour, over diften-
tion, or effufion.   The exiftence  of tumour giving com-
preffion,  may often be better difcerned in the cafe of palfy
than in that of apoplexy, as its effects often  appear  at firft
in a very partial affection.
   1147.] The other modes  of compreffion,  that  is, of
over-diftention and effufion, may, and commonly do, take
place, in hemiplegia: and when  they  do, their operation
here differs from that producing apoplexy, by  its  effects
being partial, and on one fide ofthe body only.
   It may feem difficult to conceive that an over-diftention
can take place in the the veffels on one fide of the brain on-
ly;  but it may be  underftood : and in the  cafe of a palfy
which is  both partial and tranfitory, it is perhaps the only
condition of the veffels of the brain that can be fuppofed.
In a  hemiplegia, indeed, which fubfifts  for any length of
time, there is probably ahvays an  effufion, either fanguine
or ferous:  but it is likely that even the latter muft be fup-
ported by a remaining congeftion  in the blood-veffels.
   1148.]  That a fanguine effufion can happen  without be-
coming very  foon general, and thereby occafioning apo-
plexy and  death, may alfo  feem doubtful:  but diffections
prove that in fact it does happen,  occafioning  palfy only ;
though it is true, that this more commonly depends upon
an effufion of ferous fluid,  and of this only.
    1149.]  Can a palfy, occafioned by  a compreffion, re-
main though  the compreffion be removed ?*
    1150.]  From what has been faid (1143.) it  will be ob-
vious, that the  hemiplegia may be prevented by all the fe-
veral means propofed (1124.  et. seq.) for the prevention of
apoplexy.
    1151. J Upon the fame grounds, the Cure of palfy muft
 be very much the fame with that of apoplexy (1129.  et. seq.)
 and when  palfy has begun  as an apoplexy, it is prefumed,
 that, before it is to be confidered as palfy, all thofe feveral
   * This queftion may be anfwered in the affirmative; becaufe the ftru&ure of
 the nerve may be deftroyed by the  compreffion, and the nerve may therefore
 remain impervious to the nervous  influence, after the compreffion has beea,
 removed. 
OF  PHYSIC.
65
remedies have been employed.   Indfed, even when it hap-
pens that on the firft attack of the difeafe the apoplectic ftate
is not very complete, and that the very firft appearance of
the difeafe is as a hemiplegia, the affinity between the two
difeafes (1143.) is fuch as to lead to the fame  remedies in
bot.li  cafes.   This is certainly proper in all thofe cafes in
which we can with much probability impute the difeafe to
compreffion;   and  it is  indeed feldom that a hemiplegia
from internal caufes comes on  but with a confiderable af-
fection of the internal, and  even of the external fenfes, to-
gether with other marks of a compreffion of the origin of
the nerves.
    1152.] Not  only, however, where the difeafe can be
imputed to compreffion, but even where it can be imputed
to  the application of narcotic powers, if the difeafe come
 on with the appearances mentioned at the end of the laft
paragraph, it is to be treated in the fame manner as an apo-
 plexy by ( i 130.—1138.)
    1153.] The  cure of hemiplegia, therefore, on its firft at-
 tack, is the fame, or nearly  the fame, with that of apoplexy:
 and  it feems requifite that it fhould be different only,  1.
 When the  difeafe has fubfifted for fome time ;  2. When
 the apoplectic  fymptoms, or thofe* marking a confiderable
 compreffion ofthe origin ofthe nerves, are removed; and
 oarticularly,  3. When there are no evident marks of com-
 preffion, and it  is at the fame time known that narcotic pow-
 ers have been applied.
    1154.]  In all thefe cafes, the queftion arifes, Whether
 ftimulants may be employed,  or how far the  cure may be
 entirely trufted to fuch remedies ? Upon this queftion, with
 refpect to apoplexy, I have offered my opinion in (1135.)  .
 And, with  refpect to hemiplegia, I am of opinion, that fti-
 mulants are almoft always equally dangerous as in the ca-
 fes of complete apoplexy; and particularly,  1. In all the
 cafes of hemiplegia fucceeding to a paroxyfm of complete
 apoplexy ; 2.  In all the cafes coming upon perfons ofthe
 temperament mentioned in (1094.) and after the fame an-
 tecedents as thofe of apoplexy, (1115.) and 3. In all the ca-
 fes coming on with fymptoms of apoplexy from compreffion.
    1155.]  It is, therefore, in the cafes (1153.) only,  that
    • The moft Infallible- of thefe marks is, the Litclkft-al faculties not re-
 turning. 
66                 PRACTICE
ftimulants are properly admiffiblc : And even in the  two
firft of thefe cafes, in which a plethoric ftate ofthe blood-
veffcls of the brain may have brought  on the difeafe, in
which a difpofition to that ftate may ftill continue, and in
which even fome degree of congeftion  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 ftimu-
lants are clearly indicated and admilfible.
   1156.] Thefe doubts with  refpect to the ufe of ftimu-
lants, may perhaps be overlooked or difregarded by  thofe
who alledge that ftimulants have been employed with ad-
vantage even in thofe cafes (1154.) in which I have faid
they ought to be avoided.
   1157.J To compromife this contrariety of opinion, I
muft obferve, that even in the cafes of hemiplegia depend-
ing* upon compreffion,  although the  origin of the nerves
be fo much compreffed as to prevent fo full a flow of the
nervous  power as is neceffary to mufcular motion, yet it
appears from the power of fenfe ftill remaining, that the
nerves are, to a certain  degree, ftill pervious; and there-
fore it is probable that ftimulants applied, may excite the
energy  of the brain fo much, as in fome meafure to force
open the compreffed nerves, and to fhow fome return of
motion  in paralytic  mufcles.   Nay,  further,   it may be
allowed, that if thefe ftimulants be fuch as act more upon
the nervous than upon the fanguiferous fyftem-,  they  may
poffibly be employed withoutany very hurtful confequence.
   1158.J But ftill it will be obvious, that although certain
ftimulants act chiefly upon the nervous  fyftem, yet  they
alfo act always in fome meafure upon the fanguiferous ; fo
that, when they  happen to have the latter effect in any  con-
fiderable degree, they may certainly do much harm ; and
in a difeafe which they do  not entirely cure, the mifehief
arifing from them may not be difcerned.
   1159.] Whilft the employment of ftimulants is fo often
an ambiguous practice, we may perhaps go fome length to-
wards afcertaining the matter, by confidering the nature of
the feveral ftimulants which may be employed,  and fome
of the circumftances of their  adminiftration.   With this
view, therefore, I fhall  now mention the feveral  ftimu-
lants that have been commonly employed, and offer fome
remarks upon their nature and ufe. 
O F   P FI Y S r C.                  G7
   1160.] They are in the firft place to be diftinguifhed as
external or internal.   Of the firft kind, we again diftinguifh
them as they are applied to particular parts ofthe body on-
ly, or as  they are more generally applied to the whole fyf-
tem.   Ofthe firft kind are,
   1. The concentrated acids of vitriol or nitre ;  involved
however, in oily or unctuous fubftances, which may obvi-
ate their corrofive,without deftroying their ftimulant power.*
   2. The volatile alkaline fpirits, efpecially in their cau-
ftic ftate; but involved alfo in oils, for the  purpofe juft
now mentioned.t
   3. The fame volatile fpirits are frequently employed by
being held to the nofe when they prove a powerful ftimu-
lant to the nervous fyftem ; but it is at the fame time proba-
ble, that they may alfo prove a ftrong ftimulant to the blood-
veffels of the brain.                                   ♦
   4. A brine or ftrong folution of fea-falt. J
   5. Theeffential oils of aromatic plants,|| orof their parts.
   6.  Theeffential oils of turpentine, or of other fuch re-
finous fubftances.
   7.  The diftilled oils  of amber,  or of other bituminous
fbffils.**
  * Rubefacient ointments are compofitions like the following:
           R. Azung. porcin. §ii.
              Acid, vitriol. 3'-
              M.  Or,
           R. Unguent, basilic, flav. £ii.
              Acid, vitriol. 3i.
              M.
They foon redden and inflame the Ikin; and, when this cffe£ is produced, thev
rnuft be taken off, and the part anointed with common ointment, or with oil.
  f The Linimenta volatilia ofthe Pharmacopoeias are not fo ftrong as \\\c
following •
           R. Alkal. volatil. caustic. %\.
              OI. olivar. §ii,
              M.
  In the new London Pharmacopoeia this compofition is called I.inimcntum
Ammoniac Fortius.
  \ The brine that remains in the falt-pans, after the common fait is crjjl;-
lized, is the moft effe«ftual of thefe briny ftimulants ; it is called inEdinbiii-zh
Oil of Salt.
  || The OI. Origani is generally ufed.  It ought to be mixed w.ri. font?
un&uous oil, as in the following formula :
           R. 01. origan. 3ii.
              Azung. porcin. §iv.
              M.
  The aromatic oils difiblved in fpirits make an elegant application; but the
diftilled fpirits of the plants themlelves are more in ufe.
  •• They  are  generally  ufed with  hog's-lard, in the prr-roi-ion of eiglir 
-m
PRACTICE
   8.  The lcctified cmpyreumatic oils of anima! or vegeta-
ble fubftances .*
   g.  Various vegetable acrids, particularly muftard.t
   10. The acrid matter found in  feveral  infects, particu-
larly cantharides.J
   Some of thefe ftimulants may be cither applied in fub-
ftance ;  or may be diffolved in ardent fpirits, by which their
ftimulant power may be increafed, or more  conveniently
applied.
   n6i.]Thegreaterpartof the fubftances now enumerated
fhow their ftimulant power by inflaming the ikin ofthe part
to which  they are applied ;  and when their application is
fo long continued as to produce this effea, it interrupts the
continuance of their ufe ;  and the inflammation ofthe part
does not feem to do fo much good as the frequent repeti-
tion of a more moderate ftimulus.
   1162.] Analogous to thefe ftimulants is the flinging of
 nettles, which has been frequently commended.
   Among the external ftimulants, the mechanical one of
friction with the naked hand, the flefh-brufh, or flannel, is
juftly to be ;eckoned.   Can the impregnation ofthe flan-
nels to be employed, with the fumes of burning maftic,  oli-
 banum, &c. be of any fervice ?||
    1163.] With refpea to the whole of thefe external fti-
 mulants," it is  to be obferved, that they  affea the part to
 which thev are applied much more than  than they do the
 whole fyftem, and they are therefore indeed  fafer in ambi-
 guous cafes;  but, for the fame reafon, they are of lefs ef-
 ficacv in  curing a general affeaion.
    1164.] The external applications which may be applied
 times they quantity of lard.  Some practitioners, however, take only twice
 the quantity of lard; but  they are not fo effeaual as fome of the rubefacients
 above enumerated.
   * Toe ufe of thefe empyreurr.atic oils is not fo frequently now as formerly ;
 thev are extremely acrid, ar.dif net ufed with caution, of'en corrode the fkin.
   f The form, in which  the  fiour of muftard is ufed, is called a finapifm.  It
 is mi.'ied with an equal quantity of bread-crumb or oat-meal, and made into
 a palte with vinegar.  Some  practitioners add bruifed garlic, in the propor-
 tion of one fourth of the quantity of muftard; but it  is extremely offenfive,
 ar.d the cataplafm without it anfwers fufficiently well.
   i Thefe infeas are the bafis of bliftering plafters and ointments.
   |'| Manv practitioners have thought that fuch impregnations have been of
 fnrnilar fervice.   The fumes of moft of thefe refins are either flowers, as thev
 are'called in the fnops, or effential oils, both of which are ftimulaving, and
 mav therefore be fuppofed to be a£live.  The impregnating flannels or ftefh-
 brufhes with flour of muftard is often ufed, and affilts confiderably in bringing
 on an inflr.rr.rnaticn. 
O F  P H Y S I C.                 G9
to affea the whole fyftem, are the powers of heat and cold,
and of elearicity.
   Heat, as one of the moft powerful ftimulants ofthe ani-
mal economy,  has been often employed in palfies, efpeci-
ally by warm bathing.  But as, both by ftimuiating the fo-
lids and  rarefying the fluids, this proves a ftrong ftimulus
to the fanguiferous fyftem, it is often an ambiguous reme-
dy ;  and has frequently been manifeftly hurtful in palfies.
depending upon a congeftion of blood in the veffels ofthe
brain.   The moft  certain, and therefore  the moft proper
nie of warm bathing  in palfies, feems to be  in thofe that
have  been occafioned by the application of narcotic pow-
ers.  Are the natural  baths more ufeful by the matters with
which they may be naturally impregnated ?*
   1165. J Cold applied to the body for any length of time,
is always hurtful to the paralytic perfons ;  but if it be not
very intenfe, nor the  application long continued, and if at
the fame time the body be capable of a brifk reaaion, fuch
an application  of cold is a powerful ftimulant of the whole
fyftem,  and has often been ufeful in  curing  palfy.  But,
if the power of  reaction in the body be weak, any appli-
cation of cold  may prove very hurtful.t
   1166. J  Elearicity,  in a certain manner applied, is cer-
tainly one  of the moft powerful ftimulants that can be em-
ployed to aa upon the nervous fyftem of animals; and
therefore much has  been expeaed from it in the cure of
palfy.   But, as it ftimulates the fanguiferous as well as the
nervous  fyftem, it has been often hurtful in palfies depend-
ing upon a compreffion of the brain;  and efpecially when
it has been fo applied as to aa upon the veffels of the head.
It is fafer when its operation is confined to particular parts
fomewhat remote from the head;  and, further, as the ope-
ration of elearicity, when very ftrong can deftroy the mo-
bility of the nervous power, I am of  opinion^  that it is
  * The natural baths contain fo fmall a quantity of impregnating fubftances
as induces us to fufpeft that they cannot have any beneficial powers fuperior
to thofe of ordinary warm baths.  The ufe of warm bathsf ought not to be
promifcuous.  In cafes of paliies, arifing from certain poifons, as the fumes
of arfenic or metals, and their ores, the warm baths feldom fail of procuring
relief;  and fome inftances have been given by authors of complete cures hav-
ing been performed  by the ufe of baths alone.
  j- The very great uncertainty of the power of  reaftion always  makes the
application of cold  a very doubtful remedy; and, as it is  evidently hurtful
wherever the reaction is weak, it ought to be tiled with extreme caution.
  Vol. II.                    I 
70                   PRACTICE
 always  to be employed with caution, and that it is only
 fafe when applied with moderate force, and when  confined
 to certain parts of the body remote from the head.   It is
 alfo  my opinion,  that its good effeas arc to be expeaed
 from its repetition  rather than from its force,  and that it is
 particularly fuited to the cure of thofe palfies which have
 been produced by the application of narcotic powers.
    1167. J Amongft the remedies of palfy, the ufe of exer-
 cife is not to  be omitted.   In a hemiplegia,  bodily cxer-
 cife cannot be employed ; and in a more limited affeaion,
 if depending upon a compreffion of fome part of the brain,
 it would be an  ambiguous  remedy-:  But,  in  all  cafes
 where the exercife of geftation can be employed,  they  are
 proper;  as, even in cafes of compreffion, the ftimulus of
 fuch exercife is moderate, and  therefore fafe; and, as it
 always determines to the furface of the body, it is a reme-
 dy in all cafes of internal congeftion.
    1168.] The  internal ftimulants employed in palfy  are
 various,  but chiefly the following..
    1. The  volatile alkaline falts,  or fpirits, as they  are
 called, are very  powerful  and diffuiive ftimulants, ope-
 rating efpecially on the nervous fyftem ;* and even although
 they operate on the fanguiferous, yet, if given in frequent-
 ly repeated  fmall  rather than in  large dofes, their opera-
 tion being tranfitory,  is tolerably fafe.
   2. The vegetables  of the  clafs named Tetradynamia,
 are many of them powerful  diffufive ftimulants; and at
 the fame time, as quickly pafling  out of the body, and
therefore a tranfitory operation,  they are  often employed
 with fafety.t  As  they commonly prove diuretic,  they
  * Of thefe there are feveral formuhe in the (hops, as, Spiritus volatilisaro-,
 maticu^, Spiritus volatilis oleofus, Spiritus falinus aromaticus.  Their dofe
is from ten to fixty drops.  The Eau de Luce ought to be mentioned l.ere,
though it is feldom ufed internally, but only for fmelling to,  as it is extremely
penetrating.  It is prepared thus:  Mix together in a retort forty drops of
rectified oil of amber, an ounce of re&ified  fpirit of wine,  and twelve ounces
ofthe ftrongeft cauftic volatile alkali. They muft be diftilled with a very mo-
derate fire.  It is feldom limpid, but has a milky appearance, owing to  the
imperfect folution of the oil in the fpirit; and, if the alkali be not very cauf-
tic, fcarcely any of the oil is diffolvcd.
  f White muftard feeds may be  given whole, in the quantity of two tea-
fpoonsfulin half a tea-cupful of cold water.  They ought to be fwallowed whole
that their  acrid tafte may not be perceived. The dofe  may be repeated
twice or thrice a-day.  Horfe-radifh is another plant of this clafs of vegetables
that has been much recommended; it muft be given ii> a cold watery infufion,
 or in an infufion in ale. The fcurvy-grafs is another of the fame clafs; it may
 be eaten raw, or we may give forty or fifty drops ofthe Spiritus cochlearix, 
O F  P H Y S I a"                  71
may in this way alfo be of fervice in fome cafes of ferous
palfy.                                          ■**
   3.  The various aromatics, whether employed in fub-
ftance, in tinaure, or in their effential oils, are often pdw-
erful  ftimulants;  but being more adhefive and inflamma-
tory than thofe laft mentioned, they  are therefore, in all
ambiguous cafes,  lefs fafe.*
   4.  Some other acrid vegetables have been employed;
but we are not well acquainted with their peculiar virtues,
or proper ufe.
   5.  Some refinous fubftances,  as guaiacum, and the te-
rebinthinate fubftances, or their effential oils, have been
with  fome probability, employed;  but they are apt  to be-
come inflammatory.   Decoaions  of guaiacum, and fome
other fudorifics, have been direaed to excite fweating by
the application of the fumes of burning fpirit of wine in the
laconicum, and have in that way been found ufeful.
   6.  Many of the feted antifpafmodic medicines have been
frequently  employed in palfy ;  but I do not perceive in
what manner they are adapted to the  cure of this  difeafe,
and I have not obferved their good effeas in any cafes of it.
   7.  Bitters,  and the Peruvian bark, have, alfo been em-
ployed; but  with no propriety  or advantage that I can
perceive.t
   1169.] With refpea to the whole of thefe internal ftimu-
lants, it is to be obferved, that they feldom prove very pow-
erful  ; and wherever there is any doubt concerning the na-
ture or ftate of the difeafe, they may readily do harm, and
are often therefore of ambiguous ufe.

either on a piece of fugar, or mixed with half an ounce of fyrup, four or five
times a-day.  This fpirit ought to be kept well corked, as it foon loofes all
its activity, if it be expofed to the air.
  * The aromatics belt  adapted for ftimulating,  in thefe cafes, are fuch as
Linne calls Spirantia; the chief of them are,  Marum, Rofemary, Lavender,
&c. Their fpiritous waters are much more efficacious than the plants in fub-
ftance, or in any other form ; and their efficacy is confiderably increafed by
uniting them to volatile fpirits, as in fome of  the formulae mentioned in the
firft note on this article.
  fj In fome cafes, paralytic patients, for want of exercife, fink into a ftate
of debility, with lofs of appetite, and confequent emaciation, in which bitters,
Peruvian bark, and other tonics, are frequently of fome advantage. 
                      [  72  ]

                BOOK   II.

          OF  ADYNAMIA;
OR DISEASES CONSISTING IN A irEAKNLSS OR LOSS OF MOTION
       IN EITHER THE VITAL OR NATURAL FUNCTIONS.

                     CHAP. I.

            SDf ^pncope, or jfainting.

1170.]  i HIS is a difeafe in which the aaion ofthe heart
and refpiiation  become confiderably weaker than ufual, or
in which for a certain time thefe functions ceafe altogether.
   1171.] Phyficians having obferved that this affeaion oc-
curs in different degrees, have endeavoured to diftinguifh
thefe by different appellations -. but as it is not poffible to
afcertain thefe different degrees with any precifion, fo there
can be  no  ftritt propriety in  employing  thofe  different
names; and  I fliall here comprehend the whole of the af-
fections of this  kind under the title of Syncope.
   1172.J This difeafe fometimes comes on fuddenly to a
confiderable  degree, but fometimes alfo it comes on gradu-
ally ; 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 founding  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 (hefe mo-
 tions, for a  certain time, ceafe altogether.   While thefe
 fymptoms take place, the face and whole furface of the
 body become pale, and more or lefs cold 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  continues, on the fore-
 head, as well as on fome  other parts of the body.  During
 the paroxyfms, the animal funaions,  both of  fenfe and
 motion, are always in fome degree impaired,  and very of-
 ten entirely fufpended.   A paroxyfm of fyncope is often,
 after fome time, fpontaneoufly recovered  from; and this
 recovery is generally attended with a fenfe of much  anxiety
 about  the heart. 
O F  P H Y S I C.                  73
   Fits of fyncope are frequently attended with, or end in,
 vomiting;  and fometimes with convulfions,  or an epilep-
 tic fit.
    1173.] 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 aaion of the heart.  But it
 will be a very difficult matter to  explain in  what manner
 the feveral remote caufes  operate in producing the prox-
 imate  caufe.   This, however,  I fhall attempt,  though
 w-ith that diffidence which becomes me in attempting a fub-
 jea that has not hitherto been treated with much fuccefs.
   1174.] The remote caufes of fyncope may, in the firft
 place, be referred to two general heads.   The one is, of
 thofe caufes exifting and acting in the brain, or in parts of
 the body remote from the heart, but aaing upon it by the
 intervention ofthe brain.   The other general head of the
 remote caufes of fyncope,  is of thofe exifting in the heart
 itfelf, or in parts very immediately conneaed with it, and
 thereby aai ng more direaiy upon it in producing this difeafe.
   1175. J In entering upon the confideration ofthe firft fet
 of thofe caufes (1174.)  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 action as is neceffary to the motion ofthe blood, very
 conftantly dependent upon a nervous power fent into them
 from  the brain.*   At leaft this is evident, that  there are
 certain  powers aaing primarily,  and perhaps only  in the
 brain, which influence and varioufly modify  the aaion of
 the heart.   I fuppofe,  therefore,  a force very  conftantly
 during life  exerted in the brain, with refpea to the moving
 fibres ofthe heart, as well as of every  part ofthe body;
 which force I fhall call the energy of the brain;  and which
 I fuppofe may be, on different occafions, ftronger or weak-
 er with refpea to the heart.
I   * The author here differs fomewhat in opinion from phyfioligifts.  He al- Q
"To^s, indeed, that the heart pofleffes a vis infita in a certain uegree, but he
 will not allow this vis infita tobe fufficiently itrongfor carrying on the circu-
 lation ; and he thinks that fome energy muft be imparted to  the heart frcm
 the brain, in order to enable that important mufcle to perform its office. In
 tupportof this opinion, we have a plain faft, which the author might have
 adduced, viz.  that a ligature on the nerves going to the heart immediately
 flops its motions. 
  71                 PRACTICE

     11 ;6J Admiring thefe propofitions, it will be obvious,
  that if I can explain in what manner tfie firft fet of remote    .;
  caufes (1174.) diminifh the energy ofthe brain, I  fhall at
  the fame time explain in what manner thefe caufes occafion    g
  a fyncope.
   .  n 77. J To do this, I  obferve, that one ofthe moft evi-
  dent of the remote caufes of fyncope is a hemorrhagy, or
  an evacuation of blood, whether fpoiuaneous or artificial.    ,,
  And  as it u very manifeft that the energy of the brain de-
  pends upon a certain fulnefs and tenfion of its blood-veffels,    '
  for which nature feems to have induftrioufly provided by
  fuch a conformation of thofe blood-veflels as retards the
  motion of the blood both in the arteries  and veins of the
  brain; fo we can readily perceive, that evacuations of blood,
  by taking off the fulnefs and  tenfion ofthe blood-veffels of
  the brain, and thereby diminifhing its energy with refpect
  to the heart, may occafion a fyncope.  In many perfons,
  a fmall evacuation of blood will have this effea; and in    *..
  fuch cafes there  is  often a clear proof of the  manner in
  which the caufe operates,  from this circumftance, that the    i
  effea can be prevented by laying the body in a horizontal   M
  pofture;  which,  by favoring the afflux ofthe blood by the    i
  arteries, and retarding the return of it by the veins, pfle-
  ferves the neceffary fulnefs ofthe veffels ofthe brain.
     It is farther to be remarked  here, that not only  an eva-     I
  cuation of blood occafions fyncope, but that even a change    4 j
  in  the diftribution of the blood, whereby a larger portion   gJ
  of it flows into one part of the fyftem of blood-veffels, and   J
  confequently lefs mto other,  may occafion a fyncope.  It   wk
  is thus I explain the fyncope that readily  occurs upon the
  evacuation of hydropic waters, which had before filled the
  cavities of the abdomen or thorax.  It is thus alfo I ex-.    j
  plain  the fyncope that fometimes happens on bjood-letting,    J
  but which does not happen till the ligature which had been
  employed is untied, and admits a larger afflux of blood in-
  to  the blood-veffels of the arm.  Both thefe cafes  of  fyn-
fc cope  fhow, that an evacuation  of blood does not always
  occafion the difeafe by any general effea on the whole fyf-
  tem, but often merely by taking off the requifite fulnefs of
  the blood-veffels of the brain.
     1178.J The operation of fome others of the remote
  ■caufes of fyncope, may be explained on the following prin- 
OF  P PI Y S I C.
 ciples.   Whilft the energy of the brain is,  upon^differcnt
 occafions, manifeftly ftronger or weaker, it feems to  be
 with this condition, that a ftronger exertion of it is necef-
 farily followed by a weaker ftate of the fame.   It feems to
 depend upon this law in the conftitution ofthe nervous p.ow-
 cr, that the ordinary contraaion of a mufclc is always al-
 ternated with a relaxation ofthe fame; that, unlefs a con-
 traaion proceeds  to  the degree of fpafm, the contraaed
 ftate cannot be long continued; and it feems to depend up-
 on  the fame caufe that the voluntary motions which al-
 ways require an unufual  increafe of exertion,  occafion
 fatigue, debility, and at length irrefiftible fleep.
   From this law, therefore, ofthe nervous power, wc may
 underftand why a fudden and violent exertion of the ener-
 gy of the brain is fometimes followed by 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 principle alfo, I fuppofe, that an  exqui-
 fitc pain may fometimes excite the energy ofthe brain more
 ftrongly than can be  fupported, and is therefore followed
 by fuch a diminution as muft occafion fainting.  But the
 effe6t 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 redu&ion of a painful diflocation.  "
   1179.] It feems to be quite analogous when a  fyncope
 immediately 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 rbmetimes happens
 to a  woman on the bearing of a child.  This may be well
 illuftrated by obferving,  that in perfons already much weak-
 ened, even a very moderate effort will fometimes occafion
 fainting.
   1180.] 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 influence
 of the will, fo it is well known that thofe modifications of A
 the will  which are  named Paffions and Emotions, have a
powerful influence on the energy of the brain in its aaions
upon the heart, either in increafing or diminifhing the force
of that energy.   Thus, anger has the former, and fear the
latter effett; and thence it may  be underftood how  terror 
76                 PRACTICE

often occafions a fyncope fometimes of the  moft violent
kind, named Afphyxia, and fometimes death itfelf.
   1181.]  As, from what I have juft mentioned, it appears,
that the emotions of defire  increafe, and thofe of averfion
diminifh, the energy ofthe brain; fo it may be underftood,
how a ftrong averfion, a horror, or the feeling which arifes
upon the fight of a very difagreeable objea, 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 perfon.
   1182.]  To this head of horror  and difguft,  I  refer  the
operation  of thofe  odours which in certain perfons occa-
fion fyncope.  It may be fuppofed, that  thofe odours  arc
endowed with a directly fedative power, and may thereby
occafion fyncope;  but they are, many of them, with ref-
pea to other perfons, evidently of a contrary quality; and
it appears to me, that thofe odours occafion fyncope only
in thofe perfons to whom they are extremely difagreeable.
   1183.]  It is, however,  very probable, that, among the
caufes of fyncope,  there are fome  which, analogous to all
thofe we have already mentioned, aa by a dire£lly fedative
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 fre-
quently communicates its affeaions to the brain.
   1184. J  Having now enumerated, and, as I hope,  ex-
plained the moft part of the remote caufes of fyncope, that
either operate immediately upon the brain,  or whofe ope-
ration upon  othef parts of the body is  communicated 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 fyn-
cope, deferves to be inquired into.
   It is in the firft place, obvious, that the  operation of
fome of thofe caufes depends entirely upon an idiofyncrafy
in the perfons upon whom they operate ;  which, however,
I cannot pretend to explain.  But, in the next place, with
refpea to the greater part of the other caufes, their effeas
feem  to depend upon a temperament which  is in one  de-
gree or other in common to many  perfons.   This tempe-
rament feems to confift in a great degree of fenfibility and 
OF  PHYSIC.
mobility,  arifing from  a  ftate  of debility,  fometimes de-
pending upon original conformation,  and fometimes pro-
duced by accidental occurrences in the courfe of life.
   1185. J The fecond fet of the remote caufes of fyncope
(1174.) or thofe aaing direaiy upon  the heart itfelf, are
certain organic affeaions of the heart itfelf,  or of the parts
immediately conneaed with it, particularly the great vef-
fels which pour blood into, or immediately receive it from,
the cavities of  the heart.  Thus a dilatation or aneurrfm
of the heart, a polypus in its cavities,  abfeeffes or ulcera-
tions in its fubftance, a clofe adherence ofthe pericardium
to the furface of  the heart, aneurifms of the great veffels
near to the heart, polypus  in thefe,  and oflifications in
thefe or in the valves of the heart, are one or other of them
conditions which, upon diffeaion, have  been difcovered
in thofe perfons who had before laboured under frequent
fyncope.
   1186.J 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 ofthe blood from,
the cavities of the heart;  or fuch as may otherwife difturb
its regular aaion, by  fometimes interrupting it, or fome-
times exciting  it to more violent and convulfive aaion.
The latter is  what is named the Palpitation of the Heart,
and it commonly occurs in the fame perfons who are liable
to fyncope.
   1187.] It is this, as  I judge, that leads us to perceive in
what manner thefe organic affeaions of the heart and great
veffels may occafion fyncope:  for it may be  fuppofed, that
the violent exertions made in palpitations may either give
occafion to an alternate great relaxation, (1178.) or to a
fpafmodic contraaion; and in either way fufpend the aaion
of the heart, and occafion fyncope.  It feems  to me pro-
bable, that it is a  fpafmodic contraaion ofthe heart that  ,
occafions the intermiffion ofthe pulfe fo frequently accom- f.
panying palpitation and fyncope.
   1188.] 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 thefe
difeafes, even when in a violent degree, do not always depend
on fuch caufes  aaing direaiy  on the heart, but are  often
  Vol. II.                K 
78                 PRACTICE

dependent on fome of thofe caufes which we have men-
tioned above as atting primarily on the brain.
   1189.J  I  have thus endeavored 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, (1174.) and fully  recited in (1185.)  I fuppofe to
b© generally incurable;  as our art, fo far as  I know, has
not yet taught us to  cure any of thofe feveral caufes of
fyncope (1185.)
  The cafes  of fyncope depending on the firft fet of caufes,
(1174.) and  whofe operation I have endeavored to explain
in (1177. et. seq ) I hold to be generally curable, either by
avoiding the feveral  occafional ^caufes there pointed out,
or by correaing the predifponent caufes (1184.)  The lat-
ter, I think,  may generally be done by correaing the debi-
lity or mobility of the fyftem, by the means which I have
already had occafion to point out in another place.*
                     CHAP. II.

        jOf Dyspepsia,  or Jn&igeSttom

1190.]  ±jL WANT of appetite* a fqueamifhnefs, fome-
times a vomiting, fudden and  tranfient diftentions of the
ftomach, eruaations of various kinds, heartburns, pains in
the regions ofthe  ftomach, and a bound belly, are fymp-
toms  which frequently concur in the fame perfons, 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 Dyspepsia, fet at the head
of this chapter.
   1191. J  But as this difeafe is alfo frequently a feconda-
ry and fympathic affeaion,  fo the  fymptoms above-men-
tioned are often joined with many others; and this has giv-
en 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 them; and I apprehend  the fymptoms enu-
merated above are thofe effential to the idiopathic affeaion
I  am now to treat of.
* See article 217. &c. 
                  O F  P H Y S I C.                 79

   1192.] It is indeed to be  particularly obferve^ that
thefe fymptoms are often truly accompanied with a certain
ftate of mind which may be confidered as a part of the idi-
opathic affection : 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 Hypo-
chondriafis.
   1193.] That there is  a diftina difeafe attended always
with a greater part of the above fymptoms, is rendered ve-
ry probable  by this, that all thefe feveral  fymptoms may
arife from one and the fame caufe; that is, from an imbe-
cility, lofs of tone, and weaker aaion in the mufcular fibres
of the ftomach;  and  I conclude therefore, that this imbe-
cility may  be confidered as the proximate caufe of the
difeafe I am to treat  of under the name of Dyfpepfia.
   1194. J The imbecility of the ftomach, and the  confe-
quent fymptoms (1190.) may, however, frequently depend
upon fome organic affeaion of the ftomach itfelf,  as tu-
mour, ulcer, or feirrhofity; or upon fome affeaion of other
parts of the body communicated to the ftomach, as in gout,
amenorrhcea, and, fome  others.  In all thefe cafes, how-  1
ever, the dyfpeptic fymptoms are to be confidered as fe-
condary or fympathic affeaions, to  be cured only by cur-
ing the primary difeafe.—Such fecondary and fympathic
cafes cannot, indeed, be treated of here; but as I prefume
that the imbecility of the ftomach  may often take place
without either any organic affeaion of this part, or any
more primary affeaion in any other part of the body; fo
I fuppofe and expea it will appear,  from the confideration
of the remote caufes, that the dyfpepfia may be often an
idiopathic affeaion,  and that it is therefore properly taken
into the fyftem of methodical Nofology, and becomes the
fubjea of our confideration here.
   1195.] There can be  little doubt, that in  moft cafes,
the weaker aaion ofthe mufcular fibres of the ftomach, 'is
the moft frequent and chief caufe of the fymptoms menti-
oned in (1190.)  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 animals, or at leaft a pe-
culiar quality in the  fluids, that we know to be there, up-
on which the folution of the aliments taken into the ftomach
-chiefly depends: and it is at  the fame time probable,  that 
80                 PRACTICE
the peculiar  quality of the diffolving or digefting fluids
may be varioufly changed, or  that their quantity may be,
upon occafion,  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 (1190.)
   1196.] This feems to be very well founded, and points
out another proximate caufe of dyfpepfia betide that we
have  already afligned: But, notwithflanding 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 cannot  found any
praaical doarine  upon any fuppofition with refpea to
them; and as, at the fame time, the imbecility of  the fto-
mach, either as caufing the change in the digeftive fluid, or
as being induced by that change, feems always to  be pre-
fent,  and to  have  a great fhare in  occafioning the  fymp-
toms of indigeftion; fo I fhall ftill  confider the imbecility
of the ftomach as  the proximate and almoft fole caufe of
dyfpepfia.  And I more readily admit of this manner of
proceeding;  as, in my opinion, the doarine applies very
fully and clearly to the  explaining the whole of the prac-
tice which experience fci eftablifhed as the moft fuccefsful
in this difeafe.
   1197.] 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 different
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 first is, of thofe which att direaiy
and immediately upon the ftomach itfelf:  The second is,
of thofe which a6t upon the  whole body,  or particular
parts of it,  but in confequence of which the ftomach is
cniefly or almoft only affeaed.
   1198. J Of the firft kind are,
   1. Certain fedative or narcotic fubftances taken  into the
ftomach; fuch as tea, coffee, tobacco* ardent fpirits, opi-
um, bitters, aromatics, putrids, and acefcents.
   2. The large and frequent drinking of warm water, or
of warm watry liquids. 
OF  PHYSIC.                 81
  3. Frequent furfeit,  or immoderate repletion of the
ftomach.
  4. Frequent vomiting whether fpontaneoufly arifing, or
excited by art.
  5. Very frequent fpitting, of rejeaion of faliva.
   1199.] Thofe caufes which a6t upon the whole body,
or upon particular parts and funaions 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
head, partly to the former.
   6.  The being much expofed to moift and cold air when
without exercife.
   1200.] Though the difeafe, as proceeding from the laft;
fet of caufes,  may be confidered  as a fymptomatic affec-
tion only;  yet as the affe6tion of the ftomach is generally
the firft, always the chief, and often the  only effea which
thefe  caufes produce or difcover, I think  the affeaion of
the ftomach may be confidered as the difeafe to be attend-
ed  to  in praaice;  and the more nroperly  fo, as in many
cafes the general debility  is c Vn) be cured by reftoring
the tone of the ftomach, and by  remedies firft applied to
this organ.
   1201.J  For the cure of this difeafe, we form three fever-
al indications; a prefervative, a palliative,  and a curative.
   The first is, to avoid or remove the remote  caufes juft
now enumerated.
   The second is, toremovethofefymptoms whichefpecially
contribute to aggravate and continue the difeafe.   And,
   The third is, to  reftore the tone of the ftomach; that is,
to correa or remove the proximate caufe of the difeafe.
   1202. J  The propriety and neceffity of  the firft indica-
tion is fufficiently evident, as the continued application, or
frequent repetition of thofe caufes, muft continue the dif-
eafe;  may defeat the ufe of the remedies; or, in fpite of
thefe,  may occafion the recurrence of the difeafe.   It is
commonly the neglett of this indication which renders this
difeafe fo frequently obftinate.—How the  indication is to
be executed, will be fufficiently obvious from the confi- 
82
PRACTICE.
 deration ofthe feveral caufes:  but it is proper for the prac-
 titioner to attend  to this, that the execution is often ex-
 ceedingly  difficult, becaufe it is not eafy to engage men to
 break in upon eftablifhed habits,  or  to  renounce the pur-
 fuit of pleafure; and particularly,  to perfuade  men  that
 thefe praaices are truly hurtful which they have often prac-
 tifed with  feeming impunity.
    1203. J  The  fymptoms  of this difeafe which efpecially
 contribute to aggravate and continue it, and therefore re-
 quire to be more immediately correaed or removed, arc,
 firft, the crudities ofthe ftomach already produced by the
 difeafe, and difcovered  by  a lofs of appetite, by a knk of
 weight and uneafinefs in the ftomach, and particularly by
 the eruaation of imperfeaiy digefted matters.
    Another fymptom to be immediately correaed,  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  effeas to be mentioned afterwards.
   The third fymptom aggravating the difeafe, and other-
 wife in itfelf urgent, is coftivenefs, and therefore  conftant-
 ly requiring to be relieved.
    1204. J  The first of thefe fymptoms is to be relieved by
 exciting 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 ofthe ftomach: but emetics, and
 vomiting, may alfo excite the ordinary aaion of the ftom-
 ach;  and both, by varioufly agitating the fyftem, and par-
 ticularly by determining to the furface  of the body,  may
 contribute  to remove the caufes of the difeafe.  But thefe
 latter effeas can only be obtained by the ufe of emetics of
 the more powerful kind, fuch as the antimonial emetics ef-
.pecially are.*
   1205. J The second 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 al-
 moft commonly taken in, and, as I think, always undergoes
 an acetous  fermentation  in the ftomach;  and it is therefore
 that, in the human ftomach, and in the ftomachs of allani-
  * The formulae and dofe3 of antimonial emetics have been defcribed in  a
note on Article 185. 
OF  PHYSIC.
2-3
mals ufing vegetable food, there  is always found an acid
prefent.   This acid, 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, eruaation, heartburn, gnawing pains
of the ftomach, irregular appetites and cravings, loofenefs,
griping, emaciation, and debility.   To obviate or remove
thefe effeas aggravating and continuing the difeafe, it is
not only neceffary to correa the acid prefent in the ftom-
ach;  but,  efpecially as this acid proves a ferment  deter-
mining and increafing the acefeency of the aliments after-
wards taken in, it is proper alfo, as foon as poffible, to cor-
rea  the difpofition to exceffive  acidity.
   1206.]  The acidity prefent in the ftomach may be cor-
reaed by the  ufe of alkaline falts, or abforbent earths;*
or by fuch fubftances,  containing thefe, as can be decom-
pofed by the acid of the ftomach.   Of the  alkalines,  the
cauftic is more effeaual than the mild;  and this accounts
for the effeas of  lime-water.   By employing abforbents,
we avoid the excefs  of alkali, which might fometimes take
place.  The abforbents are different, as  they form a neu-
tral more or lefs laxative; and hence the difference between
magnefia alba and other abforbents.   It is to be obferved,
  * No part of thepra&ice of phyfie requires more caution than the admini-
ftering alkaline falts, andabforbent earths.   The alkaline falts, by theircaul-
tic quality, corrode the ftomach, and blunt its adlion, when taken'in too Urge
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 urgency of
the cafe.  The abforbent earths, as  chalk, crabs eyes, fcc. if they do not meet
with an acid, are apt to concrete into a hard indiffoluble mafs, by the mucus
of the ftomach.  Magnefia is doubtlefs, in many cafes, preferable to a cal-
careous earth ; when, on account of its purgative quality, we cannot continue
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 £)i. to 3L twice or thrice  a-day; and its purgative qua-
lity may,  in many cafes, be prevented, by adding to each dofe of it ten 01
fifteen grains of rhubarb, and five or fix drops of oil of anife-feed.  The De ■
co&um cretaceum of the  Edinburgh Pharmacopoeia is a good form for the
exhibition of chalk. But chalk may be given with rhubarb 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:
           B:. Magnes. alb. vi.
              Sacch. alb.  §iii.
              Nuc. mosch. 9ii.
              M. f. trochisci cum mucilagin. gum tragacsujj. q. s. 
•4
PRACTICE
that alkalines, and abforbents may be employed to excefs;
as,  when employed in large  quantity,  they  may deprive
the animal fluids of the acid neceffary to their proper com-
petition.
   1207.] The difpofition  to acidity may be obviated by
avoiding acefcent  aliments, and ufing animal food little
capable of acefeency.   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 acefeency may in fome meafure be avoided, by choof-
ing vegetable food  the leaft difpofed to a vinous fermenta-
tion, fuch as leavened  bread and well fermented liquors,
and, inftead of frefh. native  acids, employing  vinegar.
   1208.J The acid arifing from acefcent matters in a found
ftate of the ftomach, does not proceed to any high degree,
or is again foon involved and made  to difappear: 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 acidity, or from their not being
fupplied in due quantity.   How the former  may be occa-
fioned,  we do not  well  underftand;  but we can  readily
perceive that the  latter,  perhaps the former alfo, may
proceed from a weaker aaion of the mufcular fibres ofthe
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 ufe of fti-
mulants often correas or obviates  an acidity  that would
otherwife have appeared.   From thefe confiderations, we
conclude, that the  produaion and fubfiftance of acidity in
the ftomach,  is to be efpecially prevented by reftoring and
exciting the proper aaion of it, by the feveral means to be
mentioned hereafter.
   1209.] But it  is alfo to be further obferved, that
though there are certain powers in  the  ftomach for pre-
venting a too copious acidity, or a high degree of it, they
are not however always fufficient for preventing acefeency,
or for covering the acidity produced;  and  therefore, a^
long as vegetable fubftances remain in  the ftomach, their
acefeency may go  on and increafe.   From  hence we per-
ceive,  that a f pecial caufe of the excefs of acidity may be,
the too long retention of .acefcent matters in the  ftomach; 
OF  PHYSIC.
55
v.'hether this may be from thefe matters being of more dif-
ficult folution,  or from the weaknefs of the ftomach more
flowly difcharging its contents into the duodenum, or from
fome impediment to the free evacuation of the ftomach by
the pylorus.  The latter of thefe caufes  we are well ac-
quainted with, in the cafe of a fcirrhous pylorus, producing
commonly the higheft degree of acidity.   In all the inftan-
ces of this feirrhofity I have met with,  I have found it in-
curable :  But the firft of thefe  caufes is to be obviated by
avoiding fuch aliments as are of difficult folution; and the
fecond is to be mended by the feveral remedies for exciting
the aaion ofthe ftomach, to be mentioned afterwards.
   1210.] The third  fymptom commonly accompanying
dyfpepfia, which requires to be immediately removed,  is
coftivenefs.   There is fo much conneaion between  the fe-
veral portions  of the  alimentary canal with refpea to the
periftaltic motion,  that, if accelerated or retarded  in any
one part,  the other parts of it are commonly affeaed in the
fame manner.   Thus, as the brifker aaion of the ftomach
muft accelerate the aaion of the inteftines,  fo the flower
aaion of  the  inteftines muft in fome  meafure retard that
of the ftomach.  It is therefore of confequence to the pro-
per aaion of  the ftomach, that the periftaltic motion of
the inteftines determining  their contents downwards, be
regularly continued; and that  all coftivenefs j or interrup-
tion of that determination, be avoided.  This may be done
by  the various means of exciting the aaion of the intef-
tines:  But it is  to be obferved here, that as every confi-
derable evacuation  of the inteftines weakens their aaion,
and is ready therefore to induce  coftivenefs when the eva-
cuation is over; fo  thofe purgatives which produce a large
evacuation,  are unfit  for correaing the  habit of coftive-
nefs.   This,  therefore, fhould be atlempted by medicines
which do no more than folicit the inteftines to a more rea-
dy difcharge of their prefent contents,  without either hur-
rying their aaion, or  increafing the excretions made into
their cavity; either of which effeas might produce a purg-
ing.   There  are, I  think,  certain medicines peculiarly
proper on this occafion,  as-they feem toftimulate efpeci-
ally the great guts, and to aa  little on the higher parts of
the inteftinal canal.*
 • Ten or fifteen grains of Pil. Ruf. anfwer this purpofe fufficiently well.
  Vol. II.                  h 
6€
PRACTICE
     1211.] We have  thus mentioned the feveral means of
  executing our fecond indication; and I proceed to the
  third,  which is, as we have laid, the proper curative; and
  it is to reftore the tone of the  ftomach,  the  lofs  of which
  we confider as the proximate caufe of the difeafe, 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 direaiy and chiefly on  the ftomach itfelf;
  and the other  is,  of thofe means which, operating upon
  the whole fyftem,  have their tonic effefts thereby commu-
  nicated to the ftomach.
     1212. J The medicines which operate direaiy on the fto-
  mach are either ftimulants or tonics.
     The ftimulants are faline or aromatic.
     The faline  are acids or neutrals.
     Acids of all kinds feem to have the power of ftimulat-
  ing the ftomach, and therefore often increafe appetite:  But
  the native acids, as liable to fermentation, may otherwife
  do harm, and are therefore of ambiguous ufe.  The acids,
  therefore,  chiefly and fuccefsfully  employed are the vitri-
  olic,*  muriatic,t  and  the diftilled acid  of vegetables, as
  it is found in tar-water, which are all of them antizymics.+
     The neutral falts anfwering  this intention are efpecially
  thofe which have the muriatic acid in their compofition,
r  though k is prefumed that neutrals of all kinds have more
  or lefs of the  fame virtue.|{
     1213. J The aromatics, and perhaps fome other acrids,
  certainly ftimulate the ftomach, as they obviate the acef-
  eency and flatulency of vegetable food:  but their ftimulus
  is  tranfitory;  and if frequently repeated, and taken in large
  quantities, they may hurt the tone of the ftomach.**
  It is to be-regretted that the Author did not mention thofe certain medicine*
  to which he alludes.
    * The dofe of the vitriolic acid ought not to exceed ten drops*, and it fhould
  be  well diluted with water.
    t The Tki&ura, Martis of the Edinburgh College powerfully ftimulates the
  ftomach, and acts at the fame time as a tonic; its dofe is from ten to twenty
  drops thrice a-day, in a fuiEcient quantity of any proper liquid,  and it is a
  very agreeable medicine.
    $ I. e. refift fermentation.
    || The Sal digeftivus, i. e. the muriatic acid faturated with vegetable fixed
  alkali, was thought to be preferable  to common fait in  promoting digeftion.
  Hence its old  name of Sal digeftivus.  Its Cuperiority over common fait is
  however doubtful.
    ** This caution againft the too free ufe of aromatics ought to be peculiarly
  attended to by the young praftitioner.  The fpeedy relief which they procure
  tempts the patient to have frequent recourfe to them, which, as the Author. 
OF  PHYSIC.                 87
   1214.] The tonics emplbyed to ftrengthen the ftomach
are bitters, bitters  and aftringents combined,  and chaly-
beates.
   Bitters are undoubtedly tonic medicines,  both with ref-
pea to the ftomach and the whole fyftem: But their long-
continued ufe has been found to deftroy the tone of the
ftomach and ofthe whole fyftem ; and, whether this is from
the mere repetition of their tonic operation,  or from fome
narcotic power joined with the tonic in them', I am uncertain.
   1215.J Bitters and aftringents comJbined  are prpbably
more effeaual tonics than either of them takervfingly ; and
we fuppofe fuch a  combination to take place in the Peru-
vian bark; which therefore proves a powerful tonft,' *ltath
with refpea to the ftomach  and to the whole fyftem.  But
I have fome ground to fufpea that the long  continued ufe
of this bark may, like bitters, deftroy, both the tone of the
ftomach  and ofthe whole fyftem.*
   1216.] Chalybeates may be employed as  tonics in vari-
ous forms,t and in confiderable quantities, with  fafety.
They have been often employed in the form  of mineral wa-
ters, and feemingly with fuccefs : But, whether this is ow-
ing to the chalybeate in the compoiition of thefe waters, or
to fome other circumftances attending their ufe, I dare not
pofitively determine; but the latter opinion feems to  me
the more probable.
   1217. J The remedies which ftrengthen the ftomach, by
being applied to the whole body, are, exercife, and the ap-
plication of cold.
   As exercife  ftrengthens the whole body, it muft  alfo
ftrengthen the ftomach but it does this alfo in a particular
manner,  by promoting perfpiration,  and exciting the aai-
on ofthe veffels on the furface ofthe body, which have a
particular confent with the mufcular fibres ofthe ftomach.
This particularly explains why  the exercifes of geftation,
though not  the  moft powerful in ftrengthening the whole
juftly obferves, may materially hurt the tone of the ftomach, and confequent-
ly increafe the difeafe which they were intended to remove.
  * Forms of thefe tonics may be feen in the preceding  notes on Articles
981, 982, 992.
  f See the notes on Articles 981, 982, 992.  In thefe cafes the Tindhira:'
Martis, mentioned in the note on Article 1212,  is as proper a form of chaly-
beates as any we can ufe. Its dole is from ten to twenty drops in any pro-
per vehicle. A glafs of  cold fpring water, acidulated with a few  drops of
this tincture, is agreeable and refrefhing,  and may be ufed a-, the pntirnt'3
common drink; its agreeablenefs may be conliderably increafed by adding tb,
each half pint glafs, a table-fpoonful of ample cinnamon-wa:'-;. 
S9                 PRACTICE
fyftem, are, however, very powerful  in ftrengthening the
ftomach ;  of which we have a remarkable proof in the ef-
feas of failing.  In ftrengthening the general fyftem, as fa-
tigue muft be avoided, fo bodily exercife is of ambiguous
ufe ; and perhaps it is thereby that riding on horfeback has
been fo often found to be one of the moft powerful means of
ftrengthening the ftomach,  and thereby of curing dyfpepfia.
   1218.]  The other general remedy of dyfpepfia is the ap-
plication of cold; which may be in two ways; that is, ei-
ther by thefamplication of  cold air, or of cold water.  It
is probable, that,  in  the atmofphere conftantly furrounding
our bodies, a certain degree of cold, confiderably lefs than  .
the temperature of our bodies themfelves, 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 conftriction of the pores;
a certain degree of cold in  the atmofphere, with fuch exer-
cife, 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 tone of the ftomach is confiderably flrength-
ened.  Cold air, therefore, applied with exercife, is a moft
powerful tonic  with refpect to the ftomach; and this ex-
plains why, for that purpofe, no exercifes within doors,, or
in clofe carriages, are fo ufeful as thofe in the open air.
   1219.] From the fame  reafoning, we can perceive, that
the application of cold water, or cold bathing, while it is a
tonic with refpea to the fyftem in general, and efpecially as
exciting the action of the extreme veflels, muft in both re-
fpeas be a powerful means of ftrengthening the tone of the
ftomach.
   1220. J  Thefe are the remedies to be employed towards
a radical cure of idiopathic  dyfpepfia; and it might be,
perhaps, expeaed here, that I fhould treat alfo of the vari-
ous cafes of the fympathic difeafe.  But it will be obvious
that this cannot be properly  done without treating of all
the difeafes of which 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 
OF  PHYSIC.                  *9
the mean time, it may be proper to obferve, that there  is
not fo much occafion for diftinguifh ing between the idiopa-
thic and fympathic dyfpepfia, as there is in many other cafes
of idiopathic and fympathic difeafes.  For, as the fympa-
thic cafes of dyfpepfia are owing to a lofs of tone in fome
other part of the fyftem,  which is from thence communi-
cated to the ftomach ; fo the tone of the ftomach reftored,
may be communicated to the part primarily affeaed; and
therefore the remedies of the idiopathic may be often ufe-
fully employed, and are often the  remedies chiefly em-
ployed in fympathic dyfpepfia.
   1221. J Another  part of our bufinefs  here might be to
fay, how fome other of the urgent fymptoms, befides thofe
above-mentioned, are to be palliated.  On this fubjea, I
think it is enough to fay, that the fymptoms chiefly requir-
ing to be immediately relieved, are flatulency, heartburn, o-
ther kinds of pain in the regionofthe ftomach, and vomiting.
   The dyfpeptic are ready to fuppofe that the whole of
their difeafe confifts in a flatulency.   In this it will be ob-
vious that they are miftaken;  but, although the flatulency
is not to  be entirely cured,  but by mending the imbecility
of the ftomach by the means above-mentioned; yet the fla-
tulent diftention of the ftomach may be relieved by carmi-
natives, as they are called, or medicines that produce a dif-
charge of wind from the ftomach; fuch are the various antif-
pafmodics, of which the moft effeaual is the vitriolic aether.
   The heartburn may be  relieved^by abforbents,* antif-
pafmodics,t or demulcents.J
   The other pains  of the ftomach may be fometimes re-
lieved by carminatives,|| but moft certainly by opiates:
  * The abfoiSents have been defcribe I a&ove, fee note on Article 1206.
  •f It may be doubtful whether antifpafmodics  are effectual in removing
heartburn.  Opium undoubtedly often gives relief in dofes of twenty or thir-
ty drops of laudanum.
  | Extract of liquorice is as good a demulcent in thefe cafes as^any in the
lift of the Materia Medica. Sucking a little piece of it, and drinking a. cup
or two of weak lintfeed-tea after it, feldom fail of giving relief.
  |j Carminatives fuitable in thefe cafes are the ellential oils of the feeds of
fome aromatic umbiliferous plants, as 01. Anifi. the dofe of which is t.fteen
or twenty drops on a piece of fugar, though common practice feldom goes
half that length.  The Oleum Carvi is another excellent carminative, but it
is very hot, and its" dofe muft never exceed five  drops; two drops are a mo-
derate dofe.  The Oleum  Mentha: is another good carminative ;  its dofe is
two or three drops on a piece of fugar.  Two "Tains of the Extraft of opiun.,
or forty drops of the laudanum, are ufually given in half a cupful of liuturec•-
tea. The dole may be irravafed to 100 drops of laudanum, in the f:ime quantity
«f vehicle, efpecially if the pain, of the ftomach bw ..:Lonipaiii.edv.-i:n \ urui.Ln^s. 
90
PRACTICE
    Vomiting is to, be cured moft effectually by opiates
 thrown by injection into the anus.

                     CHAP. IIL

                SDf ^pocfjonnria-sisf,
  OR THE HYPOCHONDRIAC AFFECTION, COMMONLY
           CALLED  VAPORS, OR  LOW SPIRITS.

  1222.] J_N certain perfons there is a ftate of mind diftina
  guifhed.by a concurrence of the  following circumftances z.
  A langour, liftlcffnefs,  or want of refolution and aaivity
.  with refpeft to all undertakings; a difpofition to feriouf-
  nefs, fadnefs, and timidity; as to all future events, an ap-
 prehenfion of  the worft or moft unhappy ftate  of them>
  and therefore, often upon ftight 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 feelingy
  perhaps of the fiighteft kind, they apprehend great danger,
  and even death itfelf.  In  refpea to all thefe feelings and
  apprehenfions, there is commonly the moft obftinate belief
  and perfuafion.
    1223.] This ftate of mind is the Hypochondriafis of
  medical  writers.   See  Linnaei Genera Morborum,  Gem
  76. et Scgari Syftema Symtomaticum, Clafs XIII.  Gem
Vfs.;. The fame ftate of mind is what  has been commonly
  c«flled Vapours and fyzo Spirits.  Though the term Va-
  pours may be  founded on a falfe theory, and therefore im-
  proper, I beg leave, for a pupofe that will immediately ap-
  pear, to  employ it for a little here.
    1224.] Vapours, then, or the ftate of mind defcribed
  above, is, like every other ftate of mind, conneaed with a
  certain ftate of the body, which muft be inquired into in
  orde£to its being treated as a difeafe by the art of  phytic-
    1225.] This ftate of the body, however, is not very ea-
  fily afcertained: for we can perceive, that on different oc-
  cafions it is very different; vapours being combined fome-
  times with dyfpepfia, fometimes  with hyfteria, and fome-
  times vith melancholia, which are difeafes feemingly de-
  pending on very different ftates of the body.
    1226.] The combination of vapours with dyfpepfia is
  very frequent, and in feemingly very different circumftan- 
                  OF  PHYSIC                SI
                       ==                      ?r ■'
ces.   It is, efpecially, thefe different circumftances that I
would with to afcertain; and I remark, that they are mani-
feftly of two different kinds.   Firft, as the difeafe occurs ,
in young  perfons of both fexes, in perfons of a fanguine
temperament, and of a  lax and flaccid habit?   Secondly,
as it occurs in elderly  perfons of both fcxes, of a melan-
cholic temperament, and of a firm and rigid habit.
   1227.] Thefe two different cafes of  the combination
of vapours and dyfpepfia, I confider as two diftina dif-
eafes, to be diftinguifhed chiefly by the temperament pre-
vailing in the perfons affeaed.
   As the dyfpepfia of fanguine temperaments is often with-  •
out vapours; and as the vapours when joined with dyfpep-
fia in fuch temperaments, may be confidered as, perhaps,.
always a fymptom ofthe affeaion  of the ftomach; fo to»
this  combination of dyfpepfia and  vapours,  I  would ftill
apply the appellation of Dyspepsia,  and confider it as ftria-
iy the difeafe treated of in the preceding chapter.
   But the combination of dyfpepfia and vapours in me-
 lancholic temperaments, as the vapours or the turn of mind
 peculiar to the temperament, nearly that defcribcd above
 in (1222.) are  effential circumftances ofthe difeafe; and
 as this turn  of mind  is often with few,  or only flight fymp-
 toms of dyfpepfia;  and, even though the latter  be attend-
 ing, as they feem to be rather the effeas of the general tem-
 perament, than of any primary or  topical affeaion of  the
 ftomach; I confider this combination  as a very different
 difeafe from the former, and would apply toit ftriaiy  the
 appellation of Hypochondriasis.
   1228.] Having thus pointed out a diftinaion between-
 Dyfpepfia and Hypoehondriafis, I fliall now,  ufing thefe
 terms in the ftria fenfe above mentioned, make fome obfer-
 vations which may, I think,  illuftrate the fubjea, and more
 clearly and fully eftablifh the diftinaion propofed.
   1229.] The dyfpe*piki often appears early in life, and i^
 frequently much mended as life advances:  But the hypo-
 chondriacs  feldom appears early in life, and more ufually
 in more  advanced years  only; and more  certainly  ftill,
 when it  has once taken place, it goes on increafing as lite-
 advances to old age.
    This feems to be particularly well illuftrated, by our oh
 ferving the  changes in the ftate of  the mind which ufual:;. 
 -92                 P R A C T I c r

  take  place in the courfe of life.   In youth, the mind ii   J
 ichearful, aaive, rafh, and moveable : But, as life advances*  ■
  the mind by degrees becomes more ferious, flow, cautious,  ^
  and fteady ; till at length,  in old age,  the gloomy, timid^
  diftruftfui,and obftinate ftate of melancholic temperaments,
  is more exquifitely formed.   In producing  thefe changes,
  it is true, that  moral caufes have a fhare; but it is at the
  fame time obvious, that the temperament of the body de-
  termines the operation  of thefe  moral caufes,  fooner of
  later, and in a greater or leffer degree, to have their effects.
  The fanguine temperament retains longer the charaaer of
. youth, while the melancholic temperament brings on more
  early the manners of old age.
    1230.] Upon the whole, it appears, that the ftate ofthe
  mind which attends, and efpecially diftinguifhes hypochon-
  driafis, is the effea of that fame rigidity of  the folids, tor.
  por of the nervous  power, and peculiar balance between
  the arterial and venous  fyftcms which  occur in advanced   ^
  life, and which at ail  times take place more or lefs in melan-
  cholic temperaments.   If therefore  there  be  alfo fome-
  what of a like  ftate of mind attending the dyfpepfia which
  occurs early in life in fanguine temperaments and lax ha-
  bits,  it muft depend upon a different  ftate of  the body,
  and probably upon a weak and moveable ftate of  the ner-
  vous power.                                             i
    1231.J Agreeable to all this in dyfpepfia, there is more
  of fpafmodic affeaion, and the affeaion ofthe mind (1 222.}    \
  is often abfent, and,  when  prefent, is perhaps always of a
  fiighter kind ; while in hypochondriafis the affection of the
  mind is more conftant. and the fymptoms of dyfpepfia, or
  the affeaions of the ftomach, are often abfent, or,  when
  prefent, are in  a fiighter degree.
    I believe the affeaion of the mind is commonly different
  in the two  difeafes.  In dyfpepfia, it is often languor and
  timidity only,  eafily difpelled; while, in hypochondriafis,
  it is generally the gloomy and rivetted apprehenfion of evil.
    The two difeafes are alfo diftinguifhed by  fome other
  circumftances.   Dyfpepfia, as  I have faid, is often a fymp-
  tomatic  affeaion;  while hypochondriafis is, perhaps, al-
  ways a primary and idiopathic difeafe.
    As debility  may be induced by many different caufes^ 
                   OF PHYSIC*                 *3

dyfpepfia is a frequent difeafe; while hypochondriafis, de-
pending upon a peculiar temperament, is more rare.
   1232.]  Having thus endeavoured to diftinguifh the two
difeafes, I  fuppofe the peculiar nature and proximate caufe
of  hypochondriasis will be underftood; and I proceed,
therefore,  to treat of its cure.
   So fcr as the affeaions of the body,  and particularly of
the ftomach, are the fame here as in the cafe of  dyspepsia^
the method of cure might be fuppofed to be alfo the fame;
and accordingly the praaice has been carried on with little
diftinaion: But I am perfuaded that a diftinaion is often
neceffary.
   1233.]  There  may be a foundation here for the fame
prefervative indication as firft  laid down in the cure of dys-
pepsia; (1202.)  but I cannot treat this fubjea fo clearly
or fully as I could  wifh, becaufe I have  not yet  had fo
much opportunity of obfervation as I think neceffary to
afcertain the remote caufes; ann I can  hardly make ufe of
the obfervation of others, who have feldom or never diftin-
guifhed between die two difeafes.   What, indeed has been
laid with refpea to the remote caufes of melancholia, will
often apply to the hypochondriasis*, which I now treat of;
but the fubjea of the former  has been  fo  much  involved
in a doubtful  theory,  that I find it difficult  to felea the
faas that might properly and ftriaiy apply to the  latter.
I delay this fubjea, therefore, till another occafion;  but
in the mean time truft,  that  what I have faid regarding the
nature ofthe difeafe, and fome remarks I  fhall have occa-
fion to offer in confidering the method  of cure,  may in
fome meafure fupply my deficiency on this fubjea of the
remote caufes.
   1234.]  The second indication laid down in the cure of
dyfpepfia (1201.) has properly a place here;  but it is ftill
to be executed with fome diftinaion.
   1235.]  An  anorexia, and accumulation of crudities in
the ftomach, does not commonly occur in hypochondriafis
as in dyfpepfia; and therefore  vomiting  (1204.) *s not fo
often neceffary in  the former as in  the latter.
   1236.] The fymptom of excefs of acidity, from the flow
evacuation of  the ftomach  in melancholic temperaments,
often arifes to a very high degree in hypochondriafis; and
  Vol. II.                 M 
94                 PRACTICE
therefore,  for the fame reafon as in (1205.) it is to be ob-
viated and correaed with the utmoft care.   It is upon this
account that the feveral antacids,  and the other means of
obviating acidity, are to be employed in hypochondriafis,
and with the fame attentions and confiderations as in (1206.)
and following;  with this refleaion, however, that the exr
citing1 the aaion of the ftomach there mentioned, is to be
a little differently  underftood,  as  fliall be hereafter  ex-
plained.
   1237. J  As coftivenefs, and that commonly to a confi-
derable  degree, is a very conftant attendant of  hypochon-
driafis,  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 rcftriaions a3
in (1210.)
   1238.]  It is efpecially with refpea to the  third indica-
tion laid down in the cure of dyfpepfia (1201.) that there
is a difference of praaice to be obferved in the cure of hy-
pochondriafis;  and that often one direaiy oppofite to that
in the cafe of dyfpepfia, is to be followed.
   1239.]  In dyfpepfia, the chief  remedies  are the tonic
medicines, which to  me feem neither neceffary  nor fafe in
hypochondriafis;  for in this there is not a  lofs of tone, but
a want of aaivity that is to be remedied.
   Chalybeate mineral  waters have commonly been em-
ployed  in hypochondriafis, and feemingly with fuccefs.
But this is probably  to be imputed to the amufement and
exercife ufually accompanying the ufe of thefe  waters, ra-
ther 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.
   1240.] Cold bathing is often highly ufeful  to the  dyf-
peptic,  and, as a general ftimulant, may  fometimes feem
ufeful to the hypochondriaic; but it is not commonly fo
to the latter; while, on the other hand, warm bathing, hurt.
fui to the dyfpeptic, is often extremely ufeful to the hypo-
chondriac.
   1241.J Another inftance of a  contrary praaice necef-
fary in the two difeafes, and illuftrating their refpeaive na-
tures, is, that the drinking tea and coffee is always hurtful 
0 F  P H Y S I C.                95
to the dyfpcptic, but is commonly extremely ufeful to the
hypochondriac.
   1242.]  Exercife,  as  it ftrengthens  the  fyftem,  and
thereby the ftomach, and more efpecially, as by increafing
the perfpiration,  it excites the aaion of the ftomach,  it
proves one of the moft ufeful remedies in dyfpepfia;  and
further,  as, by increafing the perfpiration, it excifes the
aaivity of the ftomach, it likewife proves an ufeful reme-
dy in the hypochondriafis.   However, in the latter cafe,
as I fhall explain  prefently, it is ftill a more ufeful reme-
dy by its operation upon the mind than by that upon the
body.
   1243.] It1S now proper that we proceed to confider the
moft  important article of our praaice in this difeafe, and
which is, to confider the treatment of the mind; an affec-
tion of which fometimes  attends dyfpepfia, but is always
the chief circumftance in hypochondriafis.  What I am to
fuggeft here, will apply to both difeafes; but it is the hy-
pochondriafis that I am to keep moft conftantly in view.
   1244..] The management ofthe mind in hypochondriacs,
is often nice and  difficult.  The firm perfuafion  that gene-
rally  prevails in fuch patients, does not allow their feelings
to be treated as imaginary, nor their apprehenfion of dan-
ger to be confidered as groundlefs, though the  phyfician
may  be  perfuaded  that it is the cafe in both refpeas.
 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
often their phyfician;  and indeed they often do it confift-
ently ;  for a phyfician who does not  admit the reality of
the difeafe, cannot be fuppofed to take much pains to cure
it, or to avert the danger of which he entertains no ap-
prehenfion.
   If inany cafe the pious fraud of a placebo be allowable,
it feems to be in treating hypochondriacs ; who, anxious
for relief, are fond of medicines, and, though  often difap-
pointed, will ftill  tafte every new  drug that can be propo-
fed to them.
   1245.] As it is the nature of man  to indulge every pre-
fent emotion, fb  the hypochondriac  cherifhes  his fears;
and,  attentive to  every feeling, finds in trifles light as air
a ftrong confirmation of his apprehenfions.   His  cure, 
96                 P R A C T I C E
therefore, depends efpecially upon the interruption of his
attention, or upon its being diverted to other objeas than
his own feelings.
  1246.3 Whatever averfion  to application of any kind
may appear in hypochondriacs,  there is nothing more per-
nicious to them than abfolute icilcnefa,  or a vacancy  from
all eameft purfuit.   It is owing to wealth admitting of in-
dolence,  and leading to the purfuit of tranfitory and unfa-
tisfying amufements, or to that of exhaufting pleafurrs
only, that the prefent times exhibit to us fo many inftances
of hypochondriacifm.
  The occupations of bufinefs  fuitable  to  their circum-
ftances and iituation  in life,  if neither attended with emo-
tion, anxiety, nor fatigue, are always to be admitted, and
periifted  in by hypochondriacs.  But occupations upon
which  a  man's fortune depends, and which  are always,
therefore, objeas  of anxiety  to melancholic men; and
more particularly where fuch occupations are expofed to
accidentalftnterruptions, difappointments, and failures,  it
is from mefc that the hypochondriac is certainly to be
withdrawn.
  1247.J The hypochondriac  who is not neceffarily, by
circumftance or habits, engaged in bufinefs, is to be drawn
from his attention to his own feelings by fome amufement.
  The various kinds of fport  and hunting,  as  purfued
wTith 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 chear-
ful kind,  will be always found of great fervice.
  Play,  in which  fome fkill is required,  and where the
ftake is not an objea of much anxiety, if not too long pro-
traaed, may often be admitted.
  In dyipeptics, however, gaming, liable to fudden  and
confiderable  emotions, is dangerous; and the long conti-
nuance of it, with night watching, is violently debilitating.
But in  melancholies, who commonly excel in fkill, and are
lefs fufceptible of violent emotions, it is more admiffible^
and is often the only amufement that can engage them. 
OF  PHYSIC.                97
   Mufic, to a nice ear, is a hazardous amufement, as long
 attention to it is very fatiguing.
   1248.]  It frequently happens, that amufements of every
 kind are rejeaed by hypochondriacs; and in that cafe, me-
 chanical means of interrupting thought are the remedies to
 be fought for.   Such is  to be found in brifk exercife,
 which requires fome attention in the condua of it.
   Walking is feldom of this kind; though, as gratifying
 to the  reftleffne fs of  hypochondriacs,  it has  fometimes
 been found ufeful.
   The required interruption of thought is beft obtained 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 attentidh,  does very little fervice.
   Exercife in an  eafy  carriage, in the direaion 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.
   1249.]  Whatever exercife may be employed, it will be
* moft effeaual when employed in the purfuit of a journey;
 firft, becaufe it withdraws  a perfon from many objeas of
 uneafinefs and care which might prefent themfel ves at home;
 fecondly,  as it engages in more conftant exercife, and in a
 greater degree of it than is commonly taken in airings a-
 bout home; and  laftly, as it is conftantly prefenting new
 objeas which call forth a perfon's attention.
   1250.]  In our fyftem of Nofology we have, next to Hy-
 pochondriafis,   placed  the  Chlorofis,   becaufe  I  once
 thought  it might be confidered as a genus, comprehending,
 befides  the  Chlorofis of Amenorrhcea, fome  fpecies of
 Cachexy: But, as I cannot find this tobe  well founded,
 and cannot diftinttly point out any  fuch difeafe, 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.
      Of Spasmodic  Affections without Fever.

