FIRST LINES
OF THE 
PRACTICE of PHYSIC,
FOR THE USE OF STUDENTS,
IN THE
UNIVERSITY OF EDINBURGH.
BY WILLIAM CULLEN, M.D. & P.
VOL. I.
ACCORDING TO THE SECOND EDITION,
PRINTED AT EDINBURGH.
PHILADELPHIA:
PRINTED BY STEINER AND CIST.
M,DCC,LXXXI.



NAMES
OF THE
SUBSCRIBERS.
N. B. Those Names that have S.M. annexed are Students
of Medicine.
A.
Thomas Austin, S.M.
John Ruder Agen, S.M.
B.
Dr. Barnabas Binney,
Robert Bell, Printer and
Bookseller, 12 Copies,
Daniel De Benneville, S.M.
Ezekiel Bull, S.M.
Abraham Bailey, S.M.
John Bartram, S.M.
Solomon Birckhead, S.M.
C.
James Craik, S.M.
Dr. Gerardus Clarkson,
Ebenezer Crosby. B.M.
James Cannon, Professor in
the Univeriity,
Samuel Chamberlain, S.M.
William Claypoole, S.M.
George Clingan, S.M.
John Crapper S.M.
Nicholas Cox, S.M.
D.
Robert Davidson, Professor
of Languages,
Sharp Delany, 2 Copies,
Elisha Dick, S.M.
James Davidson, Rector of
the Academy.
E.
John Ewing, D. D. Provost
of the University,
Edward Elliot, S.M.
Arnold Elzey, S.M.
George Eddy, S.M.
G.
Samuel Powel Griffiths, S.M.
John Gibbons, S.M.
H.
Gustavus H. Henderson,
S.M.
Dr. Solomon Halling,
James Hall, S.M.
Dr. James Hutchinson.
I.
John Jones, M.D. Professor
of Surgery, King's College,
New-York,
George Janus, Practitioner
of Physic.
L.
Michael Leib, S.M.
M.
John Morgan, M.D.
F.R.S. &c. 2 Copies,
Timothy Matlack, Esq;
Ennalls Martin, S.M.
Edward Miller, S. M.
Cadwallader Morris, S.M.
2 Copies,
Peter Miller, jun. S.M.
Thomas H. M'Calla, Sur-
geon to the Pennsylvania
Regiment of Horse,

NAMES OF THE SUBSCRIBERS.
John M'Sparrin, S.M.
N.
Daniel Neuman, Practitioner
of Physic, Lancaster.
P.
Robert Patterson, Master of
the Mathematical School,
2 Copies,
The Philadelphia Library
Company,
Pennsylvania Hospital Li-
brary,
Dr. Thomas Parke,
John Tayloe Peachy, S.M.
John Porter, S.M.
Samuel Powell, Esq;
Dr. Frederick Phile, Naval
Officer.
R.
John R. B. Rodgers, S.M.
James Ramsay, S.M.
Dr. Joseph Redman,
Benjamin Rush, M.D. 2
Copies,
Joseph Rush, S.M.
S.
Dr. Benjamin Say,
William W. Smith, M.B.
George Slough, S. M.
Stephen Shewel, jun. S.M.
T.
Dr. Robert Towers,
Dr. John Troup, 2 Copies.
W.
Mason Locke Weims, S.M.
James Weims, S.M.
Casper Wistar, S.M.
Charles Worthington, S.M.
John Watson, S. M.
Y.
Peter Yarnall, of the Penn-
sylvania Hospital. 

FROM THE EDITOR.
THE author of the following
work is too well known in
the literary world to stand in need
of much commendation. He has
produced a revolution in medicine.
The Editor is happy in an oppor-
tunity of introducing the out-lines
of the first part of his illustrious
master's discoveries of the causes
and cure of diseases to the know-
ledge of Students of Physic in
America, to whom it is recom-
mended and most respectfully in-
scribed by
BENJAMIN RUSH.
PHILADELPHIA,}
April 13, 1781.} 



PREFACE.
AN attempt to deliver a SYSTEM of the
doctrines and rules proper for directing
the PRACTICE OF PHYSIC of Physic, is an undertaking of
great difficulty; and, after an experience of
forty years in that practice, as well as much
reading and reflection, it is still with great dif-
fidence that I enter upon such a work. My
duties, however, as a Professor, have necessarily
produced the following sheets, intended chiefly
as a text-book for the use of my students. I
could have wished to confine it to the hands of
those, who attend my lectures, and hear the ex-
planations and proofs, which I deliver in sup-
port of my several opinions; but I have found
this to be impossible, and am therefore laid under
the necessity of offering my work to the public,
even in its present form. It is, indeed, proper
that the public should have access to judge of
the propriety of what I teach; and I willingly
submit to their judgment. I must acknowledge,
however, I have found the commonly received
systems to require so many alterations, as well
as additions, that it is with no small anxiety I
presume to offer my own, which is in so many
respects new. At the same time, I cannot offer
it, without a request, that, in judging of a work,
from its very nature concise, the learned will
proceed with reserve, and will not condemn my
opinions till they shall be certain that they fully
comprehend my  meaning, and shall be ac-
quainted
b 

x PREFACE.
quainted with the proofs which I can produce
to confirm my doctrines. They will, I hope,
observe, that I mean to admit no inference of
reasoning, which I cannot, at the same time,
render, in some measure, probable as a matter
of fact. As, in the conduct of the following
work, this has been my peculiar object, so, I
flatter myself, that any disputes which may hap-
pen concerning my doctrines, will always resolve
into questions with regard to facts, which I hope,
those who may differ from me will be as ready
as I am to submit to the farther examination of
the candid and unprejudiced.
CONTENTS 

CONTENTS.
INTRODUCTION Pag. I
PART I.
Of PYREXIAE, or FEBRILE DISEASES 5
BOOK. 1.
Of FEVERS 6
CHAP. I.
Of the Phænomena of Fevers - 6
CHAP. II.
Of the proximate Cause of Fever 13
CHAP. III.
OF the Difference of fever and its Causes 24
CHAP. IV.
Of the remote Causes of Fever - 32
CHAP. V.
Of the Prognosis of Fever - 38
CHAP. VI.
Of the Method of Cure in Fevers 48
Sect. I. Of the Cure of Continued Fevers ibid.
Sect. II. Of the Cure of Intermittent Fevers 81
BOOK

xii CONTENTS.
pag.
BOOK II.
Of INFLAMMATION or PHLEGMASIÆ 85
CHAP. I.
Of Inflammation in general ibid.
Sect. I. Of the Phænomena of Inflammation ibid.
Sect. II. Of the proximate Cause of Inflammation 87
Sect. III. Of the Germinations of Inflammation 91
Sect. IV. Of the remote Causes of Inflammation 97
Sect. V. Of the Cure of Inflammation 98
CHAP. II.
Of Inflammation more strictly cutaneous 103
CHAP. III.
Of Ophthalmia, or Inflammation of the Eye 104
CHAP. IV.
Of Phrensy or Phrenitis - 108
CHAP. V.
Of the Quinsy, or Cynanche 111
Sect. I. Of the Cynanche Tonsillaris ibid.
Sect. II. Of the Cynanche Maligna 114
Sect. III. Of the Cynanche Trachealis 117
Sect. IV. Of the Cynanche Pharyngea 122
Sect. V. Of the Cynanche Parotidea ibid.
CHAP. VI.
Of Pneumonic Inflammation 124
CHAP. VII.
Of the Gastritis, or Inflammation of the Stomach 140
CHAP.

CONTENTS. xiii
CHAP VIII.
Of the Enteritis, or Inflammation of the Intestines 147
CHAP. IX.
Of the Hepatitis, or Inflammation of the Liver 149
CHAP. X.
Of the Nephritis, or Inflammation of the Kidneys 153
CHAP. XI.
Of the Rheumatism - 155
CHAP. XII.
Of the Gout - 167
BOOK III.
Of EXANTHEMATA, or, ERUPTIVE FEVERS 198
CHAP. I.
Of Eryslpelas, or St. Anthony's Fire 199
CHAP. II.
Of the Plague - 204
Sect. I. Of the Phanomena of the Plague ibid.
Sect. II. Of the Prevention of the Plague 206
Sect. III. Of the Cure of the Plague. 211
CHAP. III.
Of the Small-Pox - 214
CHAP. IV.
Of the Chicken-pox - 232
CHAP. 

xiv CONTENT
pag.
CHAP. V.
Of the Measles - 233
CHAP. VI.
Of the Scarlet Fever - 239
CHAP. VII.
Of the Miliary Fever - 244
CHAP. VIII.
Of the remaining Exanthemata 252
BOOK IV.
Of HÆMORRHAGIES - 254
CHAP. I.
Of Hæmorrhagy in general - 254
Sect. I. Of the Phœnomena of Hæmorrhagy 255
Sect. II. Of the Proximate Cause of Hæ-
morrhagy - 257
Sect. III. Of the remote Causes of Hæmorrhagy 271
Sect. IV. Of the Cure of Hæmorrhagy - 272
CHAP. II.
Of the Epistaxis, or Hæmorrhagy of the nose 282
CHAP. III.
Of the Hœmoptysis, or Hæmorrhagy from the lungs 289
Sect. I. Of the Phænomena and causes of
Hœmoptysis - ibid.
Sect. II. Of the cure of Hœmoptysis 295
CHAP.

CONTENTS. xv
CHAP. IV.
Of the Phthisis Pulmonalis, or Consumption of
the lungs - 297
Sect. I. Of the Phænomena and causes of the
Phthisis Pulmonalis - ibid.
Sect. II. Of the cure of Phthisis 318
CHAP. V.
Of the Hæmorrhois, or, of the Hæmorrhoidal
Swelling and Flux - 327
Sect. I. Of the Phœnomena and Causes of the
Hæmorrhois - ibid.
Sect. II. Of the Cure of Hæmorrhoidal Af-
fections - 335
CHAP. VI.  
Of the Menorrhagia, or the immoderate Flow
of the Menses - 341
CHAP. VII.
Of the Leucorrhœa, Fluor Albus, or Whites 347
CHAP. VIII.
Of the Amenorrhœa, or Interruption of the
Menstrual Flux  - 350
BOOK V.
OF PROFLUVIA, or FLUXES with PYREXIÆ 358
CHAP. I.
Of the Catarrh - 359
CHAP. II.
Of the Dysentery - 366 



FIRST LINES
OF THE
PRACTICE OF PHYSIC.
INTRODUCTION.
I.
IN teaching the PRACTICE of PHYSIC, we teach to
discern, distinguish, prevent, and cure diseases, as
they occur in particular persons.
II.
The art of DISCERNING and DISTINGUISHING
diseases, may be best attained by an accurate and com-
plete observation of their phenomena, as these occur in
eoncourse and succession; and by a METHODICAL
NOSOLOGY, or an arrangement of diseases according to
their genera and species, established upon observation,
abstracted from all reasoning. This arrangement we
have attempted in another work, to which, in the
course of this, we shall frequently refer.
III.
The PREVENTION of diseases depends upon the
knowledge of their remote causes, which are partly de-
livered in the general Pathology, and partly to be
delivered in this treatise.
A
IV. 

2 PRACTICE
IV.
The CURE of diseases is chiefly, and almost un-
avoidably, founded in the knowledge of their proximate
causes. This last requires the knowledge of the Insti-
tutions of Medicine, or the knowledge of the structure,
action, and functions of the human body; of the several
changes which it may undergo; and of the several powers
by which it can be changed. Our knowledge of these
particulars, however, is still incomplete, is in many
respects doubtful, and has been often involved in mistake
and error. The doctrine, therefore, of proximate causes,
founded upon it, must be frequently precarious and un-
certain. It must depend, however, upon the extensive
knowledge and judgment of the physician to discern the
degree of probabilty in the several parts of medical
doctrine, to admit those only, as a foundation of practice,
which are simple, obvious, and certain; and for the
most part, to admit, as proximate causes, those only
which are established as matters of fact, rather than as
deductions of reasoning. When this cannot be done
with sufficient certainty, the judicious and prudent phy-
sician will have recourse to EXPERIENCE alone; always,
however, aware of the hitherto incomplete and falla-
cious state of Empiricism.
V.
With a strict attention to these considerations in the
whole of our conduct, we proceed to treat of particular
diseases in the order of our Methodical Nosology.
PART 

PART I.
OF PYREXIÆ,
OR
FEBRILE DISEASES.



PART I.
OF PYREXIÆ, OR FEBRILE DISEASES
DISEASES.
VI.
PYREXIÆ, or Febrile Diseases, are distinguished
by the following appearances: After beginning
with some degree of cold shivering, they shew some in-
crease of heat, an increased frequency of pulse, and
some diminution of strength in the animal functions.
VII.
These Pyrexiae form a class, which may be subdivided
into the five orders of FEVERS, INFLAMMATIONS,
ERUPTIONS, HEMORRHAGIES, and FLUXES. See
Synopsis Nosologiae Methodicae.
BOOK 

BOOK I.
OF FEVERS.
CHAP I.
OF THE PHENOMENA OF FEVERS.
VIII.
Those diseases are more strictly called FEVERS, which
have the general symptoms of pyrexia, without any
topical affection, that is essential and primary, joined with
them, as the other orders of the pyrexiae always have.
IX.
Fevers, on different occasions, have different ap-
pearances in the number and diversity of their symp-
toms, and are, therefore, very properly considered as of
different genera and species. But we suppose, that there
are certain circumstances common to all the diseases
comprehended under this order, which are therefore
those essentially necessary to, and properly constituting
the nature of fever. To investigate these especially, it
is our business; and we expect to find them occurring in
the paroxysm, or fit, of an intermittent fever, as this
is most commonly formed.
X.
The phenomena to be observed in such a paroxysm
are the following. The person is affected, first, with
a languor or sense of debility, a sluggishness in motion,
and some uneasiness in exerting it. At the same time,
the face and extremities become pale, the features shrink,
the 

OF PHYSIC. 7
the bulk of every external part is diminished, and the
skin, over the whole body, appears constricted, as if
cold had been applied to it. Now also some coldness of
the extremities, though little taken notice of by the
patient, may be perceived by another person. At length,
the patient himself feels the cold, first, commonly in
his back, but, from thence, passing over the whole body;
and now, very often, his skin feels warm to another
person. The patient's sense of cold increasing, pro-
duces a tremor in all his limbs, with frequent succussions
or rigors of the trunk of the body. When this sense
of cold, and its effects, have continued for some time,
they become less violent, and alternate, with warm flush-
ings. By degrees the cold goes off entirely, and a heat,
greater than natural, prevails, and continues over the
whole body. With this heat, the colour of the skin
returns, and a preternatural redness appears, especially
in the face. With the heat and redness, the skin is re- 
laxed and smoothed, but, for some time, it continues
dry. The features of the face, and other parts of the
body, recover their usual size, and become even more
turgid. When the heat, redness, and turgescence have
increased and continued for some time, a moisture ap-
pears upon the face, and, by degrees, becomes a sweat,
which at length prevails over the whole body. As this
sweat continues to flow, the heat of the body abates;
the sweat, after continuing some time, gradually ceases;
the body returns to its usual temperature, and most of
the functions are restored to their ordinary state.
XI.
This series of appearances gives occasion to divide the
paroxysm into three different stages, which are called
the COLD, the HOT, and the SWEATING STAGES or
fits.
In the course of these, a considerable change happens
in the state of several other functions, which is now to
be mentioned.
XII. 

8 PRACTICE
XII.
Upon the first approach, of languor, the pulse becomes
sometimes slower, and always weaker than before. As
the sense of cold comes on, the pulse becomes smaller,
very frequent, and often irregular. As the cold abates,
and the heat comes on, the pulse becomes more regular,
hard, and full; and, in these respects, increases till the
sweat breaks out. As the sweat flows, the pulse be-
comes softer, and less frequent, till, the sweat ceasing
altogether, it returns to its usual state.
XIII.
The respiration also suffers some changes. During
the cold stage, the respiration is small, frequent, and
anxious; as the hot stage comes on, it becomes fuller,
and more free, but is still frequent and anxious, till the
flowing of the sweat relieves the anxiety, and renders
the breathing less frequent and more free. With the
ceasing of the sweat, the breathing returns to its ordi-
nary state.
XIV.
The natural functions also suffer a change. Upon
the approach of the cold stage, the appetite for food
ceases, and does not return till the paroxysm be over,
or the sweat has slowed for some time. Generally,
during the whole of the paroxysm, there is not only a
want of appetite, but an aversion from all solid, and
especially, animal food. As the cold stage advances,
there frequently come on a sickness and nausea, which
often increase to a vomiting of a matter, for the most part,
bilious. This vomiting is especially troublesome to-
wards the end of the cold stage and beginning of the
hot. As the hot stage advances, the nausea and vo-
miting abate, and when the sweat breaks out, they, for
the most part, cease altogether.
XV.

OF PHYSIC. 9
XV.
A considerable degree of thirst is commonly felt
during the whole course of the paroxysm. During the
cold stage, the thirst seems to arise from the dryness and
clammminess of the mouth and sauces; but, during the
hot stage, from the heat which then prevails; and, as
the sweat flows, the mouth becomes moister, and the
thirst, together with the heat, gradually abates.
XVI.
In the course of a paroxysm there is often a consi-
derable change in the state of the secretions. The cir-
cumstances just now mentioned, show it in the secretion
of the saliva and mucus of the mouth; and it is still
more remarkable with respect to the urine. During the
cold stage, the urine is almost colourless, and without
cloud or sediment. In the hot stage, it becomes high
coloured, but is still without sediment. After the sweat
has flowed freely, the urine deposits a sediment com-
monly lateritious, and continues to do so for some time
after the paroxysm is over.
XVII.
Till towards the end of a paroxysm, stools seldom
occur, except in certain uncommon cases, which are
attended throughout with a diarrhœa.
XVIII.
Analogous to these changes in the state of the se-
cretions, it frequently happens that tumours, subsisting
on the surface of the body, suffer, during the cold stage
of fevers, a sudden and considerable diminution of their
bulk; but which returns, though not always, during
the sweating stage. In like manner, ulcers are some-
times dried up during the cold stage, and return again
to discharge matter, during the sweating stage, or after
the paroxysm is over.
B
XIX. 

10 PRACTICE
XIX.
Certain changes appear also in sensation and thought.
During the cold stage, the sensibility is often greatly
impaired; but, when the hot stage is formed, the sen-
sibility is recovered, and often considerably increased.
XX.
With respect to the intellectual functions, when the
cold stage comes on, attention and recollection become
difficult, and continue so, more or less, during the
whole paroxysm. Hence some confusion of thought
takes place, and often arises to a delirium, which some-
times comes on at the beginning of the cold stage, but
more frequently not till the hot stage be formed.
XXI.
It belongs also to this place to remark, that the cold
stage sometimes comes on with a drowsiness and stupor,
which often grow to a degree that may be called co-
matose, or apoplectic.
XXII.
We have still to add, that, sometimes, early in the
cold stage, a headach comes on; but which, more
commonly, is not felt till the hot stage be formed, and
then it is usually attended with a throbbing of the tem-
ples. The headach continues till the sweat breaks out;
but as this flows more freely, that gradually goes off.
At the same time with the headach, there are commonly
pains of the back, and of some of the great joints; and
these pains have the same course with the headach.
XXIII.
These are nearly the whole, and are, at least, the
chief of the phenomena which more constantly appear
in the paroxysm of an intermittent fever; and we have
pointed out their ordinary concourse and succession.
With 

OF PHYSIC. 11
With respect to the whole of them, however, it is to
be observed, that, in different cases, the several pheno-
mena are in different degrees; that the series of them
is more or less complete; and that the several parts or
stages in the time they occupy, are in a different pro-
portion to one another.
XXIV.
It is very seldom that the disease consists of a single
paroxysm, such as we have now described; and it more
generally happens, that, after the series of phenomena
mentioned, and after a certain length of time free from
them, the same series of phenomena again arise, and
observe the same course as before; and these states of
fever and APYREXIA often continue to alternate with
one another for many times. In these cases, the length
of time from the end of one paroxysm to the beginning
of another, is called an INTERMISSION, and the length
of time from the beginning of one paroxysm to the be-
ginning of another next succeeding, is called an IN-
TERVAL.
XXV.
When the disease consists of a number of paroxysms,
it is generally to be observed, that the intervals between
them are nearly equal; but these intervals are of dif-
ferent lengths in different cases. The most usual in-
terval is that of forty-eight hours, which is named the
TERTIAN period. The next most common is that of
seventy-two hours, and is named the QUARTAN period.
Some other intervals also are observed, particularly one
of twenty-four hours, named therefore the QUOTIDIAN,
and this is not infrequent; but all other intervals longer
than that of the quartan are extremely rare, and pro-
bably are only irregularities of the tertian or quartan
periods.
XXVI.
The paroxysms of pure intermittent fevers are always
finished 

12 PRACTICE
finished in less than twenty-four hours; and, though it
happens, that there are fevers which consist of repeated
paroxysms, without any entire intermission between
them; yet, in such cases, it is observed, that, though
the hot and sweating stages of the paroxysms do not
entirely cease before the twenty-four hours from their
beginning have expired, they suffer, however, before
that time, a considerable abatement or REMISSION of
their violence, and, at the return of the quotidian pe-
riod, a paroxysm is in some shape renewed, and runs
the same course as before. This constitutes what is
called a REMITTENT FEVER.
XXVII.
When in these remittents the remission is con-
siderable, and the return of a new paroxysm is distinctly
marked by the symptoms of a cold stage at the beginning
of it; such fevers retain strictly the appellation of RE-
MITTENTS. But, when it happens, as in certain cases,
that the remission is not considerable, is perhaps without
sweat, and that the returning paroxysm is not marked
by the most usual symptoms of a cold stage, and chiefly
by the aggravation or EXACERBATION of a hot stage,
the disease is called a CONTINUED FEVER.
XXVIII.
In some cases of continued fever, the remissions and
exacerbations are so inconsiderable as not to be easily
observed or distinguished; and this has led physicians to
imagine, that there is a species of fever subsisting for
several days together, and seemingly consisting of one
paroxysm only. This they have called a CONTINENT
FEVER; but, in a long course of practice, we have
not had an opportunity of observing such a fever.
XXIX.
With respect to the form, or TYPE of fevers, this
further may be observed, that the quartan, while it has
the longest interval, has, at the same time, the longest
and  

OF PHYSIC l3
and most violent cold stage; but, upon the whole, the
shortest paroxysm: That the tertian, having a shorter
interval than the quartan, has, at the same time, a
shorter and less violent cold stage; but a longer par-
oxysm: And, lastly, that the quotidian, with the
shortest interval, has the least of a cold stage; but the
longest paroxysm.
XXX.
The type of fevers is sometimes changed in their
course. When this happens, it is generally in the fol-
lowing manner: Both tertians and quartans change into
quotidians, quotidians into remittents, and these last
become often of the most continued kind. In all these
cases, the fever has its paroxysms protracted longer than
usual, before it changes into a type of more frequent
repetition.
XXXI.
From all this, a presumption arises, that every fever
consists of repeated paroxysms, and differs from others
only in the circumstances and repetition of the par-
oxysms; and, therefore, that it was allowable for us
to take the paroxysm of a pure intermittent as an ex-
ample and model of the whole.
CHAP. II.
OF THE PROXIMATE CAUSE OF
FEVER.
XXXII.
The proximate cause of fever seems hitherto to have
eluded the research of physicians; and we shall not
pretend 

14 PRACTICE
pretend to ascertain it in a manner that may remove
every difficulty; but shall endeavour to make an approach
towards it, and such as we hope may be of use in con-
ducting the practice in this disease.
XXXIII.
As the hot stage of fevers is so constantly preceded
by a cold stage, we presume that the latter is the cause
of the former; and, therefore, that the cause of the
cold stage is the cause of ail that follows in the course
of the paroxysm.
XXXIV.
To discover the cause of the cold stage of fevers, we
may observe, that it is always preceded by strong marks
of a general debility prevailing in the system. The
smallness and weakness of the pulse, the paleness and
coldness of the extreme parts, with the shrinking of
the whole body, sufficiently shew that the action of the
heart and larger arteries is, for the time, extremely
weakened. At the same time, the languor, inactivity,
and debility of the animal motions, the imperfect sen-
sations, the feeling of cold, while the body is truly
warm, and some other symptoms, all shew that the
energy of the brain itself is, on this occasion, greatly
weakened; and we presume, that, as the weakness of
the action of the heart can hardly be imputed to any
other cause, this weakness also is a proof of the dimi-
nished energy of the brain.
XXXV.
We shall hereafter endeavour to shew, that the most
noted of the remote causes of fever, as contagion, mi-
asmata, cold, and fear, are of a sedative nature; and,
therefore, render it probable, that a debility is induced.
When the paroxysms of a fever have ceased to be re-
peated, they may be again renewed; and are most com-
monly renewed, by the application of debilitating powers.
And, further, the debility which subsists in the animal
motions, 

OF PHYSIC. 15
motions, and other functions through the whole of
fever, renders it pretty certain, that sedative or de-
bilitating powers have been applied to the body.
XXXVI.
It is therefore evident, that there are three states which
always take place in fever, a state of debility, a state of
cold, and a state of heat; and, as these three states re-
gularly and constantly, succeed each other, in the order
we have mentioned them, it is presumed, that they are
in the series of cause and effect with respect to one
another. This we hold as a matter of fact, even although
we should not be able to explain in what manner, or by
what mechanical means these states severally produce
each other.
XXXVII.
How the state of debility produces some of the sym-
ptoms of the cold stage, we cannot particularly explain,
but refer it to a general law of the animal œconomy,
whereby it happens, that powers, which have a ten-
dency to hurt and destroy the system, often excite such
motions as are suited to obviate the effects of the noxious
power. This is the VIS MEDICATRIX NATURÆ, so
famous in the schools of physic; and it is probable,
that many of the motions excited in fever are the effects
of this power.
XXXVIII.
That the increased action of the heart and arteries,
which takes place in the hot stage of fevers, is to be
considered as an effort of the vis medicatrix naturæ, has
been long a common opinion among physicians; and
we are disposed to assert, that some part of the cold stage
may be imputed to the same power. We judge so, be-
cause the cold stage appears to be universally a means of
producing the hot; because cold, externally applied,
has very often similar effects; and more certainly still,
because it seems to be in proportion to the degree of tre-
mor 

16 PRACTICE
mor in the cold stage, that the hot stage proceeds more
or less quickly to a termination of the paroxysm, and
to a more complete solution, and longer, intermission.
See XXIX.
XXXIX.
It is to be particularly observed, that, in the time of
the cold stage of fever, there seems to be a spasm in-
duced every where on the extremities of the arteries,
particularly of those upon the surface of the body.
This appears from the suppression of all excretions, and
from the shrinking of the external parts; and although
this may, perhaps, be imputed, in part, to the weaker
action of the heart, in propelling the blood into the
extreme vessels; yet, as these symptoms often continue
after the action of the heart is restored, there is reason
to believe, that a spasmodic constriction has taken place;
that it subsists for some time, and supports the hot stage;
for this stage ceases with the flowing of the sweat, and
the return of other excretions, which are marks of the
relaxation of vessels formerly constricted.
XL.
This then may be the idea of fever; that a spasm of
the extreme vessels, however induced, may prove an
irritation to the heart and arteries; and that this con-
tinues till the spasm is relaxed or overcome. There are
many appearances which support this opinion; and there
is little doubt that a spasm does take place, and proves
an irritation to the heart; and therefore may be con-
sidered as a principal part in the proximate cause of
fever. It will still, however, remain a question, what
is the cause of this spasm, whether it be directly pro-
duced by the remote causes of fever, or if it be only a
part of the operation of the vis medicatrix naturæ.
XLI.
We are disposed to be of the latter opinion, first, be-
cause it remains still certain, that a debility lays the
foundation 

OF PHYSIC. 17
foundation of fever; secondly, because, supposing this
uncertain, we can more easily perceive how debility in-
duces spasm, than how spasm produces the debility,
which always, more or less, appears; and, thirdly, we,
especially, conclude, that the spasm depends upon the
debility; because we perceive, that the degree of spasm
formed, and the obstinacy of its continuance, depend,
in many cases, upon the power of the causes inducing
debility, and upon the debility induced; for the more
powerful the debilitating causes, and the greater the
debility produced, the paroxysms are the longer, and
the more frequently repeated.
XLII.
From hence we are led to believe, that, together with
the spasm, there is an atony subsisting in the extreme
vessels, and that the relaxation of the spasm requires the
restoring of the tone and action of these.
XLIII.
Some illustration and proof of this we expect will
arise, from considering the symptoms which take place
with respect to the functions of the stomach in fevers,
such as the anorexia, nausea, and vomiting. (XIV.)
The connection or consent, which we observe between
the perspiration and the appetite in healthy persons,
renders it probable, that the tone of the extreme vessels
on the surface of the body, and that of the muscular
fibres of the stomach, are connected or consenting with
each other; and that, therefore, in fevers, the want of
appetite or of tone in the muscular fibres of the stomach,
may depend upon the atony of the extreme vessels on
the surface of the body.
Further, that, in fevers, an atony affects the fibres
of the stomach, appears from the nausea and vomiting
which so frequently occur, and which so commonly
depend upon a state of debility in the stomach.
Lastly, that the debility of the stomach which pro-
duces vomiting, depends upon an atony of the extreme
vessels on the surface of the body, appears particularly
from
C

18 PRACTICE
from a fact observed by Dr. Sydenham. In the attack
of the plague, a vomiting happens, which prevents any
medicine from remaining upon the stomach. And Dr.
Sydenham tells us, that he could not overcome this
vomiting but by external means, applied to produce a
sweat or determination to the surface of the body.
The connection between the state of the stomach, and
that of the extreme vessels on the surface of the body,
appears from this also, that the vomiting, which so fre-
quently happens in the cold stage of fevers, commonly
ceases upon the coming on of the hot, and very cer-
tainly, upon any sweat's coming out. (XIV.) It is,
indeed, probable, that the vomiting in the cold stage of
fevers, is one of the means, employed by nature, for
restoring the determination to the surface of the body;
and it is a circumstance affording a proof, both of this
and of the general connection between the stomach and
surface of the body, that emetics thrown into the stomach,
and operating there, in the time of the cold stage, com-
monly put an end to it, and bring on the hot stage.
It also affords a proof of the same connection, that
cold water taken into the stomach produces an increase
of heat on the surface of the body, and is very often a
convenient and effectual means of producing sweat.
We draw a proof of the same connection from this
also, that cold applied to the surface of the body, when
it does not stop perspiration, is always a powerful means
of exciting appetite. It may likewise be considered,
whether the fever, so constantly accompanying the di-
gestion of food in the stomach, be not induced by filling
the stomach, by relaxing its muscular fibres, and thereby
inducing an atony of the extreme vessels.
Upon the whole, we think it sufficiently probable,
that the symptoms of an anorexia, nausea, and vomiting,
depend upon an atony subsisting in the extreme vessels
on the surface of the body, and that this, therefore, is
a principal circumstance in the proximate cause of fever.
XLIV.
It may seem difficult to explain how an atony and
spasm can subsist, at the same time, in the same vessels;
but, 

OF PHYSIC. 19
but, whatever difficulty there may be in accounting for
this, we consider it as a matter of fact, and at the same
time think it may be found analogous to what happens
upon other occasions in the system, where we often ob-
serve atony producing spasm.
XLV.
This atony we suppose to depend upon a diminution
of the energy of the brain; and that this diminution
takes place in fevers, we conclude, not only, as before,
from the debility prevailing in so many of the functions
of the body, mentioned above, but particularly from
symptoms which are peculiar to the brain itself.
(XXXIV.) Delirium is a frequent symptom of fever;
and as, from the physiology and pathology, we learn,
that this symptom commonly depends upon some in-
equality in the excitement of the brain or intellectual
organ; we hence conclude, that, in fever, it denotes
some diminution in the energy of the brain. Delirium,
indeed, seems often to depend upon an increased impetus
of the blood in the vessels of the brain, and therefore
attends phrenitis. It frequently appears also in the hot
stage of fevers, accompanied  with a headach and throb-
bing of the temples. But, as the impetus of the blood
in the vessels of the head is often considerably increased,
by exercise, external heat, passions, and other causes,
without occasioning any delirium, it must be supposed,
that the same impetus, in the case of fever, produces
delirium; for this reason only, that, at the same time,
there is some cause which diminishes the energy of the
brain, and prevents a free communication between the
parts concerned in the intellectual functions. Upon the
same principles also, we suppose there is another species
of delirium, which depends more entirely on the di-
minished energy of the brain; and may therefore arise
when there is no unusual increase of the impetus of the
blood in the vessels of the brain. Such seems to be the
delirium occurring at the beginning of the cold stage of
fevers, or in the hot stage of such fevers as shew strong
marks of debility in the whole system.
XLVI. 

20 PRACTICE
XLVI.
Upon the whole, our doctrine of fever is explicitly
this. The remote causes (XXXV.) are certain sedative
powers applied to the nervous system, which, diminish-
ing the energy of the brain, thereby produce a debility
in the whole of the functions, (XXXIV.) and parti-
cularly in the action of the extreme vessels. (XLII.
XLIII.) Such, however, is, at the same time, the
nature of the animal œconomy, (XXXVII.) that
this debility proves an indirect stimulus to the sangui-
ferous system; whence, by the intervention of the cold
stage, and spasm connected with it, (XXXVIII.
XXXIX.) the action of the heart and larger arteries
is increased, (XXXIX.) and continues so (XL.) till
it has had the effect of restoring the energy of the brain,
of extending this energy to the extreme vessels, of re-
storing, therefore, their action, and thereby especially
overcoming the spasm affecting them; upon the remov-
ing of which, the excretion of sweat, and other marks
of the relaxation of excretories, take place.
XLVII.
This doctrine will, as we suppose, serve to explain
not only the nature of fever in general, but also the
various causes of it which occur. Before proceeding,
however, to this, it may be proper to point out the opi-
nions, and, as we judge, the mistakes which have for-
merly prevailed on this subject.
XLVIII.
It has been supposed that a lentor or viscidity prevail-
ing in the mass of blood, and stagnating in the extreme
vessels, is the cause of the cold stage of fevers and its
consequences. But there is no evidence, of any such
viscidity previously subsisting in the fluids; and as it is
very improbable that such a state of them can be sudden-
ly produced, the suddenness with which paroxysms
come 

OF PHYSIC. 21
come on, renders it more likely that the phenomena de-
pend upon some cause acting upon the nervous system,
or the primary moving powers of the animal œco-
nomy.
XLIX.
Another opinion, which has been very universally
received, is, that a noxious matter introduced into, or
generated in the body, is the proximate cause of fever,
and that the increased action of the heart and arteries,
which makes so great a part of the disease, is an effort
of the vis medicatrix naturæ to expel this morbific
matter, and, particularly, to change or concoct it, so
as to render it either altogether innocent, or, at least,
fit for being more easily thrown out of the body. This
doctrine, however, although of as great antiquity as
any of the records of physic now remaining, and al-
though it has been received by almost every school of
medicine, yet appears to me to rest upon a very uncer-
tain foundation. There are fevers produced by cold,
fear, and other causes, with all the essential circum-
stances of fever, and terminating by sweat, and yet, at
the same time, without any evidence or suspicion of
morbific matter. There have been fevers suddenly cured
by a hemorrhagy, so moderate as cannot carry out
any considerable portion of a matter diffused over the
whole mass of blood; nor can we conceive how the
morbific matter could be collected or determined to pass
off by such an outlet as in that case is opened. Even
supposing a morbific matter were present, there is no
explanation given in what manner the concoction of it
is performed; nor is it shewn, that any such change
does in fact take place. In certain cases it is indeed evi-
dent, that a noxious matter is introduced into the body,
and proves the cause of fever; but, even in these cases,
it appears, that the noxious matter is thrown out again,
without having suffered any change; that the fever often
terminates before the matter is expelled; and that, up-
on many occasions, without waiting the supposed time
of concoction, the fever can be cured, and by remedies
which do not seem to operate upon the fluids, or to pro-
duce any evacuation.                            
L. 

22 PRACTICE
L.
While we thus reason against the notion of fevers be-
ing an effort of nature, for concocting and expelling a
morbific matter, we by no means intend to refute, that
the cause of fever frequently operates upon the fluids,
and particularly, produces a putrescent state of them.
We acknowledge, that this is frequently the case; but,
at the same time, we maintain, that such a change of
the fluids is not commonly the cause of fever; that very
often it is an effect only; and that there is no reason to
believe the termination of the fever to depend upon the
expulsion of the putrid matter.
LI.
Another opinion which has prevailed, remains still to
be mentioned. In intermittent fevers, a great quantity
of bile is commonly thrown out by vomiting; and this
is so frequently the case, that many have supposed an
unusual quantity of bile, and perhaps a peculiar quality
of it, to be the cause of intermittent fevers. This,
however, does not appear to be well founded. Vomit-
ing, by whatever means excited, if often repeated, with
violent straining, seems to be powerful in emulging the
biliary ducts, and commonly throws out a great deal of
bile. This will happen especially in the case of inter-
mittent fevers. For, as in the state of debility and cold
stage of these fevers, the blood is not propelled in the
usual quantity into the extreme vessels, and particularly
into those on the surface of the body, but is accumulated
in the vessels of the internal parts, and particularly in
the vena portarum; so this may occasion a more copi-
ous secretion of bile. The circumstance, however,
which chiefly occasions the appearance of bile in these
cases is, the influence of warm climates and seasons.
These seldom fail to produce a state of the human body,
in which the bile is disposed to pass off, by its secre-
tories, in greater quantity than usual, and perhaps, also,
changed in its quality, as appears from the disease of
cholera, which so frequently occurs in warm seasons.
This 

OF PHYSIC. 23
This disease, however, occurs often without fever;
and we shall hereafter render it sufficiently probable,
that intermittent fevers, for the most part, arise from
another cause, that is, marsh effluvia; while at the
same time, there is no evidence of their arising from
the state of the bile alone. The marsh effluvia, how-
ever, commonly operate most powerfully in the same
season that produces the change of the bile; and, there-
fore, considering the vomiting, and other circumstances
of the intermittent fevers which here concur, it is not
surprising, that autumnal intermittents are so often
attended with effusions of bile. This view of the sub-
ject does not lead us to consider the state of the bile, as
the cause of intermittents, but merely as a circumstance
accidentally concurring with them, from the state of
the season in which they arise. What attention this
requires in the conduct of the disease, we shall con-
sider hereafter.
LII.
From this view of the principal hypotheses which
have been maintained hitherto, with respect to the proxi-
mate cause of fevers, it will appear, that these do not
arise from changes in the state of the fluids; while, on
the other hand, almost the whole of the phenomena of
fevers lead us to believe, that they chiefly depend upon
changes in the state of the moving powers of the ani-
mal system. Though we should not be able to explain
all the circumstances of fevers, it is at least of some
advantage to be led into the proper train of investigation,
We have attempted to pursue it; and shall now en-
deavour to apply the doctrine we have delivered, to the
explaining the diversity of fevers.
CHAP. 

24 PRACTICE
CHAP. III.
OF THE DIFFERENCE OF FEVERS,
AND ITS CAUSES.
LIII.
With the most part of physicians, we suppose, that,
in every fever, there is a power applied to the body,
which has a tendency to hurt and destroy it, and pro-
duces certain motions in it, which deviate from the na-
tural state; and, at the same time, in every fever which
has its full course, we suppose, that, in consequence of
the constitution of the animal œconomy, there are
certain motions excited, which have a tendency to ob-
viate the effects of the noxious power, or to correct and
remove it. Both these kinds of motions are considered
as constituting the disease. The latter, which are of
salutary tendency, and considered as the operations of
the vis medicatrix naturæ, we shall hereafter call the
REACTION of the system.
LIV.
From what has been delivered above, (XLVI.) it
appears, that, in fever, the circumstances of debility,
spasm, and reaction, are chiefly to be considered; and
therefore, according as these are different in degree, and
different in proportion to one another, they will exhibit
the chief differences of fevers.
LV.
To apply this more exactly, we maintain, that every
fever of more than one day's duration, consists of re-
peated paroxysms; and that the difference of fevers,
from 

OF PHYSIC. 25
from the difference of the circumstances, (LIV.) appears
in the different state of paroxysms, and in the different
circumstances of their repetition. (XXXI.)
LVI.
That fevers generally consist of repeated paroxysms,
we have alledged above (XXIV. XXVI. XXVIII.
XXXI.) to be a matter of fact; but must here endeavour
to confirm it, by assigning the cause.
LVII.
In every fever, in which we can observe any number
of separate paroxysms, we constantly remark that every
paroxysm is finished in less than twenty-four hours; but,
as we cannot perceive any thing in the cause of fevers
determining to this, we must suppose it to depend on
some general law of the animal œconomy. Such a
law seems to be that which subjects the œconomy, in
many respects, to a diurnal revolution. Whether this
depends upon the original conformation of the body,
or upon certain powers constantly applied to it, and
inducing a habit, we cannot positively determine; but
the returns of sleep and watching, of appetites and ex-
cretions, and the changes which regularly occur in the
state of the pulse, shew sufficiently, that, in the human
body, a diurnal revolution takes place.
LVIII.
It is this diurnal revolution which we suppose deter-
mines the duration of the paroxysms of fevers; and
these paroxysms being so universally limited, as in
(LVII.) while no other cause of this can be assigned,
renders it sufficiently probable, that their duration de-
pends upon, and is determined by, the revolution men-
tioned. That these paroxysms are connected with
that revolution, appears further from this, that, though
the intervals of paroxysms are different, in different
eases, the times of the accession of paroxysms are
generally
D

26 PRACTICE
generally fixed to one time of the day; so that Quo-
tidians come on in the morning, Tertians at noon, and
Quartans in the afternoon.
LIX.
It is still to be remarked, that, as Quartans and
Tertians are apt to become Quotidians, these to pass into
the state of Remittents, and these last to become Conti-
nued; and that, even in the continued form, daily ex-
acerbations and remissions are generally to be observed;
all this shews so much the power of diurnal revolution,
that when, in certain cases, the daily exacerbations and
remissions are with difficulty distinguished, we may still
presume, that the general tendency of the œconomy
prevails, that the disease still consists of repeated par-
oxysms, and, upon the whole, that there is no such dis-
ease as that which the schools have called a Continent
fever. We expect that this doctrine will be confirmed
by what we shall say hereafter, concerning the periodical
movements observed in continued fevers.
LX.
It being thus proved, that every fever, of more than
one day's duration, consists of repeated paroxysms; we,
in the next place, remark, that the repetition of par-
oxysms depends upon the circumstances of the paroxysms
which are already formed. This appears from what is
observed in (XXIX. and XXX.); for from these it
appears, that the longer paroxysms are protracted, they
are the sooner repeated; and, therefore, that the cause
of the frequent repetition is to be sought for in the cause
of the protraction of paroxysms.
LXI.
The duration of the hot stage, in which the reaction
is operating to take off the spasm formed in the cold
stage, is that upon which the duration of the whole
paroxysm chiefly depends. We may, therefore, suspect,
that the longer duration of the hot stage is owing either
to 

OF PHYSIC. 27
to the obstinacy of the spasm, or to the weakness of the
reaction; and it is probable, that sometimes the one,
and sometimes the other of these circumstances, takes
place.
LXII.
Though the cause of spasm may be the same in dif-
ferent persons, it is obvious that the degree of it pro-
duced may be greater or less, according to the irritability
of each particular person; and, therefore, the reaction
in fever being given, the paroxysm, or continuance of
the hot stage, may be longer or shorter, according to
the degree of spasm that has been formed.
LXIII.
One cause of the obstinacy of spasm in fevers, may,
I think, be clearly perceived. In inflammatory diseases,
there is a diathesis phlogistica prevailing in the body,
and this diathesis we suppose to consist in an increased
tone of the whole arterial system. When, therefore,
this diathesis accompanies fever, as it sometimes does,
h may be supposed to give occasion to the febrile spasm's
being formed more strongly, and thereby to produce
more protracted paroxysms. Accordingly, we find, that
all inflammatory fevers are of the continued kind; and
that all the causes of the diathesis phlogistica have a
tendency to change intermittent into continued fevers.
As continued fevers, therefore, are often attended with
the diathesis phlogistica, we conclude, that, in many
cases, this is the cause of their continued form.
LXIV.
In many fevers, however, there is no evidence of any
diathesis phlogistica being present, or of any other cause
of more considerable spasm; and in such fevers we must
impute the protraction of paroxysms, and the continued
form of the fever, to the weakness of reaction. That
this cause takes place, we conclude from hence, that, in
many cases of fever, wherein the separate paroxysms are 
the

28 PRACTICE
the most protracted, and the most difficultly observed, we
find the most considerable symptoms of a general de-
bility; and therefore, we conclude, that, in such cases,
the protracted paroxysms and continued form depend
upon a weaker reaction; owing either to the causes of
debility applied having been of a more powerful kind,
or from circumstances of the patient's constitution,
favouring their operation.
LXV.
Upon these principles, we make a step towards ex-
plaining in general the difference of fevers, and with
some probability; but must own, that there is much
doubt and difficulty in applying the doctrine to particular
cases. It applies tolerably well to explain the different
states of intermittents, as they are more purely such, or
as they approach more and more to the continued form:
But several difficulties still remain with respect to many
circumstances of intermittents; and more still with
respect to the difference of these continued fevers, which
are formed from intermittents, and those which we have
distinguished in our Nosology, as more especially en-
titled  to the appellation of Continued. See Syn. Nos.
Meth. P. IV. Ch. I. Sect. II
LXVI.
The character of continued fevers, given in the place
referred to, is hardly sufficient. To make the distinc-
tion more accurate, it is necessary to add, that the fevers
of a continued form, which, however, still belong to
the section of intermittents, may be distinguished by
their having passed from an intermittent or remittent
form, to that of a continued; by their shewing some
tendency to become intermittent, or at least remittent;
by their being known to have been occasioned by marsh
miasmata; by the nature of the prevailing epidemic;
and, for the most part, by their having but one paroxysm,
or one exacerbation and remission, in the course of
twenty-four hours. On the other hand, continued
fevers, to be more strictly so called, may be distinguished
by

OF PHYSIC. 29
by their shewing little tendency to become intermittent
or remittent in any part of their course, and especially
after the first week of their continuance; by their being
occasioned by human contagion, at least, by other causes
than the marsh miasmata; by the nature of the prevail-
ing epidemic; and by their having pretty constantly an
exacerbation and remission twice in the course of every
twenty four hours.
LXVII.
From the view given (LXIII. and LXIV.) of the
causes of the protraction of paroxysms; and, therefore,
of the form of continued fevers, strictly so called, it
seems probable, that the remote causes of these operate
by occasioning either a phlogistic diathesis, or a weaker
reaction; for we can observe, that the most obvious
difference of continued fevers depends upon the prevail-
ing of one or other of these states.
LXVIII.
Continued fevers have been considered as of great
diversity; but physicians have not been happy in mark-
ing these differences, or in reducing them to any general
heads. The distinctions of the antients are not well
understood, and, so far as either they, or the modern
nosologists, have distinguished continued fevers by a
difference of duration, their distinctions are not well
founded, and do not apply in such a manner as to be of
any use. We think it agreeable to observation, and to
the principles above laid down, (LXIII. LXIV.) to
distinguish continued fevers, according as they shew
either an inflammatory irritation, or a weaker reaction.
LXIX.
This distinction is the same with that of fevers into
the INFLAMMATORY and NERVOUS; the distinction
at present most generally received in Britain. To the
first, as a genus, we have given the name of Synocha;
to the second that of Typhus; and, little studious
whether 

30 PRACTICE
whether these names be authorised by the antient use of
the same terms, we depend upon their being understood
by the characters annexed to them in our Nosology,
which we think are founded on observation.
LXX.
By these characters we think continued fevers may be
distinguished in practice, and, if they may, the prin-
ciples above laid down will be confirmed.
LXXL
Besides these differences of continued fever, now
mentioned, we are not certain of having observed any
other that can be considered as fundamental. But the
most common form of continued fevers, in this climate,
seems to be a combination of the two genera mentioned;
and we have therefore given such a genus a place in our
Nosology, under the title of Synochus. We think,
however, that the limits between the Synochus and
Typhus, will be with difficulty assigned; and we are
disposed to believe, that the Synochus arises from the
same causes as the Typhus, and is therefore only a va-
riety of it.
LXXII.
The Typhus seems to be a genus comprehending
several species. These, however, are not yet well as-
certained by observation; and, in the mean time, we
can perceive that many of the different cases observed do
not imply any specific difference, and seem to be merely
varieties, arising from a different degree of power in the
cause, from different circumstances of the climate or
season in which they happen, or, from different cir-
cumstances in the constitution of the persons affected. 
LXXIII.
Some effects arising from these circumstances, require
to be particularly explained. One is an unusual quantity
of 

OF PHYSIC. 31
of bile appearing in the course of the disease. This
abundance of bile may possibly attend some continued
fevers, strictly so called; but it more commonly, for
the reasons above explained, attends intermittents; and,
we believe, it might have been enumerated among the
marks distinguishing the latter kind of fevers from the
former. But, though an unusual quantity of bile
should appear with continued fevers, we consider it in
this case, as in that of intermittents, as a coincidence
only, owing to the state of the season, producing no
different species or fundamental distinction, but merely
a variety of the disease.
LXXIV.
Another effect of the circumstances occasionally va-
rying the appearance of typhus, is a putrescent state of
the fluids. Both the antients and the moderns, who
are in general much disposed to follow the former, have
distinguished fevers as putrid and non-putrid; but the
notions of the antients, on this subject, were not suf-
ficiently correct to deserve much notice; and it is only
of late that the matter has been more accurately observed,
and better explained.
From the dissolved state of the blood, as it appears
when drawn out of the veins, or as it appears from the
red blood's being disposed to be effused, and run off by
various outlets, and from several other symptoms, we
have now no doubt that a real putrescency of the fluids
takes place in fevers. This putrescency, however, often
attends intermittent, as well as continued fevers, and,
of the continued kind, both the synochus and typhus,
and all of them in very different degrees; so that,
whatever attention it may deserve in practice, there is
no fixing such limits to it as to admit of establishing a
species under the title of PUTRID.
LXXV.
Besides differing by the circumstances already men-
tioned, fevers differ also by their being accompanied
with symptoms which belong to diseases of the other
orders 

32 PRACTICE
orders of pyrexIæ. This sometimes happens in such a
manner, as to render it difficult to say which of the two
diseases is the primary one. Commonly, however, it
may be ascertained by the knowledge of the remote
cause, and of the prevailing epidemic, or by observing
the series and succession of symptoms.
LXXVI.
Most of our systems of physic have marked, as a
primary one, a species of fever, under the title of
HECTIC; but, as it is described, we have never seen
it as a primary disease. We have constantly found it as
a symptom of some topical affection, most commonly
of an internal suppuration; and, as such, we shall
consider it in another place.
LXXVII.
The distinction of the several cases of intermittent
fever we have not prosecuted here, as we suppose it may
be readily understood from what is said above, (XXV.
XXVI. and XXVII.) and more fully from the Me-
thodical Nosology, P. IV. Cl. I. Sect. I.
CHAP. IV.
OF THE REMOTE CAUSES OF
FEVER.
LXXVIII.
As fever has been considered as consisting chiefly in an
increased action of the heart and arteries, physicians
have supposed, that certain direct stimulants, fitted to
produce this increased action, are the remote causes of
fever.

OF PHYSIC. 33
fever. In many cases, however, there is no evidence of
such stimulants being applied, and, in the cases in
which they are applied, they either produce only a
temporary frequency of the pulse, which cannot be
considered as a disease; or, if they do produce a per-
manent febrile state, it is by the intervention of a topical
inflammation, which produces a disease different from      
what is strictly called a fever.
LXXIX.
That direct stimulants are the remote causes of fever,
seems farther improbable; because the supposition does
not account for the phenomena attending the accession
of fevers; and because other remote causes can with
greater certainty be assigned.
LXXX.
As fevers are so generally epidemic, it is probable,
that some matter floating in the atmosphere, and ap-
plied to the bodies of men, ought to be considered as
the remote cause of fevers. These matters present in
the atmosphere, and acting upon men, may be considered
either as MIASMATA, or as CONTAGIONS.
LXXXI.
Miasmata may arise from various sources, and be of
different kinds; but we know little of their variety or
of their several effects. We know with certainty only
one species of miasma, which can be considered as the
cause of fever; and from the universality of this, it
may be doubted if there be any other.
LXXXII.
The miasma, so universally the cause of fever, is that
which arises from marshes or moist ground, acted upon
by heat. So many observations have now been made
with respect to this, in so many different regions of
the earth, that there is neither any doubt of its being in
general
E

34 PRACTICE
general a cause of fevers, nor of its being very uni-
versally the cause of intermittent fevers, in all their
different forms. The similarity of the climate, season,
and soil, in which intermittents arise, and the similarity
of the diseases, arising in different regions, concur in
proving that there is one common cause of these diseases,
and that this is the marsh miasma.
What is the particular nature of this miasma, we
know not; nor do we certainly know whether or not it
differs in kind: But it is probable that it does not;
and that it differs only in the degree of its power, or
perhaps in its quantity, in a given space.
LXXXIII.
Contagions are next to be considered; and these also
have been supposed to be of great variety. It is possible
they may be so; but that they truly are, does not ap-
pear clearly from any thing we know at present. The
number of genera and species of contagious diseases, of
the class of pyrexiæ, at present known, is not very
great. They belong to the order of Fevers, of Exan-
themata, or of Profluvia. Whether there be any be-
longing to the order of Phlegmasiæ, is doubtful; and,
though it should be supposed, it will not much increase
the number of contagious pyrexiæ. Of the contagious
exanthemata and profluvia, the number of species is nearly
ascertained; and each of them is so far of a determined
nature, that, though they have now been observed and
distinguished for many ages, and in many different parts
of the earth, they have been always found to retain the
same character, and to differ only in circumstances,
which may be imputed to season, climate, and other ex-
ternal causes, or to the peculiar constitution of the several
persons affected. It is, therefore, probable, that, in each
of these species, the contagion is of one specific nature,
and that the number of contagious exanthemata or
profluvia is hardly greater than the number of species
taken notice of in our systems of nosology.
LXXXIV. 

OF PHYSIC. 35
LXXXIV.
While the contagious exanthemata and profluvia are
thus limited, if we should suppose the contagious py-
rexiæ to be still of great and unlimited variety, it must
be with respect to the genera and species of continued
fevers. But, if we are right in limiting, as we have
done, the genera of these fevers, it will be probable that
the contagions which produce them are not of great
variety; and this will be much confirmed, if we can
render it probable, that there is one principal, perhaps
one common source of such contagions.
LXXXV.
To this purpose it is now well known, that the effluvia
constantly arising from the living human body, if long
retained in the same place, without being diffused in the
atmosphere, acquire a singular virulence, and, in that
state, applied to the bodies of men, become the cause of
a fever which is very contagious. The late observations
on jail and hospital fevers have fully proved the existence
of such a cause; and it is sufficiently obvious, that the
same virulent matter may be produced in many other
places. At the same time, the nature of the fevers
arising renders it probable, that the virulent state of
human effluvia is the common cause of such fevers, as
they differ only in a state of their symptoms, which may
be imputed to the circumstances of season, climate, &c.
concurring with the contagion, and modifying its force.
LXXXVI.
With respect to these contagions, though we have
spoken of them above, as of a matter floating in the at-
mosphere, it is proper to observe here, that they are never
found to act but when they are near to the sources from
whence they arise; that is, either near to the bodies of
men, from  which they immediately issue, or near to
some substances, which, as having been near to the
bodies of men, are imbued with their effluvia, and in
which

36 PRACTICE
which substance these effluvia are sometimes retained in
an active state for a very long time.
The substances thus imbued with an active matter,
may be called Fomites; and it appears to me probable,
that contagions, as they arise from fomites, are more
powerful than as they arise immediately from the human
body.
LXXXVII.
We have now rendered it probable, that the remote
causes of fevers (VIII.) are chiefly Miasmata or Con-
tagions, and neither of them of great variety. We have
supposed that miasmata are the cause of intermittents,
and contagions the cause of continued fevers, strictly so
named; but we cannot, with propriety, employ these
general terms. The notion of contagion properly im-
plies a matter arising from the body of man under disease;
and that of miasma, a matter arising from other sub-
stances. But, as the cause of continued fevers may
arise from other substances than the human body, and
may, in such cases, be called a Miasma; and as other
miasmata also may produce contagious diseases, it will be
proper to distinguish the causes of fevers, by using the
terms Marsh, or Human Effluvia, rather than the
general ones Miasma, or Contagion.
LXXXVIII.
Though we have endeavoured to shew that fevers
generally arise from marsh or human effluvia, we can-
not, with any certainty, exclude some other remote
causes, which are commonly supposed to have at least
a share in producing fevers. We proceed, therefore, to
inquire concerning those causes; and the first to be
taken notice of is, the power of cold applied to the
human body.
LXXXIX.
The operation of cold on a living body, is so different
in different circumstances, as to be of difficult explana-
tion; 

OF PHYSIC. 37
tion; and this, therefore, is attempted with some dif-
fidence.
Cold, in certain circumstances, has manifestly a se-
dative power. It can extinguish the vital principle
entirely, either in particular parts, or in the whole
body; and, considering how much the vital principle of
animals depends upon heat, it cannot be doubted that
the power of cold is always more or less directly se-
dative.
But it is equally manifest, that, in certain circum-
stances, cold proves a stimulus to the living body, and
particularly to the sanguiferous system.
And, besides the sedative and stimulant powers of
cold, it is manifestly also a powerful astringent, causing
a contraction of the vessels on the surface of the body,
and thereby producing paleness, and a suppression of
perspiration. It is likewise probable that this constric-
tion is in some measure communicated to the whole
body, and that thereby the application of cold proves a
tonic power with respect to the whole system.
XC.
These several effects of cold do not all take place at
the same time, but may be variously combined. The
stimulant power taking place, obviates the effects that
might otherwise have arisen from the sedative, and, in
some measure, those from the astringent power. But
the stimulant and tonic powers of cold are commonly
conjoined, and the former, perhaps, depend in part upon
the latter.
XCI.
In what circumstances these different effects of cold
especially take place, it is difficult to determine; but the
morbid effects may be observed to be chiefly of four kinds.
One is a general inflammatory diathesis of the system;
which is commonly accompanied with rheumatism, or
other phlegmasia. A second is a catarrhal affection; a
third is gangrene; and a fourth is a proper fever. In
producing 

38 PRACTICE
producing this last, the operation of cold generally
concurs with that of marsh or human effluvia.
In all its operations, cold seems to act more power-
fully, in proportion as the body, and particularly the
vigour of the circulation, is previously more weakened.
XCII.
Besides cold, there are other powers which seem to be
the remote causes of fever, as Fear, Intemperance in
Drinking, Excess in Venery, and other causes, which
evidently weaken the system. But, whether any of these
sedative powers be alone the remote cause of fever, or if
they only operate either as they concur with the opera-
tion of marsh or human effluvia, or as they give an op-
portunity to the operation of cold, are questions not to
be positively answered.
XCIII.
As we have now mentioned the chief of the remote
causes of fevers, we can further observe, that these will
arise more or less readily, according as miasmata and
contagions are more or less powerful, or as they are
more or less favoured by the concurrence of cold, and
other sedative powers.
CHAP V.
OF THE PROGNOSIS OF FEVERS.
XCIV.
As fevers, by (XLVI. and LIII.) consist of both
morbid and salutary motions and symptoms, the ten-
dency of the disease to a happy or a fatal issue, or the
prognostic in fevers, has been established, by marking
the

OF PHYSIC. 39
the prevalence of the morbid or salutary symptoms; and
it might be properly so established, if we could certainly
distinguish between the one and the other of these kinds
of symptoms; but the operation of the re-action, or
salutary efforts of nature, in curing fevers, is still in-
volved in so much obscurity, that I cannot explain the
several symptoms of it so clearly as to apply them to
the establishing of prognostics; and this, I think, may
be done better, by marking the symptoms which shew
the tendency to death in fevers.
XCV.
This plan of the prognostics in fevers must proceed
upon our knowledge of the causes of death in general,
and in fevers more particularly.
The causes of death, in general, are either direct or
indirect.
The first are, those which directly attack and destroy
the vital principle, as lodged in the nervous system, or
destroy the organs immediately connected with it.
The second, or the indirect causes of death, are those
which interrupt such functions as are necessary to the
circulation of the blood, and thereby necessary to the
due continuance and support of the vital principle.
Of these general causes, those which operate more
particularly in fevers seem to be, first, the violence of re-
action, which, either by repeated violent excitements,
destroys the vital power itself; or, by its violence,
destroys the organization of the brain necessary to the
action of the vital principle; or, by the same violence,
destroys the organization of the parts more immediately
necessary to the circulation of the blood. Secondly, The
cause of death in fevers may be a poison, that is, a power
capable of destroying the vital principle; and this poison
may be either the miasma or contagion which was the
remote cause of the fever, or it may be a putrid matter
generated in the course of the fever. In both cases, the
operation of such a power appears either as acting chiefly
on the nervous system, inducing the symptoms of de-
bility; or, as acting upon the mass of blood, inducing
a putrescent state in it, and in the fluids derived from it.
XCVI.

40 PRACTICE
XCVI.
From all this, we think the symptoms shewing the
tendency to death in fevers, may be discovered by their
being either the symptoms of violent re-action, of great
debility, or of a strong tendency to putrefaction in the fluids;
and, upon this supposition, we proceed now to mark
those symptoms more particularly.
XCVII.
The symptoms which denote the violence of re-
action, are, 1. The increased force, hardness, and fre-
quency of the pulse. 2. The increased heat of the body.
3. Those symptoms which are the marks of a general
inflammatory diathesis, and more especially those of a
particular determination to the brain, lungs, or other
important viscera. 4. Those which are the marks of the
cause of violent reaction; that is, of a strong spasm, ap-
pearing in the suppression of excretions.
XCVIII.
The symptoms which denote a great degree of de-
bility, are,
In the ANIMAL FUNCTIONS; 1. The weakness of
the voluntary motions; 2. The irregularity of the
voluntary motions, depending on their debility; 3. The
weakness of sensation; 4. The weakness and irregularity
of the intellectual operations.
In the VITAL FUNCTIONS; 1. The weakness of the
pulse; 2. The coldness or shrinking of the extremities;
3. The tendency to a deliquium animi in an erect posture;
4. The weakness of respiration.
In the NATURAL FUNCTIONS; 1. The weakness of
the stomach, as appearing in anorexia, nausea, and
vomiting; 2. Involuntary excretions, depending upon
a palsy of the sphincters; 3. Difficult deglutition, de-
pending upon a palsy of the muscles of the sauces.
XCIX. 

OF PHYSIC. 41
XCIX.
Lastly, The symptoms expressing the putrescent state
of the fluids, are,
1. In the stomach, the loathing of animal food,
nausea, and vomiting, great thirst, and a desire of acids.
2. In the mass of blood; A. the blood drawn out of
the veins not coagulated as usual; B. hemorrhagy from
different parts, without marks of increased impetus; C.
effusions under the skin or cuticle, forming petechiæ
maculæ, and vibices; D. effusions of a yellow serum
under the cuticle.
3. In the state of the excretions, frequent, loose, and
fœtid stools; high-coloured turbid urine; fœtid sweats;
and the fœtor of blisters.
4. The cadaverous smell of the whole body.
C.
These several symptoms have very often, each singly,
a share in determining the prognostic; but more especially
by their concurrence and particular combination with one
another.
CI.
On the subject of the Prognostic, it is proper to ob-
serve, that many physicians have been of opinion, that
there is something in the nature of fevers which generally
determines them to be of a certain duration; and, there-
fore, that their terminations, whether in health or in
death, happen at certain periods of the disease rather
than at others. These periods are called the CRITICAL
DAYS, carefully marked by Hippocrates and other an-
tient physicians, and also by many moderns of the
greatest eminence in practice; whilst, at the same time,
many modems of no inconsiderable authority, deny their
taking place in the fevers of these northern regions
which we inhabit.
F
CII. 

42 PRACTICE
CII.
I am of opinion that the doctrine of the antients, and
particularly that of Hippocrates, on this subject, was
well founded; and that it is just and true, even with
respect to the fevers of our climate.
CIII.
I am of this opinion, first, because I observe, that
the animal œconomy is readily subjected to periodical
movements, both from its own constitution, and from
habits which are readily produced in it. Secondly, Be-
cause I observe periodical movements to take place in
the diseases of the human body with great constancy
and exactness, as in the case of intermittent fevers,
and many other diseases.
CIV.
These considerations render it probable, that exact
periodical movements may take place in continued fevers;
and I think there is evidence of such movements actu-
ally taking place in these fevers.
CV.
The critical days, or those on which we suppose the
termination of continued fevers especially to happen,
are, the third, fifth, seventh, ninth, eleventh, fourteenth,
seventeenth, and twentieth. We mark none beyond this
last; because, though fevers are sometimes protracted
beyond this period, it is, however, more rarely; and
we have not a sufficient number of observations to ascer-
tain the course of them; and further, because it is
probable, that, in fevers long protracted, the move-
ments become less exact and regular, and are therefore
less easily observed.
CVI. 

OF PHYSIC. 43
CVI.
That the days now mentioned are the critical days,
is, we think, proved by the particular facts which are
found in the writings of Hippocrates. From these, as
collected from the several writings of that author by
Mr. de Haen, it appears, that of one hundred and sixty-
three instances of the termination of fevers which hap-
pened on one or other of the first twenty days of the
disease, there are one hundred and seven, or more than
two-thirds of the whole number, which happened on
one or other of the eight days above mentioned; that
none happened on the second or thirteenth day; and
upon the eighth, tenth, twelfth, fifteenth, sixteenth,
eighteenth, and nineteenth, there are but eighteen in-
stances of terminations, or one ninth of the whole.
CVII.
As the terminations which happen on the seven days
last mentioned, upon the whole, are few, and, upon
any one of them, fewer than those which happened on
any of our supposed critical days, there are, therefore,
nine days which may be called NON-CRITICAL; while,
on the other hand, the many terminations which hap-
pened on the seventh, fourteenth, and twentieth days,
both give a proof of critical days in general, and that
these are the chief of them. Hereafter we shall mention
an analogy that renders the power of the other critical
days sufficiently probable.
CVIII.
It appears further, that as, of the terminations which
were final and salutary, not a tenth part happened on
the non-critical days; and of the terminations which
were final and fatal, though the greater number hap-
pened on the critical days, yet above a third of them
happened on the non-critical; so it is probable, that the
tendency of the animal œconomy is to observe the
critical days, and that it is by the operation of some
violent 

44 PRACTICE
violent and irregular cause, the course of things is some-
times turned to the non-critical.
CIX.
What has been said, renders it sufficiently probable,
that it is the general tendency of the animal œconomy
to determine the periodical movements in fevers to be
chiefly on the critical days. But, at the same time, we
must acknowledge it to be a general tendency only, and
that, in particular cases, many circumstances may occur
to disturb the regular course of it. Thus, though the
chief and more remarkable exacerbations in continued
fevers happen on the critical days, there are truly exacer-
bations happening every day, and these, from certain
causes, may become considerable and critical. Further,
though intermittent fevers are certainly very strongly
determined to observe a tertian or quartan period, we
know, there are circumstances which prevent them from
observing these periods exactly, and render them either
anticipating or postponing so much, that the days of
paroxysms come to be quite changed; and it is allowable
to suppose, that the like may happen with respect to the
exacerbations of continued fevers, and thereby disturb
the regular appearance of critical days.
A particular instance of this occurs with respect to
the sixth day of fevers. In the writings of Hippocrates,
there are many instances of terminations happening on
the sixth day; but it is not therefore reckoned among
the critical days; because, of the terminations happening
on that day, there is not one of a finally salutary kind;
that the greater number are fatal and that all the rest
are imperfect, and followed with a relapse. All this
shews, that some violent cause had, in these cases,
produced a deviation from the ordinary course of nature;
that the terminations on the sixth day are nothing more
than anticipations of the seventh, and therefore a proof
of the power of this last.
CX. 

