*Vr- ,:,-A'^-'' V^:-. ''•X,. '. -#~-V -> .'■ . '.;•:-' •: ." ."'-->■ % '.*:.; ■ --■ <«•' ..•.- >** 1 " '^ ",.-';•-'" *'': .,.:'..."*.•*'.■. ' ■■ . V .* -■rr> iV-.J»T ■ *■■■' -..*■>?■: _ '+-• ■$&&'■>& ** ■■ $iv'*~m*k£-' ■ ■■'■■■ ?/•-- .•-:■ *^.-*-- -.- ir*vv> .-fit'-'v-- 4^' i« v/.l *«! t vv*M"\ ■■■' ' ' •-•■■ ■•• ;./•• ARMY MEDICAL LIBRARY WASHINGTON Founded 183G 1W' c*'* Sect ion -Number ..3...(e..l.'/.„Ct-5- Fobm 113c, W. D.. S. G. O. "• 3—10.r>43 (Revised June 13. 1936) / + « F I $ S T'L I N E S .OT THE PRACTICE OF PHYSIC. Bv WILLIAM CULLEN, m. d. Latt Profejfor oftbt PraSict of Phyftc in the Univerftty of Edinburgh; Firjt Phyftcian to hit Majefty for Scotland ; Fellow of the Royal College efPhyficians of Edinburgh, of the Royal Societies of Lon- don, of Edinburgh, &c. &c. &c. WIT* SUPPLEMENTARY NOTES^T INCLUDING THE MORE RECENT IMPROVEMENTS IN TH£ „ PRACTICE OF MEDICINE. — ■ ■■ ■ ■ - ... ..-»»i'^t. By PETER REID. >>v> A NEW AND IMPROFED EDITION. TWO VOLUMES IN ONE. BROOKFIELD : Printed by E. MERRIAM fc? Co. For ISAIAH THOMAS, Jun. Sold BY him in Worcefier, and by Thomas fi? W hip? uz, Newburyperf, and by Thomas & Tappan, Port/mouth, May—>:2?;. «t * * PREFACE THE EDITOR. THE almoft unrivalled celebrity ofDrl Cullen, and the high eftimation which his Prattice of Medicine has univerfally acquired, render it quite unnecef- fary to expatiate on his merits. His practical remarks are almoft converted into medical axioms ; and even error it* felf was, for a time, refpecled under the venerable fanclion of his name. To him we are indebted for ftrft arranging the fcattered and infulated fubjecls of practical medicine, — into ajyftem at once luminous, profound, Jimple and conned' ed,andwhich every where exhibits the Jlamp of a vigorous S generalifing mind ; where an uncommon talent for ob/erva- ,_, fion, united with the moji ample experience, give fuch an authority to his conclujions, that, in what regards the treat- 1 ment of dijeafes, to depart from the opinion */Cullen, is - confidered fuch a fchifm from the ejiablijhed creed of medical men, as can only bejujiified by the moji decijive evidence. If Dr. Cullen has failed any where, it is where no man has yet been fuccefsful, in his attempts to theorife ; at- tempts which itfeems to be the fate of almoft every medical man of genius to make3 and in which the frequent failure has afforded more than an honeft triumph to thofe whenev- er fall, becaufe they never venture to rife, and who are not unfrequently deterred, rather by the imbecillity than the com- prehenfion of their minds, from following a like courje. In* deed, there Jeems fomething fo irrejiftibly fafcinating in prefcribing from a plaufible theory, in being able to point 2 w PREFACE. out the nature of proximate caufes, and grafp a fyftem by one daring effort of intellecl, that we have as little reafon to wonder at the manyftrange theories that have been broach- ed, as at the tenacity with which the mqft abfurd of them has been maintained; nor is it eafy to determine, whether he who follows the blind routine of empirici/m, or he whofh praclice is Jhaken by the crude conceptions of every fchool boy theoriji, is more to be pitied. There is, however, a middle way between the creeping round of mere matter offacl men, and the airy fancies ofthofe who Joar infinitely beyond the regions offoberfenfe andfottndjudgment, " The onefhould 103 BOOK II. (Of Inflammations, or Phlegmatic, - - • 107 Chap. I.—Of Inflammation in general, - ib. Sett. I.—Of the Phenomena of Inflammation, - ib. II.—Of the Proximate Caufe of Inflammation, - lot III.—Of the Terminations of Inflammation, - 11 j IV__Of the Remote Caufes of Inflammation, - iz 1 • V.—Of the Cure of Inflammation, - • ia» Chap. II.—Of Inflammation, more ftridtly Cutaneous, - 12C III.—Of Ophthalmia, or Inflammation of the Eye, - iat IV.—OfthePhrenfy, or Phrenitis, - - 13J V.—Of the Quinfy, or Cynanche, - 13s SecL I.—Of the Cynanche Ton fillaris, - - 136 II.—Of the Cynanche Maligna, - - 137 III.—Of the Cynanche Tracheaiis, ■> - 14* IV.—Of the Cynanche Pharyngaea, - - 144 V.—Of the Cynanche Parotide, * - 145 VI.—Of Pneumonia, or Pneumonic Inflammation, - 146 VIL—Of thePeripneumonia Notha, orBaftard Peripneumony, z6«v VIIL— Of the Gaftritis, or Inflammation of the Stomach, 164 IX.—Of the Enteritis, or Inflammation of the Inteftines, 1 t X.—Ot the Hepatitis, or Inflammation of the Liver, - 172 XL—Of the Nephritis, or Inflammation of the Kidneys, 176 XII.—Of the Rheumatifm, - - - 177 XIII.—Of the Toothach or Odontalgia, - - 18* XIV.—Of the Gout, - J9J Vl CONTENTS. Page. BOOK III. Of Exanthemata, or Eruptive Fevers, - * «J Chap. L—Of the Small Pox, - - .- - »*• IL— Of the Chicken Pox, - - • *J7 Obfervations on the Cow Pox, - - -338 HI—OftheMeafles, - - *43 ]V.—Of the Scarlet Fever, - - - 247 V.-Of the plague, " " , ' " *# Sett. I.—Of the Phenomena of the Plague, - - ib. II.—Of the Prevention of the Plague, - - 354 HI.—Of the Cure of the Plague, - - aj8 Chap. VL—Of Eryfipelas, or St. Anthony's Fire, a6i VIL—Of the Miliary Fever, - * m »6.S VIIL—Of the remaininK Exanthemata:—Urticaria, Pemphigus, and Aphtha, ■? - 271 BOOK IV, ©f Hemorrhages, - »73 Chap. I.—Of Hemorrhagy in genera!, - ib. Sect. L—Of the Phenomena of Hemorrhagy, ■» 374 II. - Of the Proximate Caufe of Hemorrhagy, - »?5 III.—Of the remote Caufes of Hemorrhagy* ■» a86 IV.—Of the Cure of Hemorrhagy, - a$$ IL—Of the Epiftaxis, or Hemorrhagy of the Nofe, - A95 III.—Of the Hemoptyfis, or Hemorrhagy from the Lungs, 301 Seel. L—-Of the Phenomena and Caufes of Hemoptyfis ib. II__Of the Cure of Hemoptyfis, - - 3*5 IV.—Of the Phthifis Pujmonalis, or Confumption of the Lungs,, - - - - 307 Sett. I.-vOf the Phenomena and Caufes of the Phthifis Pulmonalis, - - - ib. II—Of the Cure of Phthifis, , - 3*4 V.—OftheHemorrhois, or of theHemmorrhoidal Swelling and Flux, - - 334 Sett. I—Of the Phenomena and Caufes of the Hemorrhoid, ib. II.—»Of the Cure of Hemorrhoidal Affettions, - 340 Chap, VI.—Of the Menorrhagia, or the Immoderate Flow of the Menfes, .... 3^ VII.—Of theLeuconhoea, Fluor Albus, or Whites, - 350 VIIL—Of the Amenorrboea, or laterruption of the Menftruaj Flux, ... 3Si IX—Of Symptomatic Hemorrhagies, - - 358 Sett. I.—Of the Hematemefis, or Vomiting of Blood, 359 IL—Of the Hematuria, or the Voiding of Blood from the Urinary Paffage, - - 365 BOOK Y. O? Profluvia, or Fluxes with Pyrexia, - . 370 Chap. I.—Of the Catarrh, . . • 371 H<— Of the Dyfentery, - • • 377 •5QWTENT& «s Page, PART IL Of Nsuroses, or Nfcrvous Difeafes, - „ ^ BOOK I. Of Gomata, or the Lofs of Voluntary Motion, * - 3&3 Chap. I.—Of Apoplexy, ... u, H.-Of Palfy, - . - . 404 BOOK II. Of Adynamic,or Difeafes confiding in a Weaknefs or Lofs of Mo- tion in either the Vital or Natural Functions, - 414 Chap. I.—Of Syncope, or Fainting, - . ib. Il.-fcOf Dyfpepfia, or Indigeftion, - - A2t Ill.w-Of Hypochondriafis, or the Hypochondriac Affefticn, commonly called Vapors or Low Spirits, - - 433 BOOK m. Of Spasmodic Affections without Fever, - - 442 •Sett. L— Of the Spafmodic Affettions of the Animal Func- tions, - - 443 Cha*. I.—Of Tetanus, - - 444 II.-OfEpfiepfy, - 45fi III.—Of the Chorea, or Dance of St. Vitus, - - 474 Sett. II.—Of the Spafmodic Affettions of the vital Funttions, 4.76 CHA*.IV*.--Ofthe Palpitation of the Heart, - - ib. V.—Of Dyfpnoea, or Difficult Breathing, - - 47a VL—OfAfthma, - - - 48r VIL—Of the Chincough, or Hooping Cough, - 489 Sett. III.—Of the Spafmodic Affettions in the Natural Func- tions, - - 498 CH4flp. VIII.—Of the Pyrofis,or what is named in Scotland the Water Brafh - ib. IX.—Of the Colic, - - - 501 X.—Of the Cholera, - 508 XL—Of Diarrhoea, or Loofenefs, - - - cm XII.—Of the Diabetes, - - - 52? XIIL—Of the Hyfteria, or the Hyfteric Difeafe, - - 530 XIV.—Of Canine Madnefs and Hydrophobia, - - 533; BOOK. IV. 0# Vhahije, or of the Diforders of the Intellectual Funttions, - 53 7 Chap. I.—Of Vefanr.E in general, - - - - ib. II.—Of Mania,or Madnefs* - - - 549 III.—Of Melancholy, and other Forms of Infanity, - 558 * Though 1 have thoug bt it proper to divide this book intofeftions, I think it *ffejary,f>r the convtnit, %ce of referencest to number the chapters from the be* *'»»»£.—Author. ffii CONTENTS; Of Cachexies, Of Emaciations, PART III. BOOK I. BOOK II. Page, j6$ tn 580 581 584 59* 602 613 - 618 Of 621 6*2 °CW \"r£T**Z?r DePraved Habit- W»th Affections of the 1 tiMu Chap. I.—OfScrophula, or the Kind's Evil, . . ib itt ^^y1'8-^ the Venereal Difeafe, - V. 642 HI.—Or bcurry, . v** IV.-OfJaundice, . / / _-, Jj{ Of Intumescenti/e, or General Swellings, - Chap. L—Of Adipofe Swellings, ... ». IL—Of Flatulent Swellings, - III.—Of Watery Swellings, or Drop lies, - Sett. I.-Of Anafarca, - IL—Of the Hydrothorax, or Dropfy of the fcteaft, III.—Of Afcites, or Dropfy of the Lower Belh', Chap. IV.—Of General Swellings, arifing from anincreafed B'ulk «r « . - . the whole Subftance of Particular Parts, Of Rachitis, or Rickets, - . BOOK III. »r..TT t-^- ;>V «J JM4W TJgtfT PREFACE TO THE LAST EDITION BEFORE THE AUTHOR'S DEATH^ 10 deliver a Syftem of the Dottrines and Rules proper for diretting the Prattice of Phyfic, is an undertaking that ap- pears to me to be attended with greatdifficulty ; and, after an experience of more than forty years in that prattice, as well as after much jading and refiettion, it was with great diffidence that I ever entered upon fuch a work. It s< as, however, what feemed to be my duty as a Profeflor that in- duced me to make the attempt, and I was engaged in it by the fame fenti- ments that the illuftricus Dr. Boer haavs has expreffed in the following paffage of the Preface to his Inftitutions : " Simulenim docendo admotus e- " ramfenfi,propriorum cogitatortim explicctione decentem plusproficere, qualm "ft opus ah alio conferiptum interpretarifufcipit. Sua quippe optime intelligit, "fua cuiquepra ceteris placent, unde'clariorfiredcOrina, at que animataple- " rumquefequitur .oratio. Qui •verofenfa alttrius exfonit, infeliciusfa-penufnerO " eadem affequitur; quumquefuo quifquefenfu abundat,mulia refutemda fre- *' quer.ter invenit, undegravemfrufira labored aggravat, minufque incitata " dlttione utitur" It is well known that a Text book is not not only extreme- ly ufeful but necelTary to Students who are to to hear Lettures ; and from the fame confiderations,that moved Dr. Boerhaave, I alfo wifhed to have one for myfelf; while at the fame time, from fome peculiar circumftances vA my fituation, I had fome additional inducements to undertake fuch a work. Before I was eftablifhed as a profeflor of the Prattice of Phyfic in this U- niverfity,I had been employed in giving Clinical Lettures in the Royal _ In- firmary, and upon that occafion had delivered what, in my own opinion, Teemed moft juft with regard to both the nature and the cure of the difeafci of which I had occafion to treat; but I foon found that my dottrines were taken notice of as new and peculiar to myfelf, and were accordingly ftvere- iy criticifed by thofe who, having long before been trained Up in the fyftem of Boerhaave, had continued to think that that fyftem neither required a- ny change, nor admitted of any amendment. I found at the fame time, that my dottrines were frequently criticifed by perfons who either had not beeix informed of them correttly, or who feemed not to urderftand them fully ; and therefore as foon as I was employed to teach a mere complete Syftem of the Prattice of Phyfic, I judged it neceffary to publifh a Text book, not only for the benefit of my hearers, but that I might alfo have an opportuni- ty of obtaining the opinion ef the Public more at large, and thereby be ena- bled either to vindicate my dottrines, or be taught to corrett them. Thefe were the motives for my attempting the Volumes I formerly pubhfned ; and now, from many years experience of their utility to my hearers, as well as from the favorable reception they have met with from the Public, I am induced to give a new edition of this Work, not only, as I hope, more cor- :t PREFACE. iott in many parts, but alfo more complete and comprehenfive in its gener- al extent. At the firft publication of this Work, it was intended chiefly for the ufeof thofe Gentlemen who attended my Lettures, although even then, for the reafons I have mentioned, it was rendered more full than Text books commonly are; and in the repeated editions I have fince had occafion to give, I have been conftantly endeavoring to render it more full and com- prehenfive. In thefe refpetts, I hope the prefent edition will appear to be rendered more fit for general ufe, and better calculated to afford fatisfattion to all4 thofe who think they may ftill receive any inftruttion from reading on thisfubjett. While I thus deliver my Work in its now more improved ftate, with the hopes that it may be of ufe to others as well as to thofe who hear my Lec- tures, I mud at the fame time obferve, that it prefents a fyftem which is in many refpetts new, and therefore I apprehend it to be not only proper, but neceffary, that I Ihould explain here, upon what grounds and from what confiderations this" has been attempted. In the firft place, I apprehend that in every branch offcien.ee with ref- pett to which newfatts are daily acquired, and thefe eonfequently giving occafion to newreflettions, which corrett the principles formerly adopted, it is neceffary from time to time to reform and renew the whole.fyftem,with all the additions and amendments which it has received and is then capable of. That at prefent this is requifite with regard to the Science of Medicine, will I believe readily occur to every pcrfon who at all thinks for himfelf, and is acquainted with the Syftems which have hitherto prevailed. While there- fore I attempt this, I think it may be allowable, and upon this occafion even proper, that I ihould offer fome remarks on the principal Syftems of ■Medicine which have of late prevailed in Europe, and- that I Ihould take «otice of the. prefent ftate of Phyfic as it is influenced by thefe. Such re- marks I hope may be of fome ufe to th@fe who attempt to imprpve their knowledge by the reading of books. Whether the Prattice of Phyfic Ihould admit of reafoning, or be entire- ly retted upon experience, has long been and may ftill be a matter of difpute. I fhallnothoweverat prefent enter upon the difcuflion of this, becaufe I can venture to affert, that at almoft all times the prattice has been, and ftill is with every perfon, founded more or lefs upon certain principles ef- tablifiied by reafoning ; and therefore, in attempting to offer fome view of the prefent ftate of Phyfic, I muft give an account of thofe fyftems of the principles of the fcience which have lately prevailed, or may be fuppofed ftill to prevail in Europe. When, after many ages of darknefs, which had deftroyed almoft the whole of ancient literature, learning was again reftoredin the fifteenth cen- tury ; fo, from caufes which are well known, it was the fyftem of Galen alone that the Phyficians of thofe days became acquainted with ; and dur- ing the courfe of the fixteenth century, the ftudy of Phyficians was almoft folely employed in explaining and confirming that fyftem. Early indeed in the fixteenth century, the noted Paracelfus had laid the foundation of a Chemical Syftem, which wa3 in dirett oppofition to that of Galen, and by the efficacy of the medicines employed by Paracelfus and his followers, their fyftem came to be received by many ; butthefyftematic Phyficians con- tinued to be chiefly Galenifts, and kept poffeffion of the Schools till the middle of the feventeenth century. It is not however neceffary here fo enter into any further detail refpetting the fate of thofe two oppofite lefts, for the only cjreumftance concerning them, which I would with at pre- fent to point out, is, that, in the writings of both, the explanations they fev- erally attempted to give of the phenomena of health or ficknefs turned very entirely upon the ftate of the fl uids of the body. y Such was the ftate of the fcience of Phyfic till about the middle of the feventeenth century, when the circulation of the blood came to be general. PREFACE. fci Iy known and admitted, and when this, together with the difeovery of the receptacle of the chyle and of the thoracic duft, finally exploded the Galen- iojdyuem. About the fame period, a confiderable revolution had taken pi ace in the fyftem of Natural Philofophy. In the courfe of the feventeenth cen- tury, Galileo had introduced mathematical reafoning, arcd Lord Baeon hav- ing propofedthe method of induttion, had thereby excited a difpofition to obferve fatts, and to make experiments. Thefe new modes of philofophif- ing, it might be fuppofed, would foon have had fome influence on the ftate of medicine, but the progrefs of this was flow. The knowledge of the Cir- culation did indeed necefiarily lead to the confideration, as well as to a clear- er view of the Organic Syftem in animal bodies, which again led to the ap- plication of the mechanical philofophy towards explaining the phenomena of the animal economy; and it was applied accordingly, and'„ continued, till very lately, to be the fafhionable mode of reafoning on the fubjett. Such reafoning indeed muft ftill in feveral refpetts continue to be applied ; but it would be eafy to fhow,that it neither could nor ever can be applied to any great extent in explaining the animal economy, and we muft therefore look for other circumftances which had a greater lhare in modelling the Syftem of Phyfic. With this view it may be remarked, that till the period juft now mention- ed, every phyfician, whether Galenift or Chemift, had been fo much, accuf- tomed to confider the ftate and condition of the fiuWs both as the caufe of difeafe and as the foundation for explaining the operation of medicines, that what we may term an Humoral Pathology ftill continued .to., make a great part of every fyftem. In thefe circumftances, it was foon perceived that chemiftry promifed a much better explanation thSn the Galenic or Ar- iftotelian p'hilofophy had done i and therefore, while the latter was entirely laid afide, a chemical reafoning was every where received; Lord Bacon, with his ufual fagacity, had early obferved that chemiftry promifed a great number of fatts, and he thereby gave it credit j whilft the Corpufcularian philofophy, reftored by GafTendi, readily united with the reafonings of the Chentifts; and the philofophy of- Des Cartes readily united, with both. Prom.all thefe circumftances, an Humoral, and chiefly a Chemical Patholo- gy, came to prevail very much till the end of the laft century, and has in- deed continued to have a great fhare in our fyftems down to the prefent time. It'is proper now, however, to obferve, that about the beginning of the pref- ent century, when every part of fcience came to be on a more improved and corrett footing, there appeared in the writings of Stahl, of Hoffman, and of Boerhaave; three new, and confiderably different Syftems of Phyf- ic, which have ever fince had a great fhare in diretting the prattice of it. In order; therefore, to give a nearer view of the prefertt ftate of Phyfic, I mall offer fome remarks upon thefe different fyftems; endeavoring to point out the advantages as well as the difadvarttagesofeach,and how far they Mill prevail, or, according to my judgment, deferve to do fo. » I fhall begin with considering that of Dr. Stahl, which I tMink appeared firft, and for a long time after was the prevailing fyftem in Germany. The chief and leading principle of this fyftem is, that the rational foul of man governs the whole economy of his body. At all times Phyficians have obferved, that the animal economy has in itfelf a power or condition, by which, in many inftances, it refifts the injuries which threaten it, and by Which it alfo, on many occafions, corrects or. jmoves the diforders induced, or arifing in it. This power Phyficians very anciently attributed, under a vague idea, to an agent in the fyftem, which they called nature ; and th> language of aw confervatrix et medicatrix natura, has continued in the fchools of medicine from the moft ancient times to the prefent. Dr. Stahl has explicitly founded his fyftem on the fuppofition, that the power of nature, fo much talked of, is entirely in the rational foul. He 2 Xll PREFACE* • fuppofes, that upon many occafions the foul atts independently of the ftate of the body, and that without any phyfic.il neccffity arifing from that ftate, the foul, purely in confequence of its intelligence, perceiving the, tendency ofnoxious powers threatening, or of difordersany ways arifing in the fyftem, immediately excites fuch motions in the body as are fuited to obviate the hurtful or pernicious confequences which might otherwife take place. Ma- ny of my readers may think it was hardly neceffary for me to take notice of a fyftem founded upon fo fanciful a hypothefis ; but there is often fo much feeming appearance of intelligence and delign in the operations of the ani- mal economy, that many eminent perfons, asPerrault in France, Nichols and Mead in England,PorterfieIdandSimfontn Scotland,and Gaubius in Holland, have very much countenanced the fame opinion, and it is therefore certainly entitled to fome regard. It is not however neceffary for me here to enter in- to any refutation of it. Dr. Hoffman has done this fully, in his Commenta- ries de differentia inter liojfmatmi dotlrinam medico mechanicam et G. E. Stahlii medio organicam ; and both Boerhaave and Haller, though no fa- vorersof mateiiaiifm, have maintained a doctrine very oppofite to that of Stahl. In my Phyfiology I have offered fome arguments againft the fame: and I fhall only add now, that whoever confiders what has been faid By Dr. Nich- ols in his Oratio de Atima Medica, and by Dr. Gaubius in fome parts of his Pathology, muft perceive, that the admitting of fuch a capricious govern- ment of the animal economy, as thefe authors in fome ipftances fuppofe, would at once lead us to rejett all the phyftcal and mechanical veafoning we might employ concerning the human body. Dr. Stahl himferf feems to have been aware of this ; and therefore, in his Preface to Junker's Confpetlus Therapii* Specixiis, has acknowledged, that his general principle was not at all neceffary; which is in effett laying, that it is not compatible with any fyftem of principles that ought to govern our prattice. Upon this footing, I might have at once rejetted.the Stahlian principle; but it is even dangerous to bring any fuch principle into view: for, after all Dr. StaHl had faid in the pafiage juft how referred to, I find, that, in the whole of their prattice, both he and his followers have been very much governed by their general princi- ple. Truftinj^much to the conftant attention andwifdom of nature, they have propofed the Art of curing by expectation : have therefore, for the moft part, propofed only very inert and frivolous remedies ; have zealoufly oppotbd the ufe of fome of the moft efficacious, fuch as opium and the Per- uvian bark ; and are extremely refervedih the ufe of general remedies, fuch as bleeding, vomiting, &c. Although thefe remarks, upon a fyftem which may now be confidered as exploded or negletted, may feam fuperfluous, I have been willing to give thtfe ftrittures on the Stahlian fyftem, that I might carry my remarks a lit- tle farther, and take this opportunity of obferving, that in whatever man- ner we may explain what have been called the operations of nature, it ap- pears to me that the general dottrine of Nature curing difeafes, the fo much vaunted Hippocratic method of curing, has often had a very baneful influ- ence on the prattice of phyfic, as either leading phyficians into, or continu- ing them in a weak and feeble practice, and at the fame time fuperfeding or difcouraging all the attempts of art. Dr.Huxham has properly obferved, that even in the hands of Sydenham it had this effett. Although it may fometimes avoid themifchiefs of bold and rain prattitioners, yet it certainly produces that caution and timidity which have ever oppofed the introduc- tion of new and efficacious remedies. The oppofition to chemical medi- cines in the fixteenth and feventeenth centuries, and the noted condemna- tion of Antimony by the Medical Faculty of Paris, are to be attributed chiefly to thofe prejudices, which the phyficians cf France did not entirely get the better of for near a hundred years after. We may take notice of the referve it produced in Boerhaave, with refpett to the ufe of the Peru- vian Bark. We have had lately publifhed, under the title of C onflitutiones iipidemiex, notes of the particular prattice of the late Baron Van Swieten • PREFACE. Xlil upon which theoditer very properly obferves, That the ufe of the bark, in intermitting fevers, appears very rarely in that prattice; and we know very well where Van Svvicten learned that referve. I might go farther, andfhow how much the attention to the Autacratcia', allowed'ofT in one fhape or other, by every fett, has corrupted the prattice among all phyficians, from Hippocrates to Stahl. It muft however befwffi- ciently obvious, and I fhall conclude the fubjett with obferving, that al- though the t'is medicatrix natura. muft unavoidably be received as a fatt, yot, wherever it is admitted, it throws an obfeurity upon our fyftem ; and it is only where the impotence of our art is very mahifeft and confiderable, that we ought to admit of it in prattiee. To finifh our remarks upon the Stahlian Syftem, I fhall ftiortly obferve, that it did n >t depend entirely- upon the Aatocrateia, but alfo luppo " la mstus etfenfus impotentia, nulla febris aut humoris ilhus excretio, aceidit, " in qua non ha partes patiantur. Porro etiam omnes, qua morbos gignunt « caufa, operationemfuampotiffimumperficiunt in partes mot* et fenfupra* -" ditas, et canales ex his coagrtentatos, eorum ruotum, et cum hoc ftuidorum <« curfum, per-vertendo ; iia tamen, ut ftcuti variaindohs funt,ftc etiam -vane " in nerveas partes agant, iifdemque noxam affricent. Demm omnia quoque '" eximia "ArAutis medicamenta, non tarn in partesfiuidas, tarum crafm ac •< uUempcricm corrigenda, quam potius infolidas etnervqfus, earundem motus »« alterandoac moderando, fiium edunt operationem : de quibus tamen omm- « bus, in vulgari ufque eo- relepta morborum doHrina,.altum ejl Ahntium. It is true that Dr. Willis had laid a foundation for this dottrjne m his Pathologic Cerebri et Nervorum : and Baglivi had propofed a fyftem of thi* kind in' his Sptamen de-fibm motri'ci et morbofa. But, in thefe writers,*! was j cither not extenfively applied to difeafes, or was ftill fo involved m many. phyfiological errors, that they had attracted little attention; and Dr. Hoff- man was the firft who gave any tolerabtySimple and clear fyftem on the fub- ^ jett, or pointed out iny extenfive application of it to the explanation of difeafes. ' . • ' ■ ' . There can be no fore of doubt that the phenomena of the animal econo- my in health and in ijeknefs, can only be explained by confidering the ftate and affettidns of the primary moving powers-in it. It is to me furprifing that phyficums were fo-long of perceiving this,.and I think we are therefore particularly indebted'to Dr. Hoffman for putting - us into the proper train of inveftigation ; and it every day appears that phyficians perceive the ne? ceffity of entering more and more into this -inquiry. It was this, I think, which engaged Dr. Kaaw Boerhaave to publifh his work, intitled Impetum faciens; as well as Dr. Gaubiu-s to give the pathology of the Solidum vi« vum. Even the Baron Van Swieten has upon the fame view thought it neceffary, jn at leaft one particular, to make a very confiderable change in the dottrine )f his irafier, as he has done in his Commentary upon the 755th Aphorifm. Dr Haller has advanced this part of fcience very much by his experiment^ oti irritability anf the ccurfe of the circulation. If then we confider the inperfettion of Dr. Boerhaave's dottrine with ref- pett to the ftate and various condition of the animal fluids ; and if at the fame time we reflett how frequently he and his followers have employed the fuppofition of an acrimony, or lentor of the fluids, as caufes of difeafe, and fordirettingthc prattice ; we muft, as I apprehend, be fatisfied, that his fyftem is not only deficient and incomplete, but fallacious and apt to mif- lcad. Although it cannot be denied that the fl uids of the human body fuffer various morbid change?, and that upon thefe, difeafes may primarily depend ; yet I muft beg leave to maintain, that the nature of thefe changes is feldom underftood, and more feldom ftill is it known when they have taken place ; that our reafonings concerning them have been, for the moft part, purely hypothetical; have therefore contributed nothing to improve, and have of- ten milled the prattice of phyfic. In this, particularly they have been hurt- ful, that they have withdrawn our attention from, and prevented our ftudy of the motions of the animal fyftem, upon the ftate of which the phenomena of difeafes do more ccrtruly and generally depend. Whoever then fhall cor- fider the almoft total neglctt of the ftate of the moving powers of the animal body, and the prevalence of an hypothetical humoral -pathology, fo con- fpicuous in every part of the Boerhaavian Syftem, muft be convinced of its very great defetts, and perceive the neceffity of attempting one more cor- rett. collettion of new fatts has been acquired by obfervation and experiment This mc.eed affords the beft and moft folid rcafpn for attempting a new fyftem: for when many new fatts have been acquired,it becomes ?equifite that the.e ihould be incorporated into a fyftem, whereby not only par&u lar, PREFACE. x\n Uibje&s may be improved, but the whole may be rendered more complete, confiftent, andu&ful. Every fyftem indeed muft be valuable in proportion to the number of fatts that it embraces and comprehends; and Monf. Quefnay could not pay a higher compliment to the Syftem of Boerhaave, than by &ying» that it exhibited La medicine collective. But here it will, perhap3, be fuggefted to me, that the only ufeful work, on the fubjett of phyfic, is the making a collection of all the fatts that re* late to the art, and therefore of all that experience has taught us with re- fpett to the Cure of difeafe3,1 agree entirely in the opinion, but doubt if it can ever be properly accomplifhed without aiming at fome fyftem of prince pies, by a proper induttion and generafifation of fatte ; at leaft I am ptr- fuaded that it can be done not only very fafely, but moft ufefully in this way. This however, muft be determined by a trial. I know that the late Mr. Lieutaud has attempted a work on the plan of collecting fatts, with- out any reafoning concerning their caufes: And while I am endeavoring to give fome account of the prefent ftate of Phyfic, I cannot difmifs the fubjett without offering fome remarks upon the promifing Synopfis utiiverfa medicina, compofed by the'firft phyfician.of a learned and ingenious nation. In this work there are many fatts and much obfervation from the au- thor's own experience, which may be ufeful to thofe who have otherwife acquired fome knowledge and difcernment ; but, throughout the whole work, there is fuch total want of method, arrangement, fyftem, or decifion, that, in my humble opinion, it can be of little ufe, and may prove very per- plexing to thofe who are yet to learn. The diftinttion of the genera of difeafes, the diftinttion of the fpecies of each, and often even that of the varieties, I hold to be a neceffary fouRdation of every plan of Phyfic, wheth- er dogmatical or empirical. But very little of this diftinttiou is to be found in the work of Mr. Lieutaud ; and in his preface he tells us that he meant to neglect fuch argutafedulitss. And indeed his method of managing his fubjett, muft certainly interrupt and retard all methodical nofology. His at raagement of difeafes is according to no affinity, but that of the flighted: and uninftruttive kind, the place of the body which they happen to afTett! llis Generalia etincerta fedis, have hardly any connection at all; the titles Rbeumatifmus, Hypocondriajis, Hydrops, follow one another. When he does attempt any general dottrine, it is not till long after he has treated of the widely feattered particulars. Under each particular title which hz afiumes, he has endeavored to enumerate the whole of the fymptoms that ever appeared in a difeafe under that title ; and this without aiming at any diftinttion between the effential and accidental fymptoms, or marking the feveral combinations, under which thefe fymptoms do for the moft part fteadily appear. From the concurrence of accidental fymptoms, the vari- ety of the fame difeafe is frequently confiderable, a circumftance noccflhi'ly perplexing and diftratting to young prattitioners ; but it feems ftrange to me, that an experience of thirty ye:irs, in cop.fiderable prattice, could d° nothing to relieve them. Mr. Lieutaud has at the fame time increafed the confufion that muft arife from this want of diftinttion, by his confidering as primary difeafe?, what appear to me to be the fymptoms, effetts, and fequels of other difeafes only. Of this I think the A\(lus morbofus, Virion exolufio, Dolores, Siagnotio fanguinis, Purulentia, Tre;?:3r, Pervigilium, Raucedo, Suffocatio, Vomica, Empyema, Syngultus, Vomitus, Dolor Stomachi, Tenefmus, all treated of ui^- dcr fenarate titles, are examples. A general SymptOmatologia may be a very ufeful work, with a view to a fyftem of Pathology; but, with aricv.- to Prattice without any Syftem, it muft have bad effetts, as leading only to a paliative prattice, and diverting from the proper efforts towards obtain- ing a radical cure. Mr. Lieutaud, indeed, has endeavored to exhibit the fymptoms above mentioned as fa many primary difeafes : but he has feldom fucceeded in this j and, in delivering' the prattice, he commonly finds 'it xvm PREFACE. neceffary to confider them as fymptoms, and that not without fome theoi y, implied or ekpreffed, with refpett to their proximate caufes. His title of Dolores may betaken as an example of this; and from which it may be readily perceived how far fuch treatifes can be really ufeful. w In eftablilhing a proper Pathology, there is nothing that has been of more fervice than the Diffettion of morbid bodies. Mr. Lieutaud has been much and moft eommendably employed in this way," and in this Synopfis he has endeavored to communicate his knowledge on the fubjett ; but in my humble opinion, he has feldom" done it in a manner that can be ufeful. In the fame way that he has delivered the fymptoms of difeafes without any inftructive arrangement, fo, on the fubjett of the appearances after death, he has mentioned every morbid appearance that had ever been obferved after the difeafe of which he is then treating: but' thefw appearances are ftrangely huddled together, without any notice taken- of»thofe which be- long to one fetj of fymptoms or to another; and, with regard to the whole, without any attempt to diftinguifh between the caufes of difeafes and the caufes of death; although the want of fuch diftinttion is the well known ground of falacy uponthis fubjett. I take for an example, the appearances mentioned as having been obferved after dropfy. Here morbid appearan- ces, found in, every part of,the body, .in every cavity of it, and in every vifcus contained rn thefe cavaties, are enumerated; but which of theft morbid ftates are more frequent or more rare, and which had been more particularly connected with the different caufes, or with the diffeuent ftate of fymptoms previoufly recited, we are not informed, nor has he enabled us to. difcover. In fhort, the diffettion of morbid bodies has been, and may be highly ufeful ; but, in order to be fo, it muft be under a different man- agement from what we find either in this Synopfis, or even in the Hijlorix Andtomiio medicd. I cannot difmift this fubjett without remarking, that the diffettion of mor- bid bodies is chiefly valuable Upon account of its leading us to difcover the proximate caufes of difeafes; and the great and valuable work of the illuftri- ous Morgagni, is properly intitled Defedibus et CAUSIS. It may well feem furprifing then, that Lieutaud fhotrld find the whole of proximate caufes atraculigine merfas ; and that he fhould never have thought of applying his diffettions towards the afcertaining at leaft fome of thefe. But let me now proceed to confider the important part of every prattie- al work, and of this Synopfis univerfle med'eina ; that is, the method of cur- ing difeafes. '' * Here, again, upon the fame plan as in giving the hiftories of difeafe, the method of cure is delivered by enumerating the whole of the remedies that have ever been employed in a difeafe under the title prefixed ; without af- figning the fpecies, or the circumftances to which the remedies, though of a very different and fometimes oppofite nature, are peculiarly adapted. Ott the fubjett of Afthma, he very juftly obferves, that phyficians have been to blame in confounding under this title almoft all the fpecies of Dvfpncea • and he himfelf very properly confiders Afthma as a difeafe diftintt'from all the other cafes of Dyfpnj^a. Still, howeVer,*1ie confiders afthma as of ma- ny different fpecies, arifing from many different caufes, tvhich, till we underftand better, we cannot attempt to remove. Notwuhftanding of all this, he proceeds to deliver a very general cure.' Parum abeft,hys he, quiii fpecijici titulo gaudeant peforalia, vitlneraria, et incidentia / But- from fuchr language I receive no clear idea ; nor can "I obtain any clear direttion from the enumeration of his medicir*-,. Becc-e juniperi, gummi tragacantra- vel ammoniacum,fapo, aqua picea, terebinthina, ^c.qux tamen baud indifcrim- utatimfunt ufurpanda,fidpro re nata, deleBu opus ejl. Very juftly indeed deUau opus eft; but here,-as in many other inftances, he gives us no fort ct aniftance. Frorn his endeavors, though notalways fuccefsful, toneglctt all fyftem feu practice w generally delivered Ufa very indecifive manner; or, what has PREFACE. XX ihe fame effeft, in a way fo conditional as will render it always difficult and often impoffible, for a young practitioner to follow him. Let us take,for example, his cure of Dropfy., "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 praclifed tbe fymptoms u are aggravated and rendered more obftinate. It is not to be concealed that fomeperfons have been cured by repeated blood letting?, or fpontane- ous haemorrhages ; but it is at the fame time known, that fuch a remedy inop- portunely employed, has in many in/lances haftened on the fatal event. In the fame manner he treats of vomiting, purging, fweatiBg, and the ufe of mineral waters ; but I muft confefs that he has no where removed any of my ddubts at difficulties, and indeed he has fometimes increafed them. He fays, that hepatics or aperients, fuch as the lingua eervina, her- ba capillares, &c. deferve commendation, but that, when the difeafe has a* rifen to a certain degree, they have been, for the moft part, found to beufe- lefs. He obferves, that the powder of toads given in wine, to the quantity of a fcruple or more, has fucceetted with feverals. Such are commonly the methods of cure delivered by Mr. Lieutaud, 4on~ giori et forte felicijfima praxiedoclus. It would be tedious to enter further into that detail, which a criticifm of this immethodical and uninftruftive work might' lead me into; but if the bounds proper for this preface did not prevent me, I would particularly ftiow that the work is far from being free from thofe reafonings which the author pretends to avoid, and would affett even to defpife. He ftill holds the doctrines of the concoction and critical evacuation of morbific matter; dottrines depending upon fubtile theories, and which, in my opinion, can- in no ways be afcertained as matters of fatt. Mr- Lieutaud Lkewife is ftill very much upon, the old plan of following nature* and therefore gives often what I confider as a feeble and inert prattice. The; humeSantia, diluentia, demulcentia, et temperantia, are with him very univer- fal remedies, and often thofe which alone are to be employed. : The mention of thefe medicines might lead me to take notice of Mr. Lieutaud's fecond volume, in which, ab infulfa remediorum faraglne alien- us, he promifes a great reformation upon the fubjett ; but this falls fo far fhort of the idea of Britifli phyficians, that I need not make any remarks up- on it. With refpett to his lift of fimples, or Emporetica, as he is pleafedto term them, an Englifh apothecary would fmile at it; and with refpett to his Officinalia, I believe they are to be found no where but in the Codex Medica- tnentarius of Paris ; and in his Magiftralia, his dofes are generally fuch as the moft timid practitioner of this country "would hardly defcend to, and fuch as none of our practitioners of experience would' depend upon. In fhort, the whole bf the work, both with refpett to the theories with which it abounds, and to the fatts which it gives will not, in my apprehenfjon, bear any ferious criticifm. But I muft conclude, and fhall only fay further that fuch as I have reprefented it, is'this work, executed by a man of the firft rank in the profeffion. ft is indeed for that reafon I have chofen \t*z the example of a work, upon the plan of giving fatts only, and of avoid- ing the ftudy or even the notice of the proximate caufes of difeafes ; and with what advantage fuch a plan is perfued, I fhall leave my readers to confider. In the following treatife I have followed a different courfe. I have endeav- ored to collect the fatts relative to the difeafes of the human body, as ful- ly as the nature ,of the work and the bounds neceffarily prefcribed to it would admit: But I have not been fatisfied with giving the fatts, without en- deavoring to apply them to the inveftigation of proximate caufes, and up- on thefe to eftablifh a more fcientific and decided method of cure. |n aim- ing at this, I flatter myfelf that I have avoided hypothefis, and what have been called theories. I have;, indeedjer.deavored to eftablifh many general dottriiicc, both physiological and pathological j but Itruft that thefe are op- t XX PREFACE. ly a generalifation of fatts, or conclufions from a cautious and full induc- tion : And if any one fhall refufe to admit, or directly fhali oppofe my gen- eral dottrines, he muft do it by fhowing that I have been deficient or mis- taken in affuming and applying fatt9. I have myfelf been jealous of my be- ing fometimes imperfeft in thefe refpetts; but I have generally endeavored to obviate the eonfeqnences of this, by proving, that the proximate caufes which I have affigned, are true in fa'tt, as well as deductions from any rea- foning that I may feem to have employed. Further, to obflate any danger- ous fallacy in pt opofing a method of cure, I have always been anxious ta fuggeft that which, to the beft of my judgment, appeared to be the method approved of by experience, as much as it was the confequence of fyftem. Upon this general plan I have endeavored to' form a fyftem of phyfic that ihould comprehend the whole of the facts relating to the fciencei and: that will, I hope, coliett and arrange them in better order than has been done before, as well as point out in particular thofe which are hill wanting to eftablilh general principles. This which I have attempted, may, like other fyftems, hereafter fuffer a change ; but I am confident that we are at prefent in a better train of inveftigation than phyficians were in before the time of Dr. Hoffman. The affettions of the motions and moving powers. of the.am'mal economy, muft certainly b« the leading inquiry in confidering the difeafes of the human body. The inquiry may be difficult; but it muft be attempted, or the fubjett muft be deferted altogether. I have, therefore, affumed the general principles of Hoffman, as laid down in the pailkge which I have quoted above ; and if I have rendered them more corrett and more extenfive in their application, and more particularly,if I have avoided in- troducing the many hypothetical dottrines of the Humoral Pathology whicfc disfigured both his and all.the other fyftems »vhich' have hitherto prevailed; I hope I fhall beexcufed for attempting a fyftem, which upon the whole may appear new. Edinburgh,") Nov. 1783. 5 ART I. OF PYREXIA, O R FEBRILE DISEASES. ■mut^i ■■■ ■ ■ ■*■■————w——» ii mi ■iili ,imuu» .iut.-j FIRST LINES ©F THE PRACTICE of PHYSIC. INTRODUCTION. t. IN teaching the Practice of Phy- sic, we endeavor to give instruction for difcerningi dif tinguijhing, preventing and curing difeafes, as they occur in particular perfons. ii. The art of discerning and distinguishing di£. eafes, may be beft attained by an accurate and complete obfervation of their phenomena, as thefe occur in coh- courfe and in fucceffion, and by conftantly endeavor- ing to diftinguifh the peculiar and infeparable concur- rence of fymptoms, to eftablifh a Methodical Nosolo- gy, or an arrangement of difeafes according to their ge- , nera and fpecies, founded upon obfervation alone, afe- ftracted from all reafoning. Such an arrangement I have attempted in another work, to which, in thecourfe of the prefent, I fhall frequently refer. in. The Prevention of difeafes depends upon the knowledge of their remote caufes, which is partly deliv- ered in the general Pathology, and partly to be deliver- ed in this treatife. iv. The Cure of difeafes is chiefly, and almoft una- voidably founded in the knowledge of their proximate caufes. This requires an acquaintance with the inftitu- tions of Medicine j that is, the knowledge of the ftrec- a* PRACTICE OF PHYSIC. ture, action, and functions of the human body; of the federal changes which it may undergo ; and of the fev- eral powers by which it can be changed. Our knowl- edge of thefe particulars, however, is ftill incomplete, is in many refpects doubtful, and has been often involved in miftake and error. TJie doctrine, therefore, of prox- imate catifes, founded upon that knowledge, muft be frequently precarious and uncertain. It is however pof- fible for a judicious phyfician to avoid what is vulgarly called theory, that is, all reafoning founded upon hy- pothefis, and thereby many of the errors which have formerly taken place in the Inftitutions of Medicine. It is poffible alfo for a perfon who has an extenfive knowledge of the facts relative to the animal economy in healtft and in ficknefs, by a cautious and complete in- duction, to eftablifh many general principles which may guide his reafoning with fafety; and while at the fame time a phyfician admits, as a foundation of practice, thofe reafonings only which are fimple, obvious, and certain, and for the moft part admits as proximate cauf- „ es thofe alone that are eftablifhed as matters of fa<5t rather than as deductions of reafoning, he may with great advantage eftablifh a fyftem of practice chiefly founded on the doctrine of proximate caufes. But when this cannot be done with fufticient certainty., the jiidicious and prudent phyfician will have recourfe to Experience alone; always, however, aware of the hitherto incomplete and fallacious ftate of Empiricifm. v. With a ftricT: attention to thefe confiderations in. the whole of the following treatife, I proceed to treat of particular difeafes in the order of my Methodical Nofo* logy. PRACTICE OF PHYSIC. W PART I. OF PYREXIAE, OR FEBRILE DISEASES. vi. 1 yrexI-s;, or febrile difeafes, are diftinguifhed by the following appearances : After be- ginning with fome degree of cold fhivering, they fhow fome increafe of heat, and an increafed frequency of pulfe, with the interruption and diforder of feveral functions, particularly fome diminution of ftrength in the animal functions *. vn. Of thefe Pyrexiae I have formed a clafs, and have fubdividedit into the five orders of Fevers, Inflamma- tions, Eruptions, Hemorrhagies, and Fluxes. See Synopfis Nofologias Methodioe, Edit. 2'. 178Q. * This, if confidered as a- concife defcription of the moft ufual fymptoms which eccur in fever, is perhaps the moft judicious that could be made. As a definition, however, it is fomewhat defective; which is entirely to be afcribed to the difficulty of malting a felecfion, where there is net one fymp-* torn which deferves to be ranked as Pathognomic. As we cannot, therefore, expedt an unexeeptionaDle definition of a difeafe which affumes fo many various appearances, and to which ho peculiar fymptom exclufively belongs, it will be lufficient if thofe morbid affections are pointed out, which are generally prefent, and whofe concurrence or fucceffion ferve, in xnoft inftan- ees, to denote the exiftence of fever. « * • BOOK I. OF FEVE li S. CHAP. I. OF THE PHENOMENA OF FEYERS. yiij. 1 HOSE difeafes are more ftrictly called Fevers, which have the general fymptoms of Py- rexia, without having alongft with them any topical affection that is efTential and primary, fuch as the other orders of the Pyrexiae always have. ix. Fevers, as differing in the number and variety of their fymptoms, have been very properly confidered as of diftinct genera and fpecies*. But we fuppofe that "The following are the principal diftinclions of fevers, as eftablifhed by Dr. Cullen in his Synopfis of Nofology : Sect. I. Intermittent Fevers arifefrom marfh miafrna, cosfift of repeated paroxyfms, alternated with an apyrexia, or at leaft with a diftin another, is called, an Intermission, and the'length of P-RACTICE OF PHYSIC. 3» time from the beginning of one paroxyfm to the begin- ning of another next fiicceeding, is called ah Inter- val. xxv. When the difeafe confifts of a number of parox- yfms, it is generally to be obferved, that the intervals between them are nearly equal ; but thefe intervals are of different lengths in different cafes. The moft ufual interval is that of forty eight hours, which is named the Tertian period. The next moft common is that of feventy two hours, and is named the Quartan period. Some other intervals alfo are obferved, particularly one of twenty 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 ex- tremely rare, and probably are only irregularities of the tertian or quartan periods. xxvi. The paroxyfms of pure intermittent fevers are always finifhed in lefs than twenty four hours ; and though it happens that there are fevers which confift of repeated paroxyfms, without any entire intermiflion be- tween them; yet in fuch cafes it is obferved, that though the hot and fweating ftages of the paroxyfm do not en- tirely ceafe before the twenty four hours from their beginning have expired, they fufifer, however, before that time, a confiderable abatement or Remission'of their violence ; and, at the return of the quotidian pe- riod, a paroxyfm is in fome fhape renewed, which runs the fam'c courfe as before. This conftitutes what is call-,* ed a Remittent Fever, xxvil When in thefe remittents the remiflion is con- fiderable, and the return of a new paroxyfm is diftinctly marked by the fymptoms of a cold ftage at the begin- ning of it, fuch fevers retain ftrictly the appellation of Remittents. But when it happens, as it does in cer- tain cafes, that the remiflion is not confiderable, is per- haps without fweat, and that the returning paroxyfm is not marked by the moft ufual fymptoms of a cold ftage, but chiefly by the aggravation or Exacerbation of a hot ftage, the difeafe is called a Continued Fever. 4 V2 PRACTICE OF PHYSIC. xxvm. In fome cafes of continued fever, the remif- £ons and exacerbations are fo inconfiderable as not to W eafily obferved Of diftinguifhed ; and this has led phyficians to imagine that there is a fpecies of fever fub- fifting for feveral days together, and feemingly confut- ing of one paroxyfm only. This they Jiave called a Continent Fever ; but, in a long courfe of practice, I have not had an opportunity of obferving fuch a fe- ver. xxix. It is however to be obferved here, that the fev- ers of a continued form are to be diftinguifhed from one another ; and that, while fome of a very continued form do ftill belong the fection of intermittents, there are others which, though ftill con lifting of feparate and repeated paroxyfms, yet, as different by their caufes and circumftances from intermittents, are to be diftin- guifhed from the whole of thefe, and are more ftrictly to be called and confidered as Continued. Such are moft of thofe which have been commonly fuppofed to be Continent ; and thofe which by moft writers have been fimply named Continued ; and which,term I have employed as the title of a fection, to be diftinguifh- ed from that of Intermittent. "* I fhall here add the marks by which, in practice, thefe efferent 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 dif- tinguifhed by their having paffed from an intermittent or remittent form to that of a continued ; by their fhow- ing fome tendency to become intermittent, or at leaft remittent; by their being known to have been occaljoned by marfh miafmata ; and, for the moft part, by their having but one paroxyfm, or one exacerbation and re- miflion, in the courfe of twenty four hours. On the other hand, Continued Fevers, to be more ftrictly fo called, may be diftinguifhed by their fhowino- 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 occafioRcd PRACTICE OF PHYSIC. jj by human contagion, at leaft by other caufes than the marfh miafmata ; and by their having pretty conftant- ly an exacerbation and remiflion twice in the courfe of every twenty four hours. In t>oth cafes, the knowledge of the nature of the epideinic for the time prevailing, may have a great fhare in determining the nature of the particular fever. xxx. With refpect 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 ; out, upon the whole, the fhorteft paroxyfm : That ths tertian having a fhorter interval than the quartan, ha^, at the fame time afhorter and lefs violent cold ftage, but a longer parox- yfm : And, lattly, that the quotidian, with the fhorteft interval, has the leaft of a cold ftage, but the longeft par- oxyfm. xxxi. 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 quotidians, quotidians into remittents, and thefe laft become often of the moft Continued kind. In all thefe cafes, the fever has its paroxyfms protracted long- er thanufuaL before it chanires into a tvpe of more fre- quent repetition. ^ xxxn. From all this a prefumption arifes, that evf ry fever confifts of repeated paroxyfms, cheering from oth- ers chiefly in the circumftances and repetition of tlie paroxyfms, and therefore that it was allowable for us to take the paroxyfm of a pure intermittent as an example and model of the whole. J4 PRACTICE OF PHYSIC CHAP. II. OF THE PROXIMATE CAUSE OF FEVIR. xxxm.T'HE proximate caufe of fever feems hitherto to have eluded the refearch of phyficians, and I fhall not pretend to afcertain it in a manner that may remove every difficulty, but I fhall endeavor to make an approach towards it, and fuch as Ihope may be of ufe in conducting the practice in this difeafe ; while at the fame time I hope to avoid feveral errors which have formerly prevailed on this fubject. xxxiv. As the hot ftage of fever is fo conftantly pre- ceded by 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 paroxyfm. See Boerh. Aph. 756. xxxv. To difcover the caufe of the cold ftage of fe- vers, we may obferve, that it is always preceded by ftrong marks of a general debility prevailing in the fyf- tem. The iinallnefs and weaknefs of the pulfe, the pale- nefs and eoidnefs of the extreme parts, with the fhrink- ing of the whole body, fufficiently fhow that the action orlhe heart and larger arteries is, for. the.time, extreme- ly weakened. Together with this, the langor, inac- tivity, and debility of the animal motions, the imperfect |Tenfations, the feeling of cold while the body is truly warm, and fome other fymptoms, all fhow that the ener- gy of the brain is, oa this occafion, greatly weakened ; and I prefume that as the weaknefs of the action of the heart can hardly be imputed to any other caufe, this weak- nefs alfo is a proof of the diminifhed energy of the brain. xxxvi. I fhall hereafter endeavor to fhow, that the mpft noted of the remote caufes of fever, as contagion, miafmata, 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 PRACTICE OF PHYSIC. ss commonly renewed by the application of debilitating powers. And further, the debility which fubfifts in the animal motions andother functions through the whole of fever, renders it pretty certain that fedative or debil- itating powers have been applied to the body. xxxvu. It is therefore evident, that there are three ftates which always take place in fever, a ftate ef debility, a ftate of cold, and a ftate of heat ; and as 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 refpect to one another. This we hold as a matter of fact, even although we fhould not be able to explain in what man- ner, or by what mechanical means thefe ftates feveraHy produce each other. ' xxxviii. How the ftate of debility produces fome of the fymptoms of the cold ftage may perhaps be readily explained, but how it produces all of them, I cannot ex- plain otherwife than by referring the matter to a general law of the animal economy, whereby it happens, that powers which have a tendency to hurt and deftroy the fyftem, often excite fuch motions as are fuited to obvi- ate " the effects of the noxious power. This is the vis medicatrix nature, fo famous in .the fchools of phyfic, and it feems probable that many of the motions excited in fever are the effects of this power. xxxix. That the increafed action of the heart and arteries which takes place in the hot ftage of fevers, is to be confidered as an effort of the vis medicalrix naturd'^ Jias been long a common opinion among phyficians, and 1 am difpofed to affert that fome part of the cold ftsge may be imputed to the fame power. I judge fo, be- caufethe cold ftage appearsto.be univerfally a means of producing the hot j becaufe cold, externally applied, has very often fimilar effects ; and more certainly ftill, be- caufe it feerns to be in proportion to the degree of tremor in the cold ftage, that the hot ftage proceeds mcre t r lefs quickly to a termination of the paroxyfm, and to \i more complete folution and longer intermiflion- S:.e XXX. 36 PRACTICE OF PHYSIC. xl. It is to be particularly obfervfd, that, during the cold ftage of fever, there feems to be a fpafm induced every where on the extremities of the arteries, and more efpeciaily of thofe upon the furface of the body. This appears from the fuppreflion of all excretions and from the fhrirkirg of the external parts ; and al- though this may perhaps be imputed, in part, to the weaker action of the heart in propelling the blood into the extreme veffels; yet as thefe fymptoms often continue after the action of the heart is rcflored, there is reafon to believe, that a fpaimodic conftriction has taken place ; that it fubfifts for feme time, and fup- ports the hot ftage; for this ftage ceafes with the flowJ ing of the fweat, and the return of other excretions, which are marks, of the relaxation of veffels formerly conftricted, Hoffman, Med. Rat. Syftem. Tom. IV. P. I. ieCi. I. cap. I. art. 4. xli. The idea of fever, then, may be, that a fpafm of the extreme veffels, however induced, proves an irrita- tion to the heart and arteries j and. that this continues till the fpafm is relaxed or overcome. There are many appearances which fupport this opinion ; and there is little doubt that a fpafm does take place, which proves an irritation to the heart, and therefore may be confid- ered as a principal part in the proximate caufe of fever. It will ftill, however, remain a queftion, w}iat is the caufe of this fpafm ; whether it be directly produced by the remote caufes of fever, or if it be only a part of the operation of the vis medicatrix natures. xln. I am difpofed to be of the latter opinion ; be- caufe, in the /fry? place, while it remains ftill certain that a debility lays the foundation of fever, it is not obvious in what manner the debility produces the fpafm, and, what feems to be its effect, the increafed action of the heart and arteries ; znd,fecond/y, becaufe in almoft all the cafes in which an effort is made by the vis medicatrix natura, a cold fit, and a fpafm of the extreme veffels arc almoft always the beginnings of fuch an effort. ' See Gaub. Pathol. Medicin. art. Y50.' xliii. It is therefore prefumed, that fuch a cold fit and fpafm at the beginning of fever, is a part of the op- PRACTICE OF PHYSIC. 37 cration of the vis medicatrix ; but, it 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 fpafm requires the reftoring of the tone and action of thefe. xliv. This it may be difficult to explain ; but I think it may be afcertained 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; and vomiting (xlv.) From many circumftances it is fufficiently 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 connection of the ner- vous fyftem ; and that the confent which appears is be- tween the fentient and moving fibres of the one part with thofe of the other, is fuch, that a certain condition prevailing in the one part occafions a fimilar condition in the other. In the cafe of the ftomach and furface of the body, the confent particularly appears by the connection which is obferved between the ftate of the perfpiration and the ftate of the appetite in healthy perfons ; and if it may be prefumed that the appetite depends upon the ftate of tone in the mufcular fibres of the itomach, it will follow, that the connection of appetite and perfpir- ation depends upon a confent between the mufcular fi- bres of the ftomach and the mufcular fibres of the ex- treme veffels, or of the organ of perfpiration, on the furface of the body. It is further in proof of the connection between the appetite and perfpiration, and, at the fame time, of the circumftances on which it depends, that cold applied to the furface of the body, when it does not flop perfpira- tion, but proves a ftimulus to it, is always a powerful means of exciting appetite. Having thus eftablifhed the connection or confent mentioned, we argue, that as the fymptoms of anorexia, naufea, and vomiting, in many cafes, manifeftly depend upon a ftate of debility or lofs of tone in the mufcular ,• PRACTICE OF PHYSIC. fibres of the ftomach yfa it may be prefumed, that thefe fymptoms, in the beginning of fever, depend upon an atonv communicated to the mufcular fibres of the ftom- ach from the mufcular fibres of the extreme veffels on the furface of the body. That the debility of the ftomach, which produces vomiting 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. Sydenham. In the attack of the plague, a vomiting happens, which prevents any medicine from remaining on the ftomach j and Dr. Sydenham tells jus, that in fuch cafes he could not overcome this vomiting but by external means applied to produce a fweat ; that is, to excite the action of tjie veffels on the furface of the body. The fame connection between the ftate of the ftom- • ach, and that of the extreme veffels on the furface of the body, appears from this alfo, that the vomiting, which fo frequently happens in the cold ftage of fe- vers, commonly ceafes upon the coming on of the hot, and very certainly upon any fweats coming out, (xiv.) 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 affording proof, both of this and of the general connection between the ftom- ach and furface of the body, that emetics thrown intOf 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 connection, that cold water taken into the ftomach produces an increafe of heat on the furface of the body, and is very often a convenient and 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 a- norexia, naufea, and vomiting, depend upon, and are a proof of an atony fubfifting in the extreme veffels on the furface of the body j and that this atony therefore, now PRACTICE OF PHYSIC. 19 afcertained as a matter of fact, may be confidered as a principal circumftance in the proximate caufe of fever. xlv. This atony we fuppofe to depend upon a dimin- ution of the energy of the brain ; and that this dimin- ution takes place in fevers, we conclude, not only from the debility prevailing in fo many of the functions of the body, mentioned above (xxxv.), but particularly from fymptoms which are peculiar to the brain itfelf. Deli- rium is a frequent fymptom of fever : and as from the phyfiology and pathology we learn that this fymptom commonly depends upom fome inequality in the excite- ment of the brain or intellectual organ ; we hence con- clude, that, in fever, it denotes fome diminution in the energy of the braim Delirium, indeed, feems often to depend upon an increafed impetus of the blood in the veffels of the brain, and therefore attends phrenitis. It frequently appears alfo in the hot ftage of fevers, ac- companied with a headach and throbbing of the tem- ples. But as the impetus of the blood in the veffels of the head is often confiderably increafed by exercife, ex- ternal heat, pafilons,andothercaufes, without occasion- ing any delirium ; fo, fuppofing that the fame impe- tus, in the cafe of fever, produces 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 in- tellectual functions. Upon the fame principles alfo, I fuppofe there is another fpecies of delirium, depending more entirely on the diminifhed energy of the brain, * and which may therefore arife when there is no unu- fual increafe of the impetus of the blood in the veffels of the brain. Such feems to be the delirium occurring at the beginning of the cold ftage of fevers, or in the hot ftage of fuch fevers as fhow ftrong marks of debil- ity in the whole fyftem. xlvi. Upon the whole, our doctrine of fever is ex- plicitly this; The remote caufes (xxxvi.) are certain fedative powers applied to the nervous fyftem, which diminiffring the energy of the brain, thereby produce a debility in the whole of the functions (xxxv.) and 40 PRACTICE OF PH'xSIC. particularly in the action of the extreme veffels (xliii. xliv.) Such however is, at the fame time, the nature of the animal economy (xXxviii) that this debility proves an indirect ftimulus to the Sanguiferous fyftem ; whence, by the intervention of the cold ftage, and fpafm con- nected with it (xxxix. xl.) the adion of the heart and larger arteries is increafed (xl.) and continues fo (xli.) till it has had the efted of reftoring the energy of the brain, of extending this energy to the extreme veffels, of reftoring therefore their action, and thereby efpeciah ly overcoming the fpafm affecting them ; upon the re- moving of which, the excretion of fweat, and other marks of the relaxation of excretories take place.* * The inveftigation of the proximate caufe of fever has ever afforded an ample fcope for the difplay of the ingenuity of medical men. Innumera- ble theories have been advanced, and-received as the favorite docfrines of the day, doomed in their turn to give way to others a^ fancifulas them- felves ; and of the many volumes which have been written on this fubject, fcarcely any ferve any other purpofe than that of records of the unprofita- ble wafte of talent, asd of the vanity of hypothetical reafoning, deduced from precoaceived opinion, or founded on partial induction. This theory of fever, for which Dr. Cullen had an extreme partiality, and which he has labored with the utmoft ingenuity to fupport, notwith- flanding its general plaufibility, is liable to fome infurinountable objections. That the cold fit is the caufe of the fubfequerit hot one, may be contefted on the beft grounds ; for they are not in proportion to each other. In quartans, the cold fit is violent and protradted, while the hot is compara- tively fhort. In quotidians the reverfe of this takes place. Indeed there are cafes of fever on record where the cold ftage feemed to be altogether wnntjng. See Burferius, Vol. I. The affumption of the exciting caufe of fever being a fedative power applied to the body, appears equally gratui- tous. It is as yet fomewhat dubious, whether there is any fuch power in nature ; certain it is, that moft of thofe fubftances, which were formerly conceived to poffefs a fedative quality, produce their effecls in confequence of the exhauftion occafioned by the previous ftimulus. And this may even apply to thofe whole action is fo intenfe as immediately to extinguifh life, without any apparent increafed action, f That debility is in general the firft link of febrile action is undoubted, but the connection which it has with the fubfequent phenomena, is yet unexplained. Debility, in all its degrees, is every day induced by the moft oppofite caufes, without any fever fuper- vening. Dr. Cullen finds confiderable difficulty in accommodating the in- creafed activity of the fanguiferous fyftem to his hypothefis, and to extri- cate himfelf has recourfe to the vis medicatrix natura, to whofe fuperinten- ding care, and falutary efforts, he afcribes the fubfequent reaction, dignus vindice nodus. But this power, the admiffion of which (as the Doctor himfelf confeffes) difturbs and perplexes all our reafoning on the animal e- conomy, has never, in this fenfe of the word, been proved to exift • and when introduced, only explains one difficulty by fubftituting a greater in its place. That the animal body pofTefTes, to a certain extent, a power of pre- fcrving itfelf againft noxious caufes applied to it, muft be admitted • Thus, accrid fubftances, taken into the trachea, or prim* vise, ftimulate thofe PRACTICE OF PHYSIC. 4* xlvii. This doctrine will, as I fuppofe, ferve to ex- plain not only the nature of fever in general, but alfo the various cafes of it which occur. Before proceed- ing, however, to this, it may be proper to point out the opinions, and, as 1 apprehend, the miftakes which have formerly prevailed on this fubject. xlvin. It has been fuppofed, that a lentor or vifcidi- ty prevailing in the mats of blood, and ftagnating in the extreme veffels, is the caufe of the cold ftage of fe vers and its confequences. But there is no evidence of any fuch vifcidity previoufly fubfifting in the fluids; and as it is very improbable that fuch a ftate of them can be very quickly produced, fo the fuddennefs with which paroxyfms come on, renders it more likely that the phenomena depend upon fome caufe acting upon the nervous fyftem, or the primary moving powers of the animal economy. See Van Swieten apud Boerh. Aph. 755. xlix. Another opinion, which has been almoft uni- verfally received, is, that a noxious matter introduced into or generated in the body, is the proximate caufe of fever ; and that the increafed action of the heart and arteries, which forms fo great a part of the difeafe, is an effort of the vis medicatrix natura to expel this morbific matter, and particularly to change or concoct it, foas to parts to an increafed action, by which they are expelled : An irritating fub- ftance applied to the eye, produces an increafed fecretion of tears, by which it may be wafhed away; and thefe happen in conformity to acknowledged and eftablifhed laws of the economy. But to fuppofe that fubftances, whofe natural tendency is to diminifh action, fometimes indirectly increafe the ac- tivity of the fyftem, merely becaufe fuch activity may prove falutary, is to produce an effect without a caufe; and by introducing the old exploded doc» trine of the anima medica, tends to fubvert all our reafoning on thefe fubjedts. The exiftence of a fpafmodicconftriction of the extreme veffels in fever, has likewife been called in queftion. In the commencement of fever, the general palenefs of the furface of the body may be eafily afcribed to the en- feebled acf ion of the heart and arteries, and their confequent inability to propel the blood into the extreme veffels. In the hot ftage, however, where the action of the fanguiferous fyftem is morbidly increafed, the dry- nefs of the fkin, and apparent fuppreffion of perfpiration, are not fp eafily explained. They nsay however be in part, if not entirely, referred to the increafed evaporation from the furface of the bodv, by which the perfpira- ble matter is carried off as foon as it is excreted. The urgent thirft, likewife, would lead us to fufpeft that there is an increafed diffipation of the fluids in fever. D ^ PRACTICE OF PHYSIC, render it either altogether innocent, or, at leaft% fit for Seeing more eafily thrown out of the body. This doc- trine^ nowevcr. although of as great antiquity as any of the record? of phyfic now remaining, and although it ha* been received by almoft every fchool -of medi- cine, yet appears to me to reft upon a very uncertain iimwlzncm. There are fevers produced by cold, fear, and other chafes -accompanied with all the effential cir- cunaS, races of fever, and terminating by fweat; but at fLe isxac lime without any evidence or fufpicion of mor- bific m2# iT. There fiaveXKcrD fevers iuddenly cured by a hemorrha- gy* & tTJC'-Iarate as could not cany out any confiderable tpostic nni axnatter chflufedover the whole niafs of blood; 5i«r caa we conceive how the morbific matter could be cQlIeficii os. determined to pafs off by fuch an outlet as in thsS. cafe is opened. Even £ippofirig a morbific matter were prefent, there a> ma exphiLition given in what manner the concoction of it is performed ; nor is it fhown that any fuch change does in fact take place. In certain cafes, it is indeed evident, that a noxious matter is introducedr-into the foody, and proves die caufe of fever : but, even in thefe cifes, it appeirs that the noxious matter is thrown out again, without having fullered any change; that the fev«. r often terminates before the matter is expelled ; and that apo-i mhTiy occafions, without waiting the fuppofed dsae : j concoction, the fever can be cured, and that by remedies which do not feem to operate upon the fluids, or to produce any evacuation. i~ While wc tku< reafon againft the notion of fever being an effort of nature, for concocting and expelling a morbific matter ; I by no means intend to deny that the caufe of fever frequently operates upon the fluids, and particularly produces a putrefcent ftate of them. I acknowledge that this is frequently the cafe : but, at sh . fame time, I maintain, that fuch a change of the £Uik!s is not commonly the caufe of fever; that very •ftcn it is 371 effect only j and that there is no reafon to PRACTICE OF PHYSIC. 43 believe the termination of the fever to depend upon the expulfion of the putrid matter. li. Another opinion which has prevailed, remains ftiil to be mentioned. In intermittent fevers, a great quanti- ty 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, how- ever, docs not appear to be well founded. Vomiting, by whatever means excited, if often repeated, with vio- lent ftraining, feems to be powerful in emulging the biliary duc~t3, and commonly throws out a great, deal of bile. This will happen efpecially in the cafe of intermit- tent fevers: For as, in the ftate of debility and cold ftage of thefe fevers, the blood is not propelled jn the ufual quantity into the extreme veffels, 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 copi- ous fecretion of bile. Thefe confiderations will, in fome meafure, account for the appearance of an unufual quantity of bile in in- termittent fevers ; but the circumftance which chiefly occafions the appearance of bile in thefe cafes, is the in- fluence of warm climates and feafons. Thefe feldom fail to produce a ftate of the human body,, in w hich the bile is difpofed to pafs off, by its fecretories, in greater quantity than ufual, and perhaps 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 fufficiently probable, that inter- mittent 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, com- monly operate moft powerfully in the fame feafon that produces the change and redundance of the bile ; and, therefore, confidering the vomiting and other circum- ftances of the intermittent fevei* which here concur, it 2 44 PRACTICE OF FHYSIS. is not furpriling that autumnal intermittents aiefo often attended with elfufions of 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 accidentally concurring with them, from the ftate of the feafon in which they arife. What attention this requires in the conduct of the' dif- eafe, I thall confider hereafter. mi. From this view of the principal hypothefes which have been hitherto maintained with refpect to the prox- imate 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 believe that they chiefly depend up- on changes in the ftate of the moving powers of the an- imal fyftem. Though we fhould 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 inveftiga- tlon. I have attempted to purfue it, and fhall now en- deavor to apply the doctrine already delivered towards explaining the diverfity of fevers. CHAP. III. OF THE DIFFERENCE OF FEVERS, AND ITS CAUSES. mi. J O afcertain the difference of fevers, I think it neceffary to obferve, in the firft place, that every fever of more than one day's duration con- fifts of repeated,and in fome meafure feparate paroxyfms; ancithat the difference of fevers taken notice of above* (from xxv. to xxx.), appears to confift in the different Hate of poroxyfms, and in the different circumftances of their repetition. liv. That fevers generally confift of diflinft, and in iome meafure feparately repeated paroxyfms, I have al- ledged above to be a matter of fact ; but I fhall here en- deavor to confirm it, by affigning the caufe. PRACTICE OF PHYSIC. 451 lv. In every fever, in which we can dlftinctly obferve any number of feparate paroxyfms, we conftantly find that each paroxyfm is finifhed in lefs than twenty four hours ; but as 1 cannot perceive any thing in the caufe of fevers determining to this, I muft prefume it to de- pend on fome general law of the animal economy. Such a law feems to be that which fubjects the economy, in many refpects, to a diurnal revolution. Whether this depends upon the original conformation of the body, or upon certain powers conftantly applied to it, and in- ducing a habit, I cannot pofirively determine ; but the returns of fleep and watching, of appetites, and excre- tions, and the changes which regularly occur in the ftate of the pulfe, fhow fufEciently, that in the human body a diurnal revolution takes place. lvi. It is this diurnal revolution which, I fuppofe, determines the duration of the paroxyfms of fevers; and the conftant and univerfal limitation of thefe par- oxyfms (as obferved in lv.), while no other caufe of k can be afligned, renders it fufEciently probable that their duration depends upon, and is determined by the revolution mentioned. And that thefe paroxyfms are connected with that diurnal revolution, appears further from this, that though the intervals of paroxyfms are different in different cafes, yet the times of the acceffion of paroxyfms are generally fixed to one time of the day; fo that Quotidians come on in the morning, Ter- tians at noon, and Qmartansin the afternoon. lvii. It remains to be remarked, that as Quartans and Tertians are apt to become Quotidians, theie to pais into the ftate of Remittents, and thefe laft to become Continued ; and that, even in the Continued form, dai- ly exacerbations and remiflions are generally to be ob- ferved ; fo all this fhows fo much the power of diurnal revolution, that when, in certain cafes, the daily exa- cerbations and remifnons are with difficulty diftinguifh- ed, we may ftill prefume, that the general tendency of the economy prevails, that the difeafe ftill confifts of re- peated paroxyfms, and, upon the whole, that there is no fuch difeafe as that which the fchools have called a 3 46 PRACTICE OF PHYSIC. Continent Fever. I expect that this doctrine vyill be confirmed by what I fhall fay hereafter concerning the periodical movements obferved in continued fevers. i.vin. 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 par- oxyfms depends upon the circumftances of the parox- yfms which have already taken place. From what was obferved in xxx. and xxxi. it appears, that the longer paroxyfms are protracted, 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. lix. Agreeably to what is laid down in xlvl and to the opinion of moft part of phyficians, I fuppofe that in every fever there is a power applied to the body, which has a tendency to hurt and deftroy it, and produces in it certain motions 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 economy, there are certain motions excit- ed, which have a tendency to obviate the effedts of the noxious power, or to correct and remove them. Both thefe kinds of motion* arc confidered as conftituting.the difeafe. But the former is perhaps ftrictly the morbid ftate, while the latter is to be confidered as the operation of the vis medicatrix natura of falutary tendency, and which I fhall hereafter call the reaction of the fyftem. lx. Upon the fuppofition that thefe two ftates take place in every paroxyfm of fever, it will appear to be chiefly in the time of the hot ftage that the reaction op- erates in removing the morbid ftate ; and therefore, as this operation fucceeds more or lefs quickly, the hot ftage of paroxyfms will be fhorter or longer. But as the length of parQxyfm depends chiefly upon the dura- tion of the hot ftage, fo the longer duration of this and of paroxyfms, muft be owing cither to the obftinacy of refifijneein the morbid ftate, or to the weaknefs of the falutary reaction j and it is probable that fometimes the PRACTICE OFPIirSIC V ♦■ne and fometimes the other of thefe etfcumiunces takes place. lxi. It feems to be only by the ftate of the fpafiir, that we can judge of the refinance of the morbid ftate of fe- ver : and with refpect to this fpafm I obferve, that ei- ther die caufe exciting it may be different in eKiierenfc cafes j or, though the caufe ihould be the fame in differ- ent perfons, the different degree of irritability in each may give occafion to a. greater or lefler degrse of icviir. ; and thereafter, the reaction in fever bcir,r;< given, the continuance of the hot ftage, and of the whole par- oxyfm, may be longer or rnmter, according to tlte de- gree of fpafm that has been forrnedl . lxiu One caufe of the obftinacy of fpafm in feras may be clearly perceived. In inflammatory difeaie^there is a diathefis phlogiftica prevailing in the body; and tti* diathefis we fuppofe to confift m an increafed Kcnc. of the whole arterial fyftem. When, therefore, this, diathe- fis accompanies fevcry as it fometimes does,, it may be fuppofed to give occafion to the febrile fpafois bem& formed more ftrongly, and thereby to produce more protracted paroxyfms.' Accordingly we find that all in- flammatory fevers are of the continued kind ;. and thai all the caufes of the diathefis. phlogiftica have a tendency to change intermittent into continued fevers. Conti/T- ued fevers, then, being often attended with vhc JLuhefi> phlogiftica, we conclude, that in many cafes this is the caufe of their continued form. lxiii. In many fevers, however, there is no evidence of any diathefis phlogiftica being prefent, nor of any other caufe of more 'confiderable fpafm ; and, in fuch cafes, therefore, we muft impute the protraction,^pas:- oxyfms, and the continued form of the fever, to- the weaknefs of reaction. That this caufe takes place, we conclude from hence, that, in many cafes of fever, where- in the feparate paroxyfm* are the longeft protracted, and the moft difficulty obferved, we find the moft confider- able fymptoms of a general debility ; and therefore v/e infer, that in fuch cafes, the protracted paroxyfms, and continued form, depend upon a weaker reaction ; aw- 4 4$ PRACTICE OF PHYSIC. ing either to the caufes of debility applied, having been of a more powerful kind, or from circumftances of the patient's conftitution favouring their operation. lxiv. Upon thefe principles we make a ftep towards explaining in general, with fome probability, the dif- ference of fevers; but muft own that there is much doubt and difficulty in applying the doctrine to particu- lar cafes. It applies tolerably well to explain the different ftates of intermittents, as they are more purely fuch, or as they approach more and more to the continued form: But feveral difficulties ftill remain with refpect to many circumftances of intermittents ; and more ftill with re- fpect to the difference of thofe continued fevers, which we have diftinguifhed in our Nofology as different from intermittents, and as more efpecially entitled to the ap- pellation of Continued, (fee Syn. Nof. Meth. P. V. Ch. I. Se£t. II.) and explained more fully above. lxv. From the view given(Lxin. and lxiv.) of the caufes of the protraction of paroxyfms and therefore of the form of continued fevers, firstly fo called, it feems probable, that the remote caufes of thefe operate by oc- cafioning either a phlogiftic diathefis, or a weaker reac- tion ; for we can obferve, that the moft obvious differ- ence of continued fevers depends upon the prevalence of one or other of thefe ftates. lxvi. Continued fevers have been accounted of great dir verfity; but phyficians have not been fuccefsful in mark- ing thefe differences, or in reducing them to any general heads. The diftinctions made by the ancients are not well underftood ; and, fo far as either they or the mod- ern nofologifts have diftinguifhed continued fevers by a difference of duration, their diftinctions 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 (lxiii. lxiv.) to dif- tinguifh continued fevers according as they fhow either in inflammatory irritation, or a weaker reaction. lxvu. This diftinction is the fame with that of fevers into the Inflammatory and Nervous ; the diftinction at prefent moft generally received in Britain. To the Pit ACTIO- OF PHYSIC. 49 firft, as a genus, I have given the name of Synocha ; to the fecond, that of Typhus ; and little ftudious v> hcther thefe names be authorifed by the ancient ufe of the fame terms, I depend upon their being underitood by the characters annexed to them in our Nofology, which I apprehend to be founded on obfervation. lxviii. By thefe characters 1 think continued fever.*, may in practice be diftinguiihed ; and, if that be the cafe, the principles above laid down will be confirmed. lxix. Befide thefe differences of continued fever, now mentioned, I am not certain of having obferved any other that can be confidered as f und.un'jntal. But the moft common form of continued fevers, in this clim- ate, feems to be a combination of thefe two genera ; and I have therefore given fuch a genus a place in our No- fology, under the title of Synochus. At the fame, time, I think that the limits between the Synochus and Ty- phus will be with difficulty affigned ; and I am difpofed to believe, that the Synochus arifes from the lame caufes as ths Typhus, and is therefore only a variety of it. lxx. The Typhus feems to be a genus comprehending feveral fpecies. Thefe, however, ar^ 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 imply any fpecific difference, but feem to be merely va- rieties, arifing from a different degree of power in the caufe, from different circumftances of the climate or fea- fon in which they happen, or from different circum- ftances in the conftitution of the perfons affected. lxxi. Some of the effects arifing from iheie circum- fiances, require to be particularly explained. One is, an unufal quantity •. f bile appearing in the courfe of the difeafe. This abundance of bile may poffi- bly attend fome continued fevers, ftrictly fo called ; but, tor the reafons above explained, it more commonly attends intermittents, and,we believe, it might have been enumerated (xxix.) among the marks diftinguifhing the latter kind of fevers from the former. But, though an unufual quantity of bile fhould appear with continued fevers, it is confidered in this cafe, as in that ftf intermit- ^i MIDICAL w,,,^ I 3J- is, as we fuppofe it to be, that of !;•> degrees of Farenhcii'b thermometer *, every degree of temper;.lure lefs than that, may be confidered as cold with refpect to the human body ; and, in proportion to its degree, will have a tendency to diminifh the temperature of the body. V»ut as the living human body has in itfelf a power of generating heat |, fo it can fuftain its own proper heat * In every inftance of our mentioning degrees ofheat or cold, we fhall mention them by the degrees in Farenheit's fcale ; and the cxpreflion of higher or lower fhall always be according to that fcale. -}- As the nature of this power, by which animals preferve their temper* ature higher than that of the surrounding medium, was very imperfectly underftood at the time Dr. Cullen wrote, it will not be improper to men- tion briefly the recent difcoveries relating to it. Befide6 being intimately connected with fome of the moft important dodtiines in phyfiology and pa- thology, they illu(Irate the fwbfequent remarks on cold, and deferve ferious attention on account of their application in many difeafes. It had been long obferved that the temperature of animals feemed to be in a great meaf- ure proportioned to the perfection of their refpivatory organs; It had been i'kewife obferved that the blood, in its circulation through the lungs, under- goes a remarkable change : From the dark venous hue which it pofTefTes as it is returning to the right auricle, it affumes, in its pafTage through the Lungs, a florid arterial color. This was confidered as indicating fome cor- responding change of the blood. Dr. Black proved that the air expired from the lungB contained carbonic acid, as it rendered lime water turbid. lie likewife obferved that the procefs of refpiration feemed in fome refpefts fo refemble combuflion. The experiments of Lavoifier having afcertained the composition of atmofpheric air, were applied to this function, and it was ' found that in refpiration a qumtity of oxygen difappeared, and that carbo- nic acid supplied it? place.. As, however, it has not yet been proved wheth- er the carbon exh'lirg in the blood is pure, or an oxyd ©fthat fubftance, we cannot eftimate accurately the quantity cf oxygen that is employed in the formation of the acid ; ard fome have fuppofed that the carbonic acid expir* ed, previoufly exiftedin the blood. But this opinion, independent of other considerations, is refuted by the experiments of Mr. Davy, in which, when hydro, en sas was frequently infpired, little carbonic acid was formed. There is likewife a quantity of watery vapour expired, which was fuppofed to arife from the direct union of the oxygen of the atmofpheoe with the hy- , drogen of the blood ; but is with far greater probability referred to evapo- ration from the extenfive a»d moift furface of the bronchia, where fo many circumftances favor its production. It has then been afcertained, that of the oxygen which difappears, part it expended in the formation of caibonic acid, and part abforbed into the blood* 1 to which it imparts a florid color, and reftores the power of stimulating the heart and arteries, whofe contractions become languid, and in a fhort time altogether ceafe, if the fupply of this principle is interrupted. The generation of animal heat depends chiefly on thefe changes. We are indebted to Dr. Black for the important difcovery, that different bodies* J at equal temperatures, contain unequal quantities of caloric, which is neither proportioned to their volume, or quantities of matter : or that, befides the • caloric which affects their temperature, they contain different quantities in ?. latent ftate rot fenfible to the thermometer ; in other words, they have different capacities for caloric. Dr. Crawford, iu his mafterly and elaboii r. te Treatife on Animal Heat, has not only afcertained this difference of PRACTICE OF PHYSIC. 57 to the degree above mentioned, though furroundcd 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 the temperature of his body, uhlefs the tern* perature of the bodies applied be below 62 degrees. From hence it appears, that the abfolute power of cold in this climate, does not act upon the living human body, unlefs the cold applied be below the degree juft now mentioned. It appears alfo, that the human body's being fur- rounded by air of a lower temperature than itfelf, is necafTary to its being retained in its proper temperature bf 98 degrees : for, in this climate, every temperature of the air above 62 degrees, 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 refpect to capacity, but ingenipufly applied it to the explanation cf animal tempera- ture, and proved, from the iiiperior capacity of oxygen to carbonic acid, that when the former unites with carbon, there muft he an evolution of cal- oric. As, however, the capacity of the arterial blcod is greater than that of the venous, this caloric ie rendered latent, and becomes fenfiblc in the cwurfe of the circulation, as the blood is converting into venous, and its ca- pacity diminilhing. That this i3 the chief caufe of animal temperature, is farther confirmed by Dr. Crawford, who found that much about the fame quantity of heat is generat ed/rom theconfumption of a ^iven quantity of oxygen by. refpiration, as is produced by burning the fame quantity or that gas with carbonaceous matter. This face is corroborated by the experi- ments of Lavoificr. The erroneous opinion of Dr. Crawford refpecting the origin of the hv. drp carbon by the addition of which, he conceived that the arterial blood was converted into venous, does not in the fmalleft degree a Sect the above theory. * Thif obfervation, tha*: every Temperature above 6z° is fourd to increafe- the heat of the body, is incorrect, and arif«s from taking the fenfai'ion of *eat produced at the furface of the body as a general ftandard of its hi- creafe of temperature. In heated air there is not only lefs oxygen in a given volume, but the at- traction of the blood, for it is diminimed. Henc^, in a given time, an an- imal vitiates a lefs quantity of air in a heated than in a cold medium. That the living body pofTtilcs a power of resitting increafe of tempera- trfre, is proved by the experiments of Dr. Fordyce, who remained for 15 rmmstes in air laturatcdwith moifture, and heated to X300, the heat of tlu- body being very little raifed above the nat ural ftandard. As his whole body was covered with moifture from the condenftition of vapor, if is obviou* that the cold produced by evaporation could rot ccntributcto this effect. £ 5S PRACTICE OF PHYSIC. the human body, is very different from what it is with refpect to inanimate bodies. i.xxxix. The relative power of cold with refpeel: to the living human body, is that power by which it pro- duces a fenfation of cold in it j and with refpect to this, it is agreeable to the general principle of fenfation, that the fenfation produced is not in proportion to the abfo- lute force of impreffion, but according as the new impref- fion is ftronger or weaker than that which had been.appli- ed immediately before. Accordingly, with refpect to temperature,the fenfation produced by any degree of thi*,- depends upon the temperature to which the bodyhad been immediately before 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 oppo- fite fenfations of heat and cold may on different occa- fions arife from the fame temperature, as marked by > the thermometer. With refpect to this, however, it is to be obferved, that though every change of temperature gives a fenfa- tion of cold or heat, as it is lower or higher than the VI temperature applied immediately before, the fenfation I produced is, in different cafes, of different duration. If the temperature at any time applied is under 62 de- grees, 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 -i not continue long, but be foon changed to a fenfation of cold. In like manner, any temperature, applied to the human body, lower than that of the body itfelf, gives a fenfationof cold ; but if the temperature ap- plied does not go below 62 degrees, the fenfation of '. cold will not continue long, but be foon changed to a fenfation of heat. It will appear hereafter that the effects of the fenfa- tion of cold will be very different, according as it is more permanent or tranfitory. xc. Having thus explained the operation of cold, as abfolute or relative with refpect to the human body, I proceed to mention the general effects of cold upon it, PRACTICE OF PHYSIC. 59 1. Cold, in certain circumftances, has manifeftly a fedative power. It can extinguifh the vital principle en- tirely, either in particular parts, or in the whole body; and confidering how much the vital principle of ani- mals depends upon heat; it cannot be doubted that the power of cold is always more or lefs directly fedative. This effect may be faid to take place from every de- cree of abfolute cold ; aod when the heat of the body has upon any occafion been preternaturally increafed, every lower temperature may be ufeful in diminifhing the activity of the fyftem ; but it cannot diminifh the natural vigor of the vital principle, till the cold appli- ed is under.62 degrees ; nor.even then will it have this effect, 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 ijlimulus to the living body, and particu- larly to the Sanguiferous fyftem. i It is probable that this effect takes place in every cafe in which the temperature applied produces a fenfa- tion of cold ; and this, therefore,, as depending entirely on the relative power of cold, will be in proportion to the change of temperature that takes place. It appears to me probable, that every change of tem- perature from a higher to a lower degree, will prove more or lefs ftimulant, excepting when the cold applied is fo intenfe, as immediately to extinguifh the vital prin- ciple in the part. . 3. Befide the fedative and ftimulant powers of cold, jt is manifeftly alfo a powerful aflringent, caufing a con- traction of the veffels on the furface of the body, and thereby producing a palenefs of the fkin, and a fuppref- fiqn of perfpiration ; and it feems to have fimilar effects when applied to internal parts. It is likewife probable, that this eonftriction, as it takes place especially in con- fequence of the. fenfibility of the parts to which the cold is applied, will in fome meafure be communicated to other parts of the body ; and that thereby the applica- tion of cold proves a ionic power with refpect to the whole fyftem. PRACTICE OF PHYSIC. iheie effects 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 give* a fenfation of cold, is, in its firft effect, both aftringent .md ftimulant, though the former may be often pre- vented from being either confideraole or permanent when the latter immediately takes place*. xci. It will be obvious that thefe feveral effects of cold cannot all take place at the fame time, but may in iuccefiion be varioufly combined. The ftimulant pow- er taking place obviates the effects, at leaft the perma- nency of the effects, 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 tonic powers of cold are commonly, perhaps always conjoined. xcn. Thefe general effects of cold, now pointed out, are fometimes falutary, frequently morbid j 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 other "Plegmaiiae. 2. The fame inflammatory difpofition accompanied with Catarrh. ts. A Gangrene of particular parts. 4. A Palfy of a fingle member. 5. A Fever, or Fever ftrictly fo called (vm.) which it often produces by its own power alone, but more commonly it is only an exciting caufe of fever by con- cur ring with the opperation of human or marfh effluvia. A lithe attempts which hwe been hitherto madetoac^oimt for the op- cat'on of cold, have been uufuccefsfu!. This opinion of Dr. Cullen, though l'ornewhat obfeure, is certainly not fo contradictor)-, as; torn,;-, too much biafled by late doctrines, have imagined. Tlffe unwarrantable fiaipli- » rioafon of the laws of the animal economy, which is too much the prevail- ing Jpirit cf the day, has contributed little to the advancement of medical lcicnce; and the iuppofing the effects of cold to arife merely from the ab- straction « f the ftimulue of heat, is i epugnant to fome palpable facte. The ihoclc which its Hidden application «ivcs to the nervous fyftem, is often highly ftimulant. In fliort, its operation is fo difterent in different ftates of Mc body, that onr author is certainly juftified in concluding that its effaces are iometimet fedative, and at other time? ftimulant. PRACTICE OF PHYSIC. <-J xein. Cold is often applied to the human body with- out producing any of thefe morbid effects, and it is dif- ficult to determine in what circumftances it efpecially operates in producing them. It appears to me, that the morbid effects of cold depend partly upon certain cir- cumftances of the cold itfelf, and partly on certain cir- cumftances of the perfon to whom it is applied. xciv. The circumftances of the cold applied which feem to give it effect, are, 1. The intenfity or degree of the cold ; 2. The length of time during which it is ap- plied ; S. The degree of moifture at the fame time ac- companying it j 4. Its being applied by a wind or cur- rent of air ; .5. Its being a viciffitude, or fudden and confiderable change of temperature, from heat to cold. xcv. The circumftances ofperfons rendering them more liable to be affected by cold, feem to be, 1. The weaknefs of the fyftem, and particularly the leffened vigor of the circulation, occaftoned by fafting, by e- vacuations, by fatigue, by a laft night's debauch, by ex- cefs in venery, by long watching, by much ftudy, by reft immediately after great exercife, by fleep, and by preceding difeafe. 2. The body, or its parts, being de- prived of their accuftomed coverings. 3. One part of the body being expofed to cold, while the reft is kept in its ufual, or a greater warmth. xcvi. The power of thefe circumftances (xcv.) is demonftratcd by the circumftances enabling perfons to refift cold. Thefe are a certain vigor of conftitution, exercife of the body, the prefence of active paftions, and the ufe of cordials. Befide thefe, there are other circumftances which, by a different operation, enable perfons to refift cold acting as a fenfation ; fuch as, paftions engaging a clofe atten- tion to one objest, 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 refpect to thofe parts of the body to which cold is more conftantly applied, which both di- minifhes fenfibility, and incrcafes the power of the ac- tivity generating heat. &a PRACTICE OF PHYSIC. xcvn. Befide cold, there are other powers that feem to be remote caufes of fever; fuch as, fear, intemper- ance in drinking, excefs in venery, and other circum- ftances, which evidently weaken the fyftem. But whether any of thefe fedative powers be alone the re- mote caufe of fever, or if they only operate either as concurring with the operation of marfh or human ef- fluvia, or as giving an opportunity to the operation of cold, are queftions not to be pofitively anfwered : they may poffibly of themfelves produce fever, but meft fre- quently they operateas concurring in one or other of the ways above mentioned. xevm. Having now mentioned the chief of the re- mote caufes of fevers, it may be further obferved, that thefe will arife more or lefs readily, according as miaf- mata and contagions are more or lefs prevailing and powerful or as thefe are more or lefs favored by the, concurrence of cold and other fedative powers. CHAP. V. OF THE PROGNOSIS O? FEVERS. xcix. /IS fevers 5 PRACTICE OF PHYSIC. being truly the works of different perfons, and from the moft genuine of them having fuffered many corrup- tions ; fo that, in fhort, every thing which is inconfiftr ] ent with the facts above laid down, may be afcribed to one or other of thefe caufes. exvn. This, further, has efpecially difturbcd the doctrine of critical days, that Hippocrates himfelf at- tempted, perhaps too haftily, to eftablifh general rules, and to bring the doctrine 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, doctrines which appear fo often in the writings of Hippocrates. Thefe, however, are inconfiftent with the facts above laid down ; and indeed, as Afelepiadcs and Celfus have obferved, are inconfiftent with one an- other, cxviii. Upon the whole, therefore, it is apprehended, that the critical days above affigned are truly the critic- al days of Hippocrates, and may be confiftently explain-"] ed in the following manner : * cxix. From the univerfality of tertian or quartan periods in intermittent fercrs, we cannot doubt of their. being, in the animal economy, a tendency tp obferve fuch periods; and the critical days above mentioned.. are confiftent with this tendency of the economy, as all of them mark either tertian or quartan periods. Thefe period;, however, are not promifcuoufly mixed, but oc- cupy conftantly "their feveral portions in tjie progrefs of the difeafe ; fo that, from the beginning' to the elev- enth day, a tertian period takes place ; and, from the eleventh to the twentieth, and perhaps longer, a quar- tan period is as fteadily obferved, cxx. What determines the periods to be changed a- bout the eleventh day, wc have not clearly perceived; but the fact is certain : for there is no inftance of any termination on the thirteenth, that is, the tertian peri- od next following the eleventh; whereas, upon the fourteenth, feventeenth, and twentieth, which mark quartan periods, there are forty three inftunces of tcr- PRACTICE OF PHYSIC. 6» minations, and fix only on all the intermediate 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 mentioned as fuch in the common edition of the Aphorifms, taken from an erroneous manufcript, which Celftre alfo feems to have copied. cxxi. A confiftency with the general tendency of the fyftem, renders the feries of critical days we have men- tioned, probably the true one ; and the only remaining difficulty in finding what we have delivered to be the fame with the genuine doctrine of Hippocrates, is the frequent mention of the fourth as a critical day. It is true there are more inftances of terminations happening on this day than on fome of thofe days we have afferted to be truly critical: but its inconfiftency with the more general tendency, and fome other con- fiderations, lead us to deny its being naturally a critical day ; and to think that the inftances of terminations, which have really occurred on the fourth day, are to be reckoned among the other irregularities that happen in this matter. cxxii. I have thus endeavored to fupport the doc- trine of critical days chiefly upon the particular facts to be found in the writings of Hippocrates ; and although I might alfo produce many other teftimonies of both an- cient and modern times, yet it muft be owned that fome of thefe teftimonies may be fufpected to have arifen rather from a veneration of ftippdtrates, than from ac- curate obfervation. exxm. With refpect to the opinions of many mod- erns who deny the prevalence of critical days, they are to be little regarded ; for the obfervation of the courfe of continued fevers is known to be difficult and falla- cious ; and therefore the regularity of that courfe may have often efcaped inattentive and prejudiced obfervers. cxxiv. Our own obfervations amjunt to this, that fevers with moderate fymptoms, generally cafes of the fynocha, frequently terminate in nine days, or fodner. 7o PRACTICE OF PHYSIC. 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 fyno- chus terminate before the eleventh day ; and when they do terminate on this day,, it is for the moft part fatally. When they are protracted beyond this time, I have very conftantly found that their terminations were upon the fourteenth,,feventeenth, or twentieth day. In fuch cafes, the falutary terminations are feldom at- tended with any confiderable evacuation. . A fweating' frequently appears, but is. feldom confiderable; and I have hardly ever obferved critical and decifive termina- * tions attended with vomiting, evacuations by ftool, or- remarkable changes in the urine. < The folution of the difeafe is chiefly to be difeerned from fome return of fleep and appetite, the ceafing of delirium, and an abate- ment of the frequency of the pulfe. By thefe fyrhptoms'l we can often mark a crifis of the difeafe ; but.it feldoiafi happens fuddenly and entirely ; and it is moft common-'f| ly from fome favorable fymptoms occurring upon one £ critical day, that we can announce a more entire folu- tion upon the next following. fl Upon the whole, I am perfuaded, that, if obfervations 1 fhall be made with attention, and without prejudice, 1 fhall be allowed to conclude with the words of the learn- ed and fagacious Gaubious : tf Failor, ni fua conftiterit H " Hipfocrati auctoritas, Galeno fides, Nature vie- " tus et ordo." C H A P. VI. OF THE METHOD OF CURE IN FEVERS. Sect. I. Of the Cure of Continued Fevers. exxv. r\S it is allowed, that, in every j fever which has its full courfe, there is an effort of na- ture, of a falutary tendency, it might be fuppofed that PRACTICE OF PHYSIC. the cure of fevers fhould be left to the operations of na- ture, or that our art fhould be only directed to fupport and regulate thefe operations, and that we fhould form our indications accordingly. This plan, however, I can- not adopt, becaufe the operations of nature are very precarious, and not fo well underftood as to enable us to regulate them properly. It appears to me, that truft- ing to thefe operations has often given occafion to a negligent and inert practice; and there is reafon to be. lieve, that an attention to the operations of nature may- be often fuperfeded by art. exxvi. The plan which to me appears to be moft fuitable, is that which forms the indications of cure up- on the view of obviating the tendency to death ; while, at the fame time, the means of executing thefe indica- tions are directed by a proper attention to the proxi- mate caufe of fevers. Upon this plan, in confequence of what has been laid down above on the fubject of the prognoftic, we form three general indications in the cure of continued fe- vers ; and the one or other of thefe is to be emplcyed according as the circumftances of the fever (en.) fhall direct. The firft therefore is, To moderate the violence of re- aclion. The fecorid is, To remove the caufes or obviate the ejfecls of debility. And, The third is, To obviate or cor reel the tendency of the flu- ids to putrefaclion. cxxvu. The firft indication may be anfwered, that is the violence of reaction may be moderated. 1. By all thofe means which diminifh the action of the heart and arteries. 2. By thofe means which take off the fpafm of the extreme veffels, which we fuppofe to be the chief caufe of violent reaction. cxxvin. The action of the heart and arteries may be diminifhed, 1. By avoiding or moderating thofe irritations, which, in one degree or other, are almoft conftantly ap- plied to the body. ,2 PRACTICE OF PHYSIC. ?.. By the ufe of certain fedative powers. a. Bv diminifhing the tenfion and tone of the arteM- aifyftek cxxix. The irritations (cxxvin. 1.) almoft conftantly applied, are the impreffions made upon our fenfes, the exercife of the body and mind, and the taking in of ali- ments. The avoiding thefe as much as poflible, or the moderating their force, conftitute what is rightly called the Antiphlogistic Regimen, proper to be employed in almoft every continued fever. exxx. The conduct of this regimen is to be directed by the following rules and cbnfiderations : l. Impreffions on the external fenfes, as being ftimu- lant to the fyftem, and a chief fupport of its activity,' fhould be avoided as much as poflible ; 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, ev- ery other means of increahng the heat of the body is to' be fhunned. Both thefe precautions are to be obferved as foon as a hot ftage is fully formed, and to be attend- ed to during its continuance ; excepting in certain caf- es, where a determination to fweafihg is neceflary, or* where the ftimulant effects of heat may be compenfateri by circumftances which determine it to produce a re- laxation and revulfion. - 2. All motion of the body is to be avoided, efpecially that which requires the exercife of its own mufcles ; and that pofture of the body is to be chofen which em- ploys the feweft mufcles, and which keeps none of them long in a ftate of contraction. Speaking, as it acceler- ates refpiration, is particularly to be refrained from. It is to be obferved, that every motion of the body is" the more ftimulant in proportion as the body is weaker. 