 1251.]  U NDER this title I am to comprehend all the
 difeafes  which confift in motu abnormi;  that is, in a pre- 
9*                 PRACTICE
 ternatural ftate of the contraaion and motion of the  muf-
 cular or moving fibres in any part ofthe body.
   1252.] 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
 I expea it  will be obvious, that,  upon this occafion,  it
 would not be proper to confine  our view to the affeaions
 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, Co-
 lica, and many other difeafes, are admitted.
   1253.] It has been hitherto the method of our Nofolo-
 gifts to divide the Spafmi into the tfro orders of Tonici and
 Clonici, Spaftici  and  Agitatorii; or,  as many at prefent
 ufe the terms, into Spafms ftriaiy  fo called, and convul-
 fions.   I find, however, that many, and indeed moft of the
 difeafes to be confidered under  our  title  of Spafmodic af-
 feaions, in refpea of tonic or Clonic contractions, are of
 a mixed kind:  and, therefore,  I cannot follow the  ufual
 general divifion; but have attempted another, by arrang-
 ing the feveral Spafmodic  difeafes according as they affea
 the feveral funaions, Animal, Vital, or Natural.

                       Sect.  I.
  Of the Spasmodic Affections of the Animal Functions,
   1254.] AGREEABLE to the language of the ancients,
 the whole of the difeafes to  be  treated of in  this feaion
 might be termed spasmi; and many ofthe moderns continue
 to apply the term in the fame manner : but I think it con-
 venient to diftinguifh the terms  of Spasm and Convulsion,
 by applying the former, ftriaiy to what has been called the
 Tonic ; and the latter, to  what  has been called the Clonic
 Spafm.   There is certainly a  foundation for the ufe of
 thofe different terms, as there is  a remarkable difference in
 the ftate of the contraaion of moving fibres upon differ-
 ent occafions.  This I  have indeed pointed out  before in
 my treatife of Phyfiology,  but mult alfo repeat it here.
   1255.] In the exercife  of the feveral fun6tions of the
 animal ceconomy, the contraaions ofthe moving fibres are
excited by the will, or by certain other caufes fpecially ap-
pointed by nature for exciting thofe contraaions; and thefe 
OFPHYSIC.                 99
other caufes I name the natural causes.   In a ftate  of
health, the moving fibres are contraaed  by the power of
the will, and by the natural causes only.  At the fame time
the contraaions produced are in force and velocity regulated
by the will, or by the circumftances ofthe natural caufes;
and the contraaions, 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 natural caufes is again applied.
   1256.j Such are the conditions ofthe aaion ofthe mov-
ing fibres in a  ftate  of health;  but in a morbid  ftate the
contraaions of the mufcles and moving fibres ordinarily
depending upon the will are excited without the concur-
rence of the will,  or contrary to what the will intends; and
in the other funaions they are excited by the aaion of un-
ufual and unnatural caufes.   In both cafes, the  contrac-
tions produced may be in two different ftates.  The one is,
when the contra6tions are to a more violent degree than
 is ufual in health, and are neither fucceeded by a fpontane-
 ous relaxation,  nor even readily yield to an extenfion  ei-
 ther  from the aaion of antagonift mufcles, or from  other
 extending powers applied.   This ftate of contraaions  is
 what has been called a tonic  spasm, and is what I fhall  name
 fimply and ftriaiy a spasm.    The  other morbid ftate of
 contraaion is, when they are fucceeded by a relaxation, but
 are immediately  again  repeated without the concurrence
 ofthe will or ofthe repetition  of natural  caufes, and are
 at the fame time commonly, with refpea to velocity and
 force, more violent than in a healthy ftate.  This ftate of
 morbid contraaion is what has been named a clonic spasm,
 and what I fhall name fimply and ftriaiy a convulsion.
   In this fec\ion I  fhall follow nearly the ufual divifion of
 the fpafmodic difeafes into thefe confifting in Spafm, and
 thofe confifting in Convulfion;  but it may not perhaps be
 in my power to follow fuch divifion exaaiy.

                       CHAP. I.

                    fl)f Cetanug*

 1257.] JJOTH  Nofologifts and Praaical Writers have
 diftinguifhed Tetanic complaints into the feveral fpecies of 
iOO               PRACTICE
Tetanus, Opifthotonos, and Emprofthotonos;  and I have
in my Nofology put the Trifmus, or  Locked Jaw, as a
genus diftina from the Tetanus.  All this,  however, I
now judge tobe improper; and am of opinion  that all the
feveral  terms mentioned denote, and are applicable only
to, different degrees of one and the fame difeafe;  the hif-
tory and cure of which I  fnall  endeavour to deliver in this
chapter.
   1258.]Tetanic complaints may, from certain caufes, oc-
cur in every climate that we are acquainted with ;  but they
occur moft frequently in the warmeft climates, and molt
commonly in the warmeft feafons of fuch climates. Thefe
complaints affea all ages, fexes, temperaments, and com-
plexions.  The caufes from whence they commonly pro-
ceed,  are cold and moifture applied to the body  while it
is very warm, and efpecially the fudden viciffitudes of heat
and cold.   Or, the difeafe is  produced by punaures,  la-
cerations, or other lefions of nerves in any part of the bo-
dy.  There are,  probably, fome other caufes of  this dif-
eafe; but they are neither diftinaiy known, nor well afcer-
tained.  Though the caufes mentioned do, upon occafion,
affea  all forts of  perfons, they  feem  however to attack
perfons  of middle  age more frequently than the  older or
younger, the male fex more  frequently than the female,
and the robuft and vigorous  more  frequently than the
weaker.
   1259.]  If the difeafe proceed from cold,  it commonly
comes on in a few  days after the application of  fuch cold;
but, if it arife from a punaure or other lefion of a nerve,
the difeafe does not commonly come on for many  days af-
ter the lefion has happened, very  often when  there is nei-
ther pain nor uneafinefs remaining in the wounded or hurt
part, and very frequently when the wound has been entire-
ly healed up.
   1260. J The difeafe fometimes  comes on fuddenly to a
violent 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 dif-
ficult and painful.  As the rigidity ofthe neck comes  on
and increafes, there is commonly at the fame time  a fenfe
cf uneafinefs felt about the root of the  tongue; which by 
OF  P H Y S IC.               101
degrees, becomes a difficulty of fwallowing, and at length
an entire interruption of it.   While the rigidity  of the
neck goes on increafing there arifes a pain, often violent, at
the lower end ofthe fternum, and from thence fhoofinn in-
to the back.  When this pain arifes, all the mufcles of the
neck, and particularly thofe of the back  part of it, are im*
mediately affeaed with fpafm,  pulling the  head ftrongly
backwards.   At the fame  time, the mufcles that pull up
the lower jaw, which upon the firft approaches of the dif-
eafe were affeaed with fome fpaftic rigidity, are now gene-
rally affeaed 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 fternum
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 affeaed with fpafms.   After thofe of
the neck, thofe along the whole of the fpine become affea-
ed, bending the trunk ofthe body ftrongly backwards; and
this is what has been named the  Opisthotonos.
   In the lower extremities, both the flexor and extenfor
mufcles are commonly at the fame time affeaed, and keep
the limbs rigidly extended.   Though the extenfors of the
head and back are ufually  the moft ftrongly affeaed,  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 affeaed with fpafm.
During the whole of the difeafe, the  abdominal mufcles
are violently affeaed with  fpafm, fo that the belly is  ftrong-
ly retraaed, and feels hard as a  piece of board.
   At length the  flexors of the head and trunk  become fo
ftrongly affeaed  as to  balance the  extenfors, and to keep
the head and trunk ftraight, and rigidly extended, incapa-
ble of being moved in any way; and it is to this ftate the
term of Tetanus  has  been ftriaiy  applied.   At the fame
time,  the arms,  little affeaed before, are now  rigidly ex-
tended; the whole of the mufcles belonging to  them being
affeaed with fpafms, except  thofe that move the fingers,
  Vox., IT.                 N 
102                 PRACTICE
which often to the laft retain fome mobility.  The tongue
alfo long retains its mobility ; but at length it alfo becomes
affeaed with fpafms,  which, attacking certain of its muf-
cles only, often thrufts it violently out between the teeth.
  At the height of the difeafe, every organ of voluntary
motion feems to  be  affeaed;  and amongft the reft, the
mufcles of the face.   The forehead is drawn up into fur-
rows, the eyes, fometimes diftorted, are commonly rigid,
and immoveable in their fockets; the nofe  is drawn up,
and the cheeks are  drawn backwards towards the ears, fo
that the whole countenance expreffes the moft violent grin-
ning.   Under thefe univerfal fpafms, a violent convulfion
commonly  comes on, and puts an end to life.
  1261.] Thefe fpafms  are every where attended with
moft violent pains.   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 contrac-
tion, although of no fuch relaxation as can allow the action
of their antagonifts.   This remiflion of  contraaion gives
alfo fome remiffion of pain;  but neither  is of long dura-
tion.  From time to time, the violent contraaions and pains
are renewed fometimes every 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, endeavoring
to fwallow, and even  to  fpeak,  fometimes gives occafion
to a renewal of the fpafms over the whole body.
  1262.J The attacks of this difeafe are feldom attended
with any fever.  When the fpafms are general and violent,
the pulfe is contracted, hurried, and irregular;  and the re-
fpiration is  affeaed in  like manner: but, during the remif-
fion, both  the pulfe and refpiration ufually return to their
natural ftate.   The heat ofthe body is commonly not in-
creafed ;  frequently the face is pale, with a cold fweat up-
on it;  and  very often  the extremities are cold, with a cold
fweat over  the whole body.  When, however, the fpafms
are frequent 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.
   1263.] Although fever be not a conftant attendant of
4his difeafe, efpecially  when arifing from a lefion of nerves;
yet, in thofe cafes proceeding from cold, a fever fometimes 
OF  PHYSIC,
103
has fupcrvencd, and  is faid to have been attended with in-
flammatory fymptoms.  Blood  has  been often drawn in
this difeafe, but it never exhibits any  inflammatory cruft ;
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  ufual manner.
   1264.]  In this difeafe the head is  feldom affiled with
delirium or even confufion of thought, till the laft  ftage of
it;  when, by the repeated fhocks of  a violent  diftemper,
every funttion ofthe fyftem is greatly difordered.
   1265.J It is no lefs extraordinary, that,  in this violent
difeafe, the natural funaions are not either immediately or
confiderably affeaed.  Vomitings fometimes appear early
in the difeafe, but commonly they are not continued;  and
it is ufual  enough for the appetite of hunger  to  remain
through the whole courfe of the difeafe; and what food
happens to be taken down, feems to be  regularly  enough
digefted.   The excretions are fometimes affeaed, but not
always.   The urine is fometimes fuppreffed, or is voided
with difficulty and pain.   The belly is coftive: but, as we
have hardly any accounts excepting of thofe cafes in which
opiates have been largely employed, it  is uncertain whe-
ther the coftivenefs has been the effea of the opiates or of
the difeafe.   In feveral inftances of this  difeafe, a miliary
eruption has appeared upon the ikin; but whether this be
a fymptom ofthe difeafe, or the  effea  of  a certain treat-
ment of it, is undetermined.  In the mean while, it has not
 been obferved to denote either fafety or danger, or to have
any effett in changing the courfe of the  diftemper.
   1266.J  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, phyfi-
 cians were not  well acquainted  with a  proper method of
 cure; and that fince a more proper method has been known
and praaifed, 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 particular
 cafes, we  may remark, that, when arifing from lefions of
 the nerves, it is commonly more violent, and of more dif-
 ficult cure, than when proceeding from  cold;  that the dif-
 eafe which comes on fuddenly, and advances quickly to  a 
104
PRACTICE
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 palfed this period, he may be fuppofed to be in greater
fafety, and in general  the difeafe is the fafer the longer it
has continued.   It is however, to be particularly obferved,
that, even for many days after  the fourth, the difeafe con-
tinues to be dangerous; and, even after fome confiderable
abatement of its force, it is ready to  recur  again with its
former violence and danger.   It never admits of any fud-
den, or what is called critical folution; but always recedes
by degrees only, and it is often very long before the whole
of the fymptoms difappear.
   1267.J From the hiftory of the difeafe now defcribed,
it will-be evident, that there is no room  for diftinguifhing
the tetanus, opisthotonos, and  trismus or  locked jam,  as
different fpecies  of this difeafe, fince they all arife from
the fame caufes,  and are almoft conftantly conjoined in the
fame perfon.   I  have no doubt that the emprosthotonos be-
longs alfo to the  fame genus;  and as the ancients have fre-
quently 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 I have never feen it, nor
find any hiftories in which  this particular ftate ofthe fpafms
is faid to have prevailed, I cannot mention the other cir-
cumftances which particularly attend it, and may diftin-
guifh it from the other varieties of tetanic complaints.
   1268.] This difeafe has put on ftill a different form from
any  of  tho,fe above  mentioned.  The fpafms  have been
fometimes confined to one  fide ofthe body only, and wfiich
bend it ftrongly to that fide.   This is what has been named
by Sauvages the  Tetanus Lateralis, and by fome late wri-
ters die  Pleurosthotonos.    This form of the difeafe has cer-
tainly appeared very feldom;  and,  in any of the accounts
given of it, I cannot find any circumftances that would lead
me to confider it as any other than a variety of the fpecies
already  mentioned, or to take further notice of it here.
   1269.] The pathology of this difeafe I cannot in any
meafure attempt; as the ftruaure  of  moving  fibres, the
ftate of them  under different degrees  of contraaion, and
particularly the ftate of  the fenforium, as varioufly deter-
mining  the motion of the  nervous power;  are all matters 
O F  P H Y S I C.                 105
very  imperfeaiy, or not at all, known to me.   In fuch a
fituation, therefore,  the endeavouring to give any rules of
praaice, upon a fcientific  plan, appears  to  me vain and
fruitlefs ; and towards dire.aing the cure of this difeafe, we
mult be fatisfied with having learned fomcthing ufeful from
analogy, confirmed by  experience.
   1270.] When the difeafe is known to arife from the le-
fion of a nerve in any part of the body,  the firft, and  as I
Judge, the moft important ftep to be taken towards the cure,
is, by every poffible means, to cut off that part from all
communication with the fenforium, either  by  cutting thro'
the nerves in their  courfe, or perhaps by  deftroying,  to a
certain length, their affeaed part or extremity.
   1271.] When the cure ofthe difeafe is to be attempted
by medicine, experience has taught us that opium  has of-
ten proved an effeaual 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 fafely than the body
has been known to bear in any other condition.  The prac-
tice has been, to give the opium either in a folid or 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
feem to require.*   Even when  large  quantities have been
given in this way, it appears that the opium does not ope-
rate here in the fame manner as in moft other cafes;  for,
  * Though the exhibition of  opium  in Tetanus has been the moft. univerfal
praftice, it muft neverthelefs be acknowledged, that, in many, if not in moft
cafes,  it has been ineffectual.  The difeafe, indeed, is in general fatal; but,
as in moft of the cafes that terminated  happily, opium has been given, as the
Author defcrihes, either in large dofes, or frequently repeated fmall dofes,.
we muft neceffarily conclude that the praftice ought to be followed.  I have
feen only one cafe of Tetanus; it proceeded from a wound which a carpenter
received in the wrift of his left arm with a faw.  The inflammation was vio-
lent: The ftiffnefs of the neck at firft appeared on the third day, when the
inflammation began to abate after bleeding, and the application of  emollient
poultices:  The pulfe was weak and fmall;  thirty drops of laudanum were
given ; the fymptoms increafed ; and,  on the day-following, the jaw became
fixed.  Thirty drops of laudanum were repeated ; and the fymptoms abating
within two hours after  its exhibition, indicated a repetition of the dofe.
which, from its good effe&s, was a fourth time repeated that  fame day. The
wound fuppurated ; and the day following, with two dofes of forty drops of
laudanum, the fymptoms of Tetanus wholly difappeared, but  hf the patient
in a moft debilitated ftate.  A  coftivenefs 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 hir> former ftrength til! after
Jix weeks, although the wound healed  in half that tur.e. 
106
PRACTICE
though it procure fome remiffion ofthe fpafms and pains,
it hardly induces any fleep, or occafions that ftupor, intox-
ication, or delirium, which it often does in other circum-
ftances, when much fmaller quantities only have been given.
It is therefore very properly obferved,  that, in tetanic af-
feaions, as the opium fhows none of thofe effeas by which
it may endanger life, there is little or no reafon for being
fparing in the exhibition of it; and it may be given, proba-
bly fhould be given, as largely and as fait as the fymptoms
of the difeafe may feem to demand.
   It is particularly to be obferved,that though thefirft ex-
hibition of the opium may have produced fome remiflion
of the fymptoms, yet the effeas of opium do not long con-
tinue in the fyftem ; and this difeafe being for fome time
ready to recur, it is commonly very neceffary, by the time
that the effeas ofthe opium given may be fuppofed to be
wearing off, and efpecially upon the leaft  appearance of
the return  of the fpafms, to repeat the  exhibition of the
opium in the fame quantities as before.   This praaice is
to be continued while the difeafe continues to fhow  any
difpofition  to return ; and it is only after the difeafe has
already fubfifted for fome time, and when confiderable and
long-continued  remiffions have taken place,  that the dofes
ofthe opium may be diminifhed, and the intervals of ex-
hibiting them be more confiderable.
   1272. J The adminiftering of opium in this manner, has
in many cafes been fuccefsful; and probably would have
been equally fo in many others, if the opium had  not been
toofparingly employed, either from the timidity of praai-
tioners, or from its exhibition being prevented by that in-
terruption of deglutition which fo often attends this difeafe.
  The latter circumftance direas, that the medicine fliould
be  immediately and largely employed upon the firft ap-
proach ofthe difeafe, before the deglutition becomes diffi-
cult;  or that,  if this opportunity be loft,  the medicine,
in fufficient  quantity, and with due frequency, fhould be
thrown into the body by glyfters; which, however, does
not feem to have been hitherto often praaifed.
  1273.] It is highly probable, that, in this difeafe, the in-
teftines are affeaed with the  fpafm  that prevails  fo much
in other parts ofthe fyftem;  and therefore that coftivenefs 
O F  P H Y S I C.                1CKT
occurs here as a fymptom of the difeafe.*   It is probably
alfo increafed by the opium, which is here fo largely  em.
ployed; and, from whichever of thefe caufes it arifes, it cer-
tainly muft be held to aggravate the difeafe, and that a re-
laxation of the inteftinal canal will contribute to a relaxati-
on of the fpafms elfewhere.  This confideration directs tire
frequent exhibition of laxitives while the power of deglu-
tition remains, or the frequent exhibition of glyfters when
it does not; and the good effects of both have been fre-
quently obferved.
   1274.] It has been with fome probability fuppofed, that
the operation of opium in this  difeafe, may be much affift-
ed by joining with it fome other of the moft powerful an-
tifpafmodics.   The  moft promifing  are mufk and cam-
phire;  and fome praaitioners have been of opinion,  that
the former has proved very ufeful in tetanic complaints.
But, whether it be from its not having been employed of a
genuine kind, or in fufficient quantity, the great advantage
and propriety of its ufe are not yet clearly afcertained.  It
appears to me probable, that  analogous to what happens
with refpea to opium, both mufk and cam phi re might be
employed in  this difeafe,  in much larger quantities than
they commonly have been in other cafes.
   1275.J 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;  and, 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 occafioned death.   Partial fomenta-
tions have  been much commended, and, I believe, upon
good grounds: And I have no doubt but that fomentations
ofthe feet and legs, as we now ufually apply them in fevers,
might, without much ftirring of the patient, be very affidu-
Qufly employed with advantage.
   1276.J Unauous applications were very frequently em-
ployed in this difeafe  by the ancients: and fome modern
praaitioners have confidered them as very ufeful.   Their
effeas, however, have not appeared to be confiderable;
and, as a weak auxiliary only,  attended with fome  incon-
  * This fymptom occurred in the cafe mentioned in the preceding note. 
108                 PRACTICE
 venience, they have been very much ncgleaed by the Bii-
 tifh praaitioners.
   1277.] Bleeding  has  been formerly employed  in this
 difeafe;  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 unfavorable to blood-letting: and, if we mav
 form indications from the ftate of the blood  drawn out of
 the veins, the  ftate of this in tetanic difeafes would forbid
 bleeding in them.
   1278.J Bliftering alfo has  been formerly  employed in
 this difeafe;  but feveral praaitioners affert, that blifters
 are conftantly hurtful, and they arc now generally omitted.
   1279.] Thefe are the praaices that hitherto have been
 generally employed;  but of late we are informed by feve-
 ral Weft India praaitioners,  that in many inftances they
 have employed mercury with great advantage.  We are
 told,  that it muft be employed early in the difeafe ; that it
 is moft conveniently adminiftered by unaion,  and fhould
 be applied in that way in large quantities, fo  that the body
 may  be foon  filled with it, and a falivation raifed, which
 is to be continued till the fymptoms yield.   Whether this
 method alone  be generally fufficient for the cure of the dif-
 eafe,  or if it may be affifted by the ufe of opium, and re-
 quire this in a certain meafure to be joined with it,  I  have
 not yet certainly  learned.
   1280.] I have b6en further informed, that the tetanus,
 in all its different degrees, has been cured by giving inter-
 nally  the Piffelacum Barbadenfe, or, as it is vulgarly cal-
 led,  the Barbadoes Tar.   I think it proper to take notice
 of this here, although I am  not  exaaiy informed what
 quantities of this medicine are to be given, or in what cir-
 cumftances of the difeafe it  is molt  properly to be era-
 ployed.
   1281.] In the former edition of this work, among the
remedies of tetanus  I did not mention the ufe of cold bath-
ing; becaufe,  though I 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 in-
formed of the ordinary and  proper adminiftration of it.
But now,  from the information of many judicious praai-
tioners who have frequently employed it,  I can fay, that it 
OF  PHYSIC.               109
Is a remedy which in numerous trials has been found to be
of great fervice in this difeafe; and that, while the ufe of
the ambiguous remedy of warm  bathing is entirely laid a-
fide,  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 fre-
quently by throwing cold water from  a bafon or bucket
upon the patient's body,  and over the whole of it: When
this is done, the  body is  carefully wiped dry, wrapped in
blankets,  and  laid abed,  and at the fame time a large dofe
of an opiate is given.  By thefe  means a confiderable re-
miffion of the  fymptoms is obtained; but this remiffion, at
firft,  does not commonly remain long, but returning again
in a few hours, the  repetition both of the bathing and the
opiate becomes neceffary.  By thefe repetitions, however,
longer intervals of eafe are obtained, and at length the dif-
eafe is entirely cured; and this  even happens  fometimes
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 employed, or has been
found fo commonly fuccefsful in  the cafes  of  tetanus in
confequence of  wounds, as in thofe from the application
of cold.
   1282. J Before concluding this chapter,  it is proper for
me to take fome notice of that peculiar cafe of the tetanus,
or trifmus, which attacks certain infants foon after their
birth, and has  been  properly enough named  the Trifmus
Nufcentium.   From the fubjects it affeas, it feems  to be
a peculiar difeafe:  for thefe are infants not above  two
weeks,  and commonly before they are nine days, old; in-
fomuch that,  in countries where  the difeafe is frequent, if
children pafs the period now mentioned, they are confider-
ed as fecure againft 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
^riaiy fo called, and which occur in the other varieties of
the tetanic  complaints above defcribed.  Like  the other
varieties of tetanus,  this is moft frequent in warm climates,
but it is not, like thofe arifing from the application of cold,
  Vol. II.                  O 
110               PRACTICE
entirely confined to fuch warm climates, as inftances of it    .
have occurred in moft of the northern countries of Europe.   ;
In thefe latter it feems to be more frequent in certain dif-
trias than in others; but in what manner limited, I cannot
determine.   It  feems to be more frequent in Switzerland
than in France.   I am informed of its frequently occurr-
ing 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 knownr and various conjeaures
have been offered; but none of them are fatisfying.   It is
a difeafe that has been almoft  conftantly fatal;  and this,   1
alfo, commonly in the courfe of a few days. The women   1
are fo much perfuaded of its inevitable fatality,  that they
feldom or never call for the affiftance of our art.  This has   <J
occafioned our being  little acquainted with the  hiftory of   j
the difeafe, or with the effeas of remedies in  it.  Analogy,
however,  would lead us to employ the fame remedies that
have proved  ufeful in the other cafes of tetanus; and the   I
few experiments that are yet recorded, feem to approve of
fuch a praaice,

                     CHAP.  II.                       ,

                   ffif (Epilepsy

1283.] JlN what fenfe I ufe the  term Convulsion,  I have   j
explained above in (1256.)
   The convulfions that affea the human body are in feve-
ral refpeas various; but  I am to confider here only the    I
chief and moft frequent form in which they appear, and
which is in the difeafe named Epilepsy.   This  may  be de-
fined, 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 infenfibilky and feeming fleep.      j;
   1284.]  The general form or principal  circumftances
of this difeafe, are much the fame in all the different perfons
whom it affects.  It comes by fits, which often attacks per-
fons feemingly in perfea 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 fymp-
toms, which  to perfons who have before experienced fuch *
 a fit, may give notice of its approach, as we fhall hereafter 
OFPHYSIC.                HI
explain; but even  thefe preludes do not commonly oc-
cur long before the formal attack, which  in moft cafes
comes on fuddenly without any fuch warning.
   The perfon attacked lofes fuddenly all  fenfe and power
of motion ; fo that, if ftanding, he falls  immediately, or
perhaps, with convulfions, is thrown to the ground.   In
that fituation he is agitated with violent convulfions, vari-
oufly moving his limbs and the trunk of his body.   Com-
monly the limbs on one fide ofthe body are more violent-
 ly or more  confiderably agitated than thofe upon the o-
ther.  In all cafes the mufcles of the face and eyes are much
affeaed, exhibiting various and violent diftortions  of the
countenance.  The tongue is often affeaed, and thruft out
of the mouth ;  while the mufcles of the lower jaw are alfo
affeaed ; and, fhutting the mouth with violence while the
tongue is thruft out between the  teeth, that is often griev-
 oufly wounded.
   While  thefe convulfions continue, there is commonly
 at the fame time a frothy moifture iffuing  from the mouth.
 Thefe convulfions have  for fome moments fome remifii-
 ons, but are fuddenly again renewed with great violence.
 Generally, after no long time, the convulfions ceafe alto-
 gether ; and the perfon for fome time remains without mo-
 tion, but in a ftate of abfolute  in fenfibility,  and under the
 appearance of a profound fleep.  After fome continuance
 of this feeming fleep, the perfon  fometimes fuddenly, but
 for the molt part by degrees only, recovers his fenfes and
 power of motion ;  but without any memory of what had
 paffed from his being firft  feized with the fit.  During the
 convulfions, the pulfe and refpiration are  hurried and irre-
 gular ; but, when the convulfions ceafe, they return to their
 ufual regularity and healthy ftate.
    This is the  general form of the difeafe ; and it varies
 only in different perfons, or on different occafions in the
 fame perfon, by the phenomena mentioned being more or
 lefs violent, or by their being of longer or fhorter duration.
    1285.] With refpect to  the proximate  caufe of this dif-
 eafe,  I might fay, that it is  an affeaion of the brain, which,
 ordinarily under the direaion  of the will, is here, without
 any concurrence of it, impelled by preternatural  caufes.
 But I could go no further : For, as to what is the mecha-
 nical condition ofthe brain in the ordinary exertions of 
U2                PRACTICE

the will, I have no diftina knowledge ;  and therefore mull
be alfo ignorant ofthe preternatural ftate ofthe fame ener-    ^
gy of the brain under the irregular motions here produce d.
To form, therefore, the indications of a cure from a know-
ledge of the proximate caufe of this difeafe, I muft not at-
tempt, 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 direaions for its cure.
It fhall  therefore be my  bufinefs now to point out and
enumerate thefe remote caufes as well  as  I can.
   1286. J  The remote caufes of epilepfy may be confider-    ,
ed as occafional or predifponent.   There are, indeed, cer-
tain remote caufes which aa independently of any predif-
pofition; but, as we cannot always diftinguifh thefe  from
the others,  I  fhall confider the whole under the ufual  titles
of Occasional or Predisponent.
   1287.]  The occafional caufes may, I think, be properly
referred to two general heads; the first being of thofe which
feem to aa by diredly ftimulating and  exciting the energy    j,
of the brain;  and the second, of thofe which feem to aa by
weakening the fame.  With refpea to both,  for the bre-
vity of expreffing a faa, without meaning to explain the    |
manner in which it is brought about, I fliall ufe the terms
of Excitement and Collapse.  And though it be true, that    ]
with refpect to fome ofthe caufes I am to mention, it may
be a little uncertain whether they aa in the one way or the
other,  that does not render it  improper for us  to mark,     '
with refpea to others, the mode of their operating, where-     i
ver we can do it clearly, as  the doing  fo  may often be of
life in directing our praaice.
   1288. J Firft, then, of the occafional  caufes aaing by
excitement:  They  are either fuch as aa  immediately and
direaiy upon the brain itfelf; or thofe which are firft ap-
plied to the other parts of the body, and  are from thence    1
communicated to the brain.                               I
   1289. J  The caufes of excitement immediately and  di-
reaiy applied to the brain, may be referred to the four
heads of, 1. Mechanical Stimulants; 2. Chemical Stimu-
lants;  3. Mental Stimulants; and, 4- The peculiar Stimu-
lus of Over Diftention.
   1290. J The mechanical  ftimulants may  be, wounding
inftruments penetrating the  cranium, and entering the fub- 
0 F  P H Y S IC.               H3
ftance of the brain;  or fplinters of a  fraaured cranium,
operating in the fame manner; or fharp pointed offifica-
tions, either arifing from the internal  furface of the cra-
nium, or formed in the membranes of the brain.
   1291.]  The chemical ftimulants (1289.)  may be fluids
from various  caufes lodged in certain parts of the brain,
and become acrid by ftagnation  or otherwife.
   1292. J The mental irritations aaing by excitement, are,
all violent emotions of the aaive kind, fuch as joy and an-
ger.   The firft of thefe is  manifeftly an exciting  power,
aaing ftrongly, and immediately, on the energy of the brain.
The fecond is manifeftly, alfo, a power aaing in the fame
manner.   But it muft  be remarked, that it is not in this
manner alone anger produces its effeas: for it aas, alfo,
ftrongly on the fanguiferous fyftem, and may be a means
of giving the ftimulus of over-diftention; as, under a fit of
anger, the blood is  impelled into  the veflels  of the  head
with violence, and in a larger quantity.
   1293.] 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 fpeaator.
It may, indeed, be a queftion, Whether  this  effect be im-
putable to  the horror produced by a fight ofthe feemingly
painful agitations ofthe limbs, and ofthe diftortions in the
countenance ofthe epileptic perfon; or if it may be afcrib-
ed to the force of imitation merely ? It is poffible, that hor-
ror may fometimes produce the  effea : but certainly much
may be imputed to that propenfity to imitation, at all times
fo powerful and prevalent in human nature : and  fo often
operating in other cafes of  convulfive  diforders, which do
not prefent any fpeaacle of horror.
   1294.}  Under the  fame head of Mental Irritation, I
think proper to mention as an inftance of it, the Epilepfia
Simulata, or the Feigned Epilepfy, fo often taken notice of.
Although this, at the firft, may be  entirely feigned, I have
no doubt but  that the repetition renders it at length real.
The hiftory of Quietifin and of Exorcifms lead me to this
opinion :  and which receives a confirmation from what we
know of the power of  imagination, in renewing epileptic
and hyfteric fits.
   1295-] I come now  to the fourth head of the irritations
applied immediately to the  brain, and which I  apprehend 
iU
PRACTICE
to be that of  the Over Diftention of the  blood-veffels in
that organ.   That fuch a caufe operates in producing epi-
lepfy, is probable from this, that the diffeaions of perfons
dead of epilepfy, has commonly difcovered the marks of a
previous congeftion in the blood-veffels of the brain. This,
perhaps, may be fuppofed the effect of the fit which proved
fatal: But that the congeftion was previous thereto, is pro-
bable from the epilepfy being fo often joined with head-
ach, mania, palfy, and apoplexy; all of them difeafes de-
pending upon a congeftion in the veflels of the brain. The
general opinion receives  alfo confirmation from this cir-
cumftance, 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 compreffion of a confiderable portion
of the brain,  may, however, have been fufficient to com-
prefs fo many veflels as to render the others upon any oc-
cafion of a more than ufual turgefcence, or impulfe of the
blood into the veffels of the brain more liable to an over
diftention.
   1296.] Thefe confiderations alone might afford founda-
tion for  a probable conjeaure with refpea  to the effeas
of over  diftention.   But the opinion does  not reft  upon
conjeaure alone.   That it is alfo founded in faa, appears
from hence,  that a plethoric ftate is favourable to epilep-
fy; and that every occafional turgefcence, or unufual im-
pulfe of the blood into the veflels 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 fre-
quently the immediate exciting caufes of epileptic fits.
   1297.] I  venture to  remark further, that a piece of
theory may be admitted as a confirmation of this doarine.
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  diftention of thefe blood-veffels  may be a
caufe of violent excitement.
   1298.J We have  now enumerated the feveral remote
or occafional caufes of epilepfy,  aaing by excitement, and
aaing immediately upon the brain itfelf.   Of the caufes
aaing by excitement,  but acting upon other parts of the 
OF  PHYSI-C.               -IU
body, and from thence communicated to the brain, they
are all of them  impreffions producing an exquilite or high
degree cither of pleafure or pain.
   Impreffions  which produce neither  the one nor the o-
ther, have hardly any  fuch effects;  unlefs when fuch im-
preffions are in  a violent degree,  and their operations 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, unforeseen and unexpea~
ed, have frequently the effea of bringing on epileptic fits.
   1299.] There are certain impreffions made upon  differ-
ent parts of the body, which as they often operate without
producing any  fenfation, fo it  is uncertain to what head
they belong: But it is probable  that  the  greater part of
them a6t by excitement,  and therefore  fall to be mention-
ed here.  The chief inftances are, the teething of infants;
worms; acidity or other acrimony in the alimentary  canal;
calculi in the kidneys; acrid matter in abfeeffes or ulcers;
or acrimony  diffufed  in trie mafs of blood, as in the cafe
of fome contagions.
   1300.] Phyficians have  found no difficulty in  compre-
hending how direa ftimulants, of a certain force, may ex-
cite the aaion 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 aa, as I
fpeak, by collapfe.  Thefe, however,  have  the  effea of
exciting the aaion of the brain in fuch a manner as to oc-
cafion epilepfy.  I might upon this  fubjea,  fpeak  of the
vis medicatrix  natural; and there is a foundation for the
term; but, as I do not admit the Stahlian doarine of an ad-
miniftering foul, I make ufe of the term only as expreffing
a faa, and would not employ it with the view of convey-
ing an explanation of the manner in which the powers of
collapfe mechanically produce their effeas.   In the mean
time, however, I maintain,  that there are certain powers of
collapfe, which in effea prove  ftimulants, and  produce
epilepfy.
   1301.] That there are fuch powers, which may he term-
ed Indirea Stimulants, I conclude from hence, that feveral
of the caufes of epilepfy arc fuch as frequently  produce
fyncope, which we fuppofe always to depend upon  caufes
weakening the  energy of the brain, (1176.)   It may give 
116
PRACTICE
fome difficulty to explain, why the fame  caufe fometimes
occafion fyncope, and fometimes occafion the reaaion that
appears in epilepfy; and I fhall not attempt to explain it:
but this, I think, does not prevent my fuppofing that the
operation  of thefe caufes is by collapfe.  That there are
fuch caufes producing epilepfy, will, I think, appear very
clearly from the particular examples of them I am now to
mention.
   1302.]  The firft to be mentioned,  which  I fuppofe to
be of this kind, is hemorrhagy, whether fpontaneous or ar-
tificial.  That the fame hemorrhagy which produces fyn-
cope,  often at the fame time produces epilepfy, is well
known; and from  many experiments  and obfervations it
appears, that hemorrhagies occurring to fuch a degree as to
prove mortal, feldom do fo without firft producing epilepfy.
   1303.J  Another caufe acting, as I fuppofe, by collapfe^
and therefore fometimes producing fyncope, and fometimes
epilepfy, is terror;  that is, the fear of fome great evil fud-
denly  prefented.   As this produces at the fame time a fud-
den and confiderable emotion, (1180.) fo it more frequent-
ly produces epilepfy than fyncope.
   1304. J  A third caufe aaing by collapfe, and producing
epilepfy, is horror; or a ftrong averfion fuddenly raifed 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 explained upon this general  principle,
That as delire excites aaion and gives aaivity, fo averfion
reftrains from aaion, that is,  weakens the energy of the
brain;  and, therefore, that the higher degrees of averfion
may have  the effeas of producing fyncope or epilepfy.
   1305.J  A fourth fet ofthe caufes of epilepfy, which I
fuppofe alfo to aa by collapfe, are certain odours, which
occafion either fyncope or  epilepfy;  and, with refpea to
the former, I  have given my reafons (11 82.)  for fuppofing
odours in that cafe  to aa rather as difagreeable than as fe-
dative.  Thefe reafons will, I think, alfo apply here; and
perhaps the whole affair of odours might be confidered as
inftances ofthe effea of horror, and therefore belonging to
the laft head.
   1306. J  A fifth head of the caufes producing epilepfy by 
OF  PHYSIC.                117
collapfe, is the operation o,f many fubftances confidered,
and for the moft part properly confidered, as poifons.
Many of thefe, before they prove mortal, occafion epilepfy.
This effea,  indeed, may in fome cafes be referred to tfie
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 ofthe caufes aaing by collapfe.
   1307.]  Under the head ofthe remote caufes producing
epilepfy, we  muft now mention that peculiar one whofe
operation is accompanied with what is called the Aura Epi-
leptica.   This is a fenfation of fomething moving in fome
part  of the limbs or trunk of the body, and from  thence
creeping upwards  to  the head; and when it arrives there,
the perfon is immediately deprived  of fenfe,  and falls  into
an epileptic fit.  This motion is defcribed by the perfons
feeling it fometimes as a cold vapour, fometimes as a fluid
gliding, and fometimes as the fenfe of a fmall infea creep-
ing along their body; and very often they can give no dif-
tina idea of their fenfation, otherwife than as in general of
fomething moving along.   This fenfation might be  fup-
pofed to arife from fome affeaion of the extremity or other
part of a nerve aaed upon by  fome irritating matter;  and
that the fenfation, therefore, followed the courfe of fuch a
nerve:  but I have never found it following  diftinctly 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 prefling upon  or irritating a particu-
lar nerve, and that fometimes in confequence of contufion
or wound: But inftances of thefe are more rare : and the
more common confequence of contufions and wounds is a
tetanus. This latter effea wounds produce, without giving
any fenfation of an aura or other kind of motion proceed-
ing from the wounded part to the head ; while on the other
hand, the aura producing epilepfy, often arifes from a part
which had never been affeaed with wound or contu fion,
and in which  part the nature of the irrigation can feldom
be difcovered.  It is natural to imagine that this aura  epi-
leptica is an evidence of fome irritation or direa ftimulus
acting in the part, and from thence communicated to the
  Vol.  II.                 P 
118
PRACTICE
 brain, and fhould therefore have been mentioned among
 the caufes aaing by excitement; but the remarkable differ-
 ence  that occurs in feemingly like caufes producing teta-
 nus, give fome doubt on this fubjea.
   1308. j Having now  enumerated the occafional caufes
 of epilepfy,  I proceed to confider the predifponent.   As
 fo many ofthe above mentioned caufes aa upon certain
 perfons, and  not at all upon others, there muft be fup-
 pofed in thofe perfons a  predifpofition to this difeafe : But
 in what this predifpofition confifts, is not eafily afcertained.
   1309. J As many ofthe occafional  caufes are weak im-
 preffions, and are applied to moft perfons with little or no
 effea, I conclude, that the perfons affeaed by thofe caufes
 are more eafily moved than others ; and therefore that,  in
 this cafe, a certain mobility gives the predifpofition.   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.
   1310.] 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 quick-
 ly from one ftate to the other; if he is eafily pleafed, and
 prone to gaiety, and as eafily  provoked to anger, and ren-
 dered peevifh ; if liable, fron\ flight impreffions, to ftrong
 emotions, but tenacious  of none; this is the boyifh tempe-
 rament qui  colligit ac ponit iram temere, et mutater in horas;
 this is the varium et mutabilefoemina; and, both in the boy
 and woman, every one perceives and acknowledges a mo-
 bility of mind.   But this is neceffarily conneaed with an
 analogous  ftate of the brain ;  that is, with a mobility,  in
 refpea of every impreflion, and therefore liable to a  ready
 alteration of excitement  and collapfe, and of both to a con-
 fiderable degree.
   1311. J There is, therefore, in certain perfons, a mobi-
 lity of conftitution, generally  derived from the ftate of ori-
 ginal  ftamina, and more exquifite at a certain period  of
 life than at others ; but fometimes arifing from, and parti-
 cularly modified by, occurrences in the courfe of life.
   1312.] This mobility confifts in a greater degree of either
 feiifibility or irritability.  Thefe conditions, indeed, phy-
ficians confider as fo neceffarily conneaed that  the confti-
 tution with refpea to them, may be confidered as one and 
                   0 F PH Y SIC.     ♦          119

the fame : but I am of opinion that they are different; and
that mobility may fometimes depend upon an increafe of
the one and fometimes on that of the other.  If an  aaion
excited, is, by repetition rendered more eafily excited, and
more vigoroufly performed, I  confider this as an increafe
of irritability only.   I go no  further on this fubjea herqf^
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 repeated, aye more
eafily excited, readily become habitual, and  are therefore
of more difficult cure.     *
   1313.] However we may apply the diftinaion of fenfi-
bility and irritability, it appears that the mobility, which is
the predifponent caufe of epilepfy, depends more particu-
larly upon debility, or upon a plethoric  ftate of the  body.
   1314.] What fhare debility, perhaps  by inducing fenfi-
bility, has in this matter, appears clearly from hence, that
children, women, and other perfons of manifeft debility,
are the moft frequent fubjeas of this difeafe.
    1315.]  The effeas of a plethoric ftate in difpofing  to
this difeafe appears from hence, that plethoric perfons are
frequently the fubjeas of it;  that it is commonly excited,
as I have faid above, by the caufes of any unufual  turgef-
cence of the blood; and that it has been frequently cured
by diminifhing the plethoric ftate of the body.
   That a plethoric ftate ofthe body fhould difpofe to this
difeafe, we may underftand  from feveral confiderations.
 1st, Becaufe a plethoric ftate implies,  for the moft part a
laxity of the folids, and therefore fome debility in the mov-
ing fibres,   idly, Becaufe, in a plethoric ftate, the  tone of
the moving fibres depends more  upon their tenfion, than
 upon  theii  inherent  power:  and as their tenfion depends
upon  the quantity and impetus of the fluid in the blood-
veffels, which are  very changeable, and by many  caufes
frequently changed, fo thefe  frequent changes muft give a
 mobility to the fyftem.   %dly, Becaufe a plethoric  ftate is
 favorable to  a congeftion  of blood in ihe veffels  of the
 brain, it muft render thefe  more readily affeaed by every
 general turgefcence of the blood in the fyftem, and therefore
 more  efpecially difpofe to this difeafe.
    1316.]  There is another circumftance ofthe body dif-
 pofing to epilepfy, which I cannot fo well account for; and 
120                   Practice
  that is, the ftate of fleep:  but whether I can account for it

  or not,  it appears, in fa6t, that this ftate gives the difpofi-
  tion I fpeak of; for,  in many perfons liable  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
UttDe Haen, it appeared clearly, that the  difpofition to epi-
  lepfy depended entirely upon the ftate ofthe body in fleep.*
     1317. j  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 directions for our praaice  in  the
  difeafe.t 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.
     1318.) When this difeafe is truly fympathic, and depend-
  ing upon a primary affeaion  in fome other part ofthe  body,
  fuch as acidity  or worms  in the alimentary canal, teething,
  or other fimilar caufes, it is obvious, that fuch primary af
  feaions muft be removed for the cure ofthe epilepfy;  but

    * This was a very finguiar 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 ^landing, and,  on a more minute attention, the paroxyfms were
  found to be more frequent when the  patient was in a peculiar ftate of fleep-
  Ing, namely, when he was drowfy, or when he fnored in his deep, the parox-
  yfms were more frequent than when he enjoyed an eafy and quiet fleep.  A
  natural, quiet, and eafy fleep, was procured by the ufe of opium ; and in a fhort
  time, the difeafe was perfectly cured; but the boy died afterwards in confe-
  quence of a tumor in the groin.
    t Other caufes of Epilepfy are enumerated by medical writers, which the
  author, for the fake of brevity, left unnoticed.  Cafes have occurred in which
  the epilepfy feems to have proceeded from an hereditary taint.  Quickfilver,
  either accidentally or intentionally applied, has  been frequently found to pro-
  duce epilepfy.  Perfons employed in gilding of metals are often feized with
  tremblings of the hands, with palfy, and with epilepfy, which can be  attri-
  buted to nothing elfe than the abforption of the vapours of mercury ufed in the
  operation, which is as follows : the piece  of metal to be gilt is firft well clean-
  ed and polifhed; fome  mercury fhaken with aqua-fortis is fpread upon it, till
  the furface appears all over as  white as lilver: being then heated and re-
  touched in thofe parts that have efcaped the mixture, an amalgama of mercu-
  ry and gold is laid on it; the heat foftening the amalgama, 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 mercury evaporates, that, if any deficiencies appear, they may
  be fupplied with a little more of the amalgama before the operation is com-
  pleted. This procefs neceflarily expofes theartift to the fumes ofthe mercury.
    Van Swieten 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 mifehief.   Venery, when exceffive, has  been enumerated among the
  caufes of epilepfy by Boerhaave, but  on what authority feems uncertain. 
                  OF  PHYSIi.     1          121

it is not our bufinefs here to fay how thefe primary difea-
fes are to be treated.
  1319.] There is, however, a peculiar cafe of fympathic
epilepfy;  that is, the cafe accompanied with the aura epi-
leptica, as defcribed in (1307.) in which,  though we can
perceive by the aura epileptica arifing from a particular part,
that there is fome affeaion in that part;  yet, as  in many
fuch cafes we cannot perceive of what nature the affeaion
is, I can only  offer the following general direaions.
  1st, When the part can with fafety be  entirely dettroyed,
we fhould endeavour to do ft> by cutting it out, or by de-
ftroying it by the application  of anaaual or potential cau-
tery.
  idly, When the part cannot be properly deftroyed, that
we fhould endeavour to correa the morbid affection in it
by bliftering, or  by eftablifhing an iffue  upon the part.
  %dly, When thefe meafures cannot be executed, or do
not fucceed, if the difeafe feems  to proceed from  the ex-
tremity of a particular nerve which we can eafily  come at
in its courfe, it  will be proper to cut through that nerve,
as before propofed on the fubjea of tetanus.
  4_thly, When it cannot be perceived that the aura arifes
from any precife place or point, fo as to direa to theabove-
mentioned operations ; but, at the fame time,  we  can per-
ceive 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 pre-
venting a fit breaks the habit of  the difeafe, and becaufe
the  frequent compreffion renders the nerves lefs fit to pro-
pagate the aura.
  1320.] The cure of idiopathic epilepfy, as  I have faid
above, is to be direaed  by our knowledge of the remote
caufes.   There are therefore two general indications to be
formed.  The firft is, to avoid the occafional caufes;  and
the  fecond is, to  remove or correa the predifponent.
  This  method, however, is not always purely palliative;
as in many cafes  the predifponent may be confidered as the
only proximate caufe, fo our fecond indication may be of-
ten  confidered as properly curative.
  1321.J From the  enumeration given above, it will be
manifeft,  that for the moft part  the occafional caufe:;, fo 
ii::
PRACTICE
  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.
     1322. J  One ofthe moft frequent ofthe occafional caufes
  is that of over diftention (1314.) 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 conftitution, occafional turgefcence
  is a frequent means of exciting epilepfy, the avoiding there-
  fore of fuch  turgefcence is what  ought to be moft conftant-
  ly the objea of attention to perfons liable to epilepfy.
     1323.J  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 constitu-
  tions, break in upon the ufual force, velocity, and order of
:  the motions  of the nervous fyftem, they thereby  readily
  produce epilepfy.   Such impreffions therefore, and efpe-
  cially thofe which are fuited to excite any emotion or  paf-
  fion of the mind, are to be moft carefully guarded againft
  by perfons liable to epilepfy.
     1324.J  In many cafes of epilepfy, where  the predifpo-
  nent caufe cannot be correaed or removed, the recurrence
  of the difeafe can only be prevented, by the ftritlefl atten-
  tion to avoid the occafional; and as the difeafe is often con-
  firmed by  repetition  and habit, fo the avoiding the frequent
  recurrence of it is of the utmoft importance towards its cure.
     Thefe are the few remarks I have to offer with refpea to
  the occafional caufes; and muft 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 correaing
  the predifponent caufe.
     1325.J  I  have faid above, that the predifponent caufe
  of epilepfy is a certain mobility ofthe fenforium;  and that
  this depends upon a plethoric ftate of the fyftem, or upon
  a certain ftate of the debility in it.
     1326.]  How the plethoric  ftate of the fyftem is to be
  correaed, I  have treated of fully above in (781. et seq.)
  and I need not  repeat it here.   It will be  enough to  fay,
  that it is  chiefly to be done by  a proper management of
  exercife and diet; and, with refpea to the latter, it is  par-
  ticularly to be obferved here, that an abftemious courfe has 
                   OF PHYSIC.                123

been frequently found  to  be the moft certain  means of
curing epilepfy.
   1327.] Confidering the nature ofthe matter poured out
by iffues, thefe may be fuppofed to be a conftant means of
obviating the pf ihoric ftate of the fyftem ; and it is, per-
haps, therefore, that they have been fo often found  ufeful
in epilepfy.   Poffibly, alfo,  as an open  iffce  may be a
means ofdetermining occafional turgefcences to fuch places,
and therefore of diverting them in fome meafure  from their
aaion upon the brain; fo alfo, in this manner, iffues may
be ufeful in epilepfy.
   1328.] It might be fuppofed that blood-letting would be
the moft effeaual means  of correaing the plethoric ftate
of the fyftem; and fuch it certainly proves when the ple-
thoric ftate has  become  confiderable, and immediately
threatens morbid effeas.  It is therefore,  in fuch circum-
ftances, 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 favoring it;  fo it is not a remedy advifa-
ble in every circumftance of epilepfy.   There is, however,
a  cafe of epilepfy in which  there is a  periodical or occa-
fional recurrence of the fulnefs and turgefcence of the fan-
guiferous fyftem, giving occafion to a recurrence of the
difeafe.   In fuch cafes, when the means of preventing ple-
thora have been neglected, or may have proved ineffeaual,
it is abfolutely neceffary for the praaitioner to  watch the
returns of thefe  turgefcences, and to obviate their effeas
by the only  certain means  of doing it, that is, by a large
blood-letting.
   13 29. J The fecond caufe of mobility which we have af-
figned, is a ftate of debility.  If this is owing, as it frequent-
ly 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 poffibly may admit of being mended; and, in either
cafe,  much may be done to obviate and prevent  its effeas.
   1330.] The means of correaing debility, fo far as it can
be done, are, The perfon's being much in cool air; the
frequent ufe of cold  bathing; the ufe of exercife, adapted
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 
124                PRACTICE
power of the folids or moving fibres: but as  the ftrength
of thefe depends alfo upon their tenfion, fo when debility
has proceeded from inanition, the ftrength may be reftor-
ed, by reftoring the fulnefs and tenfion of the  veffels by  a
nourifhing diet; and we have had inftances of the proprie-
ty and fuccefs of fuch a praaice.
   1331.] The means of obviating the  effeas of debility,
and ofthe mobility depending upon it, are the ufe of tonic
and antifpafmodic remedies.
   The tonics are, Fear, or fome degree  of terror ; aftrin-
gents ; certain vegetable and metallic tonics; and cold-
bathing.
   1332.J That fear, or fome degree of terror, may be of
ufe in preventing epilepfy, we have a remarkable proof in
Boerhaave's  cure  of the epilepfy, which  happened  in the
Orphan-houfe at Haerlem.  See Kauu  Boerhaave's trea-
tife, intitled  Impetum  Faciens, § 406. And we have met
with feveral other inftances ofthe fame.
   As the operation of horror is in many refpeas analogous
to that of terror, feveral feemingly fuperltitious remedies
have been employed for the cure of epilepfy ; and, if they
have ever  been fuccefsful, I think it muft be imputed to
the horror  they had infpired.*
   1333. J  Ofthe aftringent medicines ufed for the cure of
epilepfy, the moft celebrated is the viscus 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 objea of fuperftition.   In the few inftan-
ces in which  I have feen it employed it did not prove of
any effea.f
   1334-J Among the vegetable tonics, the bitters are to be
reckoned;  and it is  by this  quality that I fuppofe  the o-
range-tree  leaves  to have been  ufeful :  but they  are  not
always fo.
   1335-J  The vegetable tonic, which from its ufe in ana-
logous cafes  is the moft promifing, is the Peruvian bark;
  *  Drinking a draught  of the blood of a gladiator juft killed; drinking a
draught of water with a toad at the bottom of the jug; eating a piece of hu-
man liver, or the marrow ofthe bones ofthe leg of a malefactor; powder of
the human  fkisll; or the mofs that grows on it; with a variety of fuch abomi-
nable remedies, were formerly in great repute, and indeed fome of them are
ftill retained in feveral foreign Pharmacopoeias.               —
  t The dofe of it was from half a drachm to a drachm in powder, or about
an ownce in i.ifuhon. 
                    OF  PHYSIC.                 133

this, upon occafion, has been ufeful, but has alfo often fail-
ed.  It is efpecially adapted to thofe epilepfies which recur
afcertain periods, and which are at the fame time without
the recurrence of any plethoric ftate, or turgefcence of the
blood; and in fuch periodical cafes, if the  bark is employed
fome time  before the expeaed recurrence, it  may be
ufeful; but it muft be given in large quantity, and as near
to the time  of the expected return as poffible.
   1336.] 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 employedin the cure of epilepfy;
and its  ufe  in intermittent  fevers gives  an analogy in its
favour.
   Preparations of tin have been  formerly recommended
in the cure  of epilepfy, and  in the  cure  of the analogous
difeafe  of hyfteria ;  and feveral confiderations render  the
virtues of tin, with refpea to thefe difeafes, probable : but
I have  had  no experience of its ufe in fuch cafes.
   A much  fafer metallic  tonic is to  be  found in the prepa-
rations of iron ;  and we have feen fome of them employ-
ed in the cure of epilepfy,  but have never found them to
be effeaual.  This, however, I think, may be imputed to
their not having been always employed in the circumftan-
ces ofthe  difeafe, and in the quantities of the medicine,
that were proper and neceffary.*
   1337.] Of the metallic tonics, the moft celebrated  and
the  moft frequently  employed is copper, under various
preparation.  What preparation  of it may be the moft ef-
feaual, I dare not determine ; but of late the cuprum am-
moniacum has been frequently found fuccefsful.t
   1338.] Lately the flowers of zinc have been recommend-
ed by a great authority as ufeful in all  convulfive difor-
ders ; but in cafes of epilepfy, I have not hitherto found
that medicine ufeful. J
    * The method cf ufing iron was defcribed in a note on article 576.
  t This was a favorite remedy of the Author's.  He firft introduced it into
practice in this country, and the  preparation of it was inferted in the Edin-
burgh 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 medicine, and
ought to be ufed with caution.
  f The great authority by which the flowers of zinc were recommended was
Gaubius.  It is as dangerous a medicine as the cuprum ammoaiacum, and
muft be ufed with the fame caution.
   Vol. II.                   Q 
126                 PRACTICE
    1339.] There have  been of late  fome  inftances of the
 cure of epilepfy by the accidental ufe  of mercury ; and if
 the late accounts ofthe cure of tetanus by this remedy are
 confirmed, it will allow us to think  that the fame may be
 adapted alfo to the cure of certain cafes of epilepfy.
    1340.] With refpea to  the employment of any ofthe
 above mentioned tonics in this difeafe,it muft be obferved,
 that in all cafes where the difeafe depends upon a conftant
 or occafional plethoric ftate ofthe fyftem  thefe remedies
 are likely to be  ineffeaual; and if fufficient evacuations
 are not made at the fame time,  thefe medicines are likely
 to be very hurtful.
    1341.] The other fet of medicines which we have men-
 tioned as fuited to obviate the effeas of the two great mo-
 bility of the fyftem, are the medicines  named  antispasmo-
 dics.   Of thefe  there is  a long;  lift  in the writers on  the
 Materia Medica, and by  thefe  authors recommended for
 the cure of epilepfy.   I'he greater part, however, of thofe
 taken from  the vegetable kingdom, are  manifeftly inert
 and infignificant.*   Eventhe root of the wild valerian hard-
 ly fupports its credit.
   1342.J Certain fubftances taken  from the animal king-
 dom  feem to be much more powerful: and of thefe  the
 chief, and feemingly  the  moft powerful, is mufk ; which
 employed in its genuine ftate, and in due quantity, has of-
 ten been an effeaual remedy.t
   It  is probable alfo, that the oleum arrimale, as it has been
  * This is certainly true ; but it muft be acknowledged that fome of them
 are manifeftly active and ufeful, as the afafcetida, fagapenum, and other fetid
 gums.  The pilulx gummofae of the  Pharmacopoeias are good formulae for
 thefe naufeous medicines ; and their being reputed inefficacious and infigni-
 ficant feems to have arifen from their not having been given in fufficient 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 ftiould
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 tea drops of lau-
danum after each dofe, as occafion may require.
  f Mufk is more eSTeclual when  given in fubftance than in any preparation
that has been attempted; it is given in dofes of from ten to thirty grains, and
frequently repeated. It may be made into a bolus, as in the following formula :
          Be. Mosch. gr.  xv.
              Tere in mortar, marmor. cum
              Sacch. alb. t^i.; et adde
              Confe£t. cardiac. 3ss.
              M. f. Bolus.
  This bolus may be repeated three or four times a-day, 
OF   PHYSIC.
127
named, when in its pureft ftate, and exhibited at a proper
time,  may be an effeaual remedy.*
   1343.]  In many difeafes, the moft powerful antifpafmo-
dic is  certainly opium ; but the propriety of its ufe in epi-
lepfy has been difputed among phyficians.  When the dif-
eafe depends upon a plethoric ftate in which bleeding may
be neceffary,  the employment  of opium is likely to be ve-
ry hurtful : but, when there is no plethoric or inflammato-
ry ftate prefent, and the difeafe feems to depend upon irri-"
tation,or upon increafed irritability, opium is likely to prove
the  moft  certain runedy.t   Whatever effeas in  this and
other  convulifve diforders have been attributed to the hy-
ofcyamus, muft probably  be attributed to its poffefling a
narcotic power fimilar to that of opium.
   1344.]  With refpea to the ufe of antifpafmodics, it is to
be obferved, that they are always moft ufeful, and perhaps
only ufeful, when  employed ata time when epileptic fits
are frequently  recurring, or near to the  times ofthe accef-
fion of fits which recur after confiderable intervals.
    1345«] Oi the fubjea of the cure of epilepfy, I have on-
ly to  add, that as the difeafe in many cafes is continued by
the power of habit only, and that in all cafes habit  has a
great  fhare in increafing mobility, and therefore in continu-
ing this difeafe;  fo the breaking in  upon fuch  habit, and
changing the whole habits ofthe fyftem, it is likely to be a
powerful  remedy in epilepfy.   Accordingly, a confidera-
ole change of climate, diet, and other circumftances in the
manner of life, has often proved a cure of this difeafe.^
   1346.] After treating of epilepfy, I might here treat of
   * The dofe of this oil is from twenty to thirty drops; it is, however, fel-
dom ufed.
   j In thofe cafes, in which fome peculiar fymptoms indicate the approach
of the rit, opium taken in a large dofe has fometimes prevented it altogether;
but moft commonly, however, fuch a dofe greatly Ieffens its violence.  Two
grains of opium in fubftance, or fixty or feventy drops of laudanum, are large
xlofes.
   J: After all that has been faid on this difeafe, we muft acknowledge that
we know but little of its true nature, and, confequently, no certain method of
cure can be given.  It has baffled the fkill cf phyficians from the earliett ages
of phyfie, 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
are few, and fuch only as are fymptomatic, or arife from peculiar mechanical
irritations.  Experience has moreover fhown us, that the difeafe often exifts
without any  apparent irritation, and without any caufe obfervable on diffec-
tion : Much  room is therefore left for future inveftigations 011 this dark fub-
jeil; and we muft at prefent content ourfelves with the hopes that time will
unfold what  human ingenuity has not yet been capable of eifefling.
«t 
 123                PRACTICE

 particular convulfions, which arc to be diftinguifhed froirV
 epilepfy by their being more partial : that is, affeaing cer-
 tain parts ofthe body  only, and by their not being attend-
 ed with a lofs of fenfe, nor ending in fuch comatofe ftate
 as epilepfy always does.
    1347.] Of fuch convulfive affeaions many different in-
 ftances have been obferved and  recorded by phyficians.
 But many of thefe have been manifeftly fympathic affetti-
*ons, to be cured only  by curing the primary difeafe 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 however have  not any  fpecific
 charaaer with which  they occur in different perfons, I
 muft therefore leave them to be treated upon the general
 principles I have laid down with refpea to epilepfy, or
 fhall lay down with refpea to the.following convulfive dif-
 order;  which, as having very  conftantly  in different per-
 fons a peculiar charaaer, I think neceffary to treat of more
 particularly.
               t——^»———.»
                      CHAP. III.

