FIRST LINES OF THE PRACTICE OF PHYSIC. BY WILLIAM CULLEN, M. D. Professor of the Practice of Physic in the University of Edinburgh; First Physician to his Britannic Majesty for Scotland; Fellow of the Royal College of Physicians of Edinburgh; Of the Royal Societies of London and of Edinburgh, Of the Royal Society of Medicine of Paris, &c. &c. &c. A NEW EDITION. From the Last BRITISH EDITION, REVISED, CORRECTED and ENLARGED, by the AUTHOR. IN THREE VOLUMES. VOL. III. PRINTED at WORCESTER, MASSACHUSETTS, BY ISAIAH THOMAS. Sold at his BOOKSTORE in WORCESTER, and by him and COMPANY in BOSTON. MDCCXC. CONTENTS OF VOL. III. PART II. BOOK III. Page OF SPASMODIC AF- FECTIONS, without FEVER 9 SECT. I. Of the SPASMODIC AFFECTIONS of the ANIMAL FUNCTIONS - 11 Chap. I. Of Tetanus - 13 Chap. II. Of Epilepsy - 33 Chap. III. Of the Chorea, or Dance of St. Vitus - 66 SECT. II. Of the SPASMODIC AFFECTIONS of the VITAL FUNCTIONS - 70 Chap. iv CONTENTS. Page Chap. IV. * Of the Palpitation of the Heart - 70 Chap. V. Of Dyspnœa, or Difficult Breathing - 75 Chap. VI. Of Asthma - 79 Chap. VII. Of the Chincough, or Hoopingcough - 94 SECT. III. Of the SPASMODIC AFFECTIONS in the NATURAL FUNCTIONS - 109 Chap. VIII. Of the Pyrosis, or what is named in Scotland the Water Brash 109 Chap. IX. Of the Colic - 114 Chap. X. Of the Cholera - 126 Chap. XI. Of Diarrhœa, or Loose- ness - 132 Chap. * Though I have thought it proper to divide this book into sections, I think it necessary, for the convenience of references, to number the chapters from the beginning. v CONTENTS. Page Chap. XII. Of the Diabetes - 153 Chap. XIII. Of the Hysteria, or the Hysteric Disease - 160 Chap. XIV. Of Canine Madness and Hydrophobia - 168 BOOK IV. OF VESANIÆ, OR OF THE DISOR- DERS OF THE INTELLECTUAL FUNCTIONS - 171 CHAP. I. Of VESANIÆ in general - 171 CHAP. II. Of MANIA, or Madness - 192 CHAP. III. Of MELANCHOLY, and other forms of Insanity - 208 A2 PART vi CONTENTS. Page PART III. OF CACHEXIES - 221 BOOK I. OF EMACIATIONS - 223 BOOK II. OF INTUMESCENTIÆ, OR GEN- ERAL SWELLINGS - 239 CHAP. I. Of ADIPOSE SWELLINGS - 241 CHAP. II. Of FLATULENT SWELLINGS - 246 CHAP. III. Of WATERY SWELLINGS, or DROP- SIES - 260 Sect. I. Of Anasarca - 277 Sect. vii CONTENTS. Page Sect. II. Of the Hydrothorax, or Drop- sy of the Breast - 296 Sect. III. Of Ascites, or Dropsy of the Lower Belly - 304 CHAP. IV. Of GENERAL SWELLINGS, arising from an increased BULK of the whole SUB- STANCE of particular PARTS - 311 Of Rachitis, or Rickets - 312 BOOK III. OF THE IMPETIGINIS, OR DEPRAV- ED HABIT WITH AFFECTIONS OF THE SKIN - 328 CHAP. I. Of SCROPHULA, or the KING'S EVIL 329 CHAP. II. Of SIPHYLIS, or the VENEREAL DIS- EASE - 344 CHAP. viii CONTENTS. Page CHAP. III. Of SCURVY - 363 CHAP. IV. Of JAUNDICE - 378 FIRST FIRST LINES OF THE PRACTICE OF PHYSIC. PART II. BOOK III. OF SPASMODIC AFFECTIONS, WITHOUT FEVER. MCCLI. UNDER this title I am to comprehend all the diseases which consist in motu ab- normi; that is, in a preter- natural state of the contrac- tion and motion of the mus- cular or moving fibres in any part of the body. MCCLII. 10 PRACTICE MCCLII. It will hence appear, why, under this title, I have comprehended many more diseases than Sauvages and Sagar have comprehended under the title of Spasmi, or than Linnæus has done under the title of Motorii. But I ex- pect it will be obvious, that, upon this occa- sion, it would not be proper to confine our view to the affections of voluntary motion only; and if those Nosologists have introduced into the class of Spasmi, Palpitation and Hysteria, it will be with equal propriety that Asthma, Col- ica, and many other diseases, are admitted. MCCLIII. It has been hitherto the method of our No- sologists to divide the Spasmi into the two orders of Tonici and Clonici, Spastici and Agitatorii; or, as many at present use the terms, into Spasms strictly so called, and Convulsions. I find, however, that many, and indeed most of the diseases to be consid- ered under our title of Spasmodic Affections, in respect of Tonic or Clonic contractions, are of a mixed kind: And, therefore, I can- not follow the usual general division; but have attempted another, by arranging the several Spasmodic Diseases according as they affect the several functions, Animal, Vital, or Natural. SECT. 11 OF PHYSIC. SECT. I. OF THE SPASMODIC AFFECTIONS OF THE ANIMAL FUNCTIONS. MCCLIV. AGREEABLE to the lan- guage of the ancients, the whole of the dis- eases to be treated of in this section might be termed Spasmi; and many of the moderns continue to apply the term in the same man- ner: But I think it convenient to distinguish the terms of Spasm and Convulsion, by apply- ing