OF PHYSIC. 45
CX.
The doctrine of critical days has been much em-
barrassed by some dissonant accounts of it, which appear
in the writings imputed to Hippocrates. But this may
be accounted for from these writings being truly the
Works of different persons, and from the most genuine
of them having suffered many corruptions; so that every
thing, which is inconsistent with the facts above laid
down, may be imputed to one or other of these causes.
CXI.
This further has especially disturbed the doctrine of
critical days, that Hippocrates himself attempted, perhaps
too hastily, to establish general rules, and to bring the
doctrine to a general theory, drawn from Pythagorean
opinions concerning the power of numbers. It is this
which seems to have produced the doctrines of odd days,
and of a quatenary and septenary period, which appear
so often in the writings of Hippocrates. These, how-
ever, are inconsistent with the facts above laid down;
and, indeed, as Asclepiades and Celsus have observed,
are inconsistent in themselves.
CXII.
We think, therefore, the critical days above assigned
are truly the critical days of Hippocrates, and may be
consistently explained in the following manner.
CXIII.
From the universality of tertian or quartan periods
in intermittent fevers, we cannot doubt of there being,
in the animal œconomy, a tendency to observe such
periods; and the critical days above mentioned are
consistent with this tendency of the œconomy, as all of
them mark either tertian or quartan periods. These
periods, however, are not promiscuously mixed, but
occupy constantly their several portions in the progress
of 

46 PRACTICE
of the disease; so that, from the beginning to the
eleventh day, a tertian period takes place; and, from
the eleventh to the twentieth, and perhaps longer, a
quartan period is as steadily observed.
CXIV.
What determines the periods to be changed about the
eleventh day, we have not clearly perceived; but the
fact is certain; for there is no instance of any termi-
nation on the thirteenth, that is, the tertian period
next following the eleventh; but, upon the fourteenth,
seventeenth, and twentieth, which mark quartan pe-
riods, there are forty-three instances of terminations,
and six only on all the intermediate days between these.
This prevalence of a quartan period leaves no room
for doubting, that the twentieth, and not the twenty-
first, is the critical day marked by Hippocrates, though
the last is mentioned as such in the common edition of
the Aphorisms, taken, from an erroneous manuscript,
which Celsus also seems to have copied.
CXV.
A consistency with the general tendency of the system
renders the series of critical days we have mentioned,
probably the true one; and the only difficulty that re-
mains in finding what we have delivered to be the same
with the genuine doctrine of Hippocrates is, the fre-
quent mention of the fourth as a critical day. There
are, indeed, more instances of terminations happening
on this day than on some of those days we have asserted
to be truly critical; but its inconsistency with the more
general tendency, and some other considerations, lead
us to refuse its being naturally a critical day, and to
think, that the instances of terminations, which have
really occurred on the fourth day, are to be reckoned
among  the other irregularities which happen in this
matter.
CXVI. 

OF PHYSIC. 47
CXVI.
We have thus endeavoured to support the doctrine of
critical days, chiefly upon the particular facts to be
found in the writings of Hippocrates: We might also
produce many other testimonies of both antient and mo-
dern times; but we must own that some of these may
be suspected to have arisen rather from a veneration of
Hippocrates than from accurate observation.
CXVII.
With respect to the opinions of many modems who
refuse the prevalence of critical days, we think they are
to be little regarded; for we know the observation of
the course of continued fevers to be difficult and fal-
lacious; and therefore the regularity of that course may
have often escaped inattentive and prejudiced observers.
CXVIII.
Our own observations amount to this, that fevers
with moderate symptoms, generally cases of the synocha,
frequently terminate in nine days or sooner, and very
constantly on one or other of the critical days which fall
within that period; but, it is very rare, in this climate,
that cases of either the typhus or synochus terminate
before the eleventh day; and, when they do terminate
on this day, it is for the most part fatally. When they
are protracted beyond this time, I have very constantly
found that their terminations were upon the fourteenth,
seventeenth, or twentieth day.
In such cases, the salutary terminations are seldom
attended with any considerable evacuation. A sweating
frequently appears, but is seldom considerable; and I
have hardly ever observed critical and decisive termina-
tions, attended with vomiting, evacuations by stool, or
remarkable changes in the urine. The solution of the
disease is chiefly to be discerned from some return of sleep
and appetite, the ceasing of delirium, and an abate-
ment of the frequency of the pulse. By these symptoms
we 

48 PRACTICE
we can often mark a crisis of the disease; but it seldom
happens suddenly and entirely, and it is most commonly
from some favourable symptoms on one critical day, that
we can announce a more entire solution on the next
following.
Upon the whole, I am persuaded, that, if obser-
vations shall be made with attention, and without pre-
judice, I shall be allowed to conclude with the words of
the learned and sagacious Gaubius, 'Fallor, ni sua con-
stiterit HIPPOCRATI auctoritas, GALENO sides, NA-
TURÆ virtus et ordo.'
CHAP. VI.
OF THE METHOD OF CURE IN
FEVERS.
SECT. I.
OF THE CURE OF CONTINUED
FEVERS.
CXIX.
As it is allowed, that, in every fever which has its full
course, there is an effort of nature of a salutary tendency,
it might be supposed that we should leave the cure of
fevers to the operations of nature, or that our art should
be only directed to support and regulate these operations,
and that we should form our indications accordingly.
This plan, however, we cannot adopt, because the
operations of nature are very precarious, and are not so
well 

OF PHYSIC. 49
well understood as to enable us to regulate them pro-
perly. We think, that trusting to these operations has
often given occasion to a negligent and inert practice;
and we believe that an attention to the operations of
nature may be often superseded by art.
CXX.
Our plan, therefore, shall be, to consider the proxi-
mate cause of fever, and to form our indications of
cure upon the means of obviating the tendency to death
in fevers.
From what has been formerly laid down on the subject
of the prognostic, we form three general indications in
the cure of continued fevers, and the one or other of
these is to be employed as the circumstances of the fever
(XCVII. XCVIII. or XCIX.) shall direct.
The first is, to moderate the violence of re-action.
The second is, to remove the causes, or obviate the
effects of debility. And,      
The third is, to obviate or correct the tendency of
the fluids to putrefaction.
CXXI.
The first indication may be answered, that is, the vio-
lence of re-action may be moderated,
1. By all those means which diminish the action of
the heart and arteries.
2. By those means which take off the spasm of the
extreme vessels, which we suppose to be the chief cause
of violent re-action.
CXXII.
The action of the heart and arteries may be di-
minished,
1. By avoiding or moderating those irritations which,
in one degree or other, are almost constantly applied to
the body.
2. By the use of certain sedative powers.
3. By
G

50 PRACTICE
3. By diminishing the tension and tone of the arterial
system.
CXXIII.
The irritations (CXXII. 1.) almost constantly ap-
plied are, the impressions made upon our senses; the
exercise of the body and mind; and the taking in of
aliments. The avoiding of these as much as possible,
or the moderating of their force, makes what is pro-
perly called the ANTIPHLOGISTIC REGIMEN, proper
to be employed in almost every continued fever.
CXXIV.
The conduct of this regimen is to be directed by the
following rules and considerations.
1. Impressions on the external senses, as stimulant to
the system, and a chief support of its activity, should
be avoided as much as possible; those, especially, of
more constant application, those of a stronger kind, and
those which give pain and uneasiness.
No impression is to be more carefully guarded against
than that of external heat; and, at the same time, every
other means of increasing the heat of the body is to be
shunned. Both these precautions are to be observed as
soon as a hot stage is fully formed, and to be attended
to during its continuance, except in certain cases, where
a determination to sweating is necessary, or where the
stimulant effects of heat may be compensated by cir-
cumstances which determine it to produce a relaxation
and revulsion.
2. All motion of the body is to be avoided, especially
that which requires the exercise of its own muscles; and
that posture of the body is to be chosen which employs
the fewest muscles, and which keeps none of them long 
in a state of contraction. Speaking, as it accelerates
respiration, is particularly to be avoided.
It is to be observed, that every motion of the body
is more stimulant, in proportion as the body is weaker.
3. The exercise of the mind also is a stimulus to the
body; and therefore, all impressions which lead to
thought, 

OF PHYSIC. 51
thought, and those, especially, which may excite emotion
or passion, are to be carefully avoided.
With respect to avoiding impressions of all kinds, an
exception is to be made in the case of a delirium coming
on, when the presenting of accustomed objects may in-
terrupt and divert the irregular train of ideas then arising
in the mind.
4. The presence of recent aliment in the stomach
proves always a stimulus to the system, and ought,
therefore, to be as moderate as possible. A total ab-
stinence for some time  may be of service; but, as this
cannot be long continued with safety, we must avoid the
stimulus of aliment, by chusing that kind which gives
the least. We suppose that alimentary matters are more
stimulant, according as they are more alkalescent; and,
this leads to avoid ail animal, and to use only vegetable
food.
Our drinks also may prove stimulant; and therefore,
aromatic and spirituous liquors are to be avoided; and,
in answering the present indication, all fermented li-
quors, except those of the lowest quality, are to be
abstained from. Watery liquors, rendered more grateful
by the addition of acids, we shall have occasion hereafter
to mention as a remedy.
CXXV.
Besides those stimulant powers more constantly ap-
plied, there are others, which, though occasional only,
yet, as they commonly accompany fevers, must be at-
tended to and removed.
One is, the sense of thirst, which, as a powerful
stimulus, in one way or other, ought always to be
removed.
Another stimulus frequently arises from crudities, or
corrupted humours in the stomach; and it is to be re-
moved by vomiting, dilution, or the use of acids.
A third stimulus often arises from the preternatural
retention of fœces in the intestines; and ought to be
removed by frequent laxative clysters.
A fourth stimulus to be constantly suspected in fevers
is, a general acrimony of the fluids, as produced by the
increase 

52 PRACTICE
increase of motion and heat, joined with an interruption
of the excretions. This acrimony is to be obviated or
removed by the taking in of large quantifies of mild
antiseptic liquors.
CXXVI.
The avoiding of irritation in all these particulars,
(CXXIII. and CXXIV.) constitutes the antiphlogistic
regimen absolutely necessary for moderating the violence
of re-action; and, if we mistake not, is proper in every
circumstance of continued fevers, as the employment
of stimulants is generally uncertain, and the measure of
the application of those above mentioned is not easily
ascertained.
CXXVII.
A second head of the means (CXXI. 1.) of moderating
the violence of re-action, comprehends certain sedative
powers, which may be employed to diminish the activity
of the whole body, and particularly that of the san-
guiferous system. 
The first of these to be mentioned is, the application
of cold. Heat is the chief support of the activity of
the animal system; and the system is, therefore, pro-
vided, in itself, with a power of generating heat. But,
at the same time, we observe, that this would go to
excess, were it not constantly moderated by a cooler
temperature in the surrounding atmosphere. When,
therefore, the generating power of heat in the system is
increased, all is commonly the case in fevers, it is ne-
cessary not only to avoid all further means of increasing
it, but it seems proper also to apply air of a cooler
temperature; or, at least, to apply it more entirely and
freely than in a state of health. Some late experiments
in the small-pox, and in continued fevers, shew, that
the free admission of cool air to the body is a powerful
remedy in moderating the violence of re-action; but
what is the mode of its operation, to what circumstances
OF fever it is peculiarly adapted, or what limitations it
requires,

OF PHYSIC. 53
requires, we shall not venture to determine, till we shall
be more particularly instructed by further experience.
CXXVIII.
A second sedative power which may be employed in
fevers, is that of certain medicines known in the writings
on the Materia Medica, under the title of REFRIGE-
RANTS. The chief of these are acids of all kinds,
when sufficiently diluted, and which are, in several
respects, remedies adapted to continued fevers. Those
especially in use are, the Vitriolic and Vegetable; and,
on many accounts, we prefer the latter.
CXXIX.
Another set of refrigerants are, the Neutral Salts,
formed of the vitriolic, nitrous, or vegetable acids,
with alkalines, either fixed or volatile. All these neu-
trals, while they are dissolved in water, generate cold;
but, as that cold ceases soon after the solution is finished,
and as the salts are generally exhibited in a dissolved
state, their refrigerant power in the animal body does
not at all depend upon their power of generating cold
with water. The neutral chiefly employed as a re-
frigerant, is Nitre; but all the others, compounded as
above mentioned, partake more or less of the same
quality.
CXXX.
Besides these neutrals, some metallic salts also have
been employed as refrigerants in fevers; and particularly
the Sugar of Lead. We think the refrigerant powers
of this are not well ascertained; and its deleterious qua-
lities are too well known to admit of its being freely
used.
CXXXI. 
The third general head (CXXII. 3.) of the means to
be employed for moderating the violence of re-action,
comprehends 

54 PRACTICE
comprehends the means of diminishing the tension,
tone, and activity of the sanguiferous system. As the
activity of this system depends, in a great measure,
upon the tone, and this again upon the tension of the
vessels, given to them by the quantity of fluids they
contain, it is evident that the diminution of the quan-
tity of these must diminish the activity of the sangui-
ferous system.
CXXXII.
The quantity of fluids contained in the sanguiferous
system may be diminished most conveniently by the eva-
cuations of blood-letting and purging.
CXXXIII.
Nothing is more evident, than that blood-letting is
one of the most powerful means of diminishing the ac-
tivity of the whole body, and especially of the sangui-
ferous system; and it must therefore be the most effectual
means of moderating the violence of re-action in fevers.
Taking this as a fact, we omit inquiring into its mode
of operation, and shall only consider in what circum-
stances of fevers it is most properly to be employed.
CXXXIV.
When the violence of re-action, and its constant at-
tendant, a phlogistic diathesis, are sufficiently evident;
when these constitute the principal part of the disease, 
and may be expected to continue through the whole of
it as in the cases of synocha; then blood-letting is the
principal remedy, and may be employed as far as the 
symptoms of the disease may seem to require, and the
constitution of the patient will bear. It is, however,
to be attended to, that a greater evacuation than is ne-
cessary, may occasion a slower recovery, may render the
person more liable to a relapse, or may bring on other
diseases.
CXXXV.

OF PHYSIC. 55
CXXXV.
In the case of synocha, therefore, there is little doubt
about the propriety of blood-letting; but there are other
cases of fever, as the synochus, in which a violent re-
action and phlogistic diathesis appear, and prevail during
some part of the course of the disease; while, at the
same time, these circumstances do not constitute the
principal part of the disease, nor are to be expected to
continue during the whole course of it; and we know,
that, in many cases, the state of violent re-action is to
be succeeded, sooner or later, by a state of debility,
from the excess of which the danger of the disease is
chiefly to arise. It is, therefore, necessary, that, in
many cases, blood-letting should be avoided; and even
although, during the inflammatory state of the disease,
it may be proper, the evacuation should not be so large
as to increase the state of debility which is to follow.
CXXXVI.
The employing, therefore, of blood-letting, in cer-
tain fevers, requires much discernment and skill, and is
to be governed by the consideration of the following
circumstances:
1. The nature of the prevailing epidemic.
2. The nature of the remote cause.
3. The season and climate in which the disease occurs.
4. The degree of phlogistic diathesis present.
5. The period of the disease.
6. The age, vigour, and plethoric state of the patient.
7. The patient's former diseases and habits of blood-
letting.
8. The appearance of the blood drawn out.
9. The effects of the blood-letting that may have
been already practised.
CXXXVII.
When, by the consideration of these circumstances,
blood-letting is determined to be necessary, we must ob-
serve,

56 PRACTICE
serve, that it is more effectual, as the blood is more sud-
denly drawn off, and as the body is, at the same time,
more free from all irritation, and, therefore, when it is
in a posture in which the fewest muscles are in action.
CXXXVIII.
Another evacuation by which the quantity of fluids
contained in the body can be considerably diminished, is
that of purging.
CXXXIX.
If we consider the quantity of fluids constantly pre-
sent in the cavity of the intestines, and the quantity
which may be drawn from the innumerable excretories
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 stimulus that is not at the same time com-
municated to the rest of the body, it may, by emptying
both the cavity of the intestines, and the arteries which
furnish the excretions poured into it, induce a con-
siderable relaxation in the whole system; and is therefore
suited to moderate the violence of re-action in fevers.
CXL.
But it is to be observed, that, as the fluid drawn from
the excretories opening into the intestines is not all
drawn immediately from the arteries, and as what is
even more immediately drawn from these, is drawn off
slowly; so the evacuation will not, in proportion to its
quantity, occasion such a sudden depletion of the red
vessels as blood-letting does; and therefore, cannot
operate so powerfully in taking off the phlogistic diathesis
of the system.
CXLI.
At the same time, the evacuation may induce a con-
siderable degree of debility; and, therefore, in those
cases 

OF PHYSIC. 57
cases in which a dangerous state of debility is likely to
occur, purging is to be employed with a great deal of
caution; and this caution is more difficult to be observed
than in the case of blood-letting.
CXLII.
As we shall observe presently, that it is of great
importance in the cure of fevers, to restore the deter-
mination of the blood to the vessels on the surface of
the body, so purging, as in some measure taking off that
determination, seems to be an evacuation not well adapted
to the cure of fevers.
CXLIII.
If, notwithstanding these doubts, (CXL. CXLI.
and CXLII.) it shall be asserted, that purging, from
the exhibition of purgatives, has often been useful in
fevers, I would maintain, that this has not happened
trom a large evacuation; and, therefore, not by mo-
derating the violence of re-action, except in the case of
a more purely inflammatory fever. In other cases, we
have seen a large evacuation by purging, of mischievous
consequence; and if, upon occasion, a more moderate
evacuation has appeared to be useful, we alledge that it
has been, only by taking off the irritation of retained
fœces, or by evacuating corrupted humours which hap-
pened to be present in the intestines: And, indeed, for
both these purposes, frequent laxatives may be properly
employed. In intermittent fevers, also, to relieve the
congestions formed in the abdominal viscera, we judge
purgatives to be often necessary.
CXLIV.
Another set of means, (CXXI. 2.) for moderating
the violence of re-action in fevers, are those suited to
take off the spasm of the extreme vessels, which we
believe to be the irritation that chiefly supports the re-
action.
CXLV. 
H

58 PRACTICE
CXLV.
For taking off this spasm of the extreme vessels, the
means to be employed are either internal or external.
CXLVI.
The internal means (CXLV.) are,
1. Those which determine the force of the circulation
to the extreme vessels on the surface of the body, and,
by restoring the tone and activity of these vessels, over-
come the spasm on their extremities.
2. Those medicines which have the power of taking
off spasm in any part of the system, and which are
known under the title of ANTISPASMODICS.
CXLVII.
Those remedies which are fit to determine to the
surface of the body, are,
1. DILUENTS.
2. NEUTRAL SALTS.
3. SUDORIFICS.
4. EMETICS.
CXLVIII.
Water enters, in a large proportion, into the com-
position of ail the animal fluids, and a large quantity of
it is always diffused through the whole of the common
mass. In a sound state, the fluidity of the whole mass
depends upon the quantity of water present in it. Water,
therefore, is the proper diluent of our mass of blood,
and other fluids are diluent only in proportion to the
quantity of water they contain.
CXLIX.
Water may be said to be the vehicle of the several
excreted fluids; and, in a healthy state, the fulness of
the extreme vessels, and the quantity of excretion, are
in 

OF PHYSIC. 59
in proportion to the quantity of water present in the
body. But in fever, though the excretions are in some
measure interrupted, they continue in such quantity as
to exhale the more fluid parts of the blood; and, while
a portion of them is, at the same time, necessarily re-
tained in the larger vessels, the smaller and the extreme
vessels, both from the deficiency of fluid, and their own
contracted state, are less filled, and therefore allowed to
remain in that condition.
CL.
To remedy this contracted state, nothing is more ne-
cessary than a large supply of water, or watery fluids,
taken in by drinking, or otherwise; for, as any super-
fluous quantity of water is forced off by the several ex-
cretories, such a force applied may be a means of di-
lating the extreme vessels, and of overcoming the spasm
affecting their extremities.
CLI
Accordingly, the throwing in of a large quantity of
watery fluids has been, at all times, a remedy much
employed in fevers; and, in no instance more remark-
ably, than by the Spanish and Italian physicians, in the
use of what they call the Diaeta aquea.
CLII.
This practice consists in taking away every other kind
of aliment and drink, and in giving in divided portions
every day, for several days together, six or eight pounds
of plain water, generally cold, but sometimes warm.
All this, however, is to be done only after the disease
has continued for some time, and, at least, for a week.
CLIII.
A second means of determining to the surface of the
body, is by the use of neutral salts. (CXLVII. 2.)
These neutrals, in a certain dose, taken into the stomach,
produce,

60 PRACTICE
produce, soon after, a sense of heat upon the surface of
the body; and, if the body be covered close, and kept
warm, a sweat is readily brought out. The same me-
dicines taken during the cold stage of a fever, very often
put an end to the cold stage, and bring on a hot one;
and they are also remarkable for stopping the vomiting
which so frequently attends the cold stage of fevers. All
this shews, that neutral salts have a power of determin-
ing the blood to the surface of the body, and may, there-
fore, be of use in taking off the spasm which subsists
there in fevers.
CLIV.
The neutral most commonly employed in fevers, is
that formed of an alkali, with the native acid of ve-
getables; but all the other neutrals have more or less of
the same virtue; and perhaps some of them, particularly
the ammoniacal salts, possess it in a stronger degree. 
CLV.
As cold water taken into the stomach, often shews
the same diaphoretic effects with the neutral salts, it is
probable that the effect of the latter depends upon their
refrigerant powers mentioned above. (CXXIX.) What
is the effect of the neutral salts, given when they are
forming, and in a state of effervescence?
CLVI.
A third means of determining to the surface of the
body, and taking off the spasm subsisting there, is by
the use of sudorifics, and of sweating. (CXLV1I 3.)
CLVII.
The propriety of this remedy has been much dis-
puted; and specious arguments may be adduced both
for and against the practice. In favour of the practice,
it may be said,
1. That 

OF PHYSIC. 61
1. That, in healthy persons, in every case of in-
creased action of the heart and arteries, a sweating takes
place, and is, seemingly, the means of preventing the
bad effects of such increased action.
2. That, in fevers, their most usual solution and
termination is by spontaneous sweating.
3. That, even when excited by art, it has been found
useful, at certain periods, and in certain species of fever.
CLVIII.
Upon the other hand, it may be urged against the
practice of sweating,
1. That in fevers, as a spontaneous sweating does
not immediately come on, there are some circumstances
different from those in the state of health, and which
may render it doubtful whether the sweating can be
safely excited by art.
2. That, in many cases, the practice has been at-
tended with bad consequences. The means com-
monly employed have a tendency to produce an inflam-
matory diathesis; which, if not taken off by the sweat
succeeding, must be increased with much danger. Thus
sweating, employed to prevent the accessions of inter-
mitting fevers, has often changed them into a continued
form, which is always dangerous.
3. The utility of the practice is doubtful, as sweating,
when it happens, does not always give a final deter-
mination, as must be manifest in the case of intermittents,
and in many continued fevers, which are sometimes, in
the beginning, attended  with sweatings which do not
prove final; and, on the contrary, whether they be
spontaneous or excited by art, seem often to aggravate
the disease.
CLIX.
From these considerations, it is very doubtful, if the
practice of sweating can be admitted very generally;
but, at the same time, it is also doubtful, if the failure
of the practice, or the mischiefs said to have arisen from
it, have not been owing to the improper conduct of the
practitioner. 

62 PRACTICE
practitioner. With respect to the last, it is almost agreed
among physicians,
1. That sweating has been generally hurtful, when
excited by stimulant, heating, and inflammatory me-
dicines.
2. That it has been hurtful, when excited by much
external heat, and continued with a great increase of the
heat of the body.
3. That it is always hurtful, when it does not re-
lieve, and rather increases the frequency and hardness
of the pulse, the anxiety and difficulty of breathing,
the headach, and delirium.
4. That it is always hurtful, if it is urged, when
the sweat is not fluid, and when it is partial, and on the
superior parts of the body only.
CLX.
In these cases, it is probable, that either an inflam-
matory diathesis is produced, which increases the spasm
on the extreme vessels, or that, from other causes, the
spasm is too much fixed to yield easily to the increased
action of the heart and arteries; and, upon either sup-
position, it must be obvious, that urging the sweat may
produce determinations to some of the internal parts,
with very great danger.
CLXI.
Though the doubts started (CLVIII.) are to be at-
tended to; and though the practices (CLIX.) have been
found hurtful, and are therefore to be rejected, it still
remains true,
1. That sweating has certainly been often useful in
preventing the accession of fevers, when the times of it
have been certainly foreseen, and a proper conduct em-
ployed.
2. That, even after fevers have in some measure come
on, sweating has interrupted their progress, when pro-
perly employed, either at the very beginning of the
disease, or during its approach and gradual formation.
3. That,

OF PHYSIC. 63
3. That, even after pyrexiæ have continued for some
time, sweating has been successfully employed in curing
them, as particularly in the case of rheumatism.
4. That certain fevers, produced by a very powerful
sedative contagion, have been generally treated most suc-
cessfully by sweating.
CLXII.
These instances (CLXI.) are in favour of sweating,
but give no general rule; and it must be left to further
experience  to determine, how far any general rule can
be established in this-matter. In the mean time, if the
practice of sweating is to be attempted, we can venture
to lay down the following rules for the conduct of it,
1. That it should be excited without the use of
stimulant, inflammatory medicines.
2. That it should be excited with as little external
heat, and with as little increase of the heat of the body
as possible.
3. That, when excited, it should be continued for
a due length of time, not less than twelve hours,
and sometimes for twenty-four or forty-eight hours;
always, however, supposing that it proceeds without
the circumstances (CLIX. 3. 4.)
4. That, for some part of the time, and as long
as the person can easily bear, it should be carried
on without admitting of sleep.
5. That it should be rendered universal over the
whole body; and, therefore, particularly, that care be
taken to bring the sweating to the lower extremities.
6. That the practice should be rendered safer by mo-
derate purging, excited at the same time.
7. That it should not be suddenly checked by cold
any how applied to the body.
CLXIII.
When attention is to be given to these rules, the
sweating may be excited, 1. By warmbathing, or a fo-
mentation of the lower extremities. 2. By frequent
draughts of tepid liquors, chiefly water, rendered more
grateful 

64 PRACTICE
grateful by the addition of a light aromatic, or more
powerful, by that of a small quantity of wine. 3. By
giving some doses of neutral salts. 4. Most effectually,
and perhaps most safely, by a large dose of an opiate,
joined with a portion of neutral salts, and of an emetic.
CLXIV.
The fourth means of determining to the surface of the
body, and thereby taking off the spasm affecting the
extreme vessels. (CXLVII. 4.) is by the use of emetics.
CLXV.
Emetics, and particularly antimonial emetics, have
been employed in the cure of fevers, ever since the in-
troduction of chemical medicines; but, for a long
time, they were employed by chemists and chemical prac-
titioners only; and, although of late their use has be-
come very general, their efficacy is still disputed, and
their manner of operating is not commonly explained.
CLXVI.
Vomiting is, in many respects, useful in fevers; as
it evacuates the contents of the stomach; as it emulges
the biliary and pancreatic ducts, and evacuates the con-
tents of the duodenum, and perhaps also of a larger
portion of the intestines; as it agitates the whole of the
abdominal viscera, it expedes the circulation in them,
and promotes their several secretions; and, lastly, as it
agitates also the viscera of the thorax, it has like effects
there. All these several effects are procured with ad-
vantage, in many cases and circumstances of fever, but
do not properly fall under our view here, where we are
to consider only the effect of vomiting in determining to
the surface of the body.
CLXVII.
This effect we do not impute to the exercise of
vomiting in agitating the whole body, but to the par-
ticular 

OF PHYSIC. 65
ticular operation of emetics upon the muscular fibres of
the stomach, whereby they excite the action of the ex-
treme arteries on the surface of the body, and thereby
effectually determine the blood to these vessels, remove
the atony, and take off the spasm affecting them.
CLXVIII. 
That such is the power of emetics, will appear from
the several considerations mentioned above (XLIII.);
and, therefore, that they are remedies well suited to the
cure of fevers.
CLXIX.
Emetics, for that purpose, are administered in two
different ways; that is, either in such doses as may ex-
cite full and repeated vomitings, or in such doses as
may excite sickness and nausea only, with little or no
vomiting at all.
CLXX.
Full vomiting is best suited to the several purposes
mentioned (CLXVI.); and is also well suited to deter-
mine to the surface of the body, and thereby to obviate
the atony and spasm which lay the foundation of fever.
Thus, vomiting excited a little before the expected ac-
cession of the paroxysm of an intermittent, has been
found to prevent the paroxysm altogether. It has been
observed also, that, when contagion has been applied to
a person, and first discovers its operation, a vomit given
will prevent the fever, which otherwise was to have
been expected.
CLXXI.
These are advantages to be obtained by exciting
vomiting at the first approach of fevers, or of the par-
oxysms of fevers; and they may also be applied after
fevers are formed, to take off, perhaps entirely, the atony
and spasm, or, at least, to moderate these, so that the
fever may proceed more gently and safely.
CLXXII.
I 

66 PRACTICE
CLXXII.
It is seldom, however, that vomiting is found to pro-
duce a final solution of fevers; and, after they are once
formed, it is commonly necessary to repeat the vomiting
several times; but this is attended with inconveniency,
and sometimes with disadvantage. The operation of
full vomiting is transitory, and the exercise of vomiting
is a debilitating power; and, therefore, when the vomit-
ing does not remove the atony and spasm very entirely, it
may give occasion to their recurrence with greater force.
CLXXIII.
For these reasons, after fevers are fully formed, phy-
sicians have thought proper to employ emetics in nau-
seating doses only. These are capable of exciting the
action of the extreme vessels, and their operation is more
permanent. At the same time, they often shew their
power by exciting some degree of sweat, and their ope-
ration is rendered more safe, by their commonly producing
some evacuation by stool.
CLXXIV.
These are the advantages to be procured by nauseating
doses of emetics; and it only remains to mention, what
are the medicines most fit to be employed; what are the
most proper times for exhibiting, and what the best
manner of administering them.
CLXXV.
The emetics chiefly in use at present, are, Ipecacuanha
and Antimony. The first may be employed for
every purpose of emetics, particularly those mentioned
(CLXVI.); and also, either in larger or smaller doses,
for determining to the surface of the body; but, even
in very small doses, it so readily excites vomiting, as to
be, with difficulty, employed for the purpose of nau-
seating only; and, however employed, there is reason
to 

OF PHYSIC. 67
to suspect, that its effects are less permanent, and less
powerfully communicated from the stomach to the rest
of the system, than those of Antimony.
CLXXVI.
This last, therefore, is generally preferred; and its
preparations, seemingly various, may all be referred to
two heads; one comprehending those in which the re-
guline part is in a condition to be acted upon by acids;
and, therefore, on meeting with acids in the stomach,
becomes active; and another, comprehending those
preparations in which the reguline part is already joined
with an acid, rendering it active.
CLXXVII.
Of each kind there are great numbers, but not dif-
fering essentially from one another. It will be enough
for us to compare the Calx Antimonii Nitrata of the
Edinburgh Dispensatory, with the Emetic Tartar of
the same. Which of these is best suited to the cure of
fevers, as above explained, seems doubtful; but it ap-
pears to me, that, though the first may have some ad-
vantages from its slower operation, and may thereby seem
to be more certainly sudorific and purgative, the un-
certainty of its dose renders it inconvenient, and has
often given occasion to the timid to be disappointed, and
to the bold to do mischief. While, on the other hand,
the dose of the Emetic Tartar can be exactly ascer-
tained; and we think it may be exhibited in such a
manner, as to produce all the advantages of the other.
CLXXVIII.
Whichsoever of these preparations be employed, we
think the most proper time for exhibiting them, is the
time of accessions, or a little before it, when that can
be certainly known. In continued fevers, the exacer-
bations are not always very observable; but there is
reason to believe, that one commonly happens about
noon, or soon after it, and another in the evening; and 
that

68 PRACTICE
that these, therefore, are the most proper times for ex-
hibiting emetics.
CLXXIX.
With respect to the manner of administration, that
of the Calx Nitrata is simple, as the whole of what is
thought a proper dose is given at once, and no more can
be properly given till the next accession. The admi-
nistration of the Emetic Tartar is different. It is to be
given in small doses, not sufficient to excite vomiting;
and these doses are to be repeated, after short intervals,
for several times, till sickness, nausea, and some, but
not much, vomiting, come on. The difference of ad-
ministration must depend upon the dose, and the length
of the interval at which it is given. If it be intended
that the medicine should certainly operate by stool, the
doses are made small, and the intervals long. On the
contrary, when vomiting is proper, or when much
purging ought to be avoided, and, therefore, some vo-
miting must be admitted, the doses are made larger,
the intervals shorter.
CLXXX.
With respect to both kinds of preparations, the re-
petition is to be made at the times of accession, but not
very often; for, if the first exhibitions, duly managed,
have little effect, it is seldom that the after exhibitions
have much; and it sometimes happens, that the repeated
vomiting, and especially repeated purging, does harm,
by weakening the patient.
CLXXXI.
The other set of internal medicines, which we sup-
pose may be useful in taking off the spasm of the extreme
vessels, are those named Antispasmodic. How many of
these may be properly employed, I am uncertain, and
their mode of operation is involved in great obscurity.
It is certain, however, that opium, camphor, musk,
and perhaps some others, have been employed in fevers
with 

OF PHYSIC. 69
with advantage; but, the circumstances in which they
are especially proper and safe, I find it difficult to as-
certain; and, therefore, cannot venture here to lay
down any general doctrine concerning them.
CLXXXII.
The external means (CXLV.) suited to take off the
spasm of the extreme vessels, are BLISTERING and
WARM BATHING.
CLXXXIII.
What are the effects of blistering, so frequently em-
ployed in fevers, is not yet agreed upon among phy-
sicians; and many different opinions have been main-
tained on this subject, drawn not only from reasoning,
but also from pretended experience. We must not,
however, enter into controversy; but shall deliver our
own opinion in a few words.
CLXXXIV.
I think, that the small quantity of cantharides ab-
sorbed from a blistering plaster, is not sufficient to change
the consistence of the mass of blood; and, therefore,
that such a quantity can neither do good, by resolving
phlogistic lentor, if it exists, nor do harm, by increasing
the dissolution of the blood arising from a putrid tendency
in it. We therefore neglect, entirely, the effects of
cantharides upon the fluids.
CLXXXV.
The inflammation produced by the application of can-
tharides to the skin, affords a certain proof of their
stimulant power; but, in many persons, the effect of
that stimulus is not considerable in many it is not
communicated to the whole system; and, even when it
does take place in the whole system, it seems to be taken
off, very entirely, by the effusion and evacuation of
serum from the blistered part. I think, therefore, that
neither 

70 PRACTICE
neither much good is to be expected, nor much harm to
be apprehended, from the stimulant power of blistering;
and the certainty of this conclusion is established, by
the great benefit arising from the proper practice of
blistering in inflammatory diseases.
CLXXXVI.
Much has been imputed to the evacuation made by
blistering; but it is never so considerable as to affect the
whole system; and therefore can, neither by a sudden
depletion, relax the sanguiferous system, nor, by any
revulsion, affect the general distribution of the fluids.
CLXXXVII. 
The evacuation, however, is so considerable as to
affect the neighbouring vessels; and the manifest utility
of blistering near the part affected, in inflammatory dis-
eases, leads us to think, that blistering, by deriving to
the skin, and producing an effusion there, relaxes the
spasm of the deeper seated vessels. It is in this manner
we suppose that the tumour of a joint, from an effusion
into the cellular texture under the skin, takes off the
rheumatic pain formerly affecting that joint.
CLXXXVIII. 
Analogous to this, we think the good effect of bli-
stering in continued fevers, arises from its relaxing the
spasm of the extreme vessels, by a communication of
the blistered part with the rest of the skin; and this is
illustrated by the effect of blistering in colic and dys-
entery.
CLXXXIX.
We think, that blistering may be employed at any
period of continued fevers; but that it will be of most
advantage in the advanced state of such fevers, when,
the re-action being weaker, all ambiguity from the sti-
mulant power of blistering is removed, and when it
may 

OF PHYSIC. 71
may best concur with other circumstances tending to a
final solution of the spasm.
CXC.
From the view of this matter, given in (CLXXXVI.
CLXXXVII.) it will appear, that the part of the body
to which blisters ought to be applied, is indifferent, ex-
cept upon the suspicion of topical affection, when the
blistering is to be made as near as possible to the part af-
fected.
CXCI.
Whether SINAPISMS, and other RUBEFACIENTA,
act in a manner analogous to what we have supposed of
blistering, may be doubtful; but their effects in rheu-
matism and other inflammatory diseases, render it pro-
bable.
CXCII.
The other external means of taking off the spasm of
the extreme vessels, is Warm Bathing. This was fre-
quently, and in different circumstances, employed by
the antients; but has, till very lately, been neglected
by modem physicians. As the heat of the bath stimu-
lates the extreme vessels, and, with the concurrence of
moisture, also relaxesthem, it seems to be a safe stimu-
lus, and well suited to take off the spasm affecting these
vessels.
CXCIII.
It may be applied to the whole body, by immersion;
but this is, in many respects, inconvenient; and, whe-
ther some of the inconveniences of immersion might not
be avoided by a vapour-bath, we have not learned from
experience; but we know, from much experience, that
most of the purposes of warm bathing can be obtained,
by a fomentation of the legs and feet, if properly ad-
ministered, 

72 PRACTICE
ministered, and continued for a due length of time, not
less than an hour.
CXCIV.
The marks of the good effects of such a fomentation,
are, the patient's bearing it easily, its relieving delirium,
and inducing sleep.
CXCV.
We have now considered the several means of satis-
fying the first general indication in the cure of fevers,
and proceed to the second, (CXX. 2.) which is to remove
the cause, or obviate the effects of debility.
CXCVI.
Most of the sedative powers inducing debility, cease
to act soon after they have been first applied; and, there-
fore, the removing them is not an object of our present
indication. There is only one which may be supposed
to continue to act for a long time, and that is, the con-
tagion applied; but we know nothing in the nature of
contagion that can lead us to any measures for removing
or correcting it. We know only its effects as a sedative
power inducing debility, or as a ferment inducing a
tendency to a putrefaction in the fluids. The obviating
the last will be considered under our third general in-
dication, and the first only is to be considered here.
CXCVII.
The debility induced in fevers by contagion, or other
causes, appears, especially, in the weaker energy of the
brain; but in what this consists, or how it may be
directly restored, we do not well know; but as Nature,
seemingly for this purpose, excites the action of the
heart and arteries, we ascribe the continuance of debility
to the weaker re-action of the sanguiferous system; and
the means, therefore, which we employ for obviating
debility, are immediately directed to support and increase
the 

OF PHYSIC. 73
the action of the heart and arteries; and the remedies
employed are, TONICS or STIMULANTS.
CXCVIII.
In contagious diseases, we know, both from the effects
which appear, and from dissections, that the tone of the
heart and arteries is considerably diminished; and that
tonic remedies, therefore, are properly indicated. We
are to consider them as of two kinds; the first being the
power of cold; the second that of tonic medicines.
CXCIX.
The power of cold, as a tonic, we have mentioned
above (LXXXIX.); and it is employed, in fevers, in
two ways; either as thrown into the stomach, or as
applied to the surface of the body.
CC.
As we have said above, that the tonic power of cold
can be communicated from any one part to every other
part of the system, so it will be readily allowed, that
the stomach is a part as fit for this communication as
any other; and that cold drink, therefore, taken into
the stomach, may prove an useful tonic in fevers.
CCI.
This, the experience of all ages has confirmed; but,
at the same time, it has been frequently observed, that,
in certain circumstances, cold drink, taken into the
stomach, has proved very-hurtful; and, therefore, that
the use of cold drink in fevers requires some limitations.
What these limitations should be, and what are all the
circumstances which may forbid the use of cold drink,
is difficult to determine; but it seems clearly forbidden,
in ail cases where a phlogistic diathesis prevails in the
system, and more especially when there are topical af-
fections of an inflammatory nature.
CII.
K 

74 PRACTICE
CCII.
The other method of employing cold as a tonic, is,
by applying it to the surface of the body. The ap-
plication of cold air to the surface of the body, as a
refrigerant power fit to moderate the violence of re-
action, we have spoken of above (CXXVII.); but
probably it may here be considered also properly as a to-
nic, and useful in eases of debility.
CCIII.
Not only cool air, but cold water also, may be ap-
plied to the surface of the body, as a tonic. The an-
tients frequently applied it with advantage, to particular
parts, as a tonic; but it is a discovery of modern times,
that, in the case of putrid fevers, attended with much
debility, the body may be washed all over with cold
water.
CCIV.
This was first practised at Breslaw in Silesia, as
appears from a dissertation, under the title of Epidemia
verna quae Wratislaviam, anno 1737, afflixit, to be
found in the appendix to the Acta nat. curios. vol. X.
And from other writers it appears, that the practice has
passed into some of the neighbouring countries; but in
this island, so far as I know, we have as yet had no ex-
perience of it.
CCV.
The medicines which have been employed in fevers as
tonics, are various. If the Saccharum Saturni has
been found useful, 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 epilepsy, are presumed to possess a tonic
power; but, whether their use in fevers be founded upon
their tonic or their emetic powers, may be uncertain.
The

OF PHYSIC. 75
The use of arsenic and of allum, in intermittent fevers,
seems manifestly to depend upon their tonic power.
And, upon the whole, there, no doubt, may occur
cases of continued fevers, which may be cured by tonics
taken from the fossil kingdom; but the use of these has
been rare, and the effects uncertain, and physicians have
employed, more commonly, the vegetable tonics.
CCVI.
A great variety of these has been employed in the cure
of intermittent fevers; but how many of them may be
employed in continued fevers, or in what circumstances
of these fevers, is not well ascertained; and we shall
now only consider the question with respect to the most
celebrated of these tonics, the Peruvian bark.
CCVII.
This bark has been commonly considered as a specific,
or as a remedy of which the operation was not un-
derstood. But it is certainly allowable to inquire into
this matter; and we think it may be explained.
CCVIII.
To this purpose we observe, that, as in many cases,
the effects of the bark are perceived soon after its being
taken into the stomach, and before it can possibly be con-
veyed to the mass of blood, we may conclude, that its
effects do not arise from its operating on the fluids; and
must, therefore, depend upon its operating on the nerves
of the stomach, and being thereby communicated to the
rest of the nervous system. This operation seems to be
a tonic power, the bark being a remedy in many cases of
debility, particularly in gangrene; and, as the re-
currence of the paroxysms of intermittent fevers de-
pends upon a recurrence of atony, (XXXIV. et seq.);
so probably the bark, by its tonic power, prevents the
recurrence of these paroxysms; and this is greatly con-
firmed by our observing, that many other tonic medicines
answer the same purpose.
CCIX. 

76 PRACTICE
CCIX.
If the operation of the bark may be thus explained,
from its possessing tonic power, we can easily perceive
why it is improper when a phlogistic diathesis prevails;
and, from the same view, we can ascertain in what cases
of continued fever it may be admitted. These cases,
are either after considerable remissions have appeared,
when it may be employed to prevent the return of exa-
cerbations, on the same footing as it is used in inter-
mittent fevers; or in the advanced state of fevers, when
all suspicion of an inflammatory state is removed, and a
general debility prevails in the system; and its being
then employed is sufficiently agreeable to the present
practice.
CCX.
With respect to the use of the bark, we think proper
to add, that good effects are to be expected from it, al-
most only when given in substance, and in large quantity.
CCXI.
Another set of medicines to be employed for obvi-
ating debility and its effects, are the direct stimulants
(CXCVII). These, in some measure, increase the
tone of the moving fibres; but are different from the
tonics, as they more directly excite and increase the
action of the heart and arteries. This mode of their
operation renders their use ambiguous; and when an in-
flammatory diathesis is present, as so often happens in
the beginning of fevers, the effects of these stimulants
may be very hurtful; but it still remains probable, that,
in the advanced state of fevers, when debility prevails,
they may be useful.
CCXII.
What are the stimulants which may be most properly
employed, we are uncertain, as the use of them, in this
age, 

OF PHYSIC. 77
age, has been rare; but we are disposed to think that,
of all kinds, wine is the best.
CCXIII.
Wine has the advantage of being grateful to the
palate and stomach, and of having its stimulant parts so
much diluted, that it can be conveniently given in small
doses; and therefore it may be employed with sufficient
caution; but it is of little service, unless taken pretty
largely.
CCXIV.
It may be suspected, that wine has an operation
analogous to that of opium; and on good grounds.
But we can distinctly mark its stimulant power only,
which renders its effects in the phrenitic delirium ma-
nifestly hurtful, and, in the mild delirium, depending
on debility, as remarkably useful.
CCXV.
These are the means of answering our second general
indication (CXX. 2.); and we now proceed to the
third, which is to obviate or to correct the tendency of
the fluids to putrefaction.
CCXVI.
This may be done,
1. By avoiding any new application of putrid or pu-
trescent matter.
2. By evacuating the putrid or putrescent matter al-
ready present in the body.
3. By correcting the putrid or putrescent matter re-
maining in the body, by diluents and antiseptics.
4. By supporting the tone of the vessels, and thereby
resisting further putrefaction, or obviating its effects.
5. By moderating the violence of re-action, consi-
dered as a means of increasing putrefaction.
CCXVII.

78 PRACTICE
CCXVII.
The further application of putrid or putrescent mat-
ter may be avoided,
1. By removing the patient from places filled with
corrupted air.
2. By preventing the accumulation of the patient's
own effluvia, by a constant ventilation, and by a fre-
quent change of bed-cloaths and body-linen.
3. By the careful and speedy removal of all excre-
mental matters from the patient's chamber.
4. By avoiding animal food.
CXVIII.
The putrid or putrescent matter, already present in
the body, may be evacuated partly, by frequently eva-
cuating the contents of the intestines, and more effectu-
ally, still, by supporting the excretions of perspiration
and urine, by the plentiful use of diluents.
CCXIX.
The putrid or putrescent matter, remaining in the
body, may be rendered more mild and innocent, by the
use of diluents; or may be corrected by the use of
antiseptics. These last are of many and various kinds;
but, which of them are conveniently applicable, or
more particularly suited to the case of fevers, is not
well ascertained. Those most certainly applicable and
useful, are, acescent aliments, acids of all kinds, and
neutral salts.
CCXX.
The progress of putrefaction may be considerably
retarded, and its effects obviated, by supporting the tone
of the vessels; and this may be done by tonic remedies;
the chief of which are, Cold, and Peruvian bark, both
sufficiently treated of above. (CXCIX.-CCX.)
CCXXI.

OF PHYSIC. 79
CCXXI.
The violence of re-action increasing the tendency to
putrefaction, may be moderated by the several means
full treated of above. (CXXI—CXCIV.)
CCXXII.
We have now finished the consideration of the three
general indications to be formed in the cure of continued
fevers, and have mentioned most of the remedies which
have been, upon any occasion, employed. It was ne-
cessary, in the first place, to consider these remedies sepa-
rately, and to explain their operation more generally; but,
from what we have now delivered, compared with what
has been said above, concerning the difference of fe-
vers, and the signification of their several symptoms in
forming the prognostic, I expect it will not be difficult
to select and combine the several remedies mentioned, so
as to adapt them to the several species and circumstances
of continued fevers.
We think it may be useful for Students to have the
whole of the Cure of CONTINUED FEVERS brought
under one View, as in the following TABLE.
IN THE CURE OF CONTINUED FE-
VERS, THE INDICATIONS ARE,
I. To moderate the violence of re-action, which may be
done, by
1. Diminishing the action of the heart and arteries, by
A. Avoiding or moderating those irritations which are
almost constantly applied to the body, as,
a. The impressions made upon our senses, particularly,
a. Increased heat, whether arising from
aa. External heat, or,
bb. The accumulation of the heat of the body.
b. The exercise of the body,
c. The exercise of the mind,
d. The taking in of aliments,
e. Particular irritations, arising from
a. The sense of thirst,
b. Crudities 

80 PRACTICE
b. Crudities, or corrupted humours in the stomach,
c. The preternatural retention of fœces,
d. A general acrimony of the fluids.
B. Employing certain sedative powers, as
a. Cold,
b. Refrigerants, the chief of which are,
a. Acids of all kinds,
b. Neutral salts,
c. Metallic salts.
C. Diminishing the tension and tone of the arterial
system, by
a. blood-letting,
b. Purging.
2. Taking off the spasm of the extreme vessels, by
A. Internal means, which are
a. Those remedies which determine to the surface, as,
a. Diluents,
b. Neutral salts,
c. Sudorifics,
d. Emetics.
b. Those remedies named Antispasmodics.
B. External means, as
a. Blistering,
b. Warm bathing.
II. To remove the causes, or obviate the effects of debi-
lity, by
I. Supporting and increasing the action of the heart and
arteries, by
A. Tonics, as
a. Cold.
b. Tonic medicines, which are either
a. Fossil, as
aa. Saccharum saturni, &c. or,
b. Vegetable, as,
aa. Peruvian bark.
B. Stimulants, as,
a. Aromatics, &c.
b. Wine.
III. To obviate or correct the tendency of the fluids to pu-
trefaction, by
I. Avoiding the application of putrid or putrescent mat-
ter, by
A. Removing the patient from places filled with cor-
rupted air,
B. Avoiding 

OF PHYSIC. 81
B. Avoiding the accumulation of the patient's own ef-
fluvia, by
a. A constant ventilation,
b. Frequently changing the bed-cloaths and body-
linen.
C. Removing carefully and speedily all excremental
matters,
D. Avoiding animal food.
2. Evacuating the putrid or putrescent matter already pre-
sent in the body, by
A. Evacuating frequently the intestines,
B. Supporting the excretions of perspiration and urine, by
a. Diluents,
b. Neutral salts.
3. Correcting the putrid or putrescent matter remaining
in the body, by
A. Diluents,
B. Antiseptics.
4. Resisting farther putrefaction, or obviating its effects, by
Supporting the tone of the vessels, by
Tonic remedies.
5. Moderating the violence of re-action, considered as a
means of increasing putrefaction, as in I.A.B.C.
SECT. II
OF THE CURE OF INTERMITTENT
FEVERS.
CCXXIII.
It still remains to consider the cure of intermittent
fevers; and, with respect to these, we form also three
general indications.
1. In the time of intermission, to prevent the recur-
rence of paroxysms.
2. In
L

82 PRACTICE
2. In the time of paroxysms, to conduct these so as
to obtain a final solution of the disease.
3. To take off certain circumstances which might
prevent the fulfilling of the two first indications.
CCXXIV.
The first indication may be answered in two ways;
1. By increasing the action of the heart and arteries
some time before the period of accession, and supporting
that increased action till the period of the accession be
over, and thus to prevent the recurrence of the atony
and spasm of the extreme vessels which give occasion to
the recurrence of paroxysms.
2. By supporting the tone of the vessels, and thereby
preventing atony, and the consequent spasm, without
increasing the action of the heart and arteries, the re-
currence of paroxysms may be prevented.
CCXXV.
For the purpose mentioned in (CCXXIV. 1.) the
action of the heart and arteries may be increased;
1. By various stimulant remedies, internally given,
or externally applied, and that, without exciting sweat.
2. By the same remedies, or others so managed as to
excite sweating, and to support that sweating till the
period of accession be for some time past.
3. By emetics, supporting, for the same time, the
tone and action of the extreme vessels.
CCXXVI.
The tone of the extreme vessels may be supported
without increasing the action of the heart and arteries,
(CCXIV. 2.) by various tonic medicines, as,
1. Astringents alone,
2. Bitters alone,
3. Astringents and bitters conjoined,
4. Astringents and aromatics conjoined,
5. Certain metallic tonics; and,
Lastly, Opiates.
A good 



OF PHYSIC. 83
A good deal of exercise, and as full a diet as the con-
dition of the patient's appetite and digestion may allow
of, will be proper during the time of intermission, and
may be considered as belonging to this head.
CCXXVII.
Of all the tonic remedies mentioned, (CCXXVI.)
the most celebrated, and perhaps the most certainly ef-
fectual, is the Peruvian bark, the tonic power of which
we have endeavoured to demonstrate above, (CCVIII.)
and have, at the same time, explained its use in conti-
nued fevers. In intermittents, the same observation, as
made in (CCX.) is more especially proper; and these
further observations or rules may be offered here:
1. That the bark may be employed with safety at any
period of intermittent fevers, providing that, at the
same time, there be neither a phlogistic diathesis pre-
vailing in the system, nor any considerable or fixed con-
gestion present in the abdominal viscera.
2. The proper time for exhibiting the bark in inter-
mittent fevers, is, during the time of intermission; and
it is to be abstained from in the time of paroxysms.
3. In remittents, though no intire apyrexia occurs,
the bark may be given during the remissions; and it
should be given, even though the remissons be incon-
siderable, if, from the known nature of the epidemic,
intermissions or considerable remissions are not to be 
soon expected, and that great danger is apprehended
from repeated exacerbations.
4. In the case of genuine intermittents, while a due
quantity of bark is to be employed, the exhibition of
it ought to be brought as near to the time of accession
as the condition of the patient's stomach will allow.
5. In all eases of intermittents, it is not sufficient
that the recurrence of paroxysms be stopped for once by
the use of the bark; a relapse is commonly to be ex-
pected, and should be prevented by the exhibition of
the bark, repeated at proper intervals.
CCXXVIII.

84 PRACTICE
CCXXVIII.
Our second indication for conducting the paroxysms
of intermittent fevers, so as to obtain a final solution of
the disease, may be answered,
1. By exhibiting emetics during the time of the cold
stage, or at the beginning of the hot.
2. By opiates given during the time of the hot stage.
CCXXIX.
The circumstances which may especially prevent the
fulfilling of those two indications, and therefore give
occasion to our third, are, a phlogistic diathesis pre-
vailing in the system, and congestions fixed in the ab-
dominal viscera. The first must be removed by blood-
letting, and the antiphlogistic regimen; the second,
by vomiting and purging.
BOOK 

BOOK II.
OF INFLAMMATIONS,
OR PHLEGMASIÆ.
CHAP. I.
OF INFLAMMATION IN GENERAL.
SECT. I.
OF THE PHENOMENA OF IN-
FLAMMATION.
CCXXX.
WHEN any part upon the surface of the body
is affected with unusual redness, heat, pain, and
tumour, we name the disease an Inflammation or Phleg-
masia. These symptoms of inflammation are never
considerable, without the whole system being, at the
same time, affected with pyrexia.
CCXXXI.
As the external, so likewise the internal parts may
be affected with inflammation; and we judge them to
be so, when, together with pyrexia, there is a fixed
pain 

86 PRACTICE
pain in any internal part, attended with some interrup-
tion in the exercise of its functions.             
CCXXXII.
We judge of the presence of inflammation also from
the state of the blood drawn out of the veins. When
the blood, after cooling and concreting, shews a portion
of the gluten separated from the rest of the mass, and
lying on the surface of the crassamentum; as such se-
paration happens in all cases of more evident phlegmasia;
so, in ambiguous cases, we, from this appearance,
joined with other symptoms, conclude the presence of
inflammation. At the same time, it must be observed,
that, as several circumstances in blood-letting may pre-
vent this separation of gluten from taking place in blood
otherwise disposed to it; so we cannot always conclude,
from the want of such appearance, against the presence
of inflammation.
CCXXXIII.
We cannot easily give any other general history of
the phenomena of inflammation than what is contained
in the three preceding paragraphs; and the variations
which may take place in its circumstances, will occur
to be more properly taken notice of under the several
heads of the particular genera and species, to be here-
after mentioned. We proceed, therefore, to inquire
into the proximate cause of inflammation in general.
SECT. 

OF PHYSIC. 87
SECT. II
OF THE PROXIMATE CAUSE OF
INFLAMMATION.
CCXXXIV.
The phenomena, of inflammation (CCXXX.), all
concur in shewing, that there is an increased impetus
of the blood in the vessels of the part affected; and as,
at the same time, the action of the heart is not always
considerably increased, we presume, that the increased
impetus of the blood in the particular part, is owing
especially to the increased action of the vessels of the
part itself.
CCXXXV.
The cause of this increased action in the vessels of a
particular part is, therefore, what we are to enquire af-
ter, and to consider as the proximate cause of inflam-
mation. In many cases, we can manifestly perceive,
that inflammation arises from the application of stimu-
lant substances to the part. When the application of
such stimulants, therefore, is evident, we seek for no
other cause of inflammation; but as, in many cases,
such application is neither evident, nor, with any pro-
bability, to be supposed, we must, in such cases, seek
or some other cause of the increased impetus of the
blood in the vessels of the part.
CCXXXVI.
Many physicians have supposed, that an obstruction
of the extreme vessels, any how produced, may prove a
cause 

88 PRACTICE
cause of inflammation: But many difficulties attend this
doctrine.
1. The supposition of an ERROR LOCI is not at all
probable; for the motion of the blood in the extreme
vessels is so weak and slow, as readily to admit a retro-
grade course of it; and, therefore, if a particle of
blood should happen to enter a vessel whose branches
will not allow its passage, it will be moved backwards
till it meet with a vessel fit for transmitting it; and the
frequent ramifications and anastomoses of the extreme
arteries are very favourable to this.
2. The supposition of a preternatural lentor, or vis-
cidity of the blood, is not well founded; for it is pro-
bable, that nature has specially provided against a state of
the fluids, so incompatible with the exercise of the most
important functions of the animal œconomy. While
motion continues to prevent any separation of parts, and
heat continues to preserve the fluidity of the more viscid,
there seems to be always so large a proportion of water
present, as to give a sufficient fluidity to the whole.
3. We presume, that no general lentor does ever take
place; because, if it did, it must shew more considerable
effects than commonly appear.
4. There are no experiments directly in proof of a
preternatural lentor prevailing in the mass of blood;
nor is there any evidence of certain parts of the blood
occasionally acquiring a greater density and force of co-
hesion than ordinary; neither is there any proof of the
denser, or more coherent parts being present in the mass
of blood in such greater proportion than usual, as to
occasion a dangerous spissitude. The experiments of
Doctor Browne Langrish on this subject afford no con-
clusion, having been made on certain parts of the blood
separated from the rest, without attending to the cir-
cumstances of blood-letting, which very much alter the
state of the separation and concretion of the blood drawn
out of the veins.
5. In the particular case of inflammation, there are
several circumstances which render it probable, that the
blood is then more fluid than usual.
6. Though an obstruction should be supposed to take
place, it will not be sufficient for producing the effects
appearing 

OF PHYSIC. 89
appearing in inflammation. An obstruction of one vessel
does not, as has been imagined, increase the velocity of
the blood in the neighbouring vessels which are free; and,
in fact, it appears from many observations and expe-
riments, that considerable obstructions may be formed,
and may subsist, without producing the symptoms of in-
flammation.
CCXXXVII.
Obstruction, therefore, is not to be considered as the
primary cause of inflammation; but, at the same time,
it is sufficiently probable, that some degree of obstruc-
tion does take place in every case of inflammation. The
distention, pain, redness, and tumour attending inflam-
mation, are only to be explained by supposing, that the
extremities of the arteries do not readily transmit the
unusual quantity of blood, impelled into them by the
increased action in the course of these vessels. Such an
obstruction may be supposed to happen in every case of
an increased impetus of the blood; but it is probable,
that, in the case of inflammation, there is also a pre-
ternatural resistence to the free passage of the fluids.
CCXXXVIII.
From the doctrine of fever, we are led to believe,
that an increased action of the heart and arteries is not
supported for any length of time, by any other means
than a spasm affecting the extreme vessels; and that the
same spasm takes place in inflammation, seems probable
from hence, that every considerable inflammation is in-
troduced by a cold stage, and is accompanied with that
and the other circumstances of pyrexia; and it seems also
probable, that something analogous to this occurs even
in the case of those inflammations, which seem less
considerable, and to be purely topical.
CCXXXIX.
From ail this, the nature of inflammation may often
be explained in the following manner. Some causes of
inequality
M 

90 PRACTICE
inequality in the distribution of the blood may throw an
unusual quantity of it upon particular vessels, to which
it must necessarily prove a stimulus. But, further, it is
probable, that, to relieve the congestion, the vis medi-
catrix naturæ increases still more the action of these ves-
sels, which it effects, by the formation of a spasm on
their extremities, as in all other febrile diseases.
CCXL.
A spasm, therefore, of the extreme arteries, sup-
porting an increased action in the course of them, may
be considered as the proximate cause of inflammation, at
least, in all eases not arising from direct stimuli applied.
CCXLI.
That, in inflammation, there is the concurrence of
a constriction of the extreme vessels, with an increased
action in the other parts of them, seems probable, from
the consideration of Rheumatism. This is a species of
inflammation which is often manifestly produced, either
by cold applied to over-distended vessels, or by causes of
an increased impetus, and over-distention in vessels previ-
ously constricted. Hence, the disease especially appears
at seasons liable to frequent and considerable vicissitudes
of heat and cold.
To this we may add, that the parts of the body most
frequently affected with inflammation, are those exposed,
both to over-distention, from a change in the distribution
of the fluids, and, at the same time, to the immediate
action of cold. Hence, quinsies and pneumonic in-
flammations are more frequent than any others.
CCXLII.
That a spasm of the extreme vessels takes place in
inflammation, we presume further from what is at the
same time the state of the whole arterial system. In
every considerable inflammation, though arising in one
part only, an affection is communicated to the whole
system, in consequence of which an inflammation is
readily 

OF PHYSIC. 91
readily produced in other parts besides that first affected.
This general affection is well known to physicians, un-
der the name of the DIATHESIS PHLOGISTICA. It
appears most commonly in persons of the most rigid
fibres is often manifestly induced by the tonic, or
astringent powers of cold; is increased by all tonic and
stimulant powers applied to the body; is always attended
with a hardness of the pulse; and is most effectually
taken off, by the relaxing power of blood-letting. From
these circumstances, it seems probable, that the diathesis
phlogistica consists in an increased tone, or contractility,
and perhaps contraction of the muscular fibres of the
whole arterial system. Such a state of the system pre-
sumes a spasm of the extreme vessels, and the general
state commonly arises from that begun in a particular
part; though it be also probable, that the general state
may arise and subsist, for some time, without the ob-
vious inflammation of any particular parts.
CCXLIII.
We have thus endeavoured, in the case of inflam-
mation, to explain the state of the whole system, as well
as that of the part more particularly affected, and this
last, as in its first formation; but, when it subsists for
some time, various changes take place in the part af-
fected, of which we must now take notice.
SECT. III.
OF THE TERMINATIONS OF IN-
FLAMMATION.
CCXLIV.
If an inflammation be cured while the state and texture
of the part remain entire, the disease is said to be ter-
minated by RESOLUTION. This happens when the
previous 

92 PRACTICE
previous congestion and spasm have been in a moderate
degree, and the increased impetus of the blood has been
sufficient to overcome the spasm, to dilate the vessels,
and to remove the congestion, so that the part is restored
to its ordinary and healthy state.
A resolution takes place also when the increased im-
petus of the fluids has produced an increased exhalation
into the adjoining cellular texture, or, an increased ex-
cretion in some neighbouring part, and has thereby re-
lieved the congestion in the vessels, and relaxed the spasm
of the inflamed part.
Lastly, a resolution may take place, when the in-
creased impetus of the blood in the whole system occa-
sions such an evacuation, which, though in a distant
part, may prove sufficient to take off the phlogistic dia-
thesis of the whole system, and thereby relieve the con-
gestion and spasm of the particular part affected by in-
flammation.
CCXLV.
The tumour which appears in inflammation may be
imputed in part to the congestion of fluids in the vessels;
but is owing chiefly to an effusion of matter into the
adjoining cellular texture, and, accordingly, tumours
seldom appear but in parts adjoining to a lax cellular
texture. If, in this case, the matter effused be only a
larger quantity of the ordinary exhaled fluid, this, when
the free circulation in the vessels is restored, will be
readily absorbed, and the state of the part will become
the same as before. But, if the increased impetus of
the blood in an inflamed part dilate the exhalant vessels
to such a degree, that they pour out an entire serum,
this will not be so readily re-absorbed; and, from the
experiments of Sir John Pringle and Mr. Gaber, we
learn, that, under stagnation, the serum may undergo a
particular change, by having the gluten present in it
hanged into a white, opaque, moderately viscid, mild
liquor, which we name Pus. When this change hap-
pens in the inflamed part, as it is at the same time at-
tended with an abatement of the redness, heat, and pain
which formerly distinguished the inflammation, the dis-
ease is said to be terminated by SUPPURATION; and an
inflamed

OF PHYSIC. 93
inflamed part containing a collection of pus, is called
an ABSCESS.
CCXLVI.
In inflammation, the tendency of it to suppuration
may be discovered, by the continuance of the inflam-
mation, without the symptoms of resolution; by some
remission of the pain of distention; and by the pain be-
ing of a throbbing kind, more distinctly connected with
the pulsation of the arteries; by the pulse of the arte-
ries being fuller and softer, and often, by the patient's
being affected frequently with cold shiverings. The
period at which this takes place is not determined, but is
sometimes sooner, sometimes later. When the tendency
is determined, the time necessary to a complete suppura-
tion is different in different cases. When pus is com-
pletely formed, the pain formerly in the part entirely
ceases, and a weight is felt in it. If the collection is
formed immediately under the skin, the tumour becomes
pointed, the part becomes soft, and the fluctuation of
the fluid within can be commonly perceived; and, at
the same time, for the most part, the redness of the
skin formerly prevailing is entirely gone.
CCXLVII.
In abscesses, while the pus is formed of one part of
the matter which had been effused, the other and thin-
ner parts are re-absorbed, so that, in the abscess, when
opened, a pus alone appears. This pus, however, is
not the converted gluten, alone; for the conversion of
this being the effect of a particular fermentation, which
may affect the solid substance of the part, and perhaps
every solid of animal bodies; so it most readily, and
particularly, affects the cellular texture, and thereby a
great deal of this is eroded, and forms a part of the pus;
and it generally happens also, that some of the smaller
red vessels are eroded, and some red blood appears mixed
with the pus in abscess. Upon the whole, the in-
ternal surface of an abscess is to be considered as an ul-
cerated part.
CCXLVIII.