      £Df tfje Cfjorca or Dance of %t. Ottus*

 1348.]  X HIS difeafe affeas both fexes, and almoft  on-
 ly young perfons.   It generally  happens  from the age of
 ten to that of fourteen years.*  It comes  on always before
 the age of puberty, and rarely continues beyond that period.
    1349.] It is chiefly marked by  convulfive motions fome-
 what varied in different perfons,  but nearly of one kind in
 all; affbaing the leg and arm on  the fame fide, and gener-
 ally on one fide only.
    1350.] Thefe convulfive motions commonly firft affeQ:
 the leg and foot.  Though the limb be at reft, the foot is
 often agitated by convulfive motions, turning it alternately
 outwards and inwards.  When walking is attempted,  the
 affeaed leg is feldom lifted as ufual in walking, but is drag-
 ged along as if the whole limb were paralytic; and, when
 it is attempted to be lifted, this  motion is unfteadily  per-
   * I have feen it in a robuft man of forty-two.  This patient, after various
 ineffectual remedies had been ufed,,- was  cured by ftrong electrical fhocks di-
 re Ac d through the v/hole body. 
0 F P H Y S I C.                 129
formed, the limb becoming agitated by  irregular convuU
five motions.
   1351.] The arm of the fame fide is generally affeaed at
the lame time; and, even when no voluntary "motion is at-
tempted, the arm is frequently agitated with various  con-
rulfive motions.   But efpecially when voluntary motions
are attempted, thefe are not properly executed, but are
varioufly hurried or interrupted by convulfive motions in
a direaion contrary to that intended.   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,
interrupted by frequent convulfive retraaions and devia-
tions, that the  cup  can be carried to the mouth.
   1352.J It appears to  me, that  the will often yields  to
thefe convulfive motions, as to a propcnfity, and thereby
they are  often  increafed, while the perfon affeaed feems to
be  pleafed with increafing  the furprife and amufement
which his motions  occafion in the byftanders.
   1353.] In this difeafe the mind is often  affeaed with
fome degree of fatuity; and often fhows  the fame varied,
defultory, and caufelefs  emotions which occur in hyfteria.
   1354. J 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 affeaing the head  and trunk of the body. •  As in
this difeafe there feem to be propenfities to motion, fo va-
rious fits of leaping and running occur in the perfons affea-
ed ; and there have been inftances of this difeafe, confift-
ing of fuch convulfive motions, appearing as an epidemic
in a certain corner  ofthe country.   In fuch inftances, per-
fons of different ages are affeaed, and may feem  to make
an exception to the general rule above laid down; but ftill
the perfons are, for the moft part, the young of both fexes,
and ofthe more  manifeftly movable conftitutions.
   1355. J The method of curing this difeafe has  been va-
rioufly propofed.  Dr.  Sydenham propofed to cure it by
alternate bleeding and purging.   In fome plethoric habits
I have found fome bleeding ufeful; but.in many cafes I
have found repeated evacuations, efpecially  by bleeding,
very hurtful.
   In many cafes, I have found the difeafe, in fpite  of re-
medies of all kinds, continue for many months;  but I have 
\:,o
PRACTICE
alfo found it often readily yield to tonic remedies, fucH as
the Peruvian bark, and chalybeates.
   The late Dr. De Haen found  feveral perfons  laboring
under this difeafe cured by the application of  elearicity.
                       Sect. II.
    Ofthe Spasmodic Affections ofthe Vital Functions.
                     CHAP. IV.*

        ©f tbe palpitation  cf t&c $>eart.

1356.]  X HE motion thus named is a contraaion or fyf-
tole of the heart, that is performed with more rapidity, and
generally alfo with more force than ufual and when at the
fame time the heart ftrikes  with more than ufual violence
againft the infide of the ribs, producing often a confidera-
ble found.
   1357.] 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 can-
not follow in  all the particulars with fufficient difcernment,
and therefore fliall here only attempt to refer all the feve-
ral cafes of this difeafe to a few general heads.
   1358.] The firft is of thofe arifing from the application
of the ufual ftimulus to the heart's contraaion; 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 man-
ner that violent  exercife occafions palpitation.
   1359. J A  fecond  head ofthe  cafes of palpitation, is  of
thofe  arifing from  any refiftance given to the free and en-
tire evacuation ofthe ventricles ofthe heart.  Thus a liga-
ture made upon the  aorta occafions  palpitations of the
moft violent  kind.   Similar refiftances, either in the aorta
or pulmonary artery,  may  be readily imagined ; and fuch
has been often found in the dead bodies of perfons who,
during life, had  been much affeaed with palpitations.
   To this head  are to be referred all thofe cafes of palpi-
  * Though I have thought it proper to divide this book into fecYions, I think
it necefTary, for the convenience of references, to number the chapters from
the beginning.  Author. 
0 F  P H V S I C.                IS1
taiion arifing from caufes  producing an accumulation of
blood in the great veffels near to the heart.
   1360.] A third head ofthe cafes of palpitation, is of thofe  m
arifing from a more violent and rapid influx ofthe nervous
power into the mufcular fibres  of the heart.  It is in this
manner that I  fuppofe various  caufes acting in  the brain,
and particularly  certain  emotions of the mind  occafion
palpitation.
   1361.] A fourth head of the cafes of palpitation, is of
thofe arifing from  caufes producing a weaknefs in the ac-
tion ofthe heart,  by  diminifhing l he energy of the  brain
with refpea to  it.   That fuch caufes operate in producing
palpitation, I prefume from hence, that all the feveral cau-
fes mentioned above (1177. et seq.), as in this manner pro-
ducing fyncope,  do often  produce palpitation.   It is on
this ground that thefe two difeafes are affeaions frequently
occurring in the  fame perfon, as the fame caufes may oc-
cafion the  one or the other, according to the force of the
caufe and mobility ofthe perfon acted upon.   It feems to
be a law of the human economy, that a  degree of debility
occurring in any  funaion, often produces a more vigour-
ous exertion of the fame, or at leaft an effort towards it.,
and that commonly in a convulfive manner.
   I  apprehend it to be the convulfive  aaion, frequently
ending in fome degree of a fpafm, that gives occafion to the
intermittent pulfe fo frequently accompanying palpitation.
   1362.] A fifth head of the cafes of palpitation  may per-
haps be of thofe arifing from a peculiar irritability or mo-
bility ofthe heart.   This, indeed, may be confidered as a
predifponent caufe only, giving occafion to the  aaion of
the greater part of the caufes recited above.   But it is pro-
per to obferve, that this  predifpofition  is  often  the chief
part of the remote caufe; infomuch that many of the caufes
producing palpitation would not have this effea but in per-
fons  peculiarly predifpofed.  This head, therefore, of the
cafes of palpitation, often requires to be diftinguifhed from
all the reft.                             r
   1363.] After thus marking the feveral cafes and caufes
of palpitation, I think it neceffary, with  a view to the cure
of this difeafe, to obferve, that the  feveral caufes of it may
be again reduced  to two heads.   The firft is, of thofe con-
fifting in, or depending upon, certain organic affeaions of 
132                PRACTICE
the heart itfelf, or of the great veffels immediately connea-
ed with it.  The fecond is, of thofe confifting  in, or de-*
pending upon, certain affeaions fublifting and acini!; in-
other parts of the body, and acting either by the force of
the caufe, or in confequence of the mobility of the hcait,
   1364.J  With refpea to the cafes depending upon the
firft fet of caufes, I muft repeat-here what I faid with ref-
pea to the like cafes of fyncope, that I do not know any
.means of curing them.   They, indeed, admit of fome pal-
liation, first, by avoiding  every  circumftance1 that may
hurry the circulation ofthe blood; and, second, by every
means of avoiding a plethoric fiate of the fyftami,  or any
occafional turgefcence of the blood.   In mahy of thefe
cafes,  blood-letting may give a temporary relief: But in
fo far as debifity and mobility are concerned, in fuch cafes
this remedy is likely to dp h-rm.
   1365.J  With refpect 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 general, that
thefe cafes may be  confidered as of two  kinds;  one de-
pending upon primary affeaions in other parts of the body,
and aaing by the force ofthe particular caufes; and ano-
ther depending upon a ftate of mobility in the heart  itfelf.
 In the firft of thefe, it is obvious, that the cure of palpita-
tion muft be obtained by  curing the primary affeaion*;
which is not to be treated of here.   In the fecond, the cure
muft be (obtained, partly by  diligently avoiding the occa-
 fional caufes, partly and chiefly by correaing the mobility
 of the fyftem, and of the heart in particular; for doing
which we have treated ofthe proper means elfewhere.

                      CHAP. V.

     ©f £>£0pnoea, or Difficult 15reatfmtg,

 1366.]  X HE exercife of refpiration,  and the organs*of
it, have  fo  conftant  and confiderable  a conneaion with
almoft the whole of  the other funaions and  parts ofthe
 human body, that upon almoft every  occafion of difeafe,
 refpiration muft be effeaed.   Accordingly, fome difficul-
 ty and diforder in this funaion, are in faa fymptoms very
 generally accompanying difeafe.               - 
■O F P H Y S IC.                  133
   1367.]  Upon this account,  the fymptom  of difficult
breathing deferves a chief place and an ample confiderati-
on in the general  fyftem  of Pathology;  but what fhare of
confideration it  ought to have in a treatife of Praaice, I
find  it difficult to determine.
   1368.]  On this fubjea, it is, in the firft place, neceffary
to diftinguifh  between the fymptomatic and idiopathic af-
feaions  ;  that is,  between thofe difficulties of  breathing
which are fymptoms only of a more general affeaion, or of
a difeafe fubfifting primarily in other parts than the organs
of refpiration, and that difficulty of breathing which depends
upon a primary affeaion ofthe  lungs  themfelves.    The
various cafes of fymptomatic  dyfpnoea I have taken  pains
to enumerate  in my Methodical  Nofology, and it will  be
obvious they are fuch as cannot be taken notice of here.
   1369.]  In my Nofology I have alfo taken pains to point
out and  enumerate the proper, or at leaft the greater part
ofthe proper, idiopathic cafes ofthe dyfpncea:  but from
that enumeration it will,  I think, readily appear, that few,
and indeed hardly any, of thefe cafes, will admit or require
much of our notice in this place.
   1370.] The Dyfpncea Sicca,* species 2d, the  Dyfpncea
Acreage sp. %d, the Dyfpnoea Terrea,\ sp. 4th, and Dyfp-
ncea Thoracica,\\  sp. jth* are  fome of them with difficulty
known,  and are all of them difeafes which  in my opinion
do not admit of cure.  All, therefore, that can be faid con-
cerning  them here is, that they may admit of fome pallia-
tion; and this, I think, is to be obtain chiefly by avoiding a
plethoric ftate of the lungs. §  and every circumftance that
may hurry refpiration.
   1371.]  Of the Dyfpncea  Extrinseca,^  sp. %th,  I can
fay no more, but that thefe external caufes marked  in the
Nofology, and perhaps fome others that might  have like
effeas, are  to  be  carefully avoided;  or, when  they have
been applied, and their effeas have taken place, the difeafe
is to be palliated by the means mentioned in the laft paragraph.
  * The definition, which the Author gives of this fpecies in his Nolblogy,:U Dnpntte cvm tustiple-
nmque sicca.  It arifes from various caufes, fome of which are extremely difficult, a net lmpoffible,
to be difcovered.                                    . .
  f The definition of this fpecies in, Dy.fpnaa a minima qua-vis tenipestatum mvtatume aucta.
  X It is defined Dyspnxa cum tuisi material terream vet cakulosam rjicuute. This is fometimes tUc
expultion of a gouty matter.                          ,  .     ,    , _ .
  If The definition of this fperfes Is, Dyspnxa a partibus thoracemci-igeutibtts lae.ts, vtl male conformant.
  & This intention is moll fpecdily obtained by occafional bleeding.
 4 It is defined Dyspnxa a causii exfsn.is manifestis.  Thefe caotes are varlOHfc as expofure to duft»
of different kind*, tSmetallic fwtnw, to vitiated air, to vapors-pf xaffercnt kHWSj «c.
  Vol. II.                  K 
1^4                 PRACTICE
   1372.]  The-other fpecies, though enumerate^, as idio-
pathic, can hardly be confidered as fuch,  or as requiring
to be treated of here.
   The Dyfpncea Qakarrhalis,* sp.  1st, may be  conffderqcj
as a fpecies of catarrh, and is pretty certainly to.be curat)
by the fame remedies as that fpecies of catarrh wj^ich rje*
pencils rather upon  the increafed afflux  of mucus  to the
bronchiae, than upon any inflammatory ftate in  them,tVl
   The Dyfpncea Aquosa,J sp. §th, is certainly to,be confi-
dered  as a fpecies of dropfy, and is to  be treate4fby  tfjfl
fame remedies as the other fpecies of that difeafe.. ,  . m,
   The Dyfpncea Pinguedinosa,\ sp. 6th, is in like manner
to be confidered as  a fymptom or local effect of the Paly-
farcia, and is pn(y to cured by correcting the  general fau^t
pf the fyftem.^                     _    ,      ,, m^   ,r
   1373, J  From this view  of thofe idiopathic cafes of 4y*
fpncea, which are perhaps all I could properly arrange unr
der this, title, it will readily appear that there is little room
for treating of them here: But tbere is ftill one cafe of d^f,
ficult breathing, which has been properly diftinguiftiedfrom
every  other under  the title  of Asthma;, and as it deferve^
our  particular attention, I fhall here feparately  confider it,

                      CHAP. VI.



1374.3  A'HE  Jterm of afthma has been commonly appli-
ed by the vulgar, and even by many writers on the Praaice
of Phyfie, to every cafe of difficult breathing,  that is, toJ
every  fpecies of Dyfpncea.   The Methodical Nofologifts,
alfo, have diftinguifhed Afthma from  Dyfpncea chiefly^
and almoft fotely, by the former being  the fame affeaion
with the latter,  but in a higher degree.   Neither of  thefe
applications 0f the term feems to have been correa or pro-
per.   I am of opinion, that the term Afthma may be moft
properly applied, and  fhould be confined, to a  cafe of dif-
ficult breatnjhg that has peculiar fymptoms, and depends
 * It U defined, Dysfnaa cum tussifrtauente mt/cum -viscidttm copiostsm encifnte.
 t The remedies fof thl» pmpofit At£ imetics/rndarlfics, n( eMpecuwMfU;  formula of Wrick
may be feem in the Motes on Article ipoc.
 | It b defined, Byspmaa arm urimphttn^tt trdemant: pedum, tint fiuctuatime in peelere, vel ahU
(baracteristicis hydrotheracis signis.
  <It is defiaed. Dyspnoea iu homimbvs vaUe obetis. .
  A low-dlet, fufficient exercife fweating, and briflt purges, will foon have the  defired effeft i an*
tfie difeafe may be prevent by aMUjaiow living. 
OF  PH Y^S IC.                155
irffrim a peculiar proximate caufe, which I hbpe to affign
with fufficient certainty.   It is this difeafe I am now to
treat of, and it is nearly what Praaical Writers have gene-
rally diftinguifhed from the other cafes of difficult breath-
ibg, by the title of Spafmodic Afthma,  or of Asthmb con-
mtsivumj although by not diftinguifhing it with fufficient ac-
curacy frorn the other cafes of Dyfpncea, they have introdu-
ced a great deal of confufion in their treatifes on this fubjea.
   1375.] The difeafe  I am to treat of, or the Afthma to
be ftrittty fo called, is often a hereditary difeafe. It* fel-
dom appears very  early in life,  and hardly till the time of
puberty, oraftei it.  Itaffeas both fexes, but moft frequent-
ly the male.   I have  not obferved it to 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 ofthe lungs
alone. h It  frequently attacks perfons of a full habit; but
it hardly ever continues to be repeated for fome length of
time without occafioning an emaciation ofthe whole body.
 »'■ 1376.] The attacks of this difeafe are generally in' the
night-time,  or towards the  approach of night; but  there
are alfo fome inftances of their coming on in the courfe of
the day.  At whatever time they come on, it is for the moft
part fuddenly, with a fenfe of tightnefs and ftriaure acrofs
 the breaft,  and a fenfe of ttraitnefs in  the lungs impeding
 infpiration.   The perfon thus attacked, if in a horizontal
 fituation, is immediately obliged  to get into fomewhat of
 an erea pofture, and requires a  free and cool air.  The
 difficulty of breathing goes on for fome  time  increafing;
 and both infpiration and exfpiration arc performed flowly,
 and with a wheezing noife.  In violent fits, fpeaking is di£
 ficult  and  uneafy.   There is often fome  propenfity. to
 coughing, but it can hardly be executed.
    1377.] Thefe fymptoms often continue tor many hours
 together, and particularly from midnight till the morning is
 far advanced.   Then commonly a remiflion takers place^by
 degrees;" the  breathing becomes lefs laborious and  mprq
 full, fo that the perfon can fpeak and cough with more eaYe;
 and,.if the  cough brings up fome mucus, theremiffionbe-
 comes immediately more confiderabW, and the f$>rfon fails
 into a much wifhed for fleep.     ..;;'•      >K     *'•
     * This defcription of the difeafe under connderatfoh ts eXcenenV 
K :
I1 RACTIGE
   137S.]  During thefe fits the puiie often continues in its
 natural ftate;  but in fome perfions the fits are attended with
 a frequency of pulfe, and with fome heat  and thirft, as
 marks of fume degree of fever.   If urine be voided at the
 beginning of a fit, it is commonly in confide;, iblc quantity,
 and with little colour or odour; but, after the fit is over,
 the urine voided is in the ordinary quantity of a high colour,
 and fometimes depofits  a fediment.  In fome  perfons,
 during the fit,  the face is a little  flufhed and turgid;  but
 more commonly  it  is fomewhat pale and fhnmk.
   1379.]  After fome fleep in the morning, the patient, for
 the reit 01  the day,  continues to have more  free and eafy
 breathiivj,  but it is  feldom entirely fuch.   He ftill feels
 fome tiqhtnefs 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  flatulen-
 cy of his ftomach, and an  unufual drowfinefs; and, very
 frequendy, thefe fymptoms precede?!the firft attacks of the
 difeafe.  But, whether thefe fymptoms appear or not, the
 difficulty of breathing returns towards  the evening;  and
 then fometimes gradually increates, till it becomes as vio-
 lent as in the night before:  or if, during the day, the  diffi-
 culty 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 morning; and is then fuddenly feiz-
 edwith a fit of difficult breathing, which 111ns the fame
 courfe as the night before.
   1380.] In this manner fits  return for feveral nights fuc-
 cefiivdly: but generally,  after fome nights  paffed in  this
 way, the fits fuffer more confiderable renditions.   This ef-
 pecially happens  when the remifiions are attended with a
 more copious expectoration in the mornings, and that this
 continues from  time to time throughout the day.   In thefe
 circumftances, afthmatics, for a long time after, have na&
 only more eafy days, but enjoy alfo nights of entire  fleep,
 without the recurrence of the-difeafe.
   1381.] 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,  hap-
pen with different circumftances in different pericm.-. 
OF  PHYSIC.               137
   1382.] In fome perfons the fits are  readily excited by
external heat, whether ofthe weather or of a. warm cham-
ber, and  particularly by warm bathing;  In fuch perfon j
fits are more frequent in fummer,.and particularly during
tjjp dog-days, than at other colder feafons.   The faiae per-
fons are alfo readily affeaed by changes of the v. eather;
efpecially by fudden changes made from a colder to a warm-
er, or what is commonly the fame thing, from  a heavier to
a lighter atmofphere.   The fame perfons are  alfo affeaed
by every circumftance ftraitenir.g the capacity of the tho-
rax, as by any ligature made, or even by  a  plaiftcr laid
upon it;  and a like effea happens from  any increafed bulk
of the ftomach, either by a full meal, or by air cpjjected in
it.  They are likewife much affeaed by cxercife, or what-
ever elfe can hurry the circulation of the blood.
   1383.] As afthmaticftfs feem thus to depend upon fome
fulnefs of the veflels of the lungs, it is probable that an ob-
ftruction of perfpiration, and the  blood being lefs determin-
ed to the furface of the body, may favor 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 haye  com-
monly more  of a catarrhal  affeaion  accompanying  the
afthma;  which therefore occurs more frequently in winter,
and more manifeftly from the application  of ccld.-
   1384.J Bcfide thefe cafes of afthma excited by  heat or
cold, there arc 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 irritations of
fmoke and duft.   That this difeafe is an  affection of the
nervous  fyftem,  and  depending upon  a  mobility of the
moving fibres  ofthe lungs',  appears pretty clearly from its
being frequently attended with other fpafmodic affeQaons
depending upon mobility;  fuch as hyfteria, hypochondria-
fis, dyfpepfia, and atonic gout.
   1385.] From the whole of the hiftory of afthma  now
delivered, I think  it will readily appear, that the proximate
caufe of this difeafe is a preternatural, and in fome meafure
a  fpafmodic,  conftriaion  of the  mufcular fibres of the
bronchia?; which  not only prevents the  dilatation of the
bronchiae neceffary to a free and full infpiration, biit gives
alfo a rigidity which prevents a  full and  free exfpiration. 
13S                 PRACTICE
This preternatural conftriftidh, like many other convulfive
arid fpafmodic  affections, is readily excited by a turgef-
cenfe  of the blood,  or other caufe of any unufual fulnefs
and diftention of the veffels of the lungs.
   1386.] This difeafe, as coming by fits, may be generally
diftinguifhed from moft other fpecies of dyfpncea, whoie
caufes being more conftantly applied, produce therefore a
more  conftant difficulty of breathing.   There may,  how-
ever,  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 appear-
ance of the genuine afthmatic fits defcribed above.  Perhaps,
however, there is ftill another cafe that may give more dif-
ficulty ; and that is  when feveral of the caufes,*which we
have affigned as caufes of feveral ofthe fpecies of difficult
breathing referred to the genus of Dyfpncea, may have the
effea  of exciting a  genuine  afthmatic  fit.   Whether this
Can happen to  any but the peculiarly predifpofed to afth-
ma, I  am uncertain; and therefore, whether in any fuch cafes,
the afthma may be confidered as fymptomatic ;  or if, in
all fuch cafes, the afthma may not ftiil be confidered and
treated a< an idiopathic difeafe.
   1387. J The afthma, though often threatening immediate"
death, feldom occafions  it, and many perfons have  lived
tong under this difeafe.   In many cafes, however, it does
prove fatal; fometimes very quickly, and perhaps always
at length.   In  fome young perfons  it has ended  foon, by
occafioning a phthifis pulmonalis.   After a  long continu-
ance,  it  often ends in a hydrothotax ;  and commonly, by
occafioning fome aneurrfm of the heart or great veffels, it
thereby proves fatal.
   1388.]  As it is feldom that an afthma has been entirely
cured ;  I therefore  cannot propofe any  method of cure
which experience has approved as generally fuccefsful. But
the difeafe admits of alleviation in feveral refpeas from the
ufe of reiriedijgs; and my bufinefs now fhall be chiefly to
offer fome Remarks upon  the choice and ufe of the remedies
which have^neen commonly employed in cafes of afthma.
  ljj&q.]  As the danger of an afthmatic fit arifes chiefly
from  the difficulttranfirmffion ofthe blood through the vef-
fels ofthe lungs, threatening fuffocation; To the moft pro- 
u *  I'WiSlC.                W
bable means of obviating this feems  to be blood-letting;
an<j[ therefore, in all violent fits, praaitioners have had re-
courfe to this remedy,   jn  firft attacks, and efpecially in
young and plethoric perfons, blood-letting  may  be \ ery
neceffary, and is commonly allowable.   But it is alfo evi-
dent, that, under the frequent recurrence c>f fits, blood-let..
^ing  cannot be frequently repeated without exhaufting and
weakening the patient too much.   It is further to be obfer-
ved  that |poodletting is not fo neceffary as might be ima-
gined, as the paflage pf the blood  through the lungs is not
fo much  interrupted as has  been commonly  fuppofed-
This I particularly conclude from hence, that, inftead o.l
the fuffufion of face, which is the ufual effea of fuch inter:
ruption, the face, in afthrpatk fits,  is often flirunk and pate*
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 expeaed.
   1390.]  As I have alledged above, that a turgefcence of
the blood is frequently the exciting caufe of afthmatic fit.:,
fo it might be fuppofed, that a plethoric ftate of the fyftem
might have a great fhare in producing a turgefcence of the
blood in the lungs; and. efpecially, therefore, that blood-
letting might be a proper remedy in afthma.   I allow it to
be fo in the firft attacks  ofthe difeafe:  but as the  difeafe,
by continuing, generally takes off the plethoric ftate of the
fyftem;  fo, after the difeafe has continued for fome time,
I alledge that blood-letting becomes lefs and lefs neceffary.
   1391. J  Upon the fuppofition of afthmatics being in a
plethoric ftate,  purging might be fuppofed to prove a re-
medy in this difeafe:  but, both becaufe the  fuppofition is
not commonly well founded, and becaufe purging is feldom
found to relieve the veffels of the thorax, this  remedy has
not  appeared to be well fuited to afthmatics* and large
purging has always been found to do much harm.   But as
afthmatics are always hurt by the ftagnation and accumula-
tion of matters in the alimentary canal, fo coftivenefs.muft
fee avoided, and an open belly proves ufeful.  In the time
of fits, the employment'of eniollient and moderately laxa-
tive glyfters* has been found to give confiderable relief.
   130,2.]  Asa  flatulency ofthe ftomach, and other fymp.
 • # A glyfter of milk, with a little fait, is generally fufficient.-—The coftivenefs may be remove*
by mucilaeSiibu* laxatives of thettdlder kKd, as manu», caifai,*&Cv or by.a proper attention to diet!,
especially 6y ufing the pulps of particular fruiu, at prunes or raifiitt bailed in barley-wares; roaifce*
applet eatciWthinrowa fugar, «c* 
U                 PRACTICE

kmns  of  indigeftion, are frequently attendants of afthma,
and verv troublcforr.c to afthmatics;  fo, both for removing
thefe fymptoms, and for taking oft all determination to the
lungs, the frequent ufe of gentle vomits* is proper in this
difeafe.   In certain cafes, where a fit was expeaed to com.e
on in the courfe of the night, a vomit given in the evening
has frequently feeined to prevent it.
   1393.] Bliftering  between the fhouldcrs, or upon  the
breaft, has been frequently employed to relieve afthmatics;
but in the pure fpafmodic afthma we treat of here, I have
rarely found blifters ufeful, either in preventing or reliev-
ing fits.
   1 394.] Iffues are certainly ufeful in obviating plethoia;
but as fuch indications feldom arife in cafes of afthma,  fo
iffues have been feldom found ufeful in this difeafe.
   1395.] As afthmatic fits are  fo frequently excited by a
turgefcence of the blood, fo the obviating and  allaying of
this by acids and neutral falts, feems to have been at  all
times the objea of praaitioners.  See Fl o yer on the Asthma.
   1396.J Although a plethoric ftate of the fyftem may
icem to  difpofe to afthma, and the occafional  turgefcence
of the blood may feem to be frequently the exciting caufe
ofthe fit; yet it is evident, that  the difeafe muft have arifen
chiefly  from a peculiar  conftitution in  the moving fibres
of the bronchiae,  difpofing them upon various occafions to
fall into a  fpafmodic conftriaion;  and therefore, that  the
entire cure of the difeafe can only be  expeaed  from  the
correcting of that predifpofition, or from correcting the pre-
ternatural mobility orirritability of thelungs in that refpea.
   1397.]  In cafes wherein this predifpofition depends up-
on original  conformation,  the cure muft be difficult, and
perhaps  impoffiblc; but it may perhaps  be moderated by
the ufe of antifpafmodics.  Upon this footing, various re-
medies of  that kind have been commonly employed, 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 heating  too much.  Some other
antifpafmodics which  might be fuppofed powerful, fuch
as mufk, have not been properly tried.  The vitriolic ether
has been found to give relief, but its effcBs are not lafting.
  » Vomits ought, in thefe cafes, to be mild. Some formula of tlcm arc given in one of the Note*
ca article 185. 
OF  PHYSIC.                141
   1398.] As in other fpafmodic affeaions, fo in this, the
molt certain and powerful antifpafmodic is opium* I have
often found  it effeaual, and  generally fafe ;  and if there
have arifen doubts with refpea to its fafety, I  believe they
have arifen from not diftinguifh ing between certain pletho-
ric and inflammatory cafes of dyfpncea, improperly named
Afthma, and the genuine fpafmodic afthma we  treat of here.
   1399.] As in many cafes  this difeafe. depends upon a
predifpofition which cannot be correaed by our art, fo in
fuch cafes the patient can only efcape the difeafe by avoid.-
ing the occafional or exciting caufes, which I have endea^
voured to point out above, It is, however, difficult to give
any general  rules  here$ as different afthmatics have their
different idiofyncrafies with refpea to externals.   Thus*
one afthmatic finds him felf eafieit living in the midft a great
city, while another cannot breathe  but in the free air ofthe
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*
   1400.] In diet, alfo, there is fome difference tobe made
with refpea  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 readily prove flatulent, are always
very hurtful In recent afthma, and efpecially in the young
and plethoric, a fpare, light, and cool diet is proper, and com-
monly neceffary ; but after the difeafe has continued for years,
afthmatics commonly bear, and even require,  a tolerable
full diet, though in all cafes a very full diet is very hurtful.
   1401. J In drinking, water, or cool watery liquors, are
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.aecount and  upon account of the liquors
weakening the nerves of the ftomach, neither  tea nor coffee
is proper in  this difeafe.
  # Theereateffieacvof opium, in cafe* of fpafmodic afthma, is fully confirmed by estperience.  ft
buRhT toTOven fn W doleS,'but not often repeated in the'day.  It feems to be motf ufefui When
etveflOccafionally to aUay the violence of the nt| or to prevent its acceffion. Thus, 4o drops£to>
lamim have been frequently found to relieve the fymptoms when the fat u v.otent • o^henuken a
the approach of the fit, to have wholly fupprcficd It, or it leaft to have confiderably blunted its violew*
   Vol. 11.                   S 
242                PRACTICE
                       =====
   1402.] Afthmatics commonly bear no bodily motion
eafily but that of the moft gentle kind.  Riding, however,
on horfeback, or going in a carriage, and efpecially failing,
are very often ufeful to afthmatics.


                    CHAP. VII.

      ©f tfje Cfnncougi), or ^oopingcougfr,

14°3-3  X HIS difeafe is commonly epidemic, and mani-
feftly contagious.   It feems to proceed from a contagion
of a fpecific nature, and of a finguiar quality,  it does not,
like  moft other contagions,  neceffarily produce a fever;
nor does it, like moft others, occafion any eruption, or pro-
duce otherwife any evident change in the ftate of the human
fluids. It has, in common with the catarrhal contagion, and
with that of the meafies, a peculiar determination to the
lungs; but with particular effeas there, very different from
thofe ofthe other  two ; as will appear from  the hiftory of
this difeafe now to be delivered.
   1404.] This contagion, like feveral others, affeas per-
fons but once in the courfe of their lives ; and therefore,
neceffarily, children  are moft  commonly the fubjeas of
this difeafe :  But  there are many inftances of it occurring
in perfons confiderably advanced in life; though it is pro-
bable, that the further that perfons- are advanced in life,
they are the lefs liable to be affeaed with this contagion.
   1405*«] The difeafe commonly comes  on with the ordi-
nary 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 evidently ari-
fing from the chincough contagion, never put on any other
form than that of a common catarrh.  This, however, fel-
dom happens; for, generally in the fecond, and at fartheft
in the third week after the attack,  the difeafe puts on its pe-
culiar and charaaeriftic fymptom, a convulfive cough. This
is a cough in which the  exfpiratory motions peculiar to
coughing are made with more frequency, rapidity, and vio-
lence, than ufual.  As thefe circumftances, however, in dif-
ferent inftances of coughing, are in  very different degrees;
fo no exaa limits  can be put to determine when the  cough
can be ftriaiy faid to be convulfive; and it  is therefore 
OF PHY.SIC.                143
efpecially by another circumftance  that the chincough is
diftinguifhed from every other form of cough.   This cir-
cumftance is,  when many exfpiratory motions  have been
convulfively made, and thereby the air is in great quantity
thrown out from the lungs,  a full infpiration is neceffarily
and fuddenly made;  which, by the air ruffling 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 dif-
eafe  is called  the Hooping Cough.  When this fonorous
infpiration has happened, the convulfive coughing is again
renewed, and continues  in the fame manner as before, till
a quantity of mucus is thrown  up from the lungs, or the
contents of  the ftomach are thrown up by vomiting.   Ei-
ther of thefe evacuations commonly puts  an end to the
coughing, and the patient remains free  from it for  fome
time after.  Sometimes it is only after feveral alternate fits
of coughing and hooping that  expeaoration or vomiting
takes place; but it is commonly after the fecond coughing
that  thefe happen, and put an end to the fit.
   1406.] When the difeafe, in this manner, has taken its
proper  form,  it generally continues for a long  time after,
and  generally  from one month to three; but  fometimes
much longer, and that with very various circumftances.
   1407. J The fits of coughing return at various intervals,
rarely obferving any exaa period.   They happen frequent-
ly in the courfe of the day, and more frequently ftill in the
courfe of the  night.    The patient has commonly  fome
warning of their coming on; and, to avoid that violent and
painful concuffion which the coughing gives to the whole
body, he clings faft to any thing that is near to him, or de-
mands 10 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 ap-
pears very little;  and children are commonly  fo entirely
relieved, that they immediately return to their play, or what
elfe  they were occupied in before.
   1408.] If it happens  that the fit of coughing ends in vo-
miting up the contents of the ftomach, the  patient is com-
monly immediately after feized with a ftrong craving and
demand for  food, and takes it in very greedily.
   1409.] At the firft coming on of this difeafe, the expec- 
144
PRACTICE
 toration is fometimes none at all, or of a thin mucus only;
 and while this continues to be the cafe, the fits of coughing
 are more violent, and continue longer;  but commonly the
 expeaoration foon becomes confiderable, 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 fhort-
 er duration.
   1410.], The violent fits of coughing frequently interrupt
 the free tranfmiffion of the blood through the lungs, and
 thereby the free return of blood from the veffels ofthe head.
 This occafions that turgefcence and fuffufion of face which
 commonly attends the fi ts 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.
   1411.] 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  accompanied with pyrexia,
 fometimes from the very beginning,  but more frequently
 only after the difeafe had continued for fome time.  When
 it does accompany the difeafe, we have not found it appear-
 ing under any regular intermittent form. It is conftantly in
 fome degree prefent;  but  with evident exacerbations to-
 wards evening,  continuing till next morning.
   1412.} Another fymptom very frequently attending the
 chincough, is a difficulty of breathing; and that not only
 immediately before and after fits of coughing, but  as con-
 ftantly prefent, though in different degrees in different per-
 fons.   I have hardly ever feen an inftance of a fatal chin-
 cough, in which a confiderable degree of pyrexia and dy-
 fpncea  had not been for fome time conftantly prefent.
   1413. J  When by the power of the contagion this dif-
 eafe 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 giving a  predif-
pofition only  ; and the frequency of fits depends in fome
meafure upon various  exciting caufes; fuch  as, violent
exercife ;  a full meal; the having taken in food of diffi-
cult folution ; irritation ofthe lungs by duff, fmoke or dif-
agreeable odours of a ftrong kind : and efpecially any con-.
{iderable emotion of the mind.
   1414.] Such are the chief circumftances of this di^afe. 
OF  PHYSIC.                145
and it is of various event; which, however, may be com-
monly forefecn by attending to thefollowing confiderations.
   The younger that children are, they are in the greater
danger 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 fecure a-
gainlt an unhappy event ; and this I hold to be a very ge-
neral rule, though I own there are many exceptions to it.
   Children  born of phthifical and afthmatic parents are
in the greateit  danger from this difeafe.
   When the difeale, beginning in the form of a  catarrh, is
attended with fever and difficult  breathing,  and  with little
expeaoration, it often proves fatal, without taking on the
form of the hoopingcough;  but, in moft fuch cafes, the
coming on ofthe convulfive cough and hooping, bringing
on at the fame time a more free expeaoration,  generally re-
moves the danger.
   When the difeafe is fully  formed, if the fits are  neither
frequent nor violent, with moderate expeaoration, and the
patient, during the intervals of the fits, is eafy,  keeps his ap-
petite, gets fleep, and is without fever or difficult breathing,
the difeafe is attended  with no danger; and thefe circum-
ftances becoming daily  more favorable, the difeafe very
foon fpontaneoufly terminates.
   An expeaoration, either very fcanty or very copious, is
attended with  danger;  efpecially if the latter circumftance
is attended with great difficulty of breathing.
   Thofe cafes in which  the fits terminate by a vomiting,
and are immediately followed by a craving of food, are
generally without danger.
   A moderate hemorrhagy from the nofe often proves falu-
tary ; but very large hemorrhagies 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 vio -
lence ofthe fits of coughing, occafioning apoplexy, epilep-
fy, or immediate fuffocation:  But thefe accidents are very
rare; and the  danger of the difeale feems generally to be in
proportion to  the fever and dyfpncea attending it.
   1415. J The cure of this difeafe has been always confi-
dered as difficult, whether the purpofe be to obviate its fa-
tal tendency when it is violent3  or  merely to fhor/-i «'^ 
 U6                PRACTICE

 courfe of it when it is mild.   When the contagion is recent,
 and continues to aa, we neither know how to correa, nor
 how to expel it; and therefore the difeafe neceffarily con-
 tinues for fome time:  But it  is probable, that  the conta-
 gion  in this as  in other inftances ceafes  at length to aa;
 and that then the difeafe continues, as in other convulfive
 affections, by the power of habit alone.
   1416. j From this view of the  matter  I maintain, that
 the praaice muft be different, and adapted to two different
 indications, according to the period of the difeafe.  At the
 beginning of the difeafe, and fome  time after, the remedies
 to be employed muft  be fuch as may  obviate the violent
 effeas of the difeafe, and the fatal tendency of it;  but, after
 the difeafe has continued for fome time, and is without any
 violent fymptoms, the only remedies which can be required
 are thofe which may interrupt its courfe,  and put an entire
 ftop to it fooner than it would have fpontaneoufly ceafed.
   1417.] Foranfwering the firft indication.  In plethoric
 fubjects,  or in others,  when from the circumftances of the
 cough and fits  it appears that the blood is difficultly tranf-
 mitted through the lungs, blood-letting* is a neceffary reme-
 dy; and it may be even neceffary to repeat it, efpecially in
 the beginning of the difeafe;  But,  as fpafmodic  affe6tions
 do not commonly admit of much bleeding, fo  it is feldom
 proper in the chincough to repeat this remedy often.
   1418.] As coftivenefs frequently attends this difeafe, fo
 it is neceffary to obviate or remove it by laxatives employ-
 ed; and keeping an open belly is generally ufeful:  But
 large evacuations in this way are commonly hurtful.t
   1419. J To  obviate or remove the inflammatory deter-
 mination to the lungs that fometimes occurs in the difeafe,
 bliftering is often ufeful, and  even repeated bliftering  has
 been  of fervice; but iffues have not  fo  much effea, and
 fhould by no means fuperfede the repeated bliftering that
 may  be indicated.  When  blifters are  proper, they  are
 more effeaual  when applied to the thorax, than when  ap-
 plied to any  diftant parts.
   1420.] Of all other remedies, emetics are the moft ufe-
 ful in this difeafe;  both in general by interrupting the re-
 * Bleeding, in thefe cafes, is beft performed by leeches; and they feem to give greater relief whea
applied about the neck than on any other part.
 t In general, the belly may be kept open by a proper attention to diet: roafted apples, eaten with
hrown fugar, ftewed prunes, and other funilar food, which children generally devour with avidity,
fufficiently anfiver the purpose of removing or preventing coftivenefs. 
O F  P H Y S I C.                  147
turn of  fpafmodic affeaions", and in particular by deter-
mining 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 employ-
ed;  and, in  the intervals neceffary to be  left between the
times of full  vomiting, naufeating dofes of the antimonial
emetics  may be ufeful.*   I have  never found the  sulphur
auratum, fo much praifed by  Cloffius, to be a convenient
medicine, on account of the uncertainty of its dofe;  and the
tarter emetic employed in the manner direaed by the late
Dr. Fothergill, has appearad*to be more ufeful.
   1421.] 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 aa, and that the dif-
eafe continues merely by  the  power of habit, a different
indication arifes, and different remedies are to be employed.
   1422.] This difeafe, which often continues for a long
time, does not, in my opinion, continue  during the whole
of that time in confequence of the contagion's remaining in
the body, and continuing to aa in  it.   That the difeafe does
often continue long after the contagion has ceafed to aa, and
that too by  the power of habit alone, appears to me proba-
ble 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  tonic
medicines ;  whilft none of all thefe means of cure can be
 fuppofed either to correa or  to  expel  a  morbific matter,
 though  they are evidently fuited  to change the ftate and ha-
 bits of  the  nervous  fyftem.
    1423.] From this view we are direaed to the indication
 that may be formed, and in a  great meafure to the remedic
 which may  be employed  in what we fuppofe to be the fe
 cond ftage of the difeafe.   It  may perhaps be alledged, thai
 this indication of fhortening the  courfe of the difeale  is not
  » The method of giving tartar-emetic in naufeating dofes has been frequently mentioned in pre-
 ceding notes ; but in cafes of chincough, where children are generally our patients, we arc under the
 neceffity of varying the dofes to tho age and conititution. When the child u under s year old, wc
 oueht to ufe the weak folution of tartar-emetic,  fpecified in the end of the lalt note on article iHs,
 in repeated dofes cf a table-fpoonful every ten or fifteen minutes, till it operates. Large dofes, efpe-   /
 ciallv to voune children, are frequently attended with dangerous confequences, of which the [ouo\v-
 ine cafe is fufficient proof.----To a child not 10 months old, that labored under the chincough, haif
 a jrrain of tartar-emetic was given in a little cinnamon water. A violent vomiting was produced, and
 the child died fuddenly, during the action of the medicine: on infpecling the body after death, we
 found the ftomach burft, there being In it a laceration th»t admitted two fingers. The nupection0.
 this body has always made me extremely cautious in adminiftering emetics to y«wng children. 
14&
PRACTICE
'very important or neceffary, as it fuppofes that the danger
 or violence is over,  and, in confequence,  that the difeafe
 w;ll foon fpontaneoufly ceafe.  The laft fuppofition, how-
 ever, is not well founded; as the difeafe, like many other
 convulfive  and fpafmodic affeaions,  may continue for a
 long time by the power of habit alone, and by the  rcpetU
 tion of paroxyfms may have hurtful effeas; more efpe-
 cially as  the  violence of paroxyfms,  and therefore their
 hurtful effeas, may be much aggravated by various exter-
 nal caufes that may be accidentally applied.   Our indica-
 tion, therefore, is proper; and we proceed to confider the
 feveral remedies which may  be employed to anfwer it.
   1424.] 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 ineffectual, and
 a high degree of it dangerous, I cannot propofe to employ it.
   1425.J The other remedies which we fuppofe fuited to
 our fecond indication, and which indeed have been frequent-
 ly employed in this difeafe,  are antifpafmodics or tonics.
   Of the antifpafmodics, caftor  has been  particularly re*
 commended by Dr. Morris;  but in many trials we have
 not  found it effeaual.
   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 deter-
 mine ; but wc have not found it commonly fuccefsful.  Of
 antifpafmodics, the moft certainly powerful is opium : and
 when there is no confiderable fever or difficulty of breath-
 ing 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 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 antifpafmodic.
 Upon this fuppofition, it is a probable remedy ; and from
 the accounts of Dr. Butter and fome others,  it  feems to have
 been often  ufeful: but,  in  our trials,  it has often difap-
 pointed us,  perhaps from the  preparation of it not  having
 been always proper.*
   1426.] Of the tonics, I confider the cupmofs, formerly
  # Experience has not found that any of the antifpafmodics have ever been emploved 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.               14*
Celebrated, as of this kind;  as alfo the bark cf the mifle-
toe ; but I have had no experience of either, as I have al-
ways 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 pre-
fent, and a fufficient quantity ofthe bark has been given, it
has feldom failed of foon putting an end to the difeafe.
   1427.J When convulfive diforders may be fuppofed td
continue by the force of habit alone, it has been found that
a confiderable change in the whole of the circumftances
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 feveral inftances I have obferved it  to be fo;
but I have never found the  effeas of it durable, or fuffi-
cient to put an entire ftop to the difeafe.

                      Sect* III.
   Of the Spasmodic Affections in the Natural functions^
                    CHAP. VIII.

 ©f t&e IPproate, or to&at its names in 9cotlasiD«
                 t&e &Oatet:*T5ra!SifK

 1428.] JL HE painful fenfations  referred to the ftomach«
and which arc probably occafioned by real affeaions of this
 organ, are of different kinds. Probably they proceed from
affeaions of  different natures, and fhould therefore be dif-
 tinguifhed by different appellations > but I muft own that
the utmoft precifion in this matter will be difficult.  In my
effay towards a methodical Nofology, I have, however, at-
 tempted it.  For thofe pains that are either acute and pun-
 gent, or accompanied with a fenfe 0$ diftention, or with a
 fenfe of conftriaion, if they are at the fame  time, not at-
 tended with any fenfe of acrimony or heat, I employ the
 appellation of Gaftrodynia,  Toexprefs thofe painful or
 uneafy fenfations which feem to arife from a fenfe of acri-
 mony  irritating the part, or from fuch a fenfe of heat as the
application of acrids, whether externally  or internally ap-
plied, often gives, I employ the term of Cardial^ja; and by
   Vei.. Ik                T 
150
PRACTICE
this I particularly mean to denote thofe feelings which are
expreffed by the term Heartburn in the Englifh language.
I think the term Soda has been commonly  employed by
praaical writers to exprefs an affeaion attended with feel-
ings of the latter kind.
   1429.] Befide  the pains denoted by the terms Caftro-
dynia, 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 Spu-
tatoria.  Under the title of Pyrofis Mr. Sauvages has form-
ed 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 Cardi-
algia ; and if there is a genus to be formed under the title
of Pyrofis, it can in  my opinion  comprehend only the fpe-
cies I 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.
   1430.] The  Gaftrodynia and Cardialgia I judge to be
for the moft part fymptomatic  affeaions; and therefore
have  given them  no place in this work : but the  Pyrofis,
as an idiopathic difeafe, and never before treated of in any
fyftem, I propofe to treat of here.
   1431.} It is a difeafe frequent among people  in lower
life, but occurs alfo, though more rarely, in people of bet-
ter 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 theage ofpuberty.  When
it has once taken  place, it is ready to recur occafionally
for.a longtime after ; but  it feldom appears in perfons con-
fiderably advanced in life* It affeas both fexes, but more
frequently the female. It fometimes attacks pregnant wo-
men, and fome women only when they arc in that condi-
tion.  Of other women, it more frequently affeas the
unmarried ; and of the married, moft frequently the bar-
ren,  I have  had many inftances of its occurring in wo-
men labouring  under a fluor albus.
   1432«J The  fits of this difeafe ufually come on in the
morning and afternoon, when the ftomach is empty „  The 
OF  PHYSIC.               151
firft fymptom of it is a pain at the pit of the ftomach, with
a fenfe of conftriaion, as if the ftomach was drawn towards
the back; the pain is increafed by raifing the body into an
erea pofture, and therefore the body is bended forward.
This pain is often very fevere ;  and, after continuing for
fome time, it brings on an eruaation of a thin watery fluid
in confiderable quantity.   This fluid has fometimes an a-
crid tafte, but is very often abfolutely infipid.   The eruc-
tation 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.
   1433.] The fits of this difeafe commonly come on with-
out any  evident exciting caufe;  and I have not found it
fteadily conneaed with any particular diet.  It attacks per-
fons ufing animal food, but I think more frequently thofe
living on milk and farinacea.   It feems often to be excited.
by cold applied to  the lower extremities;  and is readily
excited by any confiderable emotion of mind.   It is often
without any fymptoms of dyfpepfia.
   1434. J  The nature of this affeaion 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 manner, communicated to
the blood-veffels and exhalants, fo as to increafe the impetus
of the fluids in thefe veffels, while a conftriaion takes place
on their extremities.  While therefore the increafed impe-
tus determines a greater quantity than ufual of fluids into
thefe veffels, the conftriaion upon their extremities allows
only the pure watery parts  to be poured out, analogous, as
I judge, in every refpea,  to what happens in  the diabetes
hyftericus.
   1435.J The praaice in this difeafe is as difficult as the
theory.   The paroxyfm is only to be certainly relieved by
opium.   Other antifpafmodics, as vitriolic ether and vola-
tile alkali, are fometimes of fervice, but not conftantly fo.
Although opium and other antifpafmodics relieve the fits,
they have no effea  in preventing 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 as a remedy by Linnaeus, I have had
no experience. 
                   PRACTICE   *

                    CHAP.  IX.

                   Of tbe Colic.

*43^«] A HE principal fymptom of this difeafe, is a pain
felt in the lower helly.   It is feldom fixed and pungent in
one part, but is a painful diftention in fome meafure fpread-
ing over  the whole of the belly; and particularly  with a
fenfe of twitting or wringing round the navel.  At the fame
time, with this pain, the navel and teguments of the belly
are frequently  drawn inwards, and often the mufcles of the
belly are  fpafmodically contraaed, and this in feparate por-
tions, giving the appearance of a bag full of round balls.
   1437.] Such pains, in a certain degree, fometimes occur
in cafes of diarrhoea and cholera; but thefe are lefs  violent
and more tranfitory, and are named Gripings.  It is only
when more violent and permanent, and attended with cof-
tivenefs,  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 du-
odenum, and therefore frequently a quantity of bile.
   1438.] In fome cafes of colic, the periftaltip motion is
inverted  through the whole length of the alimentary canal,
in fuch a manner that the contents of the great guts, and
therefore ftercoraceous matter,  is thrown up by vomiting;
and the fame inverfion appears ftill more clearly from this,
that what is thrown into the reaum 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
ha6 been fuppofed to be a peculiar difeafe diftina from co-
lic; but to me it appears that the two difeafes are owing to
$he fame proximate caufe, and have the fame fymptoms,
pqly in a different degree.
   1439.] The colic is often without any pyrexia attending
it.  Sometimes, however, an inflammation comes upon the
part of the inteftine efpecially affeaed; and this inflamma-
 tion aggravates ail the fymptoms of the difeafe, being pro-
 bably what brings on the moft confiderable inverfion of the
 periftaltic  motion; and, as the ftercoraceous vomiting is
 what efpecially diftingujfhes the ileus, this has been confw
15* 
                  OF  PHYSIC                153

dered as always depending on an inflammation of the h>
teftines.   However, I can affirm, that as there are inflam-
mations of the inteftines without ftercoraceous vomiting,
fo I have feen inftances of ftercoraceous vomiting without
inflammation; and there is therefore no ground for diftin-
guifh ing ileus from colic,  but as a higher degree of the
fame affeaion.
   1440.J The fymptoms of the colic, and the diffeaions
of bodies dead of this difeafe, fhow very clearly that it de-
pends upon a fpafmodic conftriaion of a part of  the intef-
tines; and that this therefore is to be confidered as the proxi-
mate caufe ofthe difeafe.  In fome of the diffeaions of
perfons dead of this difeafe, an  intus-fufception  has been
remarked to have happened ; but whether this be conftant-
ly the cafe on all the appearances of ileus, is not certainly
determined.
   1441. J The colic has commonly been confidered as be-
ing of different fpecies, but I cannot follow the writers on
 this fubjea in the diftinaions they  have eftablifhed.   So
 far, however, as a difference of the remote caufe confti-
 tutes a difference of fpecies, a diftinaion may perhaps be
 admitted ; and accordingly in my Nofology I have mark-
 ed feven different fpecies : But I am well  perfuaded, that
 in all thefe different fpecies the proximate caufe is the fa:: ie,
 that is, a fpafmodic conftriaion  of a part of the inteftin"0;
 and confequently, that in all thefe cafes the indication  f
 cure is the fame, that is,  to remove the conftriaion me  -
 tioned.   Even in the feveral fpecies named Stercorea, Ccl-
 losa, and Calculosa, in which the difeafe depends upon h 1
 obftruaion of the interline, I am perfuaded that thefe ob-
 ftruaions do not produce the fymptoms of colic, except-
 ing in fo far as they produce fpafmodic conftriaions ofthe
 inteftines; and therefore, that the means of cure in thefe
 cafes, fo far as they admit of cure, muft be obtained by the
 fame means which the general indication above-mentioned
 fuggefts.
    1442.] The cure, then, of the colic univerfally,  is to be
 obtained by removing the fpafmodic  conftriaions ofthe
 inteftines; and the remedies fuited to this ptrpofe may be
 referred to three general heads:
    1. The taking off the fpafm 1^ various anfifpafmodi^
 powers.                      4P 
 ¥5-*                PRACTICE
                              ■             *
   2. The exciting the aaion ofthe inteftines by purgatives.
   3. The employing mechanical dilatation.
   a 443.J Before entering upon a particular account of
 thefe remedies, it will be proper to obferve, that in all cafes
 of violent colic, it is advifable to praaife blood-letting; both
 as it may be ufeful in obviating the inflammation which  is
 commonly to be apprehended, and even as it may be a means
 of relaxing  the fpafm of the inteftine.   This remedy may
 perhaps be  improper in perfons of a weak and  lax habit,
$mt in all perfons of tolerable vigour it will be a fafe reme-
 dy-; and in all cafes where there is the leaft fufpicion of an
 inflammation aaually coming on, it will be abfolutely ne-
 ceffary.   Nay, it will be even proper to repeat it perha.ps
 feveral times, if, with a full and hard pulfe, the appearance
 of the blood drawn, and the  relief obtained by the firft
 bleeding,  fliall authorife fuch repetition.
   1444. J The antifpafmodic powers that may be employed,
 are, the application of heat in a dry or humid form, the ap-
 plicationof blifters, the ufeof opium, and theufeof mild oils.
   The application of heat, in a dry form, has been employ-
 ed 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; but none of them feem to me
fo powerful  as the application of heat in a  humid form.
   This may be  employed either by the  immerfion of a
great part of the body in warm water,  or by fomenting the
belly with cloths wrung out of hot water.   The immerfion
has advantages from the application of it to a greater part
of the bodyj and particularly to the lower extremities: But
immerfion cannot always be conveniently praaifed, and fo-
mentation may have the advantage of being longer continu-
ed;  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.
   1445.]  From confidering that the teguments  of the
lower belly  have fuch a conneaion with the inteftines, as
at  the fame time to be affeaed with fpafmodic contra6tion,
we perceive  that blifters applied to the belly may have the
effect of taking  off the fpafms both from the mufcles of
the belly  and from  theJnteftines; and accordingly, blif-
tering has often been enjoyed in the colic with advantage. 
                  OF PHYSIC.                i'.f
        *             =?==                   m
Analogous to this, rcbefacients applied  to the belly have
been frequently found ufeful.
   1446.] The ufe of opium in  the colic  may feem to be
an ambiguous remedy.   Very certainly it may  for  fome
time relieve the pain, which is often fo violent and urgent,
that it is difficult to abftain from the ufe of fuch av remedy.
At the fame time, the ufe of opium retards or fufpends the
periftaltic motion fo much, as to allow the inteftines to fall
into conftriaions;  and may therefore, while it relieves the
pain, render the caufe of the difeafe  more ohftinatc.   O^
this account, and further as opium prevents the opefatiow*
of purgatives fo often neceffary  in this difeafe, many prac-
titioners arc averfe to the ufe of it, and fome entirely reject
the ufe of it as hurtful.   There  are, however, others who
think they can employ opium in this difeafe with much ad-
vantage.
   In  all cafes where the colic comes on without any pre-
vious coftivenefs, and arifes from cold, from paffions ofthe
mind, or other caufes which operate efpecially on the ner-
vous fyftem, opium proves a fafe and certain remedy;, but
in cafes which have been preceded by long coftivenefs, or
where the colic,  though not preceded by coftivenefs, has
however continued for fornc days without a ftool, fo that
a ftagnation of faeces in the colon is to be fufpeaed„4he ufe
of opium is  of  doubtful effea.  In fuch cafes,  unlefs a*
ftool has been firft procured by medicine, opium cannot
be employed  but with fome hazard of aggravating the dif-
eafe.   However, even  in  thofe circumftances of cofti^rev
nefs, when, without inflammation, the violence of the fpafm
is  to be fufpeaed,  when vomiting prevents .the exhibition
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  favor the opera-
tion of purgatives; and may be  fo employed, when, either
at the fame time with the opiate, or not long after it, a pur-
gative can be exhibited.
   Is the hyofcyamus, as often fhowing,  along with its nar-
coticj a purgative quality, better fuited to  this difeafe than
opium ?
   1447.] It  is feemingly  on good  grounds that  fevcral
praaitioners have recommended the large ufe of mild oils
in this difeafe, both as antifpafmocScs and as laxatives; and, 
L54                 PRACTICE
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.
   144 8. J The fecond fet of remedies adapted to the cure
of colic, are  purgatives; which,  by  exciting the aaion of
the inteftines, either above or below the obftruaed place,
may remove the  conftriaion; and therefore  thefe  purga^
rives may be  given either by the mouth, or thrown by glyf-
ters into the  anus.  As the difeafe  is often feated in the
greatiguts; as glyfters, by having a more fudden operation,
may give more immediate relief; and as purgatives given
by  the mouth are ready to be rejeaed  by vomiting;  fo it
is common, and indeed 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
quantity of mild oil;  and fuch  are fometimes fufficiently
efficacious: However, they are not always  fb; and it is
commomy neceffary to render them more  powerfully fti-
mulant  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 this or otherwife are found ineffectual, it
may be proper, inftead of thefe falts, to add to the  glyfters
an  infufion of fenna, or of fome other purgative that can
be  extraaed by  water.   The antimonial wine* may be
fometimes employed in glyfters with advantage.   Hardly
auy glyfters are more effeaual than thofe made of  turpen-
tine propcrlyt prepared.   When all other injeaions are
found ineffetlual, recourfe is to be had to the injeaion of
tobacco fmoke; and, when even this fails, recourfe is to be
had to the mechanical dilatation  to be mentioned hereafter*
   1449. J ^s gtyfters often fail altogether in relieving this
difeafe, and  as even when they give fome  relief they are
often imperfea in producing a complete cure; fo it is ge-
 * Tartar emetic is furer than the antimonial wine; but it is a very violent remedy, and ought tw
be ufed with caution even in glyfters.  Five or fix grains is the ufual quantity given in glyfters.
 t The proper manner of preparing turpentine glyfters is as follows:
          ft. Tereb. \enet. 3V1-
             Vitel. Ov.  No. ii.
 Terein mortario mannoreo donee penitus folvetur Terebinthina; dein adde gradatim,
             Aq. font.  frigida, §ii.
 Huic affunde
             Aq. font, tepid, lb i.
             M. f. EneriU, statim injiciend.
  if the turpentine does not diflblve fufficiently with the yolks ef two eggs, a third may be added. 
OF  PHYSla
1ST
neraliy proper, and often neceffary, to attempt a more en-
tire and certain cure by purgatives  given by the  mouth.
The more powerful of thefe, or, as they are called, the
Draftic  Purgatives,  may be fometimes  neceffary;   but
their ufe is to be avoided,  both becaufe  they are apt to be
rejeaed by vomiting, and becaufe when they do not fuc-
ceed in removing the obftruaion they  are  ready to induce
an  inflammation.   Upon this account  it is ufual, and in-
deed proper, at leaft in the firft place, to employ the milder
and lefs inflammatory purgatives.   None have  fucceeded,.
with me better than the chryftals  of tartar,*  becaufe  this
medicine may  be  given  in fmall but  repeated dofes to a
confiderable  quantity;  and under this management it is the
purgative  leaft ready to be rejeaed by vomiting, and much
lefs fo than the  other neutral  falts. If a ftronger purgative
be  required,  jalap,f  properly prepared,  is lefs  offenfive
to  the palate, and fits better upon the  ftomach, than moft
other powerful purgatives.   On many occafions of colic,
nothing is  more effeaually purgative  than a large dofe of
calomel.J   Some praaitioners have attempted to remove
the obftruaion  of the inteftines by antimonial emetics [|
exhibited in fmall dofes, repeated at proper intervals; and
when thefe dofes are not entirely rejeaed by vomiting, they
often prove effeaual purgatives.
   When every  purgative  has failed, the aaion of the in-
teftines has been effeaually excited  by throwing cold wa-
ter on the lower extremities.
    1450. J  The third means of overcoming the fpafm of trie
inteftines in this difeafe, is by employing a mechanical di-
latation; and is  has been frequently fuppofed that quick-
filver, given in large quantity, might operate in this man-
  * Cryftals of tartar may be given in dofes of two drachms each, repeated every two hours or of-
tener. The chief objection againft the ufe of this fait is its difficult folution in water, and therefore
many practitioners prefer theloluble tartar, er the Rochel fait.
  + The Purvis Jalap, comp. of the Edinburgh Pharmacopoeia anfwers in general very well; but the
following formula is lefs liable to be rejected by the vominhg Which fo frequently accompanies thii
difeafe.
           R. Resin. Jalap, gr.  xii.
              Amygdal. dulc. decorticat. No. vi.
              Sacch. alb.  51*
  Tere In mortario marmoreo, et adde gradatim,
              Aq. Cinnamom. simpl. %\.
              M. f. hauft.
  Half of this portion may be given at once, and theother half an hour afterward.
  X This is French practice, but it is dangerous.  It has however been ferviceable in many cafes^
when given in dofes of 1 * or 15 grains, or even a fcruple when other purgatives have failed.
  || As the ftomach, as was before obferved, is very irritable in this difeafe, the practitioner will find
conilderable difficulty in managing antimonials.  It is better to avoid them altogether, for they may
do much mifehief.
  Vol. 11.                      U 
158                 PRACTICE
ner.  I have not, however, found it fuccefsful;  and the
theory of it is with me very doubtful.   Some authors have
mentioned  the ufe of gold and filver pills,  or balls, fwal-
lowed down; but I have no experience of fuch praftices,
and I cannot fuppofe them a probable means of relief.
   1451.]  Another means of mechanical dilatation and a
more probable meafure, is by injeaing a large quantity  of    4
warm water by a proper fyringe, which may throw it with
fome force, and  in a continued ftream, into the reaum.
Both from  the experiments reported by the late Mr. De
Haen, and from thofe I my felf have had occafion to make,
I judge this remedy to be  one of  the moft  powerful and   "1
effeaual.*
   1452.]  I have now mentioned all the feveral means that
may be employed for the cure ofthe colic,  confidered as
a genus;  but before I quit this fubjea, it may be expcaed
that I fhould take notice of fome of the fpecies which may
feem to require a particular confideration.   In  this view
it may be expeaed that  I fhould efpecially take  notice of
that fpecies named the  Colic of Poitou, and particularly
known in England by-the name of the Devonfhire Colic.
   1453. J  This fpecies of the difeafe is certainly a peculiar     1
one,  both in refpea to its caufe and its effeas;  but, as to     >
the firft, it has been lately  fo much the fubje£t of investi-
gation, and is fo well afcertained by the learned phyficians-   J
Sir George Baker and  Dr. Hardy, that  it  is unneceffary
for me to fay any thing of it here.
   With refpea to the cure of it,t  fo far as  it appears in
the form of a colic,  my want of experience concerning it
does not allow me to fpeak with any confidence on the fub-
jea; but,  fo far  as I can learn from  others, it appears to
me, that it is to  be treated by all the feveral means  that I
have propofed above for the cure of colic in general.
   How far the peculiar effeas of this difeafe are to be cer-
 # It is to be thrown up, by means of a large fyringe, in fuch quantities, that the patient begins to
feel a fenfe of uneafinefs from the great diftention which it occafions. Some patien ts have borne two
gallons to be injected, and the cafes were attended with the defired fuccefs. The cafes in which
thefe large injeaions are moft ufeful, are thofe in which hardened feces are accumulated in thc~
c 'on. The warm water anfwers two intentions, viz. dilating the paflage, and foftening the faeces.
  -1  n the early ftage of this difeafe, the belly is to be kept open by the mildeft laxatives, and a
milk diet ftriftfy ufed. The following formula anfwers extremely well :
           JBc- Mannx,
              01.  Clivar. aa  5*u
              21.  f. Linftus.
  ThU quantity is a proper dele, and it mar be repeated every day with thirty or forty drop* of
Undanumat pea-time. If the fymptom*, however, do not abate, we may at the fame time gbrc
large emollient glyfters. 
OF  PHYSk.                159
frainly fbrefeen and obviated, I have not properly learned;
and I muft leave the matter to be determined by thofe who
imve had fufficient experience in it.