3. The exercife of the mind alfo is a ftimulus to the body ; fo that all impreffions which lead to thought,, and thofe efpecially which may excite emotion or paf- fion, are to be carefully fhunned. PRACTICE OF PHYSIC. n With refpect to avoiding impreffions of all kinds, an exception is to be made in the cafe of a delirium coming on, when the prefenting of accuftomed objects may have the effect of interrupting and diverting the irregu- lar 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 there- fore to be as moderate as poflible. A total abftinencc 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 aromat- ic and fpiritous liquors are to be avoided ; and, in an- fwering the prefent indication,all fermented liquors, ex- cepting thofe of the lowcft quality, are to be abftarned frorm cxxxi. Befide thefe ftimulant powers more conftant- ly applied, there are others which, although occafional only, yet, as commonly accompanying fevers, muft be attended to and removed. One is, the fenfe of thirft, which, as.a powerful ftimulus, ought always, in one way or other, to be re- moved. Another ftimulus frequently arifes from crudities, or corrupted humors in the ftomach ; and it is to be re- moved by vomiting, by dilution, or by the ufe of acidsf. A third ftimulus often arifes from the preternatural * The loathing of animal food, which is To conspicuous in fevers, is a fal- utary provision of nature, by which we are warned From taking in what would certainly not be properly digefled, and of courfe remain a noxious irritation. Indeed, there feems to be a peculiarly defective aflimilation of the aliment ia fever; hence the impropriety of being over ftudious to in- duce patients to fwallow much, in opposition to the almoft insur- mountable averfion which they often have for food. The fpareft vege- table diet, as a small quantity of panada or barley gruel, is generally suffi- cient. With refpect to the drink, cooling acidulated liquors, as cream of tartars whey, imperial, &c. or barley water, are the moft proper. •f The different vegetable acids are found moft convenient as the juices of tamarinds, lemons, oranges, currants, &c. F •4 PRACTICE OF PHYSI«. retention 01 faeces in the inteftines ; and ought to be removed by frequent laxative glyfters*. A fourth ftimulus to be conftantly fufpected in fe- vers, is a general acrimony of the fluids, as produced by the increafe of motion and heat, joined with an in- terruption of the excretions. This acrimony is to be obviated or removed by the taking in of large quanti- ties of mild antifeptic liquors. cxxxii. The avoiding of irritation in all thefe par. ticulars (exxx. and cxxxl), conftitutes the antiphlog- iftic regimen abfolutely neceflary for moderating the violence of reaction ; and, if I miftake not, is proper in almoft every circumftance of coatinued fevers, becaufe the propriety and fafety of employing ftimulants is of- ten uncertain ; and becaufe feveral of thofe above men- tioned^ befide tneir ftimulant powers, have other quali- ties by which they may be hurtful. It appears to me, that the fuppofed utility of ftimu- Iants, in certain cafes of fever, has often arifen from a miftake in having afcribed to their ftimulant what really depended upon their antifpafmodic power. gxxxiii. A fecond head of the means (exxvm. 2.) for moderating the violence of reaction, comprehends eertain fedative powers, which may be employed to di- minifh the activity of the whole body, and particular- ly that of the fanguiferous fyftem. Tnefirfi 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 net con- ftantly moderated by a cooler temperature in the fur- rounding atmofphere. When, therefore, that power of the fyftem generating heat is increafed, as i« commonly * 5, Decoct, pro enemat. J xii. OL Olivar. I ij. Sulphas Socke, J ft. m. Ft. Encm. pro re nata injei. PRACTICE OF PHYSIC. ',: the cafe in fevers, it is neceffary not only to avoid all means of increafing it further, but it feems proper alfo to apply air of a cooler temperature, 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 con- tinued fevers, fhow that the free admiflion of cool air to the body is a powerful remedy in moderating the vio- lence of reaction ; but what is the mode of its opera- tion, to what circumftances of fever it is peculiarly ad- apted, or what limitations it requires, I fhall not ven- ture to determine, till more particularly inftructed by further experience* cxxxiv. A fecondfedative power which may be em- ployed in fevers, is that of certain medicines, known, in * The circumftances which regulate the application of cold, and the value of this remedy in fever, have now been fully afcertained, and form a memo- rable era in the aiHals of Medicine. Dr. William Wright, phyfician to his majefty's forces, late in the Weft Indies, tranfmitted to the London Medical Journal, in the year 1786, an ac- count of feveral cafes of fever, fuccefsfully treated by the affufion of cold water; and to him we are indebted for introducing this valuable remedy to notice. Dr. Cnrrie of Liverpool, in a work which does him the higheft credit, has prolecuted this subject with equal ability and fuccefs. For the cold affufion, Dr. Currie prefers fait water, faturated brine, or frefh water mixed with vin- egar, to frefh water alone; as he conceives that the fait, by ftimulating the cutaneous veffels, in fome meafure obviates the debilitating effects of th« cold. Dr. Wright employed fea water. The patient isexpofed naked, and a bucket full of this is fuddenly dafhed about him. Cold water, without anv addition, may be ufed without any bad confequence,if no other can be eafily obtained. Water, at a temperature from 40 to 60, is commonly em- ployed. Its beneficial effects are moft confpicuous when ufed during the height of the diurnal exacerbation, or immediately after it begins to decline ; hence it is employed from fix to nine o'clock in the evening with moft ad- vantages ;" but it may be fafely ufed at any time of the day, when there " is no fenfe ofchillinefs prefent, when the heat of the furface is fteadily " above what is natural, and when there is no general or profufe perfpira- " tion." Thefe confederations merit the utmoft attention, and include all the reftrictions which muft be attended to in its application. With thefe cautions, the more early its application, the more decifiveare the advantages which result from it. When employed on the firft or fecond day, jt fre- quently arrefts the progrefs of the difeafe. It rarely is attended with fuch happy effects when ufed at a later period. For the firft eight or ten days, however, it in general moderates confiderably the violence of the diftemper, and haftens its favorable termination. When employed in the advanced ftage of the difeafe, where there is great proftration of ftrength, a cordial, at warm wine, fhould be adminiftered immediately after it. Its general effects are, an abatement of heat, reduction of the frequency of thepulfe, relief from oppreflion, gentle perfpiration, and propenfity to fleep. 2 :<> PRACTICE OF PHYSIC. the writings on the Materia Medica under the title of Refrigerants. The chief of thefe are acids of all kinds, when fuffi. ciently diluted ; and they are, in feveral refpects, reme- dies adapted to continued fevers. Thofe efpecially in uife are, the Vitriolic and Vegetable, and, on many ac- counts, we prefer the latter. exxxv. Another fet of refrigerants are the Neutral Salts, formed of the vitriolic, nitrous, or vegetable ac- ids, with alkalines, either fixed or volatile. All thefe neutrals, while they are diffolving in water, generate cold; but as that cold ceafes foon after the folution is finifhed, and as the falts are generally exhibited in a diffolved ftate, their refrigerant power in the animal body does not at all depend upon their power of gener- ating cold with water. The neutral chiefly employed as a refrigerant is Nitre ; but all the others, compound- ed as above mentioned, partake more or lefs of the fame quality. cxxxvi. Befides thefe neutrals, fome metallic falts alfo have been employed as refrigerants in fevers, and particularly the Sugar of Lead. But the refrigerant powers of this are not well afcertained, and its deleteri- ous qualities are too well known to admit of its being freely ufed. cxxxvu. Under the third general head (exxvm. 3.) of the means to be employed for moderating the vio- lence of reaction, are comprehended the feveral means of diminifhing the tenfion, tone, and activity of the fanguiferous fyftem. As the activity of this fyftem de- pends, in a great meafure, upon the tone, and this a- gain 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 activity of the fanguiferous fyftem. c xxxvin. The quantity of fluids contained in the fan- guiferous fyftem, may be diminifhed moft conveniently by the evacuations of blood letting and purging. ex xxix. Nothing is more evident, than that blood letting is one of the moft powerful means of diminifhing PRACTICE OF PHYSIC- V, the activity of the whole body, efpecially of the fanguif- erous fyftem, and it muft therefore be the moft effectual means of moderating the violence of reaction 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. cxl. When the violence of reaction, and its conftant attendant, a phlogiftic diathefis, are fufficiently mani- feft; when thefe conftitute the principal part of the dif- eafe, and may be expected to continue throughout the whole of it, as in the cafes of fynocha, then bloodletting is the principal remedy, and may be employed as far as the fymptoms of the difeafe may feem to require, and the conftitution of the patient will bear. It is. howev- er, to be attended to, that a greater evacuation than is neceflary, may occafion a flower recovery, may render the perfon more liable to a relapfe, or may bring on oth- er difeafes. cxli. In the cafe fynocha, therefore, there is little doubt about the propriety of blood letting; but there are other fpecies of fever, as the fynochus, in which a vi- olent reaction 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 expected to continue during the whole courfe of it; and it is well known, that, in many cafes, the ftate of violent re- action is to be fucceeded, fooner or later, by a ftate of debility, from the excefs of which the danger of the dif- eafe is chiefly to arife. It is, therefore, neceffary, that, in many cafes, blood letting fhould be avoided ; and e- ven although, during the inflammatory ftate of the dif- eafe, it may be proper, it will be neceffary to take care that the evacuation be not fo large as to increafe the ftate of debility which is to follow*. * Thofe fevers which require blood letting-, occur forrarely, that is nec- effary to cantion the practitioner, in the firongeft manner, againft having recourfe to this dubious remech-, except in very particular cafes. An emer- gency which require* the ufe of bleeding may pe.haps not occur to thofe who practife in tkis country in the courfe „of many years, or even of a life- time. S ?& PRACTICE OF PHYSIC. cxlii. From all this it muft appear, that the employ- ing blood letting, in certain fevers, requires much difc cernment and fkill, and is to be governed by the confidr eration of the following circumftances : 1. The nature of the prevailing epidemic. '-'. The nature of the remote caufe. 3. The feafon and climate in which the difeafe oc- curs. 4. The degree of phlogiftic diathefis prefent* n. The period of the difeafe. 6. The age, vigor, and plethoric ftate of the patient. 7. The patient's former difeafes and ^habits of blood letting. S. The appearance of the blood drawn out. y. The effects of the blood letting that may have been already practifed. cxliii. When, after the confidcration of thefe cir- cumftances, blood letting is determined to be neceffary, it fhould be obferved, that it is more effectual accord- ing as the blood is more fuddenly drawn off, and as the body is, at the fame time, more free from all irritation, and, confequcntly, when in a pofture in which the few- eft mufcles are in action. cxliv. Another evacuation whereby the quantity of fluids contained in the body can be considerably dimin- ifhed, is that of Purging. cxlv. If we confider the quantity of fluids conftant- ly prefent in the cavity of the inteftines, and the quanr The impending debility which fo rapidly fucceedsto this inflammatory action, and from which we have fo much to fear, is in danger of being fa- tally increafed by this evacuation. Dr. Clark of Newcaftle, wkofe extenfive practice gives particular weight to his opinion, in his Treatife on Fevers, has the following pertinent remarks: " I am fenfible, that in the beginning of fe- •" vers, venefection is the moft powerful means of abating the force and ac- " tivity of the vafcular fyftem. ]But as all fevers, at leaft fuch as have oc- " curred in my practice, are, in general,foon fucceeded by debility, or fymp- *' toms which denote a tendency to putrefaction in the fluids, this evacua- " tion ou^ht to be ufed with caution. There may be fome cafes of fever, in- " deed, that may require venefection in the beginning, particularly where " there are cvideit. fi^ns of topical determinations of blood to the head. " lun^-s, or any other part; when the patient is vigorous and plethoric, and " when the difeafe derives its origi" from other caufes than contagion. In f'feven vears practice,I have only had occafion to direct this evacuation " twice in continued fevers, unaccompanied with fymptoms ©f local affec- »' tion; and I can add, that I never loft a patient from the omifiion." PRACTICE OF PHYSIC. 79 tity which may be drawn from the innumerable excre- tories that open into this cavity, it will be obvious that a very great evacuation 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 emptying both the cavity of the inteftines, and the arteries which furnifh the excre- tions 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 reaction in fevers. cxlvi. But it is to he 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 arte- ries is drawn offflowly; fo the evacuation will not, in pr oportion to jts quantity, occafion fuch a fudden de- pletion of the red veffels as blood letting does; and therefore cannot operate fo powerfully in taking off the phlogiftic diathefis of the fyftem. cxlvii. At the fame time, as this evacuation may in- duce a confiderable degree of debility, fo, in thofe cafes in which a dangerous ftate of debility is likely to occur, purging is to be employed with a great deal of caution j and more efpecially as the due meafure of the evacua- tion is more difficult to be applied than in the cafe of blood letting*, * The cautions which the author gives about purging in fevers, plainly Jhow that it was no favorite practice of his; and indeed, exeppt where the inflammatory fymptoms run high, threatening determinations to particular parts, or the inefficacy of the common glyfters point out the propriety of their exhibition, we had betterabftain from them. When had recourfe to, thofe which procure an evacuation, with the leaft irritation, are to be pre. ferred: For this purpbfe we may take an ouncei«ran ounce and a naif of phosphorated foda, diflblved in a pint of chicken broth, of which a tea cup full is to be taken every half hour till it operates; or, §> Fruct. Tamarind. 3 ifi. Sennas, fol. 5 i. coque in aq. font. 3 xii, ad colat. J ix cujus cochl. ii. ompi femihora, donee alvus refpondeat, funt fun?. 4 So PRACTICE OF PH VSIC. cxLvm. As we fhall prefently have occafion to ob- ferve, that it is of great Importance, in the cure of fe- vers, to reftore the determination of the blood to the veffels on the furface of the body; fo purging, as in fome meafure taking off that determination, feems to be an evacuation not well adapted to the cure of fevers, cxlix. If, notwithftanding thefe doubts, (cxlvi. cxtvu. and cxlviii.) it fhall be afferted, that purging, even from the exhibition of purgatives, has often been ufeful in fevers ; I would beg leate to maintain, that this has not happened from a large evacuation ; and there- fore, not by moderating the violence of reaction, ex- cepting in the cafe of a more purely inflammatory fever, or of exanthemata of an inflammatory nature. In oth- er cafes of fever, I have feen a large evacuation by purg- ing, of mifchievous confequence; and if, upon occa- fion, a more moderate evacuation has appeared to be ufeful, it is apprehended to have been ©nly by taking off the irritation of retained faeces, or by evacuating corrupted humors which happened to be prefent in the inteftines ; for both of which purpofes frequent lax- atives may be properly employed. cl. Another fet of means (cxxvii. 2.) for moderat- ing the violence of reaction 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 re- action. Though I have put here this indication of taking off the fpafm of the extreme veffels, as fubordinate to the general indication of moderating the violence of reac- tion, it is however to be obferved here, that as fever u- niverfally confifts in an increafed action of the heart, either in frequency or in force, which in either cafe is fupported by a fpafm of the extreme veffels, fo the in- dication for removing this is a very general one, and applicable in almoft every circumftance of fever, or at leaft with a few exceptions, to be taken notice of hereaf- ter. cli. For taking off the fpafm of the extreme veffels, the means to be employed are either internal or exter nal. / PRACTICE OF PHYSIC. «i cmi. The internal means (cli.) are, 1. Thofe which determine the force of the circulation to the extreme veffels on the furface of the body, and by reftoring the tone and activity of thefe veffels, may o- vercome the fpafm on their extremities. 2 Thofe medicines which have the power of taking off fpafm in any part of the fyftem, and which are known under the tittle of Antispasmodics. cliii. Thofe remedies which are fit to determine to the furface of the body, are, 1. Diluents. 2. Neutral Salts. 3. sudorif1cs. 4. Emetics. cliv. Water enters, in a large proportion, into the compofition of all the animal fluids, and a large quanti- ty of it is always diffufed through the whole of the com- mon mafs. Indeed, in a found ftate, the fluidity of the whole mafs depends 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 pro- portion to the quantity of water they contain. clv. Water may be faid to be the vehicle of the fev- eral matters which ought to be excerned; and in a healthy ftate the fulnefs of the extreme veflels, and the quantity of excretions, are nearly in proportion to the quantity of water 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, neceffarily retained in the larger veffels, the fmaller and the extreme veffels, both from the deficiency of fluid, and their own contracted ftate, are lefs filled, and therefore allowed to remain in that condition. clvi. To remedy this contra&ed ftate, nothing is more neceffary than a large fupply of water or watery fluids, taken in by drinking, or otherwife; for as any fuperfluous quantity of water is forced off by the fever- al excretories, luch a force applied, \\u\ be a means of 8* PRACTICE OF PHYSIC. dilating the extreme veffels, and of overcoming the fpafm affecting their extremities. clvii. Accordingly the throwing in of a large quan- tity of watery fluids, has been at all times a remedy much employed in fevers ; and in no inftance more re* markably, than by the Spanifh and Italian phyficians, in the ufe of what they call the Diceta aquea. clviii. This practice confifts in taking away every other kind of aliment and drink, and in giving in di- vided portions every day, for feveral days together, fix or eight pounds of plain water, generally cold, but fome- times warm. All this, however, is to be done only af- ter the difeafe has continued for fome time, and at leaft for a week. clix A fecond means (cliii. 2.) of determining to the furface of the body, is by the ufe of neutral falts. Thefe, in a certain dofe, taken into the ftomach, produce foon after a fenfe of heat upon the furface of the body ; and, if the body be covered clofe, and kept warm, a fweat is readily brought out. The fame medicines, tak* en during the cold ftage of a fever, very often put an end to the cold ftage, and bring on the hot ; and they are alfo remarkable for flopping" the vomiting which fo frequently attends the cold ftage of fevers. All this ftiows that neutral faits have a power of determining the blood to the furface of the body, and may therefore be of ufe in taking off the fpafm which in fevers fubfifts there. clx. The neutral moft commonly employed in fe- vers, is that formed of an alkali with the native acid of vegetables* : but all the other neutrals have more or * 5> Kali praeparat. $ i. Succ. limon. recen. exprefli, J ft. vel q. ft ad alkali faturandum. Aq. font. 2; i. Aq. cinn. % <3. m. ft. hauft. tenia quaque hora, fum. Vel, $> Aq. ammon. acetat. J iij. PRACTICE OF PHYSIC. *3 Jefs of the fame virtue; and perhaps fome of them, par- ticularly the ammoniacal falts, poffefs it in a ftrongcr degree. clxi. As cold water taken into the ftomach, often fhows the fame diaphoretic effects with the neutral falts, it is probable that the effect of the latter depends upon their refrigerant powers mentioned above (cxxxiv.) What is the effect of the neutral falts, given when they are forming and in a ftate of effervefcence ? It is proba- ble that this circumftance 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 effervef- cence fhould take place in the ftomach. clxii. A third means (cliii. 3. ) of determining to the furface of the body, and taking off the fpafm fub- fifting there, is by the u'fe of fudorific medicines, and of fweating. clxiii. The propriety of this remedy has been much difputed; and fpecious arguments may be adduced both for and againft the practice. In favor of the practice, it raay be faid ; 1. That in healthy perfons, in every cafe of increafed action 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 ter- mination is by fpontaneous fweating. 3. That, even when excited by art, it has been found manifeftly ufeful, at certain periods, and in certain fpec- ies of fever. . clxiv. Upon the other hand, it may be urged againft the practice of fweating ; Aq. menth. fativse, 3 i° Aq. font. | ii. Tart. emet. gr. ij. cap. zeger coch. duo altera quaque hora. When we wilh the effervefcence to take place in the ftomach, the patient firft fwallows the acidrropeily diluted, and the:"^>?hk^ik dihited,.iiu- mediatel; after. u PRACTICE OF PHYSIC. 1. That as in fevers a fpontaneous fweating does not immediately come on, fo there muft be in thefe fome circumftances different from thofe in the ftate of health, and which may therefore render it doubtful whether the fweating can be fafely excited by art. 2. That, in many cafes, the practice has been attended with bad confequences. 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, employed to prevent the acceffion of intermitting fevers, has often changed thera into a continued form, which is always dangerous. 3. The utility of the practice is further doubtful, be- caufe fweating, when it happens, does not always givi a final determination ; as muft be manifeft in the cafe of intermittents, as well as in many continued fevers, which are fometimes in the beginning attended with fweatings that do not prove final; and, on the contra- ry, whether fpontaneous or excited by art, feem often to aggravate the difeafe. clxv. From thefe confiderations, it is extremely doubtful if the practice of fweating can be admitted very generally ; but at the fame time, it is alfo doubt- ful, if the failure of the practice, or the mifchiefs faid to have arifen from it, have not been owing to the im- proper conduct of the practitioner. With refpect to this laft, it is almoft agreed among phyficians. i, That fweating has been generally hurtful when ex- cited by ftimulant, heating, and inflammatory medi- cines. 2. That it has been hurtful when excited by much external heat, and continued with a great increafe of the heat of the body. 3. That it is always hurtful when it does not foon re- lieve, but rather increafes the frequency and hardnefs of the pulfe, the anxiety and difficulty of breathing, the headach, and delirium. PRACTICE OF PHYSIC. 8j 4. that it is always hurtful if it be urged, when the fweat is not fluid, and when it is partial, and on the fuperior parts of the body only. clxvi. In thefe cafes, it is probable, that either an inflammatory diathefis is produced, which increafes the fpafm on the extreme veffels ; or that, from other cauf- es, the fpafm is too much fixed to yield eafily to the in- creafed action of the heart and arteries ; and, upon ei- ther fuppofition, 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. clxvii. Though the doubts ftarted (clxiv.) are to be attended to ; and although the practices (clxv.) hav- ing been found hurtful, are therefore to be rejected ; it ftill remains true, 1. That fweating has certainly been often ufeful in preventing the acceffion of fevers, when the times of this have been certainly forefeen, and a proper conduct 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 gradual formation, has often prevented their further progrefs. 3. That, even after pyrexiae 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, fo far as we yet know, moft fuccefsfully by fweating. clxviii. Thefe inftances (clxvii.) are in favor of fweating, but give no general rule ; and it muft be left to further experience to determine how far any general rule can be eftablifhed in this matter. In the mean time, if the practice of fweating is to be attempted, we can venture to lay down the following rules for the conduct of it. 1. That it fhould be excited without the ufe of ftim- ulant inflammatory medicines. 16 PRACTICE OF PHYSIC. 2. That it fhould be excited with as little external heat, and with as little increafe of the heat of the body, as poflible. 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, providing that it proceeds without the circum- ftances mentioned (clxv. 3. 4.) 4. That, for fome part of the time, and as long as the perfon can eafily bear, it fhould be carried on with- out admitting of fleep. 5. That it fhould be rendered univerfat over the whole body ; and therefore, particularly, that care be taken to bring the fweating to the lower extremities. 6. That the practice fhould be rendered fafer by moderate purging, excited at the fame time. 7- That it fhould not be fuddenly checked by cold any how applied to the body. clxix. When attention is to be given to thefe rules, the fweating may be excited, 1. By warm bathing or a fomentation of the lower extremities. 2. By frequent draughts of tepid liquors, chiefly water, rendered more grateful by the addition of a light aromatic, or more powerful by that of a fmall quantity of wine. 3. By- giving fome dofes of neutral falts. 4. Moft effectually, and perhaps moft fafely, by a large dofe of an opiate, joined with a portion of neutral falts, and of an emetic. In what cafes may cold water, thrown into the ftomach in large quantities, be employed to excite fweating*, fee CelsVjs; Lib. III. chap. vii.—ix. clxx. The fourth means (cun. 1.) of determining to the furface of the body, and thereby taking off the fpafm affecting the extreme veffels, is by the ufe of em- etics. ♦Dr.Currie has afcertained, that cold water taken into the ftomach, pro- duces effects fimilar to thofe which arife from the cold affufion, and may be had recourfe to under the fame reftrictions. As a remedy in fever, it is not r.ear fo powerful as the affufion. They are both however, to be reckoned amongft the moft powerful means of inducing a diaphoresis, and are likely to fuperfede moft other medicines in this refpecl, independent of their other PRACTICE OF PHYSIC. 87 clxxi. Emetics, and particularly antimonial emetics, have been employed in the cure of fevers ever fince the introduction of chemical medicines; but, for a long time, they were employed by chemifts and chemical prac- titioners only ; and although of late the ufe of them has become very general, their efficacy is ftill difputed, and their manner of operating is not commonly explained. clxxii. Vomiting is in many refpects ufeful in fevers ; as it evacuates the contents of the ftomach ; as it emul- ges the biliary and pancreatic ducts ; as it evacuates the contents of the duodenum, and perhaps alfo of a larg- er portion of the inteftines ; as it agitates the whole of the abdominal vifecra, expedes the circulation in them, and promotes their feveral fecretions ; and, laftly, as agitating alfo the vifcera of the thoraxj it has like ef- fects there. All thefe feveral effects are, in many caf- es and circumftances of fever, procured with advantage; but do not properly fall under our view here, where we are to confider only the effect of vomiting in determin- ing to the furface of the body. clxxiii. This effect we do not impute to the exercife of vomiting in agitating the whole frame,but to the par- ticular operation of emetics upon the mufcular fibres of the ftomach, whereby they excite the action of the ex- treme arteries on the furface of the body, fo as thereby effectually to determine the blood into thefe veffels, re- move the atony, and take off the fpafm affecting them. clxxiv. That fuch is the power of emetics, will ap- pear from the feveral confiderations mentioned above (xliv.) ; and, therefore, that they are remedies well fuited to the cure of fevers. clxxv. Emetics, for that purpofe, are adminiftered in two different ways ; that is, either in fuch dofes as may excite full and repeated vomitings; or in fuch dofes as may excite ficknefs and naufea, only, with little or no vomiting at all. clxxvi. Full vomiting is beft fuited to the feveral purpofes mentioned clxxii. ; and is alfo well fuit- ed to determine to the furface of the body, fo as thereby to obviate the atony and fpafm which lay the ss PRACTICE OF PHYSIC. foundation of fever. Thus vomiting, excited a little be. fore the expected acceffion of the paroxyfm of an in- termittent, has been found to prevent the paroxyfm al- together. And it has been obferved alfo, that when contagion has been applied to a perfon, and firft difco* vers its operation, a vomit given will prevent the fever, which was othervvife to have been expected. See Lind an Fevers and Infcclion. clxxvii. Thefe are advantages to be obtained by ex- citing vomiting* at the firft approach of fevers, or of the paroxyfms of fevers ; and after fevers are formed, vomiting may alfo be employed, to take off, perhaps en- tirely the atony and fpafm, or at leaft to moderate thefe, fo that the fever may proceed more gently and fafely. clxxvjii. It is feldom, however, that vomiting is found to produce a final folution of fevers; and after they are once formed it is commonly neceflary to re- peat the vomiting feveral times ; but this is attended with inconvenience, and fometimes with difadvantage. The operation of full vomiting commonly foon ceaies, and the exercife of vomiting is often a debilitating power ; and therefore, when the vomiting does not re- move the atony and fpafm very entirely, it may give occafion to their recurring with greater force. clxxix. For thefe reafons, after fevers are fully formed, phyficians have thought proper to employ em- etics in naufeating dofes onlyj. Thefe are capable of exciting the action of the extreme veffels, and their op- eration is more permanent. At the fame time, they of- ten fhow their power by exciting fome degree of fweat; * When it is intended to excite vomiting, a table fpoonful of the follow- ing folution may be taken every twenty minutes till it enfue. &. Tart. emet. gr. v. Sp. Lavand. cornp. gutt. xv. Aq. ferven. | iv. M. t The fame objections which the author has adduced againft the repfti^ tion of vomiting, may be urged againft the exhibition of emetics in naulea- ting dofes. They are feldom productive of much advantage, and by ex- haufting the patient, and accelerating that delility, to which we fhould al" ways look forward, may prove not a little injurious. Hence, if they de ne* fpeedily relieve the fymptoms, we fhould i.ot perfevere in their ufe* PRACTICE OF PHYSIC. i9 and their operation is rendered more fafe, by their com- monly producing fome evacuation by ftool. clxxx. Such are the advantages to be procured by naufeatiiig dofes of emetics; and it only remains to mention, what are the medicines moft fit to be employ- ed in that manner, what are the moft proper timest for exhibiting, and what is the beft manner of admmiftering them. clxxxi. The emetics at prefent chiefly in ufe, are Ipecacuanha and Antimony. The former may be employed for every purpofe of emetics, particularly thofe mentioned clxxii. It may likewife be employed, either in larger or fmaller dofes, for determining to the furface of the body ; but, even in-very fmall dofes, it fo readily excites vomiting, as to be with difficulty employed for the purpofe of naufea- ting only; and, however employed, there is reafon to believe that its effects are lefs permanent, and lefs pow- erfully communicated from the ftomach to the reft of the fyftem, than thofe of Antimony. clxxxii. This, therefore, is generally preferred; and its preparations, feemihgly Various, may all be referred to two heads: the one comprehending thofe in which the reguline part is ill a condition to be acted upon by acids ; and therefore, on meeting with acids in the ftomach, becomes active : and the other comprehending thofe preparations in which the reguline part is already joined with an acid, rendering it active. clxxxiii. Of each kind there are great numbers, but not differing eflentially from one another. It will be enough for us to compare the Calx Antimonii Nitrata of the Edinburgh Difpenfatory with the Emetic Tartar of the fame* The former, as I judge, is nearly the fame with what is called James's Powder.* Which of thefe * The celebrity of James's" Powder, has rendered the nature of its ccm- pofition an interesting object ef enquiry. Dr. Pearfon, in a Memoir read before the Royal Society,'in the year 1791, has fubjecled it to an elaborate and ingenious analysis; and the remit of his experiments is as follows: " 1. That James's Powder confifts of phofphori • acid, lime, and antjmo- •* nial calx ; with a minute quantitv of calx of iron, which is confidered to " be an accidental fubftance. a. That cither thefe three efTential ingredi- ents are united with each other, forming a triple compound, or phofphop- 9° PRACTICE OF PHYSIC. h 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 thereby feem to be more certainly fudorific and purgative, yet the uncertainty of its dofe renders it inconvenient, has often given occafion to the timid tq be difappointed, and the bold to do mifchief. On the other hand, the dofe of the Emetic Tartar can be exactly afcertained ; and I think it may be exhibited in fuch a manner as to produce all the advantages of the other. clxxxiv. Whichfoever of thefe preparations be em° ployed, 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 fe- vers, the exacerbations are not always very obfervable : but there is reafon to think, that one commonly hap- pens about noon, or foon after it, and another in the evening ; and that thefe therefore are the moft proper times for exhibiting emetics. " ated lime is combined with the arttimonial calx, composing a double " compound, in the proportion of about 57 parts of cah, and 43 parts of *' phosphorated lime. .3 That this ar.timonial calx is different frr m any " other known calx of antimony, in feveral of its chemical qualities: About " three fourths of it are foluble in marine acid, and afford Algaroth pow- " der; and the remainder is'not foluble iu this menftruum, and is appar- M ently vitrified. «'It appears, by calcining together bone afhes, that is, phofphorated ** lime, and antimony in a certain proportion, and afterwards expofing the «' mixture to a white heat, a compound was formed, confifting of antimo- " nial calx and phofphorated lime, in the fime proportion, and poffeffing u the fame kind of chemical properties as James's Powder." It is however to be remarked, that almoft all experiments, whether of fynthefis or analvfis, where heat is a primary agent, are fnl>ject to fources of fallacy, which it is not always e^fy to guard againft. Mr. Chemvix has endeavored to remove thefe inconveriienciee, by effecting the combination in the humid way. He directs u=» to diffolve, together or fepa ately, equal parts of thewhiteoxydofantimony.andofphofphateof lime, in the fmalleft poffible quantity < f muriatic acid; and then to pour th;s folution gradually into diftiih d water, which has been previously alka'izated with ammoniaJ A copious wlrte precipitate takes place, which, properly warned and dried, is a fubftitute for James's Powder; and appear* to be of more con- ftant and uniform ftrength than others which have been recommended. Its pofieffing the fame general properties of James's Powder, is att-^ed by phyficians of the firft eminence. See Philofoph. Traaf. for t%ot, or Nicholfon's Journal for January i*o*. PRACTICE OF PHYSIC. 91 clxxxv. With refpect to the manner of adminiftra- tion, 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 vomiting ; and thefe dofes, after fliort intervals, are to be repeated for feveral times, till ficknefs,' naufea, and fome, but not much, vomiting come onJ The differ- ence of this adminiftration rnuft depend upon the dofe, and the length of the intervals at which it is given. If it he intended that the medicine fhould certainly oper- ate by ftool, the dofes are made fmall, and the intervals long. On the contrary, when vomiting is proper, or when much purging ought to be avoided, and therefore fome vomiting muft be admitted, the dofes are made larger, and the intervals fhorter*. . * t)r, Fordyce ha9 a peculiar opinion reflecting the operation of the preparations of antimony in fevers. He conceives that their beneficial ef- fects are not to be attributed to the ficknefs which they excite, but to fome other operation ; and he affigns the following reafons for his opinion ; il Becaufe there are many other remedies which produce ficknefs to as w great a degree as any preparation of antimony? yet thefe have no '.'power whatever, of, making tever terminate fooner than it wouid, if " it was left to purfue its own courfe. The root of the fquill, for inftance, *' often produces ficknefs to a much more fevere degree than any preparation! *' of antimony; yet it has never been alkdged, that it has the power of car- " rying off fever fooner than it would go off, fuppofing that it was allowed to f* purfue its ordinary progrefs. Moreover, the author has frequently exfcib- t* ited the root of the fquill as an emetic, and likewife in fuch dofe3 as to f produce .naufea without vomiting; alfo in fuch dofes as juft not to pro- ** duce naufea, without ever producing any. thing fimilar to the appearance! •' which takes place in a crifis of fever, or without ever once occafioning a ••■.'■ cci. Having now eonfidered the feveral means of fat- isfying the firftSgeneral indication in the cure of fevers, J proceed to the fecond (cxxvi.) which is, To remove the caurc, or obviate the effecls of debility. * ■ . ecu. Moft of the fedative powers inducing debility, ceafe to act foon after they have been: firft applied ; and therefore the removing them is not an object of our prefent indication.^ There is only one which may be fuppofed to continue ,to act for along time; and that is the contagion, applied: But we know nothing of the nature of contagion that can lead us-to anymeafures for removing or correcting it. We.know only its ef- fecbf as a fedative power inducing.debility, or as a fer- ment inducing a tendency to putrefaction in the fluids. PRACTICE OF PHYSIC. 95 The obviating the latter will be confidered under our third general indication, and the former alone is to be confidered here. cciu. The debility induced in fevers by contagion, or pther caufes, appears efpecially in the weaker energy of the brain; but in what this confifts, or how it may be di- rectly reftored, we do not well know. As nature how- ever does, feemingly for this purpofe, excite the action of the heart and arteries, we afcribe the continuance of debility to the weaker reaction of the fanguiferous fyf- tem ; fo that the means to be employed for obviating debility, are immediately directed to fupport and in- creafe the action of the heart and arteries; and tjie remidies ufed are Tonics or Stimulants. cciv. In contagious difeafes^ both from the effects which appear, and from diffections, it is known that the tone of the heart and arteries is confiderably diminifh- ed ; and that tonic remidies therefore are properly in- dicated. Thefe are to be confidered as of two kinds ; the firft being the power pf cold, |he fecond tfrat of tonic med- icines. ccv. The power of cold, as a tonic, I have mentioned above (xc); and it is employed in fevers in two ways; either as the cold matter is thrown into the ftpmach, pr as it is applied to the furface of the body. ccvi. As it has been fhown above, that the tonic power of cold can be communicated from any one part to every other part of the fyftem ; fo it will readily be allowed, that the ftomach is a part as fit for this com- munication as any other; and that cold drink, taken into the ftpmach, may therefore prove an ufeful tonic in fevers. ' ccvn. This the experience of alJ 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 circumftances which may forbid the ufe of cold drink, 4 0 PRACTICE OF PHYSIC. is difficult to determine; but it feems clearly forbidden, in all cafes where a phlogiftic diathefis prevails m the fyftem, and more efpecially when there are topical af- fections of an inflammatory nature. ccvm. The other method of employing cold as a ton- ic, is by applying it to the furface of the body. The appli. cation of cold air to the furface of the body, as a refrig- erant power fit to moderate the violence of reaaion, I < have fpoken of above (cxxxm.); but probably it may alfo be confidered here as a tonic, and ufeful in cafes of . debility. ccix. Not only cool air, but cold w^ter alfo may be 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 a tonic ; but it is a difcovery of modern times, that in the cafe of putrid fevers, attended with much debility, the body may be. wafhed all over with cold water. ccx. This was firft practifed at Breflawin Silefia, as appears from a differtation, under the title of Epidemia verna qua Wratiflaviam, anno 1737, afflixit, to be found in the appendix to the Acla Nat. Curicf. Vol. X. An4 from other writers we find, that the practice has paffec( into fome of the neighboring countries •, although in this ifland, fo far as I know, we have hitherto had no experience o( it. ccxi. The medicines which have been employed in fevers, as tonics, arc 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 preparations of iron which have been employed, can act as tonics only. The preparations of copper, from their effects in epilepfy, are prefumed to poffefs a tonic power; but whether their ufe in fevers be founded upon their tonic or their emetic powers, may be uncertain. The ufe of arfenic and of alum, in intermittent fevers, feems manifeftryj to depend upon their tonic power. And, upon theAvhole, there may occur cafes of continued fe- vers, which may be cured by tonics taken from the fof- fil kingdom : but the ufe of thefe has been rare, as welL PRACTICE OF PHYSI«. 97 as the effects uncertain ; and phyficians have employed, more commonly, the vegetable tonics. ccxn. 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 cir- cumftances of thefe fevers, is not well afcertained; anc} I fhall now only confider the queftion with refpect to the mcft celebrated of thefe tonics, the Peruvian Bark.- ccxm. This bark has been commonly confidered as a fpecific, or as a remedy of which the operation was not underftood. But it is certainly allowable to en- quire into this matter ; and I apprehend it may be ex- plained. ccxiv. To this purpofe it is to be remarked, that as in many cafes the effe&s of the bark are perceived foon after its being taken into the ftomach, and before it can poflibly be conveyed to the mafs of blood, we may con- clude, that its effects 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 com- municated to the reft of the nervous fyftem. This op- eration feems to be a tonic power, the bark being a remedy in many cafes of debility, particularly in gan- grene : and, as the recurrence of the paroxyfms of in- termittent fevers depends upon a recurrence of atony (xxxv. and xxxvi.), fo probably the bark, by its tonic power, prevents the recurrence of thefe paroxyfms; and this is greatly confirmed by obferving, that many other tonic medicines anfwer the fame purpofe. cexv. If the operation of the bark may be^ thus ex- plained, from its poffefling a tonic powei% it is eafy to perceive why it is improper when a phlogiftic diathefis prevails ; and, from the lame view, we can afc£rtain in what cafes of continued fever it may be admitted. Thefe are either after confiderable remiflions have ap- peared, when it may be employed to prevent the re- turn of exacerbations, on the fame footing that it is uf- ed in intermittent fevers; or in the advanced ftate of fevers, when all fufpicion of an inflammatory ftate is removed, and a general debility prevails in the fyftem ; 98 PRACTICE OF PHYSIC. and its being then employed is fufficiently agreeable to the prefent practice. ccxvi. With refpect to the ufe of the bark, it is prop- er to add, that good effects are to be expected from itj almoft only when given in fubftance and in large quan- tity. ccxvu. Another fet of medicines to be employe^; for obviating debility and its effects^ are the direct ftimulants (ccm.) 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 thei r op- eration renders the ufe of them ambiguous ; and when an inflammatory diathefis is prefent, as fo often happen* in the beginning of fevers, the effects of thefe ftimulants may be very hurtful; but it ftill remains probable^ that in the advanced ftate of fevers, when debility prevails^] they may be ufeful. '"*■.' ccxvm. What are the ftimulants that may be moft • properly employed,! am uncertain, as the ufe of them in this.age has been rare; but I am difpofed to believe*'. thatj of all kinds, wine is the beft. ccxix. 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 o-iven in fmall dofes ; fo that it may be employed with fuffi- cient caution ; but it is of little ferviee* unlefs taken pretty largely. ccxx. It may be fuppofed, and or; 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 dift:n PRACTICE OF PHYSIC. ccxxiv. The putrid or putrefcent matter, already prefent in the body, may be evacuated, partly by evao uating frequently the contents of the inteftines, and more effectually ftill, by fupporting the excretions of perfpiration and'urine, by the plentiful ufe of diluents. ccxxv. 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 antifeptics. Thefe laft are of many and various kinds, but which of tnem are conveniently applicable, or more particularly fuited to the cafe of fevers, is not well af. eertained, Thofe moft certainly applicable and ufeful, are, acefcent aliments, acids of all kinds, neutral falts, and fixed air. ccxxvi. The progrefs of putrefaction may be confid. erably retarded, and its effects obviated, by fupporting the tone of the veflels ; and this may be done by tonic i remedies, the chief of which are, Cold, and Peruviai j Bark, both fufliciently treated of above (ccv. etfeq.) * ccxxvn. I have now finifhed the confideration of the three general indications to be formed in the cure of con- tinued fevers, and have mentioned moft of the remedies which have been, upon any occafion, employed in this bufmefs. It was neceflary, in the firft place, to confider thefe indications and remedies feparately, and to explain the operation of the latter more generally ; but from what has been now delivered, compared with what was faid above, concerning the difference of fevers', and thq fignification of their feveral fymptoms in forming the prognoftic, I expect it will not be difficult to aflign the indication, and to felect and combine the feveral reme- dies mentioned, fo as to adapt them to the feveral fpe- ties and circumftances of continued fevers. I think it may be ufeful for my Reade-s to have the whole of the Cure of Continued Fevers brought under one view, as in the following Table: PRACTICE OF PHYSIC. IOX • IN THE CURE OF CONTINUED FEVERS, THE INDICATIONS ARE, I. To moderate the violence ofreacliom Which may be done, by 1. Diminifhing the action of the heart and arte- ries, by A. Avoiding or moderating thofe irritations which are almoft conftantly applied to the body; as, a. The impreffions made upon our fenfes, par- ticularly, «. Increafed heat, whether arifing from eccc. External heat, or /5/J. The accumulation of heat of the body, b. The exercife of the body, c. The exercife of the mind, d. The taking in of aliment. e. Particular irritations arifing from a. The fenfe of thirft, (9. Crudities or corrupted humors in the ftom- ach, y. The preternatural retention of faeces, 2. A general acrimony of the fluids. B. Employing certain fedative powers ; as, a. Cold, t>. Refrigerants j the chief of which are, a. Acids of all kinds, 0. Neutral falts. y. Metallic falts. C. Diminifhing the tenfion and tone of the arteri- al fyftem, by a. Blood letting, b. Purging. 2. Taking off the fpafm of the extreme veffels, by A. Internal means ; which are, a. Thofe remedies which determine to the furface, as, u. Diluents, ». Neutral falts, set PRACTICE OF PHYSIC. y. Sudorifics, J. Emetics.-4 ■ r b. Thofe remedies named antifpafmodics. B. External means $ as, a. Bliftering, b. Warm bathing. II. To remove the caufes, or obviate the effetts of debilty, tof 1. Supporting and increafing the action of the heart and arteries, by A. Tonics, as, a. Cold, b. Tonic medicines, which are either, a. Foflil, as, act. Saccharum faturni, &c. or, (3. Vegetable, as, . act. Peruvian Bark. B. Stimulants, as, a. Aromatics, &c. b. Wine. III. Ta obviate or cor reel the tendency of the fluids to put re- flation, by , J. Avoiding the application of putrid or putrefcentf matter, by A. Removing the patient from places filled with • corrupted air. B. Correcting the air, from which he cannot be removed. C. Avoiding the accumulation of the patient's own effluvia, by a. A conftant ventilation, b. Frequently changing the bed clothes and body linen. D. Removing carefully and fpeedily all excrement* al matters. E. Avoiding animal food, or correcting it. 2. Evacuating the putrid or putrefcent matter al- ready prefent in the body, by A. Evacuating frequently the inteftines. PRACTICE OF PHYSIC. 102 B. Supporting the excretions of perfpiration and urine, b$ a. Diluents, b. Neutral falts. 3. Correcting the putrid or putrefcent matter re- maining in the body, by A. Diluent's, B. Antifeptics, C. Fixed air. +. Refitting farther putrefaction, or obviating its effects, by Supporting the tone of the veffelsj by Tonic remedies. Sect. II. Of the Cure of Intermittent Fevers. ccxxvm. It ftill remains to confider the cure of in- termittent fevers ; and, with refpect to thefe, we form alfo three general indications ; 1. In the time of intermijffwn, to prevent the recurrence of paroxyjms. 2. In the time of paroxyfms, to conducl thefe fo as to obtain a final folution of the difeafe. 3. To take off certain circumflances which might prevent the fulfilling of the twoflrfl indications. ccxxix. The firft indication may be anfwered in two ways: i. By increafing the action of the heart and arteries fome time before the period of acceffion, and fupport- ing that increafed 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 oc- cafion to the recurrence of paroxyfms. 2. Without increafing the action of the heart and ar- teries, the recurrence of paroxyfms may be prevented, by fupporting the tone of the veffels, and thereby pre- venting atony j and the confequent fpafm. ccxxx. For the purpofe mentioned in (ccxxix. 1.), the action of the heart and arteries may be increafed ; I. By various ftimulant remedies, internally given, or externally applied, and that without exciting fweat. J04 PRACTICE OF PHYSIC. e. By the fame remedies, or others fo managed as to excite fweating, and to fupport that fweating till the pe- riod of acceffion be for fome time paft. 3. By naufeating dofes of emetics, given about an hour before the time of acceffion, thereby fupporting and increafing the tone and action of the extreme veffels; ccxxxi. The tone of the extreme Veffels may be fup- ported without increafing the action of the heart and ar- teries (ccxxix. 2.), by various tonic medicines ; as, 1. Aftringents alone. 2. Bitters alone. 3i Aftringents and bitters conjoined. 4. Aftringents' and aromatics conjoined. 5. Certain mytallic tonics*; 6. Opiates. Laftly, An impreflion of horror. * Various metallic preparations, as the flowers of zinc, fulphat of zinc, mercury, &c. have been extolled as remedies of intermittent fever. Thefe, however have now fallen into" general disrepute. The oxyd of arfenic i* the only metallic fubftance which claims diftinct notice. It is a moft powerful remedy in this difeafe ; and, were it not for the deleterious conftquencn with which it is fometimes attended^ would perhaps claim a preference to the bark itfelf. The ague drop, which empirics have converted fomuch to their emolu- ment, and which of courfe they have fo much abufed, in treating this dif- eafe, is indebted to arfenic for all; its virtues. Dr. Fowler, in hi? Reports on the Ufe of Arfenic, has given fuflicient teftimony of it s fuccefs. He prepares it in the following manner: 64 grams oftbe oxyd of arfenic are reduced to a fine powder, and mixed with an equal quantity of potafh, Which is added to half a pound of diftilled water in a florence flafk, and placed in a fand heat, where it is gently boiled till the arfenic is completely diflblved; to this fo- lution, when cold, haffan ounce of compound fpirit of lavender is added, and as much diftilled water as makes- the whole amount to a pound. Froni two to twelve drops of this folution are prefciib«d once or oftener in the day, according to the circumftances of the patient. Other refpedrable prac- titioners have corroborated Dr. Fowler's reports of the virtues of this med- icine. There are however fome confiderations which fhow that this reme- dy fhould not be employed, but with the utmoft caution, and perhaps that it mould never be had recourfe to, till other medicines, more fafe in their operation, have proved unfuccefsful. Even in fmall dofes, it fometimes caufe* exceffive vomiting, fwellings in diffetent parts of the body, headach, and tremors. It is alfo, like digitalis and mercury, apt to be accumulated in the body, and to produce alarming and unexpected effects. It has been fuggefted that it would be more fafe, and perhaps equally effectual in its op- eration, if it was brought to the ftate of a neutral fait. It is found, accord- ing to the procefs of Guyton. that, when equal quantities of nitrate of pot- afh, and oxyd of arfenic, are diftilled together by a ftrong heat, the nitric acid of the nitrate is decompofed, and the arfenic converted into an acid, which u- niting with the alkali, forms the arfenic of potati. This has been employed with advantage. PRACTICE OF PHYSIC. 105 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 inter minion, and may be confidered as belonging to this head. ccxxxn. Of all the tonic remedies mentioned, (cc- xxxi.) the moft celebrated, and perhaps the moft cer- tainly effectual, is the Peruvian bark, the tonic power of which we have endeavored to demonftrate above (ccxiv.) and have, at the fame time, explained its ufe in continu- ed fevers. The fame obfervation as made in ccxvi. is efpecially proper in the cafe of intermittents ; and further, with refpect 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 * This invaluable medicine, which is now univerfally held in the higheft eftimation, had, at it6 introduction, many prejudices to encounter. _ Its pre- mature exhibition was fuppofed to induce vifceral obftructions, jaundice, dropfy, >k c. Thefe effects, however, which were at firft afcribed to the bark, are now completely difcredited ; and the moft effectual means to prevent their fupervening,is by having recourfe to the early exhibition of this reme- dy, which, by cutting fhort the fever, obviates thofe confequences which afe to be apprehended from its degenerating into a chronic ftate. The bark, in fubftance, is much more powerful than either the extract, decoction, tincture, or infuiion ; and is always to bepreferred when it does not diforder the ftomach or bowels. Oppreflion of the ftomach may often be corrected by the addition of fome grateful aromatic ; and loofenefa will in general be reftrained by an opiate, or gum kino. As the tafte of the bark is to manv highly ungrateful, it is generally exhibited in fome. vehicle which may conceal its tafte. Milk is often had recourfe to for this purpofe. But- ter milk and liquorice have likewife been highly recommended. A few drops of the elixir of vitriol, conjoined with the bark, is often ufeful in pre- venting the naufea and loathing which frequently accompany its exhibition. In children, who often cannot be prevailed.upon to fwallow this medicine, and in adults, where it will not remain on the ftomach, it may be introduc- ed by injection. This, however, fhould never be had recourfe to, but where other means have failed. Some practitioners have been accuftomed to premife different evacuations before they prefcribed the bark; but, in general, the earlier it is had re- courfe to, the more effectually does it remove the diftemper. When the paroxyfm is violent, and the apyrexia fhort, we fhould com- mence immediately after the paroxyfm, and continue its adminiftration, in as large dofes as the ftomach can bear, till the beginning of the enfuing fit. When, however, the aoyrexia is of longer continuance, and efpecially if the difeafe is milder, it is better to delay its exhibition till within feven or eight hours of the approaching paroxyfm. When a marked inflammatory diathefis is prefent, if the heat is intenfe, the pulfe ftrong, full, and hard, the breathing very laborious, accompanied with pains in different parts of the body, the opening a vein often render* the fubfequent adminiftration of the bark confiderably mo;e effectual. H PRACTICE OF PHYSIC. fame time there be neither a phlogiftic diathefis prevail- ing in the fyftem, nor any confiderable or fixed conges- tion prefent in the abdominal vifcera. 2. The proper time for exhibiting the bark in inter- mittent fevers, is during the time of intcrmiflion ; and where intermifiions are to be expected, it is to be ab- ftained from in the time of paroxyfm. ii. In remittents, though no entire apyrexia occurs, the Bark may be given during the remiflions ; and it fhould be given, even though the remiflions be incon- fiderable, if, from the known nature of the epidemic, intermifiions or confiderable remiflions are not to be foon expected, and that great danger is apprehended from repeated exacerbations. 4. In the cafe of geauine intermittents, while a due quantity of bark is to be employed, the exhibition of it ought to be brought as near to the time of acceffion as the condition of the patient's ftomach will allow. 5. In general, in all cafes of intermittents, it is not | fufiicient that the recurrence of paroxyfms be flopped for once by the ufe of the bark ; a relapfe is commonly to be expected, and fhould be prevented by the exhibi- tion of the bark, repeated at proper intervals. ccxxxin. Our fecond general indication for conduct- ing the paroxyfms of intermittent fevers, fo as to obtain a final folution of the difeafe, may be anfwered. l. 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. ccxxxiv. The circumftances which may efpecially pre- vent the fulfilling of thofe two indications, and there- fore give occafion to our third, are, a phlogiftic diathefis prevailing in the fyftem, and congeftions fixed in the abdominal vifcera. The firft muft be removed by ; blood letting and the antiphlogiftic regimen ; the fec- ond, 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 ccxxix. rather than by thofe in article fecond of the fame paragraph. BOOK II. OF INFLAMMATIONS, OR PHLEGMASIA CHAP. f. OF INFLAMMATION IN GENERAL. Sect. I. Of the Phenomena of Inflammation. ccxxxv. When any part upon the furface of the body is affected with unufual rednefs, heat, pain and tumor, we name the difeafe an Inflammation or Phlegmafia. Thefe fymptoms of inflammation are never canfiderable, without, the whole fyftem being at the fame time affected with pyrexia. ccxxxvi. As the external, fo likewife the internal, parts may be affe' dochi.-.e of inflamrr.^ioii, which wa6 lirft advanced by Mr. Allen. It PRACTICE OF PHYSIC. «»3 that the gener;l diathefis frequently arifes from inflam- mation begun in a particular part. ccxlviii. I have thus endeavored, in the cafe of in- flammation, to explain the ftate of the whole fyftem, as well as that of the part more particularly affected. 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 affected, and of thefe I muft now take notice. Sect. III. Of the Terminations of Inflammation. ccxlix. 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 when the previous congeftion and fpafm have been in a moderate degree, and the increafed im- petus of the blood has been fufficient to overcome the fpafm, to dilate the veffels, and to remove the congeft- ion, fo that the part is reftored to its ordinary and heal- thy ftate. A refolution takes place alfo when the increafed im- petus of the fluids has produced an increafed exhala- in conceived, that inflammation, inftead of arifing from an increafed action of the vcflcis of the part, is to be afcribed to a debilitated action, or at leaft to their diminution of power to the vis atergo. It is afferted, that we can- not conceive how a more vigorous contraction of the veffels can allow them to contain a greater quantity of blood ; on the contrary, it appears that an increafed contraction fhould diminifh their area, fo that, although a greater quantity is tranfmitted through them,they muft contain lefs. The only catife of dilatation is,when there exifts a difproportion between the vis a tergo,and the contractile r ower of the veffels. It is fuppofed therefore, that in a part affected with inflammation, the fmall arteries are either in a ftate of compar- ative debility, or that the larger veffels act with difproportioned force* It is likewife fuppofed, that the inflammation fubfides in proportion as the de- bilitated action of the capillaries is removed, and that the cure is completed by reftoring the equilibrium between the action of the larger arteries and thefe veffels. JV|icrofcopic obfervation has been likwife called to the fup- port of this doctrine; and it has been obferved, that the application, of ftim- uli, while they increafed the rapidity of circulation, inftead of producing any thing like inflammation, appeared to diminifh the fizeofthe veffels, and to render the part paler to which they were applied. The ftate of the circu- lation in an inflamed part, has likewife been fubjected to examination ; and •'on obferving the part through the microfcope, where the inflammation " was greateft, the veffels were moft dilated, and the motion of the blood " was floweft." It has likewife been obferved, that the predifpofing caufes, and moft approved method ofcure,fallin with this theory of inSammation. See Dr. Wilfon en Febrile Difeafes, Vol. III. »"I4 PRACTICE OF PHYSIC. tion into the adjoining cellular texture, or an increafed excretion in fome neighboring part, and has thereby relaxed the fpafm, and relieved the congeftion, in the veffels of the part more particularly affected. 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 diftant part, may prove fufiicient to take off the phlogiftic diathefis of the whole fyftem, and thereby relieve the congeftion and fpafm of the particular part affected by inflammation. ccl. The tumor which appears in inflammation may be imputed in part to the congeftion of fluids in their im- proper veflels, but is owing chiefly to an effufion of matter into the adjoining cellular texture ; and, ac- cordingly, tumors feldom appear but in parts adjoin- ing to a lax cellular texture. If, in this cafe, the matter eflufed be only a larger quantity of the ordinary exhal- VI ing fluid, this, when the free circulation in the veffels is reftorcd, will be readily abforbed, and the ftate of the part will become the fame as before. But if the increaf- ed impetus of the blood, in an inflamed part, dilate the exhalent veffels to fuch a degree, that they pour out an entire feruni, this will not be fo readily reabforbed ; and, from the experiments of Sir John Pringle, and ef- pecially from thofe of Mr. Gaber, Mifcell. T-.iunn.Voi.U. we learn, that the ferum, under ftagnation, may fuflcr a particular change, by having the gluten prefent in it changed into a white, opaque, moderately vifcid, mild liquo,, which we name Pus *. When this change takes * This idea of the formation of pus is now generally abandoned, and it is by Hu'.ttr, with more probability, referred to a particular fecretioo. We fee, in cafes of extravafation, that ferum i* poured out, and again reabforbed, without any appearance of pus. Pus is likewife obfe-ved to be poured out, from an ope>. ulcerated furface, without any previou" ftagration or reabforp*' ■<* tion. The following obfervations on pus are ex'raited from Mr. John Hun- ter's elaborate work on Inflammation and Gun fhot Wounds. When treat. ing on pus, he remarks, that " we muft look upon it as a new combination " of the blood itfeif and muft be convinced, that, in Order to carry the de- " competitions and combination* neceflary for producing this effect, either " a new or peculiar ftructure of veffels mult be formed, or a new difpofition", — " and, of courfe, a new mode of adion of the old muft take place. This " new structure, or difpofition of veffels, I fhall call glandular and the effect, " or pus, a fecretiin."—" True pus has certain properties, viz." Globules f " fwimmiog in a fluid, which is coagulable by a folution of fal ammoniac, and, • PRACTICE OFPHVSIC. "5 place in the inflamed part, as it is at the fame time at- tended with an abatement of the rednefs, heat, and pain which before diftinguifhed the inflammation, fo the dif- eafe is faid to be terminated by Suppuration, and an inflamed part, containing a collection of pus, is called an Abscess. ccli. In ifrflammation, the tendency of it to fuppu- ration may be difcovered, by the long continuance of the inflammation, without the fymptoms of refolution ; by fome remiflion of the pain of diftenfion ; by the pain becoming of a throbbing kind, more diftinctly connect- ed with the pulfation of the arteries'rby the pulfe of the arteries being fuller and fofter ; and often, by the pa- tient's being frequently affected with cold fhivering:. The period at which this takes place is not determined, but may be fometimes fooner, fometimes later. When the tendency is determined, the time' neceffary to a complete fuppuration is different in different cafes. When pus is completely formed,.the pain in the part entirely ceafes, and a weight is felt in it. If the collec- tion be formed immediately under the fkin, the tumor becomes pointed, the part becomes foft, and the fluctu- ation of the fluid within can commonly be perceived ; while, at the lame time, for the moft part, the rednefs of the fkin formerly prevailing is very much gone. cclii. In abfeeffes, while the pus is formed of one part of the matter which had been effufed, the other and thinner parts are reabforbed, fo that, in the abfeefs, " at the fame time, a confequent of inflammation."—« Thefe globules fwim " in a flu'd, which we fhould at firft fuppofe to be the ferum <~f the blood ; " for it coagulates with heat, like ferum, and moft probably is mixed with a " fmill quantity of coagulating lymph ; for pus in part coaculates, after hav- ing been difcha-ged from the fecrctiag veffels. But although it is thus " far fimilar to terum, it has properties that ferum has not."—" The propor- " tion thit thzfe white globules in the pus bear to the other parts, depends " on the health of the parts which formed it ; for when the/ are in a large " proportion, the matter is thicker and whiter, and is called jrooti /natter 5 " for ii'.'fc appearances in the matter are no more thin the lefult of cettain " fa! ;tary nroceffes goii.jj on in the folidi: the effect of which proceffes is, to " produce the dilution on wh'u'h beih fuppinvaion and granulation de- " pe.id."—« Pus is fofar of the fame fwcific nature with the part which X " pr xluces it, that it d vs not become an irritatorof the part ; it is perfectly " i-y hvmony with it- Phis is fiir.ilar toeverv othe: lecrelion of ftimulaling "fluids.0 ', . zx6 1-RACTICE OF PHYSIC. when opened, a pus alone appears. This pus, however, is not the converted gluten alone; for the converfion of this being the effect of a particular fermentation, which may affect the folid fubftance of the part and perhaps every folid of animal bodies.; fo it moft readily,, I and particularly affects the cellular texture, eroding /'• much of it, which thereby becomes 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 abfeeffes, upon the whole, ';| the internal furface of an abfeefs is to be confidered as an ulcerated part. ccliii. This account of fuppuration explains why an , abfeefs, when formed, may either fpread into the -j cellular texture of the neighboring parts; or, by erod- j ing the incumbent teguments, be poured out upon the '[ furface of the body, and produce an open ulcer. ccliv. We have here given the idea of an abfeefs as a cellection of matter following inflammation ; but the term has been applied to every collection of matter effu- \ fed, and changed by ftagnation in an inclofed 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. id. An entire and pure ferum. 3. A quantity of red globules. 4. A matter furnifhed by particular glands feated iu the part. i 5. A mixture of matters from different fources, changed by peculiar fermentation. It is the fecond only which affords a proper pus ; the effufion whereof, whether in fuppurating parts or ul- cers, feem c- to be the peculiar effect of an imflammatory , ftate of the veffels ; and, for this reafon it is, that when | ulcers do not produce a proper pus, a circumftance al- * ways abfolutely neceflary to their healing, we, in many cafes, bring the ulcers to a ftate of proper fuppuration, , by the application of ftimulants exciting inflammation, fuch as balfams, mercury, copper, he. Missing page 117-118 PRACTICE OF PHYSIC. cclv. When the matter effufed into the cellular tex- ture of an inflamed part, is tainted with a putrid fer- ment, this produces, in the effufed matter, a ftate ap- proaching more or lefs to that of putrefaction. When this is in a moderate degree, and affects only the fluids effufed, with the fubftance of the cellular texture, the part is faid to be affected with Gangrene ; but if the putrefaction affect alfo the veffels and mufcles of the part, the difeafe is faid to be a Sphacelus. cclvi. 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 oper- ates 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 be- ing difpofed to putrefaction ; as particularly feems to be the cafe of the red globules of the blood effufed in a large quantity. In a thirdmanner alfo,a gangrene feems frequently to arife from the violent excitement of the in- flammation deftroying the tone of the veffels ; where- by the whole fluids ftagnate, and run into putrefaction, which taking place in any degree, deftroys ftill further the tone of the veffels, and fpreads the gangrene. cclvii. 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 actual 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 gangrence proceeds, the color of the part be- comes livid, and by degrees quite black ; the heat of the part entirely ceafes ; the foftnefs and flaccidity of the part increafe; it lofes its confiftence, exhales a ca- daverous fmell, and may then be confidered as affected with fphacelus. 120 PRACTICE OF PHYSIC. cclviii. Gangrene is thus a third manner in which inflammation terminates: and the fchools have com- mor.Iy marked a fourth termination of inflammation; which is by a feirrhus, or an indolent hardnefs of the part formerly affected with inflammation. This how- ever is a rare occurrence, and does not feem to depend fo much upon the nature of inflammation, as upon the circumftances of the part affected. It is in glandular parts chiefly that feirrhofity is obferved ; and it is prob- ably owing to the parts readily admitting a ftagnation of the fluids. I have obferved that inflammation feldom induces feirrhus; but that this more commonly arifes from other caufes ; and when inflammation fupervenes, which is fooner or later apt to do, it does not fo com- mo.ily increafe as change the feirrhofity into fome kind of abfeefs. From thefe confiderations, it does not feem neceflary to take any further notice of feirrhus as a termination of inflammation. cclix. 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 mate of blood, either by means of rupture or of anaftomofis, into the adjoining cellular texture. This happens efpe- cially in inflammations of the lungs, where the effufed .», matter by compreffing the veffels, and flopping the cir- culation occafions a fatal fuffocation ; and this is per- haps the manner in which pneumonic inflammation moft commonly proves fatal. cclx. Another kind of termination is, that of certain inflammations on the furface of the body, when there is poured out under the cuticle a fluid, which being too \ grofs to pafs through its pores, therefore feparates it from the ikin, and raifes it up into the form of a veficlr containing the effufed fluid ; and by which effufion the previous inflammation is taken off. cclxi. Befide thefe already mentioned, I believe there is ftill another manner in which inflammation terminates. When the internal parts are affected with inflammation, there feems to have been almoft always upon their fur- PRACTICE OF PHYSIC. til face an exudation, which appears partly as a vifcid con- cretion upon their furface, and partly as a thin ferous fluid effufed into the cavities in which the inflamed vif- cera are placed. Though we have become acquainted with thefe appearances only, as very conftantly accom- panying thofe inflammations 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 favor of this fuppofit'on that there are inftances of pneumonic inflammation terminating in a hydrothorax. Sect. IV. Of the Remote Caufes of Inflammation. cclxii. The. remote caufes of inflammation may be reduced to five heads. 1. The application of ftimulant fubftances, among which are to be reckoned the action of fire, or burning. 2. External violence operating mechanically in wounding, bruifing, comprefling, or ovcrftretching the parts. 3. Extraneous fubftances, lodged in any part of the body, irritating by their chemical acrimony or mechanical form, or comprefling by their bulk or grav- ity. 4. Cold, in a certain degree, not fufficient immedi- ately to produce gangrene. 5. An increafed impetus of the blood determined to a particular part. It will not be difficult to underftand how thefe re- mote caufes, fingly or in concurrence, produce the proximate caufe of inflammation. cclxiii. It does not appear, that in different cafes oi inflammation there is any difference in .the ftate of the proximate caufe, except in the degree of it; and though fome difference of inflammation may arife from the dif- ference of the remote caufes, yet this is not neceffary to be taken notice of here ; becaufe the different appear- ances which attend different inflammations may be re- ferred, for the moft part, to the difference of the parr 22* Practice of physic. affected, as will appear when we fhall confider the fever- al genera and fpecies marked in the Nofoiogy. When I come to treat of thefe, I fhall find a more proper occa- fion for taking notice of the different ftates of the prox- imate, or of the differences of the remote caufe, than by treating of them in general here. Sect. V. Of the Cure cf Inflammation. cclxiv. The indications of cure in inflammation are different, according as it may ftill be capable of refolu- tion, or may have taken a tendency to the feveral other terminations above mentioned. As the tendency to thefe terminations is not always immediately evident* -\ it is always proper, upon the firft apperance of inflam- mation, to attempt the cure of it by refolution. For this purpofe, the indications of cure are, 1. To remove the remote caufe^ when they are evi- dent,and continue to operate. 2. To take off the phlogiftic diathefis affecting either the whole fyftem, or the particular part. 3. To take off the fpafm of the particular part, by remedies applied either to the whole fyftem, or to the part itfelf. cclxv. The means of removing the remote caufes will readily occur, from confidcring the particular nature and circumftances of the different kinds- Acrid matters muft be removed, or their action muft be prevented, by the application of correctors or demulcents, Compref- fing and overftretching powers muft be taken away; I and, from their feveral circumftances, the means of doing fo will be obvious. cclxvi. The means of taking oft the phlogiftic dia- thefis of the fyftem, are the fame with thofe for moderat- j ing the violence of reaction in fever, which are mention- ed and treated of from cxxvu. to cxlix. and therefore , need not be repeated here. I only obferve, that in the ufe of thofe remedies, there is lefs occafion for anyr referve than in many cafes of fever ; and more particularly, ' that topical bleedings are here particularly indicated and proper. PRACTICE OF PHYSIC. I2j cclxvii. The means of taking off the fpafm of the particular part, are nearly the fame as thofe mentioned above, for taking off the fpafm of the extreme veffels in the cafe of fever, and which are treated of from cl. to cc. Only it is to be obferved here, that fome of thefe are here efpecially indicated, and that fome of them are to be directed more particularly to the part efpecially af- fected ; the management of which will be more properly confidered when we fhall treat of particular inflamma- tions. cclxviii. When a tendency to fuppuration (ccli.) is diftinctly perceived, as we fuppofe it to depend upon the effufion of a fluid which cannot be eafily reabforbed, fo it becomes neceffary that this fluid be converted into pus, as the only natural means of obtaining its evacuation ; and as the effufion is perhaps feldom made without fome rupture of the veffels, to the healing of which a pus is abfolutely neceffary ; fo, in the cafe of a tendency to fup- puration, the indication of cure always is, to promote the production of a perfect pus as quickly as poflible. cclxix. For this purpofe, various remedies, fuppof- ed to poffefs a fpecific power, have been propofed ; but I can perceive no fuch power in any of them ; and, in my opinion, all that can be done is, to favor the fuppu- ration by fuch applications as may fupport a proper heat in the part, as by fome tenacity may confine the per- fpiration of the part, and as, by an emollient quality, may weaken the cohefion of the teguments, and favor their erofion. cclxx. As in the cafe of certain effufions, a fuppura- tion is not only unavoidable, but defirable, it may be fuppofed that moft of the means of refolution formerly mentioned fhould be avoided ; and accordingly our practice is commonly fo directed. But, as we obferve, on the one hand, that a certain degree of increafed im- petus, or of the original circumftances of inflammation, is requifite to produce a proper fuppuration ; fo it is then efpecially neceffary to avoid thofe means of refolu- tion that may diminifh too much the force of the cir- 1 Ii4 PRACTICE OF PHYSIC. culation. And as, on the other hand, the impetus of Che blood, when violent, is found to prevent the proper1 fuppuration ; fo, in fuch cafes, although a tendency to fuppuration may have begun, it may be proper to contin- ue thofe means of refolution which-moderate the force of the circulation. With refpect to the opening of abfeeffes, when com- pletely formed, I refer to the writings on forgery. cclxxi. When an inflammation has taken a tenden- cy to gangrene, that event is to be prevented by every poflible means ; and thefe muft be different, according to the nature of the feveral caufes occafloning that ten- dency, as may be underftood from what has been already faid of them. After a gangrene has, in fome degree, taken place, it can be cured only by the fepara- tion of the dead from the living parts. This, in certain circumftances, can be performed by the knife, and al- ways moft properly, when it can be fo done.* In other cafes, it can be done by exciting a fuppura- tory 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 putrefaction of the part, and its fpreading wider. For this purpofe, various antifeptic applications have been propofed; but it- appears to me, that,while the teguments- * The propriety of fcarification, fo as tofeparate the dead from the found part?, is now juftly called in queftion. The inflammation which is thus excited, is apt to go greater lengths than are neceflary for throwing off the dead fi ora the living parts, and even to favor the fpreading of the gangrene; befides the introduction of putrefcent matter, where the incifion has been made, may prove a hurtful fmtation. Where the gangrene is deep, a fuper- ficial fcarification, juft fufficient to give an outlet to the vitiated matter, is advifable. Various external ftimulants have been recommended! A folu- tion offal ammoniac in vinegar and water, made by diffolving a drachm in two ounces of vinegar and fix of water,.i9 preferred by Mr. Benjamin Bell. See Vol. I. p. 160 of the feventh edition of his Surgery, which thofe who wifh farther information on this fubject would do well to confult. Birk and wine are undoubtedly valuable remedies in gangrene ; but their indifcriminate exhibition in every cafe where gangrenous fymptoms have fupervened, may do much harm. When the inflammatory diathefis ftill prevails, and the pulfe continues full and hard, with violent local fymptoms of inflammation, a continuation of the antiphlogiftic regimen will ftill be neceffary; as we know that the fubfequent gangrene i«, ceteris paribus, proportioned '.o the violence of the previous excitement. PRACTICE OP PHYSIC, **S are entire, thefe applications can hardly have any effect; and, therefore, that the fundamental procedure muft be to fcarify the part, fo as to reach the living fiibftance, and by the wounds made there, to excite the fuppura- tion required. By the fame incifions alfo, we give accefs to antifeptics, which may both prevent the progrefs of the putrefaction in the dead, and excite the inflamma- tion neceffary on the verge of the living part. cclxxii. When the gangrene proceeds from a lofs of tone, and when this, communicated to the neighboring parts,prevents that inflammation which, as I have faid,is neceffary to the feparation of the dead part from the liv- ing, it will be proper to obviate this lofs of tone by ton- ic medicines given internally; and, for this purpofe, the Peruvian bark has been found to be efpecially effectual. That this medicine operates by a tonic power, I have endeavored to prove above (ccxiv.) ; and from what is faid in ccxY. the limitations to be obferved in employ- ing it may alfo be learned. When the gangrene arifes from the violence of inflammation, the bark may not only fail of proving a remedy, but may do harm ; and its pOwcr as a tonic is efpecially fuited to thofe cafes of gangrene which proceed from an original lofs of tone, as in the cafe of palfy and oedema; or to thofe caies of inflammation where a lofs of tone takes place, while the original inflammatory fymptoms are removed. cclxxii 1. 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 forgery, rather than to this place. Having thus, therefore, delivered the general doc- trine, I proceed now to confider the particular genera :md fpecies of inflammation. It has been hinted above (cclxiil), that the differ- ence of inflammation arifes chiefly from the difference of the part affected. I have, therefore arranged them, as they are cutaneous, visceral, or articular ; and in this order they are now to be confidered. 2 n6 PRACTICE OF PHYSIC. G H A P. II. OF INFLAMMATION, MORE STRICTLY CUTANEOUS. ccixxiv.C-jUTANEOUS 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 diftinguifhed by different appellations. When the dif- eafe is an affection of the fkin alone, and very little of the whole fyftem, or when the affection of the fyftem is only fymptomatical of the external inflammation, I fhall give the difeafe the name of Erythema ; but when the external inflammation is an exanthema, andfympto- matical of an affection of the whole fyftem, 1 fhall then '^rne the difeafe Erysipelas. cclxxv. It is the erythema only that I am to confid- er here. For the diftinction between Erythema and Phlegmon, I have formerly referred to the chara£ters given of them in our Nofology. See Synopf. Nofolog. Meth. Vol. II. p. 5. gen. vii. fpec. 1. and 2. But I think it proper now to deliver the characters of them more ful- ly and exactly here, as follows : A Phlegmon is an inflammatory affection of the fkin, witlta iwelling, rifing generally to a more confiderable eminence in the middle of it ; of a bright red color ; both the fwellingand color being pretty exactly circum- fcribed ; the whole being attended with a pain of dif- tenfion, often of a Hounding or throbbing kind, and fre- quently ending in fuppuration. An Erythema, Rofe, or St. Anthony's Fire, is an in- flammatory affection of the fkin, with hardly any evident fwelling ; of a mixed and not very bright red color, readily difappearing upon preffure, but quickly returning again ; the rednefs of no regular circumfcription, but fpreading unequally, and continuing almoft conftantly PRACTICE OF PHYSIC. -1*7 to fpread upon the neighboring part, with a pain like to that from burning ; producing blifters, fometimes of a fmall, fometimes of a larger fize ; and always ending in a desquamation of the fcarf fkin, fometimes in gan- grene. This fubject I am not to profecute here, as properly belonging to forgery, 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 ap- pearances feems to depend on the different feat of the inflammation. In the phlegmon, the inflammation feems to affect efpecially the veffels on the internal fur- face of the fkin communicating with the lax fubjacent cellular texture ; whence a more copious efiufion, and that of ferum, convertible into pus, takes place. In the • rythema, the inflammation feems to have its feat in the reffels on the external furface of the fkin, communicat- M^with the rete mucofum, which does not admit of any effufion, but what feparates the cuticle, and gives occafion to the formation of a blifter, while the fmaller fize of the veffels admits only of the effufion of a thin fluid, very feldom convertible into pus. 13efides thefe differences in the circumftances of thefe two kinds of inflammation, it is probable that they alfo differ with refpect to their caufes. Erythema is the ef- fect of all kinds of acrids externally applied to the fkin ; and when arifing from an internal caufe, it is from an acrimony poured out on the furface of the fkin under the cuticle. In the phlegmon, an acrimony is not com- monly evident. cclxxvi. Thefe differences in the feat and caufes of the phlegmon and erythema being admitted,it will be ev- ident, that when an erythema affects any internal part, it can take place in thofe only whofe furfaces are covered wiih an epithelion, or membrane analogous to the cuti- cle. cclxxvu. The fame diftinction between the feat and caufes of the two difeafes- wiil, as I judge, readily explain what has been delivered by practical writers, with refpect to the cure of thefe diftlrent cutaneous in- 3 12* PRACTICE OF PHYSIC. flammations. But I fhall not, however, profecute this here, for the reafon given above (cclxxv.) ; and, for the fame reafon, fhall not fay any thing of the variety of external inflammation, that might otherwife be con* fidered here. CHAP. III. OF OPHTHALMIA*, OR INFLAMMATION OF THE EYE. cclxxviii. 1 he inflammation of the eye may .be confidered as of two kinds; according as it has its feat in the membranes of the ball of the eye, when I would name it Ophthalmia Membranarum ; or as it has its feat in the febaceous glands placed in the tarfus, or edges of the eye lids, in which cafe it may be termed Ophthalmia Tarsi. Thefe two kinds are very frequently combined to- gether, as tjhe one may readily excite the other ; but they are ftill to be diftinguifhed according as the one or the other may happen to be the primary affection, and properly as they often arife from different caufes. cclxxix. The inflammation of the membranes of the eye affects efpecially, and moft frequently the adnata, appearing in a turgefcence of its veffels ; fo that the red veffels, which are naturally there, become rot only in- creafed in fize, but there appear many more than did in a natural ftate. This turgefcence of the veflels is at- tended with pain, efpecially upon the motion of the ball of the eye ; and this, like every other irritation ap- plied to the furface of the eye, produces an effufion of t:ars from the lachrymal gland. T is inflammation commonly, and chiefly affects the adnata fpread on tfie anterior part of the bulb of the *R?dnefs and pain of 'he eve, intolerance of light, for the moft part ac- companied with an effufion of tears. Species i. Ophthalmia Membranarum. Inflammation in the coats of the eye,in general in the tunica adnata. Species a. Ophthalmia 'Turfs. Tumor, erefion in the edges of the eye- lids, with a glutinous exudation frura the tarfus. Sjn. Nos. PRACTICE OF PHYSIC. ii~ -U ■». ' "&dii/f^-1 ^"^hH&TTEB' OF PHYSIC. **•■■{ x\ violent pyrexia is always dangerous. The danger, however is chiefly denoted by the difff. culty of breathing. When the patient can lie on one fide only; when he can lie on neither fide, but upon his back only ; when he cannot breathe with tolerable eafe, except the trunk of his body be erect ; when, even in this pofture, the breathing is very difficult, and attended with a turgefcence 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 progreflive degrees, and, con- fequently, in proportion, the danger of the difeafe. A frequent violent cough aggravating the pain, is always the fymptom of an obftinate difeafe. As I apprehend that the diieafe is hardly ever refolv- ed, without fome expectoration ; fo a dry cough muft ' be always an unfavorable fymptom. As the expectoration formerly deferibcd, marks that the diieafe is proceeding to a refolution ; fo an expecto- ratfon, which has not the conditions there mentioned^ mu/:. denote at leaft a doubtful ftate of the difeafe; but PRACTICE OF PHYSIC. 1J3 the marks taken from the color of the matter, are for the moft part fallacious. An acute pain, very much interrupting infpiration,is always the mark of a violent difeafe ; though not of one more dangerous, than an obtiife pain, attended with very difficult refpiration. When the pains, which at firft had affected one fide only, have afterwards fpread into the other ; or when, leaving the fide firft affected, they entirely pafs into the other; thefe are always marks of an increafing, and therefore, of a dangerous difeafe. A delirium coming on during a pneumonic inflam- mation, is conftantly a fymptom denoting much danger. cccliii. When the termination of this difeafe proves fatal, it is on one or other of the days of the firft week, from the third to the feventh. This is the moft com- mon cafe; but, in a few inftances, death has happened at a later period of the difeafe. When the difeafe k violent, but admitting of refolu- tion, this alfo happens frequently in the courfe of the firft week ; but, in a more moderate ftate of the 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 remiflion, which, how- ever, may be often fallacious, as the difeafe does fome- times return 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 external part, and if this continue fixed, the pneu- monic inflammation does not recur. cccliv. Pneumonia, like other inflammations often ends in fuppuration or gangrene. ccclv. When a pneumonia, with fymptoms neither very violent nor very flight, has continued for many days, it is to be feared it will end in a fuppuration. This however, is not to be determined precifely by the num- ber of days ; for, not only after the fourth, but even af- ter the tenth day, there have been examples of a pneu- monia ending by a 'refolution ; and, if the difeafe has rj, PRACTICE OF > iVSIC. faffered feme mtermi/eiom and again recurred, there may be inftances of a refolution happening at a much utcr period from the bririmemgof the difeafe, than that }\iic now mentioned. ccclvi. But if a moderate difeafe, in fpite of proper remedies employed, be protracted to the fourteenth day, without any confiderble remiflion, a fuppuration is pret- ty certainly to be expected ; and it will be ftill more cer- tain, if no figns of refolution have appeared, or if an expectoration which had appeared fhall have again ccafed, and the difficulty of breathing has continued or incref- cd, while the-other fymptoms have rather abated. ccclviij That in a pneumonia, the effufion is made} which may lay the foundation of a fuppuration, we con- clude, from the difliculty of breathing becoming greater when the patient is in a horizontal pofture, or when he ■ can lie more eafily upon the affected fide. ccclviii. That, in fuch cafes, a fuppuration has actu* ally begun, may be concluded from the patient's being. - frequently affected with flight cold fliiverings, and with' a fenfe of cold, felt fometimes in one and fometimes in another part of the body. We form the fame conclufion alio from the ftate of the pulfe, which is commonly lefs frequent and fofter, but fometimes quicker an d fuller, than before. cecals. That a fuppuration is already formed, may j be inferred from there being a confiderable remiflion of the pain, which had before fubfifted, while, alongft with \ this, the cough, and efpecially the dyfpncea, continue* and are rather augmented. At the fame time, the fre- quency of the pulfe is rather increafed, the feverifh ftate fuffers confiderable exacerbations every evening, and, by degrees, a hectic, in all its circumftances, comes to be formed. ccclx. The termination of Pneumonia, by gangrene, is much more rare than has been imagined ; and, when M it does occur, it is ufually joined with the termination by effufion (cccxlvi.), and the fymptoms of the one < are hardly to be diftinguifhed from thofe of the other. ' PRACTICE OF PHYSIC. *SS ccclxi. The cure of pneumonic inflammation muft proceed upon the general plan (cclxiv.); but the im- portance of the part affected, and the danger to which it is expofed, require that the remedies be fully, as well as early, employed. ccclxii. The remedy chiefly to be depended upon, is that of bleeding at the arm, which will be performed with moft advantage in the arm of the fide affected, but may be done in either arm, as may be moft convenient for the patient or the furgeon. The quantity drawn muft be fuited to the violence of the difeafe, and to the vigor of the patient, and generally ought to be as large as this laft circumftance will allow. The remiflion of pain, and the relief of refpiration, during the flowing of the blood, may limit the quantity to be then drawn ; but if thefe fymptoms of relief do not appear, the bleed- ing fhould be continued till the fymptoms of a begin- ning 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 fymptoms com- monly, and after no long interval, recur, often with as much violence as before. In the event of fuch recur- rence, 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 perfons who, by their conftitution are ready to faint even upon a fmall bleeding ; and, in fuch perfons, this may prevent the drawing fo much blood at firft as a pneumonic inflammation might require; but, as the fame perfons are frequently found to bear after bleedings better than the firft, this allows the fecond and fubfequent bleedings to be larger, and to fuch a quantity as the fymptoms of the difeafe may feem to demand. ccclxiii. It is according to the ftate of the fymptoms that bleedings are to be repeated, and they will be more effectual when practifed in the courfe of the firft three days, than aftenvards ; but they are not to be omitted. i56 PRACTICE OF PHYSIC. although four days of the difeafe may have already elap- fed. if the phyfician fhall not have been called in fooner, or if the bleedings pradtifed during the firft days fhall not have been large enough, or even although thefe bleedings fhall have procured fome remiflion ; yet, upon the recurrence of the urgent fymptoms, the bleed- ing fhould be repeated at any period of the difeafe, efpe- cially within the firft fortnight, and even afterwards, if a tendency to fuppuration be not evident, or if, after a feeming folution, the difeafe fhall have again returned. ccclxiv. With refpect to the quantity of blood which ought, or which with fafety may be taken away, no general rules can be delivered, as it muft be very differ- ent, according to the ftate of the difeafe, and the con- ftitution of the patient. In an adult male, of tolerable ftrength, a pound of blood, avoirdupois, is a full bleed- ing. Any quantity above twenty 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 bleed- ings, and the whole of the time during which the bleedings have been employed, have been long, the quantity taken, upon the whole, may be greater. ccclxv. When a large quantity of blood has been already 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. buch a meafure will be more particularly proper, when the continuance or 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. ccclxvi. An expectoration takes place fometimes very early in this difeafe ; but if, notwithstanding that, the urgent fymptoms fhould ftill continue, the expectora- tion muft not fuperfede the bleedings mentioned, and* during the firft days of the difeafe, its folution is not to be trufted to the expectoration alone. It is in a more ad* PRACTICE OF PHYSIC. *S7 vanced 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 expectoration. ccclxvii. During the firft days of the difeafe, I have not found that bleeding flops expectoration. 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 evacuations, and the contin- uance of the difeafe, has been already exhaufted, that bleeding feems to ftop expectoration. It appears to me, that even then bleeding does not flop expectoration, fo much by weakening the powers of expectoration, as by favoring the ferous effufion into the bronchiae (cccxlvhi.), and thereby preventing it. ccclxviii. While the bleedings we have mentioned fhall be employed, it will be neceffary to employ alfo every part of the antiphlogiftic regimen (cxxx-— cxxxn.), 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 cov- er him very lightly while he lies in bed. The tem- perature of his chamber ought not to exceed fixty de- grees of Farenheit's thermometer, and whether it may be at any time colder, I am uncertain. ccclxix. 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 accompanied alfo with nitre, or fome other neutrals; but thefe falts fhould be given feparately from the drink. It has been alleged, that both acids and nitre are 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 cough fo confiderable or troublefome as to prevent our feeking the advantages otherwife to be obtained from thefe med- icines. 3 ;5S PRACTICE OF PHYSIC. ccclxx. Some practitioners have doubted, if purga- tives can be fafely employed in this difeafe ; and indeed a fpontaneous diarrhoea occurring in the beginning of the difeafe has feldom proved ufeful ; but I have found the moderate ufe of cooling laxatives generally fafe ; and have always found it ufeful to keep the belly open by fre- quent emollient glyfters. ccclxxi. To excite full vomiting by emetics, I judge to be a dangerous practice in this difeafe : but 1 have found it ufeful to exhibit naufeating dofes ; and, in a fomewhat advanced ftate of the difeafe, I have found fuch dofes prove the beft means of promoting expecto- ration.* ccclxxii. Fomentations and poultices applied to the pained part have been recommended, and may be ufe- ful ; but the application of them is often inconvenient, and may be entirely omitted for the fake of the more effectual remedy, bliftering. Very early in the difeafe, a blifter fhould be applied as near to the pained part as poflible. But, as when the irritation of a blifter is prefent, it renders bleeding lefs effectual, fo the application of the blifter fhould be de- layed till a bleeding fhall have been employed.^ If the difeafe be moderate, the blifter may be applied immedi-J ately after the firft bleeding; but if the difeafe be vio- lent, and it is prefumed that a fecond bleeding may be neceffary foon after the firft, it will then be proper to de- lay the blifter till after the fecond bleeding, when it may be fuppofed that any farther bleeding may be poftponed till the irritation arifing from the blifter fhall have ceaf- ed. It may be frequently neceffary in this difeafe to re- peat the bliftering; and, in that cafe, the plaifters fhould always be applied fome where on the thorax ; for, when applied to more diftant parts, they have little effect; The keeping the bliftered parts open, and making what * As naufea is found to reduce the ftrength and frequency of the pulfe, .it might perhaps prove ufeful in pneumonia ; but medicines employed with this intention, are fo apt to excite vomiting, and, in confequence, rupture or effufion,that it perhaps would be mare advifeable to refrain altogether from their adminiftration. PRACTICE OF PHYSIC. ii5 is called a perpetual blifter, has much lefs effect than a frefh bliftering. ccclxxiii. As this difeafe often terminates by an ex- pectoration,fo various means of promoting this have been propofed ; but none of them appear to be very ef- fectual ; and fome of tfiem being acrid ftimulant fub- ftances, 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 in- duce. The volatile alkali may be of fervfee as an expecto- rant ; but it fhould be referyed for an advanced ftate of the difeafe. Mucilaginous, and oily demulcents, appear to be ufe- ful, by allaying that acrimony of the mucus which oc- cafions too frequent coughing* ; and which coughing prevents the ftagnation and thickening of the mucus, and thereby its becoming mild. The receiving into the lungs the fleams of warm wa- ter impregnated with vinegar, has often proved ufeful in promoting expectoration!. But, of all other remedies, the moft powerful for this purpofe are antimonial medicines, given in naufeating dofes, as in clxxix. Of thefe, however, I have not found the kermes mineral more eflicacious than emetic tartar, or antimonial wine; and the dofe of the kermes is much more uncertain than that of the others. ccclxxiv. Though a fpontaneous fweating often proves the crifis of this difeafe, it ought not to be ex- cited by art, unlefs with much caution. Atjeaft, I have not yet found it either fo effectual or fafe, as fo me writ- * ft Of. Amyd, Mel. Optim.a J ft. Mucilag. gum. Arab. 3 ii. probe fuba&is add?. Aq. Hordeat. J ii. Cihnam. fimp. J ft* Succ.limon. 3" ft. M. Cap. coch. 1. urgentetufli. f.This isperhaps the fafeft and mpft powerful expectorant we can em- ploy. The impregnation cf vinegar fometimes renders it too ftimulating. la ihcfe enfes, the fteams of warm water alone fhould te inhaled. z6o PRACTICE OF PHYSIC. ers have alleged. When, after fome remiflion of the fymptoms, fpontaneous fweats of a proper kind arife, they may be encouraged; but it ought to be without much heat, and without ftimulant medicines. If, how- ever, the fweats be partial and clammy only, and a great difficulty of breathing ftill remain, it will be very dan- gerous to encourage them. ccclxxv. Phyficians have differed much in opinion with regard to the ufe of opiates in pneumonic inflam- mation. To me it appears, that in the beginning of the difeafe, and before bleeding and bliftering have pro- duced fome remiflion of the pain, and of the difficulty of breathing, opiates have a very bad effect, by their in- creafing the difficulty of breathing, and other inflamma- tory fymptoms. But, in a more advanced ftate of the difeafe, when the difficulty of breathing has abated, and when the urgent fymptom is a cough, proving the chief caufe of the continuance of the pain and of the want of fleep, opiates may be employed with great advantage and fafety. The interruption of the expectoration, which they feem to occafion, is for a fhort time only ; and they feem often to promote it, as they occafion a ftagna. tion of what was by frequent coughing diflipated infem fibly, and therefore give the appearance of what phyf|» cians have called Concocted Matter. CHAP. VII. OF THE PERIPNEUMONIA NOTHA, OR BASTARD PERI- PNEUMONY. ccci-xxvr. A disease under this name is mentioned in fome medical writings of the fixteenth cen- tury ; but it is very doubtful if the name was then ap- plied to the fame difeafe to which we now apply it. It appears to me, that unlefs fome of the cafes defcribed under the title of Catarrhus Suffocativus be fuppofed to have been of the kind I am now to treat of, there was PRACTICE OF PHYSIC. 161 no defcription of this difeafe given before that by Syd- enham, under the title 1 have-employed here. ccclxxvii. After Sydenham, Boerhaave was the firft, who in a fyftem took notice of it as a diftinct difeafe ; and he has defcribed it in his aphorifms, although with fome circumftances different from thofe in the defcrip- tion of Sydenham. Of late, Mr. Lieutaud has with great confidence afferted, that Sydenham and Boerhaave had, under the fame title, defcribed different difeafes; and that, perhaps, neither of them had on this fubject de- livered any thing but hypothefis. ccclxxviii. Notwithstanding this bold affertion, I am humbly of opinion, and the Baron Van Swietcn feems to have been of the fame, that Sydenham and Bo- erhaave 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 cffen- tially different from that defcribed by both the other authors. Nor will the doubts of the very learned, but modeft Morgagni, on this fubject, difturb us, if we con- fider, that while very few defcribers of difeafes either have it in their power, or have been fufliciently atten- tive in diftinguifhing between the effentiai and accident- al 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 won- der that the defcriptions of the fame difeafe by different perfons fhould come out in fome refpects different. I fhall, however, enter no further into this controverfy ; but endeavor to defcribe the difeafe as it has appeared to myfelf; and, as I judge, in'thc effentiai fymptoms, much the fame as it has appeared to all the other authors men- tioned. ccclxxix. This difeafe appears at the fame feafons that other pneumonic and catarrhal affections common- ly do; that is, in autumn and in fpring. Like thefe difeafes alfo, it is feemingly occasioned by Hidden chan- ges of the weather from heat to cold. It appears alfo during the prevalence of contagious catarrhs ; and it is 4 H~ PRACTICE OF PHYSIC. frequently under the form of the Peripneumonia Notha, that thefe catarrhs prove fatal to elderly perfons. This difeafe attacks moft commonly perfons fomer what advanced in life, efpecially thofe of a full phlegmat- ic habit; thofe who have before been frequently liable to catarrhal affections, and thofe who have been much addicted to the large ufe of fermented and fpiritous liq- uors. 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 fome* limes fufficiently evident; but in moft cafes thefe are very moderate, and in fome hardly at all appear. With the firft attack of the difeafe, a cough comes on, ufual- ly accompanied with fome expectoration ; and in many •''; cafes there is a frequent throwing up of a confiderable ll quantity of a vifcid opaque mucus. The cough often -, becomes frequent and violent ; is fometimes accompa- nied with a rending headach; and, as in other cafes of $ cough, a vomiting is fometimes excited by it. The face :ij fs fometimes flufhed, and fome giddinefs or drowfinefs, M aften attends the difeafe. A difficulty of breathing, with 1j a fenfe of oppreffion, or ftraitening in the cheft, with \t fome obfeure pains there, and a fenfe of laffitude over the whole body, very conftantly attend this difeafe. The blood drawn in this difeafe, fhows a buffy furface, as in other inflammatory affections. The cHfeafe has often the appearance only of a more violent catarrh, and after the employment of fome reme- dies, is entirely relieved by a free and copious expectora- tion. In other cafes, however, the feverifh and catarrhal fymptoms are at firft very moderate, and even flight 5 but, after a few days, thefe fymptoms fuddenly become confiderable, and put an end to the patient's life, when the indications of danger were before very little evident* •' ccclxxx. From the different circumftances in which this difeafe appears, the pathology of it is difficult. It is certainly often no other at firft than a catarrhal affec- tion, which in elderly perfons, is frequently attended with a large afflux of mucus to the lungs and it was oh PRACTICE OF PHYSIC. 163 this footing that Sydenham confidered it as onlv differ- ing in degree from his Febris Hyemalis. A catarrh, how- ever, is ftrictly an affection of the mucous membrane and follicles of the bronchiae alone : but it may readily have, and frequently has a degree of pneumonic inflam- mation joined to it ; and in that cafe may prove more properly the peculiar difeafe we treat of here. But, further, as pneifmonic inflammation very often produc- es an effufion of ferum into the bronchiee (cccxlviii.), fo this, in elderly perfons, may occur in confequence of a flight degree of inflammation ; and when it docs hap- pen, will give the exquifite and fatal cafes of the peri- pneumonia notha. ccclxxxi. After this attempt to eftablifh the pathol- ogy, the method of cure in the different circumftances of the difeafe will not be difficult. In cafe the fever, catarrhal and pneumonic fymptoms, 1 are immediately canfiderable, a blood letting will cer- I tainly be proper and neceflary : but, where thefe fymp- toms are moderate, a blood letting will harcfiv be requi- site ; and when an effufion is to be feared, the repetition j of blood letting may prove extremely hurtful. In all cafes, the remedies chiefly to be depended upon, are vomiting and bliftering. Full vomiting may be fre- 1 quently repeated, and naufeating dofes ought to be con- ftantly employed. Purging may perhaps be ufeful ; but as it is feldom fo in pneumonic affections, nothing but gentle laxatives are here neceffary. In all the circumftances of this difeafe, the antiphlo- giftic regimen is proper : Cold is to be guarded againft ; but much external heat is to be as carefully avoided. ccclxxxii. If a perfon fweats eafily, and it can be brought out by the ufe of mild tepid liquors only, the practice may in fuch perfons be tried. See Morgagni De Sed. et Cauf. Epift. xiii. Art. 4. ccclxxxiii. I might here, perhaps, give a feparate fection on the Carditis and Pericarditis, or the Inflam- mations of the Heart and Pericardium ; but they hardly ! require a particular confideration. An acute inflamma- 164 PRACTICE OF PHYSIC. tion of the pericardium is almoft always a part of the , fame pneumonic affection I have been treating of ; and is not always diftinguifhed 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 iticif ; and when it happens that the one or oth- er is difcovered by the fymptoms of palpitation or fyn- ., cope, no more will be implied than that the remedies of pncumor.ie inflammation fhould be employed with great- er diligence. From diffection5, which fhow the heart and pericar-; |, dium affected with erofio'ns, ulcerations, and abfeeffes,*ft! we difcover that thefe parts had been before affected f with inflammation ; and that in cafes where no fymp- ~ toms of pneumonic inflammation had appeared : it may t therefore be alleged, that thofe iaflammations of the fc heart and pericardium fhould be confidered as difeafesr It independent of the pneumonic. This inded is juft : butal the hiftory of fuch cafes proves, that thofe inflamma-*jl tions had been of a chronic kind, and hardly difcover- S ing themfelves by any peculiar fymptoms ; or, if attend-ll ed with fymptoms marking an affection of the heart, thefe were however fuch as have been known frequenly | to arife from other caufes than inflammation. There '' is therefore, upon the whole, no room for our treating , more particularly of the inflammation of the heart or pericardium. CHAp- VIIL OF THE GASTRITIS*, OR INFLAMMATION OF THE STOM- ACH. ccclxxxiv. A mong the inflammations of the abdominal region, I have given a place in our Nofology to the Peritonitis ; comprehending under that title, not * Pyrexia inclining to typhus ; anxiety ; heat and pain in the epigaftric region, increafed by whatever is fwallowed ; an inclination to vomit; the i»- gefta immediately rejected ; hiccup. Syn. Nof. PRACTICE OF PHYSIC. 165 only the inflammations affecting the pcritonccum lining the cavity of the abdomen, but alfo thofe affecting the extenfions of this membrane in the omentum and mef- entery. It is not however propofed to treat of them here, becaufe it is very difficult to fay by what fymptoms they are always to be known ; and farther, becaufe when known, they do not require any remedies befides thofe of inflammation in general. 