the former, strictly to what has been call- ed the Tonic; and the latter, to what has been called the Clonic Spasm. There is cer- tainly a foundation for the use of those dif- ferent terms, as there is a remarkable differ- ence in the state of the contraction of moving fibres upon different occasions. This I have indeed pointed out before in my treatise of Physiology, but must also repeat it here. MCCLV. In the exercise of the several functions of the animal economy, the contractions of the moving fibres are excited by the will, or by certain other causes specially appointed by nature for exciting those contractions; and these 12 PRACTICE these other causes I name the natural causes. In a state of health, the moving fibres are contracted by the power of the will, and by the natural causes only. At the same time the contractions produced are in force and velocity regulated by the will, or by the cir- cumstances of the natural causes; and the contractions, whether produced by the one or the other, are always soon succeeded by a state of relaxation, and are not repeated but when the power of the will or of the natural causes are again applied. MCCLVI. Such are the conditions of the action of the moving fibres in a state of health; but in a morbid state, the contractions of the muscles and moving fibres ordinarily depending upon the will are excited without the concurrence of the will, or contrary to what the will in- tends; and in the other functions they are excited by the action of unusual and unnat- ural causes. In both cases, the contractions produced may be in two different states. The one is, when the contractions are to a more violent degree than is usual in health, and are neither succeeded by a spontaneous relaxation, nor even readily yield to an ex- tension either from the action of antagonist muscles, or from other extending powers ap- plied. This state of contractions is what has been called a Tonic Spasm, and is what I shall name simply and strictly a Spasm. The OF PHYSIC. 13 The other morbid state of contraction is, when they are succeeded by a relaxation, but are immediately again repeated without the concurrence of the will or of the repetition of natural causes, and are at the same time com- monly, with respect to velocity and force, more violent than in a healthy state. This state of morbid contraction is what has been named a Clonic Spasm, and what I shall name simply and strictly a Convulsion. In this section I shall follow nearly the usual division of the spasmodic diseases into those consisting in Spasm, and those consisting in Convulsion; but it may not perhaps be in my power to follow such division exactly. CHAP. I. Of TETANUS. MCCLVII. BOTH Nosologists and Practical Writers have distinguished Tetanic complaints into the several species of Tetanus, Opistho- tonos, and Emprosthotonus; and I have in my Nosology put the Trismus, or Locked Jaw, as a genus distinct from the Tetanus. VOL. III. B All 14 PRACTICE All this, however, I now judge to be im- proper; and am of opinion, that all the several terms mentioned, denote, and are applicable only to, different degrees of one and the same disease; the history and cure of which I shall endeavour to deliver in this chapter. MCCLVIII. Tetanic complaints may, from certain caus- es, occur in every climate that we are ac- quainted with; but they occur most fre- quently in the warmest climates, and most commonly in the warmest seasons of such climates. These complaints affect all ages, sexes, temperaments, and complexions. The causes from whence they commonly proceed, are cold and moisture applied to the body while it is very warm, and especially the sudden vicissitudes of heat and cold. Or, the disease is produced by punctures, lacerations, or oth- er lesions of nerves in any part of the body. There are, probably, some other causes of this disease; but they are neither distinctly known, nor well ascertained. Though the causes mentioned do, upon occasion, affect all sorts of persons, they seem however to attack persons of middle age more frequently than the older or younger, the male sex more fre- quently than the female, and the robust and vigorous more frequently than the weaker. MCCLIX. 