                     CHAP.  X.

                  fl)f  tU C&olcra.

a454«]  IN this difeafe, a  vomiting and purging concur-
ring together, or frequently alternating with one another,
are the  chief fymptoms.  The  matter rejeaed both up-
wards and downwards appears manifeftly to confift chiefly
of bile.
   1455-j  From this laft circumftance I conclude, that the
difeafe depends upon an increafed  fecretion of bile, and
its  copious effufion into the alimentary canal: and, as in
this it irritates and excites the motions above mentioned, I
infer, that the bile thus effufed in larger quantity is at the
fame time alfo  of a more acrid quality.   This appears
likewife from the violent and \tery painful  gripings that at-
tend the difeafe, and which we can impute  only to the vio-
lent fpafmodic  contraaions of the inteftines that take place
here.   Thefe fpafms are commonly communicated to the
abdominal mufcles, and very frequently  to  thofe of the
extremities.
   145S.J  In the manner now defcribed,   the difeafe fre-
quently  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 recoveries feldom  happen without
the afliftance of remedies.
   1457.J  Tne attac^s of trus difeafe are feldom accompa-
nied with any fymptoms of pyrexia;  and  though,  during
the courfe  of it, both the pulle and refpiration are hurried
and irregular, yet thefe  fymptoms are generally fo entirely
removed by the remedies that quiet the fpafmodic affeaion
peculiar to the  difeafe, as to leave no ground for fuppofing
that it had  been accompanied by any proper pyrexia.
   1458.]  This is a difeafe attending a very warm ftate of 
100                PRACTICE

the air; and, in very  warm  climate?, it may perhaps ap-
pear at any time of the year:  But even in fuch climates it
is moft frequent during their warmeft  feafons; and in tern-
perate climates, it appears only in the  warm feafons.   Dr.
Sydenham confidered the appearances  of  this difeafe in
England to  be confined to the month of Au^uft; but he
himfelf obferved it to appear fometimes towards the end of
fummer, when  the feafon was unufually warm; and that,  .
in proportion to  the heat, the violence of the difeafe was
greater.  Others have obferved that it appeared more early
in fummer,  and always fooner or  later, according  as the
great heats fooner or later fet in.
   1459.} From all thefe circumftances, it is, I think, ve-
ry evident, that this difeafe is the effea of a warm atmof-
phere,  producing fome change in the ftate of the bile in
the human body:  And the change may confift,  either in
the matter ofthe bile being rendered more acrid, and there-
by fitted to excite a  more  copious fecretion ; or,  in the
fame matter, its being prepared to pafs off in larger quan-
tity than ufual.
   1460.} 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 bring on this
difeafe ; and it is very probable that  an obfiru&ed  perfpi-
ration may have alfo a fhare in this, though it is alfo cer-
tain  that  the difeafe does  appear when no  change in the
temperature  of the air, nor any application of  cold has
been obferved.
   1461.J It is poffible, that, in fome cafes, the heat ofthe
feafon  may give only a predifpofition, and  that the  difeafe
may be excited by certain ingefta or other caufes ; but it
is equally certain, that the difeafe has occurred without any
previous change or error,  either  in diet, or in the manner
of life,  that could be obferved.
   1462.j The Nofologifts  have conftituted a Genus un-
der the title of Cholera, and under this have arranged as a
fpecies every affeaion in which a vomiting and purging of
any  kind  happened to concur.  In many of thefe fpecies,
however, the matter  evacuated is not bilious;  nor does
the evacuation proceed from any caufe in the ftate  of the
atmofphere.  Further, in  many of thefe fpecies alfo, the
vomiting  which occurs is not an effential, but merely an 
OF  PHYSIC.                 1.4I
accidental fymptom from the particular violence of the
difeafe.   The appellation of Cholera therefore fliould, in
my opinion,  be confined to the difeafe I have  defcribed
above; which by its peculiar caufe, and perhaps alfo by
its fymptoms, is very different from all the otlier fpecies that
have been affociated with it.   I  believe  that all the other
fpecies arranged under the title of Cholera by Sauvages or
Sagar, may be properly enough referred to the  genus of
Diarrhcea; which we are  to  treat of in the next chapter.
   The diftinaion I have endeavoured to eftablifh between
the proper Cholera, and the other difeafes that have fome-
times got the fame appellation, will, as I judge,  fuperfede
the queftion,  Whether the Cholera, in temperate climates,
happens at any other feafon than that above affigned ?
   1i^3-] In the cafe of  a  genuine cholera, the cure of it
has been  long eftablifhed  by experience.
   In  the beginning of the difeafe,  the evacuation  of the
redundant bile is to  be favored by the plentiful exhibition
of mild diluents,* both given by the mouth,  and injeaed
by the anus;  and all evacuant medicines, employed in ei-
ther way, arc not only fuperfluous, but commonly hurtful.
   1464.] When the redundant bile appears to be  fuffici-
ently  wafhed out,  and even before that, if the fpafmodic
affeaions of the alimentary canal become very violent, and
are communicated in a confiderable degree to other parts
of the body,  or when a dangerous debility  feems to be in-
duced, 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 glyfter.t
   1465.J 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 irritability
of the inteftines, and  their difpofition to fall into painful
fpafmodic contraaions, feem to continue.  In  this fitua-
tion,  the repetition of the  opiates, for perhaps  feveral
  # Thin rice gruel is as proper a mild diluent as any we can ufe; as is alfo water in which a cruft cf
bread is boiled.  A very fmall quantity of port wine may be added to thefe diluents if the pulle tie
fmall or weak.
  t A pill confifting of a grain of opium may be given every two hours, and if it does not relieve ths
fymptoms after the third orfourth repetition, we may inject the following glyfter :
          ft.  Dococt. Hord. §x.
              Tinct.  Thebaic. 5'i-
              M. f. Enema.
  This glyfter may be repeated twice, or thrice if there fhould be occafion. 
H52                 PRACTICE
days, may come to be neceffary; and as the debility com-
monly induced by  the difeafe favours  the difpofition  to
fpafmodic affections,  it is  often ufeful and neceffary, to-
gether with the opiates,  to employ the tonic powers of the
Peruvian bark.*
                      CHAP.  XI.

            ffif Diarrhoea or Loosene&s,

 1466.]  JL HIS  difeafe confifts in evacuation by ftool,
 more frequent and of more liquid matter than ufual.  This
 leading and characteristic  fymptom is  fo diverfified in it%
 degree,  in its caufes, and in the variety of matter evacu-
ated, that it is almoft impoffible to give any general hiftory
 of the difeafe.
   1467.] It is to be diftinguifhed from dyfentery, by not
 being contagious; by being generally without fever;  and
 by being with the evacuation  of the  natural excrements,
 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
 diftinaion.t
   1468.] 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
di'werfified,  as we fhall fee prefently.  It has been common
to diftinguiffi cholera by the evacuation downwards being
 of bilious matter, and by  this  being always accompanied
 with a vomiting of the fame kind; but it does not univer-
 fally apply, as a diarrhoea  is fometimes attended  with vo-
miting, and even  of bilious matter.
   1469.] The difeafe of diarrhoea,  thus diftinguifhed, is
very greatly diverfified;  but in  all cafes, the frequency of
 * The bark in there cafes is often fuccefsfully given alone with rhubarb, m in the following formula
          ft. Pulv. Cort. Peruv. 3 ft,.
                  Rad. Rhei, 5'i.
             M. f. Pulv. in part, xqual. xii. dividend.
 Or.t of th;f- powders may be given three times a-day with a gUfs of port wine.
 t i';r.jf.Tiu« is a dirtinguiiWnf fymptom of dyfentery, but it is fometimes pretent in diarrhoea aU* J
e.*.;.i..-.:v tii j;c d'i.-rhctij which proc:ci from acrid or or putrid fubftances in the intcftine*. 
                      OF  P H Y S I€.                163

   ftools is to be imputed to a preternatural increafe  of the  „
   periftaltic. motion in the whole, or at leaft in a confidera-
   ble portion, of the inteflinal canal.  This increafed aaion
   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 referred it to the order
k  of Spafmi, and accordingly treat of it in  this place.
      1470.] Upon the fame ground, as I confider the difeafe
   named Lientery to be an increafed periftaltic  motion over
   the whole of the inteftinal canal, arifing from a peculiar ir-
   ritability,  I have confidered it as merely a fpecies of  diar-
   rhoea.   The idea of a laxity- of the inteftinal canal being
! /• the caufe  either of lientery,  or other fpecies of  diarrhoea,
 . 'Appears to me without foundation, except in  the  fingle
   cafe of frequent liquid  ftools from a palfy of the sphincter
   ani.
      1471.] The increafed aaion of the periftaltic motion, I
   confider as always the chief part ofthe proximate caufe of
   diarrhoea: but the difeafe is further,  and indeed  chiefly,
   diverfified by the different caufes of this  increafed aaion;
   which we are  now to inquire into.
      1472.] The feveral caufes of the increafed aaion ef the
   inteftines  may be referred,  I think, in  the firft place, to
   two general heads.
      The first is,  of the difeafes of certain parts of the body .
   which, either from a confent of  the inteftines  with  thefe
   parts, or from the relation which the inteftines have to the:
   whole fyftem, occafion an  increafed aaion  in the intef-
   tines, without the transference of any ftimulant matter from
   the primary difeafed part to them.
      The second head of the caufes of the increafed aaion of
   the inteltines is the ftimuli of various kinds, which are ap-
   plied direaiy to the inteftines thtmfelves.
      14:73-1 Thefe affeaions of other parts of the fyftem may
   affea  the  inteftines without  the transference or application.
 .  of any ftimulant matter, we learn from hence that the paf-
   fions ofthe mind do in fome perfons excite diarrhoea.
      1474.]  That difeafes in other parts may in like manner
   affea  the inteftines, appears from the dentition  of  infants
   frequently exciting diarrhoea.  I believe that the gout of-
   ten affords another inftance of the fame kind; and  proba-
   bly there are others alfo, though not well afcertained. 
16 i                PRACTICE
   1475.] The ftimuli (1472.) which may  be applied to
the inteftines are of very various kinds; and are either,
   1.  Matters introduced by the mouth.
   2.  Matters poured into the inteftines by the feveral ex-
cretories opening into them.
   3.  Matters poured from certain preter-natural openings
made into them  in certain difeafes.
   1476-.J Of thofe (1475,  1.) introduced by  the mouth,
the firft to be mentioned are the aliments commonly taken
in.   Too great a quantity of thefe taken in, often prevents
their due digeftion in the ftomach; and by being thus fent
in their crude, and probably acrid, ftate to the inteftines,
they frequently excite diarrhoea.
  .The fame aliments, though in proper quantity, yet hav-
ing too great a proportion, as frequently happens,  of fa-
line or faccharine matter along with them, prove ftimulant
to the inteftines,  and excite diarrhoea.
   But our aliments prove efpecially the caufes of diarrhoea,
according as they, from their own  nature, or  from the
weaknefs of the  ftomach, are difpofed to undergo an undue
degree of fermentation there, and thereby become ftimu-
lant to the inteftines.  Thus acefcent aliments are ready  to
produce diarrhoea; but whether from their having any di-
reaiy purgative  quality, or only  as mixed in am over pro-
portion with the bile, is not well determined.
   1477.J Not only the  acefcent, but alfo the putrefcent
difpofition of the aliments, feems to occafion a\diarrhcea;
and it appears that even the effluvia of putrid bodies, taken
in any way in large quantity, "have the fame effect.
   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?*
   1478.J The  other  matters  introduced by  the mouth,
which may be caufes of diarrhoea, are thofe thrown in ci-
ther as medicines, or poifons that have  the  faculty of fti-
mulating the alimentary canal.   Thus, in the lift of the
Materia Medica, we have a long catalogue of  thofe nam-
ed purgatives; and in the lift of  poifons, wc  have many
poffeffed of the fame quality*  The former,  given in a cer-
quantity, occafion  a temporary  diarrhoea; and given  in
very large dofes,  may occafion it in excefs, and  continue
 # Rancid oils and fats certainly irritate the inteftines, and may therefore produce diarrhoea. 
0 F  P H Y S I c.                les
it longer than ufual, producing that fpecies of diarrhoea
named a Hypercatharfis.
   1479-J  Tne  matters (1475, 2.) poured into the cavity
of the inteftines from the  excretories opening  into them,
and which may  occafion diarrhoea, are either thofe from
the pancreatic or biliary dua,  or thofe from the excreto-
ries in the coats of the inteftines themfelves.
   1480.] What changes may happen in the pancreatic juice
I do  not exaaiy know; but I  fuppofe  that an acrid fluid
may iffue from the pancreas, even while ftill entire in its
ftruaure;  but more efpecially when it is in a fupporated,
fcirrhous, or cancerous  ftate, that a very acrid matter may
be poured out by the pancreatic  du6t, and occafion diar-
rhoea.
   1481.]  Wre know well,  that from  the biliary  dua the
bile may be poured out in  greater quantity than ufual; and
there is little doubt of its being alfo fometimes poured out
of a more than ordinary acrid 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 com-
monly diftinguifhed from cholera I muft admit here, that
as the caufes produciiig that ftate ofthe bile which occafi-
ons cholera, may occur in  all the different poffible degrees
of force, fo as,  on one occafion,  to produce the moft vio-
lent and  diftin£tfy marked cholera;  but, upon another,  to
produce  only the gentleft diarrhoea: which, however, will
be the farfc&difeafe,  only varying in degree: So I think it
probable^.;.that in warm climates,  and in warm feafons, a
diairhazaj^iliosa 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 aaed upon
by the heat of the  climate or feafon, may be redundant
and acrid,  and prove therefore  a particular caufe of diar-
rhoea.
  1482J Befide bile from  the feveral  caufes and in the
conditions mentioned, the biliary  dua may pour out pus,
or other matter from abfeeffes in  the liver, which may be
the caufe of diarrhoea.
  Praaical writers  take notice of a diarrhoea  wherein a
thin antl bloody  liquid  is difcharged;  which they fuppofe
  ViL. II.                 X 
   >r}6                PRACTICE

   to have proceeded, from the liver, and have therefore gii-
   ven the difeafe the name of Hepatirrhoea :  but we have^iot
   met with any inftance of this kind;  and therefore cannot
   properly fay any thing concerning it.
     1483.]  A fecond fet of excretories, from which matter
   is poured into  the cavity of the inteftines,  are thoTe from
   the coats of the inteftines themfelves;  and are  either the
   exhalants proceeding direaiy from the extremities of arte-
   teries, or  the excretories from  the mucous follicles: and
/  both  thefe fources  occur in prodigious number over the
   internal furface of the whole inteftinal canal.   It is proba-
   ble that it is chiefly the effufion from thefe fources which,
   in moft inftances,  gives the matter of the liquid ftools oc-
   curring in diarrhoea.
     1484.]  The matter from  both fources  may  be poured
   out in larger quantity than  ufual, merely by the increafed
   aaion of the inteftines,  whether that be excited by the paf-
   fions of the mind (1473.) by difeafes in other parts  of the
   fyftem (1472,  1.)  or by the various  ftimulants  mentioned
   (1476.) and following;  or the quantity of matter poured
   out may be increafed, notfo much by the increafed aaion
   of the inteftines, as by an  increafea1  afflux of fluids from
   other parts of  the fyftem.
     Thus, cold  applied to the furface of the body, and fur>
   preffing perfpiration,. may determine a greater quantity of
   fluids to the inteftines.
     Thus, in the ischuria renalis, 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 been  ftagnant, and be again
   poured  out into the inteftines, as frequently happens,  in
   particular with refpea to the water of dropfies.
     1485.J  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 matters  from the mafs of blood into the
   cavity of the inteftines.  Thus it is fuppofed that the mor-
   bific matter of fevers is fometimes thrown o it into  the ca-
   vity  of  the inteftines, and gives a critical diarrhoea: and
   whether I do or do  not admit the doarine of critical eva~
   cuations,  I think it  is probable that  the morbific matter of 
                   O F  P H Y S I C.                167

the exanthemata is  frequently thrown upon the inteftines,
and occafions diarrhoea.
   i486.] It is to me further probable, that the putrefcent
matter diffufed over the mafs of blood in putrid difeafes, is
frequently poured out by the exhalants into the inteftines,
and pr6ves there the caufe, at leaft in part, of the  diar-
rhoea fo commonly attending thefe difeafes.
   1487. J Upon this fubjea of the matters poured into the
cavity of the inteftines, I have chiefly confidered them as
poured out  in unufual quantity, but it is probable that, for
the moft part, they are alfo changed in their quality, and
become of a more acrid and ftimulant nature; upon which
account efpecially it is that they excite, or at leaft increafe
a diarrhoea.
   1488.] How far, and  in what manner, the exhalant fluid
may  be changed in its  nature and quality,  we  do not cer-
tainly know: but with refpea to the fluid from the mu-
cous  excretories, we know, that, when poured out in un-
ufual  quantity, it is commonly, at the fame  time, in a
more liquid and acrid form;  and may prove, therefore,
confiderably irritating.
   1489.] Though the copious effufion of a more liquid
and acrid matter from the mucous excretories, be probably
owing to the matter being poured out immediately  as it is
Jecreted from the blood into the mucous follicles, without
being allowed to  ftagnate in the latter, fo as to acquire that
milder quality and thicker confiftence we commonly find
in the mucus in its natural ftate;  and although we  might
fuppofe the  excretions of a thin and acrid  fluid  fhould al-
ways  be the effea of every determination to the mucous
follicles, and of every ftimulant applied to them ; yet it is
certain, that  the reverfe is fometimes  the  cafe; and that,
from  the mucous follicles,  there is frequently an increafed
excretion of a mucus, which appears in its proper form of
a mild, vifcid, and thickifh matter. This commonly occurs
in the cafe of dyfentery ;  and it has been obferved to give
a fpecies of diarrhoea, which has been properly  named the
Diarrhoea Mucosa.
   1490.] A third fource of matter poured into the  cavity
of theinteftines, and occafioning diarrhoea (1475.3 )is from
thofe  preternatural  openings produced by difeafes in the
inteftines or  neighboring parts.  Thus the blood-veffels on 
158
PRACTICE
the internal furface of the inteftines may be opened by ero-
fion, rupture, or  anaftomofis,  and pour into the  cavity
their blood, which, either by its quantity, or by its acrimo-
ny, whether 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 been called
the Melcena or Morbus Niger.
   1491.] Another preternatural fource of matter poured
into the cavity ofthe inteftines, is the rupture of abfeeffes
feated either in the coats ofthe inteftines  themfelves, or in
any ofthe contiguous vifcera, which, during an inflamed
ftate, had formed an adhefion with fome  part of the intef-
tines.  The matter thus poured into their cavity may be
various;  purulent, or famous,  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.
   1492.] Amonglt the ftimuli that may be direaiy applied
to the inteftines, and which, by increafing their periftaltic
motion, may occafion diarrhoea, I muft not omit to men-
tion worms, as having frequently that effect.
   1493.] I muft alfo mention here a ftate ofthe inteftines,
wherein their periftaltic  motion is preternaturally increaf-
ed, and a diarrhoea produced; and that  is, when they arc
affeaed with an erythematic inflammation.   With refpea _
to the  exiftence of fuch a  ftate, and its  occafioning diar->3
rhoea, fee what is faid above in (398.) and  following.  WheAa
ther it  is to be confidered as a  particular and diftina  cafe^
of diarrhoea, or is always the fame with fome of thofe  pro-
duced by one or other of the caufes above-mentioned,  I
have not been  able to determine.
   1494.] Laftly, by an accumulation of alimentary or  ojF
other matter poured into  the cavity of the inteftines from
feveral of the fourcts above-mentioned, a diarrhoea  may
be efpecially occafioned when the abforption of the Meals,
or of other abforbents,  is prevented, either by an obftruc-
tionof their orifices, or be an obftruaion of the mefenteric
glands,  through which  alone the abforbed fluids can be
tranfmitted.
   In one inftance of this kind, when the  chyle prepared in
the ftomach and duodenum is -not abforbed in  the courfe
of the inteftines, but paffes  off in confiderable quantity by
the anus, the difeafe has been named Morbus Cceliacus, or 
OF  PHYSIC.
16f
  fimply and more properly Cceliaca; which accordingly I
  have confidered as a fpecies of diarrhoea.
     1495.J I have thus endeavored to, point out the various
  fpecies of difeafe that may come under the general appel-
  lation of Diarrhoea; and from that enumeration it will ap-
  pear, that many,  and indeed the greater part of the cafes
  of diarrhoea, are to be confidered as fympathetic affeaions,
  and to be cured only by curing the primary  difeafe upon
  which they depend; of which, however, I cannot proper-   *
  ly treat here.   From  our enumeration it will alfo appear,
  that many of the cafes of diarrhoea which may be confider-
  ed as idiopathic, will not require my faying much of them
  here.  In many inftances, the difeafe is afcertained,  and
  alfo the caufe affigned, by the condition of the matter eva-
  cuated ;  fo that what is  ncceffary to correa  or remove it
  will be fufficiently obvious to  petitioners of any know-
  ledge.   In  fhort, I do not find that I can offer any .general
  plan for the cure of diarrhoea; and all that I can pretend
  to do on  this fubjea, is to give fome general remarks on
  the praaice that has been commonly followed in the cure
  of this difeafe.
     1496. J The praaice in this difeafe has chiefly proceed-
  ed upon  the fuppofition of an acrimony in the fluids, or
m of a laxity in the fimple and moving fibres of the inteftines;
v and the remedies employed have accordingly been,  Cor-
^ reaors of particular acrimony, general demulcents, evacu-
d» ants by vomiting or purging, aftringents, or opiates.  Upon
 ** each of thefe kinds of remedies I fhall now offer fome re-
  marks.
     1497.] ^n ac'd acrimony  is, upon feveral occafions,
  the caufe of diarrhoea, particularly in children; and in fuch
  cafes the abforbent earths have been very properly  em-
   ployed.   The common, however, and promifcuons ufe of
   thefe, hath been very injudicious; and where there is any
  putrefcency, they muft be hurtful.
     1498.] The cafes in  which there is a putrid or putref-
  cent acrimony  prevailing, have been, I think, too feldom
  taken notice of; and, therefore, the ufe of acids too  fel-
  dom admitted.  The acrimony to be fufpeaed in bilious
  cafes, is probably of the putrefcent kind.
     1499.] The general correaors of acrimony are the mild
  diluents and demulcents.  The former have not been fb 
l7o                 'PRACTICE

much employed  in diarrhoea as they  ought;  for, joined
with demulcents, they very much increafe the effe6ts of the
latter : And although the demulcents,  both mucilaginous
and oily, may by themfelves be ufeful, yet without the af-
fiftance of diluents they can hardly  be  introduced  in fuch
■quantity as to anfwer the purpofe.*
   1500.] As indigeftion and crudities  prefent in the ftom-
ach. are fo often the caufe of diarrhoea, vomiting muft there-
fore be frequently very ufeful  in this difeafe.
   In like manner, when the difeafe proceeds, as it often
does,  from obftructed perfpiration,  and increafed afflux of
(luids to  the inteftines, vomiting is perhaps the moft effec-
tual means of reftoring  the determination  ofthe fluids to
the furface of the body.
   It is poffible alfo, that vomiting may give fome inverfion
of the periftaltic  motion,  which is determined too  much
downwards in diarrhoea; fo that upon  the whole it is a re-
medy which may be very generally  ufeful in this difeafe.t
   1501.] Purging has  been fuppofed to be more univer-
fally neceffary, and has  been more  generally  praaifed.
This, however, in  my  opinion, proceeds  upon very mif-
taken notions with refpea to the difeafe;  and  fuch a prac-
tice feems to me for the moft part fuperfluous, and in ma-
ny cafes very hurtful.   It goes upon the fuppofition of an
acrimony prefent in the inteftines, that ought  to be carried
out by purging:  but, if that acrimony has either been in-
troduced by the mouth, or brought into the inteftines from  ^
other parts ofthe body, purging can neither be a means of
correcting nor of exhaufting it; and muft rather have the
effea of increafing its afflux, and of aggravating its effects.
From whatever fource  the  acrimony  which  can excite a
 harrhoea proceeds, it may be fuppofed fufficient to evacu-
ate itfelf,  fo far as that can be  done by  purging;   and as
 # Lintfeed tea is both diluent and demulcent; but as the patient fometimes loaths it, we may in
its place ufe a decoction of marih-mallow root, or of quince feed. Thefe infulions and decoctions
ought 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.
 Wc have another in ftaaceofa diluent and demulcent in the almond emulfion, which is an exceed-
ingly elegant medicine.  The formulae iu both the London and Edinburgh Pharmacopoeias are not
well adapted to cafe.; of diarrhoea: for the former contains fugar, and the latter bitter almonds ;
both of which ingredients increafe the irritation.  In thefe cafes, therefore, an emulfion made with.
fweet almonds and gum arabic, is preferable to either of the others; as,
           ft. Amygdal. dulc. decorticat. §i.
              Gum Arabic. ^\.
 Tere in mortario marmoreo, et adde gradatim.
              Aq. font. lbl.
              M. f. Emuls.
 -f The methods of giving the tartar emetic, fcr producing either voraiting or f.-, eatiBg, may be
fcen in tlv; notes oa ar:ic:c 185. 
                    «> F  PHYSIC.                Wtf-
                    *■   ———__
in cholera, fo in the fame kind of diarrhoea, it will be more
proper to affift the evacuation by diluents and demulcents,
than to increafe the irritation by purgatives.
   1502. J If, then,  the ufe of purgatives in diarrhoea may
be confidered, even when an acrimony is prefent, as fuper-
fluous, there are many other  cafes in which it may be ex-
tremely hurtful.  If the irritability ofthe inteftines fhall,
from affeaions in other parts of the fyftem, or other caufes,
have been  already  very  much increafed, purgatives muft
neceffarily aggravate the difeafe.   In the cafe of lientery,
nobody thinks of giving a purgative; and in many cafes of
diarrhoea approaching to that, they muft be equally  im-
proper.   I have already obferved, that when diarrhoea pro-
ceeds 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, confiders the numer-
ous  and various fources  from which acrid  matter may be
poured into the cavity of  the inteftines, will readily per>-
ceive, that in many cafes of diarrhoea, purgatives may be
extremely pernicious.
   There is one cafe in particular to be taken notice of.
When, from a general and acrid diffolution of the blood,
the ferous fluids run off too copioufly in the cavity of the
inteftines, and  excite that  diarrhoea which attends the ad-
vanced ftate of heaic fever, and is properly called a. Col-
liquative Diarrhoea; I have, in fuch cafes, often feen pur-
gatives  given with the moft baneful effeas.
   There is ftill another cafe  of  diarrhoea in which purga-
tives are pernicious; and that is, when the difeafe depends,
as we have alleged  it fometimes may, upon an erythema-
tic inflammation of the inteftines.
   I  need hardly add, that  if there  be a cafe of diarrhoea
depending upon a laxity  of the  folids,  purgative^ cannot
there be of any fervice,  and  may do much harm.  Upon
the whole, it will, I think, appear, that the ufe of purga-
tives in diarrhoea is very much limited; and that the pro-
miscuous ufe of them,  which has been fo common, is in-
judicious, and  often pernicious.   I believe the  praaice
has been chiefly owing to the ufe of purgatives in dyfente-
ric cafes, in which they are truly ufeful; becaufe,  con- 
. i72                     PRACTICE
trary  to the cafe of diarrhoea, there is iii  dyfentery a con-
fiderable conftriaion of the inteftines.*
   1503. J  Another fet of remedies  employed in diarrhoea
are aftringents.    There has been fome hefitation about the
employment of thefe in recent cafes, upon the fuppofition
that  thev  might occafion  the retention of an acrid matter
that fhould be thrown out.   I cannot, however, well un-
dcrftand or affign the cafes in which fuch caution is necef-
fary ;  and  I think that the power of aftringents is feldom fb
great as to render their ufe very dangerous.
   The only difficulty which  has*occurred to me, with ref-
pea to their  ufe, has been to  judge of the  circumftances
to which they are efpecially adapted.   It appears to me to
be only in  thofe where the irritability  of  the  inteftines de-
pends upon a lofs of tone : And this,  I think,  may occur
from the debility ofthe  whole fyftem,  or  from caufes aa-
ing on the  inteftines alone.    All violent or long continued
fpafmodic  and convulfive  affeaions of the inteftinal canal
neceffarily  irwtoce a debility  there; and fuch caufes often
take  place,  from  violent irritation, in  colic,  dyfentery,
cholera, and diarrhoea.f
   1504.]  The laft of the remedies of diarrhoea  that re-
main to be mentioned are opiates.   The fame objeaions
have  been  made to the ufe of thefe, in recent cafes of diar-
rhoea,  as to  that of aftringents; but on no good grounds:
For  the effea of opiates,  as  aftringent, is never very  per-
manent ; and  an  evacuation depending  upon  irritation,
  * Notwithftanding-all the author advances concerning the danger of purgatives fn » diarrhoea,
there are fome cafes in which they are of lingular utility.  His arguments in this article »re doubtlef*
juft; and, in the fpecies of diarrhoea which he here enumerates, purgatives are certainly hurtful'
but many inltancc* of diarrhoea occur, which proceed from an acrimony that is extremely tenacious,
and that adheres clofay to the Internal furface of the inteltines, or is retained in their folds,  rh fuch-
cafes, purgatives are tfeonly remedies for removing the difeafe, and ought therefore to be ufed.  In
all otlier cafes'? as the .juthor juftly obferves, they are certainly pernicious. Having afcertained ivhen
purgatives are pro^T, the next confideration is, -what purgatives ought to be ufed .' The anfwer is
Ctivious:—Neutral falts, particularly Soda phofpliorata, Rochal fait, Glauber's falts, and Eplom  fait,
which are enumerated in the order of their being agreeable, but in a contrary order to their decree
pfefficacy; 4fce Epfom fait being the leaft agreeable, but the moft efficacious.
  i The aftringents to be ufed, when they are proper, are various: as Alum, Logwood, Catechu.
Rhubarb, St. The author juftly remarks, that aftringents are only ufeful in cafes of debility,  and
therefore the tonic aftringents are undoubtedlv preferable to any other.  Rhubarb and Peruvian
hark, each poueffing both thefe qualities, may therefore be advaniageoufly ufed conjointly, as in the
following formula:
            R. Pulv.  Cort. Peruv. .^i.
                      Rad. Rhei,  3  ft.
                M. f. Pulv.
  The dofe of this powder may be varied according to circumftances, from a fcruple to a drachm,
.twice a day, witha glafs of Port wine after it. It may not be improper to obferve,'that in diarrhoea*
in general, peculiar attention muft be paid to diet.  The oleraceous and acefcent vegetables muft
be carefully avoided;  a* muft alio all fermented liquors except Port wine: of the farinaceous vege-
tables, rice is the beft; and rice-water, with a little cinnamon and Port wine, is the moft proper
ilrink for patient* in thefe cafes.  Roafted meats are preferable to boiled: and veal, lamb, or chickens,.
preferable to beef or mutton. Perk is very improper 1 as are alfo all kinds of filh. Puddings of all
kinds without fruit are very proper food for fuch patients, efpecially rice-puddings made without
e££s., but with milk and cinnamon ; and alfo rice-milk, fago with Tort wine, blancnunije. &x. 
OF  PHYSIC.
174 -
  though it may be for fome time fufpcnded by opiates, yet
  always returns very foon.  It is only by taking off irrita-
  bility 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 correaed or  exhaufted,  opiates are the moft
  ufeful and certain remedy.  And though opiates are not
  fuited to correa or remove an irritation applied, they are
  often of great benefit in fufpending the effeas of that irri-
  tation 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.

                   ©f tfte Diabetes,

   1505.]  1  HIS difeafe  confifts in the voiding of an unu-
   fually large quantity of urine.           *>
     As hardly any fecretion can be increaferTwithout an in-
   creafed aaion of the veffels concerned in  it, and as fome
   inftances of this difeafe  are  attended with affeaions ma-
   nifeftly fpafmodic, I have had no doubt of arranging the
   diabetes under the order of Spafmi.
     1506. J This difeafe is always accompanied with a great
   degree of thirft, and therefore with the taking in of a great
   quantity of drink.   This in fome meafure accounts  for
   the  very extraordinary  quantities of urine voided: But
   ftill, independent of this, a peculiar difeafe certainly takes
   place; as the quantity of urine voided does almoft always
   exceed the whole of the liquids,  and fometimes the whole
•   of both folids and liquids, taken in.
I    1507.] The urine voided in this difeafe is always very
\  clear, and at firft fight appears entirely  without any color;
;  but viewed  in a. certain light, it generally appears to be
   flightly  tinged with  a yellowifh  green,  and m this refpea
   has been very properly compared to a folution of honey in
   a large proportion of water.
     Examined by the tafte, it is very generally found to be
   more or lefs fweet;  and  many experiments  thaehave now
   been made in different inftances of the difeafe fhow clearly
     Vol. II.                   Y 
174
PRACTICE
that fuch urine contains,  in  confiderable quantity,  a fac-
charine matter which appears to be very exaaiy of the na-
ture of common  fugar.
   1508.] Doaor Willis feems to me to have been the fit ft
who  took notice of the fweetnefs of the urine in diabetes,
and almoft every phyfician of England has  fince taken no-
tice 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 ancients, nor,  in the
other countries of Europe, the moderns, till the latter were
direaed to it by the  Englifh,  have taken notice  of the
fweetnefs of the urine,  it does not perfuade me, that either
in ancient or in modern times the urine in diabetes was  of
another kind.  I myfelf,  indeed, think I  have met  with
one inftance of diabetes in which the urine was  perfectly
infipid; and it would feem that a like obfervation had oc-
curred to Dr. Martin Lifter.   I am perfuaded, however,
that fuch inftances are very rare; and that the other is  by
much the more^common, and perhaps the almoft univerfal
occurrence.  I judge, therefore, that the prefence of fuch
a faccharine matter may be confidered as the principal cir-
cumftance in idiopathic diabetes; and  it gives at leaft the
only cafe of that difeafe that  I can properly treat of here,
for I am only certain that what I am further to mention  re-
lates to fuch a cafe.
   1509.] The antecedents of this difeafe, and confequent-
ly the remote caufes of it, have not been well afcertained.
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 conftitution, or who, as
we often exprefs it,  are in a  cacheaic  ftate;  that it fome-
times follows intermittent fevers; and that it has often oc-
curred Jrom excefs in drinking of  mineral  waters.  But
none of thefe caufes apply very generally  to the cafes that
occur: Such cafes  are  not  always, nor even frequently,
followed 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 which I have met with, I
could not refer it to any particular caufe.
   1510.] This difeafe commonly comes  on flowly, and
almoft imperceptibly, without an^ previous diforder.  it
often arifes to a confiderable degree, and fubfifts long with- 
0 F  PHYSIC.                1^5
out being accompanied with evident diforder in any parti-
cular part of the fyftem.   The  great thirft which always,
and the voracious appetite which frequently, occur in  it,
are often the only remarkable fymptoms.  Under the con-
tinuance of the difeafe, the body is often greatly emaciated;
and a great wreakncfs alfo prevails.   The pulfe is common-
ly frequent;  and an obfcure fever is for the moft part pre-
fent.   When the difeafe  proves fatal,  it generally ends
with a fever, in many circumftances,  particularly thofe of
emaciation and debility,  refembling a heaic.
   1511.] The proximate caufe of  this difeafe is not cer-
tainly or clearly known.   It feems to have been fometimes
conneaed with calculous affe6tions of the kidneys; and it
is poffible, that an irritation applied there may increafe  the
fecretion of urine.   It perhaps often does fo; but how it
fhould produce the finguiar change  that takes place in  the
ftate of the  urine, is not to be eafily explained.  It certain-
ly often happens, that calculous matters are long prefent in
the urinary  paffages, without having any fuch effea as that
of producing diabetes in any fhape.
   Some have fuppofed that the difeafe occurs from a relax-
ed ftate of the fecretory veflels of the kidneys;  and indeed
the diffeaions 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 effea than  the
caufe of the difeafe.
   That no  topical affeaion of the kidneys has a fhare in
producing this difeafe, and that a fault in the affimilation of
the  fluids is rather to be blamed, I conclude from hence,
that even the folid food taken in, increafes the quantity of
the urine voided, at the fame  time  with  an increafe of the
faccharine matter above-mentioned.
   1512.] The diabetes has been fuppofed to be o#ing to a
certain ftate of the bile:  and it is true, that this difeafe  has
fometimes occurred in  perfons  who were at the fame time
affeaed with difeafes of the liver: But this occurrence does
not often take  place; and the diabetes frequently occurs
feparately from any affeaion of the liver.   In twenty in-
ftances of diabetes which I have feenj there was not in  any
one of them any evident affection of the liver.
   The explanation that has been offered of the nature  and 
176
PRACTICE
operation of the bile, in producing diabetes is very hypo-
thetical, and no wife fatisfying.
   1513.]  As  I have already faid, I  think  it probable, that
fn molt cafes  the proximate caufe of this  difeafe  is  fome
fault in the aflimilatory powers, or  in thofe  employed  in
converting alimentary matters into the proper animal fluids.
This I formerly hinted to Dr. Dobfon, and it has been pro-
fecuted and publifhed by him; but  I muft own that it is a
theory embarraffed with fome difficulties which I cannot at
prefent very well remove.
   1514.] The proximate caufe of  diabetes  being fo little
known or afcertained,  I  cannot  propofe  any rational me-
thod 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  happened;  and when the
difeafe has been cured, I doubt much if it was effefcted by
the feveral remedies to which thefe cures have been afcribed.
In all  the inftances of this difeafe which I my felf have feen,
and in  feveral others  of which I have been informed, no
cure of it has ever been made in Scotland, though many in-
ftances of it have occurred,  and in moft of them  the reme-
dies recommended by authors have been diligently employ-
ed.   I cannot, therefore, with any  advantage, enter into a
detail of thefe remedies; and as the difeafe, together with
its feveral circumftances, when  they fliall hereafter  occur,
is likely to become the fubjea of diligent invettigation, I
avoid going farther at prefent, and judge  it prudent to fuf-
pend my  opinion till I fhall have  more  obfervations and
experiments upon which I can form it more clearly.
                     CHAP.  XIII.

   ©f «tfje  listeria,  or tfje 5>p$teric iDisease.

1515.]  i HE many and various  fymptoms which have
been fuppofed to belong to a  difeafe under this appellati-
on, render it extremely difficult to give a general charaaer
 * The difeafe !s l.app'.ly not very common: but, when a phyfician is called, he is under the neceffity
of doing fomething, and not remaining inaftive.  Some general directions mav therefore be ac-
ceptable to the yoiing practitioner. The cure will principally confift in avoiding whatever mav relax
the renal vellels, efpecially bv avoiding ftrong drink. As the quantity of urine is always lefs in pro-
portion as the perfpiration u increafed, it feems advifeable to keep the furface of the Ikin lax and
perfpirable ; and, if the patient's ftrength allows him, he ought frequently to ufe bodily exercife to
promote fweat. For a fimilar reafon, external cold muft be avoided, becaufe by diminifhing perfpi-
ntion, a larger quantity of fluids is derived to the kidneys.  In fome cafes the difeafe may be pro-
bably owing to a lax or weak itate of the kidneys: hence the indication of tonics, as Peruvian bark,
ar d other tonic bitters. 
ut  ij ri i S I C.
177
or definition of it.   It is, however,  proper in  all cafes to
attempt fome general  idea;  and therefore, by taking  the
moft  common  form, and that concurrence of fymptoms
by which it is  principally diftinguifhed, I have  formed a
character in my fyftem of Methodical Nofology,  and fhall
here endeavour to illustrate it by giving a more full  hiftory
of the phenomena.
   1516. J  The difeafe attacks in paroxyfms or fits.  Thefe
commonly begin by fome pain and fulnefs  felt in the  left
fide of the belly.   From this a ball* feems to move with
a grumbling  noife  into  the other parts of the belly; and,
making as  it  were  various  convolutions there, feems to
      O                                    ....
move into the ftomach; and more diftinctly ftill riles up to
the top of the gullet, where it remains for fome time and
by its preffure upon the larynx gives a fenfe of fuffocation.
By the time that  the difeafe has proceeded thus far, the
 patient is affeaed with  a ftupor and infenfibility, while at
the fame  time the body is agitated with various  convulfi-
ons.   The trunk of the body is wreathed to  and fro,  and
the limbs are varioufly agitated; commonly the convulfive
 motion of one arm and hand, is that  of beating with the
 doled fift,  upon the  breaft very violently and repeatedly.
 This ftate continues for fome  time, and  has during that
 time fome remiffions and renewals  of the convulfive mo-
tions; but they at length ceafe, leaving the patient in a ftu-
 pid and feemingly fleeping ftate.  More or lefs  fuddenly,
 and frequently with repeated fighing  and fobbing, toge-
 ther with a murmuring noife in the belly, the patient re-
 turns to the exercife  of fenfe  and  motion,  but generally
 without any recolleaion of the feveral circumftances that
 »iad taken place during  the fit.
    1517.] This  is the form of  what is called an  hysteric
 paroxysm, and is the moft  common form; but  its parox-
 yfms are  confiderably varied in different perfons, and even
 in the fame perfon at different times.   It differs, by  hav-
 inn more or fewer ofthe circumftances above-mentioned;
 by thefe circumftances  being more  or lefs violent; and by
 the different duration ofthe whole fit.
    Before the fit there is fometimes a fudden and unufually
 large flow of  limpid urine.   At the coming on of the fit,
 the ftomach is fometimes affeaed with vomiting, the lungs
# Commonly called Globus liysltritus by authors. 
178                 PRACTICE
with confiderable  difficulty of breathing, and  the heart
with palpitations.  During the fit, the whole of the belly,
and particularly the navel,  is drawn ftrongly  inwards; the
fpincter and ani is  fometimes fo firmly  conltriaed 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 pa-
tients are liable  to involuntary motions, to fits of laughing
and crying, with fudden tranfition  from the  one to the o-
ther; while fometimes falfe imaginations, and fome degree
of delirium, alfo occur.
   1518.] Thefe affeaions have been fuppofed peculiar to
the female fex ;  and  indeed they moft commonly appear
in females: but they fometimes,  though rarely, attack the
male fex; never, however,  that I  have obferved, 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 appears before the former
or after the latter of thefe periods.
   At all ages,  the time at which it moft readily  occurs is
that of the menftrual period.
   The difeafe more efpecially affects the females of the moft
exquifitely fanguine and plethoric habits, and frequently af-
feas thofe of the moft robuft and mafculine conftitutions.
   It affeas  the barren  more than breeding women, and
therefore frequently young widows.
   It occurs efpecially in thofe females who arc liable to the
Nymphomania; and the Nofologifts have properly enough
marked one of the varieties of this difeafe by the  title of
Hysteria Libidinosa.
   In the perfons liable to the fits of this difeafe,  it is rea-
dily excited by the paffions of the mind, and by every con-
fiderable emotion, efpecially thofe brought on by furprife.
   The perfons  liable to this difeafe acquire  often  fuch  a
degree of fenfibility, as to  be  ftrongly affeaed  by every
impreffion that comes upon them by furprife.
   1519. J  In this hiftory, there appears to be a concurrence
o^ fymptoms and circumftances properly marking  a  very
particular difeale, which I think may be diftinguifhed from
all others.  It feems to me to have  been improperly confi-
dered by phyficians as the fame with fome other difeafes3 
OF  PHYSIC.                179
and particularly with hypochondriafis.   The two difeafes
may have fome fymptoms in common, but for the moft
part are confiderably different.
   Spafmodic affeaions occur in both difeafes;  but neither
fo frequently nor to fo great a degree, in hypochondriafis
as in hylteria.
   Perfons liable to hyfteria are fometimes affeaed at the
fame time with dyfpepfia.   They are often, however, en-
tirely free from it;  but I believe this never happens to per-
fons affeaed with hypochondriafis.
   Thefe different circumftances mark fome difference in the
two difeafes; but they are ftill more certainly diftinguifhed
by the temperament* they attack, and by the timet of life
at which they appear to be moft exquifitely formed.
   It has been generally fuppofed, that the two difeafes dif-
fer only in  refpea of their  appearing  in different fexes.
But this is not well founded:  For although the hyfteria ap-
pears moft commonly in females, the male fex is not abfo-
lutely free from it, as I have obferved above; and although
 the hypochondriafis may be moft frequently in men, the
 inftances of it in the female fex are very common.^
   1520.]  From all thefe confiderations, it muft, I think,
 appear, that the hyfteria may be very well, and properly,
diftinguifhed from hypochondriafis.
   Further, it feems to me to have been with great  impro-
 priety, that almoft every degree of the irregular motions of
 the nervous fyftem has been referred to the one or 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 temperament different from
 that which is peculiar to either hyfteria or hypochondriafis,
 and without being joined with the peculiar fymptoms of ei-
 ther the one or the other difeafe: So that the appellations
 of Hyfteric and Hypochondriac are very inaccurately ap-
 plied to them.   Under what view thefe fymptoms are other-
 wife to be confidered, I am not ready to determine; but
 muft  remark, that the appellation of Nervous Difeafes is
 too vague and undefined to be of any ufeful application.
  * Hyfteria attacks the fanguine and plethoric, but Hypochondriafis the melancholic.
  t Hypochondriafis fcarcely ever appears early in life, nor Hylteria late : and Hypochondriafis be-
 comes aggravated, but Hylteria relieved by advancing age.
  J I'he Hypochondriafis in women hat been frequently miftaken for Hyfteria. 
1*0                PRACTICE
   1521.J Having thus  endeavored to diftinguifh hyfteria
 from every other difeafe, I fliall.now  attempt its peculiar
 pathology.   With refpea to this, I think it will, in the firft
 place, be obvious, that its paroxyfms begin by a convulfive
 and fpafmodic affeaion ofthe alimentary canal, which is af-
 terwards communicated to the brain, and to a great part of
 the nervous fyftem.   Although the difeafe appears to be-
 gin in the alimentary canal, yet the connection which  the
 paroxyfms fo often have with the menftrual flux, and  with
 the difeafes that depend on the ftate of the genitals, fhows,
 that the phyficians have at all times judged rightly in con-
 fidering this difeafe as an affeaion  of the uterus and other
 parts ofthe genital  fyftem.
   1522.J With regard to this, however, I can go no farther.
 In what manner the uterus, and in particular the ovaria, are
 affected in this difeafe; how the affection of thefe is commu-
 nicated, with particular circumftances, to the alimentary
 canal; or how  the affeaion of this, riling upwards, affctts
 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 firft caufes,
 or explain the whole of the phenomena, I  hope,  that with
 refpect to the general nature ofthe difeafe, I may form fome
 general conclufions, which may ferve to direa our condua
 in the cure of it.
   1523.J Thus,  from a confideration ofthe predifponent
 and occafional caufes, it  will, I think, appear, that the chief
 part of the proximate caufe is a mobility of the fyftem, de-
 pending generally upon  its plethoric ftate.
   1524.J Whether this difeafe ever arifes from a mobility
 ofthe fyftem, independent of any plethoric ftate of it, I
 cannot pofitivcly determine; but in many cafes that have
 fubfifted for fome time,  it is evident that a fenfibility,  and
 confequently a  mobility, are acquired, which often appear
 when neither a  general plethora can be fuppofed to fubfiit,.
 nor an occafional turgefcence  to have happened.   How-
 ever, as we have fhown above, that a diftention of the  vef-
 fels ofthe brain feems to occafion epilepfy, and that a  tur-
 gefcence 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 
OF  PHYSIC.                     181'
 motions  which  appear  in  hyfteria.    It will, at  the  fame

 time,  be  evident, that this affeaion ofthe genitals muft ef-

 pecially occur in plethoric habits ;  and every circumftance

 mentioned in the hiftory of  the  difeafe ferves  to  confirm

 this opinion with refpect to  its proximate  caufe.

    1525.] From this view ofthe fubjea, the analogy of hyf-

 teria and epilepfy will readily appear ;  and why, therefore,

 I am to fay that the indications of cure are the fame in both.

    As  the indications, fo the  feveral  means  of anfwering

 them are fo much the fame in both  difeafes, that the fame

 obfervations and direaions,  with regard to  the choice and

 employment of thefe remedies,  that  have been  delivered

 above on the fubjea of epilepfy, will apply pretty exaaiy

 to hyfteria;  and therefore need not  to be repeated here.*






                          CHAP.  XIV.





       SDf Canine  e^atmegg ann ^Bropbofcia,



 1526.]   X ft IS difeafe has beenfo exaaiy and  fully def-

 cribed 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

 refpea to the pathology of it, I  find that I  can  fay nothing

  * Although the indications of cure maybe the fame in both difeafes, yet in hyfteria we are more
 frequently under the neceffity of relieving the violence of the fymptoms than in epilepfy; and lor
 this purpofe we mult have recourfe to a variety of antifpafmodics.—Afafcetida, in various forms, i-s
 Ufually employed ; as are alfo volatile fpirits: but both thefe joined prove more efficacious than either
 of them (ingly. There are excellent fonnulx of this kind in the London and Edinburgh Pharma-
 copoeias, under the title of Spiritus Ammonia fectidus. Its dofe is zo or 50 drops, repeated accord-
 ing to the urgency of the cafe, Several times a day.—The TinAura Caitorei compofita of the Edin-
 burgh Pharmacopccia is another excellent formula of the fame kind : it is a remedy of real efficacy.
 The dofe of it is 30 or 40 drops repeated occafionally.—The Tinftura Valerianae volatilis of both the
 Pharmacopxias is alfc frequently ufed.  Its dofe is a tea-fpoonful or two.—Few of the compolitions
 of the (hops are found tobe more efficacious antifpafmodics, than the Spiritus  jttheris Vitriollcus
 compofitus of the London Pharmacopoeia. Its dofe is from 30 to 50 drops in two or three fpoonsful
 of cold water ; and it mutt be fwallowed immediately on pouring out ofthe vial. Thefe and other
 antifp ifmodics may be ufed promifruoufly ; for in different cafes and conftitutior.j, they prove differ-
 ently oificacin'ii. Sometimes they may be varioufly combined with one another, and with opium.
 Opium, however, ought not to be ufed, except where o "her antifpafmodics fail, as it always leaves
 the patient remarkably low, and liable to the returns of the paroxyfms.—Befides the ufe of thefe re-
 medies internally, Come of them may be ufefully employed externally; as ftrong volatile fpirits to the
 nofe, the vitriolic acclicr to the temples, &c— Thefe remedies arc chiefly defigned for occafionally re-
 moving the violence of the Iymptoms j but the fetid gums, in fubftance, mull be ufed, when we wifh
 to produce perm..nent efforts.  The formula of them are in both our Pharmacopoeias, under the title
 of Gum-pifls ; but they will be found much more efficacious by adding to them a little caftor, as in
 t&e following formula :
            R. Pilul. Gummo?. Edmb. 5 f^>.

                Castor. Russic. £i.

                Syr. simpl. q. s.

                M. f. mass, in pilulas Ixxv. equsles dividend.
  Five of thefe pilli mav be taken twice a-riay, warning them down with a tea-cupful of cold water,
with a'tea-fpoonful of volatile tinclure of valerian in it.—The Pilule foetldse ofthe Swedifh Pharma-
copoeia, In wnich caltor is one of the Ingredients, is preferable to either of ocr gum-pill*.

   \\L. 11.                       I 
18£
PRACTICE
fatisfying to my felf, or that I can expeatoprovefoto others.
I find alfo, with refpea to the cure of this difeafe, that there
is no  fubjea in which the fallacy of experience  appears
more  ftrongly than in this.   From the moft ancient to the
prefent times, many remedies for preventing  and curing
this difeafe have been recommended under the fane!ion of
pretended experience, and have perhaps alfo kept their cre-
dit for fome time:  but fucceeding times have generally,
upon  the fame ground of experience, deftroyed that credit
entirely; and moft of the remedies formerly employed are
now fallen into abfolute neglea.   In the prefent age, fome
new remedies have been propofed, and have experience al-
ledged to vouch for their efficacy; but many  doubts  ftill
remain with refpea to this:  and though I cannot determine
in this matter from my own experience, I think it incum-
bent on  me to give the beft. judgment I can form with ref-
pea to the choice of the remedies at prefent recommended.
   1527.]  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 bite has been made.  In this every body agrees;
but with this difference, that fome are of opinion that it
can only be effeaual when it is done very foon after the
wound has been made, and they therefore neglea it when
this opportunity is miffed.   There have been, however,
no experiments made proper to determine this matter: and
there are many confiderations which lead me to think, that
the poifon is not immediately communicated to the fyftem j
and therefore, that this meafure of deftroying the part may
be praaifed with advantage, even many days after the bite
has been given.
   1528.] Whilft the ftate of our experience,  with refpea
to feveral  remedies now  in ufe, is uncertain, I  cannot ven-
ture to  affert that any  of thefe is abfolutely ineffeaual;
but I can  give it as my opinion, that the efficacy of mer-
cury, given very largely,  and perfifted in for a long time,
both as  a  means of preventing the difeafe, and of curing
it when  it has aaually come on, is better fupported by ex-
perience than that of any other remedy  now propofed or
commonly employed. 
                       ,83
              BOOK   IV.
Of Vesania:, or Disorders ofthe Intellectual Functions,
                    CHAP.  I.