1 proceed, therefore, to treat of thofe inflammations, which, affecting vifcera of peculiar functions, both give occafion to peculiar fymp- toms, and require fome peculiariiie.; in the method of cure ; and I fhall begin with the inflammation of the itomach. ccclxxxv. The inflammation of the 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. ccclxxxvi. The phlegmonic inflammation of the ftomach, or what has been commonly treated of under the title of Gaftritis, is known by an acute pain in fome part of the region of the ftomach, attended with pyrex- ia, with frequent vomiting, efpecially upon occafion of any thing being taken down into the ftomach, and fre- quently with hickup. The pulfe is commonly fmall and hard ; and there is a greater lofs of ftrength in all 'the functions of the body, than in the cafe of almoft any other inflammation. ccclxxxvii. This inflammation may be produced by Various caufes ; as, by external contufion ; by acrids of various kinds taken into the ftomach ; frequently by ve- ry 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 di- geftion. All thefe may be confidered as external cauf- es ; but the difeafe fometimes arifes alfo from internal .caufes not fo well underftood. It may arife from in- * This is a new term jbut whoever confiders whr.t is faid in cclvtiv. wi.lj I expefl, perceive the propriety, a v.! even the sveo< A^- of it. Autb-r. 165 PRACTICE OJf PHYSIC. {laminations of the neighboring parts communicated to the ftomach, and is then to be confidered as a fymp. tomatic affection only. It may arife alfo from various acrimonies generated within the body, either in the ftomach itfelf, or in other parts, and poured into the cavity of the ftomach. Thefe are caufes more directly applied to the ftomach ; but there arc perhaps others o: t riginating elfewhere, and affecting the ftomach only I, fympathetically. Such may be fuppofed to have acted in the cafe of putrid fevers and exanthematic pyrexiae; in which, upon diffection, it has been difcovered that the ftomach had been affected with inflammation. c'cclxxxvi'ii. From the fenfibility of the ftomach, and its communication with the reft of the fyftem, it will be obvious, that the inflammation of this organs by whatever caufes produced, may be attended with fata|i, confequences. In particular, by the great debility which fuch an inflammation fuddenly produces, it majjftj quickly prove fatal, without running the commofij courfe of inflammations. m When it lafts long enough to follow the ordinary. courfe of other inflammations, it may terminate by ref- olution, gangrene, or fuppuration. The feirrhofities which are often difcovered affecting the ftomach, arc feldom known to be the confequences of inflammation. ccclxxxix. The tendency of this difeafe to admit of refolution, may be known by its having arifen from no violent caufe; by the moderate ftate of the fymp- toms ; and by a gradual remiflion of thefe, efpecially in confequence of remedies employed in the courfe of the firft, or at fartheft, the fecond week of the difeafe, cccxc. 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 con. fiderabie remiffion of the pain, while a fenfe of weight and an anxiety ftill remain. When an abfeefs has been formed, the frequency of the pulfe is at firft abated ; but foon after it is again in- creafed, with frequent cold (hiverings, and with marked exacerbations in the afternoon and evening, followed PRACTICE OF PHYSIC. iOy by night fweatings, and other fymptoms of hectic fever. Thefe at length prove fatal, unlefs the abfeefs open in- to the cavity of the ftomach, the pus be evacuated by vomiting, and the ulcer foon heal. cccxci. The tendency to gangrene may be fufpected from the violence of the fymptoms not yielding to the rem'edies employed during the firft days of the difeafe ; and that a gangrene has already begun, may be known from the" fudden remiffion of the pain, while the fre- quency of the pulfe continues, and at the fame time be- comes weaker, accompanied with other marks of an increafing debility in the whole fyftem. cccxcu. From the diffection of dead bodies it ap- pears, that the ftomach very often has been affected with inflammation, when the chara&eriftic fymptoms of it (ccclxxxvi.) had not appeared ; and therefore it is very difficult to lay down any general rules for the cure of this difeafe. cccxcm. It is only in the cafe of phlegmonic inflam- mation, as characterifed in ccclxxxvi. that we can ad- vife the cure or refolution to be attempted by large and repeated bleedings employed early in the difeafe : and we are not to be deterred from thefe by the fmallnefs of the pulfe ; for, after bleeding, it commonly becomes fuller and fofter. After bleeding, a blifter ought to be applied to the region of the ftomach ; and the cure will be aflifted by fomentations of the whole abdomen, as well as by frequent emollient and laxative glyfters. cccxciv. In this difeafe, the irritability of the ftpm- ach will not admit of any medicines being thrown inta it ; and if any internal medicines can be fuppofed necef- fary, 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. cccxcv. 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 vio- lence of the pain and vomiting recur at invervals only, opiates given in glyfters may be cautioufly tried, and fometimes have been employed with advantage. li% PRACTICE OF PHYSIC. cccxcvi. A tendency to fuppuration, in this difeafey is to be obviated by the means juft now propofed. Af- ter a certain duration of the difeafe,it cannot be prevent- ed by any means whatever ; and when actually begun, muft be left to nature ; the buflnefs of the phyfician be- ing only to avoid all irritation. cccxcvn. A tendency to gangrene can be obviated in no other way than by the means fuggefted cccxcm. employed early in the difeafe ; and when it does actual- ] ly fupervene, admits of no remedy. ceoxcvin. Erythematic inflammations of the ftom- ach, are more frequent than thofe of the phlegmonic kind. It appears, at leaft from diffections, that the ftomach has often been affected with inflammation, when neither pain nor pyrexia had before given any no- „ tice cf it; and fuch inflammation I apprehend to have i been chiefly of the erythematic. kind. This fpecies of inflammation alfo, is efpecially to be expected from ac- rimony of any kind thrown into the ftomach ; and, would certainly occur more frequently from fuch a caufer \ were not the interior furface of this organ commonly defended by mucu; exuding in large quantity from ■ the numerous follicles placed immediately under the vil- lous coat. Upon many occafions however, the exuda- tion 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, ev- , en of moderate acrimony, may produce an erythemas \ tic affection of the ftomache. cccxcix. From what has been faid, it muft appear. that an erythematic inflammation of the ftomach may frequently occur ; but will not always difcover itfelf, as it fometimes takes place without pyrexia, pain, or vonv t iting. " cccc. There are cafes, however, in which it may be difcovered. The affection of the ftomach fomtimes- fpreads into the cefophagus, and appears in the pharynx, as well as on the whole internal furface of the mouth. ' When, therefore, an erythematic inflammation affect? the mouth and fauces, and when at the fame time there ] PRACTICE OF PHYSIC. 159 ihall be in the ftomach an unufual fenfibility to all ac- rids, with a frequent vomiting, there can be little doubt of the ftomach being affected with the fame inflamma- tion that has appeared in the fauces. Even when no inflammation appears in the fauces, yet if fome degree of pain be felt in the ftomach, if there be a want of ap- petite, an anxiety, frequent vomiting, an unufual fenfi- bility with refpect to acrids, fome thirft, and frequency of pulfe, there will then be room to fufpect an erythe- matic inflammation of the ftomach; and we have known fuch fymptoms, after fome time, difcover their caufe more clearly by the appearance of the inflamma- tion in the fauces or mouth. Erythematic inflammation is often difpofed to fpread from one place to another on the fame furface ; and, in doing fo, to leave the place it had at firft occupied. Thus, fuch an inflammation has been known to fpread fucceflively along the whole courfe of the alimentary canal, occafioniijg in the inteftines diarrhoea, and in the ftomach vomitings; the diarrhoea ceafing when the vomitings came on, or the vomitings upon the coming on of the diarrhoea. cccci. When an erythematic inflammation of the ftomach fhall be difcovered, it is to be treated different- ly, according to the difference of its caufes and fymp- toms. When it is owing to acrid matters taken in by the mouth, and when thefe may be fuppofed ftill prefent in the ftomach, they are to be wafhed out by throwing in a large quantity of warm and mild liquids, and by excit- ing vomiting*. At the fame time, if the nature of the acrimony and its proper corrector be known, this fhould * White vitriol, on account of the vomiting which it almoft inftantsne- oufly excites, is generally employed on thefe occafions. As to the correcl-- ors of particular acrimonious fubftances, we know little. Where metalic falts have been taken, that is, the calces of metals united with acids, alka- line folu ions are moft effectual. When the oxyd of arfenic has bcea taken, Uie alkaline fulphurets have been recommend, d as depriving it of its oxygen in which ftate it is fuppofed to be inert. Their efficacy, however, is much doubted. In all cafes of this nature, we fhould endeavor, as foon as pofli- ble, to defend the ftomach and inteftines from the irritation rf theft; acrid fubftaHces, by fheathing them with oily and mucilaginous fluids. 170 PRACTICE OF PHYSIC. be thrown in ; or if a fpecific corrector be not known, fome general demulcents fhould be employed. ccccn. Thefe meafures, however, are more fuited to prevent 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 cccxcm. are to be more or lefs employed. ccccin. When an erythematic inflammation of the ftomach has arifen from internal caufes, if pain and py- rexia accompany the difeafe, fome bleeding, in perfons not otherwife weakened, may be employed : but, as the affection often arifes in putrid difeafes, and in convales- cents from fever, fo in thefe cafes bleeding is inadmiffi- ble; all that can be done being to avoid irritation, and to throw into the ftomach what quantity of acids, and of acefcent aliments, it fhall be found to bear. ^ In fome conditions of the body, in which this difeafe^ arifes, the Peruvian bark and bitters may feem to be in- dicated ; but an erythematic ftate of the ftomach doe1; not commonly allow of them. CHAP. IX, OF THE ENTERITIS*, OR INFLAMMATION OF THE INTES- TINES. cccciv. I he inflammation of the intef- tines, like that of the ftomach, may be either pkgmonic, or erythematic : but, on the fubject of the latter, I have nothing to add to what has been faid in the laft chapter; and fhall here therefore treat of the phlegmonic inflam- mation only. ccccvi. This inflammation may be known to be pref- -nt, by a fixed pain of the abdomen, attended with * Pyrexia inclining to typhus, a fmartingpain of the abdomen, accompa- nied with a fenfe of tightnefs and twitting about the umbilicus; vomiting : •bdurate coftivenefs. Syn. Nc-f. PRACTICE OF PHYSIC. *72 pyrexia, coftivenefs, and vomiting. Practical writers mention the pain in this cafe as felt in different parts of the abdomen, according to the different feat of the in- flammation ; and fo indeed it fometimes happens ; but very often the pain fpreads over the whole belly, and is felt more efpecially about the navel. ccccvn. 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 pe- culiar caufes, as fupervening upon the fpafmodic colic, incarcerated hernia, arid volvulus. ccccvm. Inflammations of the inteftines have the fame terminations as thofe of the ftomach; and, in both cafes, the feveral tendencies are to be difcovered by the fame fymptoms (ccclxxxix.—cccxci.) ccccix. The cure of the enteritis is in general the fame with that of the gaftritis (cccxciil. et feq.) ; but in the enteritis, there is commonly more accefs to the introduction of liquids, of acid, acefcent, and other cooling remedies, and even of laxatives. As, however, a vomiting fo frequently attends this difeafe,care muft be taken not to excite that vomiting by either the quantity or the quality of any thing thrown into the ftomach. The fame obfervation, with refpett to the ufe of opiates, is to be made here as in the cafe of gaftritis. ccccx. Under the title of Enteritis, it has been ufual with practical writers to treat of the remedies proper for the colic, and its higher degree named Ileus ; but, although it be true that the enteritis and colic do fre- quently accompany each other, I ftill hold them to be diftinct difeafes, to be often occurring feparately, and accordingly to require and admit of different remedies. I fhall therefore delay fpeaking of the remedies proper for the colic, till I fhall come to treat of this difeafe in its proper place. ccccxi. What might be mentioned with refpect to the fuppuration or gangrene occurring in the enteritis, may be fufEciently underftood from what has been faid on the fame fubject with refpect to the gaftritis. M -n PRACTICE OF FHYSIC. CHAP. X. OE f HE HEPATITIS*, OR INFLAMMATION OF THE LIVIR. ccccxn. I he inflammation of the liver feems to be of two kinds; the one acute, the other chrqnic. ccccxm. The acute is attended with pungent pain, confiderable pyrexia, a frequent, ftrong, and hard pulfe, and high colored urine. cgccxiv. 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 dif- fection, large abfceffesy which are prefumed to be the ef- fect of fome degree of previous inflammation. As this chronic inflammation is feldom to be certainly known, and, therefore, does not lead to any determined prac*. tice, we omit treating of it here, and fhall only treat of what relates to the acute fpecies of the hepatitis. ccccxv. The acute hepatitis may be known by a pain, more or lefs acute, in the right hypochondrium, increafed by prefling 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 in- creafed on refpiration. The difeafe is, in fome inftances, alfo attended with a cough, which is commonly dry, but fometimes humid -r and, when the pain thus refen> bles that of a pleurify, the patient cannot lie eafily except upon the fide affected. * Pyrexia, tenfion and pain in the right hypochondrium, fometimes pun- gent as in pleurify, oftener obtufe; pain at the clavicula, a-d top of the right fhoulder; a difficulty of lying on the left fide; dyfpnoca ; dry cough: vomiting ; hickup. Syn. Nof. ' Species z. Chronic inflammation often fhows no chara&eriftic marks* often however we mav fufpect its prefence from fome of the caufes of hepa- titis being applied; from a lenfe of fulnefs and weight in the right hype- chondrium ; from pain being now a.-d then felt in the fame part • from a fenfe of pain upon preffure of the right hypochondrium, or upon lyinjr en the left fide; and finally, from flight pyrexia at times accempanyine the above fymptoma. Syn.Nef. r 7 b PRACTICE OF PHYSIC. 173 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 hkkup, and fometimes with vomiting. Many practical 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 with- out any fuch fymptom. cccgxvi. The remote caufes of hepatitis are not al- ways to be difcerned, and many have been afligned on a very uncertain foundation. The following feem to be frequently evident: 1. External violence from contuk ions or falls, and efpecially thofe which have occafioned a fracture of the cranium. 2. Certain paffions of the mind, 3. Violent fummer heats. 4. Violent exercife. 5. Inter- mittent and remittent fevers. 6. Cold, applied exter- nally or internally; and, therefore, in many cafes, the fame caufes which produce pneumonic inflammation, produce hepatitis,and whence alfo the two difeafes are fometimes joined together. Ii Various folid concretions or collections of liquid matter, in the fubftance of the liver $ , produced by unknown caufes. Laftly, The acute is of- ten induced by a chronic inflammation of this vifcus. ccccxvu. It has been fuppofed, that the hepatitis may be an affection either of the extremities of the hepatic artery, or of thofe of the vena portarum ; but of the laft fuppofition there is neither evidence nor probability* ccccxvm. It feems probable, that the acute hepatitis is always an affection of the external membrane of the liver, and that the parenchymatie is of the chronic kind* The acute difeafe may be feated either on the convex or on the concave furface of the liver. In the former cafe, a more pungent pain and hickup may be produced, and the refpiration is more confiderably affected. In the latter, there occurs lefs pain, and a vomiting is pro- duced, commonly by fome inflammation communicated to the ftomach, The inflammation of the concave fur- face of the liver, may be readily communicated to the gall, bladder and biliary ducts ; and this, perhaps, is the only cafe of idiopathic hepatitis attended with jaundice* 2 *;4 PRACTICE OF PHYSIC. ccccxix. The hepatitis, like other inflammations, may end by refolution, fuppuration, or gangrene ; and the tendency to the one or the other of thefe events, may be known from what has been delivered above. ccccxx. The refolution of hepatitis is often the confe- quence of, or is attended with evacuations of different kinds. A haemorrhagy, fometimes from the right nof- tril, and fometimes, from the haemorrhoidal veffels, gives a folution of the' difeafe. Sometimes a bilious diarrhoea contributes to the fame event; and the refolution of the hepatitis, as of other inflammations, is attended with fweating, and with an evacuation of urine, depofiting a copious fediment. Can this difeafe be refolved by ex- pectoration ? It would feem to be fometimes cured by an eryfipelas appearing in fome external part. ccccxxi. When this difeafe has ended in fuppuration, the pus collected may be difcharged by the biliary ducts; or j if the fuppurated part does not any where adhere clofely to the neighboring parts, the pus may be dif- charged into the cavity of the abdomen ; but if during the firft ftate of inflammation, the affected part of the liver fhall have formed a clofe adhefion to fome of the , neighboring parts, the difcharge of the pus, after fuppu- ration, may be various, according to the different feat of the abfeefs. When feated on the convex part of the liv- er, if the adhefion be to the peritonaeum lining the com- mon teguments, the pus may make its way through thefe, and be difcharged outwardly ; or if the adhefion fhould have been to the diaphragm, the pus may pene- trate through this, and into the cavity of the thorax,' er of the lungs, and through the latter may be difcharg- ed by coughing. When the abfeefs of the liver is feat- ed on its concave part, then, in confequence of adhe- fions, the pus may be difcharged into the ftomach or the inteftines, and into thefe laft either directly, or by the interveption of the biliary ducts. ccccxxn. The prognoftics in this difeafe are eftablifh- ed upon the general principles relating to inflammation, upon the particular circumftances of the liver, and up- •ii the particular ftate of its inflammation. PRACTICE OF PHYSIC. 175 The cure of this difeafe muft proceed upon the gener- al plan ; by bleeding, more or lefs, according to the ur- gency of pain and pyrexia ; by the application of blif- ters ; by fomentations, of the external parts in the ufu- al manner, and of the internal parts by frequent emolli- ent glyfters; by frequently opening the belly, by means of gentle laxatives, and by diluent and refrigerant rem- edies. ccccxxm. Although, in many cafes, the chronic hep- atitis does not clearly difcover itfelf, yet, upon many oc- cafions, it may perhaps be difcovered, or at leaft fofpect- ed, from thofe caufes which might affect the liver (ccc- xvi.) having been applied; from fome fulnefs and fome fenfe of weight in the right 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, laft- Jy, from fome degree of pyrexia, combined with more or fewer of thefe fymptoms. When, from fome of thefe circumftances, a chronic inflammation is to befufpected, it is to be treated by the fame remedies as in the laft paragraph, employed more or lefs, as the degree of the feyeral fymptoms fhall more diftinctly indicate. ccccxxiv. When, from either kind of inflammation, a fuppuration of the liver has been formed, and the ab- feefs points outwardly, the part muft be opened, the pus evacuated, and the ulcer healed, according to the ordina- ry rules for cleanfing and healing fuch abfeeffes and ul- cers. ccccxxv. I might here confider the Splenitis or in- flammation of the fpleen ; but it does not feem necef- fary, becaufe the difeafe very feldom occurs. When it does, it may be readily known by the character given in our Nofojogy; and its various termination, as well as the practice which it requires, may be underftood from what has been already faid with refpect to the in- flammations of the other abdominal vifcera. 3 i7% PRACTICE OF PHYSIC CHAP. XI. OF THE NEPHRITIS*, ©R THE INFLAMMATION OF THE KIDNEYS. ccccxxvi. 1 his difeafe, like other internal in- flammations, is always attended with pyrexia, and i^ efpecially known from the region of the kidney being affected by pain", commonly obtufe, fometimes pungent. This pain is not increafed by the motion of the trunk of the body, fo much as a pain of the rheumatic kind af- fecting the fame region. " The pain of the nephritis may be often diftinguifhed, by its {hooting 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 affected ; although, indeed, thefe fymptoms Jj moft commonly accompany the inflammation arifing from a calculus in t^he kidney or in the ureter. The nephritis is almoft conftantly attended with, frequent vomiting, and often with coftivenefs and colic 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 cplorlefs. ccccxxvii. The remote caufes of this difeafe may be various ; as, external contufion ; violent or long continued riding; ftrains of the mufcles of the back incumbent on the kidneys; various acrids, in the courfe of the circulation, conveyed to the kidney ; and, per- haps, fome other internal caufes not yet well known. The moft frequent is that of calculous matter obftruct- ing the tubuli uriniferi, or calculi formed in the pelvis of the kidneys, and either fticking there, or fallen into the ureter. * Pyrexia ; pain in the region of the kidneys ; frequent defire to make urine, which is either of a pale or very red 'color; vomiting ; numbnefs of '1 the thigh j retraftion and pain of the tefticle of the fame fide. PRACTICE OF PHYSIC. "W ccccxxvin. The various event of this difeafe may be underftood from what has been delivered on the fubject of other inflammations. ccccxxix. Writers., in treating of.the cure of neph- ritis, have commQnly, at the fame time, treated of the cure of the Calculus renalis ; but, though this may of- ten produce nephritis, it is to be confidered as a djf- tinct and feparate difeafe ; and what I have to offer as to the mode of treating it5 muft be referved to its prop- er place. Here I fhall treat only of the cure of the Ne- phritis Vera, or Idiopathica. ccccxxx. The cure of this proceeds upon the gener- al plan, by bleeding, external fomentationa frequent emollient glyfters, antiphlogiftic purgatives, and the free ufe of mild and demulcent liquids. The application of blifters is hardly admiflible, or at leaft, will require great care, to. avoid any confiderable abforption of the cantharides. ccccxxxi. The Cyftitis, -or inflammation of the blad- der, is feldom a primary difeafe, and, therefore, is not to be treated of here. The treatment of it, fo far as neceffary to be explained, may be readily underftood from what has been already delivered. ccccxxxn. Of the vifceral inflammations, there re* mains to be confidered the inflammation of the Uterus ; but I omit it here, becaufe the confideration of it can- not be feparated from that of the difeafes of child bear- ing women. CHAP. XIL OF THE RHEUMATISM*, ccccxxxih.Of this difeafe there are two fpe- cies, the one named the Acute, the other the Chronic rheumatifm. * Amte Rheumatifm. Pyrexia, pain about the joints, following the courfe of the mufcles, generally affecling the larger joints, and increafed by external heat. 4 -;8 PRACTICE OF PHYSIC. ccccxxxiv. It is the Acute Rheumatifm which ef- pecially belongs to this place, as, from its caufes, fymp- toms, and methods of cure, it will appear to be a fpe- cies of phlegmafia, or inflammation. ccccxxxv. This difeafe is frequent in cold, and more uncommon in warm climates. It appears moft frequent- ly in autumn and fpring, lefs freqaently in winter, when the cold is confiderable andconftant, and very feldom during the heat of fummer. It may occur, however, at any feafon, if viciffitudes of heat and cold be for the time frequent. ccccxxxvi. The acute rheumatifm generally arifes from the application of cold to the body, when any way unufually warm ; or, when one part of the body Is expofed to cold, whilft the other parts are kept warm; or, laftly, when the application of the cold is long con- tinued, as it is when wet or mtoift clothes are applied to any part of the body. ccccxxxvi 1. Thefe caufes may affect perfons of all ages ; but the rheumatifm feldom appears in either very young or in elderly perfons, and moft commonly occurs from the age of puberty to that of thirty five years. ccccxxxvui. Thefe caufes (ccccxxxvi.) may alfo af- fect perfons of any conftitution; but they moft com- monly affect thofe of a fanguirie temperament. ccccxxxix. This difeafe is particularly diftinguifhed by pains affecting the joints, for the moft part the joints alone, but fometimes affecting alfo the mufcular parts. Very often the pains fhoot along the courfe of the muf- cles, from one joint to another, and are always much increafed by the a&ion of the mufcles belonging to the joint or joints affected. ccccxl. The larger joints are moft frequently affecH ed ; fuch as the hip joint, and knees of the lower, and the fhoulders and elbows, of the upper extremities. The ankles and wrifts are alfo frequently affected ; but Chronic Rheumatifm. After rheumatifm, violent fprain, or luxation ; pains of thejointsor mufcles, increafed by motion, more or lefs fleeting, alleviated by beat; the joints are weak, ftiff, and cold : no pyrexia : for the moft part without anyiwelling. Syn.N»f* . . . PRACTICE OF PHYSIC. 179 thefmaller joints, fuch as thofe of the toes or fingers, feldom fuffer. ccccxli. This difeafe, although fometimes confined to one part of the body only, yet very often affects ma- ny parts of it; and then it comes on with a cold ftage, which is immediately fucceeded by the other fymptoms of pyrexia, and particularly by a frequent, full, and hard pulfe. Sometimes the pyrexia is formed before any pains are perceived ; but more commonly pains arc felt in particular parts, before any fymptoms of pyrexia appear. ccccxlh. When no pyrexia is prefent, the pain is fome- times confined to one joint only ; but when any con- fiderabie pyrexia is prefent, although the pain may be chiefly in one joint, yet it feldom happens but that the pains affect feveral joints often at the very fame time, but for the moft part fhifting their place, and having a- bated in one joint, become more violent in another. They do not commonly remain long in the fame joint, but frequently fhift from one to another, and fometimes return to joints formerly affected ; and in this manner the difeafe often continues for a long time. ccccxlih. The pyrexia attending this difeafe has an exacerbation every evening,and is moft confiderable dur- ing the night, when the pains alfo become more vio- lent ; and it is at the fame time that the pains fhift their place from one joint to another. The pains feem to be alfo increafed during the night, by the body being cov- ered more clofely, and kept warmer. ccccxliv. 4- joint, after having been for fome time af- fected with pain, commonly becomes affected alfo with fome rednefs and fwelling, which is painful to the touch. It feldom 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 feoure the joint a- gainft a return of it. ccccxlv. This difeafe is commonly attended with fome fweating, which occurs early in the courfe of the difeafe; but it is feldom free or copious, and feldom ei- ther relieves the pains or proves critical. i*o PRACTICE OF PHYSIC. ccccxlvi. In the courfe of this difeafe the urine is high colored, and in the beginning without fediment; but as the difeafe advances,'and the pyrexia has more confiderable remiflions, the uriue^depofits a lateritious fediment. This however does not prove entirely crit- ical ; for the difeafe often continues" long after fuch a fediment has appeared in the urine. ccccxjlvh. When blood is drawn in this difeafe, it always exhibits the appearance mentioned ccxxxvn. ccccxlviii. The acute rheumatifm, though it has fo, much of the. nature of the other phlegmafite, differs from aU thofe hitherto mentioned, in this, that it is not apt to terminate in fuppuration. This almoft never happens in rheumatifm ; but the difeafe fometimes pro- duces effufions of a traniparent gelatinous fluid into the fheaths of the tendons. If we may be allowed to fup- pofe that fuch effufions are frequent, it muft alfo hap- pen that the effufed fluid is' commonly reabforbed; for it has feldom happened, and never indeed to my ob- fervation, that confiderable or permanent tumors have been produced, or fuch as required to be opened, and to have the contained fluid evacuated. Such tumors, however, have occurred to others, and the opening made in them has produced ulcers difficult to heal. Vide Storck. Ann. Med. II. ccccxlix. With the circumftances mentioned from ccccxxxix. to ccccxlviii. the difeafe often continues for feveral weeks. It feldom 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. ccccl. When the pyrexia attending rheumatifm has entirely ceafed; when the fwelling, and particularly the rednefs of the joints, are entirely gone; but when pains ftill continue to affect certain joints, which remain ftiff, which feel uneafy upon motion, or upon changes of weather, the difeafe is named the Chronic Rheumatifm, PRACTICE of physic. t$t as it very often continues for a long time. As the chronic is commonly the fequel of the acute rheuma- tifm, I think it proper to treat of the former alfo in this place. : ccccli. The .limits between the acute and chronic rheumatifm are not always exactly 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 diieafe is ;to be confider- ed as ftill partaking tfie 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 clam- my and cold on the pained joints; and when, efpccial- iy, the pains of thefe joints are increafed by cold, and relieved by heat applied to them, the cafe is to be con- fidered as that of a purely chronic rheumatifm*. cccclii. The chronic rheumatifm may affect different joints ; but is efpecially ready to affect thofe joints which are furrounded with many mufcles, and thofe of which the mufcles are employed in the moft conltant and vig- orous exertions. Such is the cafe of the vertebra: of the loins, the affection of which is named Lumbago ; cr * It is o Peon fiderabie importance to dift'nguifh acciratety between the 3 - cute and chronic rheumatifm ; and as our author has rather b.en brief on this fubject, it will be proper to give the diagnbfis more st length. The aedte rheumatifm is aU ended with feverifh fymptoms; the r.atu-al functions are much affected ; transition and exacerbation of pains ave fre- quent ; it occurs moft frequently in January, February aid March, and at- tacks chiefly perfons from the age of ten to thirty, of ftrong inflammatory habits; the pains are more general in the fyftem, affect more commonly the upper limbs, and are for the moft pa't worfe in bed; the parts aitec't-.d, owing to their increafed fenfibility, are extremely painful on preffure. The chronic rheumatifm is not accompanied with febrile fymptoms, and the natural functions are feldom affected ; the pains are generally fixed, r.nd rarely fubject to exacerbation. It more f equently attacks males, a d from the age of twenty five to fifty ; it occurs moft commonly in June, October, Novcmber,and December; it is often not eafily relieved by art,but is feMom dangerous; the pains are not fo general in the fyftem, and attack the lower limbs more commonly than the upper: they are likewife generally e Turin bed, and are not-much pakuxl on prefiuve. iSa PRACTICE Of? PHYSIC. that of the hip joint, when the difeafe is named Lchias, or Sciatica. ccccliii. Violent ftrains and fpafms occurring on fud- den, and fomewhat violent exertions, bring on rheu- matic affections, which at firft partake of the acute, but very foon change into the nature of the chronic rheu- matifm. ccccliv. I have thus delivered the hiftory of rheuma- tifm ; and fuppofe that, from what has been faid, the remote caufes, the diagnofis, and prognofis of the dif- eafe, may be underftood. The diftinction of tlie rheu- matic 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 fymp- toms peculiar to thefe difeafes. The diftinction of rheu- matifm from gout will be more fully underftood from what is to be delivered in the following chapter. cccclv. With refpect to the proximate caufe of rheu- matifm, 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 of the remote caufes, the fymptoms, and cure of the difeafe, I think the fuppofition very improb-. able. The caufe of an Ifchias Nervofa, affigned by Cotun- nius, appears to me hypothetical, and is not fupported by either the phenomena or method of cure. That, however, a difeafe of a rheumatic nature may be occa- fioned by an acrid matter applied to the nerves, is evi- dent from the toothach, a rheumatic affection generally arifing from a carious tooth. That pains refembling thofe of rheumatifm, may a- rife from deep feated fuppu rations, we know from fome cafes depending on fuch a caufe, and which, in their fymptoms, refemble the lumbago or ifchias. I believe, however, that by a proper attention, thefe cafes depend- ing on fuppuration, may be commonly diftinguifhed from the genuine cafes of lumbago and ifchias; and, from what is faid in ccccxlviii. I judge it to be at leaft PRACTICE OF PHYSIC. iSj improbable, that a genuine lumbago or ifchias does ever end in fuppuration. cccclvi. The proximate caufe of rheumatifm has been by many fuppofed to be a lentor of the fluids ob* ftructing the veffels of the part; but the fame confider- ation as in ccxli. 1, 2, -3, 4, and 5, will apply equally here for rejecting the fuppofition of a lentor. cccclvii. While I cannot, therefore, find either evi- dence or reafon for fuppofing that the rheumatifm de- pends upon any change in the ftate of the fluids, I muft conclude that the proximate caufe of acute rheumatifm is commonly the fame with that of other inflammations not depending upon a direct ftimulus. cccclviii. In the cafe of rheumatifm, I fuppofe that the moft common remote caufe of it, that is, cold appli- ed, operates efpecially on the veffels of the joints', from thefe being lefs covered by a cellular texture than thofe of the intermediate parts of the limbs. I fuppofe fur- ther, that the application of cold produces a conftric- tion of the 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 im- petus 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 form- ed excites the vis medicatrix to a further increafe of the impetus of the blood; and, to fupport this, a cold ftage arifes, a fpafm is formed, and a pyrexia and phlogiftic diathefis are produced in the whole fyftem. cccclix. According to this explanation, the caufe of acute rheumatifm appears to be exactly analogous to that of the inflammations depending on an increafed af- flux of bldod to a part while it is expofed to the action of cold. But there feems to be alfo, in the dlfe of rheumatifm, a peculiar affection of the fibres of the mufcles. Thefe fibres feem to be under fome degree of rigidity, and therefore lefs eafily admit of motion ; and are pained up- on the exertions of it. tS.t PRACTICE Oi: physic It is alfo an affection of thefe fibres which gives art opportunity to the propagation of pains from one joint to another, along t'he courfe of the mufcles ; and which wains', are more feverely felt in the extremities of the mufcles terminating in the joints, becaufe, beyond thefe, the ofcillatiohs are not propagated. This affection of the mufcular fibres attending rheu. matifm,- feems to explain why ftrains and fpafms pro- duce rheumatic affections; and,upon the whole, fhows; that with an inflammatory affection of the fanguiferous fyftem, there is alfo in rheumatifm a peculiar affection of the mufcular fibres, which has a confiderable fhare in producing the phenomena of the difeafe. cccclx. Having thus given my opinion of the prox- mate caufes of rheumatifm, I proceed to treat of the cure. cccclxi. Whatever difficulty may occur with refpect to the explanation given (cccclviii. and cccclix.), this remains certain, that in acute rheumatifm, at leaft in all thofe cafes which do not arife from direct ftimuli, there > is an inflammatory affection of the parts, and phlogiftic diathefis in the whole fyftem ; and upon thefe is found- ed the method of cure, which frequent experience has approved of. cccclx'H. The cure therefore requires, in the firft place, an antiphlogiftic regimen, and, particularly a total abftin'ence from animal food, and from all fermented \ or fpiritous liquors; fubftituting a vegetable or milk diet, and the plentiful ufe of bland diluent drinks. cccclxiii. Upon the fame principle (ccccl.) at leaft with perhaps 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, fu£ nefs, and hardnefs of the pulfe, and to the violence of the pain. For the moft part large and repeated bleed- ings, during the firft days of the difeafe, feem to be nec- etiary and accordingly have been very much employed ; but to this fome bounds are to be fet ; for very profufe PRACTICE OF PHYSIC. ?'&; bleedings occafion a flow recovery, and if not abfolutcly effectual, are ready to produce a chronic rheumatifm. cccclxiv. To avoid that debility of the fyftem, which general bleedings are ready to occafion, the urgent fymptom of pain may be often relieved by topical bleed- ings, 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 affection of particular parts, fo topical bleedings will not always fupply the place of the general bleedings propofed above, cccclxv. To take off the phlogiftic diathefis prevail- ing in this difeafe, purging may be ufeful, if procured by medicines which do not ftimulate the whole fyftem-, fuch as the neutral falts, and which have, in fome meaf- ure, 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 inconvenient, and even hurtful, by the motion and pain which they occafion. cccclxvi. In acute rheumatifm, applications to the pained parts are of little fervice. Fomentations, in the beginning of the difeafe, rather aggravate than relieve the pains. The rubefacients and camphire are more effectual in relieving 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 effectual ia removing the pain from it; but will be of little ufe, except where the pains are much confined to one part. cccclxvu. The feveral remedies mentioned from ccccli. to cccclv. moderate the violence of the difeafe, and fometimes remove it entirely ; but they fometimes fail in this, and leave the cure imperfect. The attempt- ing a cure by large and repeated bleedings, is attended with many inconveniencies (fee cxl.) ; and the moft effectual and fafe method of. curing this difeafe, is after fome general bleeding* for taking off, or at leaft dimin- iS6 PRACHCg OF PHYSIC ifiiingtlic phlogiftic diathefis, to employ fweating, con- ducted by the rules laid down* clxviii. and clxix. ccccLxvin. Opiates, except where they are directed to procure fweat* always prove hurtful in every ftage of this difeafe. cccclxix. The Peruvian bark has been fuppofed a remedy in fome cafes of this difeafe ; but we have fel- dom found it ufeful, and in fome cafes hurtful. ^ It ap- pears 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 of the difeafe are manifeftly periodical, with confiderable remiflions inter- pofed. cccclxx. Calomel, and fome other preparations of mercury, have been recommended in the acute rheuma- tifm ; but, I believe, they are ufeful only in cafes of the chronic kind, or at leaft in cafes approaching to the na- ture of thefe. cccclxxi. Having now treated fully of the cure of the acute rheumatifm, I proceed to treat of the cure of the chronic, which is fo frequently a fequel of the for- mer. cccclxxii. The phenomena of the purely chronic rheumatifm, mentioned in ccccxxxix. and ccccxl. lead me to conclude, that its proximate caufe is an atony, both of the blood veffels and of ,the mufcular fibres of the part affected, together with a degree of rigidity, and contraction in the latter, fuch as frequently attend them in a ftate of atony. * Dover's powder, or thepulv. ipeca, cornp. 'is commonly employed, ia dofes of 15 grains, or a fcruple, for thid purpofe, affifted by proper regimen* Dr. Fowler, in his reports on the effects of blood 'etting, fudorifics, and bliftering, in this difeafe, to which I wauid beg leave to refer the reader, par- ticularly recommends the tincture of guiacum, which, ns it pofTefTes a laxa- tive property, he conceives to be far preferable to Dover's powder, in cafes »t tended with coftivenefs. Of fudorifics in general, as remedies in rheuma- tifm, he thus exprefTes himfelf: " Of all the operative antirheumatic reme- *' dies which have fallen within my notice, fudorifics feem to be by far the "" moft efficaciona,in producing artificial cuica. Their curative effects ap- pear to be ftrongly connected with their operative ones. They have like- " wife this recommendation, thatflpey are not found to debilitate the pa- " ticnt-fo much as either reneated^l^ui^fltog, or the frequent ufe of pur- " gatjves." f PRACTICE OF PHYSIC. 187 cccclxxiii.- Upon this view of the proximate caufe, the general indication of cure muft be to reftore the ac- tivity and vigor of the vital principle in the part; and the remedies for this difeafe, which experience has ap- proved of, are chiefly fuch as are manifeftly fuited to the indication propofed. cccclxxiv. Thefe remedies are either external or in- ternal. The external are the fupporting the heat of the part, by keeping it conftantly covered with flannel; the in- creafing the heat of the part by external heat, applied ei. ther in a dry or in a humid form ; the diligent ufe of the ftefh brufh, or other means of friction ; tip* Application of electricity in fparks or fhocks; the application of cold water by affufion or immerfion; the application of effen- tiai oils of the moft warm and penetrating kind; the appli- cation of fait brine ; and, laftly, the employment of ex- ♦ ercife, either of the part itfelf, fo fair as it can eafily bear it; .or of the whole body, by riding or other mode of geftation. cccclxxv. The internal remedies are, 1. Large dofes of effentiai oil drawn from refinous fubftances, fuch as turpentine ; 2. Subftances containing fuch oils, as guaiac; 3. Volatile alkaline falts; 4 Thefe, or other medicines, directed to procure fweat (clxix.) ; and, laftly, calomel, or other preparation of mercury, in fmall dofes, continued for fome time*. cccclxxvi. Thefe (cccclxiii. cccclxiv.) are the remedies fuccefsfully employed in the purely chronic rheumatifm; and there are ftill others recommended, as bleeding, general and topical, burning, bliftering, and iffues ; but thefe appear to me to be chiefly, perhaps only ufeful, when the difeafe ftill partakes of the nature of acute rheumatifm. * In cafes of this nature, the following will likely be of fervice: ft Antimon. tart. Opii purif. 9 Hyd. mur. mit.a a bene trit.gr. v. Confer, rof. q. f. ut fiant. pilulsc decern, una» quarum capiat omni Roctc. ,- N 188 PRACTICE OF PHYSIC. CHAP. XIII. OF THE TOOTHACH, OR ODONTALGIA. cccclxxvu. I have formerly confidered this: difeafe as a fpecies of Rheumatifm, to* be treated upon the fame principles as thofe delivered in the preceding. chapter; but now, from more attentive confideration, I am led to confider the toothach as a diftinct difeafe. WhHft therrKj>fi of what has been delivered in the laft chapter proceeds upon the fuppofition that the rheuma- tifm depends upon a certain ftate of the blood veflels, and of the motion of the blood in them, without this being produced by the irritation of any acrid matter applied ; I j(udge, that in the toothach, Though there are often ttte^fame circumftances in the ftate of the blood veffels as» in the cafes of rheumatifm, thefe cir- cumftances in toothach always arife from the applica- tion of an acrid; matter to the nerves of the teeth, cccclxxviii. This- difeafe is often no other than a pain felt in a particular tooth, without any inflammatory affection being 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 degree of pain and of inflamma- tory affection communicated to the neighboring parts, fometimesMtorthe whole of thofe on the fame fide of the head with the affected tooth. cccclxxix. This inflammatory affection feems to me to be always an affection of mufcles, and of the mem- branous parts connected with thefe,, without any tenden- cy to fuppuration ; and fuch an affection, as is excited by cold in fimilar parts elfewhere. It is from thefe cir- cumftances that I conclude the affection to be of the rheumatic kind. cccclxxx. It is poflible that t{ie mufcles and mem- branes of the jaw may be affected by the fame caufes PRACTICE OF PHYSIC, i*; which produce the rheumatifm in other parts; and it is alfo poflible,that arheumatic diathefis at firft produced by irritation, may fubfift in the mufcles and membranes of the jaw, fo that the inflammatory affection may be renew- ed by certain caufes without any new application of acrid matter : but I am perfuaded that either of thefe occur* rences are very rare, and I have never been able to af- certain any cafes of toothach to be of thefe kinds, t confider it therefore as highly probable, that this rheu- matic affection of the jaws which we name toothach, is always dependent upon fome immediate application of acrid matter to the nerves of the teeth. - cccclxxxi. It is however to be obferved, that this application of acrid matter does not always excite a pain in the tooth itfelf, or an inflammatory affection of the neighboring parts, but that it Very often operates by producing a diathefis only ; fo that cold applied to the neighboring parts, does excite both a pain in the tooth, and an inflammatory affection of the neighboring parts which did not appear before. There feem 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 wo* men, who are more liable to toothach than other wo- men. , There are probably alfo fome cafes of increafed ir- ritability which render perfons more fubject to tooth- ach. Thus women are more liable to the difeafe than ineh, and particularly women liable to hyfteric affec- tions; cccclxxxu. The acrid nutter producing this dif- eafe, feems to be generated firft in the hard fubftances of the teeth ; and,as it often appears firft upon the ex- ternal furface of thefe,. it might be iufpected to arife from the application of external 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 iufpected, 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 of the teeth only, that it is difficult to fuppofe that any matter !$e PRACTICE OF PHYSIC. externally applied could act in fuch a partial manner; fo it is prefumed, that the acrid matter occafioning the toothach, is produced by fome vice originating in the fubftance of the tooth itfelf. When it begins upon the external furface, it is on the enamel; but upon the in- ternal furfacej 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 fufpect that it often arifes from fome more general fault in the fluids of the body. The fre- quent ufe of mercury, efpecially when thrown much upon the mouth, and the ftate of the fluids in fcurvy, feem both of them to give a difpofition to a caries in the teeth ; and it is poflible that fome other acrimoni- ous ftates of the fluids may have the fame effect. cccclxxxiii. A caries in fome part of the teeth, whether arifing upon their internal furface, or upon their external, proceeding fo 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 the 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 matters applied to th e nerves occafion the difeafe. cccclxxxiv. What is the nature of the matter pro- duced in the caries of the teeth, I do not underftand, nor have I found any proper corrector of it ; but 1 pre- fume it to be of the putrid kind, as it often taints the breath with a fetid odor. cccclxxxv. In the cure of this difeafe, a long expe- rience has fhown, that the extraction of the carious tooth proves the moft effectual, and very often the only effectual remedy of the difeafe. But as in fome cafes thi> extraction is not proper, and as in many cafes it is obftinately avoided, other means of curing the difeafej or at leaft of relieving the pain, have been fought for and much practifed. cccclxxxvi. Among thefe remedies, thofe are likely to be the moft effectual which entirely deftroy the affect- ed nerve, or at leaft fo much of it as is expofed to the PRACTICE OF PHYISC. *9* action of the acrid matter in the tooth. When an o- pening is made into the cavity of the tooth, the nerve of it may De deftroyed moft certainly by the actual cautery; and it may alfojpbflibly be done by the application of potential cauftifli either of the alkaline or acid kind*. cccclxxxvii. When thefe remedies cannot be ren- dered effectual, relief may. often be obtained by dimin- ifhing the fenfibility of the nerve affected, by the appli- cation of opium, or of the more acrid aromatic oils, di- rectly to the nerve in the tooth.t It appears alfo that the fenfibility of the affected nerve may often be for fome time diminifhed by the external application of o- pium to the extremities of thofe nerves in the fkin, which are branches of the fame fifth pair of nerves with thofe of the teeth£.' cccclxxxvih. When the difeafe confifts entirely in a pain of the nerve of the tooth, without any confider- able affection communicated to the neighboring parts, the remedies already mentioned are thofe efpecially to be employed ; but when the difeafe confifts very much in an inflammatory affection of the mufcles and mem- branes of the jaw, and when at the fame time there is little or no accefs for the above mentioned remedies to the affected nerve, other meafures are to be employed for relieving the difeafe. cccclxxxix. If the difeafe be attended with any gen- eral phlogiftic diathefis of the fyftem, or with any con- fiderable degree of pyrexia, a general bleeding may be ufeful in relieving the difeafe : but thefe circumftances * One of the moft effectual applications of this nature is ftrong nitrous acid, diluted with three or four times its weight, of fpirit of wine ; a little of this is introduced to the affected part by a hair pencil or cotton. f R Camphorse pulv. trit. Opii purif. a gr. ft. . . Olei caryophylli gutt. i. m. f.pilulaparti dolenti admovenda. Or the following, which may be applied on a little cotton: ft Camphdrse, 3 i.! Opii purif. gr. vij. Olei caryophylli gutt.or. . Alcohol. 3 ii. digereet cola. - . % The folldwing liniment, rubbed in behind the ear, may be of feroce j ft Ol. olivar. opt. 3 i. Camphorce. Tinct. opii a a 3 y.M.. 3 p9:. PRACTICE OF PHYSIC. occur very rarely, and the difeafe is for the moft part a purely topical affection, in which, asT obferved before; a general bleeding is of very little fervice. As this dif- eafe, however, is a' topical inflammation it might be fuppofed that topical bleedings would^e very ufeful, and fometimes they are fo ; but it is feldom that their effects are either cOnfidetable or permanent. The rea- fons of this I take to be, that the difeafe does not con- fift in an affection of the blood veffels alone, as in the ordinary cafes of rheumatifm; but in a peculiar affection of the fibres both of the mufcles and of the veffels of the part, induced by irritation. ^The'ineflicacy of" topical bleedings is with me a proof of the difeafe being of the latter kind. : ' '* ' • '' - ccccxc. 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 mem- branes affected. Such are bliftering, brought as near to the part affected as'can be conveniently done ; and fucli are alfo increafed excretions excited in the neighboring parts, as of the faliva and mucus of theTnouth, by the ufe of acrid mafticatories. It is often fufficient to ex- cite a ftrong fenfation in the neighboring j>arts, as, by eau de luce, fpirit 'of lavender,'or Hungary water; fnuffed up the noftrils; or by the* vitriolic aether prop- erly applied to the cheek. It is upon the fame footing that I fuppofe brandy, or other ardent fpirit, held in the mouth is often of fervice. ' cccc'xci. There are cafes of toothach \n which it does not appear that the difeafe arifes from an acrid mat- ter immediately applied to the nerve of a tooth, but from the external application of cold,br fprrfe other caufes immediately applied to the mufcles and membranes of the jaw; ancj which, therefore, feem to require 'fome remedies different from thofe above mentioned. BiitJ in all fuch cafe's, it is to be fufpectedj that the effects of cold, or of other fuch 'caufes, are owing to a diathefis, produced by anracrid matter applied to the nerve of a tooth, and continuing in fome meafure to act there $ PRACTICE OF PHYSIC. »9J and we have accordingly often found, that the action of thofe external caufes was to be obviated only by the extraction of the tooth from which the diathefis had a- rifen. CHAP. XIV, OF THE GOUT. ccccxcn. I he Gout, not only as it occurs jjn different perfons, but even as it occurs in the fame jpe.rfon at different times, is a difeafe of fuch various ap- pearance, that it is difficult to render the hiftory of it .complete and exa£, or to give a chara#er of it that will -univerfally apply. However, I fhall endeavor to de- fcribe the difeafe as it moft commonly appears, and to inark the varieties of it as well as I can. From fuch a hiftory I expect that a general character may be given ; .and fuchf think is the following, as given in the laft e- dition of our Nofology : p GEN. XXIII. PODAGRA*, Morbus haeditarius, oriens fine eaufa externa eviden- ce, fed prseunte plerumque ventriculi affectione infolita; pyrexia; dolor ad articulum et plerumque pedis pollici, eerte pedum et manuum juncturis, potiflimum infeftus; per intervalla revertens, et faepe cum ventriculi et inter- narum partium afiectionibus alternans. * Var. t. RegularCout, with a violent inflammation'remaining far a few days, and gradually receding with fwelling, itching, and defquamation of the part.'..... Var. %. Atonic Gout, is accompanied with an atony of the ftomach, or of fome other internalpart, without the expected and ufual inflammation of the joints; or with flight and temporary pains; accompanied with dyfpepfia, and other fymptoms of atpny, often alternating with each other, Var. ^.Retrograde Gaut,h marked by an inflammation of the joints fud: denly difappeafing, and an atony of fome internal part immediately follow- Var. 4. Aberrant Gout, is attended with an inflammation of an internal part; the inflammation of the joint either not preceding, or fuddenly difap- pearing. • 4 ?94 PRACTICE OF PHYSIC. ccccxcin. The Gout is generally a hereditary dif- eafe ; but fome perfons, without hereditary difpofition, feem to acquire it; and, in fome, a hereditary tlifpofi- tion may be counteracted by various caufes. Thefe cir- cumftances may feem to give exceptions to our general*,.. pofition; but the^facts directly fupporting it are very nu- merous. ccc cxciv. This difeafe attacks efpecially the male fex; but it fometimes, though more rarely, attacks alfo the female. The females liable to it are thofe of the more robuft and full habits; and it very often happens to fuch long before the menftrual evacuation has ceafed. I have \ found it occurring in feveral females, whofe menftrual e- < vacuations were more abundant than ufual. ccccxcv. This difeafe feldom attacks Eunuchs, and, when it does, they feem to be thofe wjio happen to be of a robuft habit, to lead an indolent life, and to live very full. cccxcvi. The gout attacks efpecially men of robuft and large bodies, men of large heads, of full andcorpu-j^ lent habits, and men whofe fkins are covered with a^j; thicker rete mucofum, which gives a coarfer furface. ccccxcvu. If,< with the ancients, we might afcertain, by certain terms, the temperaments of men, I would fay, that the gout attacks efpecially men of a cholorico •.. fanguine temperament, and that it very feldom attacks the purely fanguine or melancholic. It is, however, very difficult to treat this matter with due precifion. ccccxcviii'. The gout feldom attacks perfons employ- ed in conftant bodily labor, or perfons who live much npon vegetable aliment. It is alfo faid to be lefs fre- quent among thofe people who make no ufe of wine or other fermented liquors. ccccxcix. The gout does not commonly attack men till after the age of five and thirty, and generally not till a ftill later period. There are, indeed, inftances of the gout occurring more early ; but thefe are few in comparifon 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 PRACTICE OF PHYSIC. ws hereditary difpofition is very ftrong, and to whom the remote caufes, to' be hereafter mentioned, have been ap- plied in a confiderable degree. d. As the gout is a hereditary difeafe, and affects efpe- cially men of a particular habit, its remote caufes may be confidered as predifponent and occafional. di. Ihe predifponent caufe, fo far as expreffed by ex- ternal appearances, or by the general temperament we have already marked; and phyficians have been very confident in afligning the occafional caufes; but, in a difeafe depending fo much upon a predifpofition, the afligning occafional caufes muft be uncertain, as, in the predifpofed, the occafiohal'caufes may not always appear, and, in perfons not predifpofed, they may appear with- out effect. This uncertainty muft particularly affect the cafe of the gout; but I fhall offer what appears to mc moft probable on the fubject. dh. The occafional caufes of the gout feem to be of two kinds: Firft', Thofe which induce a plethoric ftate of the body : Secondly, Thofe which, in plethoric hab- its, induce a ftate of debility, vt'*' Din. Of the firft kind are a fedentary indolent man- ner of life, a full diet of animal food, and the large ufe of wine, or of other fermented liquors. Thefe circum- ftances commonly precede the difeafe; and, if there fhould be any doubt of their power of producing it, the fact, however, will be rendered fufliciently probable, by what has been obferved in ccccxcvin. div. Of the fecond kind of occafional caufes which in- duce debility, are, excefs in venery ; intemperance in the ufe of intoxicating liquors; indigeftion, produced either by the quantity or quality of aliments ; much application to ftudy or bufinefs ; night watching ; ex- ceffive evacuations; the ceafing of ufual labor ; the fud- den change from a very full to a very fpare diet; the large ufe of acids and afcefcents; and, laftly, cold appli- ed to the lower extremities. dv. The firft (diii.) feem to act by increafing,the pre- difpoutiom The laft (div.) are commonly the exciting { we fhall have occafion to defcribe in another place. AU PRACTICE OF PHYSIC. 199 t^at is neceffary to be obferved here is, that the nephrit- ic affection alternates with paroxyfms of the gout, and that the two affections, 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 which ever may have been the principal difeafe of the parent, fome of the children have the one, and fome the other. In fome of them, the nephritic affection oc- curs alone, without any gout fupervening ; and this happens to be frequently the cafe of the female offspring of gouty parents. dxviii. In the whole of the hiftory already given, I have defcribed the moft common form of the difeafe, and which, therefore, however diverfified in the manner I have faid, may be ftill called the regular ftate of the gout. Upon occafion, however, the difeafe affumes dif- ferent appearances ; but, as I fuppofe the difeafe to de- pend always upon a certain diathefis or difpofition of the fyftem ; fo every appearance which we can perceive to depend upon that fame difpofition, I ftill confider as a fymptom and cafe of the gout. The principal circum- ftance in what we term the Regular Gout, is the inflam- matory affection of the joints ; and, whatever fymp- toms we can perceive to be conneded with, or to depend upon the difpofition which produces that inflammatory affection, but without its taking place, or being prefent at the fame time, we name the Irregular Gout. dxix. Of fuch irregular gout there are three differ- ent ftates j which I name the atonic, the reirocedent, and the mifplaced gout. dxx. The atonic ftate is when the gouty diathefis prevails in the fyftem, but from certain caufes, does not produce the inflammatory affe&ion of the joints. In this cafe, the morbid fymptoms which appear are chiefly affections of the ftomach ; fuch as lof§ of appetite, indigeftion, and its various circumftances of ficknefs, naufea, vomiting, flatulency, acid eructations and pains in the region of the ftomach. Thefe fymptoms are fre- quently accompanied with pains and cramps in feveral X>o PRACTICE OF PHYSIC. parts of the trunk, and the upper extremities of the bodyy which are relieved by the difcharge of wind from the' itomach. Together with thefe affections of the ftomach,1 there commonly occurs a coftivenefs r but fometimes a loofnefs with colic pains. Thefe affections of. the ali- mentary canal are often attended with all the fump. toms of hypbehondfiafis ; as dejection of mind, a con-< ftant and anxious attention to the flighteft 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 afthma, occur. In the head alfo occur headachs, giddinefe, apoplec- tic, and paralytic affections. a dxxi. When the feveral fymptoms now mentionedj^l occur in habits having the marks of a gouty difpofitibn^fi this may be fufpected to have laid the foundation of them; and efpecially when either, in fuch habits, a manifeft tendency to the inflammatory affection has for- merly appeared ; or when the fymptoms mentioned are intermixed with, and are relieved by fome degree of the inflammatory gout. In fuch cafes there can be no doubt of considering the whole as a ftate of the gout. dxxii. Another ftate of the difeafe I name the retw cedent gout. This occurs when an inflammatory ftate ] of the joints has, in the ufual manner, come on, but which, without arifing to the ordinary degree of pain and inflammation, or at leaft, without thefe continuing for the ufual time, and receding gradually in the ufual manner, they fuddenly and entirely eeafe, while fome internal part becomes affected. The internal part moft commonly affected is the ftomach, which is then affeo j ted with anxiety, ficknefs, vomiting, or violent pain; but fometimes the internal part is the heart, which gives occafion to a fyncope ; fometimes it is the lungs which are affected with afthma; and fometimes it is the head, giving occafion to apoplexy or palfy. In all thefe ' cafes, there can be no doubt of the fymptoms being; alt PRACTICE OF PHYSIC. sot s. part of the fame difeafe, however different the affec- tion may feem to be in the parts which it attacks. dxxiii. The third date of irregular gout, which we name the mifplaced, is when the gouty diathefis, inftead of producing the inflammatory affection of the joints, produces an inflammatory affection of fome internal part, and which appears from the fame fymptoms that attend the inflammation of thofe parts arifing from other caufes. Whether the gouty diathefis does ever produce fuch inflammation of the internal parts, without having firft produced it in the joints, or if the inflammation of the internal part be always a tranflation from the joints previoufly affected, I dare not determine; but, even liippofing the latter to be always the cafe, I think the difference of the affection of the internal part muft ftill diftinguifh the mifplaced from what I have named the Retrocedent Gout. dxxiv. What internal parts may be affected by the mifplaced 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 diftinctly marked- by practical writers, except that of a pneumonic inflamma- tion. dxxv. There are two cafes of a tranflated gout; the one of which is an affection of the neck of the bladder, producing pain, ftrangury, and a catarrhus veficse: The other is an affection of the rectum, fometimes by pain alone in that part, and fometimes by haemorrhoidal fwell- ings there. In gouty perfons, I have known fuch affec- tions alternate with inflammatory affections of the joints: But whether to refer thofe affections to the retrocedent, or to the mifplaced gout, I will not prefume to deter- mine. dxxvi. From the hiftory which I have now delivered of the gout, I think it may be difcerned under all its va- rious appearances. It is however commonly fuppofed, that there are cafes in which it may be difficult to diftim giiifh gout from rheumatifm, and it is poflible there may be fuch cafes j but, for the moft part, the two difeafes acj PRACTICE OF PHYSIC. may be diftinguifhed with great certainty, by obferving the predifpofition, the antecedents, the parts affected, tht recurrences of the difeafe, and its connection with the other parts of the fyftem ; which circumftances, for the moft part, appear very differently in the two difeafes. dxxvii. With refpect to the gout, our next bufinefs is to inveftigate its proximate catife ; which muft be a difficult tafk, and I attempt it with fome diffidence. dxxviii. Upon this fubject, the opinion which has gen- erally 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 dif- eafe. dxxix This doctrine, however ancient and general; appears 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 fhow that the blood, or other humors of gouty perfons, are in any re- fpect different from thofe of other perfons. Previous to attacks of the gout, there appear no marks of any mor- bid ftate of the fluids ; for the difeafe generally attacks thofe perfons who have enjoyed the moft perfect health, and appear to be in that ftate when the difeafe comes on. At a certain period of the difeafe, a peculiar, matter in- deed appears in gouty perfons (dxvi.) : but this, which does not appear in every inftance, and which appears only after the difeafe has fubfifted for a long time, feems manifeftly to be the effect, not the caufe of the difeafe. Further, though there be certain acrids which, taken into the body, feem to excite the gout (div.), it is proba- ble that thefe acrids operate otherwife in exciting the dif- eafe, than by affording the material caufe of it. In gene- ral, therefore, there is no proof of any morbific matter being the caufe of the gout. Secondly, The fuppofitions concerning the particular nature of the matter producing the gout, have been fo various and fo contradictory to each other, as to allow us to conclude, that there is truly no proof of the exiftence PRACTICE OF PHYSIC. 303 of any of them. With refpect to many of thefe fuppofi- tions, they are fo inconfiftent with chemical philofophy, and with the laws of theanimal economy, that they muft be entirely rejected. Thirdly, The fuppofition of a morbific matter being the caufe of the gout, is not confiftent with the phenom- ena of the difeafe, particularly with its frequent and fudden tranflations from one part to another. ^ Fourthly,The fuppofition is further rendered improba- ble by this, that if a morbific matter did exift, its opera- tion fhould be fimilar in the feveral parts which it at- tacks; whereas it feems to be very different, beingfftimu- lant, and exciting inflammation in the joints, but fedative and deftroying the tone in the ftomach : Which, upon the fuppofition of particular matter acting in both cafes, is not to be explained by any difference in the part af- fecTed. Fifthly, Some fa£ts, alleged in proof of a morbific matter, are not fufficiently confirmed, fuch as thofe which would prove the difeafe to be contagious. There is, however, no proper evidence of this, the facts given being not only few, but exceptionable ; and the neg- ative obfervations are innumerable. Sixthly, Some arguments brought in ; favor of a morbific matter, are founded upon a miftaken explana- tion. The difeafe has been fuppofed to depend upon a morbific matter, becaufe it is hereditary. But the in- ference is not juft ; for moft hereditary difeafes do not depend upon any morbific matter, but upon a particular conformation of the ftru&ure of the body, tranfmitted from the parent4o the offspring ; and this laft appears to be particularly the cafe in the gout. It may be alfo obferved, that hereditary difeafes, depending upon a morbific matter, always appear much more early in life than the gout commonly does. Seventhly, The fuppofition of a morbific matter be- ing 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 praftice, and have frequently led from thofe views which might O %0A PRACTICE OF PHYSIC. be ufeful, and from that practice which experience had approved. Further, though the fuppofition of a mor- bific matter has been generally received, it has been as generally neglected in practice. When the gout has affected the ftomach, nobody thinks of correcting the matter fuppofed to be prefent there, but merely of ref- toring 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, without the fuppofition of a morbif- ic matter ; and, to this purpofe, it may be obferved, that many of the caufes (div) exciting the gout, do not op- erate upon the ftate of the fluids, but directly and fole- ly upon that of the moving powers. Laftly, The fuppofition of a morbific matter is alfo fuperfluous ; 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 an- imal economy, and with the method of cure which ex- perience has approved. I now proceed to give this explanation ; but, before entering upon it, 1 muft premife fome general obferva- tions. dxxx. The firft obfervation is that the gout is a diieafe of the whole fyftem, or depends upon a certain general conformation and ftate of the body; which manifeftly appears from the facts mentioned from cccc- xciv. to ccccxcvn. 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 affection of thefe. dxxxi. 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 occafional or exciting caufes (div.), are almoft all fuch as act directly upon the nerves and ner- vous fyftem ; and the greater part of the fymptoms of PRACTICE OF PHYSIC* 205 the atonic or retrocedent gout are manifeftly affections of the fame fyftem. dxx. and dxxii.) This leads us to feek for an explanation of the whole of the difeafe in the laws of the nervous fyftem, and particularly in the changes which may happen in the balance of its feveral parts. dxxxii. My third obfervation is, that the ftomach, which has fo univerfal a confent with the reft of the fyftem, is the internal part that is the moft frequently and often very confiderably affected by the gout. The paroxyfms of the difeafe are commonly preceded by an affection of the ftomach (dvii.) ; many of the exciting caufes (div.) act firft upon the ftomach ; and the fymp- toms of the atonic and retrocedent gout (dxx. dxxii.) are molt commonly and chiefly affections of the fame organ. This obfervation leads us to remark, that there is a balance fubfifting between the ftate of the internal and that of the external parts ; and, in particular, that the ftate of the ftomach is connected with that of the external parts fo (xliv.), that the ftate of tone in the one may be communicated to the other. Dxxxin. Thefe obfervations being premifed, I fhall now offer the following pathology of the gout. In fome perfons there is a certain vigorous and ple- thoric ftate of the fyftem (ccccxcvi.), which, at a cer- tain period of life, is liable to a lofs of tone in the ex- tremities (ccccxcix. dvi.) This is in fome meafure communicated to the whole fyftem, but appears more efpecially in the functions of the ftomach (dvii.) When this lofs of tone occurs while the energy of the brain itill retains its vigor, the vis medicatrix naturae is excit- ed to reftore the tone of the parts ; and accomplifh.es- it by exciting an inflammatory affection in fome part of the extremities. When this has fubfifted for fome days, the tone of the extremities, and of the whole fyftem, are reftored, and the patient returns to his ordi- nary ftate of health (dxi.) dxxxiv. This is the courfe of things, in the ordina- ry form of the difeafe, which we name the regular gout ; but there are circumftances of the body, in which this courfe is interrupted or varied. Thus when the 2 zo6 PRACTICE OF PHYSIC. atony (dvi. dvii.) has taken place, if the reaction (dix.) do not fucceed, the atony continues in the ftomach, or perhaps in other internal parts, and produces that ftate which we have, for reafons now obvious, named the atonic gout. dxxxv. A fecond cafe of variation in the courfe of the gout is, when, to the atony, the reaction and inflam- mation have to a certain degree fucceeded, but from caufes either internal or external, the tone of the ex- tremities, and perhaps, of the whole fyftem, is weaken- ed fo that the inflammatory ftate, before it had either proceeded to the degree, or continued for the time, re- quisite for reftoring the tone of the fyftem, fuddenly and entirely ceafes. Hence the ftomach, and other inter- nal parts, relapfe into the ftate of atony; and perhaps have this increafed by the atony communicated from the extremities : All which appears in what we have termed the retrocedent gout. dxxxvi. A third cafe^pf variation from the ordinary courfe of the gout is, when, to the atony ufually preced- ing, an inflammatory reaction fully fucceeds : But has its ufual determination to the joints by fome circum- ftances prevented ; and is therefore directed to an in- ternal part, where it produces an inflammatory affection, and that ftate of things which we have named the mif- placed gout. bxxxvii. We have thus offered an explanation of the circumftances of the fyftem in the feveral ftates of the gout ; and this explanation we fuppofe to be confiftent with the phenomena of the difeafe, and with the laws of the animal economy. There are indeed, with refpect to the theory of the difeafe, feveral queftions which might be put, to which we have not given any anfwer. But, though perhaps 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 difeafe, as may lay a foundation for the cure of it, fo far as experience has enabled us to profe- cute it. Proceeding, therefore, upon the feveral parts ©f the pathology given, as fo many matters of fa&, I PRACTICE OF PHYSIC. *e.J fhall now confider what may be attempted towards the cure of the difeafe. bxxxviii. 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 are always very tranfitory, and feldom extend to the producing any con- fiderable change of the whole habit. dxxxix. It would perhaps have been happy for gouty perfons, if this opinion had been implicitly received by them ; as it would have prevented their having been fo often the dupes of felf interefted pretenders, who have either amufed them with inert medicines, or have rafh- lyemployed thofe of the moft pernicious tendency. I am much difpofed to believe the impoffibility of a cure of the gout by medicines ; and more certainly ftill in- cline to think, that whatever may be the poflible pow- er of medicines, yet no medicine for curing the gout has hitherto been found. Although almoft every age has prefented a new remedy, yet all hitherto offered have very foon been either neglected as ufelefs, or con- demned as pernicious. dxl. Though unwilling to admit the power of medi- cines, yet I contend, that a great deal can be done towards the cure of the gout by a regimen; And from what has been obferved (ccccxcviii.), I am firmly perfuaded that any man who, early in life, will enter upon the conftant practice of bodily labor, and of abftinence from animal food, will be preferved entirely from the difeafe. Whether there be any other means of radically cur- ing the gout, I am not ready to determine. There are hiftories of cafes of the gout, in which it is faid, that by great emotions of mind, by wounds, and by other acci- dents, the fymptoms have been fuddenly relieved, and never again returned; but how far thefe accidental cures might be imitated by art, or would fucceed in other cafes, is at leaft extremely uncertain. 3 tot PRACTICE OF PHYSIC- dxli. The practices proper and neceffary in the treat- ment of the gout, are to be confidered under two heads; firfl, As they are to be employed in the intervals of paroxyfms ; or, fecondly, As during the time of thefe. Dxlii. In the intervals of paroxyfms, the indications are, to prevent the return of paroxyfms, or at leaft to render them lefs frequent, and more moderate. During the time of paroxyfms, the indications are, to moder- ate the violence, and fhorten the duration of them as much as can be done with fafety. ..... dxliii. It has been already obferved, that the gout may be entirely prevented by conftant bodily exercife and by a low diet; and I am of opinion, that this pre- vention may take place even in perfons who have a hereditary difpofition to the difeafe. I muft add here, that even when the difpofition has difcovered itfelf "by feveral paroxyfms of inflammatory gout, I am perfuaded that labor and abftinence will abfolutely prevent any re- turns of it for the reft of life. Thefe, therefore, are the means of anfwering the firft indication to be purfued in the intervals of paroxyfms; arid I muft here offer fome remarks upon the proper ufe of thefe remedies. dxliv. Exercife, in perfons difpofed to the gout, is directed to two purpofes : One of thefe is the ftrength- ening of the tone of the extreme veffels ; and the oth- er, the guarding againft a plethoric ftate. For the for- mer, if exercife be employed early in life, and before intemperance has weakened the body, a very moderate degree of it will anfwer the purpofe ; and for the lat- ter, if abftinence be at the fame time obferved, little ex- ercife will be necffeary. dxlv. With refpect to exercife, this in general is lo be obferved, that it fhould never be violent ;for, if vi- olent, it cannot be long continued, and muft always en- danger the bringing on an atony in proportion to the violence of the preceding exercife. dxlvi. It is alfo to be obferved, that the exercife of geftation, though confiderable and conftant, if it be en- tirely without bodily exercife, will not anfwer the pur- pofe in preventing the gout. For this end, therefore, PRACTICE OF PHYSIC. 209 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. dxlvii. In. every cafe and circumftance of the gout in which the patient retains the ufe of his limbs, bodily exercife, in the intervals of paroxyfms, will always be ufe- ful ; and, in the beginnings of the difeafe, when the difpo- fition to it is not yet ftrong, exercife may prevent a par- oxyfm 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 ; either as it weakens the tone of the lower extremities, or as it excites an inflammatory difpofition in them; and it is probable, that in the fame manner ftrains or contufions often bring on a paroxyfm of the gout. dxlviii. Abftinence, the other part of our regimen (dxl.) for preventing the gout, is of more difficult ap- plication. If an abftmence from animal food be entered upon early in life, while the vigor of the fyftem is yet entire, we have no doubt of its being both fafe and effectual; but if the motive for this diet fhall not have occurred till the conftitution fhall have been broken by intemperance, or by the decline of life, a low diet may then endanger the bringing on an atonic ftate. dxlix. 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 with- drawing of an accuftomed ftimulus of the fyftem may readily throw this into an atonic ftate. dl. The fafety of an abstemious courfe may be great- er or lefs according to the management of it. It is an- imal food which efpecially difpofes to the plethoric and inflammatory ftate, and that food is to be therefore ef- pecially avoided ; but, on the other hand, it is vegetable aliment of the loweft quality that is in danger of weak- ening the fyftem too much, by not affording lufficient nourifhment ; and more particularly, of weakening the tone of the ftomach by its accfcency. It is therefore a diet of a middle nature that is to be chofen > and milk 4 2I» PRACTICE OF PHYSIC. 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 nourishment, the farinaceous feeds are next to be cho- fen, and are the food moft proper to be joined with milk. dli. With refpect to drink, fermented liquors are ufe- ful only when they are joined with animal food, and that by their acefcency; and their ftimulus is only necef- fary from cuftom. When, therefore, animal food is to be avoided, fermented liquors are unneceffary; and by increafing the acefcency of vegetables, thefe liquors may be hurtful. The ftimulus of fermented or fpiritous liquors, is not neceffary to the young and vigorous; and when much employed, impairs the tone of the fyftem. Thefe liquor therefore are to be avoided, ex- cept fo far as cuftom and the declining ftate of the fyf- tem may have rendered them neceffary. For prevent- ing or moderating the regular gout, water is the only proper drink. dlii. With refpect to an abftemious courfe, it has been fuppofed, that an abftinence from animal food and fermented liquors, or the living upon* milk and farina- cea alone, for the fpace of one year, might be fufficient for a radical cure of the gout: and it is poflible, that at a certain period of life, in certain circumftances of the, conftitution, fuch a meafure might anfwer the purpofe. But this is very doubtful; and it is more probable that the abftinence muft, in a great meafure, be continued, and the milk diet be perfifted in for the reft of life. It is well known, that feveral perfons who had entered on an abftemious courfe, and had been thereby delivered from the gout, have however, upon returning to their former manner of full living, had the difeafe return up- on them with as much violence as before, or in a more irregular and more dangerous form. DLin. It has been alleged, that for preventing the re- turn of the gout, blood letting, or fcarifications of the feet, frequently repeated, and at ftated times, may be PRACTICE OF PHYSIC. zu practifed with advantage ; but of this I have had no experience. dliv. Extrcife and abftinence are the means of avoid- ing the plethoric ftate which gives the difpofition to the gout, and are, therefore, the means propofed for pre- venting paroxyfms, or, at leaft, for rendering them lefs frequent and more moderate. But many circumftances prevent the fteadinefs neceffary in purfuing thefe meaf- ures ; and, therefore, in fuch cafes unlefs great care be. taken to avoid the exciting caufes, the difeafe may fre- quently return ; and, in many cafes, the preventing of paroxyfms is chiefly to be obtained by avoiding thofe exciting caufes enumerated in div. The conduct nec- effary for avoiding them, will be fufliciently obvious to perfons acquainted with the doctrines of the Hygie- ine, which I fuppofe to have been delivered in another place. dlv. A due attention in avoiding thofe feveral caufes (diii. div.), will certainly prevent fits of the gout; and the taking care that the exciting caufes be never appli- ed in a great degree, will certainly render fits more moderate when they do come on. But, upon the whole, it will appear, that a ftrict attention to the whole con- duct of life, is in this matter neceffary ; and, therefore, when the predifpofition has taken place, it will be ex. tremely difficult to avoid the difeafe. dlvl 1 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 reluctance, men have been very difirous to find a medicine which might anfwer the purpofe, without any reftraint on their manner of living. To gratify this defire, phyfi- cians have propofed, and, to take advantage of it, em- pirics have feigned many remedies, as we have already obferved. Of what nature feveral of thefe remedies have been, I cannot certainly fay ; but, of thofe, which are unknown, we conclude, from their having been on- ly of temporary fame, and from their having foon fal- an PRACTICE OF PHYSIC. len into negledt, that they have been either inert or per: nicious, and, therefore, I make no inquiry after them ; and fhall now remark only upon one or two known rem- edies for the gout, which have been lately in vogue. dlvii. One of thefe is what has been named in En- gland the Portland Powder. This is not a new medi- cine, but is mentioned by Galen, and, with fome little variation 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 fall- en into negle&; and 1 think that this laft has been ow- ing to its having been found to be, in many inftances, pernicious. In every inftance which I have known of its exhibition for thelength of time prefcribed, the per- fons who had taken it were indeed afterwards free from any inflammatory 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. dlviii. Another remedy, which has had the appear* ance of preventing the gout, is an alkali in various forms, fuch as the fixed alkali, both mild and cauftic, lime wa- ter, foap, and abforbent earths. Since it became com- mon to exhibit thefe medicines in nephritic and calcu- lous cafes, it has often happened that they were given to thofe who were at the fame time fubject to the gout; and it has been obferved, that, under the ufe of thefe medicines, gouty perfons have been longer free from the fits of their difeafe. That, however, the ufe of thefe medicines has entirely prevented the returns of gout, I do not know; becaufe I never pufhed the ufe of thofe medicines for a long time, being apprehenfive that the long continued ufe of them might produce a hurtful change in the ftate of the fluids. dlix. With refpect to preventing the gout, I have only one other remark to offer. As the preventing the gout depends very much on fupporting the tone of the ftomach, and avoiding indigeftion ; fo coftivenefs, by occasioning this, is very hurtful to gouty perfons PRACTICE OF PHYSIC. 2Ij It is, therefore, neceffary 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 bel- ly 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 fluted to particular perfons. DLX. Thefe are the feveral meafures (from dxlii. to dlix. ) to be purfued in the intervals of the paroxyfms; and we are next to mention the meafures proper during the time of them. dlxi. As, during the times of paroxyfms, the body is in a feverifh ftite,' no irritation fhould then be added to it; and every part, therefore, of the antiphlogistic re- gimen (exxx. to exxxm.), except the application of cold, ought to be ftrictly obferved. Another exception to the general rule may occur, when the tone of the ftomach is weak, and when the patient has been before much accuftomed to the ufe of ftrong drink ; for then it may be allowable, and even neceffary, to give fome animal food, and a little wine. ' dlxii. That no irritation is to be added to the fyftem during the paroxyfms of gout, except in the caies men- tioned, is entirely agreed upon among phyficians ; but it is a more difficult matter to determine whether, dur- ing' the time of paroxyfms, any meafures may be pur- fued to moderate the violence of reaction and of inflam- mation. Dr. Sydenham has given it as his opinion, that the more violent the inflammation and pain, the paroxyfms will be the fhorter, as well as the interval be- tween 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 preffesfor relief; and, although a certain degree cf in- flammation may feem abfolutely neceffary, it is not cer- tain but that a moderitc degree of it may anfwer the purpofe ; and it is even probable, that, in many cafes, 314 PRACTICE OF PHYSIC. the violence of inflammation may weaken the tone of the parts, and thereby invite a return of paroxyfms. It feems to me to be in this way, that, as the difeafe ad- vances, the paroxyfms become more frequent. dlxiii. From thefe laft confiderations, it feems proba- ble, that, during the time of paroxyfms, fome meafures may be taken to moderate the violence of the inflamma- tion and pain ; and particularly, that, in firft parox- yfms, and in the young and vigorous, blood letting at the arm may be practifed with advantage; but I am perfuaded, that this pract*r Greerory has obferved in the fame family, the different forms of this dif afe arfe from the fame contagion. -It his. been mved, that the fcarlatina angioofa attacks people only once in their Ufe, while they may fr?- %$0 PRACTICE OF PHYSIC. have been at fome pains to eftablifh this opinion : for, from all my experience, I find that thofe two difeafes require a different treatment ; and I therefore now pro- ceed to mention more particularly the circumftances of the fcarlatina anginofa. dclvi. This difeafe commonly appears about the be- ginning of winter, and continues throughout that fea- fon. It comes on with fome cold fhivering, and other fymptoms of the fever which ufually introduces the oth- er exanthemata. But here there is no cough, nor the other catarrhal fymptoms which attend the meafles; nor is there that anxiety and vomiting which common- ly introduce the confluent 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, gen- erally more fo than in the Cynanche Maligna. Upon looking into the fauces, a rednefs and fwelling appear, in color and bulk approaching to the ftate of thefe fymp- toms in the Cynanche Tonfillaris; but in the Scarlati- na, there is always more or lefs of floughs, which feldom appear in the Cynanche Tonfillaris ; and the floughs 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 cccxiv. This eruption is commonly more confiderable and uni- verfal than in the Cynanche ; but it feldom produces a remiffion of the fever. The eruption for the moft part remains till the third or fourth day after its firft appear- ance ; but then goes off, ending in a meally defquama- mation. At this time the fever ufually fubfides; and generally at the fame time fome degree of fweat comes on. quently labor under the cynanche maligna,and even appear to acquire a pre- difpofitiantoit,in confequence of a previous attack. Dodloft'Withenng, who formerly indited much on this circumftance, has candidly retracted hi» op'uiion, obferving, that he was milled, from taking thefprciled fore throat (wh;ch is aot to occur in thofe who have been afflicted with the ulcerated fare throat) far this latter complaint; but it differs from it In almoft every effentiai circumftance; it is rot infectious nor dangerous, nor has it any thins in crrr.ncn with cynanche maligna,but thefloughs in the throat. PRACTICE OF PHYSIC, »i = The floughs on the fauces, which appeared early in the difeafe, continue for fome days; but then falling off, difcover 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 entire- ly. For the moft part this difeafe has much lefs of co- ryza attending it than the Cynanche Maligna j 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 dis- appeared, it frequently happens, that in a few days af- ter, the whole body is affected with an anafarcous fwell- ing ; which however in a few days more, gradually fubfides. We have thus defcribed the moft common circum- ftances of the Scarlatina Anginofa ; and have only to add, that during the time of its being epidemic, and ef- pecially upon its firft fetting in, there are always a few cafes in which the circumftances of the difeafe approach very nearly to thofe of the Cynanche Maligna j and it is only in thefe inftances that the difeafe is attended with any danger. pcLvn. With refpect to the cure of this difeafe, when the fymptoms of it are nearly the fame with thofe of the Cynanche Maligna, it requires exactly the fame treat- ment as directed in cccxvu. dclvih. When the fcarlet fever appears, without any affection of the throat, the treatment of it is very fim- ple, and is delivered by Dr. Sydenham. An antiphlo- giftic regimen is commonly all that is requifite ; avoid- ing, on one hand, the application of cold air; and, on the other, any increafe of external heat *. * We underftand that Dr.Currie has been equally fucctfsful in his appli- cation of the cold affufion in this difeafe. He conceives, that the heat in this affecrion often rifesto a greater height than in any other febriie diftemo- er. In fifty two cafes in which he tried this remedy, its beneficial effects were extremely confpicuous: Only two patients fell victims to the difeafe and thefe were in fuchdefperatecircmn fiances, as precluded all hopes of rc- R 251 PRACTICE OF P1IY0IC. dclix. In the ordinary ftate of the Scarlatina Angi- nofa, the fame treatment is in moft cafes fufficient; but as here the fever is commonly more confiderable, and there is likewife an affection of the throat, fome remedies may be often neceffary. dclx. 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 neceffary (cccv.) ; fo in the Scarlatina, when the ftate of the fever and the appearances of the fauces render the nature of the difeafe ambiguous, bleeding may be omitted; and, if not altogether avoided, it fhould at leaft not be large, and ought not to be re- peated. dclx:. Vomiting and efpecially naufeating dofes of emetics, notwithftanding the inflamed ftate of the fauces, have been found very ufeful in this difeafe. An open belly is proper in every form of this difeafe ; and when the naufeating dofes of emetics operate a little down- wards, they are more ferviceable. dclxii. In every form of the Scarlatina Anginofa, through the whole courfe of it, detergent gargles fhould be employed, and more or lefs as tfce quantity of floughs and the vifcid mucus in the fauces may feem to require. dclxhi. Even in the milder ftates of the Scarlatina Anginofa, it has been common with practitioners to ex- hibit the Peruvian bark through the whole courfe of the difeafe ; but we are affured, by much experience, that in fuch cafes it may be fafely omitted, though in cafes any ways ambiguous, it may not be prudent to neglect this remedy. dclxiv. The anafarcous fwelling, which frequently foiiews the Scarlatina Anginofa, feldom requires any remedy ; and, at leaft, the purgatives fo much incul- cated, and fo commonly exhibited, foon take off, the anafar-ca. PRACTICE OF PHYSIC. *jr CHAP. V. OF THE PLAGUED Sect. I. Of the Phenomena of the Plague. dclxv. X HE Prague is a difeafe which always arifes from contagion ; which affects many perfons a- bout the fame time; proves fatal to great numbers; generally produces fever ; and in moft perfons, is at- tended with buboes or carbuncles. dclxvi. Thefe are the circumftances, which, taken together, give the character of the difeafe ; but it is ac- companied with many fymptoms almoft peculiar to it- felf, that in different perfons are greatly diverfified in number and degree, and fhould be particularly ftudied. 1 would wifh to lay a foundation for this ; but think it unfit for a perfon who has never feen the difeafe to at- tempt its particular hiftory. For this, therefore, I muft refer to the authors who have written on the fubject; but allowing thofe only to be confulted, who have them- felves feen and treated the difeafe in all its different forms. dclxvii. From the accounts of fuch authors, it ap- pears to me, that the circumftances which particularly diftinguifh this difeafe, and efpecially the more violent and dangerous ftates of it, are, \fl, The. great lofs of ftrength in the animal functions, which often appears early in the difeafe. 2dly, The ftupor, giddinefs, and confequent itagger- ing, which refembles drunkennefs, or the headach, and various delirium ; which are all of them fymptoms de- noting a great diforder in the functions of the brain. 3dly, The anxiety, palpitation, fyncope, and efpecial- ly the weaknefs and irregularity of the pulfe, which de- note a confiderable difturbance in the action of the heart. Afthly, The naufea and Vomiting, particularly the vom- iting of bile, which fhows' an accumulation of vitiated bile in the gall bladder and biliary dudts, and from thence * Typhus, extremely contagious; great proftration of ftrc gth. Or an uncertain day of the diftafe, buboes break oxit. Syn. y.of. 2 -J4 PRACTICE OF PHYSIC. derived into the inteftines and ftomach; all Of which fymptoms I fuppofe to denote a confiderable fpafm, and lofs of tone in the extreme veffels on the furface of the body. 5thly, The buboes or carbuncles, which denote an acrimony prevailing in the fluids. And, Laftly, The petechias, hemorrhagies, and colliquative diarrhoea, which denote a putrefcent tendency prevail- ing to a great degree in the mafs of blood. dclxviii. From*the confideration of all thefe fymp- toms, it appears, that the plague is efpecially diftinguifh-* ed by a fpecific contagion, often fuddenly producing the moft confiderable fymptoms of debility in the nervous fyftem or moving powers, as well as of a general putref- cency in the fluids ; and it is from the confideration of thefe circumftances as the proximate caufe, that I think both the prevention and cure of the plague muft be di- rected. dclxix. If this difeafe fliould revifit the northern parts of Europe, it is probable, that, at the time, there will be no phyfician then alive, who, at the firft appear- ance of the difeafe, can be guided by his former experi- ence, but muft be inftructed by his ftudy of the wi iters on this fubject, and by analogy. It is, therefore, I hope, allowable for. me, upon the fame grounds, to offer here my opinion with refpect to both the prevention and cure of this difeafe. This paragraph was written before I had any notice of the plague of Mofcow, anno 1771 ; but I think it will ftill apply to the cafe of Great Britain, and of many other northern ftates. Sfxt. II. Of the Prevention of the Plague. dclxx. With refpect to the prevention : As we are firmly perfuaded that the difeafe never arifes in the northern parts of Europe, but in confequence of its be- ing imported from fome other country ; fo the firft meafure neceffary, is the magiftrate's taking care to prevent the importation ; and this may generally be PRACTICE OF PHYSIC. *Si done, by a due attention to bills of health, and to the proper performance of quarantains. dclxxi. With refpect to the latter, we are perfuaded, that the quaramain of perfons may fafely be much lefs than forty days ; and, if this were allowed, the execu- tion or" the quarantain would be more exact and certain, as the temptation to break it would be in a great mea- fure removed. dclxxii. With refpect to the quarantain of goods, it eannot be perfect, unlefs the fufpected goods be unpack- ed and duly ventilated, as well as the other means em- ployed for correcting the infection they may carry ; and, if all this were properly done, it is probable, that the time commonly prescribed for the quarantain oi goods might alfo be fliortened, dclxxiii. A fecond meafure, in the way of preven- tion, becomes requifite, when an infection has reached and prevailed in any place, to prevent that infection from fpreading into other places. This can be done on- ly by preventing the inhabitants, or the goods of any infected place, from going out of it, till they have un- dergone a proper quarantain. dclxxiv. The third meafure for prevention, to b^ employed with great care, is to hinder the infection from fpreading among the inhabitants of the place in which it has arifen. The meafures neceffary for this, are to be directed by the doctrine laid down in lxxxii ; and, from that doctrine, we infer, that all perfons who can avoid any near communication with infected per- fons, or goods, may efcape the infection^ dclxxv. For avoiding fuch communication, a great deal may be done by the magiftrate ; l.. By allowing as many of the inhabitants as are free from the infec- tion, and not neceffary to the fervice of the place, to go out of it: 2. By prohibiting all aflemblies, or unnecef- fary intercourfe of the people : 3. By taking care that neceffary communications be- performed without con- tact : 4. By making fuch arrangements and provifions as may render it eafy for the families remaining, to Jhut themfelves up in their own houfes: 5. By allow- 2 !$(> PRACTICE OF PHYblC. ing perfons to quit houfes in which an infection appears, upon condition that they go into lazarettos : 6. By ventilating and purifying, or deftroying, at the public expencc, all infected goods: Laftly, By avoiding hof- pitals., and providing feparate apartments for infected perfons. The execution of thefe meafures will require great authority, 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 pol- ice. dclxxvi. The fourth and laft part of the bufinefs ofprevention, refpects the conduct of perfons neceffari- ly remaining in infected places, especially of thofe oblig- ed to have fome communication with perfons infected. dclxxvii. Of thofe obliged to remain in infected places, but not obliged to have any near communication with the lick, they may be prcferved from the conta- gion, 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. dcjlxxviii. 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 contagion are in certain circumftances which render thern more liable to be affected by it, or when certain caufes concur to excite the power of it ; and, therefore, by avoiding thefe circumftances and cau- fes, they may often efcape infection. dclxxix. The bodies qf men are efpecially liable to be effected by contagions, when they are any ways confiderably weakened by want of food, and even by a fcanty diet, or one of little nourifhment j by intem- perance in drinking, which, when the ftupor of intoxi- cation is over, leaves the body in a weakened ftate ; by excefs in venery; by great fatigue j or by any confid- erable evacuation, PRACTICE OF PHYSIC/ W dclxxx. The caufes which, concurring with contag- ion, render it more certainly active, are cold, fear, and full living. The feveral means, therefore, of avoiding or guard- ing againft the action of cold (xciv. to xcvi.) are to be carefully ftudied. dclxxxi. Againft fear the mind is to be fortified as well as poffible, by infpiring a favorable idea of the power of prefervative means; by deftroying the opin- ion of the incurable nature of the difeafe ; by occupy- ing mens minds with bufinefs or labor ; and, by avoids ing all objects of fear, as funerals, palling bells, and any notice of the death of particular friends. dclxxxii. A full diet of animal food increafes the irritability of the body, and favors the operation'of contagion ; and indigeftion, whether- from the quanti- ty or quality of food, has the fame effect. dclxxxhi. Befides giving attention to obviate the feveral circumftances (dcx. dclxxix. to dclxxxii.) which favor the operation of contagion, it is probable, that fome means may be employed for ftrengthening the bodies of men, and thereby enabling them to refift contagion. For this purpofe, it is probable, that the moderate ufe of wine, or of fpiritous liquors, may have a good effect. It is probable alfo, that exercife, when it can be em- ployed, if fo moderate as to be neither heating nor fa- tiguing to the body, may be employed with advantage. Perfons who have tried cold bathmg, and commonly feel invigorating effects from it, ii: they are any ways fecure againft having already received infection, may poffibly be enabled to refift it by the ufe of the cold bath. It is probable, that fome medicines alfo may be ufe- ful in enabling men to refift infection j but amongft thefe I can hardly admit the numerous alexrpharmics formerly propofed, or, at leaft, very few of them, and thofe only of tonic power. Amongft thefe laft we reckon the Peruvian bark ; and it is perhaps the moft effectual. If any thing is to be expected from antifep- 4 *si PRACTICE OF PHYSIC. tics, I think camphire, whether internally or externally employed, is one of the moft promifing. Every perfon is to be indulged in the ufe of any means of prefervation of which he has conceived a good opinion, whether it be a charm or a medicine, if the lat- ter be not directly hurtful. Whether iffues be ufeful in preferving from, or in moderating the effects of contagion, 1 cannot determine from the obfervations I have yet read. dclxxxiv. As neither the atmofphere in general, nor any confiderable portion of it, is tainted or impregnat- ed with the matter of contagions; fo the lightning of fires over a great part of the infected city, or other general fumigations in the open air, are of no ufe for preventing the difeafe, and may perhaps be hurtful. dclxxxv. It would probably contribute much to check the progrefs of infection, if the poor were enjoin- ed to make a frequent change of clothing, and were fuitably provided for that purpofe, and if they were, at the fame time, induced to make a frequent ventilation of their houfes and furniture. Sect. III. Of the Cure of the Plague. dclxxxvi. In the cure of the plague, the indications are the fame as thofe of fever in general (cxxvi.) ; but here they are not all equally neceffary and important. dclxxxvu. The meafures for moderating the vio- lence of reaction, wh;ch operate by diminifhing the ac- tion of the heart and arteries (dcxxviii.), have feldom any place here, excepting fo far as the antiphlogiftic reg- imen is generally proper. Some phyficians, indeed, have recommended bleeding -, and there may occur caf- es in which bleecjing may be ufeful; 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 degree, it may be ufeful, in drawing off the bile, or oth- er putrefcent matters frequently prefent in the intef- tines ; but a large evacuation this way may certainly be hurtful. PRACTICE OF PHYSIC 25^ bclxxxviii. The moderating the violence of reac- tion, fo far as it can be done by taking off the fpafm of the extreme veffels (cli.) is a meafure of the utmoft neceffity in the cure of the plague; and the whole of the means (clii. to cc) fuited to\\\\s indication, are ex- tremely proper. dclxxxix. The giving an emetic, at the very firft approach of the difeafe, would probably be of great fer- vice ; 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 extreme veffels. dcxc From fome principles with refpect to fever in general, and with refpect to the plague in particular, I am of opinion, that, after the exhibition of the firft vomit, the body fhould be difpofed to fweat, which ought to be raifed to a moderate degree only, but com tinued for at leaft twenty-four hours, or longer, if the patient bear it eafily. dcxci. This fweatin2* fhould be excited and conduct- * The following mode cf promoting fweat, it isfiid, has been attended with Angular fuccefs. It was firft fuggefted by Mr. Baldwin, the Britifli a- gent at Alexandria, and has fpiead through Europe. *' Immediately after a *• perfon is perceived to be infected with the plague, he muft be taken into " a clofe room, and, over a brazier of hot coals, with a clean fporige dip- " ped in warm olive oil, his body muft be very brifkly rubbed all over, tor " the purpofe of producing a profufo fweat. During the iiidtion, lugar and " juniper berries muft be burnt in the fire, which raife a denfeand hot fmcke, " that contributes to the effedt. The friction cught not to be continued " more than four minutes, and a pint of oil is enough to be ufed at each " time. In general, the firft rubbing is followed by a very copious perfpi- " ration; but, fhould it fail of this effect, the operation, may be repeated, " firft wiping the body with a warm dry cloth"; and, in order ftill failhir to " promote peifpiration, the patient may take any warm fudorific drink. *; fuch as elder flower tea, &c. It is not neceffary to touch the eyes; and " other tender parts of the body may be rubbed more gently. Every pof- " lible precaution muft be made ufe of to prevent the patient taking cold ; " fuch as keeping covered thofe parts of the body not directly under the op- " eration ; nor muft the linen be changed till the perfpiration has entirely ** fubfided. The operation fhould be repeated once a day, until evident " fymptoms of recovery begin to appear. If there are already tumors on " the body, they fhould be gently and more frequently rubbed, till they " appear to be ina ftate of fuppuration, when they may be dreflld with tha " ufual plafters. The operation ought to be begun on the firft appearance ** of the l'ymptoms of difeafe ; if neglected till the nerves, and the mafs of «' blood are affected, or a diarrhoea has commenced, little hopes can be cn- " tertained cf a cure ; but ftill the patient Ihould not be defpaired of, as by ,: an affiduous application of the means propofed, fome tew have iccovo PRACTICE OF PHYSIC. ed agreeably to the rules laid down in clxviii. It is t© be promoted by the plentiful ufe of diluents, rendered more grateful by vegetable acids, or more powerful by being impregnated with fome portion of neutral falts. dcxcii. 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. dcxciii. If fudorific medicines are judged to be nec- , effary, opiates are the moft effe&ual and fafe : But they fliould not be combined with aromatics ; and probably may be more effectual, if joined with a portion of em- etics, and of neutral falts. dcxciv. If, notwithftanding the ufe of emetics and fudorifics, the difeafe fhould ftill continue, the cure muft depend upon the employment of means for obvia- ting debility and putrefcency ; and for this purpofe, the various remedies propofed above (from cci. to ccxxvn.) may all be adminiftered, but efpecially the tonics; ana1 of thefe the chief are cold drink and the Peruvian baric. dc xcv. In the cure of the 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 forgery. " ed even after diarrhoea had commenced. During the firft four cr five " days, the patient muft obferve a ve.y abftemious diet; the author al'ow6 " only a fmall quant'ty of vermicillr, limply boiled in water. Nor muft " any thi°g be taken f. r the fptce wf thirty or forty days, except very li.wht " food as, he fa\ s, an indigeftion, in any ftage of the diforder, might be ex- " tremely dangerous. He does not allow the ufe of wine till the expiration " of forty days. " There is no inftance oft he perfon iubbinga patirnt having taken the in* " fection. He fhould previoufly anoint himfe.fali over with oil, and muft " avoid receiving the breath of the infected perfon into his mouth and nof- " tri's. Tne prevention to be ufed, in all circumftances, if, that cf careful- " ly anointing the body, and living upon light and eafily digeftible food." PRACTICE OF PHYSIC. *6t C H A P. Vf. OF ERYSIPELAS*, OR ST. ANTHONY'S FIRE. dcxcvi In cclxxiv. I mentioned the diftinc- tion which I propofed to make between the difeafes to be named the Erythema and the Eryfipelas ; and from thence it will appear, that Eryfipelas, as an Erythema following fever, may have its place here. dcxcvh. I fuppofe the eryfipelas to depend on a matter generated within the body, and which, analog- ous to the other cafes of exanthemata, is, in confequence of fever, thrown out upon the furface of the body. I own it may be difficult to apply this to every particular cafe of eryfipelas ; but I take the cafe in which it is gen- erally fuppofed to apply, that of the eryfipelas of the face ; which I fhall therefore confider here. dcxcvih. The Eryfipelas of the face comes on with a cold fhivering, and other fymptoms of pyrexia. The hot ftage. of this L; frequently attended with a confu- fion of head, and fome degree of delirium ; and almoft always with drowfinefs, or perhaps coma. The pulfe is always frequent, and commonly full and hard. dcxcix. 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 cclxxv. 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 affe&ed the whole ; and fre- quently from the face it fpreads over the hairy fcalp, or * Synocha, of two or threedays, attended with drowfinefr, and, not un- irequently, delirium. On fome pa> t of the fkin, ofteneft on the face, an ery- thematous fwelling appear*. Species i. Eryfipelas {i>e/icu!ofurn) Merd d with erythema; a fpreading rednefs, occupying a large ipace* and mnnirg into large blifters in feveral places. Species t.Eryfipelas (phlyficenodes), attended wi'h an erythema, accom- panied with fever.il pimples cccupvinc; the trunk of the body, ar.d running iutofmall blifters, Syr.. N*f. *; dcclxxxix. Having thus mentioned the means of I preventing either the firft attacks, or the recurrence o$ ^ hemorrhagy, I muft next fay how it is to be managed • when it has actually come on. ^ dccxc. When an hemorrhagy has come on, which I appears to have arifen from a preternaturally plethoric | ftate, or from fome change in the balance of the fanguif- erous fyftem, no meafures are to be immediately taken • for fuppreffing it; as we may expect, that when the ' quantity of blood neceffary for the relief of the fyftem is poured out, the effufion will fpontaneoufly ceafe. dccxci. In many cafes, however, it may be fufpected, ' that the quantity of blood poured out, is not exactly in \ proportion to the neceflities bf the fyftem, either for re- lieving 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 inftam- \ matory 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 al- together. PRACTICE OF PHYSIC. a9J Dccxcil. An hemorrhagy may be moderated by avoid- ing any irritation that might concur to increafe it; fo that every part of the antiphlogiftic regimen is to be obferved ; in particular,.external heat, both as it rari- fies the fluids, and flimulates the folids, is to be carefuL ly avoided : and it is probable, that in all cafes an he- morrhagy may be fafely moderated by cool air applied, and cold drink exhibited, dccxciii. A fecond means, for the fame purpofe, js, the ufe of refrigerant medicines, and particularly of a- cids and nitre. dccxciv. A third means which has been frequently employed, is that of blood letting. The propriety of this practice may be doubtful, as the quantity of blood poured out by the hemorrhagy, may be fuppofed to an- fwer the purpofe of an evacuation in any other way ; and I am ready to allow, that the practice has been of- ten fuperfluous, and fometimes hurtful, by making a greater evacuation than was neceffary or fafe. At the fame time, I apprehend it is not for the mere purpofe of evacuating, that blood letting is to be practifed in the cure of hemorrhagy; but that it is further neceffary for taking off the inflammatory diathefis which prevails, and the febrile fpafm that has been formed. Accord- ingly, in the cafe of hemorrhagy, when the pulfe is not only frequent, but quick and full, and does not become fofter or flower upon the flowing of the blood, and that the effufion is profufe, and threatens to continue fo, it ■ appears to me that blood letting may be y.eceffary, and I have often found it ufeful. ItYeems probable alfo, that the particular circumftances of venefection may render it more powerful for taking off the tenfion and inflam- matory irritation of the fyftem, than any gradual flow from an artery. dccxcv. That a fpafm of the extreme veffels has a fhare in fupporting hemorrhagy, appears to me probable from hence, that bliftering has been often found ufeful in moderating and fuppreffing the difeafe. 