15 OF PHYSIC. MCCLIX. If the disease proceeds from cold, it com- monly comes on in a few days after the ap- plication of such cold; but, if it arises from a puncture or other lesion of a nerve, the disease does not commonly come on for many days after the lesion has happened, very often when there is neither pain nor uneasiness remaining in the wounded or hurt part, and very fre- quently when the wound has been entirely healed up. MCCLX. The disease sometimes comes on suddenly to a violent degree, but more generally it ap- proaches by slow degrees to its violent state. In this case it comes on with a sense of stiff- ness in the back part of the neck, which, grad- ually increasing, renders the motion of the head difficult and painful. As the rigidity of the neck comes on and increases, there is commonly at the same time a sense of un- easiness felt about the root of the tongue; which, by degrees, becomes a difficulty of swal- lowing, and at length an entire interruption of it. While the rigidity of the neck goes on in- creasing, there arises a pain, often violent at the lower end of the sternum, and from thence shooting into the back. When this pain arises, all the muscles of the neck, and partic- B2 ularly 16 PRACTICE ularly those of the back part of it, are imme- diately affected with spasm, pulling the head strongly backwards. At the same time, the muscles that pull up the lower jaw, which up- on the first approaches of the disease were af- fected with some spastic rigidity, are now gen- erally affected with more violent spasm, and set the teeth so closely together that they do not admit of the smallest opening. This is what has been named the Locked Jaw, and is often the principal part of the disease. When the disease has advanced thus far, the pain at the bottom of the sternum re- turns very frequently, and with it the spasms of the hind neck and lower jaw are renewed with violence and much pain. As the disease thus proceeds, a greater number of muscles come to be affected with spasms. After those of the neck, those along the whole of the spine become affected, bending the trunk of the body strongly backwards; and this is what has been named the Opisthotonos. In the lower extremities, both the flexor and extensor muscles are commonly at the same time affected, and keep the limbs rigidly extended. Though the extensors of the head and back are usually the most strongly affect- ed, yet the flexors, or those muscles of the neck that pulls the head forward, and the muscles that should pull down the lower jaw, are often at the same time strongly affected with spasm. During the whole of the dis- ease, the abdominal muscles are violently af- fected 17 OF PHYSIC. fected with spasm, so that the belly is strong- ly retracted, and feels hard as a piece, of board. At length the flexors of the head and trunk become so strongly affected as to balance the extensors, and to keep the head and trunk straight, and rigidly extended, incapable of being moved in any way; and it is to this state the term of Tetanus has been strictly ap- plied. At the same time, the arms, little af- fected before, are now rigidly extended; the whole of the muscles belonging to them being affected with spasms, except those that move the fingers, which often to the last retain some mobility. The tongue also long retains its mobility; but at length it also becomes af- fected with spasms, which, attacking certain of its muscles only, often thrust it violently out between the teeth. At the height of the disease, every organ of voluntary motion seems to be affected; and amongst the rest, the muscles of the face. The forehead is drawn up into furrows, the eyes, sometimes distorted, are commonly rigid, and immoveable in their sockets; the nose is drawn up, and the cheeks are drawn back- wards towards the ears, so that the whole countenance expresses the most violent grin- ning. Under these universal spasms, a vio- lent convulsion commonly comes on, and puts an end to life. B3 MCCLXI. 18 PRACTICE MCCLXI. These spasms are every where attended with most violent pains. The utmost vio- lence of spasm is, however, not constant; but, after subsisting for a minute or two, the mus- cles admit of some remission of their contrac- tion, although of no such relaxation as can allow the action of their antagonists. This remission of contraction gives also some re- mission of pain; but neither is of long dura- tion. From time to time, the violent con- tractions and pains are renewed sometimes every ten or fifteen minutes, and that often without any evident exciting cause. But such exciting causes frequently occur; for almost every attempt to motion, as attempt- ing a change of posture, endeavouring to swallow, and even to speak, sometimes gives occasion to a renewal of the spasms over the whole body. MCCLXII. The attacks of this disease are seldom at- tended with any fever. When the spasms are general and violent, the pulse is contract- ed, hurried, and irregular; and the respira- tion is affected in like manner: But, during the remission, both the pulse and respiration usually return to their