             £)f £Je#aniac in general*

J529 ]  X HE Nofologifts, Sauvages and Sagar, in a clafs
of difeafes under the title of Vesania, have comprehend-
ed the two orders, of Hallucinationes or Falfe Perceptions,
and of Morositates or Erroneous Appetites and Paffions;
and, in like manner, Linnaeus in his clafs of Men tales,
correfponding to the Vefanice  of Sauvages,  has  compre-
hended the two orders of Imaginarii and Pathetici, nearly
the  fame with the Hallucinationes and Morositates of that
author.   This, however, from feveral confiderations, ap-
pears to me improper ;  and I have therefore formed a clafs
of Vefanice nearly the fame with the Paranoias of Vogel,
excluding  from it the  Hallucinationes and  Morofitates,
which I have referred to the Morbi Locales.  Mr. Vogel
has done the like, in feparating from the Paranoial the falfe
perceptions and erroneous appetites; and has thrown thefe
into another clafs, to which he has given the tide of Hype-
raefthefes.
   1530.] It is indeed  true, that  certain  hallucinationes
and morofitates are frequently combined with what I pro-
pofe to confider as ftriaiy a vefania or an erroneous judg-
ment; and  fometimes  the hallucinationes feem to lay the
foundation  of, and to form almoft entirely, the vefania.
But as moft part of the hallucinationes enumerated by the
Nofologifts are  affeaions purely  topical,  and  induce no
other error of judgment befide that which  relates to the
fingle objea of  the fenfe or particular organ affeaed ; fo
thefe arc certainly to be feparated from the difeafes which
confift in a more general affeaion of the judgment.  Even,
when the hallucinationes conftantly accompany or feem to
induce the vefania, yet being fuch as arife from internal
caufes, and may be prefumed to arife from the  fame  caufe
as the  more general affeaion of the judgment,  they are
therefore to be confidered as fymptoms of this only.
  In like manner I judge with refpea to the morofitates,
or  erroneous paffions;  that accompany vefania; which, as 
184                PRACTICE
confequences of a falfe judgment, muft be  confidered as
arifing from the fame caufes, and as  fymptoms  only, of
the more general affection.
   There is,  indeed, one  cafe of a morofitas which feems
to induce a vefania,  or more general affedion of  the judg-
ment; 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 comprehending the morofitates
in general under the vefania?, confidered as primary difeafes.
   The limitation, therefore, of the clafs of Vefaniae to the
lefions of our judging faculty, feems from every  confider-
ation  to be proper.
   The particular difeafes to be comprehended under this
clafs, may be diftinguifhed according as they affia perfons
in the time of waking or fleeping.   Thofe  which affea
men awake,  may again  be confidered, as they confift in an
erroneous judgment, to which I fhall give the appellation
of Deliriums or as they confift in a weaknefs or imperfec-
tion  of judgment, which I fhall name Fatuity.   I begin
with the confideration of Delirium.
   1531-] As men differ greatly in the foundnefs  and force
of their judgment, fo it may be  proper here to  afcertain
more precifely what error or imperfeaion of our judging
faculty is to be confidered as morbid, and to admit of  the
appellations of Delirium and Fatuity.   In doing this,  I
fhall  firft  confider the  morbid errors of judgment under
the general appellation of Delirium,  which has been com-
monly employed to denote every mode of fuch error.
   1532.] As our judgment is chiefly exercifed in difcern-
ing and judging of the feveral relations of things, I appre-
hend that'delirium may be  defined  to be,—In a  perfon a-
wake, a falfe or miftaken judgment of thofe relations of
things,  which, as occurring moft frequently in  life,  are
thofe about  which  the generality of men form the fame
judgment; and  particularly when the judgment is very
different from what the perfon himfelf had before  ufually
formed.
   1533. J With this miftaken judgment of relations there
is frequently joined fome falfe perception of external ob-
jeas, without any evident fault in the organs of fenfe,  and
which feems therefore to  depend upon  an internal caufe;
that is, upon the imagination arifing from a condition in 
U£  PH'xSie.
185
the brain prefenting objeas which are not aftually prefent.
Such falfe perceptions muft neceffarily occafion a delirium,
or an erroneous judgment,  which is to be confidered as the
difeafe.
   1534-] Another circumftance, commonly attending de-
lirium, is a very unufual afibciation of ideas.  As, with
refpea 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 common foundation of afib-
ciation in the  memory:  And therefore this unufual and
commonly hurried afibciation of ideas, ulually is, and may
be confidered as, a part of delirium.  In particular, it may
be confidered as a certain mark of a general morbid affec-
tion of the intelleaual organs, it being an interruption or
perverfion of the ordinary operations of memory, the com-
mon and neceffary foundation of the exercife of judgment.
   1535-J A third circumftance attending delirium,  is an
emotion or paflion,  fometimes of the angry, fometimes of
the timid kind; from whatever caufe in the perception or
judgment, it is  proportioned to fuch caufe, either in the
manner  formerly  cuftomary  to  the perfon himfelf,  or in
the manner ufual with the generality of other men.
   1536.] Delirium, then, may be more fhortly defined—
In a perfon awake, a falfe judgment arifing from percep-
tions of imagination, or from falfe recolleaion, and  com-
monly producing difproportionate emotions.
   Such delirium is of two kinds;  as it is  combined with
pyrexia and comatofe affeaions:  or, as it is entirely without
any fuch combination.   It is the latter cafe that we  name
Insanity ; and it is this kind of delirium only that I am to
treat of here.
   1537.] Infanity may perhaps be properly confidered as
a genus comprehending many different fpecies, each of which
may deferve our attention; but  before proceeding to the
confideration of particular fpecies, I think  it proper  to at-
tempt  an inveftigation ofthe caufe of infanity in general.
   1538.] In doing this,  I fhall take it for  granted, as de-
monftrated elfewhere, that although this difeafe feems to be
chiefly, and fometimes  folely,  an  affeaion of the mind;
yet the conneaion between the mind and body in this cafe 
186                PRACTICE
is fuch, that thefe affedions of tjie mind muft be confider-
ed as depending upon a certain ftate of our corporeal part.
See Halleri  Prim.  Lin.  Phyfio. log.  $ 570.   See Bocr-
haavii Inft. Med. $ 581. 696.
   1539.] Admitting this propofition, I muft in the next
pla.ce affume another, which 'I likewife fuppofe to be de-
monftrated elfewhere.  This is, that the part of our body
more immediately conneaed with the mind, and therefore
more efpecially concerned in  every affeaion of the  intel-
, le&ual funaions, is the common origin of the nerves; which
I fhall, in what follows, fpeak of under the  appellation of
the Brain.
   1540.] Here, however, in affuming this laft propofition,
a very great difficulty immediately prefents itfelf.  Altha'
we cannot doubt that the operations of our intelka always
depend upon certain motions taking place in  the brain, (fee
 Gaub. Path. Med. J  523;) yet thefe motions have never
. been the objeas of our fenfes, nor have we been  able to
perceive that any particular part ofthe brain  has more con-
 cern in the operations of our intellea than any other. Nei-
 ther have we attained any knowledge of what fhare the fe-
 veral parts ofthe  brain have in that operation; and there-
 fore, in this fituation of our fcience, it muft be a very diffi-
 cult matter to difcover thofe ftates of the brain that may give
 occasion to the various ftate of our intelleaual funaions.
   '1541.]  It may be obferved, that the different ftate of
 the motion of the blood in the veflels of the brain has fome
 fhare in affeaing  the operations ofthe intellea*. and phy-
 ficians, in feeking for the caufes of the different ftates of
 our intelleaual funaions, 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 intellec-
 tual funaions ordinarily go on, and are often confiderably
 varied, without our being able to perceive  any difference
 either in the motions or in the condition of the blood.
    1542. J Upon the other hand, it is very probable that the
 ftate of the intelleaual funaions depends chiefly upon the
 ftate and condition of what is  termed the Nervous Power,
 or, as we fuppofe, ofa fubtile very moveable fluid, includ-
 ed or inherent, in a manner we do not clearly  underftand
 in every part ofthe medullary fubftance ofthe  brain and
 nerves, and which in a living  and heajthy man is  capable 
OF  PHYSIC.                W
of being moved from every one part to every other of the
nervous fyftem.
   1543-] With refpea to this power, we have pretty clear
proof that it frequently has a motion from the fentient ex-
tremities of the nerves  towards the brain, and thereby pro-
duces fenfation; and we have the  fame proof, that in con-
fequence of volition the nervous power has a motion from
the brain into the mufcles or organs of motion.   Accord-
ingly, as fenfation excites our intelle£tual operations,  and
volition is the effea of thefe, and as the conneaion between
fenfation and volition is always by the  intervention  of the
brain and  of intelleaual operations;  fo  we can  hardly
doubt, that thefe latter depend upon certain motions, and
the various modification of thefe  motions, in the brain.
   1544-J  To afcertain the different ftates of thefe motions
may be very difficult;  and phyficians have commonly con-
fidered it to be fo very myfterious, that they have general-
ly defpaired of attaining any knowledge with regard to it:
But I confider fuch abfolute defpair, and the negligence it
infpircs, to be always very blameable; and I  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.
   1545«J  To this purpofe, I think it evident, that the ner-
vous power,  in the whole as well as in  the feveral parts of
 the nervous fyftem, and particularly in the brain, is at dif-
 ferent times in different degrees of mobility and force. To
 thefe different ftates,  I beg leave to apply the terms of
 Excitement and Collapse.   To that ftate in which the mo-
 bility and force are fufficient for  the exercife of the func-
 tions, or when thefe ftates are  any way preternaturally in-
 creafed, I give the  name of Excitement; and to that ftate
 in which the mobility and  force  are not fufficient  for the
 ordinary exercife of the funaions, or when they are dimi-
 nifhed from the ftate in which they had been before, I give
 the name of  Collapse.  I beg, however, it may  be ob-
 ferved,  that by thefe terms I mean to  exprefs  matters o£
 faa only; and without intending, by  thefe terms,  to ex-
 plain the circumftance or condition, mechanical or phyfi-
 cal, of the nervous power or fluid in thefe differ«ht ftates.
    i 546.] That thefe different ftates of excitement and col-
 lapfe take place on different occafions, muft, I think, be 
188                 PRACTICE
 manifeft from numberlefs phenomena  of the animal eco-
 nomy :  But it is efpecially  to our prefent  purpofe to ob-
 ferve, 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 mobility of the nervous power,
 with  refpea to the whole  of what are called the Animal
 Funaions, entirely ceafe,  or,  as  I would exprefs it, are
 in a ftate of collapfe;  and are very different from the ftate
 of waking, which in healthy perfons I  would call a ftate of
 general and entire excitement.
   1547.] This difference in the ftates of the nervous pow-
 er in  fleeping or 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  inftantaneoufly, but  almoft
 always  by degrees, and in- fome length of time only: And
 this may be obferved with  refpea to both  fenfe and moti-
 on.   Thus when a perfon  is falling afleep, the fenfibility
 is gradually diminifhed : So that, although fome degree of
 fleep  has come on, flight impreffions will excite fenfation,
 and bring back excitement; which the  fame, or even ftron-
 ger impreffions, will be infufficient to produce when the
 ftate of fleep has continued longer,  and is,  as we may fay,
 more complete.   In like manner, the  power of  voluntary
 motion is gradually diminifhed.  In fome members it fails
 fooner than  in  others;  and it  is fome time before it be-    '
 comes general and confiderable  over the whole.
   The fame gradual progrefs may be  remarked in a per-
 fon's coming out of fleep:  The  ears in this cafe are often
 awake before  the eyes are opened or  fee clearly, and the
 fenfes are often awake before the power of voluntary motion
 is recovered; and it is curious  to obferve, that, in  fome
 cafes, fenfations may be excited without producing the or-
 dinary affociation of ideas.  See Mem. de  Berlin, 1752.
   1548.] From all this, I think it will  clearly appear, that
not only the different ftates  of excitement and collapfe can
take place in different degrees, but that they can take place
in different parts of the brain, or  at leaft, with refpect to the
differentA^inaions, in different degrees.
  As  I prefume that almoft every perfon has perceived the
gradual  approach of fleeping and waking, I likewife fup- 
OF PHYSIC.                 189
pofe 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 judgments,  and difproportionate  emo-
tions;  in fhort, all the circumftances  by which I have above
defined delirium.
   This clearly fhows that delirium may depend, and I fhall
hereafter endeavor to prove that it commonly does depend
upon fome inequality in the excitement of the brain; and
that both thefe affertions are founded on this, that, in order
to the  proper exercife of our intelleaual fanaions, the ex-
citement muft be complete, and equal in every part of the
brain.   For though we cannot fay that the veftiges of ideas
are laid up in different parts ofthe brain, or that they are
in fome meafure diffufed over the whole, it will follow upon
either  fuppofition, that as our reafoning and our intelleaual
operations always require the orderly and exaa recolleaion
or memory of affociated ideas;  fo,  if any part of the brain
is not  excited, or not excitable, that recolleaion cannot pro-
perly  take place, while at the  fame time other parts of the
brain, more excited and excitable,  may give falfe percep-
tions,  affociations, and judgments.
    1549.] It will ferve to illuftrate this, that the collapfe in
 fleep is more or lefs complete; or that the fleep, as we com-
 monly fpeak, is more or lefs profound; and therefore, that
 in many'cafes, though fleep takes place to a confiderable de-
 gree, yet certain impreffions do ftill take effea, 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
 judgments, that would have been corrected if the brain had
 been entirely excited.
    Eve*ry one,  I believe,  has  obferved, that the moft im-
 perfea fleeps, are thofe  chiefly attended with dreaming;
 that dreams, therefore,  moft  commonly occur towards
 morning, when the complete ftate of fleep is pafling away;
 and further, that dreams are  moft  commonly excited by
 ftrong and uneafy impreffions made upon the body.
    I apprehend it  may  alfo be  an illuftration of the fame
   V'JL. II.                 A A 
Bo                PRACTICE
thing, that, even in  waking hours, we have an inftance of
an unequal ftate of excitement in the brain producing deli-
rium.   Such, I think, occurs in the cafe of fever.   In this
it is manifeft, that the energy of the brain,  or its  excite-
ment, is confiderably diminifhed with refpeci to the animal
funaions:  and it is accordingly upon this ground  that 1
have explained above, in (45.) the delirium which fo com-
monly attends fever.   To what  I have  there  faid I  fhail
here only add,  that it may ferve  to confirm my doarine,
that thedelirium in fever comes onat a certain period ofthe
difeafe only, and that we can commonly difcernits approach
by a more  than ufual degree of it appearing  in the time of
the patient's falling into or coming out of fleep. It appears,
therefore, that delirium, when it firft comes on in fever,
depends upon an inequality of excitement; and it can hard-
ly be doubted, that the delirium which comes at  length to
prevail in the entirely weakened ftate of fevers, depends upon
the fame caufe prevailing in a more confiderable degree.
   1550.J  From what 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 excitement.
ofthe brain.
   How the different portions of the brain may at the fame
time be excited or collapfed in different degrees, or how the
energy of the brain may be  in different degrees of force,
with refpea to the feveral animal, vital, and natural func-
tions, I cannot pretend  to explain;  but it  is fufficiently
evident in  faa, that the brain may be at one and the fame
time in different conditions  with  refpea  to thefe functions.
Thus in inflammatory difeafes, when by a ftimulus applied
to the brain the force of the vital funaions is preternatural-
ly increafed, that of the animal is either little changed, or
confiderably diminifhed.  On the contrary, in many cafes
of mania,  the force of  the animal fun6tions depending al-
ways on the brain,  is prodigioufly increafed, while the ftate
ofthe vital funaion in the heart is very little or not at all
changed.  I muft  therefore  fay again,  that how  difficult
foever it may be to explain the mechanical or phyfical con-
dition ofthe brain in fuch cafes, the faas are fufficient to
fhow  that there is  fuch an inequality as mi.y difturb our
intelleaual operations.
   1551.]  I have thus endeavoured to explain the general 
OF  PHYSIC.
19 i
caiife of Delirium;  which is of two kinds, according as it
is with, or without, pyrexia.  Of the firft I take  no fur-
ther notice here, having explained  it as well as I could
above in (45.)
   I proceed now to confider that delirium which properly
belongs to the clafs of Vefanise,  and which I fhall treat of
under the general title of Insanity.
   i552-]  In entering  upon this fubjea, it immediately
occurs, that in many inftances  of infanity, we find, upon
diffeaion after death, that peculiar circumftances had tak-
en place in the  general condition of the brain.  In many
cafes, it has  been found of a drier,  harder, and firmer con-
fiftence, than what it is ufually of in perfons who had not
been affeaed with that difeafe.   In other cafes,  it has been
found in a more humid, foft, and flaccid ftate ; and in the
obfervations of  the late Mr. Meckel,*  it has been found
confiderably changed in its denfity or fpecific gravity.  Whe-
ther thefe different ftates have been obferved to be uniform-
ly the fame over the whole of the brain,  I cannot certainly
learn; and I fufpea  the  difleaors have not always accu-
rately inquired into this circumftance: But in feveral inftan-
ces, it appears that thefe ftates  had been different in differ-
ent parts of the brain;  and inftances of this inequality will
afford a confirmation of our general doarine.
   The accurate  Morgagni has obferved, that in maniacal
perfons the medullary portion ofthe brain is ufually dry,
hard, and firm.:  And this he had io frequently obferved,
that he was difpofed to confider it as generally the cafe.  But
in moft of the particular inftances which he has given, it
appears, that, for the moft part, while the cerebrum was of
an unufually hard and firm con fiftence, the cerebellum was
of its ufual foftnefs,.and in many ofthe cafes it was unufual-
ly foft and flaccid. In fome other cafes, Morgagni obferves,
that while a part of the cerebrum was harder and firmer than
ordinary, other parts of it were preternaturally foft.
   1553.] Thefe obfervations  tend to confirm our general
doarine: And there are others which I think will apply to
the fame purpofe.
   Upon the diffeaion of the bodies of perfons who had la-
bored under infanity, various organic affeaions have been
 # Memoir, de Berlin pour l'annee 1764.  It appeared in many Inftances  of infane perfons, that
•he medullary fubftance of the cerebrum was drier, and of a left fpecific gravity, than in perfons who
>-a ' been always of a found judgment. Author. 
192                PRACTICE
difcovered in particular parts ofthe brain; and it is fuffi-
ciently probably,  that fuch organic  affeaions might have
produced a different degree of excitement in the free and
affeaed parts, and muft have interrupted in fome meafure
the free communication  between the feveral parts of the
brain, and in either way have occafioned infanity.
   There have occurred fo many inftances of this kind, that
I believe phyficians are  generally difpofed to  fufpe£t  or-
ganic lefions ofthe  brain to ex ift in almoft every cafe  of
infanitv.
   1554.J This, however, is probably a miftake:  For we
know that there have been many inftances of infanity, from
which the perfons have entirely recovered ; and it is difficult
to fuppofe that any organic leiions of the brain had in fuch
cafe taken place.   Such tranfitory cafes, indeed, render it
probable, that a ftate of excitement, changeable by various
caufes, had been the caufe of fuch inftances of infanity.
   1555.] It is indeed further atferted, that in many inftan-
ces of infane perfons, their brain had been examined after
death, without fhowing that any organic lefions had before
fubfifted in the brain, or finding that any morbid ftate of
the brain then appeared.   This,  no doubt, may ferve to
Ihow, that organic lefions had not been the caufe of the dif-
eafe;  but it does notaffure us that no morbid change had
taken place in the brain:  For it is probable, that the diffec-
tors were not always aware  of its being the general condi-
tion of hardnefs and denfity, as  different in different parts
ofthe 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.
   1556. J Having thus endeavored to inveftigate the caufe
of infanity in general, it were to be wifhed that I could ap-
ply the doarine to the diftinguifhing the feveral fpecies of
it,  according as they depend upon the different  ftate  and
circumftances ofthe brain, and thereby to  the eftablifhing
of a  fcientific  and  accurately  adapted method of cure.
Thefe  purpofes,  however, appear to me to be extremely
difficult to be attained; and I cannot hope to execute them
here.  All I can do is to make fome attempts,  and offer
fome reft aaions, which further obfervation, and greater fa-
gacity, may hereafter render more ufeful. 
OFPHYSIC.
193
- 1557-]  The ingeniousTDr. Arnold has been commend-
ably employed in diftinguifhing the different fpecies of in-
fanity as they appear with refpea to the mind: and his la-
bors may  hereafter  prove ufeful, when we fliall come to
know fomething more  ofthe different ftates of the brain
correfpondmg to thefe  different ftates of the mind;  but at
prefent I can make little application of his numerous  dif-
tinaions.   It appears to me that he has chiefly pointed out
and enumerated diftinaions, that are merely varieties, which
can  lead to little or no variety of praaice: And I am ef-
pecially led to form the latter conclufion, becaufe thefe va-
rieties appear to me to be often combined  together, and to
be  often changed into one another, in the fame perfon; in
 whom we muft therefore fuppofe a general caufe of the dif-
eafe, which, fo far as it can be known, muft eftablifh the pa-
 thology, and efpecially direa the praaice.
   1558.]  In my limited views of the different ftates of in-
fanity, I muft go on to confider them  under the two heads
 OT  Mania and Melancholia:  And though I am fenfible that
 thefe two genera do not comprehend the whole of the fpe-
 cies of infanity, I am not clear in affigning the other fpecies
. which may not be comprehended under thofe titles. 1 fliall,
 however, endeavor, on proper occafions as I go along, to
 point them out as well as I can.
                     CHAP. II.

             SDf s@ania, or e@atme0tf.

1559.]  X HE circumftances which  I  have mentioned
above in (1536.) 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 conftant, nor
even a frequent, attendant o'f the difeafe.  The falfe judg-
ment, is of relations long before  laid up in the memory.
It very often  turns  upon  one fingle  fubjea;  but more
commonly the mind rambles from one fubjea to another
with an  equally falfe judgment concerning the moft part
of them ;  and as at the fame time there is  commonly a
falfe affociation, this, increafes the confufion of ideas, and 
194
PRACTICE
therefore the falfe judgments.  What for the  moft part
more efpecially diftinguifhcs the difeafe is a hurry of mind,
in purfuing any thing like a train of thought, and in run-
ning from one train of thought to another.   Maniacal per-
fons are in general very irafcible;  but what more particu-
larly produces  their angry emotions is,  that  their falle
judgments lead to fome action which is always pufhed with
impetuofity and violence;  when this is  interrupted or ref-
irained, they break out into violent anger and furious vio-
lence 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 refpea to  their former deareft
friends and relations;  and therefore  their refentment and
anger are particularly  directed  towards thefe.   And al-
though this fhould not be the cafe, they commonly foon
Jofe that refpea  and regard which they formerly had for
their friends and relations.   With all thefe circumftances,
it will be readily perceived, that the difeafe muft  be attend-
ed  very conftantly with that incoherent and abfurd fpeech
we  call raving.   Further, with the  circumftances menti-
oned,  there is commonly joined an unufual force in all the
voluntary motions; and an infenfibility or refiftance  of the
force of all  impreffions,  and particularly a refiftance of
the powers of fleep, of cold,  and even of hunger; though
indeed in many inftances a voracious appetite takes place.
   1560.] It  appears  to me  that the  whole of thefe cir-
cumftances and fymptoms  point  out a confiderable and
unufual excefs  in the excitement of the brain,  efpecially
with refpea to the animal funaions;  and it appears  at the
fame time to be manifeftly in  fome meafure unequal, as it
very often takes place with refpecf to thefe funaions alone,
while at the fame time  the vital and natural are commonly
very little changed from their ordinary healthy ftate.
  1561. J  How this excefs of excitement is produced, it
may be difficult to explain.   In the various inftances of
what Sauvages  has named the  Mania  Metastatica, and in
all the inftances I have mentioned in my Nofology  under
the  title of the Mania Corporea, it may be  fuppofed  that a
morbid organic affeaion is produced in fome part of the 
OF  pHtsrc.
i95-
brain;  and how that may produce an increafed of unequal'
excitement in certain parts of it,  I  have endeavoured to'
explain above in (1553.)  But  I muft at the fame time
acknowledge, that fuch remote caufes of mania have very
rarely occurred; and that therefore fome other caufes of
the difeafe muft. be fought for.
   The effeas of violent emotions or paffions of the mind
have more frequently occured as the remote caufes of ma-
nia; and it is fufficiently  probable, that fuch violent emo-
tions, as they do often immediately produce a temporary
increafe of excitement, fo-they may,  upon fome occafions
of their permanent inherence or frequent repetition, pro-
duce a more confiderable and more permanent excitement,-  t
that is, a mania.
   With refpea to thofe caufes of mania which arife in con-
fequence of a melancholia which had previoufly long fub-
fifted;  whether we confider that melancholia as a partial
infanity, or as a long perfifting attachment to one train-o?
thinking,  it will be  readily perceived, that in either cafe
fuch an increafe of excitement may take place in  fo confi-
derable a degree,  and in  fo large a portion of the brain, a?
may give occafion to a complete mania.
   1562.] Thefe confiderations with regard to the remote
caufes appear (to me to confirm fufficiently our general
doarine of increafed and unequal excitement in the mania
which I have defcribed above; but 1 muft own that I have
not exhaufted the fubjea, and that there arc cafes of ma-
nia of which  I  cannot affign  the remote caufes; but al-
though I  cannot in  all cafes explain in what manner the
mania is produced, I prefume, from the explanation given,
and efpecially from the iymptoms enumerated above, to
conclude, that  the difeafe defcribed above  depends upon
an increafed excitement of the brain; an opinion in which
I am  the more  confirmed, as I think it will  point out the
proper method  of cure.  At leaft I think it will moft clear-
ly explain the operation  of thofe remedies,  which, fo far
as I can learn from mv own experience and that of others,
have proved  the  molt fuccefsful in this difeafe;  and, to
illultrate this,  I now enter upon the confideration  of thefe
remedies, and to make  fome remarks upon the proper
manner of employing them.
   1-563.3 Reftraining the  anger and violence of madmen 
196                T R A C T I C E
is always neceffary for preventing their hurting thcmfclves
or others: But this reftraint is alfo to be confidered as a re-
medy.  Angry paffions are always rendered more violent
by the indulgence of the impetuous motions they produce;
and even in madmen the feeling of reftraint will fometimes
prevent the efforts which their paffion would otherwife  oc-
cafion.   Reftraint,  therefore, is ufeful, and ought to be
complete; but it fhould be executed in the eafielt manner
poffibly for the patient,  and the {trait waiftcoat anfwers eve-
ry purpofe better than any other that has yet been thought
of.   The reftraining madmen by  the force of other men,
as occafioning a conftant ftruggle  and violent agitation, is
often hurtful.   Although, on many occafion>,  it m*y  not
be fafe to allow maniacs tov be'upon their legs or to walk
about, it is never defirable to confine them to a horizontal
fituation; and whenever it can  be admitted, they fhould
be more or lefs in an erect pofture.   Although there may
be no fymptoms of any preternatural fulnefs or increafed
impetus of blood in the veffels  of the  brain, a  horizontal
pofture always increafes  the fulnefs and tenfion  of thefe
veffels, and may thereby increafe the excitement of the brain.
   1564.] The reftraint  mentioned requires confinement
within doors,  and it fliould be in a place which prefents as
few objeas of fight and hearing as poffible; and particu-
larly, it fhould be removed from the objeas that the  pa-
tient was formerly acquainted with, as  thefe  would more
readily call up ideas and their various affociations.  It is
for this reafon  that the confinement of madmen fliould hard-
ly ever be in their ufual  habitation; or if they are, that their
apartment fhould be ftrippedof all its former furniture. It
is alfo for the molt part proper, that maniacs fhould be
without the company of any of their former acquaintance;
the appearance of whom  commonly excites emotions that
increafe the difeafe.  Strangers  mav at firft be offenfive;
but in a little time they come to be objeas either of indif-
ference or of fear, and they fliould not be frequently changed.
   1565.] Fear being a paffion ihat diminifhes excitement,
may therefore be oppofed to theexcefs of it; and particu-
larly  to  the angry and irafcible excitement  of maniacs.
Thefe being more fufceptible'of fear than might be expea-
ed,  it appears to me to have been commonly ufeful.   In
moft cales if ha* appeared to be neceffary to employ a ve- 
Oi  physic.                isr
ry conftant impveffion  of fear; and  therefore to  infpire
them  with the awe  and dread of fome  particular per-
fons, efpecially of thofe who are to be  conftantly near
them.   This awe and dread is therefore, by one means or
other, to  be acquired;  in the firft place, by their being
the authors of all the reftraints that may be occafionally
proper; but fometimes it may be neceffary to acquire  it
even by ftripes and blows.  The former,  although having
the appearance of more feverity, are much fafer than
ftrokes or blows about the head.  Neither of them, how-
ever, fhould be employed further than feems very necef-
fary,  and fhould be  trufted only to thofe  whofe difcretion
can be depended upon.   There is one cafe in which they
are fupcrfluous; that is,  when the maniacal rage is either
not fufceptible of  fear,  or incapable of remembering the
objeas of it; for in fuch inftances, ftripes and blows would
be wanton, barbarity.  In many cafes of a moderate dif-
eafe, it is of advantage that the perfons who are the authors
of reftraint and punifhment fhould be upon other occafions
the beltowers of every indulgence and gratification that isad-
miffible; never, however, negleaing to employ their awe
when their indulgence fhall have led to any abufe.
    1566. J  Although in mania,  no particular irritation nor
 fulnefs of  the  fyftem feem  to be prefent, it is plain, that
 the avoiding all irritation and means of  fulnefs is proper;
 and therefore, that  a diet neither ftimulating nor nourish-
 ing is commonly  to be  employed.  As it  may  even  be
 ufeful to diminifli  the fulnefs of the fyftem, fo both a low
 and a fpare diet is likely in  moft cafes to be of fervice.
    1567.J Upon the fame principle, although no unufual
 fulnefs of the body  be prefent, it may be of advantage to
 diminifli even its ordinary fulnefs by different evacuations.
    Blood-letting,  in  particular, might be fuppofed ufeful;
 and in all recent cafes of mania it has been commonly prac-
 tifed, and I  think with  advantage; but  when the difeafe
 has fubfifted for fome time, I have feldom found bloodleuing
 of fervice. In thofe  inftances 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 proper and
 •vena neceffary remedy. Some praaitioners, in fuch cafes,
 have preferred to a  particular manner of blood-letting, re-
   Vol. II.                 B B 
I9rJ                PRACTICE
commending arteriotomy,  fcarifying the hind-head,  cr
opening the j ugular vein; and where any fulnefs or inflam-
matory difpofition in the veffels of the  brain is to be fuf-
peaed, the opening the veffds neareft to them is likely to
be of the greateft  fervice.  The opening,  however,  of ei-
ther the  temporal artery or the jugular vein in maniacal
perfons 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 erea pofture, and fuch a quantity
of blood drawn as nearly brings  on a deliquiuni animi,
which is  always a pretty certain mark of fome diminution
ofthe fulnefs and tenfion of the veffels of the brain.
   1568.] For the fame 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 ce-
lebrated uie of hellebore among the ancients.   1 cannot,
however,  fuppofe  anv fpecific power  in hellebore; 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 neceffary; and I have known fome bene-
fit obtained from the  frequent  ufe of pretty  draftiG purga-
tives.  In  this, however,  I have been frequently  difap-
pointed;  and I have  found  more advantage from the fre-
quent ufe of  cooling purgatives, particularly  foluble tar-
tar, than from more draftic medicines.
   1569.} Vomiting has alfo been frequently employed in
mania;  and by  determining  powerfully to the furface of
the body, it may poffibly diminifh the fulnefs and tenfion
ofthe veffels, and thereby the excitement of the brain; but
I have never carried the ufe of this remedy fo far as might
enable me  to judge  properly  of its effects.  Whether it
may do harm by  impelling the  blood too forcibly into the
veffels of the brain, or whether by its general agitation of
the whole fyftem it may remove  that inequality of excite-
ment which prevails  in mania, I have not had experience
enough to determine.
   1570.] Frequent fhaving of the head has  been found of
fervice in mania, and by promoting perfpiration it probably
takes off from the excitement of the internal parts.   This,
however, it is likely, may be more effeaually done by 
                     OF  PHYSIC                119

  bliftering, which more certainly takes  off the excitement
  of fubjacent parts.   In recent cafes it has been found ufe-
  ful by inducing fleep;  and when it has that  effea, the re-
  petition  of  it  may be proper:  but in manical cafes that
  have lafted for fome time, bliftering has not  appeared to
  me to be of any fervice;  and in fuch cafes alfo I have not
  found perpetual blifters, or any  other form of iffue, prove
  ufeful.
     1571. J As heat is-the principal means of firft exciting
  the nervous  fyftem, and eftablifliing  the nervous power
  and vital principle in animals: fo, in cafe of preternatural
1  excitement, the application of  cold might be fuppofed a
  proper remedy: but there are  many inftances of maniacs
  who have been expofed for a great length  of time to a con-
  fiderable degree of cold without  having their fymptoms
  anywife relieved.  This may render in general  the applica-
  tion of  cold a doubtful remedy; but it is at the fame time
  certain,  that maniacs have often been  relieved, and fome-
  times entirely  cured, by the ufe of cold bathing, efpecially
  when adminiftered in a certain  manner.   This feems to
  confift,  in throwing the madman in the cold water by fur-
  prife; by detaining him in it for fome length of time; and
  pouring  water frequently  upon the head, while the whole
  ofthe body  except the  head is immerfed in the water; and
  thus managing the whole procefs, fo as that, with the aflift-
  ance of fome  fear,  a refrigerant effea may be produced.
  This, I  can affirm, has been oPten ufeful; and that the
  external  application of  cold may be of fervice,  w7e know
  further from the benefit which has been received in fome ma-
  niacal cafes from the application of ice and fhow to the naked
  head, and from the application of the noted Clay Clap.
     Warm bathing alfo  has been recommended by fome
  praaical writers; and in fome rigid melancholic habits k
  may poffibly be ufeful,  or asemploycd in the manner pre-
  fcribed by fome,  of immerfing the lower parts of the body
  in warm  water, while cold water is poured upon the  head
  and upper parts.  jjOf this praaice,  however,  I have had
  no experience, and  in the common  manner of employing
  warm bathing I have found it rather hurtful to maniacs.
     1572.] According to my fuppofition that the difeafe de-
  pends upon an increafed excitement of the brain, efpecially
  with refpea  to the. animal funaions, opium, fo commonly 
2*0                PRACTICE
powerful in inducing fleep, or a confiderable collapfe as to
thefe functions, fhould be a powerful remedy  of  mania.
That it has truly proved fuch, I believe from ibe teftimony
of Bernard Iluet, whofe praClice is narrated at the  end of
Wepferi  Hiftoria Apopleaicorum.   I leave to my readers
to ftudy  this in the work I have referred to,  where every
part of the praaice  is fully, and it appears ir> 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 cafes large dofes of
opium; and when they had the effect of inducing fleep, it
was manifeftly with advantage.  At the  fame time, in fome
cafes, from doubts,  whether the difeafe might not  depend
upon  fome organic lefions of the brain, when the opium
would be fuperfluous;  and  in other cafes,  from doubts,
whether  there might not  be fome inflammatory affeaion
joined with the mania,  when the opium would  be hurtful,
I have never pufhed this remedy to the extent that might be
neceffary to make an entire cure.
   1573.} Camphire has been recommended as a remedy
©f mania, and there are inftances alledged of its having per-
formed an entire cure.  As it appears from the experiments
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 Philosophi-
cal Tranfactions,  No. 400.   I have hardly met with any
other teftimonies in its favour.
   1574.J 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-condua of any
bodily exercife is a very  certain means of diverting  the
mind from purfuing any train of thought, it is  highly pro-
bable that fuch exercife may be ufeful in many  cafes of
mania.
   I muft conclude  this fubjea with  observing, that even
in feveral cafes of complete mania I Have known a cure
take place in the courfe of a journey carried on for fome
length of time.
   1575.]  Thefe are the remedies which have been chieflv
employed in the mania that has been above defcribed,  and
I believe they have been employed promifcuoufly  without 
OF  P H Y S I C.               201
fuppofing that the mania was to be diftinguifhed into differ-
ent fpecies.   Indeed I am not ready to fay how far it is to
be fo diftinguifhed, but I fliall offer one obfervation which
may poffibly merit attention.
   it appears to me that there are two different cafes of ma-
nia that are efpecially different according to the original
temperament of the perfons whom the difeafe affeas.  It
perhaps occurs moft frequently in perfons of a melancho-
lic or atrabilarian temperament; but it certainly does alfo
often occur in perfons of that very oppofite temperament
which phyficians have named the Sanguine.   According as
the difeafe  happens to occur in perfons of the one or  other
of thefe temperaments I apprehend it may  be confidered
as of a different nature; and I believe,  that accurate ob-
fervation,  employed upon a  fufficient number of cafes,
would difcern  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, particular
averfions and refentments, are  more fixed and fteady  in the
melancholic than in the fanguine; and that fomewhat inflam-
matory 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, that it may be proper
 to make fome difference alfo in the praaice.  I am of opin-
 ion, that in the mania of fanguine perfons, bloodletting and
 other antiphlogiftic meafures are more proper, and  have
 been more ufeful, than in the melancholic. I likewife appre-
 hend that cold  bathing is more  ufeful in the fanguine than in
 the melancholic : But I have not had experience enough to
 afcertain thefe points with fufficient confidence.
    I have only to add to this other obfervation, that maniacs
 of the fanguine temperament recover  more frequently and
 more entirely  than thofe of the melancholic.

                      CHAP.  III.

   £Df apelanc&oip ami otfrer jFormg of 3|n0anitp,.

 1576.] JVLeLANCHOLY has been  commonly  confi-
 dered as 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 mif- 
202
PRACTICE
taken judgment upon one particular fubjea, and what re-
lates to it;  whilft, on every other fubjea, the perfon af-
feaed judges as the genefality of  other men do.   Such
cafes have certainly occurred; but, I believe, few in which
the partial infanity is ftriaiy limited.  In many cafes of
general infanity, there is one fubjea of anger or fear, upon
which the falfe judgment more particularly turns, or which
is at leaft more frequently than any other the prevailing ob-
ject of delirium:  and though, from the inconfiftency which
this principal objea of delirium muft produce, there is there-
fore alfo a great deal  of infanity with regard to moft other
objeas; yet this laft is in very different degrees, both in
different perfons, and in the  fame perfon at different times.
Thus perfons confidered as generally infane, will, however,
at times, and in fome cafes, pretty conftantly judge proper-
ly enough of prefent circumftances and incidental occur-
rences; though, when thefe  objeas  engaging attention are
not prefented, the operations of imagination may  readily
bring back a general confufion, or recal the particular ob-
jea of the delirium.    From thefe confiderations, I am in-
clined to conclude, that the limits between general and par-
tial infanity  cannot always be fo exaaiy afligned, as to de-
termine when the partial  affeaion is to be  confidered as
giving a peculiar fpecies of difeafe, different  from a more
general infanity.
   1577-3 When infanity, neither ftriaiy partial, nor en-
tirely 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 Mania defcribed above;
and alfo, though partial, muft be held as different from the
prpper Melancholia to be mentioned hereafter.
   1578.] Such a difeafe, as different from thofe defcribed
(1555.) requires,  in my opinion,  a different adminiftration
of remedies; and it will be proper for me to take particu-
lar notice of this  here.
   Although it may be neceffary to reftrain fuch infane per-
fons as we have mentioned (1577.) fr°m purfuing the ob-
jeas of their falfe imagination or judgment, it will hardly
be requifite  to employ the fame force of reftraint that is ne-
ceffary in  the impetuous and angry mania.   It will be ge-
nerally fufficient to acquire fome awe over them, that may 
O F  P H Y S I C.               303
 be employed, and fometimes even be neceffary, to check the
 rambling of their imagination, and incoherency of judgment.
   1579-j  The reftraint juft now mentioned as neceffary
 will generally require  the patient's being confined to one
 place, for the fake of excluding the objects, and more par-
 ticularly the perfons, that might excite ideas conneaed with
 the chief objeas of their  delirium.    At the fame  time,
 however, if it can be perceived there are objeas 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 effea of inter-
 rupting all train of thought, and by prefenting objeas en-
 gaging attention, may often be ufeful.    In fuch  cafes alfo,
 when the infanity, though more  efpecially fixed upon one
 miftaken fubjefct, is not confined to this alone, but is fur-
 ther apt to ramble over other  fubjeas, with incoherent
 ideas, I apprehend the confining or forcing fuch perfons to-*
 fome conftant uniform labor,  may prove an ufeful remedy.
   1580. J  When fuch cafes as in (1577.) 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 confiderable, blood-
 letting and purging will be the more proper and neceffary.
   1581.] To this  fpecies of infanity, when  occurring in
 fanguine temperaments, whether it be more or lefs partial,
 I  apprehend that cold bathing is particularly  adapted;
 while, in the partial infanity  of melancholic perfons, as I
 fhall fhow hereafter, it is hardly  admiffible.
   1582.] Having thus treated of a fpecies of infanity, dif-
 ferent, in my apprehenfion, from both the Mania and Me-
 lancholia, I proceed to confider what feems more properly,
 to belong to this laft.
   1583.] The difeafe which  I name Melancholia is very
 often a  partial infanity only.  But as  in many inftances,
 though the  falfe imagination of judgment feems to be with
 refpea to one fubjea only; yet it feldom happens that this
 does not produce much inconfiftency in the other intellec-
 tual operations:  And as, between a very general and a very
 partial infanity, there are all the poffible intermediate de-
 grees; fo it will be often difficult, or perhaps improper, to
diftinguifh melancholia by  the charaaer of Partial Infanity 
204                PRACTICE
alone.  If I miftake not, it muft be chiefly diftinguifhed
by its occurring in perfons of a melancholic temperament,
and by its being  always  attended with fome  feemingly
groundlefs, but very anxious fear.
   1584.] To explain the caufe of this, I  muft obferve,
that perfons of a melancholic temperament are for the molt
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 impref-
fions; and are therefore capable  of a clofer or more contin-
ued attention to one particular objea, or train of thinking.
They are even ready to be engaged 111 a conftant applica-
tion to one fubjea; and are remarkably tenacious of what-
ever emotions they happen to be affeaed with.
   1585.] Thefe circumftances ofthe melancholic charac-
ter, feem clearly to fhew, that perfons ftrongly affeaed with
it may be readily feized with an anxious fear; and that this,
when much indulged, as is natural to fuch perfons, may
eafily grow into a partial infanity.
   1586. J Fear and dejection of mind, or a timid and def-
ponding  difpofition, may arife  in certain ftates, or  upon
certain occafions of mere debility: and it is upon this foot-
ing, that I fuppofe it fometimes  to attend dyfpepfia.  But
in thefe cafes, I believe  the defpondent difpofition hardly
ever arifes to a confiderable degree, or proves fo obftinate-
ly fixed as  when it occurs in perfons of a melancholic tem-
perament.  In  thefe laft, although the fear proceeds from
the fame dyfpeptic feelings as in the other cafe, yet  it will
be obvious, that the emotion may arife toa more confiderable
degree; that it may be more anxious, more fixed, and more
attentive;  and  therefore may exhibit all the various cir-
cumftances which  I have mentioned  in  (1222.) to take
place in the'difeafe named Hypochondriasis.
   15^7-J 1° confidering  this fubjea formerly in  diftin-
guifhing  Dyfpepfia from Hypychondriafis, although the
fymptoms affecting the  body be  very much the fame in
both,  and even thofe affeaing the mind be fomewhat fimi-
lar, I  found no difficulty in diftinguifhing the latter difeafe,
merely from its occurring in perfons of a melancholic tem-
perament.  But I  muft now acknowledge, that  I am at a
lofs to determine how in  all cafes hypochondriafis and me- 
OF PHYSIC.
20J
lancholia may be diftinguifhed from  one another, whilft
the fame temperament is common to both.
   1588.] I apprehend, however,  that the diftinaion may
be generally afcertained in the following manner.
   The hypochondriafis I  would confider as being always
attended with dyfpeptic fymptoms: And though there may
be, at the fame time, an anxious melancholic fear arifing
from the feeling of thefe fymptoms;  yet while this fear is
only a miftaken judgment with refpe6t 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 a hypo-
chondriafis, and as  diftina from the proper melancholia.
But when  an  anxious fear and defpondency arifes from a
miftaken judgment with refpea to other circumftances than
thofe of 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 different from
both dyfpepfia and hypochondriafis; and it is, what I would
ftriaiy name Melancholia.
   1589.J In this there feems little difficulty; but as an  ex-
quifitely melancholic temperament may induce a torpor
and ffownefs in the aaion of the ftomach,  fo it generally
produces fome dyfpeptic fymptoms; and from thence there
may be fome difficulty in diftinguifhing fuch a cafe from  hy-
pochondriafis.  But I would maintain, however, that when
the charaaers ofthe  temperament are ftrongly mark^k and
more particularly when the falfe imagination turnsllpon
other fubjeas than that of health, or when, though relative
to the perfon's own body, it is of a groundlefs and abfurd
kind; then, notwithftanding the appearance of fome dyfpep-
tic fymptoms,  the cafe is ftill to  be confidered as that of a
melancholia, rather than a hypochondriafis.
   1590.]  The difeafe of melancholia, therefore manifeftly
depends upon  the general temperament of the  body: and
although, in many perfons, this temperament is not attend-
ed with any morbid affeaion either of mind or body;  yet
when it becomes exquifitely formed, and is in a high degree,
it may  become a difeafe affeaing both, and particularly  the
mind.   It will therefore be proper to confider in what this
melancholic temperament  efpecially confifts;  and to this
purpofe, it may be obferved, that in it there is a degree of
  Vol. II.                  C c 
20fJ
PRACTICE
torpor in the motion of the nervous power, both with rcf-
pecf to fenfation and volition; that there is a general rigid-
ity of the fimple folids; and that the balance of the  fan-
guiferous fyftem, is upon the fide of the veins.  But aH
thefe circumftances are the direaiy oppofite of thofe ofthe
fanguine temperament; and muft therefore  alfo produce
an oppofite ftate of mind.
   1591.J It is this ftate ofthe mind, and the ftate  ofthe
brain correfponding to it, that is the chief objea 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 ofthe brain; and
that this  perhaps proceeds from a certain want of fluid in
that fubftance, which appears from its being of a leffer fpe-
cific gravity than ufual.   That this  ftate of the brain in
melancholia does aaually exift, I conclude, first, from the
general rigidity of the whole habit; and, secondly, from dif-
feaions,  fhowing fuch a ftate of the  brain to have taken
place  in mania,  which is often no other than a higher degree
of melancholia.  It does not appear to me any wife difficult
to fuppofe, that the fame ftate of the brain may in  a mo-
derate degree give melancholia; and in a higher, that mania
which melancholia fo often paffes into; efpecially if I  fhall
be allowed further to fuppofe, that either a greater degree
of firmnefs in the fubftance of the brain may  render it fuf-
ceptible of a higher degree of excitement, or that one por-
tion of the brain may be liable to acquire a greater firmnefs
than others,  and confequently give occafion to that inequal-
ity of excitement upon which mania fo much  depends.
   J592'] I hive thus endeavored to  deliver what appears
to me moft  probable with refpea to the proximate caufe
of melancholia; and although  the matter fliould in fome
refpeas remain doubtful, I am well perfuaded that thefe ob-
fervations may often be employed to direa our praaice in
this difeafe, as I fhall now endeavor to fhow.
   1 S93J In moft ofthe inftances of melancholia, the mind
is to be managed very much in the fame manner as I have
advifed above with regard to hypochondriafis; but as in the
cafe of proper melancholia, there is commonly afalfeima- 
                   OF PHYSIC.                307

^nation or judgment appearing as a partial infanity, it may
be further neceffary in fuch cafes to employ fome artifices
for corre£ting fuch imagination or judgment.
   1594* J Tfie various remedies for relieving the dyfpeptic
fymptoms which always attend hypochondriafis, will feldom
be eiuier requifite or proper in melancholia.
   There is only one  of the dyfpeptic fymptoms, which,
though there fhould be no other, is very conftantly prefent
in melancholia, and that is coftivenefs.  This it is always
proper and even neceffary to  remove; and I believe it is
upon this account that the ufe of purgatives has been found
fb often ufeful in melancholia.   Whether there be any pur-
gatives peculiarly proper in this cafe, I dare not pofitively
determine;  but with refpea to the choice of purgatives in,
melancholia, I am of the fame opinion that I delivered above
on this fame  fubjec^ with refpe6t to mania.
   1595.]  With refpea to other remedies, I judge that
blood-letting will more feldom be  proper in melancholia
 than in mania; but how far it may be  in any cafe proper,
 muft  be determined by the  fame confideration as in  the
 cafe of mania.
    1596.J  The cold  bathing that I judged  to be  fo very
 ufeful in feveral cafes of infanity, is,  I believe, in melan-
 cholia, hardly ever fit to be admitted;  at leaft while this is
 purely a partial affeaion, and without any marks of violent
 excitement.   On  the contrary, upon account ofthe gener-
 al  rigidity  prevailing in melancholia,  it  is probable that
 warm bathing may be often ufeful..
    1597.J With refpea to opiates which I have fuppofed
 might often be ufeful in cafes  of mania, I believe  they can
 feldom  be properly employed in the partial infanities of
 the melancholic, except in certain inftances of violent ex-
 citement, when the melancholia approaches nearly  to the
 ftate of mania.
    1598.J In fuch cafes of melancholia  approaching to a
 ftate of mania, a low  diet may fometimes  be neceffary; but
 as the employing  a  low diet almoft unavoidably leads to
 the ufe of vegetable  food, and as this in every torpid ftate
 of the ftomach is ready to produce fome dyfpeptic  fymp-
 toms, fuch vegetable  food ought, in moderate cafes of me-
 lancholia, to be ufed with fome caution.
    Though exercife, as a tonic power, is not proper  either 
205                PRACTICE
in hypochondriafis or melancholia;  yet, with refpea to its
effects upon the mind, it may be extremely ufeful in both,
and in melancholia is to be employed in the fame manner
that I have advifed above in the cafe of hypochondriafis.
   J599.] Having now delivered  my doctrine with refpea
to the forms of infanity, I fliould in the next place proceed   <
to confider the other genera of Amentia and Oneirodynia,   J
which in the Nofology I have arranged under the order of   I
Vefaniae; but as I cannot pretend to throw much light up-
on thefe fubjeas, and as  they are feldom the  objeas of
praaice, I think it allowable  for me to pafs them over at
prefent;  and the particular circumftances of this work in
fome meafure require that I fliould do fo.
ii              '      ■                            —

                 PART   III.

            Of   CACHEXIES.

1600.]  U NDER this title I propofe toeftablifh a clafs of
difeafes, which confift in a depraved ftate of the whole, or
of a confiderable part, of the habit of  the body, without
any primary pyrexia or neurofis combined with that ftate.
   1601. J The term Cachexy has been employed by Lin-
naeus and Vogel, as it had been formerly by other authors,
for the name of a particular difeafe; but the difeafe to which
thefe authors have affixed it, comes more properly under
another appellation; and the term of Cachexy is more pro-
perly employed by Sauvages and Sagar for the name of a
clafs.  In this I have  followed the laft-mentioned nofolo-
gifts, though I find it difficult to give fuch a charaaer of the
clafs as  will clearly apply to all the fpecies I have compre-
hended  under it.  This difficulty would be ftill greater, if,
in the clafs I have eftablifhed under the title of Cachexies,
I  were to comprehend all the difeafes that thofe other no-
fologifts have done;  but I am willing to be thought defi-
cient rather than very incorrea.  Thofe difficulties,  how-
ever, which ftill remain in methodical  nofology, muft not
affea us much in a treatife of praaice.   If I can here  pro-
perly diftinguifh and defcribe the feveral fpecies that truly
and moft commonly exift, I  fhall be the lefs concerned
about the accuracy of my  general claflification ; though at 
OFPHYSIC               '2€r9
the fame time this, I think, is always to be attempted; and
I fhall purfue it as well as I can.
  ,       ______      ....   _____•_

                  BOOK   I.

         Of   E  M 4 cTa  T I 0  N S.

1602.] HjMACIATION, or a confiderable diminution
of the bulk or plumpnefs of the whole body, is for the moft
part only a fymptom of difeafe, and very feldom to be con-
fidered as a primary and idiopathic affeaion.  Upon this
account, according to  my general plan, fuch a fymptom
might perhaps have been omitted in the Methodical Nofo-
logy :  but both the uncertainty of concluding it to be al-
ways fymptomatic, and the confiftency of fyftem, made me
introduce into the Nofology, as others had done, an order
under the title of  Marcores;  and this  renders it requifite
now to take fome notice of fuch difeafes.
   1603.] Upon  this occafion, therefore, I hope it may be
ufeful to inveftigate the feveral caufes of emaciation in all
the different cafes of difeafe in which it appears.   And this
I attempt, as the fureft means of determining how far it is a
primary, or a fymptomatic affeaion only; and even in the
latter  view,  the inveftigation  may be attended with fome
advantage.
   1604. J The caufes of emaciation may, I apprehend, be
referred to two general heads; that is, either to a general
deficiency of fluid in the veffels of the body, or to the par-
ticular deficiency of the oil in the cellular  texture of it.*
Thefe caufes are frequently combined together;  but it will
be proper, in the  firft place, to confider  them feparately.
   1605.] As a great part of the body of animals is made
up of veffels filled with fluids, the bulk of the whole muft
depend very much on the fize of thefe veffels, and the quan-
tity  of fluids prefent in them :  and it will therefore be fuffi-
ciently obvious, that a deficiency of the fluids in thefe vef-
fels muft, according to its degree,  occafion a proportionate
diminution of  the bulk of the whole body.  This, how-
ever, will appear  ftill more clearly,  from confidering that
in the living and  found body the veffels every where feem
* Might not a third caufe be added, viz. a deficiency of the folid parts 1 
21ft                  PRACTICE
 to be preternaturally  diftended by  the quantity of fluids
 prefent in them; but  being at the fame  time elaftic,  and
 conftantly endeavouring to cohtraa themfelves, they muft
 on the withdrawing of the diftending force,  or,  in other
 words,  upon a diminution of  the quantity of fluids, be in
 proportion contraaed  and diminifhed in their fize.   And it
 may be further obferved, that as each part of  the vafcular
 fyftem communicates with every other part of it; fo every
 degree of diminution of the quantity of  fluid,  in any one
 part, muft in proportion diminifh the bulk of the vafcular
 fyftem, and confequently of the whole body.*
    1606. J The diminution and deficiency of the fluids may
 be occafioned by different caufes:  fuch as,  firft, by a due
 quantity of aliments not being taken in;  or by the  aliment
 taken in not being of a fufficiently nutritious quality.   Of
 the want of a due quantity of aliment not being taken into
 the body,  there is an   inftance in the  atrophia lactantium
 Sauvagelii, fpecies 3.  and many other examples have oc-
 curred of emaciation from want of food, occafioned by po-
 verty, and other accidental caufes.
    With  refpea  to the quality of food,  I apprehend it
 arifes from the want of  nutritious matter in the food em-
 ployed, that perfons living entirely on vegetables are fel-
 dom of a  plump and fucculent habit.t
   -1607.] A fecond caufe of the  deficiency  of  fluids may
 be, the aliments taken in not being conveyed to the blood-
 veffels.    This may occur from a perfon's  being  affeaed
 with a frequent vomiting;  which,  rejeaing the food  foon
 after it had been taken  in,  muft prevent the neceffary  fup-
 ply of fluids  to the  blood-veffeb.J   Another caufe, fre-
 quently interrupting  the  conveyance of the alimentary
 matter into the blood-veffels, is an obftruaion of the  con-
 globate lymphatic glands of the mefentery,  through which
 the chyle  muft neceffarily pafs to the thoracic duct. Many
 inftances  of emaciation, feemingly depending upon this
 * There may, however, be a partial without a jeneral emaciation, as is the cafe in a palfied limb •
 but this partial diminution of bulk In the difeafed limb is not owing to a leflened quantity of the ge-
 neral mafs of the circulating fluids, but to the languid circulation in that part, the arteries not pro-
 pelling the blood through it with fufficient vigor.                         "   v
 t As the author fays at the conclusion of thischapter, " After having confidered the various caufe*
 of emaciations, I fliould perhaps treat of their cure: but it will readifv appear, that the greater pare
 of the cafes above mentioned are purely fymptomatic, and confequently that the cure ofthem mult
 be that of the primary difeafes upon which they depend. Of thofe cafes that can any wife be con-
 fidered as idiopathic, it will appear that they are to be cured entirely by removing the remote caufes •'*
 it may not be improper to treat of the cure as we proceed.
 This fpecies of emaciation may be obvioufly cured by a rich and nutritious diet.
 t This fpecies may be cured bypreventing the vomiting by antifpafmodics, efpecially opium, and
by the ufe of gentle laxatives occafioually. A nutritious diet will alfo be neceffary in thefe cafe*. 
OF  PHYSIC.                211
caufe, have been obferved by phyficians, in perfons of all
ages, but efpecially in the young.  It has alfo been remarked,
that fuch cafes have moft frequently occurred in  ferophu-
lous perfons,  in whom the mefenteric glands are common-
ly affeaed with tumour or obftruaion,  and in whom, ge-
nerally at  the fame time,- fcrophula appears externally.
Hence the Tabes  scrophulosa Synop. Nosolog. vol. ii. p.
266.  And under  thefe  I have put as fynonimes Tabes
glandularis, fp.  10.  Tabes mescnterica, fp. 9. Scrophula
mesenterica, fp. 4.   Atrophia infantilis, fp.  13. Atrophia
rachitica, fp.  8.  Tabes rachialgica,  fp. 16.    At the fame
time,  I have frequently found  the  cafe occurring in per-
fons who did not fhow any external appearance  of fcro-
phula, but in whom the mefenteric  obftruaion was after-
wards difcovered by  diffeaion.   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  ge-
nerally appears; but I have met with inftances of itatfour-
teen years of age afcertained by diffeaion.   In feveral fuch
cafes which I  have feen, the patients were without anv fero-
phulous appearances at the time, or at any period of their
lives before.*
   In the cafe of phthifical perfons,  I fliall  hereafter men-
tion another caufe of  their emaciation; but it is probable
that an obftruaion of  the mefenteric glands, which fo fre-
quently happens in fuch perfons, concurs very powerfully
in producing the emaciation that takes place.
   Although a ferophulous taint may be  the moft  frequent
caufe of mefenteric obftruaions, it is fufficiently probable
that other kinds of  acrimony may produce the fame, and
the emaciation that follows.
   It may perhaps be fuppofed, that the interruption of the
chyle's palling into the blood-veffels may be fometimes ow-
ing to a fault of  the abforbents  on the internal furface of
the  inteftines.  This,  however,  cannot be readily afcer-
tained: but the interruption of the chyle's palling into the
blood-veffels  may certainly be owing to a rupture of the
thoracic dua; which,  when it does  not prove foon fatal,
 * Thefe cafes are generally incurable; if, however, there be no fufpicion of fcrophula, we may at-
tempt a cure by endeavoring to removethe ooftrudtion either by invigorating the habit, or by active
aperients. Open and pure ilr, with exercife fuited to the ftrength of the patient, the ufe of chaly-
beate waters, have admirable erfectsin thefe cafes. Peruvian bank fo often ufed as a tonic, isircjuco-
per in all cafes of obstructed gland*, as are alfo aftringents and ftyptics. 
212                 PRACTICE
 by occafioning a hydrothorax,  muft in  a fhort time pn>-
 duce a general emaciation.*
    3608.] A third caufe of the deficiency of the fluids may
 be a fault in the  organs of digeftion, as not duly convert-
 ing the aliment into a chyle fit to form in the blood-veffels
 a proper nutritious  matter.   It  is not, however, eafy to
 afcertain the cafes of emaciation which are to be attributed
 to this caufe;  but I apprehend that the emaciation which
 attends long fubfifting cafes of dyfpepfia, or of hypochon-
 driafis, is to be explained chiefly in this way.  It is this
 which I have placed in the Nofology under the title of the
 Atrophia deb}lium;  and of  which the Atrophia Nervosa,
 Sauv. fp.  1. is a proper inftance, and therefore put there
 as a fynonime.  But the other titles of Atrophia Lateralis,
 Sauv. fp.  15. and Atrophia senilis, Sauv. fp. 11. are not fo
 properly put there, as the y muft be explained in a different
 manner.t
   1609.]  A fourth caufe of a deficiency ofthe fluids in the
 body, may be exceffive evacuations made from it by differ-
 ent outlets;  and  Sauvages has  properly enumerated  the
 following fpecies, which we have put as fynonimes under
 the title of Atrophia  inanitorum,; as, Tabes nutricum, fp.
 4; Atrophia nutricum, fp. 5; Atrophia a leucorrhcea, fp.
 4; Atrophia ab alvi filuxu,  fp. 6;   Atrophia d ptyalismo,
 fp. 7; and laftly,  the Tabes d sanguifluxu; which, it is to
 be obferved, may arife not only from fpontaneous hemor-
 rhagies or accidental wounds, but alfo from blood-letting in
 too large a quantity, and too  frequent repeated.
   Upon this fubjea it feems proper to obferve, that a mea-
 gre habit of body  frequently depends upon a full perfpira-
 tion being conftantly kept up,  though  at the fame time a large
 quantity of nutritious aliment is regularly taken in.J
   1610. J  Befides this deficiency of fluids from evacuations
 by which they are carried entirely out ofthe  body,  there
 may be a deficiency of fluid and emaciation in a confider-
 able part of the body, by the fluids  being drawn into one
 part, or colleaed  into one cavity; and of this  we have an
inftance in the Tabes a hydrope, Sauv. fp. ij..||
 * This is an abfolute incurable difeafe.
 + This fpecies of emaciation may be fuecelsfully cured by the means of thofe remedies mentioned
in the Notes on Articles 1104.  1206. mo. 1212. 1213. inc. 1216. 1221.
 X In thefe cafes aftringents are the principal remedies on which we muft, depend'; and thofe aftrin*
pt nts muft be chofen which arc adapted to fupprefs the peculiar evacuation that occafions the difeafe.
 ■i The emaciation from this caufe is merely fymptomatic, and can only be cured oy curing the
jitn-.-y dileale.                                            '- 
O F  P H Y S I C.                211
   1611.] In  the  Methodical Nofology, among the other,
fynonimes of the Atrophia inanitorum I have fet down the
Tabes dorsalis;  but whether properly or not, I at prefent
verv much  doubt.  In  the evacuation  confidered as the
caufe of this tabes, as  the quantity evacuated is  never i'o
great as to account for a general deficiency of fluids in the
body, we muft  feek for another explanation  of it.   And
whether the effeas ofthe evacuation may be accounted for,
either from the quality ofthe fluid evacuated, or  from the
fingularly enervating pleafure attending the evacuation, or
from the evacuation's  taking off the tenfion  of parts, the
tenfion of which has a finguiar power in fupporting the ten-
fion  and vigour of the whole body, I  cannot pofitively de-
termine; but I apprehend that upon  one or other of thefe
fuppolitions the emaciation attending the tabes dorsalis muft
be accounted for;  and therefore, that  it is to be confidered
as an inftance ofthe Atrophia debilium,  rather than of the
Atrophia inanitorum*
   1612. J A fifth  caufe  of a deficiency of fluids and  of
emaciations  in the  whole or in a particular part of the body,
may be the concretion  of the fmall veffels, either not ad-
mitting  of fluids, or of the fame proportion as before; and
this feems to me to be the cafe in the Atrophia senilis, Sauv.
fp. 2. Or it may be a palfy of the larger trunks ofthe arte-
ries rendering them unfit to propel the blood into the fmaller
veffels;  as is frequently the cafe of paralytic limbs, in which
the arteries are affeaed as well as the  mufcles.  The Atro-
phia lateralis,  Sauv. fp. 15, feems to be of this nature.t
   1613. J A fecond general head ofthe caufes of emacia-
tion  I have  mentioned in (1603.) to be a deficiency of oil.
The extent  and quantity of the  cellular texture  in every
part of the body,  and tlierefore  how confiderable a part it
makes in the bulk of the whole is now well known.  But this
fubftance, in different circumftances,  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 fluids, for a reafon to be im-
mediately'explained, is generally  accompanied with a de
ficiency of oil:  But phyficians have commonly  attended
 * If a particular abominable praaice be the caufe, it muft be abandoned before a cure can be
""t&s is one ofthe Incurable fpecies of emaciation, and it can only be relieved by a very nutrit \vv
and invigorating djet.
  VOL.  Ii.                 £> B 
*14
PRACTICE
more to  the latter caufe  of emaciation than to the oi/.er,
that being ufually the moft evident;  and I fhall now endea-
vour to affign the feveral caufes of the deficiency of oil as
it occurs upon different occafions.
   1614.] The bufinefs of lecretion in the human  body is
in general little underftood,  and in no inftance lefs fo thai.
in that of the fecretion of oil from  blood which does  not
appear  previoufly  to have  contained i;.   It is poffible,
therefore, that our theory of the deficiency of oil may be
in  feveral refpeas  imperfea;  but  there are certain facts
that may in the mean  time apply to  the prefent purpofe.
   1615.] Firft, it is  probable,  that a deficiency of oil
may be owing to a ftate of the blood in animal bodies  lefs
fitted to afford a fecretion of oil, and confequently to fup-
ply the watte of it that is conftantly made.   This ftate of
the blo.cl muft efpecially depend upon the ftate of the ali-
ments taken in, as containing lefs  of oil or  oily matter.
From many obfervations  made^  both  with refpea to the
human body and to that of Other animals,  it appears pretty
clearly,  that the aliments taker) in  by  men and domeftic
animals, according as they contain  more of oil,  are in ge-
neial more nutritious, and in particular are better fitted to
fill the  cellular texture of  their bodies  with oil.   I might
illuftrate this,  by  a minute and particular confideration of
the difference of alimentary matters employed;  but it will
be enough to  give twTo  inftances. The  one is,  that the
herbaceous part of vegetables does not fatten animals, fo-
much as the feeds of vegetables, which manifeftly contain in
any given weight a greater proportion of oil ;  and a fecond
inftance is, that in general  vegetable aliments do not fatten
men fo much as animal  food, which generally contains a
larger proportion 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 (1605.)  DUt  mual ai^° afford
 lefs oil, to be poured into the cellular texture.   In  fuch
 cafes, therefore,  the emaciation  produced, is to be  attri-
 buted to both thefe general caufes.*
    1616. j A fecond  cafe of the deficiency of oil may be
 explained in this manner.   It is pretty manifeft, that the   j
 oil of  the  blood is fecreted and depofited in the cellular
  * The ewe of tbfrljpecitt of emaciation wiEbeoeft effettedbyarich i'.t'-.c! animal food. 
OF  PHYSIC.
215
texture in greater or  leffer quantity, according as the cir-
culation of the blood is fafter or flower ;  and therefore that
exercife, which  haftens the circulation ofthe blood,  is a
frequent caufe of emaciation.  Exercife  produces  this ef-
fea in two ways,   ift, By increafing 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 defi-
ciency of thefe,  which muft alfo caufe a deficiency of oil
in the cellular texture,  sdly, It is well known, that the
oil depofited in the cellular texture is upon  many occafi-
ons,  and  for various  purpofes of the economy, again ab-
 forbed, and mixed or diffufed in the mafs of blood, to be
irom thence perhaps  carried entirely out of the bodv by
 the  feveral excretions.   Now,  among other purpofes of
 the accumulation and reabfoption of oil, this feems to be
 one, that the oil is  requifite  to the  proper aaion  of the
 moving fibres in every part  of  the  body; and therefore
 that nature has provided for an abforption of oil to be made
 according as the aaion of the moving fibres may demand
 it.   It will thus be obvious, that the exercife of the mufcu-
 lar  and moving fibres every where,  muft occafion  an ab-
 forption of oil; and confequently that fuch exercife not
 only prevents the fecretion of oil,  as has been already faid,
 but may  alio caufe a deficiency of it,  by occafioning an
 abforption  of what  had been depofited;  and in this  way
 perhaps efpecially, does it produce emaciation.*
    1617.] A third cafe ofthe deficiency of oil may occur
 from the following  caufe.  It-is probable, that one pur-
 pofe of the accumulation of oil in the cellular texture of
 animals is,  that it may, upon occafion,  be again abforbed
 from thence, and carried into the mafs  of blood,  for the
 purpofe. of enveloping and correaing any unufual acrimo-
 ny arifing and exifting in  the ftate ofthe fluids.  Thus,  in
 moft inftances in which we can difcern an acrid ftate of the
 fluids, as in fcurvy, cancer, fyphilis, poifons, and feve-
 ral 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 pre-
 fence of acrimony in the body excites.
   * Abftinence from too fevere exercife is the only cure for th:.; fpecies of the difeafe. 
2 IS                 PRACTICE
   It is not unlikely- that certain poifons introduced into the
body,  may fubfift  there;  and, giving occafion to an ab-
forption of oil, may lay a foundation for the Tabes  a ve-
neno, Sauv. fp. 17.*
   1618.J A fourth cafe of emaciation, and which  I would
attribute toafuddenand conhderablcabforption of oil from
the cellular texture, is that of fever, which fo generally pro-
duces emaciation.   This may perhaps be in part attributed
to the increafed perfpiration, and  therefore to ihe general
deficiency of fluids that may  be fuppofed to take place :
but whatever fhare that may have in producing the effea,
we can,  from the  evident flirinking and diminution of the
cellular fubftance, wherever it fall's under our obfervation,
certainly conclude, that there has been a very confidetable
abforption of  the oil  which  had been before depofited in
that  Jubilance.   This explanation is  rendered the more
probable from this, that I  fuppofe the abforption mention-
ed is neceffarily made for the purpofe of enveloping or cor-
reaing an acrimony,  which manifeftly does in many, and
and may be fufpeaed to arife  in all, cafes of lever.   The
moft remarkable inftance of emaciation occurring in fevers,
is that which appears in the cafe of heaic fevers.  Here the
emaciation may be attributed to the profufe fweatings that
commonly  attend the difeafe;  But there is much reafon  to
believe, that  an  acrimony alfo is prefent  in the  blood;
which,  even in the beginning of  the difeafe, prevents the
fecretion and  accumulation of oil; and in the more ad-
vanced ftates of it, muft occafion a more confiderable ab-.
forption of  it; which, from the fhrinking of the cellular
fubftance,  feems  to go farther than in almoft any other in-
ftance.t
   Upon the  fubjea of emaciations from a deficiency  of
fluids, it may be  obferved, that every increafed evacuati-
on 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 watte of the  fluids
 # As this kind of emaciation proceeds from various caufes, the practitioner muft, after having af-
certained the true caufe, endeavor to remove it: and this mult be left entirely to his own  fagacity.
It may however be proper to obferve, that feveral of thefe emaciations proceed from incurable difea-
fes _; as from Cancer, Scrophula, &c.  and confequently admit of no cure : And thofe emaciations
which proceed from fcurvy, fyphilis, or thofe difeafes which we can cure, are only to be cured by
curing the primary difeafe.
  + This emaciation is purely fymptomatic, and consequently cannot be cured hut by removing the
primary difeafe, and a fubfequent very nutritious aiet, ccnuiu.-.^ chiefly cf ,-jima: fool. 
OF  PHYSIC.
2 IT
in the vafcular fyftem,  but alfo by occafioning a confider-
able abforption from the cellular texture.
   1619.] I have thus endeavoured  to explain the feveral
cafes and caufes of emaciation; but I could not profecute
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 Species of Sauvages; but
it is my opinion now, that the arrangement there given is
erroneous in both combining and feparating fpecies im-
properly :  And it feems to me more proper  here to take
notice of difeafes, and put  them together,  according to
the affinity of their nature, rather than by that of  their ex-
ternal appearances.  I doubt, if even the diftinaion ofthe
Tabes and Atrophia, attempted in the Nofology,  will pro-
perly apply; as I think  there are  certain difeafes  of the
lame nature, which fometimes appear with, and fometimes
without, fever.
    162.0.J  After  having confidered  the  various cafes of
emaciations, I fhould perhaps 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 cure of them muft be that of the primary difeafes upon
 which they depend.   Of thofe cafes that can anywife be
confidered as idiopathic, it will appear that they  are to be
cuied entirely by removing the remote caufes; the  means
of accomplifhmg which muft be  fufficiently obvious.