94 PRACTICE
CCXLVIII.
This account of suppuration explains, why an ab-
scess, when formed, may either spread into the cellular
texture of the neighbouring parts, or, by eroding the
incumbent teguments, be poured out upon the surface
of the body, and produce an open ulcer.
CCXLIX.
The matter of abscesses, and of the ulcers following
them, is various, according to the nature of what is
effused, and which may be,
1. A matter thinner than serum.
2. An entire and pure serum.
3. A quantity of red globules.
4. A matter furnished by particular glands seated in
the part.
It is the second only which affords a proper pus, the
effusion whereof, whether in abscess or ulcers, seems
to be the peculiar effect of an inflammatory state of the
vessels; and from this cause it is, that, when ulcers do
not produce a proper pus, a circumstance always ab-
solutely necessary to their healing, we, in many cases,
bring the ulcers to a state of suppuration, by the ap-
plication of stimulants exciting inflammation, such as
balsams, mercury, copper, &c.
CCL.
When the matter effused into the cellular texture of
an inflamed part, is tainted with a putrid ferment, this
produces, in the effused matter, a change, approaching
more or less to a complete putrefaction. When this is
in a moderate degree, and affects only the fluids effused,
with the substance of the cellular texture, the part is
said to be affected with GANGRENE; but, if the pu-
trefaction affect also the vessels and muscles of the part,
the disease is said to be a SPHACELUS.
CCLI.

OF PHYSIC. 95
CCLI.
A gangrene, and its consequences, may arise from a
putrid ferment acting on the matter, which is most com-
monly effused; but it may also arise from the peculiar
nature of the matter effused being disposed to putre-
faction; as particularly seems to be the case of the red
globules of the blood effused in a large quantity. In a
third manner also, a gangrene seems frequently to arise,
from the violent excitement of the inflammation de-
stroying the tone of the vessels; whereby the whole
fluids stagnate, and run into putrefaction, which taking
place in any degree, destroys further the tone of the
vessels, and spreads the gangrene.
CCLII.
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 colour of the inflamed part changing from a clear
to a dark red, by blisters arising upon the part, by the
part becoming soft, flaccid, and insensible, and by the
ceasing of all pain while these appearances take place. 
As the gangrene proceeds, the colour of the part
becomes livid, and, by degrees, quite black, the heat
of the part entirely ceases, the softness and flaccidity of
the part increases, it loses its consistence, exhales a ca-
daverous smell, and may then be considered as affected
with sphacelus.
CCLIII.
Gangrene is thus a third manner in which inflam-
mation terminates, and the schools have commonly
marked a fourth termination of inflammation; which
is, by a schirrus, or an indolent hardness of the part
formerly affected with inflammation. This, however,
is a rare occurrence, and does not seem to depend so
much 

96 PRACTICE
much upon the nature of inflammation, as upon the cir-
cumstances of the part affected. It is in glandular parts
chiefly that schirrosity is observed, and which is owing
to the parts readily admitting a stagnation of the fluids.
We have observed, that inflammation seldom induces
schirrus, which more commonly arises from other causes,
and when inflammation supervenes, which it is sooner
or later apt to do, it does not so commonly increase as
change the schirrosity, into some kind of abscess. From
these considerations, it does not seem necessary to take
any further notice of schirrus, as a termination of in-
flammation.
CCLIV.
There are, however, some other terminations of in-
flammation not commonly taken notice of, but now to
be mentioned. One is, by the effusion of a portion of
the entire mass of blood, either by means of rupture
or anastomosis, into the adjoining cellular texture.
This happens especially in inflammations of the lungs,
where the effused matter, by compressing the vessels, and
stopping the circulation, occasions a fatal suffocation;
and this is perhaps the manner in which peripneumony
most commonly proves fatal.
CCLV.
Another kind of termination is, that of certain in-
flammations on the surface of the skin, when there is
poured out under the cuticle a fluid, too gross to pass  
through its pores, and which therefore separates it from
the skin, and raises it up into the form of a vesicle con-
taining the effused fluid; and by which effusion the pre-
vious inflammation is taken off.
CCLVI.
Besides these already mentioned, I believe there is
still another manner in which inflammation terminates.
When the internal parts are affected with inflammation,
there appears almost always upon their surface an ex-
sudation, 

OF PHYSIC. 97
sudation, which appears partly in a viscid concretion
upon their surface, and partly in a thin serous fluid, ef-
fused into the cavities in which the inflamed viscera are
placed. Though these appearances very constantly ac-
company those inflammations which have proved fatal,
it is, however, probable, that like circumstances may
attend these inflammations terminated by resolution, and
may contribute to that event, as there are instances of
pneumonic inflammation terminating in a hydrothorax.
SECT. IV.
OF THE REMOTE CAUSES OF
INFLAMMATION.
CCLVII.
The remote causes of inflammation may be reduced
to four heads.
1. The application of stimulant substances, among
which are to be reckoned the action of fire, or burning.
2. External violence operating mechanically in
wounding, bruising, or overstretching the parts.
3. Extraneous substances, lodged in any part of the
body, though they be neither of an acrid quality, nor
of a pointed form.
4. Cold, in a certain degree, not sufficient imme-
diately to produce gangrene.
It will not be difficult to understand, how these re-
mote causes, singly, or in concurrence, produce the
proximate cause of inflammation.
CCLVIII.
N 

98 PRACTICE
CCLVIII.
We cannot perceive, that, in different cases of in-
flammation, there is any difference in the state of the
proximate cause, except in the degree; and, though
some difference of inflammation may arise from the dif-
ference of its remote causes, this is not necessary to be
taken notice of here; because the different appearances
which attend different inflammations, may be referred,
for the most part, to the difference of the part affected,
as will appear, when we shall consider the several genera
and species marked in the Nosology. In treating of
these, we shall find a more proper occasion for taking
notice of the different states of the proximate, or of the
differences of the remote cause, than by treating of them
in general here.
SECT. V.
OF THE CURE OF INFLAM-
MATION.
CCLIX.
The indications of cure in inflammation are different,
according as it may be still capable of resolution, or
may have taken a tendency to the several other termina-
tions above mentioned. Its tendency to these last is not
always at first obvious; and, therefore, upon the first
appearance

OF PHYSIC. 99
appearance of inflammation, the cure of it, by resolution,
is always to be attempted. The indications of cure,
for this purpose, are,
1. To remove the remote causes, when they are
evident, and continue to operate.
2. To take off the phlogistic diathesis affecting the
whole system, or the particular part.
3. To take off the spasm of the particular part, by
remedies applied to the whole system, or to the part
itself.
CCLX.
The means of removing the remote causes will readily
occur, from considering the particular nature and cir-
cumstances of the different kinds. Acrid matters must
be removed, or their action must be prevented, by the
application of demulcents. Compressing and over-
stretching powers must be taken away, and, from their
several circumstances, the means of doing so will be
be obvious.
CCLXI.
The means of taking off the phlogistic diathesis of
the system are the same with those for diminishing the
violence of re-action in fever, which are mentioned and
treated of from (CXX.) to (CXLIII), and therefore
need not be repeated here.
CCLXII.
The means of taking off the spasm of the particular
part are much the same as those mentioned above, for
taking off the spasm of the extreme vessels in the case
of fever, and which are treated of from (CXLIV.)  to
(CXCIV.) Only it is to be observed, that topical
bleedings are here especially indicated, and that some of
the other remedies are to be directed more exactly to
the part particularly affected; the management of which
will be more properly considered when we shall treat of
particular inflammations.
CCLXIII. 

100 PRACTICE
CCLXIII.
When a tendency to suppuration (CCXLVI.) is
distinctly perceived, as we suppose it to depend upon
the effusion of a fluid, which cannot be easily reabsorbed,
so it becomes necessary that this fluid be converted into
pus as the only natural means of obtaining its evacuation;
and, as the effusion is, perhaps, seldom made without
some rupture of the vessels, to the healing of which a
pus is absolutely necessary; so, in the case of a tendency
to suppuration, the indication of cure always is, to
promote the production of a perfect pus as quickly as
possible.
CCLXIV.
For this purpose, various remedies, supposed to possess
a specific power, have been proposed; but we can per-
ceive no such power in any of them; and, in my opinion,
all that can be done is, to favour the suppuration by such
applications, as may support a moderate heat in the part,
as by some tenacity may confine the perspiration of the
part, and as, by an emollient quality, may weaken the
cohesion of the teguments, and favour their erosion.
CCLXV.
As in the case of certain effusions, a suppuration is
not only unavoidable, but desireable, it may be supposed,
that most of the means of resolution formerly mentioned
should be avoided; and accordingly our practice is com-
monly so directed. But, as we observe, on the one
hand, that a certain degree of increased impetus, or of
the original symptoms of inflammation, is necessary to
produce a proper suppuration, so it is then especially ne-
cessary to avoid those means of resolution which may
diminish too much the force of the circulation. And,
on the other hand, as the impetus of the blood, when
violent, is found to prevent the proper suppuration, so,
in such cases, though a tendency to suppuration may
have

OF PHYSIC. 101
have begun, it may be proper to continue those means
of resolution which moderate the force of the circulation.
With respect to the opening of abscesses, when com-
pletely formed, we refer to the writings on surgery.
CCLXVI.
When an inflammation has taken a tendency to gan-
grene, that event is to be prevented by every possible
means; and these must be different according to the
nature of the several causes occasioning that tendency,
which may be understood from what has been already
said of these causes. After a gangrene has in some de-
gree taken place, it can be cured only by the separation
of the dead from the living parts. This, in certain
circumstances, can be performed, and most properly,
by the knife.
In other eases, it can be done by exciting a suppu-
ratory inflammation on the verge of the living part,
whereby its cohesion with the dead may be every where
broken off, so that the latter may fall off by itself.
While this is doing, it is proper to prevent the further
putrefaction of the part, and its spreading wider. For
this purpose, various antiseptic applications have been
proposed; but we are of opinion, that, while the te-
guments are entire, these applications can hardly have
any effect; and, therefore, that the fundamental pro-
cedure must be to scarify the part so as to reach the
living substance, and, by the wounds made there, to
excite the suppuration required. By the same incisions
also, we give access to antiseptics, which may both
prevent the progress of the putrefaction in the dead, and
excite the inflammation necessary on the verge of the
living part.
CCLXVII.
When the gangrene proceeds from a loss of tone,
and when this, communicated to the neighbouring parts,
prevents that inflammation which, as we have said, is
necessary to the separation of the dead part from the
living, it will be proper to obviate this loss of tone by
tonic 

102 PRACTICE
tonic medicines given internally; and, for this purpose,
the Peruvian bark has been found to be especially ef-
fectual. That this medicine operates by a tonic power,
we have endeavoured to prove above (CCVIII.); and,
from what is said in (CCIX.) the limits of its use also
may be learned. When the gangrene arises from the
violence of inflammation, the bark may not only fail of
proving a remedy, but may do harm; and its power as
a tonic is especially suited to those cases of gangrene,
which proceed from an original loss of tone, as in the
case of palsy and œdema, or in those cases of inflam-
mation where a loss of tone takes place, while the
original inflammatory symptoms are removed.
CCLXVIII.
The other terminations of inflammation, either do
not admit of any treatment, except that of preventing
them by the means of resolution, or they belong to a
treatise of surgery, rather than to this place.
And, therefore, having thus delivered the general
doctrine, we proceed now to consider the particular
genera and species of inflammation. We have hinted
above, that the difference of inflammation arises
chiefly from the difference of the part affected;
and we have, in the first place, arranged them, as they
are cutaneous, visceral, or articular; in which order
we are now to consider them.
CHAP. 

OF PHYSIC. 103
CHAP. II
OF INFLAMMATION MORE
STRICTLY CUTANEOUS.
CCLXIX.
Cutaneous inflammations are of two kinds, com-
monly distinguished by the names of PHLEGMON and
ERYSIPELAS.
Of the latter there are two cases, which ought to be
distinguished by different appellations. When the dis-
ease is an affection of the skin alone, and very little of
the whole system, or when the affection of the system is
only symptomatical of the external inflammation,
we shall give the disease the name of ERYTHEMA; and,
when the external inflammation is an exanthema, and
symptomatical of an affection of the whole system, we
shall then name the disease ERYSIPELAS.
CCLXX.
It is the erythema only that we are to consider here.
For the difference, of the appearances in the phlegmon
and erythema, we refer to our Nosology; and we shall
here only observe, that the difference of these appear-
ances seems to depend on the different seat of the in-
flammation. In the phlegmon, the inflammation seems
to affect especially the vessels on the internal surface of
the skin communicating with the lax subjacent cellular
texture; whence a more copious effusion, and that too
of serum, convertible into pus, takes place. In the
erythema, the affection is of the vessels on the external
surface of the skin, communicating with the rete mu-
cosum, which does not admit  of any effusion, but what
separates the cuticle, and gives occasion to the formation 
of

104 PRACTICE
of a blister, while the smaller size of the vessels admits
only of the effusion of a thin fluid, very seldom con-
vertible into pus.
Besides these differences in the circumstances of these
two kinds of inflammation, it is probable that they
differ also with respect to their causes. Erythema is the
effect of all kinds of acrids externally applied to the
skin; and, when it arises from an internal cause, it is
from an acrimony poured out on the surface of the skin
under the cuticle. In the phlegmon, an acrimony is
not commonly evident.
CCLXXI.
These differences in the seat and causes of the phleg-
mon and erythema, being admitted, it will appear, that
the erythema must affect those internal parts only, whose
surfaces are covered with an epithelion, or membrane,
analogous to the cuticle. The same difference of causes,
and of the seat now marked, will also explain what has
been delivered by practical writers, with respect to the
cure of these different cutaneous inflammations. But
we shall not prosecute this here, because it falls under
the province of surgery, which, in this course, we can-
not enter into. For the same reason, we shall not say
any thing of the variety of external inflammation, which
might otherwise be considered here.
CHAP. III.
OF OPHTHALMIA, OR INFLAM-
MATION OF THE EYE.
CCLXXII.
The inflammation of the eye may be considered as of
two kinds, according as it is seated in the membranes of
the 

OF PHYSIC. 105
the ball of the eye, when we name it OPHTHALMIA
MEMBRANARUM, or as it is seated in the sebaceous
glands placed in the tarsus, or edges of the eye-lids, in
which case it may be termed OPHTHALMIA TARSI.
These two kinds are very frequently connected to-
gether, as the one may readily  excite the other; but
they are still to be distinguished according as the one or
the other may happen to be the primary affection.
CCLXXIII.
The inflammation of the membranes of the eye af-
fects especially  and most frequently, the adnata, and
appears in a turgescence of its vessels; so that the red
vessels which are naturally there, become not only in-
creased in size, but many more appear than did in a na-
tural state. This turgescence of the vessels is attended
with pain, especially upon the motion of the ball of the
eye; and this irritation, like every other, applied to the
surface of the eye, produces an effusion of tears from
the lachrymal gland.
The inflammation commonly, and chiefly, affects the
adnata spread on the anterior part of the bulb of the
eye; but usually spreads also along the continuation of
the adnata on the inside of the palpebræ; and, as that
is extended on the tarsus palpebrarum, the excretories
of the sebaceous glands opening there are also frequently
affected. When the affection of the adnata is consi-
derable, it may be communicated to the subjacent mem-
branes of the eye, and even to the retina itself, which
thereby acquires so great a sensibility, that every im-
pression of light becomes painful.
CCLXXIV.
The inflammation of the membranes of the eye is in
different degrees, according as the adnata is more or less
affected, or according as the inflammation is either of
the adnata alone, or of the subjacent membranes also;
and, upon these differences, different species have been
established, and different appellations given to them.
But we shall not prosecute the consideration of these,
being
O 

106 PRACTICE
being of opinion, that all the cases of the Ophthalmia
membranarum differ only in degree, and are to be cured
by remedies of the same kind, more or less employed.
CCLXXV.
The proximate cause of Ophthalmia is not different
from that of inflammation in general; and the different
circumstances of Ophthalmia may be explained by the
difference of its remote causes, and by the different parts
of the eye which it happens to affect; as may be un-
derstood from what has been already said. We now
proceed to consider the CURE.
CCLXXVI.
The Ophthalmia membranarum requires the remedies
proper for inflammation in general; and, when the
deeper-seated membranes are affected, and especially
when a pyrexia is present, large general bleedings may
be necessary. But this last is seldom the case; and, for
the most part, the Ophthalmia is an affection purely lo-
cal, accompanied with little or no pyrexia. General
bleedings, therefore, have little effect upon it, and the
cure is chiefly to be obtained by topical bleedings, that
is, blood drawn from vessels near the inflamed part; and
opening the jugular vein or the temporal artery, may
be considered as in some measure of this kind. It is
commonly sufficient to apply a number of leeches round
the eye; and it is perhaps better still to draw blood by
cupping and scarifying upon the temples. In many
cases, the most effectual remedy is, that of scarifying
the internal surface of the inferior eye-lid, and cutting
the turgid vessels upon the adnata itself,
CCLXXVII.
Besides blood-letting, purging, as a remedy suited to
inflammation in general, has been considered as pecu-
liarly adapted to inflammations in any of the parts of
the head, and therefore to Ophthalmia; and it is some-
times useful; but, for the reasons given before with
respect 

OF PHYSIC. 107
respect to general bleeding, purging in the case of Oph-
thalmia does not prove useful in any proportion to the
evacuation excited.
CCLXXVIII.
For relaxing the spasm in the part, and taking off the
determination of the fluids to it, blistering near the part
has commonly been found useful.
CCLXXIX.
Ophthalmia, as an external inflammation, admits of
topical applications. All these, however, which en-
crease the heat and relax the vessels of the part, prove
hurtful; and the admission of cool air to the eye, and
the application of cooling and astringent medicines,
which at the same time do not produce irritation, prove
useful.
CCLXXX.
In the cure of Ophthalmia, much care is requisite to
avoid all irritation, particularly that of light; and the
only and certain means of doing this, is by keeping the
patient in a very dark chamber.
CCLXXXI.
These are the remedies of the Ophthalmia membra-
narum; and, in the Ophthalmia tarsi, so far as it is
produced by the Ophthalmia membranarum, the same
remedies may be necessary. As, however, the Oph-
thalmia tarsi may often depend upon an acrimony de-
posited in the sebaceous glands of the part, so it may
require various internal remedies according to the variety
of the acrimony in fault, for which we must refer to the
consideration of scrophula, syphilis, or other diseases
with which this Ophthalmia may be connected; and,
where these shall not be evident, certain remedies, more
generally adapted to the evacuation of acrimony, such
as mercury, may be employed.
CCLXXXII. 

108 PRACTICE
CCLXXXII.
In the Ophthalmia tarsi, it almost constantly happens,
that some ulcerations are formed on the tarsus. These
require the application of mercury or copper, which
alone may sometimes cure the whole affection; and they
may be useful even when the disease depends upon a fault
of the whole system.
CCLXXXIII.
Both in the Ophthalmia membranarum, and in the
Ophthalmia tarsi, it is necessary to obviate that gluing
together of the eye-lids which commonly happens in
sleep; and which may be done by insinuating a little of
any mild unctuous medicine between the eye-lids before
the patient shall go to sleep.
CHAP IV.
OF PHRENSY, OR PHRENITIS.
CCLXXXIV.
This is an inflammation of the parts contained in the
cavity of the cranium, and may affect either the mem-
branes of the brain, or the substance of the brain itself.
Nosologists have thought, that the two cases might be
distinguished by different symptoms, and therefore by
different appellations; but we do not find this confirmed
by observation and dissection; and therefore shall treat
of both cases under the title of Phrensy, or Phrenitis.
CCLXXXV. 

OF PHYSIC. 109
CCLXXXV.
An idiopathic phrensy is a rare occurrence, a sym-
pathic more frequent, and the ascertaining either the
one or the other is, on many occasions, difficult, as the
symptoms by which the disease is most commonly judged
to be present, appear sometimes without internal inflam-
mation; and dissections have shewn, that the brain had
been inflamed, when few of the peculiar symptoms of
inflammation had appeared before.
CCLXXXVI.
The symptoms by which it may be most certainly
known are, an acute pyrexia, a violent head-ach, a
redness of the face and eyes, an impatience of light or
noise, a constant watching, and a delirium impetuous
and furious. Some nosologists have thought these sym-
ptoms peculiar to an inflammation of the membranes,
and that the inflammation of the substance of the brain
was to be distinguished by some degree of coma attending
it. It is for this reason that in the Nosology I have
added the typhomania, to the character of Phrenitis;
but, upon farther reflection, I find no proper founda-
tion for this; and, if we pass from the characters above
delivered, there will be no fixing the variety that occurs.
CCLXXXVII.
The remote causes of phrensy, are all those which di-
rectly stimulate the membranes, or substance, of the
brain, and particularly all those which increase the im-
petus of the blood in the vessels of the brain. The
passions of the mind, and certain poisons, are amongst
the remote causes of phrensy; but, in what manner they
operate, is not well understood.
CCLXXXVIII.
The cure of phrensy is the same with that of inflam-
mation in general; but here the most powerful remedies
are 

110 PRACTICE
are to be immediately employed. Large and repeated
bleedings are especially necessary, and these too taken
from vessels as near as possible to the part affected. The
opening of the temporal artery has been recommended,
and with some reason; but the practice is attended with
inconvenience; and we believe that the opening the
jugular veins may prove more effectual; with which,
however, may be joined, the drawing of blood from
the temples by cupping and scarifying.
CCLXXXIX.
It is probable that purging may be of more use in
this than in some other inflammatory affections, as it
may operate by revulsion. For the same purpose of re-
vulsion, warm pediluvia are a remedy, but somewhat
ambiguous. The taking off the force of the blood in
the vessels of the head by an erect posture, is commonly
useful.
CCXC.
Blistering is generally useful in this disease, but
chiefly, when applied near to the part affected.
CCXCI.
Every part of the antiphlogistic regimen is here ne-
cessary, and particularly the admission of cold air. Even
cold substances applied close to the head, have been
found useful, and the application of such refrigerants as
vinegar is certainly proper.
CCXCII.
It appears certain, that opiates are hurtful in every
inflammatory state of the brain; and it is to be observed,
that, from the ambiguity mentioned in (CCLXXXV.)
the accounts of practitioners, with regard to the juvantia
and laedentia in this disease, are very uncertain.
CHAP. 

OF PHYSIC.
CHAP V.
OF THE QUINSY, OR CYNANCHE.
CCXCIII.
This name is applied to every inflammation of the in-
ternal fauces; but these are different according to the
part which may be affected, and the nature of the in-
flammation. In our Nosology, therefore, after giving
the character of the Cynanche as a genus, we have dis-
tinguished five different species, which must here like-
wise be separately considered.
SECT. I.
OF THE CYNANCHE TONSIL-
LARIS.
CCXCIV.
This is an inflammation of the mucous membrane of
the fauces, affecting especially that congeries of mucous
follicles which forms the tonsils, and from thence
spreading along the velum and uvula, so as frequently to
affect every part of the mucous membrane.
CCXCV.

112 PRACTICE
CCXCV.
The disease appears by some tumor and redness of
the parts, is attended with a painful and difficult de-
glutition; a troublesome clamminess of the mouth and
throat; a frequent, but difficult, excretion of mucus;
and the whole is accompanied with pyrexia.
CCXCVI.
This species of quinsy is never contagious; it ter-
minates frequently by resolution, sometimes by sup-
puration, but hardly ever by gangrene, although in this
disease some sloughy spots sometimes appear upon the
fauces.
CCXCVII.
This disease is commonly occasioned by cold externally
applied, particularly about the neck. It affects especi-
ally the young and sanguine, and a disposition to it is
often acquired by habit. It occurs especially in spring
and autumn, when vicissitudes of heat and cold fre-
quently take place. The inflammation and tumor are
commonly at first most considerable in one tonsil, and
afterwards abating in that, increase in the other.
CCXCVIII.
In the cure of this inflammation, some bleeding may
be proper; but large general bleedings will seldom be
necessary. The opening of the ranular veins seems to
be an insignificant remedy; and leeches set upon the ex-
ternal fauces are of more efficacy.
CCXCIX.
This inflammation may be often relieved by moderate
astringents, and particularly by acids applied to the in-
flamed parts. In many cases, nothing has been found to
give

OF PHYSIC. 113
give more relief than the vapour of warm water received
into the fauces.
CCC.
The other remedies of this disease are rubefacient, or
blistering medicines, applied externally to the neck, and
with these, the employment of antiplogistic purgatives,
as well as every part of the antiphlogistic regimen, ex-
cept the application of cold.
CCCI.
This disease, as we have said, often terminates by
resolution, frequently accompanied with sweating;
which is therefore to be prudently favoured and en-
couraged.
CCCII.
When this disease shall have taken a tendency to sup-
puration, nothing will be more useful than the frequent
taking into the fauces the steams of warm water. When
the abscess is attended with much swelling, if it break
not spontaneously, it should be opened by a lancet; and
this does not require much caution, as even the inflam-
matory state may be relieved by some scarification of the
tonsils. I have never seen any case requiring bron-
chotomy.
SECT.
P 

114 PRACTICE
SECT. II.
OF THE CYNANCHE MALIGNA.
CCCIII.
This is a contagious disease, seldom sporadic, and
commonly epidemic. It attacks persons of all ages, but
more commonly those in a young and infant state. It
attacks persons of every constitution, when exposed
to the contagion, but most readily the weak and infirm.
CCCIV.
The disease is usually attended with a considerable
pyrexia, and the symptoms of the accession of this,
such as, frequent cold shiverings, sickness, anxiety,
and vomiting are often the first appearances of the dis-
ease. About the same time, a stiffness is felt in the neck,
with some uneasiness in the internal sauces, and some
hoarseness of the voice. The internal fauces, when
viewed, appear of a deep red colour, with some tumour;
but this last is seldom considerable; and deglutition is
seldom difficult or painful. Very soon, a number of
white or ash-coloured spots appear upon the inflamed
parts. These spots spread and unite, covering almost
the whole fauces with thick sloughs, which falling off,
discover ulcerations. While these symptoms proceed in
the fauces, they are generally attended with a coryza,
which pours out a thin acrid and fœtid matter, exco-
riating the nostrils and lips. There is often also, espe-
cially in infants, a frequent purging, and a thin acrid
matter flows from the anus, excoriating this and the
neighbouring parts.
CCCV. 

OF PHYSIC. 115
CCCV.
With these symptoms, the pyrexia proceeds with a
small, frequent, and irregular pulse, and there is oc-
curring a manifest exacerbation every evening and some
remission in the mornings. A great debility appears in
the animal functions, and the sensorium is affected with
delirium, frequently with coma.
CCCVI.
On the second day, or sometimes later, efflorescences
appear upon the skin, which are sometimes in small
points, hardly eminent; but, for the most part, in
patches of a red colour, spreading and uniting, so as to
cover the whole skin. They appear fist about the face
and neck, and, in the course of some days, spread by
degrees to the lower extremities. The scarlet redness is
often considerable on the hands and extremities of the
fingers, which feel stiff and swelled. This eruption is
often irregular as to the time of its appearance, its stea-
diness, and the time of its continuance. It usually
continues four days, and goes off by some desquamation
of the cuticle; but neither on its first appearance, nor
on its desquamation, does it always produce a remission
of the pyrexia, or of the other symptoms.
CCCVII.
The progress of the disease depends on the state of the
fauces and of the pyrexia. When the ulcers on the
fauces, by their livid and black colour, by the fœtor of
the breath, and by many marks of acrimony in the
fluids, shew a tendency to gangrene, this takes place to
a considerable degree, and the symptoms of a putrid
fever constantly increasing, the patient dies often on the
third day, sometimes later, but for the most part, before
the seventh. The acrimony poured out from the dis-
eased fauces must necessarily, in part, pass into the pha-
rynx, and there spread the infection into the œsophagus,
and sometimes through the whole of the alimentary
canal, 

116 PRACTICE
canal, propagating the putrefaction, and often exhausting
the patient by a frequent diarrhoea.
The acrid matter poured out in the fauces being again
absorbed, frequently occasions large swellings  of the
lymphatic glands about the neck, and sometimes, to
such a degree, as to occasion a suffocation.
It is seldom that the organs of respiration escape en-
tirely unhurt, and very often the inflammatory affection
is communicated to them. It appears from dissections,
that, in the Cynanche maligna, the larynx and trachea
are often affected in the same manner as in the Cynanche
trachealis; and it is probable, that, in consequence of
that affection, the Cynanche maligna often proves fatal
by such a sudden suffocation as happens in the proper
Cynanche trachealis; but there is reason to suspect that
dissectors have not always distinguished properly between
the two diseases.
CCCVIII.
These are the several fatal terminations of the Cy-
nanche maligna, which, however, do not always take
place. Sometimes the ulcers of the fauces are of milder
nature, and the fever is more moderate, and of a less
putrid kind. And when, upon  the appearance of the
efflorescence on the skin, the fever suffers a remission;
when the efflorescence continues for three or four days,
till it has spread over the whole body, and ends then by
a desquamation giving a further remission of the fever;
this often terminates entirely, by gentle sweats, on or
before the seventh day; and the rest of the disease ter-
minates in a few days more, by an excretion of sloughs
from the fauces, while sleep, appetite, and the other
marks of health, entirely return. From this, and the
preceding paragraph, the prognostics in this disease may
be readily learned.
CCCIX.
In the cure of this disease, its septic tendency is chiefly
to be kept in view. The debility, with which it is at-
tended renders all evacuations by bleeding and purging
improper, 

OF PHYSIC. 117
improper, except in a few instances where the debility
is less, and the inflammatory symptoms more con-
siderable. The fauces are to be preserved from the ef-
fects of the acrid matter poured out upon them, and are
therefore to be frequently washed out by antiseptic gar-
gles or injections; and the septic tendency of the whole
system should be guarded against and corrected by internal
antiseptics, especially by the Peruvian bark given in sub-
stance from the beginning, and continued through the
course of the disease. Emetics, both by vomiting and
nauseating, prove useful. When any considerable tu-
mour occurs, blisters applied externally will be of
service, and, in any case, may be fit to moderate the in-
ternal inflammation.
SECT. III.
OF THE CYNANCHE TRA-
CHEALIS.
CCCX.
This name has been given to an inflammation of the
glottis, larynx, or upper part of the trachea, whether
it affect the membranes of these parts, or the muscles
adjoining. It may arise first in these parts, and continue
to subsist in them alone, or it may come to affect these
parts from the Cynanche tonsillaris or maligna spreading
into them.
CCCXI.
In either way it has been a rare occurrence, and few
instances of it have been marked and recorded by phy-
sicians. It is to be known by a peculiar croaking found
of the voice, by difficult respiration, with a sense of
straitening 

118 PRACTICE
straitening about the larynx, and by a pyrexia at-
tending it.
CCCXII.
From the nature of these symptoms, and from the
dissection of the bodies of persons who had died of this
disease, there is no doubt of its being of an inflam-
matory kind. It does not however always run the
course of inflammatory affections, but frequently pro-
duces such an obstruction of the passage of the air, as
suffocates, and thereby proves suddenly fatal.
CCCXIII.
If we judge rightly of the nature of this disease, it
will be obvious, that the cure of it requires the most
powerful remedies of inflammation, to be employed
upon the very first appearance of the symptoms. When
a suffocation is threatened, whether any remedies can
be employed to prevent it, we have not had experience
to determine.
CCCXIV.
The accounts which books have hitherto given us of
inflammations of the larynx, and the parts connected
with it, amount to what we have now said; and the in-
stances recorded have, almost all of them, happened in
adult persons; but there is a peculiar affection of this
kind happening to infants, which has been little taken
notice of till lately. Dr. Home is the first who has
given any distinct account of this disease; but, since he
wrote, several other authors have taken notice of it, and
have given different opinions concerning it. Concerning
this diversity of opinions, I shall not at present inquire,
but shall deliver the history and cure of this disease, in
so far as these have arisen from my own observation,
from that of Dr. Home, and of other skilful persons in
this neighbourhood.
CCCXV. 

OF PHYSIC. 119
CCCXV.
This disease seldom attacks infants till after they have
been weaned. After this period, the younger they are,
the more they are liable to the disease. The frequency
of it becomes less as children become more advanced;
and there are no instances of children above twelve years
of age being affected with it. It attacks children of
the midland countries, as well as those who live near the
sea. It does not appear to be contagious, and its attacks
are frequently repeated in the same child. It is often
manifestly the effect of cold applied to the body; and
therefore appears most frequently in the winter and spring
seasons. It very commonly comes on with the ordinary
symptoms of a catarrh; but sometimes the peculiar sym-
ptoms of the disease shew themselves at the very first.
CCCXVI.
These peculiar symptoms are the following: A
hoarseness, with some shrillness and ringing sound, both
in speaking and coughing, as if the noise came from a
brazen tube. At the same time, there is a sense of pain
about the larynx, some difficulty of respiration, with a
whizzing sound in inspiration, as if the passage of the
air were straitened. The cough which attends it, is
commonly dry; and, if any thing be spit up, it is a
matter of a purulent appearance, and sometimes films,
resembling portions of a membrane. With all these
symptoms, there is a frequency of pulse, a restlessness,
and an uneasy sense of heat. When the internal fauces
are viewed, they are sometimes without any appearance
of inflammation, but frequently a redness, and even
swelling appears, and sometimes there is an appearance
of matter like to that rejected by coughing. Together
with the symptoms now described, and particularly with
great difficulty of breathing, and a sense of strangling
in the fauces, the patient is sometimes suddenly taken off.
CCCXVII. 

120 PRACTICE
CCCXVII.
Many dissections have been made of infants who had
died of this disease, and almost constantly there has ap-
peared a preternatural membrane lining the whole in-
ternal surface of the upper part of the trachea, and ex-
tending in the same manner downwards into some of its
ramifications. This preternatural membrane may be
easily separated, and sometimes has been found separated
in part from the subjacent proper membrane of the tra-
chea. This last is commonly found entire, that is,
without any appearance of erosion or ulceration, but it
frequently shows the vestiges of inflammation, and is
covered by a matter resembling pus, like to that rejected
by coughing; and very often a matter of the same kind
is found in the bronchiæ, sometimes in considerable
quantity.
CCCXVIII.
From the remote causes of this disease; from the
catarrhal symptoms commonly attending it; from the
pyrexia constantly present with it; from the same kind
of preternatural membrane being found in the trachea,
when the Cynanche maligna is communicated to it; and
from the vestiges of inflammation on the trachea dis-
covered upon dissection, we must conclude, that this
disease consists in an inflammatory affection of the mu-
cous membrane of the larynx and trachea, producing
an exsudation analogous to that found on the surface of
inflamed viscera, and appearing partly in a membranous
crust, and partly in a fluid resembling pus.
CCCXIX.
Though this disease consists in an inflammatory af-
fection, it does not commonly end either in suppuration
or gangrene. The troublesome circumstance of it seems
to consist in a spasm of the muscles of the glottis,
threatening suffocation.
CCCXX. 

OF PHYSIC. 121
CCCXX.
When this disease terminates in health, it is by re-
solution of the inflammation, by a ceasing of the spasm
of the glottis, by an expectoration of the matter ex-
suding from the trachea, and of the crusts formed there,
and frequently it ends without any expectoration, or at
least with such only as attends an ordinary catarrh.
CCCXXI.
When the disease ends fatally, it is by a suffocation
seemingly depending upon a spasm affecting the glottis;
but sometimes, probably, depending upon a quantity of
matter filling the bronchiæ.
CCCXXII.
As we suppose the disease to be an inflammatory af-
fection, so we attempt the cure of it by the usual re-
medies of inflammation,and which for the most part we
have found effectual. Bleeding, both general and to-
pical, has often given immediate relief, and, by being
repeated, has entirely cured the disease. Blistering also,
near to the part affected, has been found useful. Upon
the first attack of the disease, vomiting, immediately
after bleeding, seems to be of considerable use, and
sometimes suddenly removes the disease. In every stage
of the disease, the antiphlogistic regimen is necessary,
and particularly the frequent use of laxative glysters.
Though we suppose that a spasm affecting the glottis is
often fatal in this disease, we have not found anti-
spasmodic medicines to be of any use.
SECT.
Q

122 PRACTICE
SECT. IV.
OF THE CYNANCHE PHA-
RYNGÆA.
CCCXXIII.
In the Cynanche tonsillaris the inflammation of the
mucous membrane often spreads upon the pharynx, and
into the beginning of the œsophagus, and thereby ren-
ders deglutition more difficult and uneasy; but such a
case does not require to be distinguished as a different
species from the common Cynanche tonsillaris, and only
requires that blood-letting, and other remedies, should
be employed with greater diligence than in ordinary
cases. We have never seen any case in which the in-
flammation began in the pharynx, or in which this part
alone was inflamed; but practical writers have taken
notice of such a case, and to them, therefore, I must
refer, both for the appearances which distinguish it, and
for the method of cure.
SECT. V.
OF THE CYNANCHE PARO-
TIDÆA.
CCCXXIV.
This is a disease known to the vulgar in every country
of Europe, but has been little taken notice of by me-
dical

OF PHYSIC. 123
dical writers. It is often epidemic, and manifestly con-
tagious. It comes on with the usual symptoms of pyrexia
which is soon after attended with a considerable tumour
of the external fauces and neck. This tumour appears
first as a glandular moveable tumour at the corner of the
lower jaw; but the swelling soon becomes uniformly
diffused over a great part of the neck, sometimes on one
side only, but more commonly on both. The swelling
continues to increase till the fourth day; but from that
period it declines, and in a few days more passes off en-
tirely. As the swelling of the fauces recedes, some
tumour affects the testicles in the male sex, or the breasts
in the female. These tumours are sometimes large,
hard, and somewhat painful; but are seldom either very
painful or of long continuance. The pyrexia attending
this disease is commonly slight, and recedes with the
swelling of the fauces; but sometimes, when the swelling
of the testicles does not succeed to that of the fauces, or
when the one or the other has been suddenly repressed,
the pyrexia becomes more considerable, is often attended
with delirium, and has sometimes proved fatal.
CCCXXV.
As this disease commonly runs its course without
either dangerous or troublesome symptoms; so it hardly
requires any remedies. An antiphlogistic regimen, and
avoiding cold, are all that will be commonly necessary.
But when, upon the receding of the swellings, the pyr-
exia comnes to be considerable, and threatens an affection
of the brain, it will be proper, by warm fomentations,
to bring back the swelling, and, by vomiting, bleeding,
or blistering, to obviate the consequences of its absence.
CHAP. 

124 PRACTICE
CHAP. VI.
OF PNEUMONIC INFLAM-
MATION.
CCXXVI.
Under this title I mean to comprehend the whole of
the inflammation affecting either the viscera of the tho-
rax, or the membrane lining the interior surface of that
cavity; for neither do our diagnostics serve to ascertain
exactly the seat of the disease, nor does the difference in
the seat of the disease give any considerable difference in
the state of the symptoms, or lead to any difference in
the method of cure.
CCCXXVII.
Pneumonic inflammation, however various in the seat
of it, seems to me to be always known and distinguished
by the following symptoms; pyrexia, difficult breathing,
cough, and pain in some part of the thorax; but these
symptoms are on different occasions variously modified.
CCCXXVIII.
The disease almost always comes on with a cold stage,
and is accompanied with the other symptoms of pyrexia,
though, in a few instances, the pulse may be not more
frequent, nor the heat of the body increased beyond
what is natural. Sometimes the pyrexia is from the be-
ginning accompanied with the other symptoms; but
frequently the pyrexia is formed for some hours before
the other symptoms become considerable, and particu-
larly before the pain be felt. For the most part, the
pulse 

OF PHYSIC. 125
pulse is frequent, full, strong, hard, and quick; but,
in a few instances, especially in the advanced state of the
disease, the pulse is weak and soft, and at the same time
irregular.
CCCXXIX.
The difficulty of breathing is always present, and
most considerable in inspiration, both because the lungs
do not easily admit of a full dilatation, and because the
dilatation aggravates the pain attending the disease. The
difficulty of breathing is also greater when the patient
is in one posture of the body rather than another. It is
generally greater when he lies upon the side affected;
but sometimes the contrary happens. Very often the
patient cannot lie easy upon either side, and can find
ease only when lying on the back; and sometimes he
cannot breathe easily, except when in somewhat of an
erect posture.
CCCXXX.
A cough always attends this disease; but, in different
cases, is more or less urgent and painful. It is some-
times dry, that is, without any expectoration, especially
in the beginning of the disease; but more commonly it
is, even from the first, moist, and the, matter spit up
various, both in consistence and colour; and frequently
it is streaked with blood.
CCCXXXI.
The pain attending this disease, is, in different cases,
felt indifferent parts of the thorax, but most frequently
in one side. It has been said to affect the right side more
commonly than the left; but this is not certain; while,
on the other hand, it is certain, that the left side has
very often been affected. The pain is sometimes felt as
if it were under the sternum, sometimes in the back,
between the shoulders, and, when in the sides, its place
has been higher or lower, more forward or backward;
but the place of all others most frequently affected, is
about 

126 PRACTICE
about the sixth, or seventh rib, near the middle of its
length, or a little more forward. The pain is often
severe and pungent, but sometimes more dull and obtuse,
with a sense of weight rather than of pain. It is most
especially severe and pungent when occupying the place
last mentioned. For the most part, it continues fixed
in one place, but sometimes shoots from the side to the
scapula, on one hand, or to the sternum and clavicle on
the other.
CCCXXXII.
The different state of symptoms now mentioned does
not always ascertain exactly the seat of the disease. To
me it seems probable, that the disease is always seated, or
at least begins in some part of the pleura, taking that
membrane in its greatest extent, as now commonly un-
derstood; that is, as covering not only the internal sur-
face of the cavity of the thorax, but also as forming the
mediastinum, and as extended over the pericardium, and
over the whole surface of the lungs.
CCCXXXIII.
There is therefore little foundation for distinguishing
this disease by different appellations taken from the part
which may be supposed to be chiefly affected. The term
Pleurisy might be properly applied to every case of the
disease; and is very improperly limited to that inflam-
mation which begins in and chiefly affects the pleura
costalis. We believe that such a case does truly occur;
but we also believe it to be a rare occurrence, and that
the disease much more frequently begins in, and chiefly
affects the pleura investing the lungs, producing all the
symptoms supposed to belong to what has been called the
Pleuritis vera.
CCCXXXIV.
Some physicians have imagined, that there is a case
of pneumonic inflammation, particularly entitled to the
appellation of Peripneumony, and that is, the case of an
inflammation 

OF PHYSIC. 127
inflammation beginning in the parenchyma, or cellular
texture of the lungs, and having its seat chiefly there.
But it seems to me very doubtful, if any acute inflam-
mation of the lungs, or any disease which has been called
peripneumony, be of that kind. It seems probable,
that every acute inflammation begins in membranous
parts; and, in every dissection of persons dead of peri-
pneumony, the external membrane of the lungs, or
some part of the pleura, has appeared to have been con-
siderably affected.
CCCXXXV.
An inflammation of the pleura covering the upper
surface of the diaphragm, has been distinguished by the
appellation of Paraphrenitis, as supposed to be attended
with the peculiar symptoms of delirium, risus sardonicus,
and other convulsive motions; but it is certain, that an
inflammation of that portion of the pleura, and affecting
also even the muscular substance of the diaphragm, has
often taken place without any of the symptoms men-
tioned; and I have met neither with dissections, nor
any accounts of dissections, which support the opinion,
that an inflammation of the pleura covering the dia-
phragm, is attended with delirium more commonly than
any other pneumonic inflammation.
CCCXXXVI.
With respect to the seat of pneumonic inflammation,
we must observe further, that, although it may arise and
subsist chiefly in one part of the pleura only, it is how-
ever frequently communicated to other parts of the same,
and commonly communicates a morbid affection to the
whole extent of it.
CCCXXXVII.
The remote cause of pneumonic inflammation is,
commonly, cold applied to the body, obstructing per-
spiration, and determining to the lungs, while at the
same time the lungs themselves are exposed to the action 
of

128 PRACTICE
of cold. These circumstances operate especially when
an inflammatory diathesis prevails in the system; and,
therefore, upon persons of the greatest vigour; in cold
climates; in the winter-season; and particularly in the
spring, when vicissitudes of heat and cold are frequent.
The disease, however, may arise in any season when
such vicissitudes take place.
Other remote causes also may have a share in this
matter, such as every means of obstructing, straining,
or otherwise injuring the pneumonic organs.
The pneumonic inflammation has been sometimes so
much an epidemic, as to occasion a suspicion of its de-
pending upon a specific contagion; but we have not met
with any evidence in proof of this. See Morgagni de
causis et sedibus morborum, episte. 21. art. 26.
CCCXXXVIII.
The pneumonic, like other inflammations, may ter-
minate by resolution, suppuration, or gangrene; but it
bas also a termination peculiar to itself, as has been
hinted above, (CCLIV.) and which is, when it is at-
tended with an effusion of blood into the cellular texture
of the lungs, which soon interrupting the circulation of
the blood through this viscus, produces a fatal suffo-
cation. This indeed seems to be the most common ter-
mination of pneumonic inflammation, when it ends fa-
tally; for, upon the dissection of almost every person
dead of that disease, it has appeared that such an effusion
had happened.
CCCXXXIX.
From the same dissections, we learn, that pneumonic 
inflammation commonly produces an exsudation from the
internal surface of the pleura, which appears partly as
a soft viscid crust, often of a compact membranous form,
covering every where the surface of the pleura, and par-
ticularly those parts where the lungs adhere to the pleura
costalis, or mediastinum; and this crust seems always to
be the cement of such adhesions.
The 

OF PHYSIC. 129
The same exsudation shews itself also by a quantity of
a serous fluid commonly found in the cavity of the tho-
rax; and some exsudation or effusion is usually found to
have been made also into the cavity of the pericardium.
CCCXL.
It seems probable also, that a like effusion is sometimes
made into the cavity of the bronchiæ; for, in some per-
sons who have  died after labouring under a pneumonic
inflammation for a few days only, the bronchiæ have
been found filled with a considerable quantity of a serous
and thickish fluid, which I think must be considered
rather as the effusion above mentioned, having had its
thinner parts taken off by respiration, than as a pus so
suddenly formed in the inflamed part.
CCCXLI.
It is, however, not improbable, that this effusion, as
well as that, made into the cavities of the thorax and
pericardium, may be a matter of the same kind with that
which, in other inflammations, is poured into the cel-
lular texture of the parts inflamed, and there converted
into pus; but, in the thorax and pericardium, it does
not always put on that appearance, because the crust
covering the surface prevents the absorption of the
thinner part. This absorption, however, may be com-
pensated in the bronchiæ, by the drying power of the
air; and therefore the effusion into them may put
on a more purulent appearance. In many cases of pneu-
monic inflammation, when the SPUTA are very copious,
it is difficult to suppose, that the whole of them proceed
from the mucous follicles of the bronchiæ. It seems
probable that a great part of them may proceed from
the effused serous fluid we have been mentioning; and
this too will account for the sputa being so often of a
purulent appearance. Perhaps the same thing will ac-
count for that purulent expectoration, and that pu-
rulent matter found in the bronchiæ, which the learned
Mr. de Haen says he had often observed, when there
was no ulceration of the lungs; and this explanation is
at
R 

130 PRACTICE
at least more probable than Mr. de Haen's supposition of
a pus formed in the circulating blood.
CCCXLII.
To conclude this subject, we are of opinion, that the
effusion into the bronchiæ, which we have mentioned
(CCCXL.) often concurs with the effusion of red
blood (CCCXXXVIII.) in occasioning the suffocation
which fatally terminates pneumonic inflammation; that
the effusion of serum alone may have this effect; and,
that the serum poured out in a certain quantity, rather
than any debility in the powers of expectoration, is the
cause of that ceasing of expectoration which precedes
the fatal event; for, in many cases, the expectoration
has ceased, when no other symptoms of debility have
appeared, and when, upon dissection, the bronchiæ
have been found full of liquid matter. Nay, it is even
probable, that, in some cases, such an effusion may take
place, without any symptoms of violent inflammation;
and, in other eases, the effusion taking place may seem
to remove the symptoms of inflammation which had ap-
peared before, and thus account for those unexpected
fatal terminations which have sometimes happened. Per-
haps this effusion will account also for many of the
phenomena of the Peripneumonia Notha.
CCCXLIII.
Pneumonic inflammation seldom terminates by reso-
lution, without being attended with some evident evacu-
ation. An hemorrhage from the nose happening on
some of the first days of the disease, has sometimes put
an end to it; and it is said, that an evacuation from
the hemorrhoidal veins, a bilious evacuation by a stool,
and an evacuation of urine, with a copious sediment,
have severally had the same effect; but such occurrences
have been rare and unusual.
The evacuation most frequently attending, and seem-
ing to have the greatest effect in promoting resolution,
is an expectoration of a thick white or yellowish matter,
a little 

OF PHYSIC. 131
a little streaked with blood, copious, and brought up
without much or violent coughing.
Very frequently the resolution of this disease is
attended with, and perhaps produced by a sweat, which
is warm, fluid, copious, over the whole body, and at-
tended with an abatement of the frequency of the pulse,
of the heat of the body, and of other febrile symptoms.
CCCXLIV.
The prognostics in this disease are formed from the
state of the principal symptoms. (CCCXXVII.)
A violent pyrexia is always dangerous.
The danger, however, is chiefly denoted by the dif-
ficulty of breathing. When the patient can lie on one
side only; when he can lie on neither side, but upon his
back only; when he cannot breathe with tolerable ease,
except when the trunk of his body is erect; when, even
in this posture, the breathing is very difficult, and at-
tended with a turgescence and flushing of the face, with
partial sweats about the head and neck, and an irregular
pulse; these circumstances mark the difficulty of breath-
ing in different degrees, and, consequently, in pro-
portion, the danger of the disease.
A frequent violent cough aggravating the pain, is al-
ways the symptom of an obstinate disease.
As we believe that the disease is hardly ever resolved,
without some expectoration, so a dry cough must be
always an unfavourable symptom.
As the expectoration described (CCCXLIII.) is a
mark that the disease is proceeding to a resolution, so an
expectoration, which has not these conditions, must de-
note at least a doubtful state of the disease; but the
marks taken from the colour of the matter are for the
most part fallacious.
An acute pain, very much interrupting inspiration,
is always the mark of a violent disease, but not of a
more dangerous disease than an obtuse pain, attended
with very difficult respiration.
When the pains which at first had affected one side
only, shall afterwards spread into the other, or, when
leaving 

132 PRACTICE
leaving the side first affected, they entirely pass into the
other, these are always marks of a dangerous disease.
A delirium coming on during a pneumonic inflam-
mation, is always a symptom denoting much danger.
CCCXLV.
When the termination of this disease proves fatal, it
is on one or other of the days of the first week, from
the third to the seventh. This is the most common
case; but, in a few instances, death has happened at a
later period of the disease.
When the disease is violent, but admitting of reso-
lution, this also happens frequently in the course of the
first week; but, in a more moderate disease, the reso-
lution is often put off to the second week.
The disease generally suffers a remission on some of
the days from the third to the seventh; which, however,
may be often fallacious, as the disease sometimes returns
again with as much violence as before, and in such case
with great danger.
Sometimes the disease disappears on the second or third
day, while an erysipelas makes its appearance on some
external part; and, if this continues fixed, the pneu-
monic inflammation does not recur.
If the disease continue beyond the fourteenth day, it
generally terminates in a suppuration.
CCCXLVI.
The consideration of this termination by suppuration,
is referred to our chapter on Phthisis.
The termination by gangrene is much more rare than
has been imagined; and, when it does occur, it is
usually joined with the termination by effusion,
(CCCXXXVIII) and the symptoms of the one are
hardly to be distinguished from those of the other.
CCCXLVII.
The cure of pneumonic inflammation must proceed
upon the general plan (CCLIX); but the importance
of 

OF PHYSIC. 133
of the part affected, and the danger to which it is ex-
posed, requires that the remedies be fully, as well as
early, employed.
CCCXLVIII.
The remedy chiefly to be depended upon is that of
bleeding at the arm, which will be performed with most
advantage in the arm of the side affected, but may be
done in either arm, as may be most convenient for the
patient or the surgeon. The quantity must be suited to
the violence of the disease, and the vigour of the pa-
tient; and, generally, ought to be as large as this last
circumstance will allow. The remission of pain, and
the relief of respiration, during the flowing of the
blood, may limit the quantity to be then drawn; but, if
these symptoms of relief do not appear, the bleeding
should be continued till the symptoms of a beginning
syncope come on. It is seldom that one bleeding, how-
ever large, will prove a cure of this disease; and, though
the pain and difficulty of breathing may be much relieved
by the first bleeding, these symptoms commonly, and
after no long interval, recur; often with as much vio-
lence as before. In the event of such recurrence, the
bleeding is to be repeated, even in the course of the
same day, and perhaps to the same quantity as before.
Sometimes the second bleeding may belarger than the
first. There are persons who, by their constitution, are
ready to faint even upon a small bleeding; and, in such
persons, this may prevent the drawing so much blood at
first as a pneumonic inflammation may require; but, as
the same persons are sometimes found to bear after-bleed-
ings better than the first, this allows the second and sub-
sequent bleedings to be larger, and to such a quantity as
the symptoms of the disease may seem to require.
CCCXLIX.
It is according to the state of the symptoms, that
bleedings are to be repeated; and they will be more
effectual when practised in the course of the first three
days than afterwards; but they are not to be omitted,
although 

134 PRACTICE
although four days of the disease may have already
elapsed. If the physician shall not have been called in
sooner, or if the bleedings shall not have been large
enough during the first days, or even although these
bleedings shall have procured some remission; yet, upon
the recurrence of the urgent symptoms, bleeding should
be repeated at any period of the disease, especially within
the first fortnight; and even afterwards, if a tendency
to suppuration  be not evident, or if, after a seeming
solution, the disease shall have again returned.
CCCL.
With respect to the quantity of blood which ought,
or which with safety may be taken away, no general
rules can be delivered, as it must be very different, ac-
cording to the state of the disease, and the constitution of
the patient. In an adult male of tolerable strength, a
pound of blood, Averdupois, is a full bleeding. Any
quantity above twenty ounces is a large, and any quan-
tity below twelve, a small bleeding. A quantity of
from four to five pounds, in the course of two or three
days, is generally as much as such patients will safely
bear; but, if the intervals between the bleedings, and
the whole of the time during which the bleedings have
been employed has been long, the quantity taken upon
the whole may be greater.
CCCLI.
When a large quantity of blood has been already
taken from the arm, and it is doubtful if more can be
taken with safety in that manner, some blood may still
be taken by cupping and scarifying. Such a measure
will be especially proper, when the continuance or re-
currence of pain, rather than the difficulty of breathing,
becomes the urgent symptom; and then the cupping
and scarifying should be made as near to the pained part
as can conveniently be done.
CCCLII.

OF PHYSIC. 135
CCCLII.
An expectoration takes place sometimes very early in
this diaeaae; but if, notwithstanding thereof, the urgent
symptoms should still continue, the expectoration must
not superaede the bleedings we have mentioned; and,
during the first days of the disease, its solution is not to
be trusted to the expectoration alone. It is in a more
advanced state only, and when the symptoms have suf-
fered a considerable remission, that we may trust the en-
tire cure to a copious and free expectoration.
CCCLIII.
During the first days of the disease, we do not find
that bleeding stops expectoration. On the contrary, we
have often found bleeding promote it; and it is in a
more advanced state of the disease only, when the patient,
by large evacuations, and the continuance of the disease,
has been already exhausted, that bleeding seems to stop
expectoration. We are of opinion, that even then
bleeding does not stop expectoration, so much by
weakening the powers of expectoration, as by favouring
the serous effusion into the bronchiæ, (CCCXL.) and
thereby preventing it.
CCCLIV.
While the bleedings we have mentioned shall be em-
ployed, it will be necessary to employ also every part of
the antiphlogistic regimen, (CXXIII. ÇXXIV.) and
particularly to prevent the irritation which might arise
from any increase of heat. For this purpose, it will be
proper to keep the patient out of bed, while he can
bear it easily, and, when he cannot, to cover him very
lightly while he lies in bed. The temperature of his
chamber ought not to exceed sixty degrees of Fahren-
heit's thermometer; and whether it may be at any time
colder, I am uncertain.
CCCLV. 

136 PRACTICE
CCCLV.
Mild and diluent drinks, moderately tepid, at least
never cold, given by small portions at a time, ought to
be administered plentifully. These drinks may be im-
pregnated with vegetable acids. They may be properly
accompanied also with nitre, or some other neutrals;
but these salts should be given separately from the drink.
It has been alledged, that both acids and nitre are
ready to excite coughing, and in some persons they cer-
tainly have this effect; but, except in persons of a pe-
culiar habit, we have not found their effects in exciting
coughs so considerable or troublesome as to prevent our
seeking the advantages otherwise to be obtained from
these medicines.
CCCLVI.
Some practitioners have doubted, if purgatives can
be safely employed in this disease; and indeed a sponta-
neous diarrhoea occurring in the beginning of the dis-
ease has seldom proved useful; but we have found the
moderate use of cooling laxatives generally safe; and
we have always found it useful to keep the belly open by
frequent emollient clysters.
CCCLVII.
To excite vomiting by emetics, we judge to be a dan-
gerous practice in this disease; but we have found it
useful to exhibit nauseating doses; and, in a somewhat
advanced state of the disease, we have found such doses
have proved the best means of promoting expectoration.
CCCLVIII.
Fomentations and poultices applied to the pained part
have been recommended, and may be useful; but the ap-
plication of them is often inconvenient, and we omit it
entirely

OF PHYSIC. 137
entirely for the sake of the more effectual remedy,
blistering.
Very early in the disease, a blister should be applied as
near to the pained part as possible. But as, when the
irritation of a blister is present, it renders bleeding less
effectual; so the application of the blister should be
delayed till a bleeding shall have been employed. If the
disease be moderate, the blister may be applied immedi-
ately after the first bleeding; but, if the disease be
violent, and it is presumed that a second bleeding may
be necessary soon after the first, it will then be proper to
delay the blister till after the second bleeding, when it
may be supposed that any farther bleeding may be post-
poned till the irritation arising from the blister shall have
ceased. It may be frequently necessary in this disease to
repeat the blistering, and, in that case, the plasters
should always be applied somewhere on the thorax; for,
when applied to more distant parts, they have little ef-
fect. The keeping the blistered parts open, and making
what is called a perpetual blister, has much less effect
than a fresh blistering.
CCCLIX.
As this disease often terminates by an expectoration,
some means of promoting this have been often proposed;
but none of them appear to be very effectual, and some
of them, being acrid stimulant substances, cannot be
very safe.
The gums usually employed seem too heating; squills
seem to be less so; but they are not very powerful, and
sometimes inconvenient, by the confiant nausea they
induce.
The volatile alkali may be of service as an expec-
torant; but it should be reserved for an advanced state of
the disease.
Mucilaginous and oily demulcents appear to be useful,
by allaying that acrimony of the mucus which occasions
too frequent coughing; and which coughing prevents
the stagnation and thickening of the mucus, and thereby
its becoming mild.
S The

138 PRACTICE
The receiving the steams of warm water into the
lungs, impregnated with vinegar, has often proved
useful in promoting expectoration.
But, of all other remedies, the most powerful for
this purpose, are antimonial medicines, given in nau-
seating doses, as in (CCCLVII.) Of these, however,
we have not found the kermes mineral more efficacious
than emetic tartar, or antimonial wine; and the dose
of the kermes is much more uncertain than that of the
others.
CCCLX.
Though a spontaneous sweating often proves the
crisis of this disease, it ought not to be excited by art,
unless with much caution. At least, we have not yet
found it either so effectual or safe as some writers have
alledged. When, after some remission of the symptoms,
spontaneous sweats of a proper kind arise, they may be
encouraged; but it ought to be without much heat, and
without stimulant medicines. If, however, the sweats
be partial and clammy only, and a great difficulty of
breathing still remain, it will be very dangerous to en-
courage them.
CCCLXI.
Physicians have differed much in opinion with regard
to the use of opiates in pneumonic inflammations. To
me it appears, that, in the beginning of the disease,
and before bleeding and blistering have produced some
remission of the pain, and of the difficulty of breathing,
opiates have a very bad effect by their increasing the
difficulty of breathing, and other inflammatory sym-
ptoms. But, in a more advanced state of the disease,
when the difficulty of breathing has abated, and when
the urgent symptom is a cough, proving the chief cause
of the continuance of the pain, and of the want of
sleep, opiates may be employed with great advantage
and safety. The interruption of the expectoration,
which they seem to occasion, is for a short time only;
and they seem often to promote it, as they occasion a
stagnation 

OF PHYSIC. 139
stagnation of what was by frequent coughing dissipated
insensibly, and therefore give the appearance of what
physicians have called Concocted Matter.
CCCLXII.
We might here give a section on the Carditis and
Pericarditis, or the inflammations of the Heart and
Pericardium; but they hardly require a particular con-
sideration. An acute inflammation of the Pericardium
is almost always a part of the same pleuritic affection we
have been treating of, and is not always distinguished
by any different symptoms; or, if it be, does not
require any different treatment. The same may be said
of an acute inflammation of the heart itself; and, when
it happens that the one or other is discovered by the
symptoms of palpitation or syncope, no more is implied,
than that the remedies of pneumonic inflammation
should be employed with greater diligence.
From dissections, which shew the heart and peri-
cardium affected with erosions, ulcerations, and ab-
scesses, we discover, that these parts had before been
affected with inflammation; and while, at the same
time, no symptoms of pneumonic inflammation had
appeared, it may be alledged, that those inflammations
of the heart and pericardium should be considered as
diseases independent of the pneumonic. This indeed is
just; but the history of such cases proves, that the
inflammation had been of a chronic kind, and hardly
discovering themselves, by any peculiar symptoms, or,
if attended with such as marked an affection of the heart,
these are, at the same time, such as have been known
frequently to arise from other causes than inflammation.
There is, therefore, upon the whole, no room for our
treating more particularly of the inflammation of the
heart or pericardium.
CHAP.

140 PRACTICE
CHAP. VII.
OF THE GASTRITIS, OR INFLAM-
MATION OF THE STOMACH.
CCCLXIII.
Among the inflammations of the abdominal region,
we have given a place in our Nosology to the Peritonitis,
comprehending under this title, not only the inflam-
mations affecting the peritonæum lining the cavity of
the abdomen, but those also affecting the extensions of
this membrane in the omentum and mesentery. We are
not, however, to treat of them here, because we cannot
say by what symptoms they are always to be known; and
farther, because, when known, they do not require any
remedies besides those of inflammation in general. We
proceed, therefore, to treat of those inflammations
which, affecting viscera of peculiar functions, both give
occasion to peculiar symptoms, and require some peculi-
arities in the method of cure. We begin with the in-
flammation of the stomach.
CCCLXIV.
The inflammation of the stomach is of two kinds,
Phlegmonic, or Erysipelatous. The first may be seated
in what is called the Nervous Coat of the stomach, or
in the peritonaeum investing it. The second is always
seated in the Villous coat and cellular texture im-
mediately subjacent.
CCCLXV. 

OF PHYSIC. 141
CCCLXV.
The phlegmonic inflammation of the stomach, or
what has been commonly treated of under the title of
Gastritis, is known by an acute pain in some part of the
region of the stomach, attended with pyrexia, frequent
vomiting, especially upon any thing being taken down
into the stomach, and frequently with hiccup. The
pulse is commonly small and hard, and there is a greater
loss of strength in all the functions than in the case of
almost any other inflammation.
CCCLXVI.
This inflammation may be produced by various
causes; as, by external contusion; by acrids of various
kinds taken into the stomach; frequently by very cold
drink taken into it, while the body is very warm, and
sometimes by over-distention, from the having taken in
a large quantity of food of difficult digestion. All these
may be considered as external causes; but the disease
sometimes arises also from internal causes not so well
understood. It may arise from inflammations of the
neighbouring parts communicated to the stomach, and
then is to be considered as a symptomatic affection. It
may arise also from various acrimony generated within
the body, either in the stomach itself, or in other parts,
and poured into the cavity of the stomach. These are
causes more directly applied to the stomach; but there
are others originating perhaps elsewhere, and affecting
the stomach only sympathically. Such seem to have
acted in the case of putrid fevers and exanthematic pyr-
exiæ, in which we have found, upon dissection, the
stomach to have been affected with inflammation.
CCCLXVII.
From the sensibility of the stomach, and its commu-
nication with the rest of the system, it will be obvious,
that the inflammation of this organ, by whatever causes
produced, may be attended with fatal consequences.
Particularly, 

142 PRACTICE
Particularly, by the great debility which it suddenly
produces, it may prove suddenly fatal, without running
the common course of inflammations.
When it lasts long enough to follow the ordinary
course of other inflammations, it may terminate by
resolution, gangrene, or suppuration. The schirrosities
which are often found to affect the stomach, are seldom
known to be the consquences of inflammation.
CCCLXVIII.
The tendency of this disease to admit of resolution,
may be known by its having arisen from no violent
cause, by the moderate state of the symptoms, and by a
gradual remission of these symptoms in the course of the
first, or, at most, of the second week of the disease.
CCCLXIX.
The tendency to gangrene may be suspected from the
violence of the symptoms not yielding to the remedies
employed during the first days of the disease; and that
a gangrene has already begun, may be known from the
sudden remission of the pain, while the frequency of
the pulse continues, and, at the same time, becomes
weaker, accompanied with other marks of the increasing
debility of the whole system.
CCCLXX.
The tendency to suppuration may be known by the
symptoms continuing, but in a moderate degree, for
more than one or two weeks, and by a considerable
remission of the pain, while a sense of weight and an
anxiety still remain.
When an abscess has been formed, the frequency of
the pulse is at first abated; but soon after it is again
increased, with frequent cold shiverings, and with
marked exacerbations in the afternoon and evening,
followed by night sweatings, and other symptoms of
hectic fever. These at length prove fatal, unless the
abscess 

OF PHYSIC. 143
abscess open into the cavity of the stomach, the pus be
evacuated by vomiting, and the ulcer soon healed.
CCCLXXI.
It appears, from the dissection of dead bodies, that
the stomach very often has been affected with inflam-
mation, when the characteristic symptoms of it had not
appeared; and therefore we cannot lay down any general
rules for the cure of this disease.
CCCLXXII.
It is only in the case of phlegmonic inflammation, as
characterised in (CCCLXV.), that we can advise the
cure or resolution to be attempted by large and repeated
bleedings employed early in the disease; and from these
we are not to be deterred by the smallness of the pulse;
for, after bleeding, it commonly becomes fuller and
softer. After bleeding, a blister ought to be applied to
the region of the stomach, and the cure will be assisted
by fomentations of the whole abdomen, and by frequent
emollient and laxative clysters.
CCCLXXIII.
The irritability of the stomach, in this disease, will
admit of no internal medicines being thrown into it;
and, if any can be supposed necessary, they must be ex-
hibited in clysters. The giving of drink may be tried;
but it ought to be of the very mildest kind, and in very
small quantifies at a time.
CCCLXXIV.
Opiates, in whatever manner exhibited, are very
hurtful during the first days of the disease; but, when
the violence of the disease shall have abated, and when
the violence of the pain and vomiting recur at intervals
only, opiates given in clysters may be cautiously tried,
and sometimes have been employed with advantage.
CCCLXXV. 