394 PRACTICE OF PHYSIC. dccxcvi. Do emetics and vomiting contribute to the} cure of hemorrhagy ? See Dr. Bryan Robinson on the J virtues and power of medicines. \ dccxcvii. When an hemorrhagy is very profufe, and | feems to endanger life, or even threatens to induce a dan- , gerous infirmity, it is agreed on all hands, that it is to be immediately fuppreffed by every means in our power; and particularly, that, befidesthe means above mention- ed for moderating the difeafe, aftringents, internal or external, where the latter can be applied, are to be em- ployed for fupprefling it. dccxcvih. The internal aftringents are either vegeta- ble or foffil. The vegetable aftringents are feldom very powerful in the cure of any hemorrhagies, except thofe of the alimentary canal. The foffil aftringents are more powerful; but fomev i choice amongft the different kinds may be proper. ^ The chalybeates, fo frequently employed, do not ap? \ pear to me to be very powerful. The preparations of lead are eertainly more fo, butn ; are otherwife of fo pernicious a quality, that they fhould g ,* not be employed except in cafes of the utmoft dangeftvi J The Tinctura Saturnina, or Antiphthifica, as it has,rl been called, appears to be of little efficacy ; but whether from the fmall portion of lead which it contains, or from ; the ftate in which the lead is in it, I am uncertain. The foffil aftringent that appears to me the moft pow- erful, and at the fame time the moft fafe, is alum. dccxcix. External aftringents, when they can be ap- plied, are more effectual than the internal. The choice of thefe is left to the furgeons. dccc. The moft powerful of all aftringents appears to me to be cold, which may be employed either by apply- ing cold water to the furface of the body or by throwing it into the internal parts. dccci. For fupprefling hemorrhagies, many fuperfti- tious remedies and charms have been recommended, and pretended to have been employed with fuccefs. The feeming fuccefs of thefe however, has been generally "' PRACTICE OF PHYSIC. ?*5 owing to the by ftanders miftaking a fpontaneous ceaf- ing of the hemorrhagy for the effect, of the remedy. At the fame time, I believe, that thofe remedies may have been fometimes ufeful, by impreffing the mind with hor- ror, awe, or dread. dcccii. Upon occafion of profufe hemorrhagies, opi- ates, have been employed with advantage; and, when the fulnefs and inflammatory diathefis of the fyftem have been previoufly taken off by the hemorrhagy itfelf, or by bloodletting, I think opiates may be employed with fafety. dccciii. 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 appear tome to be of uncertain and ambigu- ous ufe. dccciv. In the cafe of profufe hemorrhagies, no pains are to be taken to prevent a Deliquium Animi, or faint- ing, as the happening of this is often the moft certain means of flopping the hemorrhagy. dcccv. Having thus delivered the general doctrine o£ hemorrhagy, 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 elfewhere more properly than here. CHAP. II. OF THE EPISTAXIS*, OR HEMORRHAGY OF THE NOSE. ncccvi. 1 he ftate of the veffels upon the inter- nal furface of the nofe being fuch as already mentioned (dcclvii.), renders an hemorrhagy from that more fre- quent than from any other part of the body. * Pain, or heavinefs of the head, rednefs of the face, accompanied witk a Row of blood from the noftrils. Syn. Nof. a9(; PRACTICE OF PHYSIC. dcccvii. The blood commonly flows from one nof- tril only, and probably becaufe an hemorrhagy from one veffel relieves the congeftion in all the neighboring veffels. t ....' The blood flowing from both norftrils at the fame time, fhows commonly a more confiderable difeafe. i dcccviii. This hemorrhagy happens to perfons of every conftitution and temperament, but moft frequent- ly to thofe of a plethoric habit, and fanguine tempera- ment. It happens to both fexes, but moft frequently to the male. dcccix. This hemorrhagy may occur at any time of life ; but moft commonly happens to young perfons, ,. owing to the ftate of the balance of the fyftem peculiar to that age, as mentioned in dcclvi. dcccx. Although generally it happens to perfons be- t fore they have arrived at their full growth, and more j rarely afterwards, yet fometimes it happens to perfons M after their acme, and during the ftate of manhood : ana | 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 weaknefe j of thefe. ' „ dcccxi. In all thefe cafes the difeafe may be confider- j ed as an hemorrhagy purely arterial, and depending up- on an arterial plethora ; but it fometimes occurs in the ^j decline of life, when probably it depends upon, and may be confidered as a mark of a venous plethora of the vef- 1 fels of the head. See dcclxxii. + < dcccxii. This hemorrhagy happens alfo at any period | of life, in certain febrile difeafes, which are altogether or pardyofan inflammatory nature, and which fhow a , particular determination of the blood to the veffels of 1 the head. Thefe difeafes often admit of a folution by this hemorrhagy, when it may be properly termed crit- ical. dcccxiii. The difeafe fometimes comes on without .j any previous fymptoms ; particularly when fome exter- nal violence has a fhare in producing it. But when it proceeds entirely from an internal caufe, it is common*? PRACTICE OF PHYSIC. S97V preceded by hcadachs, rednefs of the eyes, a florid col- or of the face, an unufual pulfation in the temples, a fenfe of fulnefs about the nofe, and an itching of the noftrils; A bound belly, pale urine, coldncfs of the feet, and cold fhivering over the whole body, are alfo fome- times among the fymptoms that precede the difeafe, dccc'xiv. From the weaknefs of the veffels of the nofe, the blood often flows from them without any confider- able effort of the whole fyftem, and therefore without any obfervable febrile diforder ; which, however, in many cafes is, in all its circumftances, very difcernible. dcccxv. An hemorrhagy of the nofe happening to young perfons, is, and may generally be confidered as a flight difeafe of little confequence, and hardly requiring any remedy. But even in young perfons, when it re- curs very frequently, and is very copious, it will require particular attention, as it is to be confidered as a mark of arterial plethora ; and, as frequently returning, it may increafe the plethoric ftate, which in a more advan- ced ftage of life, may give the blood a determination to parts from which the hemorrhagy would be more dan- gerous. All this will more particularly require atten- tion, according as the marks of plethora, and of partic- ular congeftion, preceding the hemorrhagy, are more confiderable ; and as the flowing of the blood is attend- ed with a more confiderable degree of febrile diforder. dcccxvi. When the epiftaxis happens to perfons after their acme, returning frequently, and flowing copioufly, it is always to be confidered as a dangerous difeafe, and as more certainly threatening the confequences mention- ed in the laft paragraph. dcccxvii. When this hemorrhagy happens in the de- cline of life, it may be confidered as in itfelf very faluta- ry : 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, palfv, or fuch like dif- eafes. 2<)t PRACTICE OF PHYSIC. dcccxviii. When an hemorrhagy from the nofe hap- pens in febrile difeafes, as mentioned in dcccxil, and is in pretty large quantity, it may be confidered as critical and falutary ; but it is very apt to be profufe, and even in this way dangerous. It upon fome occafions occurs during the eruptive fe- ver of feveral exanthemata, and is in fuch cafes fome- times falutary ; but if thefe exanthemata be accompani- ed with any putrid tendency, this hemorrhagy, like ar- tificial blood lettings, may have very bad effects. dcccxix. Having thus explained the feveral circum- ftances of epiftaxis,I proceed to confiderfathe management and cure of it. I ufe the expreffion of management, be- caufe 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 internal caufes, that is, from a ftate of the fyftem fuppofed to require fuch evacuation. dcccxx. I am however of opinion, for the reafons-* < given in dcclxxix, that this difeafe is very feldom to be left to the conduct of nature ; and that in all cafes it fhould be moderated by keeping the patient in cool air ; by giving cold drink ; by keeping the body and head erect ; by avoiding any blowing of the nofe, fpeaking, or other irritation : and when the blood has flowed for fome time, without fhowing any tendency to ceafe, a profufe bleeding is to be prevented by meafures employed to flop it, fuch as preffing the noftril from which the blood flows, wafhing the face with cold water, or ap- plying this to other parts of the body. dcccxxi. Even in the cafe of young perfons, where the difeafe is leaft hazardous, and even in the firft attacks, I judge fuch meafures to be proper : but they will be ftill more proper if the difeafe frequently recurs with- out any external violence; if the returns fhall happen to perfons of a habit difpofed to be plethoric ; and more particularly, if the marks of a plethoric ftate appear in the precedent fymptoms, (dcccxiii.) dcccxxii. Even in young perfons, if the bleeding be very profufe and long continued, and more efpecially if PRACTICE OF PHYSIC. *99 the pulfe become weak and the face pale, I apprehend it will be proper to fupprefs the hemorrhagy by every means in our power. See dccxcvu. and the following paragraphs. dcccxxiii. Further, in the fame cafe of young per- fons, when the returns of this hemorrhagy become fre- quent, and efpecially with the marks of a plethoric hab- it, I think it neceflary to employ fuch a regimen as may prevent a plethoric ftate ( dcclxxxiii.—dcclxxx vii.) At the fame time, care fliould be taken to avoid all circumftances which may determine the blood more fully to the veffels of the head, or prevent its free return from them; and by keeping an open belly, to make fome derivation from them. dcccxxiv. In adult perfons, liable to frequent returns of the epiftaxis, the whole of the meafures propofed (dcccxxiii.), are more certainly and freely to be employ- ed. When, with the circumftances mentioned in dccc- xhi. the tendency to a profufe hemorrhagy appears, a bleeding at the arm may be proper, even in young per- fons ; but, in the cafe of adults, it will be ftill more al- lowable, and even neceffary. dcccxxv. In perfons of any age liable to frequent re- turns of this hemorrhagy, when the meafures propofed in dcccxv. et feq. fhall have been neglected, or, from pe- culiar circumftances in the balance of the fyftem, fhall have proved ineffectual, and the fymptoms threatening hemorrhagy (dcccxxxviii) fhall appear,it will then be proper, by blood letting, cooling purgatives, and every part of the antiphlogiftic regimen, to prevent the hemor- rhagy, or at leaft to prevent its being profufe when it does happen. dcccxxvi. In the circumftances juft now mentioned (dcccxxv,), the meafures propofed are proper, and even neceffary ; but it fhould at the fame time be obferved, that thefe are ptactifed with much lefs advantage than thofe pointed out in dcccxxiv. : becaufe, though thofe fuggefted here may prevent the coming on of the he- morrhagy for the prefent, they certainly however dif- pofe to the return of that plethoric ftate which required U joe PRACTICE OF PHYSIC. their being ufed ; and there can be no proper fecurity againft returns of the difeafe, but by purfuingthc means propofed in dcccxxiii. dcccxxvii. WThen the hemorrhagy of the nofe hap- pens to perfons approaching to their full growth, and when its returns have been preceded by the fymptoms dcccxiii. it may be fuppofed, that if the returns can be prevented by the meafures propofed in dcccxxv., 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 evacuations practifed upon this plan will have all the confequences which, I have already obferved, may follow the recurrence of the he- morrhagy itfelf. dcccxxviii. When the hemorrhagy of the nofe fhalj be found to make its returns at nearly ftated periods, the meafures for preventing it (dcccxxv.) may be practi- fed with greater certainty; and, upon every repetition of blood letting, by diminifhing the quantity taken away, its tendency to induce a plethora may be in fome meafure avoided. When indeed the repetition of evacu- ations is truly unavoidable, the diminifhing them upon ever\r repetition is properly practifed : but it is a practice of nice and precarious management, and fhould by no means be trufted to, fo far as to fuperfede the meafures propofed in dcccxxv. wherever thefe can be admitted. dcccxxix. When the hemorrhagy of the nofe hap- pens in confequence of a venous plethora in the veffels of the head, as in dcclxxii., the flowing of the blood pret- ty largely may be allowed, efpecially when it happens after the fuppreffion or ceafing of the menftrual or he- morrhoidal flux. But though the flowing of the blood is on its firft occurring, 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 dcc- lxxxiii. etfeq. but as the effects of a plethoric ftate of the veffels of the head are very uncertain, fo, upon any appearance of it, and efpecially upon any threatening of hemorrhagy, the plethora is to be removed, and the PRACTICE OF PHYSIC. 3ei hemorrhagy to be obviated immediately by proper e- vacuations, as blood letting, purging, and iffues, or by reftoring fuppreffed evacuations, where this can be done. CHAP. III. PF THE HEMOPTYSIS »,OR HEMORRHAGY FROM THE LUNGS. Sect. I. Of the Phenomena and Caufes of Hemoptyfis, dcccxxx. When, after fome affection of the breaft, blood is thrown out from the mouth, and is brought out with more or lefs 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 confiderations to be mentioned hereafter, are often nec- effary to afcertain the exiftence of an hemoptyfis. dcccxxxi. The blood-veffels of the lungs are more numerous than thofe of any other part of the body of the fame bulk. Thefe veffels, of the largeft fize, as they arife from the heart, are more immediately than in any other part fubdivided into veffels of the fmalleft fize $ and thefe fmall veffels, fpread out near to the internal furfaces of the bronchial cavities, are fituated in a loofe cellular texture, and covered by a tender membrane on- ly : 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 fliock given to the whole body fo readily occafions an hemoptyfis. * Rednefs of the cheeks; fenfe of uneafineft or pain, and fometimes of heat, in the breaft; dyfpneea; tickling of the fauces; ceugh, accompanied with th« rejection of blood, which is not unfrequently frcthy. Syn. Nof. 3ci PRACTICE OF PHYSIC. dcccxxxii. An hemoptyfis may be occafioned by ex- ternal violence, at any period of life ; and I have ex- plained above dcclx.), why, in adult perfons, while the arterial plethora ftill prevails in the fyftem, that is, from the age of fixteen to that of five and thirty, an hemopty- fis may at any time be produced, merely by a plethoric ftate of the lungs. dcccxxxiii. But it has been alfo obferved above (dcclxi.), that an hemoptyfis more frequently arifes from a faulty proportion between the capacity of the veffels of the lungs and that of thofe of the reft of the body. Accordingly it is often a hereditary difeafe, which implies a peculiar and faulty conformation. And the difeafe alfo happens efpecially to perfons who difcov- er the fmaller capacity of their lungs, by the narrow- nefsof their cheft, and by the prominency of their fhoulders ; which laft is a mark of their having been iong liable to a difficult refpiration. dcccxxxiv. 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 flender delicate make, of which along neck is a mark ; to perfons of much fen- fibility, and irritability, and therefore of quick parts, whofe bodies are generally of a delicate ftructure ; 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 for- merly been liable to, the moft frequent inftance cf which is in females who have fuffered a fuppreffion of their menftrual flux ; and laftly, to perfons who have fuffered the amputation of any confiderable limb. dcccxxxv. In moft of thefe cafes (dcccxxxiv.), the dif- eafe happens efpecially to perfons about the time of their coming to their full growth, or foon after it, and this for the reafons fully fet forth above. dcccxxxvi. From all that has been faid from dcccxxxvi. to dcccxxxv. the predifponent caufe of hemoptyfis will be fufficiently underftood, and the difeafe may happen from the mere circumftance of the predifponent caufe PRACTICE OF PHYSIC. 3°3 arifing to a confiderable degree. In the predifpofed, how- ever it is often brought on by the concurrence of various occafional and exciting caufes. One of thefe, and perhaps a frequent one, is external heat, which, even when in no great degree, will bring on the difeafe in fpring, and the beginning of fummer, while the heat rarities the blood more than itrelaxes the folids, which had been before contracted 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 ex- ercife. This effort too, alone, may often, in the predifpo- fed, be the exciting caufe, and more particularly, any vio- lent exercife of refpiration. In fhort, in the predifpofed, any degree of external violence alfo may bring on the difeafe. dcccxxxvii. Occafioned by one or other of thefe caufes (bcccxxxvi.), the difeafe comes on with a fenfe of weight and anxiety in the cheft, fome uneafinefs in breathing, fome pain of the breaft, or other parts of the thorax, and fome fenfe of heat under the flernum ; and very often, before the difeafe appears, a faltifh tafte is perceived in the mouth. dcccxxxviii. Immediately before the appearance of blood, a degree of irritation is felt at the top of the lar- ynx. To relieve this, a hawking is made, which brings up a little blood, of a florid color, and fomewhat frothy. The irritation returns ; and, in the fame man- ner, more blood of a like kind is brought up, with fome noife in the wind-pipe, as of air palling through a fluid. dcccxxxix. This is commonly the manner in which the hemoptyfis 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. dcccxl. 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 ap- pear at times for feveral days together. It is fometimes profufe; but rarely in fuch quantity as, either by its ex- cefs, or by its fudden fuffocation, to prove immediate!v 3 J04 PRACTICE OF PHYSIC. mortal. It commonly cither ceafes fpontaneoufly, or is flopped by the remedies employed. dcccxli. 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 of the mouth itfelf, from the fauces, or adjoining cavities of the nofe, from the ftomach, or from the lungs. It is however very neceffary to diftinguifh the different cafes; and, in moft inftances, it may be done by attending to the following confiderations. dcccxlii. 'When the blood fpit out proceeds from fome part of the internal furface of the mouth itfelf, it comes out without any hawking or coughing ; and gen- erally, upon infpection, the particular fource of it be- comes evident. dcccxlui. When blood proceeds from the fauces, or adjoining cavities of the nofe, it may be brought out by hawking, and fometimes by coughing, in the manner we have defcribed in dcccxxxvii. and dcccxxxix. ; fo that in this way a doubt may arife concerning its real fource. A patient often lays hold of thefe circumftances to pleafe himfelf with the opinion of its coming from the fauces, and he may be allowed to do fo : but a phy- fician cannot rtadily be deceived, if he confider, that a bleeding from the fauces is more rare than one from the lungs; that the former feldom happens but to perfons who have been before liable either to an hemorrhagy of the nofe, or to fome evident caufe of erofion ; and in moft cafes, by looking into the fauces, the diflillation of the blood, if it comes from thence, will be perceived. dcccxliv. 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 circumftances which may occur to point it out, fuch as the period of life, the habit of body, and other marks of a predifpofition (dcccxxxiii.—dcccxxxv.) ; and, together with thefe the occafional caufes (dccc- xxxvi.) having been immediately before applied. dcccxlv. When vomiting accompanies the throwing ©ut of blood from the mouth, as vomiting and cough- PRACTICE OF PHYSIC. ing often mutually excite each other ; fo they may be frequently joined, and render it doubtful, whether the blood thrown out proceeds from the lungs or from the ftomach. We may, however, generally decide, by con- fidering, that blood does not fo frequently proceed from the ftomach as from the lungs ; that blood proceeding from the ftomach commonly appears in greater quanti- ty, than when it proceeds from the lungs; that the blood proceeding from the lungs is ufually of a florid color, and mixed with a little frothy mucus only ; whereas the blood from the ftomach is commonly of a darker color, more grumous, and mixed with the other contents of the ftomach ; that the coughing or vomit- ing, according as the one or the other firft arifes in the cafes in which they are afterwards joined, may fometimes point out the fource of the blood ; and, laftly, that much may be learned from the circum- ftances and fymptoms which have preceded the hemor- rhagy. Thofe which precede the hemoptyfis, enumerated in dcccxxxvii., are moft of them evident marks of an af- fection of the lungs. And, on the other hand, the he- matemefisjor iffuing of blood from the ftomach, has -al- fo its peculiar fymptoms and circumftances preceding it; as, for inftance, fome morbid affection of this organ, or, at leaft, fome pain, anxiety, and fenfe of weight, refer- red diftinctly to the region of the ftomach. To all this maybe added, that the vomiting of blood happens more frequently to females than to males ; and to the for- mer, in confequence of a fuppreffion of their menftrual flux, and, by attending to all thefe confiderations (dccc- xlii—dcccxlv.), the prefence of the hemoptyfis may commonly be fufficiently afcertained. Sect. II. Of the Cure ofHenwptyfis. dcccxlvi. This difeafe is fometimes attended with little danger ; as, when it happens to females in confe- quance of a fuppreffion of the menfes ; when, without 4ny marks of a predifpofition, it arifes from external v4 306 PRACTICE OF PHYSIC. violence ; or when from whatever caufe arifing, it leaves behind it no cough, dyfpneea, or other affection of the lungs. Even in fuch cafes, however, a danger may arife from too large an wound being made in the veffels of the lungs ; from a quantity of red blood being left to ftagnate in the cavity of the bronchise ; and particular- ly, from any determination of the blood being made in- to the veffels of the lungs, which, by renewing the he- morrhagy, may have dangerous confequences. In every inftance, therefore, of hemoptyfis, the effufion is to be moderated by the feveral means mentioned (Dccxcn.to DCCXCV.) dcccxlvii. Thefe meafures are efpecially neceffary when the hemoptyfis arifes in confequence of predifpofi- tion ; and in all cafes where there is the appearance of a large effufion, or where the hemorrhagy frequently returns, the effufion is not only to be moderated, but to be entirely flopped, and the returns of it prevented by every means in our power. See dccxcvu. and fol- lowing. dcccxlviii. To flop an hemoptyfis, of prevent the returns of it, two medicines have been frequently em- ployed, neither of which I can approve of. Thefe are chalybeates, and the Peruvian bark. As both of them contribute to increafe the phlogiftic diathefis of the fyf- tem they can hardly be fafe in any cafe of active hemor- rhagy, and I have frequently found them hurtful. dcccxlix. As the hemoptyfis which happens in con- fequence of predifpofition, is always attended with a phlogiftic diathefis ; and, as the bad confequences of the difeafe are efpecially to be apprehended from the contin- uance of that diathefis; fo this is to be induftrioufly taken off by blood letting, in greater or fmaller quanti- ty, and more or lefs frequently repeated, according as the fymptoms fhall direct. At the fame time, cooling purgatives are to be employed, and every part of the an- tiphlogiftic regimen is to be ftrictly enjoined. The re- frigerants may alfo be adminiftered, taking care, howev- er, that the acids, and more efpecially the nitre, do not excite coughing. PRACTICE OF PHYSIC. joj dccci.. From what was obferved in dccxcv. 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. dcccli. The avoiding of motion is generally a prop- er part of the antiphlogiftic regimen ; and, in the he- moptyfis, nothing is more neceffary than avoiding bodi- ly exercife ; but fome kinds of geftation, as failing, and travelling in an eafy carriage on fmooth roads, have oft- en proved a rc%iedy. dccclii. Such is the treatment I can propofe for the hemoptyfis, confidered merely as an hemorrhagy : But when, in fpite of all our precautions, it continues to re- cur, it is often followed by an ulceration of the lungs, and a phthifis pulmonalis. This, therefore, I muft now proceed to confider ; but as it arifes alfo from other caufes befides the hemoptyfis, it muft be treated of with a more general view. CHAP. IV. OF THE PHTHISIS PULMONALIS*, OR CONSUMPTION OF THE LUNGS. Sect. I. Of the Phenomena and Caufes of the Phthifis Pulmonalis. dcccliu. 1 he Phthifis Pulmonalis I woul4 define to be, an expectoration of pus or purulent matter from the lungs, attended with a hectic 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 pulmon- alis. dcccliv. I have met with fome inftances of an expect- oration of purulent matter, continuing for many years, ♦Emaciation of the body, and debility, attended with a cough; hectic fever j and generally a purulent expectoration. Syn. Nof. 3oi Practice of physic accompanied with very few fymptoms of hectic, and at leaft without any hectic 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 definition. dccclv. In every inftance of an expectoration of pus, I prefume there is an ulceration of the lungs. The late Mr. De Haen is the only author that I know of who has advanced another opinion,and has fuppofed, that pus may be formed in the blood-veffels, and be from thence poured into the bronchiie. Admitting nis fact, 1 have attempted an explanation of the appearance of pus without ulceration in cccxlix. ; but, after all, I cannot help fufpecting the accuracy of his obfervations ; muft entirely reject his explanation of them ; muft, howev- er, allow, that we ftill want facts to fupport the explan- ation I have offered, and doubt much if it will apply to any cafe of phthifis. For thefe reafons, I ftill conclude,* '"J agreeably to the faith of all other diffections, and the o- pinions of all phyficians, .that the fymptoms mentioned , in our definition depend always upon an ulceration formed in the lungs. dccclvi. It has fometimes happened, that a catarrh was attended with an expectoration of a matter fo much refembling pus, that phyficians have been often uncer- i tain whether it was mucus or pus, and, therefore, whether the difeafe was a catarrh or a phthifis. It is often of confequence to determine thefe queftions ; and it appears to me that it may be generally done, with fuffi- cient certainty, from the following confiderations, of which each particular is not always fingly decifive, but when they are taken together can hardly deceive us: 1. From the color of the matter; as mucus is nat- urally tranfparent, and pus always opaque. When mu- cus becomes opaque, as it fometimes does, it becomes white, yellow, or greenifh ; but the laft mentioned col- or is hardly ever fo remarkable in mucus as in pus. 2. From the confiftence, as mucus is more vifcid and coherent, and pus lefs fo, and may be faid to be more friable. When mucus is thrown into water, it is not practice of physic. iOf readily diffuffed, but remains united in uniform and cir- cular maffes ; but pus, in the fame circumftances, though not readily diffufed, does not remain fo uniformly unit- ed, and by a little agitation is broken into ragged frag- ments. 3. From the odor, which is feldom perceived in mu- cus, but frequently in pus. It has been propofed to try the odor of the matter expectorated, by throwing it upon live coals ; but in fueh a trial both mucus and pus give out a difagreeable fmell, and it is not eafy to diftin- guifh between them. 4. From the fpecific gravity compared with water j and, indeed, it is ufual for the mucus of the lungs to fwim on the furface of water, and for pus to fink in it. But in this we may fometimes be deceived, as pus which has entangled a great deal of air may fwim, and mucus that is free from air may fink. 5. From the mixture which is difcernible in the mat- ter brought up ; for if a yellow or greenifh matter ap- pears furrounded with a quantity of tranfparent or lefs opaque and lefs colored matter, the more ftrongly col- ored matter may be generally confidered as pus ; as it is not eafy to underftand how one portion of the 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 of the late Mr. Charles Darwin : a. That the vitriolic acid diffolvcs both mucus and pus, but moft readily the former : That if water be added to fuch a folution of mucus, this is feparated, and either fwims on the furface, or, divided into flocculi, is fufpended in the liquor ; whereas, when water is added to a like folution of r>us, this falls to the bottom, or by agitation is diffufed fo as to exhibit an uniformly turbid liquor, b. That a folution of the cauftic fixed alkali, after fom« time, diffolves mucus, and generally pus; and if water be added to fuch folutions, the pus is precipitat- ed, but the mucus is not. From fuch experiments it is jie PRACTICE OF PHYSIC. fuppofed, that pus and mucus may be certainly diftin- guifhed from each other. 7. From the expectoration's being attended with a hectic fever. A catarrh, or expectoration of mucus, is often attended with fever; but never, fo far as I have ob- ferved, with fuch a fever as I am prefently to defcribe as a hectic. This, in my opinion, is the moft certain mark of a purulent 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 mor- tal nature of a confirmed or purulent phthifis, they have confidered every cafe in which a recovery happened, as a catarrh only: but that they may have been miftaken in this, fhall be fhown hereafter. dccclvh. Having thus confidered the firft part of the character of the phthifis pulmonalis as a mark of an ul- ceration of the lungs ; and having juft now faid, that the other part of the character, that is, the hectic fever, is a mark or indication of the fame thing; it is proper now to confider this here, as I had with that view omit- ted it before (lxxiv.) dccclviii. A hectic fever has the form of a remittent, which has exacerbations twice every day. The firft of thefe occurs about noon, fometimes a little fooner or later ; and a flight remiffion of it happens about five af- ternoon. This laft is foon fucceeded by another exacer- bation, 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 morn- ing advances. The exacerbations are frequently attend- ed with fome degree of cold fhivering; or at leaft the pa- tient is exceedingly fenfible to any coolnefs of the air,feeks external heat,and often complains of ajfenfe of cold, when, to the thermometer, his fkin is preternaturally warm. Of thefe exacerbations, that of the evening is always the moft confiderable. dccclix. It has commonly been given as a part of the character of a hectic fever, that an exacerbation of it commonly appears after the taking food; and it is true that dinner, which is taken at noon, or after it, does PRACTICE OF PHYSIC. jn feem to occafion fome exacerbation. But this muft not make us judge the mid day exacerbation to be the ef- fect of eating only ; for I have often obferved it to come on an hour before 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 ob- ferved, that in almoft every perfon, the taking food oc- cafions fome degree of fever : but I am perfuaded this would not appear fo confiderable in a hectic, were it not that an exacerbation of fever is prefent from another caufe ; and accordingly, the taking food in the morn- ing has hardly any fenfible effect. dccclx. I have thus defcribed the general form of hectic 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 of the difeafe. Almoft from the firft appearance of the hectic, the u- rine is high colored, and depofits a copious branny red fediment, which hardly ever falls clofe to the bottom of the veffel. In the hectic, the appetite for food is generally lefs im- paired than in any other kind of fever. The thirft is feldom confiderable; the mouth is com- monly moift ; and as the difeafe advances, the tongue becomes free from all fur, appears very clean ; and in the advanced ftages of the difeafe, the tongue and fauces ap- pear to be fomewhat inflamed, and become more or lefs covered with aphthae. As the difeafe advances, the red veffels of the adnata of the eye difappear, and the whole of the adnata be- comes of a pearly white. The face is commonly pale ; but, during the exacer- bations, a florid red, and an almoft circumfcribed fpot, appear on each cheek. For fome time, in the courfe of a hectic, the belly is bound ; but, in the advanced ftages of it, a diarrhoea al- 3i» PRACTICE OF PHYSIC. moft always comes on, and continues to recur frequent- ly during the reft of the difeafe, alternating in fome meaf- ure 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 af* fected with cedematous fwellings. The exacerbations of the fever arc 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 moft part, is confident and full of hope. Some days before death, a delirium comes on, and 1 commonly continues to the end. j dccclxi. The hectic fever now defcribed (dccclviii. ] —dccclx.) as accompanying a purulent ftate of die lungs, is perhaps the cafe in which it moft frequently ap- pears : but I have never feen it in any cafe, when there was not evidently', or when I had not ground to fup- pofe there was a permanent purulency or ulceration in fome external or internal part*. It was for this reafon, 1 that in lxxiv, I concluded it to be a fymptomatic fever only. Indeed, it appears to me to be always the effect of • This opinion is extremely quefticnable. There are cafes on record, . mhere a well formed hectic was obferved, without any ulceration ever hav- ing been detected on diffeclion. It has indeed been attempted to be prov- ed, that thofe fevers, whofe origin cannot be traced to the abforption of ae- rated purulent matter, df^er from the genuine hectic ; but the reafoning em- < ployed does net appear altogether fatisfadtory. See Dr. Drake's Paper an Confinnption in the id. Vol. of Medical Journal. There is no doubt, however, that the abforption ».-f aerated matter is the «hief caufe of hectic ; its being expofed to fhe air giving it a lingular virulence, which is fuppofed to arife from its attraction for oxygen, and the confequent formation cf an acid. The learned author of the the Zoonomia, has the following remarks: ] «• Mitt-r produced by fuppuration, will lie concealed in the body many " weeks, or even months, without producing hectic fever ; but as foon ai " the wound is opened, fo as to admit air to the furface of the Ulcer, abec- " tic fever supervene., even in a very few hours. Hence, when ulcers are " to be healed, it is neceffary, carefully to exclude the air from them. " Heace we have one caufe which prevents pulmonary ulcers from bealiDg, ' " which is, their being perpetually expofed to the air." PRACTICE OF PHYSIC. 313 an acrimony abforbed from abfeeffes or ulcer:., although it is not equally the effect of every fort of acrimony ; for the fcorbutic and cancerous kinds often fubfift long in the body without producing a hectic. What is the pre- cife ftate of the acrimony producing this I cannot deter- mine, but it feems to be chiefly that of a vitiated puru- lency. dccclxu. However this may be, it appears, that the hectic's depending in general upon an acrimony, ex- plains its peculiar circumftances. The febrile ftate feems to be chiefly an exacerbation of that frequency of the pulfe, which occurs twice every day to perfons in health, and may be produced by acrimony alone. Thefe exac- erbations, indeed, do not happen without the pioper circumftances of pyrexia ; but the fpafm of the extreme veffels in a hectic does not feem to be fo confiderable as f in other fevers : and hence the ftate of fweat and urine which appears fo early and fo conftantly in hectics. Up- 1 on 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. dccclxiii. Having thus confidered the characterift- ical fymptoms and chief part of the proximate caufe of ■i the phthifis pulmonalis, I proceed to obferve, that an ulcer of the lungs, and its concomitant circumftances of hectic fever, may arife from different previous affec- tions of the lungs : all of which however may, in my opinion, be referred to five heads; that is, 1. To an hemoptyfis ; 2. To a fuppuration of the lungs in confe- quence of pneumonia ; 3. To catarrh ; 4. To afthma ; or, S. To a tubercle. Thefe feveral a flections, as caufes of ulcers,fhall now be confidered in the order men- tioned. dccclxiv. It has been commonly fuppofed,that an he- moptyfis was naturally, and almoft neceffarily followed v by an ulcer of the lungs ; but I will prefume to fay, that "■ in general this is a miftake ; for there have been many inftances of hemoptyfis occafion ed by external violence, without being followed by any ulcer of the lungs ; and there have alfo been many inftances of hemoptyfis from 314 PRACTICE OF PHYSIC. an internal caufe, without any confequent ulceration. And this too has been the cafe, not only when the he moptyfis happened to young perfons, and recurred for feveral times, but when it has often recurred during the courfe of a long life. It is indeed eafy to conceive, that a rupture of the veflels of the lungs, like that of thq 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 particular 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 rupture, or fre- quently 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 bnjfl- J chiae, become acrid, and erode the parts. Thefe howev- er are but fuppofitions, not fopported by any clear evi- dence. And if we confider that thofe cafes of hemopty- fis which follow the predifpofition (dcccxxxii —dccc- xxxv.) are thofe efpecially which end in phthifis, we fhall be led to fufpect that there are fome other circum- ftances which concur here to determine the confequence of hemoptyfis, as Ifliall hereafter endeavor to fhow. dccclxv. Any fuppofition, however, which we can make with refpect to the innocence of an hemoptyfis, muft not fuperfede the meafures propofed above for its, cure: both becaufe we cannot certainly forefee what may be the confequences of fuch an accident, and becaufe the meafures above fuggefted are fafe ; for upon every fuppofition, it is a diathefis phlogiftica that may urge . on every bad confequence to be apprehended. i dccclxvi. The fecond caufe of an ulceration of the lungs, to be confidered, is a fuppuration formed in con- fequence of pneumonia. DcccLxvii. From the fymptoms mentioned in dccc- lviii.—bccclix., it may with reafon be concluded, that ■ an abfeefs, or, as it is called, a vomica, is formed in fome part of the pleura, and moft frequently in that portion of it invefting the lungs. Here purulent matter frc* PRACTICE OF PHYSIC. 315 quently remains for fome time, as if inclofed in a cyfl: but commonly it is not long before it comes to be either abforbed, and transferred to fome other part of the body; or that it breaks through into the cavity of the lungs, or into that of the thorax. In the latter cafe, it produces the difeafe called empyema ; but it is only when the matter is poured into the cavity of the bronchiae, that it proper- ly conftitutes the phthifis pulmonalis. In the cafe of em- pyema, the chief circumftances of a phthifis are indeed alfo prefent ; but 1 fhall here confider that cafe only in which the abfeefs of the lungs gives occafion to a purulent expectoration. d'cclxvih. An abfeefs of the lungs, in confequence of pneumonia, is not always followed by a phthifis; for fometimes a hectic fever is not formed : the matter poured into the bronchire is a proper and benign pus, which is frequently coughed up very readily, and fpit out: and though this purulent expectoration fhould con- tinue for fome time, yet if a hectic does not come on, the ulcer foon heals, and every morbid fymptom difappears. This has happened fo 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 ab- feefs of the lungs, therefore, does not neceffarily produce the phthifis pulmonalis ; and if it be followed by fuch a difeafe, it muft be in confequence of particular circum- ftances which corrupt the purulent matter produced, render it unfuitable to the healing of the ulcer, and at the fame time make it afford an acrimony, which being abforbed, produces a hectic and its confequences. dccclxix. The. corruption of the matter of fuch ab- feeffes maybe owing to feveral caufes ; as, 1. That the matter effufed during the inflammation, had not been a pure ferum 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 connection with an empyema, had been fo corrupted as W 316 PRACTICE OF PHYSIC. to become unfit for the purpofe of pus, in the healing of the ulcer. Thefe feem to be poffible caufes of the corrup- tion of matter in abfeeffes, fo as to make it the occafion of a phthifis in perfons otherwife found ; but it is proba- ble, that a pneumonic abfeefs 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. dccclxx. The third caufe fuppofed to produce phthi- fis, 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 expectoration of pus; and at the fame time, by the addition of a hectic fever, the dif- eafe, which was at firft a pure catarrh, is converted into a phthifis. This fuppofition, however, is not eafily to be admitted. The catarrh is properly an affection of the mucous glands of the trachea and bronchiae, analogous to the coryza, and lefs violent kinds of cynanche tonfil- laris, which very feldom terminate in fuppuration. And although a catarrh fliould 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 iipt produce a phthifis. dcc£lxxi. Further, the catarrh, as purely the effect of cold is generally a mild difeafe, as well as of fliort du- ration • and 01 the numerous inftances of it, there are at moft but very few cafes which can be faid to have ended in phthifis. In all thoic cafes in which this feems to have happened, it is to me probable", that the perfons affected were peculiarly predifpofed to phthifis. And the begin- ning of phthifis fo often refembles a catarrh, that the former may have been miftaken for the latter. Befides, to increafe the fallacy, it often happens that the applica- tion of cold, which is the moft frequent caufe of catarrh, is alfo frequently the exciting caufe of the cough which proves the beginning of phthifis. ncccLXxur It is to me therefore probable, that a ca- tarrh is very feldom the foundation of phthifis ; but I would not pofitively affert that it never is fo : for it is poffible, that the cafes of a more violent catarrh may PRACTICE OF PHYSIC. 317 have joined with them a pneumonic affection, which may end in a fuppuration ; or it may happen, that a long continued catarrh, by the violent agitation of the lungs in coughing, will produce fome of thofe tubercles which afe prefently to be mentioned as the moft frequent caufe of phthifis. dccclxxiii. It muft be particularly obferved here, that nothing faid in dc cclxxii. fhould allow us to neg- lect any appearance of catarrh, as is.too frequently done j 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 produce a phthifis, as in dc cclxxii. dccclxxiv. Many phyficians have fuppofed an acri- mony of the fluids eroding fome of the veffels of the lungs, to be a frequent caufe of ulceration and phthifis. But this appears to me to be a mere fuppofition : for, in any of the inftances of the production of phthifis which I have feen, there was no evidence of any acrimo- ny of the "blood capable of eroding the veffels. It is true, indeed, that in many cafes an acrimony fobfifting in fome part of the fluids, is the caufe of the difeafe ; but it is at the fame time probable, that this acrimony oper- ates by producing tubercles, rather than by any direct erofion. dccclxxv. It has been mentioned in DcccLxni.that an afthma may be confidered as one of the caufes of phthifis : and by afthma, I mean that fpecies of it which has been commonly named the fpafmodic. This difeafe frequently fubfifts very long without producing any other, and may have its own peculiar fatal termination, as fhall be explained hereafter. But I have feen it fre- quently end in phthifis ; and in fuch cafes I fuppofe it to operate in the manner above alleged of catarrh, that is, by producing tubercles, and their confequences, which fhall be prefently mentioned. dccclxxvi. I come now to confider the fifth head of the caufes of phthifis, and which I apprehend to be the moft frequent of any. This I have faid, in general, to !>e tubercles; by which term are meant, certain fmali jiS PRACTICE OF PHYSIC tumours, which have the appearance of indurated glands. Diffections have frequently fliown fuch tubercles formed in the lungs ; and although at firft indolent, yet at length they become inflamed, and are thereby changed into lit- tle abfeeffes, or vcmiccc, which breaking, and pouring their matter into the bronchiae, give a purulent expec- toration, and thus lay the fonndation of phthifis. dccclxxvii. Though the matter expectorated upon thefe occafions has the appearance of pus, it is feldom that of a laudable kind ; and as the ulcers do uot read- ily heal, but are attended with a hectic fever, for the moft part ending fatally, I prefume that the matter of the ul- cers is imbued with a peculiarly noxious acrimony, which prevents their healing, and produces a phthifis in all its circumftances, as mentioned above. dccclxxvhi. It is very probable that the acrimony which thus difcovers itfelf in the ulcers, exifted before and produced the tubercles themfelves ; 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 cafes, of different kinds ; and it will not be eafv to determine its varieties ; but to a certain length I fhall attempt it. dccclxxix. In one cafe, and that too a very frequent one, of phthifis, it appears, that the noxious acrimony is of the fame kind with that which prevails in the fcro- phula. This may be concluded from obferving, that a phthifis, at its ufual period, frequently attacks perfons born of fcrophulous parents ; that is, of parents who had been affected with fcrophula in their younger years : that very often, when the phthifis appears, there occur at the fame time fome lymphatic tumours in the exter- nal parts ; and very often I have found the tables me- fenterica, which is a fcrophulous affection, joined with the phthifis pulmonalis. To all this I would add, that even when no fcrophulous affection has either manifeft- ly preceded or accompanied a phthifis, this laft however moft commonly affects perfons of a habit refembling the fcrophulous; that is, perfons of a fanguine, or of a fan- guinco-melancholic temperament, who have very fine PRACTICE OF PHYSIC. m fkins, rofy complexions, large veins, foft flepi, and thick upper lip : and further, that in fuch perfons the phthifis comes on in the fame manner that it does in perfons having tubercles, as fhall be immediately explained. dccclxxx. Another fpecies of acrimony producing tubercles of the lungs, and thereby phthifis, may be faid to be the exanthematic. It is well known, that the fmall-pox fometimes, and more frequently the meafles, lay the foundation of phthifis. It is probable alfo, that other exanthemata have the fame effect; and from the phenomena of the difeafe, and the diffection s of perfons who have died of it, it is probable, that all the exanthemata may occafion a phthifis, by affording a matter which in the firfl place produces tubercles. dccclxxxi. Another acrimony, which feems fome- times to produce phthifis, is the fiphylitic : but whether fuch an acrimony produces phthifis in any other perfons than the previoufly difpofed, does not appear to me cer- tain. dccclxxxii. What other fpecies of acrimony, fuch as from fcurvy, from pus abforbed from other parts of the body, from fuppreffed eruptions, or from other four- ces, 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. dccclxxxhi. 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 form- ed in the lungs, and coughed up, frequently with a lit- tle blood, fometimes with mucus only, and fometimes with pus. How this matter is generated, or in what pre- cife part of the lungs it is feated, I acknowledge myfelf ignorant. In three cafes of this kind which have occur- red to me, there was at the fame time no appearance of ftony or earthy concretions in any other part of the bo- dy. In one of thefe cafes, an exquifitely formed phthifis came on, and proved mortal : while in the other two, the fymptoms of phthifis were never fully formed ; and after fome time, merely by a milk diet, and avoiding ir- ritation, the patients entirely recovered. 3 3»« PRACTICE OF PHYSIC. dccclxxxiv. Another foundation for phthifis, analo- gous, as I judge, to that of tubercles, is that which oc- curs to certain artificers, whofe employments1 keep them almoft conftantly expofed to. dull; fuch as ftone-cutters, millers, flax-dreffers, and fome others. I have not obferv- ed in this country many inftances of phthifis which could be referred to this caufe ; but from Ramazzini, Mor- gagni, and fome other writers, we muft conclude fuch cafes to be more frequent in the fouthern parts of Europe. dccclxxxv. Befides thofe now mentioned, there are probably fome other caufes producing tubercles, which have not yet been afcertained \>y obfervation ; 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 ob- fervation and inquiry. dccclxxxvi. It has been frequently fuppofed by phy- ficians, that the phthifis is a contagious difeafe ; and I dare not affert that it never is fuch: but in many hundred in- ftances of the difeafe which I have feen, there has been hardly one which to me could appear to have arifen from contagion. It is polEble, that in warmer climates the effects of contagion may be more difcernfole. After having faid that a phthifis arifes from tubercles more frequently than from any other caufe, and after having attempted to aflign the variety of thefe, I now proceed to mention the peculiar circumftances and fymp- toms which ufiially accompany the coming on of the difeafe from tubercles. dccclxxxvii. A tuberculous and purulent ftate of the lungs has been obferved in very young children, and in fome others at feveral different periods before the age of puberty 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 peri- od which I have afligned for the coming on of the he- moptyfis. dccclxxxviii. The phthifis from tubercles does alfo generally affect the fame habits as the hemoptyfis, that is, perfons of a flender make, of long necks, narrow chefts, and prominent fhoulders ; but very frequently the per- PRACTICE OF PHYSIC. 3*: ions liable to tubercles have lefs of the florid countenance, and of the other marks of an exquifitely fanguine temper- ament, than the perfons liable to hemoptyfis. dccclxxxix. This difeafe, arifing from tubercles, ufu- ally commences with a flight and fhort cough, which be- comes habitual, is often little remarked by thofe affected, and fometimes fb 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 become languid and indolent. This ftate fome- times continues for a year, or even for two years, with- out the perfons making any complaint of it, excepting only that they are affected by cold more readily than u- fual, which frequently increafes' their cough, and pro- duces 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. dcccxc. Upon one or other of thefe occafions of catch- ing cold, as we commonly fpeak, the cough becomes more confiderable ; is particularly troublefome upon the pa- tient's lying down at night, and in this ftate continues longer than is ufual in the cafe of a fimple catarrh. This is more efpecially to call for attention, if the increafe and continuance of cough come on during the fummer feafon. dcccxci. The cough which comes on as in dccclxxx- ix. is very often, for a long time, without any expector- ation ; but when, from repeatedly catching cold, it be- comes more conftant, it is then, at the fame time, attend- ed with fome expectoration, which is moft confiderable in the mornings. The matter of this expectoration be- comes by degrees more copious, more vifcid, and more. opaque ; at length of a yellow or greenifh color, ?^nd of a purulent appearance. The whole of the matter, how- ever, is not always at once entirely changed in ih\s man- ner ; but, while one part of it retains the ufual form of mucus, another fuffers the changes now defended. dcccxcii. When the cough increafes, ai\d continues very frequent through the night, and whoa the matter 4 PRACTICE OF PHYSIC. expectorated undergoes the changes I have mentioned the breathing at the fame time becomes more difficult, and the emaciation and weaknefs go on alfo increafing. In the female fex, as the difeafe advances, and fometimes early in its progrefs, the menfes ceafe to flow ; and this circumftance is to be confidered as commonly the effect, although the fex themfelves are ready to believe it the fole caufe of the difeafe. dcccxciii. When the cough comes onasinDcccLxxx- ix. the pulfe is often natural, and for fome timeafter con- tinues to be fo ; but the fymptoms have feldom fubfifted long before the pulfe becomes frequent, and fometimes to a confiderable degree, without much of the other fymptoms of fever. At length, however, evening exa- cerbations become remarkable, and by degrees thejever affumes theexquifitc form of hectic, as defcribed in dccc- LVHI.--DCCCLX. dcccxciv. It is feldom that the cough, expectoration, and fever go on increafing, in the manner now defcrib- ed, without fome pain being felt in fome part of the thorax. It is ufually and moft frequently felt at firft un- der the flernum, and that efpecially, or almoft only, up- on occafion of coughing ; but very often, and that too early, in the courfe of the difeafe, a pain is felt on one fide, fometimes very conftantly, and fo as to prevent the perfon from lying eafily upon that fide ; but, at other times, the pain is felt only upon a full infpiration, or upon coughing. Even when no pain is felt, it generally happens, that phthifical perfons cannot lie eafily on fome oneof their fides,without having their difficulty of breath- ing increafed, and their cough excited. dcccxcv. The phthifis begins, and fometimes proceeds to its fatal iffue, in the manner defcribed from dccc- lxxxix. to dcccxcv., without any appearance of he- moptyfis. Such cafes are, indeed, rare ; but it is very common for the difeafe to advance far, and even to an evident purulency and hectic ftate, without any appear- ance of blood in the fpitting ; fo that it may be affirmed the difeafe is frequently not founded in hemoptyfis. At the fame time, we mult allow, not only that it fometimes PRACTICE OF PHYSIC. 3*j begins with an hemoptyfis, as is faid in dccclxiv. ; but further, that it feldom happens, that, in the progrefs of the difeafe,more or lefs of an hemoptyfis does not appear. Some degree of blood-fpitting does, indeed, appear fome- times in the ftate mentioned dccclx^cxix. dcccxchi., but more commonly in the more advanced ftages of the difeafe only, and particularly upon the firft appearance of purulency. However this may be, it is feldom, in the phthifis from tubercles, that the hemoptyfis is confidera- ble, or requires any remedies different from thofe which are otherwife neceffary for the ftate of the tubercles. dcccxc vi. I have now defcribed a fucceffion of fymp- toms which, in different cafes, occupy more or lefs time. In this climate they very often take up fome years, the fymptoms appearing efpecially in the winter and fpring; commonly becoming eafier, and fometimies almoft difap- pearing, during the fummer ; but returning again in winter, they at length, after two or three years, prove fatal, towards the end of fpring or beginning of fummer. dcccxcvii. In this difeafe, the prognofis is, for the moft part, unfavorable. Of thofe affected with it, the greater number die ; but there are alfo many of them who recover encirely, after having been in very unpro- mifing circumftances. What are, however, the circum- ftances more certainly determining to a happy or to a fa- tal event, I have not yet been able to afcertain. dcccxcviii. The following aphorifms are the refult of my obfervations. 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 (dccclxiv.); but even when followed by an ulceration, the ulceration is fome- times attended with little of hectic, and frequently ad- mits of being foon healed. Even when the hemoptyfis and ulceration have happened to be repeated, there are inftances of perfons recovering entirely after feveral fuch repetitions. A phthifis from a fuppuration in confequence of pneumonic inflammation, is that which moft ran1/ 4*4 PRACTICE OF PHYSIC. occurs in this climate ; and a phthifis does not always follow fuch fuppuration, when the abfeefs formed foon breaks, and difcharges a laudable pus ; but, if the abfeefs continue long fhut up, and till after a confiderable degree of hectic has been, formed, a phthifis is then produced, equally dangerous as that from other caufes. A phthifis from tubercles has, I think, been recover- ed ; but it is, of all others, the moft dangerous ; and, when arifing from a hereditary taint, is 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 hectic and its confequences have arrived. From a certain degree of emaciation, debility, profufe fweating, and diarrhoea, 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 the going off of the mania, the phthifis has recurred, and proved fatal. The pregnancy of women has often retarded the pro- grefs of a phthifis ; but commonly it is only till after de- livery, when the fymptoms of phthifis return with vio- lence., and foon prove fatal. Sect. II. Of the Cure of Phthifis. dcccxcix. From what has been juft now faid, it will' readily appear, that the cure of the 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 imperfection of our art, or to the abfolutely incurable nature of the difeafe. I am extremely averfe in any cafe to admit of the latter fuppofition, and can always readily allow of the for- mer ; but, in the mean time, muft mention here, what has been attempted towards either curing or moderating the violence of this difeafe. dcccc. It muft be obvious, that, according to the dif- ferent circumftances of this difeafe, the method of cure PRACTICE OF PHYSIC. 3'S muft be different. Our firft attention fhould be em- ployed in watching the approach of the difeafe, and pre- venting its proceeding to an incurable ftate. In all perfons of a phthifical habit, and efpecially in thofe born of phthifical parents, the flighteft fymptoms of the approach of phthifis, at the phthifical period of life, ought to be attended to. Dcccci. 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 againft them. This is efpecially to be done, by employing every means of moderating the hemorrh- agy, and of preventing its return, directed in dcccxcii, etfeq. ; and thefe precautions ought to be continued for feveral years after the occurrence of the hemoptyfis. dccccii. The phthifis which follows a fuppuration from pneumonic inflammation, can only be prevented with certainty, by obtaining, a refolution of fuch inflam- mation. What may be attempted towards the cure of an abfcefp and ulcer which have taken place, I fhall fpeak of hereafter. dccccih. I have faid, it is doubtful if a genuine ca- tarrh ever produces a phthifis, but have allowed that it poffibly may ; and both upon this account and upon ac- count of the ambiguity which may arife, whether the appearing catarrh be a primary difeafe, or the effect of a tubercle, I confider it as of confequence to cure a catarrh as foon as poffible after its firft appearance : More efpe- cially, 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 neceflary for prevent- ing its producing a phthifis fhall be mentioned immedi- ately, as they are the fame with thofe I fhall point out as neceffary for preventing a phthifis from tubercles. dcccciv. The preventing of a phthifis from afthma muft be, by curing, if poffible, the afthma, or at leaft by moderating it as much as may be done ; and as it is 326 PRACTICE OF PHYSTC. probable that afthma occafions phthifis, by producing tu- bercles, the meafures neceffary for preventing phthifis from afthma, will be the fame with thofe neceffary in the cafe of tubercles, which 1 am how about to mention. dccccv. I confider tubercles as by much the moft fre- quent caufe of phthifis;. and, even in many cafes where this feems to depend upon hemoptylis, catarrh, or afth- ma, it does, however, truly arife from tubercles. It is up- on this fubject, therefore, that I fhall have occafion to treat of the meafures moft commonly requifite for cur- ing phthifis. dccccvi. When, in a perfon born of phthifical par- cuts, of a phthifical habit, at the phthifical period of life, the fymptoms (occclxxxix.) in the fpring, or beginning of fummer, fhall appear in the flighteft 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 for- mation, or for procuring their refolution, fhould be em- ployed immediately, even although the patient himfelf fliould overlook or neglect the fymptoms, as imputing them to accidental cold. dccccvii. 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 of tuber- cles, or of refolving them when formed. The analogy of fcrophula gives no affiftance in this matter. In fcroph« ula, the remedies 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 certain difeafes, in perfons who were fuppofed at the time to have tubercles formed, or form- ing, in their lungs ; but though the mercury proved a cure for thofe other difeafes, it was of no fervice in pre- venting phthifis, and in fome cafes feemed to hurry it on. dccccviii. Such appears to me to be the prefent ftate of our art, with refpect to the cure of tubercles ; but I PRACTICE OF PHYSIC. %%r do not defpair of a remedy for the puTpofe 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 avoiding the inflammation of tubercles. It is probable, that tubercles may fubfift long without produc- ing any diforder ; and I am difpofed to think, that na- ture fometimes refolves and difcuffes tubercles which have heen formed ; but that nature does this only when the tubercles remain in an uninflamed ftate ; and, therefore, that the meafures neceffary to be taken, are chiefly thofe for avoiding the inflammation of the tu- bercles. dccccix. The inflammation of a tubercle of the lungs is to be avoided upon the general plan of avoiding in- flammation, 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 a- lone ; but it has been found, that it is not neceffary for the patient to be confined to vegetables of the weakeft nourifhment, it being fufficient that thefarinacea.be em- ployed, and, together with thefe, milk *. * The method here recommended of averting impending phthifis, by con- fining thofe who are threatened with it to a low diet, baa of late been much controverted ; and many cafes are adduced, where an oppolite plan feems to have been attended with the beft effect?. Indeed, it appears at firft sibht rather extraordinary, that we fhould endeavor to combat the prog- refs of a difeafe by fuch means as are calculated to increafe that ..debility with which it is fo intimately connected. Dr. Beddoes, in his very intereft- ing work on Confumption,from a comparative furveyof thecbffes of man- kind moft fubiccft to phthifis, has afcertained, th, t thofe who confume moft animal food, are in general far lefs fubject to this difeafe. It has likewife been obferved, that where children are fed on vegetables, fcrophulous affec- tions are prevalent. The apprehension cf exciting inflammation of the tu- bercles, feems, except in particular cafes, to be groundlefs. The inactive nature of fcrophulous tuTours, which analogy would lead us to fufpect, are of a fimilar nature with thofe formed in the lungs ; and their being appar- ently f) connected with a debilitated action of the lymphatics, indicate the propriety of a tome pan in phthifis. Dr. Beddoes has the following pertirent remarks: " In the preceding cafe?, I not only p^rmit'ed, but enjoined a full " diet. It gave me the greateft fatisfaction to hear from my patients, that " they reliflied animal food twice in the day, or once in the day, and once " in the niehr. The principle upon which I have advifed this regimen is " fimple. Since digitalis fucceeds worft with the puny and the neceffitou.', " and beft with the robuft and the well fed, I conceded that a generous die t, «' by bringing the confutation t~waids the moft favorable ftate, would gm " the greateft chance of, ccove-y. I ftip^fed alfo, that fi;nply tubercuL-- 3a8 PRACTICE OF PHYSIC. dccc ex. Milk has been generally confidered as the chief remedy in phthifis, and in the cafe of every ten- dency to it ; but whether from its peculiar qualities, or from its being of a lower quality, with refpect to nour- ifhment, than any food entirely animal, is not certainly determined. The choice and adminiftration of milk will be properly directed, by confidering the nature of the milk of the feveral animals from which it may be taken, and the particular ftate of the patient with refpect td the period and circumftances of the difeafe, and to the habits of his ftomach with refpect to milk. dccccxi. A fecond means of preventing the inflam- mation of the tubercles of the lungs, is, by avoining any particular irritation of the affected part, which may arife from any violent exercife of refpiration ; from any con- fiderable degree of bodily exercife ; from any pofitionof 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 particularly to the lungs. dccccxh. From the laft mentioned confideration, the application of cold in general, and, therefore, the winter feafon, in cold climates, as diminifhing the cutaneous perfpiration, is to be avoided ; but more particularly that application of cold is to be fhunned that may fup- prefs perfpiration, to the degree of occafioning a catarrh, which confifts in an inflammatory determination to the lungs, and many, therefore, moft certainly produce an inflammation of the tubercles there. " ed, and tuberculato-ulcerated limps, are in a condition onalagous to other " pat ts affected with fcrophnla. As to the precautions which we find re- " commended on account of the structure at d fi'uation of the lungs, experi- " ence feems to me to fhow that.' hey are hieMy exaj crated at letft, if not al- " together chimerical. In add-tion to animal food, I often allowed fermen- " ted liquors, but under certain limitations. Ii any particular fermented " liquor?, but under certain limitations. If a*r, particular fermented liquor, " or if all kinds produced coughing and heat of .he fkin, they were prohib- " ited. I alfo recommeadH wine (or wine and water,)at any time rather " than after a full meal. A full meal gene a'ly produ ,e? constitutional ac- " tion enough, or more than enough ; in which latter cafe, the quantity of " food taken at one time ihould be diminifhed. In the fore part of the day, " langor and coldnefs will often occur, efpecially where an invalid fafts too " long, and then vinous liquor may be tak. n with advantage." See BerMoea on the Medical Management of the Confumptive, p. 155 ; likewife Pear's Cafes of Phthifis. PRACTICE OF PHYSie. o»9 By confidering, that the avoiding heat is a part of the antiphlogiftic regimen above recommended, and by'com- paring this with what has been juft now faid refpecting the avoiding cold, the proper choice of climates and fea- fons for phthifical patients will be readily underftood. dccccxiii. A third means of avoiding the inflamma- tion of the tubercles of the lungs, cofifts in diminifhing the determination of the blood to the lungs, by fupport- ing and increafing the determination to the furface of the body, which is to be chiefly and moft fafely done by warm clothing*, and the frequent ufe of the exereifes of geftation. * The erroneous notions which have till of late prevailed, refpecting the- effects of the warm bath, have prevented us from deriving any affiftance from* this powerful remedy. Dr. Marcard has however afcertained^ that, inftead of debilitating, its effects are highly tonic, and that it may be ranked amongft the moft permanent and falutary flimuli. The experiments of others have confirmed the accuracy of his obfervations, and it bids fair for being foon generally reforted to with this intention, in fpite of the inveterate prejudices which it has had to encounter. It is rather furprifing, that the well known frequency of baths amongft the ancients, did not fooner lead to the fufpicion of its being lefs debilitating than had been imagined. Falfe medical theory, however, combined with popular prejudice to oppofe its introduction. Its effects on dead matter were, by a falfe analogy, transferred to the living fyftem. Hence proceeded the idea of its relaxing, unbracing, &e. More recent doctrines had likewife tended to confirm thefe vague notions, by giv- ing them a form which was more definite, though not much more fatisfactory. Heat is a ftimulus, and muft, according to its intenfity,exhauft the excitabil- ity —is their language ; a language which by no means applies to the effects produced on fuch a complicated machine as the animal body; where one ac- tion often introduces a feries, the ultimate confequences of which we can- not always predict. The effects of this remedy in invigorating the fyftem, and determining to the furface, by fupporting the action of the cutaneous veffels, render it of high importance in incipient phthifis. Dr. Beddoes mentions, that hia " own experience of the blood-warm bath, extends to a confiderable «' number of cafe?, particularly of perfons, who, from the lofs of relations by " consumption, with obfeure, but alarming feelings of indifpofition,or with. ** fome of the more evident fymptoms dreaded an attack of this difeafe. Sen- " fible benefit was received by moft ; permanent benefit bv feveral; injury " by none. The reduction of the pulfe, during the time of immerfion, was " perfectly afcertained in a number of inftances ; and the ftrengthening ef- " feet of the bath w as fometimes fo apparent, that feveral of thofe whom I " delired to bathe every other day, have affured me, that on the day of " bathing, they felt capable of greater exertion than on the following or pre- " ceding day." The temperature of the bath fhould not exceed that of the body nor fall much below 90' ; as be'-ween thefe it is found moft effectual. It fliould always however be accommodated to the patient's feelings. The fafeft time of immerfion is between breakfaft and dinner; and they fhould continue in the bath from a quarter of an hour to an hour, according as they find it agreeable. PRACTICE OF PHYSIC dccccxiv. Every mode of geftation has been found of ufe In phthifical cafes ; but riding on horfeback, as be- ing accompanied with a great deal of bodily exercife, is lefs iare in perfons liable to an hemoptyfis. Travelling in a carriage, unlefs upon very fmooth roads, may alfo be of doubtful effect; and all the modes of geftation that are employed on land, may fall fhort of the effects expected from them, becaufe they cannot be rendered fuflicLntly conftant; and therefore it is, that failing, of all other modes of geftation, is the moft effectual in pneumonic cafes, as being both the fmootheft 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 tlv.it any impregnation of this which can be fuppofed to take place, can be of fervice to phthifical perfons. It is, however, probable, that frequently fome benefit may be derived from the more moderate temper- ature and greater purity of the air upon the fea. dccccxv. In order to take off any inflammatory de- termination of the blood into the veffels of the lungs, blifters applied to fome part of the thorax may often be of fervice; and, for the fame purpofe as well as for moderating the general inflammatory ftate of the body, iffues of various kinds may be employed with advantage. dcCCCXvi. The feveral meafures to be purfued in the cafe of what is properly called an Incipient phthifis, have now been mentioned ; but they have feldom been em- ployed in fuch cafes in due time, and have, therefore, perhaps, feldom proved effectual.. It has more common- ly happened, that, after fome time, an inflammation has come upon the tubercle, and an abfeefs has been formed which opening into the cavity of the bronchia, has pro- duced an ulcer, and a confirmed phthifis. dccccxvii. In this ftate of matters, fome new indica- tions, different from the former, may be fuppofed toa- rife ; and indications for preventing abforption, for pre- venting the effects of the abforbed matter upon the blood, and for healing the ulcer, have been actually propofed. I cannot find, however, that any of the means propofed PRACTICE OF PHYSIC. 33* for executing thefe indications, are either probable, or have proved effectual. If, upon fome occafions, they have appeared to be ufeful, it has been probably by an- fwering fome other intention. While no antidote againft the poifon which efpecially operates here, feems to have been as yet found out, it appears to me that too great a degree of inflammation has a great fhare in preventing the healing of the ulcer which occurs; and fuchT inflammation is certainly what has a great fhare in urging on its fatal confequences. The only practice, therefore, which I can venture to pro- pofe, is the fame in the ulcerated as in the crude ftate of a tubercle ; that is, the employment of means for mod- erating inflammation, which have been already mention- ed (dccccix. etfeq.) dccccxvhi. The balfamics, whether natural or artificial, which have been fo commonly advifcd in cafes of phthi- fis, appear to me to have been propofed upon no fuftlcient grounds, and to have proved commonly hurtful. The refinous and acrid fubftance Of myrrh, lately recom- mended, has not appeared to me to be of any fervice, and in fome cafes to have proved hurtful. dccccxix. Mercury, fo often ufeful in healing ulcers, has been fpecioufly enough propofed in this difeafe, but whether that it be not adapted to the particular na- ture of the ulcers of the lungs occurring in phthifis, or that it proved hurtful becaufe it cannot have effe5© PRACTICE OF PHYSIC. 35* lcccclxxxviii. The leucorrhcea, of which I am to treat, as afcertained by the feveral circumftances (bcccc- Ilxxxvi.) feems to proceed from the fame caufes as that Jpecies of menorrhagia which I fuppofe to arife from the laxity of the extreme veffels of the uterus. It according- ly often follows or accompanies fuch a menorrhagia ; but though the leucorrhcea depends chiefly upon the laxity mentioned, it may have proceeded from irritations; inducing that laxity, and feems tb be always increafed by any irritations applied to the uterus. dcccclxxxix. Some authors have alleged that a varie- ty of circumftances in other parts of the body may have a fhare in bringing on and in continuing this af- fection of the uterus now under confideration : but I cannot difcover the reality of thofe caufes ; and it feems to me, that this leucorrhcea, excepting in fo far as it depends upon a general debility of the fyftem, is always primarily an affection of the uterus ;* and the affections of other parts of the body which may happen to accom- pany it, are for the moft part to be confidered as effects, rather than as caufes. dccccxc. The effects of the leucorrhcea are much the fame with thofe of menorrhagia ; inducing a general debility, and, in particular, a debility in the functions of the ftomach. Jf, however, the leucorrhcea be moderate, and be not accompanied with any confiderable degree of menorrhagia, it may often continue long without induc- ing any great degree of debility, and it is only when the difcharge has been very copious as well as conftant, that its effects in that way are very remarkable. dccccxci. But, even when its effects upon the whole body are not very confiderable, in may ftill be fuppofed to weaken the genital fyftem j and it feems fufliciently probable that this difcharge may often have- a fhare in occafioning barrennefs. dccccxcii. The matter difcharged in the leucorrhcea, is at firft generally mild : but after fome continuance of the difeafe, it fometimes becomes acrid ; and by irritat- ing, or perhaps eroding the furfaces over which it paf- fes, induces various painful diforders.. a is* PRACTICE OF PHYSIC. dccccxcih. As I have fuppofed that the leucorrhcea proceeds from the fame caufes as that fpecies of menor- rhagia which is chie%, owing to a laxity of the uterine veffels, it muft be treated, and the cure attempted, by the fame means as delivered in dcccclxxxii. for the cure of menorrhagia, and with lefs referve in refpect of the ufe of aftringents. dccccxciv. As the leucorrhcea generally depends up- on a great lofs of tone in the veffels of the uterus, the difeafe has been relieved, and fometimes cured, by cer- tain ftimulant medicines, which are commonly deter- mined to the urinary paffages, and from the vicinity of thefe are often communicated to the uterus. Such, for example, are cantharides, turpentine, and other balfams of a fimilar nature. CHAP. VIIL ©F THE AMENORRHOEA*, OR INTERRUPTION OF THE MENSTRUAL FLUX. dccccxcv. Whatever, in a fyftem of methodi- cal nofology, may be the fitteft place for the amenor- rhoea, it cannot be improper to treat of it here as an object of practice, immediately after haying confidered the menorrhagia. dccccxcvi. The interruption of the menftrual flux is to be confidered as of two different kinds ; the one be- ing when the menfes do not begin to flow at that Deri- od 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 concep- tion, ceafe to return at their ufual periods : The * Gen. Either a complete ftoppage, or unufually fcanty difcharge of the menfes in women who are not pregnant. Species i. Amenorrboea (retention of the menfes) in young women who have paffed the age when the menfes ufed to appear, and who are trouble^ with various difeafed affections. Spteies a. Amenorrhea (fuppr.'Jion of the menfes)™ adults, whofe nscnfea after having flowed regularly, arc fuprrefTed. Syn. Ncf. PRACTICE OF PHYSIC. 35 J ;jormer of thefe cafes is named the retention, and the lat- ter the fuppreffion of the menfes. dccccxc vn. As the flowing of the menfes depends up- on the force of the uterine arteries impelling the blood into their extremities, and opening thefe fo as to pour out red blood, fo the interruption of the menftrual flux muft depend, either upon the want of due force in the action of .the uterine arteries, or upon fome preternatur- al refiftance in their extremities. The former J fuppofe to be the moft ufual caufe of retention, the latter the moft common caufe of fuppreffion ; and of each of thefe I it. all now treat more particularly. dccccxcviii. The retention of the menfes, thl eman- flio menflum of Latin writers, is not to be confidered as a difeafe merely from the menfes not flovving at that pe- riod which is ufual .with moft other women. This pe- riod is fo different in different women, that no time can be precifely affigned as proper to the fex in general. In this climate, the menfes ufually appear about the age of fourteen ; but in many they appear more early, and in many not till the fixteenth year : in which laft cafe it is often without any diforder being thereby occasioned. It is not therefore from the age of the perfon, that the retention is to be confidered as a difeafe ; and it is only to be confidered as fuch, when, about the time the menfes ufually appear, fome diforders arife in other parts of the body which may be imputed to their retention ; being fuch as, when arifing at this period, are Jsnown from experience to be removed by the flowing of the menfes. dccccxcix. Thefe diforders are. a fluggiflinefs, and frequent fenfe of laffitude and debility, with various fym- toms of dyfpepfia ; and fometimes with a preternatural appetite. At the fame time the face lofes its vivid col- or, 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 laborious motion of the body, and the heart is liable to palpitation and fyncope. A headach 4 354 PRACTICE OF PHYSIC. fometimes occurs; but more certainly pains of the back, loins, and haunches. ^ m. Thefe fymptoms, when occurring in a high degree conftitute the chlorofis of authors, hardly ever appearing feparate from the retention of the menfes ; and, attend- ing to thefe fymptoms, the caufe of this retention may, I think, be perceived. ,. Thefe fymptoms manifeftly fhow a confiderable laxity and flaccidity of the whole fyftem ; and therefore give reafon to conclude, that the retention of the menfes ac- companying them, is owing to a weaker action of the veffels of the uterus ; which therfore do not impel the blood into their extremities with a force fufficient to o- pen thefe and pour out blood by them, mi. How it happens that at a certain period of life a flaccidity of the fyftem arifes in young women not orig- inally affected with any fuch weaknels or laxity, and of which, but a little time before, they had given no indi- cation, 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 prefumed that the ftate of the ovaria and that of the u- terine veffels are in fome meafuie connected together; and as generally 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 evaria has a great ftiare in exciting the action of the uterine veffels, and producing the menftrual flux. But, analogous to what happens in the male fex, it may be prefumed, that in females a cer- tain ftate of the genitals is neceffary to give tone and ten- fion to the whole fyftem ; and therefore that, if the ftim- ulus arifing from the genitals be wanting, the whole fyf- tem may fall into a torpid and flaccid ftate, and from thence the chlorofis and retention of the menfes may a- rife. mil It appears to me, therefore, that the retention of the menfes is to be referred to a certain ftate or affection of the ovaria: but what is precifely the nature of tins PRACTICE OF PHYSIC. 255 affection, or what are the caufes of it, I will not pretend to explain ; nor can I explain in what manner that pri- mary caufe of retention is to be removed. In this, there- fore, as in many other cafes, where we cannot affign the proximate caufe of difeafes, our indications of cure muft be formed for obviating and removing the morbid ef- fects or fymptoms which appear. miii. the effects, as has been faid in m. confift in a general flaccidity of the fyftem, and cortfequcntly in a weaker action of the veffels of the uterus ; fo that this debility may be confidered as the more immediate caufe of the retention. This, therefore, is to be cured by re- ftoring the tone of the fyftem in general, and by excit- ing the action of the uterine veffels in particular. miv. The tone of the fyftem in general is to be reftor- ed by exercife, and- in the beginning of the difeafe, by cold bathing. At the fame time, tonic medicines" m-ay be employed ; and of thefe the chalybeates have been chiefly recommended. mv. The action of the veffels of the uterus may be ex- cited : ' ; 1 ft, By determining the blood into them more copi- oufly ; which is to be done by determining the blood into the dcfcending aorta, by purging, by the exercife of walking, by friction, and by warm bathing of the lower * R Limat. Ferr. P.aepar. gr. x. Pulv. Aromat. gr. v. M. Fiat Pulv. te.'.in dielurrend. Ve!, ft Pulv. Cort. P^ruv. Jj. Conf. Cort. Aurarit. Jfs. Limat. Ferr. P aep. 31 j. Syr. Simp.vel'Z,enzib. gr. 1. Sumat Cochl. Parv. bis vel ter in die. 1 Vel, ft Limat. Ferr. Piaepar. 31J. Extr. Gent, vel Cinchonas. Sapon. Hii'pan. aa, 31. Pulv. Aloes Socotorin. gr. x. M. fiat Mafs. in Pilul. asqual. xlviii. Dividenda-r-Quarum Sumat ij.bis terve in die. Ve=, ft Vin.AIoetici, 3J. Tincr. Ferri. Muriat. gutt. xx. DecocL Cort. Periiv. Jij. Syr. Aurant. 3^j. M. fiat hauflus bis in die fumendus. 35 6 PRACTICE OF PHYSIC. extremities. It is alfo probable that the blood may be .determined more copioufly into the hypogaftric arteries which go to the uterus, by a compreflion of the iliacs; but the trials of this kind hitherto made have feldom fucceeded. mvi. 2dly, The action of the uterine veffels may be ex- cited by ftimulants applied to them. Thus thofe purga- tives which particularly itimulate theinteftinum rectum, may alfo .prove ftimulant to the uterine veffels connect- ed with thofe of the rectum. The exercife -of venery certainly 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 ftimulants of the uterine veffels, under the title of Em- menagogues, have never appeared to me to be effectual; and I cannot perceive that any of them are poffeffed of a fpecific power in this refpect. Mercury, as an univerfal ftimulant, may act upon the uterus, but cannot be very fafely employed in chlorotic 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 veffels of the uterus. mvii. The remedies (mhi.-----mvi.) now mentioned, are thofe adapted to the retention of the menfes ; and I am next to confider the cafe of fuppreffion. In entering upon this, I muft obferve, that every interruption of the ilux, after it has once taken place, is not to be confiderec-l as a cafe of fuppreffion ; for the flux, upon its firft ap- pearance, 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 dif- eafe appears with the fymptoms peculiar to that ftate. mviii. Thofe which may be properly confidered as cafes of fuppreffion, are fuch as occur after the flux has been for fome time eftablifhed in its regular courfe, and in which the interruption cannot be referred to the caufes of retention (mil mhi.) but muft be imputed to PRACTICE OF PHYSIC 357 fome refiftance in the extremities of the veffels of the uterus. Accordingly, we often find the fuppreffion induced by cold, fear, and other caufes which may pro- duce a conftrictic^n of thefe extreme veffels. Some phyficians have funpofed an obftructing lentor of the 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 confideratfons improbable. mix. 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 foch cafes, the fuppreffion always appears as fymptomat- ic of other affections, and is therefore not to be confider- ed here. mx. The idiopathic cafes of fuppreffion (mviii.) fel- dom continue long without being attended with vari- ous fymptoms or diforders in different parts of the body; very commonly arifing from the blood which fhould have paffed by the uterus, being determined more ccpi- oufly into other parts, and very often with fuch force as to produce hemorrhagies in thefe. Hence hemor- rhagies from the nofe, lungs, ftomach, and other parts, have appeared in confequence of fuppreffed menfes. Be- fides thefe, there are commonly hyfteric and dyfpeptic fymptoms produced by the fame caufe; and frequently colic pains, with a bound belly. mxi. In the idiopathic cafes of fuppreffion, (mviii.) the indication of cure is to remove the conftriction af- fecting the extreme veffels of the uterus ; and for this purpofe, the chief remedy is warm bathing applied to the region of the uterus. This, however, is not always effectual, and I do not know of any other remedy adapt- ed to the indication. Befides this, we have perhaps no other means of removing the conftriction in fault, but that of increafing the action and force of the veffels of the uterus, fo as thereby to overcome the refiftance or conftriction of their extremities. This therefore is to be attempted by the fame remedies in the cafe of fuppref- fion, as thofe prefcribed in the cafes of retention (miv. V, PRACTICE OF PHYSIC. "J . ......... —mvi.) The tonics, however, and cold bathing (m;v.) feem to be lefs properly adapted to the cafes of fopprci- iion, and have appeared to me of ambiguous effect. mxii. It commonly happens in the cafes of fuppreffion that though the menfes do not flow*' at their ufual peri- ods, there are often at thofe periods fome marks of an effort having a tendency to produce the difcharge. It is therefore at thofe times efpecially when the efforts of the fyftem 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 fhey be fuch as' require fome continuance in their ufe to produce their effects. mxiii. Nearly fimilar to fhe cafes of fuppreffion arc thofe cafes in which the menfes flow after longer inter- vals and in leffer quantity than ufual; and when thefe cafes are attended with the diforders in the fyftem (mx.) they are to be cured by the fame remedies as the cafes of entire fuppreffion. mxiv. It may be proper in this place to take notice of the dyfmenorrhea, 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 action of the veffels of the uterus, and-partly, perhaps more efpe- cially, to a fpafm of its extreme veffels. We have com- monly found the difeafe relieved by employing fome of the remedies of fuppreffion immediately before the ap- proach of the period, and at the fame time employing o- piatcs. CHAP. IX. OF SYMPTOMATIC HEMORRHAGIES. mxv. I have thought it very improper in this work, to treat of thofe morbid affections that are almoft always fymptomatic of other more primary difeafes : and PRACTICE OF PHYSIC. 2S9 this for feveral reafons, particularly becaufe it introduces. a great deal of confufion in directing practice, and leads phyficians to employ palliative meafures only. I fhall here, however, deviate a little from my general plan, to make fome reflections upon fymptomatic hemorrhagies.- mx vi. 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 paflage. Upon thefe 1 am here to make fome remarks ; becaufe, .though they are very generally fymptomatic, it is poffible they may be fome- times primary and idiopathic affections ; and becaufe they have been treated of as primary difeafes in almoft every fyftem of the practice of phyfic. Sect. I. OftheHematemefis9or Vomiting of Blood. mxvii. I have faid above (in DCCCXLv,)in what man- ner blood thrown out.from the mouth may be known to proceed 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 cough- ing; 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 bjack and grumous appearance, and when it is manifeftly mixed with other. contents of the ftomach; we can feldom nave any doubt cf the fource from whence the.blood proceeds, and therefore of the exiftence of the difeafe we treat of. .: mxviii. We muft allow it to be poffible that a plethor- ic ftate of the body from general caufes may be accom- panied with caufes of a peculiar determination and afflux of blood to the ftomach, fo as to occafion an liemorrha- gy there, and thence, a vomiting of blood ; and in fuch a cafe this appearance might be confidered as a primary diieafe. But the hiftory of difeafes in the records of phytic, afford little foundation for fuch a fuppofition ; and on the contrary, the whole of the inftances of a vein- 36e PRACTICE OF PHYSIC. iting of blood which have been recorded, pretty mank ieftly fymptomatic of a more primary affection. Of fuch fymptomatic vomitings of blood, the chief in. fiances are the following. mxix. One of the 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 an- other part of the body, particularly that of the menftru- al flux iri women. mxx. There are inftances of a vomiting of blood hap. peningfrom the retention of the menfes ; but fuch inftan- ces are very uncommon, as a retention of the menfes rarely happens in confequence of, or even with, a pleth- oric ftate of the body; and as rarely does it produce that, or the hemorrhagy in queftion. There are.inftances of a vomiting of blood happening to pregnant women ; that might therefore alio be im- puted to the fuppreffion of the menfes, which happens to women in that ftate. There have indeed been more inftances of this than of the former cafe ; but the latter are ftill very rare : for although the blood which ufed to flow monthly before impregnation is, upon this tak- ing 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. The vomiting of bloody therefore, that is vicarious of the menftrual flux, is that which commonly and almoft Ohly happens upon a fuppreffion of that flux, after it had been for fome time eftablifhed. Mxxi. When fuch a fuppreffion happens, it may be fuppofed to operate by inducing a plethoric ftate of the whole body, and thereby occafioning hemorrhagy from other parts of it; and hemorrhagies from many differ- ent parts of the body have been obferved by phyficians as occurring in confequence of the fuppreffion We fpeak of. It is, however, the great variety of fuch hemorrha- gies, that leads me to think, that with the plethoric ftate of the whole body there muft be always fome pecu- liar circumftances in the part from which the blood PRACTICE OF PHYSIC. 362 flows, that determines its afflux to that particular, often Angularly odd, part; and therefore, that fuch hemor- rhagies may from thefe circumftances occur without any confiderable plethora at the fame time prevailing in the whole fyftem. mxxii. It is to be obferved^ that if we are to expect an hemorrhagy in confequence of a fuppreffion of the menfes inducing a plethoric ftate of the fyftem, we fhould expect efpecially an hemoptyfis, or hemorrhagy from the lungs, as a plethora might be expected to fhow its ef- fects efpecially there ; and accordingly, upon occafion of fuppreffed menfes, that hemorrhagy occurs more fre- quently 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 confidera- ble or dangerous plethora prevails in the body. Mxxm. Thefe confiderations in mxxi. mxxii. will, I apprehend, apply to our prefent fubject; and I would therefore allege, that a hematemefis may perhaps depend upon particular circumftances of the ftomach determin- ing an aflux of blood to that organ, and may therefore occur without any confiderable or dangerous plethora prevailing in the fyftem. What are the circnmftances of the ftomach, which, upon the occafion mentioned, may determine an afflux of blood to it, I cannot certain- ly or clearly explain ; but prefume that it depends upon the connection and confent which we know to fubfift between the uterus and the whole of the alimentary ca- nal, and efpecially that principal part of it the ftomach. mxxiv. From thefe reflections we may, I think, draw the following concluftons. I. That the hematemefis we fpeak of is hardly ever a dangerous difeafe. II. That it will hardly ever require the remedies fuit- ed to the cure of active hemorrhagy; and at leaft that it will require thefe only in thofe unufual cafes in whichf there appear ftrong marks of a general plethora, and m which the vomiting of blood appears to be considerably active, very profufe, and frequently recurring. 363 PRACTICE OF PHYSIC. III. That a vomiting of blood from fuppreffed menfes, ought feldom to prevent the ufe of thefe, remedies of amenqrrhcea, which might be improper in the cafe of an active idiopathic hemorrhagy. mxxv. Another cafe of. fymptomatic hematemefis quite analogous to that already mentioned, is the hema- temefis following, and feemingly depending upon the fuppreffion of an hemorrhoidal flux, which had been ef- tablifhed and frequent for fome time before. This may perhaps be explainedlby a general plethoric itate induced by fuch a fuppreffion, and indeed fome de* gree of a plethoric ftate muft in fuch 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 to expect an. hemoptyfis (mxxii.) 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 got from the connection between the different parts of the fanguifer- ous veflels of the alimentary canal, or from the connec- tion of the whole of thefe veffels with the vena porta- rum, 1 fhall not venture to determine. But in the mean time 1 imagine, that the explanation required is rather to be obtained from that connection of the .ftomach with the, hemorrhoidal affection that I have taken notice of in dccccxlvi. mxxvi. However we may explain the hematemefis occafioned by a fuppreffion of the hemorrhois, thecon- fiderations in mxxi. mxxii. will apply here as in the analogous cafe of hematemefis from fuppreffed menfes; and will therefore allow us alfo to conclude here, that the difeafe we now treat of will feldom be danger- ous, and will feldom require the fame remedies that idi- opathic and active hemorrhagy does. mxxvii. The cafes of hematemefis already mentioned, may be properly fuppofed to be hemorrhagies, of the ar- terial kind ; but it is probable that the ftomach is alfo liable to hemorrhagies of the venous kind, (dcclxviii.) PRACTICE OF PHYSIC. 363 In the records of phyfic there are many inftances of vomitings of blood, which were accompanied with a tum- efied fpleen, which had compreffed the vas breve, and thereby prevented the free return of venous blood from the ftomach. How fuch an interruption of the venous blood may occafion an hemorrhagy from either the ex- tremities of the veins themfelves, or from the extremities of their correfpondent arteries; we have explained above in dcclxix. and the hiltories of tumefied fpleens com- prefling the vafa brevia afford an excellent illuftration and confirmation of our doftrine on that fubjed, and render it fufficiently probable that vomitings of blood of- ten arife from fuch a caufe. mxxviii. It is alfo poffible, that an obftruction of the liver refitting the free motion of the blood in the vena portarum, may fometimes interrupt the free teturn of the venous blood from the veffels of the ftomach, and thereby occafion a vomiting of blood ; but the inftances of this are neither fo frequent nor fo clearly explained as thofe of the former cafe. mxxix. Befide thefe cafes depending on the ftate of the liver or fpleen, it is very probable that other hemor- rhagies of the ftomach are frequently of the venous kind. The difeafe named by Sauvages Melaena, and by other writers, commonly termed the Morbus Niger, dc clxxii. confifting in an evacuation either by vomiting or by flool, and fometimes in both ways of a black and grum- ous blood, can hardly be otherwife occafioned, than by a venous hemorrhagy from fome part of the internal fur- face of the alimentary canal. It is, indeed, poffible, that the bile may fometimes put on a black and vifcid appearance, and give a real foundation forthe appellation of an Atra Bilis : but it is certain, that inftances of this are very rare ; and it is highly probable, that what gave occafioh to the notion of an atra bilis among the ancients, was truly the appear- ance of blood poured intoThe alimentary canal in the manner I have mentioned ; and which appearance, we know, the blood always puts on when it has ftagnated 7 364 PRACTICE OF PHYSIC. there for any length of time. I fuppofe it is now gener- ally thought, that Boerhaave's notion of fuch a matter exifting in the mafs of blood, is without any founda- tion ; whilft, by diffections in modern times, it appears very clearly, that the morbus niger prefenting fuch an appearance of blood, always depends upon the effufion and ftagnation I have mentioned. mxxx. From this account of the melaena it will ap- pear, that vomitings of blood may arife in confequence of blood being poured out in the manner I have men- tioned, either into the cavity of the ftomach itfelf, or in- to the fuperior portions of the inteftines, from whence matters often pafs into the ftomach. mxxxi. Both in the cafe of the melaena, and in the' analogous cafes from affections of the fpleen or liver, it will appear, that the vomitings of blood occurring muft be confidered as fymptomatic affections, not at all to be treated as a primary active hemorrhagy, but by reme- dies, if any fuch be known, that may refolve the prima- ry obftructions. mxxxii. I believe I have now mentioned almoft the whole of the caufes producing a hematemefis ; and cer- tainly the caufes mentioned, are thofe which moft com- monly give occafion to that fymptom. Poffibly, howev- er, there may be fome other caufes of it, fuch as that lin- gular one mentioned by Sauvage of an aneurifm of the aorta burfting into the ftomach : and it is poffible, that fome difeafes of other contiguous parts, which have be- come elofely adhering to the ftomach, may fometimes, by a rupture into the cavity of the ftomach, pour blood into it, which is afterwards rejected by vomiting. It is poffible alfo, that abfeeffes and ulcerations of the ftomach itfelf, may fometimes pour blood into its cavity to be thrown up by vomiting. I did not think it neceffary, among the fymptomatic vomitings of blood, to enumerate thofe from external violence, nor, what is analogous to it, that which arifes from violent ftraining to vomit; which laft, however, is much more rare than might be expected. In either of thefe cafes the nature of the difeafe cannot be doubtful, PRACTICE OF PHYSIC. 36S and the management of it will be readily underftood from what has been delivered above with refpect to moderating and reftraining< hemorrhagy in general. Sect. II. Of the Hematuria, or the Voiding cf Blood from the Urinary Paffage. mxxxiii. It is alleged, that an hematuria has occurred without any other fymptom of an affection of the kid- neys or urinary paffages being prefent at the fame time ; and as this happened to plethoric perfons, and recurred at fixed periods, fuch a cafe has been fuppofed to be an inftance of idiopathic hematuria, and of the nature of thofe active hemorrhagies I have treated of before. mxxxiv. I cannot pofitively deny the exiftence of fuch a cafe ; but muft obferve, that there are very few inftances of fuch upon the records of phyfic ; that none have ever occurred to my obfervation, or to that Of my friends ; and that the observations adduced may be fal- lacious, as I have frequently obferved an hematuria with- out fymptoms of other affection of the kidney or urina- ry paffages being, for the time, prefent ; whilft, howev- er, fits of a nephralgia calculofa having, before or foon after, happened, rendered it to me fufficiently probable, that the hematuria was owing to a wound made by a ftone prefent in fome part of the urinary paffages. mxxxv. The exiftence of an idiopathic hematuria is further improbable, as a general plethora is more likely to produce an hemoptyfis (mxxii.), and as we do not well know of any circumftances which might determine more particularly to the kidneys. An idiopathic hema- turia, therefore, muft certainly be a rare occurrence ; and inftances of fymptomatic affections of the fame kind are very frequent. mxxxvi. One of the moft frequent is, that hematuria which attends the nephralgia calculofa, and feems mani- feftly to be owing to a ftone wounding the internal fur- face of the pelvis of the kidney or of the ureter. In fuch cafes, the blood difcharged with the urine is fometimes of a pretty florid color, but for the moft part is of a dark 2 ;M PRACTICE OF PHYSIC. 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, ?. portion of it is depofited to the bottom of the veffel containing the voided blood and urine. On different occafions, the blood voided puts on different appearances. If the blood poured out in the kidney has happened to flagnate for fome time in the ureters or bladder, it is fometimes coagulated, and the coagulated part is afterwards broken down into a gru- mous mafs of a black or dark color, and therefore gives the fame color to the urine voided ; or if the quantity of broken down blood is fmall, it gives only a brownifh 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 red globules, thefe worm like appear- ances have their external furface whitifh, and the whole feemingly forming a tube containing 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. mxxxvii. Thefe are the feveral appearances of the blood voided in the hematuria calculofa, when it pro- ceeds efpecially from the kidneys or ureter ; and many of the fame apfrearances 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 difficultly thrown out from this, the pain and uneafinefs on fuch an occafion may appear chiefly to be in the blad- der, though it contains no ftone ; but the antecedent fymptoms will commonly difcover the nature of the dif- eafe. ?vix:;xviii. In any of the cafes of the hematuria calcu- lofa, it will hardly be neceffary to employ the remedies fuited to an active hemorrhagy. It will be proper only PRACTICE OF PHYSIC 567 to -cmpToy the regimen fit for moderating hemorrhagy i:i general, and particularly here to avoid every thing or cn\.,imftance that might irritate the kidneys or ureters. O: fuch cafes of irritation there is none more frequent or moie confiderable than the prefence of hardened faxes in the colon ; and thefe therefore are to be frequently re- moved, by the frequent ufe of gentle laxatives. mxxxix. The hematuria calculofa may be properly coniidered as a cafe of the hematuria violenta : and therefore I fubjoin to that the other inftances of hema- turia 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 in- cumbent on the kidneys. Ap. inftance of the latter caufe occurs efpecially in riding. mxl, It may alfo be confidered as a cafe of the hem- aturia violenta, when the difeafe occurs in confequence of the taking in of certain acrid fubftances, which pafs again efpecially-by the urinary paffages ; and, by inflam- ing and fwelling the neck of the bladder, bring on a rupture of the overdiftended blood-vcffels, and give oc- cafion 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. mxli. Befide thefe moft frequent inftances 'Of hematu- ria, which cannot be confidered as idiopathic hemorrha- gies, there are fome other inftances of hematuria men- tioned by authors, that are ftill however manifeftly fymp- tomatic ; fuch as a difcharge of blood from the urinary paffages, in confequence of a fuppreffion of either the menftrual or hemorrhoidal flux. Thefe may be confid- ered 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 mxxiv. Inftances, however, of either of thefe cafes, and efpecially of the firft, have been extremely rare. mxlii. Of fuch fymptomatic hematuria there is, how- ever, one inftance deferring notice ; and that is, when a 3 36* PRACTICE OF PHYSIC. fuppreffion of the hemorrhoidal flux, either by a com- munication of veffels, or merely by the vicinity of parts, occafions 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 the urine. This cafe is what has been nam- ed the Hemorrhoides Veficae ; and with fome propriety, when it is manifeftly an evacuation vicarious of what had before been ufually made from the rectum. With refpect to the management of the hemorrhoides veficae^ I wrould apply the whole of the doctrines that I have de- livered above, with refpect to the cure of the proper hemorrhoidal affection. mxliii. There remains ftill to be mentioned one other inftance of fymptomatic hematuria, which is that which happens in the cafe of confluent and putrid fmall pox, as well as in feveral other inftances of putrid difeafes. The blood, in fuch cafes, may be prefumed to come from the kidneys ; and I apprehend that it comes from thence in confequence of that fluidity which is always produced in the blood approaching to a putrid ftate. Such hema- turia, therefore, is not to be confidered as a fymptom of any affection of the kidneys, but merely as a mark of the putrefcent ftate of the blood. mxliv. In certain difeafes the urine is discharged of fuch a deep red color, as to give a fufpicion of its being tinged 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 which, however, he fuppofes to be without any blood prefent in the urine. In many cafes it is of im- portance, in afcertaining the nature of a difeafe, to de- termine whether the red color 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 conflitu- ent parts of the urine ; and the queftion may be com- monly determined by the following confiderations. It has been obferved above, that when any confidera- ble quantity of blood is voided with the urine, there is always a portion of it depofited at the bottom of the PRACTICE OF PHYSIC. 369 ireffel containing the voided blood and urine ; and in fuch a cafe there will be no doubt in attributing the color of the urine floating above, to fome part of the blood dif- fufed in it. The queftion, therefore, with refpect to the prefence of blood in the urine, can only occur when no fuch dcpofition as 1 have mentioned appears ; and when the blood that may be fuppofed to be prefent is diffolved or -diffufed, and therefore entirely fufpended in the urine. In this cafe the prefence of blood may be commonly known, 111, By the color which blood gives,-different from any urine without blood that I have ever feen ; and 1 think a little experience will enable moft perfons to -make this diftinction. 2dly, By this, that the pref- ence of blood always diminifhes the tranfparency of the urine with which it is mixed : and it is very feldom that urine,1though very high colored, lofes its tranfparency ; at leaft this hardly ever appears, if the urine is examined when recently voided. 3dly, When urine has blood mix- ed with it, it tinges a piece of linen dipped into it with a red color, which the higheft colored urine without blood never does. 4thly, Highjcolored urine without blood, upon cooling, and remaining at reft in a veffel, almoft always depofits a lateritious fediment ; and if upon any occafion bloody urine fhould depofit a fediment that may be of a portion of die blood formerly diffufed in it, the difference however may be difcorned by this that the fediment depofited by urine without blood, «upon the urine's being again heated, will be entirely rediflblved, which will not happen to any fediment from blood'. Laftly, we know no ftate of urine without blood, which fhows any portion of it coagulable by a heat equal to that of boiling water ; but blood duffufed in urine is ftill coagulable by fuch a heat : and by this tell, therefore, the prefence of blood in urine may be commonly afcer- tained. * BOOK V. OF PROFLUVI A*3 OR FLUX- ES, WITH PYREXIA. INTRODUCTION. mxlv. j? 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 dif- charge of fluids, and which alfo are, in other repects, very defferent from one another ; I have avoided fo im- proper an arrangement, and have diftributed moft of the difeafes comprehended in fuch a clafs by the nofologifts, into places more natural and proper for them. I have, indeed, ftill employed here the general title ; but I con- fine it to fuch fluxes only, as are conftantly attended with pyrexia, and which therefore neceffarily belong to the clafs of difeafes of which I am now treating. Of the fluxes which may be confidered as being very conftantly febrile difeafes, there are only two, the catarrh and dyfentery ; and of thefe therefore I now proceed to treat. * Pyrexia, attended with an increafed excretion of a matter not naturally bloody. Syn. Nof. PRACTICE OF PHYSIC. 3,1 CHAP. I. OF THE CATARRH*. mxlvi. 1 he catarrh is an increafed excretion of mucus from the mucous membrane of the nofe, fau- ces, and bronchias, attended with pyrexia. Practical writers and nofologifts have diftinguifhed the difeafe by different appellations, according as it hap- pens to affect thofe different parts of the mucous mem- brane, the one part more or lefs than the other : But I am of opinion, that the difeafe although affecting differ- ent parts, is always of the fame nature, and proceeds from the fame caufe. Very commonly indeed thofe dif- ferent parts are affected at the fame time ; and therefore there can be little room for the diftinction mentioned. The difeafe has been frequently treated of under the title of Tuffis, or Cough ; and a cough, indeed, always attends the chief form of catarrh, that is, the increafed excretion from the bronc]hias : but a cough is fo often a fymptom of many other affections, which are very differ- ent fro m one another, that it is improperly employed as a generic title. mxlvii. The remote caufe of catarrh is, moft common- ly, cold applied to the body. This application of cold producing catarrh, can in many cafes be diftinctly obferv- ed ; and I believe it would always be fo, were men ac- quainted with, and attentive to, the circumftances which determine cold to act upon the body. See xciv.