                 BOOK   II.

      Of Intumesentiae oi" General Swellings.

 1621. J  X HE fwellings tobe treated of in this place, are
 thofe which extend over the  whole or a great part of  the
 body;  or  fuch at leaft,  as,  though of fmall extent,  are
however of the fame nature with thofe that are more gene-
rally extended.
    The fwellings comprehended under this artificial order,
 are hardly to be diftinguifhed from one another otherwife
 than by  the matter they contain or confift of:  And in this
view I have divided the order into  four  feaions,  as  the
fwelling happens to  contain,  is.', Oil;  2d,   Air;  3d,  A
watery fluid; or, 4/A, As the increafed bulk depends upon 
«m                PRACTICE

the enlargement of the whole fubftance of certain parts,
and particularly of one or more of the abdominal vifcera.

                    CHAP.  I.



1622.]  J_ HE only difeafe to  be mentioned in this chap-
ter,  I have, with other  Nofologifts,  named Polysarcia;
and in Englifli it may be named Corpulency, or, more
itriaiy, Obefity; as it is placed here  upon  the  common
fuppofition of its depending chiefly  upon the increafe of
oil in the cellular texture of  the body.   This corpulency,
or obefity, is in very different degrees  in different perfons,
ani is often confiderable  without being confidered as a dif-
eafe.   There is, however, a certain  degree of it, which
will be generally allowed to be a difeafe; as, for example,
when it renders perfons, from a difficult refpiration, uneafy
in themfelves, and,  from the inability of exercife,  unfit
for difcharging the duties of life to others:  And for that
reafon I have  given fuch a difeafe a  place here.  Many
phyficians have confidered it as  an "objed of praaice, and
as giving,' even in a very  high degree,  a difpofition to ma-
ny difeafes; J am of opinion that it fhould be an objea of .
praaice more frequently than it has been,  and therefore
that it merits our confideration here.
   1623.]  It may perhaps be alledged,  that I have not been
fufficiently correa, inputting the difeafe of corpulency as
an intumefcentia pinguedinofa, and therefore  implying its
being an increafe of the bulk of the body from an accumu-
lation of oil in the cellular texture only.  I  am aware of'
this objeaion: and as I have already laid, that emaciation
{1604.) depends either upon a general deficiency of fluids
in the  vafcular fyftem, or upon a deficiency of oil in the
cellular texture;  fo I fhould perhaps have obferved farther,
that  the corpulency, or general fulnefs  of the body, may
depend upon the  fulnefs  of the  vafcular fyftem  as well as
upon, that of the  cellular texture.  This is true; and for
the fame reafons I ought, perhaps, after Linnaeus and Sa-
gar,  to have fet down plethora as a particular  difeafe, and
as an inftance  of morbid  intumefcence.  I have, however,
avoided this, as Sauvages and Vogel have done;  becaufe I 
O F  P H y SIC.                2i9
apprehend  that plethora is to be confidered as a ftate of
temperament only,  which may indeed difpofe to difeaf-;
but not as a difeafe in itfelf, unlefs, in tire language of the
Stahlians, it be a plethora commota, when it produces a dif-
eafe accompanied with particular fymptoms,  which give oc-
cafion  to its being diftinguifhed by a differcm appellation.
Further, it appears to me, that  the fymptoms which  Lin-
naeus, and more particularly thofe which  Sagar employs in
the character of plethora, never do occur but when the m-
tumefeentia pinguedinofa has  a great fhare in  producing
them.   It is, however, very neceffary to  obferve here, that
plethora and obefity are  generally combined  together; and
that in fome cafes of corpulency it may be difficult to deter-
mine which ofthe caufes has the greateft fhare in producing
it.  It is indeed very poffible that a  plethora may occur
without great obefity; but I apprehend  that obefity never
happens to a confiderable degree without producing a ple-
thora ad spatium in a great part of the fyftem of the aorta,
and therefore a plethora ad molem in the lungs, and in the
veffels of the brain.
   1624.] In attempting the aire of polyiarcia, I «-.m of
opinion that the  conjunaion of plethora and  obefity, m the
manner juft now mentioned, fhould be conftantly attended
to; and when the morbid  effeas of the plethoric habit art"
threatened, either in the  head or lungs, that blood-letting is
to be praaifed:  but at the fame time it  is to be obferved,
that perfons of much obefity do not bear blood-letting well;.
and when the circumftances I have mentioned do not im-
mediately require it, the praaice upon account of obefity
alone,  is hardly ever to be employed.   The fame remark
is to be made with refpea to any other evacuations that may
be propofed  for the cure of corpulency: for without the
other means I am to mention, they can give but a very im-
perfea relief;  and, in fo far as they can either empty 01
weaken the fyftem,  they may favor the return of plethora,
and the increafe of obefity.
   1625.] 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 cur-
ed, or the effeas of it are to be obviated, by diet and exer-
cife.  The diet  muft be fparing; or rather, what is  more
admiffiblej  it mufl be fuch as affords little nutritious  mat* 
£20                 P R A C T I C E'

ter.  It fnuft therefore be chieflv, or almoft only, of vegeta-
ble matter,  and at the very utmoft of milk.  Such a diet
fhould be employed, and generally ought to precede cxer-
cife: for obefity does not eafily admit of bodily cxercife j
which is, however, the onlv mode tffat can be very effedua!.
Such, indeed, in many cafes,  may feem difficult to be ad-
mitted; but I am of opinion,  that even the moft corpulent
may be brought to bear it, by at firlt  attempting  it very
moderately, and increafing it by degrees very  (lowly, but
at the fame time perfilting in fuch attempts  with great con-
ftancy.*
   1626.] As thefe. though the only effeaual  meafures,
are often difficult to be admitted or carried  into execution,
fome other means have been thought of and employed 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  tobe the  clfc-as  of vinegar
and  of foap, which have  been propofed.   I'he latter,  I
believe, hardly paffes into the blood-vcffels, without being
refolved and formed into a  neutral fait, with the acid which
it meets with in the ftomach.   How well acrid and  faline
fubftances are fitted to diminifh obefity, may appear from
what  has been  faid above in  (1616.)   What effeas vine-
gar, foap,  or other fubftances employed,  have had in re-  *
dueins; 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 confequences than the  corpulency it  was in-
tended to correct; and that no perfon fliould hazard thefe,
while he may have recourfe  to the more fafe  and certain
means of abftinence and exercife.

                     CHAP. II.

             £)f JFiatulent ^toeliingai.

1627.]  X  HE cellular texture of the human body very
readily admits of air, and allows the fame to pafs from any
one to every other part of it.    Hence Emphyfemata have
often appeared  from air colleaed in the cellular texture
under the fkin,  and in feveral  other parts ofthe body. The
 * Befides the mear.s mentioned by the author, evacuatic-.-i if different kinds ought to be occaflon-
alry made, efpecially by purging and fweating. 
OF  PHYSIC,               221
flatulent  fwellings under the fkin, have indeed moft com-
monly appeared in confequence of air immediately intro-
duced from  without:  But  in fome  inftances of flatulent
fwellings, efpecially thofe of the  internal parte not com-
municating with the alimentary canal, fuch an  introduaion
cannot be perceived or fuppofed;  and therefore,  in thefe
cafes, fome other caufe  of  the produaion and colfeaion
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 confiderable
quantity of air in a fixed ftate, which may be again reftored
to its  elaftic ftate, and feparated from thofe fubftances, by
the power of heat, putrefacfion, and perhaps other caufes:
But which of thefe may have  produced the feveral inftan-
ces of pneumatofis  and flatulent fwellings that have been
recorded  by authors,  I cannot pretend to afcertain.  In-
deed  upon account of  thefe difficulties, I cannot proceed
with  any clearnefs on the general fubjecf of pneumatofis;
and therefore, with regard to flatulent fwellings,  I find it
neceffary to confine my felf to the confideration of thofe of
the abdominal region alone; which I fhall now treat of un-
der the general name of Tympanites.
   1628.J The tympanites is a fwelling  of the abdomen;
in which  the  teguments appear to be much ftretched by
fome  diftending  power  within,  and equally ftretched in
every pofture of the body.  The fwelling does not readily
yield  to any preffure;  and in fo far as it does, very quick-
ly recovers its former ftate upon the preffure being removed.
Being ftruck, it gives a found like a drum, or other ftretch-
ed animal membranes.  No fluctuation within is to be per-
ceived;  and the whole feels lefs weighty than  might be ex-
peaed from its bulk.   The uneafinefs of the diftention is
commonly relieved  by  the difcharge of  air from  the ali-
mentary canal, either upwards or downwards.
   1629.] Thefe are the chafers by which the tympanites
may  be diftinguifhed  from the afcites or phyfeonia; and
many experiments fhow, that the tympanites always de-
pends upon a preternatural  colfeaion  of air, fomewhere
within the teguments of the abdomen: But  the feat of the
air is in different cafes fomewhat  different; and this pro-
duces the different fpecies of the difeafe.
  Vol. II.                 E E 
222                PRACTICE
  One fpecies is, when the air colleaed is entirely confin-
ed within the cavity of the alimentary canal, and chiefly in
that of the inteftines.  This fpecies, therefore, ?s named the
Tympanites intestinalis, Sauv. fp. 1.   It is,  of all others,
the moft common;  and to it efpecially belong  the charac-
ters given above.
  A fecond fpecies is, when the air colleaed is not  en-
tirely confined to the cavity  of  the inteftines, but is alfo
prefent between their coats;  and fuch is that which is nam-
ed by Sauvages Tympanites enterophysodes,  Sauv. fp. 3.
This has certainly been a rare occurrence;  and has proba-
bly occurred only in confequence of the tympanites intes*
tinalis, by the air efcaping from the cavity  of the inteftines
into  the interftices 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 ca-
vity, to efcape into the interftices of their coats, though in
the whole of their cavity there has been  no previous accu-
mulation.
   A third fpecies is, when the' air is colleaed in  the fac of
the peritonaeum,  or what is  commonly called the cavity
of the abdomen, that is, the fpace between  the peritonaeum
and vifcera; and then the difeafe is named Tympanites ab-
dominalis,  Sauv. fp. 2.  The exiftence of fuch a tympan-
ites, without any tympanites intestinalis^ has been difputed;
and it certainly has been a rare occurrence:  But from fe-
veral diffeaions, it is unqueftionable  that fuch a difeafe has
fometimes truly occurred.
   A fourth fpecies of tympanites is,  when the tympanites
intestinalis and abdominalis are  joined together, or  take
place at the fame time. With refpea to this, it is probable
that the tympanites  intestinalis is the  primary difeafe ; and
the other, only a confequence of the air efcaping, by an e-
rofion or rupture of the coats of the inteftines, from the ca-
vity of thefe into that of the abdomen. It is indeed poffible
that in confequence of erofion or rupture, the air which is
fo conftantly prefent in the inteftinal canal, may efcape from
thence in fuch quantity into the cavity of the abdomen, as
to give a tympanites abdominalis, whilft there was no pre-
vious confiderable accumulation of air in the inteftinal ca-
vity itfelf; but  I  have not faas to afceruin this matter
properly.                            ( 
OF  PHYSIC.                223
  A fifth fpecies  has alfo been enumerated.  It is when a
tympanites abdominalis happens to be joined with the hy-
drops ascites; and fuch a difeafe therefore is named by Sau-
vages Tympanites asciticus, Sauv.fp. 4.   In moft cafes of
tympanites, indeed, fome quantity of ferum has,  upon dif-
feaion, been found in  the fac of the peritonaeum ; but that
is not enough to conftitute the fpecies now mentioned; and
when the colfeaion of ferum is more confiderable, it is com-
monly where, both from the caufes which have preceded,
and likewife from the  fymptoms which attend, the afcites
may be confidered as the primary difeafe; and  therefore
that this combination  does not exhibit a proper fpecies of
the tympanites.
   1630.] 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 diftinguifh-
ed, nor, as confidered  in themfelves, admitting of  any cure,
I fhall here take no further notice of them ; confining my-
felf, in what follows, to the confideration of the  moft fre-
quent cafe, and almoft the only objea of praaice* the tym-
panites intestinalis*
   1.6-3,1.] With refpea to this, I cannot perceive that it a-
rifes  in any peculiar temperament, or depends upon any
predifpofition,  which  can be difcerned.  It  occurs in ei-
ther fex, at every age, and frequently in young perfons.
   1632.} Various remote caufes of it have been affigned :
But many of thefe have not commonly the effect of produ-
cing this difeafe; and although fome of them have been truly
antecedents of it,  I can in few inftances difcover the man-
ner in> which they produce the difeafe, and therefore cannot
 certainly afcertain them to have been caufes of iu
   1633.]  The phenomena of this difeafe in its feveraf fta-
 ges are the following.
   The tumour 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, howTever,
 the tympanites comes on gradually, and is  introduced by
 an unufual flatulency of the ftomach and inteftines,  with
 frequent borborygmy, and an uncommonly frequent ex-
 pulfion of air upwards and downwards.  This ftate is alfo
 frequently attended with colic pains, efpecially felt about
 the navel, and upon the fides towards die back ^ but gep.e- 
224                PRACTICE
rally as the difeafe advances,  thefe pains become lefs con-
fiderable.   As the difeafe advances, there is a pretty con-
ftant defire to  difcharge air, but it  is accomplifhed with
difficulty; and when obtained, although it give fome relief
from the fenfe of diftention, this relief is commonly tran-
fient and of fhort duration.  While the difeafe  is coming
on, fome inequality of tumour and tenfion may be perceiv-
ed in different parts of the belly; but the diftention foon
becomes equal over the whole, and exhibits the  phenome-
na mentioned in the charaaer.   Upon the firft coming on
of the  difeafe, as well as during its progrefs, the belly is
bound,  and the faeces difcharged are commonly hard and
dry.  The urine,  at the beginning,  is ufually  very little
changedin quantity  or quality from its natural ftate:  But
as the difeafe continues,  it is commonly changed in both
refpeas; 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
confiderably emaciated.   Together  with thefe fymptoms,
a thirft and uneafy fenfe of heat at length come on, and a
confiderable frequency of pulfe occurs, which continues
throughout the courfe of the difeafe.  When the tumour
of the belly arifes to a confiderable bulk, the breathing be-
comes 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 probably in confequence  of a gangrene
coming upon the inteftines.
   1634. J The tympanites is commonly of fome duration,
and to be reckoned a chronic difeafe.  It is very feldom
quickly fatal, except where  fuch  an  affeaion fuddenly
arifes in fevers.  To  this Sauvages has properly given a
deferent appellation, that of Meteorismus; and I judge it
may always be confidered as a fymptomatic  affection, en-
tirely diftina from the tympanites we are now confidering.
   1635.] The tympanites is generally a fatal difeafe,  fel-
dom admitting of cure; but what may be attempted in this
way, I  fhall try to point out, after I fhall have endeavour-
ed to explain the proximate caufe, which alone can lay the
foundation of what may be rationally attempted towards
its cure, 
OF  PHYSIC!               525
   1636.] 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 prefent in the
alimentary canal,  owing to the extrication and detachment
of a greater quantity of  air than ufual from the alimentary
matters taken in.   Our vegetable aliments,  I believe,  al-
ways undergo  fome degree of fermentation ;  and in confe-
quence, a quantity of air is extricated  and detached from
them in  the ftomach and inteftines:  But it appears, that
the mixture of the animal fluids which  our  aliments meet
with in the  alimentary canal,  prevents the fame quantity
of air from being detached from them that would have been
in their fermentation without  fuch mixture; and it is pro-
bable that the fame mixture contributes alfo  to the reab-
forption 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 certain circum-
ftances, 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 alfo to occafion that reabforp-
tion of air which in found perfons commonly happens. An
unufual quantity of air  in  the alimentary canal, whether
owing to the nature of the aliments taken in, or to the fault
of the digeftive fluid, does certainly fometimes take place;
and may poffibly have, and in fome meafure certainly has,
a fhare in producing certain flatulent diforders of  the ali-
mentary canal; but cannot be fuppofed to produce the
tympanites, which often occurs when no previous diforder
had appeared in the fyftem.   Even in  thofe cafes of tym-
panites which are attended at  their beginning with flatulent
diforders in the whole of the alimentary canal, as we know
that a firm tone of the inteftines both moderates the extri-
cation of air and contributes to its reabforption or ready
expulfion,  fo  the flatulent fymptoms which  happen to ap-
pear 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.
   1637.] Thefe, and other confiderations, lead me to con-
clude, that the chief part of the proximate caufe of tympa-
nites, is a lofs of tone in the mufcular fibres of the inteftines.
But further, as air of any kind accumulated in the cavity of 
<.2S                PRACTICE
the inteftines fhould, even by its own clafticity, find its way
either upwards or downwards, and  fhould alfo, by the at-
fiftance of infpiration, be entirely thrown out of the body;
fo, when neither the  reabfoption nor the expulfion takes
place, and the air is accumulated  fo as to produce tympa-
nites, it is probable  that the paffage of the air along the
courfe ofthe inteftines is in fome places of thefe interrupt-
ed.   This  interruption, however, can hardly be fuppofed
to proceed from any other  caufe than fpafmodic  conftric-
tions  in  certain parts  ofthe canal; and I conclude, there-
fore,  that fuch conftriaions concur as part in the proximate
caufe of tympanites.—Whether  thefe fpafmodic  conttric-
tions  are to be atributed 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.
   1638. J Having thus endeavoured to afcertain the proxi-
mate  caufe of tympanites, I proceed  to  treat of  its cure;
which indeed has feldom fucceeded, and almoft never but
in a  recent difeafe.  I  muft, however, endeavour  to fay
what  may be reafonably attempted;   what has commonly
been  attempted; and what  attempts  have  fometimes fuc-
ceeded in the cure of this difeafe.
   1639.J It muft be a firft indication to evacuate this air
accumulated in the inteftines: and for this purpofe it is ne-
celiary that thofe conftriaions, which had efpecially  occa-
fioned its accumulation, and continue to interrupt its paf-
fage along  the courfe of the inteftines fhould be removed.
As diefe, however, can hardly be removed but by exciting
the periftaltic motion in the adjoining portions of the intef-
tines, purgatives have been commonly employed; but it is
at the fame time agreed, that the more gentle laxatives on-
ly ought to be employed, as the  more draftic, in  the over-
fhetched and tenfe ftate of the inteftines, are in danger of
bringing on inflammation.
   It  is for this reafon, alfo, that glyfters have been frequent-
ly employed;  and they are the more neceffary, as  the faeces
collected are generally  found to be in a hard and  dry ftate.
Not  only upon account of this ftate of the fasces, but, far-
ther,  when glyfters produce a confiderable evacuation of air,
and thus fhow that they have fome effea in relaxing the fpafms
of the inteftines, they ought to be  repeated very frequently. 
OF  PHYSIC.
227
   1640.]  In order to take off the conftriaions  of the  in-
teftines, and with fome view alfo to the carminative effeas
of the medicines, various antifpafmodics have been propof-
ed, and commonly employed; but their effeas are feldom
confiderable, and it is alledged that their heating and inflam-
matory powers have fometimes been hurtful.    It is, how-
ever, always proper to join  fome ofthe milder kinds with
both the purgatives and glyfters that are employed;* and
it has been very properly advifed to give always the chief
of antifpafmodics, that is, an opiate, after the operation of
purgatives  is finiflied.
   1641. J In confideration of the overftretched tenfe, and
dry ftate of the  inteftines, and efpecially of the fpafmodic
conftriaions that prevail, fomentations and warm  bathing
have been propofed as a remedy; and are faid to have been
employed  with advantage: but it has been  remarked, that
very warm baths  have not been  found fo ufeful  as tepid
 baths long continued.
    1642.]  Upon the fuppofition that this  difeafe  depends
 efpecially  upon an atony of the  alimentary  canal, tonic re-
 medies feem to be properly indicated.  Accordingly cha-
 lybeates, and various bitters, have been employed; and, if
 any tonic, the  Peruvian bark might probably be ufeful.
    1643.]  But  as no tonic remedy is more powerful than
 cold applied to the furface of the body, and cold drink thrown
 into the ftomach; fo fuch a remedy has been thought of in
  this difeafe.  Cold drink has been conftantly prefcribed,
  and cold bathing has been employed with  advantage;  and
  there have been feveral inftances  of the difeafe being  fud-
  denly  and  entirely  cured  by the repeated application of
  fnow to the lower belly.
     1644.]  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  proba-
  ble, that the foffil acids  and neutral falts, as antizymics,
  may be  ufeful.t
     16*45.]  In  °bftinate and defperate cafes of tympanites,
   * The antifpafmodics that are to be joined with purgatives ought to be effential olU, efpecially the
  effential oils of umbelliferous plants, as oil of annffccd, oil of carui, &c. and their dofe ought to be
  moderate.  In manv cafes they may be ufed in repeated fmall dofes by themfelves oa a piece of fu-
  ear. 'Hie dofe of the ol. anifi ought not to exceed ten or twelve drops, nor of the: ol. carui hvc
  5rops; larcer dofes arc too heating.  It may be proper aho 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 tlie aromatics, as cloves, cinnamon, &c.                        .  . .  .
   + The foffil acids arc undoubtedly very powerful in refitting fermentation; and It tW air in tH«
  iatcftincii is produced by ienucnuuon, they art confequently nlgbly ufeful. 
22S
PRACTICE
the operation of the paracentefis has been propofed: but
it is a very doubtful remedy, and there is hardly any tefti-
mony of its having been praaifed with fuccefs.   It muft
be obvious, that this operation is a remedy fuited efpecial-
ly, and almoft only, to the  tympanites abdominalis;  the
exiftence of which, feparately from the intestinalis, is very
doubtful, at  leaft not eafily afcertained.   Even if its exift-
ence could be afcertained, yet it is not very likely to be
cured by this remedy; and how far the operation might be
fafe in the tympanites intestinalis, is not yet determined by
any proper experience.
                    CHAP.  III.




1646.] A. PRETERNATURAL colfeaion of ferous
or watery fluids, is often formed in different parts ofthe
human body;  and although  the difeafe thence arifing be
diftinguifhed according  to the different parts which it oc-
cupies, yet the whole of fuch colfeaions come under the
general appellation of Dropfies.   At the fame time, al-
though the particular inftances of fuch colfeaion 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.
   1647.] In perfons in health, a  ferous or watery  fluid
feems to be conftantly poured out, or exhaled in vapour,
into every cavity and interftice of the human body capable
of receiving  it; and the fame  fluid, without  remaining
long or being accumulated in thefe fpaces, feems conftant-
ly to be foon again abforbed from thence by veffels adapted
to the purpofe.  From this view of  the animal economy,
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 unulual accumulation of ferous flu-
id will be made in  fuch parts; or  though the quantity
poured  o«:t bs not more than ufual, yet if the abforption 
OF  PHYSIC.
229
be anywife interrupted or diminifhed, from this caufe alfo
an unufual colfeaion of fluids may be occafioned.
   Thus,  in general, dropfy may be imputed to an increaf-
ed effufion, or to a diminiihed abforption; and I therefore
proceed to inquire into  the feveral caufes of thefe.
   1648.3 An increafed effufion may happen, either from
a preternatural increafe of the ordinary exhalation, or from
the rupture of veffels carrying, or of facs containing, fe-
rous or watery fluids.
   1649. J The  ordinary  exhalation may be increafed by
various caufes,  and particularly by an interruption given
to the  free return  of the venous blood from the extreme
veffels of the body to the right ventricle of the heart. This
interruption feems to operate by refifting the free paflageof
the blood from the arteries into the veins, thereby increaf-
ing the force of the arterial fluids in the exhalants, and con-
fequently the quantity of fluid which they pour out.
   1650. J The interruption ofthe free return ofthe venous
blood  from the extreme veflels, may  be owing to certain
circumftances affeaing 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 obftruaions
in the veffels ofthe lungs preventing the entire evacuation
of the right venticle, and thereby hindering  its  receiving
the ufual quantity of blood from the cava.   Thus, a poly-
pus in  the right ventricle of the heart, and the oflification
of its valves,  as well as all  confiderable and permanent ob-
ftruaions  of the lungs, have been  found to be caufes of
dropfy.
   1651.] It may ferve  as an wluftration of the operation
of thefe general caufes,  to remark, that the return  of the
venous blood  is in fome meafure refitted when the pofture
of the body is fuch  as gives occafion to the gravity of the
blood to oppofe the motion of it in the veins,  which takes
effea when the force of the circulation is weak; and from
whence it is that an upright pofture of the body produces
or increafes ferous fwellings in the lower extremities.
   1652.] 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
  Vor..  II.                   F f 
250                PRACTICE

effea of increafing exhalation,  and  producing dropfy..
The moft remarkable inftance of this is, when confiderable
obftrufctions of the liver prevent the blood  from flowing
freely into  it from the vena  portarum and its  numerous
branches;  and hence thefe obftru6tions are a frequent caufe
of dropfy.
   1653.J  Scirrhofities of  the fpleen and other vifcera, as
well as the feirrhofity of the liver, have been confidered as
caufes of dropfy; but the manner in which they can pro-
duce the difeafe, I do not  perceive,  except it  may  be
where they happen to be near fome confiderable vein,  by
the compreffion of which they may occafion fome degree
of afcites; or, by compreffing the  vena cava,  may pro-
duce an anafarca of the lower  extremities.  It is indeed
true, that feirrhofities of the fpleen and other vifcera,  have
been frequently difcovered in the bodies of hydropic per-
fons: But I believe that they have been feldom found un-
lefs when feirrhofities of the liver were alfo prefent;  and I
am inclined to think,  that the former have been the effeas
of the latter, rather than the caufe of the dropfy; or that,
if feirrhofities ofthe other vifcera have  appeared in hydro-
pic bodies when that of the liver  was not prefent, they muft
have been the effe6ts of fome of thofe  caufes of dropfy to
be hereafter mentioned; and confequently to be the  acci-
dental attendants, rather than the caufes, of fuch dropfies.
   1654.]  Even in fmaller portions ofthe venous fyftem,
the interruption of the motion of the  blood in particular
vqins has had the fame  effea.  Thus a polypus formed in
the cavity of a vein, or tumours formed in  its coats, pre-
venting the free paffage ofthe blood through it, have had
the effea of producing dropfy in parts towards the extremi-
ty of fuch veins.
   1655 J  But the  caufe moft frequently interrupting the
motion of the  blood through the veins is, the compreffion
of tumours exifting near to them; fuch as aneurifms in die
arteries, abfeeffes, and fcirrhous or  fteatomatous tumours
in  the adjoining parts.
   To  this  head  may be  referred the compreffion of the
defcending cava by the bulk of the uterus in pregnant wo-
men, and  the compreffion ofthe fame by the bulk of wa-
ter in the  afcites; both of which compreffions  frequently
produce ferous fwellings in the lower extremities. 
OF  PHYSIC.
251
   1656. J It may be fuppofed, that a general preternatural
plethora ofthe venous fyftem may  have the effea of in-
creafing 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 body, fuch as
the menftrual and hemorrhoidal fluxes.   A dropfy,  how-
ever, from fuch a caufe, has been at leaft a rare occurrence;
and when it feems to have happened, I fhould fuppofe it
owing to the  fame caufes as the  fuppreffion itfelf, rather
than to the plethora  produced by  it.
   1657.]  One of the moft frequent caufes of an increafed
exhalation,  I apprehend to be the  laxity of the exhalant
veffels.  That fuch a caufe may operate, appears probable
from this, that paralytic limbs, in  which fuch a laxity is to
be fufpected, are frequently affeaed wkh ferous, or, as they
are  called, cedematous fwellings.
   But a much more remarkable and frequent example  of
its operation occurs  in the cafe of a general debility of the
fyftem, which is fo often attended with dropfy.  That a
general debility  docs induce  dropfy, appears fufficiently
from its being fo commonly the confequence of powerful-
ly debilitating caufes; fuch as fevers, either of the continu-
ed or intermittent kind, which have lafted long;  long con-
tinued and fomewhat exceflive evacuations of any kinds;
and in fhort, almoft  all difeafes that have been of long con-
 tinuance, and  have  at the fame time induced the  other
 fymptoms of a general debility.
   Among other caufes inducing  a general debility  ofthe
 fyftem, and thereby dopfy, there is one to be mentioned
as frequently  occurring, and that is, intemperance in the
 ufe of intoxicating liquors; from whence it is that drunk-
ards of all kinds, and efpecially dram-drinkers, are  fo  af-
 feaed with this difeafe.
    1658. ]  That a general debility may produce a laxity of
 the exhalants, will be readily allowed: and that by this ef-
 pecially 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 of general debi-
 lity gives rife to increafed exhalation into every cavity and
and interftice of the  body, and therefore brings on a gener-
al difeafe.   Thus, we have feen effufions of a ferous fluid .
made, at the fame time, into the cavity of the cranium, in- 
232                PRACTICE

to that ofthe thorax and of the abdomen, and likewife in-
to the cellular texture almoft over the whole of the  body.
In fuch cafes, the operation of a general caufe difcovered
itfelf, by thefe feveral droplies increafing in one part as they
diminifhed in another, and this alternately in the different
parts.  This combination, therefore, of the different  fpe-
cies of dropfy, or rather, as it may be termed,  this univer-
sal dropfy, muft,  I think, be referred to a general  caufe;
and in moft  inftances, hardly any other can be thought of,
but a general laxity of the exhalants.  It is this, therefore,
that  I call the hydropic diathesis; which  frequently ope-
rates by itfelf; and frequently, in  fome meafu e, concur-
ring with other caufes, is efpecially that which gives them
their full effea.
   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 inftance of it that has
occurred to  me, I have always confidered, and  have  always
found, it to  be the beginning of general dropfy.
   1659.] ^he  feveral caufes of dropfy already mentioned
may produce"the difeafe, although there be no preternatu-
ral abundance of  ferous or watery  fluid in the blood-vef-
fels;  but it  is now'to be remarked,  that a preternatural
abundance of that kind may often give occafion to  the dif-
eafe, and more efpecially when  fuch abundance 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 drinking,  has fome-
times occafioned a dropfy.   Large quantities of water, it is
true, are  upon  many occafions taken in;  and being as rea-
dily  thrown out again by  ftool, urine, or  perfpiration,
have not produced any difeafe.   But it is alfo certain, that,
upon fome  occafions, an unufual quantity of watery li-
quors taken in has run off by the feveral internal exhalants,
and  produced a dropfy.  This feems  to have happened,
either 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 obftruaed by accidentally concurring caufes.
Accordingly it is faid, that the fudden  taking in of a large
quantity of very cold water, has produced dropfy, probably
from the  cold producing a conftriaion of the excretories. 
OF  PHYSIC.
233
  The proportion of watery fluid in the blood may be in-
creafed, not 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 atmof-
phere by the  fkin in an abforbing or imbibing ftate.  It is
well  known  that the fkin may be, at leaft, occafionally in
fuch a ftate;  and it is probable, that in many cafes of  be-
ginning dropfy, when  the circulation of the blood on  the
furface of the body 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.
   1660.J A fecond caufe of a preternatural abundance of
watery fluids in the  blood-veffeLs,  may be, an interruption
of the ordinary watery  excretions; and accordingly it is
ailedged,  that  perfons much expofed to a cold and moift
air are liable to dropfy.   It is alfo faid, that an interrup-
tion, or confiderable diminution,  of the urinary fecretion,
has produced the difeafe: and it is certain, that, in the cafe
of an ischuria  renalis, the ferofity retained in the blood-
veffels has been poured out into fome internal cavities, and
has occafioned dropfy.
   1661. J 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 fpontaneous
or artificial.   Thefe evacuations, by abftraaing a large
proportion of red globules and gluten,  which are the prin-
cipal means of retaining ferum in the red veffels, allow the
ferum to run off more readily by the exhalants:  And hence
dropfies have been frequently the confequence of fuch eva-
cuations.
   It is poffible alfo, that large and long-continued iffues,
by abftraaing a large porportion of gluten, may have  the
fame effea.
   An over-proportion ofthe ferous parts ofthe blood, may
not  only  be owing to  the spoliation juft now mentioned,
but  may, I apprehend, be likewife owing to a fault in the
digefting and alfimilating powers in the ftomach and other
organs; whereby they  do  not prepare and convert the  ali-
ments 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 over-proportion, and confequently ready to run off 
134                PRACTICE
in too large quantity  by the exhalants.   It is in this man-
ner that we explain the dropfy, fo often attending chlorofis:
which appears always at firft by a  pale colour of the whole
body, fhowing a manifeft deficiency of red blood; which
in that difeafe can only be attributed to an imperfect* digef-
tion and affimilation.
   Whether a like imperfeaion takes place in what has been
called a Cachexy, I dare not determine.  This  difeafe in-
deed has been commonly and very evidently owing to the
general caufes of debility above-mentioned: and it being
probable that the general debility may affea the organs of
digeftion and affimilation;  fo  the imperfett.  ftate of thefe
funaions,  occafioning a deficiency of red globules and glu-
ten, may often concur with the laxity of the exhalants in
producing dropfy.
   1662.]  Thefe are the feveral caufes of increafed exhala-
tion, which  I have mentioned as  the chief caufe of the ef-
fufion producing dropfy; but I have  likewife obferved in
(1648.) that with the fame effea, an effufion may  alfo be
made by the rupture of veffels carrying watery fluids.
   In this way, a rupture of the thoracic dua, has given oc-
cafion to an effufion of chyle and lymph into the cavity of
the thorax; and a rupture of the  laaeals has occafioned a
like effufion into the cavity ofthe abdomen; and in either
cafe, a dropfy has been produced.
   It is fufficiently probable, that  a rupture of lymphatics,
in confequence  of ftrains, or  the violent compreffion of
neighbouring mufcles, has occafioned an effufion; which,
being diffufed in the cellular texture, has produced dropfy.
   It belongs to this head of caufes, to remark, that  there
are many  inftances of a rupture or erofion of the  kidney,
ureters, and bladder of urine;  whereby the urine has been
poured into the  cavity of the abdomen, and produced an
afcites.
   1663.]  Upon this fubjea, of the rupture of  veffels car-
rying,  or of veficles containing, watery fluids,  I muft ob-
ferve,  that the diffeaion of dead bodies has often fhown
veficles formed upon the furface of  many of the  internal
parts;  and it has been fuppofed,  that the rupture of  fuch
veficles, commonly named Hydatides, together with their
continuing to pour out a watery fluid, has been frequently
the caufe of dropfy.   I cannot deny the poffibility of fuch 
                  O F  P H Y S I C.                iii

a caufe, but fufpea the matter muft be explained in a dif-
ferent manner.
  There have been frequently found, in almoft every dif-
ferent part of animal bodies, colfeaions of fpherical vefi-
cles, containing a watery fluid; and in many cafes of  fup-
pofed dropfy, particularly in thofe called the preternatural
encylted droplies,  the fwelling has been  entirely owing to
a colfeaion of fuch hydatides.   Many conjectures have
been formed  with  regard to the nature and produaion of
thefe veficles: but the matterat laft feems to be afcertained.
It feems to be certain, that each of thefe veficles has with-
in it, or annexed to it,  a living animal of the worm kind;
which feems to have  the power of forming a veficle for the
purpofe of its  own economy,  and of filling it with a wa-
tery fluid drawn from the neighbouring parts:  And this
animal has therefore  been properly named by late natura-
lifts the Tcenia hydatigena.  The origin and economy of
this animal, or an account of  the feveral parts of the hu-
man 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 con-
clude with obferving, I am well perfuaded, that moft of
the inftances of preternatural encyfted droplies which have
appeared in many different parts ofthe human body, have
been truly colfeaions 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
praaice,  I cannot at prefent determine.
   1664.] After having mentioned thefe, I return to  con-
fider the other general caufe of dropfy,  which  I have faid
in (1647.) mav Dc>  ^n interruption or  diminution of the
abforption that fhould take up the exhaled fluids from the
feveral  cavities and  interftices  of  the body; the caufes of
which interruption, however, are not eafily afcertained.
    1665.] It feems probable,  that  abforption  may be di-
minifhed,  and  even  ceafe  altogether, from a lofs of  tone
in the abforbent extremities of the lymphatics.   I cannot
indeed doubt that a  certain degree of tone  or aaive power
is neceffary in thefe abforbent  extremities; and  it appears
probable, that the lame general debility which produces
that laxity of the exhalant veffels, wherein  I have fuppofed
the hydropic diathefis to confift, will  at the fame time oc- 
2ZS                 P R A C if I C E

cafion a lofs of tone in the abk|rbents; and  therefore that
a laxity of the exhalants will generally beaccompanied with
a lofs of tone in the abforbents;  and that this will have a
fhare in the produaion of dropfy.  Indeed it is probable
that the diminution of abforption has a confiderable fhare
in the matter; as dropfies are often cured  by  medicines
which feem to operate by exciting the action of the abfor-
bents.
   1666.]  It has been fuppofed, that the  abforption per-
formed by the extremities of  lymphatics may be interrupt-
ed by an obftruaion of thefe veffels, or at leaft of the con-
globate glands throuoh which  thefe  veffels pafs.  This, how-
ever, is very doubtful.   As the lymphatics have branches
frequently communicating with one another, it is not pro-
bable that the obftruction of any one, or even feveral of
thefe, can have any confiderable effea in  interrupting the
abforption of their extremities.
   And for the lame reafon it is as little probable that the
obftruaion of conglobate glands can have  fuch an  effea;
at leaft it is only  an obftruction of the glands of the mefen-
tery, through which fo confiderable a portion ofthe lymph
paffes, that can poffibly have  the effect of interrupting  ab-
forption.  But  even this  we fliould not readily fuppofe,
there  being reafon to believe that  thefe glands,  even in  a
confiderably tumefied ftate,  are  not entirely obftruaed:
And accordingly I  have known  feveral  inftances of the
moft part ofthe mefenteric glands being confiderably tume-
fied, without either interrupting the tranfmiffion of fluids
to the blood-velfels, or occafioning any dropfy.
   An hydropic fwelling, indeed, feems often to affea 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 axillary vein, rather than
loan obftruction of the lymphatics.
   1667. J  A particular interruption of abforption may be
fuppofed to take place in the brain.   As no lymphatic vef-
fels 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 extremities of veins,
or by veflels that carry the fluid direaiy into the veins;  fo
that any impediment to the free motion of  the blood in the
veins ef the brain,  may interrupt the abforption there, and 
OF  PHYSIC.
&37
occafion that accumulation of  ferous fluid which fo fre-
quently occurs from a congeftion of  blood in thefe veins.
But I give all this as a matter of conjeaure only.
   1668.] Having thus explained the general  caufes of
dropfy, I fhould proceed,  in the next place, to mention
the feveral parts of the body in which ferous  collections
take place, and fo to mark the different fpecies of dropfy:
But I do not think it neceffary for me to enter into any mi-
nute detail upon this fubjea.   In many cafes, thefe  col-
feaions are not to be afcertained by any external fymptoms,
and therefore cannot be the objeas of praaice;  and many
of them, though in fome meafure difcernible, do not feem
to  be curable by  our  art.   I the more efpecially avoid
mentioning very  particularly the feveral fpecies, becaufe
that has already been fufficiently done by  Dr. D. Monro,
and other writers,  in every body's hands.   I muft confine
myfelf here to the  confideration of thofe fpecies which are
the moft frequently occurring and the moft  common ob-
jeas of our  pra6tice; which are, the Anafarca, Hydro-
thorax, and Afcites; and each  of thefe I  fhall treat of in
fo many feparate feaions.

                       Sect.  I.

                    Of Anasarca.
   1669.] THE Anafarca is a  fwelling upon the furface
ofthe 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 readily receiving the pref-
fure 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 erea pofture during the day; but there  are  many
inftances of the exercife of  walking  preventing altogether
its otherwife ufual  coming on.   Although this fwelling ap-
pears at firft only upon  the feet and about the ankles;  yet
if the caufes producing  it  continue to aa,  it gradually ex-
  Vol. II.                C c 
238               PRACTICE

tends  upwards, occupying 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,  which again generally difappears almoft en-
tirely in the courfe of the day.
   1670.]  The terms  of  Anasarca and Lewcophlegmatia
have been  commonly confidered as fynonymous; but fome
authors  have  propofed to confider them as  denoting dif-
tina difeafes.   The authors who are of this opinion em-
ploy the name of Anasarca for'that difeafe which begins in
the lower  extremities, and is  from thence gradually ex-
tended upwards in the manner I have juft  now defcribed;
while they term Leucophlematia, that  in which  the fame
kind of fwelling appears even at firft very generally over
the whole body.  They  feem to think alfo, that the two
difeafes proceed from different caufes;.  and that,  while the
anafarca may arife from the feveral  caufes in (1649.—
 1660.)  the leucophlegmatia  proceeds efpecially from  a
deficiency of  red blood,  as we have mentioned in (1661.
et seq.)  I cannot,  however, find any proper foundation for
this diftinaion.  For although in dropfies'proceeding from
the caufes mentioned in (1661. et seq.) the difeafe appears
in fome cafes more immediately affeaing the whole body;
yet that does  not eftablifh 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 occa-
fioned by a deficiency of red blood,  I have frequently ob-
ferved it to come on exaaiy in the manner of an  anafarca,
as above defcribed.
   1671.J An anasarca is evidently a preternatural collec-
tion of ferous fluid in the cellular texture immediately un-
der the  fkin.  Sometimes pervading the  fkin itfelf, it oozes
out through the pores of the cuticle;  and fometimes,  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, as to give anafarcous tumours an unufual firm-
nefs.   It  is in thefe laft circumftances alfo that an erythe-
matic inflammation is ready to come upon anafarcous
fwellings.
    1672. J An anafarca may immediately arife from  any  o£ 
OF  PHYSIC.
339
The feveral caufes of dropfy which aa more generally up-
on  the fyftem:  And even when other fpecies of dropfy,
from particular circumftances, appear firft; yet whenever
■thefe proceed from any caufes more generally affeaing the
fyftem,  an anafarca fooner or later comes always to be
joined with them.
   1^73-] The manner in which this difeafe commonly firft
-appears, will be readily explained  by what I have faid in
{11651.) refpeaing the effeas  of the pofture ofthe body.
lis  gradual progrefs,  and its affeaing, after  fome time,
not only the cellular texture under  the fkin, but probably
alfo much of the fame texture in the internal parts, will be
underftood partly from the communication  that is readily
made  between the  feveral parts  of the cellular .texture ;
but efpecially from the fame  general caufes of the difeafe
producing their effeas in every part of the body.  It ap-
pears to me,  that the wrater 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.
  - 1674. J  An  anafarca is almoft always attended  witha
fcarcity of urine;  and the urine voided, is, from its fear-
city,  always of a high color; and from the fame caufe,
after cooling, readily lets fall a copious reddifh fediment.
This fcarcity of urine may fometimes  be owing to an ob-
ftruaion of  the kidneys; but probably is generally occa-
fioned by the watery parts of the blood  running off into the
^cellular texture, and being thereby prevented from pafling
•in the ufual quantity to the kidneys.
   The difeafe is alfo generally attended  with an unufual
degree of thirft ; a circumftance I would attribute to a like
abftraaion of fluid  from the tongue and fauces, which are
extremely fenfible.to every diminution  ofthe fluid in thefe
parts.
   1675.]  The cure of anafarca is*o  be attempted upon
three general indications.
    1.  The removing the remote caufes  of the difeafe.
   2.  The evacuation of the ferous fluid already colleaed
in the cellular texture.
   3.  The reftoring  the tone of the   fyftem,,  the lofs  of
which may be confidered in  many cafes as the proximate
caufe of the difeafe. 
240                PRACTICE
   1676.] The remote caufes are very often fuch as had
not only been  applied, but had alfo been removed* long
before the difeafe came on.   Although, therefore, their ef-
feas  remain,  the caufes themfelves cannot be the objeas
of praaice; but if the caufes ftill continue to be applied,
fuch as intemperance, indolence, and fome others, they
muft be removed.   For the moft part, the remote caufes
are certain difeafes previous to the dropfy, which are to be
cured by the remedies particularly adapted to them, and
cannot be treated of here.  The curing of thefe, indeed,
may be often difficult; but it was proper to lay down the
prefent indication,  in  order to fhow,  that when thefe re-
mote caufes cannot be removed, the cure of the dropfy
muft be  difficult, or perhaps impoffible.   In many cafes,
therefore, the  following  indications  will  be to little pur-
pofe; and particularly, that often the execution of the fe-
cond will not only give the patient a  great deal of fruitlefs
trouble,  but commonly alfo hurry on his fate.
   1677.J The fecond indication for evacuating the col-
leaed  ferum, may be fometimes executed with advantage,
and often, at leaft, with temporary relief.   It may be per-
formed in two ways.   Firft,  by drawing off the water di-
rectly from  the dropfical  part, by  openings made into it
for that purpofe: Or, fecondly,  by exciting certain  ferous
excretions;  in confequence of which, an abforption may
be excited in the dropfical parts, and thereby the  ferum
abforbed and carried into the blood-veffels may afterwards
be direaed to  run out, or may fpontaneoufly pafs out, by
one or other of the common excretions.
   1678.J 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  many
finall punaures reaching  the cellular texture.  Formerly,
confiderable incifions were employed for this purpofe: but
as any wound  made in dropfical parts, which, in order to
their healing, muft neceffarily inflame ahd fuppurate, are
liable t to become gangrenous;  fo it is found to be much
fafer to make the openings by fmall punaures only, which
may heal up by the firft intention.  At the fame time, even
with refpecl to thefe punaures, it is proper to obferve, that
 * Thefe are large evacuations of different kinds, but efpecially hemorrhagies, which have ceafed
before the dropfy came on.      f Peculiarly liable in this di&afe on account of the dirainUhed
tone, and couiequently the dinurulhed ft.-engt± of the parts.                     ™ 
OF  PH'iSIC.
/. 11
they fhould be made at fome  diftance from one another,
and that care fhould be taken to avoid making them in the
moft depending parts.
   1679.] The water of  anafarcous  limbs may be fome-
times drawn off by pea-iffues,  made by cauftic a little be-
low the knees:  for as the great fwelling of the lower ex-
tremities is chiefly occafioned by the ferous fluid exhaled
into the upper parts conftantly falling down to the lower;
fo the iffues now mentioned, by evacuating the water from
thefe upper parts, may very much  relieve the whole ofthe
difeafe.  Unlefs,  however, the iffues 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 affeaed with gangrene.
   Some praaical writers have advifed the employment of
fetons, for the fame purpofe  that I have propofed iffues;
but I apprehend,  that fetons will be more liable than iffues
to the accident juft now mentioned.
   1680.]  For the  purpofe  of  drawing out ferum from
anafarcous 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 mentioned above to
be fit for the employment of iffues.
   1681.]  Colewort-leaves applied to the flan, readily oc-
cafion a watery exfudation from its furface; and applied to
the feet and legs affeaed with anafarca, have fometimes drawn
 off the water very copioufly, and with great advantage.
   Analogous, as I  judge, to this, oiled iilk-hofe put upon
 the feet and legs, fo as to fhut out  all communication with
 the  external air, have been  found  fometimes  to  draw  a
 quantity of water from the pores of the fkin,  and  are faid
 in this way to have relieved  anafarcous fwellings; but in
 feveral trials made,  I have never found either the  applica-
 tion  of thefe hofe,  or that of the colewort-leaves, of much
 fervice.*
    1682.] The  fecond  means propofed  in  (1677.)  for
 drawing off the water from dropfical places, may be the em-
 ployment of emetics, purgatives,  diuretics, or  fudcnfics.
    1683.J As fpontaneous vomiting has fometimes . xe:'ed
  « Hew doss tliis l»lt agree wi;h the firft fentence of tLi> article I 
 £*:                    PRACTICE

 an abforption in hydropic parts, and thereby drawn off the
 waters lodged in them, it is reafonable to fuppofe that vo-
 miting excited by art  may have the fame effea;  and ac-
 cordingly it has been often practifed with advantage.   The
 praaice, however, requires that the ftrong antimonial eme-
 tics be employed,  and  that they be repeated frequently af-
 ter fhort intervals.
    1684. J  Patients fu limit more readily to  the ufe of pur-
 gatives, than to that of emetics; and indeed they common-
 ly bear the former more  eafily than  the  latter.   At the
 fame time, there are no means wc can employ to procurea
 copious evacuation  of ferous fluids  with greater certainty
 than the operation of purgatives,  and it is  upon  thefe ac-
 counts that purging is the evacuation which has  been moft
 frejq wmlv^euid perhaps with  moft  fuccefs,  employed in
^lrop"tp*-^Tnas been generally found neceffary to employ
~p.urgai.ives of the more draftic kind;  which are commonly
 known, and need not be enumerated here.t   I believe, in-
 deed,  that the more draftic purgatives are the moft effeaual
 for exciting abforption, as  their  ftimulus  is  moft readily
 communicated to  the other parts ofthe 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 cryitals vulgarly called the
 Cream of Tartar,  which in large dofes, frequently repeat-
 ed, have fometimes anfwered the purpofe of exciting large
 evacuations both by ftool  and urine, and has  thereby cured
 dropsies.   This medicine, however, has frequently  failed,
  + The Draftic purgatives arc Jalap, Colycynth, Gambogc^Scaremony, Src.  Their Draftic quality
 however, depends very much on the dofe in which they ..re given, ("mail dofes being gently laxative,
 while large ones are very violent in their operation.  Tney ought feldom to he given alone, but in
 •conjunction with fome aromatic, which greatly increafes their action, and at the fame time prevents
 the UT.ea'nefs of griping, with which their operation is frequently attended : molt of thefe drattict
 being relinous fubftances, they are difficultly fallible in tire alimentary canal, or if reduced to a pow-
 der they are liable to concrete  ; in cither cafe their action is impeded. To remedy thefe inconveni-
 >encies, it is ufual to add to them fotne fait, which both divides the relin and prevents its concretion ;
 r.nd confequently increafes its  action.  For thefe reafons, we find in the fhops manv formulx, in
 which the draftee refins are mixed with either falts or aromatics, or both: As, the Pulvis Alretiors,
 Pulvis e Scammonio compofitus, Pulvis e Scammoniorurn Aloe, Pulvls e fenna compofitus, and Hec-
 tnarium e Scammonio ofthe London Pharmacopxia; and, the Pulvis e  Jalappa compofitus, Pulvis
 c cc.immonio ccmpolitus Pilulx Alceticse, Pilulae ex colocynthide cum Alee, Pilulae, e Jalappa, and
 I'ilulse Rufi of the Edinburgh Pharmacopccia.
  Any of the foregoing coaipofition% it given in fufficient dofes, are very active and brilk purges.
 Many more might be contrived, and on fome occafioiv ^ia.y be nrcelfary. For procuring a brilk dif-
 charge of fluids, an addition of Calomel is remarkably effkaciou.,, as in the following formulx:
            R. Scammon.
               Calomel.
               Crem. Tart.
               Zinzib aa. p. a?.
               M. f. Pulv.
  The .-lofc of this powder is two fcruples or a drachm, it is extremely active and ought to be ufed
 ■with care, the patients being kept moderately warm, and drinking lome thin mucilaginous liguer
 during its operation. 
OF  PHYSIC.
2*3
both in its operation and effects, when the draftic  purga-
tives have been more fuccefsful.
   Practitioners have  long  ago obferved, that, in the em-
ployment of purgatives, it is requifite they be repeated af-
ter as fhort intervals as the patient can bear; probably for
this reafon,  that when the purging is  not carried to  the de-
gree of foon exciting an abforption, the evacuation weakens
the fyftem, and thereby increafes the afflux of fluids to the
hydropic  parts.
   1685. ) 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 always properly employ-
ed in the cure of dropfy.   The various  diuretics that may
be employed, are enumerated in every treatife  of the Ma-
teria Medica and of the Practice of  Phyfie, and  therefore
need not be repeated here.   It happens, however, unluck-
ily, that none of them are of very  certain  operation; nei-
ther is it well known why they fometimes fucceed, and
why they fo often fail; nor why one medicine fliould prove
of fervice when another does not..   It has been  generally
the fault of writers upon the Practice of Phyfie,  that they
give us inftances of cafes in which certain medicines have
proved very efficacious, but neglecl to tell us in how many
inftances the fame have failed.
   1686.J Itdeferves 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 (1659.; tnat a  *ar§e qua-
lity of common water,  or of watery  liquors  taken in  by
drinking, has fometimes proved a caufe  of dropfy; and
practitioners have  been formerly fo much afraid that watery
liquors taken in by drinking might run off into the dropfi-
cal places and increafe the difeafe, that they have generally
enjoined the abftaining, as much as poffible, from  fuch li-
quors.  Nay, it has been further aliened, that by avoiding
this fupply  of exhalation, and by  a  total abftinence  from
drink, dropfies have been entirely cured.   What  conclu-
fion is to be drawn from thefe facts, is however,  very doubt-
ful.   A dropfy arifing from a large  quantity of liquids ta- 
tU                "PRACTICE
 ken 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 produc-
 ing  any degree  of  dropfy.   With refpecl to the total ab-
 ftinence from drink,  it is  a practice of the  moft difficult
 execution;  and therefore has been fo  feldom pra£tifed,
 that we cannot poffibly know how far it might prove effec-
 tual.  The practice of giving drink very fparingly, has in-
 deed been often employed: but in a hundred inftances I
 have feen it carried to a great length without any manifeft
 advantage;  while, on the  contrary, the practice  of giving
 drink very largely has been found not only fafe,  but very
 often eff'cftual in curing the  difeafe.  The ingenious and
 learned Dr. Millmanhas, in my opinion, beencommendably
 employed in reftoring the praQice of giving large  quanti-
 ties  of watery liquors for  the cure of dropfy.  Not only
 from the inftances he mentions from his own practice, and
 from that of feveral eminent phyficians in other parts  of
 Europe, but alfo from many inftances in the records of
 phyfie, of the good effefts of drinking large quantities  of
 mineral waters in the cure of dropfy, I can have no doubt
 ofthe practice recommended by Dr. Millman being very
 often extremely proper.   I  apprehend it to be efpecially
 adapted to thofe cafes in which the  cure is chiefly attempt-
 ed by  diuretics.   It is very probable that thefe medicines
 can hardly be carried in any quantity to the  kidneys with-
 out being accompanied with a large portion of water; and
 the late frequent employment of the cryftals of tartar  has
 often fhown, that the diuretic efFerita. of that medicine* are
 almoft only  remarkable when accompanied with  a large
 quantity of water; and that without this, the diuretic effects
 of the medicine feldom appear.
   I  fliall conclude this fubject with obferving, that as there
 are fo many cafes of dropfy abfolutely incurable, the prac-
 tice now under confideration" may often fail, yet in moft
 cafes it may be fafely tried;  and  if it appear  that  the water
 taken in pades readily by the urinary fecretion, and efpeci-
ally that it increafes  the urine beyond the quantity^of drink
 taken in, the practice may probably he continued w-ith great
 advantage: but, on the contrary, if the urine be not increa f-
cd, or  be  not even in proportion to the drink taken in. it 
                  OF  PHYSIC.     '          245

may be concluded, that the water  thrown in runs off by
the exhalants, and will augment the difeafe.
   »687.]  Another fet of remedies which may be employ-
ed  for exciting a ferous excretion,  and thereby curing
dropfy, is that of fudorifics. Such remedies, indeed, have
been fometimes employed; but however ufeful they may
have been thought, there are few accounts of their having
effected a cure; and although I have  had fome examples
of  their fuccefs, in moft  inftances of their trial they have
been ineffectual.
   Upon this fubject it is proper to take notice ofthe fever-
al means that have been propofed and employed  for difli-
pating the humidify ofthe body; and particularly that of
heat externally applied to the furface of it.   Of  fuch ap-
plications I have had  no experience;  and their propriety
and utility muft reft upon the credit of the authors who re-
late them.  I fhall offer only this conjecture upon the fub-
ject:  That if fuch meafures have been truly ufeful, as it
has feldom been by the drawing out of any fenfible humid-
ity, it has probably been by their reftoring the perfpiratiorj,
which is fo often greatly diminifhed in this difeafe; or, per-
haps, by changing the ftate of the ,fkin, from the imbibing
condition which is alledged  to take place, into that of pert-
piring.
   1688.] When, by the feveral means now mentioned,
we fhall have fucceeded in evacuating the water of dropfies,
there will  then efpecially be occafion for our third indica-
tion ;  which is, to reftore the tone qf the fyftem, the lofs
of which is fo often the caufe of the difeafe.  This ^indica-
tion,  indeed, may properly have place from; die very firft
appearance of the difeafe;   and  certain meafu?es adapted
to this purpofe  may, upon  fuch firft appearance, be  em-
ployed with advantage.  In .many cafes of a moderate dif-
eafe,  I am perfuaded that  they  may obviate any  future
increafe of it.
   1689. J Thus,  upon what is commonly the firft fymp-
toms 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.
   1690.] That fome degree of external compreffion  is
   Vol. 11.                 H k 
246                PRACTICE
fuited to fupport the tone of the veffels, and particularly to
prevent the effects of the weight of the blood in  dilating
thofe of the lower extremities, mult be fufficiently evident;
and the giving that compreffion by  a bandage properly ap-
plied, has been often ufeful.  In applying fuch a bandage,
care is to be taken that the compreffion may never be great-
er on the upper than on  the lower part ofthe limb; and
this, I think,  can hardly  ever be fo certainly avoided, as
by employing a properly  conftructed laced flocking.
   1691.] Friction is another means by which the action of
the blood-veffels may be  promoted, and  thereby  the ftag-
nation of fluids  in their extremities prevented. According-
ly, theufe ofthe flefh-brufh has often contributed to difcufs
cedematous fwellings.   It appears to me, that friction, 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 friction being
made from below upwards only, is more ufeful  than when
made alternately upwards and downwards.   It has been
common, inftead of employing the  flefh-brufh,  to make
friction by warm and dry flannels; and this may in fome
cafes be the moft convenient: but I cannot perceive that
the impregnation of thefe  flannels with certain dry  fumes is
of any benefit.
   1692.]  With refpect to exercife,  I  muft obferve,  that
although perfons being much in an erett pofture during the
day, may  feem to increafe the fwelling which comes on at
night; yet as the action of the mufcles has a great fhare in
promoting the motion of the venous blood, fo I am certain,
that as much exercife in walking as the patient can eafily
bear, will often prevent that cedematous fwelling,  w'hich
much ftanding,  and even fitting, would  have brought on.
   1693.]  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 vio-
lent difeafe; and fuch therefore will require more power-
ful remedies.   Thefe are, exercife and tonic  medicines;
which may be employed both during the courfe of the dif-
eafe and efpecially after the water has been evacuated.
   1694.J  Exeroife  is fuited to affift in every  function of
the animal ceconomyj particularly to promote perfpiration, 
OF PHYSIC.                *47
and thereby prevent the accumulation of watery fluids in
the body.  I apprehend alfo, that it may be the moft ef-
fectual means for preventing the fkin from being in an im-
bibing ftate; and, as has been hinted above on the  fubject
of Emaciation^ 1608.) I am perfuaded,  that  a full  and
large  perfpiration will  always  be  a means of exciting-
abforption in every part of the fyftem.   Exercife,  there-
fore,  promifes to be highly ufeful in  dropfy; and  any
mode of it may be employed that the patient can moft con-
veniently admit of. It fhould, however, always be as much
as he can eafily bear: and in anafarca, the fhare" which the
exercife of mufcles has in promoting the motion  of the ve-
nous blood, induces  me to think  that bodily exercife, to
whatever degree the  patient can bear it, will always be the
molt ufeful.   From fome experience alfo, I am perfuaded,
that by exercife alone, employed early in the difeafe, many
droplies may be cured.
   1695.] Befides exercife, various tonic remedies are pro-
perly employed to reftore the tone ofthe fyltem. 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 ftrengthen-
ing the organs of digeftion, which in dropfies are frequent-
 ly very  much weakened;  and for the  fame purpofe alfo
aromatics may be frequently joined with the tonics.
    1696.] Cold bathing is upon many occafions the moft
 powerful  tonic we can employ; but at the beginning of
 dropfy,  when the  debility of the fyftem is confiderable, it
 can hardly be attempted with fafety.  After, however, the
 water of dropfies  lias been very fully evacuated,  and the
 indication is to ftrengthen the fyftem for preventing a re-
 lapfe, cold bathing  may perhaps  have a place.  It is, at
 the fame time, to be admitted with caution; and can fcarce-
 ly be employed till the fyftem  has otherwife  recovered a
 good deal of vigour.   When that indeed has happened,
 cold bathing may be very ufeful in confirming and com-
 pleting it.
    1697. J In perfons recovering from dropfy, while the fe-
 veral  means now  mentioned for  ftrengthening  the fyftem
 are employed, it  will be proper at the  fame time .ta  keep
 conftantly in view the fupport of the wratery excretions.;
 and confequently the keeping up the perfpiration by a great 
243
PRACTICE
deal of exercife, and continuing the full flow of the urina-
ry excretion by the frequent ufe of diuretics.
                   ---—»©<■■---
                      Sect. II.