144 PRACTICE
CCCLXXV.
A tendency to gangrene in this disease is to be obviated
only by the means just now proposed; and, when it does
actually supervene, admits of no remedy.
CCCLXXVI.
A tendency to suppuration is only to be obviated by
the same means employed early in the disease. After a
certain period, it cannot be prevented by any means
whatever; and, when actually begun, must be left to
nature; the only thing that can be done by art, being
to avoid all irritation.
CCCLXXVII.
Erysipelatous inflammations of the stomach, are more
frequent than those of the phlegmonic kind. It appears,
at least, from dissections, that the stomach has often been
affected with inflammation, when neither pain nor pyr-
exia had before given any notice of it; and such we
judge to have been chiefly of the erysipelatous kind.
This kind of inflammation also, is especially to be ex-
pected from acrimony of any kind applied to the stomach,
and would certainly occur more frequently from such a
cause, were not the interior surface of this organ com-
monly defended by mucus exsuding in large quantity
from then umerous follicles placed immediatly under the
villous coat. On many occasions, however, the exsu-
dation of mucus is prevented, or the liquid poured out
is of a less viscid kind, so as to be less fitted to defend
the subjacent nerves; and it is in such cases that acrid
matters may readily produce an erysipelatous affection of
the stomach.
CCCLXXVIII.
From what has been said, it must appear, that an
erysipelatous inflammation of the stomach may frequently
occur, 

OF PHYSIC. 145
occur, but will not always discover itself, as it some-
times takes place without pyrexia, pain, or vomiting,
CCCLXXIX.
There are cases, however, in which it may he dis-
covered. The affection of the stomach sometimes spreads
into the œsophagus, and appears in the pharynx, and on
the whole internal surface of the mouth. When, there-
fore, an erysipelatous inflammation affects the mouth
and fauces, and there shall be at the same time in the
stomach an unusual sensibility to all acrids, and also a
frequent vomiting, there can be little doubt of the
stomach's being affected with the same inflammation that
has appeared in the fauces. Even when no inflam-
mation appears in the fauces, if some degree of pain be
felt in the stomach, if there be a want of appetite, an
anxiety, and frequent vomiting, and unusual sensibility
with respect to acrids, some thirst, and frequency of
pulse, there will then be room to suspect an inflammation
of the stomach; and we have known such symptoms,
after some time, discover their cause more clearly by the
inflammation's appearing in the fauces or mouth.
Erysipelatous inflammation is often disposed to spread
from one place to another on the same surface, and, in
doing so, to leave the place it had at first occupied.
Thus, we have known such an inflammation spread suc-
cessively along the whole length of the alimentary canal,
occasioning in the intestines diarrhœa, and in the stomach
vomitings, the diarrhœa ceasing when the vomitings
come on, and, on the other hand, the vomitings on
the coming on of the diarrhœa.
CCCLXXX.
When an erysipelatous inflammation of the stomach
is discovered, it is to be treated differently according to      
the difference of its causes and symptoms.
When it is owing to acrid matters taken in by the
mouth, and these may be supposed still present in the
stomach, they are to be washed out by throwing in a
large quantity of warm and mild liquids, and by ex-
citing
T

146 PRACTICE
citing vomiting. At the same time, if the nature of the
acrimony and its proper corrector be known, this should
be thrown in; or, if a specific corrector be not known,
some general demulcents should be employed.
CCCLXXXI.
These measures, however, are more suited to prevent
than to cure inflammation, after it has taken place.
When this last may be supposed to be the case, if it be
attended with a sense of heat, with pain and pyrexia,
according to the degree of these symptoms, the measures
proposed in (CCCLXXII. et seq.) are to be more or
less employed.
CCCLXXXII.
When an erysipelatous inflammation of the stomach
has arisen from internal causes, if pain and pyrexia ac-
company the disease in persons not otherwise weakened,
some bleeding may be employed; but, as the affection
often arises in putrid diseases, and in convalescents from
fever, in such cases, bleeding is not admissible, all that
can be done being to avoid irritation; and only throwing
into the stomach what quantity of acids, and of acescent
aliments, it shall be found to bear. In some conditions
of the body, in which this disease arises, the Peruvian
bark and bitters may seem to be indicated; but an erysi-
pelatous state of the stomach does not commonly allow
of them.
CHAP.

OF PHYSIC. 147
CHAP. VIII.
OF THE ENTERITIS, OR INFLAM-
MATION OF THE INTESTINES.
CCCLXXXIII.
The inflammation of the intestines, like that of the
stomach, may be either phlegmonic, or erysipelatous;
but, on the subject of the latter, I have nothing to add
to what I have said in the last chapter; and shall here
therefore treat of the phlegmonic inflammation only.
CCCLXXXIV.
This inflammation may be known to be present by a
fixed pain in the abdomen, attended with a pyrexia,
costiveness, and vomiting. Practical writers mention
the pain in this case as felt in different parts of the ab-
domen, according to the different seat of the inflam-
mation; and so indeed it sometimes happens, but very
often the pain spreads over the whole belly, and is felt
more especially about the navel.
CCCLXXXV.
The enteritis and gastritis arise from like causes; but,
the former, more readily than the latter, from cold ap-
plied to the lower extremities, or to the belly itself.
The enteritis has likewise its peculiar causes, as super-
vening upon the spasmodic colic, incarcerated hernia,
and volvulus.
CCCLXXXVI. 

148 PRACTICE
CCCLXXXVI.
Inflammations of the intestines have the same termi-
nations as those of the stomach, and, in both cases, the
several tendencies are to be discovered by the same sym-
ptoms (CCCLXVIII. CCCLXIX. CCCLXX.)
CCCLXXXVII.
The cure of the enteritis is in general the same with
that of the gastritis (CCCLXXII. et seq.); but, in the
former, there is commonly more access to the intro-
duction of liquids, of acid, acescent, and other cooling
remedies, and even of laxatives; but, as a vomiting so
frequently attends the enteritis, care must be taken not
to excite that vomiting by either the quantity or the
quality of any thing thrown into the stomach.
CCCLXXXVIII.
Under the title of Enteritis, it has been common with
practical writers to treat of the remedies proper for the
colic, and its higher degree, named Ileus; but, though
it be true that the enteritis and colic frequently accom-
pany each other, we still hold them to be distinct dis-
eases, to be often occurring separately, and accordingly
to require and admit of different remedies. We shall
therefore delay speaking of the remedies proper for the
colic till we shall come to treat of this disease.
CCCLXXXIX.
What occurs to be said with respect to the sup-
puration, or gangrene, occurring in the enteritis, may
be sufficiently understood from what has been said on
the same subjects with respect to the gastritis.
CHAP.

OF PHYSIC. 149
CHAP. IX.
OF THE HEPATITIS, OR INFLAM-
MATION OF THE LIVER.
CCCXC.
The inflammation of the liver seems to be of two
kinds, the one acute, the other chronic.
CCCXCI.
The acute is attended with pungent pain, considerable
pyrexia, a frequent, strong, and hard pulse, and high
coloured urine.
CCCXCII.
The chronic hepatitis very often exhibits none of
these symptoms, (CCCXCI) and we only discover it to
have happened by our finding large abscesses in the liver,
which are presumed to be the effect of some degree of
inflammation. As this chronic inflammation is not to
be certainly known, and therefore does not lead to any
certain practice, we omit treating of it here, and shall
only treat of what relates to the acute species of the
hepatitis.
CCCXCIII.
The acute hepatitis may be known by a pain more or
less acute in the right hypochondrium, increased by
pressing upon the part. The pain is very often in such
a part of the side as to make it appear as that of a pleu-
risy; and frequently, like that, is increased on inspi-
ration. 

150 PRACTICE
ration. The disease is sometimes also attended with a
cough, which is commonly dry, but sometimes humid.
When the pain thus resembles that of a pleurisy, the
patient cannot lie easily except upon the side affected.
In every kind of acute hepatitis, the pain is often ex-
tended to the clavicle, and to the top of the shoulder.
The disease is attended sometimes with hiccup, and
sometimes with vomiting. Many practical writers have
mentioned the jaundice, or a yellow colour of the skin
and eyes, as a very constant symptom of the hepatitis;
but experience hath shown, that the disease may often
occur without any such symptom.
CCCXCIV.
The remote causes of hepatitis are not always to be
discerned, and many have been assigned on a very uncer-
tain foundation. It is to be observed, that, in many
cases of pneumonic inflammation, the liver appears con-
siderably enlarged, and sometimes the pneumonic inflam-
mation is joined with the hepatitis.
CCCXCV.
It has been supposed that the hepatitis may be an af-
fection either of the extremities of the hepatic artery,
or those of the vena portarum; but of the last sup-
position there is neither evidence nor probability.
CCCXCVI.
It seems probable that the acute hepatitis is always
an affection of the external membrane of the liver, and
that the parenchymatic is of the chronic kind. The
acute disease may be seated either on the convex or on
the concave surface of the liver. In the former case, a
more pungent pain and hiccup may be produced, and
the respiration is more considerably affected. In the
latter, there occurs less pain, and a vomiting is pro-
duced, commonly by some inflammation communicated
to the stomach. The inflammation of the concave sur-
face of the liver may be readily communicated to the
gall- 

OF PHYSIC. 151
gall-bladder and biliary ducts; and this perhaps is the
only case of idiopathic hepatitis attended with jaundice.
CCCXCVII.
The hepatitis, like other inflammations, may end by
resolution, suppuration, or gangrene; and the tendency
to the one or the other of these events may be known
from what has been delivered above (CCXLIV. CCXLV.
CCXLVI. CCL. CCLI. CCLII. CCCLXVIII.
CCCLXIX. CCCLXX.)
CCCXCVIII.
The resolution of hepatitis is often the consequence
of, or is attended with evacuations of different kinds.
A hemorrhagy sometimes from the nose, and sometimes
from the hemorrhoidal vessels, gives a solution of the
disease. Sometimes a bilious diarrhœa contributes to
the same event; and the resolution of the hepatitis, as
of the other inflammations, is attended with sweating,
and with an evacuation of urine, depositing a copious
sediment. Can this disease be resolved by expectoration?
It would seem to be sometimes cured by an erysipelas ap-
pearing in some external part.
CCCXCIX.
When this disease has ended in suppuration, the pus
collected may be discharged by the biliary ducts; or, if
the suppurated part does not any where adhere closely to
the neighbouring parts, the pus may be discharged into
the cavity of the abdomen; but if, during the first state
of inflammation, the affected part of the liver shall have
formed a close adhesion to some of the neighbouring
parts, the discharge of the pus after suppuration may be
various, according to the different seat of the abscess.
When seated on the convex part of the liver, if the
adhesion be to the peritonæum lining the common tegu-
ments, the pus may make its way through these, and be
discharged outwardly; or, if the adhesion shall have
been to the diaphragm, the pus may penetrate through 
this,

152 PRACTICE
this, and into the cavity of the lungs; and through
this may be discharged by coughing. When the abscess
of the liver is seated on its concave part, in consequence
of adhesions, the pus may be discharged into the
stomach or intestines; and into these last, either directly,
or by the intervention of the biliary ducts.
CCCC.
The prognostics in this disease are established upon
the general principles relating to inflammation, upon
the particular circumstances of the liver, and upon the
particular state of its inflammation.
CCCCI.
The cure of this disease must proceed upon the general
plan, by bleeding, more or less, according to the ur-
gency of pain and pyrexia; by the application of blisters;
by fomentations of the external parts in the usual man-
ner, and of the internal parts by frequent emollient
clysters; by frequently opening the belly by means of
gentle laxatives; and by diluent and refrigerant re-
medies.
CCCCII.
When a suppuration has been formed, and the abscess
points outwardly, the part must be opened, the pus
evacuated, and the ulcer healed, according to the or-
dinary rules for cleansing and healing such abscesses and
ulcers.
CCCCIII.
We might here consider the splenitis, or inflammation
of the spleen. It does not, however, seem necessary,
because the disease very seldom occurs. When it does,
it may be readily known by the character given in our
Nosology; and its various event, and the practice it
requires, may be understood from what has been said above
on the inflammations of the other abdominal viscera.
CHAP. 

OF PHYSIC. 153
CHAP. X.
OF THE NEPHRITIS, OR INFLAM-
MATION OF THE KIDNEYS.
CCCCIV.
This disease, like other internal inflammations, is
always attended with pyrexia, and is especially known
from the region of the kidney being affected by a pain,
commonly obtuse, sometimes pungent. This pain is
not increased by the motion of the trunk of the body so
much as a pain of the rheumatic kind affecting the same
region. The pain of the nephritis may be often distin-
guished by its shooting along the course of the ureter,
and is frequently attended with a drawing up of the
testicle, and with a numbness of the limb on the side af-
fected; altho', indeed, these symptoms most commonly
attend the inflammation arising from a calculus in the
kidney or in the ureter. The nephritis is almost con-
stantly attended with frequent vomiting, and often with
costiveness and colic pains. The state of the urine is
commonly changed; it is most commonly of a deep red
colour, is voided frequently, and in a small quantity,
at a time. In more violent cases, the urine is some-
times colourless.
CCCCV.
The remote causes of this disease may be various; as
external contusion; violent or long continued riding;
strains of the muscles of the back incumbent on the
kidneys; various acrids in the course of the circulation
conveyed to the kidney; and perhaps some other internal
causes not yet well known. The most frequent is that
of
U 

154 PRACTICE
of calculous matter obstructing the tubuli uriniferi, or
calculi formed in the pelvis of the kidneys, and either
sticking there, or fallen into the ureter.
CCCCVI.
The various event of this disease may be understood
from what has been delivered on the subject of other
inflammations.
CCCCVII.
Writers, in treating of the cure of nephritis, have
commonly at the same time delivered the cure of the
Calculus renalis; but, though this may often produce
nephritis, it is to be considered as a distinct and separate
disease; and the treatment of it must be reserved to its
proper place. Here we shall treat of the cure of the
nephritis vera, or idiopathica only.
CCCCVIII.
The cure of this proceeds upon the general plan, by
bleeding, external fomentation, frequent emollient
clysters, antiphlogistic purgatives, and by the free use
of mild and demulcent liquids. The use of blisters is
hardly admissible, or, at least, will require great care to
avoid any considerable absorption of the cantharides.
CCCCIX.
The cystitis, or inflammation of the bladder, is sel-
dom a primary disease, and is therefore not to be treated
of here. The treatment of it, so far as necessary to be
explained, may be readily understood from what has
been already delivered.
CCCCX.
Of the visceral inflammations, there remains to be
considered the inflammation of the uterus; but we omit
it 

OF PHYSIC. 155
it here, because the consideration of it cannot be se-
parated from that of the diseases of child-bearing
women.
CHAP. XI. 
OF THE RHEUMATISM.
CCCCXI.
Of this disease there are two species, the one named
the acute, the other the chronic rheumatism.
CCCCXII.
It is the acute rheumatism which especially belongs to
this place, as, from its causes, symptoms, and methods
of cure, it will appear to be a species of phlegmasia or
inflammation.
CCCCXIII.
This disease is frequent in cold, and more uncommon
in warm climates. It appears most frequently in autumn
and spring, less frequently in winter, while the frost is
confiant, and very seldom during the heat of sum-
mer. It may occur, however, at any season, if vicis-
situdes of heat and cold be for the time frequent.
CCCCXIV.
For the most part, the acute rheumatism arises from
the application of cold to the body when any how un-
usually warm; or when the cold is applied to one part
of the body, whilst the other parts are kept warm; or,
lastly, when the application of the cold is long con-
tinued, 

156 PRACTICE
tinued, as it is when wet or moist cloaths are applied
to any part of the body.
CCCCXV.
These causes may affect persons of all ages; but the
rheumatism seldom appears either in very young or
in elderly persons, and most commonly occurs from the 
age of puberty to that of thirty-five years.
CCCCXVI.
These causes (CCCCXIV.) may also affect persons
of any constitution, but they most commonly affect
those of a sanguine temperament.
CCCCXVII.
This disease is particularly distinguished by pains af-
fecting the joints, for the most part the joints alone, but
sometimes affecting also the muscular parts. Very often
the pains shoot along the course of the muscles, from
one joint to another, and are always much increased by
the action of the muscles belonging to the joint, or
joints affected.
CCCCXVIII.
The larger joints are most frequently affected, such
as the hip-joint and knees of the lower, and the shoul-
ders and elbows of the upper extremities. The ankles
and wrists are also frequently affected; but the smaller
joints, such as those of the toes or fingers, seldom
suffer.
CCCCXIX.
This disease, although sometimes confined to one part
of the body only, yet very often affects many parts of
it; and then it begins with a cold stage, which is im-
mediately succeeded by the other symptoms of pyrexia,
and particularly by a frequent, full, and hard pulse.
Sometimes 

OF PHYSIC. 157
Sometimes the pyrexia is formed before any pains are
perceived, but more commonly pains are felt in particular
parts, before any symptoms of pyrexia appear.
CCCCXX.
When no pyrexia is present, the pain may be con-
fined to one joint only; but, when any considerable
pyrexia is present, although the pain may be chiefly in
one joint, yet it seldom happens but that the pains affect
several joints, often at the very same time, but for the
most part shifting their place, and, having abated in
one joint, become more violent in another. They do
not commonly remain long in the same joint, but fre-
quently shift from one to another, and sometimes return
to joints formerly affected; and in this manner the dis-
ease often continues for a long time.
CCCCXXI.
The pyrexia attending this disease has an exacerbation
every evening, and is most considerable during the
night, when the pains also become more violent; and it
is at the same time that the pains shift their place from
one joint to another. The pains seem to be also increased
during the night, by the body being covered more
closely, and kept warmer.
CCCCXXII.
A joint, after having been for some time affected with
pain, commonly becomes affected also with some swelling
and redness, which is painful to the touch. It seldom
happens, that a swelling coming on does not alleviate
the pain, which had been before in the joint; but the
swelling does not always take off the pain entirely, nor
secure the joint against a return of it.
CCCCXXIII.
This disease is commonly attended with some sweating,
which occurs early in the course of the disease, but is
seldom 

158 PRACTICE
seldom free or copious, and seldom either relieves from
the pains, or proves critical.
CCCCXXIV.
In the course of this disease the urine is high coloured,
and in the beginning without sediment; but, as the dis-
ease advances, and the pyrexia has more considerable
remissions, the urine deposits a lateritious sediment.
This, however, does not prove entirely critical; for
the disease often continues long after such a sediment has
appeared in the urine.
CCCCXXV.
When blood is drawn in this disease, it always ex-
hibits the appearance mentioned (CCXXXII.)
CCCCXXVI.
The acute rheumatism, though it has so much of the
nature of the other phlegmasiæ, differs from all these hi-
therto mentioned, in this, that it is not liable to ter-
minate in suppuration. This almost never happens in
rheumatism; but the disease sometimes produces effusions
of a transparent gelatinous fluid into the sheaths of the
tendons. If we may be allowed to suppose that such
effusions are frequent, it must also happen, that the
effused fluid is commonly re-absorbed; for it has seldom
happened, and never indeed to my observation, that
considerable or permanent tumours have been produced,
or such as required to be opened, and to have the con-
tained fluid evacuated. Such tumours have indeed oc-
curred to others, and the opening made in them has pro-
duced ulcers difficult to heal. Vide Storck. Ann.
Med. II.
CCCCXXVII.
In the circumstances mentioned from (CCCCXVII,
to CCCCXXIV.), the disease often continues for
several 

OF PHYSIC. 159
several weeks. It seldom, however, proves fatal; and
it rarely happens that the pyrexia continues to be con-
siderable for more than two or three weeks. While the
pyrexia abates in its violence, if the pains of the joints
continue, they are less violent, more limited in their
place, being confined commonly to one or a few joints
only, and are less ready to change their place.
CCCCXXVIII.
When the pyrexia attending rheumatism has entirely
ceased, when the swelling, and particularly the redness
of the joints, are entirely gone, but there are pains
which still continue to affect certain joints, which re-
main stiff, which feel uneasy upon motion, on changes
of weather, or in the night time only, the disease is
named the Chronic Rheumatism, as it very often con-
tinues for a long time. As the chronic is commonly
the sequel of the acute rheumatism, we think it proper
to treat of the former also in this place.
CCCCXXIX.
The limits between the acute and chronic rheu-
matisms, are not always exactly marked.
When the pains are still ready to shift their place,
when they are especially severe in the night-time, when,
at the same time, they are attended with some degree of
pyrexia, and with some swelling, and especially some
redness of the joints; the disease is to be considered as
partaking of the nature of the acute rheumatism.
But, when there is no degree of pyrexia remaining,
when the pained joints are without redness, when they
are cold and stiff, when they cannot easily be made to
sweat, or when, while a free and warm sweat is brought
out on the rest of the body, it is only clammy and cold
on the pained joints; and when, further, the pains of
these are increased by cold, and relieved by heat applied
to them, the case is to be confidered as that of a purely
chronic rheumatism.
CCCCXXX. 

160 PRACTICE
CCCCXXX.
The chronic rheumatism may affect different joints,
but is especially ready to affect those joints which are
surrounded with many muscles, and those of which the
muscles are employed in the most constant and vigorous
exertions. Such is the case of the vertebræ of the loins,
the affection of which is named Lumbago, or of the
hip-joint, when the disease is named Ischias, or Sciatica.
CCCCXXXI.
Violent strains and spasms occurring on sudden and
somewhat violent exertions, bring on rheumatic af-
fections, which at first partake of the acute, but very
soon change into the nature of the chronic rheumatism.
Such are frequently the lumbago, and other affections
which seem to be more seated in the muscles, than in the
joints, as the torticolis or obstipitas catarrhalis of Sau-
vages, and the pleuritis spuria, or the pleurodyne ple-
thorica and rheumatica of the same author.
CCCCXXXII.
We have thus delivered the history of rheumatism,
and suppose that, from what has been said, the remote
causes, the diagnosis, and prognosis of the disease, may
be understood. The distinction of the rheumatic pains
from those resembling them, which occur in the syphilis
and scurvy, will be obvious, either from the seat of
those pains, or from the concomitant symptoms peculiar
to these diseases. The distinction of rheumatism from
gout will be more fully understood from what is to be
delivered in the following chapter.
CCCCXXXIII.
With respect to the proximate cause of rheumatism,
there have been various opinions. It has been imputed
to a peculiar acrimony; of which, however, I can find
no evidence; and the consideration of the remote causes,
the 

OF PHYSIC. 161
the symptoms, and cure of the disease, renders the sup-
position very improbable. The cause of an Ischias
nervosa assigned by Cotunnius, appears to me hypo-
thetical, and is not supported by either the phænomena
or method of cure. That, however, a disease of a
rheumatic nature may be occasioned by an acrid matter
applied to the nerves, is evident from the tooth-ach, a
rheumatic affection generally arising from a carious
tooth.
That pains resembling those of rheumatism may arise
from deep seated suppurations, we know from some cases
depending on such a cause, and which, in their sym-
ptoms, resemble the lumbago or ischias. We believe,
however, that, by a proper attention, these cases de-
pending on suppuration, may be commonly distinguished
from the genuine cases of lumbago and ischias, and,
from what is said in (CCCCXXVI), we judge it to be
at least improbable, that a genuine lumbago or ischias
should ever end in suppuration.
CCCCXXXIV.
The proximate cause of rheumatism has been by
many supposed to be a lentor of the fluids obstructing
the vessels of the part; but the same considerations as in
CCXXXVI. 2, 3, 4, and 5, will apply equally here
for rejecting the supposition of a lentor.
CCCCXXXV.
While we cannot, therefore, find either evidence or
reason for supposing that the rheumatism depends upon
any change in the state of the fluids, we must conclude
that the proximate cause of acute rheumatism, is the
same with that of other inflammations not depending
upon a direct stimulus.
CCCCXXXVI.
In the case of rheumatism we suppose, that the most
common remote cause of it, that is, cold applied, ope-
rates especially on the vessels of the joints, these being
less
X 

162 PRACTICE
less covered by a cellular texture than those of the inter-
mediate parts of the limbs. We suppose farther, that
the application of cold produces a constriction of the
extreme vessels, and at the same time, an increase of tone
or phlogistic diathesis, in the course of them, from
which arises an increased impetus of the blood, and, at
the same time, a resistance to the free passage of it, and
consequently inflammation and pain. Further, we sup-
pose, that the resistance formed, excites the vis me-
dicatrix to a further increase of the impetus of the blood;
and, to support this, a cold stage arises, a spasm is
formed, and a pyrexia and phlogistic diathesis are pro-
duced in the whole system.
CCCCXXXVII.
According to this explanation, the cause of acute
rheumatism appears to be exactly analogous to that of
inflammations depending on an increased afflux of blood
to a part, while it is exposed to the action of cold.
But there seems to be further, in the case of rheu-
matism, some peculiar affection of the fibres of the
muscles. These fibres seem to be under some degree of
rigidity, and therefore less easily admit of motion, and
are pained upon the exertions of it. This also seems
to be the affection which gives opportunity to the pro-
pagation of pains from one joint to another, and which
are most severely felt in the extremities terminating in
the joints, because, beyond these, oscillations are not
propagated.
This affection of the muscular fibres, explains well in
what manner strains and spasms produce rheumatic af-
fections; and, upon the whole, shews, that, with an
inflammatory affection of the sanguiferous system, there
is also in rheumatism a peculiar affection of the muscular
fibres, which has a considerable share in producing the
phenomena of the disease.
CCCCXXXVIII.
Having thus given our opinion of the proximate cause
of rheumatism, we proceed to treat of the cure.
CCCCXXXIX.

OF PHYSIC. 163
CCCCXXXIX.
Whatever difficulty may occur with respect to the ex-
planations given (CCCCXXXVI. CCCCXXXVII.)
this remains certain, that in acute rheumatism, there is
an inflammatory affection of the parts, and a phlogistic
diathesis in the whole system, and upon these is founded
the method of cure, which frequent experience has
approved.
CCCCXL.
The cure therefore requires, in the first place, an an-
tiphlogistic regimen, and, particularly, a total absti-
nence from animal food, and from all fermented or
spirituous liquors; substituting a mild vegetable or milk
diet, and the plentiful use of bland diluent drinks.
CCCCXLI.
Upon the same principle (CCCCXXXIX) blood- 
letting is the chief remedy of acute rheumatism. The
blood is to be drawn in large quantity, and the bleeding
is to be repeated in proportion to the frequency, fullness,
and hardness of the pulse, and the violence of the pain.
For the most part, large and repeated bleeding, during
the first days of the disease, seem to be necessary, and
accordingly have been very much employed; but to this
some bounds are to be set; for very profuse bleedings
occasion a slow recovery, and, if not absolutely effectual,
are ready to produce a chronic rheumatism.
CCCCXLII.
To avoid that debility of the system, which general
bleedings are ready to occasion, the urgent symptom of
pain may be often relieved, by topical bleedings; and,
then any swelling and redness have come upon a joint,
the pain of it may be very certainly relieved by topical
bleedings; but, as the continuance of the disease seems
to depend more upon the phlogistic diathesis of the whole
system, 

164 PRACTICE
system, than upon the affection of particular parts, so
topical bleedings will not supply the place of the general
bleedings proposed above.
CCCCXLIII.
To take off the phlogistic diathesis prevailing in this
disease, purging may be useful, if procured by medicines
which do not stimulate the whole system, such as the
neutral salts, which have in some measure a refrigerant
power. Purging, however, is not so powerful as bleeding
in removing phlogistic diathesis; and, when the disease
has become general and violent, frequent stools are in-
convenient, and even hurtful, by the motion and pain
which they occasion.
CCCCXLIV.
In acute rheumatism, applications to the pained parts
are of little service. Fomentations, in the beginning
of the disease, rather aggravate than relieve the pains.
The rubefacients and camphire are more effectual in
relieving the pains; but generally they only shift the
pain into another part, and do not prove any cure of the
general affection. Blistering also may be very effectual
in removing the pain from a particular part; but will be
of little use, except where the pains are much confined
to one part.
CCCCXLV.
The several remedies mentioned from (CCCCXXXIX,
to CCCCXLIV.) moderate the violence of the disease,
and sometimes remove it entirely; but they sometimes
fail in this, and leave the cure imperfect. The at-
tempting a cure by large and repeated bleedings, is at-
tended with many inconveniences (see CXXXIV.);
and the most effectual and safe method of curing this
disease, is, after some general bleedings for taking off,
or at least diminishing the phlogistic diathesis, to employ
sweating, conducted by the rules laid down (CLXII.
and CLXIII.)
CCCCXLVI. 

OF PHYSIC. 165
CCCCXLVI.
Opiates, except where they are directed to procure
sweat, always prove hurtful in every stage of this
disease.
CCCCXLVII.
The Peruvian bark has been supposed a remedy in
some cases of this disease; but we have seldom found it
useful, and, in some cases, hurtful. It appears to me
to be fit in those cases only in which the phlogistic dia-
thesis has much abated, and, at the same time, the ex-
acerbations of the disease are manifestly periodical, with
considerable remissions interposed.
CCCCXLVIII.
Calomel, and some other preparations of mercury,
have been recommended in the acute rheumatism; but I
believe they are useful only in eases approaching to the
nature of the chronic.
CCCCXLIX.
Having now treated fully of the cure of the acute
rheumatism, we proceed to treat of the cure of the
chronic, which is so frequently a sequel of the former.
CCCCL.
The phenomena of the purely chronic rheumatism
mentioned in (CCCCXXVIII. and CCCCXXIX.)
lead me to conclude, that its proximate cause is an atony,
both of the blood-vessels and of the muscular fibres of
the part affected, together with such a degree of rigidity,
and contraction in the latter, as frequently attend them
in a state of atony.
CCCCLI. 

166 PRACTICE
CCCCLI.
Upon this view of the proximate cause, the general
indication of cure must be to restore the activity and
vigour of the vital principle in the part; and the re-
medies for this disease, which experience has approved
of, are chiefly such as are manifestly suited to the indi-
cation proposed.
CCCCLII.
These remedies are either external or internal.
The external are, the supporting the heat of the part,
by keeping it constantly covered with flannel; the in-
creasing the heat of the part by external heat, applied
either in a dry or in a humid form; the diligent use of
the flesh-brush, or other means of friction; the appli-
cation of electricity in sparks or shocks; the ap-
plication of cold water by affusion or immersion; the
application of essential oils of the most warm and
penetrating kind; the application of salt brine; and,
lastly, the employment either of exercise, of the part
itself, so far as it can easily bear or by riding, or other
mode of gestation.
CCCCLIII.
The internal remedies are, 1. large doses of essential
oils drawn from resinous substances, such as turpentine;
2. substances containing such oils, as guaiac; 3. volatile
alkaline salts; 4. these, or other medicines directed to
procure sweat, (CLXIII.) and, lastly, calomel, or
other preparation of mercury, in small doses, continued
for some time.
CCCCLIV.
These (CCCCLII. and CCCCLIII.) are the reme-
dies successfully employed in the purely chronic rheu-
matism; and there are still others recommended, as
bleeding, general and topical, burning, blistering, and
issues; 

OF PHYSIC. 167
issues; but these appear to me to be chiefly, perhaps
only, useful when the disease still partakes of the nature
of acute rheumatism.
CHAP. XII.
OF THE GOUT.
CCCCLV.
The Gout, not only as it occurs in different persons,
but even as it occurs in the same person at different
times, is a disease of such various appearance, that it is
difficult to render the history of it complete and exact,
or to give a character of it that will universally apply.
However, I shall endeavour to describe the disease as it
most commonly appears, and to mark the varieties of it
as well as I can. From such a history we expect, that
a general character may be given, and such we think is
the following, as intended for the next edition of our
Nosology.
GEN. XXIII. PODAGRA.
Morbus hæreditarius, oriens sine causa externa
evidente, sed præeunte plerumque ventriculi affectione
insolita; pyrexia; dolor ad articulum et plerumque pedis
pollici, certe pedum et manuum juncturis, potissimum
infestus; per intervalla revertens, et sæepe cum ventriculi
et internarum partium affectionibus alternans.
CCCCLVI.
The Gout is generally a hereditary disease; but some
persons, without hereditary disposition, seem to acquire
it; 

168 PRACTICE
it; and, in some, a hereditary disposition may be coun-
teracted by various causes. These circumstances may
occasion exceptions to our general position; but the facts
supporting it are very numerous.
CCCCLVII.
This disease attacks the male sex especially; but it
sometimes, though more rarely, attacks also the female.
The females liable to it are those of the more robust and
full habits; and it very often happens to such before the
menstrual evacuation has ceased. I have found it oc-
curring in several females, whose menstrual evacuations
were more abundant than usual.
CCCCLVIII.
This disease seldom attacks Eunuchs; and, when it
does, seems to be those who happen to be of a robust
habit, to lead an indolent life, and to live very full.
CCCCLIX.
The gout attacks especially men of robust and large
bodies, men of large heads, of full and corpulent
habits, and men whose skins are covered with a thicker
rete mucosum, which gives a coarser surface.
CCCCLX.
If, with the antients, we might ascertain, by certain
terms, the temperaments of men, I would say, that
the gout attacks especially men of a cholerico-sanguine
temperament, and that it very seldom attacks the purely
sanguine or melancholic. It is, however, very difficult
to treat this matter with due precision.
CCCCLXI.
The gout seldom attacks persons employed in con-
stant bodily labour, or persons who live much upon
vegetable aliment.
CCCCLXII.

OF PHYSIC. 169
CCCCLXII.
The gout does not commonly attack men, till after
the age of five and thirty; and generally not till a still
later period. There are indeed instances of the gout
occurring more early; but these are few, in comparison
of the numbers which agree with what we have given as
the general rule. When the disease does appear early in
life, it seems to be in those in whom the hereditary dis-
position is very strong, and to whom the remote causes,
to be hereafter mentioned, have been applied in a con-
siderable degree.
CCCCLXIII.
As the gout is a hereditary disease, and affects espe-
cially men of a particular habit, its remote causes may
be considered as predisponent and occasional.
CCCLXIV.
The predisponent cause, so far as expressed by ex-
ternal appearances, we have already marked; and phy-
sicians have been very confident in assigning the occa-
sional causes; but, in a disease depending so much upon
a predisposition, the assigning occasional causes must be
uncertain; as, in the predisposed, the occasional causes
may not always appear, and, in persons not predisposed,
they may appear without effect. This uncertainty
must particularly affect the case of the gout; but I shall
offer what appears to me most probable on the subject.
CCCCLXV.
The occasional causes of the gout seem to be of two
kinds. First, those which induce a plethoric state of
the body. Secondly, those which, in plethoric habits,
induce a state of debility.
Y CCCCLXVI. 

170 PRACTICE
CCCCLXVI.
Of the first kind are, a sedentary indolent manner of
life, and a full diet of animal food. These circum-
stances commonly precede the disease, and if there should
be any doubt as to their effects in producing it, the fact,
however, will be rendered sufficiently probable by what
has been observed in (CCCCLXI.)
CCCCLXVII.
Of the second kind of occasional causes which in-
duce debility are, excess in venery; intemperance in
the use of intoxicating liquors; indigestion produced
either by the quantity or the quality of aliments; much
application to study or business; night watching; ex-
cessive evacuations; the ceasing of usual labour; the
sudden change from a very full, to a very spare diet;
the large use of acids and acescents; and, lastly, cold
applied to the lower extremities.
CCCCLXVIII.
The first (CCCCLXVI.) seem to act by increasing
the predisposition. The last (CCCCLXVII.) are
commonly the exciting causes, both of the first attacks,
and of the repetitions of the disease.
CCCCLXIX.
It is an inflammatory affection of some of the joints
which especially constitutes what we call a paroxysm of
the gout. This sometimes comes on suddenly, without
any warning, but is generally preceded by several sym-
ptoms; such as the ceasing of a sweating which the feet
had been commonly affected with before; an unusual
coldness of the feet and legs; a frequent numbness, al-
ternating with a sense of prickling along the whole of
the lower extremities; frequent cramps of the muscles
of the legs; and an unusual turgescence of the veins.
CCCCLXX.

OF PHYSIC. 171
CCCCLXX.
While these symptoms take place in the lower ex-
tremities, the whole body is affected with some degree
of torpor and languor, and the functions of the stomach,
in particular, are more or less disturbed. The appetite
is diminished, and flatulency, or other symptoms of in-
digestion, are felt. These symptoms, and those of
(CCCCLXIX.) take place for several days, sometimes
for a week or two, before a paroxysm comes on; but
commonly, upon the day immediately preceding it, the
appetite becomes greater than usual.
CCCCLXXI.
The circumstances of paroxysms are the following,
They come on most commonly in the spring, and sooner
or later, according as the vernal heat succeeds sooner or
later to the winter's cold; and, perhaps, sooner or later
also, according as the body may happen to be more or
less exposed to vicissitudes of heat and cold.
CCCCLXXII.
The attacks are sometimes felt first in the evening,
but more commonly about two or three o'clock of the
morning. The paroxysm begins with a pain affecting
one foot, most commonly in the ball or first joint of the
great toe, but sometimes in other parts of the foot.
With the coming on of this pain, there is commonly
more or less of a cold shivering, which, as the pain in-
creases, gradually ceases, and is succeeded by a hot stage
of pyrexia, which continues for the same time with the
pain itself. From the first attack, the pain becomes, by
degrees, more violent, and continues in this state with
great restlessness of the whole body, till next midnight,
after which it gradually remits; and, after it has con-
tinued for twenty-four hours from the commencement of
the first attack, it commonly ceases very entirely, and,
with the coming on of a gentle sweat, allows the patient
to fall asleep. The patient, upon coming out of his 
sleep

172 PRACTICE
sleep in the morning, finds the pained part affected with
some redness and swelling, which, after having continued
for some days, gradually abate.
CCCCLXXIII.
When a paroxysm has thus come on, although the
violent pain after twenty-four hours be considerably
abated, the patient is not entirely relieved from it. For
some days he has every evening a return of more con-
siderable pain and pyrexia, and which continue with
more or less violence till morning. After continuing in
this manner for several days, the disease sometimes goes
entirely off, not to return till after a long interval.
CCCCLXXIV.
When the disease, after having thus remained for
some time in a joint, ceases very entirely, it generally
leaves the person in very perfect health, enjoying greater
ease and alacrity in the functions of both body and mind,
than he had for a long time before experienced.
CCCCLXXV.
At the beginning of the disease, the returns of it are
sometimes only once in three or four years; but, as it
advances, the intervals become shorter, and at length,
the attacks are annual; afterwards come twice each year,
and at length recur several times during the whole course
of autumn, winter, and spring; and as, when the fits
are frequent, the paroxysms become also longer, so, in
the advanced state of the disease, the patient is hardly
ever tolerably free from it, except perhaps for two or
three months in summer.
CCCCLXXVI.
The progress of the disease is also marked by the
parts which it affects. At first, it commonly affects
one foot only, afterwards, every paroxysm affects both
feet, the one after the other; and, as the disease proceeds,
it 

OF PHYSIC. 173
it not only affects both feet once, but after having
ceased in the foot which was secondly attacked, returns
again into the first, and perhaps a second time also into
the other. Its changes of place are not only from one
foot to another, but from the feet into other joints,
especially those of the upper and lower extremities; so
that there is hardly a joint of the body that, on one
occasion or other, is not affected. It sometimes affects
two different joints at the very same time, but more com-
monly is at any one time severe in a single joint only, and
passes successively from one joint to another; so that the
patient's affliction is often protracted for a long time.
CCCCLXXVII.
When the disease has often returned, and the paroxysms
have become very frequent, the pains are commonly less
violent than they were at first; but the patient is more
affected with sickness, and the other symptoms of the
atonic gout, which shall be hereafter mentioned.
CCCCLXXVIII.
After the first paroxysms of the disease, the joints
which have been affected are entirely restored to their
former suppleness and strength; but, after the disease
has recurred very often, the joints affected do neither so
suddenly nor entirely recover their former state, but con-
tinue weak and stiff, and these effects at length proceed
to such a degree, that the joints lose their motion entirely.
CCCCLXXIX.
In many persons, but not in all, after the disease has
frequently recurred, concretions of a chalky nature are
formed upon the outside of the joints, and for the most
part immediately under the skin. The matter seems to
be deposited, at first, in a fluid form, afterwards becoming
dry and firm. In their firm state, these concretions are
a friable earthy substance, very entirely soluble in acids.
After they have been formed, they contribute, with
other circumstances, to destroy the motion of the joint.
CCCCLXXX. 

174 PRACTICE
CCCCLXXX.
In most persons who have laboured under the gout for
many years, a nephritic affection comes on, and discovers
itself by all the symptoms which usually attend calculous
concretions in the kidneys, and which we shall have
occasion to describe in another place. All that is ne-
cessary to be observed here is, that the nephritic affection
alternates with paroxysms of the gout, and that the two
affections, the nephritic and the gouty, are hardly ever
present at the same time. This also may be observed,
that children of gouty or nephritic parents, commonly
inherit one or other of these diseases; but which ever
may have been the principal disease of the parent, some
of the children have the one, and some the other. In
some of them, the nephritic affection occurs alone,
without any gout supervening; and this happens to be
frequently  the case of the female children of gouty
parents.
CCCCLXXXI.
In the whole of the history already given, we have
described the most comm	on form of the disease, and
which therefore, however diversified in the progress of
it, may be still called the regular state of the gout.
Upon occasion, however, the disease assumes different
appearances; but, as we suppose the disease to depend
always upon a certain diathesis, or disposition of the
system; so every appearance which we can perceive to
depend upon that same disposition, we still consider as a
symptom and case of the gout. The principal cir-
cumstance, in what we term the Regular Gout, is the
inflammatory affection of the joints; and, whatever
symptoms we can perceive to be connected with, or to
depend upon, the disposition which produces that inflam-
matory affection, but without its taking place, or being
present at the same time, we name the Irregular Gout.
CCCCLXXXII. 

OF PHYSIC. 175
CCCCLXXXII.
Of such irregular gout there are three different states,
which we name the atonic, the retrocedent, and the mis-
placed gout.
CCCCLXXXIII.
The first is when the gouty diathesis prevails in the
system, but, from certain causes, does not produce the
inflammatory affection of the joints. In this case, the
morbid symptoms which appear, are chiefly affections of
the stomach, such as loss of appetite, indigestion, and
its various circumstances of sickness, nausea, vomiting,
flatulency, acid eructations, and pains in the region of
the stomach. These symptoms are frequently accom-
panied with pains and cramps in several parts of the
trunk, and the upper extremities of the body, which
are relieved by the discharge of wind from the stomach.
Together with these affections of the stomach, there
commonly occurs a costiveness; but sometimes a loose-
ness, with colic pains. These affections of the alimentary
canal are often attended with all the symptoms of hypo-
chondriasis, as dejection of mind, a constant and anxious
attention to the slightest feelings, an imaginary aggra-
vation of these, and an apprehension of danger from
them.
In the same atonic gout, the viscera of the thorax
also are sometimes affected, and palpitations, faintings,
and asthma, occur.
In the head also, occur headachs, giddiness, apoplectic
and paralytic affections.
CCCCLXXXIV.
When the several symptoms now mentioned, occur
in habits having the marks of a gouty disposition, this
may be suspected to have laid the foundation of them;
and especially, when, either in such habits, a manifest
tendency to the inflammatory affection has formerly
appeared; or when the symptoms mentioned are inter-
mixed 

176 PRACTICE
mixed with, and are relieved by some degree of the
inflammatory gout. In such cases there can be no doubt
of considering the whole as a state of the gout.
CCCCLXXXV.
Another state of the disease we name the retrocedent
gout. This occurs when an inflammatory state of the
joints has, in the usual manner, come on, but without
arising to the ordinary degree of pain and inflammation,
or at least, without these continuing for the usual time,
or without their receding gradually in the usual manner;
these affections of the joint suddenly, and entirely cease,
while some internal part becomes affected. The internal
part most commonly affected is the stomach, which then
is affected with anxiety, sickness, vomiting, or violent
pain; but sometimes the internal part is the heart,
which gives occasion to a syncope; sometimes it is the
lungs, which are affected with asthma; and sometimes
it is the head, giving occasion to apoplexy or palsy. In
ail these cases there can be no doubt of the symptoms
being all a part of the same disease, however different
the affection may seem to be in the parts which it
attacks.
CCCCLXXXVI.
The third state of irregular gout, which we name the
misplaced, is when the gouty diathesis, instead of pro-
ucing the inflammatory affection of the joints, pro-
duces an inflammatory affection of some internal part,
and which appears from the same symptoms that attend
the inflammations of those parts, arising from other
causes.
Whether the gouty diathesis does ever produce such
inflammation of the internal parts, without having first
produced it in the joints, or, if the inflammation of the
internal part be always a translation from the joints pre-
viously affected, we dare not determine; but, even sup-
posing the latter to be always the case, we think the
difference of the affection of the internal part must still
distinguish 

OF PHYSIC. 177
distinguish the misplaced from what we have named the
retrocedent gout.
CCCCLXXXVII.
What internal parts may be affected by the misplaced
gout, I cannot precisely say, because I have never met
with any cases of the misplaced gout in my practice;
and I find no cases of it distinctly marked by practical
writers, except that of a pneumonic inflammation.
CCCCLXXXVIII.
There are two cases of a translated gout; the one of
which is an affection of the neck of the bladder, pro-
ducing pain, strangury, and a catarrhus vesicæ: The
other is an affection of the rectum, sometimes by pain
alone in that part, and sometimes by hemorrhoidal sym-
ptoms. In gouty persons, I have known such af-
fections alternate with inflammatory affections of the
joints: But whether to refer those affections to the re-
trocedent, or to the misplaced gout, I will not presume
to determine.
CCCCLXXXIX.
From the history which I have now delivered of the
gout, I think it may be discerned under all its various
appearances. It is, however, commonly supposed, that
there are cases in which it may be difficult to distinguish
gout from rheumatism, and it is possible there may be
such cases; but, for the most part, the two diseases
may be distinguished with great certainty, by observing
the predisposition, the antecedents, the parts affected,
the recurrences of the disease, and its connection with
the system; which circumstances, for the most part,
appear very differently in the two diseases.
CCCCXC.  
Z 

178 PRACTICE
CCCCXC.
With respect to the gout, our next business is to in-
vestigate its proximate cause, which must be a difficult
task, and I attempt it with some diffidence.
CCCCXCI.
Upon this subject, the opinion which has, generally
prevailed is, that the gout depends upon a certain mor-
bific matter, always present in the body; and that this
matter, by certain causes, thrown upon the joints or
other parts, produces the several phenomena of the
disease.
CCCCXCII.
This doctrine, however antient and general, appears
to me very doubtful; for,
First, there is no direct evidence of any morbific
matter being present in persons disposed to the gout.
There are no experiments or observations which shew
that the blood, or other humours of gouty persons, are
in any respect different from those of others. Previous
to attacks of the gout, there appear no marks of any
morbid state of the fluids; for the disease generally at-
tacks those persons who have enjoyed the most perfect
health, and appear to be in that state when the disease
comes on. At a certain period of the disease, a peculiar
matter indeed appears in gouty persons, (CCCC-
LXXIX.); but this, which does not appear in every
instance, and which appears only after the disease has
subsisted for a long time, seems manifestly to be the effect,
not the cause of the disease. Further, though there be
certain acrids which, taken into the body, seem to excite
the gout, (CCCCLXVII.) it is probable, that these
acrids operate otherwise in exciting the disease, than by
affording the material cause of it. In general, there-
fore, there is no proof of any morbific matter being
the cause of the gout.
Secondly, 

OF PHYSIC. 179
Secondly, the suppositions concerning the particular
nature of the matter producing the gout, have been so
various, and so contradictory to each other, as to allow
us to conclude, that there is truly no proof of the
existence of any of them. With respect to many of these
suppositions, they are so inconsistent with chemical phi-
losophy, and with  the laws of the animal œconomy,
that they must be entirely rejected.
Thirdly, the supposition of a morbific matter, as the
cause is. not consistent with the phenomena of the dis-
ease, particularly with its frequent and sudden transla-
tions from one part to another.
Fourthly, the supposition is further rendered im-
probable by this, that, if a morbific matter did exist,
its operation should be similar in the several parts which
it attacks; whereas it seems to be very different, being
stimulant, and exciting inflammation in the joints, but
sedative and destroying the tone in the stomach: Which,
upon the supposition of particular matter acting in both
cases, is not to be explained by any difference in the
part affected.
Fifthly, some facts, alledged in proof of a morbific
matter, are not sufficiently confirmed, such as those
which would prove the disease to be contagious. There
is, however, no proper evidence of this, the facts given
being not only few, and exceptionable, and the negative
observations innumerable.
Sixthly, some arguments brought in favour of a mor-
bific matter, are founded upon a mistaken explanation.
The disease has been supposed to depend upon a morbific
matter, because it is hereditary. But the inference is
not just; for most hereditary diseases do not depend
upon any morbific matter, but upon a particular con-
formation of the structure of the body, transmitted from
the parent to the offspring; and this last appears to be
particularly the case in the gout. It may be also ob-
served, that hereditary diseases, depending upon a mor-
bific matter, appear always much more early in life than
the gout commonly does.
Seventhly, the supposition of a morbific matter being
the cause of the gout, has been hitherto useless, as it
has not suggested any successful method of cure. Par-
ticular

180 PRACTICE
ticular suppositions have often corrupted the practice,
and have frequently led from those views which might
be useful, and from that practice which experience had
approved. Further, though the supposition of a mor-
bific matter has been generally received, it has been as
generally neglected in practice. When the gout has
affected the stomach, nobody thinks of correcting the
matter supposed to be present there, but merely of re-
storing the tone of the moving fibres.
Eighthly, the supposition of a morbific matter is quite
superfluous; for it explains nothing, without supposing
that matter to produce a change in the state of the
moving powers, and a change in the state of the moving
powers, produced by other causes, explains every cir-
cumstance without the supposition of a morbific matter;
and, to this purpose, it may be observed, that many of
the causes (CCCCLXVII.) exciting the gout, do not
operate upon the state of the fluids, but directly and
solely upon that of the moving powers.
Lastly, the supposition of a morbific matter is super-
fluous; because, without that, the disease can be ex-
plained in a manner more consistent with its phenomena,
with the laws of animal œconomy, and with the method
of cure which experience has approved. We now pro-
ceed to give this explanation; but, before entering upon
it, we must premise some general observations.
CCCCXCIII.
The first observation is, that the gout is a disease of
the whole system, or depends upon a certain general
conformation and state of the body, which manifestly
appears from the facts mentioned from (CCCCLVI. to
CCCCLXII.). But the general state of the system
depends chiefly upon the state of its primary moving
powers; and therefore the gout may be supposed to be
an affection of these chiefly.
CCCCXCIV.
My second observation is, that the gout is manifestly
an affection of the nervous system; in which the primary
moving

OF PHYSIC. 181
moving powers of the whole system are lodged. The
occasional or exciting causes (CCCCLXVII.) are al-
most all, such as act directly upon the nerves and nervous
system; and the greater part of the symptoms of the
atonic or retrocedent gout are manifestly affections of
the same system. (CCCCLXXXIII. CCCCLXXXV.)
This leads us to seek for an explanation of the whole of
the disease in the laws of the nervous system, and par-
ticularly in the changes which may happen in the balance
of its several parts.
CCCCXCV.
My third observation is, that the stomach, which has
so universal a consent with the rest of the system, is the
internal part that is the most frequently, and often very
considerably, affected by the gout. The paroxysms of
the disease are commonly preceded by an affection of the
stomach (CCCCLXX.); many of the exciting causes
(CCCCLXVII.) act first upon the stomach; and
the symptoms of the atonic and retrocedent gout
(CCCCLXXXIII. CCCCLXXXV.) are almost com-
monly and chiefly affections of the same organ. This
observation leads us to remark, that there is a balance
subsisting between the state of the internal, and that of
the external parts; and, in particular, that the state of
the stomach is connected with that of the external parts,
(XLIII.) so that the state of tone in the one, may
be communicated to the other.
CCCCXCVI.
These observations being premised, I shall now offer
the following pathology of the gout.
In some persons there is a certain vigorous and ple-
thoric state of the system (CCCCLXVII.), which at
a certain period of life, is liable to a loss of tone in the
extremities (CCCCLXIX.). This is in some measure
communicated to the whole system, but appears more
especially in the functions of the stomach (CCLXX).
When this loss of tone occurs while the energy of the brain
still retains its vigour, the vis medicatrix naturæ is excited
to 

182 PRACTICE
to restore the tone of the parts; and accomplishes it, by ex-
citing an inflammatory affection in some part of the extre-
mities. When this has subsisted for some days, the tone of
the extremities, and of the whole system, are restored, and
the patient returns to his ordinary state of health
(CCCCLXXIV.).
CCCCXCVII.
This is the course of things, in the ordinary form of
the disease, which we name the regular gout; but there
are circumstances of the body, in which this course
is interrupted or varied. Thus, when the atony
(CCCCLXIX. CCCCLXX.), has taken place, if the
reaction (CCCCXCVI.) do not succced, the atony
continues in the stomach, or perhaps in other internal
parts, and produces that state which we have, for reasons
now obvious, named the atonic gout.
CCCCXCVIII.
A second case of variation in the course of the gout
is, when to the atony, the reaction and inflammation
have to a certain degree succeeded, but from causes either
internal or external, the tone of the extremities, and
perhaps of the whole system, is weakened; so that the
inflammatory state, before it had either proceeded to the
degree, or continued for the time requisite for restoring
the tone of the system, suddenly and entirely ceases;
Whence the stomach, and other internal parts, relapse
into the state of atony; and perhaps have that increased
by the atony communicated from the extremities: All
which appears in what we have termed the retrocedent
state of the gout.
CCCCXCIX.
A third case of variation from the ordinary course of
the gout, is, when to the atony usually preceding, an
inflammatory reaction fully succeeds: But has its usual
determination to the joints by some circumstances pre-
vented; and is therefore directed to some internal part,
where 

OF PHYSIC. 183
where it produces an inflammatory affection, and that
state of things which we have named the Misplaced Gout.
D.
We have thus offered an explanation of the circum-
stances of the system in the several states of the gout;
and this explanation we suppose to be consistent with the
phenomena of the disease, and with the laws of the
animal œconomy. There are indeed several questions
which might be put with respect to the theory of the
disease; any answers to which we have not given. But,
though we could perhaps give an answer to many of
these questions, it does not here appear necessary, as at
present we intend only to establish such general facts
with regard to this disease, as may lay a foundation for
the cure of it, so far as experience has enabled us to
prosecute it. Proceeding, therefore, upon the several,
parts of the pathology given, as so many matters of fact
we shall now consider what may be attempted towards
the cure of the disease.
DI.
In entering upon this, we must observe, in the first
place, that a cure has been commonly thought im-
possible; and we acknowledge it to be very probable,
that the gout, as a disease of the whole habit, and very
often depending upon original conformation, cannot be
cured by medicines, the effects of which are always
very transitory, and seldom extend to the producing any
considerable change of the whole habit.
DII.
It would perhaps have been happy for gouty persons,
if this opinion had been implicitly received by them; as
it would have prevented their having been so often the
dupes of self-interested pretenders, who have either
amused them with inert medicines, or have rashly em-
ployed those of the most pernicious tendency. I am
much disposed to believe the impossibility of a cure of 
the

184 PRACTICE
the gout by medicines; and more certainly still incline
to think, that, whatever may be the possible power of
medicines, yet no medicine for curing the gout has hi-
therto been found. Although almost every age has pre-
sented a new remedy, all hitherto offered have, very
soon after, been either neglected as useless, or condemned
as pernicious.
DIII.
Though unwilling to admit the power of medicines,
yet I contend, that a great deal can be done towards the
cure of the gout, by a regimen: And from what has
been observed (CCCCLXl.), I am firmly persuaded,
that any man who, early in life, will enter upon the
constant practice of bodily labour, and of abstinence
from animal food, will be preserved entirely from the
disease.
Whether there be any other means of radically curing
the gout, I am not ready to determine. There are
histories of eases of the gout, in which it is said, that,
by great emotions of mind, by wounds, and by other
accidents, the symptoms have been suddenly relieved,
and never again returned; but how far these accidental
cures might be imitated by art, or would succeed in other
cases, is at least extremely uncertain.
DIV.
The practices proper and necessary in the treatment of
the gout, are to be considered under two heads: First,
As they are to be employed in the intervals of paroxysms;
or, secondly, As during the time of these.
DV.
In the intervals of paroxysms, the indications are,
to prevent altogether the return of paroxysms, or at least
to render them less frequent, and more moderate. During
the time of paroxysms, the indications are, to moderate
the violence, and shorten the duration of them as much
as can be done with safety.
DVI.

OF PHYSIC. 185
DVI.
It has been already observed, that the gout may be
entirely prevented by constant bodily exercise, and by a
low diet; and I am of opinion, that this prevention
may take place even in persons who have a hereditary
disposition to the disease. I must add here, that even
when the disposition has discovered itself by several
paroxysms of inflammatory gout, I am persuaded, that
labour and abstinence will absolutely prevent any returns
of it for the rest of life. These, therefore, are the
means of answering the first indication to be pursued in
the intervals of paroxysms; and I must here offer some
remarks upon the proper use of these remedies.
DVII.
Exercise in persons disposed to the gout, is directed to
two purposes: One of these is the strengthening of the
tone of the extreme vessels, and the other, the guarding
against the plethoric state. For the former, if exercise
be employed early in life, and before intemperance has
weakened the body, a very moderate degree of it will
answer the purpose; and, for the latter, if abstinence
be at the same time observed, little exercise will be
necessary.
DVIII.
With respect to exercise, this in general is to be ob-
served, that it should never be violent; for, if violent,
it cannot be long continued, and must always endanger
the bringing on an atony in proportion to the violence
of the preceding exercise.
DIX.
It is also to be observed, that the exercise of gestation,
though considerable and constant, if it be entirely
without bodily exercise, will not answer the purpose
in preventing the gout. For this end, therefore, the
exercise
A a

186 PRACTICE
exercise must be in some measure that of the body, and
must be moderate, but, at the same time, constant and
continued thro' life.
DX.
In every case and circumstance of the gout in which
the patient retains the use of his limbs, bodily exercise,
in the intervals of paroxysms, will always be useful;
and, in the beginnings of the disease, when the dis-
position to it is not yet strong, exercise may prevent a
paroxysm which otherwise might have come on. In
more advanced states of the disease, however, when there
is some disposition to a paroxysm, much walking will
bring it on; either as it weakens the tone of the lower
extremities, or as it excites an inflammatory disposition
in them; and thus it seems to be, that strains or con-
tusions often bring on a paroxysm of the gout.
DXI.
Abstinence, the other part of our regimen (DIII.)
for preventing the gout, is of more difficult application.
If an abstinence from animal food be entered upon early
in life, while the vigour of the system is yet entire, we
have no doubt of its being both safe and effectual; but,
if the motive for this diet shall not have occurred till
the constitution shall have been broken by intemperance,
or by the decline of life, a low diet may then endanger
the bringing on an atonic state.
DXII.
Further, if a low diet be entered upon only in the de-
cline of life, and be at the same time a very great change
in the former manner of living, the withdrawing of an
accustomed stimulus of the system may readily throw
this into an atonic state.
DXIII. 

OF PHYSIC. 187
DXIII.
The safety of an abstemious course may be greater or
less according to the management of it. It is animal
food which especially disposes to the plethoric and inflam-
matory state, and that food is to be therefore especially
avoided; but, on the other hand, it is vegetable aliment
of the lowest quality that is in danger of weakening the
system too much, by not affording sufficient nourishment,
and more particularly, of weakening the tone of the
stomach by its acescency. It is therefore a diet of a
middle nature that is to be chosen; and milk is precisely
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 greatest portion of
nourishment, the farinaceous seeds are next to be chosen,
and are the food most proper to be joined with milk.
DXIV.
With respect to drink, fermented liquors are useful
only when they are joined with animal food, and that
by their acescency; and their stimulus is only necessary
from custom. When, therefore, animal food is to be
avoided, fermented liquors are unnecessary; and, by
increasing the acescency of vegetables, these liquors may
be hurtful. The stimulus of fermented, or spirituous
liquors, is not necessary to the young and vigorous, and,
when much employed, impairs the tone of the system.
These liquors, therefore, are to be avoided, except so
far as custom and the declining state of the system may
have rendered them necessary. For preventing or mo-
derating the regular gout, water is the only proper
drink.                   
DXV.
With respect to an abstemious course, it has been
supposed, that an abstinence from animal food and fer-
mented liquors, or the living upon milk and farinacea
alone 

188 PRACTICE
alone for the space of one year, might be sufficient for a
radical cure of the gout: And it is possible that, at a
certain period of life, in certain circumstances of the
constitution, such a measure might answer the purpose.
But this is very doubtful; and it is more probable, that
the abstinence must, in a great measure, be continued,
and the milk diet be persisted in for the rest of life. It
is well known, that several persons who had entered on
an abstemious course, and had been thereby delivered
from the gout, have, however, upon returning to their
former manner of full living, had the disease return upon
them with as much violence as before, or in a more ir-
regular, and more dangerous form.
DXVI.
It has been alledged, that, for preventing the return
of the gout, blood-letting, or scarifications of the feet
frequently repeated, and at stated times, may be prac-
tised with advantage; but of this I have had no
experience.
DXVII.
Exercise and abstinence are the means of avoiding the
plethoric state which gives the disposition to the gout,
and are therefore the means proposed for preventing
paroxysms, or at least for rendering them less frequent,
and more moderate. But many circumstances prevent
the steadiness necessary in pursuing these measures; and,
therefore, in such eases, unless great care be taken to
avoid the exciting causes, the disease may frequently
return; and, in many cases, the preventing of paroxysms
is chiefly to be obtained by avoiding those exciting causes
enumerated in (CCCCLXVII.). The conduct ne-
cessary for avoiding them, will be sufficiently obvious to
persons acquainted with the doctrines of the Hygieine,
which we suppose to have been delivered in another
place.
DXVIII. 

OF PHYSIC. 189
DXVIII.
A due attention in avoiding those several causes, will
certainly prevent fits of the gout; and the taking care
that those exciting causes be never applied in a great
degree, will certainly render fits more moderate when
they do come on. But, upon the whole, it will appear,
that a strict attention to the whole conduct of life, is in
this matter necessary; and, therefore, when the pre-
disposition has taken place, it will be extremely difficult
to avoid the disease.
DXIX.
I am indeed firmly persuaded, that, by obviating the
predisposition, and by avoiding the exciting causes, the
gout may be entirely prevented: But, as the measures
necessary for this purpose will, in most cases, be pursued
with difficulty, and even with reluctance, men have
been very desirous to find a medicine which might answer
the purpose, without any restraint on their manner of
living. To gratify this desire, physicians have proposed,
and to take advantage of it, empirics have feigned many
remedies, as we have already observed. Of what nature
several of these remedies have been, I cannot certainly
say; but, of those which are unknown, we conclude,
from their having been only of temporary same, and
from their having soon fallen into neglect, that they
have been either inert or pernicious, and therefore I
make no inquiry after them; and shall now remark only
upon one or two known remedies for the gout which
have been lately in vogue.
DXX.
One of these is what has been named in England, the
Portland Powder. This is not a new medicine, but is
mentioned by Galen, and, with same little variation in
its composition, has been mentioned by the writers of
almost every age since that time. It appears to have
been at times in fashion, and to have again fallen into
neglect; 

190 PRACTICE
neglect; and I think that this last has been owing to its
having been found to be, in many instances, pernicious.
In every instance which I have known of its exhibition
for the length of time prescribed, the persons who had
taken it were indeed afterwards free from any inflam-
matory affection of the joints; but they were affected
with many symptoms of the atonic gout; and all, soon
after finishing their course of the medicine, have been
attacked with apoplexy, asthma, or dropsy, which proved
fatal.
DXXI.
Another remedy which has had the appearance of
preventing the gout, is, an alkali in various forms, such
as the fixed alkali, both mild and caustic, lime-water,
soap, and absorbent earths. Since it became common
to exhibit these medicines in nephritic and calculous
cases, it has often happened, that they were given to
those who were at the same time subject to the gout;
and it has been observed, that, under the use of these
medicines, gouty persons have been longer free from the
fits of their disease. That, however, the use of these
medicines has entirely prevented the returns of gout, I
do not know; because I never pushed the use of those
medicines for a long time, being apprehensive that the
long continued use of them might produce a hurtful
change in the state of the fluids. 
DXXII.
With respect to preventing the gout, I have only one
other remark to offer. As the preventing the gout de-
pends very much on supporting the tone of the stomach,
and avoiding indigestion; so costiveness, by occasioning
this, is very hurtful to gouty persons. It is therefore
necessary for such persons to prevent or remove costive-
ness, and, by a laxative medicine, when needful; but
it is at the same time proper, that the medicine employed
should be such as may keep the belly regular, without
much purging. Aloetics, rhubarb, magnesia alba, or
flowers 

OF PHYSIC. 191
flowers of sulphur, may be employed, as the one or the
other may happen to be best suited to particular persons.
DXXIII.
These are the several measures from (DV. to DXXII.)
to be pursued in the intervals of the paroxysms; and
we are next to mention the measures proper during the
time of them.
DXXIV.
As during the time of paroxysms the body is in a
feverish state, no irritation should then be added to it;
and every part, therefore, of the antiphlogistic regimen,
(CXXIV. CXXV.) except the application of cold,
ought to be strictly observed.  
Another exception to the general rule may occur,
when the tone of the stomach is weak, and when the
patient has been before much accustomed to the use of
strong drink; for then it may be allowable, and even
necessary, to give some animal food, and a little wine.
DXXV.
That no irritation is to be added to the system during
the paroxysms of gout, except in the cases mentioned,
is entirely agreed upon among physicians: But it is a
more difficult matter to determine, whether, during the
time of paroxysms, any measures may be pursued to
moderate the violence of reaction and of inflammation.
Dr. Sydenham has given it as his opinion, that the more
violent the inflammation and pain, the paroxysms will
be the shorter, as well as the interval between the pre-
sent and next paroxysm longer; and, if this opinion
be admitted as just, it will forbid the use of any remedies
which might moderate the inflammation; which is, to
a certain degree, undoubtedly necessary for the health of
the body. On the other hand, acute pain presses for
relief; and, although a certain degree of inflammation
may seem absolutely necessary, it is not certain but that
a moderate degree of it may answer the purpose: And 
it

192 PRACTICE
it is even probable, that, in many eases, the violence
of inflammation may weaken the tone of the parts, and
thereby invite a return of paroxysms. It seems to me
to be in this way, that, as the disease advances, the
paroxysms become more frequent.
DXXVI.
From these last considerations, it seems probable,
that, during the time of paroxysms, some measures
may be taken to moderate the violence of the inflam-
mation and pain, and particularly, that in first par-
oxysms, and, in the young and vigorous, blood-letting
at the arm may be practised with advantage: But I am
persuaded, that this practice cannot be repeated often
with safety, because blood-letting not only weakens the
tone of the system, but may also contribute to produce
Plethora. I believe, however, that bleeding by leeches
on the foot, and upon the inflamed part, may be prac-
tised, and repeated with greater safety; and I have
known instances of its having been practised with safety,
to moderate and shorten paroxysms; but how far it may
be carried, we have not had experience enough to de-
termine. 
DXXVII.
Besides blood-letting, and the antiphlogistic regimen,
it has been proposed to employ remedies for moderating
the inflammatory spasm of the part affected, such as
warm bathing and emollient poultices. These have
sometimes been employed with advantage and safety;
but, at other times, have been found to give occasion
to a retrocession of the gout.
DXXVIII.
Blistering is a very effectual means of relieving and
discussing a paroxysm of the gout; but has also fre-
quently had the effect of rendering it retrocedent.
DXXIX.