— xcvi. From the fame paragraphs we may learn what in fome perfons gives a predifpofition to catarrh. mxlviii. The difeafe, of which I am now to treat, generally begins with fome difficulty of breathing through the nofe, and with a fenfe of fome fulnefs flop- ping up that paffage. This is alfo often attended with fome dull pain and a fenfe of weight in the forehead, as * Pyrexia, often contagious, accompanied with an increafed excretion of mucus from the membrane ci: the r.ofe, fauce~; and bronchue. Syn. Naf. 37a PRACTICE OF PHYSIC. well as fome ftifthefs in the motion of the eyes. Thefe feelings, fometimes at their very firft beginning, and al- ways foon after, are attended 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 paffes. mxlix. Thefe fymptoms conftitute the coryza and gravedo of medical authors, and are commonly attended with a fenfe of laffitude over the whole body. Some- times cold fliiverings are felt, at leaft the body is more fenfible than ufual to the coldnefs of the air ; and with all this the pulfe becomes, efpecially in the evenings, more frequent than ordinary. ml. Thefe fymptoms feldom continue long before they are accompanied with fome hoarfenefs, and a fenfe of roughnefs arid forenefs in the trachea, and with fome difficulty of breathing, attributed to a fenfe of ftraitnefs of the cheft, and attended with a cough which feems to arife from fome irritation felt at the glottis. The cough is generally at firft dry, occafioning pains about the cheft and more efpecially in the breaft. Sometimes, togeth- er with thefe fymptoms, pains refembling thofe of the rheumatifm, are felt in feveral parts of the body, partic- ularly about the neck and head. While thefe fymptoms take place, the appetite is impaired, fome thirft arifes, and a general laffitude is felt over all the body. mll Thefe fymptoms (mxlvhi.—ml.) mark the vio- lence and height of the difeafe ; which, however, does 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 hoarfenefs and forenefs of the trachea likewife going off, the febrile fymptoms abating, the cough becoming lefs frequent, and with lefs expectora- tion the difeafe¥oon after ceafes altogether. mlii. Such is generally the courfe of this difeafe which is commonly neither tedious nor dangerous ; but upon fome occaflions, it is in both refpects otherwife. PRACTICE OF PHYSIC. 3U A perfon affected with catarrh feems to be more than u- fually liable to be affected by cold air ; and in that con- dition, 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 it would have been, but alfo more dan- gerous by the fupervening of other difeafes. ' mliii. Some degree of the cynanche tonfillaris often accompanies the catarrh ; and, when the latter is aggra- vated 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. ' mliv. When a catarrh has been occafioned by a vio- lent' caufe ; when it has been aggravated by improper management ; and efpecially when it has been rendered more violent by frefh and repeated applications of cold, it often paffes into a pneumonic inflammation attended with the utmoft danger. mlv. Unlefs, however, fuch accidents as thefe of mlii. —mliv. happen, a catarrh, in found perfons not far ad- vanced in life, i% I think, always a flighfdifeafe, and at- tended with little danger. But in perfons of a phthifical difpofition, a catarrh may readily produce a hemoptyfis, or perhaps form tubercles in the lungs; and more cer- tainly, in perfons who have tubercles already formedin the lungs, an accidental catarrh may occafion the in- flammation of thefe tubercles, and in confequence pro- duce a phthif|s pulmonalis. mlvi. In elderly 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 great- ■ er quantity, and confequemly requiring a frequent ex- pectoration. If therefore a catarrh happen to fuch per- fons, and increafe the afflux of fluids to the lungs, with fome degree of inflammation, it may produce the peri- pneumonia notha, which in fuch cafes is very often fa- tal. See ccclxxvi.—ccclxxxii. mlvii. The proximate caufe of catarrh feems to be an increafed afflux of fluids to the mucous membrane of 374 PRACTICE OF PHi SIC. the nofe, fauces, and bronchise, along with fome degree of inflammation affecting thefe parts. The latter cir- cumftance is confirmed by this, that in the cafe of ca- tarrh, the blood drawn from a vein commonly exhib- its the fame inflammatory cruft which appears in the cafe of phlegmafice. mlviii. The application of cold which occafions a ca- tarrh, probably operates by diminifhing the perfpiration ufually made by the fkin, and which is therefore deter- mined to the mucous membrane of the parts above men- tioned*. As a part of the weight which the body dai- ly lofes by infenfible evacuation, is owing to an exhala- tion from the lungs, there is probably a connection be- tween this exhalation and the cutaneous perfpiration, fo that the one may be increafed in proportion as the other is diminifhed : and therefore we may underftand how the diminution of cutaneous perfpiration, in confequence of the application of cold, may increafe the afllux of flu- ids to the lungs, and thereby produce catarrh. mlix. There are fome obfervations made by Dr. James Keil which may feenVto render this matter doubtful; but there is fallacy in his obfervations. The evident ef- ^ fects 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 of the body. mlx. 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 time determined to the mucous glands,and there ex-' * This explanation of the operation of the exciting caufe of catarrh, is by no means fatiifadtoi y; it is not eafily conceivable how an obftniinued effort, whether ^depending on the will, cr upon a propensity ; and in this way a fainting fometimes happens to a woman on the bearing of a child. This may be well illuftratcd by obfervin-.,, that in perfons already mull weakened, even a very moder- ate effort will fometimes occafion fainting. mclxxxi. To axplain the operation of fome other i caufes of fyncope, it may be obferved, that as the exer- tions of the energy of the brain are efpecially under the influence of the will, fo it is well known that thofe mod- ifications of the will which are named Paffions and . Emotions, have a powerful influence on the energy of the brain in its actions upon the heart, either in increaf- ing or diminifhing the force of that energy. Thus an- ger has the former, and fear the latter effect ; and thence it may be underftood hew terror often occafions a fyncope fometimes of the moft violent kind, named Afphyxia, and fometimes death itfelf. mclxxxii. As, from what I have juft mentioned, it appears, that the emotions of defire increafe, and thofe of averfion diminifh the energy of the brain ; fo it may be underftood, how a ftrong averfion, a horror, or the i feeling which arifes upon the fight of a very difagreea- ble object, may occafion fainting. As an example of this, 1 have* known more than one inftance of a perfons, fainting r.t the fight of a fore in another perfon. PRACTICE OF PHYTIC. 41* mclxxxh. To this head of horror and difguft, I re- fer the operation of thofe odors which in certain per- fons occafion fyncope. It may be fuppofed, that" thofe odors are endowed with a directly fedative power, and may thereby occafion fyncope ; but they are, many of them, with refpect to other perfons, evidently of a con- trary quality : and it appears to me, that thofe odors occafion fyncope only in thofe perfons to whom they are extremely difagreeable. mclxxxiv. It is however very probable, that among the caufes of fyncope, there are fome which, analogous to all thofe we have already mentioned, act by a direct- ly fedative power : and fuch may either be diffufed in the mafs of blood, and thereby communicated to the brain, or maybe only taken into the ftomach, which fo readily and frequently communicates its affections to the brain. mclxxxv. Having now enumerated, and, as I hope, explained the moft part of the remote caufes of fyncope, that either operate immediately upon the brain, or whofe operation upon other parts of the body is com- municated to the brain, it is proper to obferve, that the moft part of thefe caufes operate upon certain perfons more readily and more powerfully than upon others ; and this circumftance, which may be confidered as the predifponent caufe of fyncope, deferves to be inquired into. It is, in the firft place, obvious, that the operation of fome of thofe caufes depends entirely upon an idiofyn- crafy in the perfons upon whom they operate ; which, however, I cannot pretend to explain. But, in the next place, with refpect to the greater part of the other caufes, their effects feem to depend upon a temperament which is in one degree or other in common to many perfons. This temperament feems to confift in a great degree of fenfibility and mobility, arifing from a ftate of debility, fometimes depending upon original conformation, and fometimes produced by accidental occurrences in the courfe of life* 4*0 PRACTICE OF PHYSIC. mclxxxvi. The fecond fet of the remote caufes of fyncope (mclxxiv.), or thofe acting directly upon the heart itfelf, are certain organic affections of the heart it- felf, or of the parts immediately connected with it, par- ticularly the great veffels which pour blood into, or im- mediately receive it from the cavities of the heart. Thus a dilatation, or aneurifm of the heart, a polypus in its cavities, abfeeffes or ulcerations in its fubftance, a clofe adherence of the pericardium to the furface of the heart, aneurifms of the great veffels near to the heart, polypus in thefe, and offification in thefe or :n the valves of the heart, are one or other of them conditions, which, upon diffection, have been difcovered in thofe perfons who had before labored under frequent fyn- cope. mclxxxvu. It is obvious, that thefe conditions are all of them, either fuch as may, upon occafion, difturb the free and regular influx into, or the free egrefs of the blood from the cavities of the heart; or fuch as may otherwife difturb its regular action, by fometimes inter- rupting it, or fometimes exciting it to more violent and convulfive action. The latter is what is named the Pal- pitation of the heart, and it commonly occurs in the fame perfons who are liable to fyncope. mclxxxviii. It is this, as I judge, that leads us to perceive in what manner thefe organic affections of the heart and great veffels may occafion fyncope ; for it may be fuppofed, that the violent exertions made in palpita- tions may either give occafion to an alternate great re- laxation (mclxxvih.), or to a fpafmodic contraction ; and in either way fufpend the action of the heat, and occafion fyncope. It feems to me probable, that it is a fpafmodic contraction of the heart that occafions the in- termiffion of the pulfe fo frequently accompanying pal- pitation and fyncope. mclxxxix. Though it frequently happens that pal- pitation and fyncope arife, as we have faid, from the or- ganic affections above mentioned, it is proper to obferve, that thefe difeafes, even when in a violent degree, do not always depend on fuch caufes acting directly on the PRACTICE OF PHYSIC. 421 heart, but arc often dependent on ibmc of thofe caufes which we have mentioned above as acting primarily on the brain. mcxc. I have thus endeavored to give the pa- thology of fyncope ; and of the cure lean treat very fhortly. The cafes of fyncope depending on the fecond fet of caufes (mclxxiv.), and fully recited in mclxxxv., I fuppofe to be generally incurable ; as our art, fo far as I know, has not yet taught us to euro any one of thofe feveral caufes of fyncope (mclxxxv.) The cafes of fyncope, depending on the firft fet of cauf- es (mclxxiv.), and whofe operation I have endeavored to explain in ?.iclxxvii. etfeq. I hold to be generally cu- rable, either by avoicmg the feveral occafional caufes there pointed out, or by correcting the predifponent caufes (mclxxxiv.) The latter, I think, may generally be done by correcting the debility or mobility of the fyftem, by the means which I have already had occafion to point out in another place. CHAP. II. OF D IS PEPSI A *, OR INDIGESTION. i mcxci. ;;\ waxt of appetite, a fqueaniifibneis, fometimes a vomiting, fudden and transient diftenfions of the ftomach, eruciations of various kind:, heartburn, pains in the region of the ftomach, find a bound belly, are fymptoms which frequently concur in the fame r-.tr- fon, and therefore may be prefumed to deperd upon one and the fame proximate ca;:fe. In both views, therefore, they may be 'confidered as forming one and the fame difeafe, to which we have given the arrjUation oiByfpcpfui, fet at the head of this clwprrr. * L^rs of .-fipefae, naufea, vomiting diftenfion of the fSro:-r..~~h, ruction, pr.i.iii! th" i>\'!'>n of tin-itim.ich, heartburn, And corCwrreh : rt. It n't the t.oa=:irrcnceof mnfr of the a'-~v • fymt-.torus, \» iiV^it any o:her dife-fcof t!•• ? ftomach or nf o!hi:-.- pa:t\ Syn. Xf. 4%2 PRACTICE OF PHYSIC. mcxcii. But as this difeafe is alfo frequently a iccon- ■clary and fympathic affection, fo the fymptoms above mentioned are often joined with many others ; and this has given occafion to a very confufed and undetermined ; defcription of it, under the general title of Nervous Dif- eafes, or under that of Chronic Weaknefs. It is proper, however, to diftinguifh, and I apprehend the fymptoms enumerated above are thofe effentiai to the idiopathic af* fection I am now to treat of. mcxc in. It is indeed to be particularly obferved, that thefe fymptoms are often truly accompanied with a cer- tain ftate of mind which may be confidered as a part of the idiopathic affection : but I fhall take no further no- tice of this fymptom in the prefent chapter, as it will be fully and more properly confidered in the next, under the title of Hypochondriasis. mcxciv. That there is a diftinct difeafe attended al- ways with the greater part of the above fymptoms, is rendered very probable by this, that all thefe feveral' ; fymptoms may arife from one and the fame caufe ; that ( is, from an imbecillity, lofs of tone, and weaker action in the mufcular fibres of the ftomach : and I conclude 9 therefore that this imbecillity may be confidered as the j proximate caufe of the difeafe I am to treat of under thqff name of Dyfpepfia. 1 mcxcv. The imbecillity of the ftomach, and the^ * confequent fymptoms (mcxc), may, however, frequent- '■ ly depend upon fome organic affection of the ftomach itfelf, as tumor, ulcer, cr feirrhofity; or upon fome affec- tion of other parts of the body communicated to the ftom- ach, as in gout, arnenarrhcea, and fome others. In all thefe ; cafes however, the dyfpeptic fymptoms are to be confid- ered as fecondary or fympathic affections, to be cured only by curing the primary difeafe. Such fecondary and fympathic cafes cannot, indeed, be treated of here : but as I prefume that the imbecillity of the ftomach may often take place without either any organic affection of this part, or any more primary affection in any other part, of the body ; fo I fuppofe and expect it will appear, from the confideration of the remote caufes, that the PRACTICE OF PHYSIC. 433 dyfpepfia, may be often an idiopathic affection, and that it is therefore properly taken into the fyftem of method- ical Nofology, and becomes the fubject of our confidera- tion here. mcxc vi. There can be little doubt, that, in moft cafes, the weaker action of the mufcular fibres of the ftomach, is the moft frequent antl chief caufe of the fymptoms mentioned in mcxc ; but I dare not maintain it to be the only caufe of idiopathic dyfpepfia. There is, pretty certainly, a peculiar fluid in the ftomach of animals, or at leaft a peculiar quality in the fluids, that we know to be there, upon which the folution of the aliments taken into the ftomach chiefly depends : and it is at the fame time probable, that the peculiar quality of the diffolving or digefting fluids may be varioufly changed, or that their quantity may be, upon occafion, diminifhed. It is there- fore fufliciently probable, that a change in the quality or quantity of thefe fluids may produce a confiderable difference in the phenomena ofdigeftion, and particular- ly may give occafion to many of the morbid appearances mentioned in mcxc. mcxcvii. This feems to be very well founded, and points out another proximate caufe of dyfpepfia befide that we have already affigned: But, notwithstanding 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 practical doctrine upon any fuppofi- tion with refpect to them ; and as, at the fame time, the imbecillity of the ftomach, either as caufing the change in the digeftive fluid, or as being induced by that change, feems always to be prefent, and to have a great fhare in occafioning the fymptoms of indigeftion ; fo I fhall ftill confider the imbecillity 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 opinon, the doctrine applies very fully and clearly to the explaining the whole of the practice wThich experience has eftablifhed as the moft fuccefsful in this difeafe. 4*4 PRACTICE OF PHYSIC. mcxcviii. Confidering this, then, as the proximate caufe of dyfpepfia, I proceed to mention the feveral re- mote caufes, of this difeafe ; as they are fuch as, on dif- ferent occafions, feems to produce a lofs of tone in the mufcular fibres of the ftomach. They may, I think, be confidered under two heads. The firft is, of thofe whicK act directly and immediately upon the ftomach itfelf: g The fecond is, of thofe which act upon the whole body,' or particular parts of it, but in confequence of which the ftomach is chiefly or almoft only affected. mcxcix. Of the firft kind are, I. Certain fedative or narcotic fubftances taken into the ftomach ; fuch as tea, coffee, tobacco, ardent fpirits, ( opium, bitters, aromatics, putrids, and acefcents. 2. The large and frequent drinking of warm water, I or of warm watery liquids. 3. Frequent forfeit, or immoderate repletion of the ftomach. , 4. Frequent vomiting, whether fpontaneoufly arifing, or excited by art. 5. Very frequent fpi'tting, or rejection of faliva. mcc. Thofe caufes which aft upon the whole body or upon particular parts and functions of it are, 1. An indolent and fedentary life. 2. Vexation of mind, and diforderly paffions of any kind. t 3. Intenfe ftudy, or clofe application to bufinefi 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. i Though the difeafe, as proceeding from the laft fet of < caufes, may be confidered as a fymptomatic affection on- ly ; yet as the affection of the ftomach is generally the « firft, always the chief, and often the only effect which I thefe caufes produce or difcover, I think the affection of j the ftomach may be confidered as the cifeafe to be at- tended to in practice ; and the move properly fo, as in PRACTICE OF PHYSIC. . 4*5 Many cafes the general debility is only to be cured by re- ftoring the tone of the ftomach, and by remedies firft ap- plied to this organ. mcci. For the cure of this difeafe, we form three fev- eral indications ; a prefervative, a palliative, and a cura- tive. The firft is, to avoid or remove the remote caufes juft now enumerated. The fecond is, to remove thofe fymptoms which efpe- cially contribute to aggravate and continue the difeafe* And, The third is, to reftore the tone of the ftomach ; that is, to correct or remove the proximate caufe of the dif- eafe. keen. 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 difeafe ; may defeat the ufe of remedies ; or, iu fpite of thefe, may occafion the recurrence of the difeafe. It is commonly the neglect of this indication which renders this difeafe fo frequently obftinate. How the indication is to be executed, will be fufficiently obvious from the confideration of the feveral caufes : but it is proper for the practitioner to attend to this, that the execution is of- ten exceedingly difficult, becaufe it is not eafy to engage men to break in upon eftablifhed habits, or to renounce the purfuit of pleafure ; and particularly, to perfuade men that thefe practices are truly hurtful which they have often practifed with feeming impunity. mcciii. The fymptoms of this difeafe which efpecially contribute to aggravate and continue it, and therefore re- quire to be more immediately corrected or removed, are, firft, the crudities of the ftomach already produced by the difeafe, and difcovered by a lofs of appetite, by a fenfe of weight and uneafinefs in the ftomach, and par- ticularly by the eructation of imperfectly digefted mat- ters. Another fymptom to be immediately corrected, is an unufual quantity, or a higher degree than ufual, of acid- ity prefent in the ftomach, difcovered by various difor* 4j6 PRACTICE OF PHi'SIC. ders in digeftion, and by other effects 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. mcciv: The firft o f thefe fymptoms is to be relieved by exciting vomiting ; and the ufe of this remedy, there- fore, ufually and properly begins the cure of this difeafe. The vomiting may be excited by various means, more gentle or more violent. The former may anfwer the purpofe of evacuating the contents of the ftomach : but emetics, and vomiting, may alfo excite the ordinary ac- tion of the ftomach ; and both, by varioufly agitating the fyftem, and particularly by determining to the fur- face of the body, may contribute to remove the caufes of the difeafe. But thefe latter effects can only be obtained . by the ufe of emetics of the more powerful kind,'fuch as the antimonial emetices efpecially are. , mccv. The fecond fymptom to be palliated, is an excefs of acidity, either in quantity or quality, in the contents * of the ftomach. In man there is a quantity of acefcent * aliment almoft conftantly taken in, and, as I think, al- ways undergoes an acetous fermentation in the ftomach ; and it is, therefore, that in the human ftomach, and in the ftomachs of all animals uftng vegetable food, there i is always found an acid prefent. This acid however, is " generally innocent, and occafions no diforder, unlefs either the quantity of it is very large, or the acidity pro- ceeds to a higher degree than ufual. But, in either of thefe cafes, the acid occafions various diforders, as fla- tulency, eructation, heartburn, gnawing pains of the ftomach, irregular appetites and cravings, loofenefs, grip- ing, emaciation, and debility. To obviate or remove thefe effects aggravating and continuing the difeafe, it is not only neceffary to correct the acid prefent in the ftom- ach ; but, efpecially as this acid proves a ferment deter-' I mining and increafing the acefcency of the aliments af- terwards taken in, it is proper alfo, as foon as poflible, to correct the difpofition to excefllve acidity. PRACTICE OF PHYSIC. 43? mccvi. The acidity prefent in the ftomach, may be Corrected by the ufe of alkaline falts, or abforbent earths, or by fuch fubftances containing thefe, which can be de- compofed by the a id of the ftomach. Of the alkalines, the cauftic is more effectual than the mild ; and this accounts for the effects of lime water. By employing ab- forbents we avoid the excefs of alkali, which might fometimes take place. The abforbents are different, as they form a neutral more or lefs laxative ; and hence the difference between magnefia alba and other abforbents. It is to be obferved, that alkalines and abforbents may be employed to excefs ; as, when employed in large quanti- ty, they may deprive the animal fluids cf the acid necef- fary to their proper compofition. mccvii. The difpofition to acidity may be obviated by avoiding acefcent aliments, and ufing animal food little capable of acefcency. This, however, cannot be long continued without corrupting the ftate of our blood; and, as vegetable food cannot be entirely avoided, the excefs of their acefcency may, in fome meafure, be avoid- ed, by choofing vegetable food the leaft difpofed to a vin- ous fermentation, fuch as leavened bread and well fer- mented liquors, and, inftead of frefh native acids, em- ploying vinegar. mccviii. 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 a- cidity, 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 for- mer may be occafioned, we do not well underftand ;• but we can readily perceive that the latter, perhaps the former alfo, may proceed from a weaker action of the mufcular fibres of the ftomach. In certain cafes, fedative paffions, immediately after they arife, occafion the ap- pearance of acidity in the ftomach which did not appear before ; and the ufe of ftimulants often corrects, or ob- viates an acidity that would otherwife have appeared. B B 4a8 PRACTICE OF PHYSIC. From thefe confiderations, we conclude, that the produc- tion and fubfiftance of acidity in the ftomach, is to be ef- pecially prevented by reftoring and exciting the proper action of it, by the feveral means to be mentioned here- after. mccix. But it is alfo to be further obferved, that though there are certain powers in the ftomach for pre- venting a too copious acidity, or a high degree of it, they are not however always fufficient for preventing acef- cency, or for covering the acidity produced ; and there- fore, as long as vegetable fubftances remain in the ftom- ach, their acefcency may go on and increafe. From hence we perceive,, that a fpecial caufe of the excefs of acidity may be, the too long retention of acefcent matters in the ftomach ; whether this may be from thefe matters being of more difficult folution, or from the weaknefs of the ftomach more flowly difcharging its contents into the duodenum, or from fome impediment to the free evacu- ation of the ftomach by the pylorus. The latter of thefe * caufes we are well acquainted with, in the cafe of a fchir- rhous pylorus, producing commonly the higheft degree { of acidity. In all the inftances of this fchirrofity I have met with, I have found it incurable : but the firft of thefe caufes is to be obviated by avoiding fuch aliments as are of difficult folution ; and the fecond is to be mended by the feveral remedies for exciting the action of the ftom- ach, to be mentioned afterwards. mccx. The third fymptom commonly accompanying dyfpepfia, which requires to be immediately removed, is" coftivenefs. There is fo much connection between the feveral portions of the alimentary canal with refpect to the periftaltic motion, that if accelerated or retarded in any one part, the other parts of it are commonly affect- ed in the fame manner. Thus, as the brifker action of the ftomach muft accelerate the action of the inteftines, fo the flower action of the inteftines muft in fome meaf- ure retard that of the ftomach. It is, therefore, of confequence to the proper action of the ftomach, that the periftaltic motion of the inteftines deter- mining their contents downwards, be regularly con- * PRACTICE OF PHYSIC. 429 fcinued ; and that all coftivenefs, or Interruption of th^t determination, be avoided. This may be done by the various means of exciting the action of the inteftines ; but it is to be obferved here, that as every confiderable evacuation of the inteftines weakens their action, and is ready, therefore, to induce coftivenefs when the evacua- tion is over ; fo thofe purgatives which produce a large evacuation, are unfit for correcting the habit of coftive- nefs. This, therefore, fhould be attempted by medi- cines which do no more than folicit the inteftines to a more ready difcharge of their prefent contents, without either hurrying their action, or increafing the excretions made into their cavity ; either of which effects might produce a purging. There are, I think, certain medi- cines peculiarly proper on this occafion, as they feem to flimulate efpecially the great guts, and to act little on the higher parts of the inteftinal canal. mccxi. We have thus mentioned the feveral means of executing our fecond indication ; and I proceed to the third, which is, as we have faid, 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 directly and chiefly on the ftomach itfelf ; and the other is, of thofe means which, operating upon the whole fyftem, have their tonic effects thereby com. municated to the ftomach. mccxi 1. The medicines which operate directly on the ftomach, 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 ftim dat- ing the ftomach, and therefore. often increafe appetite ; but the native acids, as liable to fermentation, may oth- erwife do harm, and are therefore of ambiguous ufe. The acids, therefore, chiefly and fuccefsfully employed, are the vitriolic muriatic, and the diftilled acid of vege- tables, as^ it is found in tar water, which are all of them antizymics. 4-o PRACTICE OF PHYSIC. The neutral falts anfwering this intention, are efpecial- ly thofe which have the muriatic acid in their compofi- tion, though it is prefumed that neutrals of all kinds have more or lefs of the fame virtue. mccxiii. The aromatics, and perhaps fome other acrids, certainly ftimulate the ftomach,. as they obviate the acef- cency, and flatulency of vegetable food : but their ftimu- lus is tranfitory ; and if frequently repeated, and taken in large, quantities, they may hurt the tone of the ftom- ach. mccxiv. The tonics employed to flrengthen the ftom- ach are bitters, bitters and aftringents combined, and chalybeates. Bitters are undoubtedly tonic medicines, both with refpect to the ftomach and the whole fyftem : but their long continued ufe has been found to deftroy the tone of the ftomach, and of the whole fyftem ; and, whether this is from the mere repetition of their tonic operation* or from fome narcotic power joined with the tonic in them, I am uncertain.. mccxv. Bitters and aftringents combined, are, proba- bly, more effectual tonics than either of them taken fingly ; and we fuppofe fuch a combination to take place in the Peruvian bark ; which therefore proves a power- ful tonic, both with refpect to the ftomach and to the whole fyftem.. But I have fome ground to fufpect, that the long continued ufe of this bark may, like bitters def- troy both the tone of the ftomach and of the whole fyftem. mccxvi. Chalybeates may be employed as tonics rn various forms, and in confiderable quantities, with fafe- ty*. They have been often employed in the form of mineral waters, and feemingly with fuccefs : but whether this is owing to the chalybeate in the compofition 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. * See the Fovmulsc for Amenonhoea. PRACTICE OF PHYSIC. 43 * mccxvii. The remedies which ftrengthen the ftomach, by being applied to the whole body, are, exercife and the application of cold. As exercife ftren^thens the whole body, it muft alfo ftrengthen the ftomach ; but it does this alfo in a partic- ular manner, by promoting perfpiration, and exciting the action of the veffels on the furface of the body, which have a particular confent with the mufcular fibres of the ftomach* This particularly explains why the ex- ercifes of geftation, though not the moft powerful in ftrengthening the whole fyftem, are, however, very pow- reful in ftrengthening the ftomach ; of which we have a remarkable proof in the effects of failing. In ftrengtli- ening the general fyftem, as fatigue 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 ftrength- ening the ftomach, and thereby of curing difpcpfia. mccxviii. The other general remedy of dyfpepfia, is the application of cold : which may be in two ways 4 that is, either by the application of cold air, or of cold water. It is probable, that, in the atmofphere conftant- ly furrounding our bodies, a certain degree of cold con- fiderably lefs than the temperature of our bodies them- felves, is neceffary to the health of the human body. Such a degree of cold feems to ftrengthen the veffels on the furface of the body, and therefore the mufcular fi- bres 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 exercife, will render the perfpiration more confiderable. From the fharp appetite that in fuch circumftances is commonly produced, we can have no doubt, that by the application of fuch cold, the tone of the ftomach is considerably ftrengthened. Cold air, therefore, applied with exer- cife, is a moft powerful tonic with refpect to the ftom- ach : and this explains why, for that purpofe, no exer- 3 4jl PRACTICE OF PHYSIC. cifes within doors, or in clofe carriages, are fo ufeful as thofe in the open air. ^ mccxix. From the fame reafoning, we can perceive, that, the application of cold water, or cold bathing, while it is a tOnic with refpect to the fyftem in general, and efpecially as exciting the action of the extreme veffels, muft in both refpects be a powerful means of ftrengthen- ing the tone of the ftomach. mccxx. Thefe are the remedies to be employed to- wards a radical cure of idiopathic dyfpepfia ; and it' might be, perhaps, expected here, that 1 fhould treat al- fo of the various cafes of the fympathic difeafe. But it will be obvious that this cannot be properly done with- out treating of all the difeafes of which the dyfpepfia is a fymptom, which cannot be proper in this place. It has been partly done already, and will be further treated of in the courfe of this work. In the mean time, it may be proper to obferve, that there is not fo much Occafion for diftinguifh ing between the idiopathic and fympathic dyf- pepfia, as there is in many other cafes of idiopathic and fympathic difeafes. For, as the fympathic cafes of dyfpepfia are owing to a lofs of tone in fome other part of the fyftem, which is from thence communicated to the ftomach ; fo- the tone of the ftomach reftored, may be communicated to the part primarily affected ; and therefore the reme- ; dies of the idiopathic may be often ufefully employed, and are often the remedies chiefly employed, in fym- pathic dyfpepfia.' mccxxi. Another part of our bufinefs here might be to fay, how fome other of the urgent fymptoms, befide thofe above mentioned, are to be palliated. On this fub- ject, I think it is enough to fay, that the fymptoms chiefly requiring to be immediately relieved, are flatulen- cy, heartburn, other kinds of pain in the region of the itomach, and vomiting. The dyfpeptic are ready to fuppofe that the whole of their difeafe confifts in a flatulency. In this it will be obvious that they are miftaken ; but, although the flatu- lency is not to be entirely cured, but by mending the im- becillity of the ftomach by the means above mentioned ; PRACTICE OF PHYSIC. 433 yet the flatulent diftenfion of the ftomach may be reliev- ed by carminatives, as they are called, or medicines that produce a difcharge of wind from the ftomach ; fuch are the various antifpafmodics, of which the moft effectual is the vitriolic aether. The heartburn may be relieved by abforbents, antif- pafmodics, or demulcents. The other pains of the ftomach may be fometimes re- lieved by carminatives, but moft certainly by opiates. Vomiting is to be cured moft effectually by opiates thrown by injections into the anus. CHAP. III. OF HYPOCHONDRIASIS, or the HYPOCHONDRIAC AFFEC- TION, commonly called vapors or low spirits. mccxxii. In certain perfons there is a ftate ofmind diftinguifhed by a concurrence of the following circum- ftances : A langor, liftleffnefs, or want of refolution and activity with refpect to all undertakings; a difpofition to ferioufnefs, fadnefs, and timidity ; as to all future c- vents, an apprehenfion of the worft or moft unhappy ftate of them ; and therefore, often upon flight grounds, an apprehenfion of great evil. Such perfons are particular- ly attentive to the ftate of their own health, to every the fmalleft change of feeling in their bodies ; and from any unufual feeling, perhaps of the flighteft kind, they appre- hend great danger, and even death itfelf. In refpect to all thefe feelings and apprehenfions, there is commonly the moft obflinate belief and perfuafion. mccxxiii. This ftate of mind is the Kypochondriafis of medical writers. See Linnan Genera Morborum, Gen. 76. Sagari SyftemaSymptomaticum, Clafs XIII. Gen. 5. The fame ftate of mind is what has been com- monly called Vapors and Low Spirits. Though the term Vapors may be founded on a falfe theory, and therefore 4 4 34 FRACTICE OF PHYSIC. improper, I beg leave, for a purpofe that will immediate- ly appear, to employ it for a little here. mccxxiv. Vapors, then, of the ftate of mind defcribed above, is, like every other ftate of mind, connected with a certain ftate of the body, which muft be inquired into, in order to its being treated as a difeafe by the art of phyfic. mccxxv. This ftate of the body, however, is not very eafily afcertained ; for we can perceive, that on dif- ferent occafions it is very different ; vapors being com-' bined fometimes with dyfpepfia, fometimes with hyfter- ia, and fometimes with melancholia, which are difeafes feemingly depending on very different ftates of the body. mccxxvi. The combination of vapors with dyfpepfia is very frequent, and in feemingly very different circum- ftances. It is efpecially thefe different circumftances that I would wifh to afcertain ; and I remark, that they are manifeftly of two different kinds. Firft, as the difeafe occurs in young perfons of both fexes, in perfons of a fanguine temperament, and of a lax and flacid habit. Secondly, as it occurs in elderly perfons of both fexes, of a melancholic temperament, and of a firm and rigid habit. mccxxvh. Thefe two different cafes of the combina- tion of vapors and dyfpepfia, I confider as two diftinct difeafes, to be diftinguifhed chiefly by the temperament prevailing in the perfons affected. * As the dyfpepfia of fanguine temperaments is often without vapors ; and as the vapors, when joined with dyfpepfia in fuch temperaments, may be confidered as perhaps always a fymptom of the affection of the ftom- ach ; fo to this combination of dyfpepfia and vapors, I would ftill apply the appellation of dyfpepfia, and confid- er it as ftrictly the difeafe treated of in the preceding chapter. But the combination of dyfpepfia and vapors in mel- ancholic temperaments, as the vapors or the turn of mind peculiar to the temperament, nearly that defcribed above in mccxxil, are effentiai circumftances of the difeafe: and as this turn of mind is often with few, or only flight PRACTICE OF PHYSIC. 43S fymptoms of dyfpepfia, and even though the latter be at- tending, as they feem to be rather the effects of the gene- ral temperament, than of any primary or topical affection of the ftomach ; I confider this combination as a very difterent difeafe from the former, and would apply to it ftrictly the appellation of hypochondriafls. mccxxviii. Having thus pointed out a diftinction be- tween Dyfpepfia and Hypochondriafis, I fhall now, ufing thefe terms in the ftrict fenfe above mentioned, make fome obfervations which may, I think, illuftrate the fub- ject, and more clearly and fully eftablifh the diftinction. propofed. mccxxix. The dyfpepfia often appears early in life and is frequently much mended as life advances ; but the hy- pochondriafis feldom appears early in life, and more u- iiially in more advanced years only ; and more certainly ftill when it has once taken place, it goes on increafing as life advances to old age. This feems to be particularly well illuftrated, by our obferving the chaages in the ftate of the mind which u- fually take place in the courfe of life. In youth, the mind is cheerful, active, rafh, and moveable ; but as life advan- ces, the mind by degrees becomes more ferious, flow, cau- tious, and fteady ; till at length, in old age, the gloomy, timid, diftruftful, and obftinate ftate of melancholic tem- peraments is more exquifitely formed. In producing thefe changes, it is true that moral caufes have a fhare ; but it is at ths fame time obvious, that the temperament of the body determines the operation of thefe moral cau- fes fooner or later, and in a greater or leffer degree, to have their effects. The fanguine temperament retains longer the character of youth, while the melancholic temperament brings on more early the manners of old age. mccxxx. Upon the whole, it appears, that the ftate a>f the mind which attends, and efpecially diftinguifhes hypochondriafis, is the effect of that fame rigidity of the folids, torpor of the nervous power, and peculiar^alance between the arterial and venous fyftems which occur in advanced life, and which at all times take place more or 4j4 PRACTICE OF PHYSIC. lefs in melancholic temperaments. If therefore there be alfo fomewhat of a like ftate of mind attending that di£ pepfia which occurs early in life in fanguine tempera- ments and lax habits, it muft depend upon a different ftate of the body, and probably upon a weak and move- able ftate of the nervous power. mccxxxi. Agreeable to all this, in dyfpepfia, there is more of fpafmodic affection, and the affection of the mind (mccxxii.) is often abfent, and when prefent, is perhaps always of aflighter kind : while, in hypochondriafis, the affection of the mind is more conftant, and the fymptoms of dyfpepfia, or the affections of the ftomach, are often abfent, or when prefent, are in a flighter degree. I believe the affection of the mind is commonly differ- ent in the two difeafes. In dyfpepfia, it is often languor ' and timidity only, eafily difpelled; while in hypochon- driafis, it is generally the gloomy and rivetted apprehen- fion of evil. The two difeafes are alfo diftinguifhed by fome other circumftances. Dyfpepfia, as I have faid, is often a fymp- tomatic affection ; while hypochondriafis is perhaps al- ways a primary and idiopathic difeafe. As debility may be induced by many different caufes* \ dyfpepfia is a frequent difeafe ; while hypochondriafis . depending upon a peculiar temperament, is more rare. mccxxxii. Having thus endeavored to diftinguifh the two difeafes, I fuppofe the peculiar nature and proximate 1 caufe of hypochondriafis will be underftood; and I pro- ceed therefore to treat of its cure. So far as the affections of the body, and particularly of the ftomach, are the fame here as in the cafe of dyfpepfia, ! the method of cure might be fuppofed to be alfo the fame; / and accordingly the practice has been carried on with lit- tle diftinction : But I am perfuaded that a diftinction is often neceffary. mccxxxiii. There may be a foundation here for the fame prefervative indication as firft laid down in the cure of dyjjpepfla (mccii.); but I cannot treat this fubject fo clearTy or fully as 1 could with, becaufe I have not yet ' had fo much opportunity of obfervation as I think nee- ' PRACTICE OF PHYSIC. 437 effary to afcertain the remote caufes ; and I can hardly make ufe of the obfervations of others, who have feldom or never diftinguifhed between the two difeafes. What indeed has been faid with refpect to the remote caufes of ?nelancholia, will often apply to the hypochondriafis, which I now treat of; but the fubject of the former has been fo much involved in a doubtful theory, that I find it dif- ficult to felect the facts that might properly and ftrictly apply to the latter. I delay this fubject, therefore, till another occafion ; but in the mean time truft, that what I have faid regarding the nature of the difeafe, and fome remarks I fhall have occafion to offer in confidering the method of cure, may in fome meafure fupply my defi- ciency on this fubject of the remote caufes. mccxxxiv. The fecond indication laid down in the cure of dyfpepfia (mcci.) has properly a place here ; but it is ftill to be executed with fome diftinction. mccxxxv. An anorexia, and accumulation of crudities in the ftomach, does not fo commonly occur in hypo- chondriafis as in dyfpepfia ; and therefore vomiting (mcciv,) is not fo often neceffary in the former as in the 3atter. mccxxxvi. The fymptom of excefs of acidity, from the flow evacuation of the ftomach in melancholic tem- peraments, often arifes to a very high degree in hypo- chondriafis ; and therefore, for the fame reafon as in mccv. it is to be obviated and corrected with the utmoft care. It is upon this account that the feveral antacids, and the other means of obviating acidity, are to be em- ployed in hypochondriafis, and with the fame attentions and confiderations as in mccvi. and following : with this reflection, however, that the exciting the action of the ftomach there mentioned, is to be a little differently un- derftood, as fhall be hereafter explained. mccxxxvii. As coftivenefs, and &that commonly to a confiderable degree, is a very conftant attendant of hy- pochondriafis, fo it is equally hurtful as in dyfpepfia. It may be remedied by the fame means in thciyner as ia the latter, and they arc to be employed \vifh the fame reftrictions as in mccx. 43* PRACTICE OF PHYSIC mccxxxviii. It is efpecially with refpect to the third indication laid down in the cure of dyfpepfia (mcci.) that there is a difference of i ractice to be obferved in the cure of hypochondriafis ; and that often one directly op- pofite to that in the cafe of dyfpepfia, is to be followed. mccxxxix. In dyfpepfia, the chief remedies are the to- nic 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 activity, 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, rather than fo the tonic power of the fmall quantity of j iron which they contain. Perhaps the elementary water, by favoring the excretions, may .have a fhare in relieving the difeafe. ' mccxl. Cold bathing is often highly ufeful to the dyf- peptic, and as a general ftimulant, may fometimes feem * ufeful to the hypochondriac ; but it is not commonly fo to the latter : while on the other hand, warm bathing, t hurtful to the dyfpeptic, is often extremely ufeful to the hypochondriac. mccxli. Another inftance of a contrary practice necef- fary in the two difeafes, and illuftrating their refpective I natures, is, that the drinking tea and coffee is always hurtful to the dyfpeptic, but is commonly extremely ufe- ful to the hypochondriac. mccxlii. Exercife, as it ftrengthens the fyftem, and thereby the ftomach, and more efpecially, as by increafing the perfpiration it excites the action of the ftomach, it proves one of the moft ufeful remedies in dyfpepfia ; and further, as by increafing the perfpiration, it excites the activity of the ftomach, it likewife proves an ufeful rem- edy in the hypochondriafis. However, in the latter cafe, as I fhall explain prefently, it is ftill a more ufeful remedy by its operation upon the mind than by that up- on thek^dy. Mccx^Lie It is now proper that we proceed to confider the moft important article of our practice in this difeafe, PRACTICE OF PHYSIC. 439 and which is, to confider the treatment of the mind, an affection of which fometimes attends dyfpepfia, but is al- ways the chief circumftance in hypochondriafis. What I am to fuggefthere, will apply to both difeafes ; but it is the hypochondriafis that I am to keep moft conftantly in view. mccxliv. The management of the mind, in hypochon- driacs, is often nice and difficult. The firm perfuafion that generally prevails in fuch patients, does not allow their feelings to be treated as imaginary, nor their appre- henfion of clanger to be confidered as groundlefs, though the phyfician may be perfuaded that it is the cafe in both refpects. Such patients, therefore, are not to be treated either by railery or by reafoning. It is faid to be the manner of hypochondriacs to change often their phyfician, and indeed they often do it confiftently : 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 en- tertains no apprehenfion. If in any cafe the pious fraud of a placebo be allowa- ble, it feems to be in treating hypochondriacs; who, anxious for relief, are fond of medicines, and, though often difappointed, will ftill take every new drug that can be propofed to them. mccxlv. As it is the nature of man to indulge ev- ery prefent emotion, fo the hypochondriac cherifhes his fears, and attentive to every feeling, finds in trifles light as air a ftrong confirmation of his apprehenfions. His cure therefore depends efpecially upon the interruption of his attention, or upon its being diverted to other ob- jects than his own feelings. mccxlvi. Whatever averfion to application of any kind may appear in hypochondriacs, there is nothing more pernicious to them than abfolute idlenefs, or a va- cancy from all earneft purfuit. It is owing to wealth admitting of indolence, and leading to the purfuit of tranfitory and unfatisfying amufements, or toAat of exhaufting pleafures only, that the prefent timeTexhibit to us fo many inftances of hypochondriacifm. 44* PRACTICE OF PHYSIC. The occupations of bufinefs fuitable to their circum- ftances and situation in life, if neither attended with emotion, anxiety, nor fatigue, are always to be admit- ted, and perfifted in by hypochondriacs. But occupa- tions-upon which a man's fortune depends, and which are always, therefore, objects of anxiety to melancholic men ; and more particularly where fuch occupations are expofed to accidental interruptions, difappointments, and failures, it is from thefe that the hypochondriac is certainly to be withdrawn. mccxlvii. The hypochondriac who is not neceffarily, by circumftances 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, with fome ardor, and attended with exercife if not too violent^ are amongft the moft ufeful. All thofe amufements which are in the open air, join- ed with moderate exercife, and requiring fome dexteri- ty, are generally of ufe. . Within doors, company which engages attention,' which is willingly yielded to, and is at the fame time of a cheerful kind, will be always found of great fervice. , Play, in which fome fkill is required, and where the i flake is not an object of much anxiety, if not too long protracted, may often be admitted. . < In dyfpeptics, however, gaming, liable to fudden and'.; confiderable emotions, is dangerous ; and the long con- , tinuance of it, with night watching, is violently debilita- ] ting. But in melancholies, who commonly excel in fkill and are lefs fufceptible of violent emotions, it is more ad- miflible, and is often the only amufement that can en- gage them. Mufic, to a nice ear, is a hazardous amufement, as long attention to it is very fatiguing. mccxlviii. It frequently happens, that amufements of every kind are rejected by hypochondriacs ; and in that i cafejmechanical means of interrupting thought are the rem^^s to be fought for. PRACTICE OF PHYSIC. 44* Such is to be found in brifk exercife, which requires fome attention in the conduct of it. Walking is feldom of this kind ; though, as gratify- ing to the reftleffnefs of hypochondriacs, it has fome- times 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 attention, does very little fervice. Exercife in an eafy carriage, in the direction of which the traveller takes no part, unlefs it be upon rough roads, Or driven pretty quickly, and with long continu- ance, is of little advantage. mccxlix. Whatever exercife may be employed, it will be moft effectual when employed in the purfuit of a journey ; firft, becaufe it withdraws a perfon from ma- ny objects of uneafinefs and care which might prefent themfelves at home ; fecondly, as it engages in more con- ftant exercife, and in a greater degree of it than is com- monly taken in airings about home; and, laftly, as it is conftantly prefenting new Objects which call forth a per- fon's attention. mccl. In our fyftem of Nofology, we have, next to Hypochondriafis, placed the Chlorofis, becaufe I once thought it might be confidered as a genus, comprehend- ing, befides the Chlorofis Of Amenorrhcea, fome fpecies of Cachexy : but, as I cannot find this to be well found- ed, and eannot diftinctly point out any fuch difeafe, I now omit confidering Chlorofis as a genus here ; and as a fymptom of Amenorrhoea, I have endeavored before to explain it under that title. ^ BOOK III. OF SPASMODIC AFFECTIONS, WITHOUT FEVER. INTRODUCTION. mccli. Under this title I am to comprehend all the difeafes which confift in motuabnornii; that is, in a preternatural ftate of the contraction and motion of the mufcular or moving fibres in any part, of the body. mcclh. It will hence appear, why, under this title, I have comprehended many more difeafes than Sauvages and Sagar have comprehended under the title of Spaf- mi, or than Linnaeus has done under the title of Moto- rii. But I expect it will be obvious, that, upon this oc- cafion, it would not be proper to confine our view to the affections of voluntary motion only ; and if thofe Nofol- ogifts have introduced into the clafs of Spafmi, Palpitatio i and Hyfteria, it will be, with equal propriety, that afth- ma, Cholica, and many other difeafes, are admitted. mccliii. It has been hitherto the method of our Nof- ologifts to divide the Spafmi into the two orders of Ton- ici and Clonici, Spaftici, and Agitatorii ; or, as many at prefent ufe the terms, into Spafms ftrictly fo called, and Convulfions. I find however, that many, and indeed < moft of the difeafes to be confidered under our title of Spafmodic Affections, in refpect of Tonic or Clonic con- tractions, are of a mixed kind : and therefore, 1 cannot follow the ufual general divifion ; but have attempted another, by arranging the feveral Spafmodic Difeafes ac- PRACTICE OF PHYSIC. 443 cording as they affect the feveral functions, Animal, Vi- tal, or Natural. SECT. I. Of the fpafmodic Afeclions of the Animal Functions. mccliv. Agreeable to the language of the ancients, the whole of the difeafes to be treated of in this fection might be termed Spafmi ; and many of the moderns continue to apply the term in the fame manner : but I think it convenient to diftinguifh the terms of Spafm and Convulfion, by applying the former, ftrictly 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 remark- able difference in the ftate of the contraction of moving fibres upon difterent occafions. This I have indeed point- ed out before in my treatife of Phyfiology, but muft alfo repeat it here. mcclv. In the exercife of the feveral functions of the animal economy, the cantractions of the moving fibres are excited by the will, or by certain other caufes fpecial- ly appointed by nature for exciting thofe contractions ; and thefe other caufes I name the natural caufes. In a ftate of health the moving fibres are contracted by the power of the will, and by the natural caufes only. At the fame time, the contractions produced are in force and velocity regulated by the will, or by the circumftan- ces of the natural caufes ; and the contractions, whether produced by the one or the other, are always foon fuc- ceeded by a ftate of relaxation, and are not repeated but when the power of the will or of the natural caufes is a- gain applied. mcclvi. Such are the conditions of the action of the moving fibres in a ftate of health; but in a morbid ftate, the contractions of the mufcles and moving fibres ordi- narily depending upon the will, are excited without the concurrence of the will, or contrary to what the will in- tends ; and in the other functions they are excited by E e 444 PRACTICE OF PHYSIC. the action of unufual and unnatural caufes. In both ca- fes, the contractions produced may be in two different ftates. The one is, when the contractions are to a more violent degree than is ufual in health, and are neither fucceeded by a fpontaneous relaxation, nor even readily yield to an extenfion either from the action of antago- nist mufcles, or from other extending powers applied. This ftate of contractions is what has been called a Tonic Spafm, and is what 1 fhall name limply and ftrictly a Spafm. The other morbid ftate of contractions is, when they are fucceeded by a relaxation, but are immediately again repeated-without the concurrence of the will or of the repetition of natural caufes, and are at the fame time commonly, with refpect to velocity and force, more vio- lent than in a healthy ftate. This ftate of morbid con- traction is what has been named a Clonic Spafm, and what I fhall name fimply and ftrictly a- Convulfion. In this fection I fhall follow nearly the ufual divifion of the fpafmodic difeafes, into thofe confuting in Spafm-, and thofe confifting in Convulfion ; but it may not per> haps be in my power to follow fuch divifion exactly. CHAP. I. OF TETANUS*. mcclvii. .Both Nofologifts and Practical Writers have diftinguifhed Tetanic complaints into the feverad fpecies of Tetanus, Gpifthotonos, and Emprofthotonos ; and I have in my Nofology put the Trifmus, or Locked Jaw, as a genus diftinct from the Tetanus. All this, however, I now judge to be improper ; and am of opin- ion, that all the feveral terms mentioned, denote and are applicable only to different degrees of one and the fame difeafe ; the hiftory and cure of which I fhall endeavor to deliver in this chapter. * A fpaftic rigidity of feveral mufcles. Syn, Nof. PRACTICE OF PHYSIC. *45 mcclvih. Tetanic complaints may, from certain cauf- es, occur in every climate that we are acquainted with ; but they occur moft frequently in the warmeft climates, and moft commonly in the warmeft feafons of fuch cli- mates. Thefe complaints affect all ages, fexes, tempera- ments, and complexions. The caufes from whence they commonly proceed, 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 produ- ced by punctures, lacerations, or other lefions of nerves in any part of the body. There are, probably, fome oth- er caufes of this difeafe ; but they are -neither diftinctly known, nor well afcertained. Though the caufes men- tioned do, upon occafion, affect all forts of perfons, they feem however to attack perfons of middle age more fre- quently than the older or younger, the male fex more frequently than the female, and the robuft and vigorous more frequently than the weaker. mcclix. If the difeafe proceed from cold, it common- ly comes on in a few days after the application of fuch cold ; but, if it arife from a puncture or other lsfion of a nerve, the difeafe does not commonly come on for ma- ny days after the lefion has happened, very often when their is neither pain nor uneafinefs remaining in the wounded or hurt part, and very frequently when the wound has been entirely healed up. mcclx. The difeafe fometimes comes 6n 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 ftiffhefs in the back part of the neck, which, gradually increafing, renders the motion of the head difficult and painful. As the rigidity of the neck comes on and increafes, there is commonly at the fame time a fenfe of uneafinefs felt about the root of the tongue ; which, by degrees, becomes a difficulty of fwallowing, and at length an entire interruption of it. WThile the regidity of the neck goes on increafing, there arifes a pain, often violent, at the lower end of the flernum, and from thence fhooting into the back. When this pain a- rifes, all the mufcles of the neck, and particularly thofe 2 446 PRACTICE OF PHYSIC. .of the back part of it, are immediately affected 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 difeafe were affected with fome fpaftic rigidity, are now generally affected with more violent fpafm, and fet the teeth fo clofely together, that they do not admit of the fmalleft opening. Thisvis what has been named the Locked Jaw, and is often the principal part of the difeafe. When the dif- eafe has advanced thus far, the pain at the bottom of the flernum returns very frequently, and with it the fpafms of the hind neck and lower jaw, are renewed with voilence and much pain. As the difeafe thus proceeds, a greater number of mufcles come to be affected with ipafms. After thofe of the neck, thofe along the whole of the fpine become affected, bending the trunk of the body ftrongly backwards; and this is what has been named the Opifthotonos. In the lower extremities, both the flexor and extenfor mufcles are commonly at the fame time affected, and keep the limbs rigidly extended. Though the extenfors of the head and back are ufually the molt ftrongly affected, 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 affec- ted with fpafm. During the whole of the difeafe, the abdominal mufcles are violently affected with fpafms, fo that the belly is ftrongly retracted, and feels hard as a piece of board. At length the. flexors of the head and trunk become fo ftrongly affected as to balance the extenfors, and-to keep the head and trunk ilraight, and rigidly extended, inca- pable of being moved in any way ; and it is to this ftate the term of Tetanus has been ftrictly applied. At the fame time, the arms, little affected before, are now rig- idly extended; the whole of the mufcles belonging to them being affected with fpafms, except thofe that move the fingers, which often to the laft retain fome mobility. The tongue alfo long retains its mobility ; but at length it alfo becomes affected with fpafms, which attacking cer- PRACTICE OF PHYSIC. 44f tain of its mufcles only, often thruft it violently out be- tween the teeth. At the height of the difeafe, every organ of voluntas ry motion feems to be affected ; and amongft the reft, the mufcles of the face. The forehead is drawn up into furrows ; the eyes, fometimes diftorted, are commonly rigid, ancj. 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 vi- olent grinning. Under thefe univerfal fpafms, a violent convulfion commonly comes on, and puts an end to life. mcclxi. Thefe fpafms are every where attended with moft violent pains. The utmoft violence of fpafm is, however, not conftant; but after fubfilling for a minute or two, the mufcles admit of fome remiffion of their contraction, although of no fuch relaxation as can allow the action of their antagonifts. This remiffion of con- traction gives alfo "fome remiffion of pain ; but neither are of long duration. From time to time, the violent contractions and pains are renewed fometimes every ten or fifteen minutes, and that often without any evident exciting caufe. But fuch exciting caufes frequently oc- cur ; for almoft every attempt to moti°n, 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. mcclxii. The attacks of this difeafe are feldom attend- ed with any fever. When the fpafms are general and violent, the pulfe is contracted, hurried, and irregular ; and the refpiration is affected in like manner : but, dur- ing the remiffion, both the pulfe and refpiration ufually return to their natural ftate. The heat of the body is commonly not increafed ; frequently the face is pale, with a cold fweat upon it ; and very often the extremities are cold, with a cold fweat over the whole body. 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. S 448 PRACTICE OF PHYSIC. mcclxiIi. Although fever be not a conftant attend- ant of this difeafe, efpecially when arifing from a lefjon of nerves; yet, in thofe cafes proceeding from cold, a, fever fometimes hasfupervened, and is faid to have been attended with inflammatory fymptoms. Blood has been often drawn in this difeafe, but it never exhibits any in- flammatory cruft ; and all accounts feem to agree, that the blood drawn feems to be of a looker texture than ordinary, and that it does not coagulate in the ufual man- ner. mcclxiv. In this difeafe the head is feldom affected with delirium, or even confufion of thought, till the laft ftage of it; when, by the repeated fliocks of a violent diftempcr, every function of the fyftem is greatly difor- ered. mcclxv. It is no lefs extraordinary, that, in this vio- lent difeafe, the natural functions are not either immedi- ately or confiderably affected. Vomitings fometimes ap- pear early in the difeafe, but commonly they are not con- tinued ; and it is ufual enough for the appetite of hun- ger to remain through the whole courfe of the difeafe ; and what food happens to be taken down, feems to be reg- ularly enough digefted. The excretions are fometimes affected, but hot always. The urine is fometimes fup- preffed, or is voided with difficulty and pain- The bel- ly is coftive : but, as we have hardly any accounts, ex- cepting of thofe cafes in which opiates have been largely employed, it is uncertain whether the coftivenefs has been the effect of the opiates or of the difeafe. In feveral in- ftances of this difeafe, a miliary eruption has appeared upon the fkin ; but whether this be a fymptom of the difeafe, or the effect of a certain treatment of it, is unde- termined. In the mean while, it has not been obferved to denote either fafety or danger, or to have any effect in changing the courfe of the diftemper. mcclxvi. This difeafe has generally proved fatal ; and this indeed may be juftly fuppofed to be the confe- quence of its nature ; but as we know that, till very lately? phyficians were not well acquainted with a prop- er method of cure; and that, fince a more proper PRACTICE OF PHYSIC. 449 jnethod has been known and practifed, many have re- covered from this difeafe ; it many be therefore con- cluded, that tine fatal tendency of it is not fo unavoida- ble as has been imagined. In judging of the tendency of this difeafe, in particu- lar cafes, we may remark, that, when arifing from lefions of the nerves, it is commonly more violent, and of more difficult cure, than when proceeding from cold ; that the difeafe which comes on fuddenly, and advan- ces quickly to a violent degree, is always more danger- ous than that which is flower in its progrefs. Accord- ingly, the difeafe often proves fatal before the fourth day; and, when a patient has pafled this period, he may be fufpofed to be in great 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 af- ter the fourth, the difeafe continues 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 fudden, or what may be called a critical folution, but always recedes by degrees only, and it is often very long before the whole of the fymptoms difappear. mcclxvii. From the hiftory of the difeafe now def- cribed, it will be evident, that there is no room for dif- tinguifhing the tetanus, opiflfiotonos, and trifmus or locked jaw, as different fpecies of this difeafe, fince they all a- rife from the fame caufes, and are almoft conftantly con- joined in the fame perfon. I have no doubt that the em- profthotonos belongs alfo to the fame genus ; and as the ancirnts have frequently mentioned it, we can have no doubt of its having occurred : but, at the fame time, it is certainly in thefe days a rare occurrence ; and, as I have never feen it, nor find any hiftories in which this particular ftate of the fpafms is faid to have prevailed, I cannot mention the other circumftances which particular- ly attend it, and may diftinguifh it from the other vari- eties of tetanic complaints. MCClxviii. This difeafe has put on ftill a different form from any of thofe above mentioned. The fpafms have 4 45« PRACTICE OF PHYSIC. been fometimes confined to one fide of the body only, and which bend it ftrongly to that fide. This is what has been named by Sauvages the Tetanus Lateralis, and by fome late writers the Pleurofthctonos. This form of the difeafe has certainly appeared very feldom ; and, in any of the accounts given of it, I cannot find any cir- cumftances 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. mcclxix. The pathology of this difeafe I cannot in any meafure attempt, as the ftructure of moving; fibres, the ftate of them under different degrees of contraction, and particularly the ftate of the fenforiuin, as varioufly determining the motion of the nervous power, arc all matters very imperfectly, or not at all kr.owu to me. In fuch a situation, therefore, the endeavoring to give any rules of practice, upon a1 fcientific plan, ip^ears to me vain and fruitlefs ; and towards directing the cure of this difeafe, we muft be fatisfied wirh having learned fomething ufeful from analogy, confirmed by experi- ence. mcclxx. When the difeafe is known to arife from the lefion of a nerve in any part of the body, the firft, and, as I judge, the moft important 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 through the nerves in their courfe, or perhaps by deftroying, to a certain lenth, their affected part or extremity. mcclxxi. When the cure of the difeafe is to be at- tempted by medicine, experience has taught us that opi* um has often proved an effectual remedy ; but that, to render it fuch, it muft be given in much larger quanti- ties 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 practice has been, to give the opium either in a folid or a liquid form, not in any very lare dofe at once, but in moderate dofes, frequently repeated, at the interval of one, two, three, or more PRACTICE OF PHYSIC. 451 hours, as the violence of the fymptoms feems to require. Even when large quantities have been given in this way, it appears that the opium does not operate here in the fame manner as in moft other cafes ; for, though it pro- cure fome remiflion of the fpafms and pains, it hardly induces any fleep, or occafions that ftupor, intoxication, or delirium, which it often does in other circumftances, when much fmaller quantities only have been given. It is therefore very properly obferved, that, in tetanic af- fections, as the opium fhows none of thofe effects 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, probably fhould be given, as largely and as fall as the fymptoms of the difeafe may feem to demand. It is particularly to be obferved, that though the firfl: exhibitions of the opium may have produced fome re- miflion of the fymptoms, yet the effects of opium do not long continue in the fyftem ; and this difeafe being for fome time ready to recur, it is commonly very neceffary by the time that the effects of the opium given may be fuppofed to be wearing off, and efpccia-Iy upon the leaft appearance of a return of the fpafms, to repeat the exhi- bition of the opium in the fame quantities as before. This practice is to be continued while the difeafe contin- ues to fhow any difpofition to return ; and it is only af- ter the difeafe has already fubfifted fpr fome time, and when confiderable and lomr, continued remiflions have ta- ken place, that the dofes orthe opium may be diminifh- ed, and the intervals of exhibiting them b t more confid- erable. mcclxxii. 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 too fparingly employed, either from the timid- ity of practitioners, or from its exhibition being prevent- ed by that interruption of deglutition which fo often at- tends this difeafe. This latter circumftance directs, that the medicine fhould be immediately and largely employ- ed upon the firft approach of the difeafe, before the de- glutition becomes difficult ; or that if this opportunity be 45» PRACTICE OF PHYSIC. loft, the medicine, in fufficient quantity, and with due frequency, fhould be thrown into the body by glyfter ; which, however, does not feem to have been hitherto of- ten practifed. mcclxxhi. It is highly probable, that in this difeafe, the inteftines are affected with the fpafm that prevails fo much in other parts of the fyftem ; and, therefore, that coftivenefs occurs here as a fymptom of the difeafe. It is probably alfo increafed by the opium, which is here fo ' largely employed ; and, from whichever of thefe caufes it arifes, it certainly muft be held to aggravate the difeafe and that a relaxation of the inteftinal canal will contribute to a relaxation of the fpafms elfewhere. This confidera- < tion directs the frequent exhibition of laxatives while the power of deglutition remains, or the frequent exhi- bition of glyfters when it does not ; ^nd the good effect^ of both have been frequently obferved. mcclxxiv. It has been with fome probability fuppofed^ % that the operation of opium in this difeafe, may be muclj \ affifted by joining with it fome other of the moft power- ful antifpafmodics. The moft promifing are mufk and ' camphire; and fome practitioners have been of opinion, that the former has proved very ufeful in tetanic com- plaints. But, whether it be from its not having been em- ployed of agenuine kind,or in fufficient quantity,the great advantage and propriety of its ufe are not yet clearly afcer- tained. It appears to me probable, that analogous to what happens with refpect to opium, both mufk and camphire might be employed in this difeafe, in much larger quanti- ties than they commonly have been in other cafes. mcclxxv. Warm bathing has been commonly em- ployed as a remedy in this difeafe, and often with advan- tage ; but, fo far as I know, it has not alone proved a cure ; and, in fome cafes, whether it be from the mo- tion of the body here required, axciting the fpafms, or from the fear of the bath, which fome perfons were feiz- edwith I cannot determine ; but it is allowed, that the warm bath hath in fome cafes done harm, and even occafioned death. Partial fomentations have beenmuch commended, and, I believe, upon good grounds : And I PRACTICE OF PHYSIC. 453 have no doubt but that fomentations of the feet and legs, as we now ufually apply them in fevers, might, with- out much ftirring of the patient, be very afliduoufly employed with advantage. mcclxxvi. Unctuous applications were very frequent- ly employed in this difeafe by the ancients : and fome modern practitioners have confidered them as very ufe- ful. Their effects, however, have not appeared to be confiderable ; and, as a weak auxiliary only, attended with fome inconvenience, they have been very much neglected by the Britifh practitioners. mcclxxvii. Bleeding has been formerly employed in this difeafe ; but of late it has been found prejudicial, ex- cepting in a few cafes, where, in plethoric habits, a fever has fopervened. In general, the ftate of mens' bodies in warm climates is unfavorable to blood letting : and, if we may form indications from the ftate of the blood drawn out of the veins, the ftate of this in tetanic difeaf- es would forbid bleeding in therm mcclxxviii. Bliftering, alfo, has been formerly em- ployed in this difeafe ; but feveral practitioners affert, that blifters are conftantly hurtful, and they are now generally omitted. mcclxxix. Thefe are the practices that hitherto have been generally employed ; but of late we are informed by feveral Weft India practitoners, that in many inftances they have employed mercury with great advantage. We are told, that it muft be employed early in the dif- eafe ; that it is moft conveniently adminiftered by unct- ion, and fhould be applied in that way in large quantities, fo that the body may be foon filled with it, and a faliva- tion raifed , which is to be continued till the fymptoms yield. Whether this method alone be generally fuffi- cient for the cure of the difeafe, or if it may be affifted by the ufe of opium, and require thisin a certain meafure to be joined with it, I have not yet certainly learned. mcclxxx. I have been further informed, that the Tetanus, in all its different degrees, has been cured by giving internally the Fiffelaeum Barbadenfe, or, as it is vulgarly called, the Barbadoes Tar. I think it proper to 454 PRACTICE OF PHYSIC. take notice of this here, although I am not exactly in- formed what quantities of this medicine are to be given, or in what circumftances of the difeafe it is moft pro- perly to be employed. mcclxxx. In the former edition of this work, among the remedies of tetanus I did not mention the ufe of cold bathing; becaufe, though I had heard of this, I was not informed of fuch frequent employment of it as might confirm my opinion of its general efficacy ; nor was t fufficiently informed of the ordinary and proper adminif- tration of it. But now, from the information of many judicious practitioners who have frequently employed it, I can fay that it is a remedy which in numerous trials ha$». been found to be of great fervice in this difeafe ; and that, while the ufe of the ambiguous remedy of warm bathing is entirely laid afide, the ufe of cold bathing is o- ver the whole of the Weft Indies commonly employed. The adminiftration of it is fometimes by bathing the perfon in the fea, or more frequently by throwing colci, water from a bafon or bucket upon the patient's body* and over the whole of it: when this is done, the body is carefully wiped dry, wrapped in blankets, and laid a bed^. and at the fame time a large dofe of an opiate is given. By thefe means a confiderable remiffion of the fymptoms, is obtained ; but this remiffion, at firft, does not conw monly remain long, but returning again in a few hours^ the repetition both of the bathing and the opiate become^ neceffary. By thefe repetitions, however, longer inter- vals of eafe are obtained, and at length the difeafe is en- tirely cured; and this even happens fometimes very quickly. I have only to add, that it does not appear to me, from any accounts I have yet had, that the cold bath- ing has been fo frequently employed, or has been found fo commonly fuccefsful in the cafes of tetanus in confe- quence of wounds, as in thofe from the application of cold. mcclxxxi. Before concluding this chapter, it is prop- er for me to take fome notice of that peculiar cafe of the tetanus, or trifmus, which attacks certain infants foon after their birth, and lias been properly enough named PRACTICE OF PHYSIC 4SS the Trifmus Nafcentium. From the fubjects it affects, it feems to be a peculiar difeafe : for thefe are infants not above two weeks, and commonly before they are nine days old ; infomuch that, in countries where the difeafe is frequent, if children pafs the period now mentioned, they are confidered 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 ftrictly fo called,' and which oc- cur in the other varieties of tetanic complaints above de- fcribed. Like the other varieties of tetanus, this is moft frequent in warm climates ; but is not, like thofe arifing from the application of cold, entirely confined to fuch warm climates, as inftances of it have occurred in moft of the northern countries of Europe. In thefe latter it feoms to be more frequent in certain diftricts than in others ; but in what manner limited, I cannot determine. It feems to be more frequent in Switzerland than in France. I am informed of its frequently occurring in the Highlands of Scotland ; But I have never met with any inftance of it in the low country. The particular caufes of it are not well known ; and various conjectures have been offered ; but none of them are fatisfying. It is a difeafe that has been almoft conftantly fatal; and this, alfo, commonly in the courfe of a few days. The women arc fo much perfuaded of its inevitable fatality, that they feldom or never call for the affiftance of out- art. This has occafioned our being little acquainted with the hiftory of the difeafe, or with the effects 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 few experiments that are yet re- corded, feem to approve ©f fuch a practice, 4i6 PRACTICE OF PHYSIC. CHAP. II. OF EPILEPSY*. mccxxxii. In what fenfe I ufe the term ConvuU flion, I have explained above in mcclvi. The convulfions that affect the human body are in fev- eral refpects various ; but I am to confider here only thd.. chief and moft frequent form in which they appear, and which is in the difeafe named Epilepfy. 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 infenfibility, and feeming fleep. mcclxxxiii. The general form or principal circuni- fiances of this difeafe, are much the fame in all the differ- ent perfons whom it effects. It ccTmes by fits, which of- ten attack perfons feemingly in perfect health ; and, alter lafling for fome time, pafs off, and leave the perfons a- gain in their ufual ftate. Thefe fits are fometimes pre- '■' ceded by certain fymptoms, which, to perfons who have ; before experienced fuch a fit, may give notice of its ap- proach, as we fhall hereafter explain ; but even thefe ■ preludes do not commonly occur long before the formal.j attack, which in moft cafes comes on fuddenly withotit| any fuch warning. The perfon attacked lofes fuddenly all fenfe and pow- er of motion ; fo that, if Handing, he falls immediately, or perhaps, with convulfions, is thrown to the ground. In that fituation he is agitated with violent convulfions, varioufly moving his limbs, and the trunk of his body. Commonly the limbs on one fide of the body, are more violently or more confiderably agitated than thofe upon j * Convulfion of the mufcles, accompanied with fopor. 1 Spec. i. Epilepfy (cerebralis) attacking fuddenly, without any manife* 1 caufe, and without any preceding unpleafant fenfation, unlefs a flight giddi* nefs or tranfitory imperfection ofvifion. Spec. ». Epilepfy (fympathica) without any obvious caufe, but the fenfe of an aura gradually riling from fome part of the body to the head. Soec.3. Epilepfv (occafionafis) arifing from a manifeft irritation, and ceafi.Qg.oa its removal. Syn. Nof. PRACTICE OF PHYSIC. 4J« the other. In all cafes the mufcles of the face and eyes are much affected, exhibiting various and violent diftor- tions of the countenance. The tongue is often affected,, and thruft out of the mouth ; while the mufcles of the lower jaw are alfo affected ; and, fhutting the mouth with violence while the tongue is thruft out between the teeth, that is often grievoufly 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 remiflions, but are fuddenly again renewed with great violence. Generally, after no long time, the con- vulfions ceafe altogether ; and the perfon for fome time remains without motion, but in a ftate of abfolute infen- fibility, and under the appearance of a profound fleep. After fome continuance of this feeming fleep, the perfon fometimes fuddenly, but for the moft part by degrees on- ly, recovers his fenfes and power of motion ; but with- out any memory of what had paffed from his being firft feized with the fit. During the convulfions, the pulfe and refpiration are hurried and irregular ; but, when the convulfions ceafe, they return to their ufual regularity and healthy ftate. This is the general form of the 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 dura- tion; mcclxxxiv. With refpect to the proximate caufe of this difeafe, I might fay, that it is an affection of the en- ergy of the brain, which, ordinarily under the direction of the will, is here, without any concurrence of it, im- pelled by preternatural caufes. But I could go no fur- ther : For, as to what is the mechanical condition of the brain in the ordinary exertions of the will, I have no dif- tinct knowledge ; and therefore muft be alfo ignorant of the preternatural ftate of the fame energy of the brain un- der the irregular motions here produced. To form therefore, the indications of a cure, from a knowledge of the proximate caufe of this difeafe, I muft not attempt; 45» PRACTICE OF PHYSIC but from a diligent attention to the remote caufes which firfl induce and occafionallv excite the difeafe, I think we may often obtain fome ufeful directions for its cure. It fhall therefore be my bufinefs now, to-point out and enumerate thefe remote caufes as well as 1 cam mcclxxxv. The remote caufes of epilepfy may be con- fidered as occafional or predifponent. There are indeed, certain remote caufes which act independently of any predifpofition ; but, as we cannot always diftinguilh thefe from the others, I fhall confider the whole under the ufual titles of Occafional or Predifponent, mcclxxxVi. The occafional caufes may, I think, be properly referred to two general heads ; the firft being. of thofe which feem to act by directly ftimulating and ex- citing the energy of the brain ; and the fecond, of thofe which feem to act by weakening the fame. With refpect to both, forthe brevity of expreffing a fact, without mean- ing to explain the manner in which it is brought about, I fhall ufe the terms of Excitement and Collapfe. And though it be true,i:hat with refpect to fome of the caufes I am to mention, it may be a little uncertain whether they act in the one way or the other, that does not render it improper for us to mark, with refpect to others, the mode of their operating, wherever we can do it clear- ly, as the doing fo may often be of ufe in directing our practice. mcclxxxvii. Firft, then, of the occafional caufes acting by excitement: They are either fuch as act immediately and directly upon the brain itfelf; or thofe which are firft applied to the other parts of the body, and are from thence communicated to the brain. mccxxxviii. The caufes of excitement immediately and directly applied to the brain, may be referred to the four heads of, 1. Mechanical Stimulants; 2. Chemical Stimulants ; 3. Mental Stimulants; and, 4. The pecu- liar Stimulus of over diftenfion. mccxxxix. The mechanical ftimulants may be,wound- ing inftruments penetrating the cranium, and entering the fubftance of the brain ; or fplinters of a fractured cranium, operating in the fame manner ; or fliarp point* PRACTICE OF PHYSIC ^.'9 ^d oflificalioHS, either arifing from the internal furface of the cranium, or formed in the membrane of.the brain. ' * mccxc. The chemical ftimulants (mcclxxxviii.) may be fluids from various caufes lodged in certain parts of the brain, and become acrid by ftagnation or otherwife. mccxci. The mental irritations acting by excitement. arc, all violent emotions of the active kind, fuch as joy and anger. The firft of thefe is manifeftly an exciting power, acting ftrongly, and immediately, on the energy of the brain. The fecond is manifeftly, alfo, a power act- ing in the fame manner. But it muft be remarked, that it is not in this manner alone anger produces its effects: for it acts, alfo, ftrongly on the fanguiferous fyftem, and may be a means of giving the ftimulus of over diften- fion ; as, under a fit of anger, the blood is impelled into the veffels of the head with violence,, and in a larger quantity. . mccxcii. 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 fpectator. It may, indeed, be a queftion, Whether this effect be imputable to the horror produced by a fight of the feemingly painful agitations of the limbs, and of the diftortions" in the countenance of the epileptic perfon ; or if it may be afcribed to the force of imitation mere- ly ? It is poffible, that horror may fometimes produce the effect : but certainly much may he imputed to that propenfity to imitation, at all times fo powerful and prev- alent in human nature; and fo often operating in eth- er cafes of convulfive diforders, which do not prefent a- nyfpectacle of horror. mccxciii. 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 firft, may be entirely ieigned, 1 have no doubt but that the repetition renders it at length real. The hiftory of Quietifm and of Exorcifms leads mz to this opinion ; and which receives a c^n-firmaiiaa 4^o PRACTICE OF PHYSIC. from what we know of^ the power of imagination; fo renewing epileptic and hyfteric fits. mccxciv. Tcome now to the. fouftn head of the irrita- tions applied immediately to the brain and which I appre- hend to be that of the Over diftenfion of the blood vef- fels in that organ. That fuch a caufe operates in pro- ducing epilepfy, is probable from this, that the diffection 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 probable from the epilepfy being fo often joined with headach, mania, palfy, and apoplexy : all of them difeafes depending upon a congeftion in the veffels of the brain. The general opinion receives alfo confirmation from this circumftance, that in the brain of perfons dead of epilepfy, there have been often found tumors and effufions, which, though feemingly not fuf- ficient to produce thofe difeafes which depend on the compreffion of a confiderable portion of the brain, may however, have been fufficient to comprefs fo many vef- fels as to render the others, upon any occafion, of a more than ufual turgefcence, or impulfe of the blood into the veflels of the brain more liable to an over diftention. . mccxcv. Thefe confederations alone might afford foun- dation for a probable conjecture witK refpect. to the ef- fects of over diftention. Bat the opinion does not reft upon conjecture alone. That it is alfo founded in factr. appears from hence, that a plethoric ftate is favorable to epilepfy; and that every occafional turgefcence, or unu- fual impulfe of the blood into the veffels of the brain, fuch "as a fit of anger, the heat of the fun, or of a warm chamber, violent exercife, a forfeit, or a fit of intoxica- tion, are frequently the immediately exciting caufes of epileptic fits. . , mccxcvi. I venture to remark further, that a piece of theory may be admitted as a confirmation of this doc- trine. As I have formerly maintained, that a certain fulnefs and tenfion of the veffels of the brain, is neceffa- ry tq^he fupport of its ordinary and conftant energyj ir PRACTICE OF PHYSIC. 461 the diftribution of the nervous power ; fait muft be fufficiently probable, that an over diftenfion of thefe blood veflels may be a caufe of violent, excitement. mccxcvii. We have now enumerated the feveral re- mote or occafional caufes of epilepfy, acting by excite- ment, and acting immediately upon the brain itfelf. Of the caufes acting by excitement, but acting upon oth- er parts of the body, and from thence ^communicated to the brain, they are all of them imprefitons producing an exquifite or high degree either of pleafure or pain. Impreffions which produce neither the one nor the other, have hardly any fuch effects ; unlefs when fuch impreffions are in a violent degree, and then their opera- tion may be confidered as a mode of pain. It is, howev- er, to be remarked, that all ftrong impreffions which are fudden and furprifing, or, in other words, unforeseen and unexpected, have frequently the effect of bringing on epileptic fits..... t' mccxcviii. There are certain impreffions made upon different 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 act by excitement, and therefore fall to be mentioned here. The chief inftances are, The teething of infants ; worms ; acidity or other acrimonv in the alimentary canal ; calculi in the kidneys ; acrid matter in abfeeffes or ulcers ; or acrimony diffufed in the, mafs of blood, as in the cafe of fome contagions. mccxcix. Phyficians have found no difficulty in com- prehending how direct ftimulants, of a certain force, may excite the action of the brain, and occafion epilepfy ; but they have hitherto taken little notice of certain caufes which manifeftly weaken the energy of the brain, and act as I fpeak, by collapfe. Thefe however, have the effect of exciting the action of the brain in fuch. a manner as to Occafion epilepfy. I might j upon this fubject, fpeak of the vis medicatrix naturae ; and there is a foundation for the term : but, as I do not admit the Stahlian doctrine of an adminiftering foul, I make ufe of the term only as ex- jprefling a fact, and would not employ it with, the view 2 45* PRACTICE OF PIIJ'SIC. of conveying any explanation of the manner in whicn the powers of collapse mechanically produce their effects. In the mean time, however, I maintain, that there are certain powers of collapfe, which in effect prove flimu- 1 mis, and produce epilepfy. mccc. That there are fuch powers, which may be term- ed Indirect Stimulants, 1 conclude from hence, that fev- eral of the caufes of epilepfy are fuch as frequently pro- duce fyncope, which we fuppofe always to depend upon caufes weakening the energy of the brain (mclxxvi.) It may give fome difficulty to explain, wny the fame cauf- es fometimes occafion fyncope, and fometimes accafion the reaction that appears in epilepfy ; and I fhall not at- tempt to explain it :- but this, I think, does not prevent my fuppofing that the operation of thefe caufes is by col- lapfe. That there are fuch caufes producing epileply, wild, I think, appear very clearly from the particular ex. amples of them I am now to mention. i.iccci. The firft to be mentioned, which I fuppofe to bG of this kind, is hemorrhagy, whether fpontaneous or artificial. That the fame hemorrhagy which produces- fyncope, often at the fame time produces epilepfy, is well known ; arid from many experiments and obfervations it appears, that hemorrhagies occurring to fuch a degree as to prove mortal, feldom dofo without firft producing, epileply. /cjcii. Another caufe.acting, as I fuppofe, by collapfe,' and therefore fometimes producing fyncope and fome- x imes epilepfy, is terror ; that is, the fear of fome great evil fuddenly prefented. As this produces at the fame time a fudden and confiderable emotion, (mclxxx.) fo--' it more frequently produces epilepfy than fyncope. mccciii. A third caufe acting by collapfe, andproducing epilepfy, is horror ; or a ftrong averfion fuddenly raifed by a very difagreeablc 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 ep- ileply ; and it may perhaps be explained upon this gene ral principle, That as defire excites action and gives ao PRACTICE OF PHYSIC 4*3 uvity, fo averfion reftrains from action, that is, weakens the energy of the brain ; and, therefore, that the higher degrees of averfion may have the affect of producing fyn- cope or epilepfy. mccciv. A fourth fet of the caufes of epilepfy, which I fuppofe alfo to act by collapfe, are certain odors, which occafion either fyncope or epilepfy ; and, with refpect to the former, I have given my reafons (mclxxxii.) for fuppofing odors in that cafe to act rather as difagreeal \ ■ than as fedative. Thefe reafons will, I think, alfo ap- ply here ; and perhaps the whole affair of odors might be confidered as inftances of the effect of horror, and there- fore belonging to the laft head. mcccv. A fift,h head of the caufes producing epilepfy by collapfe, is the operation of many fubftances confider- ed, and for the moft part properly confidered, as poi- fons. Many of thefe, before they prove mortal, occa- fion epilepfy. This effect, indeed, may in fome cafes be referred to the inflammatory operation which they fometimes difcover in the ftomach and other parts of the alimentary canal ; but as the greater part of the vegefa ble poifons fhow chiefly a narcotic, or ftrongly fedative power, it is probably by this power that they produce epilepfy, and therefore belong to .this head of the caufes acting by collapfe. mcccvi. Under the head of the remote caufes produc- ing epilepfy, we muft now mention that peculiar one whofe operation is accompanied with what is called the Aura Epileptica. This is a fenfation of fomething mov- ing 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 depriv- ed of fenfe, and falls into an epileptic fit. This motion is defcribed by the perfon's feeling it fometimes as a cold vapor, fometimes as a fluid gliding, and sometimes as the fenfe of a fmall infect creeping along their body ; and very often they can give.no diftinct idea of their fen fa- tion, otherwife than as in general of fomething moving along. This fenfation might be fuppofed to arife from fome affection of the extremity or other part of a n-1 v- 464 PRACTICE OF PHYSIC. acted upon by fome irritating matter ; and that the fen- fation, therefore, followed the courfe of fuch a nerve : but I have never found it following diftinctly the courfe ut any nerve ; and it generally feems to pafs along tliC teguments. It has been found in fome inftances to arife from fomething preffing upon or irritating a particular nerve j and that fometimes in confequence of contufion or wound : but inftances of thefe are more rare ; ano! the more common confequence of contufions and wounds is a tetanus. This latter effect wounds produce, without giving any fenfation of an aura, or other kind of motion proceeding from the wounded part to the head ; while, on the other hand, the aura producing epilepfy often a- rifes from a part which had never before beeh affected with wound or contufion, and in which part the nature of the irritation can feldom be difcovered. It is natural to imagine that" this aura epileptica is an evidence of fome irritation or direct ftimulus acting in the part, and from thence communicated to the brain, and fhould therefore have been mentioned among the caufes acting by excitement; but the remarkable differ- ence that occurs in feemingly like caufes producing te- tanus, gives fome doubt on this fubject. mcccvii. Having now enumerated the occafional caufes of epilepfy, I proceed to confider the predifponent. As fo many of the above mentioned caufes act upon certain perfons, and not at all upon others, there muft be fuppof- ed in thofe perfons a predifpofition to this difeafe: But in what this predifpofition confifts, is not to be ea-. fit y afcertained. f mcccviii. As many of the occafional caufes arc weak impreffions, and are applied to moft perfons v/ith little or no effect, I conclude, that the perfons affected by thofe caufes are more eafily moved than others ; and there- fore that, in this cafe, a certain mobility gives the predif- pofition. It will, perhaps, make this matter clearer, to fhow, in the firft place, that, there is a greater mo- bility of conftitution in fome perfons than in others. tvicccix. This mobility appears moft clearly in the ftate of the mind. If a perfon is readily elated by hope, and PRACTICE OF PHYSIC. 465 as readily depreffed by fear, and paffes eafily and quickly from the one ftate to the other ; if he is eafily pleafed, and prone to gaiety, and as eafily provoked to anger, and rendered peevifh ; if liable, from flight impreffions, to ftrong emotions, but tenacious of none ; this is the boyifh temperament, qui colligit ac ponit iram te?nere, et mutatur in horas ; this, is the varium et mutabile fcemina ; and, both in the boy and woman, every one perceives and acknowledges a mobility of mind. But this is necef- farily connected with an analogous ftate -'of the brain ; that is, with a mobility, in refpect of every impreflion, and therefore liable to a ready .alter nation of excitement and collapfe, and of both to a confiderable'degree. mccCx. There is, therefore, in certain perfons, a mobil- ity of conftitution, generally derived from the ftate of original ftamina, and more exquifite at a certain period of life than at others ; but fometimes arifing from, and particularly modified by occurrences in the couTfe of life. mcccxi. This mobility confifts in a greater degree of either fenfibility or irritability. Thefe conditions, in- deed, phyficians confider as fo neceffarily connected, that the conftitution, with refpect to them, may be confider- ed as one and the fame : but I am of opinion that they are different; and that mdbility may fometimes depend •Tapcvn an increafe of the one, and fometimes on that of the other. If an action excited is, by repetition, render- ed more eafily excited, and more vigorously performed, I confider this as an increafe of irritability only. I go no farther on this fubject here, as it was only neceffary to take notice of the cafe juft now mentioned, for the purpofe of explaining why epilepfy, and convulfions of all kinds, by being repeated, are more eafily excited, readily become habitual, and are therefore of more diffi- cult cure. mcccxii. However we may apply the diftinction of fen- fibility and irritability, it appears that the mobility, which is the predifponent caufe of epilepfy, depends more particularly upon debility, or upon a plethoric ftate of the body. 4 4*>6 PRACTICE OF PHYSIC. * mcccxiii. What fliare debility, perhaps by inducing fenfibility, has in this matter, appears clearly from hence, that children, women, and other perfons of manifeft de- bility, are the moft frequent fubjccts of this difeafe. mcccxiv. The effects of a plethoric ftate in difpofing to this difeafe appears from hence, that plethoric perfons arc frequently the fubjects of it ; that it is commonly excited, as I have laid above, by the caufes of any unuf- ival turgefcence of the blood ; and that it has been fre- quently cured by diminifhing the plethoric ftate of the body. That a plethoric ftate of the body fhould difpofe to t his difeafe, we may underftand from feveral confidera- liorrs. 1ft, Becaufe a plethoric ftate implies, for the moft part, a laxity of the folids, and therefore fome debility in the moving fibres. Idly, Becaufe, in a plethoric ftate, the tone of the moving fibres depends more upon their tenfion than upon their inherent power : and as their tenfion depends upon the quantity and impetus of the fluids in the blood veffels, which are very changeable, and by many caufes frequently changed, fo th* fe frequent changes muft give a mobility to the fyftem. Sdly, Be- caufe a plethoric ftate is fovorabie to a congeftion of blood in the veffels of the brain, it muft render thefe more readily affected by every general turgefcence of the blood in the fyftem, and therefore more efpecially dif- pofe to this difeafe. mcccxv. There is another circumftance of the body difpofing to epilepfy, which I cannot fo well account for ; and that is, the ftate of fleep : but whether I can account for it or not, it appears, in fact, that this ftate reives the difpofition i fpeak of; for, in many perfons 'iable this difeafe, the fits happen only in the time of ileep, or immediately upon the perfons earning out of it. In a cafe reiatectby De Hacn, it appeared clearly, that the difpofition to epilepfy depended entirely upon the ftate of the body in fleep. mcccxvj. Having thus confidered the whole of the re- mote caufes of epilepfy, I proceed to treat of its cure, as 1 have laid it is from the confideration of thofe r^.r.ote PRACTICE OF PHYSIC. 46; p.vacs only, that'we can obtain any directions for our prac- tice in this difeafe. I begin with obferving, that as the difeafe may be con- fidered as fympathic or idiopathic, I muft treat of thefe feparately, and judge it proper to begin with the former. mcccxvii. When this difeafe is truly fympathic, and depending upon a primary affection in fome other part of the body, fuch as acidity or worms in the alimentary canal, teething, or other fimilar caufes, it is obvious, that fuch primary affections muft be removed for the cure cf the epilepfy ; but it is not Our bufinefs here to fay how thefe primary difeafes are to be treated. mcccxviii. There is, however, a-peculiar cafe of fym- pathic epilepfy ; that is the cafe accompanied with the aura cpileptica, as defcribed in mcccvi, in which, though we can perceive by the aura epiliptica ajrifing from a par- ticular part, that there is fome affection in that part; yet, as in many fuch cafes we cannot perceive of what nature the affection is, I can only offcr the following general di- rections : 1/?, When the part can with fafety be entirely deftroy- ed, we fliould endeavor to do fo by cutting it out, or by deftroying it by the application of an actual or potential cautery. ' 2dly, When the part cannot be properly deftroyed, that we fliould endeavor to correct the morbid affection in it by bliftering, or by eiiablifhingan iffue upon the part. 3dly, 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 fubject of tetanus. 4/^/y, When it cannot be perceived that the aura arifes from any precife place or point, fo as to direct to the a- bove mentioned operations ; but, at the fame time, we can perceive its progrefs along the limb ;. it frequently happens that the epilepfy can be prevented by a ligature applied upon the limb, above the part from which the aura arifes; and this is always proper to be done, both becaufe the Preventing a fit breaks the habit cf the dif- 4&8 PRACTICE OF PHYSIC. cafe, and becaufe the frequent compreffion renders the nerves lefs fit to propagate the aura. mcccxix. The cure of idiopathic epilepfy, as I have faid above, is to be directed by our knowledige of the re- mote caufes. There are therefore two general indica- a tions to be formed : The firft is, to avoid the occafional caufes ; and the fecond is, to remove or correct the pre- difponent. 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 often confidered as properly curative. mcccxx. From the enumeration given above, it will be manifeft, that for the moft part the occafional caufes, fo far as they are in our power, need only to be known, in order to be avoided ; and the means of doing this will ', be fufficiently obvious. I fhall here, therefore, offer only ' a few remarks. mcccxxi. One of the moft frequent of the occafional caufes is that of over diftenfion (mcccxiv.), which, fo far as it depends upon a plethoric ftate of the fyftem, I fhall fay hereafter how it is to be avoided. But as, not only < in the plethoric, but in every moveable conftitution, oc- cafional turgefcence is a frequent means of exciting epi- \ lepfy, the avoiding therefore of fuch turgefcence, is what ought to be moft conftantly the object of attention to per- J fons liable to epilepfy. "' * mcccxxii. Another of the moft frequent exciting cauf- es of this difeafe are, all ftrong impreffions fuddenly made upon the fenfes ; for as fuch impreffions, in moveable conftitutions, break in upon the ufual force, velocity, and order of the motions of the nervous lyftem, they thereby readily produce epilepfy. Such impreffions therefore, and efpecially thofe which are fuited to excite any emotion or paffion of the mind, are to be moft care- fully guarded againft by perfons liable to epilepfy. mcccxxiii. In many cafes of epilepfy, where the predif- ponent caufe cannot be corrected or removed, the recur- rence of the difeafe can only be prevented by the ftricteft attention to avoid the occafional ; and as the difeafe is PRACTICE OF PHYSIC. 4<9 often confirmed by repetition and habit, fo the avoiding the frequent recurrence of it is of the utmoft importance towards its cure. Thefe are the few remarks I have to offer with refpect 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 correcting the predifponent caufe. mcccxxiv. I have faid above, that the predifponent caufe of epilepfy is a certain mobility of the fenforium ; and that this depends upon a plethoric ftate of the fyf- tem, or upon a certain ftate of debility in it. mcccxxv. How the plethoric ftate of the fyftem is to be corrected, I have treated of fully above in dcclxxxiii. etfeq. and I need not repeat it here. It will be enough to fay,'that it is chiefly to be done by a proper manage- ment of exercife and diet; and, with refpect to the lat- ter, it is particularly to be obferved here, that an abfte- mious courfe has been .frequently found to be the moft certain means of curing epilepfy. ■'-' mcccxxvi. Confidering the nature of the matter pour- ed out by iffues, thefe may be fuppofed to be a conftant • means of obviating the plethoric ftate of the fyftem ; and it is perhaps therefore that they have been fo often found ufeful in epilepfy. Poffibly alfo, as an open iffue mav be a means of determining occafional turgefcences to fuch places, and therefore of diverting them in fome meafure from their action upon the brain ; fo alfo, in this manner, iffttes may be ufeful in epilepfy. mcccxxvu. It might be fuppofed that bloodletting would be the moft effectual means of correcting the ple- thoric ftate of the fyftem ; and fuch it certainly proves when the plethoric ftate has become confiderable, and immediately threatens morbid effects. It is therefore, in fuch circumftances, proper and neceffary : but as we have faid above, that blood letting is not the proper means of -obviating a recurrence of the plethoric ftate, and, on the contrary, is often the means of fevoring it ; fo it is a remedy not advifable in every circumftance of epilepfy. There is, however, a cafe of epilepfy in whicli there ii a „;u PRACTICE OF PHYSIC. periodical or occafional recurrence of the iV.focio and tui- ' gefcence of the fanguiferous fyftem, giving occafion to a recurrence of the difeafe. In fuch cafes, when the me uis of preventing plethora have been neglected, or may have proved ineffectual, it is abfolutely nccdhry for the prac- titioner to watch the returns of thefe turgefcences, and to obviate their effects by the only certain mean:; of do- ing it, that ?s, by a large blood letting. mcccxxviii. The fecond caufe of mobility w hich we have affigned, is a ftate of debility. If this is owing, as it frequently 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 mend- ed ; and in either cafe, much may be done to obviate and prevent its effects. mcccxxix. The means of correfe the orange tree leaves to have been ufeful: but they are not always fo.. mcccxxxiv. The vegetable tonic, which from its ufe in analogous cafes is the moft promising, is the Peruvian bark ; this, upon occafion, has been ufeful, but has alfo Often failed. It is efpefcially adapted to thofe epilepfies which recur at certain periods, and which are at the- fame time without the recurrence of any plethoric ftate, or turgefcence of the blood; and in fuch periodical cafes, if the bark is employed fome time before the expected re- currence, it may be ufeful: but it muft be given in large quantity, and as near to the time of the expected return as poffible. mcccxxxv. The metallic tonics feem to be more pow- erful than the vegetable, and a great variety of the former have been employed. Even arfenic has been employed in the cure of epilep- fy ; and its ufe in intermittent •fevers gives analogy in its favor. ■*>' 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 refpect to thefe difeafes, probable : but 1 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 havefeen fome of them employ- 47* PRACTICE' OF PHYSIC. ed in the cure of epilepfy, but have never found them to be effectual. This, however, 1 think, may be imputed to their not. having heen always employed in circumftan- ces of the difeafe, and in the quantities of the medicine, that were proper and neceffary. / mcccxxxvi. Of the metallic tonics, the moft celebra- ted, and the moft frequently employed is copper, under* various preparation. What preparation of it may be the moft effectual, I dare not determine; but of late the cuprum ammoniacum has been frequently found fuccefs- ful. . . . „.......... -, , mcccxxxvii. Lately the flowers of zinc have been rec^ ommended by a great authority as ufeful in all convuh five diforders ; but in cafes of epilepfy, I have not hither^ to found that medicine ufeful. .. ■ . . I j mcccxxxviii. There have been of late fome inftance* j of the cure of epilepfy by the accidental ufe of mercury ^ ' and if the late accounts of the, cure of tetanus by this remedy are confirmed it will allow us to think that the fame may be adapted alfo to the cure of certain cafes of . epilepfy. r ; . mcccxxxix. With refpect to the employment .of any of the above mentioned tonics in this difeafe,.it muflbcV obferved, that in all cafes where the difeafe depends upon ' a conftant or occafional plethoric ftate of the fyftem; ' thefe remedies are likely to be ineffectual.; and if fuffi- cient evacuations are not made at the fame time, thefe i ineci'cines r.re likely to be very hurtful. mcccxl. The other fet of medicines which we have mentioned ab fuiced to obviate the effects of the too great mobility of the fyftem, are the medicines named antif- pafmodics. Of thefe there is a long lift in the writers on the Materia Medica, and by thefe authors recommended for the cure of epilepfy. The greater part, however, .of thofe taken . om the vegetable kingdom, are manifeftly. inert and 'nngi.ifrjant. Even the root of the wild vale- rian harcdy fimports its credit. •. « mcccx, i. Cer-ain fubftances taken from the animal kingcon .cemtc be much more powerful: and of thefe the chieiy and feemingly the moft powerful, is mufk ; PRACTICE OF PHYSIC. 4 73 which, employed in its genuine ftate, and in due quanti- ty, has often been an effectual remedy. It is probable alfo, that the oleum animate, as it has been named, when in its pureft ftate, and exhibited at a prop- er time, may be an effectual remedy. mcccxlii. In many difeafes, the moft powerful antif- pafmodic is certainly opium ; but the propriety of its ufe in epilepfy has been difputed among phyficians. When the difeafe depends upon a plethoric ftate, in which bleed- ing may be neceffary, the employment of opium is like- ly to be very hurtful ; but when there is no plethoric or inflammatory ftate prefent, and the difeafe feems to de- pend upon irritation or upon increafed irritability, opi- um is likely to prove the moft certain remedy. What- ever effects in this and other convulfive diforders have been attributed to the hyofcyamus, muft probably be at- tributed to its poffeffing a narcotic power fimilar to that of opium. mcccxliii. With refpect to the ufe of antifpafmodics^ it is to be obferved, that they are always moft ufeful, and perhaps only ufeful when employed at a time when epi- leptic fits are frequently recurring, or near to the times of the acceffion of fits which recur after confiderable in- tervals. mcccxliv. On the fubject of the cure of epilepfy,. I have only to add, that as the difeafe in many cafes is con- tinued by the power of habit only, and that in all cafes habit has a great fhare in increafing mobility, and there- fore in continuing this difeafe ; fo the breaking in upon fuch habit, and changing the whole habits of the fyftem 9i is likely to be a powerful remedy in epilepfy. Accord- ingly, a confiderable change of climate, diet, and other circumftances in the manner of life, has often proved 2 cure of this difeafe. mcccxlv. After treating of epilepfy, I might here treat of particular convulfions, which are to be diftin- guifhed from epilepfy by their being more partial; that is, affecting certain parts of the body only, and by their not beings attended with a lofs of fenfe, nor ending m fuch a comatofe ftate as epilepfy always does. A;A PRACTICE OF PHYSIC. mcccxlvi. Of fuch convulfive affections, many ditliv- ent inftances have been obferved and recorded by phyfi- cians. But many of thefe have been manifeftly fym- pathic affections, 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 character with which they occur in different perfons, I muft therefore leave them to be treat- ed upon the general principles I have laid down with re- fpect to epilepfy, or fhall lay down with refpect to the following convulfive diforder; which as having very con- ftantly in different perfons a peculiar character, I thinL neceffary to treat of more particularly. C II A P. III. OF THE CHOREA*, OR DANCE OF ST. VITUS. mcccxlvh. I his difeafe affects both fexes/^ * and almoft only 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 contin-. '! ues beyond that period. mcccxlviii. It is chiefly marked by convulfive motions,. } fomewhat varied in different perfons, but nearly of one kind in all; affecting the leg and arm on the fame fide, and generally on one fide only. mcccxlix. Thefe convulfive motions commonly firft affect 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 affected leg is feldom lifted,as ufual in walk- i ing, but is dragged along as if the whole, limb were para- lytic ; and, when it is attempted to be lifted, this motion ■ * Attacking young people cf both fexp»> for the moft part between -'e tenth and fourteenth year of their age, with convulfive motions of the hand nnd arms, not altogether invHuntary, chiefly cf nn- fi.V; in waiting, the fTe&ed leg is dragged after the otbw. Syi. N>f. PRACTICE OF PHYSIC. 