      Of the Hydrothorax or Dropsy of the Breast.
   1698.] THE preternatural collection of ferous fluid in
the thorax, to which we give the  appellation of Hydrotho-
rax, occurs more frequently than has been imagined.   Its
prefence, however, is not always to be very certainly known;
and it often takes place to a confiderable degree before it
be difcovered.
   1699.] Thefe collections of watery fluids in the thorax*
ate found in different fituations.  Very often the water is
found at the fame time in both facs of the pleura,  but fre-
quently it? one of them only.   Sometimes it is found in the
pericardiuLi alone;  but for the moft part it only  appears
there when at  the fame time a collection is prefent in one
or both cavities of the thorax.  In  fome inftances, the col-
lection is found to be only in that cellular texture of the
lungs which furrounds the bronchiae, without there being
at the fame time any effufion into the cavity of the thorax.
   Pretty frequently  the water collected confifts chiefly of
a great number of hydatides in different fituations; fome-
times feemingly floating into the  cavity, but frequently
connected with and attached to particular parts of the inter-
nal furface of the pleura.
   170x3.] From the collection of water being thus in  vari-
ous fituations and circumftances, fymptoms arife which are
different in different cafes;  and from thence it becomes of-
ten difficult to afcertain the prefence and nature of the af-
fection.  I fhall, however, endeavor here to point out the
moft  common fymptoms, and efpecially thofe of that  prin-
cipal  and moft frequent form of the difeafe,  when the fe-
rous fluid is prefent in  both facs of the pleura, or, as we
ufually fpeak, in both cavities of the thorax.
   1701. J The difeafe frequently comes on with a fenfe of
anxiety about the lower part of the fternum.  This, before
it has fubfifted long, comes to be joined with fome difficul-
ty of breathing ; which at firft appears only upon the per-
fon's  moting a little falter than ufual, dpon his talking up 
OF  PHYSIC.
249
sm acclivity, or upon his afcending a ftaircafe: But after
fome time, this difficulty of breathing becomes more con-
ftant and confiderable, efpecially during the night, when the
body is in a horizontal fituation.   Commonly, at the fame
time, lying upon one fide is more eafy than upon the other,
or perhaps lying upon the back more eafy than upon either
fide. Thefe circumftances are ufually attended with a  fre-
quent cough, that is at firft dry; but which, after fome time,
is accompanied with an expectoration of this mucus.
   With all thefe fymptoms, the hydrothorax is not certain-
ly difcovered, as the fame fymptoms often attend other dif.
eafes of the breaft. When however, along with thefe fymp-
toms there is at the fame time an cedematous fwelling of
the feet and legs,  a leucophlegmatic 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 ofthe ferotum appears;  but
I have never met  with any inftance of this.
   1702. J  Whilft the prefence of the difeafe is fomewhat
uncertain, there is a fymptom which fometimes take place,
and has been thought to be  a  certain characteriftic 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  erect 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
ofthe thorax;  and therefore,  when it attends a difficulty
of breathing, accompanied with any the fmalleft fymptom of •
dropfy, I haveliad no doubt in concluding the prefence of
water in the cheft, and have always had my judgment con-
firmed by the fymptoms which afterwards appeared.
   1703.]  The hydrothorax often occurs with very few, or
almoft  none,  ofthe  fymptoms above-mentioned; and is
hot, therefore, very certainly difcovered till  fome ethers
appear.   The moft  decifive fymptom  is a fluctuation of
water in the cheft, perceived by the patient himfelf, Or by 
250                PRACTICE
 the phyfician, upon certain motions of the body.   How
 far the method propofed by Aucnbrugger will apply to af-
 certain the prefence of water and the quantity of it in the
 cheft, I have not had occafion or opportunity to obferve.
   It has been faid, that in this difeafe fome tumour appears
 upon  the fides or upon the back, but I  have not met with
 any inftance of this.  In one inftance of the difeafe, I found
 one fide ofthe thorax confiderably enlarged, the ribs itand-
 ing out farther on that fide than upon the other.
   A numbnefs and a degree of palfy in  one or both arms,
 has been frequently obferved to attend a hydrothorax.
   Soon after this difeafe has made fome progrefs, the pulfe
 commonly becomes irregular, and frequently intermitting:
 but this happens in fo  many other  difeafes of the breaft,
 that, unlefs when it is attended with fome other ofthe above-
 mentioned fymptoms, it cannot be  confidered as denoting
 the hydrothorax.
    1704.] This difeafe, as other dropfies, is commonly at-
 tended with thirft and a fcarcity of  urine, to be explained
 in the fame manner as  in the cafe of anafarca (1674.) The
 hydrothorax, however, is fometimes without thirft, or any
 other febrile fymptom; although I  believe this happens in
 the cafe of partial affections only, or when a more  general
 affedion is yet but in a flight degree.   In both cafes, how-
 ever,  and more efpecially when the difeafe is  confiderably
 advanced, fome degree of fever is generally prefent:  and
 I apprehend it to be in fuch cafe, that the perfons affected
 are more than ufually fenfible to cold, and complain of the
 coldnefs ofthe air when that is not perceived by other perfons.
    1705.] 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 affection, as being either of one fide of the thorax
 only, or being a collection of hydatides in one part of the
 cheft.  The hydrothorax, however, is very often a part of
' more  univerfal dropfy, and when at the fame time there is
 water in all the three principal cavities and in the cellular
 texture of a great  part of  the body.   I have met with fe-
 veral inftances in which fuch univerfal dropfy began firft by
 an effufion into the thorax.  The hydrothorax, however,
 more  frequently, comts on from an anafarca gradually in-
 creafing; and, as I have faid above, the general diathefis 
0 F  PH Y S 1C.                  251
feems often to affect the thorax fooner than it does either
the head or the abdomen.
   1706.]  This difeafe feldom admits of a cure, or even of
alleviation, from remedies.   It commonly proceeds to give
more and more difficulty of breathing, till the action of the
lungs be entirely interrupted by  the quantity of water ef-
fufed; and the fatal event frequently happens  more fud-
denly than was expected.   In many of  the inftances of a
fatal  hydrothorax, I have remarked a fpitting of  blood to
come on feveral days before the  patient died.
   1707.J  The caufe of  hydrothorax  is often manifeftly
one or other  of the general caufes of dropfy pointed out
above:  but what it is that determines thefe general  caufes
to act more efpecially in the thorax, and  particulaily what
it is that produces the partial collections that occur there,
I do not find to be eafily afcertained.
   1708.]  From what has been  faid above, it will be evi-
dent, that  the cure  of hydrothorax  muft be very much tlie
fame with that of anafarca; and  when the former is joined
with the latter as an  effect of the  fame general  diathefis,
there can  be no doubt of the method  of  cure being the
fame in both.  Even  when the hydrothorax is alone, and
the difeafe partial,  from particular caufes acting in the tho-
rax only, there can hardly be any other meafures employ-
ed, than the general ones propofed above.   There is only
one  particular meafure adapted to the hydrothorax; and
that  is,  the drawing off the accumulated waters bv a para-
centefis ofthe thorax.
   1709.J  To what cafes this operation may be moft pro-
 perly adapted, I find it  difficult to determine.   That  it
may  be executed with fafety, there is no doubt;  and  that
it has been fometimes  practifed  with fuccefs, feems to  be
very well vouched.*   When  the difeafe  depends upon  a
general  hydropic diathefis, it  cannot alone prove a cure,
but may give a temporary relief; and when ether remedies
  # la the memoirs of the Academy of Sciences at Paris, for 1703, M. De Verney relates ihs cafeef
a woman who had both an Afcites and Hydrothorax. He firft emptied the abdomen by tapping, anj?;
a few davs afterwards he pierced the thorax with a trochar, near to the (pine, between the t=:o$i.
and third falfe ribs; by which opening he drevr orf a conilderable quantity of water: the operation
jave immediate relief  to the patient, and (he was able to return to her ordinary employment**!
about a month's time.—Biarichi alfo relates a fuccefofu! operation of tapping the thorax; but te
feems to be timid in his practice, and confeiies that he h.-.s feldom v-jnttyred on the 0jw.1t' jr..— The
practice of evacuating water contained in the thorax by an incifi< 'i is very old. W<_ i-mi it recom-
mended by Hippocrates, with particular directions for performing the operation, in ::'■' r^con.l book
on difeafes.  See the Geneva edition of Foefius's Hippocrates, pa". 4 J?.—."that the y.*tii-:e wa;; fre-
quently attended with fuccefs, in thofe early ages, is fun.ciently evident by the context; for Hippo-
crates, after defcribing the operation, ind the Fjbfequent managenieuffof the patent, fays, " If pio*
*ppj»r on the plafter covering the wound on the f.fth day after the qjjeration, the puieat ge-i;t.ii.y
recovers; if not, he is leised with a cough and tuirit, ar.d dies.'' -  >  ■ 
,€52                PRACTICE
feem tri .be employed with)advantage, the drawing off the
water may very^much favour a complete cure.   I have
not, however, been fo fortunate as to fee it practifed with
a«y fuccefs j and even where it was moft promifing, that is,
in cafes of partial affection, my jexpectations have been dif-
appointed from it.

                      Sect. III.

       Of Aicites, or,Dropsy of the Lower Belly.
   1710.3 THE name  of Ascites is given to every collec-
tion of waters canting a general fwelling and diftention of
the lewerheHy;  and fuch collections are more frequent
than thofe which happen in the thorax.
 -  171.1.. J The -collections in the lower belly, like thofe of
the thorax, are found in different fituations.  Moft com-
monly they are in the  fac of the peritonaeum, or  general
cavity of the  abdomen: 'but they often begin by facs form-
ed upon, arid connected with, one or other of the vifcera;
and perhaps the moft frequent inftances  of this kind occur
in the ovaria of females.   Sometimes the water of afcites
is found entirety without the peritonaeum, and between this
and the abdominal mufcles.
   1712.) Thefe collections connected with particular vif-
cera, and thofe formed without the peritonaeum, form that
difeafe which; authors have termed the encysted dropsy, or
hydrops saccaiks.   Their precife feat, and thek exiftence,
is Very often difficult to be afcertained.  They are gen<&saily
formed bycorte&ions of hydatides.
   1713.] In  the moft ordinary  cafe, that  of abdominal
dropfy, the fwelling at firft is in forme meafure over die whole
fcelly,  but generally appears moft confiderable in  theepi-
gamium.   As the difeafe, however, advances, the fwelling
becomes more uniform over the  whole.  The diftention,
and fenfe of weight, though cflwfiderable, vary a little ac-
cording as the pofture of the body isTchanged ; the weight
being felt the  moft upon the fide on which the ptaiient lies,
while at the fame time  on  the oppofite  fide the  diftention
becomes fomewhat'fefs.  In almoft all the inftances of af-
cites, the fluctuation^©f the water within, may be perceived
by the practitioner's feeling, and fometimes by his hearing.
This perception of fluctuation does not certainly diftinglifh 
Or  PHYSIC.               25*
 the different ftates of dropfy; but ferves very well to dif-
 tinguifh dropfy from tympanites, from cafes of phyfeonia,
 and from the ftate of pregnancy in women.
   1714.]  As afcites frequently occurs when no other fpe*
 cies of dropfy does at the fame time appear;  but fometimes
 the afcites is a part only of univerfal dropfy.   In this cafe,
 it ufually conies on in confequence of  an  anafarca,  gra-
 dually increafing; but its being joined with anafarca, does
 not always denote any general diathefis, as for the moft part
 an afcites fooner or later occafions cedematous fwellings
 of the lower extremities.   When the collection of water in
 the abdomen, from whatever caufe, becomes confiderable,
 it is always attended with a difficulty of breathing; but this
 fymptom occurs often when, at the fame time, there is no
 water in the thorax.  The afcites is fometimes unaccompa-
 nied with any fever; but frequently there is more or lefs of
 fever prefent with it.  This difeafe is never  confiderable,
 without being attended with thirft and fcarcity of urine.
   1715. J  In the diagnofis of afcites, the greateft 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 en*
 cyfted dropfy above-mentioned.  There is, perhaps, no cer-
 tain 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 ofthe body;  and
 when, from its firft appearance, the fwelling has been equal-
 ly over the whole belly, we may generally prefume that the
 water is in the cavity of the abdomen.   But when an  af-
 cites has not been preceded by any  remarkable cachectic
 ftate of the fyftem, and when at  its beginning the tumour
 and tenfion had appeared in one part of the belly more than
 another, there is reafon  to fufpect an  encyfted dropfy.
 Even when the tenfion and  tumour of the belly have be-
 come general and uniform  over  the whole; yet if the fyf-
 tem ofthe body in general  appear to be little affected; if
 the patient's ftrength be little impaired; if the appetite con-
 tinue pretty entire, and the natural fleep be little interrupt-
ed ; if the menfes in females continue to flow as ufual; if
there be yet n© anafarca; or, though it may have already
  t0L. II.                I 1 
:^4                practicl
taken place, if it be ftill confined to the lower extremities',.
aj^d there be no leucophlegmatic palenefs or fallow colour
in the countenance;  if there  be no fever,  nor fo  much'
thirft, or fcarcity of urine, as occur in a more general affec-
tion ;  then, according as more of thefe different circum-
ftanees 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 general
rule, will, in my opinion,  be  when  the afcites may with
much probability, be prefumed to have come on in confe-
quence of a fcirrhous liver; which, I apprehend, may oc-
cafion a collection of water in  the cavity of the abdomen,
while the general fyftem of the body  may not be otherwife
much affected.
   1716.] With refpect to the cure of afeftes when  of the
encyfted kind, it.does.not, fo far as I know, admit of any.
When the collection of water is in the  abdominal  cavity
alone, without any other fpecies of dropfy prefent  at the
fame  time, I apprehend the afcites will always be of diffi-
cult cure;  for it may  be prefumed to depend upon  a feir-
rhofity  of the liver, or other confiderable affection  of the
abdominal vifcera, wrhich 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.
   1717.]  When the afcites is apart 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 ob-
tained by the fame means as above propofed  for the cure
of general anafarca.*
   It  frequently happens that  the afcites is attended 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  friction  ofthe
fkin over the whole of the abdomen, by the fingers  dipped
in oil.  This  has fometimes been ufeful in  exciting an in-
creafed flow of urine; but in moft of the trials of it which
I have known made, it has failed in  producing that  effect.
            * Sec the notes on article 1664. 
O F  P H Y S I C.
255
   1718.] The afcites admits of a particular means for im-
mediately drawing off the collected waters: and that is the
well-known operation ofthe  paracentefis of the abdomen.
In what  circumftances of afcites this operation  can riioft
properly be propofed, it is difficult to determine; but, fo
far as I can judge, it muft be regulated by very much the
fame confiderations as thofe above-mentioned  with regard
to the paracentefis of the thorax.
   The manner of performing the paracentefis of the abdo-
men, 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 forme to  offer any direc-
tions upon that fubject  here; efpecially after the  full  and
judicious information and  directions given by Mr. Bell,
in the fecond volume of his System of Surgery.

                     CHAP.  IV.

              £>f General ^toelitnpf,
 ARISING FROM AN INCREASED BULK OF THE WHOLE SU^SfANCE
                  OF  PARTICULAR PARTS.

 1719.]  LJ PON the fubjects of this chapter, feveral no-
 fological difficulties occur,, and particularly.with refpect to
admitting the Physconva into the order of General Swel-
 lings. At prefent, however, it is not neceffary forme todifcufs
 this point, as I am here to omit entirely the confideration of
 Phyfconia; both becaufe it can feldom admit of any fuccefs-
 ful practice,and becaufe I cannot deliverany thing ufefulei-
 ther withregard to the pathology or practice in fuch a difeafe.
   1720.] The only other  genus of difeafe comprehended
 under the title of the prefent chapter, is the Rachitis;  and
 this being both a proper example ofthe  clafs of Cachexy,
 and of the order of Intumesccntice or General  Swellings, I
 fliall offer fome obfervations with regard to it.

              Of RACHITIS, or RICKETS.
   1721.] THIS difeafe has been fuppofed to have appear-
 ed only in modern times, and not above two hundred years
 ago. This opinion, notwithstanding it has been maintained
 by perfons of the moft refpectable authority,* appears to
  * Boerhaave was of this opinion, See Van Swielca's Commentary on AphorUffi 148a. 
»»6                PRACTICE
me, from many confiderations^ improbable ; but  it is  a
point of two litde confequence to detain my readers here.
The only  application of it  which defervcs any notice  is,
that it has led to a notion of the difeafe having arifen from
the lues venerea,  which had certainly made its firft appear*-
ance in Europe not very long before  the date commonly
affigned for the appearance of rachitis : But I  fhall hereaf-
ter fhow, that the fuppofed connection between the Siphy-
lis and Rachitis is without foundation.t
   1722.]  In delivering the hiftory of the Rickets, I muft,
in the firft place,  obferve, that with refpect to the antece-
dents of the difeafe, every thing to be found in authors up-
on this fubject, appears to me to reft upon a very uncertain
foundation.  In particular, with refpect to the ftate  ofthe
parents whofe offspring become affected with this difeafe, I
have met with many inftances  of it, in children from feem-
ingly  healthy parents, and have met likewife with many in-
ftances of children who never  became affected with it, al-
though born of parents who, according to the  common ac-
counts, fhould have produced  a rickety offspring : So that
even making allowance for the uncertainty of fathers, I do
not find the general  opinion of authors upon this fubject to
be properly fupported.
   1723.]  The difeafe, however, may be juftly confidered
as proceeding from parents ; for it often appears in a great
number of the fame family :  And my obfervation leads
jne to judge, that it originates  more  frequently from mo-
thers  than from fathers.  So far as I can refer the difeafe
of the children to the ftate of  the parents, it has appeared
to me moft  commonly to arife from fome weaknefs, and
pretty frequently  from a fchropbulous habit in the mother,
To conclude the  fubject, I muft remark, that in many ca-
fes I have not been able to difcern  the condition of the pa-
rents, to which I  could refer it.
   When nurfes, other than the mothers, have been employ-
ed to fuckle children, it has been fuppofed that fuch nurfes
have  frequently given occafion to the difeafe  :J and when
nurfes have both  produced and have fuckled children who
became rickety,  there may be ground to fufpect their hav-
ing occafioned the difeafe in the children of other perfons:
But I have had few opportunities of afcertaining  this mat-
 t See Artkte 17*8.      t Thi««pi»ion was held by Boerhaave, and notyrtthftandine what
tkc Autfer fay* at UK CWl Of tfiU fwagrajA, the ofttiog h certainly foaiiacd on experience? 
OF  PHYSIC.
257
ter.   It has in  fome meafure appeared to me,  that thofe
nurfes are moft likely to produce this difeafe, who give in-
fants a large quantity of very watery milk, and who conti-
nue to fuckle them longer than the ufual time.  Upon the
whole, however, I am of opinion, that hired  nurfes feldom
occafion the difeafe, unlefs when a predifpofition to it has
proceeded from the parents.
   1724. With regard to the other antecedents, which have
been ufually enumerated by authors as the remote caufes of
this difeafe, I judge the accounts given  to be extremely fal-
lacious;  and I am very much perfuaded, that the circum-
ftances in the rearing.of children, have lefs  effect in prou
ducing rickets than has been imagined.  It is indeed not
unlikely, that fome of thefe circumftances mentioned as re*
mote caufes may favor, while other circumftances may re-
fift, the coming on of the difeafe ; but  at the fame time,  I
doubt if any of the former would produce it where there
was no predifpofition in the  child's  original conftitution.
This opinion of the remote caufes, I have formed from obi
ferving, that the difeafe comes on  when none of thefe had
been applied; and more frequently that many of them had
been applied without occafioning the difeafe.  Thus the
learned Zevi an i alleges, that the difeafe is produced by
an acid from the milk with which a child is ferjifor the firft
nine months of its life: But almoft all children are fed with
the fame food, and in which alfo an acid is always produc-
ed; while at the fame time, not one in a thbufand of the
infants fo fed becomes affected with the rickets.  If, there-
fore, in the infants who become affeQed with this difeafe, a
peculiarly noxious acid is produced, we muft feek for fome
peculiar  caufe of its production,  either  in  the quality of
the milk, or in the conftitution of the child; neither of which
however, Mr. Zeviani has explained.  I cannot indeed be-
lieve that the ordinary acid of milk has any fhare in pro-
ducing this difeafe, becaufe I have known many inftances
of the acid being produced and occafioning various difor-
ders, without, however, its ever producing rickets.
   Another of the remote caufes commonly affigned, is the
child's being fed with unfermented farinaceous food;  But
over the  whole world, children are fed with fuch farinacea,
while the difeafe of rickets is a rare occurrence : And  I
have known many inftancest where cbjldrenj^ayg, beeojggi 
258                PRACTICE
 with a greater than ufual proportion of fermented  farina-
 cea, and alfo a greater proportion of animal food, without
 thefe preventing the difeafe.  In my apprehenfion, the like
 obfervations might be made with refpect to moft ofthe cir-
 cumftances  that have been mentioned as the remote caufes
 of rickets.
   1725.] Having thus offered my opinion concerning the
 fuppofed antecedents of this difeafe, I proceed now to men-
 tion the phenomena occurring after it has actually come on.*
   The difeafe feldom appears before the ninth month, and
 feldom begins after the fecond year, of a child's age.  111
 the interval  between thefe periods, the appearance of the
 difeafe L> fometimes fooner, fometimes later; and common-
 ly at firft the difeafe comes on  flowly.   The firft  appear-
 ances are, a flaccidity of the flefh, the  body at the fame
 time becoming leaner, though food be taken in pretty large-
 ly.   The head appears  large with refpect to the body;
 with the fontanelle, and perhaps  the futures, more open
 than ufual  in  children of the  fame age.   The  head  con-
 tinues to grow larger; in particular, the forehead becom-
 ing unufually prominent; and at the fame time the neck
 continues flender, or feems to be more fo, in proportion to
 the head.  The dentition is flow, or much later than ufual;
 and thofe teeth which come out,  readily become black,
 and frequently again fall out.   The ribs lofe their convex-
 ity, and become flattened on the fides;  while the fternum
 is pufhed outward, and forms a fort of ridge.   At the fame
 time, or perhaps fooner, the epiphyfes at the feveral joints
 of the limbs become fwelled; while the limbs between the
joints appear,  or perhaps actually become, more flender.
 The bones feem to be every where flexible, becoming va-
 rioufly diftorted;  and particularly the fpine ofthe back be-
 coming incurvated in different parts of its length.   If the
 child, at the  fame time the difeafe comes on, had acquired
 the power of walking, it becomes daily more feeble imits
 motions, and more averfe to the exertion of them, lofing at
 length the power of walking altogether.  Whilft thefe fymp-
 toms go on increafing, the abdomen is always full, and preter-
 naturally tumid.  The appetite is often good, but the ftools
 are generally frequent and loofe.   Sometimes the faculties
 ofthe mind are impaired, and ftupidity or fatuity prevails;
 » '1«.. admirable defcription of the difcafe merits the peculiar attention of the young practitioner. 
                  Or  r K T 3 I C.                25?

but commonly a premature fenfibility appears,  and they
acquire the faculty of fpeech  fooner  than ufual.   At th#
firft coming on of the difeafe, there is generally rro fever at-
tending it:  but it feldom continues long, till a frequent
pulfe, and other febrile fymptoms, come to be conftantly
prefent.  With thefe  fymptoms the difeafe proceeds, and
continues in fome inftances for fome years;  but very often,
in the courfe of that time, the difeafe ceafes  to advance,
and the health  is entirely eftablifhed, except  that  the dis-
torted limbs, produced during the difeafe, continue for the
reft of life.   In other cafes, however, the difeafe proceeds
increafing, till it has affected almoft every function of the
animal ceconomy, and at length terminates in death.   The
variety of fymptoms which in fuch cafes appear, it does
not feem neceffary to enumerate,  as they are  not effential
to the conftitution of the difeafe, but are merely confe-
quences of the more violent conditions of it.   In the bo-
dies of thofe whohave died, various morbid affections have
been difcovered in the internal parts.   Moft of the vifcera
of the abdomen have been found  to be preternaturally en-
larged.  The lungs have alfo been found in a morbid ftate,
 feemingly from fome inflammation that had  come on to-
wards the end of the difeafe.  The brain has beqn com
monly found in a flaccid ftate, with effufions of a ferous
 fluid into its cavities.  Very univerfally  the bones have
 been found very foft, and fo much foftenedas  tobe readily
 cut by a knife.   The fluids have  been always found in a
 diffolved ftate,  and the  mufcular parts very  foft  and ten-
 der; and the whole  of the dead  body without any degree
 of that rigidity which is fo common  in almoft all odiers.
    1726.] From thefe circumftances ofthe difeafe, it feems
 to confift in a deficiency of that matter which fliould form
 the folid parts of the body. This  efpecially appears  in the
 faulty ftate of offification,  feemingly depending upon the
 deficiency of that matter which fliould  be depofited in the
 membranes which are deftined tobecome bony, and fhould
 give them their due firmnefs and  bony hardnefs.. Itappears
 that this matter is not fupplied  in due quantity;  but that
 in place of it,  a matter fitted to increafe their bulk, parti-
 cularly in the epiphyfes, is applied too  largely. What this
 deficiency of matter depends upon, is difficult to be afcer-
 tained. It may be a fault in the organs- of digeftion and af- 
260                 PRACTICE
                        es. ___
finidation, which prevents the fluids in general from being
properly prepared:  or. it may  be a fault in the organs  of
nutrition, which prevents the fecretion of a proper matter
to be applied.   With refpect to the latter, in what it may
confift, I am  entirely  ignorant,  and cannot even difcern
that fuch a condition exifts: but  the former caufe, both in
its nature and exiftence, is more readily perceived; and it
is probable that it has a confiderable influence in the mat-
ter; as in rachitic perfons a thinner ftate of the blood, both
during life and after death, fo  commonly appears.   It is
this ftate of the fluids,  or a deficiency of bony matter  in
them, that I confider as the proximate caufe ofthe difeafe;
and which again may in fome meafure depend upon a ge*
neral  laxity and debility of the moving fibres of the organs.
that perform the functions of digeftion and affimilation.
   1727.] There is,  however, fomething ftill wanting to ex-
plain, why thefe circumftances difcover themfelves at a par-
ticular time of life, and hardly ever either before or after a
certain period ;  and as to this I would offer  the following
conjectures. Nature having intended that human life fhould
proceed in a  certain manner, and that certain functions
mould be exercifed at a certain period of life only ;  fo it
has generally provided, that at tharperiod, and not fooner,
the body fliould be  fitted for the  exercife of the functions,
fuited to it.   To apply this to our prefent fubject, Nature
feems to  have intended that children fhould walk only at
twel ve months old; and accordingly has provided that againft
that age, and no fooner, a matter fhould be prepared fit to give
that firmnefs to the bones which is neceffary to prevent their
bending too eafily under the weight of the body.  Nature,
however,  is not always fteady and exact  in executing her
own purpofes; and  if  therefore  the preparation  of bony
matter fhall not have been made againft the time there is a
particular occafion for it, the difeafe of rickets, that is,  of
foft and flexible bones, muft come on ;  and will difcover
itfelf about the particular period we have mentioned.  Fur-
ther, it will be equally probable, that if at the period men-
tioned, the bones fhall 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 
OF  PHYSIC.                261
foft and flexible during the reft of life;  unlefs it happen,
as indeed it  fometimes does, that certain caufes  occur  to
wafh  out  again  the  bony matter from the membranes in
which it had been depofited.  The account I have now
given of the period at which the rickets occur,  feems to
confirm the opinion of its proximate caufe being a deficien-
cy of bony matter in the fluids ofthe body.
   1728.]  Ii has been frequently fuppofed, that a fiphylitic
taint has a fhare in producing rickets;  but fuch a fuppofi-
tion is altogether improbable.  If our opinion ofthe rick-
ets having exifted in Europe before the fiphylis was brought
into it, be well founded, it wilhhen be certain that the difeafe
may be occafioned without any fiphylitic acrimony having
a fhare in its production.  But  further, when a  fiphylitic
acrimony  is tranfmitted from the parent to the offspring,
the fymptoms do not appear at a particular time of life on-
ly, and commonly more early than the period of rickets;
the fymptoms alfo are very different from thofe of rickets,
and unaccompanied with any appearance ofthe latter; and,
laftly, the  fymptoms of fiphylis  are  cured by means
which, in the cafe of rickets, have either no effect, or a bad
one.  It may  indeed poffibly happen, that  fiphylis and
rickets may appear in the  fame perfon; but it is to be con-
fidered as an accidental complication : and the very few in-
ftances of it that have occurred, are by no means fufficient tcT
eftablifh any neceffary connection between the two difeafes.
   1 729.]  With refpect to the deficiency of bony matter?
which I confider as the proximate caufe of rickets, fomei
further conjectures might be offered concerning its remote
caufes;  but none of them  appear  to me very fatisfying;
arid 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.
   1730.]  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 arc not only  fuited to improve the
rone of the ftomach itfelf, but by that means to improve
alfo the tone of the whole fyftem.
   1731.]  Of tonic remedies, one ofthe  moft promifing
  V u. 11.                 K. s 
362                  PRACTICE
   feems to have been cold bathing;  and I have found it the
   moft powerful in preventing the difeafe.   For a long time
   paft, it has been  the practice 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 has been the practice with people of better
   rank to have them dipped entirely in cold water every morn-
   ing:  And wherever this practice has been purfued, I have
   not met with any inftance of rickets.   Arnongft our com-
   mon people, although  they wafh their children with cold
   water only,  yet they do not fo commonly prafctife immer-
   fion:  And  when arnongft thefe  I  meet with inftances of
   rickets,  I prefcribe cold bathing;  which accordingly has
   often checked the progrefs of  the difeafe, and fometimes
   feems to have cured it  entirely.
      1732.] The remedy of  Ens Veneris, recommended by
   Mr.  Boyle,  and fincehis time very univerfally employed,
   is to be confidered as  entirely a tonic remedy.   That or
   fome other  preparation  of iron  I  have almoft conftantly
   employed, though not indeed always with fuccefs.   I have
   been perfuaded,  that the  ens veneris  of Mr. Boyle, not-
   withftanding his giving  it this appellation, was  truly a pre-
   paration of iron,  and no other than  what we  now name  the
   Flores Martiales:* But it appears,  that both Benevoli and
<v, Huchner have employed a preparation of copper;  and I
   am ready to believe it to be a more powerful tonic than the
   preparations of iron.t
      1733.] Upon the fuppofition  of tonic remedies being
   proper in this difeafe, I have  endeavoured to employ  the
   Peruvian bark; But from the difficulty of adminiftering it
   to infants in any  ufeful quantity,  I  have not been  able to
   difcover its  efficacy; but I am very ready  to believe the
   teftimi^y.of De  Haeri  upon this  fubjeft.J
      17§'4-] Exercife; which is one of the moft powerful to-
   nics, has been properly recommended for the cure of rick-
   ets ;  and as the exercife of geftation only can be employed,
     * The dofe of tM» medicine is from four to twenty grains, it muft be given in the form of abolu*.
   The young practitioner ought to beware of preferring Flores martiales in pills, which will fwell and
   crumble to pieces if they arc not compofed of a conilderable quantity of fome ?ummj refin.—The
   Flores martiales may be very conveniently given in a tinfture of proof fpirit.  There is a formula 0*
   it in the laft London Pharmacopoera, under, the name of Tinrlura ferri Aminoniacalis. The dofe of
   it is a tea-fpoonfifl in a wine glafs of cold water, and it is a very elegant form of adminiftering the
   chalybeates.
     t Copper is a very dangerous remedy, as was mentioned above in the note* on article 1337. The
   Authsr had a very high opinion of copper as a tonic.
     t It Is doubtlefs difficult to make children fwallow a fufficient quantity of bark to produce any
   good effett.;, yet it is not impofiible.  The formula beft adapted fur children, is the powder of the
   extract; but as it fometiines occafionu eonftipation, this efleft mirft be guarded againft by fome pro- 
OF  F H 1 S I C.                263
it fhould always be, with the child laid in a horizontal fi-
tuation;  as the carrying them, or moving them in any de-
gree of an erect pofture, is very apt to occafion fome diftor-
tion.   It is extremely probable, that, in this  difeafe, fric-
tion with dry flannels may be found an ufeful remedy.
   1735.] It is alfo fufficiently probable, that the avoiding
of rnoifture is not only advifeable, but may likewife be of
fervice in the cure of this difeafe.
   There is no doubt that a certain diet may  contribute to
the fame  end; but what may be the moft eligible, I dare
not determine.  I have no doubt that leavened bread may
be  more proper than unfermented farinacea; but I cannot
find any reafon to believe that  ftrong beer can  ever be  a
proper remedy.
   Practitioners have been divided in opinion concerning
the ufeof milk in this difeafe.  Zeviani, perhaps from theo-
ry,  condemns the  ufe  of  it;  but  Benevoli employed  it
without  its impeding the cure of the difeafe.  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 ricke-
ty children;  and in many inftances I  can affirm, that it did
not prevent the cure of the difeafe..   In cafes, however,  of
any appearance of rickets, and particularly of a flow den-
tition, I  have diffuaded the continuance of a child updn
the breaft;  becaufe the milk of women.is a more watery
nourifhment than that of cows: And I have  efpecially dif-
fuaded 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 the rickets.*
    1736.3 Befides the remedies and regimen now mention-
ed, practitioners have commonly employed in this difeafe,
both emetics and purgatives*   When the appetite and di-
geftion are confiderably impaired, vomiting,  if neither vio-
lent, nor frequently repeated, feems to be of fervice; and
per laxative, specially by Rhubarb gTven either with the bark or feparately.  The following formul*!
U a proper dole for a child of two years old,, to berepeated twice a day:
          ft. Extr. Cort. Peruv. dur. gr. viii.
             Pulv. Rad. Rhei. gr. x.
              Sacch. alb. gr. xv.
             M. f. pulv.
           * How does this accord with the Iaftientence of article 17x^7 
264                PRACTICE
by a moderate agitation ofthe abdominal vifcera, may in
fome meafure obviate the ftagnation i.nd confequent fwel-
ling 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 obviat-
ing this, and by deriving from the abdominal  vifcera, fre-
quent gentle purgatives may be of fervice. Zev;ar.i, v-ei haps
properly, recommends in particular rhubarb; which, befides
its purgative quality, has thofe alio of bitter and ailringcnt;
   1737-J * nave now mentioned moft ofthe remedies com-
monly employed by the practitioners of former times; but
I muft not  omit  mentioning fome  others that have been
lately fuggefted.   The  late Mr. De  Haen  recommends
the teftacea; and allures us of their having been employed
with  fuccefs-: But in the few trials which I have had occa-
fion to make, their good effects did not appear.
   The late Baron Van Sweiten 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 Impetiginesj  or Depraved Habit, with Affections
                     of the Skin.

1738.] JL FINIJ.it difficult to give any fufficiently correct
and proper character of this order.  The difeafes compre-
hended under it, depend, for the moft part, upon a deprav-
ed ftate  of the whole of the fluids, producing tumours,
eruptions, or other preternatural affe6tions  of the fkin.
Although it be extremely  difficult  to find a  general  cha-
racter of the order that will apply to the genera and fpecies,
I fhall here treat of the principal genera which have been
commonly comprehended under this  order, and which  I
have enumerated in my Nofology.

                     CHAP.  I.
      fflf Scwp&ula, or t&e &:ng'ai  <£t>iL

1739.]  JL HE 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 delivered, 
i-  . ^ . S I C.               265
   1740.] It is commonly, and very generally, a hereditary
difeafe; and  although it fometimes may, yet it rarely ap-
pears, but in  children whofe parents had at fome period of
their lives been affected with it.  Whether it may not fad
to appear in  the children  of fciQphulous parents, and dif-
cover itfelf afterwards  in  their offspring in the fucceeding
generation, I cannot certainly determine ; but believe that
this has frequently happened.  It appears to me to be deriv-
ed  more commonly from  fathers than from mothers; but
whether this  happens from there being more ferophulous
men than ferophulous women married, I am not certain.
   With refpect to the influence of parents in producing this
difeafe, it deferves to be remarked, that in a family of many
children,  when one of the parents has been affected with
fcrophula, and the other not; as it is ufual for fome of the
children to be in  conftitution pretty exactly  like  the one
parent,  a-id  others of  them like the other;  it commonly
happens, that thofe children who  moft refemble the  fero-
phulous parent become affected with fcrophula, while thofe
refembling the other parent entirely efcape.
   1741.] The fcrophula  generally appears at a particular
period  of life.  It feldom appears in the. firft,  or even in
the fecond year of a child's life; and moft commonly it oc-
curs from the fecond, or, as foniealledge, and perhaps more
properly, from the third, to the feventh year.  Frequently,
however, it difeovers itfelf ata later period; and there are
inftances of its firft appearance, at every period till the age of
puberty; after which,  however, the firft  appearance  of it
is very  rare.
   1742.] When it does  not  occur very early, we can ge-
nerally diftinguifh the habit of body peculiarly difpofed to
it.   It  moft  commonly aficcts children of foft am\Jlaccid
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 middle of it; and this tumour is often con-
fiderable, and extended to the columna nafi and lower part
of thenoftrils.  The difeafe is foretimes joined with, or
follows rickets; and although it frequently appears in chil-
dren who have not had rickets in any great degree, yet it
often attacks thofe who, by a protuberant forehead, by tu- 
266                PRACTICE
mid joints, and a tumid abdomen, fhow that they had fome
rachitic  difpofition.   In parents who without having had
the difeafe themfelves, feem to produce ferophulous chil-
dren, we can commonly 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. De Haen afferts its
followirigthe inoculated, more frequently than the natural,
fmall pox.  This laft pofition, however, we can confident-
ly affirm to be a miftake; although it muft be allowed, that
in fact the fcrophula does often come on  immediately af-
ter 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  feropriulous difpofition; and I
have had feveral inftances of the  natural fmall pox coming
upon children  affetted at the fame time with   fcrophula,
not only without this difeafe being any ways aggravated by
the fmall pox, but  even of its being for  fome  time  after
much relieved.
   1743.] The fcrophula generally fhows itfelf firft ata
particular 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 pecu-
liar to this difeafe, appear firft in the fpring, the ulcers are
frequently healed up in the courfe of the  fucceeding  fum-
mer, and do not break Out again till the enfuing fpring, to
follow again with the feafon the fame courfe as  before.
   1744.] Frequently the  firft appearance of the difeafe is
the tumid and chopped lip above-mentioned.  Upon other
occaflnns the  firft appearance is that of finall fpherical or
oval tumours, moveable under  the fkin.   They are foft,
but  with fome elafticity.   They are without pain; and
without any change in the colour of the fkin.   In this ftate
they often  continue for a long  time; even for a  year or
two, and fometimes longer.  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 lym-
phatic glands only;  and not at all the falivary  glands, till- 
OF  PHYSIC.
ser
the difeafe is very greatly  advanced.   The  difeafe fre-
quently affects, and even at firft appears in, other parts of
the body.  In particular, it affefts the joint* of the elbows
and ankles, or thofe of the fingers and toes. The appear-
ances about  the joints  are  not commonly, as elfewhere,
fmall moveable fwellings; but a tumour almoft uniformly
furrounding the joint, and interrupting its motion.
   1745-J Thefe tumours, as I have faid, remain for fome
time little changed; and, from  the time they firft appeared
in the fpring, they often  continue in this way till the return
of the fame feafon in the next,  or perhaps the  fecond year
after.  About that time, however, or perhaps in the courfe
ofthe feafon in which they firft appear, the tumour be-
comes larger and more fixed; the fkin upon it acquires a
purple,  feldom a  clear  rednefs:  but growing redder by
degrees,  the tumour becomes fofter, and allows the fluc-
tuation of a liquid  within to be perceived.  All this pro-
cefs, however, takes place with very littiepain attending
it.   At length fome part of  the fkin becorfres  paler;  and
by one or more fmall  apertures a liquid is poured out.
   j 746.] The matter poured  out has at firft the appear-
ance of pus, but  it is ufually  of a thinner kind than that
from phlegmonic abfeeffes;  and the matter as  it continues
to be difcharged, becomes daily lefs purulent, and appears
more and more a vifcid ferum, intermixed with fmall pieces
of a white fubftance refembling the curd of milk.   By de-
grees the tumour almoft entirely fubfides while the ulcer
opens more, and fpreads broader:  unequally, however, in
different directions, and therefore is without any  regular
circumfcription.—The  edges of the ulcer arc comrr.or.lv
flat and fmooth, both on their outfide and their inner edge,
which feldom puts on a  callous appearance.  The ulcer?,
however, do not generally fpread much, or become deep-
er;  but  at the fame time their edges do not advance, or
put on any appearance of forming a cicatrix.
   1747.] In this condition the ulcers often continue for a
long Dme; while new tumours, with ulcers fucceeding them
in the manner  above defcribed,  make their appearance
in different  parts of the body.  Of the firft ulcers, how-
ever, fome heal up, while other tumours 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, 
268                PRACTICE
 at leaft to a certain degree, in  the courfe of fummer, and
 breaking out in the fucceeding fpring: Or it continues, by
 new tumours and ulcers fucceeding them, in the fpring fea-
 fon, making their appearance fuccetfively for fevcral years.
   1748.] In this way the difeafe goes on for fevcral years;
 but very commonly in four or five years it is fpontaneouf-
 ly 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 fhriveiled; or, where it had oc-
 cupied the joints, leaving the motion of thefe impaired, or
 entirely deftroyed.
   1749.] Such is the moft favourable courfe of this dif-
 eafe; 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 at the
 fame time affected; the ulcers alfo feeming to be imbued;
 with a peculiarly fharp acrimony, and therefore becoming
 more deep, eroding, fpreading, as well as feldomer healing
 up.   In fuch cafes,  theVyes are often particularly affeBed.
 The edges of the eyelids are affected with tumour and fuper-
 ficial  ulcerations; and thefe commonly excite obftinate in-
 flammation in the adnata,  which frequently produces an
 opacity <?? the cornea.
   When the fcrophula efpecially  affects the joints, it fome-
 times produces there confiderable tumours; in the abfeef-
 fes following which, the  ligaments and cartilages are erod-
 ed, and the adjoining bones are affected  with a caries of a
 peculiarkind. In thefe cafes, alfo,  of more violent fcrophu-
 la, while every year produces a number of new tamours and
 ulcers, their acrimony feems at  length to taint the whole
 fluids of the body, occafioning various diforders;  and par-
 ticularly a hectic  fever,  vith all  its  fymptoms, which at
 length proves fatal, with  fometimes the fymptoms of a
 phthifis pulmonalis.
   1750.J The bodies of perfons who have died of this
 difeafe fhow  many of the  vifcera in a very morbid ftate ;
 and particularly  moft of the glands of the mefentcry very
much tumefied, and frequently in  an ulcerated ftate. Com-
monly alfo a great number  of tubercles or cylts, contain-
ing matter of various kinds, appear in the lunqs."
   1751.] Such is the hiftory ofthe difeafe; and from thence 
OF  PHYSIC.               269
it may appear, that the nature of it is not eafily to be  af-
certained.   It feems  to be a peculiar affection of the lym-
phatic 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
the proximate  caufe of the difeafe; although of what  na-
ture this is, has not yet been difcovered. It may perhaps be
generally  diffufed in the fyftem, and exhaled into the fe-
veral cavities and cellular texture ofthe body;  and there-
fore,  being taking 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 many  other acrimonies which
may be 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 tranfmiffion of a peculiar
conftitution, are all of them circumftances which lead  me
to conclude, upon the whole, that this difeafe depends up-
on a peculiar constitution of the  lymphatic system.
   1752. J It feems proper to obferve here, that the fcro-
phula does not appear to be a contagious difeafe; at leaft
I have known many inftances of found children having had
frequent and clofe intercourfe with ferophulous children
without being infected with the difeafe.   This certainly
fhows, that in this difeafe the peculiar acrimony of it is  not
exhaled from the furface of the  body, but  that it depends
efpecially upon a peculiar conftitution of the fyftem.
   1753.J 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 inftances,
there can hardly be any fufpicion of the parents producing
this difeafe having been imbued with fiphylis, or with any
fiphylitic taint;  and I have known feveral examples of pa-
rents  conveying fiphylis to their offspring,  in whom, how-
ever, no ferophulous fymptoms at any time afterwards ap-
peared.  Further, the fymptoms of the two difeafes  are
very different;  and the difference of their natures appears
particularly from hence, that while mercury commonly and
readily cures the  fiphylis, it docs no fervice  in fcrophula,
and very often rather aggravates the difeafe.
  Vol. II.                L l 
*7t>                PRACTICE
   1754.] For the cure of fcrophula, we have not yet learn-
ed any practice that is certainly or even generally fuccefsful.
   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 waffling 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 hadihortened.the duration of the difeafe more than had
often happened when no fuch remedy had been employed.
   1755. J  With regard to the choice of the mineral waters
moft fit for the purpofe, I cannot with any confidence give
an opinion.   Almoft all kinds of mineral waters, whether
chalybeate, fulphureous  or faline, have been employed for
the cure of  fcrophula, and feemingly with equal fuccefs
and reputation; A circumftance which leads me to think,
that, if they are ever fuccefsful, it is the elementary water
that is the chief part of the remedy.
   Of late, fea water has been efpecially recommended and
employed;  but after numerous trials, I cannot yet difcover
its fuperior efficacy.
   1756. J  The other remedies propofed by practical wri-
ters are very numerous; but, upon that very account,  I
apprehend  they  are little to be  trufted:  and as I  cannot
perceive any juft reafon  for  expecting fuccefs  from them,
I have very feldorn  employed them.
   Of late, the Peruvian bark has been much recommend-
ed : And as in ferophulous perfons there are generally fome
marks of laxity and flaccidity, this tonic may  poffibly  be
of fervice;  but in a great variety of trials,  I  have never
feen it produce any immediate cure of the difeafe.
   In feveral inftances, the leaves of coltsfoot have appear-
ed to me to be fuccefsful.   I have ufed it frequently in
ftrong decoction, and even then  with advantage; but have
found  more benefit from  the expreffed juice,  when the
plant could be had in  fomewhat of a  fucculent ftate, foon
after its firft appearance  in the fpring.
   1757.]  I have alfo frequently employed the hemlock,
and have fometimes found it ufeful in difcuffing obftinate
fwellings:  But in this, it has alfo often difappointed me;
and I  have not at any  time obferved that it difpofed fero-
phulous ulcers to heal. 
OF PHYSIC.
271
   I cannot conclude the fubject of internal medicines with-
out remarking, that I have never found, either mercury or
antimony, in any fhape, of ufe in this difeafe; and when
any degree of a feverifh ftate had come on, the ufe of mer-
cury proved manifeftly hurtful.
   1758.] In the progrefs  of fcrophula, feveral external
medicines are requifite.   Several applications have been V
ufed for difcuffing the tumours upon their firft coming on;
but hitherto my own pra6tice, in thefe reflects,  has  been
attended with very little fuccefs.  The folution of faccha-
rum faturni has teemed to be ufeful; but it has  more fre-
quently failed:  And I have had no better fuccefs with the
fpiritus Mindereri.   Fomentations of every kind frequent-
ly have been found to do harm;  and poultices feem only
to hurry on a fuppuration.    I am doubtful if thi., laft be
ever pra6tifed with advantage; for  ferophulous tumours
fometimes fpontaneoufly difappear, but never  after any
degree of inflammation has come  upon  them; and there-
fore  poultices,  which  commonly  induce  inflammation,
prevent that difcuffion of tumours, which might  otherwife
have happened.
   Even when ferophulous tumours have advanced  towards
fuppuration, I am unwilling to haften the fpontaneous open-
ing, or to make it by the lancet;  becaufe I  apprehend the
ferophulous matter is liable to be rendered more acrid by
 communication with the air,  and  to  become more  eroding
 and fprcading than when in its inclofed ftate.
    1759-J  1 ne  management  of ferophulous ulcers has,  fo
 far as  I know, been as little fuccefsful  as that of the tu-
mours. Efcharotic preparations, ofeither mercury or cop-
 per, have  been  fometimes  ufeful in bringing on a proper
 fuppuration, and thereby difpofing the ulcer  to heal;  but
 they have  feldom fucceeded,  and  more commonly  they
 have caufed the ulcer to  fpread more.   The efcharotic
 from which I have received moft benefit  is burnt alum, and
 a portion of that mixed with a mild ointment, has been as
 ufeful an application as any I have tried.-   The  applica-
 tion, however, that I have found moft ferviceable and very
 univerfally admiffible, is  that  of linen cloths wetted with
 cold water, and frequently changed when they are becom-
 ing dry, it being inconvenient to let them be glued to the
 fore. They are therefore to be changed frequently during 
272                 PRACTICE
the day; and a cloth fpread with a mild ointment or plafter
may be  applied for the  night.    In this practice  I have
fometimes employed fea water; but generally it proved too
irritating;  and neither that nor any mineral water has ap-
peared to be of more fervice than common water.
   1760.]  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.

                     CHAP.   II.

      £Df ^ipbiUaf, or  tfce Oenereal Disease,

1761.] XjlFTER  practitioners have had fo much expe-
rience in treating this difeafe, and after fo many books have
been publifhed upon the fubject, it does not feem neceffa-
ry, or even proper, for me to attempt any full treatife con-
cerning it; and  I fhall therefore confine myfelf  to fuch
general remarks,  as may ferve to illuftrate fome parts of
the pathology or of the practice.
   1762. J  It is fufficiently probable, that anciently, in cer-
tain parts  of Afia, where the leprofy prevailed,  and in Eu-
rope after  that difeafe had been introduced into it, a difeafe
ofthe genitals, refembling that which now commonly arifes'
from fiphylis, had frequently appeared: but  it  is equally
probable,  that a new difeafe, and what we at prefent term
Siphylis,  was firft brought into  Europe about  the  end  of
the fifteenth century ; and that the diftemper now   fo fre-
quently occurring, has been very entirely derived from that
which was imported from America at the period mentioned.*
   3 763-]  This difeafe,  at leaft in its principal circumftan-
ces, never arifes in any perfon but from fome communica-
tion with a perfon already affe£ted with it.  It is moft com-
monly contracted in confequence of coition with an infect-
ed perfon ;  but in what manner  the  infection is communi-
cated, is not clearly explained. I am perfuaded, that in coi-
tion, it is communicated without  there being  any open  ul-
  * Various opinions have been held by different phyficians about the origin of this difeafe;  fome
fuppofing it to have exifted in the old world, while others tliinlc it was imported from the new world
difcovered by Columbus. The difpute produced many controvcrfial traits, from the perufal of which,
the young practitioner can gain little advantageous knowledge. All that we certainly kilowabout the
origin of the difeafe is, that it was firft obferved among the French, when they were at Naples in the
year 14.03, and that it was brought into France by the French who returnee! thither with Charles
Columbus landed at Paloson the 15th March in the fame year, on his return from his lirft voyage*
.The difeafe therefore, if imported by Columbus's crew muft have fpread rapidly through Europe. ' 
OF  PHYSIC.    •            273
cer either in the perfon communicating or in the perfon re-
ceiving the  infection ;  but in all other cafes, I believe it is
never communicated in any other way than by a contact of
ulcer, either in the perfon communicating, or in the perfon
receiving the infection.
   1764.J As it thus arifes from the contact of particular
parts, fo it always appears firft in the neighborhood ofthe
parts to which the infecting matter  had been immediately
applied; and therefore, as moft commonly contracted by
coition, it generally appears firft in  the genitals.
   1765.] After its firft appearance in particular parts', more
efpecially when thefe are the genitals of either fex, its ef-
fects for fome time feem to be confined to thefe parts; and
indeed, in many cafes, neverextcnds  further.  In other cafes
however, the infecting  matter paffes from the parts firft af-
fected, and from the genital, therefore, into the blood-vef-
fels; and being there diffufed, produces diforders in many
other parts  of the body.
   From this view of the circumftances, phyficians have
very properly diftinguifhed the different ftates ofthe dif-
eaje, according as they are local or are more univerfal. To
the former they have adapted appellations fuited to the man-
ner in  which the difeafe appears: and to the other the gene-
ral affection, they have almoft totally confined the appella-
tions of Siphylis, Lues Venerea, or Pox.  In the remarks I
am now to offer, I fhall  begin with confidering the local
affection.
   1 j66.] This local affeftion appears chiefly in the form
of gonorrhoea or chancre.
   The phenomena of gonorrhoea,either upon its firft com-
ing on or in its after progrefs,  or the  fymptoms of ardor
urina?, chordee, or others attending  it, it is not neceffary for
me to defcribe.   I fliall  only  here  obferve, that the chief
circumftance to be taken notice of, is the inflamed ftate of
the urethra,  which I take to be infeparable from the difeafe.
   1767.] In  thefe well known circumftances,  the gonor-
rhoea continues for a time longer  or fhorter, according to
the conftitution of the patient;  it ufually remaining longeft
in the moft  vigorous and robuft,  or according  to the pa-
tient's regimen, and the care taken  to relieve or cure  the
difeafe.  In many cafes,  if by a proper regimen the irrita-
tion of the inflamed ftate is carefully avoided,  the gonor- 
£74                PRACTICE
rhoEa fpomaneoufly ceafe?, the fymptoms of inflammation
gradually abating,  the  matter difcharged becoming of a
thicker and more vifcid confiftence, as well as of a whiter
colou-; till at length, the flow of it ceafes altogether; and
whether it be  thus cured fpontaneoufly,  or by art, the dif-
eale often exifts without communicating any infection to
the other parts ofthe body.
   1768.]  In other cafes, however, the difeafe having been
neglected, or by an improper regimen aggravated, it con-
tinues with all its fymptoms for a long time;  and produces
various other diibiders, in the genital parts, which, as com-
monly taken  notice of by authors, need not be defcribed
here.  I flnJl only obferve, that the inflammation  ofthe
urethra, which at firft feems to be feated chiefly, or only,
in its anterior parts, is  in fuch neglected  and aggravated
cafes fpread  upwards along the urethra, even to the neck
ofthe bladder.   In thefe circumftances, a more confider-
able inflammation  is occafioned in certain parts ofthe ure-
thra; and confequently, fuppuration and ulcer are produc-
ed by which  the venereal poifon is fometimes communi-
cated to the fyftem, and gives rife to a general fiphylis.
   1769.3 It  was fome time  ago a  pretty  general fuppofi-
tion, that the gonorrhoea depended always upon ulcers of
the urethra, producing a difcharge of purulent matter; and
fetch ulcers do indeed fometimes occur in the manner that
has been juft now mentioned.  We are now afiured, how-
ever, from  many directions of perfons who had died when
labouring under a gonorrhoea, that the  difeafe  may  exift,
and from  many confiderations it is probable that it com-
monly does exift,  without any ulceration of the urethral
fo that the difcharge which appears, is entirely that of a vi-
tiated mucus from the mucous follicles ofthe urethra.
   1770.3 Although moft of the fymptoms of  gonorrhoea
fhould be removed, yet it often happens that a mucous fluid
continues to be difchanied from the urethra for a longtime
aiter, and  fometimes  for a  great  part of a perfon's life.
This difcharge is what is commonly called a Gleet.
   With refpect to this, it is proper to obferve, that in fome
cafes, when it is certain the matter difcharged contains no
venereal poifon, the matter may, and often docs put on that
puriform appearance, and that yellow and greenifh colour,
which appears in the difcharge at the beginning and durin* 
O F  P H Y S I C.                z,l5
the courfe of a virulent gonorrhoea.   Thefe appearances
in the matter of a gleet  which before had been of a lefs co-
loured kind, have frequently given occafion to fuppofe that
a frefh infefction had been received:  But I am certain that
fuch appearances may be brought on by, perhaps, various
other caufes; and particularly, by intemperance in venery
and drinking concurring together.   I believe, indeed, that
this feldom happens to any but thofe who had  before fre-
quently laboured under a virulent  gonorrhoea, and have
more or lefs of gleet  remaining with them:  But I muft al-
fo obferve, that  in perfons  who at no period of their life
had ever  laboured under a virulent gonorrhoea, or any
other fymptom of fiphylitic  affection,  I have met with in-
ftances of difcharges  from the urethra refembling; thofe of
a virulent gonorrncea.
   The purpofe of thefe obfervations is, to fuggeft to prac-
tioners what I have not found them always aware of, that
in perfons laboring under a gleet, fuch a return of the ap-
pearances of a virulent gonorrhoea may happen without
any new infection having been received, and confequently
not requiring the treatment  which a new infection might
perhaps demand. When, in the cure of gonorrhoea, it was
the praBice to employ purgatives very frequently,and fome-
times thofe of the draftic kind, I  have known the gleet, or
fpurious gonorrhoea, by fuch a practice much increaicdand
long continued, and the patient's conftitution veiy much
hurt. Nay in order more certainly further to prevent mif-
takes, it is to be obferved, that  the  fpurious 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.
   1771.3 With refpect to the cure of a virulent gonorrhoea,
I have only to remark, that  if it be true, as I have menti-
oned above, that the  difeafe will often, under a proper re-
gimen, 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 requi-
red of practitioners,  but to  moderate and remove that in-
flammation  which continues the dileale, and occaiions ;]!
the troublefome fymptoms  that ever attend it.   The fole
bufinefs therefore of our art in  the  cure of gonorrhoea,  is 
276                    PRACT/CE
to take off the inflammation accompanying it:  And this I

think may commonly be done,  by  avoiding exercife, by

ufing a low and cool diet, by abftaining entirely from ler-

mcnted and fpirituous liquors, and by taking plentifully of

mild diluent drinks.*

   1772.J The heat of  urine, which is fo  troublefome. in

this difeafe, as it arifes from the increafed fenfibility of the

urethra in its inflamed ftate;  fo, on the other hand, the ir-

ritation of the urine has the effect  of increafing the  inflam-

mation, and is therefore to be removed as foon as poffible.

This can  be done moft effeaually by taking in a large quan-

tity of mild watery  liquors.    Demulcents may  be employ-

ed; but  unlefs they be accompanied with  a large quantity

of water, they will have little effect.t  Nitre had been com-

monly  employed  as a  fuppofed  refrigerant:   Bur., from

much obfervation,  I am convinced, that  in a fmall  quanti-

ty it  is ufelefs,  and in a large quantity certainly hurtful ;J

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  increaf-

ed fenfibility, the injection  of mucilage or  of mild oil into

it has been  practifed;   but I  have  feldom  found  this of

much fervice.