OF PHYSIC. 193
DXXIX.
The stinging with nettles I consider as analogous to
blistering; and I think it probable that it would be
attended with the same danger.
DXXX.
The burning with moxa, or other substances, I con-
sider as a remedy of the same kind. I have had, indeed,
no evidence of this proving hurtful; but neither have I
had any proper evidence of its having proved a radical
cure.
DXXXI.
Camphire, and some aromatic oils, have the power
of allaying the pain, and of removing the inflammation
from the part affected; but these remedies commonly
make the inflammation only shift from one part to
another, and therefore with the hazard of its falling
upon a part where it may be more dangerous, and they
have sometimes rendered the gout retrocedent.
DXXXII.
From these reflections (DXXX et seq.) it will ap-
pear, that some danger must attend every external appli-
cation to the parts affected, during a paroxysm; and
that therefore the common practice of committing the
person to patience and flannel alone, is established upon
the best foundation.
DXXXIII
Opiates give the most certain relief from pain, but,
when given in the beginning of gouty paroxysms, oc-
casion these to return with greater violence. When,
however, the paroxysms shall have abated in their vio-
lence, but still continue to return, so as to occasion
painful and restlees nights, opiates may be then given
with
Bb 

194 PRACTICE
with safety and advantage, especially in the case of
persons advanced in life, and who have been often
affected with the disease.
DXXXIV.
When, after paroxysms have ceased, some swelling
and stiffness shall remain in the joints, these symptoms
are to be discussed by the diligent use of the flesh-brush.
DXXXV.
Purging, immediately after a paroxysm, will be always
employed with the hazard of bringing it on again.
DXXXVI.
I have now finished what has occurred to be said upon
the means of preventing and curing the regular gout;
and shall now consider its management when it has
become irregular, of which I have observed there are
three different cases.
DXXXVII.
In the first case, which I have named the atonic
gout, the cure is to be accomplished by carefully
avoiding all debilitating causes, and by employing, at
the same time, the means of strengthening the system in
general, and the stomach in particular.
DXXXVIII.
For the avoiding debilitating causes, I must refer to
the doctrines of the Hygieine, as in (DXVII).
DXXXIX.
For strengthening the system in general, I must re-
commend frequent exercise on horseback, and moderate
walking. Cold bathing also may answer the purpose,
and may be safely employed, if it appear to be powerful
in

OF PHYSIC. 195
in stimulating the system, and be not applied when the
extremities are threatened with any pain.
For supporting the tone of the system in general,
when threatened with atonic gout, some animal food
ought to be employed, and the more acescent vegetables
ought to be avoided. In the same case, some wine also
may be necessary; but it should be in moderate quantity,
and of the least acescent kinds; and, if every kind of
wine shall be found to increase the acidity of the stomach,
ardent spirits and water must be employed.
DXL.
For strengthening the stomach, bitters and the Pe-
ruvian bark may be employed; but care must be taken
that they be not constantly employed for any great length
of time.
The most effectual medicine for strengthening the
stomach is iron, which may be employed under various
preparations; but, to me, the best appears to be the
rust in fine powder, which may be given in very large
doses.
For supporting the tone of the stomach, aromatics
may be employed; but should be used with caution, as
the frequent and large use of them may have an opposite
effect, and they should therefore be given only in com-
pliance with former habits, or for palliating present
symptoms.
When the stomach happens to be liable to indigestion,
gentle vomits may be frequently given, and proper laxa-
tives should be always employed to obviate, or to re-
move costiveness.
DXLI.
In the atonic gout, or in persons liable to it, to guard
against cold is especially necessary; and the most certain
means of doing this, is by repairing to a warm climate
during the winter season.
DXLII. 

196 PRACTICE
DXLII.
In the more violent cases of the atonic gout, blistering
the lower extremities may be useful; but that remedy
should be avoided when any pain threatens the extremities.
In persons liable to the atonic gout, issues may be esta-
blished in the extremities, as, in some measure, a sup-
plement to the disease.
DXLIII.
A second case of the irregular gout, is that which I
have named the Retrocedent.
When this affects the stomach and intestines, relief
is to be instantly attempted by the free use of strong
wines, joined with aromatics, and given warm; or, if
these shall not prove powerful enough, ardent spirits
must be employed, and are to be given in a large dose.
In moderate attacks, ardent spirits, impregnated with
garlic, or with asa fœtida, may be employed; or, even
without the ardent spirits, a solution of asa fœtida, with
the volatile alkali, may answer the purpose. Opiates
are often an effectual remedy, and may be joined with
aromatics, as in the Electuarium Thebaicum; or they
may be usefully joined with volatile alkali and camphire.
Musk has likewise proved useful in this disease.
When the affection of the stomach is accompanied
with vomiting, this may be encouraged, by taking
draughts of warm wine, at first with water, and after-
wards without it; having at length recourse, if ne-
cessary, to some of the remedies above mentioned, and
particularly the opiates.
In like manner, if the intestines be affected with
diarrhœa, this is to be at first encouraged, by taking
plentifully of weak broth; and when this shall have
been done sufficiently, the tumult is to be quieted by
opiates.
DXLIV. 

OF PHYSIC. 197
DXLIV.
When the retrocedent gout shall affect the lungs, and
produce asthma, this is to be cured by opiates, by an-
tispasmodics, and, perhaps, by blistering on the breast
or back.
DXLV.
When the gout, leaving the extremities, shall affect
the head, and produce pain, vertigo, apoplexy, or
palsy, our resources are very precarious. The most
probable means of relief is, blistering the head; and, if
the gout shall have receded very entirely from the extre-
mities, blisters may be applied to these also. Together
with these blisterings, aromatics, and the volatile alkali,
may be thrown into the stomach.
DXLVI.
The third case of the irregular gout is what I name
the Misplaced, that is, when the inflammatory affection
of the gout, instead of falling upon the extremities,
falls upon some internal part. In this case, the disease
is to be treated by blood-letting, and by such other re-
medies as would be proper in an idiopathic inflammation
of the same parts.
DXLVII.
Whether the translation so frequently made from the
extremities to the kidneys, is to be considered as an
instance of the misplaced gout, seems, as we have said
before, uncertain; but I am disposed to think it some-
thing different; and therefore am of opinion that, in
the Nephralgia Calculosa produced upon this occasion, the
remedies of inflammation are to be employed no farther
than they may be otherways sometimes necessary in that
disease, arising from other causes than the gout.
BOOK

198 PRACTICE
BOOK III.
OF EXANTHEMATA, OR ERUP-
TIVE FEVERS.
DXLVIII.
THE diseases comprehended under this title, which
make the third order of Pyrexiæ in our Nosology,
are generally such as do not arise but upon occasion of a
specific contagion applied, which first produces fever,
and then an eruption upon the surface of the body; and,
in respect of both, a disease, which, for the most part,
affects persons but once in the course of their lives.
DXLIX.
Whether the character of the order may be thus
limited, or if the order may be allowed to comprehend
the eruptive fevers produced by a matter generated in the
body itself, as also those cases of eruption which do not
depend upon contagion, or upon a matter generated
before the fever, but are symptoms only of certain con-
ditions of fever, we shall not determine here. We leave
these questions for a nosological discussion, to be entered
into in another place; and proceed now to consider the
particular diseases which are commonly enumerated
under the title of Exanthemata, or Eruptive Fevers.
CHAP. 

OF PHYSIC. 199
CHAP. I.
OF ERYSIPELAS, OR ST. AN-
THONY's FIRE.
DL.
In (CCLXIX.) I mentioned the distinction which
I proposed to make between the diseases to be named the
Erythema and Erysipelas; and from thence it will ap-
pear, that Erysipelas, as an Erythema following fever,
may have its place here.
DLI.
We suppose the erysipelas to depend on a matter ge-
nenerated within the body, and which, analogous to the
other cases of exanthemata, is, in consequence of fever,
thrown out upon the surface. We own it may be dif-
ficult to apply this to every particular case of erysipelas;
but we take the case in which it is generally supposed to
apply, that is, the case of the erysipelas of the face;
which we now, therefore, proceed to treat of.
DLII.
The erysipelas of the face comes on with a cold
shivering, and other symptoms of pyrexia. The hot
stage of this is frequently attended with a confusion of
head, and some degree of delirium; and almost always
with drowsiness, or perhaps coma. The pulse is always
frequent, and commonly full and hard.
DLIII. 

200 PRACTICE
DLIII.
When these symptoms have continued for one, two,
or at most three days, there appears, on some part of
the face, a redness, such as that described under the
title of Erythema (see Synops. Nosolog.). This red-
ness, at first, is of no great extent, but gradually
spreads from the part it first occupied to the other parts
of the face, till it has affected the whole; and frequently
from the face, it spreads over the hairy scalp, or descends
on some part of the neck. As the redness spreads, it
commonly leaves, or at least is abated in, the parts it
had before occupied. All the parts which the redness
affects are, at the same time, affected with some swelling,
which continues sometimes after the redness has abated.
The whole face becomes considerable turgid; and the
eye-lids are often so much swelled, as entirely to shut up
the eyes.
DLIV.
When the redness and swelling have proceeded for
some time, there commonly arise, sooner or later, blisters
of a larger or smaller size, on several parts of the face.
These contain a thin colourless liquor, which sooner or
later runs out. The surface of the skin, in the blistered
places, sometimes becomes livid and blackish; but this
livor seldom goes deeper than the surface, or discovers
any degree of gangrene affecting the skin. On the
parts of the face not affected with blisters, the cuticle
suffers, towards the end of the disease, a considerable
desquamation.
Sometimes the tumour of the eye-lids ends in a sup-
puration.
DLV.
The inflammation coming upon the face does not
produce any remission of the fever which had before
prevailed; and sometimes the fever increases with the
spreading and increasing inflammation.
DLVI.

OF PHYSIC. 201
DLVI.
The inflammation commonly continues for eight or
ten days; and, for the same time, the fever and sym-
ptoms attending it also continue.
DLVII.
In the progress of the disease, the delirium and coma
attending it sometimes go on increasing, and the patient
dies apoplectic on the seventh, ninth, or eleventh day
of the disease. In such cases, it has been commonly
supposed, that the disease is translated from the external
to the internal parts. But I have not seen a case, in
which it did not appear to me, that the affection of the
brain was merely a communication from the external
affection, as this continued increasing, at the same time
with the internal.
DLVIII.
When the fatal event does not take place, the inflam-
mation, after having affected the whole of the face, and,
perhaps, the other external parts of the head, ceases;
and with that the fever also; and, without any other
crisis, the patient returns to his ordinary state of health.
DLIX
This disease is not commonly contagious; but, as the
disease may arise from an acrid matter externally applied,
so, it is possible, that the disease may sometimes be com-
municated from one person to onother.
Persons who have once laboured under this disease are
liable to returns of  it.
DLX.
The event of this disease may be foreseen from the
state of the symptoms which denote more or less affection
of the brain. If neither delirium nor coma come on,
the
CC

202 PRACTICE
the disease is seldom attended with any danger; but,
when these symptoms appear early in the disease, and
are in a considerable degree, the utmost danger is to be
apprehended.
DLXI.
As this disease often arises in the part, at the same
time with the coming on of the pyrexia; as we have
known it, with all its symptoms, to arise from an acri-
mony applied to the part; as it differs from pure Ery-
thema, by being attended with a full, and frequently
with a hard pulse; as the blood drawn in this disease
shews the same crust upon its surface, as appears in the
phlegmasiæ; and, lastly, as the swelling of the eye-lids,
in this disease, frequently ends in a suppuration; so,
from all these considerations, it seems doubtful, if this
disease be properly, in Nosology, separated from the
Phlegmasiæ. At any rate, I take the disease we have
described, to be what physicians have named the Ery-
sipelas Phlegmonodes, and that it partakes a great deal
of the nature of the Phlegmasiæ.
DLXII.
Upon this conclusion, the erysipelas of the face is to
be cured very much in the same manner as phlegmonic
inflammations, by blood-letting, cooling purgatives,
and by employing every part of the antiphlogistic regi-
men; and our experience has confirmed the fitness of
this method of cure.
DLXIII.
The evacuations of blood-letting and purging, are to
be employed more or less, according to the urgency of
symptoms, particularly those of the pyrexia, and of
those which mark an affection of the brain. As the
pyrexia continues, and often increases with the inflam-
mation of the face; so the evacuations mentioned may
be employed at any time in the course of the disease.
DLXIV.

OF PHYSIC. 203
DLXIV.
In this, as in other diseases of the head, it is proper
to put the patient, as often as he can easily bear it, into
somewhat of an erect posture.
DLXV.
As, in this disease, there is always an external affection,
and as, in many eases, there is no other; so various ex-
ternal applications have been proposed to be made to the
part affected; but almost all of them are of doubtful
effect. The narcotic, refrigerant, and astringent appli-
cations, are suspected of disposing to gangrene. Spi-
rituous applications seem to increase the inflammation;
and all oily or watery applications seem to occasion its
spreading. The application which seems to be the most
safe, and what is now most commonly employed, is that
of a dry mealy powder, frequently sprinkled upon the
inflamed parts.
DLXVI.
An erysipelas phlegmonodes frequently appears on
other parts of the body, besides the face; and such other
erysipelatous inflammations frequently end in sup-
puration. These cases are seldom dangerous. At coming
on, they are sometimes attended with drowsiness, and
even with some delirium; but this seldom happens; and
these symptoms do not continue after the inflammation
is formed. I have never seen an instance of the trans-
lation of an inflammation from the limbs to an internal
part; and, though these inflammations of the limbs be
attended with pyrexia, they seldom require the same
evacuations as the erysipelas of the face. At first they
are to be treated by dry mealy applications only; and all
humid applications, as fomentations, or poultices, are
not to be applied, till, by the continuance of the disease,
by the increase of swelling, or by a throbbing felt in
the part, it appears that the disease is proceeding to sup-
puration.
DLXVII. 

204 PRACTICE
DLXVII.
We have hitherto considered erysipelas as in a great
measure of a phlegmonic nature; and, agreeably to that
opinion, we have proposed our method of cure. But,
it is probable, that an erysipelas is sometimes attended
with, or is a symptom of a putrid fever; and, in such
cases, the evacuations proposed above may be improper,
and the use of the Peruvian bark may be necessary; but
I cannot be explicit upon this subject, as such putrid
cases have not come under my observation.
CHAP. II.
OF THE PLAGUE.
SECT. I.
OF THE PHENOMENA OF THE
PLAGUE.
DLXVIII.
The plague is a disease which always arises from
contagions; which affects many persons about the same
time; proves fatal to great numbers; generally pro-
duces fever; and, in most persons, is attended with bu-
boes or carbuncles.
DLXIX. 

OF PHYSIC. 205
DLXIX.
These are the circumstances which, taken together,
give the character of the disease; but it is attended with
many symptoms almost peculiar to it, which, in different
persons, are greatly diversified in number and degree,
and should be particularly studied. We should wish to
lay a foundation for this; but we think it unfit for a per-
son who has never seen the disease to attempt a particular
history of it. For this, therefore, we must refer to the
authors who have written on the subject; but we allow
only those to be consulted, who have themselves seen
and treated the disease in all its different forms.
DLXX.
From the accounts of such authors, it appears to me,
that the circumstances which particularly distinguish
this disease, and especially the more violent and dangerous
states of it, are, 1st, The great loss of strength in the
animal functions, which often appears early in the dis-
ease.
2dly, The stupor, giddiness, and consequent stag-
gering, which resembles drunkenness, or the head-ach,
and various delirium, all of which symptoms denote a
great disorder in the functions of the brain.
3dly, The anxiety, palpitation, syncope, and espe-
cially the weakness and irregularity of the pulse, which
denote a considerable disturbance in the action of the
heart.
4thly, The nausea and vomiting, particularly the
vomiting of bile, which shews an accumulation of
vitiated bile in the gall-bladder, and biliary ducts, and
from thence derived into the intestines and stomach; all
of which symptoms we suppose to denote a considerable
spasm, and loss of tone in the extreme vessels on the
surface, of the body.
5thly, The buboes or carbuncles, which denote an
acrimony prevailing in the fluids; and, lastly, The
petechiæ, hemorrhagies, and colliquative diarrhœa,
which 

206 PRACTICE
which denote a putrescent tendency prevailing to a great
degree in the mass of blood.
DLXXI.
From the consideration of all these symptoms, it ap-
pears, that the plague is especially distinguished by a
specific contagion, often suddenly producing the most
considerable symptoms of debility in the nervous system,
or moving powers, and of a general putrescency in the
fluids; and it is from the consideration of these circum-
stances as the proximate cause, that I think both the
prevention and cure of the plague must be directed.
DLXXII.
If this disease should revisit the northern parts of
Europe, it is probable, that, at the same time, there
will not be a physician alive, who, at the first appear-
ance of the disease, can be guided by his former expe-
rience, but must be guided by his study of the writers on
this subject, and by analogy. It is, therefore, I hope,
allowable for me, upon the same grounds, to give here
my opinion with respect to both the prevention and cure
of this disease.
SECT. II
OF THE PREVENTION OF THE
PLAGUE.
DLXXIII.
With respect to the prevention: As we are firmly
persuaded that the disease never arises in the northern
parts 

OF PHYSIC. 207
parts of Europe, but in consequence of its being im-
ported from some other country, so the first measure
necessary, is the Magistrate's taking care to prevent the
importation; and this may generally be done by a due
attention to bills of health, and to the proper performance
of quarantains.
DLXXIV.
With respect to the latter, we are persuaded, that the
quarantain of persons may, safely, be much less than
forty days; and, if this were allowed, the execution of
the quarantain would be more exact and certain, as the
temptation to break it would be, in a great measure,
avoided.
DLXXV.
With respect to the quarantain of goods; it cannot
be perfect, unless the suspected goods be unpacked, duly
ventilated, and other means be employed for correcting
the infection they may carry; and, if all this be pro-
perly done, it is probable, that the time commonly pre-
scribed for the quarantain of goods might also be
shortened.
DLXXVI.
A second measure, in the way of prevention, is required,
when an infection has reached and prevailed in any
place, to prevent that infection from spreading into
other places. This can be done only by preventing the
inhabitants, or the goods of any infected place, from
going out of it, till they have undergone a proper qua-
rantain.
DLXXVII.
The third measure for prevention, to be employed
with great care, is to prevent the infection from spreading
among the inhabitants of the place in which it has
arisen; and the measures necessary for this are to be di-
rected 

208 PRACTICE
rected by the doctrine laid down in (LXXXVI.); and
from that doctrine we infer, that all persons who can
avoid any near communication with infected persons, or
goods, may be saved from the infection.
DLXXVIII.
For avoiding such communication, a great deal may
be done by the Magistrate. 1. By allowing as many of
the inhabitants as are free from infection, and are not
necessary to the service of the place, to go out of it. 2.
By discharging all assemblies, or unnecessary intercourse
of the people. 3. By rendering some necessary com-
munications to be performed without contact. 4. By
making such arrangements and provisions as may render
it easy for the families remaining to shut themselves up
in their own houses. 5. By allowing persons to quit
houses in which an infection appears, upon condition
that they go into lazarettos. 6. By ventilating and pu-
rifying, or destroying, at the public expence, all infected
goods. Lastly, By avoiding hospitals, and providing
separate apartments for infected persons.
The execution of these measures will require a great
authority, and much vigilance and attention on the part
of the magistrate; but it is not our province to enter
into any detail on this subject of the public police.
DLXXIX.
The fourth and last part of the business of prevention,
respects the conduct of persons necessarily remaining in
infected places, especially those obliged to have some
communication with persons infected.
DLXXX.
Of those obliged to remain in infected places, but
not obliged to have any near communication with the
sick, they may be preserved by avoiding all near com-
munication with other persons, or their goods; and, it
is probable, that a small distance will serve, if, at the
same 

OF PHYSIC. 209
same time, there be no stream of air to carry the effluvia
of persons, or goods, to some distance.
DLXXXI.
For those who are necessarily obliged to have a near
communication with the sick, it is proper to let them
know, that some of the most powerful contagions do
not operate but when the bodies of men exposed to it
are in certain circumstances, which render them more
liable to be affected by it; or, when certain causes
concur to excite the power of it; and, therefore, by
avoiding these circumstances and causes, they may often
escape infection.
DLXXXII.
The bodies of men are especially liable to be affected
by contagions, when they are any how considerably
weakened, as they may be by want of food, and even
by a scanty diet, or one of little nourishment; by in-
temperance in drinking, which, when the stupor of
intoxication is over, leaves the body in a weakened
state; by excess in venery; by great fatigue; or, by
any considerable evacuation.
DLXXXIII.
The causes which, concurring with contagion,
render it more certainly active, are cold, fear, and full
living.
The several means, therefore, of avoiding or guarding
against the action of cold, are to be carefully studied.
DLXXXIV.
Against fear the mind is to be fortified as well as pos-
sible; by giving them a favourable idea of the power of
preservative means; by destroying the opinion of the in-
curable nature of the disease; by occupying mens minds
with business or labour; and, by avoiding all objects of
fear
D d 

210 PRACTICE
fear, as funerals, passing bells, and any notice of the
death of particular friends.
DLXXXV.
A full diet of animal food increases the irritability of
the body, and favours the operation of contagion; and
indigestion, whether from the quantity or quality of
food, is very favourable to the same.
DLXXXVI.
Besides giving attention to the several means
(DLXXXI. DLXXXII.) which favour the operation
of contagion, it is probable, that some means may be
employed for strengthening the bodies of men, and
thereby enabling them to resist contagion.
For this purpose, it is probable, that the moderate
use of wine, or of spirituous liquors, may have a good
effect.
It is probable also, that exercise, when it can be em-
ployed, if it be so moderate as to be neither heating nor
fatiguing to the body, may be employed with advantage.
Persons who have tried cold bathing, and commonly
feel the invigorating effects of it, if they are any ways
secure against their having already received infection,
may possibly be enabled to resist it by the practice of
cold bathing.
It is probable, that some medicines, also, may be
useful in enabling men to resist infection, but, among
these, we can hardly admit the numerous alexipharmics
formerly proposed, or, at least, very few of them, and
those only of tonic power; among which we reckon the
Peruvian bark; and it is, perhaps, the most effectual.
If any thing is to be expected from antiseptics, I think
camphire, whether internally or externally employed,
is one of the most promising.
Every person is to be indulged in the use of any means
of preservation, which he has conceived a good opinion
of, whether it be a charm or a medicine, if the latter be
not directly hurtful.
Whether

OF PHYSIC. 211
Whether issues be useful in preserving from the effects
of contagion, or in moderating these, I cannot determine
from the observations I have yet read.
DLXXXVII.
As the atmosphere, in general, or any considerable
portion of it, is not tainted or impregnated with the
matter of contagions, so the lighting of fires over a great
part of the infected city, or other general fumigations in
the open air, are of no use for preventing the disease,
and may be perhaps hurtful.
DLXXXVIII.
It would probably contribute much to check the pro-
gress of infection, if the poor were enjoined to make a
frequent change of cloathing, and were provided for
that purpose; and if they were, at the same time, en-
gaged to make a frequent ventilation of their houses and
furniture.
SECT. III.
OF THE CURE OF THE PLAGUE.
DLXXXIX.
In the cure of the plague, the indications are the
same as those of fever in general; CXX.) but they are
not all equally necessary and important here.
DXC.
The measures for moderating the violence of reaction,
which operate by diminishing the action of the heart
and 

212 PRACTICE
and arteries, (CXXI. I.) have seldom any place here,
excepting so far as the antiphlogistic regimen is generally
proper. Some physicians, indeed, have recommended
bleeding, and there may be cases in which bleeding may
be useful; but, for the most part, it is unnecessary, and
in many cases it might be very hurtful.
Purging has also been recommended; and, in some
degree, it may be useful in drawing off the bile, or other
putrescent matters frequently present in the intestines;
but a large evacuation this way may certainly be hurtful.
DXCI.
The moderating the violence of reaction, so far as it
can be done by taking off the spasm of the extreme
vessels, (CXXL 2.) is a measure of the utmost necessity
in the cure of the plague; and the whole of the means
(CXLVI. 1. CXLVII.) suited to this indication, are
extremely proper.
DXCII.
The giving an emetic at the very first approach of the
disease, would probably be of great service; and, it is
probable, that, at some other periods of the disease,
emetics might be useful, both by evacuating bile,
abundant in the alimentary canal, and by taking off the
spasm of the extreme vessels.
DXCIII.
From some principles with respect to fever in general,
and with respect to the plague in particular, I am of
opinion, that, after the exhibition of the first vomit,
the body should be disposed to sweat, which should
be raised to a moderate degree only, but continued
for at least twenty-four hours, or more, if the patient
bears it easily.
DXCIV.
This sweating should be excited and conducted agree-
ably to the rules laid down in (CLXII.). It is to be
promoted 

OF PHYSIC. 213
promoted by the plentiful use of diluents, rendered more
grateful by vegetable acids, or more powerful, by being
impregnated with some portion of neutral salts.
DXCV.
To support the patient under the continuance of the
sweat, a little weak broth, acidulated with juice of le-
mons, may be given frequently, and sometimes a little
wine, if the heat of the body is not considerable.
DXCVI
If sudorific medicines are judged to be necessary,
opiates are the most effectual and safe; but they should
not be combined with aromatics; and, probably, may
be more effectual, if joined with a portion of emetics,
and of neutral salts.
DXCVII.
If, notwithstanding the use of emetics and sudorifics
in the beginning, the disease should still continue, the
cure must turn upon the use of means for obviating
debility and putrescency; and, for this purpose, the
various remedies proposed above, (CXCVII. to CCXXI)
may all be employed, but especially the tonics; and of
these the chief are cold drink, and the Peruvian bark.
DXCVIII.
In the cure of die plague, some attention is due to
the management of buboes and carbuncles; but we do
not touch this, as belonging to the province of surgery.
CHAP.

214 PRACTICE
CHAP. III.
OF THE SMALL-POX.
DXCIX.
The small-pox is a disease arising from a contagion of
a specific nature, which first produces a fever, and, on
the third or fourth day of that, produces an eruption of
small inflamed pimples. They are afterwards formed
into pustules, containing a matter, which, in the course
of eight days from the eruption, is changed into pus.
After this the matter is dried, and falls off in crusts.
DC.
This is a general idea of the disease; but there are
two particular forms, or varieties of it, well known
under the appellations of the Distinct and Confluent,
which require to be specially described.
DCI.
In the former, or distinct small-pox, the eruptive
fever is moderate, and appears to be evidently of the
inflammatory kind, or what we name a synocha. It
generally comes on about mid-day, with some symptoms
of a cold stage, and commonly with a considerable lan-
guor and drowsiness. A hot stage is soon formed, and
becomes more considerable on the second and third day.
During this course, children are liable to frequent
startings from their slumbers; and adults, if they are
kept-a-bed, are disposed to much sweating. On the
third day children are sometimes affected with one or two
epileptic fits. Towards the end of the third day, the
eruption commonly appears, and gradually increases
during 

OF PHYSIC. 215
during the fourth; appearing first upon the face, and
successively on the inferior parts, so as to be compleated
over the whole body on the fifth day. From the third
day the fever abates, and against the fifth it entirely
ceases. The eruption appears first in small red spots,
hardly eminent, but by degrees rising into pimples.
These are generally upon the face in small number;
but, even when more numerous, they are separate and
distinct from one another. On the fifth or sixth day, a
small vesicle, containing an almost colourless, or whey-
coloured fluid, appears upon the top of each pimple.
For two days these vesicles increase in breadth only, and
there is a small hollow pit in their middle, so that it is
only against the eighth day that they are raised into
spheroidical pustules. These vesicles or pustules, from
their first formation, continue to be surrounded with an
exactly circular inflamed margin, which, when the
pustules are numerous, diffuses some inflammation over
the neighbouring skin, so as to give somewhat of a da-
mask rose colour to the spaces between the pustules. As
the pustules increase in size, if they be numerous on
the face, the whole of the face, against the eighth day,
becomes considerably swelled; and, in particular, the
eye-lids are so much swelled, as entirely to shut the eyes.
As the disease thus proceeds, the matter in the pustules
becomes, by degrees, more opaque and white, and at
length of a yellowish colour. On the eleventh day,
the swelling of the face is abated, and the pustules seem
quite full. On the top of each a darker spot appears;
and at this place the pustule, on the eleventh day, or
soon after, is spontaneously broken, and a portion of the
matter oozes out; in consequence of which, the pustule
is shrivelled, and subsides, while the matter oozing out
dries, and forms a crust upon its surface. Sometimes
a little only of the matter oozes out, and what remains
in the pustule becomes thick, and even hard. After
some days, both the crusts and the hardened pustules fall
off, leaving the skin which they covered of a brown
red colour; and it is only after many days that this
part resumes its natural colour. In some cases, where
the matter of the pustules has been more liquid, the
crusts formed by it are later in falling off, and the part
they 

216 PRACTICE
they covered suffers some desquamation, and a small
hollow or pit is left in it.
This is the course of things on the face; and suc-
cessively, the pustules on the rest of the body take the
same. The matter of the pustules, on the arms and
hands, is frequently absorbed; so that, at the height of
the disease, these pustules appear as empty vesicles.
On the tenth and eleventh days, as the swelling of the
face subsides, a swelling arises in the hands and feet;
but which again subsides, as the pustules come to ma-
turity.
When the pustules on the face are numerous, some
degree of pyrexia appears on the tenth and eleventh
days, but disappears again after the pustules are fully
ripened; or, perhaps, remains in a very slight degree
till the pustules on the feet have finished their course.
It is seldom that any fever continues longer in the distinct
small-pox.
When the pustules on the face are numerous upon the
sixth or seventh day, some uneasiness in the throat, with
a hoarseness of the voice, comes on, and a thin liquid
is poured out from the mouth. These symptoms increase
with the swelling of the face; and the liquids of the
mouth and throat becoming thicker, are more difficultly
thrown out; and there is, at the same time, some dif-
ficulty of swallowing, so that liquids taken in to be
swallowed are frequently rejected, or thrown out by the
nose. But all these affections of the fauces are abated,
as the swelling of the face subsides.
DCII.
In the other form of small-pox, or what is called the
Confluent, the course of the disease is, in general, the
same with that we have described; but the symptoms of
every stage are more violent, and several of the circum-
stances are different.
The eruptive fever is particularly more violent; the
pulse is more frequent and more contracted, approaching
to that state of pulse which is found in the typhus. The
coma is more considerable, and there is frequently a de-
lirium. Vomiting, also, is a common symptom, espe- 
cially 

OF PHYSIC. 217
cially at the coming on of the disease. In very young
infant, epileptic fits are sometimes frequent on the first
days of the disease, and sometimes prove fatal before any
eruption appears; or they usher in a very confluent and
putrid small-pox.
DCIII.
The eruption appears more early on the third day,
and it is frequently preceded, or accompanied, with an
erysipelatous efflorescence. Sometimes the eruption ap-
pears in clusters, like that of the measles. When the
eruption is compleated, the pimples are always more
numerous upon the face, and, at the same time, smaller
and less eminent. Upon the eruption, the fever suffers
some remission, but never goes off entirely; and, after
the fifth or sixth day, it increases again, and continues
considerable through the remaining course of the disease.
The vesicles formed on the top of the pimples appear
sooner; and, while they increase in breadth, they do
not retain a circular, but are every way of an irregular
figure. Many of them run into one another, insomuch
that very often the face is covered rather with one vesicle
than with a number of pustules. The vesicles, so far as
they are any ways separated, do not arise to a spheroidical
form, but remain flat, and sometimes the whole of the face
is of an even surface. When the pustules are in any
measure separated, their circumference is not bounded
by an inflamed margin, and the part of the skin that is
free from pustules is commonly pale and flaccid.
The liquor that is in the pustules changes from a clear
to an opaque appearance, and becomes whiteish or brown-
ish, but never acquires the yellow colour and thick con-
sistence that appears in the distinct small-pox.
The swelling of the face which attends the distinct
pox when they are numerous, and almost then only,
always attends the confluent, comes on more early, and
arises to a greater degree, but abates on the tenth day,
and on the eleventh still more. At this time the pustules
or vesicles break, and shrivelling pour out a liquor,
which is formed into brown or black crusts, which do
not fall off for many days after. Those of the face, in
falling off, leave the parts they covered subject to a de-
squamation, which pretty certainly produces pittings.
On
E e 

218 PRACTICE
On the other parts of the body, the pustules of the
confluent pox are more distinct than upon the face, but
never acquire the same maturity and consistence of pus,
as in the properly distinct kind.
The salivation, which sometimes only attends the
distinct small pox, very constantly attends the confluent;
and both the salivation, and the affection of the fauces
above mentioned, are, especially in adults, in a higher
degree. In infants, a diarrhœa comes frequently in
place of the salivation.
In the confluent pox, there is often a considerable pu-
trescency of the fluids, as appears from petechiæ, from
serous vesicles, under which the skin shews a disposition
to gangrene, and from bloody urine, or other hæmorr-
hagy, all of which symptoms frequently accompany this
disease.            
In the confluent small-pox, the fever, which had only
suffered a remission from the eruption to the maturation,
at, or immediately after this period, is often renewed
again with considerable violence. This is what has been
called the secondary fever, and is, in different cases, of
various duration and event.
DCIV.
We have thus endeavoured to describe the various
circumstances of the small-pox; and, from the dif-
ference of these circumstances, the event of the disease
may be determined. The whole of the prognosis may
be nearly comprised in the following propositions.
The more exactly the disease retains the form of the
distinct kind, it is the safer; and the more compleatly
the disease takes the form of the confluent kind, it is
the more dangerous.
It is only when the distinct kind shews a great num-
ber of pustules on the face, or otherwise, by fever or pu-
trescency, approaches to the circumstances of the con-
fluent, that the distinct kind is attended with any danger.
In the confluent small-pox there, is always danger;
and this is always more considerable and certain, as the
fever is more violent and permanent, and especially as
the marks and symptoms of putrescency are more evident.
When 

OF PHYSIC. 219
When the putrid disposition is very great, the disease
sometimes proves fatal before the eighth day; but in
most eases it is on the eleventh that death happens; and
sometimes it is put off till the fourteenth or seven-
teenth day.
Though the small-pox be not immediately fatal, the
more violent kinds are often followed by a morbid state of
the body, of various kind and event. These con-
sequences, as I judge, may be imputed sometimes to an
acrid matter produced by the preceding disease, and de-
posited in different parts; and sometimes to an inflam-
matory diathesis produced and determined to particular
parts of the body.
DCV.
It is, I think, agreed among practitioners, that, in
the different cases of small-pox, the difference chiefly
depends upon the appearance of distinct or confluent;
and, from the above description of these kinds, it will
appear, that they chiefly differ in the time of eruption,
in the number of pustules produced, in the form of the
pustules, in the state of the matter contained in them, in
the continuance of the fever, and, lastly, in the danger
of the disease.
DCVI.
In inquiring into the causes of these differences, we
might readily suspect, that it depended upon a difference
of the contagion producing the disease; but this is not
probable; for there are innumerable instances of the
contagion arising from a person labouring under the
small-pox, of the distinct kind, producing the con-
fluent; and, on the contrary. Since the practice of
inoculation became frequent, we have known the same
variolous matter, in one person, produce the distinct,
and, in another, the confluent small-pox. It is, there-
fore, highly probable, that the difference of the small-
pox does not depend upon any difference of the contagion,
but upon some difference in the state of the persons to
whom 

220 PRACTICE
whom it is applied, or in the state of certain circum-
stances concurring with the application of the contagion.
DCVII.
To find out wherein the difference in the state of the
persons to whom the contagion of the small-pox is ap-
plied, consists, I observe, that the difference between
the distinct and confluent small-pox consists especially in
the number of pustules produced, which, in the distinct,
are generally few; in the confluent always many; if,
therefore, we can find what, in the state of different
persons, can give occasion to more or fewer pustules, we
shall probably be able to account for all the other dif-
ferences of the distinct and confluent small-pox.
DCVIII.
It is evident that the contagion of the small-pox is a
ferment, with respect to the human fluids, and assimilates
a great part of them to its own nature; and, it is pro-
bable, that the quantity thus assimilated is, in proportion
to their several bodies, nearly the same in different per-
sons. This quantity passes again out of the body,
partly by insensible perspiration, and partly by being
deposited in pustules; but, if the quantities generated
be nearly equal, the quantities passing out of the body
by the two ways mentioned, are very unequal in different
persons; and, therefore, if we can find the causes
which determine more to pass by the one way than by
the other, we may thereby find the causes which give
occasion to more pustules in one person than in another,
DCIX.
The causes which determine more of the variolous
matter to pass by perspiration, or to form pustules, are
probably certain circumstances of the skin, which de-
termine more or less of the variolous matter to stick in
it, or to pass freely through it.
DCX. 

OF PHYSIC. 221
DCX.
The circumstance of the skin, which seems to de-
termine the variolous matter to stick in it, is a certain
state of inflammation, depending much upon the heat
of it: Thus we have many instances of parts of the
body, from being more heated, having a greater number
of pustules than other parts. In the present practice of
inoculation, in which few pustules are produced, much
seems to be owing to the care that is taken to keep the
skin cool. Parts covered with plasters, especially with
those of a stimulant kind, have more pustules than other
parts. Further, certain circumstances, such as adult
age, and full living, determining to a phlogistic dia-
thesis, seem to produce a greater number of pustules;
and on the contrary.
DCXI.
It is, therefore, probable, that an inflammatory state
of the whole system, and more particularly of the skin,
gives occasion to a greater number of pustules; and the
causes of this may produce most of the other circum-
stances of the confluent small-pox; such as the time of
eruption; the continuance of the fever; the effusion of a
more putrescent matter, and less fit to be converted into
pus; and, what arises from this, the form and other
circumstances of the pustules.
DCXII.
Having thus attempted to account for the chief dif-
ference which occurs in the state of the small pox, we
shall now try the truth of our doctrine, by its appli-
cation to practice.
DCXIII.
In considering the practice, we consider it first in
general, as suited to render the disease more generally
benign and safe, and this by the practice of inoculation.
DCXIV. 

222 PRACTICE
DCXIV.
It is not necessary here to describe the operation of
inoculating; and what we name the practice of inocu-
lation, comprehends all the several measures which
precede or follow that operation, and are supposed to
produce its salutary effects.
These measures are chiefly the following:
1. The choosing for the subject of inoculation persons
otherwise free from disease, and not liable, from their
age, or otherwise, to any incidental disease.
2. The choosing a person at a time of life the most
favourable to a mild disease.
3. The choosing for the practice, a season the most
favourable to a mild disease.
4. The preparing the person to be inoculated, by
enjoining abstinence from animal food for some time
before inoculation.
5. The preparing the person by courses of mercurial
and antimonial medicines.
6. The taking care at the time of inoculation to avoid
cold, intemperance, fear, or other circumstances which
might aggravate the future disease.
7. After these preparations and precautions, the
choosing a fit matter to be employed in inoculation, by
taking it from a person of a found constitution, and free
from any disease, or suspicion of it; by taking it from
a person who has had the small-pox of the most benign
kind; and, lastly, by taking the matter from such per-
sons, as soon as it has appeared in the pustules, either on
the part inoculated, or on other parts of the body.
8. The introducing, by inoculation, but a small
portion of the contagious matter.
9. After inoculation, the continuing the vegetable
diet, and the employment of mercurial and antimonial
medicines, and, at the same time, employing frequent
purging.
10. Both before and after inoculation, taking care to
avoid external heat, either from the sun, artificial fires,
warm chambers, much clothing, or being much in bed;
and,

OF PHYSIC. 223
and, on the contrary, exposing the person to a free and
cool air.
11. Upon the appearance of the eruptive fever, the
rendering that moderate by the employment of purgatives,
by the use of cooling and antiseptic acids; and espe-
cially, by exposing the person frequently to a cool, and
even a cold air, at the same time giving freely of cold
drink.
12. After the eruption, the continuing the appli-
cation of cold air, and the use of purgatives, during
the course of the disease, till the pustules are fully
ripened.
DCXV.
These are the measures proposed and practised in the
latest and most improved state of inoculation; and the
advantages obtained by the whole of the practice, or at
least by most of the measures above mentioned, are now
ascertained by a large experience; but it will still be
useful, for the proper conduct of inoculation, to consider
the importance and utility of the several measures above
mentioned, that we may thereby more exactly determine
upon what the advantages of inoculation more certainly
depend.
DCXVI.
As the common infection may often seize persons
under a diseased state, which may render the small-pox
more violent, it is evident, that inoculation must have a
great advantage, by avoiding such concurrence. But,
as the avoiding of such concurrence may often, in the
mean time, leave persons exposed to the common in-
fection, it is worth our pains to inquire what are the
diseased states which should restrain from the practice of
inoculation. This is not yet sufficiently ascertained by
observation; and we have frequently observed, that the
small-pox have often occurred with a diseased state of
the body, without being thereby rendered more violent;
particularly, we have observed, that a scrophulous habit,
or even the presence of scrophula, did not render the
small-pox

224 PRACTICE
small-pox more violent; we have observed also, that
several diseases of the skin are equally innocent. I am
of opinion, that they are the diseases of the febrile kind,
or ailments ready to induce or aggravate a febrile state,
that especially give the concurrence which is most dan-
gerous with the small-pox. I dare not attempt any
general rules; but, I am disposed to maintain, that,
though a person be in a diseased state, if that state be of
uncertain nature and effect, and, at the same time the
small-pox be exceedingly rise, so that it be extremely
difficult to guard against the common infection, we
judge it will always be safer to give the small-pox by
inoculation, than to leave the person to take them by
the common infection.
DCXVII.
Though inoculation has been practised with safety
Upon persons of all ages; yet, from what has happened
in fact, in the cases of common infection, and from
several other considerations, we have reason to conclude,
that adults are more liable to a violent disease than per-
fons of younger years. At the same time, it is observed,
that children, in the time of their first dentition, are
liable, from the irritation of that, to have the small-pox
rendered more violent; and that infants, before the time
of dentition, upon receiving the contagion of the small-
pox, are liable to be affected with epileptic fits, which
frequently prove fatal; it is, therefore, upon the whole,
evident, that, though circumstances may admit, and
approve of inoculation at any age; yet, for the most
part, the practice will have advantage, in choosing per-
sons at an age, after the first dentition is over, and before
the time of puberty.
DCXVIII.
Though inoculation has been practised with safety at
every season of the year; yet, as it is certain, that the
cold of winter may increase the inflammatory, and the
heats of summer increase the putrescent state of the
small-pox, it is highly probable that inoculation may
have                

OF PHYSIC. 225
have some advantage, from avoiding the extremes either
of cold or heat.
DCXIX.
As the use of animal food may increase both the in-
flammatory and putrescent state of the human body, so
it must render persons, in receiving the contagion of the
small-pox, less secure against a violent disease; and,
therefore, that inoculation may derive some advantage
by enjoining abstinence from animal food for some time
before the inoculation is performed; but, I am of opinion,
that a longer time is necessary than is commonly pre-
scribed.
DCXX.
I cannot deny that mercurial and antimonial medicines
may have some effect in determining to a more free per-
spiration, and, therefore, may be of some use in pre-
paring a person for the small-pox; but there are many
observations which render their effect doubtful. The
quantities of both these medicines, particularly the an-
timony, commonly employed, is too inconsiderable to
have any effects. It is true, that the mercurials have
often been employed more freely; but even their salutary
effects have not been evident, and their mischievous
effects have sometimes been more so. I doubt, therefore,
upon the whole, if inoculation derives any advantage
from these pretended preparatory courses.
DCXXI.
As it has been often observed, in the case of almost all
contagions, that cold, intemperance, fear, and some
other circumstances, concurring with the application of
the contagion, have greatly aggravated the future disease,
so it must be the same in the case of the small-pox;
and, it is undoubted, that inoculation must derive a great,
and perhaps its principal advantage, by avoiding the
concurrences above mentioned.
DCXXII. 
F f

226 PRACTICE
DCXXII.
It has been commonly supposed that inoculation has de-
rived some advantage from the choice of the matter that is
employed in it; but, from what was observed in (DCV.),
it is very doubtful if any choice is necessary, or can give
any benefit in determining the state of the disease.
DCXXIII.
It has been supposed, by some persons, that inoculation
has an advantage, by introducing a small portion only
of the contagious matter; but this rest upon an un-
certain foundation. It is not known what quantity is
introduced by the common infection, and it may be a
small quantity only. Although it were larger than that
thrown in by inoculation, it is not known that it would
have any effect. A certain quantity of ferment may be
necessary to excite fermentation in a given mass; but
that quantity given, the fermentation and assimilation
are extended to the whole mass; and we do not find that
a greater quantity than is just necessary, either increases
the activity of the fermentation, or more certainly se-
cures the assimilation of the whole. In the case of the
small-pox, a considerable difference in the quantity of
contagion introduced, has not shewn any effects in
modifying the disease.
DCXXIV.
Purging has the effect of diminishing the activity of the
sanguiferous system, and of obviating the inflammatory
state of it; and, therefore, it is probable, that the fre-
quent use of cooling purgatives is a practice attending
that of inoculation which may give considerable ad-
vantage; and, probably, it does this also by diminishing
the determination to the skin. And, it appears to me,
that mercurials and antimonials, as they are commonly
managed, are only useful as they make a part of the
purging course.
DCXXV. 

OF PHYSIC. 227
DCXXV.
It is probable, that the state of the small-pox depends
very much upon the state of the eruptive fever, and
particularly in avoiding the inflammatory state of the
skin; and, therefore, it is probable, that the measures
taken for moderating the eruptive fever, and inflammatory
state of the skin, afford the greatest improvement which
has been made in the practice of inoculation. The
tendency of purging, and the use of acids, to this pur-
pose, is sufficiently obvious; and, upon the same grounds
we should suppose, that blood-letting might be useful;
but, probably, this has been omitted; and, perhaps,
other remedies might also be so, since we have found a
more powerful and effectual one in the application of
cold air, and the use of cold drink. Whatever doubts
or difficulties our theory might present to us on this
subject, they may be entirely neglected, as the practice
of Indostan had long ago, and the practice of this
country has lately, by a large and repeated experience,
ascertained the safety and efficacy of this remedy; and
as it may, and can be more certainly employed with the
practice of inoculation, than it can be in cases of com-
mon infection, it must give a singular advantage to the
former.
DCXXVI.
The continuing, after the eruption, the application
of cold air, and the use of purgatives, has been espe-
cially the practice of inoculators; but it cannot be
otherwise said to give any peculiar advantages to inocu-
lation; and, if I mistake not, the employment of pur-
gatives has often led to an abuse. When the state of the
eruption is determined, when the number of pustules is
very small, and the fever has entirely ceased, I suppose
that the safety of the disease is absolutely ascertained,
and further remedies absolutely superfluous; and, there-
fore, that, in such eases, the use of purgatives is un-
necessary, and may often be hurtful.
DCXXVII.

228 PRACTICE
DCXXVII.
We have thus considered the several circumstances
and practices accompanying inoculation, and have en-
deavoured to ascertain the utility and importance of each.
Upon the whole, we hope, we have sufficiently ascertained
the utility and great advantage of this practice, par-
ticularly consisting in this, that, if certain precautions,
preparations, and remedies are of importance, all of
them can be employed  more certainly with the practice
of inoculation, than in the case of common infection.
It remains now that we should make some remarks on
the conduct of the small-pox, as received by infection,
or even when, in consequence of inoculation, the sym-
ptoms shall prove violent. The latter sometimes hap-
pens, although every precaution and remedy have been
employed. The cause of this is not well known; but,
it appears to me, to be commonly owing to a disposition
of the fluids to putrescency. But, however this may
be, it will appear, that, not only in the case of common
infection, but even in that of inoculation, there may be
occasion for studying the conduct of this disease, in all
the possible varying circumstances of it.
DCXXVIII.
When, from the prevailing of small-pox as an
epidemic, and, more especially, when it is known, that
a person not formerly affected with the disease has been
exposed to the infection, if such person should be affected
with the symptoms of fever, there can be little doubt of
its being an attack of the small-pox; and, therefore,
he is to be treated, in every respect, as if the disease had
been received by inoculation. He is to be freely exposed
to a cool air, to be purged, and to have cooling acids
given liberally.
DCXXIX.
If these measures moderate the fever, nothing more is
necessary; but, if the nature of the fever attacking a
person

OF PHYSIC. 229
person be uncertain, or if, with suspicions of the small-
pox, the symptoms of the fever be violent, or even if,
knowing the disease to be small-pox, the measures
mentioned (DCXXIV.) do not moderate the fever suf-
ficiently, it will be proper to let some blood; and, it
will be more especially proper, if the person be an adult
of a plethoric habit, and accustomed to full living.
DCXXX.
In the same circumstances, we judge it will be always
proper to give a vomit, as useful in the beginning of all
fevers, and more especially in this, where a deter-
mination to the stomach appears by pain, and sponta-
neous vomiting.
DCXXXI.
It frequently happens, especially in infants, that,
during the eruptive fever of the small-pox, convulsions
occur. Of these, if only one or two fits appear on the
evening preceding the eruption, they give a favourable
prognostic of a mild disease, and require no remedy; but,
if they occur more early, and be violent, and frequently
repeated, they are very dangerous, and require a speedy
remedy. For this purpose, bleeding is hardly ever of
service; blistering always comes too late; and the only
remedy I have found effectual, is an opiate given in a
large dose.               
DCXXXII. 
These are the remedies necessary during the eruptive
fever; and if, upon the eruption, the number of the
pimples upon the face be very few and distinct, the dis-
ease is no further of any danger, requires no remedies,
and the purgatives which are continued, as was said
before, by some practitioners, are often hurtful.
But when, upon the eruption, the pimples on the
face are very numerous, when they are not distinct, and
especially, if upon the fifth day the fever does not suffer
a considerable

230 PRACTICE
a considerable remission, the disease will still require a
great deal of attention.
DCXXXIII.
If, after the eruption, the fever shall still continue,
the avoiding of heat, and the continuing to expose the
body to a cool air, will still be proper. If the fever is
considerable, with a full and hard pulse, in an adult
person, a bleeding will be necessary; and, more cer-
tainly, a cooling purgative. It is, however, seldom
that a repetition of the bleeding is necessary, as a loss of
strength commonly very soon comes on; but the repe-
tition of a purgative, or the frequent use of laxative
clysters, is commonly useful.
DCXXXIV.
When a loss of strength, with other marks of a
putrescent tendency of the fluids, appears, it will be
necessary to exhibit the Peruvian bark in substance, and
in large quantity. In the same case, the free use of
acids, and of nitre, is useful; and, it is commonly
proper, also, to give wine very freely.
DCXXXV.
From the fifth day of the disease, onward through
the whole course of it, it is proper to give an opiate
once or twice a day, taking care, at the same time, to
obviate costiveness, by purgatives, or laxative clysters.
DCXXXVI.
In a violent disease, from the eighth to the eleventh
day of it, it is proper to lay on blisters successively, on
different parts of the body, and that without regard to
the parts being covered with pustules.
DCXXXVII. 

OF PHYSIC. 231
DCXXXVII.
If, in this disease, the tumour of the fauces is con-
siderable, the deglutition difficult, the saliva and mucus
viscid, and with difficulty thrown out, it will be proper
to apply blisters to the external fauces, and to employ
diligently detergent gargles.
DCXXXVIII.
During the whole course of the disease, when any
considerable fever is present, the frequent exhibition of
antimonial medicines, in nauseating doses, has been
found useful; and these, commonly, sufficiently answer
the purpose of purgatives.
DCXXXIX.
The remedies mentioned (from DCXXXI. to
DCXXXVI.) are those frequently necessary, from the
fifth day, till the suppuration is finished. But as, after
that period, the fever is sometimes continued and in-
creased; or, as sometimes, when there was little or no
fever before, a fever now arise, and continues with
considerable danger; this is what is called the Secon-
dary fever, and requires particular treatment.
DCXL.
When the secondary fever follows the distinct small-
pox, and the pulse is full and hard, the case is to be
treated as an inflammatory affection, by bleeding and
purging. But, if the secondary fever follows the con-
fluent small-pox, and is a continuance or exacerbation
of the fever which had subsisted before, it is to be con-
sidered as of the putrid kind; and in that case, bleeding
is improper. Some purging may be necessary; but the
remedies to be chiefly depended on, as the Peruvian bark
and acids.
When the secondary fever first appears, whether it is
after a distinct or a confluent small-pox, it is useful to
exhibit

232 PRACTICE
exhibit an antimonial emetic in nauseating doses, but in
such manner as to produce some vomiting.
DCXLI.
For avoiding the pits which frequently follow the
small-pox, many different measures have been proposed,
but none of them appear to be sufficiently certain.
CHAP. IV.
OF THE CHICKEN-POX.
DCXLII.
This disease seems to depend upon a specific con-
tagion, and to affect persons but once in their lives. It
is hardly ever attended with any danger; but, as it
seems frequently to have given occasion to the suppo-
sition of a person's having the small-pox twice, it is
proper to study this disease, and to distinguish it from
the genuine small-pox.
DCXLIII.
This may be commonly done by attending to the
following circumstances.
The eruption of the chicken-pox comes on with very
little fever, or with one of no determined duration
preceding it.
The pimples of the chicken-pox, more quickly than
those of the small-pox, are formed into little vesicles
or pustules.
The 

OF PHYSIC. 233
The matter in these pustules remains fluid, and never
acquires the colour or consistence of the pus which ap-
pears in the pustules of the small-pox.
The pustules of the chicken-pox are always, in three
or four days from their first appearance, formed into
crusts.
See Doctor Heberden in Med. Transact. vol. 1. art.
xvii.
CHAP. V.
OF THE MEASLES.
DCXLIV.
This disease also depends upon a specific contagion,
and affects persons but once in their lives.
DCXLV.
It appears most frequently in children; but no age is
exempted from it, if the persons have not been subjected
to it before.
DCXLVI.
It commonly appears as an epidemic, first in the
month of January, and ceases soon after the summer
solstice; but various accidents, introducing the con-
tagion, may produce the disease at other times of the year.
DCXLVII.
The disease always begins with a cold stage, which is
soon followed with a hot, with the ordinary symptoms
of
G g

234 PRACTICE
of thirst, heat, anorexia, anxiety, sickness and vo-
miting; and these are more or less considerable in
different cases. Sometimes from the beginning, the
fever is sharp and violent; often, for the first two days,
it is obscure and inconsiderable, but always becomes
violent before the eruption, which commonly happens
on the fourth day.
DCXLVIII.
This eruptive fever, from the beginning of it, is
always attended  with hoarseness, a frequent hoarse dry
cough, and frequently with some difficulty of breathing.
At the same time, the eye-lids are somewhat swelled, the
eyes are a little inflamed, and pour out tears; and, with
this, there is a coryza, and frequent sneezing. For
the most part, a constant drowsiness attends the be-
ginning of this disease.
DCXLIX.
The eruption, as we have said, commonly appears
upon the fourth day, first on the face, and successively
on the lower parts of the body. It appears first in small
red points; but, soon after, a number of these appear
in clusters, which do not arise in visible pimples, but,
by the touch, are found to be a little prominent. This
is the case on the face; but, in other parts of the body,
the prominency, or roughness, is hardly to be perceived,
On the face, the eruption retains its redness, or has it
increased for two days; but, on the third, the vivid
redness is changed to a brownish red; and, in a day or
two more the eruption entirely disappears, while a
mealy desquamation takes place. During the whole
time of the eruption, the face is somewhat turgid, but
seldom considerably swelled.
DCL.
Sometimes after the eruption has appeared, the fever
ceases entirely; but this is seldom the case; and more
commonly the fever continues, or is increased after the
eruption, 

OF PHYSIC. 235
eruption, and does not cease till after the desquamation.
Even then, the fever does not always cease, but continues
with various duration and effect.
DCLI.
Though the fever happens to cease upon the eruption's
taking place, it is common for the cough to continue
till after the desquamation, and sometimes much longer.
In all cases, while the fever continues, the cough also
continues, generally with an increase of the difficulty
of breathing; and both of these symptoms sometimes
arise to a degree which denotes a pneumonic affection.
This may arise at any period of the disease; but very
often it does not come on till after the desquamation of
the eruption.
After the same period, also, a diarrhœa frequently
comes on, and continues for some time.
DCLII.
It is common for the measles, even when they have
not been of a violent kind, to be followed by inflam-
matory affections, particularly ophthalmia and phthisis.
DCLIII.
If the blood be drawn from a vein, in the measles,
with the circumstances necessary to favour the separation
of the gluten, this always appears separated, and lying
on the surface of the crassamentum, as in inflammatory
diseases.
DCLIV.
For the most part, the measles, even when violent,
are without any putrid tendency; but, in some cases,
such a tendency appears both in the course of the disease,
and especially after the ordinary course of it is finished.
See Dr. Watson, in London Med. Observations, vol.
iv. art. xi.
DCLV.

236 PRACTICE
DCLV.
From what is delivered (from DCXLIV. to DCLIII.)
it will appear, that the measles are distinguished by a
catarrhal affection, and by an inflammatory diathesis,
to a considerable degree; and, therefore, the danger
attending them arises chiefly from the coming on of a
pneumonic inflammation.
DCLVI.
From this consideration, it will be obvious, that the
remedies especially necessary, are those which may
obviate and diminish the inflammatory diathesis; and,
therefore, in a particular manner, blood-letting. This
remedy may be employed at any time in the course of
the disease, or after the ordinary course of it is finished.
It is to be employed more or less, according to the
urgency of the symptoms of fever, cough, and dys-
pnoea; and generally may be employed very freely. But,
as the symptoms of pneumonic inflammation seldom
come on during the eruptive fever; and, as this is some-
times violent, immediately before the eruption, though
a sufficiently mild disease be to follow, bleeding is seldom
very necessary during the eruptive fever, and may often
be reserved for the times of greater danger, which are
perhaps to follow.
DCLVII.
In all cases of measles, where there are no marks of
putrescency, and where there is no reason, from the
known nature of the epidemic, to apprehend putres-
cency, bleeding is the remedy to be depended upon; but,
assistance may also be drawn from cooling purgatives;
and particularly from blistering on the sides, or between
the shoulders.
DCLVIII.

OF PHYSIC. 237
DCLVIII.
The dry cough may be alleviated by the large use of
demulcent pedtorals, mucilaginous, oily, or sweet. It
may, however, be observed, with respect to these de-
mulcents, that they are not so powerful in involving and
correcting the acrimony of the mass of blood as has been
imagined, and that their chief operation is by besmearing
the fauces, and thereby defending them from the irritation
of acrids, either arising from the lungs, or distilling
from the head.
DCLIX.
For moderating and quieting the cough in this disease,
optates certainly prove the most effectual means, when-
ever they can be safely employed. In the measles, in
which an inflammatory state prevails in a considerable
degree, opiates may be supposed to be inadmissible; and,
in those cases in which a high degree of pyrexia and
dyspnœa shew either the presence, or at least the danger
of pneumonic inflammation, we think that opiates
might be very hurtful; but, in cases in which the
dyspnœa is not considerable, and in which bleeding, to
obviate or abate the inflammatory state, has been duly
employed, in such cases, while the cough and watch-
fulness are the urgent symptoms, we think that opiates
may be safely exhibited, and with great advantage. I
think, further, that, in all the exanthemata, there is
an acrimony diffused over the system, which gives a
considerable irritation; and, for obviating the effects of
this, opiates are useful, and always proper, when no
particular contra-indication prevails.
DCLX.
When the desquamation of the measles is finished,
though then there should be no disorder remaining, phy-
sicians have thought it necessary to purge the patient
several times, with a view to draw off the dregs of this
disease, that is, a portion of the morbific matter which
is 

238 PRACTICE
is supposed to remain long in the body. We cannot
reject this supposition, but, at the same time, cannot
believe that the remains of the morbific matter, diffused
over the whole mass of blood, can be wholly drawn off
by purging; and, we think, that, to avoid the conse-
quence of the measles, it is not the drawing off the
morbific matter which we need to study, so much as to
obviate and remove the inflammatory state of the system
which had been induced by the disease. With this last
view, indeed, purging may still be a proper remedy;
but bleeding, in proportion to the symptoms of inflam-
matory disposition, is still more so.
DCLXI.
From our late experience of the use of cold air in the
eruptive fever of the small-pox, some physicians have
been of opinion, that the practice may be transferred to
the measles; but we have not yet had experience to de-
termine this. We are certain, that external heat may
be very hurtful in the measles, as in most other inflam-
matory diseases; and, therefore, that the body ought to
be kept in a moderate temperature during the whole
course of the measles; but how far, at any period of
the disease, cold air may be applied with safety, we are
uncertain. Analogy, though so often the resource of
physicians, is, in general, fallacious; and, further,
though the analogy with the small-pox might lead to the
application of cold air during the eruptive fever of the
measles, the analogy with catarrh seems to be against the
practice. When the eruption is upon the skin, we have
had many instances of cold air making it disappear, and
thereby producing much disorder in the system; and,
we have also had frequent instances of these disorders
being removed by restoring the heat of the body, and
thereby again bringing out the eruption.
CHAP. 

OF PHYSIC. 239
CHAP. VI.
OF THE SCARLET FEVER.
DCLXII.
It may be doubted if the scarlet fever be a disease
specifically different from the cynanche maligna above
described. The latter is almost always attended with a
scarlet eruption; and, in all the instances I have seen of
what may be called the scarlet fever, the disease has, in
almost every person affected, been attended with an ul-
cerous sore throat.
DCLXIII.
This view of the matter may give some doubt; but
I am still of opinion that there is a scarlet fever, which
is a disease specifically different from the cynanche ma-
ligna.
Doctor Sydenham has described a scarlet fever, which
he had seen prevailing as an epidemic, with all the cir-
cumstances of the fever and eruption, without its being
accompanied with any affection of the throat; he at
least does not take notice of any such affection, which
such an accurate observer could not miss to have done,
if any such symptom, as we have commonly seen making
a principal part of the disease, had attended those cases
which he had observed. Several other writers have de-
cribed the scarlet fever in the same manner; and I know
physicians who have seen the disease in that form; so
that there can be no doubt of there being a scarlet fever
not necessarily connected with an ulcerous sore throat,
and therefore a disease different from the cynanche ma-
ligna.
DCLXIV.

240 PRACTICE
DCLXIV.
But, further, although in all the instances of scarlet
fever which I have seen, and in the course of forty years
I have seen it five or six times prevailing as an epidemic
in Scotland, the disease, in almost all the persons affected,
was attended with an ulcerous sore throat, or was what
Sauvages names the Scarlatina Anginosa; that, even
in some instances, the ulcers of the throat were of a
putrid and gangrenous kind, and, at the same time, the
disease, in all its symptoms, resembled, very exactly,
the Cynanche Maligna; yet, I am still persuaded, that
not only the Scarlatina of Sydenham, but that even the
Scarlatina Anginosa of Sauvages, is a different disease
from the Cynanche Maligna; and I have formed this
opinion from the following considerations.
DCLXV.
There is a scarlet fever entirely free from any affection
of the throat, which sometimes prevails as an epidemic;
and, therefore, that there is a specific contagion pro-
ducing a scarlet eruption without any determination to
the throat.
Even the Scarlatina, which, from its matter being
generally determined to the throat, may be properly
termed Anginosa, has, in many eases of the same epi-
demic, been without any affection of the throat;
and, therefore, the contagion, may be supposed to be
more especially determined to produce the eruption only.
Though in all the epidemics which I could alledge
were those of the Scarlatina Anginosa, there have been
some cases which, in the nature of the ulcers, and in
other circumstances, exactly resembled the cases of  the
Cynanche Maligna; yet, I have as constantly observed,
that these eases have not been above one or two in a
hundred, while the rest have all of them been with ulcers
of a benign kind, and with circumstances hereafter to be
described, somewhat different from those of the Cy-
nanche Maligna.
On 

OF PHYSIC. 241
On the other hand, as I have two or three times seen
the Cynanche Maligna epidemically prevailing, so,
among the persons affected, I have seen instances of
cases as mild as the cases of the Scarlatina Anginosa
commonly are; but here the proportion was reversed;
and these mild cases were not one fifth of the whole, while
the rest were of the putrid and malignant kind.
It applies to the same purpose to observe, that, of the
Cynanche Maligna, most of the instances prove fatal,
and, of the Scarlatina Anginosa, a very few of the cases
prove so.
DCLXVI.
From these considerations, though it may appear that
there is some affinity between the Cynanche Maligna and
Scarlatina Anginosa, it will still remain probable, that
the two diseases are specifically different. I have been
at some pains to establish this opinion; for, from all my
experience, I find, that those two diseases require a
different treatment; and I therefore, also, now proceed
to mention more particularly the circumstances of the
Scarlatina Anginosa.
DCLXVII. 
The disease commonly appears about the beginning
of winter, and continues through that season; it comes
on with some cold shivering, and the other symptoms
of the fever which commonly introduces the other ex-
anthemata. But here there is no cough, nor the other
catarrhal symptoms which attend the measles; nor is
there here that anxiety and vomiting which commonly
introduce the confluent small-pox, and which still more
certainly introduce the Cynanche Maligna.
Early in the disease, some uneasiness is felt in the
throat, and frequently the deglutition is difficult, ge-
nerally more so than in the Cynanche Maligna. Upon
looking into the fauces, a redness and swelling appear,
in colour and bulk approaching to the state of these
symptoms in the Cynanche Tonsillaris; but here, in
the Scarlatina, there is always more or less of sloughs,
which
H h 

242 PRACTICE
which seldom appear in the Cynanche Tonsillaris; but
the sloughs are commonly whiter than those in the Cy-
nanche Maligna.
While these circumstances are seen in the fauces, on
the third or fourth day a scarlet eruption appears on the
skin, in  the same form as described in (CCCVI.).
This eruption is commonly more considerable and uni-
versal here than in the Cynanche; but it seldom pro-
duces a remission of the fever; the eruption is commonly
steady to the third or fourth day after its first appearance,
but then goes off, ending in a mealy desquamation. At
this time the fever commonly subsides; and, generally,
at the same time, some degree of sweat comes on.
The sloughs in the fauces, which appeared early in
the disease, continue for some days; but then falling off,
discover the swelling abated, and an ulcer formed on
one or both tonsils, shewing a laudable pus; and soon
after the fever has subsided, these ulcers heal up entirely.
For the most part, this disease has much less of coryza
attending it than the Cynanche Maligna; and, when
there is a coryza attending Scarlatina, the matter dis-
charged is less acrid, and has not the fœtid smell which
it has in the other disease.
In the Scarlatina, when the eruption has entirely dis-
appeared, it frequently happens, that, a few days after,
the whole body is affected with an anasarcous swelling,
which, however, in a few days more, gradually subsides.
We have thus described the most common circum-
stances of the Scarlatina Anginosa; and have only to
add, that, during the time of its being epidemic, and
especially upon its first setting in, there are always a few
cases, in which the circumstances of the disease approach
very nearly to those of the Cynanche Maligna and it
is only in these circumstances that the disease is attended
with any danger
DCLXVIII.
With respect to the cure of this disease, when the
symptoms of it are nearly the same with those of the
Cynanche Maligna, it requires exactly the same treat-
ment as directed in (CCCIX.)
DCLXIX.