475 is unfteadily performed, the limb becoming agitated by irregular convulfive motions. mcccl. The arm of the fame fide is generally affected at the fame time ; and, even when no voluntary motion is attempted, the arm is frequently agitated with various convulfive motions. But efpecially when voluntary mo- tions are attempted, thefe are not properly executed, but are varioufly hurried or interrupted by convulfive mo- tions in a direction contrary to that intended. The moft common inftance of this is in the perfon's attempt- ing to carry a cup of liquor to his mouth, when it is on- ly after repeated efforts, interrupted by frequent convul- five retractions and deviations, that the cup can be carri- ed to the mouth. mcccli. It appears to me, that the will often yields to thefe convulfive motions, as to a propensity, and thereby they are often increafed, while the perfon affected feems pleafed with increafing the furprife and amufement which his motions occafion in the byftanders. mccclii. In this difeafe the mind is often affected with fome degree of fatuity ; and often fhows the famer varied, defultory, and caufelefs emotions which occur in hyfteria. mcccliii. Thefe are the moft common circumftances of this difeafe ; but at times and in different perfons, it is varied by fome difference in the convulfive motions, particularly by thefe affecting the head and trunk of the body. As in this difeafe there feems to be propensities to motion, fo various fits of leaping and running occur in the perfons affected ; and there have been inftances of this difeafe, confuting of fuch convulfive naotions, ap- pearing as an epidemic in a certain corner of the coun- try. In fuch inftances, perfons of different ages are af- fected, and may feem to make an exception to the gen- eral rule above laid down ; but ftill the perfons are, for the moft part, the young of both fexes, and of the more manifeftly moveable conftitutions. mcccliv. The method of curing this difeafe has been varioufly propofed. Dr. Sydenham propofed to cure it by alternate bleeding and purging. In fome plethoric G G 47« PRACTICE OF PHYSIC. habits I have found fome bleeding ufeful; but in many cafes I have found repeated evacuations, efpecially by bleeding, very hurtful. In many cafes, I have found the difeafe, in fpite of remedies of all kinds, continue for many months; but I have alfo found it often readily yield to tonic remedies, fuch as the Peruvian bark, and chalybeates. The late Dr. De Haen found feveral perfons labor- ing under this difeafe cured by tfie application of elec- tricity. SECT. II. Of the Spafmodic Affeclions of the Vital FunclionL CHAP. IV*. OF THE PALPITATION f OF THE HEART. mccclv. 1 he motion thus named is a contraction l or fyftole of the heart, that is performed with more ra- pidity, and generally alfo' with more force, than ufual; and when at the fame time the heart flrikes with more than ufual violence againft the infide of the ribs, produ- cing often a confiderable found. mccclvi. This motion, or palpitation, is occafioned, j by a great variety of caufes, which have been recited with great pains by Mr. Senac and others, whom, how- ever, I cannot follow in all the particulars with fufficient difcernment, and therefore fhall here only attempt to re- fer all the feveral cafes of this difeafe to a few general' heads. ...., J mccclvii. The firft is of thofe arifing from the appli- cation of the ufual ftimulus to the heart's contraction y that is, the influx of the venous blood into its cavities, * Though I have thought "it proper to divide this book into fedUons, I thnk it neceflary, for the convenience of references, to number the chapter* from the beginning. Author. f Irregular and violent action of the heart. Syn. Nof. PRACTICE OF PHYSIC. 4?7 being made with more velocity, and therefore, in the fame time, in greater quantity than ufual. It feems to be in this manner that violent exercife occafions palpita- tion. mccclviii. A fecond head of the cafes of palpitation, is of thofe arifing from anv- refiftance given to the free and entire evacuation of the ventricles of the heart. Thus a .ligature made upon the aorta occafior s palpitations of the moft violent kind. Similar refiftances, either in the aorta or pulmonary artery, may be readily imagined;; and fuch have been often found in the dead bodies of perfons who, during life, had been much affected with palpitations. To this head are to be referred all thofe cafes of palpi- tation arifing from caufes producing an accumulation of blood in the great veflels near to the heart. mccclix. A third head of the cafes of palpitation, is of thofe arifing^from a more violent and rapid influx of the nervous power into the mufcular fibres of the heart. It is in this manner that I fuppofe various caufes acting in the brain, and particularly certain emotions of the mind, occafion palpitation. mccclx. A fourth head of the cafes of palpitation, is of thofe arifing from caufes producing a weaknefs in the action of the heart, by diminifhing the energy of the brain with refpect to it. That fuch caufes operate in producing palpitation, I prefume from hence, that all the feveral caufes mentioned above (mclxxvii. etfeq.), as in this manner producing fyncope do often produce palpi- tation. It is on this ground that thefe two difeafes are affections frequently occurring in the fame perfon, as the fame caufes may occafion the one or the other, according to the force of the caufe and mobility of the perfon acted upon. It feems to be a law of the human economy, that a degree of debility occurring in any function, often produces a more vigorous ex- ertion of the fame, or at leaft an effort towards it, and that commonly in a convulfive manner. I apprehend it to be the convulfive action, frequently ending in fome degree of a fpafm, that gives occafion to 2 Alt PRACTICE OF PHYSIC. the intermittent pulfe fo frequently accompanying palpi- tation. mccclxi. A fifth head of the cafes of palpitation may perhaps be of thofe arifing from a peculiar irritability or mobility of the heart. This, indeed, may be confidered as a predifponent caufe only, giving occafion to the ac- tion of the greater part of the caufes recited above. But it is proper 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 effect but in perfons peculiarly predifpofed. This head, therefore, of the cafes of palpitation, often requires to be diftinguifhed from all the reft. mccclxh. After thus marking the feveral cafes and caufes of palpitation, I think it neceflary, with a view to the cure of this difeafe, to obferve, that the feveral cauf- es of it may be again reduced to two heads. The firft is, of thofe confifting in, or depending upon, certain organic affections of the heart itfelf, or of the great veffels im- mediately connected with it. The fecond is, of thofe confifting in, or depending upon, certain affections fub- iifting and acting in other parts of the body, and acting either by the force of the caufe, or in confequence of the mobility of the heart. mccclxiii. With refpect to the cafes depending up- on the firft fet of caufes, I muft repeat here what I faid with refpect to the like cafes of fyncope, that I do not know a'ny means of curing them. They, indeed, admit of fome palliation, firft by avoiding every circumftance that may hurry the circulation of the blood ; and+fecond- ly, by every means of avoiding a plethoric ftate of the fyftem, or any occafional turgefcence of the blood. In many of thefe cafes, blood letting may give a temporary relief: but in fo far as debility and mobility are con- . cerned, in fuch cafes this remedy is likely to do harm. mccclxiv. With, refpect to the cafes depending up- on the other fet of caufes, they may be various and re- quire very different meafures : but I can here fay in gen- eral, that thefe cafes may be confidered as of two kinds; one depending upon primary affections in other parts of PRACTICE OF PHYSIC. 479 the body, and acting by the force of the particular cauf- es ; and another depending upon a ftate of mobility in the heart itfelf. In the firft of thefe, it is obvious, that the cure of the palpitation muft be obtained by curing the primary affection ; which is not to be treated ot here. In the fecond, the cure -muff be obtained/ partly by diligently avoiding the occafional caufes, partly and chiefly by correcting the mobility of the fyftem, and of the heart in particular ; for doing which we have treat- ed, of the proper means elfewhere. CHAP. V. OF DYSPNOEA*, OR DIFFICULT BREATHING. mccclxv. .1 he ;exercife of refpiration, and the or- gans of it, have fo conftant and confiderable a connec- tion with almoft the whole of the other functions and parts of the human body, that upon almoft every occa- fion of difeafe, refpiration muft be affected. According- ly fome difficulty and diforder in this function, are in fact fymptoms very generally accompanying difeafe. mccclxvi. Upon this account the fymptom of dif- ficult breathing deferves a chief place and an ample con- fideration in the general fyftem of Pathology ; but what fhare of confideration it ought to have in a treatife of Practice, I find it difficult to determine. mccclxvii. Oji this fubject, it is, in the firft place, nec- effary to diftnguifh between the fymptomatic and idio- pathic affections; that is, between thofe difficulties of breathing which are fymptoms only of a more general affection, or of a difeafe fubfifting primarily in other parts than the organs of refpiration, and that difficulty of breathing which depends upon a primary aiiection of the lungs themfelves. The various cafes of fyir.ptornai.ic * Perpetual diiii.Milty of breathinjr, without any ftraitnefe, tut rathe: with a fenfe of diftenfion and inhrdion in the breaft ; a i. .^ut-rt cough •Iv.ciigh t'it- whole cf-m"re of thedii%a'p. f.v, Nof. 48c PRACTICE OF PHYSIC. dyfpneea I have taken pains to enumerate in my Method- ical Nofology, and it will be obvious they are fuch as cam not be taken notice of here. mccclxvih. In my Nofology I have alfo taken pains to point out and enumerate the proper, or at leaft the greater part of the proper, idiopathic cafes of dyfpneea ; but from that enumeration it will, I think, readily ap- pear, that few, and indeed hardly any, of thefe cafes will admit or require much of our notice in this place. mccclxix. The Dyfpneea Sicca, fpecies 2d, the Dyf- pneea Aerea,fp. 2d, the Dyfpneea, Terea, fp. Atih, and Dyf- pneea Th'jracica,fp. 7th, are fome of them with difficulty known, and are all of them difeafes which in my opinfon do not admit of cure. All, therefore, that can be faid concerning them here is, that they may admit of fome palliation ; and this, I think, is to be obtained chiefly by avoiding a plethoric ftate of the lungs, and every circum- itance that may hurry refpiration. mccclxx. Of the Dyfpneea jtxtrinfeca, fp. 8th, I can fay no more, but that thefe external caufes marked in the Nofology, and perhaps fome others that might have like effects, are to be carefully avoided ; or when they have been applied, and their effects have taken place, the difeafe is to be palliated by the means mentioned in the laft paragraph. mccclxxi. The other fpecies, though enumerated as idiopathic, can hardly be confidered as fuch, or as requir- ing to be treated of here. The Dyfpneea Catarrhalis,fp. \ft, may be confidered as a fpecies of catarrh, and is pretty certainly to be cured by the fame remedies as that fpecies of catarrh which de- pends rather upon the increafed afflux of mucus to the bronchia?, than upon any inflammatory ftate in them. The Dyfpneea Aquofa,fp. 5th. is certainly to be confid- ered as a fpecies of dropfy, and is to be treated by the fame remedies as the other fpecies of that difeafe. The Dyfpnoz2iPinguedinofa,fp. 6th, is in like manner to be confidered as a fymptom or local effect of the Polyfar- cia, and is only to be cured by correcting the general fault of the fyftem. PRACTICE OF PHYSIC. . 4?* mccclxxii. From this view gf thofe idiopathic cafes of •dyfpneea, which are perhaps all I could properly arrange under this title, it will .readily appear that there is little room for treating of them here : but there is ftill one cafe of difficult breathing, which has been properly diflin- guiihed from every other under the title of Afthma ; and *ls it deferves our particular attention, I fhall here fepa- rately confider it. CHAP. VI. OF ASTHMA.* mccclxxiii. 1 he term of Afthma has been com- monly applied by the vulgar, and even by many writers on the Practice of Phyfic, to every cafe of difficult breath- ing, that is, to every fpecies of Dyfpneea. TheMethodica Nofologifts, alfo, have diftinguifhed Afthma from Dyfp- neea chiefly, and almoft folely, by the former being the fame affection with the latter, but in a higher degree. Nei- ther of thefe applications of the term feems to have been correct or proper. I am of opinion, that the term afth- ma may be moft properly applied, and fliould be confin- ed, to a cafe of difficult breathing that has peculiar fymp- toms, and depends upon a peculiar proximate caufe, which I hope to afiign with fufficient certainty. It is this difeafe I am now to treat of, and it is nearly what Practical writers have generally diftinguifhed from the other cafes of difficult breathing, by the title of Spafmo- dic Afthma, or of Afthma Convulfivum ; although, by not d ftinguifhiag it with fufficient accuracy from the other cafes of Dyfpneea, they have introduced a great deal of confufion into their treatifes on this fubject. mccclxxiv. The difeafe I am to treat of, or the Afth- ma to be ftrictly fo called, is often a hereditary difeafe. * A difficulty of breathing, recurring at intervals, with a fenfe of ftraitnefs \tt the breaft ; refpiration ia peiformed with a wheezh g roife : coujjh about the beginning of the paroxyfm is difficult, and imperfect ; towaids the end it becomes fee, and is attended with a copious mucus expecloraticn. Syn. Ncr 4 Alz PRACTICE OF PHYSIC. It feldom appears very early in life, and hardly till thw time of puberty, or after it. It affects both fexes, but moft frequently the male. I have not obferved it to be more frequent in one kind of temperament than in an- other ; and it does not feem to depend upon any gener- al temperament of the whole body, but upon a particular conftitution of the lungs alone. 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 of the whole body. mccclxxv. The attacks of this difeafe are generally in the night time, or towards the approach of night ; but there are alfo fome inftances of their coming on in the courfe of the day. At whatever time they come on, it is for the moft part fuddenly, with a fenfe of tightnefs t and ftricture acrofs the breaft, and a fenfe of ftraitnefs in the lungs, impeding infpiration. The perfon thus at- tacked if in a horizontal situation, is immediately oblig- ed to get into fomewhat of an erect pofture, and requires a free and cool air. The difficulty of breathing goes on for fome time increafing, and both infpiration and expi: ration are performed flowly, and with a wheezing noife. In violent fits, fpeaking is difficult and uneafy. There is often fome propenfity to coughing, but it can hardly be executed. mccclxxvi. Thefe fymptoms often continue for ma- ny hours together, and particularly from midnight till the morning is far advanced. Then commonly a remif- fion takes place by degrees ; the breathing becomes lefs laborious and more full, fo that the perfon can fpeak and ' cough with more eafe ; and, if the cough brings up fome mucus, the remiflion becomes immediately more confid- erable, and the perfon falls into a much wifhed for fleep. mccclxxvIi. During thefe fits, the pulfe often contin- ues in its.natural ftate ; but, in fome perfons, the fits are attended with a frequency of pulfe, and with fome heat and thirft, as marks of fome degree of fever. If urine be voided at the beginning of a fit, it is commonly irt confiderable quantity, and with little color or odor ; but^ • after the fit is over, the urine voided is in the ordinary PRACTICE OF PHYSIC. 48/* quantity, of a high color, and fometimes depofits a fedi- ment. In fome perfons, during the fit, the face is a little flufhed and turgid ; but more commonly, it is fomewhat pale and fhrunk. mccclxxviii. After fome fleep in the morning, the pa: tient, for the reft of the day, continues to hive more free and eafy breathing, but it is feldom entirely fuch. He ftill feels fome tightnefs acrofs his breaft, cannot breathe eafily in a horizontal pofture, and can hardly bear any motion of his body, without having his breathing ren- dered more difficult and uneafy. In the afternoon, he has an unufual flatulency of his ftomach, and an unufual drowfinefs ; and, very frequently, thefe fymptoms pre- cede the firft attacks of the difeafe. But whether thefe fymptoms appear or not, the difficulty of breathing re- turns towards the evening, and then fometimes gradually increafes, till ft becomes as violent as in the ni^ht before ; or if, during the day, the difficulty of breathing has been moderate, and the perfon gets fome fleep in the firft part of the night, he is however waked about midnight, or at fome time between midnight and two o'clock in the morning, and is then fuddenly feized with a fit of dnli- :u!t breathincc, which runs the fame courfe as the nifht before. mccclxxix. In this manner, fits return for feveral nights fucceflively; but generally, after fome nights piifed in this way, the fits fuller more con Inferable remiiiic-ik. This efpecially happens when the remiflions 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 not only more eafy days, but enjoy alfo nights of entire fleep, without the recurrence of the difeafe. mccclxxx. When this difeafe, however, has once tak- en place, in the manner above defcribed, it is ready to return at times for the whole of life after. Tiide re- turns, however, happen with different circumftance^ !** different perfons. mccclxxxi. In fome perfons, the-fits are readily excit- ed by external h<"-.at, whether of the weather or of a warn: lU PRACTICE OP PHYSIC. chamber, and particularly by warm bathing. In fuch perfons, fits are more frequent in fummer, and particu- larly during the j,dog days, than at other colder feafons. The fame perfons are alfo readily 'affected by changes of the weather, efpecially by fudden changes made from a colder to a warmer, or, what is commonly the fame thing, from a heavier to a lighter atmofphere. The fame perfons are'alfo affected by every circumftance ftrait- ening the capacity of the thorax, as by any ligature made, or even by a plafter laid upon it ; and a like effecr, hap- pens from any increafed bulk of the ftomach, either by a full meal, or by air collected in it. They are likewife much affected by exercife, or whatever elfe can hurry the, circulation of the blood. mccclxxxii. As afthmatic fits feem thus to depend upon fome fulnefs of the veffels of the lungs, it is proba- ble that an obftruction of perfpiration, and the blood be- ing Jefs determined to the furface of the body, may fa- vor an accumulation in the lungs, and thereby be a means of exciting afthma. This feems to be the cafe of thofe afthmatics who have fits moft frequently in the winter feafon, and who have commonly more of a catarrhal af- fection accompanying the afthma ; which, therefore, occurs more frequently in winter, and more manifeftly from the application of cold. mccclxxxiii. Befide thefe cafes of afthma excited by heat or cold, there are others, in which the fits are efpe- cially excited by powers applied to the nervous fyftem, as by paffions of the mind, by particular odors, and by irritations of fmoke and dull. That this difeafe is an affection of the nervous fyftem, and depending upon a mobility of the moving fibres of the lungs, appears pretty clearly from its being frequent- ly connected with other fpafmodic affections depending upon mobility; fuch as hyfteria, hypochondriafis, dyfpep- fia, and atonic gout. mccclxxxiv. From the whole of the hiftory of afth- ma now delivered, I think it will readily appear, that the proximate caufe of this difeafe is a preternatural, and in fome meafure a fpafmodic conftriction of the mufcular PRACTICE OF PHYSIC. 4%S fibres of the bronchiae, which not only prevents the dila- tation of the bronchize neceffary to a free and full infpi- ration, but gives alfo a rigidity which prevents a full and fr»ee expiration. This preternatural conftriction, like ma- ny other convulfive and fpafmodic affections, is readily excited by a turgefcence of the blood, or other caufe of any unufual fulnefs and diftenfion of the veffels of the lungs. mccclxxxv. This difeafe, as coming by fits, may be generally diftinguifhed from moft other fpecies of dyf- pneea, whofe caufes being more conftantly applied, pro- duce, therefore, a more conftant difficulty of breathing. There may, however, be fome fallacy in this matter, aj fome of thefe caufes may be liable to have abatements and intenfities, whereby the ciyfpncea produced by them may feem to come by fits; but 1 believe it is feldom that fuch fits put on the appearance of the genuine afthmatic fits defcribed above. Perhaps, however, there is ftill an- other cafe that may give more difficulty ; and that is, when feveral of the caufes, which we have afligned as caufes of feveral of the fpecies of difficult breathing re- ferred to the genus of Dyfpneea, may have the effect of exciting a genuine afthmatic fit. Whether this can hap- pen to any but the particularly predifpofed to afthma, I am uncertain ; and, therefore, whether, in any fuch caf- es, the afthma may be confidered as fymptomatic, or if, in all fuch cafes, the afthma may not ftill be confidered and treated as an idiopathic difeafe. mccclxxxvi. The afthma, though often threatening immediate death, feldom occafions it; and many perfons have lived long under this difeafe. In many cafes, how- ever, it does prove fatal fometimes very quickly, and per- haps always at length. In fome young perfons it has ended foon, by occafioning a phthifis pulmonalis. After a long continuance, it often ends in hydrothorax ; and commonly, by occafioning fome aneurifm of the heart or great veflels, it thereby proves fatal. mccclxxxvii. 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 fuc- t PRACTICE OF PHYSIC. cefsful. Bat the difeafe admits of alleviation in feveral refpects from the ufe of remedies ; and my bufinefs now fhall be chiefly to offer fome remarks upon the choice \ and ufe of the remedies which have been commonly j employed in cafes of afthma. ^ mccclxxxvih. As the danger cf an afthmatic fit arifes chiefly from the difficult tranfmiffion of the blood • through the veffels of the lungs, threatening fuffocation ; fo the moft probable means of obviating this feems to be bloodletting.; and, therefore, in all violent fits, practi- ■ tioners have had recourfe to thjs remedy. In firft at-, a tacks, and efpecially in young and plethoric perfons, blood letting may be very neceffary, and is commonly ah lowable. But it is alfo evident, that, under the frequent J recurrence of fits, blood letting cannot be frequently re- \ peated, without exhaufting and weakening the patient too much, It is further to be obferved, that blood letting is not fo neceffary as might be imagined, as the paffage \ of the blood through the lungs is not fo much interrupt- \ ed as has been commonly fuppofed. This I particularly conclude from hence, that, inftead of the fuffufion efface which is the ufual effect of fuch interruption, the face, in afthmatic fits, is often ftirunk and pale. I conclude the fame alfo from this, that, in afthmatic fits, blood letting * does not commonly give fo much relief as, upon the con* { trary fuppofition, might be expected. mccclxxxix. As I have alleged above, that a turgef- *• cence of the blood is frequently the exciting caufe of afth- matic fits, 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, J therefore, that blood letting might be a proper remedy iri ; afthma. I allow it to be fo in the firft attacks of the dif- eafe ; 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 allege that blood letting becomes lefs and lefs neceffary. Mcjfccxc. Upon the fuppofition of afthmatics being in a plfthoric ftate, purging might be fuppofed to prove a remedy in this difeafe ; but, both becaufe the fuppofition PRACTICE OF PHYSIC. 4$; fa 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 ftagna- tion and accumulation of matters in the alimentary ca- nal, fo coftivenefs muft be avoided, and an open belly proves ufeful. In the time of fits, the employment of e- mollient and moderately laxative glyfters has been found to give confiderable relief. mcccxci. As a flatulency of the ftomach, and other fymptoms of indigeftion, are frequent attendants of afth- ma, and very troublefome to afthmatics; fo both for removing thefe fymptoms, and for taking off all deter- mination to the lungs, the frequent ufe of gentle vomits is proper in this difeafe. In certain cafes, where a fit was expected to come on in the courfe of the night, a vomit given in the evening has frequently feemed to prevent it. mcccxcii. Bliftering between the fhoulders, or upon the breaft, has been frequently employed to relieve afth- matics ; but in the pure fpafmodic afthma we treat of here, I have rarely found blifters ufeful, either in prevent- ing or relieving fits. mcccxciii. Iffues are certainly ufeful in obviating ple- thora ; but as fuch indications feldom arife in cafes of afthma, fo iffues have been feldom found ufeful in this difeafe. mcccxci v. As aftmatic 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 object of practitioners. See Floyer on the Afthma. mcccxcv. Although a plethoric ftate of the fyftem may feem to difpofe to afthma, and the occafional turgef- cence of the blood may feem to be frequently the excit- ing caufe of the fits ; 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 conftriction ; 488 PRACTICE OF PIP. SIC. < and therefore, that the entire cure of the difeafe can on- ly be expected from the correcting of that predifpofition, or from correcting the preternatural mobility or irrita- bility of the lungs in that refpect. mcccxcvi. In cafes wherein this predifpofition depends upon original conformation, the cure muft be difficult,* j and perhaps impoflible ; but it may perhaps be moder- ated by the ufe of antifpafmodics. Upon this footing, various remedies of that kind have been commonly em- ployed, and particularly the feited gums ; but we have not found them of any confiderable efficacy, and have I 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 proper- ly tried. The vitriolic ether has been found to give re- lief, but its effects are not lafting. mcccxcvii. As in other fpafmodic affections, fo in this, the moft certain and powerful antifpafmodic is opium. ? 1 have often found it effectual, and generally fafe ; and. if there have arifen doubts with refpect to its fafety, I believe they have a rifen from not diftinguifhing between ''\ certain plethoric and inflammatory cafes of dyfpncea,im- * properly named Afthma, and the genuine fpafmodic afth- , ma we treat of here. ; lcccxcvhi. As-m many cafes this difeafe depends up- \ on a predifpofition which cannot be corrected by our . art, fo in fuch cafes the patient can only efcape the dif* i eafe by avoiding the occafional or exciting caufes, which* t I have endeavored fo point out above. It is however difficult to give any general rules here, as different afth- \ matics have their different idiofyncrafies with refpect to externals. Thus one afthmatic finds himfelf eafieft living in the midft of a great city, while another cannot breathe but in the free air of the country. In the latter cafe, however, moft afthmatics bear the air of alow ground, if tolerably free and dry, better than that of the moun- tain. mcccxcix. In diet alfo, there is fome difference to be* made with refpect to different afthmatics. None of them baer a large or full meal, or any food that is of flow and PRACTICE OF PHYSIC. 489 difficult folution in the ftomach ; but many Of them bear animal food of the lighter kinds, and in moderate quan- tity. The ufe of vegetables, which readily prove flatu- lent, are always very hurtful. In recent afthma, and ef- pecially in the young and plethoric, a fpare, light, and cool diet is proper, and Commonly neceffary ; but after the difeafe has continued for years, afthmatics common- ly bear, and even require a tolerably full diet, though in all cafes a very full diet is very hurtful. mcccc. In drinking, water, or cool watery liquors, is the only fafe and fit drink for afthmatics ; and all liquors ready to ferment, and become flatulent, are hurtful to them. Few afthmatics can bear any kind of ftrong drink; and any excefs in fuch is always very hurtful to them. As afthmatics are commonly hurt by taking warm or tepid drink, fo both upon that account, and up- on account of the liquors weakening the nerves of the ftomach, neither tea nor coffee is proper in this dif- eafe. mcccci. Afthmatics commonly bear no bodily motion eafily, but that of the moft gentle kind. Riding, howev- er, on horfeback, or going in a carriage, and efpecially failing, are very often ufeful to afthmatics. C H A I*. VIL OF THE CHINCOUGH*, OR HOOPING COUGH. mccccii. 1 His difeafe is commonly epidemic, and manifeftly contagious. It feems to proceed from a contagion of a fpecific nature, and of lingular quality. It does not, like moft other contagions, neceffarily pro- duce a fever; nor, does it, like moft others ©ccafion any eruption, or produce otherwife any evident change in the ftate of the human fluids. It has, in common with the catarrhal contagion, and with that of the meafles, a * A contagious difeafe; convulfive and fuffocating cough, with repeated fonorous infpiration, not unfrequently attended with vomiting. Syn. Nof. 4go PRACTICE OF PHYSIC. peculiar determination to the lungs, but with particular , effects there, very different from thofe of the other two : as will appear from the hiftory of the difeafe now to be delivered. mcccciii. This contagion, like feveral others, affects perfons but once in the'eourfe of their lives ; and there- fore, neceffarily, children arc moft commonly the fubjects of this difeafe : but there arc many inftances of it occur- ring in perfons ccnfiderably advanced in life ; though it; is probable, that the further that perfons are advanced in life, they are the lefs liable to be affected with * this contagion. mcccciv. The difeafe commonly comes on with the ordinary fymptoms of a catarrh arifing from cold ; and often, for many days, keeps entirely to that appearance; and I have had inftances of a difeafe which, though evi- dently arifing from the chincough contagion, never put on any other form than that of a common catarrh. This however feldom happens ; for generally in the fecond, and, at fartheft in the third week after the^ at- ta-k, the difeafe p~< s on its peculiar and characteristic fymptom, a convulfive cough. This is a cough in which the exfpiratory motions peculiar to coughing are made with more frequency, rapidity, and violence, than ufu- al. As thefe circumftances, however, in different in- ftances of coughing, are in very different degrees ; fo no exact limits can be put to determine when the cough can be ftrictly faid to be convulfive ; and it is therefore efpe- cially by another circumftance that the chincough is dif- tinguifhed from every other form of cough. This circum- ftance is when many expiratory motions have been con- vulfively made, and thereby the air is in great quantity thrown out of 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 U In general called a Hoop ; and from it the whole of the difeafe is called the Hooping Cough. When this fonorous infpiration has happened, the convulfive cough- irrr k -rr-:'n renewed, and continues in the fame manner PRACTICE OF PHYSIC' 49* Is before, till a quantity of mucus is thrown up from the lungs, or the contents of the ftomach are thrown up by vomiting. Either of thefe evacuations commonly puts an end to the coughing, and the patient remains free from it for fome time after. . Sometimes it is only after feveral alternate fits of coughing and'hooping that ex- pectoration or vomiting takes place ; but it is common- ly after the fecond coughing that thefe happen, and put an end to the fit. mccccv. When the difeafe, in this manner, has taken its proper form, it generally continues for a long time after, and generally from one month to three; but fometimes much longer, and that with very various ch> cumftances. mccccvi. The fits of coughing return at various in- tervals, rarely obferving any exact period. They hap- pen frequently in the courfe of the day, and more fre- quently ftill in the coUrfe of the night. The patient has commonly fome warning of their coming on ; and, to avoid that violent and painful concuflion which the Coughing gives to the whole body, he clings faft to any thing that is near to him, or demands to be held faft by any perfon that he can come at. Wheh the fit is over, the patient fometimes breathes faft, and feems fatigued for a little after : but in many this appears very little ; and children are commonly fo entirely relieved, that they immediately return to their play, or what elfe they were occupied in before. mccccvIi. If it happens that the fit of coughing ends in vomiting up the contents of the ftomach, the patient is commonly immediately after feized with a ftrong cra- ving and demand for food, and takes it in very greed- ily. mccccviii. At the firft coming on of this difeafe, the expectoration is fometimes none at all, or of a thin mu- cus, only ; and while this continues to be the cafe, the fits of coughing are more violent, and continue longer : but commonly the expectoration foon becomes confider- able, and a very thick mucus, often in great quantity, is H h 4 mccccxxviii. Befide the pains denoted by the terms Gaftrodynia, Periadynia, Cardialgia, and Soda, there is, I think, another painful fenfation different from all of thefe, which is named by Mr. Sauvages Pyrofis Suecica ; •and his account of it is taken from Linnaeus, who names It Cardialgia Sputatoria. Under the title of Pyrofis Mr. * A burning pain of the epigaftrium, with the erudtation of a quantity §f wa-.ej-j liquid, generally infipid, fometime^ acrid. Syn. Nof. PRACTICE OF PHYSIC. 499 $auvages has formed a genus, of which the whole of the fpecies, except the eighth, which he gives under the title of Pyrofis Suecica, are all of them fpecies of theGaftrodyn- ia or of theCardialgia ; and if there is a genus to be form- ed under the title of Pyrofis, it can in my opinion compre- hend only the fpecies I have mentioned. In this cafe, in- deed, I own that the term is not very proper ; but my averfion to introduce new names has made me continue to employ the term of Mr. Sauvages. mccccxxix. The Gaftrodynia and Cardialgia I judge to be for the moft part fymptomatic affections ; and therefore have given them no place in this work : but the Pyrofis, as an idiopathic difeafe, and never before treated of in any fyftem, I propofe to treat of here. mccccxxx. It is a difeafe frequent among people in lower life ; but occurs alfo, though more rarely, in peo- ple of better condition. Though frequent in Scotland, it is by no means fo frequent as Linnaeus reports it to be in Lapland. It appears moft commonly in perfons under middle age, but feldom in any perfons before the age of puberty. When it has once taken place, it is ready to recur occafionally for a long time after ; but it feldom appears in perfons confiderably advanced in life. It af- fects both fexes, but more frequently the female. It Xometunes attacks pregnant women, and fome women only when they are in that condition. Of other women, it more frequently affects the unmarried; and of the married, moft frequently the barren. I have had many inftances of its occurring in women laboring under a ftuor albus. mccccxxxi. The fits of this difeafe ufually come on in the morning and forenoon, when the ftomach is empty. The firft fymptom of it is a pain at the pit of the ftom- ach, with a fenfe of conftriction, as if the ftomach was drawn towards the back ; the pain is increafed by rait- ing the body into an erect pofture, and therefore the bo- dy is bended forward. This pain is often very fevere; and, after continuing for fome time it brings on an eruc- tation of a thin watery fluid in confiderable quantity. This fluid has fometimes an acid tafte, but is very often 500 PRACTICE OF PHYSIC. flbfolutely infipid. The eructation is for fome time frc quently repeated ; and does not immediately give relief to the pain which preceded it, but does fo at length, and puts an end to the fit. mccccxxxii. The fits of this difeafe commonly come on without any evident exciting caufe : and I have not found it fteadily connected with any particular diet. It attacks perfons ufing animal food, but I think more fre. quently thofe living on milk and farinacea. It feems of- ten to be excited by cold applied to the lower extremi- ties ; and is readily excited by any confiderable emotion of mind. It is often without any fymptoms of dyfpepfia. mccccxxxjii. The nature of this affection 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 4 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 conftriction takes place on their extremities. While therefore the increafed impetus determines a greatec quantity than ufual of fluids into thefe veffels, the con- ftri&ion upon their extremities allows only the pure wa- tery parts to be poured out, analogous, as I judge, in ev- ery refpect, to what happens in the diabetes hyftericus. mccccxxxiv. The practice in this difeafe is as -difficult as the theory. The paroxyfm is only to be certainly re- lieved by opium. Other antifpafmodics, as vitriolic eth- er and volatile alkali, are fometimes of fervice, but not conftantly fo. Although opium and other antifpafmo- dics relieve the fits, they have no effect in preventing their recurrence. For this purpofe, the whole of the remedies of dyfpepfia have been employed without fuc- cefs. Of the ufe of the nux vomica, mentioned as a rem- edy by Linnaeus, I have had no experience. PRACTICE OF PHYSIC. set CHAP. IX. OF THE COLIC*. mcccc xxxv. 1 he principal fymptom of this difeafe, is a painfelt in the lower belly. It is feldom fixed and pungent in one part, but is a painful diftenfion in fome meafure fpreading over the whole of the belly ; and par- ticularly with a fenfe of twifting 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 con- tracted, and this in feparate portions, giving the appear- ance of a bag full of round balls. mccccxxxvi. Such pains, in a certain degree, fome- times occur in cafes of diarrhoea and cholera ; but thefe are lefs violent and more tranfitory, and are named Gri- pings. It is only when more violent and permanent, and attended with coftivenefs, that they conftitute colic. This is alfo commonly attended with vomiting, which in many cafes is frequently repeated, efpecially when any thing is taken down into the ftomach ; and in fuch vom- itings, not only the contents of the ftomach are thrown up, but alfo the contents of the duodenum, and therefore frequently a quantity of bile. mccccxxxvii. In fome cafes of colic, the periftaltic mo- tion is inverted through the whole length of the alimen- tary canal, in fuch a manner that the contents of the great guts, and therefore flercoraceous matter, is thrown up by vomiting; and the fame inversion appears ftill more clearly from this, that what is thrown into the rec- tum by glyfter is again thrown out by the mouth. In thefe circumftances of inverfion the difeafe has been nam- ed Ileus, or the Iliac Paflion ; and this has been fuppofed to be a peculiar difeafe diftinct from colic; but to me it appears that the two difeafes are owing to the fame prox- imate caufe, and have the fame fymptoms, only in differ- ent degree. *Pain of the abdomen, principally twifting about the umbilicus ; vomit- ing ; cofiivenefs. Syn. Nof. $*» PRACTICE OF PHYSIC. mccccxxxviii. The colic is often without any pyrexia attending it. Sometimes, however, an inflammation comes upon the part of the inteftine efpecially affected j and this inflammation aggravates all the fymptoms of the difeafe, being probably what brings on the moft con- fiderabie inverfion of the periftaltic motion j and, as the ftercoraceous vomiting is what especially diftinguifhcs the ileus, this has been confidered as always depending on an inflammation of the inteftines. However, I can affirm, that as there are inflammations of the inteftines with- out ftercoraceous vomiting, fo I have feen inftances of ftercoraceous vomiting without inflammation ; and there is therefore no ground for diftinguifhing ileus from col* ic, but as a higher degree of the fame affection. mccccxxxix. The fymptoms of the coUc, and the dif- fections of bodies dead of this difeafe, fhow very clearly, that gripes, and fpafms of the inferior extremities. Syn. Nof. PRACTICE OF PHYSIC. 5<*> while a coldnefs of the extremities, cold fweats, and faint- ings coming on. an end is put to the patient's life, fome- times in the courfe of one day. In other cafes the dif- eafe is lefs violent, continues for a day or two, and then ceafes by degrees, though fuch recoveries feldom happen without the affiftance of remedies. . mcccclvi. The attacks of this difeafe are feldom accom- paniedwith any fymptoms of pyrexia ; and though, du- ring the courfe of it, both the pulfe and refpiration arc hurried and irregular, yet thefe fymptoms are generally fo entirely removed by the remedies that quiet the fpaf- modic affections peculiar to the difeafe, as to leave no ground for fuppofing that it had been accompanied by any proper pyrexia. mcccclvii. This is a difeafe attending a very warm ftate of the air; and in very warm climates, it may per- haps appear at any time of the year ; but even in fuch climates it is moft frequent during their warmeft fea- fons; and in temperate climates, it appears onlyin the]warm feafons. Dr. Sydenham confidered the appearances of this difeafe in England to be confined to the month cf Au- guft ; but he himfelf obferved it to appear fometimes to- wards the end of fummer, when the feafon was unufual- ly warm; and that in proporcion 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. mcccclviii. From all thefe circumftances,it is, I think, very evident, that this difeafe is the effect of a warm at- mofphere, producing fome change in the ftate of the bile in the human body ; and the change may confift either in the matter of the bile being rendered more acrid, and thereby fitted to excite a more copious fecretion ; or in the fame matter its being prepared to pafs off in larger quantity than ufual. mcccclix. It has been remarked, that i 1 warm cli- mates 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 obftructed perfpiration may have alfo a fhare in this, 2 5-3 PRACTICE OF PHYSIC. though it is alfo certain that the difeafe does appear" when no change in the temperature of the air, nor any application of cold, have been obferved. mcccclx. It is poffible that, in fome cafes, the heat of the 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. mcccclxi. The Nofologifts have conflituted a Genus under the title of Cholera, and under this have arranged as fpecies every affection in which a vomiting and purg- ing of any kind happened to concur. In many of thefe ipecies, 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 al- fo, the vomiting which occurs is not an effentiai, but merely an- accidental fymptom from the particular vio- lence of the difeafe. The appellation of Cholera there- fore fhould, in my opinion, be confined to the difeafe I have defcribed above ; which by its peculiar caufe, and perhaps alfo by- its fymptoms, is very different from all the other fpecies that have been affociated with it. I be- lieve that all the other- fpecies arranged under the title of Cholera by Sauvages or Sagar, may be properly enough referred to the genus of Diarrhoea ; which we are to treat of in the next chapter.- Toe diftinction I have endeavored to eftablifh between the proper Cholera* and the other difeafes that have fome- times got the fame appellation, will, as I judge, fuperfedc the queftion, Whether the Cholera, in temperate clim- ates, happens at any other, feafon than that above afiign ed? mcccclxii. 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 exhibi- tion of mild diluents, both given by the mouth and in- jected by the anus; and all evacuant medicines, employ- TRA.CTICE OF PHYSIC. 5" red in either way, are not only fuperfluous, but common- ly hurtful. mcccclxhi. 'When the redundant bile appears to be fufliciently wafhed out, and even before that, if the fpaf- modic affections of the alimentary canal become very violent, and are communicated in a confiderable degree to other parts of the body, or when a dangerous debili- ty feems to be induced, the irritation is to be immedi- ately obviated by opiates, in fufficiently large dofes, but in fmall bulk, and given either by the mouth or by glyfter. mcccc lxiv. Though the patient- bein this manner re- lieved, it frequently happens, that when s the-operation of the opium is over, the difeafe-Aiows a tendency to re- turn ; and, for at leaft fome days after the firft attack, the irritability of the inteftines, and their difpofition to fall into painful fpafmodic contractions, feem to contin- ue. In this fituation, the repetition of the opiates, for perhaps feveral days, may come to be neceffary ; and as the debility commonly induced by the difeafe favors the difpofition to fpafmodic affections, it is often ufeful and neceffary, together with the opiates, to employ the tonic ; powers of the Peruvian bark. CHAP. XL OF DIARRHOEA,* OR LOOSENESS. mcccclxv. 1 his difeafe confifts in-evacuations by flool, more frequent and of more liquid matter than ufual. This leading and charaCteriftic fymptom is fo di- verfified in its degree, in its caufes, and in the variety of matter evacuated, that it is almoft inrnofllble togive any general hiftory of the difeafe. mcccclxvi. It is to be diftinguifhed from clyfentery, by not being contagious ; by -being generally without fe- ver ; and by being with the evacuation of the natural ex- crements, which are, at leaft for fome time, retained in * Frequent ftools; the difeafe is not contagious ; kind there is no Prima- ry pyrexia. Syn. Nof. 3 5»* PRACTICE OF PHYSIC. dyfentery. The two difeafes have been commonly dif- tinguifhed 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 diftinction. mcccclxvii. A diarrhoea is to be diftinguifhed from cholera chiefly by the difference of their caufes ; which, in cholera, is of one peculiar kind ; but in diarrhoea is prodigioufly diverfified, as we fhall fee prefently. It has been common to diftinguifh 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 univerfally apply, as a diarrhoea is fome- times attended with vomiting, and even of bilious mat- ter. ■ - ' mcccclxviii. The difeafe of diarrhoea, thus diftin- guifhed, is very greatly diverfified ; but in all cafes, the frequency of ftools is to be imputed to a preternatural increafe of the piriftaltic motion in the whole, or at leaft a confiderable portion, of the inteftinal canal. This in- creafed action 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 refer- red it to the order of Spafmi, and accordingly treat of it in this place. mcccclxix. Upon the fame ground, as I confider the difeafe named Lientery to be an increafed periftaltic mo- tion over the whole of the inteftinal canal, arifing from a peculiar irritability, I have confidered it as merely a fpe- cies of diarrhoea. The idea of a laxity of the inteftinal canal being the caufe either of lientery, or other fpecies of diarrhoea, appears to me to be without foundation, ex- cept in the fingle cafe of frequent liquid ftools from a palfy of the fphincler ani. mcccclxx. The increafed action of the periftaltic mo- tion, I confider as always the chief part of the proximate caufe of diarrhoea ; but the difeafe is further, and indeed chiefly, diverfified by the different caufes of this increaf- ed action ; which we are now to inquire into. PRACTICE OF PHYSIC. 515 •mcccclxxi. The feveral caufes of the increafed a&ion of the inteftines may be referred, I think, in the firft place, to two general heads. The firft 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 action in the in- teftines, without the transference of any ftimulant mat- ter from the primary difeafed part to them. The fecond head of the caufes of the increafed action of the inteftines is of the ftimuli of various kinds, which are applied directly to the inteftines themfelves. mcccclxxii. That affections of other parts of the fyf- tem may affect the inteftines without the transference or application of any ftimulant matter, we learn from hence, that the paffions of the mind do in fome perfons exdte diarrhoea. mcccclxxiii. That difeafes in other parts may in like manner affect the inteftines, appears from the dentition of infants frequently exciting diarrhoea. I believe that the gout often affords another inftance of the fame kind ; and probably there are others alfo, though not well af- certained. mcccclxxiv. The ftimuli (mcccclxxi.) 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 excretories opening into them. 8. Matters poured from certain preternatural openings made into them in certain difeafes. mcccclxxv. Of thofe (mcccclxxi. 1.) introduced by the mouth, the firfl to be mentioned are the aliments com- monly 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 ac- rid ftate, to the inteftines, they frequently excite diar- rhoea. The fame aliments, though in proper quantity, yet having too great a proportion, as frequently happens, of 4 514 PRACTICE OF PHYSIC. faline or faccharine matter along with them prove ftim- ulant to the inteftines, and excite diarrhoea. But our aliments prove efpecially the caufes of diar- rhoea, 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 be- come ftimulant to the inteftines. • Thus acefcent aliments are ready to produce diarrhoea ; but whether from their having any directly purgative quality, or only as mixed in an over proportion with the bile, is not well deter- mined. < .-.•■:,,. mcccclxxvi. Not only the acefcent, but alfo the pu- trefcent difpofition of the aliments, feems to occafion a diarrhoea ; and it appears that even the effluvia of pu- trid 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 ? mcccclxxvii. The other matters introduced by the mouth, which may be caufes of diarrhoea, are thofe thrown in either as medicines, or poifons that have the faculty of flimulating the alimentary canal. Thus, in the lift of the Materia Medica, we have a long catalogue of thofe named purgatives; and in the lift of poifons, we have many poffeffed of the fame' quality. The for- mer, given in a certain' quantity, occafion a temporary diarrhoea ; and given in very large dofes, may occafion it in excefs, and continue it longer than ufual, produc- ing that fpecies of diarrhoea named a Hypercatharfis. mcccclxxvih.' The matters (mcccclxxiv. 2.) poured into the cavity of the inteftines from the excretories o- pening into them, and which may occafion diarrhoea, are either thofe from the pancreatic or biliary duct, or thofe from the excretories in the coats of the inteftines themfelves. mcccclxxix. What changes may happen in the pan- creatic juice, I do not exactly know ; but I fuppofe that an acrid fluid may iffue from the pancreas, even while ftill entire in its ftructure ; but more efpecially, when it PRACTICE OF PHYSIC. S*S. is in a fuppurated, fcirrhous, or cancerous ftate, that a very acrid matter may be poured out by the pancreatic duct, and occafion diarrhoea. mcccclxxx. We know well, that from the biliary duct the bile may be poured out in greater quantity than* ufual; and there is little doubt of its being alfo fome- times poured out of a more than ordinary acrid quality. It is very probable, that in both ways the bile is fre- quently 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 producing that ftate of the bile which occafions cholera, may occur in all the different poflible degrees of force, fo as, on one occafion, to produce the 1 moft violent and diftinctly marked cholera ; but upon jj( another^ to produce only the gentleft diarrhoea ; which, however; will be the fame difeafe, only varying in degree; \ fo I think it 'probable, that in warm climates, and in warm feafons,, a diarrhoea biliofa of this kind may fre- quently occiir, not to be always certainly diftinguifhed from cholera. However this may be, it is fufficiently probable, that, 1 in fome cafes, the bile, without having been acted upon by the heat of the climate or feafon, may be redundant and acrid, and prove therefore a particular caufe of di- arrhoea.1 ■■* mcccclxxxi. Befides bile from the feveral caufes and in the conditions mentioned, the biliary duct may pour out pus, or other matter, from abfeeffes in the liver, I which may be the caufe of diarrhoea. f Practical writers take notice of a diarrhoea wherein a thin and bloody liquid is difcharged ; which they fuppofe to have proceeded from the liver, and have therefore t given the difeafe the name of Hepatirrhcea : but we have ) not met with any inftance of this kind ; and there- fore cannot properly fay any thing concerning it. mcccclxxxii. A fecond fet of excretories, from which matter is poured into the cavity of the inteftines, are thofe from the coats of the inteftines themfelves ; and are either the exhalants proceeding directly from the fi6 PRACTICE OF PHYSIC. extremities of arteries, or the excretories from the mu- cous follicles : and both thefe fources occur in prodig- ious number over the internal furface of the whole inteft- inal canal. It is probable that it is chiefly the effufion from thefe fources which, in moft inftances, gives the matter of the liquid ftools occurring in diarrhoea. mcccclxxxiii. The matter from both fources may be poured out in larger quantity than ufual, merely by the increafed action of the inteftines, vdiether that be excited by the paffions of the mind {mccccxxii.), by difeafes in other parts of the fyftem (mcccclxxi. i.), or by the various ftimulants mentioned mcccclxxv. and following; or the quantity of matter poured out may be increafed, not fo much by the increafed action of the inteftines, as by an increafed afflux of fluids from other parts of the fyftem. Thus cold applied to the furface of the body, and fop- preffing perfpiration, may determine a greater quantity of fluids to the inteftines. Thus, in the ifchuria 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 hap- pens, in particular with refpect to the water of drop- fees. mcccclxxxiv. It is to be obferved here, that a diar- rhoea 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 biood into the cavity of the inteftines. Thus it is fuppofed that the morbific matter of fevers is fome- times thrown out into the cavity of the inteftines, and gives a critical diarrhoea : and whether I do, or do not admit the doctrine of critical evacuations, I think it is probable that the morbific matter of the exanthemata is frequently thrown upon the inteftines, and ocafions diar- rhoea. PRACTICE OF PHYSIC. 5if mcccclxxxv. It is to me further probable, that the jmtrefcent matter diffufed over tl.-.e mafs of blood in put- red difeafes, is frequently poured out by the exhalants into the inteftines, and proves there the caufe, at leaft in part, of the diarrhoea fo commonly attending thefe dif- eafes. mcccclxxxvi. Upon this fubject 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 chang- ed 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. mcccclxxxvii. How far, and in what manner the ex- .halant fluid may be changed in its nature and quality, we do not Certainly know : but with refpect to the fluid I from the mucous excretories, we know, that when poured out in unufual quantity, it is commonly, at the fame time, in a more liquid and acrid form ; and may ! prove therefore considerably irritating, i mcccclxxxviii. Though the copious effufion of a more liquid and acrid matter from the mucous excreto- ries, be probably owing to the matter being poured out immediately, as it is fecreted from the blood into the mucous follicles, without being allowed to flagnate in the latter, fo as to acquire that milder quality and thick- er consilience we commonly find in the mucus in its na- '. tural ftate ; and although we might fuppofe that the ex- cretions of a thin'and acrid fluid fhould always be the effect 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 ex- cretion of a mucus, which appears in its proper form, of a mild,, vifcid, and thickifli matter. This commonly occurs in the cafe of dyfentery ; and it has been obferv- ed to give a fpecies of diarrhoea, which has been properly named the Diarrhcea Mucofa. mcccclxxxix. A third fource of matter poured into the cavity of the inteftines, and occafioning diarihcca il* PRACTICE of physic. (mcccclxxiv. 3.), is from thofe preternatural openings. produced by difeafes in the inteftines or neighboring parts. Thus the blood veffels on the internal furface of the inteftines may be opened by erofion, rupture, or an- aftomofis, and pour into the cavity-their blood, which, either by its quantity or by its acrimony, whether in- herent, or acquired by ftagnation, may fometimes give a diarrhoea evacuating bloody matter. This is what 1 think happens in that difeafe which has been called the Melana or Morbus Niger. mccccxc. Another preternatural fource of matter poured into the cavity of the inteftines, is the rupture of abfeeffes feated either in the coats of the inteftines them- felves, or in any of the contiguous vifcera, which, dur- ing an inflamed ftate, had formed an adhefion with fome part of the inteftines. The matter thus poured into. their cavity may be various ; purulent, or 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. mccccxci. Amongft the ftimuli that may be directly appled to the inteftines, and which by increafing their periftaltic motion, may occafion dirrhcea, I muft not omit to mention worms, as having frequently that effect. mccccxcii. I muft alfo mention here a ftate of the in- teftines, wherein their periftalatic motion is preternatur- ally increafed, and a diarrhoea produced; and that is, when they are affected with an erythematic inflamma- tion. With refpect to the exiftence of fuch a ftate, and its occafioning diarrhoea, fee what is faid in cccxcvm. and following. Whether it is to be confidered as a par- ticular and diftinct cafe of diarrhoea, or is always the fame with fome of thofe produced by one or other of the caufes above mentioned, I have not been able to deter- mine. mccccxciii. Laftly, by an accumulation of alimentary or of other matter poured into the cavity of the inteft- ines from feveral of the fources above mentioned, a diar- rhoea may be efpecially occafioned when the abforption PRACTICE OF PHYSIC." 5*9 '«f thelacteals, or of other abforbents, is prevented eith- er by an obftruction of their orifices, or by an obftruc- tion of the mefenteric glands, through which alone the abforbed fluids can be tranfmitted. In one inftance of this kind, when the chyrle prepared ih 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 the Morbus Ccdiacus, or fimply and more properly Cceliaca ? •which accordingly I have confidered as a fpecies of diar- rhoea. mccccxciv. I have thus endeavored to point out the various fpecies of difeafe that may come under the gen- eral appellation of Diarrhoea ; and from that enumera- tion it will appear, that many, and indeed the greater part of the cafes of diarrhoea, are to be confidered as fympathic affections, and to be cured only by curing the primary difeafe upon which they depend; of which however I cannot properly treat here. From our enu- meration it will alfo appear, that many of the cafes of diarrhoea which may be confidered as idiopathic, will not require my faying much of them here. In many in- ftances the difeafe is afcertained, and alfo the caufe af- figned, by the condition of the matter evacuated; fo that what is neceffary to correct or remove it, will be fufficiently obvious to practitioners of any knowledge. In fhort I do not find that I can offer any general plan for ; the cure ©f diarrhoea ; and all that I can propofe to do on this fubject, is to give fome general remarks on the practice that has been commonly followed in the cure of this difeafe. mccccxcv. The practice in this difeafe has chiefly pro- ceeded upon the fuppofition of an acrimony in the flu- ids, or of a laxity in the fimple and moving fibres of the inteftines ; and the remedies employed have accord- ingly been correctors of particular acrimony, general demulcents, evacuants, by vomiting or purging, aftrin- gents, or opiates. Upon each of thefe kinds of remedy 1 fhall now offer fome remarks. j*6 PRACT.CE OF PHYSIC. mccccxcvi. An 'acrid acrimony is, upon feveral occa- fions, the caufe of diarrhoea, particularly in children ; ancf ia fuch cafes theabforbent earths have been very proper- ly employed. The common, however, and promifcuous ufe of thefe has been very injudicious; and where there is any putrefcency, they muft be hurtful. mccccxcvii. The cafes in which there is a putrid of putrefcent acrimony prevailing, have been, I think, too feldom taken notice of ; and therefore the ufe of acids too feldom admitted. The acrimony to be fufpected in bilious C3fes, is probably of the putrefcent kind. mccccxcviii. The general correctors of acrimony are the mild diluents and demulcents. The former have not been fo much employed in diarrhoea as they ought ;» for, joined with demulcents, they very much increafe the effects of the latter : and although the demulcents, both mucilaginous and oily, may by themfelves be ufeful yet without the affiftance of diluents, they can hardly be introduced in fuch quantity as to anfwer fhe purpofe. mccccxcix. As indigeftion and crudities prefent in the ftomach, are fo often the caufe of diarrhoea, vomiting muft therefore be frequently very ufeful in this difeafe.' In like manner, when the difeafe proceeds, as it often does, from obstructed perfpiration, and increafed afflux of fluids to the inteftines, vomiting is perhaps the moft effectual means of reftoring the determination of the flu- ids to the furface of the body. It is poflible alfo, that vomiting may give fome inver- fion of the periftaltic motion, which is determined too much downwards in diarrhoea ; fo that upon the whole it is a remedy which may be very generally ufeful in this difeafe. md. Purging has been fuppofed to be more univerfally / neceffary, and has been more generally practifed. This however, in my opinion, proceeds upon very miftaken notions with refpect to the difeafe ; and fuch a practice feems to me for the moft part fuperfluous, and in many cafes very hurtful. It goes upon the fuppofition of ah acrimony prefent in the inteftines that ought to be carri- " ed out by purging : but, if that acrimony has either been PRACTICE OF PHYSIC. introduced by the mouth, or brought into the inteftines from other parts of the body, purging can neither be a means of correcting nor of exhausting it; and muft rath- er have the effect of increafing its afflux, and of aggrava- ting its effects. From whatever fource the acrimony which can excite a diarrhoea proceeds, it may be fuppofed fufficient to evacuate itfelf, fo far as that can be done by purging ; and as in cholera, fo in the fame kind of diar- rhoea, it will be more proper to aflift the evacuation by diluents and demulcents, than to increafe the irritation by purgatives. mdi. If, then, the ufe of purgative in diarrhoea may be^ confidered, even when an acrimony is prefent, as fuper- fluous, there are many other cafes in which it may be ; extremely hurtful. If the irritability of the inteftines , fhall, from affections in other parts of the fyftem, or r 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 improper. I have already obferved, that [when diarrhoea proceeds from an afflux of fluids to the inteftines, whether in too great quantity, or of an acrid Quality, purgatives may be hurtful ; and whoever there* fore, confiders the numerous and various fources from . which acrid matter may be poured into the cavity of the inteftines, will readily perceive, that in many cafes of di- arrhoea, purgatives may be extremely pernicious. « There is one cafe in particular to be taken notice of. I When, from a general and acrid diffolution of the blood, the ferous fluids run off too copioufly into the cavity of the inteftines, and excite that diarrhoea which attends the , advanced ftate of hectic fever, and is properly called a Colliquative Diarrhoea; I have, in fuch cafes often feen purgatives given with the moft baneful effects. There is ftill another cafe of diarrhoea in which purga- tives are pernicious ; and that is, when the difeafe de- pends, as we have alleged it fometimes may, upon an e- \ rythematic inflammation of the inteftines. ci% PRACTICE O^ PHYSIC. ... r> I need hardly add, that if there be a cafe of diarrhoea depending upon a laxity of the folids, purgatives cannot there be of any fervice, and may do much harm. Upon the whole, it will f think, appear, that the ufe of purga- tives in diarrhoea is very much limited ; and that the promifeuous ufe of them, which has been fo common, is injudicious, and often pernicious. I believe the practice has been chiefly owing to the ufe of purgatives in dyfen- teric cafes, in which they are truely ufeful ; becaufe, con- trary to the cafe of diarrhoea, there is in dyfentery a confiderable conftriction of the inteftines. • mdii.'. Another fet of remedies employed in diarrhoea are aftringents. There has been fome hefitation about the employment of thefe in recent cafes, upon the fup- pofition that they might occafion the retention of an a- crid matter that fliould be thrown out. I cannot, how- ever, well underftand or aflign the cafes in which fuch caution is neceffary ; and I think that the power . of af- tringents is feldom fo great as to render their ufe very . dangerous. The only difficulty which has occurred to me, with refpect 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 depends upon a lofs of tone : and this, I think, may occur either from the debility of the whole fyftem, or from caufes acting on the inteftines alone. All violent or long continued fpafmodic and convulfive affections of the inteftinal canal neceffarily induce a de- bility there ; and fuch caufes often take place, from vio- lent irritation, in colic, dyfentery, cholera, and diarrhoea. mdiii. The laft of the remedies of diarrhoea that re- main to be mentioned are opiates. The fame objections have been made to the ufe of thefe, in recent cafes of diarrhoea, as to that of aftringents ; but on no good grounds; for the effect of opiates, as aftringent is never very permanent ; and an evacuation depending upon irri- tation, though it may be for fome time fufpended by o- piates, yet always returns very foon. It is only by tak- ing off irritability that opiates are ufeful in diarrhoea; , and therefore, when the difeafe depends upon an increafe ' PRACTICE OF PHYSIC. 5^3 of irritability alone/or when, though proceeding from ir- ritation, that irritation is corrected or exhaufted, opiates are the moft ufeful and certain remedy. And though opiates are not fuited to correct or remove an irritation applied, they are often of great benefit in fufpending the effects of that irritation whenever thefe are violent : and, upon the whole, it will appear, that opiates may be very frequently, and with great propriety, employed in the •ure of diarrhoea. CHAP. XII. OF THE DIABETES*. mp iv. This difeafe confifts in the voiding of an unufually large quantity of urine. As hardly any fecretion can be increafed without an increafed action of the veffels concerned in it, and as fome inftances of this difeafe are attended with affections manifeftly fpafmodic, I have had no doubt of arranging the diabetes under the order of Spafmi. mdv. 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 j 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. mdvi. The urine voided in this difeafe is always very clear, and at firft fight appears entirely without any col. or ; but, viewed in a certain light, it generally appear* to be flightly tinged with a yellowifh green, and in this * As the nature of this complaint has been of late much illuftrated, and its pathognomic fymptonis more attended to, I feleft the following defimtwa from Dr. Rollo : . Art infatiable de&re of food; perpetual thirft ; the urine increafed m quantity, and fweetifh, pulfe frequent j heat ^little incrwftd; ikin dry with emaciation. 5W ■ PRACTICE OF PHYSIC. refpect has been very properly compared to a folution o.c honey in a large proportion of water. Examined by the tafte, it is very generally found tc be more or lefs fweet; and many experiments that have now been made in different inftances of the difeafe, fhow clearly that fuch urine contains, in confiderable quantity, a faccharine matter, which appears to be very exactly of the nature of common fugar. mdvii. Doctor Willis feems to me to have been the firft who took notice of the fweetnefs of the urine in di- abetes, and almoft every phyfician of England has fince taken notice of the fame. It is to be doubted, indeed, if there is any cafe of idiopathic diabetes in which the u- rine is of a different kind. Though neither the ancients, nor, in the other countries of Europe, the moderns, till the latter were directed to it by the Englifli, have taken notice of the fweetnelsof the urine, it does not perfuade me, that either in ancient or in modern times the urine in diabetes v/as of another kind. Imyfelf, indeed, think I have'} $ met with one inftance of diabetes in which the.urine was perfectly infipid ; and it would feem that a like obferva- tion had occurred to Dr. Martin Lifter. I am perfua- ded, however, that fuch inftances are very rare ; and that the other is by much the more common, and perhaps thealmofi univerfal occurrence. I judge, therefore, that the prefence of fuch a faccharine matter may be confid- ered as the principal eircumftance in idiopathic diabetes; ,1 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 1 am further to mention relates to fuch a cafe. mdvIii. The antecedents of this- difeafe; and confe- quently the remote caufes of it, have not been well af- certained. It may be'true that it frequently happens to men who, for a long time before, had been intemperate in drinking ; that it happens to perfons of a broken con- ftitution, or who," as we often exprefs it, are in a cachec- tic ftate ; that it fometimes follows intermittent fevers ; and that it has often occurred from excefs in the drink- ing of mineral waters. But none of thefe caufes apply very generally to the cafes that occur: fuch caufes are not always, nor even frequently, follpwed by a diabetes;. a PR/lCTlCE OF PHYSIC. 51J i.nd 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 a- ny particular caufe. mdix. This difeafe commonly comes on flowly, and almoft imperceptibly, without any previous diforder. It often arifes to a confiderable degree, and fubfifts long without being accompanied with evident diforder in a« ny particular part of the fyftem. The great thirft which always, and the voracious appetite which frequently oc- curs in it, arc often the only remarkable fymptoms. Under the continuance of the difeafe, the body is often greatly emaciated; and a great weaknefs alfo prevails. The pulfe is, commonly frequent ; and an obfcure fever is for the moft part prefent; When the difeafe proves fatal, it generally ends with a fever, in many circumftan- ces, particularly thofe of emaciation and debility, refem- bling a hectic. j mdx. The proximate caufe of this difeafe is not cer- tainly or clearly known. It feems to have been fometimes connected with calculous affections of the kidneys; and it is poflible, that an. irritation applied there may increafe the fecretion of urine. It perhaps often does fo; but how it fhould produce the lingular change that takes place in the ftate of the urine, is not to be eafily explained. It cer- tainly often happens that calculous matters are long pref- ent in the urinary paffages, without having any fuch ef- fect as that of producing diabetes in any fhape. Some have fuppofed that the difeafe occurs from a re- laxed ftate of the fecretory veffels of the kidneys ; and indeed the diffections of perfons who had died of this dif- eafe have fhown the kidneys in a very flaccid ftate. Thisr however, is probably to be confidered as rather the effect than the caufe of the difeafe. : That no topical affection of the kidneys has a fhare in producing this difeafe, and that a fault in the aflimilation 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* jafi- PRACTICE OF PHYSIC. r.iDxi. The diabetes has been fuppofed to be owing tOv a certain ftate of the bile ; and it is true, that this difeafe has fometimes occurred in perfons who were at the fame time affected with difeafes of the liver : but this concur- rence does not often take place ; and the diabetes fre- quently occurs feparately from any affection of the liv- er. In.twenty inftances of diabetes which I have feen there was not in.any-one of them,' any evident affection of the liver. The explanation that has been offered of the nature and operation of the bile, in producing diabetes, is very hypothetical, and no ways fatisfying. Mbxh. As I have already faid, I think it probable, that in moft cafes the proximate caufe of this difeafe is fome fault in the aflimilatory powers, or in thofe employed in converting alimentary matters into the proper animal fluids. This I formerly hinted to Dr. Dobfon, and it has been profecuted 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. mdxiii. The proximate caufe of diabetes being fo lit- tle known or afcertained, I cannot propofe any rational method of cure in the difeafe. From the teftimony of feveral authors, I believe that the difeafe has been cur- ed: but I believe alfo, that this has feldom happened ; and when the difeafe has been cured, I doubt much if It was effected by the feveral remedies to which thefe cures have been afcribed. In all the inftances of this difeafe which V myfelf have feen, and in feveral others of which I have been-informed;, no cure of it has ever been madek in Scotland, though'many inftances of it have occured; and in moftof them the remedies recom- mended by authors have been diligently employed. I cannot, therefore, with any advantage, enter into a de- tail of thefe remedies ; and as the difeafe, together with its feveral-circumftances, when they fhall hereafter oc- cur, is likely to become the fubject of diligent inveftiga- tton, Iavoid going farther at prefent, and judge it pru- dent to fufpend my opinion till I fhall have more obfer- vations and experiments upon which I can form it more dearly. NOTE ON DIABETES, X he attention of the medical world has of late been forcibly called to this difeafe, by a new and fuccefsful method of cure, propofed by fDr. Rollo, who, in a learned and ingenious publication onthisfubjeft, ha* endeavored to eftablifh a new and highly plaufible theory of Diabetes, found- ed on powerful fafts, and fupported by its application to practice. We cannot do better than ftate his theory of the proximate caufe of this difeafe in his own words : " The proximate caufe of the Diabetes Meliitue, frems to " us to confift in a morbidly increafed adtion of the ftomach, with confequent " fecretion, and vitiation of the gaftric fluid, marked by an eagernefe of ?.p- " petite and acidity ; thedireft effects of which are the formation or evolu- " tion of faccharine matter, with a certain defedt of affimilation, preventing " the healthy combinations, and exciting the immediate feparation of the im- « perfectly formed chyle by the kidneys. The more remote confequences " will be fi'.ch changes in the natural ftruclure of the ;parts, as may prevent " the entire reftoration of health." In al*oft every Cale of diabetes, a vorac- ity of appetite is amongft the firft fymptoms; hence we Ihould be led to fufpedt a derangement of the organs of affimilation, rather than any primary morbid affection of the kidneys ;as in the latter cafe, this infatiable appetite, if it occurred at all, Ihould follow and not precede the formation of the dif- eafe. The fympathy of the ftomach with the kidneys is well known ; and anorexia, inftead of infatiable-appetite, is the general confequence of the dif- eafes of the latter. It has been objected, that faccharine matter has net been detected in the blood. Although, however, the experiments of late made to decide this point, have not actually afceitained the prefence of fugar in the blood, they have fliown that it deviates not a little from the healthy ftate. Dr. Rollo found that the blood taken from a diabetic patient, did not under- " go the ufual putrefactive procefs, unlefs the throwing out a flight animal " fmell for two or three day*, with a mould on the furfaceof the craffa- « mentum, be fuppofed marks of it." This certainly denotes that it was not properly animalized, and that it approached fomewhat a vegetable ra- ture. Dr. Dobfon affirms, that he did deteel faccharine matter in the blood of a diabetic patient; and, although others have not been equally fuccefsful, their failure does not difprove the fa a he has adduced. It is likewife eafily conceivable, how a fmall quantity of fugar, when blended with fuch a large mafs of fluid as the blood, may efcape detection: yet. when collected in the bladder, which is the proper refervoir for fuch cxcrerrentitious mailers, it be- comes raanifeft. It appears likewife, from experiments made by Dr. Rollo and Mr. Cruickftianks, by mixine certain quantities of fugar with blood, " that fugar, and the pureft diabetic extract, may be contained in the ferum "of the blood, without being detected by the tafle ; that with a certain « quantity of the former, it goes through fermentative changes ; and tha: • it PRACTICE OF PHYSIC. " it is probable, in two or three ounces of diabetic ferum from blood, taken " at a proper time after eating, the faccharine matter might be obtained." Betides, the kidneys are to be confidered not as fecreting organs, but as mere filters, deftined to feparate the excrementitious part of the blood ; hence the probability of their being fo modified in their action as to form faccharine matter, is much invalidated. It has been afferted, that Diabetes has been produced by injuries received on the region of the kidneys. It is probable, however, and in many cafes it has been afcertained, that the difeafe produced by this caufe is the Diabetes Infipidus, which appears to differ effentially from the Diabetes Mellitus. The obfervation, that the Mellitus has been marked to have paffed into thp Insipidus, does not militate againft this conclusion as we can eafily underftand how the unufual irritation of faccharine matter may produce fuch derang. ment in the ftructure of the kidneys, as may continue the increafed flow of the urine, after the caufe which firft excited it is removed. It is likewife to be obferved, that we cannot eafily account for the fudden ceffation of the difeafe froma'diet of animal food, upon any other principle than its counteracting the formation or evolution of faccharine matter in the ftomach. The faccharine qualities of the fugar will often di(- appear in two or three days after having recourfe to animal food. The fol- lowing, then are the facts which are thus briefly ftated by Dr. Rollo in fup- port of this doctrine : ifl," That a ftomach affection generally precedes the urinary characterise " fymptoms of the difeafe. zdly, " That a ftomach affection always attends the difeafe, which materi- *' ally differs from that, fympatnetic of primary kidney affection. 2,dly," That a diet of animal food, wi'h an entire abftinence from vegeta- *' ble, or other matter capable of forming fugar in the ftomach, removes *' fpeedily the general fymptoms ; the facchaiino matter, the quantity of the " urine, and its unnatural ftate. 4thly, " That diffection has fliown'no morbid condition of the kidneys, " but what may be referable to a continuance of increafed action, from the "application of a fimple ftimulus, and probably fympathy, augmenting " merely the capacity of the veffels." The indications of cure which Dr. Rollo has eftablifhed, as founded on his experience, and on his idea of the proximate caufe of Diabetes, are, ifl, To prevent the formation or evolution of faccharine matter in the ftomach. And, zdly, To remove the morbidly increafed atlion of the ftomach, and r ft ore it to a healthful condition. As the morbid action of the ftomach feems to be of fuch a nature as to produce faccharine matter from vegetables, they are to be ftrictly prohibited, and animal food alone is to be allowed. Rancid meat, old animal fats, anil pork, are to be preferred, when th^e patient can be perfuaded to perDft in their ufe, as, by more quickly deftroying the action of the ftomach, they fooner remove the difeafe. The drink fhould confift of water which has been boiled, or a decoction of beef or mutton. As little exercife as peffitle is to be recommended. When the patient, from his former habits, feels languid and uneafy from drinking water alone, a little brandy may be added to it. All feafoning or condiments, except a little fait, fhould be avoided. Various medicines have been employed with a view of diminifhing the morbidly in- creafed action of the ftomach. Dr. Rollo found the hepatifed ammonia* powerful auxiliary in this refpect. It is made by paffing a ftream of ful- phurated hydrogen gas, through the aq. amnion, pur. until it takes up no more, or until the alkali is faturated. The fulphurated hydrogen ga« may be obtained from artificial pyrites, or fulphuvet of iron, diflbived in the muriatic acid. Mr. Cruickfhanks defcribes the following method of pre- paring it: " The eafieft method of making the artificial pyrites, is to raift; " a piece of iron, in a fmith's forge, to a white heat, and then to rub ir ?.- PRACTICE OF PHYSIC. 'S*9 . "gainft iheend ofaroll of fulphur ; the iron, at this temperature, immediate- ** ly combines with the fulphur, and forms globules of pyrites, which fhould *' be received into a veffel, filled with water ; thofe globules are to be reduc- " ed to powder, and introduced into the proof, to which a fcfficient quantity " of the muriatic acid is to be added. " The dofe to an adult fhould not at firft exceed five or fix drops, to be " given three or four times a day ; and-this dofe to be increafed, fo as to " produce flight giddinefs ; but, as it is very powerful, and, in large dofes, " a dangerous medicine, great caution fhould be ufed in its exhibition." :Asit appears from the ingenious experiments of Mr. Cruickfhanks on fugar that the pure alkalis, lime water, and the different fulphureti, counteract the formation of fugar, thefe have been employed in Diabetes with consid- erable advantage. A drachm of the kali fulphuratum, diffolved in four quarts of water, may be ufed for common drink. Emetics, as inducing fickr.e.rs,anddiftujbing the ufual action of the ftomach •have been employed with advantage. Opium likewife, as deftroying the morbid appetite, has produced the beft effects. It is, upon the whole, to be obferved, that, although there are many well authenticated cafes, where the animal diet performed a cure, it appears in other cafes to have failed. However,* from the extrerre reluctance with which patients are perfuaded to perfevere in this regimen, it is not eafy to af- certain whether the failure was to be afcribed to the inveteracy of the difeafe, or to the want of refolution in the patients to perfift in fuch an ungrateful scurfefor a fufficient length of time. 4 53» PRACTICE OF PHYSIC. CHAP. XIII. OF THE HYSTERIA*, OR THE HYSTERIC DISEASE. mdxiv. 1 he many and various fymptoms which have been fuppofed to belong to a difeafe under this ap- pellation, render it extremely difficult to give a general character 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 No- fology, and fhall here endeavor to illuftrate it by giving a more full hiftory of the phenomena. mdxv. The difeafe .attacks in paroxyfms or fits. Thefe commonly begin by fome pain and fulnefs felt in the left iide of the belly. From this a ball feems to move, with a grumbling noife, into the other parts of the belly, and making as it were various convolutions there, feems to move into the ftomach; and more diftinctly ftill rifes up to the top of the gullet, where it remains for fome time, and by its preffure upon the larynx gives a fenfe of fuffocation. By the time that the difeafe has proceed- ed thus far, the patient is affected with a ftupor and infenfibility, while at the fame time the body is agitat- ed with various convulfions. The trunk of the body is writhed to and fro, and the limbs are varioufly agitated ; commonly the convulfive motion of one arm and hand, is that of beating, with the clofed fift, upon the breaft very violently and repeatedly. This ftate con- tinues for fome time, and has during that time fome re- miflions and renewals of the convulfive motions ; but they at length ceafe, leaving the patient in a ftupid and * Grumbling of the belly ; a fenfation as if a ball were moving up and down the abdomen, and then afending to the ftomach and fauces, and there exciting a fenfe of fuffocation; infenfibility ; convulfions ; a flow of limpid urine j great mobility of mind. Syn. Nof. PRACTICE QF PHYSIC 33* feemingly fleeping ftate. More or lefs fuddenly, and fre- quently with repeated fighing and fobbing, together with a murmuring noife in the belly, the patient returns to the exercife of fenfe and motion, but generally without any recollection of the feveral circumftances that had taken place during the fit. mdxvi. This is the form of what is called an hyfteric paroxyfm, and is the moft common form ; but its parox- yfms are confiderably varied in different perfons, and e- yen in the fame perfon at different times. It differs, by having more or fewer of the circumftances above men- tioned ; by thefe circumftances being more or lefs vio- lent ; and by the different duration of the whole fit. Before the fit, there is fometimes a fudden and unu- fually large flow of limpid urine. At the coming on of the fit, tlqte ftomach is fometimes affected with vomiting, the lungs with confiderable difficulty of breathing, and the heart with palpitations. During the fit, the whole of the belly, and particularly the navel, is drawn ftrong- ly inwards ; the fphincter ani is fometimes fo firmly con- stricted as not to admit a finall glyfter pipe, and there is at the fame time an entire fuppreffion of urine. Such fits are, from time to time, ready to recur ; and during the intervals, the patients are liable to involuntary mo- tions, to fits of laughing and crying, with fudden tran- iitions from the one to the other; while fometimes falfe imaginations, and fome degree of delirium, alfo occur. mdxvii. Thefe affections have been fuppofed peculiar to the female fex ; and indeed they moft commonly ap- pear in females ; but they fometimes, though rarely, at- tack alfo the male fex ; never, however, as I have obferv- ed, in the fame exquifite degree. In the female fex the difeafe occurs especially 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 exquifitcly fanguine and plethoric habits, and fre- 53* PRACTICE OF PHYSIC. quently affects thofe of the moft robuft and malculint conftitutions. It affects the barren more than the breeding women, and therefore frequently young widows. It occurs efpecially in thofe females who are liable to the Nymphomania ; and the Nofologifts have properly enough marked one of the varieties of this difeafe by the title of Hifteria Libidinofa. In the perfons liable to the fits of this difeafe, it is read- ily excited by the paffions of the mind, and by every confiderable emotion, efpecially thofe brought on by fur- prife. The perfons liable to this difeafe acquire often fuch a degree of fenfibility, as to be ftrongly affected by every impreflion that comes upon them by furprife. mdxviii. In this hiftory, there appears to be a concur- rence of fymptoms and circumftances properly marking a very particular difeafe, which I think may be diflim guifhed from all others. It feems to me to have been improperly confidered by phyficians as the fame with fome other difeafes, and particularly with hypochondri- afis. The two difeafes may have fome fymptoms in com- mon, but for the moft part are confiderably different. Spafmodic affections occur in both difeafes; but nei- ther fo frequently, nor to fo great a degree in hypochon- driafis as in hyfteria. Perfons liable to hyfteria are fometimes affected at the fame time with dyfpepfia. They are often, however, entirely free from it ; but I believe this never happens to perfons affected with hypochondriafis. Thefe different circumftances mark fome difference in the two difeafes ; but they are ftill more certainly dif- tinguifhed by the temperament they attack and by the time of life at which they appear to be moft exquifitely formed. It has been generally fuppofed, that the two difeafes differ only in refpect of their appearing in different fex- es : but this is not well founded : for although the hyf- teria appears moft commonly ia females, the male fex is not absolutely free from it, as I have obferved; above and PRACTICE OF PHYSIC. Sji although the hypochondriafis may be moft frequent in men the inftances of it in the female fex are very com- mon. mdxix. 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 im- propriety, that almoft every degree of the irregular mo- M tions of the nervous fyftem has been referred to the one or other of thefe two difeafes. Both are marked by a J, peculiarity of temperament, as well as by certain fymp- toms commonly accompanying that ; but fome of thefe, , and many others ufually marked by the name of nervous J, fymptoms, may, from various caufes, arife in tempera- s-men ts different from that which is peculiar to either hyf- |teria or hypochondriafis, and without being joined with . the peculiar fymptoms of either the one or the other ['-difeafe : fo that the appellations of Hyfteric and Hy- pochondriac are very inaccurately applied to them. Un- der what View thefe fymptoms are otherwife to be con- sidered, 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. ■> mdxx. Having thus endeavored to diftinguifli hyfter- ia from every other difeafe, 1 fhall how attempt its pecu- r liar pathology. With refpect to this, I think it will, in 1 the firft place, be obvious, that its paroxyfms begin by a { convulfive and fpafmodic afleetion of the alimentary ca- nal, which is afterwards communicated to the brain, and to a great part of the nervous fyftem. Although the difeafe appears to begin 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, shows, that phyficians have at all times judged rightly in confidering this difeafe as an af- fection of the uterus and other parts of the genital fyf- tem. mdxxi. With regard to this, however, I can go no ; farther. In what manner the uterus, and in particular the ovaria, are affected in thris difeafe ; how the affection of thefe is communicated with particular circumftances to £o* PRACTICE OF PHYSIC. the alimentary canal ; or how the affection of this, ril- ing upwards, affects the brain, fo as to occafion the par- ticular convulfions which occur in this difeafe, I cannot pretend to explain. But although I cannot trace this difeafe to its firft cauf- es, or explain the whole of the phenomena ; I hope, that with refpect to the general nature of the difeafe, I may- form fome general conclusions, which .may ferve to di- rect our conduct in the cure of it. mdxxii. Thus, from a confideration of the predifpo- nent and occafional caufes, it will I think, appear, that the chief part of the proximate caufe is a mobility of the fyftem, depending generally upon its plethoric ftate. mdxxiii. Whether this difeafe ever arifes from a mo- bility of the fyftem, independent of any plethoric ftate of it, I cannot pofitively determine; but in many cafes that have fubfifted for fome time, it is evident that a fenfibilr ity, and confequently a mobility, are acquired, which of- ten appear when neither a general plethora can be fup- pofed to fubfift, nor an occafional turgefcence to have happened. However, as we have fliown above, that a diftenfion of the veffels of the brain feems to occafion epilepfy, and that a turgefcence of the blood in the vef- fels 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 oc- cafion the fpafmodic and convulfive motions which ap- pear in hyfteria. It will at the fame time be evident, that this affection of the genitals muft efpecially occur in plethoric habits; and every circumftance mentioned in the hiftory of the difeafe ferves to confirm this opim ion with refpect to its proximate caufe. mdxxiv. From this view of the fubject, the analogy of hyfteria 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 directions, with regard to the choice and employment of thefe remedies, that Ir.ve PRACTICE OF PHYSIC. 5i'i been delivered above on the fubjett of epilepfy, will ap- ply pretty exactly to hyfteria ; and therefore need not be repeated here. CHAP. XIV. OF CANINE MADNESS AND HYDROPHOBIA*.' mdxxv. This difeafe has been fo exactly arid fully defcribed in books that are in every body's liands, that it is on no account neceffary for me to give any hiftory of it here ; and with refpect to the pa- thology of it, 1 find that I can fay nothing fatisfyirig to myfelf, or that I can expeft to prove fo to others. T find alfo, with refpect to the cure of this difeafe, that there is no fubject in which the fallacy of experience ap- pears more ftrongly than in this. From the moft an- cient to the prefent times, many remedies for prevent- b ing and curing this difeafe have been recommended \ tinder the fafcctiori of pretended experience, and have perhaps alfo kept their credit for fome time : but fuc- ' eeeding 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 neglect; In the prefent age, fome new remedies k'have been propofed, and have experience alleged to vouch for their efficacy j but many doubts ftill remain with refpect to this : and though I connot determine i; in this matter from my own experience, I think it incum- bent on me to give the beft judgment I can form with refpefr to the choice of the remedies at prefent recom- mended. * Horror and averfion to any drink, exciting painful convulfion of the pharynx; generally arifing from the bite of a mad animal. Spec. 1. Hydrophobia Rabiofa, with a defireto bite, from the bite of a mad animal. . j„r.« ♦« u;»- Spec. %, Hydrophobia Simplex, without rage or any denre to bite. Syn. Nof. •36 PRACTICE OF PHYSIC. * ! . fidxxvi. I am, in the firft place, firmly perfuaded, ] that the moft certain means of. preventing the confer quences 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 effectual when it is done \ very foon after the wound has been made, and they therefore neglect it when this opportunity is miffed. There have been, however, no experiments made proper to determine this matter ; and there are many confid- erations which lead me to think that the. poifon is not immediately communicated to the fyftem ; and there-, fore, that this meafure of deftroying the part may be practifed with advantage, even many days after the bite has been given. mdxxvu. WhiKt the ftate of our experience, with.- refpect to feveral remedies now in ufe, is uncertain, I, cannot venture,to affert that any of thefe is abfolutety, $ ineffectual ; ,but I can give it as my opinion, that the efficacy of mercury, given very largely, and perfifted in, for a long time, both as a means of preventing the dif*-„ eafe, and of curing it when it has actually come on, is, better fupported by experience than that of any other j remedy now propofed, or commonly employed. BOOK IV. OF V E S A N I M.- OR OE the Disorders of the intellectual func- tions. chap, r. OF VESANIA IN GENERAL." mdxxviii. The Nofologifts, and Sauvages and 3agar, in a clafs of difeafes under the title of Vesanle, have comprehended the two orders of Hallucinations, or Falfe Preceptions, and of Morofitates, or Erroneous Ap- petites 'and Paflions ; and in like manner, Linnaeus in his clafs of Mentales, cofrefponding to the Vefaniae of Sauvages, has comprehended the two orders of Imaginarii and Pathetici, nearly the fame with the Hallucinationes and Morofitates of that author. This, however, from feveral confiderations, appears to me improper ; and I have therefore formed a clafs of Vefaniae, nearly the fame with the Paranoiae of Vogel, excluding from it the Hallucinationes and Morofitates, which I have referrd Jo the Morbi Locales. Mr. Vogel has done the like, in feparating from fhe Paranoise the falfe perceptions and * Diforders of thefunflions of the judgment, without pyrexia or coma Syn. Nof. •;38 PRACTICE OF PlIYSiC. erroneous appetites; and has thrown thefe into anoth- er clafs, to which he has given the title of Hyperasfthe- fes. rioxxix. It is indeed true, that certain hallucinationes and morofitates are frequently combined with what I propofe tO'Confider as ftrictly a vefania, or an erroneous judgment; and fometimes the hallucinationes feem to lay the foundation of, and to form almoft entirely the vefania. But as moft part of the hallucinationes enume- rated by the Nofologifts are affections purely topical, and induce no other error of judgment befide that which re- lates to thefingle object of the fenfe or particular organ affected ; fo thefe are certainly to be feparated from the difeafes which coniiit in a more general affection 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 a- rife from the fame caufe as the more general affection of the judgment:, they are therefore to be confidered as fymptoms of this only.' -f, In like manner I judge with refpect to the morofitates, or erroneous paffions that accompany vefannia; which,.' as 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 affection 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 vefaniae, confidered as primary difeafes. The limitation therefore of the clafs of vefaniae to the lefion of our judging faculty, feems from every con- fideration to be proper. The particular difeafes t© be comprehended under this clafs, may be diftinguifhed according as they affect per- fons in the time of walking or of sleeping. Thofe which affect men awake," may again be confidered, as they con- fift in an erroneous judgement, to which I fhall give the .~>.<4 PRACTICE OF PHYSIC. S39 appellation of Delirium ; or as they confift in a weaknefs Or imperfection of judgment, which I fhall name Fatuity, X begin with the confideration of Delirium. mdxxx. As men differ greatly in the foundnefs and force of their judgment, fo it may be proper here to afcertain more precifely what error or imperfection 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 or judgment, under the general appellation of Delirium, "which has been commonly employed to denote every mode of fuch error. . . .r mdxxxi. As our judgment is chiefly exercifed in dif- cerning and judging of the feveral relations of things, I apprehend that delirium may be defined to be,—-In a per- fon awake, a falfe or miftaken judgment of thofe rela- tions 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 judg- ment is very different from what the perfon himfelf had before ufually formed. mdxxxh. With this miftaken judgment of relations, there is frequently joined fome falfe perceptions of ex- ternal objects, 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 the brain, prefenting objects which are not actually prefent. Such falfe perceptions muft neceffarily Occafion a delirium, or an eroneous judg- ment, which is to be confidered as the difeafe. mdxxxiii. Another circumftance, commonly attend- ing delirium, is a very unufual affociation of ideas. As, with refpect 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 affociation in the memory: and therefore this unufual, and commonly hurried, affociation of ide- as, ufually K and may be confidered as a part of dehn- 54» PRACTICE OF PHYSIC. um. In particular it may be confidered as a certain mark of a general morbid affection of the intellectual organs, it being an interruption or perversion, of the or- dinary operations of memory, the common and neceffa- ry foundation of the exercife of judgment. mdxxxiv. A third circumftance attending delirium, is an emotion or paflion, fometimes of the angry, fome- times of the timid: kind ;. and, from whatever caufe in the perception or judgment, it is not proportioned to fuch caufe, either in the manner formerly cuftomary to the perfon himfelf, or in the manner ufual with the gen- erality of other" men. mdxxxv. Delirium, then, may be more shortly de- fined—In a-perfon awake, a falfe judgment arifing from perceptions of imagination, or from falfe recollection, and cammonly producing difproportionate emotions. Such delirium is of two'kinds; as it is combined with ■ pyrexia and coirtatofe affections; or, as it is entirely without any fuch combination. It is the latter cafe that we name Infinity ; and it is this kind of delirium only, that I am to treat of here.' mdxxxvi. Infanity may perhaps be properly confider- ed as a; genus" comprehending many different fp'ecies, each of which may deferve our attention ; but beforfe proceeding to the confideration of particular fpecies, I think it proper1 to- attempt an inveftigatio'n of the caufe of infanity in general;: mdxxxvii. In doing this, rfhalf take it for granted, as- demonftrated elfewhere, that although this difeafe feems to be chiefly, and fometimes' folely, an affection of the mind ; yet the connection between the mind and body in this life is fuch, that thefe affections-of the mind' muft be confidered as depending upon a certain ftate of our corporeal part. See Halleri Prim. Lin. Phyfiolog. § dlxx. See Boerhaavii Inft. Med. § dlxxxi. dcxcvi. mdxxxviii. Admitting this propofition, Lmuft in the next place affume another, which Tlikewife fuppofe to be demonstrated elfewhere. This is, that the part of our body more immediately connected with the mind, and therefore more efpecially concerned in every affection PRACTICE OF PHYSIC. J4« of the intellectual fundions, is the common origin of the nerves ; which I fhall, in what follows, fpeak ot under the appellation of the Brain. mdxxxix.. Here, however, in affuming this laft prop- ofition, a very great difficulty immediately prefents it- felf. Although we cannot doubt that the operations of our intellect always depend upon certain motions tak- ing place in the brain, (fee Gaub. Path. Med. §523.) ; yet.thefe motions have never been the objects of our fenfes, nor have.we been able to perceive that any par- ticular part of the brain has more concern in the opera- tions of our intellect than any. other.. Neither have we attained any knowledge, of what fhare the feveral parts of .the brain have in that operation,; and, therefore, in this fituation of our fcience, it muft be a very difficult matter to difcover thofe ftates of the brain that may give occafion to the various ftate of our intellectual func- tions. ..,<.'■■ ;. mpxl. It may be, obferved, that the different ftate of (he motion of the blood.in the veffels of the brain, has fome fhare in affecting the operations of the intellect ; and phyficians, in feeking for.the caufes of the different ftates of our intellectual functions, have hardly looked further than into the ftate of the motion of the blood, or into the condition of the jDlood itfelf ; but it is e vident that the operations of the intellectual functions ordinarily go on, and are often confiderably varied, without our be* ing able to perceive any difference either in the motions or in ,the condition of the blood. mdxu. Upon the other hand, it is very probable that the ftate of the intellectual functions depends chiefly u;pon the ftate and condition of what is termed the Ner- vous power, or, as we fuppofe, of a fubtile very moveable fluid, included or inherent, in a manner we do not clear- ly underftand, in every part of the medullary fubftance of the brain and nerves, and which, in a living and healthy man, is capable of being moved from every one part to every other of the nervous fyftem. mdxlii. With refpect to this power, we have pretty clear proof that it frequently has a motion from the fen- 2 TRACTICE OF PHYSIC. ticnt extremities of the nerves towards the brain, and thereby produces fenfation ; and we have the fame proof,. that in confequence of volition, the nervous power has a motion from the brain into the mufcles or organs of motion. Accordingly, as fenfation excites our intellect- ual operations, and volition-is the eflectof thefe, and as the connection between fenfation and volition, is always bv the intervention of the brain, and of intellectual op- erations ; fo we can hardly doubt, that thefe latter de- pend upon certain motions, and the various modifica- tion of thefe motions, in the brain. mdxliii. To afcertain the different ftates of thefe mo- tions may be very difficult; and phyficians have com- monly confidered it to be fo very myfterious, that they have generally defpaired of attaining any knowledge with regard to it : but I confider fuch abfolute defpair, and the negligence it infpires, to be always very blamea- fele; 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. mdxl'iv. To this purpofe, I think it evident, that the nervous power, in the whole as well as in the feveral parts- of the nervous fyftem, and particularly in the brain, ■ is at different times in different degrees of mobility and force. To thefe different ftateSj I beg leave to apply the terms of Excitement and Collapfe. To that ftate in which the mobility and force are fufficient for the exercife of the functions, or when thefe ftates are any way preter- naturally increafed, Igive the name of Excitement ; and to that ftate in which the mobility and force are not fuf- ficient for the ordinary exercife of the functions, or when they are diminiihed from the ftate in which they had been before, I give the name of Collapfe. I beg, hewev- ever, it may be obferved, that by thefe terms 1 mean to- exprefs matters of fact only ; and without intending, by thefe terms, to explain the circumftance or condition,. mechanical or physical, of the nervous power or fluid in thefe different ftates,. mdxlv. That thefe different ftates of excitement and collapfe take place on different occafions, muft, I think, PRACTICE OF PHYSIC. 5*3 be manifeft from numberlefs phenomena of the animal economy : but it is efpecially to our prefent purpofe to obferve, that the different ftates of excitement and col- lapfe, are in no inftance more remarkable, than in the different ftates of waking and fleeping. In the latter, when quite complete, the motion and mobility of the nervous power, with reject to the whole of what are called the Animal Functions, 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 .excite- ment. mdxlvi. This difference in the ftates of the nervous power in fleeping and waking being admitted, I muft, in the next place obferve, that when thefe ftates are changed from the one into the other, as commonly hap- pens every day, the change is hardly ever made inftanta- neoufly, but almoft always by degrees, and in fome length of time only : and this may be obferved with refpect to both fenfe and motion. Thus when a perfon is falling afleep, the fenfibility is gradually diminifhed; fo that, although fome degree of fleep has come on, flight ' impreffions will excite fenfation, and bring back excite- ment ; which the fame, or even ftronger impreffions, will be infuflicient to produce when the ftate of fleep has continued longer, and is, as we may fay, more com- plete. In like manner, the power of voluntary motion is gradually diminifhed, In fome members it fails foon^ er than in others; and it is fome time before it becomes general and confiderable over the whole. 5 The fame gradual progrefs may be remarked in a per fon's coming out of fleep : The ears in this cafe arc- often awake before the eyes are opened or fee clearly and the fenfes are often awake before the power of vol- untary motion is recovered ; and it is curious to ob- ferve, that, in fome cafes, fenfations maybe excited with- out producing the ordinary affociation of ideas. See Mem. de Berlin, 1752. mdxlvii. From all this, I think it will clearly appear, tfiat not only the different ftates of excitement and col- m 3 544 PRACTICE OF PHYSIC. lapfe 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 different functions, in different de- grees. ' ' • * As I prefume that almoft every perfon has perceived the gradual approach of fleeping and waking, 1 likewife fuppofe every perfon has obferved, that in fuch interme- diate 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 percep- tions, falfe affociations, falfe judgments, and difpropor- tionate emotions ; in fhort, all the circumftances by wjhich 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 intel- lectual functions,' the excitement muft be complete, and equal in every part of the brain. For though we can- not fay that the veftiges of ideas are laid up in different parts of the brain, or that they are in fome meafure dif- fufed over the whole, it will follow upon either fuppofi* tion that as our reafoning or intellectual operations, al- ways require the orderly and exact recollection or mem- ory of affociated ideas ; fo if any part of the brain is not excited, or not excitable, that recollection cannot proper- ly take place, while, at the fame time, other parts of the brain, more excited and excitable, may give falfe percep« tions, affociations, and judgments. ' mdxlvhi. It willferve to illuftrate this, that the col- lapfe in fleep is more or lefs complete; or that the fleep, as we commonly fpeak, is more or lefs profound : and, therefore, that, in many cafes, though fleep takes place to a confiderable degree, yet certain impreffions do ftill t^ke effect, 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 general- ly of the delirious kind, or dreams, confuting of falfe PRACTICE OF PHYSIC. 34S perceptions affociations, and judgments, that would have been corrected if the brain had been, entirely excited. Every one,.I believe, has obferved, that themoft imper- fect fleeps are thofe chiefly attended with dreaming: that dreams therefore,moft;commonly occur towards morn- ing, when the complete-f late of fleep is pafling.away ; and, ■further, that dreams are moft commonly excited by -ftrong and uneafy impreffions made upon fhe body. I apprehend it may alfo be an illuftration of the fame thing, that, even in waking hours, we-have an Inftance of an unequal ftate of excitement in the'brain, produc- ing delirium. Such, I think, occurs in the cafe of fever. In this, it is manifeft, that the energy of the brain, or its excitement, is confiderably diminifhed with refpect to the animal functions : and it is accordingly upon this ground that Thave explained above, in xlv. the delirium which fo commonly attends fever. To what I have there faid, I fhall here only add, that it may fenve to confirm my doctrine, that the delirium in fever comes on at a certain period of the difeafe only, and that we can commonly difcern its approach, by a mere than ufu- al degree of it appearing in the time of the patient's falling into or coming out of fleep. It appears, there- fore, that delirium, when it firft comes on in fever, de- pends upon an inequality of excitement ; and it can hardly be doubted, that the delirium, which comes at length to prevail in the entirely weakened ftate of fevers^ depends upon the &me caufe prevailing in a more .con- fiderable degree. mdxlix. From what has been now delivered, I hope it will be fufliciently evident, that .delirium may be, and frequently is occafioned by an equality in the excitement of the brain. How the different portions of the brain may at the fame time be excited or collapfed in different degrees, or how the energy of the brain may be in different degrees of force, with refpect to the feveral animal, vital, and natur- al functions, I cannot pretend to explain ; but it is fuffi- ciently evident in fact, that the brain may be at one and the fame time in different conditions with repect to thefe 4 ■546 PRACTICE OF PHYSIC. functions. Thus in inflammatory difeafes, when by a ftimulus applied to the brain the force of the vital func- tions is preternaturally increafed, that of the animal is either little changed, or confiderably diminifhed. On the contrary, in many cafes of mania, the force of the animal functions depending always on the brain, is pro* digioufly increafed, while the ftate of the vital function in the heart is very little'or not at all changed. 