natural state. The heat of the body is commonly not increased; frequently 19 OF PHYSIC. frequently the face is pale, with a cold sweat upon it; and very often the extremities are cold, with a cold sweat over the whole body. When, however, the spasms are frequent and violent, the pulse is sometimes more full and frequent than natural; the face is flushed, and a warm sweat is forced, out over the whole body. MCCLXIII. Although fever be not a constant attendant of this disease, especially when arising from a lesion of nerves; yet, in those cases proceed- ing from cold, a fever sometimes has super- vened, and is said to have been attended with inflammatory symptoms. Blood has been often drawn in this disease, but it never ex- hibits any inflammatory crust; and all ac- counts seem to agree, that the blood drawn seems to be of a looser texture than ordinary, and that it does not coagulate in the usual manner. MCCLXIV. In this disease the head is seldom affected with delirium, or even confusion of thought, till the last stage of it; when, by the repeated shocks of a violent distemper, every function of the system is greatly disordered. B4 MCCLXV. 20 PRACTICE MCCLXV. It is no less extraordinary, that, in this vi- olent disease, the natural functions are not either immediately or considerably affected. Vomitings sometimes appear early in the dis- ease, but commonly they are not continued; and it is usual enough for the appetite of hunger to remain through the whole course of the disease; and what food happens to be taken down, seems to be regularly enough di- gested. The excretions are sometimes affect- ed, but not always. The urine is sometimes suppressed, or is voided with difficulty and pain. The belly is costive: But, as we have hardly any accounts excepting of those cases in which opiates have been largely employed, it is uncertain whether the costiveness has been the effect of the opiates or of the disease. In several instances of this disease, a miliary eruption has appeared upon the skin; but whether this be a symptom of the disease, or the effect of a certain treatment of it, is unde- termined. In the mean while, it has not been observed to denote either safety or danger, or to have any effect in changing the course of the distemper. MCCLXVI. This disease has generally proved fatal; and this indeed may be justly supposed to be the 21 OF PHYSIC. the consequence of its nature: But, as we know, that, till very lately, physicians were not well acquainted with a proper method of cure; and that, since a more proper method has been known and practised, many have re- covered from this disease; it may be therefore concluded, that the fatal tendency of it is not so unavoidable as has been imagined. In judging of the tendency of this disease, in particular cases, we may remark, that, when arising from lesions of the nerves, it is com- monly more violent, and of more difficult cure, than when proceeding from cold; that the disease which comes on suddenly, and advances quickly to a violent degree, is al- ways more dangerous than that which is slow- er in its progress. Accordingly, the disease often proves fatal before the fourth day; and, when a patient has passed this period, he may be supposed to be in greater safety, and in general the disease is the safer the longer it has continued. It is, however, to be partic- ularly observed, that, even for many days after the fourth, the disease continues to be dangerous; and even after some considerable abatement of its force, it is ready to recur again with its former violence and danger. It never admits of any sudden, or what may be called a critical solution; but always re- cedes by degrees only, and it is often very long before the whole of the symptoms dis- appear. VOL. 3. B5 MCCLXVII. 22 PRACTICE MCCLXVII. From the history of the disease now des- cribed, it will be evident, that there is no room for distinguishing the tetanus, opisthotonos, and trismus or locked jaw, as different species of this disease, since they all arise from the same causes, and are almost constantly conjoined in the same person. I have no doubt that the emprosthotonos belongs also to the same genus; and as the ancients have frequently mentioned it, we can have no doubt of its having occurred: But, at the same time, it is certainly in these days a rare occurrence; and, as I have never seen it, nor find any histories in which this particular state of the spasms is said to have prevailed, I cannot mention the other circumstances which particularly attend it, and may distinguish it from the other va- rieties of tetanic complaints. MCCLXVIII. This disease has put on still a different form