   1773J  In gonorrhoea,  as coftivenefs  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 a-

voidinjj of hardened faeces;  fo coftivenefs  is to be  careful-

ly avoided or removed ;  and the frequent  ufe of large gly-


  *This (imple method of curings gonorrhoea is, in many cafes fufficient, but it can only bedepend-
rd on when the difeafe is (light and the patient of a heahhy conftitution.  As every virulent gono»-
rbcea is evidently produced by the action of the venereal poifon, the judicious practitioner will fel-
dom truit to this method without the I'fe of merci.ri.ili after the inflammatory fymptorns have been
scire vSatfubducd.  They ought to be given in fuch cafes in very final! quantities, fo  as to produce
only a flight effect on the mouth  ; and their ufe ought to be continued till every fymptom difappears.
Mercury may be ufeJ internally or externally a, occafion may require ; if it floes not affect the bow-
*•:•. nor purge,  the common mercurial pill of the  Edinburgh Pli^rmacopoca is as good a formula as
iv.v we have in the (hops.   It:, dufe mult be regulated by the erfecls it produces.  In general, we be-
gin with a four j_rain piU every night, and continue that quantity till the gums be (lightly affected,
cr .1 coppery taile be perceived in the meuth.  V. lien either of thefe fymptoms appear, we are cer-
tain that the irt-rcury i» received, in a fufficientquar.titv, into the general mafs of the bloccl, for
deltrcying tr:e venereal virus, and then a p'-il may be given once in two or three days, fo as to keep up
the fame fligi t affeflion of the mouth, hut without incrcifinp it.  If the pill purges, we then are to
have recourfe to the itrong mercurial ointment,  half a drachm of which rnuft be rubbed into the
h«:v  night ar/j rr.ori:.rg, till the mouth be affected in the manner above defcribed.  The patient
ought to wearfiai ;ieldr?'ver> during the v.lole time of the continuing the rubbing, which ought to
he regulated by t..e ■:.•[ ree 01" affection perceived in the mouth.  The  ufe either of  the pill or of
friction rnut he (. ,::t':: red lU ht  or ten days after every fymptom of the difeafe has difappeared.
  + Lintfeed-tea, u  very  bin decoction of marlh-mallow root, or thin barley-water, will, in moil
cafes anfwer the intent". '. ^ciently well.  Th« common almond *nnuliion has been recommended
i; -li.cfc cafes. sn. w' c;. ii .1 in lar^e quantities is cettainly very efficacious. It may  be ufed as the
j ..ti^nc'* cc-?..-.-n ti.-u.k.
  i i lie u(e cf i,:tre has beer, ftrongly recommended by many practical writers, in cafes of f rr-!e
g-:.c.rri.o:a acccmpar.xd v.-iv, hi; lya-.-.vcm ; but it mull be acknowledged, fa» the author juftly ob-
ferves,; to be i .^tlbi i,y it.  iuin;; ruai.' y.  It h ceu:.:.-.!y a rcfrircrtnt, pr.d as, fu.h is ufeful in
abvnj theism.:: st<;.-y ;w..j>icms, i.Jt it is inadrr.iirb'.: in cafes \niere the ardor li~- «e U violcat. 
OF  PHYSIC.
277
 fters of water and oil,  I have found of remarkable benefit
 in this difeafe.  If glyfters, however, do not entirely obvi-
 ate coftivenefs, it will be neceffary to give laxatives by the
 mouth:  which,  however, fliould be of the  mildeft kind,
 and fhould do no more than keep the belly regular and a
 little loofe, without much purging.*
   The practice of frequent purging, which was formerly
 fo much in  ufe,  and is not yet entirely laid afide, has al-
 ways appeared to me to  be generally fuperfluous, and of-
 ten very hurtful.   Even what  are fuppofed to be cooling
 purgatives,  fuch as Glauber's fait, foluble tartar, and  cry-
 ftals of tarter, in fo  far 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 liquid ftools,  the
 matter of which is generally acrid, they irritate the rectum,
 and confequently the  urethra.   This laft  effect, however,
 the acrid, and in any degree draftic, purgatives, more cer-
 tainly produce.
   J774']  1° cafes  of a gonorrhoea attended with violent
 inflammation, blood-letting may  be of fervice; and in the
 cafe of perfons of a robuft and  vigorous habit,  in whom
 the difeafe is commonly the moft violent, blood-letting may
 be very properly employed.  As general  bleedings, how-
 ever,  when  there is no  phlogiftic diathefis in  the fyftem,
 have little effect in removing topical inflammation; fo in
 gonorrhoea, when the inflammation is confiderable, topical
 bleeding applied to the urethra by leeches, is  generally
 more  effectual in relieving the inflammation.t
   1775. J When there is any phymofis attending a gonor-
 nicea, emollient fomentations applied to the whole penis are
 often  of fervice.  , In fuch cafes  it is neceffary, and in all
 others ufeful,  to keep  the penis laid up to  the belly, when
 the patient either walks about or is fitting.^
 # A tea-fpoonful of the following electuary taken occafionally will keep the belly fufficiently open.
           ft. Pulv. Jalap. 5i.
                 Nitri. 311.
              Elect. Lenitiv. 5*1.
              Syr. Simpl. q. s.
             M. f. Elect.
 f The good effects of leeches in thefe cafes are confirmed by experience.  They may be applied
en the under fide of the penis, and three or four thus applied have frequently produced amazing
effects. The operation, however, is extremely painful,  and is ieldom fubmittcd to a fecond time
by a patient who has once experienced it.
 % In all cafes of inflammation of the urethra thefe emollient applications 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 lmtXcecl-tea while he is fitting up.
  Vol. H.                   M m 
278                    PRACTICE
   1776.]  Upon occafion of frequent priapifm and chor-
dee, it has been found ufeful to  apply to the  whole ofthe
penis a poultice of crumb  of bread moiftened with a ftrong
folution  of fugar  of lead.   I have, however,  been often
difappointed in this praBice, perhaps by the poultice keep-
ing the penis too warm, and thereby exciting the very fymp-
toms I wifhcd to prevent.   Whether lotions  of the exter-
nal  urethra with a folution of the fugar of lead, might  be
ufeful in this cafe, I have not properly tried*
   1777.]  With refpea to the ufe of injcBions, fo frequent-
ly employed in gonorrhoea, I am perfuaded, that the early
ufe of aftringent injections is pernicious; not by occafion-
ing  a  fiphylis,  as has  been commonly  imagined;  but  by
increafing and giving occafion to all  the confequences  of
the  inflammation, particularly  to  the very  troublefome
 fymptoms of fwelled tefticles.   When, however,  the  dif-
eafe has  continued  for fome time,  and the inflammatory
 fymptoms have very much abated, I  am  of opinion, that
 by  injections of moderate aftringency, or at leaft of  this
 gradually increafed, an end may be fooner put  to  the dif-
 eafe than would otherwife have happened;  and that a gleet,
 fo readily occurring, may be generally pre vented.t
    1778.] Befides the  ufe of aftringent  injections, it  has
 been  common enough to employ thofe of a mercurial kind.
 With refpeft: to thefe,  although I  am convinced  that  the
infection  producing gonorrhoea, and that  producing chan-
 cres and fiphylis, are one and the fame;  yet  1 apprehend,
that in gonorrhoea mercury cannot be of ufe by correcting
 the virulence ofthe infection;   and therefore that  it is  not
  * The fugar of lead folution may perhaps be objected againft on account of its flopping the dip- '
charge, and inducing i fwelled fefticle, which has fometimes followed its application. Wrapping
the penis up in linen rags wet with cold water, frequently anfwers the purpofe of preventing the vi-
olence of the fymptoms, as well as any more complicated application.  The cold wet rags ought to
be renewed whenever they grow warm.
  t The practice of uling aftringent injections is extremelv common ; but (as the author jullly ob-
ferves} their ufe is frequently attended with difagreeable confcquences.  In  general they do  harm
when ufed during the continuance ofthe inflammatory fymptoms, or even too foon after thefe fymp-
toms have disappeared.  If, however, (after the inflammatory fvmptoms are overcome, and mercury
has been ufed for fix -v^eeks or two months in the manner defenbed in the note on article 1771J the
running ftill continues, \ve^nay then have recourfe to thefe altringent injections. They may be made
cf fugar of lead and white vitriol, well diluted wich water, as in the following :
            R. Sacch. Saturn.
               Vitriol, alb. a a 3ss.
               Aq. font. §viii.
               M.  et cola per chartam.
  Half an ounce of this injection flightfy warmed, may he thrown up in the urethra 'wlce a dav • but
if it produce any finarting, it ought to be diluted with more water__Solutions «f copper haveaHTi
been ufed with advantage in there cak s, but they are of To corrolivea nature a.-: frequently to tin harm
if not very much diluted.—An imprudent or too frequent ufe of any of  thefe injection efreriallvif
thev are coo ftrong or not fufficiently diluted, fometimes inflames or even excoriate* tlir uivrlirj anrf
Jience much mifehief arifes. The cautious j-raCtitior.tr mult therefore uever ufe tiiem  ia ii'i/po',  t»
produce much fawning.        '                                 »ui.s.uu» 
OF  PHYSIC.
379
univerfally neceffary in this difeafe,   I am perfuaded, how-
ever, that mercury applied 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 if.
Upon this fuppofition, I have frequently employed mercurial
injections;  and, as I judge, with advantage;  thofe injec-
tions often bringing on fuch a ftate of the confiftence and
colour of the matter difcharged, as we know ufually to pre-
cede its fpontaneous  ceafing.   I  avoid thefe  injections,
however,  in recent cafes, or while much inflammation is
ftill prefent;  but when that inflammation has fomewhat
abated,  and the difcharge notwithflanding ftill continues in
a virulent form,  I employ mercurial injections freely.   I
employ thofe only that contain mercury entirely in a liquid
form, and avoid thofe which may depofit an acrid powder
in the urethra.   That which I have found moft ufeful is a
folution of the corrofive fublimate in water;  fo much di-
luted as not to occafion  any violent fmarting, but not fo
much diluted  as to give no fmarting at all.   It is fearce
 neceffary to add, that when there is reafon to fufpect there
 are ulcerations already formed in the urethra, mercurial
 injections are  not only proper, but  the only effectual re-
 medy that can be employed.
    1779.]  With  regard to the cure of gonorrhoea, I  have
 onlv one other remark to offer.  As moft of the fymptoms
 arife from the irritation of a ftimulus applied, the effects of
 this irritation may be often Icffcncd  by diminifhing the ir-
 ritability of the fyftem; and  it is well known, that the moft
 certain  means of accomplifhing this is by employing opium.
 For that reafon, I confider the practice  both of applying
 opium directly to the urethra,* and of  exhibiting it by the
 mouth, to be extremely ufeful in molt  cafes of gonorrhoea.
    1780.]  After thus  offering fome remarks with refpect
 to gonorrhoea in general, I might proceed to confider par-
 ticularly the various fymptoms which  fo frequently attend
 it; but it does not feem neceffary for me to attempt this af-
 ter the  late publications of  Dr.  Foart Simmons, and  of
 Dr. Schwediaur, who have treated the fubject fo fully, and
 with fo much difcernment and fkill.t
  * Opium mav be very conveniently applied to the urethra by injeaion ; and for this purpofe a di-
 luent folution of opium in water is preferable to a fpirituous or vinous folution.. A grain of opium
 dilfolved in an ounce of water, and the folution (trained, may be injected twice or thrice a day; and
 thirty or forty drops of laudanum may be given every night at bed tirne.            ,
  + As a fwelled tclticlc frequently attends a fuppreffed gonorrhoea, it may be proner to give the
 young practitioner fome directions concerning the management of it,—Sometimes without any other 
280
PRACTICE
   1781.] The other form of the local affeaion 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 I believe
 chancres never appear in any degree without immediately
 communicating to the blood more or  lefs of the venereal
 poifon: For I have conftantly, whenever chancres had ap-
 peared, found, that unlefs mercury was immediately given
 internally, fome fymptoms of a general fiphylis did certain-
 ly come on  afterwards;  and  though  the  internal ufe  of
 mercury fliould prevent any fuch appearance, it  is ftill to
 be prefumed that the poifon had been communicated,  be-
 caufe mercury could act upon it in no other manner than
 as diffufed in the fluids.
   1782.]  It has  been a queftion among practitioners, up-
 on the fubject  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 healing
 up of chancres might immediately foYce into the blood a
poifon which might have been excluded by being difcharg-
ed from the chancre.   This, however, is a fuppofition that
 is very doubtful; and, upon the other hand,  I am certain,
 that the longer a chancre  is kept open, the more poifon it
 perhaps generates, and certainly fupplies it more copioufly
 to the blood.   And although the above-mentioned  fuppo-
fition  were true, it will be of little  confequence,  if the in-
 ternal ufe of the mercury, which I judge neceffary in eve-
 ry cafe of chancre,  be immediately employed.  I have of-
 ten feen very troublefome confequences follow  from  al-
SStif JeS&^dlSmu'^ThU * .Prema^ ft°PPine °f * gonorrhoea, a pain is felt in the
noWle or'fo "Ses'm^'Zl^'io If TT "* ^» «^«^W i *?*
mmMmwmfm
within twenty fourhours -but it will hr np&ffb, 65ncriluX al'aysthe violence of the fymptoms,
^mV^^^^«^^yTm\m^^tat^fTC thC Ufe.,°f the coM Placets and
have been completely removed, the w eE&ut ilW56- ^ 5heJPain dwelling
penfory bandage for "the fcrotum. a/thweMn of tfc tefticleT hvft^lf"1 foJ *jm to ufe a ful-
will be a_pt to occafion the return of all thefvmDtomV-wVH^:. X ftretchu?g the fpermatic cords,
the rwelSngt of the epididvmiTand tenidesl will te^^^?h?I„C„8;0S0rrh.a!?Alf St has P«ceded
happens that, on difcuffing the tumor in the^return t^e Plana If Ik" ; ^V* J1*""1* fometimes
to fwell In thefe cafes wl muft apply cold pedee^to thefe ^,nHche gTT be*in £° be Pilnful »n<l
ru, at theftme time, fome ftrong TOrSlPdr&*OT ttegtofiHi nV^f" l8-*? the fcJ0tnm ' ™d
the lymphatics going to thefe elands- andif th*n-nic k?J. .■ a e of *»e thighs, in the courfe of
mercurialomtientLK
fcruple of
 uce.
 Ieldom 
OF  PHYSIC.
251
  lowing chancres to remain unhealed;  and the fymptoms of
  general  fiphylis have always feemed to me to be more con-
  fiderable and violent in proportion as chancres had beea
  fuffered to remain longer unhealed.   They fhould always,
  therefore, be healed as foon as poffible;  and that, by  the
  only very effeaual means, the application of mercurials to
  the chancre itfelf.    Thofe  that  are  recent, and have  not
  yet formed 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  ap-
  plication of red precipitate in a dry powder.*
    1783.] When, in confequence of chancres, or of the
  other circumftances  above-mentioned,  by which it may-
  happen the venereal poifon has been communicated to  the
  blood, it produces many different  fymptoms in different
  parts of the body, not neceffary  to be  enumerated and def-
  cribed here, that having been already done by many author*
  with  great accuracy.
     1784.] Whenever any of thofe fymptoms do in any de-
  gree  appear, or as foon as it is known t.hat the circumftan-
  ces which give  occafion to the communication  of the ve-
  nereal poifon have taken place, I hold the internal ufe of
 mercury to be immediately neceffary; and I  am well per-
  fuaded, that mercury employed without delay, and in fuf-
 ficient 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 con-
 fequences of fiphylis from that infection.
    17^5-j  This advice for the early and full ufe of mercu-
 ry, I  take to be the moft important that can be given with
 refpect to the venereal difeafe:  And although I muft ad-
 mit that the virulence of the poifon may be greater in one
 cafe than in another, and even that one conftitution may  be
 more  favourable than another to  the violence of the dif-
 eafe;  yet I am  thoroughly convinced, that moft of the in-
 ftances which have occurred of the violence and obftinacy
  * Although chaicre* may be very fpeedily healed by red precipitate alone, yet it will be necefTary
fometimes to ufe an ointme:u made of the red precipitate, and twice or thrice its weight of freih
hogs lard  The precipitate wiil by this means be more conftantly kapt on the part. Tue practitioner,
however, muft be cautious left he ufe too great a quantity of precipitate, which by its corrolive quali-
ty, fometimes increafes the  ulcer it was meant to heal.—During the ufe of this application, it will be
neceflTary alfo to ufe mercury either internally or externally, in  the manner defcribed in the note en
article 1771—The application of the laps infernalis to chancres, comes recommended tousonthe
authority oT forie eminent practitioners. It is however, a dangeroiu application, and frcqutiitij'iirB-
<luce» ulcers that are extremely difficult to heal. 
PRACTICE
 of fiphylis have been owing very entirely to the neglect of
 the early application of mercury.*
   1786.J Whatever other remediesf of fiphylis  may  be
 known, or may hereafter  be found out, I cannot pretend
 to determine;  but I am well perfuaded, that in moft caufes
 mercury properly employed will prove a very certain  and
 effectual remedy.   With  refpect to otheis that have been
 propofed, I fhall offer this remark only, that I have found
 the decoction of the mezereon contribute to the healing of
 ulcers which feemed to have rcfifted the power of mercury.
   1787.J With regard to the many  and various prepara-
 tions of mercury, I do not think it neceffary to give any
 enumeration of them here, as they arc commonly very 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 effected by many different preparations, if
 properly adminiftercd.  The proper adminiftration^ feems
 to confift, first, In the choofing thofe preparations which
 are the leaft ready  to run off by ftool;  and therefore  the
 applications  externally by unction, are in many cafes the
 moft convenient,   idly, In employing the unction, or in
 giving a preparation of mercury internally, in fuch quanti-
 ty as may fhow its  fenfible effects in  die mouth.   And,
 %dly, without carrying thefe effects to a greater length,  In
 the continuing  the employment  of  mercury for feveral
 weeks, or till the fymptoms ofthe difeafe fhall  have  for
 fome  time entirely difappeared.   I fay nothing of the re-
 gimen proper and neceffary for patients during the employ-
 ment of mercury, becaufe I prefume it to be very well known.
  1788.J  Among the other preparations of mercury, I be-
 lieve the corrofive  fublimate has often been employed with
 advantage: But I  believe alfo, that it requires being con-
 tinued for a longer time than is neceffary in the  employ-
ment of other preparations in the manner above propofed •
and I fufpe6fc it has often failed in making a cure becaufe
employed while perfons were at the fame'tirne expofed to
the free  air.                                  *
  1789.]  Upon thefe points, and others relative to the ad- 
OF  PHYSIC.
283
miniftration of mercury, and the cure of this difeafe, I might
offer  fome particular remarks: But I believe they are ge-
nerally underftood; and it is enough far me to fay here,
that if practitioners will attend, and patients will fubmit, to
the general rules given above, they will feldom fail  of ob-
taining a certain and  fpeedy cure of the difeafe.
                    CHAP.  III.

                    £Df ^ctmjp*

179°J  J- HIS difeafe appears fo frequently, and the ef-
fects of it are fo often fatal in fleets and armies, that it has
very properly engaged the particular attention of phyficians.
It is indeed furprifing that it had not fooner attracted the
efpecial notice both of ftatefmen and phyficians, fo as to
have produced thofe meafures 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 exa£tly afcertained, as to render
all further labor upon the fubject fuperfluous. This perhaps
may be true ; but it appears to me, that there are ftill fev-
eral  circumftances regarding the difeafe not agreed upon a-
mong phyficians,as well as different opinions formed, fome
of which may have a bad effect upon the practice ; and this
feems to be fo much the cafe, that I hope I fhall be excuf-
ed in endeavoring hereto ftate the faBs as they appear to me
from the beft authorities, and to offer remarks upon opini-
ons  which  may influence the praaice in the prevention and
cure of this difeafe.
   179*•]  With refpect 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  difeerning
the difeafe when it is prefent,  or in diftinguifhing it from
almoft every other ailment.  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 clima^s and
feafons, as'depending every where upon nearly the fame
caufes; and that it is not at all diverfified, either in its phe-
nomena or its caufes, as had been imagined fome tim? V.go. 
584                PRACTICE

   1702 } The phenomena^ffeurvy, therefore, are not to
be defcribed here, as it has been fo fully and accurately done
elfewhere; and I fliall only endeavor to afcertain thofe fads
with refpea to the prevention and cure of the difeafe which
feem not yet to be exaaiy agreed upon.  And firft, with re-
fpea to the antecedents that may be confidered as the re-
mote caufes of the difeafe.
   J793-] The moft remarkable circumftances arnongft the
antecedents of this difeafe is, that it has moft commonly hap-
pened to men living very much on faked meats ;  and whe-
ther 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 dif-
eafe has been efpecially attributed.  Whether the circum-
ibnees of the meat's being faked, has any effea in produc-
ing the difeafe, otherwife than by being  rendered more in-
digcftible, is a queftion that remains ftill in difpute.
   1794. J It feems to me, that the fait concurs in produc-
ing the effect; for there  is hardly any inftance of the dif-
eafe appearing unlefs where fait meats had been employed,
and fcarcely an example where the long continued ufe of
thefe did not produce it; befides all which, there are fome
inftances where, by avoiding faked meats, or by diminifh-
ing the proportion of them in diet, while other circumftan-
ces remained much  the fame, the difeafe was prevented
from appearing.   Further, if it may be admitted as an ar-
gument upon this fubjea, I fliall hereafter endeavor to
fhow, that the large ufe of fait has  a tendency to aggravate
and increafe the proximate caufe of feurvy.
 . J795-] Ic muft, however, be allowed, that the principal
circumftance in caufing feurvy, 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 frefh
vegetable food will always certainly prevent the difeafe.
   1796. J While it has  been held, that, in thofe circum-
ftances in which feurvy is produced, the animal food em-
ployed was efpecially hurtful by its being of difficult digef-
tion, this opinion has been attempted to be confirmed, by
obferving, that the reft  of the food employed in the fame
circumftances was alfo of difficult  digeftion.  This is fup-
pofed to be efpecially the cafe of unfermented farinacea 
OF  PHYSI C.
which fo commonly makes a part of the fea-diet.  But I
apprehend this opinion to be very ill-founded.; for the un-
fermented farinacea, which  are in a great proportion the
food of infants, of women, and ofthe greater part of man-
kind, can hardly be fuppofed to be food of difficult digef-
tion : and with refpea to the produaion of feurvy, there
are faas which fhow, that unfermented farinacea, employed
in large proportion, have had a confiderable effea in pre-
venting the difeafe.
   1797.] It has been imagined, that a certain impregnation
of the air upon the fea had an effea in producing feurvy.
But it is altogether improbable: for the only impregnations
which could be fufpetted, are thofe of inflammable or me-
phitic air;  and it is now well known, that thefe impregna-
tions 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 lea-air.  If therefore, fea-air have any ef-
fea in producing  feurvy, it muft be by its fenfible qualities
of cold or rnoifture.
   1798.J That cold has an effea in favouring the produc-
tion of feurvy,  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 clothing has a
confiderable effea in preventing it.
   1799.] Moifture may in general have an effea in favour-
ing the produaion of feurvy, where that of the atmofphere
in which men are placed is very confiderable : but the or-
dinary moifture ofthe fea-air is far from being fuch.   Pro-
bably it is never confiderable, except in the cafe of unufu-
al rains; and even then it is perhaps by the application of
moifture to the bodies of men in damp clothing only  that
it has any fhare in the produaion of feurvy.  At the fame
time, I believe, there  is no  inftance of either cold or moif-
ture producing feurvy, without the concurrence of the faul-
ty fea diet.
   1800. J Under thofe circumftances which produce feur-
vy, it commonly  feems to occur moft readily in the perfons
who are the leaft exercifed; and it is therefore probable,
that confinement and  want of exercife may have a great
fhare in producing the difeafe.
   1801.] It appears that weaknefs, in whatever manner
  Vol. II.                  Nn 
2ft6                PRACTICE

occafioned, is favourable to the produaion of feurvy.   It
is therefore probable, that unufual labour and fatigue may
often have fome fhare in bringing it on:  Ami upon the
fame account, it is probable, that fadnefs and defpondency
mav induce a weaknefs of the circulation; and thereby,  as
has been remarked, be favorable to the produaion of feurvy.
   1802 ] Ithas alio been obferved, that perfons negligent
in keeping their fkin clean by  warning and change ol cloth-
ing  arc more liable than others to be affeaed with feurvy.
   180" 1 Several of thefe caufes, now mentioned, con-
curring together, feem to produce feurvy; but there is no
proper evidence that anv  one of them  alone will produce
it, or that all the other uniting together will  do it, without
the  particular concurrence of the fea  diet.  Along with
this however, feveral ofthe  other circumftances  mention-
ed, have a great effea in producing it fooner, and in a more
confiderable degree, than fhould  otherwife have  happened
from the diet alone.
   1804.] From this view of the remote caufes, it will rea-
dily r.ppear, that the prevention of the difeafe may in fome
meafure depend upon the avoiding of  thofe circumftances
which we  have enumerated as contributing to bring on the
difeafe fooner than it would  otherwife come on.   At  the
fame time, the  only effeaual means will be, by  avoiding
the diet of failed meats; at leaft  by leffening the propor-
tion of thefe, and ufing*meat perferved otherwife than  by
fait;  by ufing in diet any kind of efculent vegetable matter
that can be obtained;  and efpecially  by ufing  vegetable
matter the moft difpofed to acefeency, fuch as malt; and
by drinking a large quantity  of pure water.
   1805. J The cure of feurvy feems now to be  very well
afcertained; and when the neceffary means can be obtain-
ed,  the difeafe is commonly removed very  quickly.   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 effectual are the acid fruits, and, as  be-
ing ofthe fame nature, all fort of fermented liquor.
   1806.] The plants named alkalescent, fuch  as thofe of
th- garlic tribe and ofthe tetradynamise,* are alfo particu-
lar lv ufeful in the cure of this difeafe;  for, notwithftanding
  * The plarita of this clafs ought to be ufed in large quantities, and raw. The rc'^e aaive fpecies
ar- ilorfe-ndifh, Muftard, Water-crels, garden-cre&, Scurvy grafc: The milder fttcies are, Ra-
dices, Turnip*, Cabbages, Cauliflower*, Brocoh, &c.
  To the above lift, may be added fome other antifcorbutics of different chiles -. ;s ;%'.:, Spinach, 
OF  PHYSIC.
237
their appellation, they in the firft part of their fermentation
undergo an acefeency, 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 paffes by
urine, probably by perfpiration; and by promoting both ex-
cretions, are ufeful in the difeafe.   It is probable, that fome
plants ofthe coniferous tribe, fuch as the fpruce fir, and other
poffeffed of a diuretic power, may likewife be of fome ufe.
   1807. J  ^ *s fufficiently probable, that milk of every
kind, and particularly its produaions whey and butter milk,
may prove a cure of this difeafe.
   1808.]  It has been common in this difeafe to employ
the foffil acids; but there is reafon to doubt if they be of
any fervice, and it  is certain they are not effettual reme-
dies.    They can  hardly be thrown in fuch quantity as to
be ufeful antifeptics;  and as they  do not feem to enter
into the compofition ofthe animal fluids, and probably pafs
off unchanged by the excretions, fo they  can do little in
changing the ftate of the fluids.
   1809. J The great debility which conftantly attends feur-
vy, has naturally led phyficians to employ tonic and ftrengh-
ening medicines, particularly the Peruvian bark; but the
efficacy of it feems to me very doubtful.  It  is furprifing
how  foon the  ufe of a vegetable diet reftores the ftrength
of fcorbutic perfons; which feems to fhow  that the pre-
ceding debility had depended upon the ftate of the fluids;
and confequently, till the found ftate of thefe  can be re-
 ftored, no tonic remedy can have much effea: but as the
 Peruvian bark has little power in changing the ftate of the
 fluids, fo it can have little effea in feurvy.
    1810. J I fhall conclude my obfervations  upon the  me-
 dicines employed in feurvy, with remarking, that the ufe
 of mercury is  always manifeftly hurtful.
    1811.] After having obferved that both the  prevention
 and  cure of this difeafe are now  very well  known, it may
 feem unneceflary to  enter into much difcuffion concerning
 its proximate caufe: but as fuch difcuffions can hardly be
 avoided, and  as falfe opinions may in  fome meafure  cor-
 rupt the praaice, I fhall venture to fuggeft here what ap-
 pears to me moft probable upon the fubjea.
 lieet, Carrots, Celery, Endive, Lettuce, Afparagus, the young fhoots of Hops, Purflain, with feve-
 jal others. All thele freih vegetables muft be eaten in large quantities; they eught indeed to con-
 ftitute th* patient's chief food, and bis drink may be a freln injufron ol malt. 
288
P R,A CTICE
   1812.] Notwithflanding what has been afferted by fome
eminent perfons, I truft to the concurring teftimony ofthe
moft part ofthe authors upon the fubject,  that in feurvy
the fluids fuffer a confiderable change.
   From  thefe authors wc learn, that in the blood  drawn
from  the veins of perfons laboring under the  feurvy, the
craffamentum is different both in color and confidence from
what it is in healthy perfons;  and that at the fame time the
ferum is commonly changed  both in color and tafte.   The
excretions alfo, in'fcorbutic perfons, fhow  a change in the
ftate of the fluids.  The breath is  fetid; the urine is al-
ways high colored, and more acrid than ufual; and  if that
acrid exfudation from the feet, which Dr. Hulme takes no-
tice of, happens efpecially in feorbutic perfons, it  will be a
remarkable proof to the fame purpofe.   But however this
inav be.  there is evidence enough that in feurvy the natur-
al ftate of the  fluids is confiderably changed.   Further, I
apprehend it may be  confidently prefumed from this, that
the difeafe is  brought on by a particular nourifhment in-
troduced into the body, and is as certainly cured by the
taking in of a different diet.  In the latter cafe, the diet ufed
has no other evident operation, than that of giving a  parti-
cular ftate and condition of the fluids.
   1813.] Prefuming therefore,  that the difeafe depends
upon  a particular condition  ofthe fluids ofthe body, the
next fiiclject of inquiry is, What that condition may be?
   With this view I muft obferve, that the animal economy
has a lingular power of changing acefcent aliments, in fuch
a manner, as to render them much more difpofed  to putre-
faction; and  although, in a living ftate, they hardly ever
proceed to an actually putrid ftate; yet in man, whofe ali-
ment is of a mixed kind, it is pretty certain, that if he were
to live entirely upon animal food, without a frequent fup-
ply of vegetable aliment,  his-fluids would advance further
towards putrefaction than is  confiftent with health.—This
advance  toward* puirefa6tion  feems to confift in the pro-
duaion and evolution of a faline  matter which did not ap-
pear in the vegetable aliment,  and could not be produced
or evolved in  it, bur by carrying on its fermentation to a
putrefactive ftate.  That this faline ftate is conftantly  in
fome meafure produced and evolved by the animal procefs,
appears from  this,  that certain excretions of faline mat- 
OF  PHYSIC.                239
ter are conftantly made from the human body,  and are
therefore prefumed neceffary to its health.
   From all this,'it may be readily  underftood, how the
continual ufe of animal food, efpecially when already in a
putrefcent flate, without a mixture of vegetable, may have
the effect of carrying the animal procefs too farx and par-
ticularly of producing and evolving a larger proportion of
faline matter.   That fuch a preternatural quantity of faline
matter does exift in the blood of feorbutic perfons,  appears
from the ftate of the fluids above-mentioned.   It will be a
confirmation of all this to obferve, that every interruption
of perfpiration, that is. the  retention  of laline matter, con-
tributes to the produaion of feurvy; and this interruption
is efpecially owing to the application of cold, or to what-
ever elfe weakens  the force of the circulation, fuch as the
negfea or want of exercife,  fatigue, or defpondency ofthe
mind.   It deferves indeed to be  remarked here, that one
of the firft effe6ts of the feurvy once induced, is very foon
to occafion a great debility ofthe 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 feurvy.
   1814.J  It is  poffible that this debility may have a great
fhare  in producing feveral of the phenomena of  feurvy;
but a preternatural faline, and confequently diffolved, ftate
ofthe blood, will account for them with more probability;
and  I  do not think it neceffary to  perfons who are at all ac-
cuftomed to reafon upon the animal  economy, to  explain
this  matter more  fully.   I have  only to add, that if my
opinion in fuppofing the proximate caufe of feurvy to be
a preternatural faline ftate of the blood, be at all founded,
it  will be fufficiently 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.    Evert
fuppofing fuch fait to fuffer no change in the animal body,
the effect of it may be confiderable;  and this will  be ren-
dered  ftill more probable,  if it may  be prefumed, that aU
neutral falts, confifting of a  fixed alkali, are changed in the
animal body into an ammoniacal fait; which I  apprehend 
220
PRACTICE
to be that efpecially prevailing in  feurvy.   If I be at all
right in concluding, that meats, from being faked, contri-
bute to the production of feurvy, it will readily appear,
how dangerous it may be to  admit the conclufion from
another theory, that they are perfectly innocent.
   1815. J Having thus endeavored to explain what relates
to the cure of feurvy in general, I judge it proper to leave
to other authors, what relates  to the management of thofe
fymptoms which require a particular treatment.

                   CHAP.  IV.

                   £Df Jauntrice,

1816.] X HAVE here paffed over feveral ofthe titles in
my nofology, becaufe they are difeafes not of this ifland.
In thefe, therefore, I have no  experience;  and without
that, the compiling from other writers is always extremely
fallacious.   For thefe reafons I omit them; and fhall now
only offer fome remarks upon the  fubjea of jaundice, the
laft in order that I can poffibly introduce in my courfe of
Leaures.
   1817.] The jaundice confifts in a yellow color ofthe
fkin over the  whole body, and particularly of the adnata
of the eyes.   This yellow  color may occur from different
caufes: but in the jaundice, hereafter to be more exaaiy
charatterifed,  I judge it to depend upon a quantity of bile
prefent in the mafs of blood;  and which, thrown out upon
the furface, gives its own proper color to the fkin and eyes.
   1818.J That the difeafe  depends  upon this  we know
particularly 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 paffed the fecre-
tory  organ of the liver.  The bile, therefore, cannot ap-
pear in the mafs of blood,  or upon the furface of the body,
that is, produce jaundice from any interruption of its fe-
cretion;  and accordingly,  if jaundice does appear, it muft
be in confequence  ofthe  bile, after it had been fecerned,
being again taken into the  blood-veffels.
   This may happen in two ways;  either by an interruption
of its excretion, that is, of its paffage into  the duodenum, 
OF  PHYSIC.               291
 which  by accumulating it in the biliary veffels, may give
 occafion to its pafling again into the blood-veffels;  or it
 may pafs into thefe, by its being abforbed from the alimen-
 tary canal, when it happens to be accumulated there in an
 unufual quantity.  How far the latter caufe can take place,
 or in what circumftances it does occur, I  cannot  clearly
 afcertain, and 1 apprehend that jaundice is feldom produc-
 ed in that manner,
    1819.] The former caufe of flopped excretion may be
 underftood more clearly;  and we have very certain proof
 of its being the ordinary, and indeed the  almoft univerfal,
 caufe of this difeafe.  Upon this  fubjea it will be obvious,
 that the interrupted excretion ofthe bile muft depend upon
 an  obftruaion of the ductus communis choledochus;  the
/ moft common caufe of which is a biliary concretion form-
 ed  in the gall-bladder, and from thence  falling down into
 the duaus communis, it being  at the fame time of fuch a
 fize as not to pafs readily through that dua into the duo-
 denum.   This dua may likewife be obftruacd by a fpaf-
 modic conftriaion  affecting it: and fuch fpafm may hap-
 pen, either in the duct itfelf, which we fuppofe to  be con-
 tractile; or in the duodenum preffing the fides of the dua
 clofe together;  or, laftly, the dua may be obftruaed by a
 tumour compreifing it,  and that arifing either in the coats
 of the dua itfelf, or in  any of the neighboring partt that
 are, or may come to be, contiguous to it.
    1820.] When fuch obftruaion happens, the fecreted bile
 muft be accumulated in the biliary duas;  and from thence
 it may either be abforbed and carried by the lymphatics in-
 to  the blood-veffels, or  it may regurgitate in the  duas
 themfelves, and pafs from them direaiy into the afcending
 cava.   In either way, it comes to be diffufed in the mafs ot
 blood; and from thence may pafs by every exhalant veflel,
 and produce the difeafe in queftion.
     1821.] I have thus fhortly explained the ordinary pro-
 duaion of jaundice:, but it muft be obferved further, that
 it is at all times  accompanied with certain other fymptoms,
  fuch as a whitenefs of the faeces  alvina,  which we readily
 account for from the abfence of bile in the inteftines; and
  -enerally, alfo,  with a certain confidence of the faeces, the
 caufe  of which  is not fo eafy to explain.  The difeafe is
 always accompanied alfo with urine of a. yellow color, or 
252                PRACTICE
 at leaft with urir.e that tinges a linen cloth with a yellov/
 color.  Thefe are  conftantly  attending fymptoms;  and
 though not always, yet there is commonly, a pain felt in
 the  epigaftrium, correfponding, as we fuppofe, to the feat
 of the ductus communis.  This pain is often accompanied
 with vomiting; and even when the pain is not confiderable,
 a vomiting fometimes occurs.   In  fome cafes, when the
 pain is confiderable, the pulfe becomes frequent, full, and
 hard, and fome other fymptoms of pyrexia appear.
   1822.]  When the jaundice is occafioned by tumours of
 the  neighboring parts compreifing the biliary dua, I be-
 lieve the difeafe can very feldom be  cured.  That fuch is
 the caufe of jaundice, may with fome probability be  fup-
 pofed, when it has come on in confequence of other  dif-
 eafes which had fubfifted long before, and more efpecially
 fuch as had been attended with fymptoms of obftructed vif-
 cera.  Even when the jaundice has fubfifted long without
 any  intermiffion, and without any pain in  the epigaftrium,
 an external compreffion is to be fufpeaed.
   1823.] In fuch circumftances, I confider the difeafe as
 incurable; and it is almoft only when  the  difeafe is occa-
 fioned by biliary  concretions  obftruaing  the biliary dua,
 that we may commonly expea  relief, and  that our art may
 contribute to the obtaining it.   Such cafes may be general-
 ly known by the difeafe frequently difappearing and return-
 ing again;  by our finding, after the former accident, bilia-
 ry concretions arnongft the fasces; and by the difeafe be-
 ing frequently accompanied with pain of the epigaftrium,
 and with vomitings arifing from fuch pain.
   1824.] In thefe cafes, we know of no  certain and  im-
 mediate means of expediting the paffage of the biliary con-
 cretions.   This is generally a work of time depending up-
 on the gradual dilatation of the biliary dua;  and it is  fur-
 prifing to obferve, from the fize ofthe ftones which fome-
 tines pafs through, what dilatation the dua will admit of.
 It proceeds, however, fafter or flower upon different oc-
 cafions; and therefore the jaundice, after a various dura-
 tion, often ceafes fuddenly 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 differ-
ent remedies.  Many of thefe, however, are perfeaiy in-
ert, and many others of them fuch as cannot be fuppofed 
OF  PHYSIC.
293
to have any, effect in expediting the paffage of a biliary con-
cretion.   I fhall here, therefore, take no notice ofthe nu-
merous remedies of jaundice mentioned by the writers on
the Materia Medica, or even of thofe to be found in prac-
tical authors;  but fhall confine my felf to the mention of
thofe that may with probability be fuppofed to  favor the
paffage of the concretion, or remove the  obftacles  to it
which may occur.
   1825. J In the  treatment  of this difeafe, it is in the firft
place, to be attended to, that as the diftenfion of the bilia-
ry dua, by a hard mafs that does not eafily pafs through it,
may excite inflammation there; fo, in perfons of tolerable
vigor, blood-letting may be an  ufeful precaution;   and
when much pain, together with any degree of pyrexia, oc-
curs, it becomes an abfolutely neceffary remedy.   In fome
inftance.s of jaundice accompanied with thefe fymptoms, I
have  found  the blood drawn covered with an inflammato-
ry cruft as thick as in cafes of pneumonia.
   1826. J There is no means of pufhing forward a biliary
concretion that is more probable than the aaion of vomit-
ing;  which, by comprefling the whole abdominal vifcera,
and particularly the full and diftended gall-bladder and bi-
liary  veflels, may contribute, fometimes gently enough, to
the dilatation ofthe biliary  dua.  Accordingly vomiting
has often  been found ufeful for this purpofe;  but at the
fame time it is poffible, that the force exerted in the aa of
vomiting  may be too violent, and therefore gentle vomits
ought only to be employed.  And either when, by the long
continuance of the jaundice, it may be fufpeaed that the fize
of the concretion then paffing is large; or more efpecially
when pain attending  the difeafe gives apprehenfion of in-
flammation, it may be prudent to a void vomiting altogether.
   1827.] It has been ufual in the jaundiqe to employ pur-
gatives; and it is poffible that the aaion ofthe  inteftines
may excite the aaion of the biliary duas, and thus favor
the expuliion of the biliary concretion: but this, I think,
cannot be of much effea; and the attempting it by the fre-
quent ufe of purgatives, may otherwife hurt the patient.
For this reafon I  apprehend, that purgatives can never be
proper, excepting when there is a flow and bound belly.*
 * The good effects of purgatives, in removing biliary concretion* in the duft, are fufficiently. ap-
parent by daily experience. It is true, indeed, that ail purgative* have not this effect, efpecially
  Vol. 11.               O o 
294
PRACTICE
   1828.] As the relaxation of the fkin contributes to re-
lax the whole fyftem, and particularly  to relieve  the  con-
ftriaion of fubjacent parts;  fo, when  the jaundice is at-
tended with pain, fomentations of the epigaftrium may be
of fervice.
   1829.] 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 dua readily admit of
fuch dilatation as to render their paffage through it eafy,
were it  not that the diftenfion  occafions a  preternatural
fpafmodic contraaion ofthe parts below.   Upon this ac-
count, opium is often of great benefit in jaundice; and the
benefit refulting from its ufe, proves fufficiently  the truth
ofthe theory upon which the ufing of ittias been  founded.
   1830. J It were much to be wifhed,  that a  folvent of bi-
liary concretions, which might be applied to them in the
gall-bladder or biliary  duas,  was difcovered;  but none
fuch, fo far as I know, has yet been found;   and the em-
ployment of foap in this difeafe, I  confider as a  frivolous
attempt.   Dr. White of York has found a folvent of bilia-
ry concretions when thefe are out of the  body;  but there
is not the  leaft probability that it could reach them while
lodged within.
fuch as are of a gentle and flow operation. The draftic purges, however, whofe adtion is both brifft,
and of long continuance, have frequently been attended with good effects. Some formulae of thefe
brilk draftic* have been defcribed in the notes on article 1683. 
INDEX
                           TO THE
            TWO  VOLUMES.
N. B.  The Cyphers refer to the number ofthe Paragraphs.
Ai
A
   .BSCESS,              250
Abscesses and ulcers, the cau-
  ses of their different states, 254
Acids employed in fever,    134
  refrigerant in fever,       ibid
Action of the heart & arteries,
  how increased for prevent-
  ing the  recurrences  of the
  paroxysms of intermitting
  fever,                   230
Adynamia,                1170
Amenorrhea,              994
  from retention,          995
  when occurring,         997
  symptoms of,            998
  causes of,        999—1000
  cure of,              1001—5
  fijom suppression,         995
     when occurring,       1007
     symptoms of,          1009
     causes of,          1007—8
     cure of,         1010—-11
Amentia,                  1599
Anasarca,                 1699
  the character of,         ibid
  phenomena of,     1669—74
  cure of,            1675—97
  distinguished from Leuco-
     phlegmatia,           1670
St. Anthonys Fire, See Erythema.
Antimonial Emetics, employ-
  ed in fevers,              181
  their different kinds,      ibid
  the administration of them
     in fevers,        183—186
Antiphlogistic  Regimen,     129
•  how conducted,           130
  when employedin intermit-
     tent fever,            234
Antispasmodics, employed in
     fevers,          152—187
Aphtha,                   732
Apoplexy                 1093
  distinguished from palsy,  ibid
  distiugui shed from syncope ibid
  predibponent cause of,   1094
  exciting causes of,
             [1097—1114—15
  proximate causes of,  1099—20
  Serosa, proximate cause of 1113
    prognostic,       1121—22
    frequently ending  in he-
       miplegia,           1121
    prevention of,         1123
  whether sanguine or serous,
  stimulants hurtful in it 1135-36
  from powers that destroy
   the mobility of the ner-
   vous power,
  cure of,
Apyrexia,
Ascites,
  character of,
  its various seat,
  the phenomena of,
  its particular seat difficult-
   ly ascertained,
  the cure of,
Asthma,
  phenomena of,
  exciting causes of,
  proximate cause of,
  distinguished from  other
    kinds of dyspnoea,       1
  some times occasions  phthi-
   sis pulmonalis,          1387
  frequently ends  in hydro.
   thorax,
  seldom entirely cured,
Astringents, employed  in in
     termittent fevers,
  joined with aromatics, em-
     ployed  in intermittent
«   :  fevers                231
    1137
1130—38
      1\
    1710
     ibid
1711—12
1713—14
    1715
1716—18
    1374
    1376
    1382
    1385
86
ibid
*31

231 
                       I  N  D
Atrabilis,                 1028
Atrophia ab alvi fluxu,     1608
  debilium,               1607
  inanitorum,             1608
  infantilis,               1606
  lactantium,              ibid
  lateralis,           1607—12
  a leucorrhcea,           1608
  nervosa,                1607
  nutrieum,               1608
  a ptyalisma              ibid
  rachitica,               1606
  senilis,            1607—12
Aura Epileptic a,           1307
               B
Bitters employed in interrait-
     ent fevers,            231
  joinedwith aftringtnts,em-
    ployed in'intermittents,   ibid
Blistering, its effects,  189—197
   its mode of  operation in
    the cure of fevers,  190—194
   when to be employed in fe-
    vers,                    195
   where to be applied in fevers 196
Bloodletting, the employment
    of it in fevers,     138—143
   the circumstances  direct-
    ing its use in fevers,      142
   the administration of it in
    fevers,                  143
   ■when employed in inter-
    mittent fevers,          234
                C
 Cachexies, character of the
    class,                  1600
 Cachexy, the term, how ap-
    plied by authers,        1601
 Calculus renalis,            428
 Calx nitrata antimonii, its use
    in fevers,         183—185
 Canine Madness,          1526
   the cure of,       1526—1528
 Cardialgia,                1428
 Carditis,                   383
   of the chronic kind,       ibid
 Cams,                    1093
 Cataphora,                 ibid
 Catarrh,                  1045
   predisposition to,        1046
   symptoms of,           1047
   remote causes of,        1046
   proximate cause of,      1056
E X.	
Catarrh, cure of,	1064
produces pthisis,	1054
passes into pneumonia	l, 1053
produces a peripneumonia	
notha,	1055
Catarrh, contagious,	1061
Catarrhus suffocative,	376
Chancre, method of treating, 1782	
Chicken Pox,	630
how distinguished from	
small pox,	631
Chincough,	1403
contagious,	ibid
frequently accompanied	
with fever,	1411
phenomena of,	1405
prognostic in,	1414
cure of,	1415
Chlorosis,	997
Cholera,	1454
symptoms of,	1454—57
remote causes of,	1459—61
proximate cause cf,	1455
cure of,	1463—65
Chorea,	1348
phenomena of,	1348—54
cure of,	1355
Chronic weakness,	1191
Codiaca,	1494
Cold, its operation,	88
absolute,	ibid
relative,	89
its general effects on the	
human body,	90—91
its morbid effects,	92
moderates the violence of	
reaction in fever,	133
its tonic power, how	to be
employed in fevers,	205
Cold drink, an useful tonic in	
fevers,	206
the limitation of its use in	
fevers,	207
air applied in fevers;	208
water applied to the surface	
of the body in fever	3,205-209
Colic,	1436
symptoms of,	1436—39
proximate cause ofy	1440
cure of,	1442
Devonshire,	1452
of Poitou,	ibid
cure of,	1453
 
INDEX.
 Coma,                     1093
 Comata,                   1092
 Contagions,                  78
   their supposed variety,     79
 Convulsions,               1253
 Corpulency,                1622
 Cynanche,                  300
   maligna,                 31 1
   parotidia,                332
   pharyngea,               331
   tonsillaris,               301
   trachealis,               318
     as affecting infants. 322-329
     the cure of it,          330
 Cystitis,                    430
               D
 ■Days,critical, in fevers, 107-124
   noncritical,               113
 Death, the causes of in general 100
   the direct causes of,       ibid
   the indirect causes of,     ibid
   the causes of in fever,      101
 Debility in fevers, the symp-
    toms  of,                104
   how obviated,            202
 Delirium in general,   1530—5 1
   in fever, of two kinds,      45
   or insanity without fever,
                      1551—58
 Diabetes,                  1500
   symptoms of,       1505—19
   remote caufes of.         1505
   proximate  cause of,  1511—13
   cure of,                 1514
 Dixta Afuea,               157
 Diarrhxa,                 1466
   distinguished from dysen-
    tery,                   1467
   distinguish'd from cholera 1468
   proximate cause of,       1469
   remote causes of,   1472—94
   care of,          1495—1504
   biliosa,                  1481
   colliq\tat ive,              1502
   mucosa,                  1489
 Diathesis phlogistica  62—247
   how removed,            266
 Diluents, their use in fevers,,
                     154—158
Diseases,  the distinguishing
   of them, how attained,      2
  the prevention of them, on
   what founded,             3
 Diseases, the cure of them,
    on what founded,          4
 Dropsies,                 1646
   in  general, the  cause  of
    them,                 1647
   of the breast.  See Hydro-
    thorax.
   of the lower belly. See As-
    cites.
 Dysentery,                1066
   contagious,             1074
   remote causes of,        1071
   proximate cause of,      1076
   cure of,                 1079
   use of mild cathartics to be
    frequentlyrepeatediiiit,  ibid
   rhubard improper  in it,    ibid
 Dysenteria alba,           1069
 Bysmenorrhaa,            1013
 Dyspepsia,                \ 190
   remote causes of,         1198
   proximate cause of,      1193
   cure of,                 1201
   flatulence in it, cure of,   1221
   heartburn in it, cure of,    ibid
   painsofstomachin,curcof ibid
   vomiting  in it, cure of,    ibid
 Dyspnea,                 1366
              E
 Effluvia, human,             85
   from marshes,            ibid
 Emaciations,              1601
   causes of,          1603—19
   cure of,                 1620
Emansio mensium,          997
Emetics, suited to the cure
   of fevers,                 174
   their effects,       176—180
   a mean of removing spasm, 170
   the administration of in fe-
   vers,                   175
   their  use  in intermittent
   fevers,            230—233
Emprosthotonos,            1267
Enteritis,                 404
   phlegmonic orerithematic, ibid
causes of,	406
cure of,	408
Epilepsy,	1283
phenomena of,	1284
proximate cause of,	12S5
remote causes of,	1286
predisponeut causes of.	1J1I
 
INDEX.
Epilepsy, srmpithic,-      1317
           cure of,        1318
  idiopathic,              1317
     cure of,              1320
Epistaxis,                  jj05
  the causes of it,          807
  the various circumstances
   ofit»             806—817
  the management and cure
   of>               818—828
Erisipclas,                 *274
  of the face,              ^qj
  symptoms of,       704__707
  prognosis of,              705
  penmate cause of,       696
  cure ef,            707__710
  phlegm onodes in different
   parts of the body,       711
  attending putrid fever,    712
Ery:hema,                  274
Exanthemata,              534
Exercise, useful in intermit-
   tent fevers,              231
              F
Fainting.  See Syncope.     1 170
Fatuity,                   1530
Fear, a remote cause of fever, 97
Fever,                        3
  strictly so called, the cha-
   racter of,             8—32
  phenomena of               8
  remote causes of, are of a
   sedative nature,          36
  proximate cause of,        33
  atcisy of the-extreme ves-
   sels, a principal circum-
   stance  in the proximate
   cause of it,          43__4,4
  spasm, a principal part in
   the proximate cause of it,  40
  general doctrine of,        46
  the causes of death in it,  101
  the prognosis of,          99
  •indications of cure in,     126
  differences of,              53
  continent,                 28
  continued,                 27
  inflammatory,              67
  miliary. See Miliary Fever.
  nervous,                   67
  bilious,                    71
  scarlet. Zee Scarlet Fever.
  putnd,                    72
 Fever, named synocha,        6T
             synochus,       69
             typhus,         67
   hectic,                    74
   intermittent,  the  parox-
     ysms of, described,       10
     the cold stage of,         11
     the hot stage of,       ibid
     the sweating stage of,  ibid
     of a tertian period,       25
     of a quartan period,    ibid
     of a quotidian period,  ibid
     caused by marsh effluvia,  84
     bile not the cause of  it,   51
     cure of,               228
     its parexysms, how pre-
        vented,             229
     attended  with phlogis-
        tic diathesis,         234
     attended with congesti-
        tion in the abdominal
        viscera,             ibid
   remittent,                26
 Fluxes, without fever.  See
     Profluvia.
 Fluor albous.  See  Leucor-
     rhcea.
 fomentation of the lower ex-
    trejnetirs, its use in fevers 199
 Fomites of contagion,        82
 Functions, intellectual,disor-
    ders of,           1529—30
               G
 Gangrene of inflamed parts,
    the cause of,      255—S56
   marks of the tendency to  257
   marks of itshavingcomeon, ib
 Gastritis,                  384
   phlegmonic or erythematic, 385
   phlegmonic, the seat of,   ibid
     the symptoms of,       386
     the causes of,          387
     the cure of,       393—397
   erythematic, howdiscover'd 400
     the seat of,            385
     the cure of,            401
Gastrodyniu,              1428
Gleet,                     1770
Gonorrha.!,               1766
   phenomena of,      1768—70
   cure of,             1771—79
Gout, the character of,       491
   a hereditary disease,      499 
                       I  N  D
Gout, distinguished from
    rheumatism,            525
   predisponentcauses of 492-499
   occasional causes of, 501—504
   proximate cause of,  526—532
   not a morbific matter,     528
   Regular, described,  505—517
     pathology of,          532
     cure of,          563—572
     no effectual or safe reme-
      dy yet found  for  the
      cure  of it,            538
     medicinesemployedforit 555
     whether it can be radi-
       cally cured,
      treatment in the inter-
       vals of paroxysms,
      treatment in the time of
       paroxysms,
      regimen during the pa-
       roxysms,
      external  applications,
       how far safe,    567—568
      blood-letting in the  in-
       tervals of paroxysms,
      blood-letting   in  the
        time of paroxysms,
      costiveness hurtful,
      laxatives to be employed, ibid
      effects of alkalines,     '557
         of Portland powder,  556
  Irregularf
  Atonic,
    pathology of,
    cure of,
   Retrocedent,
    pathology of,
    cure of,
   Misplaced,
    pathology of,
    cure of,           582-
   Translated, two particular
      cases of,
                H
   Hematemesis,
    arterial and venous,
    from obstructed menstru-
      ation,
    from suppression  of  the
      hemorrhoidal flux,      1024
    from compression of the
     vasabrevia,by the spleen, 1026
     obstruction of the liver,  1027
539

541

559

560
552

562
558
573-
      517
      578
      533
570—581
      521
      534
579—581
      522
      535
    -583

      524

     1016
     1026

     1019
 E   X.
Hemeturia,               1032
  idiopathic,improbable 1032-33
  calculosa,              1036
     cure of,              1037
  violenta,               1038
  from suppression of ac-
    customed discharges   1040
  putrida,                1042
  spuria et lateritia,       1043
 Hemiplegia,               1139
   causes of,               1110
   frequently occasioned by
    apoplexy,             1141
   frequently atlernates vrith
    apoplexy,             1143
   cure of,                155 1
   stimulants, of ambiguous
    use in,                1159
   stimulants, external, in, 1160
 Hemoptysis,
   the symptoms of,    837—839
   thecausesof, 759-62-829-835
   how distinguished from o-
    other spittings of blood 840-44
    cure of,             845—5 1
  Hemorrhagia uteri,         965
  Hemorrhagy,
    active or  passive,
    character of,
    arterial,
    venous,
    the causes ofthe different
     species appearing at dif-
     ferent periods of life, 749-772
    general phenomena of, 7 37-74-
    the remote causes of,     773
    cure of,                 775-
    ---whether tobe attempt-
     ed by art,          775-
    prevention  of the first.ai-
     tacks, or  cf the  recur-
     rence of,         783^
    treatment  of  when pr«i.
     sent,             788«—804
    symptomatic,           1014
  Hemorrhoides vesica,      1041
  Hemorrhois
    external  and internal,     724
    phenomena of,      924—930
    nature of the tumours,    931
    causes of,          932—94 J
     acquire a connection with  *
      the system,        ;->'*2—94>
734
735
743
767
-80
-788 
INDEX.
Hamorrhois,   particularly
  •  with the stomach,       945
  cure of,            946—964
Hepatirrhaa,              1482
Hepatitis,                  411
  acute and chronic,       ibid.
  acute, symptoms of, 412—414
     combined,  with pneu-
      monic inflammation,
     remote causes of it,
     seat of,
     various exit of pus pro-
      duced in,
     cure of,
  chronic, the seat of,
     how discovered,
ffoapingcovgh.   See Chin-
 cough,                   1403
Horror, impression of, em-
    ployed  in  intermittent
    fevers,
Human effluvia, the cause of
    fever,
  body, its temperature,
  body  has a  power of ge-
    nerating heat,          ibid.
Hydrophobia,              1526
Hydrothorax,              1698
  when seated,            1699
  symptoms of,       1702—04
  ofjten  combined with uni-
    versal dropsy,          1705
  proximate cause of,      1707
  cure of,            1708—09
  paracentesis in it, when
 415
ibid.
 417

 420
 421
 417
 422
231

 81
 88
proper,		1709
Hyparcatharsis,		1478
Hypochondriasis,		1223
phenomena of,		ibid.
distinguished from	dys-	
pepsia,		1227
proximate cause of,		1231
cure of,		1233
treatment of the mind in,		1245
Hysteria,		1515
symptoms of,	1 5 1 €	— 17
paroxysm or fit described,		ibid.
i arely appears in ma	les,	1518
how distinguished	from	
hypochondriasis,	1519	—20
p.oximate cause of,		1523
analogy between and epi-		
lepsy,		1524
Hysteria, cure of,         1525
  libidinosa,               1518
Hysteric disease.   See Hysteria.

James's powder,  its use in
   fever,                  183
Jaundice,             1816—17
  causes of,           1817—22
  cure of,             1824—30
Icterus.  See  Jaundice.
Iliac passion.  See Ileus.
Ileus,                     1438
Impetigines,               1738
  character of the order,   ibid.
Indigestion. See Dyspepsia.
Inflammation, phenomena of, 235
  internal, the marks of,    236
  the state of  the  blood in,   237
  the proximate cause of,    239
  not depending upon a len-
   tor of the blood,        241
  spasm the proximate cause
   of,                243-248
  terminated by resolution,  249
     by suppuration,         250
     by gangrene,          255
     by scirrhus,            258
     by effusion,            259
     by blisters,             260
     by exsudation,         261
  the remote causes of,     262
  the cure of in general,     264
     by resolution,         ibid.
  the cure of,  Avhen tending
   to suppuration,     268—70
     when tending to gan-
     grene,                271
  its general divisions,      273
  mere strictly cutaneous,  274
  of the bladder.  See Cystitus.
  of the brain. See Phrenitis.
  of the heart. See Carditis.
  of the intestines. SteEnteritis.
  of the kidneys.  See Nephritis.
  of the liver. See Hepatitis.
  of the lungs. See  Pneumonia*
  of the pericardium.  See Peri-
   carditis.
  of the peritonzeum.   Set Peri-
   tonitis.
  of the spleen. See Splenitis.
  ©f the stomach.  See Gastritis.
  of the uterus,             431 
INDEX.
Insanity,                  1536
  causes of,          1551—58
  of different species,      1558
  partial  and general, dif-
    ference of,
Intemperance in drinking,
  a remote cause of fever,
Intermission  of fever,
Interval of fever,
Intumcscentie,
  character ofthe order,
               K.
King's Evil.  See  Scrophula
               L.
 Leucoplegmatia,
 Leucort hoea,
   character  of,
   appearance of the matter
    discharged in,     986-
   the causes of,
   the effects of,
   the cure of,
 hethargus,
 Lientery,
 Looseness.  See Diarrhaa.
               M.
 Madness. See Mania.
    Canine. See Canine.
 Mania,
    the symptoms of,
    the remote causes of,  1569-62
    the treatment of,     1563-75
    occurring  in  sanguine
     temperaments,          1577
    in sanguine temperaments,
     cure of,                1578
 Marcores,                  1601
 Marsh effluvia, cause of fever, 84
 Measles,                   632
    the symptoms of,   636—641
    the  nature of,            643
    the  cure of,        644—649
    of a putrid kind,          642
 Medicine, the institutions of,  4
 Melena,
 Melancholia,
    how distinguished
     hypochondriasis,
    the  character of,
    the  proximate cause of,   1791
    the  treatment of,    159 3—9 8
 Melancholic temperament,   1230
 Melancholy. Sec Meianchplia
     965
     ibid
967—74
     971
1576

  97
  24
ibid.
1621
ibid.
1670
 984
 985

-991
 987
 989
 992
1093
1470
1559
ibid.
Menorrhagia,
  active or passive,
  when a disease,
  effects of,
  proximate cause of,
  remote causes of,
  cure of,
Menses, immoderate flow of
 them.  See Menorrhagia.
Metallic tonics, employed in
    intermittent fevers,
  salts, refrigerant,
Meteorismus,
Miasmata,
Miliary fevir,
  the general history of, 713-714
  of two kinds, red and white, 715
  white, symptoms of, 716—718
  the  cure of,
 Morbus caliacus,
   mucosus,
   niger,
               N.
 Nephritis
   the symptoms of,
   the remote causes of,
   the cure of,
 Nervous Diseases. See Neuroses*
 Neuroses,                 1089
 Neutral Salts, diaphoretic
     in fevers,          159—161
                            135
1016
1576
from
1588-
1583«
976
977
979
 231
 136
1634
  78
 719
1494
1069
1028

 425
 ibid
 426
 429
1622
1599
 278
 ibia
     refrigerant in fevers,
  Nosology, Methodical,
                O
  Obesity, when a disease.
  Onerodynia,
  Ophthalmia,
     membranarum*
       it3 different degrees 279-280
       its remote causes,       280
       the cure of,      288—290
     tarsi,                    2^8
       the  cure of,     288—290
  Opiates, employed in the hot
     stage of intermittent fevers 233
   .• in the interval of intermit
      tent fevers,
  Opisthotonos. See Tetanus.
                 P
  Palpitation of the heart,
     the phenomena of,
     the causes of,
     the cure of,
P P
231
1356
 ibid
1357
1364 
INDEX.
Palsy,                     1139
  distinguish, from apoplexy 1093
  causes of,               1140
Paracentesis in ascites, when
    to be attempted,       1718
  hydrothorax,when proper, 1709
Paraphrenias,              343
Paroxysm of intermittent fe-
    vers, the recurrence how
    to be prevented,         229
Pemphigus,                 731
Pericarditis,                383
Peripneumonia notha,        376
  symptoms of,             379
  pathology of,             380
  the cure of,        381—382
  some symptoms explained,  350
Peripneumony,              342
Peritonitis,                 384
Peruvian Bark, not a specific, 2 13
  its tonic power,           214
  when proper in fever,     215
  how effectually employed,  216
  the administration of, in
    intermittent fevers,      232
  the tonic chiefly employed
    in intermittent fevers,   ibid.
Petechia,                  733
Phlegmasia,                235
Phlegmon,                  274
P/fenitts,                  291
  the character of,          293
  the remote causes of,     294
  the cure of,        295—299
Phrensy.  See Phrenitis.
Physie, practice of, how taught,  1
  theory of, how employed,    4
Physeonia,                1719
Phthisis pulmonalis, the ge-
    neral character of,        852
  always with an ulceration
    of the lungs,             854
  the pus coughed up in, how
    distinguished from mucus, S55
  accomp. with hectic fever,  85 6
  the various causes of it,   862
  from hxmoptysis,   863—864
  from pneumonia,    865—868
  from catarrh,        869—872
  from asthma,              87-4
  from tubercles,      875—88 1
  from calcareous matter in
    the lungs,               88n
Pthisis Pulm. if contagious,  885
  frcm tubercles, symptoms,  888
  its different duration,      895
  the prognosis in,          896
  the cure ef,         898—923
  the treatment of when ari-
   sing from tubercles, 905-920
  the palliation of  symp-
   toms,             921—923
Plague,  general character of, 664
  phenomena of,            ibid
  principal symptoms of,     666
  proximate cause of,       667
  prevention of,      669—684
  cure of,            685—694
Pleurisy,                   341
Pleurosthotonos.  See Tetanus.
Pneumonia, or Pneumonic Inflam-
 mation,                   334
  general symptoms of, 335-339
  seat of,            340—344
  prognosis of,       352—360
  cure of,                  361
  the management of blood-
   letting in the cure of, 362-367
  the use of purgatives  in,   370
  the use of emetics in,     371
  the use of blisters in,     372
  the  means of promoting
   expectoration in,        373
  the use of sweating in,   374
  the use of opiates in,     375
 Polysarcia,  when a disease  1 622
  cure  of,            1624—26
 Profluvia,                  1044
  character of the  class,    ibid
 Pulse, the  state of the, du-
    ring the paroxysm of an
    intermittent fever,        12
 Purging, its use in continu-
    ed fevers,               144
   intermittent fevers,       234
 Pus, how produced,         250
 Putresctncy of the fluids in
    fever, the symptoms of,   105
   the tendency to  in fever,
    how to be corrected, 222-226
 Pylorus, Scirrhous.  See Dyspepsia,
 Pyrexia, character  ofthe class, 6
  orders of the class,          7
 Pyrosis,                   U28
   symptoms ef,            1432.
   nrnvimatp raucr  nf       t ,n. 
INDEX.
Pyrosis, remote caulks of,  1433
  cure of,                 1435
Pyrosis Suecica of Sauvages, 1429

Quinsy. See Cynanche.
              R.
Rachitis,                  1720
  its origin,               1721
  remdte causes of, 1722—1724
  phenomena of,          1725
  proximate cause of, 1726-1729
  cure of,          1730—1737
 Reaction of the system,       59
   violentin fever, symptoms,  103
   yiownce of, how moderated, 127
 Refrigerants,  the use  of
    ihtem in fever,          134
 Remedies, table of those em-
    ployed in continued fevers, 227
 Remission of fever,          26
 Resolution of inflammation,
     how produced,          249
 Respiration, changes, during
   paroxysmof an intermittent, 13
 Revolution, diurnal, in the
     human body,             55
 Rheumatism, acute orchronic 432
   Acute, remote causes of,   435
     proximate cause of, 444-459
     symptoms of,    438—446
     cure of,         460—469
   Chronic, symptoms of,    449
     how distinguished from
       the acute,       •    450
     proximate cause of,     471
    , cure of,          472—475
     how distin. from gout,   525
 Rickets. See Rachitis.
 Rose. See Erythema.
                S.
 Scarlet Fever,              650
   the symptoms of,         655
   different  from  cynanche
     maligna,          650—654
   the cure of,        656—663
 Scrophula,                 1739
   the phenomena  of, 1739-1750
   the proximate cause  of,  1751
   not contagious,         1752
   not arising from the  lues
     venerea,               1753
   the cure of,         1754—60
    *'•■-.  i  ■ m.             1607
Scurvy,                   1790
  remote causes of,  1793—1803
  cure of,           1805—10
  proximate cause of, 1812—15
Sinapisms, effects of them,    197
Skin, affections of. See Impeiigines
Small Pox, gen. character of,  586
  symptoms of distinct kind  5 88
     of confluent k'uid,  589-592
  general differences between
  .  distinct and confluent,    593
  causes  of these  differen-
    ces,              594—599
  prognosis in,             592
  cure of,           600—629
   inoculation of,           601
     the several practices of«
      which it consists,      602
    importance of several prac-
      tices belonging to, 603-614
   management of small pox
    received by infection, 61 5-629
 Soda,                     1428
 Spasm, internal, means  of
    removing in fevers,  152-187
   the proximate cause of in-
    flammation,       243—248
   Spasmodic affections with-
    out fever,             1251
   of the animal functions,  1254
   of the  vital functions,    1356
   of the  natural functions, 1428
 Sphacelus,                 255
 Splenitis,                  424
 Stimulants, when to be em-
    ployed in fevers,        2 17
   their use in intermittent
    fevers,                 230
 Stomach, its consent with the
    vessels on the  surface  of
    the body,                44
 Sudoriflcs, arguments for their
    use in fevers,      16*—167
   against their use  in fevers, 164
 Suppuration of inflamed parts,
    the causes of,            251
   the marks of tendency to,   iind
   formed, the marks ef,  *   ibid
 Surface of the body, its con-
    sent with the stomach,    44
 Swellings, general.  See Intumes-
  centhx.
adipose,
1622 
                        I  N  D
'Swellings, flatulent,         1627
♦■  watery. See Dropsies.
 Sweating, when hurtful in
    continued fevers,        165
   rules for the conduct of
    continued fevers,        168
   qse of in intermittent fe-
    vers,                    230
 Syncope, phenomena  of,     1170
   remote causes of,  1173—1178
   predisposition to,         1184
   cure of,                 1189
   distinguished from  apo-
    plexy,                 1093
 Synocha.  See Fever.            ..
 Synochus. See Fever.
 Syphilis,                   1761
   originally from America,  1762
   how propagated,         1763
   and gonorrhoea, ho w dii, tin-
    guished,               1765
   cure of,          1784—1789
               T.
 Tabes a hydrope,           1610
   a sanguifluxu,           1609
   dorsalis,                 1611
   glandularis,              1607
   mesenterica,              ibid
   Butricum,               1609
   rachialgia,               1607
   scrophulosa,              ibid
 Tartar Emetic, its  use in
    fevers,                  185
 Tetanus,                   1257
   remote causes of,         1268
   cure of,                 1270
   pissileum Barbadense,  or
    Barbadoes tar, in       1280
   lateralis,                1268
 Tonic medicines.employed in
    continued fevers          211
   do. in intermittent fevers   231
 Toothach, how far different
    from Rheumatism, 476—479
   symptoms of,             477
   predisposition to,          480
   remote causes of,    480—481
fe   X.
  proximatdkatfseof,     ..  482
  cure of, '           484--490
Trismus. See  Tetanuy
  nascent ium,     V       1282
Tussis.  See Catarrh.
Tympanites,  character of
>s,
     1623
1629—31
     1629
 (p   ibid
      ibid
      .bid
     1633
1636—37
1638—45

      >0

 See
  different species
  intestinalis
  enterophysodcs
  abdominalis
  asciticus
  phenomena of,
  proximate cause  of,
  cure of,          ,,
Typhus. See Fever.
  the species of,
               V
Vapor?, or low spirits,
   Hypochondriasis.
Venereal Disease. See Siphylis.
Venery, excess in, a  remote
   cause of fevej,            97
Vesanie, in general,        1529
Vis medicatrix nature,       381
St. Vitus's Dance. See Chorea.
Vomiting of Blood. See Hema-
   teinesis.
  effects of in continued fe-
   ,ver,              172—173
  the use of in intermitting
   fevers,             230—34
               U
Urine, bloody. See Hematuria.
Urticaria.,  the  history and
   treatment  of,
               W
Water-BrasIi*See Pyrosis.
Whites. See Leucorrhcea.
Warm-Bathing, the effects
   of in fever,
  administration of in fever
  marks of the good effects 200
Wine, the most proper stimu-
   lant in fevers,           218
  its convenient use in fe^rs 219
  Avhen hurtful or  useful in
   fevers^
729
198
199
THE    END.
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