1 muft there- fore fay again, that how difficult foever it may be to ex- plain the mechanical or physical condition of the brain in fuch cafes, the facts are fufficient to fhow that there is fuch an inequality as may difturb our intellectual opera- tions. mdl. I have thus endeavored to explain the general caufe of Delirium ; which is of two kinds ; according as it is with or without pyrexia. Of the firft I take no further notice here, having explained it as well as I could above in xlv. I proceed now to confider that delirium which pro- perly belongs to the clafs of Vefaniae, and which I fhall treat of under the general title of Infanity, mdli. In entering upon this fubject, it immediately occurs, that in many inftances of infanity, we find upon diffection after death, that peculiar circumftances had taken place in the general condition of the brain. In many cafes, it has been found of a drier, harder, and firmer confiftence, than what it is ufually of in perfons who had not been affected with that difeafe. In other cafes, it has been found in a more humid, foft, and flac- cid ftate ; and in the obfervations of the late Mr. Meck- el*, it has been found confiderably changed in its denfity or fpecific gravity. Whether thefe different ftates have been obferved to be uniformly the fame over the whole of the brain, I cannot certainly learn ; and fufpect the diffectors have not always accurately inquired into this circumftance : but in feveral inftances,. it appears that thefe ftates had been different in different parts of the * Memoir, de Berlin pour I'annee 1764. It appeared in man^ inftances of infene perfons, that the medullary fubftance of the cerebrum was drier, and of a lefs fpecific gravity than in perfons who had been always of found judgment. Authsr. PRACTICE OF PHYSIC. J4f £>rain ; and inftances of this inequality will afford a con- firmation of our general doctrine. The accurate Morgagni has obferved, that in maniacal perfons the medullary portion of the brain is ufiiaflydry, hard, and firm ; And this he had fo frequently obferved, that he was difpofed to confider it as generally die cafe. But in moft of the particular inftances which he has given, it appears, that, for the moft part, while the cere- brum was of an unufually hard and firm confiftence, the k cerebellum was of its ufual foftnefs, and in many of the cafes it was unufually foft and flaccid. In fome other cafes, Morgagni obferves that while a part of the cere- j- brum w*as harder and firmer than ordinary, other parts > of it were preternaturally foft. mdlh. Thefe obfervations tend to confirm our gener- al doctrine : and there are others which I think will ap- ' ply to the fame purpofe. I/ Upon the diffection of the bodies of perfons who had labored under infanity, various organic affections have been difcovered in particular parts of the brain ; and it is fufficiently probable, that fuch organic affections might ' have produced a different degree of excitement in the free ^nd affected parts, and muft have interrupted in fome ,: meafure the free communication between the feveral P- parts of the brain, and in either way have accafioned in- [ fanity. : There have occurred fo many inftances of this kind, that I believe phyficians are generally difpofed to fufpect organic lefions of the brain to exift in almoft every cafe of infanity. mdliii. This, however, is probably a miftake : for we know that there have been many inftances of infan- ity from which the perfons have entirely recovered j, and it is difficult to fuppofe that any organic lefions of the brain had in fuch cafe taken place. Such tranfitory caf- es, indeed, render it probable, that a ftate of excitement, changeable by various caufes, had been the caufe of fuch inftances of infanity. mdliv. It is indeed further afferted, that in many in- ftances of infaae perfons, their brain had been examined MS PRACTICE OF PHYSIC. 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 fhow that organic lefions had not been the caufe of the difeafe ; but it does not affure us that no morbid change had tafcen place in the brain : for it is probable, that the diffectors were not always aware of its being the general condition of hardnefs and denfity, as different in different parts of the brain, that was to be at- tended to, in order to difcover the caufe of the preced- ing difeafe ; and therefore many of them had not with this view examined the ftate of the brain, as Morgagni feems carefully to have done. mdlv. Having thus endeavored to inveftigate the % caufe of infanity in general, it were to be wifhed that I could apply the doctrine to the diftinguifhing the feveral J fpecies of it, according as they depend upon the different ftate and circumftances of the brain, and thereby to the eftablifhing of a feientific and accurately adapted meth- od 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 at- tempts, and offer fome reflections, which further obfer- vation, and greater fagacity, may hereafter render more ufeful. mdlvi. The ingenious Dr. Arnold has been commend- ably employed in diftinguifhing the different fpecies of infanity as they appear with refpect to the mind ; and Us labors may hereafter prove ufeful, when we fhall cqne to know fomething more of the different ftates of the brain correfponding to thefe different ftates of the mind; but at prefent I can make little application of his numerous diftinctions. It appears to me that he has chiefly pointed out and enumerated diftinctions, that are merely varieties, which can lead to little or no variety of practice; and I am efpecially led to form the latter con- clusion, becaufe thefe varieties appear to me to be often combined together, and to be often changed into one another, in the fame perfon ; in whom we muft there- fore fuppofe a general caufe of the difeafe, which, fo far PRACTICE OF PHYSIC. $*i as if: can be known, muft eftablifh the pathology and ef- pecially direct the practice. mdlvii. In my limited views of the different ftates of infanity, I muft go on to confider them under the two i heads of Mania arid Melancholia : and though I am fen- iible that thefe two genera do not comprehend the whole of the fpecies of infanity, I am not clear in afligning the other fpecies, which may not be comprehended Under thofe titles. I fhall, however, endeavor, on proper oc- cafions as I go along, to point them out as well as I can. CHAP. II. OF MANIA, OR MADNESS*. molviii. 1 he circumftances which I have men- tioned above in mdxxxv. as constituting 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 of the difeafe. The falfe £' judgment, is of relations long before laid up in the mem- ory. It very often turns upon one fingfe fubject : but more commonly the mind rambles from one fubject 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 therefore the falfe judgments. What for the moft part more efpecially diftinguifhes the difeafe, is a hurry of mind, in purfuing any thing like a train of thought, and in running from one train of thought to another. Maniacal perfons are in general very irafcible: put what more particularly produces their angry emo- tions is, that their falfe judgments leading to fome action which is always pufhed with impetuofity and violence $ * Univerfal infanity. Syn. Nof. $50 PRACTICE OF PHYSIC. when this is interrupted or reftrained, they break out in- to violent anger and furious violence againft every per- fon 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 refpect to their former deareft friends and re- lations ; and therefore their refentment and anger is par- ticularly directed towards thefe. And although this fhould not be the cafe, they commonly foon lofe that re- fpect 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 mentioned, there is commonly joined an unufual force in all the voluntary motions ; and an infenfibility or re- fiftance 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. mdlix. 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, efpecial- ly with refpect to the animal functions ; and it appears at the fame time to be manifeftly in fome meafure une- qual, as it very often takes place with refpect to thefe functions alone, while at the fame time the vital and nat* ural are commonly very little changed from their ordi- . nary healthy ftate. mdlx. How this excefs of excitement is produced, it may be difficult to explain. In the various inftances of what Sauvages has named the Mania Metaftatica, 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 affection is produced in fome part of the brain ; and how that may produce an increafed or une- qual excitement in certain parts of it, I have endeavor- ed to explain*above in mdlii. But I muft at the fame time acknowledge, that fuch remote caufes of mani^ PRACTICE OF PHYSIC. nave very rarely occurred ; and that therefore fome o~ ther caufes of the difeafe muft be fought for. The effects of violent emotions or paffions of the mind have more frequently occurred as the remote caufes"of mania ; and it is fufficiently probable that fuch violent emotions, as they do often immediately produce a tem- porary increafe of excitement, fo they may, upon fome occafions of their permanent inherence of frequent repe- tition, produce a more confiderable and more permanent- excitement, that is, a mania. With refpect to thofe caufes of mania which arife in confequence of a melancholia which had previoufly long ' fubfifted ; whether we confider that melancholia as a * partial infanity, or as a long perfifting attachment to one train of thinking, it will be readily perceived, that in ei- ' ther cafe fuch an increafe of excitement may take place in fo confiderable a degree, and in fo large a proportion ©f the brain, as may give occafion to a complete mania. mdlxi. Thefe confiderations with regard to the re- mote caufes, appear to me to confirm fufficiently our general doctrine of increafed and unequal excitement in the mania whichT have defcribed above; but I muft own, that I have not exhaufted the fubject, and that there are cafes of mania of which I cannot affign the rc- * mote caufes: but, although I cannot in all cafes explain in what manner the mania is produced, I prefume, from the explanation given, and efpecially from the fymptoms » enumerated above, to conclude, that the difeafe defcrib* ed 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 clearly explain the operation of thofe remedies, which, fo far as I can learn from my own experience and that of others, have proved the t mofi: fiiccefsful in this difeafe ; and, to illuftrate this, I " now enter upon the confideration of thefe remedies, and to make- fome remarks upon the proper manner of em- ' ploying them. mdlxii. Reftraining the anger and violence of mad- men is always neceffary for preventing their hurting ssz PRACTICE OF PHYSIC. themfelves or others; but this reftraint is alfo to be con- fidered as a remedy. Angry paflions are always render- ed more violent by the indulgence of the impetuous mo- tions they produce ; and even in madmen the feeling of reftraint will fometimes prevent the efforts which their paflion would otherwife occafion. Reftraint, therefore, is ufeful, and ought to be complete ; but it fhould be ex- ecuted in the eafieft manner poflible for the patient, and the ftrait waiftcoat anfvvers every purpofe better than any. other that has yet been thought of. The reftraining madmen by the force of other men, as occafioning a con- ftant ftruggle and violent agitation, is often hurtful. Alr though, on many occafions, it may npt be fafe to allow maniacs to be upon their legs or to y/alk about, it is nev- er deferable to confine them to a horizontal fitu'ation ; 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 impeV tus of blood in the veffels of the brain, a horizontal pof- ture always increafes the fulnefs and tenfion of thefe veC fels, and may thereby increafe the excitement of the brain. MDLxm. The reftraint mentioned requires confine- ment within doors, and it fhould be in a place which prefents as few objects of fight and hearing as poflible,^ and particularly, it fliould be removed from the objects that the patient was formerly acquainted with, as thefe" would more readily call up ideas and their various affo- ciations. It is for this reafon that the confinement, of madmen fhould hardly ever be in their ufual habitation ;'; or if they are, that their apartment fhould be flopped? of all its former furniture. It is alfo for the moft part proper, that maniacs fhould be without the company of any of their former acquaintance ; the appearance of whom commonly excites emotions, that increafe the dif- eafe. Strangers may at firft be offenfive ; but in a little. time they come to be objects either of indifference or of fear, and they fhould riot be frequently changed. mdlxiv. Fear being a paflion that diminifhes excite-' ment, may therefore be oppofed to the excefs of it -7 and' PRACTICE OF PH^SIGi 553 particularly to the angry and irafcible excitement of maniacs. Thefe being more fufceptible of fear than might be expected, it appears to me to have been com- monly ufeful. In moft cafes it has appeared fo me nec- effary to employ a very conftant impreflion of fear; and therefore to infpire them with the awe and dread of fome particular perfons, efpecially of thofe who are to be con- ftantly 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 restraints that may lie occaftonally proper j but fometimes it may be neceffa- to acquire it even by ftripes and blows* TheTormer, although having the appearance of more feverity, are much fafer than ftrokes or blows about the head. Nei- ther of them, however, fliould be employed further than P feems very neceffary, and fhould be trufted only to thofe Whofe discretion can be depended"upon. There is one cafe in which they are fuperfluous ; that is, when'the ma- riiacal rage is either rtot fufceptible of fear, or incapable of remembering the object's of it j for in fuch inftances, j; ftripes and blows would be wanton barbarity. In many w cafes of a moderate difeafe, it is of advantage that the fc.perfons who are the authors of reftraint and punifliment Bfliould be upon other occafions the beftowers of every B indulgence and gratification that is admiflible ; never* .however, neglecting to employ their awe when their in- I dulgertce fhall have led to any abufe. mdlxv. Although in mania, no particular irritation £ rior fulnefs of the fyftem feem. to be prefent, it is plain, I that the avoiding all irritation and means of fulnefs is proper; and therefore,, that a diet neither ftimulating nor nourifhing is commonly to be employed. As it may even be ufeful to diminifh the fulnefs of the fyftem, fo | both a low and a fpare diet is likely in moft cafes to be of fervice. mdlxvi. Upon the fame principle, although no un- • ufual fulnefs of the body be prefent, it may be of advan- k tage to diminifh even its ordinary fulnefs by different I evacuations. \ ;5o PRACTICE OF PHYSIC. Blood letting, in particular, might be fuppofed ufeful; and in all recent cafes of mania it has been commonly practifed, and I think with advantage ; but when the difeafe has fubfifted for fome time, Ihave feldom found blood letting 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 even a neceffary rem- edy. Some practitioners, in fuch cafes, have preferred a particular manner of blood letting, recommending arte- riotomy, fcarifying the hind head, or opening the jugular vein ; and where any fulnefs or inflammatory difpofi- tion in the veffels of the brain is to be fufpected, the open- ing of the veffels neareft to them is likely to be of the greateft fervice. The opening, however, of either the temporal artery or the jugular vein in maniacal perfons is very often inconvenient ; and it may generally be fuffi- cient to open a vein in the arm, while the body is kept in fomewhat of an erect pofture, and fuch a quantity of blood drawn as nearly brings on a deliquium animi, which is always a pretty certain mark of fome diminu- tion of the fullnefs and tenfion of the veffels of the brain. mdlxvii. 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 celebrated ufe of hellebore among the ancients. I cannot, however fuppofe any fpecific power in hellebore; and can by no means find that, at leaft the black hellebore, 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 fome- times very neceffary ; and I have known fome benefit obtained from the frequent ufe of pretty draftic purga- tives. In this, however, I have been frequently difap. pointed ; and I have found more advantage from the frequent ufe of cooling purgatives, particularly the folu- ble tatar, than from more draftic medicines. mdlxvih. Vomiting has alfo been frequently employ- ed in mania ; and by determining powerfully to the fur- face of the body, it may poflibly diminifh the fulnefs and PRACTICE OF PHYSIC. SSS tenfion of the veffels, and thereby the excitement of the brain ; but I have never carried the ufe of this remedy fo far as might enable me to judge properly of its ef- fects. 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 excitement which prevails in mania, I have not had experience enough to determine. mdlxix. 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 effectually done by bliftering, which mote certainly takes off the excitement of fubjacent parts. In recent cafes it has been found ufeful by inducing fleep ; and when it has that effect, the repetition of it may be proper : but in maniacal cafes that have lafted for fome time, blifter- ing has not appeared to me to be of any fervice ; and in fuch cafes alfo I have not found perpetual blifters, or any other form of iffue, prove ufeful. mdlxx. As heat is the principal means of firft excit- ing the nervous fyftem, and eftablifhing the nervous power and vital principle in animals ; fo in cafes of pre- ternatural excitement, the application of cold might be [ -fuppofed a proper remedy : but there are many inftan- ces of maniacs who have been expofed for a great length of time to a confiderable degree of cold without having their fymptoms any ways relieved, This may render in general the application of cold a doubtful remedy ; but it is at the fame time certain, that maniacs have often been relieved, and fometimes entirely cured by the ufe ,of cold bathing, efpecially when adminiftered in a certain manner. This feems to confift, irt throwing the mad- man into the cold water by furprife; by detaining him in it for fome length of time ; and pouring water fre- quently upon the head, while the whole Of the body ex- cept the head is immerfed in the water ; and thus man- aging the whole procefs., fo as that, with the affiftance of fome fear, a refrigerant effect may be produced. This, I can affirm, has been.often .ufeful -T and that the exter- M ivr \ }i*> PRACTICE OF PHYSIC. nal application of cold may be of fervice, we know fur- ther, from the benefit which has been received in fome maniacal cafes from the application of ice and fnow to the naked head, and from the application of the noted Clay Cap. Warm bathing alfo has been recommended by fome practical writers, and in fome rigid melancholic-habits it may poffibly be ufeful, or as employed in the manner prescribed by fome, of immerfing the lower parts of the body in warm water, while cold water is poured upon the head and upper parts. Of this practice, however, I have had no experience; and in the common manner of employing warm bathing I have found it rather hurt- ful to maniacs. mdlxxi. According to my fuppofition that the difeafe depends upon an increafed excitement of the brain, efpe- cially with refpect to the animal functions, opium, fo commonly powerful in inducing fleep, or a confiderable collapfe as to thefe functions, fhould be a powerful rem- edy of mania. That it has truly proved fuch, I believe from the teftimony of Bernard Huet, whofe practice is narrated at the end of Wepferi Hiftoria Apoplecticorum. I leave to my readers to ftudy this in the work I have re- ferred to, where every part of the practice, is fully, and, as it appears to me, very judiciously delivered. I have never indeed carried the trial fo far as feems to be requi- fite 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, wheth- er there might not be fome inflammatory'affection join- ed with the mania, when the opium would be hurtful; I have never puihed this remedy to the extent that might be neceffary to make an entire cure. mdlxxii. Camphire has been recommended as a rem- edy of mania, and there are inftances alleged of its hav- ing performed an entire cure. As it appears from the PRACTICE OF PHYSIC. SSI experiments of Beccaria that this fubftance is poffeffed of a fedative and narcotic virtrte, thefe cures are not alto- gether improbable; but in feveral trials, and even in large dofes, I have found iio benefit from it ; and ex- cepting thofe In the Philofophical trahfactions,' No- 400,1 have hardly met with any other teftimonies in its favor. "Mdlxxiii. I have been informed that fome maniacs have been cured by being compelled to conftant and even hard labor ; and as a forced attention to the conduct of any bodily exercife, is a very certain means of diverting the mind from purfuing any train of thought, it Is high- ly probable that fuch exercife may be ufeful in many cafes of mania. I muft conclude this fubject with obferving, 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. mdlxxiv. Thefe are the remedies which have been chiefly employed in the mania that has been above de- fcribed, and I believe they have been employed prbmif- cuoufly, without fuppofing that the mania was to be dif- tinguifhed into different fpecies. Indeed I atii hot ready to fay how far it is to be fo diftinguifhed, but I fhall of- fer one obfervation which^may poffibly merit attention. It .appears to me, that there are two different cafes of mania that are efpecially different, according to the orig- inal temperament of the perfons whom the difeafe af- fects. It perhaps occurs moft frequently in perfons of a melancholic Or atrabilarian temperament; but it certain- ly 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 be- lieve, that accurate obfervation, employed upon a fuffi- cient number of cafes, would difcern fome pretty con-. ftant 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, aje 5i8 PRACTICE OF PHYSIC. more fixed and ftcady in the melancholic than in the finguine; and that fomewhat inflammatory is more commonly joined with mania in the fanguine than in the melancholic. If fuch difference, however, does truly take place, it will be obvious, that it may be proper to make fome difference alfo in the practice. I am of opin- ion, that in the mania of fanguine perfons, blood letting, and other antiphlogiftic meafures are more proper, and have been more ufeful than in the melancholic. I like- wife apprehend that cold bathing is more ufeful in the fanguine than in the melancholic: but I have not fyad experience enough to afcertain thefe points with fufficient confidence. 1 have only to add this other obfervation, that mani- acs of the fanguine temperament recover more frequent- ly and more entirely than thofe of the melancholic. CHAP. III. OF MELANCHOLY*, AND OTHER FORMS OF IMSANlTY. mdlxxv. JVIelakcholy has been commonly confidered as a partial infanity ; and as fuch it is defined in my Nofology ; but I now entertain doubts if this be altogether proper. By a partial infanity, I underftand a falfe and miftaken judgment upon one particular fubject, and what relates to it ; whiilft, on every other fubject, l he perfon affected judges as the generality of other men do. Such-cafes have certainly occurred j but I believe few in which the partial infanity is ftrictly limited. In many cafes of general infanity, there is one fubject of an- rrer or fear, upon which the falfe judgment more partic- ularly turns, or which is at leaft more frequently than any other, the prevailing object of delirium ; and though, from the inconsistency which this principal object of de- lirium muft produce, there is therefore alfo a great.deal of infanity with regard to moft other objects j yet this * P.irtial infinity, without dyfpepfia. Syn. fhf.: PRACTICE OF PHYSIC. SS'1 laft is in very different degrees, both in different per- fons, 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 oc- currences ; though, when thefe objects engaging atten- tion are not prefented, the operations of imagination may readily bring back a general confufion, or recal the particular object of the delirium. From thefe confider- ations, I am inclined to conclude, that the limits between general and partial infanity, cannot always be fo exactly affigned,as to determine when the partial affeaion is to be confidered as giving a peculiar fpecies of difeafe, different from a more general infanity. mdlxxvi. When infanity neither ftrictly partial nor entirely nor "conftantly general, occurs in perfons of a fanguine temperament, and is attended with agreea- ble, 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 proper Melancholia to be mentioned hereafter. mdlxxvii. Such a difeafe, as different from thofe defcribed mdliv. requires, in my opinion, a different adminiftration of remedies; and it will be proper for me to take particular notice of this here. Although it may be neceffary to restrain fuch infane perfons as we have mentioned mdlxxvi. from purfumg the objects of their falfe imagination or judgment, it will hardly be requifite to. employ the fame force of .reftraint that is neceffary in the impetuous and angry mania. It will be generally fufficient to acquire fome awe over them, that may be employed, and fometimes even be neceffary, to check the rambling of their imagin- ation, and incoherency of judgment. mdlxxviu. The reftraint juft now mentioned as nec- effary, will generally require the patient's being confined to one place, for the fake of excluding the objects, and more particularly the perfons, that might excite ideas connected with the chief objects of their delirium. At 3 S(>9 PRACTICE OF PHYSIC. the fame time, however, if it can be perceived there are objects or perfons that can call off their attention from the purfuit of their own difordered imagination, and can fix it a little upon fome others, thefe laft may be fre- quently prefented to them : and, for this reafon, a jour- ney, both by its having the effect of interrupting all train of thought, and by prefenting objects engaging attention, may often be ufeful. In fuch cafes alfo, when the infanity, though more efpecially fixed upon one mif- taken fubject, 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. mdlxxix. When fuch cafes as in mdlxxvi. 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, bloodletting *nd purging will be the more proper and neceffary. mdlxxx. To this fpecies of infanity, when occurring in fanguine temperaments, whether it be more or lefs partial I apprehend that cold bathing is particularly a- dapted ; while, in the partial infanity of melancholic per- fons, as I fhall fhow hereafter, it is hardly admiflible. mdlxxxi. Having thus treated of a fpecies of infani- ty, different, in my apprehenfion, from both the Mania and Melancholia, 1 proceed to confider what feems more properly to belong to this laft. mdlxxxii. The difeafe which I name Melancholia is very often a partial infanity only. But as, in many in- ftances, though the falfe imagination or judgment feems to be with refped to one fubjea only, yet it feldom hap- pens that this does not produce much inconfiftency in the other intellectual operation: And as, between a very general and a very partial infanity, there are all the pofli- ble intermediate degrees, fo it will be often difficult, or perhaps improper, to diftinguifh Melancholia by the character of Partial Infanity alone. If I miftake not, it mult be chiefly diftinguifhed by its occurring in perfons PRACTICE OF PHYSIC. 561 of melancholic temperament, and by its being always at- tended with fome feemingly groundlefs, but very anxious fear. mdlxxxiii. To explain the caufe of this, I muft ob- ferve, that perfons of a melancholic temperament are, for the moft part, of a ferious thoughtful difpofition, and difpofed to fear and caution, rather than to hope and te- merity. Perfons of this caft are lefs moveable than oth- ers by any impreffions, and are, therefore, capable of a clofer or more continued attention to one particular ob- jed or train of thinking. They are even ready to be engaged in a conftant application to one fubjea, and are remarkably tenacious of whatever emotions they happen to be affeaed with. mdlxxxiv. Thefe circumftances of the melancholic charaaer feem clearly to fhow, that perfons ftrongly af- feaed 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. mdlxxxv. Fear and dejeaion of mind, or a timid and defponding difpofition, may arife in certain ftates, or upon certain occafions of mere debility ; and it is up- on this footing that I fuppofe it fometimes to attend dyf- pepfia. But, in thefe cafes, I believe the defpondent dif- pofition hardly ever arifes to a confiderable degree, or proves fo obftinately fixed as when it occurs in perfons of a melancholic temperament. In thefe ^ laft, although the fear proceed from the fame dyfpeptic feeling as in the other cafe, yet it will be obvious, that the emotion may rife to a more confiderable degree ; that it may be more anxious, more fixed, and more attentive ; and, therefore, may exhibit all the various circumftances which I have mentioned in mccxxii. to take place in the difeafe named Hypochondriasis. mdlxxxvi. in confidering this fubjea formerly, in diftinguifhing Dyfpepfia from Hypochondriafis, al- though the fymptoms affeaing the body be very much the fame in both, and even thofe affeaing the mind be fomewhat fimilar, I found no difficulty in diftinguifhing the latter difeafe, merely from its occurring in perfons $6j PRACTICE OF PHYSIC. of a melancholic temperament. But I muft now ac- knowledge, that I am at a k)fs to determine, how, in all cafes, hypochondriafis and melancholia may be diftin- guifhed from one another, whilft the fame temperament is common to both. mdlxxxvii. I apprehend, however, that the diftinc- tion may be generally afcertained in the following man- ner : 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 refpea to the ftate of the perfon's own health, and to the danger to be from thence apprehended, I would ftill confider the dif- eafe as a hypochondriafis, and as diftina from the prop- er melancholia. But when an anxious fear and defpon-i dency arifes from a miftaken judgment with refpect. to other circumftances than thofe of health, and more efpe- cially 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 hy- pochondriafis, and it is what I would ftrictly name Mel- ancholia. mdlxxxviii. In this there feems little difficulty ; but as an exquififely melancholic temperament may induce a torpor and flownefs in the aaion of the ftomach, fo it generally produces fome dyfpeptic fymptoms, and from thence there may be fome difficulty in diftingnifhing fuch a cafe from hypochondriafis. But I would maintain, however, that when the charaders of the temperament are ftrongly marked, and more particularly when the falfe imagination tilrns upon other fubjects than that of health ; or when, though relative to the perfon's own body, it is of a groundlefs and abfurd kind; then, not- withstanding the appearance of fome dyfpeptic fymp- toms, the cafe is ftill to be confidered as that of a melan- cholia, rather than a hypochondriafis. mdlxxxix. The difeafe of melancholia, therefore, manifeftly depends upon the general temperment of the PRACTICE OF PHYSIC. sH body: and although, in many perfons, this temperament is not attended with any morbid affection 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 tempera- ment efpecially confifts : and to this purpofe, it may be obferved, that in it there is a degree of torpor in the motion of the nervous power, both with refpea to fen- fation and volition ; that there is a general rigidity of the fimple folids ; and that the balance of the fanguifer- ous fyftem is upon the fide of the veins. But all thefe circumftances are the direaiy opposite of thofe of the fanguine temperament j and muft therefore alfo produce an oppofite ftate of mind. mdxc It is this ftate of the mind, and the ftate of the brain correfponding to it, that is the chief objea of our prefent confideration. But what that ftate of the brain is will be fuppofed to be difficult to explain j and it may perhaps feem rafh in me to attempt it. I will however, venture to fay, that it is probable the -melancholic temperament of mind depends upon a drier and firmer texture in the medullary fubftance of the brain; and that this perhaps proceeds from a certain want of fluid in that fubftance, which appears from its being of a leffer fpecific gravity than ufual. That this ftate of the brain in melanchbltzilioes aaually exift, I con. elude,firft, from the general rigidity of the whole habit -w and, fecondly, from diffeaions, mowing 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 ways difficult to fuppofe, that the fame ftate of the brain may in a moderate degree give melan- cholia, and in a higher that mania which melancholia fo Often paffes into ; efpecially ifl {hall be allowed further to fuppofe, that either a greater degree of firmnefs in the fubftance of the brain may render it fufceptible of a higher degree of excitement, or that one portion of the brain may be liable to acquire a greater firmnefs than others, and confequently give occafion to that ineqality of excitement, upon which mania fo much depends. J<»4 PRACTICE OF PHYSIC. mdxci. I have thus endeavored to deliver what ap- pears to me moft probable with refpea to the proximate caufe of melancholia ; and although the matter fhould in fome refpeas. remain doubtful, I am well perfuaded that thefe obfervations may often be employed to direft our praaice in this difeafe, as I fhall now endeavor to fhow. mdxcii. In moft of the 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 com- monly a falfe imagination or judgment appearing as a partial infanity, it may be further neceffary in fuch cafes to employ fome artifices for correaing fuch imagination or judgment. mdxchi. The various remedies for relieving the dyf- peptic fymptoms which always attend hypochondriafis will feldom be either requifite or proper in melancholia. There is only one of the dyfpeptic fymptoms, which, though there fhould be no other, is very conftantly pref- ent in melancholia, and that is coftivenefs. This it is al- ways proper and even neceffary to remove; and I be- lieve it is upon this account that the ufe of purgatives has been found fo often ufeful in melancholia. Wheth- er there be any purgatives 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'o- pinion that I delivered above on this fame fubjea with refpea to mania. mdxciv. With refpea to other remedies, I judge that blood letting will more feldom be proper in melan- cholia than in mania ; but how far it may be in any cafe proper, muft be determined by the fame confiderations as in the cafe of mania. mdxcv. 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 PRACTICE OF PKXailC., j&J of the general rigidity prevailing in melancholia, it is probable that warm bathing may be often ufeful. mdxcvi. With refpea to opiates which I have fup- pofed might often be ufeful in cafes of mania, I believe they can feldom be properly employed in the partial in- finities of the melancholic, except in certain inftances of violent excitement, when the melancholia approaches nearly to the ftate of mania. mdxcvii. In fuch cafes of melancholia approaching to a ftate of mania, a low diet may fometimes be neceffary; but as the employing a low diet almoft unavoidably leads to the ufe of vegetable food, and as this in every torpid ftate of the ftomach is ready to produce fome dyf- peptic fymptoms, fuch vegetable food ought, in moder- ate cafes of melancholia, to be ufed with feme caution. Though exercife, as a tonic power, is not proper ei* ther in hypochondriafis or melancholia j yet, with ref- pea to its effeas upon the mind, it may be extremely nfeful in both, and in melancholia is to be employed in the fame manner that I have advifed above in the cafe pf hypochondriafis. mdxcviii. Having now delivered my doarine with refpea to the chief forms of infanity, I fliould in the next place proceed to confider the other genera of A- mentia* and Oneirodynia!, which in the Nofology I have arranged under the order of Vefaniae; but as I cannot pretend to throw much light upon thefe fubjeas and as they are feldom the objeas of praaice, I think it allowable for me to pafs them over at prefent; and the particular circumftances of this work in fome meafure requires that I fhould do fo. * Weaknefs of the judgment, whereby the relations of things are either not perceived or not remembered. Syn. Nof. f The imagination, during fleep, unufually active or troublefom. Syn. Ntf pat in. of CACHEXIES, PART IIL OF CACHEXIES*. INTRODUCTION. mdxcix. Under this title I propofe to eftablifh 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 combin- ed with that ftate. mdc. The term Cachexy has been employed by Linnae- us and Sagar, 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 juftly employed by Sauvages and Sagar for the name of a clafs. In this I have followed the }aft men- tioned Nofologift, though I find it difficult to give fuch a charaaer of the clafs as will clearly apply to all the fpe- cies I have comprehended under it. This difficulty would be ftill greater, if in the clafs I have eftablifhed un- der the title of Cachexies, I were to comprehend all the difeafes that thofe other nofologifts have done; but I am willing to be thought deficient rather than very incor- * Depraved habit of the whole, or great part cf the body, without primary pyrexia or neurofis. Syn. Nof. |?9 PRACTICE OF PHYSIC. rea. Thofe difficulties, however, which ftill remain in methodical nofology, muft not affea us much in a trea- tife of praaice. If I can here properly diftinguifh and defcribe the feveral fpecies that truly and moft common- ly exift, I fhall be the lefs concerned about the accuracy of my general claffification : though at the fame time this 1 think, is always to be attempted ; and I fhall purfue it as well as 1 can. BOOK I. OF EMACIATIONS*. mdci. JlLmaciation, or a confiderable dim- inution of the bulk or plumpnefs of the whole body, is for the moft part only a fymptom of difeafe, and very feldom to be confidered as a primary and idiopathic af- feaion. Upon this account, according to my general plan, fuch a fymptom might perhaps have been omitted in the Methodical Nofology ; but both the uncertainty of concluding it to be always fymptomatic, and the con- fiftency of fyftem, made me introduce into the Nofology as others had done, an order under the title of Mar cores ; and this renders it requifite now to take fome notice of fuch difeafes. mdcii. 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 j and even in the latter view, the inveftigation may be attended with fome advantage. mdciii. 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 particular deficiency of the oil in the cellular texture of it. Thefe caufes are frequently combined to- gether ; but it will be proper, in the firft place, to confid- tr them feparately. * Wafting of the whole body. Syn. Nof. N N j:a PRACTICE OF PHYSIC. mdciv. 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 vef- fels, and the quantity of fluids prefent in them : and it will therefore be fufliciently obvious, that a deficiency of the fluids in thefe veflels muft, according to its degree, occafion a proportionate diminution of the bulk of the whole body. This however will appear ftill more clear- ly, from confidering that in the living and found body, the veffels every where feem to be preternaturally dif- tended by the quantity of fluids prefent in them; but being at the fame time elaftic, and conftantly endeavor- ing to contraa themfelves, they muft, on the withdraw- ing 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 de- gree of diminution of the quantity of fluid in any one part, muft in proportion diminifh the bulk of the vafcu- lar fyftem, and confequently of the whole body. mdcv. 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 nutri- tious quality. Of the want of a due quantity of aliment not being taken into the body, there is an inftance in the Atrophia laclantium Sauvagefii, fpecies 3. and many other examples have occurred of emaciation from want of food, occafioned by poverty, and other accidental caufes. With refpea to the quality of food, I apprehend it a- rifes from the want of nutritious matter in the food employed, that perfons living very entirely on vegetables are feldom of a plump and fucculent habit. * mdcvi. A fecond caufe of the deficiency of fluids may be, the aliments taken in not being conveyed to the blood veffels. This may occur from a perfon's being af- feaed with a frequent vomiting ; which, rejeaing the PRACTICE OF PHYSIC. 573 food foon after it had been taken in, muft prevent the neceffary fupply of fluids to the blood veffels. Another caufe, frequently interrupting the convey- ance of the alimentary matter into the blood veffels, is an obftruaion of the conglobate or lymphatic glands of the mefentery, through which the chyle muft neceffari- ly pafs to the thoracic dua. Many inftances of emacia- tion, feemingly depending upon this caufe, have been obferved by phyficians, in perfons of all ages, but efpe- cially in the young. It has alfo been remarked, that fuch cafes have moft frequently occurred in fcrophulous perfons, in whom the mefenteric glands are commonly affeaed with tumor or obftruaion, and in whom, gene- rally at the fame time, fcrophula appears externally. Hence the Tabes fcrophulofa Synop. Nofolog. vol. ii. p. 266.: And under thefe I have put as fynonimes Tabes glandula- ris, fp. 10. ; Tabes mefenterica, fp. 9. ; Scrophula mefente- rica, fp. 4. ; Atrophia infantilis, fo. 13. ; Atrophia rachiti- ca. fp. 8 ; Tabes rachialgica, fp. 16. At the fame time, I have frequently found the cafe occurring in perfons who did not fhow any external appearance of fcrophula, but in whom the mefenteric obftruaion was afterwards dif- covered 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 re- ceived its name from the time of life at which it gener- ally appears ; but I have met with inftances of it at four- teen years of age, afcertained by diffeaion. In feveral fuch cafes which I have feen, the patients were without any fcrophulous appearances at the time, or at any peri- od of their lives before. In the cafe of phthifical perfons, I fhall hereafter men. tion another caufe of their emaciation ; but it is probable that an obftruaion of the mefenteric glands which fo frequently happens in fuch perfons, concurs very power- fully in producing the emaciation that takes place. Although a fcrophulous taint may be the moft frequent caufe of mefenteric obftruaions, it is fufficiently probable that other kinds of acrimony may produce the fame, and the emaciation that follows. 2 JM PRACTICE OF PHYSIC. It may perhaps be fuppofed, that the interruption of the chyle's paffing into the blood veffels may be fome- times owing to a fault of the abforbents on the inter- nal furface of the inteftines. This, however cannot be readily afcertained : but the interruption of the chyle's paffing into the blood veffels may certainly be owing to a rupture of the thoracic dua; which when it does not prove foon fatal, by occafioning a hydrothorax, muft in a fhort time produce a general emaciation. mdcvii. A third caufe of the deficiency of the fluids may be a fault in the organs of digeftion, as not duly converting 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 appre- hend that the emaciation which attends long fubfifling cafes of dyfpepfia, or of hypochondriafis, is to be explain- ed chiefly in this way. It is this which I have placed in the Nofology under the title of the Atrophia debilium ; and of which the Atrophia nervofa, Sauv. fp. 1. is a proper in- ftance, and therefore put there as a fynonime. But the other titles of Atrophia lateralis, Sauv. fp. 15. and Atro- phia fenilisy Sauv. fp. 11. are not fo properly put there, as they muft be explained in a different manner. mdcviii. A fourth caufe of a deficiency of the fluids in the body, may be exceflive evacuations made from it by different outlets : and Sauvages has properly enumer- ated the following fpecies, which we have put as fynon- imes under the title of Atrophia inanitorum ; as, Tabes nutricum, fp. 4. Atrophia nutricum, fp. 5. Atrophia a leu- corrhcea, fp. 4. Atrophia ab alvifluxut fp. 6. Atrophia a piyalifmo, fp. 7. and, laftly. the Tabes a fanguifluxu ; which, it is to bz obferved, may arife not only from fpontaneous hemorrhagies or accidental wounds, but al- fo from blood lettings in too large a quantity, and too frequently repeated. Upon this fubjea it feems proper to obferve, that a meagre habit of body frequently depends upon a full perfpiration being conftantly kept up, though at the, PRACTICE OF PHYSIC. 57S fame time a large quantity of nutritious aliment is reg- ularly taken in. mdcix. Befides this deficiency of fluids from evacua- tions by which they are carried entirely out of the body, there may be a deficiency of fluid and emaciation in a confiderable part of the body, by the fluids being drawn into one part, or colfeaed into one cavity ; and of this we have an inftance in the Tabes a hydrope, Sauv. fp. 5. mdcx. In the Methodical Nofology, among the other fynonimes of the Atrophia, inanitorum I have fet down the Tabes dorfalis ; but whether properly or not, I at prefent very much doubt. In the evacuation confidered as the caufe of this tabes, as the quantity evacuated is never fo great as to account for a general deficiency of flu- ids in the body, we muft feek for another explanation of it. And whether the effeas of the evacuation may be accounted for, either from the quality of the fluid evac- vated, or from the Angularly enervating pleafure at- tending the evacuation, or from the evacuation's taking off the tenfion of parts, the tenfion of which has a Angu- lar power in fupporting the tenfion and vigor of the whole body, I cannot pofitively determine ; but I appre- hend that upon one or other of thefe fuppofitions the emaciation attending the tabes dorfalis muft be account- ed for ; and therefore that it is to be confidered as an inftance of the Atrophia debilium, rather than of the Atre» i phia inanitorum. mdcxi. A fifth caufe of a deficiency of fluids and of e- j- maciations in the whole or in a particular part of the bo- dy, may be the concretion of the fmall veffels, either not admitting of fluids, or of the fame proportion as before; and this feems to me to be the cafe in the Atrophia feni- lis, Sauv. fp. 2. Or it may be a palfy of the larger trunks \ of the arteries rendering them unfit to propel the blood into the fmaller veffels\ as is frequently the cafe of par- alytic limbs, in which the arteries arc affeaed as well as I the mufcles. The Atrophia lateralis, Sauv. fp. 15. feems [ to be of this nature. mdcxii. A fecond general head of the caufes of ema- ciation, I have mentioned in mdcii. to be a deficiency SI* PRACTICE OF PHYSIC. of oil. The extent and quantity of the cellular texture in every part of the body, and therefore how confidera- ble 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 immediately explained, is gen- erally accompanied with a deficiency of oil; but phyfi- cians have commonly attended more to the latter caufe of emaciation than to the other, that being ufually the moft evident; and I fhall now endeavor to aflign the feveral caufes of the deficiency of oil as it occurs upon different occafions. mdcxiii. The bufinefs of fecretion in the human body is in general little underftood, and in no inftance lefs fo than in that of the fecretion^of oil from blood, which does not appear previoufly to have contained it. It is pofli- ble, therefore, that our theory of the deficiency of oil may be in feveral refpeas imperfea ; but there are cer- tain faas that may in the mean time apply to the prefent purpofe. mdcxiv. Firft, it is probable, that a deficiency of oil may be owing to a ftate of the blood in animal bodies lefs fitted to afford a fecretion of oil, and confequently to fupply the wafte of it that is conftantly made. This ftate of the blood muft efpecially depend upon the ftate of the aliments taken in, as containing lefs of oil or oily matter. From many obfervations made, both with ref- pea to the human body and to that of other animals, it appears pretty clearly, that the aliments taken in by men and domeftic animals, according as they contain more of oil, are in general more 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 par- ticular confideration of the difference of alimentary mat- ters employed ; but it will be enough to give two inftan- ces. The one is, that the herbaceous part of vegetables, does not fatten animals, fo much as the feeds of vegeta- PRACTICE OF PHYSIC. Sll bles, 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 propor- tion of oil. It will be obvious, that upon the fame principles a want of food, or a lefs nutritious food, may not only occafion a general deficiency of fluids (mdciv.), but muft alfo afford lefs oil, to be poured into the cellular texture. In fuch cafes, therefore, the emaciation produced, is to be attributed to both thefe general caufes. mdcxv. A fecond cafe of the deficiency of oil may be axplained in this manner. It is pretty manifeft, that the oil of the blood is fecreted and depofited in the cellular texture in greater or leffer quantity, according as the circulation of the blood is fatter or flower ; and there- fore that exercife which haftens the circulation of the blood is a frequent caufe of emaciation. Exercife pro- duces this effea in two ways, lft, By increafing the perfpiration, and thereby carrying off a greater quantity of the nutritious matter, it leaves lefs of it to be depofit- ed in the cellurly texture ; thereby not only preventing an accumulation of fluids, but, as 1 have faid above, eaufing a general deficiency of thefe which muft alfo caufe a deficiency of oil in the cellular texture. 2dly, It is well known, that the oil depofited in the cellular texture is upon many occafions, and for various pur- pofes of the economy, again abforbed, and mixed or dif- fufed in the mafs of blood, to be from thence perhaps car- ried entirely out of the body by the feveral excretions. Now, among other purpofes of the accumulation and re- abforption 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 mufcuhr and moving fibres every where, muft occafion an abforp- tion of oil ; and confequently that fuch exercife not on- ly prevents the fecretion of oil, as has been already faid, 4 $1* PRACTICE OF PHYSIC. but may alfo caufe a deficiency of it, by occafioning an abforption of what had been depofited ; and in this way, perhaps efpecially, does it produce emaciation. mdcxvi. A third cafe of the deficiency of oil may oc- cur from the following caufe. It is probable, that one purpofe of the accumulation of oil in the cellular tex- ture of animals is, that it may, upon occafipn, be again abforbed from thence, and carried into the mafs of blood, for the purpofe of inveloping and correaing any tinufual acrimony arifing and exifting in the ftate of the fluids. Thus, in moft inftances in which we can difcern an acrid ftate of the fluids, as in fcurvy, cancer, fyphilis, poifons, and feveral other difeafes, we find at the fame time a deficiency of oil and an emaciation take place ; which, in my apprehenfion, muft be attributed to the abforption of oil, which the prefence of acrimony in the body excites. It is not unlikely that certain poifons introduced in- to the body, may fubfift there ; and, giving occafion to an abforption of oil, may lay a foundation for the Tabes a veneno, Sauv. fp. 17. mdcxvii. A fourth cafe of emaciation, and which I would attribute to a fudden and confiderable abforption of oil from the cellular texture, is that of fever, which fo generally produces emaciation. This may perhaps be in part attributed to the increafed perfpiration, and there- fore to the general deficiency of fluids that may be fup- pofed to take place : but whatever fhare that may have in producing the effect, we can, from the evident fhrinking and diminution of the cellular fubftance, where ever it falls under our obfervation, certainly conclude, that there has been a very confiderable abforption of the oil which had been before depofited in that fubftance. This explanation is rendered the more probable from this, that I fuppofe the abforption mentioned is neceffa- rily made for the purpofe of inveloping or correaing an acrimony, which manifeftly does in many, and may be fufpeaed to arife in all cafes of fever. The moft re-. markable inftance of emaciation occuring in fevers, is that which appears in the cafe of heaic fevers. Here the emaciation may be attributed to the profufe fweat- PRACTICE OF PHYSIC. J'9 ings that commonly attend the difeafe: but there is much reafon to believe, that an acrimony alfo is pref- ent in the blood, which, even in the beginning of the difeafe, prevents the fecretion and accumulation of oil; and in the more advanced ftates of it, muft occafion a more confiderable abforption of it ; which, from the fhrinking of the cellular fubftance, feems to go farther than in almoft any other inftance. Upon the fubject of emaciations from a deficiency of fluids, it may be obferved, that every increafed evacua- tion excites an abforption from other parts, and particu- larly from the cellular texture ; and it is therefore proba- ble, that a deficiency of fluids, from increafed evacua- tions, produces an emaciation, not only by the wafte of the fluids in the vafcular fyftem, but alfo by occafioning a confiderable abforption from the cellular texture. mdcxviii. I have thus endeavored to explain the fev- eral 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 fpecies of 5auvages ; but it is my opinion now, that the arrange- ment there given is erroneous,in both combining and fep- arating fpecies improperly: and it feems to me more prop- er here to take notice ofdifeafes, and put them to togeth- er, according to the affinity of their nature, rather than by that of their external appearances. I doubt, if even the diftinaion of the Tabes and Atrophia, attempted in the Nofology, will properly apply ; as I think there arc cer- tain difeafes of the fame nature, which fometimes appear with, and fometimes without fever. mdcxix. After having confidered the various cafe: of emaciations, I fhould perhaps treat of their cure : but it will readily appear, that the greater part of the cafes a- bove mentioned,are purely fymptomatic,and confequent- ly that the cure of them muft be that of the primary dif- eafes upon which they depend. Of thofe cafes that cm any ways be confidered as idiopathic, it will appear that they are to be cured entirely by removing the remote caufes ; the means of accomplifliing which muft bn. fuf- ficiently obvious. BOOK II. OF IN TUMESCENT!^*, OR GENERAL SWELLINGS. INTRODUCTION, mdcxx. 1 he fwellings to be treated of in this place, are thofe which extend over the whole, or a great part of the body ; or fiich at leaft, as, though of fmall extent, are however of the fame nature with thofe that are more generally extended. The fwellings comprehended under this artificial or- der, 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 fec- tions, as the fwelling happens to contain, \ft, Oil; 2d, Air ; 3d, A watery fluid ; or, 4th, As the increafed bulk depends upon the enlargement of the whole fub- ftance of certain parts, and particularly of one or more of the abdominal vifcera. * External fwelling of the whole or great part of the body. Syn. Nof. PRACTICE OF PHYSIC. j«? CHAP. I. OF ADIPOSE SWELLINGS. * mdcxxi. 1 he only difeafe to be mentioned in this chapter, I have, with other Nofologifts, named Polyfarcia ; and in Englifli it may be named Corpulency, or, more ftriaiy, Obefity ; as it is placed here upon the common fuppofition of its depending chiefly upon the in- creafe of oil in the cellular texture of the body. This corpulency, or obefity, is in very different degrees in different perfons, and is often confiderable without be- ing confidered as a difeafe. There is, however, a certain degree of it, which will be generally allowed to be a dif- eafe ; 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, 1 have given fuch a difeafe a place here. Many phyficians have confidered it as an objea of praaice, and as giving, even'in no very high degree, a difpofition to many difeafes ; I am cf o- pinion, that it fhould be an object of praaice more fre- quently than it has been, and therefore that it merits our confideration here. mdcxxii. It may perhaps be alleged, that I have not been fufficiently correa, in putting the difeafe of corpu- lency as an intumefcentia pinguedinofa, and therefore implying its being an increafe of the bulk of the body, from an accumulation of oil in the cellular texture only. I am aware of this objeaion : and, as I have already faid .that emaciation (mdcii.) depends either upon a general deficiency of fluids in the vafcular fyftem, or upon a de- ficiency of oil in the cellular texture ; fo I fhould per- haps have obferved farther, that the corpulency, or gen- eral fulnefs of the body, may depend upon the fulnefs of the vafcular fyftem as well as upon that of the cellular tex- ture. This is true ; and for the fame reafons I ought, * Swelling of the body from fat. Syn. Nof. 58i PRACTICE OF PHYSIC. perhaps, after Linnaeus and Sagar, 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 apprehend that plethora is to be confidered as a ftate of tempera- ment only, which may indeed difpofe to difeafe: but not as a difeafe in itfelf, unlefs, in the language of the Stahiians, it be a plethora commota, when it produ- ces a difeafe accompanied with particular fymptoms, which give occafion to its being diftinguifhed by a dif- ferent appellation. Further, it appears to me, that the fymptoms which Linnaeus, and more particularly thofe which Sagar employs in the charaaer of plethora, never do occur but when the intumefcentia 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 determine which of the caufes has the greateft fhare in producing it. It is in- deed very poffible, that a plethora may occur without great obefity ; but I apprehend, that obefity never hap. pens to a confiderable degree, without producing a pleth- ora adfpatium 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. mdcxxiii. In attempting the cure of polyfarcia, I am of opinion, that the conjunaion of plethora and obefity, in the manner juft now mentioned, fhould be conftantly attended to ; and when the morbid effeas of the pleth- oric habit are 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 circum- ftances I have mentioned do not immediately require it, the praaice, upon account of obefity, alone, is hardly ev- er to be employed. The fame remark is to be made, with refpea to ar.y other evacuations that may be pro- pofed for the cure of corpulency; for, without the other means I am to mention, they can give but a very imper- fea relief ; ar.d, in fo far as they either empty or weak- PRACTICE OF PHYSIC. 5»3 en the fyftem, they may favor the return of plethora, and the increafe of obefity. mbcxxiv. Polyfarcia,or corpulency, whether it depend upon plethora or obefity, whenever it can either be confidered as a difeafe, or threatens to induce one, is to be cured, or the effeas of it are to be obviated, by diet and exercife. The diet muft be fparing; or rather, what is more admiflible, it muft be fuch as affords little nutritious matter. It muft, therefore, be chiefly, or al- moft only, of vegetable matter, and at the very utmoft of milk. Such a diet fliould be employed, and general- ly ought to precede exercife : for obefity does not eafi- ly admit of bodily exercife ; which is, however, the on- ly mode that can be very effeaual. Such, indeed, in many cafes, may feem difficult to be admitted ; but I am of opinion, that even the moft corpulent may be brought to bear it, by at firft attempting it very moderately, and increafing it by degrees very flowly, but at the fame time perfifting in fuch attempts with great conftancy. mdcxxv. As thefe, though the only effeaual meafures, are often difficult to be admitted or carried into execu- tion, fome other means have been thought of and em- ployed for reducing corpulency. Thefe, if I miftake not, have all been certain methods of inducing a faline ftate in the mafs of blood ; for fuch I fuppofe to be the elfeas of vinegar and of foap, which have been propofed. The latter, I believe, hardly paffes into the blood veffels, without being refolved and formed into a neutral fait, with the acid which it meets with in the ftomach. How well acrid and faline fubftances are fitted to diminish obe- fity, may appear from what has been faid above in mdc- xv. What effeas vinegar, foap, or other fubftances em- ployed, have had in reducing corpulency, there have not proper opportunities of obferving occurred to me : but I am well perfuaded, that the inducing a f;dine and acrid ftate of the blood, may have worfe confequences, than the corpulency it was intended to correct ; and that no perfon fhouldliazard thefe, while he may have recourfe to the more fafe and certain means 01? abftinence and exercife. 5*4 PRACTICE OF PHVSIC. CHAP. II. OF FLATULENT SWELLINGS. mdcxxvi. 1 he, cellular texture of the hu- man body very readily admits of airland 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 of the body. The flatulent fwellings under the fkin, have indeed moft commonly appeared in confequence of air immediately introduced from without : but in fome inftances of flatulent fwellings, efpecially, thofe of the internal parts not communicating with the alimentary canal, fuch an introduaion cannot be perceived orfuppof. ed ; 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 re- stored to its elaftic ftate, and feparated from thofe fub- ftances, by the power of heat, putrefaaion, and perhaps other caufes : but which of thefe may have produced the feveral inftances of pneumatosis and flatulent fwellings that have been recorded by authors, I cannot pretend to afcertain. Indeed, upon account of thefe difficulties, I cannot proceed with any clearnefs on the general fubjea of pneumatofis* ; and, therefore, with regard to flatu- lent fwellings, I find it neceffary to confine myfelf to the confideration of thofe of the abdominal region alone; which I fhall now treat of under the general name of Tympanitesf. * Tenfe elaftic fwelling of the body, crackling from preffure. Syn. Nof. f A tenfe, elaftic, and fonorous fwelling of the abdomen; conftivenefs ; emaciation of other parta. Spec. x. Tympanites finteflinalis ), accompanied with a fwelling of the abdomen, often unequal, and a frequent expulfion of air, alleviating the renfion and pain. PRACTICE OF PHYSIC. sfy mdcxxvii. The tympanites is a fwellingof the abdo- men ; in which the teguments appear to be much ftretch- ed by fome diftending power within, and equally ftretch- ed in every pofture of the body. The fwelling does not readily yield to any preffure; and in fo far as it does, very quickly recovers its former ftate upon the preffure being removed. Being ftruck, it gives a found like a drum, or other ftretched animal membranes. No fluc- tuation within is to be perceived ; and the whole feels lefs weighty than might be expected from its bulk. The uneafinefs of the diftenfion is commonly relieved by the difcharge of air from the alimentary canal, either up- wards or downwards. mdcxxviii. Thefe are the charaaers by which the tympanites may be diftinguifhed from the afcites or phyfeonia ; and many experiments fhow, that the tym- panites always depends upon a preternatural colleaion of air, fomewhere within the tegument:: of the abdomen: but the feat of the air is in different cafes fomewhat differ- ent ; and this produces the different fpecies of the difeafe. One fpecies is, when the air collected, is entirely con- fined within the cavity of the alimentary canal, and chiefly in that of the inteftines. This fpecies, therefore, is named the Tympanites inteftinalis, Sauv. fp. 1. It is, of all others, the moil common : and to it efpecially belong the charaaers given above. A fecond fpecies is, when the air colfeaed, is not en- tirely confined to the cavity of the inteftines, but is alfo prefent between their coats; and fuch is that which is named by Sauvages Tympanites enterophyfides, Sauv. fp. 3. This has certainly been a rare occurrence ; and has probably occurred only in confequence of the tympa- nites inteftinalis, by the air efcapingfrom the cavity of the inteftines into the interftices of the coats. It is, howev- er, poflible, that an erofion of the internal coat of the in- teftines may give occafion to the air, fo conftantly pref- ent in their cavity, to efcape into the interftices of their Spec. z. Tympanites (abdominalisJ, iVtendedvriih a more diftinfl: found, and a more equal fwelling ; the air is lefs frequently expelled, and gives lefs relief. Syn. Nof. 586 PRACTICE OF PHYSIC. coats, though in the whole of their cavity there has been no previous accumulation. A third fpecies is, when the air is colfeaed in the fac of the peritonaeum, or what is commonly called the cav- ity of the abdomen, that is, the fpace between the peri. tonasum and vifcera ; and then the difeafe is named Tympanites abdominal is, Sauv. fp. 2. The exiftence of fuch a tympanites without any tympanites inteftinalis, has been difputed ; and it certainly has been a- rare occurrence : but from feveral diffeaions, it is unqueftionable that fuch a difeafe has fometimes truly occurred. A fourth fpecies of tympanites is, when the. tympanites inteftinalis, and abdominalis, are joined together, or take place at the fame time. With refpea to this, it is prob- able that the tympanites inteftinalis, is the primary difeafe; and the other only a confequence of the air efcaping, by an erofion or rupture of the coats of the inteftines, from the cavity of thefe, into that of the abdomen. It is in- deed poflible, that in confequence of erofion or rupture, the air which is fo conftantly prefent in the inteftinal ca- nal, may efcape from thence in fuch quantity into the cavity of the abdomen, as to give a tympanites abdominalis, whilft there was no previous confiderable accumulation of air in the inteftinal cavity itfelf; but I have not faas to afcertain this matter properly. A fifth fpecies has alfo been enumerated. It is when a tympanites abdominalis, happens to be joined with the hy- drops afcites ; and fuch a difeafe therefore is named by Sauvages Tympanites afciticus, Sauv. fp. 4. In moft cafes of tympanites, indeed, fome quantity of ferum has, upon diffeaion, been found in the fac of the perito- naeum ; but that is not enough to conftitute the fpecies now mentioned; and when the colfeaion of ferum is more confiderable, it is commonly where, both from the caufes which have preceded, and likewife from the fymptoms which attend, the afcites may be confidered as the primary difeafe ; and therefore that this combina- tion does not exhibit a proper fpecies of the tympan« PRACTICE OF PHYSIC. 587 mdcxxix. As this laft is not a proper fpecies, and as fome of the others are not only extremely rare, but even, when occurring, are neither primary, nor to be eafily diftinguifhed, nor, as confidered in themfelves, admit- ting of any cure, I fhall here take no further notice of them ; confining myfelf, in what follows, to the confid- eration of the moft frequent cafe, and almoft the only objea of praaice, the tympanites inteftinalis. mdcxxx. With refpea to this, I cannot perceive that it arifes in any peculiar temperament, or depends upon any predifpofition, which can be difcerned. It occurs in either fex, at every age, and frequently in young perfons. mdcxxxi. Various remote caufes of it have been af- firmed : but many of thefe have not commonly the ef- fect of producing this difeafe ; and although fome of them have been truly antecedents of it, I can in few in* ftances difcover the manner in which they produce the difeafe, and therefore cannot certainly afcertain them to have been caufes of it. mdcxxxii. The phenomena of this difeafe in its fev- eral ftages are the following. The tumor of the belly fometimes grows very quickly to a confiderable degree, and feldom in the flow manner the afcites commonly comes on. In fome cafes, howev- er, the tympanites comes on gradually, and is introduc- ed by an unufual flatulency of the ftomach and intef- tines, with frequent borborygmi, and an uncommonly frequent expulsion of air upwards and downwards. This ftate is alfo frequently attended with colic pains, ef- pecially felt about the navel, and upon the fides towards the back; but generally as the difeafe advances, thefe pains become lefs comfiderable- As the difeafe advances, there is a pretty conftant defire to difcharge air, but it is accomplifhed with difficulty; and when obtained, al- though it give fome relief from the fenfe of diftenfion, this relief is commonly tranfient and of fhort duration. While the difeafe is coming on, fome inequality of tu- mor and tenfion may be perceived in different parts of the belly; but the diftenfion foon becomes equal over O o S%3 PRACTICE OF PHYSIC. the whole, and exhibits the phenomena 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 u- rine, at the beginning, is ufually very little changed in quantity or quality from its natural ftate ; but as the dif- eafe continues, it is commonly changed in both refpeas, and at length fometimes a ftrangury, and even an ifchu- ria, comes on. The difeafe ha^ feldom advanced far be- fore the appetite is much impaired, and digeftion ill per- formed ; and the whole body, except the belly, becomes confiderably emaciated. Together with thefe fymp- toms, 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 tumor of the belly arifes to a confiderable bulk, the breathing becomes very difficult, with a frequent dry cough. With all thefe symptoms the ftrength of the pa- tient declines; and the febrile fymptoms daily increaf- ing, death at length enfues, fometimes probably in con- fequence of a gangrene coining upon the inteftines. mdcxxxiii. The tympanites is commonly of fome du» ration, and to be,reckoned a chronic difeafe. It is very feldom quickly fatal, except where fuch an affeaion fud- denly arifes in fevers, 'lo this Sauvages has properly given a different appellation,, that of Meteorifmus ; and I judge it may always be confidered as a fymptomatic af- feaion, entirely diftina from the tympanites we are now confidering. mdcxxxiv. The tympanites is generally a fatal dif- eafe, feldom admitting of cure ; but what may be at- tempted in this way, 1 fhall try to point out, after I fhall have endeavored to explain the proximate caufe, which alone can lay the foundation of what may be rationally attempted towards its cure. mdcxxxv. To afcertain the proximate caufe of tym- panities, 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 ufua] PRACTICE OF PHYSIC. 589 from the alimentary matters taken in. Our Vegetable aliments, I believe, always undergo fome degree of fer- mentation ; and in confequence, a quantity of air is ex- tricated and detached from them in the ftomach and in- teftines : 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 de- tached from them that would have been in their fer- mentation without fuch mixture, and it is probable that the fame mixture contributes alfo to the reabforption of the air that had been before in fome meafure detached. The extrication, therefore, of an unufual quantity of air from the aliments, may, in certain circumftances, be fuch, perhaps, as to produce a tympanites; fo that this difeafe may depend upon a fault of the digeftive fluids, whereby they are unfit to prevent the too copious extrication of air, and unfit alfo to occafion that reabforption of air which in found perfons commonly happen. An unufu* al 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 poflibly have, and in fome meafure certainly has, a fhare in producing certain flatulent diforders of the alimentary canal; but cannot be fuppofed to pro- duce the tympanites, which often occurs when no pre- vious diforder had appeared in the fyftem. Even in thofe cafes of tympanites which are attended at their be- ginning with flatulent diforders in the whole of the ali- mentary canal, as we know that a firm tone of the intef- tines both moderates the extrication of air, and contri- butes to its reabforption or ready expulfion, fo the flatu- lent fymptoms which happen to appear at the coming on of a tympanites, are, in my opinion, to be referred to a lofs of tone in the mufcular fibres of the inteftines, rath- er than to any fault in the digeftive fluids. mdcxxxvi. Thefe, and other confiderations, lead me to conclude, that the chief part of the proximate caufe of tympanites, is a lofs of tone in the mufcular fibres of the inteftines. But further, as air of any kind accumu- lated in the cavity of the inteftines fhould, even by its 2 PRACTICE OF PHYSIC. own elafticity, find its way either upwards or down- wards, and mould alfo, by the affiftance of infpiration, be entirely thrown out of the body ; fo, when neither the reabforption nor the expulfion takes place, and fhe air is accumulated fo as to produce tympanites, it is prob- able that the paffage of the air along the courfe of the inteftines is in fome places of thefe interrupted. This in- terruption, however, can hardly be fuppofed to proceed from any other caufe than fpafmodic conftriaions in cer- tain parts of the canal; and I conclude, therefore, that fuch conftriaions concur as part in the proximate caufe of tympanites. Wether thefe fpafmodic conftriaion s are to be attributed to the remote caufe of the difeafe, or may be confidered as the confequence of fome degree of atony firft arifing, I cannot with certainty, and do not find it neceffary to determine. mdcxxxvii. Having thus endeavored to afcertain the proximate 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, endeav- or to fay what may be reafonably attempted ; whathas commonly been attempted; and what attempts have fometimes fucceeded in the cure of this difeafe. mdcxxxviii. It muft be a firft indication to evacuate the air accumulated in the inteftines ; and for this pur- pofe it is neceffary that thofe conftriaions, which had ?^. pecially occafioned its accumulation, and continue to in- terrupt its paffage along the courfe of the inteftines, ' fhould be removed. As thefe, however- can hardly be removed but by exciting the periftaltic motion in the 'adjoining portions of the inteftines, purgatives have been commonly employed ; but it is at the fame time a- greed, that the more gentle laxatives only ought to be employed, as the more draftic, in the overftretched and tenfe ftate of the inteftines, are in danger of bringing on inflammation. It is for this reafon, alfo that glyfters have been fre- quently employed ; and they are the more neceffary, as the faeces colfeaed are generally found to be in a hard and dry ftate* Not only upon account of this ftate of PRACTICE OF PHYSIC the fasces, but, farther, when glyfters produce a confider- able evacuation of air, and thus fnow that they have fome cffea in relaxing the fpafms of the inteftines, they ought to be repeated very frequently. mdcxxxix. In order to take off the conftriaions of the inteftines, and with fome view alfo to the carmina- tive effeas of the medicines, various antifpafmodics have been propofed, and commonly employed ; but their effeas are feldom confiderable, and it is alleged that their heating and inflammatory powers have fometimes been hurtful. It is, however, always proper to join fome of the milder kinds with both the purga- tives and glyfters that are employed ; and it has been very properly advifed to give always the chief of antif- pafmodics, that is, an opiate, after the operation of pur- gatives is finifhed. mdcxl. In confideration of the overftretched, tenfe, and dry ftate of the inteftines, and efpecially of the fpaf- modic 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. mdcxli. Upon the fuppofition that this difeafe de- pends efpecially upon an atony of the alimentary canal, tonic remedies feem to be properly indicated. Accord- ingly chalybeates, and various bitters, have been em- ployed ; and, if any tonic, the Peruvian bark might probably be ufeful. mdcxlii. But as no tonic remedy is more powerful than cold applied to the furface of the body, and cold drink thrown into the ftomach ; fo fuch a remedy has been thought of in this difeafe. Cold drink has been conftantly prefcribed, and cold bathing has been employ- ed with advantage ; and there have been feveral in- ftances of the difeafe being fuddenly and entirely cured by the repeated application of fnow to the lower belly. mdcxliii. 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 3 592 PRACTICE OF PHYSIC. it is probable, that the foffil acids and neutral falts, as antizymics, may be ufeful. mdcxliv. In obftinate and defperate cafes of tympan- ites, the operation of the paracentefis has been propofed: but it is a very doubtful remedy, and there is hardly any teftimony of its having been praaifed with fuccefs. It muft be obvious, that this operation is a remedy fuit- ed efpecially, and almoft only, to the tympanites abdomin- alis ; the exiftence of which, feparately from the inteftin- alis, is very doubtful, at leaft not eafily afcertained. E- ven if its exiftence 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 inteftinalis, is not yet determined by any proper experience. CHAP. III. OP WATERY SWELLINGS, OR DROPSIES. mdcxlv. A preternatural colfeaion of ferous or watery fluids, is often formed in difterent parts of the human body ; and although the difeafe thence arifing be diftinguifhed according to the different parts which it occupiesy yet the whole of fuch colfeaions come under the general appellation of Dropfies. At the fame time, although the particular inftances of fuch colfeaion are to be diftingufhed from each other according to the parts they occupy, as well as by other circumftances at- tending 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 endeavor to affign the general caufes of dropfy. mdcxi.vi. In perfons in health, a ferous or watery fluid feems to be conftantly poured out, or exhaled in vapor, 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, PRACTICE OF PHYSIC. 593 feems conftantly 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 quan- tity poured out into any fpace, happens to be greater than the abforbents can at the fame time take up, an unufual accumulation of ferous fluid will be made in fuch parts ; or though the quantity poured out, be not more than ufual, yet if the abforption be any ways in- terrupted or diminifhed, from this caufe alfo an unufual colfeaion of fluids may be occafioned. Thus, in'generaj, dropfy may be imputed to an increaf- ed effufion, or to a diminifhed abforption ; and I there- fore proceed to inquire into the feveral caufes of thefe. mdcxlvii. An increafed effufion may happen, either from a preternatural increafe of the ordinary exhalation, or from the rupture of veffels carrying, or of facs con- taining ferous or watery fluids. mocxlviii. The ordinary exhalation may be increaf- ed by various caufes, and particularly by an interrupt- tion 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 refift- ing the free paffage of the blood from the arteries into the veins, thereby increafing the force of the arterial flu- ids in the exhalants, and confequently the quantity of fluid which they pour out. mdcxlix. The interruption of the free return of the venous blood from the extreme veffels, may be owing to 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 re- ceiving the ufual quantity of blood from the vena cava; or to obftruaions in the veffels of the'lungs preventing the entire evacuation of the right ventricle, and thereby hindering its receiving the ufual quantity of blood from the cava. Thus, a polypus in the right ventricle of the heart, and the offification of its valves, as well as all con- fiderable and permanent obftruaions of the lungs, have ').cen found to be caufes of dropfy. 4 514 PRACTICE OF PHYSIC. mdcl. It may ferve as an illuftration of the operation of thefe general caufes, to remark, .that the return of the venous blood is in fome meafure refitted when the pof- ture 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. mdcli. 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 effea of increafing exhalation, and producing drop- fy. The moft remarkable inftance of this is when con- fiderable obftruaions of the liver prevent the blood from flowing freely into it from the vena portarum and its nu- merous branches ; and hence thefe obftruaions are a fre- quent caufe of dropfy. mdclii. 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 produce 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 ofafcites; or, by comprefling the vena cava, may produce 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 perfons : but I believe they have been feldom found, un- lefs when feirrhofities of the liver were alio prefent; and I 3m inclined to think, that the former have been the ef- feas of the latter, rather than the caufe of the dropfy : or that, if feirrhofities of the other vifcera have appeared in hydropic bodies when that of the liver was not pref- ent, they muit have been the effeas of fome of thofe caufes of dropfy to be hereafter mentioned; and confe- quently to be the accidental attendants^ rather than the caufes of fuch dropfies. mdcliii. Even in fmaller portions of the venous fyf- tem, the interruption of the motion of the blood in par- PRACTICE OF PHYSIC. 59; ticular veins has had the fame effea. Thus, a polypus formed in the cavity of a vein, or tumors formed in its coats, preventing the free paffage of the blood through it, have had the effea of producing dropfy in parts to- wards the extremity of fuch veins. mdcliv. But the caufe moft frequently interrupting the motion of the blood through the veins, is' the com- prefion of. tumors exifting near to them; fuch as aneu- rifms in the arteries, abfeeffes, and feirrhous or fteato- matous tumors in the adjoining parts. To this head may be referred, the compreffion of the defcending cava by the bulk of the uterus in pregnant women, and the compreffion of the fame by the bulk of water in the afcites; both of which compreffions fre- quently produce ferous fwellings in the lower extremi- ties. mdclv. It may be fuppofed, that a general preternat- ural plethora of the venous fyftem may have the effea of increafing exhalation; and that this plethora may happen from the fuppreffion of fluxes, or evacuations of blood, which had for fome time taken place in the body, fuch as the menftrual and hemorrhoidal fluxes. A dropfy, however, from fuch a caufe, has been at leaft a rare occurrence; and when it feems to have happened, I fhould fuppofe it owing to the fame caufes as the fup- preffion itfelf, rather than to the plethora produced by it. mdclvi. One of the moft frequent caufes of an increaf- ed exhalation, i apprehend to be the laxity of the exha- lant veffels. That fuch a caufe may operate, appears probable from this, that paralytic limbs, in which fuch \ laxity is to be fufpeaed, are frequently affeaed with fe- rous, or, as they are called, cedematous fwellings. But a much more remarkable and frequent example of its operation occurs in the cafe of a general debility of the fyftem, which is fo often attended with dropfy. That a general debility does induce dropfy, appears fufli- ciently from its being fo commonly the confequence of powerfully debilitating caufes ; fuch as fevers, either ot the continued or intermittent kind, which have hfted 5 ducing a conftriaion of the excretories. The proportion of watery fluid in the blood may be increafed, not only by the taking in a large quantity of water by drinking, as now mentioned, but it is poflible that it may be increafed alfo by water taken in from the atmofphere by the fkin in an abforbing or imbibing ftate. It is well known, that the fkin may be, at leaft occafion- ally, in fuch a ftate ; and it is probable, that in many cafes of beginning 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 imbib- ing ftate; and thus, at leaft, the difeafe may be very much increafed. moclix. A fecond caufe of a preternatural abundance of watery fluids in the blood veffels, may be, an inter- ruption of the ordinary watery excretions ; and accord. ingly it is alleged, that perfons milch expofed to a cold 59$ PRACTICE OF PHYSIC. and moift air are liable to dropfy. It is alfo faid, that an i interruption, or confiderable diminution, of the urinary fecretion, has produced the difeafe; and it is certain, that, in the cafe of an ifchuria renalis, the ferofity retain- ed in the blood veffels has been poured out into fome in- ternal cavities, and has occafioned dropfy. mdclx. A third caufe, of an over proportion of fe- rous fluid in the blood ready to run off by the exhalants, has been very large evacuations of blood, either fponta- neous or artificial. Thefe evacuations, by abflraaing a large proportion of red globules and gluten, which are the principal 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 evacuations. * It is poffible alfo, that large and long-continued iffues, by abflraaing a large proportion of gluten, may have the * fame effect. An over proportion of the ferous parts of the blood, may not only be owing to the fpollution yifi now mention-'* ed, but many, I apprehend, be likewife owing to a fault in the digefting and affimilating powers in the ftomach and other organs ; whereby they do not prepare and con- vert the aliments taken in, in fuch a manner as to pro- duce 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 confequent- ly ready to run off in too large quantity by the exhalants. It is in this manner that we explain the dropfy, fo often, attending chlorofis ; which appears always at firft by a pale color of the whole body, fhowing a manifeft defi- ciency of red blood ; which in that difeafe can only be attributed to an imperfea digeftion and aflimilation. Whether a like imperfeaion take place in what has been called a Cachexy, I dare not determine. This difeafe indeed has been commonly and very evidently owing to the general caufes of debility above mentioned : and it being probable that the general debility may effea the organs of digeftion and aflimilation; fo the imperfea ftate of thefe functions, occafioning a deficiency of red glodulea PRACTICE OF PHYSIC. 59? and gluten, may often concur with the laxity of the ex- halants in producing dropfy. • .mdclxi. Thefe are the feveral caufes of increafed ex- halation, which I have mentioned as the chief caufe of the effufion producing dropfy ; but I have likewife obferv- ed in mdcxlvii. that with the fame effea, an effufion may alfo be made by the rupture of veffels cayrying wa- tery fluids. In this way, a rupture of the thoracic dua, has given occafion to an effufion of chyle and lymph into the cavity of the thorax; and a rupture of the lacteals, has occafion- |ed a like effufion into the the cavity of the abdomen ; and in either cafe, a dropfy has been produced. It is fufficiently probable that a rupture of lymphatics, in conference of strains, or the violent compreffion of neighboring mufcles, has occafioned an effufion , which, being diffufed in the cellular texture, lias produced con- fiderable dropfy. It belongs to this head of caufes, to remark, that there 1 are many inftances of a rupture or erofion of the kidneys, , ureters, and bladder of urine ; whereby the urine has ' been poured into the cavity of the abdomen, and pro- f duced an afcites. :'• mdclxii. Upon this fubject, of the rupture of veffels carrying, or of veficles containing watery fluids, I mult obferve, that the diffeaion of dead bodies has often ' (hown veficles formed upon the furface of many of the internal parts ; and it has been fuppofed, that the rupture ' or fuch veficles, commonly named Hydaiides, together with their continuing to pour out a watery fluid, has been frequently the caufe of dropfy. I cannot deny the poffibility of fuch a caufe, but fufpect the matter muft be i. explained in a different 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 oi fuppofed dropfy, particularly in thofe called the preter- natural encyfted dropfies, the fwelling has been entirely owing to a collection of fuch hydatids. Many conjec- tures have been formed with regard to the nature and 600 PRACTICE OF PHYSIC. produaion of thefe veficles; but the matter at laft feems ; to be afcertained. It feems to be certain, that each of thefe veficles has within it, or annexed to it, a living an- imal of the worm kind ; which feems to have the pow- er of forming a veficle for the purpofe of its own econo- my, and of filling it with a watery fluid draw from the neighboring parts: and this animal has therefore been i properly named by late naturalists, the Tania hydatigcna. The origin and economy of this animal, or an account of the feveral parts of the human body which it occupies1,1 cannot profecute further here; but it was proper for j me, in delivering the caufes of dropfy, to fay thus much*^ of hydatides : and I muft conclude with obferving, I am*. Nof. PRACTICE OF PHYSIC. only upon the feet and about the ankles ; yet if the cau- fes producing it continue to aa, it gradually extends up- wards, occupying the legs thighs, and trunk of the bo- dy, and fometimes even the head. Commonly the fwel- ling of the lower extremities diminifhes during the night; and in the morning, the fwelling of the face is moft confiderable, which again generally difappears al- moft entirely in the courfe of the day. mdclxix. The terms of Anafarca and Leucophlegmatia have been commonly confidered as fynonymous ; but fome authors have propofed to confider them as denot- ing diftina difeafes. The authors who are of this laft opinion employ the name of Anafarca for that difeafe which begins in the lower extremities, and is from thence gradually extended upwards in the manner I have juft now defcribed ; while they term Leucophlegmatia, that in which the fame kind of fwelling appears even at firft very generally over the whole body. They feem to think al- io, that the two difeafes proceed from different caufes ; and that, while the anafarca may arife from the feveral caufes in mdcxlviii.—mdclix. the leucophlegmatia pro- ceeds efpecially from a deficiency of red blood, as we have mentioned in mdclx. et feq. I cannot, howler, find any proper foundation for this diftinaion ; for al- though in dropfies proceeding from the caufes mentioned in mdclx. et feq. 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 the cafes occafioned by a deficiency of red blood, I have frequently obferved it to come on exaaiy in the manner of an anafarca, as a- bove defcribed. mdclxx. An anafarca is evidently a preternatural col- feaion of ferous fluid in the cellular texture immediately under the fkin. Sometimes pervading the fkin itfelf, it oozes out through the pores of the cuticle ; and fome- . times, too grofs to pafs by thefe?-it raifes the cuticle in blifters. Sometimes the fkin, not allowing the water to pervade it, is compreffed and hardened, and at the fame 6c4 PRACTICE OF PHYSIC. time fo much diftended, as to give anafarcous tumors air unufual firmnefs. It is in thefe laft circumftances alfo that an erythematic inflammation is ready to come upon anafarcous fwellings. mdclxxi. An anafarca may immediately arife from any of the feveral caufes of dropfy which aa more gen- erally upon 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. mdclxxii. The manner in which this difeafe com- monly firft appears, will be readily explained by what I have faid in mdcl. refpeaing the effeas of the pofture of the body. Its 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 inter- nal parts, will be underftood partly from the communi- cation that is readily made between the feveral parts of the cellular texture ; but efpecially from the fame gener- al caufes of the difeafe producing their effeas in every part of the body. It appears to me that the water of a- nafarcous fwellings is more readily communicated to the cavity of the thorax, and to the lungs, than to the cavi- ty of the abdomen, or to the vifcera contained in it. mdclxxiif. An anafarca is almoft always attended' with a fcarcity of urine; and the urine voided, is from its fcarcityr always of a high color , and from the fame caufe, after coolings readily lets fall a copious reddifh fed- iment. This fcarcity of urine may fometimes be owing to an obftruction; of the kidneys^ but probably is gener- ally occafioned'by the watery parts of the blood running off into the cellular texture, and being thereby prevent- ed from paffing 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 of the fluids in thefe parts. PRACTICE O PHYSIC. 605 mdclxxiv. The cure of anafarca is to be attempted upon three general indications. I. 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. mdclxxv. 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 effeas 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 oth- ers, they muft be removed. For the moft part, the re- mote caufes are certain difeafes previous to the dropfy, which are to be cured by the remedies particularly a- dapted 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 remote caufes cannot be removed, the cure of the dropfy muft be difficult, or perhaps im- poffible. In many cafes, therefore, the following indica- tions will be to little purpofe ; and particularly, that oft- en the execution of the fecond will not only give the pa- tient a great deal of fruitlefs trouble, but commonly alfo hurry on his fate. mdclxxvi. The fecond indication for evacuating the colfeaed ferum, may be fometimes executed with advan- tage, and often, at leaft, with temporary relief. It may be performed in two ways. Firft, by drawing off the water direaiy from the dropfical part, by openings made into it for that purpofe: Or, fecondly, by exciting cer- tain ferous excretions ; in confequence of which, an ab - forption may be excited in the dropfical parts, and there- by the ferum abforbed and carried into the blood veffels, may afterwards be direaed to run out or may fpontane- oufly pafs out, by one or other of the common excre- tions. 2 fcO* PRACTICE OF PHYSIC- mdclxxvii. In an anafarca, the openings into the drop- fical part are commonly to be made in fome part of the lower extremities; and will be moft properly made by many fmall punaures reaching the cellular texture. For- merly, confiderable incifions were employed for this pur- pofe : but as any wound made in dropfical parts, which, in order to their healing, muft neceffarily inflame and fuppurate, are liable to become gangrenous ; fo it is found to be much fafer to make the openings by fmall punc- tures only, which may heal up by the firft intention. At the fame time, even with refpect to thefe puaures, it is proper to obferve, that they fhould be made at fome dif- tance from one another, and that care fliould be taken to avoid making them in the moft depending parts. mdclxxviii. The water of anafarcous limbs may fome- times be drawn off by pea iffues, made by cauftic a little below the knees : for as the great fwelling of the lower extremities is chiefly occafioned by the ferous fluid exhal- ed 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 of the 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 if- fues ; but I apprehend that fetons will be more liable than iffues to the accident juft now mentioned. mdclxxix. For the purpofe of drawing out feruin 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. Blifter- ing 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. mdclxxx. Colewort leaves applied to the fkin, read- ily occafion a watery exfudation from its furface ; and applied to the feet and legs afleaed with anafarca, have PRACTICE OF PHYSIC. *o.7 fometimes drawn off the water very copioufly, and with great advantage. Analogous, as I judge, to this, oiled filk hofe put upon the feet and legs, fo as to 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 appli- cation of thefe hofe, or that of the colewort leaves, of much fervice. mdclxxxi. The fecond means propofed in mdclxxvi. for drawing off the water from dropfical places, may be the employment of emetices, purgatives, diuretics, or fudorifics. mdclxxxn. As fpontaneous vomiting has fometimes excited an abforption in hydropic parts, and thereby drawn off the waters lodged in them, it is reafonable to fuppofe, that vomiting excited by art may have the fame effea; and accordingly it has been often praaifed with advantage. The practice however requires that the ftrong antimonial emetics be employed, and that they be repeat- ed frequently after fhort intervals. mdclxxxiii. Patients fubmit more readily to the ufe of purgatives, than to that of emetics; and indeed they commonly bear the former more eafily than the latter. At the fame time, there are no means we can employ to procure a copious evacuation of ferous fluids with greater certainty than the operation of purgatives; and it js upon thefe accounts that purging is the evacuation which has been moft frequently, and perhaps with moft fuccefs, em- ployed in dropfy. It has been generally found necefla- ry to employ purgatives of the more draftic kind ; which are commonly know, and need not be enumerat- ed here. I believe indeed, that the more draftic purga- tives are the moft effeaual for exciting abforption, as their ftimulus is moft readily communicated to the oth- er parts of the fyftem ; but of late, an opinion has pre- vailed, that fome milder purgatives may be employed with advantage. This opinion has prevailed particular- ly with regard to the cryftals vulgarly called the Cream 6o8 PRACTICE OF PHYSIC. of Tartar, which in large dofes frequently repeated, have fometimes anfwered the purpofe of exciting large evacu- ations, both by ftool and urine, and has thereby cured dropfies. This medicine, however, has frequently failed, both in its operation and effeas, when the draftic purga- tives have been more fuccefsful. , Praaitioners have long ago obferved, that in the em- ployment of purgatives, it is requifite they be repeated after as fhort intervals as the patient can bear ; probably for this reafon, that when the purging is not carried to the degree of foon exciting an abforption, the evacuation weakens the fyftem, and thereby increafes the afflux of fluids to the hydropic parts. mdclxxxiv. 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 confiderable 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 employed in the cure of dropfy. The various diuretics that may be employed, are enumerated in every treatife of the Materia Medica and of the Praaice of Phyfic, and therefore need not be repeated here. It hap- pens, however, unluckily, that none of them are of very certain operation ; neither is it well known why they fometimes fucceed, and why they fo often fail; nor why one medicine fliould prove of fervice when another does not. It has been generally the fault of writers upon the Praaice of Phyfic, that they give us inftances of cafes in which certain medicines have proved very efficacious, but neglea to tell us in how many other inftances the fame have failed. mdcl xxxv. It deferves to be particularly obferved here, that there is hardly any diuretic more certainly Powerful than a large quantity of common water taken in by drinking. I have indeed' obferved above, in mdc- lvui. that a large quantity of water, or of watery liquors, taken in by drinking, has fometimes proved a caufe of dropfy ; and praaitioners have been formerly fo much afraid, that watery liquors taken in by drinking, might PRACTICE OF PHYSIC. §09 run off into dropfical places and increafe the difeafe, that they have generally enjoined the abftaining as much as pof- fible from fuch liquors. Nay, it has been further afferted, that by avoiding this fupply of exhalation, and by a to- tal abftinence from drink, dropfies have been entirely cured. What conclufion is to be drawn from thefe faas is, however, very doubtful. A dropfy arifing from a large quantity of liquids taken into the body, has been a very rare occurrence ; and thereare, on the other hand, innumerable inftances of very large quantities of water having been taken in and running off again very quick- ly by ftool and urine, without producing any degree of dropfy. With refpea to the total abftinence from drink, it is a praaice of the moft difficult execution ; and there- fore has been fo feldom praaifed, that we cannot poffi- bly know how far it might prove effeaual. The praaice of giving drink very fparingly, has indeed been often employed ; but in a hundred inftances, I have feen it car- ried to a great length without any manifeft advantage ; while, on the contrary, the praaice of giving drink very largely has been found not only fafe, but very often effeaual in curing the difeafe. The ingenious and learn- ed Dr. Millman has, in my opinion, fbeen commendably employed in reftoring the praaice of giving large quan- tities of watery liquors for the cure of dropfy. Not only from the inftances he mentions from his own praaice, and from that of feveral eminent phyficians in other parts of Europe,but alfo from many inftances in the re- cords of phyfic, of the good effeas of drinking large quantities of mineral waters in the cure of dropfy,! can have no doubt of the praaice recommended by Dr. Millman being very often extremely proper. 1 appre- hend it to be efpecially adapted to thofe cafes In which the cure is chiefly attempted by diuretics. It is very probable, that thefe medicines can hardly be carried in any quantity to the kidneys without being accompanied with a'large portion of water ; and the late frequent em- ployment of the crystals of tartar has often fliown, that the diuretic effeas of that medicine are almoft only re- markable when accompanied with a large quantity of 4 6l£ PRACTICE OF PHYSIC. water; and that without this, the diuretic effeas of the medicine feldom appear. I fhall conclude this fubjea with obferving, that as there are fo many cafes of dropfy abfolutely incurable, the praaice now under confideration may often fail, yet in moft cafes it may be fafely tried ; and if it appear that the water taken in paffes readily by the urinary fecretion, and efpecially that it increafes the urine beyond the quantity of drink taken in, the praaice may probably be continued with great advantage: but on the contrary, if the urine be not increafed, or be not even in proportion to the drink taken in, it may be con- cluded, that the water thrown in runs off by the exha- lants, and will augment the difeafe. mdclxxxvi. Another fet of remedies which may be employed for exciting a ferous excretion, and thereby curing dropfy, is that of fudorifics. Such remedies in- deed have been fometimes employed : but however ufe. ful they may have been thought, there are few accounts of their having effeaed a cure; and although I have had fome examples of their fuccefs, in moft inftances of their trial they have been ineffeaual. Upon this fubjea it is proper to take notice of the fev- eral means that have been propofed and employed for diffi- pating the humidity of the 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 relate them. I fhall offer only this conjeaure upon the fubjea: That if fuch meafures have been truly ufeful, as it has feldom been by the drawing out of any fenfible humidity, it has probably been by their reftoring the perfpiration, which is fo often greatly diminifhed in this difeafe; or perhaps by changing the ftate of the fkin, from the imbibing condition which is alleged to take place, into that of perfpiring. mdclxxx.vii. When, by the feveral means now men- tioned; we fhall have fucceeded in evacuating the water of dropfies, there will then efpecially be occafion for our third indication; which is, to reftore the tone of the fyftem, the lofs of which is fo often the caufe of the dif- PRACTICE OF EHYSIC. 611 eafe. This indication, indeed, may properly have place from the very firft appearance of the difeafe; and certain meafures adapted to this purpofe may, upon fuch firft ap- pearance, be employed with advantage. In many cafes of a moderate difeafe, I am perfuaded that they may ob- viate any future increafe of it. mdclxxxviii. Thus, upon what is commonly the firft fymptom of anafarca, that is, upon the appearance of what are called Oedematous Swellings of the feet and legs, the three remedies of bandaging, friaion, and exercife, have often been ufed with advantage. mdclxxxix. That fome degree of external compref- i fion, is fuited to fupport the tone of the veffels, and par- ticularly to prevent the effeas of the weight of the blood in dilating thofe of the lower extremities, muft be fuffi- ciently evident; and the giving that compreffion by a i' bandage properly applied, has been often ufeful. In ap- ; plying fuch a bandage, care is to be taken that the com- preffion may never be greater on the upper than on the lower part of the limb; and this, I think, can hardly ev- er be fo certainly avoided, as by employing a properly r. conftruaed laced flocking. mdcxc. Friaion is another means by which the aaion of the blood veffels may be promoted, and thereby the ftagnation of fluids in their extremities prevented. Ac- ( cordingly, the ufe of the flefh brufh has often contribut- r ed to difcufs oedematous fwellings. . It appears to me, that friaion, 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 con- fiderable degree of it has already come on. 1 apprehend alfo, that friaion 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 brufli, to make the friaion by warm and dry- flannels ; and this may in fome cafes be the moft conve- nient : but I cannot perceive that the impregnation of thefe flannels with certain dry fumes is of any benefit. mdcxci. With refpea to exercife, I muft obferve, that although perfons being much in an erea pofture during *r* PRACTICE OF PHYSIC. the day, may feem to increafe the fwelling which comes on at night; yet as the aaion of the mufcles has a great fliare in promoting the motion of the venous blood, fo I am certain, that as much exercife in walking as the pa- tient can eafily bear, will often prevent that oedematous fwelling which much Handing, and even fitting, would have brought on. mdcxcii. Thefe meafures, however, although they may be ufeful at the coming on of a dropfy, whofe cauf es are not very powerful, will be often infufficient in a more violent diieafe; and fuch therefore will require more powerful remedies. Thefe are exercife and tonic medicines; which may be employed both during the courfe of the difeafe, and efpecially after the water has been evacuated. mdcxchi. Exercife is fuited to aflift in every funaion of the animal economy, particularly to promote perfpir- ation, and thereby prevent the accumulation of watery fluids in the body, I apprehend alfo, that it may be the moft effeaual means for preventing the fkin from being in an imbibing ftate.; and, as has been hinted above on the fubjea of Emaciation (mdcvii.), I am perfuaded, that a full and large perfpiration will always be a means of exciting abforption in every part of the fyftem. Ex- ercife, therefore, promifes to be highly ufeful in dropfy ; and any mode of it may be employed that the patient can moft conveniently admit of. It fliould, however, always be as much as he can eafily bear: and in anaf- arca, the fhare which the exercife of mufcles has in promoting the motion of the venous blood, indu- ces me to think that bodily exercife, to whatever de- gree the patient can bear it, will always be the moft ufeful. From fome experience alfo, I am perfuaded, that by exercife alone, employed early in the difeafe, many dropfies may be cured. mdcxc v. Befides exercife, various tonic remedies are properly employed to reftore the tone of the fyftem. The chief of thefe are, chalybeates, the Peruvian bark, and various bitters. Thefe are not only fuited to re- ftore the tone of the fyftem in general, but are particu- PRACTICE OF PHYSIC. 6ij larly ufeful in ftrengthening the organs of digeftion, which in dropfies are frequently very much weakened: and for the fame purpofe alfo aromatics may be frequent- ly joined with the tonics. mdcxcv. Cold bathing is upon many occafions the moft powerful tonic we can employ ; but at the begin- ning of dropfy, when the'debility of the fyftem is confid- erable, it can hardly be attempted with fafety. After, however, the water of dropfies has been very fully evacu- ated, and the indication is to ftrengthen the fyftem for preventing a relapfe, cold bathing may perhaps have a place. It is, at the fame time, to be admitted with cau- tion ; and can fcarcely be employed till the fyftem has otherwife recovered a good deal of vigor. When that indeed has happened, cold bathing may be very ufeful in confirming and completing it. mdcxcvi. In perfons recovering from dropfy,while the feveral means now mentioned for ftrengthening the fyf- tem are employed, it will be proper at the fame time to keep conftantly in view the fupport of the watery excre- tions ; and confequently the keeping up the perfpiration by a great deal of exercife, and continuing the full flow ofthe urinary excretion by the frequent ufe of diuretics. Sect. II. Ofthe Hydrothorax*, or Dropfy of the Breaft. mdcxcvii. The preternatural colfeaion of ferous fluid in the thorax, to which we give the appellation of Hydro- thorax, 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. mdcxcviii. Thefe colleaions of watery fluids in the thorax, are found indifferent filiations. Very often the water is found at the fame time in bothfacs of the pleu« ra, but frequently in one of them only. Sometimes it is found in the pericardium alone ; but for the moft part * Dyfpneea; palenefs ofthe face ; edematous fwellings of the feet; fcan- ty urine : difficulty in lying in bed; fudden and fpontaneous ftartmg fioci fleep, with pa'pitation ; water fluctuating in tfy? breaft. Syn. Nqf. &i4 PRACTICE OF PHYSIC. it only appears there when at the fame time a colfeaion «j is prefent in one or both cavities of the thorax. Iji fome inftances, the colfeaion is found to be only in that cellu- lar texture of the lungs which furrounds the bronchiae, whithout there being at the fame time any effufion into the cavity ofthe thorax. Pretty frequently the water colfeaed confifts chiefly of a great number of hydatides in different fituations ; fometimes feemingly floating in the cavity, but frequent- ly conneaed with and attached to the particular parts of the internal furface ofthe pleura mdcc. From the colfeaion of water being thus in va- rious fituations and circumftances, fymptoms arife which are different in different cafes ; and from thence it be- comes often difficult to afcertain the prefence and nature of the affeaion. I fhall, however, endeavor here to point out the moft common fymptoms, and efpecially thofe of that principal and molt frequent form of the difeafe, when the ferous fluid is prefent in both facs of the pleu- ra, or, as we ufually fpeak, in both cavities of the tho- rax. mdcci. The difeafe frequently comes on with a fenfe of anxiety about the lower part of the fternum. This, be- fore it has fubfifted long, comes to be joined with fome difficulty of breathing.; which at firft appears only upon the perfon's moving a little fafter than ufual, upon his walking up an acclivity,or upon his afcending a flair cafe: but after fome time, this difficulty of breathing becomes more conftant and confiderable, efpecially during the night, when the body is in a horizontal fituation. Com- monly, 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 ufu- ally attended with a frequent cough, that is at firft dry ; but which, after fome time, is accompanied with an ex- peaoration of thin mucus. With all thefe fymptoms, the hydrothorax is not cer- tainly difcovered, as the fame fymptoms often attend other difeafes of the breaft. When, however, along with ;hefe fymptoms, there is at the fame time an oedematous FRANTIC" OF PHYSIC. 