OF PHYSIC. 243
DCLXIX.
When the scarlet fever appears, without any affection
of the throat, the treatment of it is very simple, and is
delivered by Dr. Sydenham. An antiphlogistic regimen
is commonly all that is necessary, avoiding, on one
hand, the application of cold air, and, on the other,
any increase of external heat.
DCLXX.
In the ordinary state of the Scarlatina Anginosa, the
same treatment is commonly sufficient; but as here the
fever is commonly more considerable, and there is an
affection of the throat, some remedies may be often
necessary.
DCLXXI.
When there is a somewhat high degree of fever, with
a full pulse, and a considerable swelling of the tonsils,
bleeding is very proper, especially in adults; and it has
been frequently practised with advantage; but, as even
in the Cynanche Tonsillaris, much bleeding is seldom
necessary, (CCXCVIII.) so, in the Scarlatina, when
the state of the fever, and the appearances of the fauces
render the nature of the disease ambiguous, bleeding
may be omitted, and, if not altogether, it at least should
not be large, nor be repeated.
DCLXXII.
Vomiting, and especially nauseating doses of emetics,
notwithstanding the inflamed state of the fauces, have
been found very useful in this disease. An open belly is
proper in every form of this disease; and when the
nauseating doses of emetics operate a little downwards,
they are more serviceable.
DCLXXIII. 

244 PRACTICE
DCLXXIII.
In every form of the Scarlatina Anginosa, through
the whole course of it, detergent gargles should be em-
ployed, and more or less as the quantity of sloughs, and
the viscid mucus in the fauces may seem to require.
DCLXXIV.
Even in the milder states of the Scarlatina Anginosa,
it has been common with practitioners to exhibit the
Peruvian bark through the whole course of the disease;
but we are assured, by much experience, that, in such
cases, it may be safely omitted, though in cases any
ways ambiguous it may not be prudent to do so.   
DCLXXV.
The anasarcous swelling which frequently follows the
Scarlatina Anginosa, seldom requires any remedy; and,
at least, the purgatives so much inculcated, and so com-
monly practised, soon take off the anasarca.
CHAP. VII.
OF THE MILIARY FEVER.
DCLXXVI.
This disease is said to have been unknown to the
antients, and that it appeared, for the first time, in
Saxony about the middle of the last century. It is said
to have since spread from thence into all the other coun-
tries 

OF PHYSIC. 245
tries of Europe; and, since the period mentioned, to 
have appeared in many countries in which it had never
appeared before.
DCLXXVII.
From the time of its having been first taken notice
of, it has been described and treated of by many different
writers, and by all of them, till very lately, has been
considered as a peculiar idiopathic disease.
It is said to have been constantly attended with pe-
culiar symptoms. It comes on with a cold stage, which
is often considerable. The hot stage, which follows, is
attended with great anxiety, and frequent sighing. The
heat of the body becomes great, and soon produces profuse
sweating, preceded, however, with a sense of pricking, as
of pin points in the skin; and the sweat is of a peculiarly
rank and disagreeable odour. The eruption appears,
sooner or later, indifferent persons, but at no determined
period of the disease. It seldom or never appears upon
the face; but appears first upon the neck and breast, and
from thence often spreads over the whole body.
DCLXXVIII.
The eruption named miliary is said to be of two kinds,
the one named the Red, the other the White Miliary.
The former, which in English is strictly named a Rash,
is commonly allowed to be a symptomatic affection;
and, as the latter is the only one that has any pre-
tensions to be considered as an idiopathic disease, it is
this only that we shall more particularly describe and
treat of in this chapter.
DCLXXIX.
What is then called the White Miliary eruption, ap-
pears at first like the red, in very small red pimples, for
the most part distinct, but sometimes clustered together.
Their little prominence is better distinguished by the
finger than by the eye. Soon after the appearance of
this eruption, and, at least, on the second day, a small
vesicle 

246 PRACTICE
vesicle appears upon the top of the pimples. At first
the vesicle is whey coloured, but soon becomes white,
and stands out like a little globule on the top of the
pimple. In two or three days, these globules break, or are
rubbed off, and are succeeded by small crusts, which soon
after fall off in small scales. While one set of pimples
take this course, another set arise to run the same, so
that the disease often continues upon the skin for many
days together. Sometimes when one crop of this
eruption has disappeared, another, after some interval, is
produced. And, it has been further observed, that, in
some persons, there is such a disposition to this disease,
that they have been affected with it several times in the
course of their lives.
DCLXXX.
This disease is said to affect both sexes, and persons
of all ages and constitutions, but it has been observed,
at all times, to affect especially, and most frequently,
lying-in women.
DCLXXXI.
This disease is often accompanied with violent sym-
ptoms, and has frequently proved fatal. The symptoms,
however, attending it are very various; and they are, up-
on occasion, every one attending febrile diseases; but I
cannot find that any symptom, or concourse of symptoms,
are steadily the same in different persons, so as to give
any specific character to the disease. When the disease
is violent, the most common symptoms are phrenetic, co-
matose, and convulsive affections, which are also sym-
ptoms of all fevers treated by a very warm regimen.
DCLXXXII.
While there is such a variety of symptoms appearing
in this disease, it is not to be expected that any one par-
ticular method of cure can be proposed; and, ac-
cordingly, we find, in different writers, different methods
and remedies prescribed; frequent disputes about the 
most

OF PHYSIC. 247
most proper, and those received and practised by some,
opposed and deserted by others.
DCLXXXIII.
I have now given an account of what I have found
delivered by authors who have considered the white
miliary fever as an idiopathic disease; but, now, after
having often observed the disease, I doubt much if it
ever be such an idiopathic as has been supposed; and I
suspect that there is much fallacy in what has been de-
livered on the subject.
DCLXXXIV.
It appears to me very improbable that this was really
a new disease, when it was first considered as such.
There appear to me very clear traces of it in authors who 
wrote long before that period; and, though there were
not, we know, that antient descriptions were inaccurate
and imperfect, particularly with respect to cutaneous
affections; and we know very well, that those affections
which commonly appeared as symptomatic only, were
commonly neglected, or confounded together under a
general appellation.
DCLXXXV.
The antecedent symptoms of anxiety, sighing, and
pricking of the skin, which have been spoken of as pe-
culiar to this disease, are, however, common to many
others, and, perhaps, to all those in which sweatings
are forced out by a warm regimen.
Of the symptoms said to be concomitant of this
eruption, there are none which can be said to be constant
and peculiar but that of sweating. This, indeed, al-
ways precedes and accompanies the eruption; and, while
the miliary eruption attends many different diseases, it
never, however, appears in any of these, but after sweating;
and, in persons labouring under the same diseases, it
does not appear, if in such persons sweating is avoided.
It is, therefore, probable, that the eruption is the effect
of 

248 PRACTICE
of sweating, and that it is the effect of a matter not
before prevailing in the mass of blood, but generated,
under particular circumstances, in the skin itself. That
it depends upon particular circumstances of the skin,
appears further from hence, that the eruption seldom or
never appears upon the face, although it affects the
whole of the body besides; and that it comes upon
those places especially which are more closely covered;
and that it can be brought out upon particular places by
external applications.
DCLXXXVI.
It is to be observed, that this eruptive disease differs
from the other exanthemata in many circumstances; in
its not being contagious, and therefore never epidemic; in
this that the eruption appears at no determined period of
the disease; that the eruption has no determined duration;
that successive eruptions frequently appear in the course
of the same fever; and that such eruptions frequently
recur in the course of the same person's life.
All this renders it very probable, that, in the miliary
fever, the morbific matter is not a subsisting contagion
communicated to the blood, and thence, in consequence
of fever and assimilation, thrown out upon the surface
of the body, but a matter occasionally produced in the
skin, itself by sweating.
DCLXXXVII.
This conclusion is further rendered probable from
hence, that, while the miliary eruption has no peculiar
symptoms, or concourse of symptoms belonging to it,
it, upon occasion, accompanies almost every febrile dis-
ease, whether inflammatory or putrid, if these happen
to be attended with sweating; and from thence it may
be presumed, that the miliary eruption is a symptomatic
affection only, produced in the manner we have said.
DCLXXXVIII. 

OF PHYSIC. 249
DCLXXXVIII.
But, as this symptomatic affection does not always
accompany every instance of sweating, it may be proper
to inquire, what are the circumstances which especially
determine this eruption to appear? and to this I can
give no full and proper answer. I cannot say that there
is any one circumstance which in all cases gives occasion
to this eruption; nor can I say what different causes, in
different cases, may give occasion to it. There is only
one observation I can make to the purpose of this in-
quiry; and it is, that these persons sweating, under
febrile diseases, are especially liable to the miliary
eruption, who have been previously weakened by large
evacuations, particularly of blood. This will explain
why it happens to lying-in women more frequently than
to any other persons; and to confirm this explanation,
I have observed, that the eruption has happened to other
women, though not in child-bed, but who had been
much subjected to a frequent and copious menstruation,
and to an almost constant fluor albus. I have also ob-
served it to have happened to men in fevers, after
wounds, from which they had suffered a great loss of
blood.
Further, that this eruption is produced by a certain
state of debility, will appear probable, from its so often
attending fevers of the putrid kind, which are always
attended with great debility. It is true, that it also
sometimes attends inflammatory diseases, when it may
not be accounted for in the same manner; but I believe
it may be observed, that it especially attends those in-
flammatory diseases in which the sweats have been long
protracted, or frequently repeated, and which have
thereby produced a debility, and, perhaps, a debilitating
putrid diathesis.
DCLXXXIX.
It appears so clearly to me that this eruption is always
a symptomatic and factitious affection, that I am per-
suaded it may be, in most eases, prevented merely by
avoiding
I i

250 PRACTICE
avoiding sweats. Spontaneous sweatings, in the be-
ginning of disease, are very rarely critical; and all
sweatings, not evidently critical, should be prevented;
and the promoting them, by increasing external heat, is
commonly very pernicious. Even critical sweats should
hardly be encouraged by such means. If, therefore,
spontaneous sweats arise, they are to be checked by the
coolness of the chamber; by the lightness and looseness
of the bed-clothes; by the persons laying out their
arms and hands; and by their taking cold drink; and,
in this way, I think I have frequently prevented miliary
eruptions, which were otherwise likely to have appeared,
particularly in lying-in women.
DCXC.
But, it may happen, when these precautions have
been neglected, or from other circumstances, that a mi-
liary eruption does actually appear; and the question
will then be put, how the case is to be treated? It is a
question of consequence, as I believe that the matter
here generated is often of a virulent kind; it is often
the offspring of putrescency; and, when treated by
increasing the external heat of the body, it seems to
acquire a virulence which produces those symptoms
mentioned in (DCLXXXL), and proves certainly
fatal.
It has been an unhappy opinion with most physicians,
that eruptive diseases were ready to be hurt by cold,
and that it was therefore necessary to cover up the body
very closely, and thereby increase the external heat. We
now know that this is a mistaken opinion; that in-
creasing the external heat of the body is very generally
mischievous; and that several eruptions not only admit,
but require the application of cold air. We are per-
suaded, therefore, that the practice which formerly pre-
vailed, in the case of miliary eruptions, of covering up
the body close, and both by external means, and in-
ternal remedies, encouraging the sweatings which ac-
company this eruption, was highly pernicious, and
commonly fatal. I am therefore of opinion, that, even
when a miliary eruption has appeared, in all cases in
which 

OF PHYSIC. 251
which the sweating is not manifestly critical, we should
employ all the several means of stopping the sweating
that are mentioned above; and I have sometimes had
occasion to observe, that even the admission of cool air
was safe and useful.
DCXCI.
This is, in general, the treatment of miliary erup-
tions; but, at the same time, the remedies suited to the
primary disease are to be employed; and, therefore,
when the eruption happens to accompany inflammatory
affections, and the fulness and hardness of the pulse, or
other symptoms, shew an inflammatory state present,
the case is to be treated by blood-letting, purging, and
other antiphlogistic remedies. Upon the other hand,
when the miliary eruption attends diseases, in which
debility and putrescency prevail, it will be proper to
avoid all evacuations, and to employ tonic and antiseptic
remedies, particularly the Peruvian bark, cold drink,
and cold air.
We shall conclude this subject with observing, that
the venerable octogenarian practitioner, de Fischer,
when treating of this subject, in laying down the indi-
cations of cure, has given this as one of them: 'Ex-
'cretionis periphericæ non primariam habere rationem.'
CHAP. 

252 PRACTICE    
CHAP. VIII.
OF THE REMAINING EXAN-
THEMATA.
URTICARIA, PEMPHIGUS, AND
APHTHA.
DCXCII.
The Nettle Rash is a name applied to two different
diseases. The one is the chronic eruption, described by
Dr. Herberden in the Medical Transactions, vol. I.
art. xvii. which, as not being a febrile disorder, does
not belong to this place. The other is the Urticaria
of our Synopsis, which, as taken into every system of
Nosology as one of the Exanthemata Febrilia, is properly
to be treated of here.
DCXCIII.
I have never seen this disease as contagious and epi-
demic; and the few sporadic cases of it which I have
seen, have seldom taken that regular course described by
authors. At the same time, as the accounts of different
authors are not very uniform, and hardly consistent, I
cannot enter further into the consideration of this disease;
and, I hope, it is not very necessary, as on all hands it
is agreed, that this disease is a mild one, and seldom
requires the use of remedies. It is generally sufficient
to observe an antiphlogistic regimen, and to keep the
patient in a temperature that is neither hot nor cold.
DCXCIV. 

OF PHYSIC. 253
DCXCIV.
The Pemphigus, or Vesicular fever, is a rare and
uncommon disease, and very few instances of it are re-
corded in the writings of physicians. I have never had
occasion to see it, and, therefore, it would be improper
for me to treat of it myself, and I don't choose to repeat
after others, while the disease has yet been little observed,
and its character does not yet seem to be exactly ascer-
tained. Vid. Acta Helvetica, vol. 2. p. 260.
DCXCV.
The Aphtha, or Thrush, is a disease better known;
and, as it commonly appears in infants, it is so well
known as not to need our treating of it here. As an
idiopathic disease, affecting adults, we have not seen it;
but it seems to be more frequent in Holland; and, there-
fore, for the study of it, we refer to Dr. Boerhaave,
and his commentator Van Swieten, whose works are in
every body's hands.
DCXCVI.
The Petechia has been, by all our Nosologists, enu-
merated amongst the exanthemata; but as we judge it,
and as we believe that most other physicians judge it, to
be always a symptomatic affection only, we cannot give
it a place here.
BOOK 

254 PRACTICE
BOOK IV.
OF HEMORRHAGIES.
CHAP. I.
OF HEMORRHAGY IN GENERAL.
DCXCVII.
IN establishing a class, or order of diseases, under the
title of HEMORRHAGIES, the Nosologists have em-
ployed the single circumstance of an effusion of red
blood, as the character of such a class or order. By
these means, they have associated diseases, which in their
nature are very different; but, in every methodical
distribution, such arbitrary and unnatural associations
should be avoided as much as possible. Further, by that
management, the Nosologists have suppressed or lost
sight of an useful distinction before established, and very
well founded, which is that of Active and Passive He-
morrhagies.
DCXCVIII.
We mean to restore this distinction; and, therefore,
here, under the title of Hemorrhagies, we comprehend
those only which have been commonly called Active, that
is, those which are attended with some degree of pyrexia;
which seem always to depend upon an increased impetus
of the blood in the vessels pouring it out, and which
chiefly arise from an internal cause. In this matter we
follow 

OF PHYSIC. 255
follow Dr. Hoffman, who joins the Active Hemorrha-
gies with the febrile diseases; and we have accordingly
established these hemorrhagies as an order in the class of
pyrexiæ. From this order we exclude all those effusions
of red blood which are owing entirely to external vio-
lence; and all those which, though from internal
causes, are however, without pyrexia, and seem to be
owing to a putrid fluidity of the blood, to the weak-
ness, or to the erosion of the vessels, rather than to any
increased impetus of the blood in them.
DCXCIX.
With a view to treat of those proper hemorrhagies of
which we have formed an order in our Nosology, we
shall first treat of active hemorrhagy in general; and we
judge the several genera and species, to be treated of par-
ticularly afterwards, to have so many circumstances in
common with one another, that the general consideration
is both proper, and may be very useful.
SECT. I.
OF THE PHENOMENA OF HE-
MORRHAGY.
DCC.
We begin first with marking the phenomena of He-
morrhagy, which are generally the following.
Hemorrhagies happen especially in plethoric habits,
and in persons of a sanguine temperament; they appear
most commonly in the spring, or in the beginning of
summer.
For 

256 PRACTICE
For some time, longer or shorter in different cases,
before the blood flows, there are some symptoms of ful-
ness and tension about the part from which the blood is
to issue. In such parts as fall under our view, there
are some redness, swelling, and sense of heat, or of
itching; and, in the internal parts, from which blood
is to flow, there is a sense of weight and heat; and, in
both cases, various pains are often felt in the neigh-
bouring parts.
DCCI.
When these symptoms have subsisted for some time,
some degree of a cold stage of fever comes on, and a hot
stage is formed, during which the blood flows of a florid
colour, in a greater or less quantity, and continues to
flow for a longer or shorter time; but commonly, after
some time, the effusion spontaneously ceases, and with
that the fever also.
DCCII.
During the hot stage which precedes a hemorrhagy,
the pulse is frequent, quick, full, and often hard; but,
as the blood flows, the pulse becomes softer, and less
frequent.
DCCIII.
In hemorrhagies, blood drawn from a vein, upon its
concreting, commonly shews the gluten separated, or
a crust formed, as in the cases of phlegmasiæ.
DCCIV.
Hemorrhagies, from internal causes, having once
happened, are apt, after a certain interval, to return;
sometimes very often, and frequently at stated periods.
DCCV. 

OF PHYSIC. 257
DCCV.
These are, in general, the phenomerta of hemorrhagy;
and if, in some cases, all of them be not exquisitely
marked; or if, perhaps, some of them do not at all ap-
pear, it imports only, that, in different eases, the system
is more or less generally affected; and that, in some
cases, there are purely topical hemorrhagies, as there are
purely topical inflammations.
SECT. II.
OF THE PROXIMATE CAUSE OF
HEMORRHAGY.
DCCVI.
The pathology of hemorrhagy seems to be sufficiently
obvious. Some inequality in the distribution of the
blood, occasions a congestion in particular parts of the
sanguiferous system; that is, a greater quantity of
blood is poured into certain vessels than their natural
capacity is suited to receive. These vessels become,
thereby, preternaturally distended; and this distention
proves a stimulus to them, exciting their action to a greater
degree than usual, which, pushing the blood with un-
usual force into the extremities of these vessels, opens
them by Anastomosis, or rupture; and, if these ex-
tremities be loosely situated on external surfaces, or on
the internal surfaces of certain cavities opening exter-
nally, a quantity of blood flows out of the body.
DCCVII.
K k

258 PRACTICE
DCCVII.
This will, in some measure, explain the production
of hemorrhagy; but, it appears to me, that, in most
cases, there is something more to be taken into the ac-
count; for it is probable, that, in consequence of con-
gestion, a sense of resistence arises, and excites the
action of the Vis Medicatrix Naturæ; and the exer-
tions of this are usually made by the formation of a cold
stage of fever, inducing a more vigorous action of the
vessels; and the concurrence of this exertion more ef-
fectually opens the extremities, and occasions the flow-
ing out of the blood.
DCCVIII.
What is delivered in the two preceding paragraphs,
seems to explain the whole phenomena of hemorrhagy,
except the circumstance of its frequent recurrence,
which we apprehend may be explained in the following
manner. The congestion and consequent irritation are
taken off by the flowing of the blood; which, therefore,
after some time, spontaneously ceases; but, at the same
time, the internal causes which before produced the
unequal distribution of the blood, commonly remain,
and must now operate the more readily, as the over-
stretched and relaxed vessels of the part will now more
readily admit of a congestion of blood in them, and,
consequently produce the same series of phenomena as
before.
DCCIX.
This may sufficiently explain the ordinary return Of
hemorrhagy; but there is still another circumstance,
which, as commonly concurring, is to be taken notice
of; that is, the general Plethoric state of the system,
which renders every cause of unequal distribution of
more considerable effect. Though hemorrhagy may
often depend upon the state of the vessels of a particular
part, favourable to a congestion's being formed in them;
yet, 

OF PHYSIC. 259
yet, in order to that state's producing its effect, it is
necessary that the whole system be in its natural plethoric
condition; and, if this should be in any degree beyond
what is natural, it will more certainly determine the
effects of topical conformation to take place. The
return of hemorrhagy, therefore, will be more certainly
occasioned, if the system becomes preternaturally ple-
thoric; but hemorrhagy has always a tendency to in-
crease the plethoric state of the system, and, consequently,
to occasion its own return.
DCCX.
To shew that Hemorrhagy does contribute to produce
or increase the plethoric state of the system, it is only
necessary to observe, that the quantity of serous fluids
being given, the state of the excretions depends upon a
certain balance between the force of the larger arteries,
propelling the blood, and the resistence of the excre-
tories; but the force of the arteries depends upon their
fullness and distention, chiefly given to them by the
quantity of red globules and gluten, which are, for the
greatest part, confined to the red arteries; and, there-
fore, the spoliation made by a hemorrhagy, being chiefly
of red globules and gluten, the effusion of blood must
leave the red arteries more empty and weak. In con-
sequence of the weaker action of the red arteries, the
excretions are in proportion diminished; and, there-
fore, the ingesta continuing the same, more fluids will
be accumulated in the vessels. It is by these means that
the loss of blood by hemorrhagies, whether artificial or
spontaneous, if within certain bounds, is commonly
so soon recovered; but, as the diminution of the ex-
cretions, from a less quantity of fluid being impelled
into the excretories, gives occasion to these vessels to fall
into a contracted state; so, if this shall continue long,
these vessels will become more rigid, and will not yield
to the same impelling force as before. Though the
arteries, therefore, by new blood collected in them,
shall have recovered their former fullness, tension, and
force, yet this force will not be in balance with the
resistence of the more rigid excretories, so as to restore
the

260 PRACTICE
the former state of excretion; and, therefore, a further
accumulation will take place in the arteries, and an in-
crease of their plethoric state be thereby induced. In
this manner we perceive more clearly, that hemorrhagy,
as producing a more plethoric state of the system, has a
tendency to occasion its own recurrence with greater
violence; and, as the renewal and further accumulation
of blood require a determined time, so, in the several
repetitions of hemorrhagy, that time will be nearly the
same; and, therefore, the returns of hemorrhagy will
be commonly at stated periods, as has been observed fre-
quently to happen.
DCCXI.
We have thus explained the nature of hemorrhagy in
general, as depending upon some inequality in the dis-
tribution of the blood, occasioning a congestion of it
in particular parts of the sanguiferous system. It
is indeed probable, that, in most persons, the several
parts of the sanguiferous syetem are in balance with
one another, and that the density, and consequently
the resistence, in the several vessels, is in propor-
tion to the quantity of blood that each should receive;
and hence it frequently happens, that no inequality in
the distribution of the blood shall appear in the course
of a long life. But, if we consider that the sangui-
ferous system is constantly in a plethoric state, that is,
that the vessels are constantly distended beyond that size
which they would be of, if they were free from any dis-
tending force, we shall perceive, that this state may be
readily changed. For as, on one hand, the vessels are
elastic, and therefore under a constant tendency to con-
tract farther upon the withdrawing of any part of the
distending force; and, on the other hand, they are not
so rigid but that, by an increase of the impetus of the
blood in them, they may be more than ordinarily dis-
tended; so we can perceive, that, in most persons,
causes of an increased contraction or distention may
arise in one part or other of the system, or that an un-
equal distribution may take place; and, in an exquisitely
distended or plethoric system, a small inequality in the
distribution 

OF PHYSIC. 261
distribution of the blood may form those congestions
which give occasion to hemorrhagy.
DCCXII.
In this manner we explain how hemorrhagy may be
occasioned at any period of life, or in any part of the
body; but hemorrhagies happen in certain parts more
frequently than in others, and at certain periods of life
more readily than at others; and therefore, it may be
required, in delivering the general doctrine of he-
morrhagy, that we should explain those circumstances
which produce the specialities mentioned; and we at-
tempt it as follows.
DCCXIII.
The human body, from being of a small bulk at its
first formation, grows afterwards to a considerable size.
This increase of bulk consists, in a great measure, in the
increase of the quantity of fluids, and a proportional en-
largement of the containing vessels. But, at the same
time, the quantity of solid matter is also gradually in-
creased; and, in whatever manner we may suppose this
to be done, it is probable that the progress, in the whole
of the growth of animal bodies, depends upon the ex-
tension of the arterial system.
DCCXIV.
If this be so, it will be equally manifest, that the
extension of the arterial system depends upon the quan-
tity of fluids accumulated in it, and upon the force of
the heart impelling the fluids, being such as to keep the
arteries constantly in a distended state, and, therefore,
always with a tendency to be extended in every dimension.
DCCXV.
As the state of the animal solid is, at the first for-
mation of the body, very lax and yielding, so the ex-
tension of the system proceeds, at first, very fast; but,
as 

262 PRACTICE
as the extension gives occasion to the apposition of more
matter to the solid parts, these are, in proportion to
their extension, constantly acquiring a greater density,
and therefore giving more resistance to their further ex-
tension and growth. Accordingly, we observe, that,
as the growth of the body advances, the increase of it,
in any given time, becomes proportionally less and less,
till at length it ceases altogether.
DCCXVI. 
This is the general idea of the growth of the human
body, till it attains the utmost bulk which it is capable
of acquiring; but, it is to be observed, that this growth
does not proceed equally in every part of the body, as
it is for the purpose of the œconomy that certain parts
should be first evolved, and that these also should acquire
their full bulk sooner than others. This appears par-
ticularly with respect to the head, the parts of which
appear to be first evolved, and soonest to acquire their
full size.
DCCXVII.
To favour this unequal growth, it is presumed, that
the dimensions or the laxity of the vessels of the head,
or that the direction of the force of the blood, are suited
to the purpose; but, it will also certainly follow, that,
as the vessels of the head grow fastest, and soonest ac-
quire their full size, so they will soonest, also, acquire
that density which will prevent their further extension.
While, however, the force of the heart, and the quan-
tity of the fluids, with respect to the whole system,
remain the same, the distending and extending powers
will be directed to such parts as have not yet acquired the
same density and dimensions as those first formed; and
thus the distending and extending powers will
proceed to operate till every part of the system, in
respect of density and resistence, shall be brought to be in
balance with every other, and till the whole be in balance
with the force of the heart, so that there can be no fur-
ther growth in any particular part, unless some pre-
ternatural circumstance shall happen to arise.
DCCXVIII. 

OF PHYSIC. 263
DCCXVIII.
In this process of the growth of the body, as in ge-
neral it seems to depend upon a certain balance between
the force of the heart, or distending power, and the
resistence of the solids; so it will appear, that, while
the solids remain very lax and yielding, some occasional
increase of the distending power may arise without pro-
ducing any very perceptible disorder in the system. But,
it will also appear, that, in proportion as the distending
power and resistence of the solids come to be more
nearly in exact balance with one another, so any increase
of the distending power will more readily produce a rup-
ture of vessels which do not readily yield to extension.
DCXIX.
From all this, it must appear, that the effects of any
unusally plethoric state of the system, will be different
according as they shall occur at different periods of the
growth of the body. It is, therefore, evident, that,
if the plethoric state arises while the head is yet growing,
and the determination of the blood be still more to the
head than to the other parts, the increased quantity of
the blood will be especially determined to the head; and
as there also, at the same time, the balance between the
distending and extending powers is most nearly adjusted,
so the determination of the blood will most readily pro-
duce, in that part, a rupture of the vessels, or a he-
morrhagy. Hence it is, that hemorrhagies of the nose
so frequently happen in young persons, and in these
more readily, as they approach nearer to their acmé, or
full growth; or, it may be said, perhaps more properly,
as they approach nearer to the age of puberty, when,
perhaps, in both sexes, but especially in the female, a
new determination arises in the system.
DCCXX.
The determination of a greater quantity of blood to
the vessels of the head, might be supposed to occasion a
rupture 

264 PRACTICE
rupture of vessels in other parts of  the head, as well as
in the nose; but such a rupture does not commonly
happen; because, in the nose, for the purpose of sense,
there is a considerable net-work of blood vessels ex-
panded on the internal surface of the nostrils, and
covered only with thin and weak teguments. From this
circumstance it is, that, upon any increased impetus of
the blood, in the vessels of the head, those of the nose
are most easily broken; and the effusion from the nose
being made, not only relieves the other extremities of
the external carotid, to which those of the nose chiefly
belong, but relieves also, in a great measure, the system
of the internal carotid; for, from the internal carotid,
certain branches are font to the nose, are expanded on
its internal surface, and probably inosculated with the
extremities of the external carotid; so that whichsoever
of the extremities are broken, the vis derivationis of
Haller will take place; the effusion will relieve the
whole sanguiferous system of the head; and the same
effusion will also commonly prevent a hemorrhagy hap-
pening in any other part of the body.
DCCXXI.
From these principles, it will appear why hemorrha-
gies of the nose, so frequent before the period of puberty,
or of the acmé, seldom happen after these periods; and
we must observe further, that, though they should hap-
pen, they would not afford any objection to our prin-
ciples, as such hemorrhagies might be imputed to a pe-
culiar laxity, and perhaps to a habit acquired, with
respect to the vessels of the nose, while the balance of
the system might be otherwise duly adjusted.
DCCXXII.
When the process of the growth of the body goes on
regularly, and the balance of the system is properly
adjusted to the gradual growth of the whole, as well as
to the successive growth of the several parts, even a
plethoric state does not produce any hemorrhagy, or at
least any after that of the nose; but if, while the ple-
thoric 

OF PHYSIC. 265
thoric state continues, any inequality also shall subsist in
any of the parts of the system, congestions hemorrhagic,
or inflammatory, may readily be formed.
DCCXXIII.
In general, it may be observed, that, when the se-
veral parts of the system of the aorta have attained their
full growth, and are duly balanced with one another,
if then any considerable degree of plethora remain or
arise, the nicety of the balance will be between the
systems of the aorty and pulmonary artery, or between
the vessels of the lungs, and those of all the rest of the
body: And though the lesser capacity of the vessels of
the lungs is commonly compensated by the greater ve-
locity of the blood in them; yet, if this velocity be not
always adjusted to the necessary compensation, it is pro-
bable that a plethoric state of the whole body will al-
ways be especially felt in the lungs; and, therefore,
that a hemorrhagy, as the effect of a general plethora,
might be frequently occasioned in the lungs, even though
there were no fault in their conformation.
DCCXXIV.
In some cases, perhaps, a hemorrhagy from the lungs,
or a hemoptysis, does arise from the general plethoric
state of the body; but a hemoptysis more frequently
does, and may be expected to happen, from a faulty
proportion between the capacity of the lungs and that
of the rest of the body.
DCCXXV.
When such a disproportion takes place, it will be
evident, that a hemoptysis will especially happen about
the time that the body is approaching to its acmé; that
is, when the system of the aorta has arrived at its ut-
most extension and resistence, and when, therefore, the
plethoric tate of the whole must especially affect the
lungs.
DCCXXVI.
L l 

266 PRACTICE
DCCXXVI.
Accordingly, it has been constantly observed, that,
in fact, the hemoptysis especially happens about the
time of the body's arriving at its acmé; but we say
also, that the hemorrhagy may happen sooner or later,
as the balance between the vessels of the lungs, and
those of the system of the aorta, happen to be more or
less exactly adjusted to one another; and it may often
occur much later than the period mentioned, when that
balance, though not quite even, is not, however, so ill
adjusted, but that some other concurring causes are ne-
cessary to give it effect.
DCCXXVII.
It was antiently observed by Hippocrates, and has
been confirmed by modern observation, that the he-
moptysis generally happens to men between the age of
fifteen and that of five and thirty; that it may happen
at any time between these two periods; but that it seldom
happens before the former, or after the latter; and it is
proper for us here to inquire into the reason of these
two limitations.
DCCXXVIII.
With respect to the first, the reason of it has been
already explained in (DCCXVIII. and DCCXIX.).
With respect to the second limitation, we expect that
the reason of it will be understood from the following
considerations.
We have said already, that the extension and growth
of the body requires the plethoric state of the arterial
system; and nature has provided for this, partly by
giving a certain density and resistence to the several ex-
halants and excretories through which the fluids might
pass out of the red arteries; partly by the constitution
of the blood being; such, that a great portion of it is
unfit to pass into the exhalants and excretories; and
partly, 

OF PHYSIC. 267
partly, but especially, by a resistence in the veins to the
free passage of the blood into them from the arteries.
DCCXXIX.
With respect to this last, and chief circumstance, it
appears from the experiments of Sir Clifton Wintrig-
ham, in his Experimental Inquiry, that the proportional
density of the coats of the veins to that of the coats of
the arteries is greater in young animals than in old;
and, therefore, it may be presumed, that the resistence
to the passage of the blood from the arteries into the
veins is greater in young animals than in old; and,
while this resistence continues, the plethoric state of the
arteries must be constantly continued and supported.
But, as the density of the coats of the vessels, consisting
chiefly of a cellular texture, is increased by pressure,
so, in proportion as the coats of the arteries are more
exposed to pressure by distension than those of the veins,
the former, in the progress of the growth of the body,
must increase much more in density than the latter; and,
therefore, the coats of the arteries, in respect of density
and resistence, must come, in time, not only to be in
balance with those of the veins, but to prevail over
them; and the experiments of the above mentioned in-
genious author sufficiently shew that this truly happens.
By these means, the proportional quantities of blood in
the arteries and veins must change, in the course of life.
In younger animais, the quantity of blood in the ar-
teries must be proportionally greater than in old ones;
but, by the increasing density of the arteries, the quan-
tity of blood in them must be continually diminishing,
and that of the veins be proportionally increasing, and
at length be in a proportionally greater quantity than
that of the arteries. When this change happens in the
proportional quantities of the blood in the arteries and
veins, it is evident that the plethoric state of the arteries
must be in a great measure taken off; and, therefore,
that the arterial hemorrhagy is no longer likely to hap-
pen, and that, if a general plethoric state afterwards
take place in the system, it must especially appear in the
veins.
DCCXXX. 

268 PRACTICE
DCCXXX.
The change we have mentioned to happen in the state
of the arterial and venous systems, is properly supposed
to take place in the human body about the age of
thirty-five, when it is manifest that the vigour of the
body, which depends so much on the fullness and tension
of the arterial system, no longer increases; and there-
fore it is, that the same age is the period after which the
arterial hemorrhagy, hemoptysis, hardly appears. It is
true, there are instances of the hemoptysis happening
at a later period, but it is for the reasons given,
(DCCXI.), which shew that a hemorrhagy may happen
at any period of life, from accidental causes forming
congestions, independent of the state of the balance of
the system at particular periods of it.
DCCXXXI.
Wehave said, (DCCXXIX.) that, after the age of
thirty-five, if a general and preternatural plethoric state
occurs, it must especially appear in the venous system;
and I must now observe, that this venous plethora may
also give occasion to hemorrhagy.
DCCXXXII.
If a plethoric state of the venous system takes place,
it is presumed, that it will especially, and, in the first
place, affect the system of the vena portarum, in which
the motion of the venous blood is more slow than else-
where; in which the motion of the blood is little assisted
by external compression; and in which, from the want
of valves in the veins which form the vena portarum,
the motion of the blood is little assisted by the com-
pression that is applied; while, from the same want of
valves in those veins, the blood is more ready to regur-
gitate in them. Whether any regurgitation of the blood
can produce any action in the veins, and which inverted,
or directed towards their extremities, can force these,
and occasion hemorrhagy, may perhaps be disputed; 
but  

OF PHYSIC. 269
but we think that a hemorrhagy produced by a plethoric
state of the veins may be explained in another and more
probable manner. If the blood is accumulated in the
veins, from any resistence to its proper course, this re-
sistence, and consequent fullness, must also resist the
free passage of the blood from the arteries into the veins.
This again must produce some congestion in the extre-
mities of the red arteries, and, therefore, some increased
action in them, which must be determined with more
than usual force, both upon the extremities of the arte-
ries, and upon the exhalants proceeding from them; and
this force, may occasion an effusion of blood, either by
anastomosis, or rupture.
DCCXXXIII.
This is the account we would give of the hemorrhoidal
flux, so far as it is depending upon the state of the whole
system. This flux appears most commonly to be from
the extremities of the hemorrhoidal vessels, which are
the most dependent and distant branches of those veins
which form the vena portarum; and, therefore, the
most readily affected by every accumulation of blood in
that system of veins, and, consequently, by any general
plethora in the venous system.
DCCXXXIV.
It is here to be observed, that we have spoken of this
hemorrhagy as proceeding only from the hemorrhoidal
vessels, as is commonly does; but it will be readily un-
derstood, that the same accumulation and resistence to
the venous blood may, from various causes, affect many
of the extremities of the vena portarum, which lie very
superficially upon the internal surface of the alimentary
canal, and give occasion to what has been called the
Morbus Niger or Melæna.
DCCXXXV.
Another part in which an unusually plethoric state of
the veins may have particular effects, and occasion he-
morrhagy,

270 PRACTICE
morrhagy, is the head. In this the venous system is of
a peculiar conformation, and such as seems intended by
nature to give a flower motion to the venous blood there.
If, therefore, the plethoric state of the venous system
in general, which seems to increase as life advances,
should at length increase to a great degree, it may very
readily affect the venous vessels of the head, and give
there such a resistence to the arterial blood, as to de-
termine this to be poured out from the nose, or into the
cavity of the cranium. The special effect of the latter
effusion is to produce the disease named Apoplexy, and
which, therefore, is properly named, by Doctor Hoff-
man, Hemorrhagia Cerebri; and the explanation of its
cause, which we have now given, explains well why it
happens, especially to men of large heads and short
necks, and to men in the decline of life, when the
powers, promoting the motion of the blood, are much
weakened.
DCCXXXVI.
We have thus attempted to give the history of the
plethoric and hemorrhagic states of the human body, as
they occur at the different periods of life, and hope we
have thereby explained not only the nature of hemorrhagy
in general, but also of the particular hemorrhagies
which most commonly appear, and as they occur suc-
cessively at the different periods of life.
SECT. 

OF PHYSIC. 271
SECT. III.
OF THE REMOTE CAUSES OF
HEMORRHAGY.
DCCXXXVII.
In the explanation given, we have especially considered
the predisposition to hemorrhagy; but it is proper also,
and even necessary, to take notice of the occasional
causes, which not only concur with the predisponent,
in exciting hemorrhagy, but may also sometimes be the
sole causes of it.
DCCXXXVIII.
These occasional causes are,
1. External heat, which, rarefying the blood, gives
or increases the plethoric state of the body; and the same
heat, as giving a stimulus to the whole system, must
urge any particular determinations before established,
still further, or may urge any inequality, otherwise
innocent, to excess; and, in either way, external heat
may immediately excite hemorrhagies, to which there
was a predisposition, or form congestions where there
were none before, and thereby occasion hemorrhagy.
2. A considerable and sudden diminution of the weight
of the atmosphere, which seems to produce the same
effects with those of heat, by producing also an ex-
pansion of the blood.
3. Whatever increases the force of the circulation,
and thereby the velocity of the blood, which may operate
in the same manner as heat, in urging not only previous
determinations with violence, but also in urging in-
equalities, otherwise innocent, to excess. All violent
exercise,

272 PRACTICE
exercise, therefore, and especially all violent efforts,
which not only by a larger and longer inspiration, but
also by the simultaneous action of many muscles in-
terrupting the free motion of the blood, impel it with
unusual force into the extreme vessels more generally,
and, according to the different postures of the body,
and mode of the effort, into certain vessels more par-
ticularly. Among the causes increasing the force of
the circulation, anger, and other violent active passions,
are to be reckoned.
4. The violent exercise of particular parts of the
body, already affected with congestions, or liable to
them, which exercise may be considered as a stimulus
applied to the vessels of that particular part. Thus,
any violent exercise of respiration may excite hemoptysis,
or occasion its return.
5. The postures of the body increasing determi-
nations, or ligatures occasioning accumulations of the
blood in particular parts of the body.
6. External violence producing hemorrhagy, and,
by being frequently repeated, giving an habitual de-
termination into certain vessels.
7. Cold, externally applied, as changing the distri-
bution of the blood, and determining it in greater
quantity into the internal parts.
SECT. IV.
OF THE CURE OF HEMORRHAGY.
DCCXXXIX.
Having thus considered the proximate and remote
causes of hemorrhagy in general, our next business is
to consider the cure in the same manner.
In 

OF PHYSIC. 273
In entering upon this subject, the first question which
presents itself is, Whether hemorrhagies may be cured
by art, or should be left to the conduct of nature?
DCCXL.
The latter opinion was the favourite doctrine of the
celebrated Dr. Stahl, and his followers. They main-
tained that the human body is much disposed to a ple-
thoric state; and, in consequence, to many disorders
which nature endeavours to obviate and relieve, by ex-
citing hemorrhagy; that this, therefore, is often ne-
cessary to the balance and health of the system; that it
is accordingly to be generally encouraged, and sometimes
solicited, and is not to be suppressed, unless when it
goes to great excess, or happens in parts in which it
may be dangerous.
DCCXLI.
Much of this doctrine may be admitted. The human
body, on many occasions, becomes preternaturally ple-
thoric, and the dangerous consequences of this state,
which might be apprehended, seem to be obviated by a
hemorrhagy taking place; and, further, the necessity of
hemorrhagy often appears from hence, that the sup-
pression of it seems to occasion many disorders.
All this is true; but there is a fallacy in the con-
clusion drawn from it.
DCCXLII.
We maintain that hemorrhagy, either on its first at-
tack, or on its after recurrence, is never necessary to the
health of the body, but upon the supposition that we
cannot otherwise prevent or remove the plethoric state
which seems to require the evacuation; but, as we judge
it possible to prevent or remove a plethoric state, so we
do not think that hemorrhagy is, in all cases, necessary.
In general, we think that hemorrhagy is to be avoided,
1. Because it does not always happen in places where
it is safe. 2. Because, often, while it may relieve a
plethoric
M m

274 PRACTICE
plethoric state, it may, at the same time, induce a very
dangerous disease.
3. Because it may often go to excess, and either en-
danger life, or induce a dangerous infirmity.
And, lastly, Because it has a tendency to increase the
plethoric state it was meant to relieve, to occasion its
own recurrence, and thereby to induce a habit, which,
if left to the precarious and unequal operation of nature,
may, from the frequent errors of this, be attended with
much danger.
DCCXLIII.
It is further to be considered, that hemorrhagies do
not always arise from the necessities of the system, but
often proceed from incidental causes, more than from
predisposition. We judge that all such hemorrhagies
may be immediately suppressed, and the repetition of
such, as it induces a plethora, and a habit not other-
wise necessary, may be, with great advantage, prevented.
DCCXLIV.
Upon the whole of this subject, I conclude, that
preternatural hemorrhagy, that is, every one but that
of the menses in females, is to be avoided, and especially
the returns of it prevented; and I therefore now pro-
ceed to say how hemorrhagy, and its recurrences, may,
and should be prevented.
DCCXLV.
From the principles delivered above, it will imme-
diately appear, that the prevention, either of the first
attacks, or of the returns of hemorrhagy, will chiefly,
and in the first place, depend upon the preventing or
removing of any considerable degree of a plethoric state
which may happen to prevail in the body. It is true,
that, where the hemorrhagy depends upon the particular
conformation of certain parts, rather than upon the gene-
ral plethoric state of the whole, the measures for removing
or preventing the latter may not always be sufficient for
preventing

OF PHYSIC. 275
preventing hemorrhagy; but, at the same time, it will be
evident, that determinations, in consequence of the con-
formation of particular parts, will always be urged more
or less, in proportion to the greater or lesser plethoric
state of the whole system; and, therefore, that, even
in the cases depending upon particular conformation,
the preventing or removing of an unusually plethoric
state, will always be a chief means of preventing he-
morrhagy. It is to be taken notice of, further, that
there may be several inequalities in the balance of the
system, which may have little or no effect, unless when
the system becomes preternaturally plethoric; and, there-
fore, that, in all eases, the preventing or removing of
the plethoric state of the system will be a chief means
of preventing the first attacks, or the returns of he-
morrhagy. We are now, therefore, to say how the
plethoric state of the system is to be avoided or removed.
DCCXLVI.
The fluids of the human body are in continual waste
by the excretions, but are commonly replaced by the
aliments taken in; and, if the quantity of aliments,
in any measure, exceed that of the excretions, an in-
crease of the quantity of the fluids of the body, or a
plethoric state, must arise. This, to a certain degree,
is necessary for the growth of the body; but, even then,
if the proportion of the aliments to the excretions be
greater than is suited to the growth of the body, and
more certainly, if this disproportion continue after the
growth is compleated, when an equality between the
ingesta and the excreta should be established, a preter-
natural plethoric state must arise. In both cases, it is
evident, that the plethora must be prevented or corrected
by adjusting the ingesta and excreta to each other, which
generally may be done, either by diminishing the ingesta,
or increasing the excreta. The former may be effected
by the management of diet, the latter by the manage-
ment of exercise.
DCCXLVII. 

276 PRACTICE
DCCXLVII.
The ingesta may be diminished, either by giving
aliment in less quantity than usual, or by giving ali-
ments of a less nutritious quality; that is, aliments of
a substance, which, under the same bulk and weight,
contain less of a matter capable of being converted into
animal fluids, and more of a matter ready to pass off by
the excretions, and, consequently, less of a matter to
be retained and accumulated in the vessels.
The choice of aliments suited to these purposes, must
be left to be directed by the doctrines of the Materia
Medica.
DCCXLVIII.
The increasing of the excreta, and thereby di-
minishing the plethoric state of the system, is to be ob-
tained by increasing the exercise of the body; and
generally for adjusting the balance between the ingesta
and excreta, and thereby obviating the plethoric state,
it is necessary that exercise, in a due measure, be very
constantly employed.
DCCXLIX.
The observing of abstinence, and the employment of
exercise, for obviating or removing the plethoric state of
the body, we formerly, when treating of the gout,
(DVI. DXV.) considered pretty fully, so that less is
necessary to be said here; and, it is only now requisite
to observe, that the same doubts, as in cases of the
gout, do not arise here, with regard to the safety of
those measures, which, in a plethoric state of the body
disposing to hemorrhagy, are always admissible and pro-
per. But here it is to be observed, that some choice of
the mode of exercise is necessary, and that it should be
different, according to the particular determinations
which may happen to prevail in the system. In general,
in the case of plethora disposing to hemorrhagy, bodily
exercise 

OF PHYSIC. 277
exercise will always be hazardous, and gestation more
generally safe.
DCCL.
Artificial evacuations may be employed to diminish
the plethoric state of the body; and when, at any time,
the plethoric state has become considerable, and imme-
diately threatens a disease, these evacuations should be
made to the quantity that the symptoms seem to require.
But it is constantly to be attended to, that blood-lettings
are improperly employed, to prevent a plethora, as they
have a tendency to increase it, whereby they require to
be often repeated, and induce a habit which may be at-
tended with much danger.
DCCLI.
While a plethora is avoided or removed, and thereby the
predisposition to hemorrhagy, the other measures necessary
for preventing it, are those for avoiding the occasional
causes. These are enumerated in (DCCXXXVIII.),
and the means of avoiding them, so far as within our
power, are sufficiently obvious.
DCCLII.
We have now mentioned the means of preventing
either the first attacks, or the returns of hemorrhagy;
and must next say how it is to be managed when it has
come on.
DCCLIII.
When a hemorrhagy has come on, which appears to
have arisen from a preternaturally plethoric state, or from
some change in the balance  of the sanguiferous system,
no measures are to be immediately taken for suppressing
it, as we may expect that, when the quantity of blood
necessary for the relief of the system is poured out, the
effusion will spontaneously cease.
DCCLIV. 

278 PRACTICE
DCCLIV.
In many cases, however, it may be suspected, that
the quantity of blood poured out is not exactly in pro-
portion to the necessities of the system, either for re-
lieving a general plethora, or particular congestions,
but that it is often to a greater quantity than these re-
quire. This we suppose to happen in consequence of
an inflammatory diathesis prevailing, and of a febrile
spasm being formed; and, therefore, in many eases, it
is proper, as well as for the most part safe, to moderate
the evacuation, and, when it threatens to go to excess,
to suppress it altogether.
DCCLV.
A hemorrhagy may be moderated by avoiding any
irritation that might concur to increase it; and, there-
fore, every part of the antiphlogistic regimen is to be
observed; and, in particular, external heat, both as it
rarefies the fluids, and stimulates the solids, is to be
carefully avoided; and, it is probable, that, in all eases,
a hemorrhagy may be moderated by cool air applied, and
cold drink exhibited.
DCCLVI.
A second means for the same purpose, is the use of
refrigerant medicines, and particularly of acids and
nitre.
DCCLVII.
A third means  which has been frequently employed,
is that of blood-letting. The propriety of this practice
may be doubtful, as the quantity of blood poured out
by the hemorrhagy, may be supposed to answer the pur-
pose of an evacuation in any other way; and we are
ready to allow, that the practice has been often super-
fluous, and sometimes hurtful, by making a greater
evacuation than was necessary or safe. At the same
time, 

OF PHYSIC. 279
time, we apprehend it is not for the mere purpose
of evacuating, that blood-letting is to be practised in
the cure of hemorrhagy; but that it is necessary for
taking off the inflammatory diathesis which prevails,
and the febrile spasm that has been formed. In the case
of hemorrhagy, therefore, when the pulse is not only
frequent, but quick and full, and does not become softer
or slower upon the flowing of the blood, and that the
effusion is profuse, and threatens to continue so, I think
that blood-letting may be necessary, and that I have
often found it useful. I believe further, that the par-
ticular circumstances of venesection may render it more
powerful for taking off the tension and inflammatory
irritation of the system, than any gradual flow from an
artery.
DCCLVIII.
That a spasm of the extreme vessels has a share in
supporting hemorrhagy, appears to me probable from
hence, that blistering has been found often useful in
moderating and suppressing hemorrhagy.
DCCLIX.
Do emetics and vomiting contribute to the cure of
hemorrhagy? See Doctor Bryan Robertson on the vir-
tues and power of medicines.
DCCLX.
When a hemorrhagy is very profuse, and seems to
endanger life, or even threatens to induce a dangerous
infirmity, it is agreed on all hands, that it is to be im-
mediately suppressed by every means in our power; and
particularly, that, besides the means above mentioned
for moderating hemorrhagy, astringents, internal or ex-
ternal where they can be applied, are to be employed.
DCCLXI. 

280 PRACTICE
DCCLXI.
The internal astringents are either vegetable or fossil.
The vegetable astringents are seldom very powerful
in the cure of any hemorrhagies, except those of the
alimentary canal.
The fossil astringents are more powerful, but some
choice of the different kinds may be proper.
The chalybeates, so frequently employed, do not ap-
pear to me to be very powerful.
The preparations of lead are certainly more so, but
are otherwise of so pernicious a quality, that they should
not be employed but in cases of the utmost danger.
The Tinctura Saturnina, or Antiphthisica, as it has
been called, appears to be of little power; but whether
from the small portion of lead which it contains, or
from the state in which the lead is in it, I am uncertain.
The fossil astringent that appears to me the most pow-
erful, and at the same time the most safe, is alum.
DCCLXII.
External astringents, when they can be applied, are
more effectual than the internal. The choice of those
is left to the surgeons.
DCCLXIII.
The most powerful of all astringents appears to me to
be cold, which may be employed either by applying cold
water to the surface of the body, or by throwing the
same into the internal parts.
DCCLXIV.
For suppressing hemorrhagies, many superstitious
remedies and charms have been recommended, and said
to have been employed with success. We are of opi-
nion, that the seeming success of these has been generally
owing to the by-standers mistaking a spontaneous ceasing
of the hemorrhagy for the effect of the remedy. But,
at 

OF PHYSIC. 281
at the same time, I believe, that those remedies have been
sometimes useful, by impressing the mind with horror,
awe, or dread.
DCCLXV.
Upon occasion of profuse hemorrhagies, opiates have
been employed with advantage; and, when the fullness
and inflammatory diathesis of the system have been pre-
viously taken off by the hemorrhagy itself, or by blood-
letting, I think opiates may be employed with safety.
DCCLXVI.
For restraining hemorrhagy, ligatures have been ap-
plied upon the limbs, for retarding the return of the
venous blood from the extremities; but they appear to
me to be of uncertain and ambiguous use.
DCCLXVII.
In the case of profuse hemorrhagies, no pains are to
be taken to prevent a Deliquium Animi, or fainting,
as this happening is often the most certain means of
stopping the hemorrhagy.
DCCLXVIII.
We have thus delivered the general doctrine of he-
morrhagy, and are now to consider the particular cases
of it. It may appear, that we have marked fewer of
these than are commonly enumerated by the nosologists;
but our reason for differing from these authors, must be
left to a nosological discussion, to be entered into in
another place more properly than here.
CHAP.
N n

282 PRACTICE
CHAP. II.
OF THE EPISTAXIS,
OR HEMORRHAGY OF THE NOSE.
DCCLXIX.
The state of the vessels upon the internal surface of
the nose being, such as mentioned (DCCXX.), renders
a hemorrhagy from that more frequent than from any
other part of the body.
DCCLXX.
The blood commonly flows from one nostril only,
and probably because a hemorrhagy from one vessel re-
lieves the congestion in all the neighbouring vessels.
The blood flowing from both nostrils at the same time,
shews a more considerable disease.
DCCLXXI.
This hemorrhagy may occur at any time of life, but
most commonly happens to young persons, as mentioned
in (DCCXIX.), owing to the state of the balance of
the system peculiar to that age.
DCCLXXII.
Though it generally happens to persons before they
have arrived at their full growth, and more rarely af-
terwards; yet sometimes it happens to persons after
their acme, and during the state of manhood; and
it must then be imputed to a plethoric state of the
system; 

OF PHYSIC. 283
system; to a determination of the blood by habit to
the vessels of the nose; or to the particular weakness of
these.
DCCLXXIII.
In all these cases, the disease may be considered as an
hemorrhagy purely arterial, and depending upon an
arterial plethora; but, the disease sometimes occurs in
the decline of life, when probably it depends upon, and
may be considered as a mark of a venous plethora of
the vessels of the head. See (DCCXXXV.)
DCCLXXIV.
This hemorrhagy happens at any period of life, in
certain febrile diseases, which are altogether, or partly,
of an inflammatory nature, and which shew a particular
determination of the blood to the vessels of the head.
These diseases often admit of a solution by this he-
morrhagy, when it may be called critical.
DCCLXXV.
This hemorrhagy happens to persons of every con-
stitution and temperament, but most frequently to those
of a plethoric habit, and sanguine temperament. It
happens to both sexes, but most frequently to the male.
DCCLXXVI.
The disease sometimes comes on without any previous
symptoms; particularly, when some external violence
has a share in bringing it on. But, when it proceeds
entirely from an internal cause, it is commonly preceded
by head-achs, redness of the eyes, a florid colour of the
face, an unusual pulsation in the temples, a sense of full-
ness about the nose, and an itching of the nostrils. A
bound belly, pale urine, coldness of the feet, and cold
shivering over the whole body, are also sometimes
among the preceding symptoms.
DCCLXXVII. 

284 PRACTICE
DCCLXXVII.
From the weakness of the vessels of the nose, the
blood often flows from them without any considerable
effort of the whole system; and, therefore, without
any observable febrile disorder; which, however, in
many cases, is, in all its circumstances, very discernible.
DCCLXXVIII.
A hemorrhagy of the nose happening to young per-
sons, is, and may generally be, considered as a slight
disease, of little consequence, and hardly requiring any
remedy. But, even in young persons, when it recurs
very frequently, and is very copious, it will require
particular attention. It is to be considered as a mark of
arterial plethora; as it may go to a dangerous excess,
and, as frequently returning, it increases the plethoric
state; which, in a more advanced stage of life, may
give the blood a determination to parts from which the
hemorrhagy would be more dangerous. All this will
more particularly require attention, as the marks of
plethora, and of particular congestion, preceding the
hemorrhagy, are more considerable; and as the flowing
of the blood is attended with a more considerable degree
of febrile disorder. 
DCCLXXIX.
When the epistaxis happens to persons after their
acmè, returning frequently, and flowing copiously, it
is always to be considered as a dangerous disease, and as
more certainly threatening the consequences mentioned
in the last paragraph.
DCCLXXX.
When this hemorrhagy happens in the decline of life,
it may be considered as in itself very salutary, but, at
the same time, as a mark of a very dangerous state of
the system; that is, as a mark of a very strong tendency
to 

OF PHYSIC. 285
to a venous plethora in the vessels of the head; and I
have accordingly observed it often followed by apoplexy,
palsy, or such like diseases.
DCCLXXXI.
When a hemorrhagy from the nose happens in febrile
diseases, as mentioned in (DCCLXXI.), and is in
pretty large quantity, it may be considered as critical
and salutary; but it is very apt to be profuse, and even
in this way dangerous.
It sometimes occurs during the eruptive fever of se-
veral exanthemata, and is in such cases sometimes sa-
lutary; but if these exanthemata be accompanied with
any putrid tendency, this hemorrhagy, like artificial
blood-lettings, may have very bad effects.
DCCLXXXII.
Having thus explained the several circumstances of
epistaxis, I proceed to consider the management and
cure of it. I say the management, because it has been
usually thought to require no cure, but that nature should
be allowed to throw out blood in this way very fre-
quently, and as often as it appears to arise from internal
causes, that is, from a state of the system supposed to
require such evacuation.
DCCXXXIII.
For the reasons given in (DCCLXXVIII.), I am of
opinion, that this disease is very seldom to be left to the
conduct of nature; and that, in all cases, it should 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 nose, speaking, or other
irritation; and, when the blood has flowed for some
time, and does not shew any tendency to cease, a pro-
fuse bleeding is to be prevented by measures employed
to stop it, such as pressing the nostril from which the
blood flows, washing the face with cold water, or ap-
plying this to some other parts of the body.
DCCLXXXIV.

286 PRACTICE
DCCLXXXIV.
These measures we judge to be proper even in the
case of young persons, in whom the disease is least ha-
zardous, and even in first attacks; but these measures
will be still more proper, if the disease frequently re-
curs, without any external violence; if the returns shall
happen to persons of a habit disposed to be plethoric;
and, more particularly, if the marks of a plethoric state
appear in the preceding symptoms. (DCCLXXV.).
DCCLXXXV.
Even in young persons, if the bleeding be very pro-
fuse, and long continued, and more especially, if the
pulse become weak, and the face pale, we judge it pro-
per to suppress the hemorrhagy by every means in our
power. See (DCCLIX.), and following paragraphs.
DCCLXXXVI.
In the same case of young persons, when the returns
of this hemorrhagy become frequent, and especially with
the marks of a plethoric habit, we think it necessary to
advise such a regimen as may prevent a plethoric state.
(DCCXLV.—DCCXLIX.). We would advise, at
the same time, to avoid all circumstances which may
determine the blood more fully to the vessels of the head,
or prevent its free return from them; and, by keeping
an open belly, to make some derivation from them.
DCCLXXXVII.
In adult persons, liable to frequent returns of
the epistaxis, the whole of the measures proposed
(DCCLXXXIL—DCCLXXXVI.), are more cer-
tainly and freely to be employed. When, with the
circumstances mentioned in (DCCLXXXIV.), the
tendency to a profuse hemorrhagy appears, even in
young persons, a bleeding at the arm may be proper;
but

OF PHYSIC. 287
but will be still more allowable, proper, and even ne-
cessary, in the case of adults here mentioned.
DCCLXXXVIII.
In persons of any age liable to frequent returns of
this hemorrhagy, when the measures proposed in
(DCCLXXXVI.) shall have been neglected, or from
peculiar circumstances in the balance of the system,
shall have proved ineffectual, and the symptoms threaten-
ing a hemorrhagy (DCCLXXVI.) shall appear, it
will then be proper, by blood-letting, cooling purga-
tives, and every part of the antiphlogistic regimen, to
prevent the hemorrhagy; or, at, least, to prevent its
being profuse when it does happen.
DCCLXXXIX.
In the circumstances just now mentioned (DCC-
LXXXVIII.), the measures proposed are proper, and
even necessary; but it should, at the same time, be
observed, that these are practised with much less ad-
vantage than those proposed in DCCLXXXVI.); be-
cause, though these proposed here may prevent the
coming on of the hemorrhagy for the present, they
certainly, however, dispose to the return of that ple-
thoric state which required their being used, and there can
be no proper security against returns of the disease, but
by pursuing the means proposed in (DCCLXXXVI.)
DCCXC.
When the hemorrhagy of the nose happens to persons
approaching to their full growth, and its returns have
been preceded by the symptoms (DCCLXXVI.), it
may be supposed, that, if the returns can be prevented
by the measures proposed in (DCCLXXXVIII.), these
will be safely employed, as the plethoric state induced
will be rendered safe, by the change which is soon to
take place in the balance of the system. This, how-
ever, cannot be admitted, as the evacuations practised
upon 

288 PRACTICE
upon this plan will have all the consequences which we
have said may follow the recurrence of the hemorrhagy
itself.            
DCCXCI.
When the hemorrhagy of the nose shall be found to
make its returns at nearly slated periods, the measures
for preventing it (DCCLXXXVIII) may be practised
with greater certainty; and, upon every repetition of
the evacuation by diminishing the quantity of it, its ef-
fects in inducing a plethora, may be in some measure
avoided. When, indeed, the repetition of evacuations
is truly unavoidable, the diminishing of them upon
every repetition is properly practised, but it is a practice
of nice and precarious management, and should by no
means be trusted, so far as to supersede the measures pro-
posed in (DCCLXXXVI.), wherever these can be
admitted.
DCCXCII.
When the hemorrhagy of the nose happens in con-
sequence of a venous plethora in the vessels of the head,
as in (DCCLXXI.), the flowing of the blood pretty
largely may be allowed, especially when it happens
after the suppression or ceasing of the menstrual or he-
morrhoidal flux. But, though the flowing of the blood
is, on its first occurring, to be allowed, there is nothing
more proper than guarding against the returns of it.
This is to be done not only by the measures proposed in
(DCCLXXXVI.), but, as the effects of a plethoric
state of the vessels of the head are very uncertain, so,
upon any appearance of it, and especially upon any
threatening of hemorrhagy, the plethora is to be re-
moved, and the hemorrhagy to be obviated immediately
by proper evacuations, as blood-letting, purging, and
issues, or by restoring suppressed evacuations, where this
can be done.
CHAP.

OF PHYSIC. 289
CHAP. III.
OF THE HEMOPTYSIS, OR HE-
MORRHAGY FROM THE LUNGS.
SECT. I.
OF THE PHENOMENA AND CAUSES
OF HEMOPTYSIS.
DCCXCIII.
When blood thrown out from the mouth appears
after some affection of the breast, and is brought out
with more or less of coughing, we can have no doubt
that it comes from the lungs, and this ascertains the
disease we are now to treat of. But there are cases in
which the source of the blood spit out is uncertain; and,
therefore, some other considerations, to be mentioned
hereafter, are often necessary to ascertain the existence of
a hemoptysis.
DCCXCIV.
The blood-vessels of the lungs are more numerous
than those of any other part of the body of the same
bulk. These vessels of the largest size, as they arise
from the heart, are  more immediately, than in other
parts, sub-divided into vessels of the smallest size; and
these small vessels are spread out near to the internal
surfaces
O o 

290 PRACTICE
surfaces of the bronchial cavities, situated in a loose
cellular texture, and covered by a tender membrane only;
so that, considering how readily and frequently these
vessels are gorged with blood, we may understand why a
hemorrhagy from these vessels is, next to that of the
nose, the most frequent of any; and particularly, why
any violent shock given to the whole body so readily oc-
casions a hemoptysis.
DCCXCV.
A hemoptysis may be occasioned by external violence
at any period of life; and we have explained above
(DCCXXIV.), why, in adult persons, while the ar-
terial plethora, nicely adjusted, prevails in the system,
that is, from the age of sixteen to that of five and thirty,
a hemoptysis may at any time be produced, merely by a
plethoric state of the lungs.
DCCXCVI.
But, we have also observed above, (DCCXXIV.),
that a hemoptysis more frequently arises from a faulty
proportion in the capacity of the vessels of the lungs to
those of the rest of the body. Thus it is often a here-
ditary disease, which implies a peculiar and faulty con-
formation. The disease too, especially happens to persons
who discover the smaller capacity of their lungs, by the
narrowness of their chest, and by the prominency of their
shoulders, which last is a mark of their having been
long liable to a difficult respiration.
DCCXCVII.
In such cases too, the disease especially happens to
persons of a sanguine temperament, in whom particu-
larly the arterial plethora prevails. It happens, also, to
persons of a slender delicate make, of which a long
neck is a mark; to persons of much sensibility, and
irritability, and, therefore, of quick parts; to persons
who have been formerly liable to frequent hemorrhagies
of the nose; to persons who have suffered a suppression 
of

OF PHYSIC. 291
of any hemorrhagy they had formerly been liable to, the
most frequent instance of which is in females, who have
suffered a suppression of their menstrual flux; and,
lastly, to persons who have suffered the amputation of
any considerable limb.
DCCXCVIII.
In most of these cases, (DCCXCVII.), the disease
especially happens to persons about the time of their
coming to their full growth, or soon after it, and this
for the reasons fully set forth above (DCCLXXV.)
DCCXCIX.
From all that has been said from (DCCXCIV. to
DCCXCVIII.), the predisponent cause of hemoptysis
will be sufficiently understood, and the disease may hap-
pen from merely the predisponent cause arising to a con-
siderable degree. But, in the predisposed, it is often
brought on by the concurrence of various occasional and
exciting causes. One of these, and perhaps a frequent
one, is external heat, which, even when in no great
degree, brings on the disease in spring, and the be-
ginning of summer, while the heat rarefies the blood
more than it relaxes the solids, which had before been
contracted by the cold of winter. Another exciting
cause is a sudden diminution of the weight of the at-
mosphere, especially when concurring with any effort
in bodily exercise. This effort, too, alone may often,
in the predisposed, be the exciting cause; and, more
particularly, any violent exercise of respiration. In the
predisposed, any degree of external violence also may
ring on the disease.
DCCC.
Occasioned by one or other of these causes (DCC-
XCIX.), the disease comes on with a sense of weight,
and anxiety in the chest, some uneasiness in breathing,
some pain of the breast, or other parts of the thorax,
and some sense of heat under the sternum; and very
often

292 PRACTICE
often before the disease appears, a saltish taste is per-
ceived in the mouth.
DCCCI.
Immediately before the appearance of blood, a degree
of irritation is felt at the, top of the larynx. To re-
lieve this, a hawking is made, which brings up a little
blood, of a florid colour, and somewhat frothy. The
irritation returns; and, in the same manner, more blood
of a like kind is brought up, with some noise in the
wind-pipe, as of air passing through a fluid.
DCCCII.
This is commonly the manner in which the hemoptysis
first begins; but sometimes, at the very first, the blood
comes up by coughing, or at least somewhat of coughing
accompanies the hawking mentioned.
DCCCIII.
The blood issuing is sometimes at first in very small
quantity, and soon disappears altogether; but, in other
cases; especially when it repeatedly occurs, it is in
greater quantity, and frequently continues to appear at
times for several days together. It is sometimes profuse,
but rarely in such quantity as either by its excess, or by
a sudden suffocation, to prove immediately mortal. It
commonly either ceases spontaneously, or is stopped by
the remedies employed.
DCCCIV.
When blood is thrown out from the mouth, it is not
always easy to determine from what internal part it pro-
ceeds; whether from the internal surface of the mouth
itself, from the fauces, or adjoining cavities of the nose,
from the stomach, or from the lungs. It is, however,
very necessary to distinguish the different eases; and, in
most instances, it may be done by attending to the fol-
lowing considerations.
DCCCV. 