from any of those above mentioned. The spasms have been sometimes confined to one side of the body only, and which bend it strongly to that side. This is what has been named by Sauvages the Tetanus Lateralis, and by some late writers the Pleurosthotonos. This form of the disease has certainly appear- ed very seldom; and, in any of the accounts given 23 OF PHYSIC. given of it, I cannot find any circumstances that would lead me to consider it as any other than a variety of the species already mention- ed, or to take further notice of it here. MCCLXIX. The pathology of this disease I cannot in any measure attempt; as the structure of moving fibres, the state of them under differ- ent degrees of contraction, and particularly the state of the sensorium, as variously deter- mining the motion of the nervous power, are all matters very imperfectly, or not at all, known to me. In such a situation, therefore, the endeavouring to give any rules of prac- tice, upon a scientific plan, appears to me vain and fruitless; and towards directing the cure of this disease, we must be satisfied with hav- ing learned something useful from analogy, confirmed by experience. MCCLXX. When the disease is known to arise from the lesion of a nerve in any part of the body, the first, and, as I judge, the most important step to be taken towards the cure, is, by every possible means to cut off that part from all communication with the sensorium, either by cutting through the nerves in their course, or perhaps by destroying, to a certain length, their affected part or extremity. B6 MCCLXXI. 24 PRACTICE MCCLXXI. When the cure of the disease is to be at- tempted by medicine, experience has taught us that opium has often proved an effectual remedy; but that, to render it such, it must be given in much larger quantities than have been employed in any other case; and in these larger quantities, it may, in this disease, be given more safely than the body has been known to bear in any other condition. The practice has been, to give the opium either in a solid or a liquid form, not in any very large dose at once, but in moderate doses, frequent- ly repeated, at the interval of one, two, three, or more hours, as the violence of the symp- toms seem to require. Even when large quantities have been given in this way, it ap- pears that the opium does not operate here in the same manner as in most other cases; for, though it procures some remission of the spasms and pains, it hardily induces any sleep, or occasions that stupor, intoxication, or de- lirium, which it often does in other circum- stances, when much smaller quantities only have been given. It is therefore very prop- erly observed, that, in tetanic affections, as the opium shows none of those effects by which it may endanger life, there is little or no reason for being sparing in the exhibition of it; and it may be given, probably should be 25 OF PHYSIC. be given, as largely and as fast as the symp- toms of the disease may seem to demand. It is particularly to be observed, that though the first exhibitions of the opium may have produced some remission of the symp- toms, yet the effects of opium do not long continue in the system; and this disease be- ing for some time ready to recur, it is com- monly very necessary, by the time that the ef- fects of the opium given may be supposed to be wearing off, and especially upon the least appearance of a return of the spasms, to re- peat the exhibition of the opium in the same quantities as before. This practice is to be continued while the disease continues to show any disposition to return; and it is only after the disease has already subsisted for some time, and when considerable and long contin- ued remissions have taken place, that the dos- es of the opium may be diminished, and the intervals of exhibiting them be more consid- erable. MCCLXXII. The administering of opium in this man- ner, has in many cases been successful; and probably would have been equally so in many others, if the opium had not been too sparingly employed, either from the timidity of practitioners, or from its exhibition being prevented by that interruption of deglutition which so often attends this disease. This lat- ter 26 PRACTICE ter circumstance directs, that the medicine should be immediately and largely employed upon the first approach of the disease, before the deglutition becomes difficult; or that, if this opportunity be lost, the medicine, in suf- ficient quantity, and with due frequency, should be thrown into the body by glyster; which, however, does not seem to have been hitherto often practised. MCCLXXIII. It is highly probable, that, in this disease, the