6tS 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 of the fcrotum appears ; but I have never met with any in- ftance of this. mdcCii. Whilft the prefence of the difeafe is fome- what uncertain, there is a fymptom which fometimes takes place, and has been thought to be a certain char- aaeriftic 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 palpi- tation ofthe heart. Thefe feelings immediately require an erea pofture ; and very often the difficulty of breath- ' ing continues to require and to prevent fleep for a great i part of the night. This fymptom 1 have frequently j 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 fymp- tom attending the empyema, or any other difeafe of the thorax; and therefore, when it attends a difficulty of breathing, accompanied with any the fmalleft fymptom of dropfy, I have had no doubt in concluding the pref- ence of water in the cheft, and have always hadiny judg- ment confirmed by the fymptoms which afterwards ap- peared. mdccii. The hydrothorax often occurs with very few, or almoft none, ofthe fymptoms above mentioned ; and is nor, therefore, very certainly difcovered till fome oth- ers appear. The moft decifive fymptom is a fluauation of water in the cheft, perceived by the patient himfelf, or by the phyfician, upon certain motions of the body. How far the method propofed by Auenbrugger will ap- ply to afcertain 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 tumor appears upon the fides or upon the back ; but I have not met with any inftance of this, fci one inftance of the difeafe. 6i& PRACTICE OF PHYSIC. I found one fide ofthe thorax confiderably enlarged, the ribs ftanding 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 inter- mitting : but this happens in fo many other difeafes of the breaft, that unlefs when it is attended with fome other of the above mentioned fymptoms, it cannot be confidered as denoting the hydrothorax. mdcciii. This difeafe, as other dropfies,*is commonly attended with thirft and a fcarcity of urine, to be ex- plained in the fame manner as in the cafe of anafarca (mdclxxiii.) The hydrothorax, however, is fometimes without thirft, or any other febrile fymptom; although \ I believe this happens in the cafe of partial affeaions only, or when a more general affeaion is yet but in a flight degree. In both cafes, however, 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 affeaed are more than ufu- ally fenfible to cold, and complain of the coldnefs of the air when that is not perceiyed by other perfons. mdcciv. The hydrothorax fometimes appears alone, without any other fpecies of dropfy being prefent at the fame time: and in this cafe the difeafe, for the moft part, is a partial affeaion, as being either of one fide of the thorax only, or being a colfeaion 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 cavi- ities, and in the cellular texture of a great part of the bo- dy. I have met with feveral inftances, in which fuch u- niverfal dropfy began firft by an effufion into the thorax. The hydrothorax, however, more frequently comes on from an anafarca gradually increafing; and, as I have faid above, the general diathefis feems often to affea the tho- rax fooner than it does either the head or the abdomen. PRACTICE OF PHYSIC. 61: mdccv. 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 ac- tion of the lungs be entirely interrupted by the quanti- ty of water effufed; and the fatal event frequently hap- pens more fuddenly than was expeaed. In many of the inftances of a fatal hydrothorax, I have remarked a fpit- ting of blood to come on feveral days before the patient died. mdccvi. The caufe of hydrothorax is often manifeftly one or other of the general caufes of dropfy pomted out above: but what it is that determines thefe general cau- fes to aa more efpecially in the thorax, and particular- ly what it is that produces the partial collections that occur there, I do not find to be eafily afcertained. mdccvii. From what has been faid above, it will be evident, that thecure of hydrothorax muft be very much the fame with that of anafarca ; and when the former is joined with the latter as an effea ofthe fame general di- athefis, there can be no doubt of the method of cure be- ing the fame in both. Even when the hydrothorax is alone, and the difeafe partial, from particular caufes aa- ing in the thorax only, there can hardly be any other meafures employed, than the general ones propofed above. There is only one particular meafure adapted to the hydrothorax ; and that is, the drawing off the accumulated waters by a paracentesis ofthe thorax. mdccvii 1. To what cafes this operation may be moft properly adapted, I find it difficult to determine. That it may be executed with fafety, there is no doubt; and that it has been fometimes praaifed with fuccefs, feems to be very well vouched. When the difeafe depends upon a general hydropic diathefis, it cannot alone prove a cure, but may give a temporary relief; and when other remedies feem to be employed with advantage, the drawing off the water may very much favor a complete cure. I have not, however, been fo fortunate as to fee it praaifed with any fuccefs; and even where it was moft promifing, that is, in cafes of partial affeaion, my expectations have been disappointed from it. lit PRACTICE of physic. Sect. 111. Of Afcites*, or Dropfy of the Lower Melly. mdccix. The name of Afcites is given to every collec- tion of waters caufing a general fwelling and diftenfion ofthe lower belly; and fuch colfeaions are more fre- quent than thofe which happen in the thorax. mdccx. The colfeaions 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 formed upon, and conneaed 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 entirely without the peritonae- um, and between this and the abdominal mufcles. mdccxi. Thefe colfeaions conneaed with particular vifcera, and thofe formed without the peritonaeum, form that diieafe which authors have termed the encyfted dropfy or hydrops faccatus. Their precife feat, and even their exiftence, is very often difficult to be afcertained. They are generally formed by colfeaions of hydatides. mdccxii. In the moft ordinary cafe, that of abdomin- al dropfy, the fwelling at firft is in fome meafure over the whole belly, but generally appears moft confiderable in the epigaftrium. As the difeafe, however, advances the fwelling becomes more uniform over the whole. The diftenfion, and fenfe of weight, though confiderable, vary a little according as the pofture ofthe body is changed ; the weight being felt the moft upon the fide on which the patient lies, while at the fame time on the oppofite fide the diftenfion becomes fomewhat lefs. In almoft all the inftances of afcites, the fluauation ofthe water with- in, may be perceived by the praaitioner's feeling, and sometimes by his hearing. This perception of fluaua- tion does not certainly diftinguifh the different ftates of * A tenfe fluctuating fwellinp of the abdomen, little elaftic. Spec. i. Afcites (abdominalisJ, with an. equal fwelling of the "abdomen, and with an evident fluctuation. Spec. a. Afcites (faccatus), with a partial (at leaft in the beginning) fwel- ':ng of the abdomen, and with a lefs evident fluctuation. Syn. Nof. PRACTICE OF PHYSIC. 619 dropfy ; but ferves very well to diftinguifh dropfy from tympanites, from cafes of phyfeonia, and from the ftate of pregnancy in women. mdccxiii. An afcites frequently occurs when no other fpecies of dropfy does at the fame time appear ; but fometimes the afcites is a part only of univerfal dropfy. In this cafe, it ufually comes on in confequence of an an- afarca, gradually 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 oedematous fwellings of the lower extremities. When the colfeaion of water in the abdomen, from whatever caufe, becomes confiderable, it is always attended with a difficulty of breathing : but this fymptom occurs of- ten when, at the fame time, there is no water in the thorax. The afcites is fometimes unaccompanied with any fever ; but frequently there is more or lefs of fever prefent with it. The difeafe is never confiderable, with- out being attended with thirft and a fcarcity of urine. mdccxiv. In the diagnofis of afcites, the greateft dif- ficulty that occurs, is in difcerning when the water is in the cavity of the abdomen, or when it is in the differ- ent ftates of encyfted dropfy above mentioned. There is, perhaps, no certain means of afcertaining this in ail cafes ; but in many we may attempt to form fome judg- ment with regard to it. When the antecedent circumftances give fufpicion of a»general hydropic diathefis ; when at the fame time fome degree of dropfy appears in other parts of the body ; and when, from its firft appearance, the fwelling has been equally over the whole, belly, we may generally prefume that the water is in the cavity of the abdomen. But when an afcites has not beer* preceded by any re- markably cacheaic ftate of the fyftem, and when at its beginning the tumor and tenfion had appeared in one part of the belly more than another, there is reafon to fufped an encyfted dropfy. Even when the tenfion and tumor of the belly have become general and uniform over the whole ; yet if the fyftem ofthe body in gener- al appear to be little affeaed ; if the patient's ftrength 2 « 6ao PRACTICE OF PHYSIC. i be little impaired ; if the appetite continue, pretty entire, and the natural fleep be little interrupted ; if the menfes in females continue to flow as ufual; if there be yet no an- afarca ; or, though it may have already taken place,if it be ftill confined to the lower extremities, and there be no leu- cophlegmatic palenefs or fallow color in the countenance; if there be no fever, nor fo much thirft, or fcarcity of urine, as occur in a more general affeaion ; then, accord- ing as more of thefe different circumftances 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 con- fequence of a fchirrous liver ; which, I apprehend, may occafion a colfeaion of water in the cavity of the abdo- men, while the general fyftem of the body may not be otherwife much affeaed. mdccxv. With refpea to the cure of afcites when of the encyfted kind, it does not, fo far as I know, admit of any. When the celfeaion 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 difficult cure : for it may be prefumed to depend up- on a feirrhofity of the liver, or other confiderable affec- tion of the abdominal vifcera, which I conceive to be of very difficult cure, and therefore the afcites depending upon them. At the fame time, fuch cafes may often admit of a temporary relief by the paracentefis. mdccxvi. When the afcites is a part of univerfal drop- fy, it may, as far as other cafes of that kind can, admit of a cure ; and it will be obvious, that fuch a cure muft be obtained by the fame faeans 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 al- moft alone. PRACTICE OF PHYSIC. 621 The diuretics that may be employed, are chiefly thofe above mentioned ; but in afcites, a peculiar one has been found out. It is a long continued gentle friaion of the fkin over the whole of the abdomen, by the fingers dip- ped in oil. This has fometimes been ufeful in exciting an increafed flow of urine ; but in moft of the trials of it which I have known made, it has failed in producing that effea. mdccxvii. The afcites admits of a particular means for immediately drawing off the colfeaed waters ; and that is the well known operation of the paracentefis of the abdomen. In what circumftances of afcites this oper- ation can moft properly be propofed, it is difficult to de- termine ; 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 tho- rax. The manner of performing the paracentefis of the ab- domen, and the precautions to be taken with refpea to it, are now fo commonly known, and delivered in fo many books, that it is altogether unneceffary for me to offer any direaions upon that fubjea here ; efpecially after the full and judicious information and direaions given by Mr. Bell, in the fecond volume of his Syftem of Surgery, CHAP. IV. OF GENERAL SWELLINGS, ARISING FROM AN INCREASED BULK OF THE WHOLE SUBSTANCE OF PARTICULAR PARTS. mdccxviii. Upon the fubjeas of this chapter, fev- eral nofological difficulties occur, and particularly with refped to admitting the Phyfconia into the order of Gen- eral Swellings. At prefent, however, it is not neceffary for me to difcufs this point, as I am here to omit entirely the confideration of Phyfconia 5 both becaufe it can fel- 2 6ii PRACTICE OF PHYSIC. dom admit of any fuccefsful praaice, and becaufe I can- not deliver any thing ufeful either with regard to the pa- thology or praaice in fuch a difeafe. mdccxix. The only other genus of difeafe compre- hended under the title ofthe prefent chapter, is the Rachitis ; and this as being both a proper example of the clafs of Cachexy, and of the order of Intumefcentia or General Swellings, I fhall offer fome obfervations with regard to it. Of Rachitis*, or Rickets. mdccxx. This difeafe has been fuppofed to have ap- peared only in modern times, and not above two hun- dred years ago. This opinion, notwithftanding it has been maintained by perfons of the moft refpeaable au- thority, appears to me, from many confiderations, im- probable ; but it is a point of too little confequence to detain my readers here. The only application of it which deferves 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 appearance in Europe not very long before the date commonly affigned for the ap- pearance of rachitis : But I fhall hereafter fhow, that the fuppofed conneaion between the Siphylis and Ra- chitis is without foundation. mdccxxi. In delivering the hiftory of the Rickets, 1 muft, in the firft place, obferve, that with refpea to the antecedents of the difeafe, every thing to be found in authors upon this fubjea, appears to me to reft upon a very uncertain foundation. In particular, with refpea to the ftate of the parents whofe offspring become affec- ted with this difeafe, I have met with many inftances of it in children from feemingly healthy parents; and have met likewife with many inftances of children who never became affeaed with it, although born of parents who, according to the common accounts, fliould jhave * The head is large proportioned to the reft of the body, and projecls for- ward ; the joints are fwelled; the ribs flattened ; the abdomen tumid, and the other parts emaciated. Syn. Nof. PRACTICE OP PHYSIC. 623 produced a rickety offspring; fo that, even making al- lowance for the uncertainty of fathers, I do not find the general opinion of authors upon this fubjea to be prop. erly fupported. mdccxxh. The difeafe, however, may be juftly con- fidered as proceeding from parents ; for it often appears in a great number of the fame family: And my obferva- tion leads me to judge, that it originates more frequently from mothers than from fathers. So far as I can refer the difeafe of the children to the ftate of the parents, it has appeared to me moft commonly to arife from fome weaknefs, and pretty frequently from a fcrophulous hab- it in the mother. To conclude the fubject, I muft re- mark, that in many cafes I have not been able to difcern the condition of the parents, to which I could refer it. When nurfes, other than the mothers, have been em- ployed to fuckle children, it has been fuppofed that fuch nurfes have frequently given occafion to the difeafe; and when nurfes have both produced and have fuckled chil- dren who became rickety, there may be ground to fuf- pea their having occafioned the difeafe in the children of other perfons: But I have had few opportunities of afcertaining this matter. It has in fome meafure appear- ed to me, that thofe nurfes are moft likely to produce this difeafe, who give infants a large quantity of very watery milk, and who continue to fuckle them longer than the ufual time. Upon the whole, however, I am of opinion, that hired nurfes feldom occafion this difeafe, unlefs when a predifpofition to it has proceeded from the parents. mdccxxiil 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 ex- tremely fallacious; and I am very much perfuaded, that the circumftances in the rearing of children, have lefs ef- fea in producing rickets than has been imagined. It is indeed not unlikely, that fome of thefe circumftances mentioned as remote caufes may favor, while other cir- cumftances may refift the coming on of the difeafe; but at the fame time, I doubt if any of the former would 6z4 PRACTICE OF PHYSIC. produce it where there was no predifpofition in the child's original conftitution. This opinion of the remote caufes, I have formed from obferving, 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 Ze- viani alleges, that the difeafe is produced by an acid from the milk with which a child is fed for the firft nine months of its life: But almoft all children are fed with the fame food, and in which alfo an acid is always pro- duced ; while at the fame time, not one in a thoufand of the infants fo fed becomes afleaed with the rickets. If, therefore, in the infants who become affeaed with this difeafe, a peculiar noxious acid is produced, we muft feek for fome peculiar caufe of its Produaion, 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 believe that the ordinary acid of milk has any fhare in producing this difeafe, becaufe I have known many inftances of the acid being produced and occafion- ing various diforders, without however its ever produc- iig 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 occur- rence : and I have known many inftances where chil- dren have been fed with a greater than ufual proportion of fermented farinacea, and alfo a greater proportion of animal food, without thefe preventing the difeafe. In my apprehenfion, the like obfervations might be made with refpea to moft of the circumftances that have been men- tioned as the remote caufes of rickets. 'i.iDccxxiv Having thus offered my opinion concern- ing the fuppofed antecedents of this difeafe, 1 proceed now to mention the phenomena occurring after it has actually come on. The difeafe feidom appears before the ninth month, and feldom begins after the fecond year of a child's age. In the interval between thefe periods, the appearance of PRACTICE OF PHYSIC. ■«« the difeafe is fometimes fooner, fometimes later; and commonly at firft the difeafe comes on flowly. The firft appearances are a flaccidity of the flefh, the body at the fame time becoming leaner, though food be taken in pretty largely. The head appears large with refpea to the body; with the fontanelle, and perhaps the futures, more open than ufual in children of the fame age. The head continues to grow larger, in particular, the fore- head becoming unufually prominent ; and at the fame time the neck continues flender, or feems to be more fo, in proportion to the head. The dentition is flow, or much later than ufual, and thofe teeth which come out, readily become black, and frequently again fall out. The ribs lofe their convexity, and become 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 varioufly distorted; and particularly the fpine of the back becoming incur- vated in different parts of its length. If the child, at the time the difeafe comes on, had acquired the power of walking, it becomes daily more feeble in its motions, and more averfe to the exertion of them, lofing at length the power of walking altogether. Whilft thefe fymptoms go on increafing, the abdomen is always full, and preternat- urally tumid. The appetite is often good, but the ftools are generally frequent and loofe. Sometimes the facul- ties of the mind are impaired, and ftupidfty or fatuity prevails ; but commonly a premature fenfibility appears, and they acquire the faculty of fpeech fooner than ufual. At the firft coming on of the difeafe, there is generally no fever attending it; but it feldom continues long, till a frequent pulfe, and other febrile fymptoms, come to be conftantly prefent. With 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 diftorted limbs produced during the dif. 626 PRACTICE OF PHYSIC. eafe continue for the reft of life. In other cafes, howev- er, the difeafe proceeds increafing till it has afleaed al- moft every function of the animal economy, and at length terminates in death. The variety of fymptoms which in fuch cafes appear, it does not feem neceffary to enumer- ate, as they are not effentiai to the conftitution of the dif- eafe, but are merely confequences of the more violent conditions of it. In the bodies of thofe who have died, various morbid afteaions have been difcovered in the in- ternal parts. Moft of the vifcera of the abdomen have been found to be preternaturally enlarged. The lungs have alfo been found in a morbid ftate, feemingly from fome inflammation that had come on towards the end of the difeafe. The brain has been commonly found in a flacid ftate, with effufions of a ferous fluid into its cavi- ties. Very univerfally the bones have been found very foft, and fo much foftened as to be readily cut by a knife. The fluids have been always found in a diffolved ftate, and the mufcular parts very foft and tenderjf and the whole ofthe dead body without any degree of that rig- idity which is fo common in almoft all others. mdccxxv. From thefe circumftances of the difeafe, it feems to confift in a deficiency of that matter which fhould form the folid parts of the body. This efpecially appears in the faulty ftate of offification, feemingly de- pending upon the deficiency of that matter which fhould be depofited in the membranes which are deftined to be- come bony, and fhould give them their due firmnefs and bony hardnefs. It appears that this matter is not fuppli- ed in due quantity ; but that, in place of it, a matter fitted to increafe their bulk, particularly in the epiphy- fes, is applied too largely. What this deficiency of mat- ter depends upon, is difficult to be afcertained. It may be a fault in the organs of digeftion and aflimilation, which prevents the fluids in general from being proper- ly prepared ; or it may be a fault in the organs of nutri- tion, which prevents the fecretion of a proper matter to be applied. With refpea 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 / PRACTICE OF PHYSIC. Czj in its nature and exiftence, is more readily perceived; and it is probable that it has a confiderable influence in the matter ; as in rachitic perfons athinner ftate ofthe blood, both during life and after death, fo commonly appears. IUs this ftate ofthe fluids, or a deficiency of bony mat- ter in them, that I confider as the proximate caufe of the difeafe ; and which again may in fome meafure de- pend upon a general laxity and debility of the moving fibres of the organs that perform the funaions of digeft- ion and aflimilation. mdccxxvi. There is however fomething ftill want- ing to explain why thefe circumftances difcover them- felves at a particular 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 funaions fhould be exercifed at a certain pe- riod of life only; fo it has generally provided, that at that period, and not fooner, the body fhould be fitted for the exercife of the funaions fuited to it. To apply this to our prefent! fubjea, Nature feems to have intendedthat children Ihould walk only at twelve months old ; and accordingly has provided, that againft that age, and no fooner, a mat- ter fhould be prepared fit to give that firmnefs to the bones which is neceffary to prevent their bend'ag too eafily under the weight of the body. Nature, however, is not always fteady and exaa in executing her own pur- pofes ; and if therefore the preparation of bony matter fhall not have been made againft the time there is partic- ular occafion for it, the difeafe of rickets, that is, of foft and flexible bones, muft come on ; and will difcover it- felf 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 be- coming again foft and flexible, during the reft of life ; un- lefs it happen, as indeed it fometimes does, that ceutais 6s8 PRACTICE OF PHYSIC. 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 oc- cur, feems to confirm the opinion of its proximate caufe being a deficiency of bony matter in the fluids ofthe body. mdccxxvii. It has been frequently fuppofed, that a_ fiphylitic taint has a fhare in producing rickets ; but fuch a fuppofition is altogether improbable. If our opinion of the rickets having exifted in Europe before the fiphylis was brought into it, be well founded, it will then, be cer- tain that the difeafe may be occafioned without any fiph- ylitic acrimony having a fhare in its produaion. 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 only, and commonly more ear- ly than the period of rickets ; the fymptoms alfo are very different from thofe of rickets, and unaccompanied with any appearance of the latter ; and, laftly, the fymptoms of fiphylis are cured by means which, in the cafe of ric- kets, have either no effea, or a bad one. It may indeed poffibly happen, that fiphylis and rickets may appear in the fame perfon ; but it is to be confidered as an accidental complication : and the very few inftances of it that have occurred, are by no means fufficient to eftablifh any nec- effary conneaion between the two difeafes. mdccxxviii. With refpea to the deficiency of bony matter,which i confider as the proximate caufe of rickets, fome further conjeaures might be offered concerning its rer.ote caufes : but none of them appear to me very fat- isfying ; and whatever they might be, it appears to me they muft again be refolved into the fuppofition of a gen- eral laxity and debility ofthe fyftem. mdccxxix. It is upon this fuppofition almoft alone that the cure of rickets has entirely proceeded. The reme- dies have been fuch efpecially as were fuited to improve the tone of the fyftem in general, or of the ftomach in particular : and we know that the latter are not only fuited to improve the tone of the ftomach itfelf, but by that means to improve alfo the tone of the whole fyf- tem. PRACTICE OF PHYSIC. 629 mdccxxx. Of tonic remedies, one ofthe moft promifing feems to have been cold bathing ; and I have found it the moft powerful in preventing the difeafe. For along time paft, it has been the praaice 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 praaice with people of better rank to have them dipped entirely in cold water every morning : and wherever this praaice has been purfued, I have not met with any inftance of rickets. Amongft our common people, although they wafh their children with cold water only, yet they do not fo commonly praaife immerfion: and when a- mongft 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. mdccxxxi. The remedy of Ens Veneris, recommend- ed by Mr. Boyle, and fince his time very univerfally em- ployed, 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, notwithftanding his giving it this appellation, was truly a preparation of iron, and no other than what we now name the Flores Martiales : but it appears, that both Benevoli and Buchner have employed a preparation of copper ; and I am ready to believe it to be a more powerful tonic than the preparations of iron. ^ mccxxxii. Upon the fuppofition of tonic remedies being proper in this difeafe, I have endeavored to em- ploy the Peruvian bark: but from the difficulty of ad- minifterihg it to infants in any ufeful quantity, I have not been able to difcover its efficacy; but I am very ready to believe the teftimony of De Haen upon this fubjea. md:cxxxiii. Exercife, which is one of the moft pow- erful tonics, has been properly recommended for the cure of rickets ; and as the exercife of geftation only can be employed, it fhould always be with the child «»3* PRACTICE OF PHYSIC. laid in a horizontal situation, as the carrying them, or moving them in any degree of an ered pofture, is very apt to accafion fome distortion. It is extremely proba- ble, that, in this difeafe, friaion with dry flannels may be found an ufeful remedy. mdccxxxiv. It is alfo fufliciently probable, that the avoiding of moifture 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 farina- cea ; but I cannot find any reafon to believe that ftrong beer can ever be a proper remedy. Praaitioners have been divided in opinion concern- ing the ufe of milk in this difeafe. Zeviani, perhaps from theory, condemns the ufe of it ; but Benevoli em- ployed it without its impeding the cure of the difeafe. This laft I have often remarked in the courfe of my own praaice. As it is difficult to feed children entirely without milk; fo I have commonly admitted it as a part ofthe diet of rickety children ; and in many inftan- ces 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 dentition, I have diffuaded the continuance of a child upon the breaft ; becaufe the' milk of women is a more watery nourifhment than that of cows: and I have efpecially difluaded 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 fufpea, that the milk of fuch nurfes has a tendency to favor the coming on of rickets. mdccxxxv. Befides the remedies and regimen now mentioned,praaitioners have commonly employed in this difeafe both emetics and purgatives. When the appetite and digeftion are confiderably impaired, vomiting, if neither violent, nor frequently repeated, feems to be of fervice ; and by a moderate agitation of the abdominal PRACTICE OF PHYSIC. 631 vifcera, may in fome meafure obviate the ftagnation and confequent fwelling that ufually occur in them. As the tumid ftate ofthe abdomen, fo conftantly to be met with in this difeafe, feems to depend very much upon a tympanitic affeaion of the inteftines ; fo, both by obviating this, and by deriving from the abdominal vifcera, frequent gentle purgatives may be of fervice. Zeviani, perhaps properly, recommends in particular rhubarb ; which befides its purgative quality, has thofe alfo of bitter and aftringent. mdccxxxvi. I have now mentioned moft of the rem- edies commonly employed by the praaitioners 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 affures us of their having been employed with fuccefs : but in the few trials which I have had occafion to make, their good effeas did not appear. The late Baron Van Swieten gives us one inftance of rickets cured by the ufe of hemlock; but I do not know that the praaice has been repeated. BOOK HI. OF THE IMPETIGINES; ,. OR DEPRAVED HABIT, WITH AFFECTIONS OF THE SKIN. INTRODUCTION. mdccxxxvii. I find it difficult to give any fuffi- * ciently correa and proper charaaer of this order. The difeafes comprehended under it, depend, for the moft part, upon a depraved ftate of the whole of the fluids, producing tumors, eruptions, or other preternatural aT- feaions of the fkin. Although it be extremely difficult to find a general charaaer of the order that will apply to each of the genera and fpecies, I fhall here treat of the principal genera which have been commonly compre- hended under this order, and which 1 have enumerated in my Nofology. CHAP. I. OF SCROPHULA*, OR THE KING'S EVIL. mdccxxxviii. The charaaer of this difeafe I have attempted in my Nofology ; but it will be more proper- ly taken from the whole of its hiftory, now to be deliv- ered. * Swellings of the conglobate glands, chiefly in the neck: the ^Pe1".1]? and columna naft are tumid; the face is of a Sond complexion; the fltin foft, and the belly Iweiled. Sjn. Nof. «34 PRACTICE OF PHYSIC. mdccxxxix. It is commonly, and very generally, a hereditary difeafe ; and although it fometimes may, yet it rarely appears, but in children whofe parents had at fome period of their lives been affeaed with it. Wheth- er it may not fail to appear in the children of fcrophulous parents, and difcover itfelf afterwards in their offspringin the fucceeding generation, I cannot certainly determine; but believe that this has frequently happened. It appears to me to be derived more commonly from fathers than from mothers ; but whether this happens from their be- ing more fcrophulous men than fcrophulous women married, I am not certain. With refpea 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 af- * feaed with fcrophula, and the other not; as it is ufual for fome of the children to be in conftitution pretty exaaiy like the one parent, and others of them like the other ; it commonly happens that thofe children who moft re- femble the fcrophulous parent become affeaed with fcrophula, while thofe refembling the other parent en- tirely efcape. mdccxl. The fcrophula generally appears at a partic- ular period of life. It feldom appears in the firft, or even in the fecond year of a child's life ; and moft commonly it occurs from the fecond, or, as fome allege, and per- haps more properly, from the third, to the feventh year. Frequently, however, it difcovers itfelf at a later period ; and there are inftances of its firft appearance, at every period till the age of puberty ; after which, however, the firft appearance of it is very rare. mdccxli. When it does not occur very early, we can generally diftinguifh the habit of body peculiarly difpof- ed to it. It moft commonly affeas children of foft and flaccid habits, of fair hair and blue eyes ; or at leaft af feas thofe much more frequently than thofe of an oppo- fite complexion. It affeas 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 tumor is often confiderable, and extended to the PRACTICE OF PHYSIC. 635 columna nafi and lower part of the noftrils. The difeafe is fometimes joined with,or follows rickets; and although it frequently appears in children who have not had rickets , in any great degree, yet it often attacks thofe who by a protuberant forehead, by tumid joints, and a tumid ab- domen, fhow that they had fome rachitic difpofition. In parents who, without having had the diieafe themfelves, feem to produce fcrophulous children, 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 af- ferts its following the inoculated more frequently than the natural fmall pox. This laft pofition, however, we can confidently affirm to be a miftake ; although it muft be allowed, that in faa the fcrophula does often come on immediately after the fmall pox. It is, however, difficult to find any conneaion between the two difeafes. Ac- cording to my obfervation, the accident only happens in children who have pretty manifeftly the fcrophulous dif- pofition ; and i have had feveral inftances of the natural fmall pox coming upon children afleaed 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. mdccxlii. The fcrophula generally fhows itfelf firft at a particular feafon of the year ; and ac fome time be- tween the winter and fummer folftice ; but commonly long before the latter period. It is to be obferved fur- ther, that the courfe of the difeafe is ufually conneaed with the courfe ofthe feafons. Whilft the tumors and ulcerations peculiar to this difeafe, appear firft in the fpring, the ulcers are frequently healed up in the courfe of the fucceeding fummer, and do not break out again till the enfuing fpring, to follow again with the feafon the fame courfe as before. mdccxliii. Frequently the firft appearance of the dif- eafe is the tumid-and chopped lip above mentioned. Up- on other occafions the firft appearance is that of frrfalf ipherkal or oval tumors, moveable under the fkin. They R R mdccliv. With regard'to the-choice of the mineral waters moft fit for the purpofe, I cannot with any confidence give an opinion. Almoft all kinds of mine- ral waters, whether chalybeate, fulphureous, or faline, have been employed for the cure of fcrophula, and feem- ingly with equal fuccefs and reputation : a circumftance which leads me to think, that if they are ever fuccefsful, 3 640 PRACTICE OF PHYSIC. 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. mdcclv. The other remedies propofed by praaical writers 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 expeaing fuccefs from them, I have very feldom employed them. Of late, the Peruvian bark has been much recommend- ed; and as in fcrophulous 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. 1 have ufed it frequently in a ftrong decoaion, 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. mdcclvi. I have alfo frequently employed the heim lock, and have fometimes found it ufeful in difcuffing obftinate fwellings ; But in this it has alfo often difap- pointed me; and I have not at any time obferved that ft difpofed fcrophulous ulcers to heal. I cannot conclude the fubjea of internal medicines without remarking, that I have never found either mer- cury or antimony, in any fhape, of ufe in this difeafe ; and when any degree of a feverish ftate had come on, the ufe of mercury proved manifeftly hurtful. mdcclvii. In the progrefs of fcrophula, feveral exter- nal medicines are 'requisite. Several applications have been ufed for difcuffing the tumors upon their firft com- ing on ; but hitherto my own praaice, in thefe refpeas, has been attended with very little fuccefs. The folution of faccharum faturni has feemed to be ufeful; but it has more frequently failed: And I have had no better fuc- cefs with the fpiritus Mindereri. Fomentations of every kind have been frequently found to do harm ; and poul- PRACTICE OF PHYSIC. '641 tices feem only to hurry on a fuppuration. I am doubt- rful if this laft be ever praaifed with advantage ; for fcrophulous tumors fometimes fpontaneoufty difappear, but never after any degree of inflammation has come up- on them ; and therefore poultices which commonly in- duce inflammation, prevent that difcuffion of tumors, which might otherwife have happened. Even when fcroplfulous tumors have advanced towards fuppuration, I am unwilling to haften the fpontaneous o- pening, or to make it by the lancet, becaufe I apprehend the fcrophulous matter is liable to be rendered more acrid by communication with the air, and to become more e- roding and fpreading than when in its inclofed ftate. mdcclvhi. The management of fcrophulous ulcers has, fo far as I know, been as little fuccefsful as that of the tumors. Efcharotic preparations, of either mercury or copper, have been fometimes ufeful*in bringing on a proper fuppuration, and thereby difpofling the ulcer to heal; but they have feldom fucceeded, and more com- monly they have caufed the ulcer to fpread more. The efcharotic from which I have received moft benefit is burnt alum ; and a portion of that mixed with a mild ointment, has been as ufeful an application as any I have tried. The application, however, that I have found moft ferviceable, and very univerfally admiflible, is that of lin- en cloths wetted with cold water, and frequently chang- ed when they are becoming dry, it being inconvenient to let them be glued to the fore. They are therefore to be changed frequently during the day -; and a cloth fpread with a mild ointment or plafter may be applied for the night. In this praaice I have fometimes employed fea water ; but generally it proved too irritating ; and nei- ther that nor any mineral water -has appeared to be of more fervice than common water. mdcclix. To conclude what I have to offer upon the cure of fcrophula, I muft obferve, that cold bathing feems to have been of more benefit than any other remedy that I have had occafion to fee employed*. * Of la'e the muriate of lime has been highly extolled as a remedy of .iirophula, and numerous well authenticate^cafcs-of itgfupe:ior efficacy 4 *4a PRACTICE OF PHYSIC. CHAP. II. OF SIPHYLIS*, OR THE VENEREAL DISEASE. mdcclx. After praaitioners have had fo much experience in treating this difeafe, and after fo ma- ny books have been publifhed upon the fubjea, it does 9pt feem neceffary, or even proper, for me to attempt any full treatife concerning it; and I fhall therefore con- fine myfelf to fuch general remarks, as may ferve to il- luftrate fome parts of the pathology or of the praaice. mdcclxi. It is fufficiently probable, that anciently, in certain parts of Afia, where the leprofy prevailed, and in Europe after that difeafe had been introduced into it, a difeafe of the genitals, refembling that which now com- monly arifes from fiphylis, had frequently appeared : but it is equally probable, that a new difeafe, and what we at prelent term Siphylis, was firft brought into Europe a- bout the end of the fifteenth century ; and that the dif- temper now fo frequently occurring, has been very en- tirely derived from that which was imported from A- merica at the period mentioned. mdcclxii. This difeafe, at leaft in its principal cir- cumftances, never arifes in any perfon but from fome communication with a perfon already affeaed with it. have heen recorded. A drachm diluted with water is confidered the medium dofe for an adult in the day. The following cafe is felecled from thofe ic- lated by Dr. Beddoes: A bny, of eleven years, with a very fcrophulous afpetf, was brought to me : I found hia fubmaxillary glands enlarged. The mufcular irritability, under a florid appearance, was excefiive. He could not lift a weight at arms length, which, in a healthy boy oteight years, did not requiie an effort. On placing him upon hie hands and knees, and then laying a load of twenty pounds, he complained of pain. A two months courfe cf muriate of lime, to which, as in other cafes, a few drops of muriatic acid were ?dded, to make it palatable, effected a re- duction of the fwoln gland?, rendered hi* fiefli firm, and enabled him to fupport infinitely more exertion without fatigue. He could now hear fev. enty pounds upon his loins without any inconvenience; and I did not with to load him to the ex!ent of hi* ability." * Contagions difeafe ; ulcers of the tonfils appear after impure connection, and difeafe ofthe genitals : cluftered pimples on the fkin, efpecially at the margin of the hair, ending in crufts or lea bby ulcers; pains of the bores, ith hard tumor?. Syn. Nof. PRACTICE OF PHYSIC. 643 It is moft commonly contraaed in confequence of coition with an infeaed perfon; but in what manner the infec- tion is communicated, is not clearly explained. I am perfuaded, that in coition, it is communicated without there being any open ulcer either in the perfon commu- nicating, or in the perfon receiving the infeaion ; but in all other cafes, I believe it is never communicated in any other way than by a contaa of ulcer, either in the perfon communicating or in the perfon receiving the in- feaion. mdcclxih. As it thus arifes from the contaa of par- ticular parts, fo it always appears firft in the neighbor- hood ofthe parts, to which the infeaing matter had been immediately applied ; and therefore, as moft com- monly contraaed by coition, it generally appears firft in the genitals. mdcclxiv. After its firft appearance in particular parts, more efpecially when thefe are the genitals of either fex, its effeas for fome time feem to be confined to thefe parts ; and indeed in many cafes never extends further. In other cafes, however, the infeaing matter paffes from the parts firft affeaed, and from the genitals therefore into the blood veffels ; 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 of the difeafe, according as they are local or are more univerfal. To the former, they have adapted appellations fuited to the manner in which the difeafe appears ; and to the other, the general affeaion, they have almoft totally con- fined the appellations of Siphylis, Lues Venerea, or Pox. In the remarks I am now to offer, I fhall begin with con- fidering the local affeaion. mdcclxv. This local affeaion appears-^ chiefly in the form of gonorrhoea or chancre. The phenomena of gonorrhoea either upon its firft coming on or in its after progrefs, or the fymptoms of ardor urinae, chordee, or others attending it, it is not neceffary for me to defcribe. I fhall only here obferve, :hat the cheif circumftance to be taken notice of, is the $1*1 PRACTICE OF PHYSIC. inflamed ftate of the urethra, which I take to be infepar- able from the difeafe. mdcclxvi. In thefe well known circumftances, the gonorrhoea continues for a time longer or fhorter, accord- ing to the conftitution of the patient ; it ufually remain- ing longeft in the moft vigorous and robuft, or accord- ing to the patient's regimen, and the care taken to relieve or cure the thfeafe. In many cafes, if by a proper regi- men the irritation ofthe inflamed ftate is carefully avoid- ed, the gonorrhoea fpontaneoufly ceafes, the fymptoms of inflammation gradually abating, the matter difcharg- ed becoming of a thicker and more vifcid confiftence, as well as of a whiter color ; till at length, the flow of it ceafes altogether ; and whether it be thus cured fponta- neoufly, or by art, the difeafe often exifts without com- municating any infeaion to the other parts of the body. mdcclxvii. In other cafes, however, the difeafe hav- ing been negfeaed, or by an improper regimen aggrav- ated, it continues with all its fymptoms for a long time ; and produces various other diforders in the genital parts, which, as commonly taken notice of by authors, need not be defcribed here. I fliall only obferve, that the inflammation of the urethra, which at firft feems to be feated chiefly, or only, in its anterior parts, is in fuch negfeaed and aggravated cafes fpread upwards along the urethra, even to the neck of the bladder. In thefe circumftances, a more confiderable inflammation is occafioned in certain parts of the urethra : and confe- quently, fuppuration and ulcer are produced, by which the venereal poifon is fometimes communicated to the fyftem, and gives rife to a general fiphylis. mdcclxviii. It was fome time ago a pretty general fup- pofition, that the gonorrhoea depended always upon ul- cers ofthe urethra producing a difcharge of purulent mat- ter ; and fuch ulcers do indeed fometimes occur in the manner that has been juft now mentioned. We are now allured, however, from many diffeaions of perfons who had died when laboring under a gonorrhoea, that the difeafe may exift,and from many confiderations it is prob- able that it commonly does exift, without any ulceration of •PRACTICE OF PHYSIC. 645 the urethra ; fo that the difcharge which appears, is en- tirely that of a vitiated mucus from the mucous follicles of the urethra. mdcclxix. Although moft of the fymptoms of gonor- rhoea fhould be removed, yet it often happens that a mu- cous fluid continues to be difcharged from the urethra for a long time after; and fometimes for a great part of a perfon's life. This difcharge is what is commonly cal- led a. Gleet. With refpea to this, it is proper to obferve, that in fome cafes, when it is certain that the matter difcharged contains no venereal poifon, the matter may, and often does put on that puriform appearance, and that yellow and greenifh color, which appears in the difcharge at the beginning and during the courfe of a virulent gonor^ rhcea. Thefe appearances in the matter of a gleet, which before had been of a lefs colored kind, have frequently given occafion to fuppofe that a frefh infeaion had been received ; but I am certain that fuch appearances may be brought on by perhaps various other caufes ; and partic- ularly, by intemperance in venery and drinking concur-* ring together, I believe, indeed, that this feldom hap- pens to any but thofe who had before frequently labor- ed under a virulent gonorrhoea, and have more or lefs of gleet remaining with them : but I muft alfo obferve, that in perfons who at no period of their life had ever labor- ed under a virulent gonorrhoea, or any other fymptom of fiphylitic affeaion, I have met with inftances of dif- charges from the urethra refembling thofe of a virulent gonorrhoea. The purpofe of thefe obfervations is, to fuggeftto praaitioners what I have not found them always aware of, that in perfons laboring under a gleet fuch a return of the appearances of a virulent gonorrhoea may happen without any new infeaion having been received, and confequently not requiring the treatment which a new infeaion might perhaps demand. When in the the cure of gonorrhoea it was the praaice to employ purgatives very frequently, and fometimes thofe ofthe draftic kind, I have known the gleet, or fpurious gonorrhoea, by fuch a praaice much increafed, and long continued, and the PRACTICE OF PHYSIC. * patient's conftitution very much hurt. Nay, in order more certainly further to prevent miftakes, it is to be obferved, that the fpurious gonorrhoea is fometimes at- tended with heat of urine, and fome degree of inflam- mation ; but thefe fymptoms are feldom confiderable, and, merely by the afliftance of a cool regimen, common- ly difappear in a few days. mdcclxx. With refpea to the cure of a virulent gon- orrhoea, I have only to remark, that if it be true, as I have mentioned above, that the difeafe will often, under a proper regimen, be fpontaneoufly cured ; and that the whole ofthe virulent matter may be thus entirely dif- charged without the afliftance of art ; it would feem that there is nothing required of praaitioners, but, to moderate and remo\ e that inflammation which contin- ues the difeafe, and occafions all the troublefome fymp- toms that ever attend it. The fole bufinefs therefore of our art in the cure of gonorrhoea, is to take off the in- flammation accompanying it : and this I think may commonly be done, by avoiding exercife, by ufing a low and cool diet, by abstaining entirely from fermented and fpiritous liquors, and by taking plentifully of mild diluent drinks. mdcclxxi. The heat of urine, which is fo trouble- fome in this difeafe, as it arifes from the increafed fenfi- bility of the urethra in its inflamed ftate ; fo, on the oth- er hand, the irritation Of the urine has the effea of in- creafing the inflammation, and is therefore to be remov- ed as foon as poffible. This can be done moft effeaually by taking in a large quantity of mild watery liquors. Demulcents may be employed ; but unlefs they be ac- companied with a large quantity of water, they will have little effea. Nitre has been commonly employed as a fuppofed refrigerant ; but, from much obfervation, I am convinced, that in a fmall quantity it is ufelefs, and in a large quantity certainly hurtful ; and, for this rea- fon, that every faline matter paffing with the urine gen- erally gives fome irritation to the urethra. To prevent the irritation of the urethra arifing from its increafed rJnfibilitVj the injeaion of mucilage or of mild oil into PRACTICE OF PHYSIC. 649 it has been praftifed ; but I have feldom found this of much fervice. mdcclxxii. 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 al- ways by the voiding of hardened faeces; fo coftivenefs is to be carefully avoided or removed ; and the frequent ufe of large glyfters of water and oil, I have found of re- markable benefit in this difeafe. If glyfters, however, do not entirely obviate coftivenefs, it will be neceffary to give laxatives by the mouth ; which, however, fhould be of the mildeft kind, and fhould do no more than keep the belly regular and a little loofe, without much purging. The praaice of frequent purging, which was formerly fb much in ufe, and is not yet entirely laid afide, has al- ways appeared to me to be generally fuperfluous, and often very hurtful? Even what are fuppofed to be cooling purgatives, fuch as Glauber's fait, foluble tartar» and cryftals of tartar, in fo 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 reaum, and confequently the urethra. This laft effea, however, the acrid, and in any degree draftic purgatives, more certainly produce. mdcclxxiii. In cafes of 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 gen- eral bleedings, however, when there is no phlogiftic dia- thefis in the fyftem, have little effea in removing topical inflammation ; fo in gonorrhoea, when the inflammation is confiderable, topical bleeding applied to the urethra by leeches, is generally more effeaual in relieving the inflammation. mdcclxxiv. When there is any phymofis attending a gonorrhoea, emollient fomentations applied to the whole penis are often of fervice. In fuch cafes it is nec~ 648 PRACTICE OF PHYSIC. effary, and in all others ufeful, to keep the penis laid up to the belly, when the patient either walks about or is fitting. mdcclxxv. Upon occafion of frequent priapifm and chordee, it has been found ufeful to apply to the whole ofthe penis a poultice of crumb of bread moistened with a ftrong folution of fugar of lead. I have, however, been often difappointed in this praaice, perhaps by the poul- tice keeping the penis too warm, and thereby exciting the very fymptoms I wifhed to prevent. Whether lotions of the external urethra, with a folution ofthe fugar of lead, might be ufeful in this cafe, I have not properly tried. mdcclxxvi. With refpea to theufe of injeaions, fo frequently employed in gonorrhoea, I am perfuaded, that the early ufe of aftringent injeaions is pernicious ; not by occafioning 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 fymptom of fwelled tefticles; When, however, the difeafe has continued for fome time, and the inflammatory fymptoms have very much abated, I am of opinion, that by injeaions of moderate aftrin- gency, or at leaft of this gradually increafed, an end may be fooner put to the difeafe than would otherwife have happened; and that a gleet, fo readily occurring, may be generally prevented. ♦ mdcclxxvii. Befides the ufe of aftringent injeaions, it has been common enough to employ thofe of a mercu- rial kind. With refpea to thefe, although I am convin- ced that the infeaion producing gonorrhoea, and that producing chancres and fiphylis, are one and the fame ; yet I apprehend, that in gonorrhoea mercury cannot be of ufe by correaing the virulence of the infeaion ; and therefore that it is not univerfally neceffary in this dif- eafe, I am perfuaded, however, that mercury applied to the internal furface of tbe urethra, may be of ufe in pro- moting the more full and free difcharge of virulent mat- ter from the mucous glands of it. Upon this fuppofi- tion, I have frequently employed mercurial injeaions j and, as I judge, with advantage ; thofe ^injeaions often PRACTICE OF PHYSIC. 641 bringing on fuch a ftate of the confiftence and color ofthe matter difcharged, as we know ufually to precede its fpontaneous ceafing. I avoid thefe injeaions, however, in recent cafes, or while much inflammation is ftill pref- ent ; but when that inflammation has fomewhat abated, and the difcharge notwithftanding ftill continues in a vir- ulent form, I employ mercurial injeaions freely. I em- ploy thofe only that contain mercury entirely in a liquid form, and avoid thofe which may depofit an acrid pow« der in the urethra. That which I have found moft ufe- ful is a folution of the corrofive fublimate in water; fo much diluted as not to occafion any violent fmarting, but not fb much diluted as to give no fmarting at alb It is fearce neceffary to add, that when there is reafon to fufpea there are ulcerations already formed in the ure- thra, mercurial injeaions are not only proper, but the on- ly effeaual remedy that can be employed. mdcclxxviii. With regard to the cure of gonorrhoea, I have only owe other remark to offer. As moft of the fymptoms arife from the irritation of a ftimulus applied, the effeas of this irritation may be often leffened by di- minifhing the irritability of the fyftem; and it is well known, that the moft certain means of accomplishing this is by employing opium. For that reafon I confider the practice both of applying opium direaiy to the urethra, and of exhibiting it by the mouth, to be extremely ufe- ful in moft cafes of gonorrhoea. mdcclxxix. After thus offering fome remarks with refpea to gonorrhoea in general, 1 might proceed to con- fider particularly the various fymptoms which fo frequent- ly attend it; but it does not feem neceffary for me to at- tempt this after the late publications Dr. Foart Simmons, and of Dr. Schwediauer, who have treated the fubjea fo fully, and with fo much difcernment and fkill. mdcclxxx. 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 with- out :'..mediately communicating to the blood more ov 6iO PRACTICE OF PHYSIC. lefs of the venereal poifon ; for I have conftantly, when- ever chancres had appeared, found, that unlefs mercury was immediately given internally, fome fymptoms of a general fiphylis did certainly come on afterwards ; and though the internal ufe of mercury fhould prevent any fuch appearance, it is ftill to be prefumed that the poifon had been communicated, becaufe mercury could aa upon it in no other manner than as diffufed in the fluids. mdcclxxxi. It has been a queftion among practition- ers, upon the fubjea of chancres, Whether they may be immediately healed up by applications made to the chan- cres, or if they fhould be left open for fome time with- out any fuch application ? It has been fuppofed, that the fudden healing up of chancres might immediately force into the blood a poifon, which might have been excluded by being difcharged from the chancre. This, however, is a fuppofition that is very doubtful; and, upon the other had, I am certain, that the longer a chancre is kept open, the more poifon it perhaps generates, and certainly fup- plies it more copioufly to the blood. And although the above mentioned fuppofition were true, it will be or little confequence, if the internal ufe of mercury, which I judge neceffary in every cafe of chancre, be immediately employed. I have often feen very troublefome confe- quences follow from allowing chancres to remain unheal- ed ; and the fymptoms of general fiphylis have always feemed to me to be more confiderable and violent in pro- portion as chancres had been fuffered to remain longer unhealed. They fliould always, therefore be healed as foon as poflible; 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 con- fiderable ulcer, may often be healed by the common mercurial ointment; but the moft powerful means of healing them, has appeared to me to be the application of red precipitate in a dry powder. mdcclxxxh. When, in confequence of chancres, or of the other circumftances above mentioned, by which it may happen ; the venereal poifon has been communicat- ed to the blood, it produces many different fymptoms in PRACTICE OF PHYSIC. 6$» different parts of the body, not neceffary to be enumerat- ed and defcribed here, that having been already done by many authors with great accuracy. mdcclxxxiii. Whenever any of thofe fymptoms do in any degree appear, or as foon as it is known that the circumftances which give occafion to the commu- nication of the venereal poifon have taken place, I hold the internal ufe of mercury to be immediately neceffary ; and I am well perfuaded, that mercury employed with- out delay, and in fufficient quantity, will pretty certain- ly prevent the fymptoms which would otherwife have foon appeared, or will remove thofe that may have al- ready difcovered themfelves. In both cafes, it will fecure the perfon from any future confequencesaof fiphylis from that infeaion. mdcclxxxiv. This advice for the early and full ufe of mercury, I take to be the moft important that can be given with refpea to the venereal difeafe : And al- though I muft admit that the virulence of the poifon, may be greater in one cafe than in another ; and even that, one conftitution may be more favorable than anoth- er, to the violence of the difeafe ; yet I am thoroughly convinced, that moft of the inftances which have oc- curred of the violence and obftinacy of fiphylis, have been owing very entirely to the negfea of the early ap- plication of mercury. mdcclxxxv. Whatever other remedies of fiphylis may be known, or may hereafter be found out, I cannot pre- tend to determine ; but I am well perfuaded, that in moft cafes mercury properly employed will prove a very certain and effeaual remedy. With refpea to .others that have been propofed, I fhall offer this remark only, that I have found the decoaion of the mezereon con- tribute to the healing of ulcers which feemed to nave re- fifted the power of mercury. mdcclxxxvi. With regard to the many and various preparations of mercury, I do not think it neceffary to give any enumeration of them here, as they are com- monly very well known, and have been lately well en- umerated by Dr. Schwedisiuer. The choice of them 65* PRACTICE OF PHYSIC. *eems to be'for the moft part a matter of indifference ; as I believe cures have been, and ftill may be effeaed by ma- ny different preparations, if properly adminiftered. The proper adminiftration feems to confift, \ft, In the choof- ing thofe preparations which are the leaft ready to run off by ftool ; and therefore the applications externally by unaion, are in many cafes the moft convenient. 2dly, In employing the unaion, or in giving a preparation of mercury internally, in fuch quantity as may fhow its fen- fible effeas in the mouth. And, 3dly, Without carrying thefe effeas to a greater length, in the continuing the employment of mercury for feveral weeks, or till the fymptoms of the difeafe fhall have for fome time entire- ly difappeared. I fay nothing of the regimen proper and neceffary for patients during the employment of mercu- ry, becaufe I prefume it to be very well known. mccclxxxvii. Amongft the other preparations of mercury, I believe the corrofive fublimate has often been employed with advantage ; but I believe alfo, that it re- quires being continued for a longer time than is neceffary in the employment of other preparations in the manner above propofed ; and I fufpecT: it has often failed in mak- ing a cure, becaufe employed while perfons were at the fame time expofed to the free air. mdcclxxxviii. Upon thefe points, and others relative to the adminiftration of mercury, and the cure of this difeafe, I might offer fome particular remarks ; but I be- lieve they are generally underftood ; and it is enough for me to fay here, that if praaitioners will attend, and pa- tients will fubmit to the general rules given above, they will feldom fail of obtianing a certain and fpeedy cure of the difeafe*. * The nitrous acid has of late been powerfully recommended in the vene- real difeafe: Numerous well authenticated cafes have been adduced by men of high profeffional character, where ii appears to have effected a cure in the moft formidable ftages of this diflemper ; and a general fpirit of inquiry has been excited to afcertain its real merits. It is, however, to be regietted, that our prefent expe ienee does not enable us to eftablifh its character as a fub- ftitute f< r mercury. That it pcffeffes ftrong antifiphylitic powers is un- doubted, but it is extremely doubtful whether it affoids equal fecurity with that remedy. Indeed the contradictory experience of phyficians, equally diftinguifhed and equally unbiaffed, while it repreffes too fanguine expecta- tion, calls upon us to paufe until time has fettled the rank which it ought to PRACTICE OF PHYSIC. 653 CHAP. III. OF SCURVY*. mdcclxxxix. J. his difeafe appears fo frequently, and the effeas of it are fo often fatal in fleets and armies, that it has very properly engaged the particular attention of phyficians. It is indeed furprifing, that it had not fooner attraaed theefpecial notice both of ftatefmen and phyficians, fo as to have produced thofe meafures and regulations that might prevent the havoc which it fo hold amongft the remedies of the lues venerea. The nitrous acid has fuc- ceeded in many very unpromi fing cafes, but in others, apparently flight, it has failed. Nor have thofe peculiar circumftances of conftitution or difeafe, which indicate the propriety of its exhibition, been as yet pointed out. It muft however be allowed, that the nitrous acid is a highly valuable ac- quilition to our lift of fiphylitic remedies. It is not attended with any of thofe difagreeable confequences which fo frequently follow the ufe of mercu- ry : but on the contrary, feems to increafe the appetite and improve the gen- eral health of the patient. D-. Beddoes (to whofe exertions on this fubject the public are much indebted)Obferves, *' that where the conftitution isbro- «* ken, the habit fcbleor fcrophulous, the cure fliould always be attempted " by the nitrous ac'd, in preference to any other medicine." It likewife feems in many cafes to be conjoined with mercury with great advantag^,and in this way cures have been eifvcted, after each had been tried feparately in vain ; and it is obferved, that when combined in this manner, pateir.ts both re quire lef9 mercury, and bear the neceffary quantity of it much letter, than when it is exhibited aloi:e. Dr. Rutherford remarks in his letter to Dr. Beddoes, that he has " feen an inftance or two where the difeafe was (o invet- " erate. and the conftitution fo broken, that neither the acid nor mercury were " adequate to check the progrefs ofthe difeafe, as trial had been made of both «' in fuccc-ffion, but without any confpicuous advantage ; iu thefe theveiore, " nitrous acid has been ufed at the fame time with themercury, and the two " together have produced a moft favorable change in almoft every fymp- " iora." This is likewife corroborated by Mr. Blair, whofe experience has been rather unfavorable to the acid; but although he dees not admit that it can be depended on for a radical cure of the fecondary fymptoms of lues, he efteems it extremely ufeful in conjunction or alternated with mercury. The atminiftration of this medicine is perfectly fimple. A drachm of nitrous acid is added to a pint of water, and three or four ounces of fimple fyiup ; we begin with thiaiquantity as a dofe for the day, but it may be gradually in- cseifed to two and a half or three drachms. Thofe who wifli more minute information on thisinterefting fubject. may confult the different Reports of Dr. Beddces on the Nitrous Acid, Mr. Blair's Effays on the Venereal Difeafe, and Mr. Pearibn on the fame diftemp.er. * Extreme debility, bleeding of the gums, varicus colored fpots upon the Ikin, more particularly livid, and chiefly at the roots ofthe hair ; thefe fymp- toms generally fupervene in cold climates after a continued animal diet, con- fining chiefly of putrid falted meat, and when there is a deficiency of freflj -egetabks. Syn. Nof. 2 16s* PRACTICE OF PHYSIC often occafions. Within thefe laft fifty years, however^ t has been fo much attended to and ftudied, that we might fuppofe every cicumftance relating to it fo fully and exaaiy afcertained, as to render all further labor up- on the fubjea fuperfluous. This perhaps may be true ; but it appears to me, that there are ftill feveral circum- ftances regarding the difeafe not agreed upon among phyficians, as well as different opinions formed, fome of which may have a bad effea upv3n the praaice : And this feems to me to be fo much the cafe, that I hope I fhall be excufed in endeavoring here to ftate the faas as they ap- pear to me from the beft authorities, and to offer re- marks upon opinions which may influence the praaice in the prevention and cure of this difeafe. moccxc. With refpea to the phenomena of the dif- eafe, they have now been fo fully obferved, and fo accu- rately defcribed, that there is no longer any doubt in dis- cerning the difeafe when it is prefent, or in diftinguifh- ing it from almoft every other ailment. In particular it feems now to be fully determined, that there is one dif- eafe only entitled to the appellation of Scurvy ; that it is the fame upon the land as upon the fea ;lthat it is the fame in all climates and feafons, as depending every where upon nearly the fame caufes; and that it is not at all di- verfified, either in its phenomena or its caufes, as had been imagined fome time ago. mdccxci. The phenomena of fcurvy, therefore, are not to be defcribed here, as it has been fo fully and ac- curately done elfewhere; and I fhall only endeavor to afcertain thofe faas with refpea to the prevention and cure of the difeafe which feem not yet to be exaaiy a- greed Upon. And, firft, with refpect to the antecedents- that may be confidered as the remote caufes of the dif- eafe. mdccxcii. The moft remarkable circumftance amongft the antecedents'^ this difeafe is, that ithas moft common- ly happened to men living very much on falted meats ; and whether it ever arife in any other circumftances, is extremely doubtful. Thefe meats are often in a putref- cent ftate j and to the circumftance of the long continued PRACTICE OF PHYSIC. 655 ufe of animal food in a putrefcent and fomewhat indigef- tible ftate, the difeafe has been efpecially attributed. Whether the circumftance of the meat's being falted, has any effea in producing the difeafe, otherwife than by be- ing rendered more indigeftible, is a queftion that remains ftill in difpute. mdccxciii. It feems to me, that the fait concurs in producing the effea; for there is hardly any inftance of the difeafe appearing unlefs where falted meats had been employed, and fcarcely an example where the long con- tinued ufe of thefe did not produce it: Befides all which, there are fome inftances where, by avoiding falted meats, or by diminifhing the proportion of them in diet, while other circumftances remained much the fame, the difeafe was prevented from appearing. Further, if it may be admitted as an argument upon this fubjea, I fhall here- after endeavor to fhow, that the large ufe of fait has a tendency to aggravate and incr^jfe the proximate caufe •of fcurvy. mdccxciv. It muft, however, be allowed, that the principal circumftance in caufing fcurvy, is the living very much and very long upon animal food, efpecially when in a putrefcent ftate; and the clear proof of this is, that a quantity of frefh vegetable food will always certainly prevent the difeafe. mdccxcv. While it has been held, that, in thofe cir- cumftances in which fcurvy is produced, the animal food employed was efpecially hurtful by its being of difficult digeftion, this opinion has been attempted to be confirm- ed, by obferving, that the reft of the food employed in the fame circumftances was alfo of difficult digeftion. This is fuppofed to be efpecially the cafe of unfermented farinacea which fo commonly makes a part ofthe fea diet: but I apprehend this opinion to be very ill founded ; for the unfermented farinacea, which are in a great propor- tion the food of infants, of women, and of the greater part of mankind, can hardly be fuppofed to be food of difficult digeftion : and with refpea to the produaion of icurvy, there are faas which fhow, that unfermented 3 656 PRACTICE OF PHYSIC. farinacea, employed in large proportion, have had a con- fiderable effea in preventing the difeafe. mdccxcvi. It has been imagined,that a certain impreg- nation of the air upon the fea had an effea in producing fcurvy. But it is altogether improbable : for the only impregnations which could be fufpeaed, are thofe of in- flammable or mephitic air ; and it is now well known, that thefe impregnations are much lefs in the air upon the fea than in that upon the land; befides, there are otherwife many proofs of the falubrity ofthe fea air. If, therefore, fea air have any effea in producing fcurvy, it muft be by its fenfible qualities of cold or moifture. mdccxcvii. That cold has an effea in favoring the produaion of fcurvy, is manifeft from hence, that the difeafe is more frequent and more confiderable in cold than,in warm climates and feafons ; and that even warm clothing has a confideable effea in preventing it. mdccxcviii. MpUJMre may in general have an effea in favoring the profflrction of fcurvy, where that ofthe atmofphere in which men are placed is very confidera- ble : but the ordinary moifture of the fea air is far from being fuch. Probably it is never confiderable, except in the cafe of unufual rains ; and even then, it is perhaps by the application of moifture to the bodies of men in damp clothing only that it has any fhare in the produc- tion of fcurvy. At the fame time, I believe there is no inftance of either cold or moifture producing fcurvy, without the concurrence of the faulty fea diet. mdccxcix. Under thofe circumftances which produce • fcurvy, it commonly feems to occur moft readily in the perfons who are the leaft exercifed ; and it is therefore probable, that confinement and want of exercife may have a great fhare in producing the difeafe. mdccc. It appears that weaknefs, in whatever manner occafioned, is favorable to the produaion of fcurvy. It is therefore probable, that unufual labor and fatigue may often have fome fhare in bringing it on : and upon the fame account, it is probable, that fadnefs and defponden- cy may induce a weaknefs of the circulation, and be there- PRACTICE OF PHYSIC. $5; by, as has been remarked, favorable to the produaion of fcurvy. mdccci. It has alfo been obferved, that perfons negli- gent in keeping their fkin clean by wafhing and change of clothing, are more liable than others to be affeaed with fcurvy. mdccch. Several of thefe caufes, now mentioned, concurring together, feem to produce fcurvy ; but there is no proper evidence that any one of them alone will produce it, or that all the others uniting together will do it, without the particular concurrence of the fea diet. Alongft with this, however, feveral of the other circum- ftances mentioned, have a great effea in producing it fooner, and in a more confiderable degree, than would otherwife have happened from the diet alone. mdcccih. From this view ofthe remote caufes, it will readily appear that the prevention of the difeafe may in fome meafure depend upon the avoiding of thofe circum- ftances 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 falted meats; at leaft by leffening the proportion of thefe, and ufing meat preferved other- wife than by fait; by ufing in diet any kind of efculent vegetable matter that can be obtained j and efpecially by ufing vegetable matters the moft difpofed to acefcency, fuch as malt; and by drinking a large quantity of pure water. mdccciv. The cure of fcurvy feems now to be very well afcertained ; and when the neceffary means can be obtained, the difeafe is commonly removed very quickly. The chief means is a food of frefh and fucculent vegeta- bles, and thofe almoft of any kind that are at all efculent. Thofe moft immediately effeaual are the acid fruits, and, as being of the fame nature, all fort of fermented liquor. mdcccv. The plants mme^alkalefcent, fuch as thofe of the garlic tribe and of the tetradynamiae, are alfo partic- ularly ufeful in the cure of this difeafe ; for, notwith- ftanding their appellation, they in the firft part of their fermentation undergo an acefcency, and feem to contain 4, tit PRACTICE OF PHYSIC. a great deal of acefcent matter. At the fame time, they have generally in their composition an acrid matter that readily paffes by urine, probably by perfpiration ; and, by promoting both excretions, are ufeful in the difeafe. •It is probable;- that fome plants of the coniferous tribe, fuch as the'fprXice.fir, and others poffeffed of a diuretic power, may likewife be of fome ufe. .. fyfocccvi. Jt is fufficiently probable, that milk of eve- ry kind* and particularly its produaions, whey and but- ter milk, may prove a cure of this difeafe. TMDcccyii. It has been common in this difeafe toem- *''• ploy the foflil acids ; but there is reafon to doubt if they be of any*fervice, and it is certain they are not effeaual renaedies. They can hardly be thrown in,.in fuch quan- . tity as to be ufeful antifepties; \ 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. .► htbcccvm. The great debility whicK conftantly attends fcurvy^has naturally led phyficians to employ tonic and ftrengthening medicines, particularly the Peruvian bark; but the efficacy of it feems to me very doubtful. It is furprifing how foon the ufe of a vegetable diet reftores the ftrength of fcorbutic perfons ^ which feem to fhow that the preceding'debility had depended upon the ftate of the fluids; and confequently till the found ftate of thefe can be restored, 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 ef- fea in fcurvy. - mdcccix. I fhall conclude my obfervations upon the medicines employed in fcurvy, with remarking, that the ufe of mercury is always manifeftly hurtful. mdcccx. After having obferved that both the preven- tion and cure of this difeafe are now very well known, it '■.. may feem unneceffary to e#ter into much difeuflion con- cerning its proximate caufe : but as fuch difcuflionsfcan hardly be avoided, and as falfe opinions may in fome meafure corrupt the praaice, I fhall venture to fuggeft here what appears to me moft probable upon the fubjea. PRACTICE OF PHYSIC. 6s* mdcccxi. Notwithftanding what has been afferted by fome eminent perfons, I truft to the concurring teftimo- ny of the moft part of the autho^pu^on the fubjea, that in fcurvy, the fluids, fuffer a confiderable change. From thefe authors we learn, that in tjie blood drawn from the veins of perfons laboring under the fcurvy, the craffamentum is different both in color «ancl confiftence 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. u- rjne is always high colored,and more'acrict than ufual; and if that acrid exfudation from the feet, which Dr. Hulme'1 takes notice of, nappens efpecially in fcorbutic peffons, it will be a remarkable prOof to the fame ^ufpofe. But however this may be, there is evidence enough thafcvin • fcurvy the natural' ftate of the fluids is considerably changed. Further, I apprehend it may be confidently prefumed from this, that the difeafe is brought.on by a* particular nourifhment introduced into the body, and is as certainly cured by the taking in of a different diet. In the latter cafe, the diet ufed has no other evident operation, than that of giving a particular ftate and con- dition to the fluids. mdcccxii. Prefuming, therefore, that the difeafe de- pends upon a particular condition of the fluids of the bor dy, the next fubjea of inquiry is, what that condition may be ? With this view, I muft obferve, that the animal econ- omy has a Angular power of changing acefcent aliments* in fuch a manner as to render them much more difpof- ed to putrefaaion :, and although, in a living ftate, they hardly ever proceed to an aaually putrid ftate ; yet in man, whofe aliment is of a mixed kind it is pretty cer- - tain, that if he were to live entirely upon animal food, without a frequent fupply of vegetable aliment, his fluids would advance further towards putrefaaion than is con- fiftent with health. This advance towards putrefaaion feems to confift in the produaion and evolution of a fa- line matter which did not appear in the vegetable aliment5 66o PRACTICE OF PHYSIC. and could not be produced or evolved in it, but by car- rying on its fermentation to a putrefaaive ftate. That this faline ftate, is donfjantly in fome meafure produced and evorved by the animal procefs, appears from this, that certain excretions of faline matter are conftantly made from the human body, and are therefore prefumed necef- fary to its health. JJrom all this, it may be readily underftood, how the continual ufe of animal food, efpecially when already in a putrefcent ftate, without a mixture of vegetable, may have the effea of carrying the animal procefs too far, and particularly of producing and evolving a larger propor- tion of faline matter. That fuch a preternatural quan- tity of faline matter does exift in the blood of fcorbutic perfons, appears from the ftate of the fluids above men- tioned. It will be a confirmation of all this to obferve, that every interruption of perfpiration, that is, the reten- tion of faline matter, contributes to the produaion of fcurvy ; and this interruption is efpecially owing to the application of cold, or to whatever elfe weakens the force of the circulation, fuch as the negfea or want of exercife, fatigue, and defpondency of the mind. It deferves in- deed to be remarked here, that one ofthe firft effeas of the fcurvy 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 ofthe fluids may induce fuch debility is not well underftood; but that it does depend upon fuch a ftate of the fluids, is render- ed fufficiently prefumable from what has been faid above with regard to both the caufes and the cure of fcurvy. mdcccxiii. It is poflible, that this debility may have a great fliare in producing feveral of the phenomena of fcurvy ; but a preternaturally faline, and confequently diffolved ftate of the blood, will account for them with more probability ; and I do not think it neceffary to perfons who are at all accuftomed to reafon upon the an- imal economy, to explain this matter more fully. I have only to add, that if my opinion in fuppofing the proximate caufe of fcurvy to be a preternaturally faline ftate of the blood be at ail founded, it will be fufficiently PRACTICE OF PHYSIC. 66i obvious, that the throwing into the body, along with the aliment, an unufual quantity of fait, may have a great fhare in producing the difeafe. Even fupppfing fuch fait to fuffer no change in the animal body, the ef- fea of it may be confiderable ; and this will be rendered ftill more probable, if it may be prefumed, that all neu- tral falts, confifting of a fixed alkali, are changed in the animal body into an ammoniacal fait ; which I apprehend to be that efpecially prevailing in fcurvy. If I be at all right in concluding, that meats, from being falted contribute to the produaion of fcurvy, it will readily appear, how dangerous it may be, to admit the conclu- fion from another theory, that they are perfeaiy inno- cent. mdcccxiv. Having thus endeavored to explain what relates to the cure of fcurvy in general, I judge it proper to leave to other authors what relates to the management of thofe fymptoms, which require a particular treatment, CHAP. IV. OF JAUNDICE*. mdcccxv. Ihave here paffed over feveral of the titles in my Nofology, becaufe they are difeafes not of this ifland. In thefe, therefore, I have no experience; and 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 1 can poffibly introduce into my courfe of Leaures. mdcccxvi. The jaundice confifts in a yellow color ot the fkin over the whole body, and particularly of the adnata ofthe eyes. This yellow color may occur from different caufes : but in the jaundice, hereafter to be more exaaiy charaaerifed, 1 judge it to depend upon a *Ayellownefs of the fkin and eyes ; whitenefs of the feces, the urine flightly red, and tinging cloth immeifed with a yellow color. Syn. So/. <,bi PRACTICE OF PHYSIC, 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. mdcccxvu. 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 fecretory organ of the liver. The bile therefore can- not appear in the mafs of blood, or upon the furface of the body, that is, produce jaundice from any interrup- tion of its fecretion ; and accordingly, if jaundice does appear, it muft be in confequence of the bile, after it had been fecerned, being again taken into the blood veffels. This may happen in two ways ; either by an interrup- tion of its excretion, that is, of its paffage into the duo- denum, which by accumulating it in the biliary veffels, may give occafion to its paffing again into the blood vef- fels ; or it may pafs into thefe, by its being abforbed from the alimentary canal when it happens to be accumulated there in an unufual quantity. How far the latter caufe can take place, or in what circurnftances it does occur, I cannot clearly afcertain, and I apprehend that jaundice is feldom produced in that manner. mdcccxviii. The former caufe of flopped excretion may be underftood more clearly; and we have very cer- tain proof of its being the ordinary, and indeed almoft the 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 duclus communis tholedochus; the moft common caufe of which is a biliary concretion formed in the gall bladder, and from thence fallen 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 duodenum. This dua may likewife be obftruaed by a fpafmodic conftriaion affeaing it; and fuch fpafm may happen, either in the dua itfelf, which we fuppofe to be contraaile ; or in the duodenum pref- fing the fides of the dua clofe together; or laftly, the jiuct. may be obftruaed by a tumor comprefling it, and « PRACTICE OF PHYSfC. • 663 that arifing either in the coats of the dua itfelf, or in any of the neighboring parts that are or may come to be contiguous to it. mdcccxix. When fuch obftruaion happens, the fecret- ed bile muft be accumulated in the biliary duas ; and from thence it may either be abforbed and carried by the lymphatics into 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 dif- fufed in the mafs of blood ; and from thence may pafs by every exhalant veffel, and produce the difeafe in quef- tion. mdcccxx. I have thus fhortly explained the ordinary produaion 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 faces alvina, which we readily account for from the abfence of bile in the inteftines ; and generally alfo, with a certain confiftence of the feces, the caufe of which it is not fo eafy to ex- plain. The difeafe is always accompanied alfo with urine of a yellow color, or at leaft with urine that tinges a lin- en cloth with a yellow color. Thefe are conftantly at- tending fymptoms ; and though not always, yet there is commonly a pain felt in the epigaftrium, correfpond- ing, as we fuppofe, to the feat of the duaus 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, fufl>nd hard, and fome oth- er fymptoms of pyrexia appear. mdcccxxi. When the jaundice is occafioned by tu- mors ofthe neighboring parts comprefling the biliary dua I believe the difeafe can very feldom be 'cured. That fuch is the caufe of jaundice, may with fome pro- bability be fuppofed, when it has come on inconse- quence of other difeafes which had fubfifted long before, and more efpecially fuch as had been attended wira fvmptoms of obftructed vicera. Even when the jaun- dice has fubfifted long without any intermiffion, and SU PRACTICE OF PHYSIC. without any pain in the epigaftrium, an external com. preffion is to be fufpeaed. mdcccxxii. In fuch circumftances, I confider the dif- eafe as incurable ; and it is almoft only when the dif- eafe is occafioned by biliary concretions obstructing the biliary dua, that we may commonly expea relief, and that our art may contribute to the obtaining it. Such cafes may be generally known, by the difeafe frequently difappearing and returning again ; by our finding, after the former accident, biliary concretions amongft the faeces ; and by the difeafe being frequently accompanied with pain of the epigaftrium, and with vomitings arifing from fuch pain. mdcccxxiii. In thefe cafes, we know of no certain and immediate means of expeding the paffage of the bil- iary concretions. This is generally a work of time, de- pending upon the gradual dilatation ofthe biliary duaj and it is furprifing to obferve, from'the fize of the ftones which fometimes pafs through, what dilatation the dua will admit of. It proceeds, however, falter or flower up- on different occafions ; and therefore the jaundice, after a various duration often ceafes fuddenly and fpontaneoufly. It is this which has given rife to the belief, that the jaun- dice has been cured by fuch a number and fuch a variety of different remedies. Many of thefe however, are perfeaiy inert, and many others of them fuch as cannot be fuppof- ed to have any effea in expeding the paffage of a biliary concretion. I fhall here, therefore, take no notice of the numerous remedies of jaundice mentioned by the writers on the Materia Medica, or even of thofe to be found in praaical authors ; but fliall confine myfelf 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. mdcccxxiv. In the treatment of this difeafe, it is, in the firft place, to be attended to, that as the diftenfion of the biliary 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 pre- caution ; and when much pain, together with any de- PRACTICE OF PHYSIC. 66S gree of pyrexia, occurs, it becomes an abfolutely neceffa- ry remedy. In fome inftances of jaundice accompanied with thefe fymptoms, I have found the blood drawn cov- ered with an inflammatory cruft as thick as in cafes of pneumonia. mdcccxxv. There is no means of pufhing forward a biliary concretion that is more probable than the aaion of vomiting; which, by comprefling the whole abdom- inal vifcera, and particularly the full and diftended gall bladder and biliary veffels, may contribute, fometimes gently enough, to the dilatation ofthe biliary dua. Ac- cordingly 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 jaun- dice, it may be fufpeaed that the fize of the concretion then paffing is large ; or more efpecially when pain at- tending the difeafe gives apprehenfion of inflammation, it may be prudent to avoid vomiting altogether. mdcccxxvi. It has been ufual in the jaundice to em- ploy purgatives: And it is poffible that the aaion of the inteftines may excite the aclion ofthe biliary duas, and thus favor the expulsion of the biliary concretion : But this, I think, cannot be of much effea; and the attempt- ing it by the frequent ufe of purgatives, may otherwife hurt the patient. For this reafon, I apprehend that pur- gatives can never be proper, excepting when there is a flowand bound belly. mdcccxxvii. As the relaxation of the fkin contributes to relax the whole fyftem, and particularly to relieve the conftriction of fubjacent parts ; fo, when the jaundice is attended with pain, fomentations ofthe epigaftrium may be of fervice. mdcccxxviii. As the folids ofthe living body are very flexible and yielding; fo it is probable, that biliary con- cretions 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 preter- natural fpafmodic contraaion of the parts below. Up- 666 PRACTICE OF PHYSIC. onthis account, opium is often of great benefit in jaun- dice ; and the benefit refulting from its ufe, proves fuf- ficiently the truth ofthe theory upon which the ufing of it has been founded. md.cccxxix. It were much to be wifhed that a fol- vent of biliary concretions, which might be applied to them in the gall bladder, or biliary duas, was difcover- ed : but none fuch, fo far as I know, has yet been found ; and the employment of foap in this difeafe, I confider as a frivolous attempt. Dr. White of York has found a fol- vent of biliary concretions when thefe are out of the body; but there is not the leaft probability, that it could reach them while lodged within. INDEX. N. B. The Cyphers refer to the Number of the Paragraphs. A. XXBSCESS, 250. Abfeeffes and Ulcers, the caufes of their different ftate?, 454* Acids employed in fever, 134. refrig- erant in fever, ibid. AStion of the heart and arterie3, how increafed for preventing the recur- rence of the paroxyfms of inter- mitting fever, 330. Adynamia?, 1171. Amenorrhoea, 995. from retention, 996. when occurring, 998, fymp- toms of, 999. caufes of, ieoo—a. cure of, iooz—6.from fuppreffion, 996. when occurring, 1008. fymp- toms of, 1010. caufes of, 1008—9. cure of, ion—1*« Amentia, 1598. Anafarca, 1668. the character of, ibid, phenomena of, ibid.—1673. cure of, 1674—96. diftinguifhed from Leucophlegmatia, 1669. St. Anthony's Fire. See Erythema. Antimonial Emetics, employed in fe- vers, 181. their different kinds, ibid, the adminiftration of them in fevers, 183—6. Antiphlogiftic Regimen, ia9- how conducted, 13a- when employed in intermittent fever, 334. Antifpafmodics, employed in fevers, 15a, 187. Aphtha, 733. Apoplexy, 1094. diftingmftied from palfy, ibid, diftinguifhed from fyn- cope, ibid. predifponent caufes of, x#f5. exciting caufes of, 1098— 1115—16. proximate caufe of,iieo —ax. Serofa, proximate caufe of, .1114. prognoftic, uaa—23. fre- quenly ending in hemiplegia, 112a. prevention of, 11*4. whe- ther fanguine or ferous, ftimulants hurtful in it, 1136—37. from pow- ers that deftroy the mobility of the nervous power, 1138. cure of* 1131—9. Apyrexia, 24. Afcites, 1709. character of, ibid, it* various feat, 1710—11. the phe- nomena of, 171a—43. its particu- lar feat difficultly afcertained, 1714. the cure of, 1715—17. Afthma, 1373. phenomena of, 1375.' exciting caufes of, 1381. proxi- mate caufe of, 1384. diftinguifhed from other kinds of dyfpnoea, 1385. fometimes occafions phthifia pulmonalis, 1386. frequently end* in hydrothorax, ibid, feldom en- tirely cured, 1387. Adringents employed in intermittent fevers, 231.joined with aromatic* employed in intermittent fevers, ibid, joined with bitters, employed in intermittent fevers, ibid. Atrabilis, 1029. Atrophia ab alvi fluxu, 1607. debi-' tium, 1606. inanitorum, 16*7. in fantilis, 1605. lactantium, ibid* lateralis, 1606—11. a leucorrhcea, 1607. nervofa, 1606. nutricum, 1607. a ptyalifma, ibid, rachitics, 16*5. fenilis, 1606—n. Aura Epileptica, 1306. ut INDEX. B. Bitters employed in intermittent fe- vers, 231. joined with aftringents, employed- in intermittents, ibid. Bliftering, its effects, 189—197. its mode of operation in the cure of fevers, 190—94. when to be em- ployed in fevers, 195. where to be applied in fevers, 196. Blood letting, the employment of it in fevers, 138—143* the circum- ftances directing its ufe in fevers, 142. the adminiftration of it in fevers, 143. when employed in in- termittent fevers, »34« Cachexies, character of the clafs, 1599. Cachexy, the term, how applied by authors, 1600. Calculus Renalis, 429. Calx Nitrata Antimonii, its ufe id fevers,i83—185. Canine Madnefs, 15Z5. the cure of, ibid—1527. Cardialgia, .1427. Carditis, 383. ofthe chronic kind, ibid. Car us, 1094-. Cataphora, ibid. Catarrh, 1046. predifpofition to, 1047. fymptoms of, 1048. remote caufes of, 1047. proximate canfe of, 1057. cure of, 1065. produces phthifis, 1055. paffes into pneu- monia, 1054. produces a perip- neumonia notha, 1056. Contagi- ous, 1062. Catarrhus Suffocativus, 376. Chancre, method of treating, 1781. Chicken pox, 631. how diftinguifhed from fmall pox, 632. Chincough, 1402. contagious, ibid. frequently accompanied with fe- ver, 1410. phenomena, 1404. prog- noftic in, 1413, cure of, 1414. Chlorofis, 998. Cholera, 1453- fymptoms of, i4<3-«» 56. remote caufes of, 1458—60. proximate caufe of, 1454. cure of, 1462—64. Chorea, 1347. phenomena of, 1347 —S3- cure of, 1354. Chronic wtaknefs, J191, Cceliaea, 1493. Cold, its operations, 88. abfoluteft ibid, relative, 89. its general ef- fects on the human body, 90—91. its morbid effects, 9a. moderates the violence of reaction in fever, 133. its tonic power, how to be employed in fevers, 205. Drink, an ufeful tonic in fevers, 206. the limitation of its ufe in fevers, 207. Air applied in fevers, *o8. Water applied to the furface of the body in fevers, 205—209. Colic, 1435. fymptoms of, 1435—38. proximate caufe of, 1439.cnre off 1441. Devonfhire. fee Colic of, Poitou. of Poitou, 1451. cure of, i45*« Coma, 1094. Comata, X093. Contagions, 78. their fuppofed vari- ety, 79. Convulfions, 125 3. Corpulency, 16 21. *r, Cynanche. 300. Maligna, 311. ParO' tidea, 332. Pharyngea, 331. Ton- fillaris, 301. Trachealis, 318. as af- fecting infants, 312—29. the cure of it, 330. Cyftitis, 431. D. Days, critical in fevers, 107—34. non critical, 113. Death, the caufes of in general, io». the direct caufes of, ibid. Uie in- direct caufes of,, ibid, the caufes of in fever, 101. Debility in fevers,, the fymptoms of, 104. how obviated, 202. Deliriuman general explained, 1529 —50. in fever, of two kinds, 45. or Infanity without fever, 1550—$?' Diabetes, 1504. fymptoms of, 1504. —9. remote caufes of, 15*8. prox- imate caufe of, 1510—12. cure of, 1513- Diceta Aquea. 157. Diarrhaa, 1465. diftinguiflied from dyfentery, 1466. diftinguifhed from cholera, 1467. proximate caufe of, 1468. remote caufeB of, 1471— 93. cure of, 1494—1503. Biliofa, 1480. Coliquative, ijoi. Murofa, 1488. INDEX. ft, Diathefis Phlogiftica, 62, 247. how removed, 266. Diluents, their ufe in fevers, 154— 58. Jbifeafes, the diftinguifhing of them, how attained, a. the prevention of of the«i, on what founded, 3. the cure of them, on what founded, 4. Sropfies, 1645. >n general, the caufe of them, 1646. of the breaft, fee Hydrothorax. ofthe lower belly, fee cure Afcites. Dyfentery, 1067. contagious, 1075. remote caufes of, 1072. proximate caufe of, 1077. cure of, 1080. ufe of mild cathartics to be frequent- ly repeated in it, ibid, rhubarb im- proper in it, ibid. Dyfenteria Alba, 1070* Dyfmenorrbaa, 1014. Pjfp'pja* 1190, remote caufes of, 1198. proximate caufe of, 1193. cure of, 1201. flatulence in it, cure of,ia2i. heartburn in it, cure of, ibid, pains of ftomach,in it, cure of, ibid, vomiting in it, cure of, ibid. Dyfpnaa, 1365. E. Effluvia^ human, 85. from marfhes, ibid. Emaciations, 1600. caufes of, 1602 —18. cure of, 1619.. Emanfio Men/turn, 998. Emetics, fuited to the cure of fevers, 174. their effects, 176—80. a mean of removing fpafm, 170. the ad- miniftration of in fevers, 175*. their ufe in intermittent fevers, 230—33. Emprofthotonos, 1267. Enteritis, 404. phlegmonic or ery- thamatic, ibid, caufes of, 407. cure of, 409. Epilepfy, 1282. phenomena of, 1283. proximate caufe of 1284. remote caufes of, 1285. predifponent caufes of, 1310. fympathic, 1316. cure of, 1317. idiopathic, 1316. cure of, 13*9. Epl/iaxis, 806. the caufes of it, 8a8. the various circumftances of, 8cv —18. the management and cure of, 819—29. Eryfipelas, 274. of the face, 708. fymptoms of, 705—.8. prognofi3 e'f 706. proximate caufe of, 697. cure of, 708—11. phlegmonodes in 2 different parts of the body, 71a. attend ing put rid fever, 713. < Erythema, 274. Exanthemata, 585. Exercife, ufeful in intermittent fevers, 231. F. Fainting fee Syncfipe, n jt. Fatuity, 1529. Fear, a remote caufe of fever, 97. •ver, 8. ftrictly fo called, the char- acter of,ibid, phenomena of, ibid.— 3* remote caufes of are ofa fedative nature, 36. proximate caufe of, 35 atony of the extreme veffels, a principal circuftance in the proxi- mate caufe of it, 43—44. fpafm, 3 principal part in the proximate caufe of it, 40. general doctrine of, 46. the caufes of death in it, ioi» the prognofis of, 99. indications ot cure in, 116. differences of, 53, continent, 28. continued, 27. in- flammatory, 67. miliary, fee Mili- ary Fever, nervous, 67. bilious, ji. Fever, putrid, fcarlet, fee Scarlet 72. named fynocha, 67. fynochus,, 69 . typhus, 67. hectic, 74. in- termittent, the paroxyfms of defcribed, 10. the coldftag-e of, 11. the hot ftage of, ibid, the fweating ftage -of, ibid, of a ter- tian period, 25. of a quartan peri- od, ibid, of a quotidian period, ibid, caufedby marfh effluvia, 84. bile not the caufe of it, 51. cure of, 228. its paroxyfms, how prevented 229. attended with phlogiftic dia- thefis, 234. attended with congeft- ion in the abdominal vifcera, ibid. remittent, 26. Fluxes, without fever, fee Prqfiuvia, Fluor Albus, fee jLeucorrhaa, Fomentation of the lower extremi- ties, its ufe in fevers, 199. Fomites of contagion, 8a. Funclions intellectual, diforders of, 1528—29.. G. Gangrene of inflamed parts, the caufe of, 255—56. marks of the tendency to, 257. marks of its having come on, ibid. Gaftritis, 384. phlegmonic, or ery- thematic, 385. phlegmonic, th* 670 INDEX feat of, ibid, the fymptoms of, 386. the Caufes of, 387. the cure of, 393—97. erythematic,, how difcovered, 400. the feat of, 38$. the cure of, 401. Caflrodynia, 1427. Gleet, 1769. Gonorrhea, 1765. phenomena of, 1767—69. cure of, 1770—78. Gout, the character of, 49 a. a hered- itary difeafe, 500. diftinguifhed from rheumatifm, 5a6. -predifpo- nent caufes of, 493—50*. occa- fional caufes -of, 50a—5. proxi- mate caufe of, 52?—33. not a morbific matter, 5a9, Regular, defcribed, 506—18. pathology of, 533. cure of, 537—73« no effectu- al or fafe remedy yet found for the cure of it, 539. medicines em- ployed for it, 556. whether it can be radically cured. 540. treat- ment in the intervals of parox- yfms, 54a. treatment in the time of paroxyfms,56o.regimen during the paroxyfms, 561. external ap- plications, how fariafe, 568—69. blood letting in the intervals of paroxyfms, ss3' in the time of paroxyfms, 563. coftivenefs hurt- ful, 559. laxatives to be employed, 559.effects of alkalines, 558. ef- fects of Portland powder, 557. Ir- regular, 518. Atonic, 574—79. pathology of, 534. cure of, 580— 82. Retrocedent, 522.pathology of, 535. cure of, 580—8a. Mifplaced. 523-pathology of, 536. cure of, 583—84. Trcnfluted, two partic- ular cafes of, 525. H. Hematemefis, 1017. arterial and ven- ous,io27.fromobftructed menftru- ation, 1020. from fuppreffion ofthe hemorrhoidal flux, 1025. from compreffion of the vafa brevia by the fpleen, 1027. fr°m obftruction ofthe liver, ioa8. Hematuria, 1033. idiopathic, im- probable, 1033—34' calculofa, 1037. cure of. 1038. violentia, 1039. from fuppreffion of accuf- tomed difcharges, 1041. putrida. 1043. fpurfa et lateritia, 1044. Hemiplegia, 11 40. caufes of 1141. frequently cculioned by apoplexy, 112a. frequently alternates with apoplexy, 1144. cure of, 115 2. ftimulants, of ambiguous ufe in, 1160. ftimulants external in, »i6i. Hamoptyfis, the fymptoms of, 838— 40. the caufes of, 760—63—830. —-36. how diftinguifhed from other fpittings of blood, 841 —45. cure of, 846—52.. Hamorrhagia Uteri, 96$. Hemorrhagy, active or paffive, 735. character of, 736. arterial, 744. venous, 768. the caufes of the dif- ferent fpecies appearing at different periods of life, 750—73. the gener- al phenomena of, 738—43. the remote caufes of, 774. cure of, 776. whether to be attempted by art, 776—81. prevention of the firft attacks, or of the recurrence of, 782—89. treatment of when prel- ent, 789—805. fymptomatic, 1*15. Hemorrhoides Veftcee, 1*42. Hemorrhois, external and internal, 925. phenomena of 925—31. na- ture of the tumors, 03a. caufes of, 933—43.acquire a connection with the fyftem, 943—44. particularly with the ftomach, 946. Cure of, 947—65. Hepatirrhaa, 1481. Hepatitis,4iz. acute and chronic,ibid. acute, the fymptoms of, 413—415.. combined with pneumonic inflam- mation, 416. remote caufes of it, ibid, feat of, 418. various exit of pus produced in, 421. cure of, 42a. chronic, the feat of, 418. how dif- covered, 423. Hooping cough, fee Chincough, 1402. Horror, impreffion of, employed in intermittent fevers, 231. Human effluvia, the cauie of fever, 81. body, its temperature, 88. body hasa power of generating heat,ibid. Hydrophobia, 1525. Hydrothorax, 1697. where feated, 1698. fymptoms of, 1701—3. often combined with univeifal droply, i7©4. proximate caufe of, 1706. cure of, 1707—8. paracentefis in it, when proper, 1708. Hypercatharfts, 1477. Hypochondriafts, 1222. phenomena of, ibid, diftinguifhed from dyfpepfia, jaa6. proximate caufe of, ia3o. cure of, 123a. treatment of the mind in, 1244. ind : Hyfteria, 1514. fymptoma of 1515— 16, paroxyfm or fit defcribed, ibid. rarely appears in males, 1517. how diftinguifhed from hypochondria- fis, 1518—19. proximate caufe of, 152a. analogy between and epilep- fy* iJ*3« cure of, 1524. Libidinofa, 1517. Hyfteric difeafe, fee Hyfteria. I. fames1 s Powder, itsufein fever, 183. Jaundice, 1815—J6. caufes of, 1816 —21, cure of, 1823—29. ISerus, fee Jaundice. Iliac paflion, fee///«j. Ileus, 1437. Impetigents, 173 7. character of the order, ibid. Indigeftion, fes Dyfpepfia. Inftammation, the phenomena of, 235. internal, the marks of, 236. the ftate of the blood in, 237. the prox- imate caufe of, 239. not depending upon a lentor ofthe blood, 241. fpafm the proximate daufe of, 243 —48. terminated by refolution, 249. by fuppuration, 250. by gangrene, 255. by fchirrus, 258. by effufion, 259. by blifters, 260. by exfudation, 261. the remote caufes of, 262. the cure of in general, 264. by refolu- tion, \\ tfi\ when tending to fuppu- ratior^O.liJ—70. when tending to gangi^ifc.', 271. its general divifions, 273. more ftrictly cutaneous, 274- of the bladder, fee Cyftitis. of the brain, fee Phrenitis. of the heart, fee Carditis, of the inteftines, fee Enteritis, of the kidneys, fee Neph- ritis, of the liver, fee Hepatitis, of the lungs, fee Pneumonia, of the pericardium, fee Pericarditis, of the peritonasum, fee Paritonitis. of the fpleen, fee Splenitis, of the fto- mach, fee Gaftritis. of the uterus, Infanity, 1535' caufes of, 1550—57. of different fpecies, 1557. partial and general, difference of, 15 75- Intemperance in drinking, a remote caufe of fever, 97. Inter miffion of Fever, 24. Interval of Fever, ibid. Intumefcentia, 1630. character of the order, ibid. : x. 67s K. King's Evil, fee Scrophula. L. Leucophlegmatia, 1669. Leucorrhcea, 985. character of, 986. appearance of the matter difcharg- ed in, 987—92. the caufes of, 998. the effects of 990. the cure of, 993. Lethargus. 1094. Lientery, 1469. Looftnefs, fee Diarrhaa. M. Madnefs, fee Mania Canine,fce Canine Mania, 1558. the fymptoms of, ibid. the remote caufes of, 1559—61.. the treatment of, 1562—74. occur- ring in fanguine temperaments, 1576. in fanguine temperaments cure of, 1577. Marc ores, 1600. Marfh Effluvia, a caufe of fever, 84. Meafles, 633. the fymptoms of, 637 —42. the nature of, 644. the cure of, 645—50. of a putrid kind, 643. Medicine, the inltitutions of, 4. Melana, 1017. Melancholia, 1575. how diftinguifhed from hypochondriafis, 1587—88. the character of, 1582—89. the proximate caufe of, 1590. the treat- ment of, 159a—97. Melancholic Temperament, 1230. Melancholy, fee Melancholia. Menorrhagia, 966. active or paffive, ibid, when a difeafe, 968—75. ef- fects of, 972, proximate caufe of, 977. remote caufes of, 978. cure of, 980. Menfes, imrffoderate flow of them, fee Menorrhagia., Metallic Tonics, employed in inter- mittent fevers, 231. Salts, refriger- ant, 136. Meteorifmus, 1633. Miafmata, 78. Miliary Fever, the general hiftory of, 714—15. of two kinds, red and white, 716. white, the fymptoms of, 717—19. the cure of, 720. Morbus Cceliacus, 1493. Mueofus, Io;». Niger, 1029. N. Nephritis, 426. the fymptoms of,ibid. the remote caufes of, 417. the cure of, 430. Nervous Difeafes, fee Neurofes. Neurofes, 1090. Neutral Salts, diaphoretic in fevers, 1.59-61. refrigerant in fevers, 135. Nofology, Methodical, 2. Q- Obefity, when a difeafe, 1621. Oneirodynia, 1598. Ophthalmia, 278. membranarum, ibid, its different degrees, 279-80. its remote caufes, ibid, the cure of, 388—90. tarfi, 278. the cure of, 288—90. Opiates, employed in the hot ftage of intermittent fevers, 233. in the in- tervals of intermittent fevers, 231. Opifthotonos, fee Tetanus. P. Palpitation of the heart, 1355. the phenomena of, ibid, the caufes of, 1156. the cure of, 1363. Palfy, 1140. diftinguifhed from apo- plexy, 1094. caufes of, 1141. Paracentefis in afcites, when to be at- tempted, 1717. in hydrothorax, when proper, 1708. Paraphrenias, 343. Paroxyfm of intermittent fevers, the recurrence, how to be prevented, 229. Pemphigus, 732. Pericarditis, 383. Peripneumonia Notha, $76. fymp- toms of 379. pathology-of, 380. the cure of, 381—82. fome of the fymptoms explained, 350. Peripneumony, 34a. Peritonitis, 384. Peruvian Bark, not a fpecific, 213. its tonic power, 214. when pioper in fever, 215. how moft effectually em- ployed, 216. the adminiftration of in intermittent fevers, 232. the to- nic chiefly employed in inter- mittent fevers, 23 2. Petechia, 734.. Phlegmafie, 235. Pklfgman, 274. Phrenitis, 291. tb? character of, 293. » E X. the remote caufes ef, 294. the cure of, 295—99. Phrenfy, fee Phrenitis. Phyfic, the practice of, how taught, 1. the theqry of, how to be em- ployed, 4. Phyfconia, 1718. Phthifis Pulmonalis, the general char.. acter of, 853. always with an ulcer- ation of the lungs, 855. the pus coughed up, in how diftinguifhed from mucus, 856. accompanied with hectic fever, 857. the various caufesofit, 863. from hzemopty- fis, 864—65. from pneumonia, 866 —69. from catarrh. 870—73. from afthma, 875. from tubercles, 876 —82. from calcareous matter in the lungs, 884. if contagious, 886. from the tubercles, fymptoms of, 889. its different duration, 896. the prognofis in, 897. the cure of, 899 —934. the tieatment of when arif- ing from tubercles, 906—21. the palliation of fymptoms, 922—24. Plague, the general character of, 665. phenomena of,ibid.principal fymp- toms of, 667. proximate caufe of, 668. prevention of, 670—85. cur« of, 686—95. Pleurify. 341. Pleurofthotonos, fee Tetanus. Pneumonia, or Pneumonic inflamma- tion, 334. general fympt-u !«■#, 335 —39. feat of, 340—44wprignofi8 of, 35 a—60. cure of, 361, die man - agement, of blood letting in the cure of, 362—67. the ufe of purga- tive in, 370. the ufe of emetics in, 371. the ufe of blifters in, 372. the means of promoting expectoration m» 373- the ufe of fweating in, 374. the uie of opiates in, 375. Polyfarcia, when a difeafe, i6ai. cure of, 1623—25' Proftuvia, 1045. character ofthe clafs, ibid. Pulfe, the ftate of it during the pa- roxyfm of an intermittent fever, 12. Purging, its ufe in continued fevers, 144. intermittent fevers, 234. Pus, how produced, 250. Putrefcency ofthe fluids in fever, the fymptoms of, 105. the tendency to, in fever, how to be corrected, 222—26. PyhrusfcirrhouSf fee Dyfpepfia. INDEX. 6* Pyrexia, 6. character of the clafs, ibid, orders ofthe clafs, 7. Pyrofis, 1427. fymptoms of, 1431. proximate caufe of, 1433. remote caufes of, 143a. cure of, 1434. Suecica of Sauvages, 1428. Q. Quinfy, fee Cynanche. R. Rachitis, 1719. its origin, 1720. re- mote caufes of, 1721—23. phenom- ena of, 1724. proximate caufe of, 1725—28. cure of, 1739—36. Reaction of the fyftem, 59. violent in fever,fymptoms of, 103. violence of, how moderated, 127. Refrigerants, the ufe of them in fever, 134. Remedies, table of thofe employed in continued fevers, 227. Remiffion of fever, 26. Refolution of inflammation, how pro- duced, 249. Refpiration, the changes of, during the paroxyfm of an intermittent. x3- Revolution, diurnal, in the human body. J5>. Rheumatifm, acute or chronic, 433. Acute, the remote caufes of, 436. the proxim.lte caufe of, 45?--'-6o. the fynotcJms of, 439—47- cure of, 461—70 ^Chronic, fymptoms of, 450. how diftinguifhed from the acute, 451. proximate caufe of, 472. cure of, 473—76. how diftin- guifhed from gout, 526. Rickets, fee Rachites. Rofe, fee Erithema. Rubefacients, the effects of them. S. Scarlet fever, 651. the fymptoms of, 656. different from cynanche ma- ligna, 651—55 • the cure of, 657— 64. Scrophula, 1738'. the phenomena of, 1738__49k proximate% caufe of, 1750. not eontagious, 1751. not arifing from the lues venerea, 1752. the cure of I753—59* mefenterica, 1606. Scurvy, 1789. remote caufes of, 179** —i8«a. cure of, 1804—9. proxi mate caufe of, 1811—14. Sinapifms, the effects of them, 197. Skin, affections of, fee Impetigines. Small Pox, general character of, 587. fymptoms ofthe diftinct kind, 589. of the confluent kind, 590—93. general differences between diftinct and confluent, 594. caufes of thefe differences, 595—600. prognosis in, 593. cure of, 601—30. inoculation of, 602. the feveral practices Of which it confifts, 603. the impor- tance of the feveral practices be- longing to, 604—15. management of fmall pox received by infection, 616—30. Soda,1427. Spafm, internal, means of removing in fevers, 152—87. the proximate caufe of inflammation, 243—48. Spafmodic affections without fever, 1251. of the animal functions, 1254, of the vital functions, 1355. ofthe natural functions, 1427. Sphacelus, 25 5. Splenitis, 425. Stimulants, when to be employed in fevers, 217. tbeir ufe in intermit- tent fevers, 230. Stomach, its confent with tlie veflels on the furface ofthe body, 44. Sudorifics, arguments for their ufe in fevers, i63*-67. againft their ufe in fevers, 164. Suppuration of inflamed parts, the caufes of, 251. the marks of a ten- dency to, ibid, formed, the marks of, ibid. Surface of the body, its confent with the ftomach, 44. Swellings, general. See Intumefcentia. adipofe, i6ai. flatulent, 1626. wa- tery. See Dropfies. Sweating, when hurtful in continu- ed fevers, 165. rules for the con- duct of in continued fevers, i68>. the ufe of in intermittent fevere, 430. Syncope, 1171. phenomena of, ibid. remote caufes of, 1174—78. pre- difpofition to, 1184- cure of, 1189^ diftinguifhed from apoplexy, 1094. Synocha. See Fever. Synochus. See Fever. Siphylis, 1760. originally from Ame- rica, 1761. how propagated, 1762. ,y4 I N D and gonorrhoea, how diftinguifhed 1764. cure of, 1783—88. T. 5*&?/ahydrope, 16*9. a fanguifluxu, 1608. dorfalis, 1610. glandularis, 1606. mefenterica, ibid, nutricum, 1608. rachialgia,i6o6. fcrophulofa, ibid. Tartar Emetic, its ufe in fevers, i8f. Tetanus, 1257- remote caufes of, 1268. cure of, 1270. piffoleum Barbadenfe, or Barbadoes tar, in, ia8o. Lateralis, 1268. Tonic medicines employed in contin- ued fevers, 211. intermittent fe- vers, 231. Toothach, how far different from rheumatifm, 477—80. fymptoms of, 478 predifpofition to, 481. re- mote caufes of, 481—82. proxi- mate caufe of, 483. cure of, 485— 91. Trifmus. See Tetanus. Nafcenhm. 1281. Tufifis. See Catarrh. Tympanites, the character of, 1627. the different fpecies 0^1628—30. inteftinalis, i&ag.enterophyiodes, ibid, abjdominalis, ibid.afciticus, ibid.phenomena of, 1632. proxi- mate caufe of, 1635—36. cure of, 1637—44. Typhus, fee Fever, the fpecies of, 70. ;xj v. Vapors, or low fpirits, fee'Hypochon- driafis. Venereal difeafe, fee Siphylis. Veniry, excefs in, a remote caufe of fever, 97. Vefania, in general, 1528. Vis Medicatrix Natura, 38. 5/. Vitus's Dance, fee Chorea. Vomiting of blood, fee Hematemefis, effects of incontinned fevers, 172 —73. Vomiting, the ufe of in intermitting fevers, 230—34' Vomiting of blood fee Hamatemefism U. Urine, bloody fee Hematuria. Urticaria, the hiftory and treatment of, 730. W. Water brafb,fee Pyrofis. Whites, fee Leucorrhea. Warm bathing, the effects of in fever, i»8. the adminiftration of Id fevers, 199. the marks ofthe good effects, 200. Wine, the moft propei simulant in fevers, 218. its con'enient ufe in feyers, 219. when hu,ytful or ufeful in fevers, 22c FINIS,