OF PHYSIC. 293
DCCCV.
When the blood spit out proceeds from some part of
the internal surface of the mouth itself, it comes out
without any hawking or coughing; and generally, upon
inspection, the particular source of it becomes evident.
DCCCVI.
When blood proceeds from the fauces, or adjoining
cavities of the nose, it may be brought out by hawking,
and sometimes by coughing, in the manner we have
described in (DCCCL and DCCCII.); and, in this
way, a doubt may arise concerning its real source. A
patient often lays hold of these circumstances, to please
himself with the opinion of its coming from the fauces,
and he may be allowed to do so; but a physician cannot
readily be deceived, if he consider, that a bleeding from
the fauces is more rare than one from the lungs; that
the former seldom happens but in persons who have
been before liable to a hemorrhagy of the nose, or to
some evident cause of erosion; and, in most cases, by
looking into the fauces, the distillation of the blood
from thence will be perceived.
DCCCVII.
When blood proceeds from the lungs, the manner in
which it is brought up will commonly shew from whence
it comes; but, independent of that, there are many
circumstances which may concur to point it out, such as
the period of life, the habit of body, and other marks of
a predisposition (DCCXCIV.—DCCXCVIII.); and
together with these, the occasional causes (DCCXCIX.)
having been immediately before applied.
DCCCVIII.
When vomiting accompanies the throwing out of
blood from the mouth, as vomiting and coughing often
mutually excite each other; so they may be frequently
joined,

294 PRACTICE
joined, and render it doubtful, whether the blood
thrown out, proceed from the lungs, or from the sto-
mach. We may, however, generally decide, by con-
sidering that blood does not so frequently proceed from
the stomach as from the lungs; that blood proceeding
from the stomach commonly appears in greater quantity
than when it proceeds from the lungs; that the blood
proceeding from the lungs is usually of a florid colour,
and mixed with a little frothy mucus only; whereas,
the blood from the stomach is commonly of a darker
colour, more grumous, and mixed with the other con-
tents of the stomach; that the coughing or vomiting,
as the one or the other first arises in the cases in which
they are afterwards joined, may sometimes point out the
source of the blood; and, lastly, that much may be
learned from the circumstances and symptoms which
have preceded the hemorrhagy. Those which precede
the hemoptysis, enumerated (DCCC), are most of
them evident marks of an affection of the lungs. And,
on the other hand, the hematemesis, or issuing of blood
from the stomach, has also its peculiar symptoms and
circumstances preceding it; as some morbid affection of
this organ, and, at least, some pain, anxiety, and sense
of weight, referred distinctly to the region of the sto-
mach. To all this may be added, that the vomiting of
blood happens more frequently to females than to males;
and to the former, in consequence of a suppression of
their menstrual flux. By attending to all these con-
siderations (DCCCV.—DCCCVIII.), the presence of
the hemoptysis may be commonly well ascertained.
SECT. 

OF PHYSIC 295
SECT. II.
OF THE CURE OF HEMOPTYSIS.
DCCCIX.
This disease may sometimes be of not more danger
than a hemorrhagy from the nose, as, when it happens
to females, in consequence of a suppression of the menses;
when, without any marks of a predisposition, it arises
from external violence; or, from whatever cause arising,
when it leaves no cough, dyspnœa, or other affection of
the lungs, behind it. But, even in these cases, a danger
may arise, from too large a wound being made in the
vessels of the lungs, from any quantity of red blood
being left to stagnate in the cavity of the bronchiæ, and
particularly, from any determination of the blood being
made into the vessels of the lungs, which, by renewing
the hemorrhagy, may have these consequences. In
every instance, therefore, of hemoptysis, the effusion
is to be moderated by the several means mentioned
(DCCLIV. DCCLVIII).
DCCCX.
These measures are especially necessary when the he-
moptysis arises in consequence of predisposition, and in
all cases where there is the appearance of large effusion,
or where the hemorrhagy frequently returns, the effusion
is not only to be moderated, but to be entirely stopped,
and the returns of it prevented by every means in our
power. See DCCLIX. DCCLXV.
DCCCXI. 

296 PRACTICE
DCCCXI.
Two medicines have been frequently employed to stop
a hemoptysis, or prevent the returns of it; neither of
which I can approve of. These are chalybeates, and
the Peruvian bark. As both of these contribute to in-
crease the phlogistic diathesis of the system, they can
hardly be safe in any case of active hemorrhagy, and I
have frequently found them hurtful.
DCCCXII.
As the hemoptysis which happens in consequence of
predisposition, is always attended with a phlogistic dia-
thesis; and, as the bad consequences of the disease are
especially to be apprehended from the continuance of
that diathesis, so this is to be industriously taken off by
blood-letting, in greater or smaller quantity, and more
or less frequently repeated, according as the symptoms
shall direct. At the same time, cooling purgatives are
to be employed, and every part of the antiphlogistic
regimen is to be strictly enjoined. The refrigerants may
also be administered, taking care, however, that the
acids, and more especially the nitre, do not excite
coughing.
DCCCXIII.
The avoiding of motion is generally a proper part of
the antiphlogistic regimen; and, in the hemoptysis,
nothing is more necessary than avoiding bodily exercise;
but some kinds of gestation, as failing, and travelling
in an easy carriage on smooth roads, have often proved
a remedy.
DCCCXIV.
Such is the treatment we can propose for the he-
moptysis, considered as merely a hemorrhagy; but when,
in spite of all our precautions, it continues to recur, it
is often followed by an ulceration of the lungs, and a
phthisis 

OF PHYSIC. 297
phthisis pulmonalis. This, therefore, we must consider
here; but, as it proceeds also from other causes besides
the hemoptysis, we shall treat of it more generally.
CHAP. IV.
OF THE PHTHISIS PULMONALIS,
OR
CONSUMPTION OF THE LUNGS.
SECT. I.
OF THE, PHENOMENA, AND CAUSES
OF THE PHTHISIS PULMONALIS.
DCCCXV.
We define the pthisis pulmonalis to be an expec-
toration of pus or purulent matter from the lungs, at-
tended with a hectic fever.
As this is the principal species of phthisis, we shall
frequently, in this chapter, employ the general term of
phthisis, though we strictly mean the phthisis pul-
monalis.
DCCCXVI.
P p

298 PRACTICE
DCCCXVI.
We have met with some instances of an expectoration
of purulent matter, continuing for many years, ac-
companied with very few symptoms of hectic, and, at
least, without any hectic exquisitely formed; but, in
none of these instances were the person so entirely free
from symptoms of hectic, as to form any exception to
our general definition.
DCCCXVII.
In every instance of a phthisis pulmonalis, we suppose
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 supposed that pus may be
formed in the blood-vessels, and be from thence poured
into the bronchiæ. Admitting his fact, I have attempted
an explanation of the appearance of pus without ul-
ceration. (CCCXLI.) But, after all, I cannot help
suspecting the accuracy of his observations, must en-
tirely reject his explanation of it, must allow that we
still want facts to support the explanation I had offered,
and doubt much if it will apply to any case of phthisis.
Therefore I still conclude, agreeably to the faith of all
other dissections, and the opinion of all physicians, that
the symptoms mentioned in our definition depend always
upon an ulceration formed in the lungs.
DCCCXVIII.
It sometimes happens that a catarrh is attended with
an expectoration of a matter so much resembling pus,
that physicians have been often uncertain whether it was
mucus or pus, and, therefore, whether the disease was a
catarrh or a phthisis. It is often of consequence to de-
termine these questions; and we are of opinion that it
may be generally done, with sufficient certainty, from
the following considerations, of which each particular
is not always singly decisive, but, when they are taken
together, can hardly deceive us.
1. From 

OF PHYSIC. 299
1. From the colour of the matter, as mucus is na-
turally transparent, and pus always opake. When
mucus becomes opake, as it sometimes does, it becomes
white, yellow, or greenish, but the latter colour is
hardly ever so considerable in mucus as in pus.
2. From the consistence, as mucus is more viscid,
and coherent, and pus is less so, and may be said to be
more friable. When mucus is thrown into water, it is
not readily diffused, but remains united in uniform and
circular masses; but pus, in the same circumstances,
though not readily diffused, does not remain so uniformly
united, and, by a little agitation, it is broken into
ragged fragments.
3. From the odour, which is seldom perceived in
mucus, but frequently in pus. It has been proposed to
try the odour of the matter expectorated by throwing it
upon live coals; but in such a trial, both mucus and
pus give out a disagreeable smell, and it is not easy to
distinguish between the two,
4. From the specific gravity compared with water;
and it is usual for the mucus of the lungs to swim on
the surface of water, and for pus to sink in it. But,
in this, we may sometimes be deceived; as pus, which
has entangled a great deal of air, may swim, and mucus,
that is free from air, may sink.
5. From the mixture which is discernible in the matter
brought up; for, if a yellow or greenish matter appears
surrounded with a less quantity of transparent, or less
opake and coloured matter, the more strongly coloured
matter may be generally considered as pus; as it is not
easy to understand how one portion of the mucus of the
lungs can be very considerably changed, while the rest
of it is very little so, or remains in its ordinary state.
6. From the admixture of certain substances with the
matter thrown out from the lungs. To this purpose,
we are informed by the experiments of the late Mr.
Charles Darwin: a That the vitriolic acid dissolves
both mucus and pus, but most readily the former:
That, if water is added to such a solution of mucus,
this is separated, and either swims on the surface, or,
divided into flocculi, is suspended in the liquor; whereas,
when water is added to a like solution of pus, this falls
to 

300 PRACTICE
to the bottom, or, by agitation, is diffused so as to ex-
hibit an uniformly turbid liquor. b. That a solution
of the caustic fixed alkali, after some time, dissolves
mucus, and generally pus; and, if water be added to
such solutions, the pus is precipitated, but the mucus is
not. From such experiments, it is supposed that pus
and mucus may be certainly distinguished 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, so far as I have
observed, with such a fever as we are presently to de-
scribe as a hectic. This, I am of opinion, is the most
certain mark of a purulent state in some part of the
body; and, if other persons have thought differently, I
am persuaded that it has been owing to this, that, pre-
suming upon the mortal nature of a confirmed or pu-
rulent phthisis, they have considered every case in which
a recovery happened, as a catarrh only; but, that they
may have been mistaken in this, we shall shew hereafter.
DCCCXIX.
Having thus considered the first part of the character
of the phthisis pulmonalis as a mark of an ulceration of
the lungs; and having just now said, that the other part
of the character, that is, the hectic fever, is a mark of
the same, it is proper now to consider this here, as I
had omitted it before (LXXVI).
DCCCXX.
A hectic fever has the form of a remittent, which has
exacerbations twice every day. The first of these occurs
about noon, sometimes a little sooner or later; and a
slight remission of it happens about five afternoon. This
is soon succeeded by another exacerbation, gradually in-
creasing, till after midnight; but, after two o'clock of
the morning, a remission takes place, which becomes
more and more considerable as the morning advances.
The exacerbations are frequently attended with some
degree of cold shivering, or, at least, the patient is ex-
ceedingly 

OF PHYSIC. 301
ceedingly sensible to any coolness of the air, seeks ex-
ternal heat, and often complains of a sense of cold,
when, to the thermometer, his skin is preternaturally
warm. Of these exacerbations, that of the evening is
always the most considerable.
DCCCXXI.
It has commonly been given as a part of the character
of a hectic fever, that am exacerbation of it commonly
appears after the taking in of food; and it is true that
dinner, which is taken at noon, or after it, does seem
to occasion some exacerbation. But this must not make
us judge the mid-day exacerbation to be the effect of
çating only; for I have often observed it to come on an
hour before noon, and often some hours before dinner,
which, in this country now, is not taken till some time
after noon. It is, indeed, to be observed, that, in al-
most every person, the taking in of food occasions some
degree of fever; but I am persuaded this would not
appear so considerable in a hectic, were it not that an
exacerbation of fever is present from another cause, and
accordingly the taking in of food in the morning has
hardly any sensible effect.
DCCCXXII.
We have thus described the general form of hectic
fever, but many circumstances attending it are further
to be taken notice of.
The fever we have described does commonly not sub-
fist long, till the evening exacerbations become attended
with sweatings, which continue to recur, and to prove
more and more profuse, through the whole course of the
disease. Almost from the first appearance of the hectic,
the urine is high coloured, and deposites a copious
branny red sediment, which hardly ever falls close to the
bottom of the vessel. In the hectic, the appetite for
food is generally less impaired than in any other kind of
fever. The thirst is seldom considerable; the mouth is
commonly moist; and, as the disease advances, the
tongue becomes free from all fur, appears very clean, 
and,

302 PRACTICE
and, in the advanced stages of the disease, the tongue
and fauces appear to be somewhat inflamed, and become
more or less covered with aphthæ. As the disease ad-
vances, the red vessels of the adnata of the eye disappear,
and the whole of the adnata becomes of a pearly white.
The face is commonly pale; but, during the exacer-
bations, a florid red, and an almost circumscribed spot,
appear on the cheeks. For some time, in the course of
a hectic, the belly is bound; but, in the advanced
stages of it, a diarrhœa almost always comes on, and
continues to recur frequently during the rest of the dis-
ease, alternating in some measure with the sweatings
mentioned above. The disease is always attended with a
debility, which gradually increases during the course of
it. During the same course, an emaciation takes place,
and goes to a greater degree than in almost any other
case. The falling off of the hairs, and the adunque
form of the nails, are also symptoms of the loss of nou-
rishment. Towards the end of the disease, the feet are
often affected with œdematous swellings. The exacer-
bations of the fever are seldom attended with any head-
ach, and scarcely ever with delirium. The senses and
judgment commonly remain entire to the very end of the
disease; and the mind, for the most part, is confident,
and full of hope. Some days before death, a delirium
comes on, and commonly continues to the end.
DCCCXXIII.
The hectic fever now described, (DCCCXXI.
DCCCXXII.) as accompanying a purulent state of
the lungs, is perhaps the case in which it most frequently
appears; but I have never seen it in any case, when
there was not evidently, or when I had not ground to
suppose, there was a permanent purulency or ulceration
in some external or internal part. It was for this reason
that, in (LXXVI.) I concluded it to be a symptomatic
fever only. It appears to me to be always the effect
of an acrimony absorbed from abscesses or ulcers; but
it is not equally the effect of every fort of acrimony;
for the scorbutic and cancerous often subsist long in the
body without producing a hectic. What is the precise
state 

OF PHYSIC. 303
state of the acrimony producing this, I cannot de-
termine, but it seems to be chiefly that of a vitiated
purulency.
DCCCXXIV.
However this may be, it appears that the hectic's
depending in general upon an acrimony, explains its
peculiar circumstances. The febrile state seems to be
chiefly an exacerbation of that frequency of the pulse,
which occurs twice every day to persons in health, and
may be produced by acrimony alone. These exacer-
bations, indeed, do not happen without the proper cir-
cumstances of pyrexia; but, the spasm of the extreme
vessels in a hectic does not seem to be so considerable as
in other fevers; and hence the state of sweat and urine
which appear so early and so constantly in hectics. Upon
the same supposition, of an acrimony corrupting the
fluids, and debilitating the moving powers, we think
that most of the other symptoms may also be explained.
DCCCXXV.
Having thus considered the characteristical symptoms,
and chief part of the proximate cause of the phthisis
pulmonalis, we proceed to observe, that an ulcer of the
lungs, and its concomitant circumstances of hectic
fever, may again arise from different previous affections
of the lungs; all of which, however, as we judge, may
be referred to five heads, that is, 1. To a hemoptysis,
2. To a suppuration of the lungs, in consequence of
pneumonia, 3. To a catarrh, 4. To an asthma, or, 5.
To a tubercle. These several affections, as causes of
ulcers, we shall now consider in the order mentioned.
DCCCXXVI.
It has been commonly supposed, that a hemoptysis
was naturally, and almost necessarily, followed by an
ulcer of the lungs; but we presume to say, that, in
general, this is a mistake; for we have seen many in-
stances of a hemoptysis occasioned by external violence,
without

304 PRACTICE
without being followed by any ulcer of the lungs; and
we have also seen many instances of hemoptysis from an
internai cause, without any consequent ulceration. And
this, not only when the hemoptysis happened to young
perons, and recurred for several times, but when it has
often recurred during the course of a long life; and it has
easy to conceive that a rupture of the vessels of the
lungs, like that of the vessels of the nose, may be often
healed, as the surgeons speak, by the first intention. It
is probable, therefore, that it is a hemoptysis in par-
ticular circumstances only, which is necessarily followed
by an ulcer; but what these circumstances are it is
difficult to determine. It is possible, that merely the
degree of rupture, or frequently repeated rupture, pre-
venting the wound to heal by the first intention, may
occasion an ulcer; or it is possible that red blood effused,
and not brought up entirely by coughing, may, by stag-
nating in the bronchiæ, become acrid, and erode the
parts. These, however, are but suppositions, not sup-
ported by any clear evidence. And, if we consider
that those cases of hemoptysis which follow the predis-
position (DCCXCVI.—DCCXCVIII.) are these
especially which end in a phthisis, we shall be led to
suspect that some other circumstances concur here
to determine the consequences of hemoptysis, as we
shall hereafter endeavour to shew.
DCCCXXVII.
Any supposition, however, we can make, with respect
to the innocence of a hemoptysis, must not supersede the
measures proposed above for the cure of it; both because
we cannot certainly foresee what may be the conse-
quences of such an accident, and because the measures
proposed are safe, as, upon every supposition, it is a
diathesis phlogistica, which may urge on every bad con-
sequence that can be apprehended.
DCCCXXVIII.
The second cause of an ulceration of the lungs to be
considered, is a suppuration formed in consequence of
pneumonia; 

OF PHYSIC. 305
pneumonia; and we have reserved for this place, though
perhaps not very properly, to explain upon what oc-
casion, and with what symptoms, this suppuration
occurs.
DCCCXXIX. 
When a pneumonia, with symptoms neither very vi-
olent, nor very slight, has continued for many days, it is
to be feared it will end in a suppuration; but this is not
to be determined by the number of days; for, not only
after the fourth, but even after the tenth day, there have
been examples of a pneumonia ending by a resolution;
and, if the disease has suffered some intermission, and
again recurred, there may be instances of a resolution
happening at a much later period from the beginning of
the disease, than that just now mentioned.
DCCCXXX.
But, if a moderate disease, in spite of proper reme-
dies employed, be protracted to the fourteenth day,
without any considerable remission, a suppuration is
pretty certainly to be expected; and it will be more
certain still, if no signs of resolution have appeared, or
if an expectoration which had appeared, shall have again
ceased, and the difficulty of breathing has continued or
increased, while the other symptoms have been rather
abated.
DCCCXXXI.
That, in a pneumonia, the effusion is made, which
may lay the foundation of a suppuration, we conclude
from the difficulty of breathing becoming greater when
the patient is in a horizontal posture, or when the pa-
tient can lie more easily on the affected side.
DCCCXXXII.
That, in such eases, a suppuration has actually be-
gun, we conclude from the patient's being frequently
affected 
Q q

306 PRACTICE
affected with slight cold shiverings, and with a sense of
cold felt sometimes in one, sometimes in another part of
the body. We form the same conclusion also from the
state of the pulse, which is commonly less frequent and
softer, but sometimes quicker than before.
DCCCXXXIII.
That a suppuration is already formed, we conclude
from there being a considerable remission of the pain
which had before subsisted, while, at the same time, the
cough, and especially the dyspnœa, continue, and are
rather increased. At the same time the frequency of the
pulse is rather increased, the feverish state suffers con-
siderable exacerbations every evening, and, by degrees,
a hectic, in all its circumstances, comes to be formed.
DCCCXXXIV.
In this state of symptoms, we conclude very confi-
dently, that an abscess, or, as it is called, a vomica, is
formed in some part of the pleura, and most frequently
in that portion of it investing the lungs. Here purulent
matter frequently remains for some time, as if inclosed
in a cyst; but commonly not long, before it comes to
be either absorbed, and transferred to some other part of
the body, or breaks through into the cavity of the
lungs, or into that of the thorax. In the latter case, it
produces the disease called empyema; but it is when the
matter is poured into the cavity of the bronchiæ that it
properly constitutes the phthisis pulmonalis. In the
case of empyema, the chief circumstances of a phthisis
are indeed also present; but we shall here consider only
that case in which the abscess of the lungs gives oc-
casion to a purulent expectoration.
DCCCXXXV.
An absscess of the lungs, in consequence of pneu-
monia, is not always followed by a phthisis; for some-
times a hectic fever is not formed; the matter poured
into the bronchiæ is a proper and benign pus, which
frequently 

OF PHYSIC. 307
frequently is coughed up very readily, and spit out;
and, though this purulent expectoration should continue
for some time, if it be without hectic, the ulcer soon
heals, and every morbid symptom disappears. This has
so frequently happened, that we  may conclude, that
neither the access of the air, nor the constant motion
of the lungs, will prevent an ulcer of these parts from
healing, if the matter of it be well conditioned. An
abscess of the lungs, therefore, does not necessarily
produce the phthisis pulmonalis; and, if it is followed
by such a disease, it must be in consequence of particular
circumstances which corrupt the purulent matter pro-
duced, render it unsuitable to the healing of the ulcer,
and, at the same time, make it afford an acrimony,
which, absorbed, produces a hectic, and its conse-
quences.
DCCCXXXVI.
The corruption of the matter of such abscesses may
be owing to several causes, as, 1. That the matter ef-
fused, during the inflammation had not been a pure
serum fit to be converted into a laudable pus, but had
been joined with other matters which prevented that,
and gave a considerable acrimony to the whole: Or, 2.
That the matter effused, and converted into pus, merely
by long stagnation in a vomica, or by its connection
with an empyema, had been so corrupted, as to become
unfit for the purpose of pus, in the healing of the ulcer.
These seem to be possible causes of the corruption of
matter in abscesses, so as to make it the occasion of a
phthisis in persons otherwise found; but, it is probable
that a pneumonic abscess especially produces phthisis
when it happens to persons previously disposed to that
disease, and therefore only as concurring with some other
causes of it.
DCCCXXXVII.
The third cause supposed to produce a phthisis is a
catarrh, which, in many cases, seems, in length of
time, to have the expectoration of mucus proper to it,
gradually 

308 PRACTICE
gradually changed to an expectoration of pus; and, at
the same time, by the addition of a hectic fever, the
disease, which was at first a pure catarrh, is changed
into a phthisis. But this supposition is not easily to be
admitted. The catarrh is properly an affection of the
mucous glands of the trachea and bronchiæ analogous
to the coryza, and less violent kinds of cynanche ton-
sillaris, which very seldom end in suppuration. And,
although a catarrh should be disposed to do so, the ulcer
produced might readily heal up, as it does in the case of
a cynanche tonsillaris; and therefore should not produce
a phthisis.
DCCCXXXVIII.
Further, the catarrh, as purely the effect of cold, is
generally a mild disease, as well as of short duration;
and there are, at most, but very few cases of the nu-
merous instances of it, which can be said to have ended
in a phthisis. In all these cases in which this seems to
have happened, it is to me probable that the persons
affected were peculiarly predisposed to phthisis. And the
beginning of phthisis so often resembles a catarrh, that
it may have been mistaken for such a disease. It often
happens also, to increase the fallacy, that the application
of cold, which is the most frequent cause of catarrh,
is also frequently the exciting cause of the cough, which
proves to be the beginning of a phthisis.
DCCXXXIX.
It is to me, therefore, probable, that a catarrh is very
seldom the foundation of a phthisis; but I would not
positively assert that it never is so; for it is possible that
the cases of more violent catarrh may have a pneumonic
affection joined with them, which may end in a sup-
puration; or it may happen that a long continued ca-
tarrh, by the violent agitation of the lungs in coughing,
shall produce some of these tubercles which we are pre-
sently to mention as the most frequent cause of phthisis.
DCCCXL. 

OF PHYSIC. 309
DCCCXL.
We would have it particularly to be observed here,
that nothing we have said in (DCCCXXXIX.) should
allow us to neglect any appearance of catarrh, as is too
frequently done; for it may be either the beginning of
a phthisis, which they mistake for a genuine catarrh,
or that, even as a catarrh, continuing long, it may
produce a phthisis, as in (DCCCXXXIX.)
DCCCXLI.
Many physicians have supposed that an acrimony of
the fluids eroding some of the vessels of the lungs is a
frequent cause of ulceration and phthisis; but this ap-
pears to me to be a mere supposition; for, in any of
the instances of the production of the phthisis which
I have seen, there was no evidence of any acrimony of
the blood capable of eroding the vessels. It is true, in-
deed, that, in many cases, an acrimony subsisting in
some part of the fluids is the cause of the disease; but
it is, at the same time, probable, that this acrimony
operates, by producing tubercles, rather than by any
direct erosion.
DCCCXLII.
I have said (DCCCXXV.) that an asthma may be
considered as one of the causes of phthisis; and, by
asthma, I mean that species which has been commonly
named the spasmodic. This disease frequently subsists
very long without producing any other, and may have
its own peculiar fatal termination, as we shall explain
hereafter. But I have seen it frequently end in a
phthisis; and, in such cases, I suppose that it operates
in the manner I have alleged of catarrh, that is, by
producing tubercles, and their consequences, which
shall be presently mentioned.
DCCCXLIII.

310 PRACTICE
DCCCXLIII.
We are now come to consider the fifth head of the
causes of phthisis, and which we suppose to be the most
frequent of any. This we have said, in general, to be
tubercles; and, by this term, we mean certain small
tumours, which have the appearance of indurated
glands. Dissections have frequently shewn such tu-
bercles formed in the lungs; and we suppose them to
be at first indolent, but, at length, they become in-
flamed, and are thereby changed into little abscesses, or
vomicæ, which breaking, and pouring their matter into
the bronchiæ, give a purulent expectoration, and thus
lay the foundation of a phthisis.
DCCCLXIV.
Though the matter expectorated on these occasions
has the appearance of a pus, it is seldom that of a
laudable kind; and, as the ulcers do not readily heal,
but are attended with a hectic fever, for the most part
ending fatally, we presume that the matter of the ulcers
is imbued with a peculiarly noxious acrimony, which
prevents their healing, and produces a phthisis, in all
its circumstances, as mentioned above.
DCCCXLV.
It is very probable that the acrimony, which thus
discovers itself in the ulcers, existed before, and pro-
duced the tubercles themselves; and it is to this acrimony
that we must trace up the cause of the phthisis following
these tubercles. This acrimony is probably in different
cases of different kinds, and it will not be easy to de-
termine its varieties; but, to a certain length, we shall
attempt it.
DCCCXLVI.
In one case, and a very frequent one, of phthisis, it
appears that the noxious acrimony is of the same kind
with 

OF PHYSIC. 311
with that which prevails in the scrophula. We con-
clude this from observing, that a phthisis, at its usual
periods, frequently attacks persons who had been born
of scrophulous parents, that is, of parents who had
been affected with scrophula in their younger years;
that, very often, when the phthisis appears, there occur
at the same time some lymphatic tumours in the external
parts; and very often I have found the tabes mesen-
terica, which is a scrophulous affection, joined with the
phthisis pulmonalis. To all this I would add, that, even
when no scrophulous affection has either manifestly
preceded or accompanied a phthisis, this last, however,
most commonly affects persons of a habit resembling the
scrophulous, that is, persons of a sanguine, or a san-
guineo-melancholic temperament, who have very fine
skins, rosy complexions, large veins, and soft flesh;
and further, that in such persons the phthisis comes on
in the same manner, as we shall explain immediately,
it does in persons having tubercles.
DCCCXLVII.
Another species of acrimony producing tubercles of
the lungs, and thereby phthisis, may be said to be the
exanthematic. It is well known that the small-pox some-
times, and more frequently the measles, lay the foun-
dation of a phthisis. It is probable, also, that other
exanthemata have the same effect; and, from the phe-
nomena of the disease, and the dissections of persons
who have died of it, it is probable that all the exan-
themata occasion a phthisis, by affording a matter which,
in the first place, produces tubercles.
DCCCXLVIII.
Another acrimony, which seems sometimes to produce
a phthisis, is the siphylitic; but whether such an acri-
mony produces phthisis in any other persons than the
previously disposed, does not appear to me certain.
DCCCXLIX.

312 PRACTICE
DCCCXLIX.
What other species of acrimony, as from scurvy, from
pus absorbed from other parts of the body, from sup-
pressed eruptions, or from other sources, may also pro-
duce tubercles and phthisis, we cannot now decide, but
must leave it to be determined by persons who have had
experience of such eases.
DCCCL.
There is one peculiar case of phthisis, which, from
our own experience, we can take notice of. This is the
case of phthisis from a calcareous matter formed in the
lungs, and coughed up, frequently with a little blood,
sometimes with mucus only, and sometimes with pus.
How this matter is generated, or in what part of the
lungs precisely it is seated, I acknowledge myself ig-
norant. In three cases of this kind which have oc-
curred to me, there was, at the same time, no appearance
of stony or earthy concretions in any other part of the
body. In one of these cases, an exquisitely formed
phthisis came on, and proved mortal; while, in the
other two, the symptoms of phthisis were never fully
formed, and, after some time, merely by a milk diet,
and avoiding irritation, the patients entirely recovered.
DCCCLI.
Another foundation for phthisis, analogous, as I
judge, to that of tubercles, is that which occurs to
certain artificers, whose employments keep them almost
constantly exposed to dust, such as stone-cutters, millers,
flax-dressers, and some others. We have not observed,
in this country, many cases of phthisis which could be
referred to this cause; but, from Ramazzini, Mor-
gagni, and some other writers, we must conclude such
cases to be more frequent in the southern parts of
Europe.
DCCCLII. 

OF PHYSIC. 313
DCCCLII.
Besides these now mentioned, there are probably some
other causes producing tubercles, which have not yet
been ascertained by observation; and there is probably,
in the state of tubercles, a variety not yet accounted for;
but all this we must leave to future observation and
inquiry.
DCCCLIII.
It has been frequently supposed by physicians, that
the phthisis is a contagious disease, and I dare not assert
that it never is contagious; but, in many hundred in-
stances of the disease which I have seen, there has been
hardly one I could judge to have arisen from contagion.
It is possible that, in warmer climates, the effects of
contagion may more readily appear.
After having said that a phthisis arises from tubercles
more frequently than from any other cause, and after
having attempted to assign the variety of these, I now
proceed to mention the peculiar circumstances and sym-
ptoms which usually accompany the coming on of the
disease from tubercles.
DCCCLIV.
A tuberculous and purulent state of the lungs has
been observed in very young children, and in some others,
at several different periods, before the age of puberty
and full growth; but instances of this kind are rare;
and the attack of a phthisis, which we have reason to
impute to tubercles, usually happens at the same period
which we have assigned for the coming on of the he-
moptysis.
DCCCLV.
The phthisis from tubercles does also generally affect
the same habits as the hemoptysis does, that is, persons
of a slender make, of long necks, narrow chests, and
prominent
R r 

314 PRACTICE
prominent shoulders; but very frequently the persons
liable to tubercles have less of the florid countenance,
and of the other marks of an exquisitely sanguine tem-
perament, than the persons liable to hemoptysis.
DCCCLVI.
This disease, arising from tubercles, usually com-
mences with a slight and short cough, which becoming
habitual, is often little remarked by the persons affected,
and sometimes so little as to be absolutely denied by them.
At the same time, their breathing becomes easily hurried by
any bodily motion, their body grows leaner, and they
become languid and indolent. This state sometimes
continues for a year, or even for two years, without
the person's making any complaint of it, excepting
only that they are affected by cold more readily than
usual, which frequently increases their cough, and pro-
duces some catarrh. This again, however, is some-
times relieved, is supposed to have arisen from cold
alone, and therefore gives no alarm either to the pa-
tient, or to his friends, nor leads them to take any
precautions.               
DCCCLVII.
Upon one or other of these occasions of catching
cold, as we commonly speak, the cough becomes more
considerable, is particularly troublesome upon the pa-
tient's lying down at night, and, in this state, continues
longer than is usual in the case of a simple catarrh.
This is more especially to call for attention, if the in-
crease and continuance of cough come on during the
summer season.
DCCCLVII.
The cough, which comes on as in (DCCCLVI.),
is very often for a long time without any expectoration;
but, on the occasions, as in (DCCCLVII), when it
grows more constant, it comes to be, at the same time,
attended with an expectoration, which is most consi-
derable 

OF PHYSIC. 315
derable in the mornings. The matter of this expecto-
ration becomes, by degrees, more copious, more viscid,
and more opake; at length of a yellow or greenish co-
lour, and of a purulent appearance. The whole of the
matter, however, is not always at once entirely changed
in the manner now mentioned; but, while one part of
it retains the usual form of mucus, another suffers the
changes we have described.
DCCCLIX.
When the cough increases, and continues very fre-
quent through the night, and when the matter ex-
pectorated undergoes the changes we have mentioned,
the breathing, at the same time, becomes more difficult,
and the emaciation and weakness go on also increasing.
In the female sex, according as the disease advances, and
sometimes early in its progress, the menses cease to flow;
and this circumstance we consider as commonly the ef-
fect of the disease, although the sex themselves, are
ready to believe it to be the sole cause of the disorder.
DCCCLX.
When the cough comes on as in (DCCCLVI.), the
pulse is often natural, and, for some time after, con-
tinues to be so; but the symptoms have seldom subsisted
long before the pulse becomes frequent, and sometimes
to a considerable degree, without much of the other
symptoms of fever; but, at length, evening exacer-
bations become remarkable, and, by degrees, the fever
assumes the exquisite form of hectic, as described in
(DCCCXX.—DCCCXXII).
DCCCLXI.   
It is seldom that the cough, expectoration, and fever,
go on increasing, in the manner we have described,
without some pain being felt in some part of the thorax.
It is usually, and most frequently, felt at first under the
sternum, and that especially, or almost only, upon oc-
casion of coughing; but very often, and that too, early
in 

316 PRACTICE
in the course of the disease, a pain is felt on one side,
sometimes very constantly, and so as to prevent the
person from lying easily upon that side; but at other
times the pain is felt only upon a full breathing, or
upon coughing. Even when no pain is felt, it generally
happens that phthisical persons cannot lie easily on one
or other side, without having their difficulty of breathing
increased, and their cough excited.
DCCCLXII.
The phthisis begins, and sometimes proceeds to its
fatal issue, in the manner described in (DCCCLVI.-
DCCCLXI.), without any appearance of hemoptysis.
Such cases are, indeed, rare; but it is very common for
the disease to advance very far, and even to an evident
purulency and hectic state, without any appearance of
blood in the spitting; so that it may be affirmed, the
disease is frequently not founded in hemoptysis. At the
same time, we must allow not only that it sometimes
begins with a hemoptysis, as said in (DCCCXIV.), but
farther, that it seldom happens that, in the progress of
the disease, more or less of a hemoptysis does not appear.
Some degree of blood-spitting does, indeed, appear
sometimes in the state mentioned (DCCCLVI.
DCCCLVII.), but more commonly in the more ad-
vanced stages of the disease only, and, particularly,
upon the first appearance of purulency. However this
may be, in the phthisis from tubercles, it is seldom that
the hemoptysis is considerable, or requires any remedies
different from those which are otherways necessary for the
state of the tubercles.
DCCCLXIII.
We have now described a succession of symptoms
which, in different cases, occupies more or less time.
In this climate, it very often takes up some years, the
symptoms appearing especially in the winter and spring,
commonly becoming easier, and sometimes almost dis-
appearing, during the summer; but returning again in
winter, 

OF PHYSIC. 317
winter, they at length, after two or three years, prove
fatal, towards the end of spring, or beginning of
summer.
DCCCLXIV.
In this disease, the prognosis is for the most part un-
favourable. Of those affected with it, the greater num-
ber generally die; but there are also many of them who
recover entirely, after having been in very unpromising
circumstances. What are, however, the circumstances,
more certainly determining to a happy or to a fatal event,
I have not yet been able to ascertain.
DCCCLXV.
The following aphorisms are the result of my ob-
servations.
A phthisis pulmonalis from hemoptysis, is more fre-
quently recovered than one from tubercles.
A hemoptysis is not only not always followed by
a phthisis, as we have said above, (DCCCXXVI.) but,
even when followed by an ulceration, the ulceration is
sometimes attended with little of hectic, and frequently
admits of being soon healed. Even when the hemoptysis
and ulceration have happened to be repeated, we have
had instances of persons recovering entirely after several
such repetitions.
A phthisis from a suppuration in consequence of
pneumonic inflammation, is that which most rarely oc-
curs in this climate; and a phthisis does not always
follow such a suppuration, when the abscess formed
soon breaks and discharges a laudable pus; but, if the
abscess continues long shut up, and till after a con-
siderable degree of hectic has been formed, a phthisis is
then produced, equally dangerous as that from other
causes.
A phthisis from tubercles has, I think, been re-
covered; but it is of all others the most dangerous, and
when arising from a hereditary taint, is almost certainly 
The

318 PRACTICE
The danger of a phthisis, from whatever cause it may
have arisen, is most certainly to be judged of by the
degree to which the hectic and its consequences have
arrived. From a certain degree of emaciation, debility,
profuse sweating, and diarrhœa, no person recovers.
A mania coming on has been found to remove all the
symptoms, and sometimes has entirely cured the disease;
but, in other cases, upon the going off of the mania,
the phthisis has recurred, and proved fatal.
The pregnancy of women has often retarded the pro-
gress of a phthisis; but commonly it is only till after
delivery, when the symptoms of phthisis return with
violence, and soon prove fatal.
SECT. II.
OF THE CURE OF PHTHISIS.
DCCCLXVI.
From what has been just now said, it will readily
appear, that the cure of the phthisis pulmonalis is ex-
ceedingly difficult, and that the utmost care and at-
tention in the employment of remedies have seldom suc-
ceeded. It may be doubtful whether this failure is to be
imputed to the imperfection of our art, or to the absolutely
incurable nature of the disease. I am extremely averse in
any case to admit of the latter supposition, and can al-
ways readily allow of the former; but, in the mean
time, we must mention here what has been attempted
towards curing or moderating the violence of this disease.
DCCCLXVII.
It will be obvious, that, according to the different
circumstances of this disease, the method of cure must
be 

OF PHYSIC. 319
be different. Our first attention should be employed in
watching the approach of the disease, and preventing its
proceeding to an incurable state.
In ail persons of a phthisical habit, and especially in
those born of phthisical parents, the slightest symptoms
of the approach of phthisis, at the phthisical period of
life, ought to be attended to.
DCCCLXVIII.
When a hemoptysis occurs, though it be not always
followed by ulceration and phthisis; these, however,
are always to be apprehended; and every precaution is
to be taken against them. This is especially to be done
by employing every means of moderating the he-
morrhagy, and of preventing the return of it, as di-
rected in (DCCCX. et seq.); and these precautions are
always to be continued for several years after the oc-
currence of the hemoptysis.
DCCCLXIX.
The phthisis which follows a suppuration from
pneumonic inflammation, can only be prevented with
certainty by obtaining a resolution of such inflammation,
What may be attempted towards the cure of an abscess
and ulcer which have taken place, we shall consider
afterwards.
DCCCLXX.
We have said, it is doubtful if a genuine catarrh ever
produces a phthisis; but we have allowed that it possibly
may, and both upon this account, and upon account of
the ambiguity which may arise, whether the appearing
catarrh be a primary disease, or the effect of a tubercle,
we consider it as of the utmost consequence to cure a
catarrh as soon as possible after its first appearance.
And more especially when it shall linger, and continue
for some time, or shall, after some intermission, fre-
quently return, the cure of it should be diligently at-
tempted. The measures requisite for this purpose shall
be 

320 PRACTICE
be mentioned afterwards, when we come to treat of
catarrh as a primary disease; and, in the mean time,
the means necessary for preventing its producing a
phthisis, we shall mention immediately, as they are the
same with those we shall point out, as necessary for
preventing a phthisis from tubercles.
DCCCLXXI.
The preventing of a phthisis from asthma must be by
curing, if possible, the asthma, or, at least, by mo-
derating it as much as may be done; and, as it is pro-
bable that asthma occasions phthisis, by producing
tubercles, the measures necessary for preventing phthisis
from asthma, will be the same with those necessary in
the case of tubercles, which we are now about to men-
tion.
DCCCLXXII.
We consider tubercles as by much the most frequent
cause of phthisis; and even in many cases, where this
seems to depend on hemoptysis, catarrh, or asthma, it
does, however, truly arise from tubercles. It is upon
this subject, therefore, that I shall have occasion to treat
of the measures most commonly requisite for curing
phthisis.
DCCCLXXIII.
When, in a person born of phthisical parents, of a
phthisical habit, at the phthisical period of life, the sym-
ptoms, in the spring, or beginning of summer,
(DCCCLVI.) shall appear in the slightest degree, we
may presume that a tubercle, or tubercles, have been
formed or are forming in the lungs, and therefore, that
every means that we can devise for preventing their for-
mation, or for procuring their resolution, should be em-
ployed immediately, though the patient himself should
overlook or neglect the symptoms, as imputing them to
accidental cold.
DCCCLXXIV. 

OF PHYSIC. 32l
DCCCLXXIV.
This is certainly the general indication; but how it
can be executed I cannot readily say. I do not know
that, at any time, physicians have proposed any remedy
capable of interrupting the formation of tubercles, or of
resolving them when formed. The analogy of scro-
phula gives no assistance on this subject. In scrophula
the remedy seemingly of most power is sea-water, or
certain mineral waters; but these have generally proved
hurtful in the case of tubercles of the lungs. I have
known several instances of mercury very fully employed
for certain diseases, at a time when it was to be suspected,
that tubercles were formed, or forming in the lungs;
but, though the mercury proved a cure for those other
diseases, it was of no service in preventing a phthisis;
and, in some eases, it seemed to hurry it on.
DCCCLXXV.
Such appears to me to be the present state of our art
with respect to the cure of tubercles; but I do not de-
spere of a remedy for the purpose being found hereafter.
In the mean time, all that at present seems to be within
the reach of our art, is to take the measures proper for
avoiding the inflammation of tubercles. It is probable
that tubercles may subsist long without producing any
disorder; and I am disposed to think, that nature some-
times resolves and discusses tubercles which have been
formed, but that nature does this only while the tu-
bercles remain in an uninflamed state; and, therefore,
that, in the case of tubercles, the measures necessary are
chiefly those for avoiding the inflammation of them.
DCCCLXXVI.
The inflammation of a tubercle of the lungs is to be
avoided upon the general plan of avoiding inflammation,
by blood-letting, and by an antiphlogistic regimen,
the chief part of which, in this case, is the use of a low
diet. This supposes a total abstinence from animal
food,
S s 

322 PRACTICE
food, and the using of vegetable food almost alone; but
it has been found that it is not necessary for the patient
to be confined to vegetables of the weakest nourishment,
but that it is enough the farinacea be employed, and,
together with these, milk.
DCCCLXXVII.
Milk has been generally considered as the chief remedy
in phthisis, and in the case of every tendency to it; but,
whether from its peculiar qualities, or from its being of
a lower quality, with respect to nourishment, than any
food entirely animal, is not certainly determined. The
choice and administration of milk will be properly di-
rected, by considering the nature of the milk of the
several animals from which it may be taken, and the
particular state of the patient, with respect to the period
and circumstances of the disease, and to the habits of
his stomach, with respect to milk.
DCCCLXXVIII.
A second means of preventing the inflammation of
the tubercles of the lungs, is, by avoiding any par-
ticular irritation of the affected part, which may arise
from any violent exercise of respiration; from any con-
siderable degree of bodily exercise; from any position of
the body which straitens the capacity of the thorax;
and, lastly, from cold applied to the surface of the
body, which determines the blood in greater quantity to
the internal parts, and particularly to the lungs.
DCCCLXXIX.
From the last mentioned consideration, the application
of cold is, in general, to be avoided; and therefore the
winter-season, in cold climates, as diminishing the cu-
taneous perspiration; but, more particularly, is that
application of cold to be avoided, which may suppress
perspiration, to the degree of occasioning a catarrh,
which consists in an inflammatory determination to the
lungs,  

OF PHYSIC. 323
lungs, and therefore may most certainly produce an in-
flammation of the tubercles there.
By considering that the avoiding of heat is a part of
the antiphlogistic regimen recommended above, and by
comparing this with what has been just now said with
respect to avoiding cold, the proper choice of climates
and seasons for phthisical patients will be readily un-
derstood.
DCCCLXXX.
A third means of avoiding the inflammation of the
tubercles of the lungs consists in diminishing the de-
termination of the blood to the lungs, by supporting
and increasing the determination to the surface of the
body; which is to be chiefly and most safely done by
warm cloathing, and the frequent exercise of gestation.
DCCCLXXXI.
Every mode of gestation has been found of use in
phthisical cases; but riding on horseback, as being ac-
companied with a great deal of bodily exercise, is less
safe in persons liable to a hemoptysis. Travelling in a
carriage, unless upon very smooth roads, may also be
of doubtful effect; and all the modes of gestation that are
employed on land may fall short of the effects expected
from them, because they cannot be rendered sufficiently
constant; and it is therefore that failing, of all other
modes of gestation, is the most effectual in pneumonic
cases, as being both the smoothest and most constant.
It has been imagined, that some benefit is derived
from the state of the atmosphere upon the sea; but I
cannot find that any impregnation of this which can be
supposed to take place, can be of service to phthisical
persons. It is, however, probable, that frequently
some benefit may be derived from the more moderate
temperature of the air upon the sea.
DCCCLXXXII. 

324 PRACTICE
DCCCLXXXII.
For taking off any inflammatory determination of the
blood into the vessels of the lungs, blisters, applied to
some part of the thorax, may often be of service; and, for
the same purpose, as well as for moderating the general
inflammatory state of the body, issues of various kinds
may be properly employed.
DCCCLXXXIII.
We have now mentioned the several measures to be
pursued in the case of what is properly called an incipient
phthisis; but they have seldom been employed, in such
cases, in time, and have, therefore, perhaps, seldom
proved effectual. It has more commonly happened,
that, after some time, an inflammation has come upon
the tubercle, and an abscess has been formed, which
opening into the cavity of the bronchiæ has produced
an ulcer, and a confirmed phthisis.
DCCCLXXXIV.
In this state of, matters, some new indications dif-
ferent from the former may be supposed to arise; and
indications for preventing absorptions, for preventing the
effects of the absorbed matter upon the blood, and for
healing the ulcer, have been actually proposed; but I
cannot find that any of the means proposed for executing
these indications are either probable, or have proved
effectual. If, upon some occasions, they have appeared
to be useful, it has been probably by answering some
other intention.
While no antidote against the poison which especially
operates here, seems to have been as yet found out, it
appears to me, that too great a degree of inflammation
has a great share in preventing the healing of the ulcer
which occurs; and it is certainly what has a great share
in urging on the fatal consequences of it. The only
practice, therefore, which we can propose, is the same
in the ulcerated as in the crude state of a tubercle, that
is, 

OF PHYSIC. 325
is, the employment of means for moderating inflam-
mation, which we have already mentioned (DCCC-
LXXVI. et seq.)
DCCCLXXXV.
The balsamics, whether natural or artificial, which
have been so commonly advised in cases of phthisis, ap-
pear to me to have been proposed upon no good ground,
and commonly to have proved hurtful. The resinous
and acrid substance of myrrh lately recommended, has
not appeared to me to be of any service, and, in some
cases, to have proved hurtful.
DCCCLXXXVI.
Mercury, so often useful in healing ulcers, has been
speciously enough proposed in this case; but whether
that it be not adapted to the particular nature of the
ulcers of the lungs occurring in phthisis, or that be-
cause it cannot have effect here, without exciting such
an inflammatory state of the whole system, as, in  a
hectic state, proves very hurtful, I cannot determine.
Upon many trials which I have seen made, it has proved
of no service, and commonly has appeared to be ma-
nifestly pernicious.
DCCCXXXVII.
The Peruvian bark has been recommended for several
purposes in phthisical eases; and is said, on some oc-
casions, to have been useful; but I have seldom found
it to be so; and as, by its tonic power, it increases the
phlogistic diathesis of The system, I have frequently
found it hurtful. In some cases, where the morning
remissions of the fever were considerable, and the noon
exacerbations well marked, I have known the Peruvian
bark given in large quantities, with the effect of stopping
these exacerbations, and, at the same time, of relieving
the whole of the phthisical symptoms; but, in these
cases, the fever shewed a constant tendency to recur;
and

326 PRACTICE
and at length the phthisical symptoms also returned,
and proved quickly fatal.
DCCCLXXXVIII.
As antiseptic and refrigerant, acids of all kinds are
useful in cases of phthisis; but the native acid of ve-
getables is more useful than the fossil, as it can be given
in much larger quantifies, and more safely than vinegar,
being less liable to excite coughing.
DCCCLXXXlX.
Though our art can do so little towards the cure of
this disease, we must, however, palliate the uneasy sym-
ptoms of it as well as we can. The symptoms especially
urgent are the cough and diarrhœa. The cough may
be in some measure relieved by demulcents, (DCXXVIII)
but the relief obtained by these is imperfect and transi-
tory, and very often the stomach is disturbed by the
quantity of oily, mucilaginous, and sweet substances,
which are on these occasions taken into it.
DCCCXC.
The only certain means of relieving the cough, is by
employing opiates. These, indeed, certainly increase
the phlogistic diathesis of the system, but commonly
they do not so much harm in this way, as they do ser-
vice by quieting the cough, and giving sleep. They are
supposed to be hurtful, by checking expectoration; but
they do it for a short time only; and after a sound sleep,
the expectoration in the morning is more easy than
usual. In the advanced state of the disease, opiates seem
to increase the sweatings which occur; but they com-
pensate this, by the ease they afford in a disease which
cannot be cured.
DCCCXCI. 

OF PHYSIC. 327
DCCCXCI.
The diarrhœa which happens in the advanced state of
this disease, is to be palliated by moderate astringents,
mucilages, and opiates.
Rhubarb, so commonly prescribed in every diarrhœa,
and all other purgatives, are extremely pernicious in the
colliquative diarrhœa of hectics.
Fresh subacid fruits, supposed to be always laxative,
are often in the diarrhœa of hectics, by their antiseptic
quality, very useful.
CHAP. V.
OF THE HÆMORRHOIS,
OR 
OF THE HEMORRHOIDAL
SWELLING AND FLUX.
SECT. I.
OF THE PHENOMENA AND CAUSES
OF THE HÆMORRHOIS.
DCCCXCII.
A discharge of blood from small tumours, on the
verge of the anus, is the symptom which generally con-
stitutes

328 PRACTICE
stitutes the hamorrhois, or, as it is vulgarly called, the
hæmorrhoidal flux. But a discharge of blood from
within the anus, when the blood is of a florid colour,
shewing it to have come from no great distance, is also
considered as the same disease; and physicians have
agreed in making two cases, or varieties of the same,
under the names of external and internal haemorrhois.
DCCCXCIII.
In both cases it is supposed, that the flow of blood is
from tumours, previously formed, which are named
hæmorhoids or piles; and it frequently happens, that
the tumours exist without any discharge of blood, in
which case, however, they are supposed to be a part of
the same disease, and  are, in that case, named Hæ-
morrhoides Cæcæ, or Blind Piles.
DCCCXCIV.
These tumours, as they appear without the anus,
are sometimes separate, round, and prominent on the
verge of the anus; but frequently the tumour is only
one tumid ring, forming, as it were, the anus pushed
without the body.
DCCCXCV.
These tumours, and the discharge of blood from them,
sometimes come on as an affection purely topical, and
without any previous disorder in other parts of the body;
but it frequently happens, even before the tumours are
formed, and more especially before the blood flows,
that various disorders are felt in different parts of the
body, as headach, vertigo, stupor, difficulty of breathing,
sickness, cholic pains, pain of the back and loins; and
often, together with move or fewer of these symptoms,
there occurs a considerable degree of pyrexia.
The coming on of the disease with these symptoms
is usually attended with a sense of fullness, heat, itching,
and pain, in and about the anus.
Sometimes

OF PHYSIC. 329
Sometimes the disease is preceded by a discharge of
serous matter from the anus; and sometimes this serous
discharge, accompanied with some swelling, seems to be
in place of the discharge of blood, and to relieve the
disorders of the system we have mentioned. This se-
rous discharge, therefore, has been named the Hæ-
morrhois Alba.
DCCCXCVI.
In the hæmorrhois, the quantity of blood discharged
is different, upon different occasions. Sometimes the
blood flows only upon the person's going to stool; and,
commonly, in larger or lesser quantity, follows the dis-
charge of the fæces. In other cases, the blood flows
without any discharge of fæces; and then, generally,
in consequence of the previous disorders above men-
tioned, when it is also commonly in larger quantity.
This is often very considerable; and, by the repetition,
so great, as we could hardly suppose the body to bear
but with the hazard of life. Indeed, though rarely, it
has been so great as to prove suddenly fatal. These
considerable discharges occur especially to persons who
have been frequently liable to the disease. They often
induce great debility; and frequently a leucophlegmatia,
or dropsy, which proves fatal.
The tumours and discharges of blood in this disease,
often recur at exactly slated periods.
DCCCXCVII.
It often happens, in the decline of life, that the hæ-
morrhoidal flux, formerly frequent, ceases to flow; and,
upon that event, it generally happens that the persons
are affected with apoplexy or palsy. 
DCCCXCVIII.
Sometimes hæmorrhoidal tumours are affected with
considerable inflammation, which, ending in suppu-
ration, gives occasion to the formation of fistulous ul-
cers in those parts.
DCCCXCIX.
T t

330 PRACTICE
DCCCXCIX.
The hæmorrhoidal tumours have been often con-
sidered as varicous tumours, or dilatations of veins; and
it is true, that in some cases varicous dilatations have ap-
peared upon dissection. These, however, do not always
appear; and, we presume, it is not the ordinary case,
but that the tumours are formed by an effusion of blood
into the cellular texture of the intestine near to its ex-
tremity. These tumours, eepecially when recently
formed, frequently contain fluid blood; but, after they
have remained for some time, they are commonly of a
firmer substance.
DCCCC.
From a consideration of their causes, to be hereafter
mentioned, it is sufficiently probable, that hæmorrhoidal
tumours are produced by some interruption of the free
return of blood from the veins of the lower extremity
of the rectum; and it is possible, that a considerable
accumulation of blood in these veins may occasion a
rupture of their extremities, and thus produce the hæ-
morrhagy or tumours we have mentioned. But, con-
sidering that the hæmorrhagy occurring here is often
preceded by pain, inflammation, and a febrile state, and
with many other symptoms which shew a connection of
the topical affection with the state of the whole system,
it is probable that the interruption of the venous blood,
which we have supposed, operates as in (DCCXXXII.)
and, therefore, that the discharge of blood is here com-
monly from arteries.
DCCCCI.
Some physicians have been of opinion, that a dif-
ference of the hæmorrhois, and of its effects upon the
system, might arise from the difference of the hæmor-
rhoidal vessels from which the blood issued. But I am
of opinion, that it is hardly in any case, we can dis-
tinguish the vessels from which the blood flows; and
that 

OF PHYSIC. 331
that the frequent inoculations, of both the arteries and
veins, that belong to the lower extremity of the rectum,
will render the effects of the hæmorrhagy nearly the
same, from whichsoever of these vessels the blood
proceeds.
DCCCCII.
In (DCCXXXII.) we have explained the manner in
which a certain state of the sanguiferous system might
give occasion to a hæmorrhoidal flux; and I have no
doubt, that this flux may be produced in that manner.
But I cannot by any means think, that the disease is so
often produced in that manner, or that, on its first ap-
pearance, it is so frequently a systematic affection, as
the Stahlians have imagine and would have us to
believe. It happens to many persons before the period of
life at which the venous plethora takes place; it happens
to females, in whom a venous plethora, determined to
the hæmorrhoidal vessels, cannot be supposed; and it
happens to both sexes, and to persons of all ages, from
causes which do not affect the system, and are manifestly
suited to produce a topical affection only.
DCCCCIII.
These causes of a topical affection are, in the first
place, the frequent voiding of hard and bulky fæces,
which, not only by their long stagnation in the rectum,
but especially when voided, must press upon the veins
of it, and interrupt the course of the blood in them. It
is, for this reason, that the disease happens so often to
persons of a slow and bound belly.
DCCCCIV.
From the causes just now mentioned, the disease hap-
pens especially to persons liable to some degree of a
prolapsus and. Almost every person in voiding fæces
has the internal coat of the rectum more or less protruded
without the body; and this will be to a greater or lesser
degree, according as the hardness and bulk of the fæces
occasion 

332 PRACTICE
occasion a greater or lesser effort or pressure upon the
anus. While the gut is thus pushed out, it often hap-
pens, that the sphincter ani is contracted before the gut
is replaced; and, in consequence thereof a strong con- 
striction is made, which preventing the fallen out gut
from being replaced, and, at the same time, preventing
the return of blood from  it, occasions its being consi-
derably swelled, and its forming a tumid ring round the
anus.
DCCCCV.
Upon the sphincter's being a little relaxed, as it is
immediately after its strong contraction, the fallen out
portion of the gut is commonly again  taken within the
body; but, by the frequent repetition of such an acci-
dent, the size and fullness of the ring formed by the
fallen out gut is much increased. It is therefore more
slowly and difficultly replaced; and in this consists the
chief uneasiness of hæmorrhoidal persons.
DCCCCVI.
As the internal edge of the ring mentioned, is ne-
cessarily divided by clefts, the whole often puts on the
appearance of a number of distinct swellings; and it
also frequently happens, that some portions of it are
more considerably swelled, become more protuberant,
and form those small tumours more strictly called Hæ-
morrhoids or Piles.
DCCCCVII.
From considering that the pressure of fæces, and other
causes interrupting the return of venous blood from the
lower extremity of the rectum, may operate a good deal
higher up than that extremity, we can understand, that
tumours may be formed within the anus; and probably
it also happens, that some of the tumours formed without
the anus, as in (DCCCCV.) may continue when taken
within the body, and even be increased by the causes
just now mentioned. It is thus that we explain the
production 

OF PHYSIC. 333
production of internal piles, which, oh account of
their situation and bulk, are not protruded on the per-
son's going  to stool, and are often, therefore, more
painful. The same internal piles are especially painful,
when affected by the hæmorrhagic effort described in
(DCCCXCV.).
DCCCCVIII.
The production of piles is particularly illustrated by
this, that pregnant women are frequently affected with
that disease. This is to be accounted for, partly by the
pressure of the uterus upon the rectum, and partly by
the costive habit to which pregnant women are usually
liable. I have known many instances of piles happening
for the first time during  the state of pregnancy; and
there are few women who have born children, who are
afterwards entirely free from piles. The Stahlians have
generally asserted, that the male sex is more frequently
affected with this disease than the female; but I have
constantly found it otherways in this country.
DCCCCIX.
It is commonly supposed that the frequent use of pur-
gatives, of those especially of the more acrid kind,
and more particularly of alœtics, is apt to produce the
hæmorrhoidal affection; and, as these purgatives sti-
mulate particularly the great guts, it seems sufficiently
probable that they excite this disease.
DCCCCX.
We have now mentioned several causes which may
produce the hæmorrhoidal tumours and flux, as a topical
affection only; but must observe farther, that, although
the disease appears first as a purely topical affection, it
may, by frequent repetition, become habitual, and, there-
fore, may become connected with the whole system, in
the manner we have explained, with respect to hæ-
morrhagy in general, in (DCCVIII.—DCCX.).
DCCCCXI. 

334 PRACTICE
DCCCCXI.
The doctrine referred to, it is apprehended, will ap-
ply very fully to the case of the hæmorrhoidal flux; and
more readily from the person who has been once affected
being much exposed to a renewal of the causes which
first occasioned the disease; from many persons being
much exposed to a congestion in the hæmorrhoidal vessels,
in consequence of their being often in an erect position of
the body, and in an exercise which pushes the blood into
the depending vessels, while, at the same time, the ef-
fects of these circumstances are much favoured by the
abundance and laxity of the cellular texture about the
rectum.
DCCCCXII.
It is thus that the hæmorrhoidal flux is so often ar-
tificially rendered an habitual and systematic affection;
and I am persuaded, that it is this which has given oc-
casion to the Stahlians to consider the disease as almost
universally such.
DCCCCXIII.
It is to be particularly observed here, that when the
hæmorrhoidal disease has either been originally, or has
become, in the manner just now explained, a systematic
affection, it then acquires a particular connection with
the stomach, so that certain affections of the stomach
excite the hæmorrhoidal disease, and certain states of the
hæmorrhoidal affection excite disorders of the stomach.
It is perhaps owing to this connection, that the gout
sometimes affects the rectum. See (CCCCLXXXVIII.)
SECT. 

OF PHYSIC. 335
SECT. II.
OF THE CURE OF HÆMOR-
RHOIDAL AFFECTIONS.
DCCCCXIV.
Almost at all times, it has been an opinion amongst
physicians, and from them spread amongst the people,
that the hæmorrhoidal flux is a salutary evacuation,
which prevents many diseases that would otherways have
happened; and that it even contributes to give long life.
This opinion, in latter times, has been especially main-
tained by Dr. Stahl, and his followers; and has had a
great deal of influence upon the practice of physic in
Germany.
DCCCCXV.
The question arises with respect to hæmorrhagy in
general, and it has been extended so far by the Stahlians.
We have accordingly considered it as a general question,
(DCCXL—DCCXL1V.) but it has been more
especially agitated upon the occasion of our present
subject; and as to this, I am more particularly of opi-
nion, that the hæmorrhois may take place in consequence
of the general state of the system, or, what is still more
frequent, that by repetition, it may become connected
with the general state of the system, and, in either case,
cannot be suppressed without great caution. But not-
withstanding I must maintain, that the first is a rare
case; that generally the disease first appears as an af-
fection purely topical; and that the allowing it to be-
come habitual, is never proper. It is a nasty disagree-
able

336 PRACTICE
able disease, ready to go to excess, and to be thereby
very hurtful, as well as sometimes very fatal. At best,
it is liable to accidents, and thereby to unhappy con-
sequences. I am, therefore, of opinion, that not only
the first approaches of the disease are to be guarded
against, but even that, when it has taken place for
some time, from whatever cause this may have pro-
ceeded, the flux is always to be moderated, and the
necessity of it, if possible, superseded.
DCCCCXVI.
Having delivered these general rules, I proceed to
mention more particularly how the disease is to be treated,
according to the different circumstances in which it may
appear.
When we can manifestly discern the first appearance
of the disease, to arise from causes acting upon the part
only, we should employ the strictest attention in guarding
against the renewal of these causes.
DCCCCXVII.
One of the most frequent of the remote causes of the
hæmorrhoidal affection, is a slow and bound belly,
(DCCCCIII.) and this is to be constantly obviated by
a proper diet, which every individual's own experience
must direct; or, if the management of diet be not ef-
fectual, the belly must be kept regular by medicines,
which may prove gently laxative, without irritating the
rectum. In most cases, it will be of advantage to ac-
quire a habit with respect to time, and to observe it
exactly.
DCCCCXVIII.
Another cause of hæmorrhois to be especially attended
to, is the prolapsus or protrusion of the anus, which is
apt to happen on a person's having a stool, (DCCCCIV.)
If it shall occur to any considerable degree, and be not
at the same time easily and immediately replaced, it most
certainly produces piles, or increases them when other-
ways

OF PHYSIC. 337
ways produced. Persons, therefore, liable to this pro-
lapsus, should, upon their having been at stool, take
great pains to have the gut immediately replaced, by
lying down in a horizontal posture, and pressing gently
upon the anus, till the reduction shall be completely
obtained.
DCCCCXIX.
When the prolapsus we speak of is occasioned only
by voiding hard and bulky fæces, it should be obviated
by the means mentioned in (DCCCCXVII.) and may
be thereby avoided. But in some persons, it is owing to a
laxity of the rectum; and in such persons, it is often
most considerable upon occasion of a loose stool. In
such cases, the disease is to be treated by astringents,
and by proper artifices for preventing the falling down
of the gut.
DCCCCXX.
These are the means to be employed upon the first ap-
proaches of the hæmorrhoidal affection; and when from
neglect it shall have frequently recurred, and has become
in some measure established, they are no less proper;
but, in the latter case, some other means are also ne-
cessary. It is particularly proper to guard against a ple-
thoric state of the body; and, therefore, to avoid a
sedentary life, a full diet, and particularly intemperance
in the use of strong liquor, which I should have ob-
served before, is, in all eases of hæmorrhagy, of the
greatest influence in increasing the disposition to the
disease.
DCCCCXXI.
I need hardly repeat here, that exercise of all kinds,
is a chief means of obviating and removing a plethoric
state of the body; but upon occasion of the hæmorrhoidal
flux, when this is immediately to come on, both walk-
ing and riding, as increasing the determination of the
blood into the hæmorrhoidal vessels, are to be avoided.
At
U u 

338 PRACTICE
At other times, when no such determination is already
formed, those modes of exercise may be very properly
employed.
DCCCCXXII.
Cold bathing is another remedy that may be employed
to obviate plethora, and prevent hæmorrhagy; but it is
to be employed with caution. When the hæmorrhoidal
flux is approaching, it may be dangerous to turn it
suddenly aside, by cold bathing; but, during the in-
tervals of the disease, this remedy may be employed with
advantage; and in persons liable to a prolapsus ani, the
frequent washing of the anus with cold water may be
very useful.
DCCCCXXIII.
These are the means for preventing the recurrence of
the hæmorrhoidal flux; and in ail cases, when it is not
immediately approaching, they are to be employed; and,
when it has actually come on, means are to be employed
for moderating it, as much as possible, by the person's
lying in a horizontal position upon a hard bed, by
avoiding exercise in an erect posture, by using a cool
diet, and by avoiding external heat. From what has
been said above, about being careful not to increase the
determination of the blood into the hæmorrhoidal
vessels, the propriety of these measures will sufficiently
appear; and, if they were not so commonly neglected,
many persons would escape the great trouble, and the
many bad consequences which frequently attend this
disease.
DCCCCXXIV.
With respect to the further cure of this disease, it is
almost in two eases only, that hæmorrhoidal persons call
for the assistance of the physician. The one is, when
the affection is accompanied with much pain, and of
this there are two cases, according as the pain happens
to attend the external or the internal piles.
DCCCCXXV. 

OF PHYSIC. 339
DCCCCXXV.
The pain of the external piles arises especially, when
a considerable protrusion of the rectum has happened,
and while it remains unreduced, it is strangled by the
constriction of the sphincter; and, at the same time, no
bleeding happens, to take off the swelling of the pro-
truded portion of the intestine. Sometimes an inflam-
mation supervenes, and greatly aggravates the pain. To
relieve the pain in this case, emollient fomentations and
poultices, are sometimes of service; but a more effectual
relief is to be obtained by applying leeches to the tumid
parts.
DCCCCXXVI.
The other case, in which hæmorrhoidal persons seek
assistance, is that of excessive bleeding. Upon the opi-
nion so generally received of this discharge being
salutary, and from observing, that, upon the discharge
occurring, persons have sometimes found relief from
various disorders; the most part of persons liable to it
are ready to let it go too far; and indeed, the Stahlians
will not allow it to be a disease, unless when it has ac-
tually gone to excess. We are, however, well persuaded,
that this flux ought always to be cured as soon as
possible.
DCCCCXXVII.
When the disease occurs, as a purely topical affection,
there can be no doubt of the propriety of our rule; and,
even when the disease has occurred as a critical discharge
in the case of a particular disease, if this disease shall
be entirely cured and removed, the preventing any re-
turn of the hæmorrhois seems to be safe and proper.
DCCCCXXVIII.
It is only when the disease arises from a plethoric state
of the body, and from a stagnation of blood in the
hypochondriac 

340 PRACTICE
hypochondriac region, or when, though originally to-
pical, the disease, by frequent repetition, has become
habitual, and has thereby acquired a connection with
the whole system, that any doubt can arise as to the safety
of curing it entirely. In any of these cases, we judge
it will be always proper to moderate the bleeding, left
by its continuance or repetition the plethoric state of
the body, and the particular determination of the blood
into the hæmorrhoidal vessels, be increased, and the re-
currence of the disease, with all its inconveniences and
dangers, be too much favoured.
DCCCCXXIX.
Even in the eases stated, (DCCCCXXVIII.) in so
far as the plethoric state of the body, and the tendency
to that state, can be obviated and removed, this is al-
ways to be diligently attempted; and if it can be exe-
cuted with success, the flux may be entirely suppressed.
DCCCCXXX.
The Stahlian opinion, that the hæmorrhoidal flux is
only in excess, when it occasions great debility, or a
leucophlegmatia, is by no means safe; and we are of
opinion, that the smallest approach towards producing
either of these effects should be considered as an excess,
which ought to be prevented from going farther.
DCCCCXXXI.
In all cases, therefore, of excess, or of any approach
towards it, we are of opinion, that astringents, both
internal and external, may be safely and properly ap-
plied; not indeed to induce an immediate and total
suppression, but to moderate the hæmorrhagy, and, by
degree, to suppress it altogether, while, at the same
time, measures are taken for removing the necessity of
its recurrence.
DCCCCXXXII. 

OF PHYSIC. 341
DCCCCXXXII.
When the circumstances (DCCCCXIII.) marking a
connection between the hæmorrhoidal affection, and
the state of the stomach occur, the measures necessary are
the same as in the case of atonic gout.
CHAP. VI.
OF THE MENORRHAGIA,
OR THE
IMMODERATE FLOW OF THE
MENSES.
DCCCCXXXIII.
The flow of the menses is considered as immoderate,
when it recurs more frequently, when it continues
longer, or when, during the ordinary continuance, it
is more abundant than is usual with the same person at
other times.
DCCCCXXXIV.
As the most part of women are liable to some ine-
quality with respect to the period, the duration, and the
quantity of their menses; so it is not every inequality
in these respects that is to be considered as a disease;
but only those deviations which are excessive in degree,
which 

342 PRACTICE
which are permanent, and which induce a manifest
state of debility.
DCCCCXXXV.
The circumstances (DCCCCXXXIII. DCCCC-
XXXIV.) are those which chiefly constitute the me-
norrhagia; but it is proper to observe, that, though we
llow that the frequency, duration, and quantity of the
menses are to be judged of by what is usual with the
same individual at other times; yet we observe so much
uniformity in these particulars, in the whole of the sex,
that, in any individual in whom there occurs a con-
siderable deviation from what is usual with the generality
of the sex, such a deviation, constant in the same in-
dividual, may, be considered as at least approaching to a
morbid state, and as requiring most of the precautions
which we shall hereafter mention as necessary to be at-
tended to by persons who are actually in such a state.
DCCCCXXXVI.
Blood discharged from the vagina may proceed from
different sources in the internal parts; but here we mean
to treat of those discharges only in which the blood may
be presumed to flow from the same sources from which
the menses proceed, in their natural state, and which
discharges alone are those properly comprehended under
our title, The title of hæmorrhagia uteri might com-
prehend a great deal more.
DCCCCXXXVII.
The menorrhagia may be considered as of two kinds;
either as it happens to pregnant and lying-in women,
or as it happens to women who are neither pregnant nor
have recently born children. The first kind, as con-
nected with the circumstances of pregnancy and child-
bearing, (which are not to be treated of in our present
course) we are not to consider here, but confine our-
selves to the consideration of the second kind of me-
norrhagia only.
DCCCCXXXVIII. 

OF PHYSIC. 343
DCCCCXXXVIII.
We treat of menorrhagia here, as an active hæ-
morrhagy, because we consider menstruation, in its na-
tural state, to be always of that nature; and though
there should be eases of menorrhagia which might be
considered as purely passive, I am of opinion they can-
not be so properly considered in any other place.
DCCCCXXXIX.
However we may determine with respect to the cir-
cumstances, (DCCCCXXXIII-DCCCCXXXV.)
we still allow that the immoderate flow of the menses is
especially to be determined by the symptoms, affecting
other functions, which accompany and follow the
discharge.
When a larger flow of the menses has been preceded
by head ach, giddiness, or dispnœea, and has been
ushered in by a cold stage, and is attended with much
pain of the back and loins, with a frequent pulse, heat,
and thirst, it may then be considered as preternaturally
large.
DCCCCXL.
When in consequence of the circumstances, (D-
CCCCXXXIII—DCCCCXXXV.) and the repe-
tition of them, the face becomes pale; the pulse be-
comes weak; an unusual debility is felt in exercise; the
breathing is hurried by moderate exercise; where farther
the back becomes pained from any continuance in an
erect posture, when the extremities become frequently
cold, and when at night the feet appear affected with
œdematous swelling; from these symptoms we may cer-
tainly conclude that the flow of the menses has been
immoderate, and has already induced a dangerous state
of debility.
DCCCCXLI. 

344 PRACTICE
DCCCCXLI.
The debility in this case induced, often appears also
by affections of the stomach, an anorexia, and other
symptoms of dyspepsia; by a palpitation of the heart,
and frequent faintings; by a weakness of mind liable to
strong emotions from slight causes, especially those pre-
sented by surprise.
DCCCCXLII.
That flow of the menses, (DCCCCXXXIII.) which
is attended with barrenness in married women, may be
generally considered as immoderate and morbid.
DCCCCXLIII.
Generally, also, that flow of the menses may be con-
sidered as immoderate, which is preceded and followed
by a leucorrhœa.
DCCCCXLIV.
The menorrhagia (DCCCCXXXIII. et seq.) has for
its proximate cause, either the hæmorrhagic effort of the
uterine vessels preternaturally increased, or, a preter-
natural laxity of the extremities of the uterine arteries;
the hæmorrhagic effort remaining as in the natural state.
DCCCCXLV.
The remote causes of the menorrhagia may be, 1st,
Those which increase the plethoric state of the uterine
vessels; as a full and nourishing diet, much strong
liquor, and frequent intoxication. 2dly, Those which
determine the blood more copiously and forcibly into the
uterine vessels; as violent strainings of the whole body;
violent shocks of the whole body from falls; violent
strokes or contusions on the lower belly; violent exercise,
particularly in dancing; and violent passions of the
mind. 3dly, Those which particularly irritate the vessels 
of

OF PHYSIC. 345
of the uterus; as excess in venery; the exercise of
venery in the time of menstruation; a costive habit,
giving occasion to violent straining at stool; and cold
applied to the feet. 4thly, Those which have forcibly
overstrained the extremities of the uterine vessels; as
frequent abortions; frequent child-bearing without
nursing; and difficult tedious labours. Or, lastly, Those
which induce a general laxity; as living much in warm
chambers, and drinking much of warm enervating li-
quors, such as tea and coffee.
DCCCCXLVI.
The effects of the menorrhagia are pointed out in
(DCCCCXXXVIII.—DCCCCXLI.) where we have
mentioned the several symptoms accompanying the dis-
ease, and from these the consequences to be apprehended
will also readily appear.
DCCCCXLVII.
The treatment and cure of the menorrhagia, must be
different according to the different causes of the disease.
In all cases, the first attention ought to be given to
avoiding the remote causes, whenever that can be done,
and by such attention the disease may be often entirely
cured.
When the remote causes cannot be avoided, or when
the avoiding them has been neglected, and a copious
menstruation has come on; it should be moderated as
much as possible, by abstaining from all exercise at the
coming on, or during the continuance of the men-
struation; by avoiding even an erect posture as much as
possible; by shunning external heat, and therefore warm
chambers and soft beds; by using a light and cool diet;
by taking cold drink, at least as far as former habits will
allow; by avoiding venery; by obviating costiveness,
or removing it by laxatives which give little stimulus. 
The sex are commonly negligent, either in avoiding
the remote causes, or in moderating the first beginnings
of this disease. It is by such neglect that it so fre-
quently becomes violent and of difficult cure; and the
frequent
X x 

346 PRACTICE
frequent repetition of a copious menstruation may be
considered as a cause of great laxity in the extreme
vessels of the uterus.
DCCCCXLVIII.
When the coming on of the menstruation has been
preceded by some disorder in other parts of the body,
and is accompanied with pains of the back, somewhat
like parturient pains, with febrile symptoms, and when,
at the same time, the flow seems to be copious, a bleeding
at the arm may be proper; but is not often necessary;
and it will in most cases be sufficient to employ, with
great attention and diligence, those means for moderating
the discharge which we have mentioned in the last pa-
ragraph.
DCCCCXLIX.
When the immoderate flow of the menses shall seem
to be owing to a laxity of the vessels of the uterus, as
may be concluded from the general debility and laxity
of the person's habit; from the remote causes that have
occasioned the disease; from the absence of the sym-
ptoms which denote increased action in the vessels of the
uterus; from the frequent recurrence of the disease;
and particularly from this, that the person in the in-
tervals of menstruation is liable to a leucorrhœa, in
such a case the disease is to be treated, not only by em-
ploying all the means mentioned in (DCCCCXLVII.)
for moderating the hemorrhagy, but also by avoiding
ail irritation, every irritation having the greater effect,
in proportion as the vessels are more lax and yielding.
If, in such a case of laxity, it shall appear that some
degree of irritation concurs, opiates may be employed
to moderate the discharge; but in using these much
caution is requisite.
If, notwithstanding these measures having been taken,
the discharge shall prove very large, astringents, both
external and internal, may be employed. In such cases,
may small doses of emetics be of service?
DCCCCL. 

OF PHYSIC. 347
DCCCCL.
When the menorrhagia depends on the laxity of the
uterine vessels, it will be proper, in the intervals of
menstruation, to employ tonic remedies; as cold bathing
and chalybeates. The exercises of gestation, also, may
be very useful, both for strengthening the whole system,
and for taking off the determination of the blood to the
internal parts.
DCCCCLI.
The remedies mentioned in these two last paragraphs,
may be employed in all eases of menorrhagia, from
whatever cause it may have proceded, if it shall have
already induced a considerable degree of debility in the
body.
CHAP. VII.
OF THE LEUCORRHEA, FLUOR
ALBUS, OR WHITES.
DCCCCLII.
Every serous or puriform discharge from the vagina
may be, and has been comprehended under the appel-
lations we have given to this chapter. Such discharges,
however, may be various, and may proceed from various
sources not yet well ascertained; but we confine our-
selves here to that alone which we judge proper for this
place, and that is, to treat of such discharges only, as
we 

348 PRACTICE
we presume to proceed from the same vessels which, in
their natural state, pour out the menses.
DCCCCLIII.
We conclude a discharge from the vagina to be of this
kind, 1. From its happening to women who are liable to
an immoderate flow of the menses, and who are liable to
this from causes weakening the vessels of the uterus. 2.
From its appearing chiefly, and often only a little before,
and immediately after, the flow of the menses. 3. From
the flow of the menses being diminished in proportion as
the leucorrhea is increased. 4. From the leucorrhea con-
tinuing after the menses have entirely ceased, and with
some appearance of the leucorrhea's observing a peri-
odical movement. 5. From the leucorrhea's being ac-
companied with the effects of the menorrhagia. (D-
CCCCXLIV.) 6. From the discharge's neither having
been preceded by, nor accompanied with, symptoms of any
topical affections of the uterus. 7. From the leucorrhea
not having appeared soon after communication with a
person who might be suspected of communicating in-
fection, and from the first appearance of the disease not
being accompanied with any inflammatory affection of
the pudenda.
DCCCCLIV.
The appearance of the matter discharged in the leu-
corrhea is very various in respect of consistence and co-
lour; but from these appearances it is not always possible
to determine concerning its nature, or the particular
source from which it proceeds.
DCCCCLV.
The leucorrhea, of which we are to treat, as ascer-
tained by the several circumstances (DCCCCLIII.)
proceeds from the same causes as the menorrhagia, that
is, from the laxity of the extreme vessels of the uterus.
This accordingly It often follows and accompanies; but,
though the leucorrhea depends chiefly upon the laxity
mentioned, 

OF PHYSIC. 349
mentioned, it may have proceeded from irritations in-
ducing that laxity, and it seems to be always increased
by any irritations applied to the uterus.
DCCCCLVI.
Some authors have alleged that a variety of circum-
stances in other parts of the body may have a share in
bringing on, and continuing the affection of the uterus
we treat of; but I cannot discover the reality of those.
causes, and it seems to me that the leucorrhea we treat
of, excepting so far as it depends upon a general debility
of the system, is always primarily an affection of the
uterus; and the affections of other parts of the body
which may chance to accompany that, are for the most
part to be considered as effects, rather than causes.
DCCCCLVII.
The effects of the leucorrhea are much the same with
those of the menorrhagia; inducing a general debility,
and, in particular, a debility in the functions of the
stomach. But, if the leucorrhea be moderate, and be
not accompanied with any considerable degree of the
menorrhagia, it may often last long without inducing
any great degree of debility, and it is only when the
discharge has been very copious as well as constant, that
its effects in that way are very remarkable.
DCCCCLVIII.
But, even when its effects on the whole body are not
very considerable, it may still be supposed to weaken
the genital system; and it seems sufficiently probable that
this discharge has often a share in occasioning barrenness.
DCCCCLIX.
The matter discharged in the leucorrhea is, at first,
generally mild; but, after some continuance of the dis-
ease, it sometimes becomes acrid, and by irritating, or
perhaps 

350 PRACTICE
perhaps eroding the surfaces over which it passes, in-
duces various painful disorders.
DCCCCLX.
As the leucorrhea proceeds from the same causes as
the menorrhagia, that is, chiefly from the laxity of the
uterine vessels; the former is to be treated and cured
very much in the same manner as the latter, and with
less reserve in respect of the use of astringents.
DCCCCLXI.
As the leucorrhea depends so often on a great loss of
tone in the vessels of the uterus, the disease has been
relieved, and sometimes cured, by certain stimulant
medicines, which are naturally directed to the urinary
passages, and from their vicinity are often communicated
to the uterus. Such are cantharides, turpentine, and
other balsams a-kin to it.
CHAP. VIII.
OF THE AMENORRHEA,
OR
INTERRUPTION OF THE MEN-
STRUAL FLUX.
DCCCCLXII.
Whatever may be the fittest place for the amenorrhea,
in a system of methodical nosology, it cannot be im-
proper 

OF PHYSIC. 351
proper to treat of it here as an object of practice, im-
mediately after treating of the menorrhagia.
DCCCCLXIII.
The interruption of the menstrual flux is to be con-
sidered as in two different states; the one is, when the
menses do not begin to flow at the period of life at
which they may be expected; and the other state is,
when, after they have taken place for some time, they
do, from other causes than conception, cease to return
at their usual periods. The former of these cases we
shall name the retention, and the latter the suppression of
the menses.
DCCCCLXIV.
All the flowing of the menses depends upon the
force of the uterine arteries impelling the blood into
their extremities, and opening these so as to pour out
red blood; so the interruption of the menstrual flux
must depend, either upon the want of due force in the
action of the uterine arteries, or upon some preter-
natural resistence in their extremities. The former we
suppose to be the most usual cause of retention, the latter
the most common cause of the suppression of the menses.
But of each of these now more particularly.
DCCCCLXV.
The retention of the menses, the emansio of Latin
writers, is not to be considered as a disease, merely from
the menses not flowing at the period which is usual with
many other women. This period is so different in dif-
ferent women, that no time can be precisely assigned
as proper to the sex in general. In this climate, the
menses usually appear about the age of fourteen; but
in many, they appear more early, and in many not till
the sixteenth year; and in the latter case, it is often
without any disorder being thereby occasioned. It is
not therefore from the age of the person that the re-
tention is to be considered as a disease; and indeed it
is 

352 PRACTICE
is to be considered as such, only when, about the time
the menses usually flow, some disorders arise which may
be imputed to the retention; being such as we know
from experience, when arising at the usual period, to
be removed by the flowing of the menses.
DCCCCLXVI.
These disorders are a sluggishness and frequent sense
of lassitude and debility, with various symptoms of
dyspepsia, and sometimes with a preternatural appetite.
At the same time the face loses its vivid colour, becomes
pale, and sometimes of a yellowish colour; the whole
body becomes pale and flaccid, and the feet, and per-
haps also a great part of the body, become affected with
œdematous swelling. The breathing is hurried by any
quick or laborious motion of the body, and the heart is
liable to palpitation and syncope. A head-ach some-
times occurs, but more certainly pains of the back,
loins, and haunches.
DCCCCLXVII.
These symptoms, when in a high degree, constitute
the Chlorosis of authors, hardly ever appearing separate
from the retention of the menses; and from the con-
sideration of these symptoms we are led to perceive the
cause of this retention.
These symptoms manifestly shew a considerable laxity
and flaccidity of the whole system, and lead us there-
fore to judge, that the retention of the menses accom-
panying them is owing to a weaker action of the vessels
of the uterus; which therefore do not impel the blood
into their extremities, with a force sufficient to open
these and pour out blood by them.
DCCCCLXVIII.
How it happens that at a certain period of life a flac-
cidity of the system arises in young women not origi-
nally affected with any such weakness or laxity, and of
which,

OF PHYSIC. 353
which, but a little time before, they gave no indication,
may be difficult to explain; but we attempt it in this
way.
As a certain state of the ovaria in females prepares
and disposes them to the exercise of venery about the
very period at which the menses first appear, it is pre-
sumed that the state of the ovaria and of the uterine
vessels are some how connected together; and as
generally symptoms of the former appear before those of
the latter, it may be presumed that the state of the ovaria
has a great share in exciting the action of the uterine
vessels, and producing the menstrual flux. But, ana-
logous to what happens in the male sex, it may be pre-
sumed that a certain state of the genitals in females, is
necessary to give tone and tension to the whole system
in them; and therefore that, if the stimulus arising from
the genitals is wanting, the whole system may fall into
a torpid and flaccid state, and from thence the chlorosis
and retention of menses may arise.
DCCCCLXIX.
We are of opinion, therefore, that the retention of
the menses is to be referred to a certain state or affection
of the ovaria; but what is precisely the nature of this
affection, or what are the causes of it, I will not pre-
tend to explain, nor can I explain in what manner
that primary cause of retention is to be removed. In
this case, therefore, as in many others, where we cannot
assign the proximate cause of diseases, our indications
of cure must be formed for obviating and removing the
morbid effects or symptoms which appear.
DCCCCLXX.
The effects, as we have said in (DCCCCLXVII.)
consist in a general flaccidity of the system, and there-
fore in a weaker action of the vessels of the uterus; and
these maybe considered as the more immediate cause of
the retention. This, therefore, is to be cured by re-
storing the tone of the system in general, and by ex-
citing the action of the uterine vessels in particular.
DCCCCLXXI.
Y y 

354 PRACTICE
DCCCCLXXI.
The tone of the system in general is to be restored by
exercise, and, in the beginning of the disease, by cold
bathing. At the same time, tonic medicines may be
employed, and, of these, the chalybeates have been
chiefly recommended.
DCCCCLXXII.
The action of the vessels of the uterus may be excited,
1st, By determining the blood into them more copi-
ously, and this by determining the blood into the de-
scending aorta; by purging; by the exercise of walking;
by friction; by warm bathing of the lower extremities;
and it is probable that the blood may be determined
more copiously into the hypogastric arteries which go to
the uterus, by a compression of the iliacs; but trials
made of this kind have seldom succeeded.
DCCCCLXXIII.
2dly, The action of the uterine vessels may be excited
by stimulants applied to them. Thus those purgatives
which particularly stimulate the intestinum rectum, may
also prove stimulant to the uterine vessels connected with
those of the rectum. The exercise of venery certainly
proves a stimulus to the vessels of the uterus, and there-
fore may be useful when it can be properly employed.
The various medicines recommended as stimulants of
the uterine vessels, under the title of emmenagogues,
have never appeared to me, to be effectual; and I cannot
perceive that any of them are possessed of a specific power
in this respect. Mercury, as an universal stimulant,
may act upon the uterus, but cannot be very safely em-
ployed in chlorotic persons. One of the most powerful
means of exciting the action of the vessels in every part
of the system is, the electrical shock, and it has often
been employed with success for exciting the vessels of
the uterus.
DCCCCLXXIV.

OF PHYSIC. 355
DCCCCLXXIV.
The remedies (DCCCCLXXI.-DCCCCLXXIII.)
now mentioned, are those adapted to the retention of the
menses; and we are next to consider the case of sup-
pression. In entering upon this, we must observe, that
every interruption of the flux, after it has once taken
place, is not to be considered as a case of suppression.
For the flux, upon its first appearance, is not imme-
diately established in its regular course; and therefore,
if an interruption happen soon after the first appearance,
or even in the course of the first or perhaps second year
after, it may often be considered as a case of retention,
especially when the disease appears with the symptoms
peculiar to retention.
DCCCCLXXV.
These which may be properly considered as cases of
suppression, are such as occur after the flux had been
for some time established in its regular course, and in
which the interruption cannot be referred to the causes
of retention (DCCCCLXVIL—DCCCCLXIX.)
but must be imputed to some resistence in the extreme
vessels of the uterus. Accordingly, we often find the
suppression induced by cold, fear, and other causes which
may produce a constriction of those extreme vessels.
Some physicians have supposed an obstructing lentor of
the fluids to occasion the resistence mentioned; but this
is purely hypothetical, without any proper evidence of
the fact which, from other considerations also, is im-
probable.
DCCCCLXXVI.
There are, indeed, some cases of suppression which
seem to depend upon a debility of the system in general,
and consequently of the vessels of the uterus. But in
such cases the suppression always appears as symptomatic
of other affections, and therefore not to be considered
here. 
DCCCCLXXVII.

356 PRACTICE
DCCCCLXXVII.
The idiopathic cases of suppression, (DCCCC-
LXXV.) are attended with various symptoms or disor-
ders in different parts of the body; very commonly
arising from the blood which should have passed by the
uterus, being determined more copiously into other
parts, and very often with such force as to produce
hæmorrhagy. Hence hæmorrhagies from the nose,
lungs, stomach, and other parts have appeared in con-
sequence of suppressed menses. Besides these, there are
commonly hysteric and dyspeptic symptoms produced by
the same cause, and frequently cholic pains, with a
bound belly.
DCCCCLXXVIII.
In those cases of suppression (DCCCCLXXV.) the
indication of cure is to remove the constriction affecting
the extreme vessels of the uterus; and for answering
this purpose, the chief remedy is warm bathing applied
to the region of the uterus. This, however, is not
always effectual, and I don't know of any other remedy
adapted to the indication. Besides this, we have, per-
haps, no other means of removing the constriction in
fault, but that of increasing the action and force of the
vessels of the uterus, so as thereby to overcome the re-
sistence or constriction of their extremities. This leads,
therefore, to employ the same remedies in the case of
suppression, as those prescribed above for the cases of
retention (DCCCCLXXL—DCCCCLXXIIL). The
tonics, however, and cold bathing (DCCCCLXXI.)
seem to be less properly adapted to the cases of sup-
pression, and have appeared to me of ambiguous effect.
DCCCCLXXIX.
It commonly happens in the eases of suppression, that
though the menses do not flow at their usual periods,
there are often, at those periods, some marks of an
effort having a tendency to produce the discharge. It is,
therefore, 

OF PHYSIC. 357
therefore, at those times especially when the efforts of
the system are concurring, that we ought to employ the
remedies for curing a suppression, and it is commonly
fruitless to employ them at other times, unless they be
such as require some continuance in the use to produce
their effects.
DCCCCLXXX.
Nearly a-kin to the eases of suppression, are those
cases in which the menses flow after longer intervals,
and in lesser quantity than usual; and when these cases
are attended with the disorders in the system, they are to
be cured by the same remedies as the cases of entire
suppression.
DCCCCLXXXI.
It may be proper in this place to take notice of the
dysmorrhea, or cases of menstruation in which the
menses seem to flow with difficulty, and are accompanied
with much pain in they back, loins, and lower belly.
We impute this disorder partly to some weaker action
of the vessels of the uterus, and partly, perhaps more
especially, to a spasm of its extreme vessels. We have
commonly found the disease relieved by employing some
of the remedies of suppression immediately before the
approach of the period, and at the same time employing
opiates.
BOOK

358 PRACTICE
BOOK V.
OF PROFLUVIA,
OR
FLUXES WITH PYREXIA.
DCCCCLXXXII.
FORMER nosologists have established a class of
diseases under the title of Fluxes, or Profluvia;
but, as in this class they have brought together a great
number of diseases which have nothing in common, but
the single circumstance of an increased discharge of
fluids, and are in other respects very different from one
another, we have avoided so improper an arrangement,
and have distributed most of the diseases comprehended
in that class by the nosologists into places more natural
for them. We have, indeed, still employed here the
general title; but we confine it to such fluxes only, as
are constantly attended with pyrexia, and which there-
fore necessarily belong to the class of diseases we are now
treating of.
Of the fluxes which may be considered as being very
constantly febrile diseases, there are only two, namely,
the catarrh and dysentery; and of these therefore we
now proceed to treat.
CHAP. 

OF PHYSIC. 359
CHAP. I.
OF THE CATARRH.
DCCCCLXXXIII.
The catarrh is an increased excretion of mucus from
the mucous membrane of the nose, fauces, and bron-
chiæ, attended with pyrexia.
Practical writers and nosologists, have distinguished
the disease by different appellations, according as it
happens to affect those different parts of the mucous
membrane; the one part more or less than the other;
but we are of opinion that the disease in those different
parts is always of the same nature, and proceeds from
the same cause in the one as in the other. Very com-
monly indeed those different parts are affected at the same
time; and therefore there is little room for the distinction
mentioned.
The disease has been frequently treated of under the
title of tussis, or cough; and a cough, indeed, always
attends the chief form of catarrh, that is, the increased
excretion from the bronchiæ; but it is so often also a
symptom of many other affections, which are very dif-
ferent from one another, that it is improperly used as a
generic title.
DCCCCLXXXIV.
The disease we are to treat of generally begins with
some difficulty of breathing through the nose, and with
a sense of some fullness stopping up that passage. This
again is often attended with some dull pain and a sense
of weight in the forehead, as well as some stiffness in
the motion of the eyes. These feelings, sometimes at
their very first beginning, and always soon after, are
attended with the distillation of a thin fluid from the
nose, and sometimes from the eyes, and these fluids are
often 

360 PRACTICE
often found to be somewhat acrid, both by their taste,
and by their fretting the parts over which they pass.
DCCCCLXXXV.
These symptoms constitute the coryza and gravedo of
authors, and are commonly attended with a sense of las-
situde over the whole body. Sometimes cold shiverings
are felt; at least the body is more sensible than usual to
the coldness of the air; and with all this the pulse is
more frequent than ordinary, especially in the evenings.
DCCCCLXXXVI.
These symptoms have seldom continued long before
they are accompanied with some hoarseness, and a sense
of roughness and soreness in the trachea, with some
difficulty of breathing, expressed by a sense of straitness
in the chest, and with a cough which seems to arise from
some irritation felt at the glottis. This cough is ge-
nerally at first dry and painful, occasioning pains about
the chest, and more especially in the breast; sometimes,
together with these symptoms, pains resembling those of
the rheumatism are felt in several parts of the body,
particularly about the neck and head. With all these
symptoms, the appetite is impaired; some thirst arises,
and a feverish lassitude is felt all over the body.
DCCCCLXXXVII.
These symptoms (DCCCCLXXXVI.) mark the
violence and height of the disease; but commonly it
does not continue long. By degrees the cough becomes
attended with a more copious excretion of mucus, which
is at first thin, but gradually becoming thicker, is
brought up with less frequent and less laborious
coughing. The hoarseness and soreness of the trachea
are also relieved or removed, and the febrile symptoms
abating, the expectoration becomes again less, and the
cough less frequent, till at length they cease altogether.
DCCCCLXXXVIII. 

OF PHYSIC. 361
DCCCCLXXXVIII.
Such is generally the course of this disease, neither
tedious nor dangerous; but it is sometimes in both
respects otherwise. The body affected with catarrh
seems to be more than usually liable to be affected by
cold air; and if the body affected with catarrh be ex-
posed to cold, the disease, which seemed to be yielding,
is often brought back with greater violence than be-
fore, and is rendered not only more tedious than other-
wise it would be, but also more dangerous, by the
supervening of other diseases.
DCCCCLXXXIX.
Some degree of the cynanche tonsillaris often ac-
companies the catarrh; and, when this is aggravated by
a fresh application of cold, the cynanche also becomes
more violent and dangerous, from the cough, which is
present at the same time.
DCCCCXC.
When a catarrh has been occasioned by a violent
cause, when it has been aggravated by improper ma-
nagement, and especially when it has been rendered
more violent by fresh and repeated applications of cold,
it often passes into a pneumonic inflammation, attended
with the utmost danger.
DCCCCXCI.
Unless, however, such accidents as those of (DCCCC-
LXXXVIII.—DCCCCXC.) happen, a catarrh, in
found persons not far advanced in life, is, I think, al-
ways a slight and safe disease. But in persons of a
phthisical disposition, a catarrh may readily produce a
hemoptysis, or perhaps form tubercles in the lungs;
and, more certainly in persons who have tubercles al-
ready formed in the lungs, an accidental catarrh may
occasion
Z z 

362 PRACTICE
occasion the inflammation of these tubercles, and, in
consequence, produce a phthisis pulmonalis.
DCCCCXCII.
In elderly persons, a catarrh sometimes proves a dan-
gerous disease. Many persons, as they advance in life,
and especially after they have arrived at old age, have
the natural mucus of the lungs poured out in greater
quantity, and requiring a frequent expectoration. If,
therefore, a catarrh happen to such persons, and in-
crease the afflux of fluids to the lungs, with some degree
of inflammation, it may produce the peripneumonia
notha, which in such cases is very often fatal. See
(CCCXLII.)
DCCCCXCIII.
The proximate cause of catarrh seems to be an in-
creased afflux of fluids to the mucous membrane of the
nose, fauces, and bronchiæ, along with some degree
of inflammation affecting the same. The latter circum-
stance is confirmed by this, that, in the case of catarrh,
the blood drawn from a vein commonly exhibits the same
inflammatory crust which appears in the case of phleg-
masiæ.
DCCCCXCIV.
The remote cause of catarrh is, most commonly, cold
applied to the body. This application of cold pro-
ducing catarrh is generally evident and observed; and, I
believe, it would always be so, were men acquainted
with, and attentive to, the circumstances which de-
termine cold to act upon the body. See XCI.)
From the same paragraph we may learn what in some
persons gives a predisposition to catarrh.
DCCCCXCV.
The application of cold, which occasions a catarrh,
probably operates by stopping the perspiration usually
made 

OF PHYSIC. 363
made by the skin, and which is therefore determined to
the mucous membrane of the parts above mentioned.
As a part of the weight which the body daily loses by
insensible evacuation, is owing to an exhalation from the
lungs, there is probably a connection between this ex-
halation and the cutaneous perspiration; so that the one
may be increased according as the other is diminished;
and therefore, we may understand how the diminution
of cutaneous perspiration by the application of cold,
may increase the afflux of fluids to the lungs, and
thereby produce a catarrh.
DCCCCXCVI.
There are some observations of Dr. James Keil which
may render this matter doubtful; but there is a fallacy
in those observations. The evident effects of cold in
producing coryza, leave the matter, in general, without
doubt; and there are several other observations which
shew a connection between the lungs and the surface of
the body.
DCCCCXCVII.
Whether from the suppression of perspiration, a
catarrh be produced merely by an increased afflux of
fluids, or whether further the matter of perspiration be
at the same time determined to the mucous glands, and
there excites a particular irritation, may be uncertain;
but the latter supposition is sufficiently probable.
DCCCCXCVIII.
Although, in the case of a common catarrh, which is
in many instances sporadic, it may be doubtful whether
any morbific matter be applied to the mucous glands;
we are, however, certain that the symptoms of a catarrh
do frequently depend upon such a matter being applied
to these. glands, as appears from the case of measles,
chincough, and especially from the frequent occurrence
of contagious and epidemical catarrh.
DCCCCXCIX.

364 PRACTICE
DCCCCXCIX.
The mention of this last leads me to observe, that
there are two species of catarrh, as we have marked
in our Synopsis of Nosology. One of these, as we
suppose, is produced by cold alone, as has been explained
above; and the other seems manifestly to be produced by
a specific contagion.
Of such contagious catarrhs we have pointed out in
the Synopsis many instances, occurring from the XIV th
century, down to the present day. Of all these, the
phenomena have been much the same; and the disease
has always been particularly remarkable for this, that
it has been the most widely and generally spreading epi-
demic known. It has seldom appeared in any one
country of Europe, without appearing successively in
every different part of it; and, in some instances, it has
been also transferred to America, and has been spread
there in like manner, so far as we have had opportunities
of being informed.
M.
The catarrh from contagion, appears with nearly the
same symptoms as those mentioned (DCCCCLXXXIV.
—DCCCCLXXXVII.). It seems often to come on
in consequence of the application of cold. It comes on
with more cold shivering, than the catarrh arising from
cold alone; and the former does also not only sooner
shew febrile symptoms, but to a more considerable degree.
Accordingly, it more speedily runs its course, which is
commonly finished in a few days. It sometimes ends
by a spontaneous sweat; and this, in some persons, pro-
duces a miliary eruption. It is, however, the febrile
state of this disease especially, that is finished in a few
days; for the cough, and other catarrhal symptoms, do
frequently continue longer; and often when they ap-
pear to be going off, they are renewed by any fresh ap-
plication of cold.
M. 

OF PHYSIC. 365
MI.
Considering the number of persons who are affected
with catarrh, of either the one species or the other,
and escape from it quickly without any hurt, it may be
allowed to be a disease very free from danger; but it is
not always to be treated as such, for in some persons it
is accompanied with pneumonic inflammation. In the
phthisically disposed, it often accelerates the coming on
of phthisis; and in elderly persons it often proves fatal
in the manner (DCCCCXCII.) we have explained
above.
MII.
The cure of catarrh is nearly the same, whether it
proceeds from cold or contagion; only in the latter case
remedies are commonly more necessary than in the former.
In the cases of a moderate disease, it is commonly
enough to avoid cold, or to abstain from animal food for
some days, or perhaps for the same time to lie a-bed,
and by taking frequently some mild and diluent drink,
a little warmed, to promote a very gentle sweat, and
after this to take care to return very gradually only, to
the use of the free air.
MIII.
When the disease is more violent, not only the anti-
phlogistic regimen, exactly observed, but various re-
medies also, become necessary.
To take off the phlogistic diathesis, which always
attends this disease, blood-letting, more or less, ac-
cording as the symptoms shall require, is the proper
remedy.
After blood-letting for restoring the determination of
the fluids to the surface of the  body, and, at the same
time, for expediting the secretion of mucus in the lungs,
which may take off the inflammation of its membrane,
vomiting is the most effectual means. 
For

366 PRACTICE
For the last mentioned purpose, it has been supposed
that squills, gum ammoniac, the volatile alkali, and
some other medicines, might be useful; but their efficacy
has never appeared to me to be considerable; and if
squills have ever been very useful, it seems to have been
rather by their emetic, than by their expectorant powers.
When the inflammatory affections of the lungs seem
to be considerable, it is proper, besides blood-letting,
to apply blisters to the back or sides.
As a cough is often the most troublesome circumstance
of this disease, so demulcents may be employed to al-
leviate it. See (CCCLIX.)
But after the inflammatory symptoms are much abated,
if the cough still remain, opiates afford the most effectual
means of relieving it; and, in the circumstances just
now mentioned, they may be very safely employed. See
(CCCLXI.)
After the inflammatory and febrile states of this dis-
ease are very much gone, the most effectual means of
discussing all remains of the catarrhal affection, is by
some exercise of gestation diligently employed.
CHAP.II.
OF THE DYSENTERY.
MIV.
The dysentery is a disease in which the patient has
frequent stools, accompanied with much griping, and
followed by a tenesmus. The stools, though frequent,
are generally in small quantity, and the matter voided is
chiefly mucus, sometimes mixed with blood. At the
same time, the natural fæces seldom appear, and, when
they do, it is generally in a compact and hardened form.
MV. 

OF PHYSIC. 367
MV.
This disease occurs especially in summer and autumn,
at the same time with autumnal, intermittent, and re-
mittent fevers; and with these it is often complicated.
MVI.
The disease comes on sometimes with cold shiverings,
and other symptoms of pyrexia; but more commonly the
symptoms of the topical affection appear first. The
belly is costive, with an unusual flatulence in the bowels.
Sometimes, though more rarely, some degree of di-
arrhœa is the first appearance. In most eases, the disease
begins with griping, and a frequent inclination to go to
stool. In indulging this, little is voided, but some te-
nesmus attends it. By degrees the stools become more
frequent, the griping more severe, and the tenesmus
more considerable. With these symptoms there is a loss
of appetite, and frequently sickness, nausea, and vo-
miting, also affecting the patient. At the same time
there is always more or less of pyrexia present. It is
sometimes of the remittent kind, and observes a tertian
period. Sometimes the pyrexia is manifestly inflam-
matory, and very often of a putrid kind. These febrile
states continue to accompany the disease during its whole
course, especially when it terminates soon in a fatal
manner. In other cases, the febrile state almost entirely
disappears, while the proper dysenteric symptoms remain
for a long time after.
MVII.
In the course of the disease, whether for a shorter or
a longer time, the matter voided by stool is very various.
Sometimes it is merely a mucous matter, without any
blood, exhibiting that disease which Dr. Rœderer has
named the morbus mucosus, and others the dysenteria
alba. For the most part, however, the mucus discharged,
is more or less mixed with blood. This sometimes ap-
pears only in streaks amongst the mucus, but at other
times 

368 PRACTICE
times is more copious, tinging the whole; and upon
some occasions a pure and unmixed blood is voided in
considerable quantity. In other respects the matter
voided is variously changed in colour and consistence,
and is commonly of a strong and unusually fœtid odour.
It is probable, that sometimes a genuine pus is voided,
and frequently a putrid sanies, proceeding from gan-
grenous parts. There are very often mixed with the
liquid matter, some films of a membranous appearance,
and frequently some small masses of a seemingly seba-
ceous matter.
MVIII.
While the stools voiding these various matters are,
in many instances, exceedingly frequent, it is seldom
that natural fæces appear in them, and when they do
appear, it is, as we have-said, in the form of scybala,
that is, in somewhat hardened, separate balls. When
these are voided, whether by the efforts of nature, or,
as solicited by art, they procure a remission of all the
symptoms, and more especially of the frequent stools,
griping, and tenesmus.
MIX.
Accompanied with these circumstances, the disease
proceeds for a longer or a shorter time. When the
pyrexia attending it is of a violent inflammatory kind,
and more especially when it is of a very putrid nature,
the disease often terminates fatally in a very few days,
with all the marks of a supervening gangrene. When
the febrile state is more moderate, or disappears alto-
gether, the disease is often protracted for weeks, and
even for months; but, even then, after a various du-
ration, it often terminates fatally, and generally in
consequence of a return and considerable aggravation of
the inflammatory and putrid states. In some eases, the
disease ceases spontaneously, the frequency of stools,
the griping, and tenesmus gradually diminishing, while
natural stools return. In other cases, the disease, with
moderate 

OF PHYSIC. 369
moderate symptoms, continues long, and ends in a
diarrhœa, sometimes accompanied with lienteric sym-
ptoms.
MX.
The remote causes of  this disease have been variously
judged of. It generally arises in summer or autumn,
after considerable heats have prevailed for some time,
and especially after very warm, and at the same time
very dry states of the weather; and the disease is much
more frequent in warm, than in cooler climates. It
happens, therefore, in the same circumstances and sea-
sons, which considerably affect the state of the bile in
the human body; but the cholera is often without any
dysenteric symptoms, and copious discharges of bile
have been found to relieve the symptoms of dysentery:
So that it is difficult, to determine what connection the
disease has with the state of the bile.
MXI.
It has been observed, that the effluvia from very pu-
trid animal substances readily affect the alimentary canal,
and, upon occasion, they certainly produce a diarrhœa;
but, whether they ever produce a genuine dysentery, I
have not learned with certainty.
MXII.
The dysentery dots often manifestly arise from the
application of cold, but the disease is always contagious;
and, by the propagation of such contagion, independent
of cold, or other exciting causes, it becomes epidemic
in camps and other places. It is, therefore, to be
doubted, if the application of cold ever produces the
disease, unless where the specific contagion has been pre-
viously received into the body: And, upon the whole,
it is probable that a specific contagion is to be considered
as always the remote cause of this disease.
MXIII.
A a a 

370 PRACTICE
MXIII.
Whether this contagion, like many others, be of a
permanent nature, and only shews its effects in certain
circumstances which render it active, or if it be occa-
sionally produced, we cannot determine. Neither, if
the latter supposition be received, can we say by what
means it may be generated. As little do we know any
thing of its nature, considered in itself; or at most,
only this, that, in common with many other contagions,
it is very often somewhat of a putrid nature, and capable
of inducing a putrescent tendency in the human body.
This, however, does not at all explain the peculiar
effect of inducing those symptoms which properly and
essentially constitute the disease of dysentery (MIV.)
MXIV.
Of these symptoms the proximate cause is still ob-
scure. The common opinion has been, that the disease
depends upon an acrid  matter thrown upon, or some-
how generated in the intestines, exciting their peristaltic
motion, and thereby producing the frequent stools which
occur in this disease. But this supposition cannot be
admitted; for, in all the instances known, of acrid
substances applied to the intestines, and producing fre-
quent stools, they at the same time produce copious
stools, as might be expected from acrid substances ap-
plied to any length of the intestines. This, however,
is not the case in dysentery, in which the stools, how-
ever frequent, are generally in very small quantity, and
such as may be supposed to proceed from the lower parts
of the rectum only. With respect to the superior por-
tions of the intestines, and particularly those of the
colon, it is probable they are under a preternatural and
considerable degree of constriction: For, as we have
said above, the natural fæces are seldom voided, and
when they are, it is in a form which gives reason to
suppose they have been long retained in the cells of the
colon, and consequently that the colon had been affected
with a preternatural constriction. This is confirmed by
almost 

OF PHYSIC. 371
almost all the dissections which have been made of the
bodies of dysenteric patients, in which, when gangrene
had not entirely destroyed the texture and form of the
parts, considerable portions of the great guts have been
found affected with a very considerable constriction.
MXV.
We judge, therefore, that the proximate cause of
dysentery, or at least the chief part of the proximate
cause, consists in a preternatural constriction of the colon,
occasioning, at the same time, those spasmodic efforts
which are felt in severe gripings, and which efforts pro-
pagated downwards to the rectum, occasion there the
frequent mucous stools and tenesmus. But, whether
this explanation shall be admitted or not, it will still
remain certain, that hardened fæces retained in the colon,
are the cause of the griping, frequent stools, and te-
nesmus; for the evacuation of these fæces, whether by
nature or by art, gives relief from the symptoms men-
tioned; and it will be more fully and usefully confirmed
by this, that the most immediate and successful cure of
dysentery is obtained by an early and constant attention
to the preventing the constriction, and the frequent stag-
nation of fæces in the colon.
MXVI.
We have thus endeavoured to ascertain the proximate
cause of dysentery, and therefore to point out also the
principal part of the cure, which, from want of the
proper view of the nature of the disease, seems to have
been, in several respects, fluctuating and undetermined
among practitioners.
MXVII.
The most eminent of our late practitioners, and of
greatest experience in this disease, seem to be of opinion,
that the disease is to be cured most effectually by purging,
assiduously employed. The means may be various;
but the most gentle laxatives are usually sufficient; and,
as 

372 PRACTICE
as the medicine must be frequently repeated, these are
the most safe; the more especially as an inflammatory
state so frequently accompanies the disease. Whatever
laxatives produce an evacuation of natural fæces, and
a consequent remission of the symptoms, will be sufficient
to effectuate the cure. But, if the gentle laxatives shall
not produce the evacuation now mentioned, somewhat
more powerful must be employed; and we have found
nothing more proper or convenient than tartar emetic,
given in small doses, and at such intervals as may de-
termine their operation to be chiefly by stool. Rhubarb,
so frequently employed, is, in several respects, amongst
the most unfit purgatives.
MXVIII.
Vomiting has been held a principal remedy in this
disease, and may be usefully employed in the beginning
of the disease, with a view to both the state of the sto-
mach, and of the fever; but it is not necessary to repeat
it often; and, unless the emetics employed operate also
by stool, they are of little service. Ipecacuanha is by
no means a specific; and it proves only useful, when so
managed as to operate chiefly by stool.
MXIX.
For relieving the constriction of the colon, and eva-
cuating the retained fæces, clysters may sometimes be
useful, but they are seldom so effectual as laxatives,
given by the mouth; and acrid clysters, if they be not
effectual in evacuating the colon, may prove hurtful by
stimulating the rectum too much.
MXX.
The frequent and severe griping attending this disease,
leads almost necessarily to the use of opiates, and they
are very effectual for the purpose of relieving from the
gripes; but, by occasioning an interruption of the
action of the small guts, they favour the constriction of
the colon, and thereby aggravate the disease; and if, at
the 

OF PHYSIC. 373
the same time, the use of them supersede in any mea-
sure the employing purgatives, it is doing much mis-
chief; and we believe it to be only the neglect of purging
that renders the use of opiates very necessary.
MXXI.
When the gripes are both frequent and severe, they
may sometimes be relieved by the employment of semi-
cupium, or by a fomentation of the abdomen, continued
for some time. In the same case, the pains may be re-
lieved, and, as I think, the constriction of the colon
may be taken off, by blisters applied to the lower belly.
MXXII.
At the beginning of this disease, when the fever is
any way considerable, blood-letting, in patients of
tolerable vigour, may be proper and necessary; and,
when the pulse is full and hard, with other symptoms
of an inflammatory disposition, blood-letting ought to
be repeated. But, as the fever attending dysentery is
often of a putrid kind, or does, in the course of the
disease, become soon of that nature, blood-letting must
be cautiously employed.
MXXIII.
From our account of the nature of this disease, it
will be sufficiently obvious, that the use of astringents,
in the beginning of it, must be absolutely pernicious.
MXXIV.
Whether an acrid matter be the original cause of this
disease, may be uncertain; but, from the indigestion
and the stagnation of fluids which attend the disease, we
may suppose that some acrid matters are constantly pre-
sent in the stomach and intestines, and therefore that
demulcents may be always usefully employed. At the
same time, from this consideration that mild oily matters
thrown into the intestines in considerable quantity,
always 

374 PRACTICE
always prove laxative, we are of opinion that the olea-
ginous demulcents are the most useful.
MXXV.
As this disease is so often of an inflammatory, or of
a putrid nature, it is evident, that the diet employed
in it should, be vegetable and acescent. Milk, in its
entire state, is of doubtful quality in many cases; but
some portion of the cream is often allowable, and whey
is always proper.
In the first stages of the disease, the sweet and subacid
fruits are allowable, and even proper. It is in the more
advanced stages only that any morbid acidity seems to
prevail in the stomach, and to require some reserve in
the use of acescents. At the beginning of the disease,
absorbents seem to be superfluous; and, by their astrin-
gent and septic powers, they may be hurtful.
MXXVI.
When this disease is complicated with an intermittent
fever, and is protracted from that circumstance chiefly,
it is to be treated as an intermittent, by administering
the Peruvian bark, which, in the earlier periods of the
disease, is hardly to be admitted. 

INDEX.
N.B. The Cyphers refer to the Numbers of the Paragraphs.
A.
ABSCESS, what 245
ABSCESSES AND ULCERS, the causes of their different
states 249
ACIDS, employed in fever 128
ACTION, of the heart and arteries, how increased for
preventing the recurrence of the paroxysms
of intermittent fever 252
AMENORRHEA, by retention 962—965
when occurring 965
the causes of it 967—969
the symptoms of it 966
the cure of it 970—973
by suppression 963
when occurring 975
the symptoms of it 977
the cure of it 978—979
ST. ANTHONY'S FIRE. See Erysipelas.
ANTIMONIAL EMETICS, their different kinds 176—177
employed in fevers 175
the administration of them
in fevers 178—180
ANTIPHLOGISTIC REGIMEN, what 123
when employed in in-
termittent fevers 229
ANTISPASMODICS, employed in fevers 146—181
APHATHA 695
APOPLEXY, one cause of it 735
APYREXIA, what 24
ASTRINGENTS, employed alone in intermittent fevers 226
joined with aromatics, employed in
intermittent fevers 226
joined with bitters, employed in in-
termittent fevers 226
ATONY, of the extreme vessels in fever. See Fever.
B.
BITTERS, employed alone in intermittent fevers 226
joined with astringents, employed in inter-
mittent fevers 226 

376 INDEX.
BLISTERING, its effects 183-187
its use in fevers 188
when to be employed in fevers 189
where to be employed in fevers 190
BLOOD, the appearance of it in inflammation 232
BLOOD LETTING, the employment of it in fevers 133
the circumstances directing its use
in fevers 136
the administration of it 137
when employed in intermittent
fevers 229
C.
407
CALCULUS RENALIS 407
CALX NITRATA ANTIMONII, its use in fevers 177
CARDITIS, the acute 362
the chronic kind 362
CATARRH 983
the predisposition to it 994 
the remote causes of it 994                     
how occasioned by cold 995
the proximate cause of it 993
the symptoms of it 984-987
the mucus coughed up in it, how distin-
guished from pus 818
accompanied with cynanche tonsillaris 989
produces a phthisis pulmonalis 991
passes into pneumonia 990
produces a peripneumonia notha 992
the cure of it 1002—1003
CONTAGIOUS 999
the symptoms of it 1000
CHICKEN-POX 642
CHLOROSIS 967
COLD, its operations 89
the application of it as a sedative in fevers 127
its tonic power, how to be employed in fevers 199
drink, an useful tonic in fevers 200
the limitations of its use in fevers 201
air, applied in fevers 202
water, applied to the surface of the body in
fevers 199                       
CONSUMPTIONS OF THE LUNGS, vide phthisis pul-
monalis.
CONTAGIONS 83
CORYZA 984 

INDEX. 377
COUGH. See Catarrh.
CRITICAL DAYS 101-105
CYNANCHE 273
TONSILLARIS 294
the cure of it 298—302
MALIGNA 303
the symptoms of it 303—308
the cure of it 309
TRACHEALIS 310
as described by former wri-
ters 310—313
as affecting infants 315-321
as affecting infants, the cure
of it 322
PHARYNGEA 323
PAROTIDEA 324
CYSTITIS 409
D
DAY CRITICAL, in fevers 101—105
non critical 107
DEATH, the causes of it in general 95
the direct causes of it 88
the indirect causes of it 95                 
the causes of it in fever. See Fever.
the tendency to it, how discovered 96
DEBILITY IN FEVER, the symptoms of it 98
DELIRIUM, of two kinds 45
the cause of it in fever. See Fever.
DIET, a full one useful in intermittent fevers 226
DILUENTS, their use in fevers 148
DISEASES, the distinguishing of them, how attained 2
the prevention of them, on what founded 3
the cure of them, on what founded 4
febrile. See febrile diseases.
DYSENTERY 1004
the character of it 1004
the remote causes of it 1010-1012
the proximate cause of it 1014—1015
the symptoms of it 1006—1009
the cure of it 1017—1026
DYSMENORRHEA 980
E
EFFLUVIA, human 85
from marshes 82
EMANSIO MENSIUM 964
Bbb 

378 INDEX.
EMETICS, suited to the cure of fevers 168
which kind employed in fevers 165—175
the administration of them in fevers 169
their use in intermittent fevers 225—228
EMETIC TARTAR, its use in fevers 177
EMPIRICISM, the state of it 4
ENTERITIS, phlegmonic, or erysipelatous 383
the causes of it 385
EPIPLOITIS 363
EPISTAXIS 769
the causes of it 719
the various circumstances of it 769—781
the management and cure of it 782—792
ERUPTIVE FEVERS. See Exanthemata.
ERYSIPELAS 269—550
of the face 552
phlegmonodes, in different parts of the
body 561—566
attending putrid fever 567
ERYTHEMA 269—270
EXANTHEMATA 548
EXERCISE, useful in intermittent fevers 226
F.
FEAR, a remote cause of fever 92
FEBRILE DISEASE. See Pyrexiæ.
FEVER 8
bilious 73
continent 28
continued 27
eruptive. See Exanthemata.
hectic. See Hectic.
inflammatory 69
intermittent 24
miliary. See Miliary Fever.
nervous 69
putrid 74
remittent 26, 27
scarlet. See Scarlet Fever.
named synocha 69
synochus 71
typhus 69
vesicular. See Vesicular Fever.
strictly so called, the character of it 8
the phenomena of it 8-31
an exacerbation in it, what 27
an intermission in it, what 24

INDEX. 379
FEVER
a remission in it, what 26
the remote cause of it 78
the proximate cause of it 32—46
the cold stage of it, the cause of the hot 33
the symptoms of debility in it 34
atony of the extreme vessels in it 42, 43
the spasm of the extreme vessels occurring in it 39
the cause of delirium in it 44
the differences of it 53
the prognosis in it 94
the causes of death in it 95
continued, strictly so called, the character of it 66
the cure of it 119
intermittent, in a continued form, how distin-
guished 66
the paroxysms of it described 10
the cold stage of it 11
the hot stage of  it 11
the sweating stage of it 11
an interval of it, what 24
of a quotidian period 25
of a tertian period 25
of a quartan period 25
the cure of it 223
attended with congestion in the ab-
dominal viscera 229
attended with phlogistic diathesis 229
epidemic, when arising 93
FLUOR ALBUS. See Leucorrhea
FLUXES, with pyrexiæ. See Profluvia
FOMITES of contagion, what 86
G.
GANGRENE of inflamed parts, the causes of it 250, 251
marks of the tendency to it 252
marks of its having come on 252
GASTRITIS 363
phlegmonic, or erysipelatous 363
the seat of it 364
the causes of it, external and
internal 366
the terminations of it 367
the cure of it 372-376
erysipelatous, the seat of it 364
how discovered 379
the cure of it 380

380 INDEX.
GOUT 455
the character of it 455
the regular 481
the paroxysms of it described 469—474
the predisponent cause of it 464
the occasional causes of it 465-468
the proximate cause of it 490
a hereditary disease 456
not depending upon a morbific matter 492
a disease of the whole system 493
an affection of the nervous system 494
an affection of the stomach 495
pathology of the regular 496
how distinguished from rheumatism 489
the irregular 481
the atonic described 483
the pathology of it 497
the cure of it 537-542
the retrocedent described 485
the pathology of it 498
the cure of it 543—545
the misplaced described 842, 846
the pathology of it 499
the cure of it 546
translated, two particular eases of it 488
regular, the cure of it 500
no effectual or safe medicine yet found for the
cure of it 502
the medicines which have been employed for it 519
whether it can be radically cured 503
the treatment of it in the intervals of paroxysms 505
in the time of the paroxysms 524-533
the management of diet in it 511-515
the management of exercise in it 507-510
the use of blood-letting in the paroxysms of it 522
costiveness hurtful in it 522
the laxatives to be employed in it 522
the use of opiates in it 533
the effects of alcalines in it 521
the effects of the Portland powder in it 520
external applications, how far safe in it 532
the use of emollient applications in it 527
the use of moxa in it 530
the use of blistering in it 528
the use of rubefacients in it 529
the use of camphire and aromatic oils in it 531
GRAVEDO 984 

INDEX. 381
H.
HECTIC FEVER described 820-822
explanation of the symptoms of it 824
HÆMOPTYSIS 793
how distinguished from other spittings of
blood 804-808
the causes of it 723-727 & 794-799
the symptoms of it 800—803
the cure of it 809-814
HÆMORRHAGY 697
active or passive 697
the character of it 698
arterial 706
venous 731
the causes of the different species, ap-
pearing at different periods of life 712-736
in general, the phenomena of it 700
the remote causes of it 737, 738
the proximate cause of it 706
the cure of it 739
the cure of it, whether to be
attempted by art 739-744
the recurrence of it, how to be pre-  
vented 745-752
when present, how to be treated 752—767
of the brain 735
of the lungs. See Hæmoptysis.
of the nose. See Epistaxis.
HÆMORRHOIS 892
the phenomena of it 892-901
the cause of it 902-913
the cure of it 914-932
if to be cured by art 914, 915
ow to be treated, according to its
different circumstances 916
HÆMORRHOIDAL SWELLING and FLUX. See Hæ-
morrhois.
HEPATITIS 390
acute and chronic 390
the seat of it 396
the symptoms of it 391, 393
combined with pneumonic inflam-
mation 394
the cure of it 401
the various exit of pus produced in it 399
chronic, the seat of it 396
HUMAN EFFLUVIA. See Effluvia. 

382 INDEX.
I. 
ILEUS 388
INFLAMMATION 230
the phenomena of it 230
internal, the marks of it 231
the state of the blood in it 232
the remote cause of it 257
the proximate cause of it 234
not depending upon obstruction 236
a lentor of the
blood 236
terminated by resolution 244
suppuration 245
gangrene 250
schirrus 253
effusion 254
blisters 255
exsudation 256
the cure of it in general 259
by resolution 259
when tending to suppu-
ration 263
when tending to gan-
grene 266
of the bladder. See Cystitis.
brain. See Phrenitis.
more strictly cutaneous 269
of the eye. See Ophthalmia.
heart. See Carditis.
intestines. See Enteritis.
kidneys, See Nephritis.
liver. See Hepatitis.
the lungs. See Pneumonia.
mesentery. See Mesenteritis.
omentum. See Omentitis.
pericardium. See Pericarditis.
peritonæum. See Peritonitis.
pleura. See Pneumonia.
spleen. See Splenitis.
stomach. See Gastritis.
uterus 410
INTEMPERANCE IN DRINKING, a remote cause of
fever 92
INTERVAL, what. See Fever Intermittent.
IPECACUANHA, employed in fevers 175
not specific in dysentery 1018
ISCHIAS 430 

INDEX. 383
L.
LEUCORRHOEA, what properly such 952, 953
the cause of it 955
the cure of it 960, 961
LUMBAGO 430, 431
M.
MARCH EFFLUVIA. See Effluvia.
MEASLES, the nature of them 655
the symptoms of them 647-653
the cure of them 656, 661
of a putrid kind 654
MEDICINE, the institutions of 4
MELÆNA 734
MENORRHAGIA 933
when a disease 934, 935, & 939-943
how distinguished from the hæ-
morrhagia uteri 936
the remote causes of it 945
the proximate cause of it 944
the treatment and cure of it 947-951
MENSES, difficult. See Dysmenorrhea.
diminished. See Amenorrhea.
immoderate flow of them. See Menorrhagia.
interruption of them. See Amenorrhea.
retained. See Amenorrhea.
suppressed. See Amenorrhea.
MESENTERITIS 363
METALLIC TONICS, employed in intermittent fevers 22
MIASMATA, what 81, 82
MILIARY FEVER, of two kinds, red and white 678
white, the symptoms of it 677-681
the common history of it 676
if an idiopathic disease
683-687
as a symptomatic affection,
how produced 688
the treatment of it, as a
symptomatic affection
689-691
the cure of it 682
MORBUS NIGER 734
N.
NATURÆ VIS MEDICATRIX 37
NEPHRALGIA CALCULOSA 547
NEPHRITIS 404
the symptoms of it 404
the cure of it 408

384 INDEX.
NETTLE RASH. See Urticaria.
NEUTRAL SALTS, refrigerant in fevers 129
diaphoretic in fevers 154
NOSOLOGY, methodical, what 2
O.
OBSTIPITAS CATARRHALIS 431
OMENTITIS 363
OPHTHALMIA 272
membranarum 272, 273
its different degrees
273, 274
the cure of it, 276-280
tarsi 272-281
the cure of it 281-283
OPIATES, employed in the hot stage of intermittent
fevers 228
in the intervals of intermittent
fevers 226
P.
PAROXYSM of intermittent fevers described 10
the recurrence, how
to be prevented 224
PEMPHIGUS. See Vesicular fever.
PERICARDITIS 362
PERIPNEUMONY 334
PERIPNEUMONIA NOTHA 342
PERITONITIS 363
PERUVIAN BARK, whether a specific 207
a tonic medicine, useful in fevers 20
in what eases of fever proper 209
how most effectually employed 210
the tonic, chiefly employed in in-
termittent fevers 227
the administration of it in inter-
mittent fevers 227
PETECHIA 696
PHYSIC, the institutions of 4                      
the practice of it, how taught 1            
PHLEGMA 230
PHLEGMON 269
PHRENITIS 284
PHRENSY 284
the character of it 286
the remote causes of it 287
the cure of it 288-292

INDEX. 385
PHTHISIS PULMONALIS, the general character of it 815
always with an ulceration of
the lungs 817
the pus coughed up in it,
how distinguished from
mucus 818
the various causes of it 825
arising from Hæmoptysis 826
arising from an abscess of the
lungs, in consequence of
pneumonia 835, 836
arising from a catarrh 837, 839
how it may arise from an
acrimony of the fluids 841
arising from asthma 842
arising from tubercles 843, 844
from tubercles, what symptoms
it comes on with 856—862
the prognosis in it 864, 865
its different duration 863
if contagious 853
the cure of it 866-891
the treatment of it, when
arising from tubercles 872-888
the palliation of symptoms
of it 889-891
PLAGUE, the general character of it 568
the phænomena of it 568
the principal symptoms of it 570
the proximate cause of it 571
the prevention of it 573
the cure of it 589-598
PLEURISY 333
PLEURITAS SUPURIA 431
PLEURODYNE plethorica 431
rheumatica 431
PNEUMONIA, or pneumonic inflammation 326
the seat of it 332-336
the symptoms of it 327
the terminations of it 338-343
the remote causes of it 337
the prognosis in it 333-336
the cure of it 347
the management of blood-letting in the
cure of it 348-353
the use of purgatives in it 356
C c c

386 INDEX.
PNEUMONIA
the use of emetics in it 357
the use of sweating in it 360
fomentations and poultices, inconvenient
in the cure of it 358
the use of blisters in it 358
the means of promoting expectoration in it 359
the use of opiates in it 361
PODAGRA 450
PORTLAND POWDER, the effects of it 520
PROFLUVIA 982
PURGING, its use in continued fevers 139
its use in intermittent fevers 229
PUS, how produced 245
PUTRESCENCY OF THE FLUIDS in fever, the sym-
ptoms of it 99
the tendency to it, how to be corrected 216
PYREXIÆ, the character of the class 6
the orders of the class 7
Q.
QUINSY. See Cynanche.
R.
REACTION OF THE SYSTEMS, what 53
violent, symptoms of it 97
REFRIGERANTS, the use of them in fevers 128
REMEDIES, table of those employed in continued
fevers 222
REMISSION, what. See Fever.
RESOLUTIONS OF THE INFLAMMATION, how produced 244
RHEUMATISM, acute or chronic 411
acute, the predisposition to it 413-416
the remote causes of it 414
its proximate cause 433-438
the symptoms of it 417-427
the cure of it 440-449
chronic, the symptoms of it 427-430
the proximate cause of it 450
how distinguished from the
acute 429
the cure of it 451-454
RHEUMATIC PAINS, distinguished from those of scurvy 432
distinguished from those of syphilis 432
RHEUMATISM, how distinguished from gout 489
RUBEFACIENTS, the effects of them 191

INDEX. 387
S.
SCARLET FEVER, the symptoms of it 667
different from Cynanche Maligna
663-666
the cure of it 668-675
SCIATICA 430
SEDATIVE POWDERS, the remote causes of fever 92
SINAPISMS, the effects of them 191
SMALL-POX, general character of the disease 599
symptoms of the distinct kind 601
symptoms of the confluent 602
distinct and confluent, how in general
they differ 603
the causes of its difference 606-611
prognosis in it 604
the cure of it 613-641
the inoculation of it 614
inoculation, the several practices of which
it consists 614
inoculation, of the importance of the se-
veral practices belonging to it 616-626
the management of it received by in-
fection 627-641
SPASM, of the extreme vessels in fever. See Fever.
SPASMS induce rheumatic affections 431
SPHACELUS 250
SPLENITIS 403
STRAINS, how related to rheumatism 431
STIMULANTS, when to be employed in fevers 211
SUDORIFICS, arguments for their use in fevers 157-161
arguments against their use in fevers 158
SUPPURATIONS of inflamed parts, the causes of it 245
the marks of the tendency to it 246
formed, the marks of it 246
SWEATING, when hurtful in continued fevers 159
the use of it in intermittent fevers 215
the administration of it in continued
fevers 162, 163
SYNOCHA. See Fever.
SYNOCHUS. See Fever.
T.
THRUSH. See Aphtha.
TONIC MEDICINES, employed in continued fevers 205
employed in intermittent fevers 226
remedies necessary in continued
fevers 198

388 INDEX.
TOOTHACH, a rheumatic affection 433
TORTICOLIS 431
TUBERCLES of the lungs, at what period of life they
are especially formed 854
in what persons especially arising 855
TUSSIS. See Catarrh.
TYPHUS. See Fever.
the species of it 72
U.
VENERY, excess in it a remote cause of fever 92
VESICULAR FEVER 694
VIS MEDICATRIX NATURÆ. See Naturæ.
VOMITING, the effects of it 166-167
the use of it in intermittent fevers 229
See Emetics.
URTICARIA, the history and treatment of it 693
WARM-BATHING, the effects of it in fevers 229
the administration of it in fevers 193
the marks of its good effects 194
WHITES. See Leucorrhœa.
WINE, the most proper stimulant in fevers 212
its convenient use in fevers 213
when hurtful or useful in fevers 214
THE END.