intestines are affected with the spasm that prevails so much in other parts of the system; and therefore, that costiveness occurs here as a symptom of the disease. It is probably also increased by the opium, which is here so largely employed; and, from whichever of these causes it arises, it certainly must be held to aggravate the disease, and that a relaxation of the intestinal canal will contribute to a re- laxation of the spasms elsewhere. This con- sideration directs the frequent exhibition of laxatives while the power of deglutition re- mains, or the frequent exhibition of glysters when it does not; and the good effects of both have been frequently observed. MCCLXXIV. It has been with some probability suppos- ed, that the operation of opium in this dis- ease, 27 OF PHYSIC. ease, may be much assisted by joining with it some other of the most powerful antispasmod- ics. The most promising are musk and cam- phire; and some practitioners have been of opinion, that the former has proved very use- ful in tetanic complaints. But, whether it be from its not having been employed of a gen- uine kind, or in sufficient quantity, the great advantage and propriety of its use are not yet clearly ascertained. It appears to me prob- able, that analogous to what happens with respect to opium, both musk and camphire might be employed in this disease, in much larger quantities than they commonly have been in other cases. MCCLXXV. Warm bathing has been commonly em- ployed as a remedy in this disease, and often with advantage; but, so far as I know, it has not alone proved a cure; and, in some cases, whether it be from the motion of the body here required, exciting the spasms, or from the fear of the bath, which some persons were seized with, I cannot determine; but it is al- lowed, that the warm bath hath in some cases done harm, and even occasioned death. Par- tial fomentations have been much commend- ed, and, I believe, upon good grounds: And I have no doubt but that fomentations of the feet and legs, as we now usually apply them in fevers, might, without much stirring of the patient, 28 PRACTICE patient, be very assiduously employed with advantage. MCCLXXVI. Unctuous applications were very frequent- ly employed in this disease by the ancients: And some modern practitioners have consid- ered them as very useful. Their effects, however, have not appeared to be considera- ble; and, as a weak auxiliary only, attended with some inconvenience, they have been very much neglected by the British prac- titioners. MCCLXXVII. Bleeding has been formerly employed in this disease; but of late it has been found prejudicial, excepting in a few cases, where, in plethoric habits, a fever has supervened. In general, the state of men's bodies in warm climates are unfavourable to bloodletting; and, if we may form indications from the state of the blood drawn out of the veins, the state of this in tetanic diseases would forbid bleeding in them. MCCLXXVIII. Blistering also has been formerly employed in this disease; but several practitioners assert, that 29 OF PHYSIC. that blisters are constantly hurtful, and they are now generally omitted. MCCLXXIX. These are the practices that hitherto have been generally employed; but of late we are informed by several Westindia practitioners, that in many instances they have employed mercury with great advantage. We are told, that it must be employed early in the disease; that it is most conveniently administered by unction, and should be applied in that way in large quantities, so that the body may be soon filled with it, and a salivation raised, which is to be continued till the symptoms yield. Whether this method alone be gen- erally sufficient for the cure of the disease, or if it may be assisted by the use of opium, and require this in a certain measure to be joined with it, I have not yet certainly learned. MCCLXXX. I have been further informed, that the te- tanus, in all its different degrees, has been cured by giving internally the Pisselæum Bar- badense, or, as it is vulgarly called, the Bar- badoes Tar. I think it proper to take notice of this here, although I am not exactly in- formed what quantities of this medicine are to be given, or in what circumstances of the disease it is most properly to be employed. *MCCLXXX. 30 PRACTICE *MCCLXXX. In the former edition of this work, among the remedies of tetanus I did not mention the use of cold bathing; because, though I had heard of this, I was not informed of such fre- quent employment of it as might confirm my opinion of its general efficacy; nor was I suf- ficiently informed of the ordinary and proper administration of it. But now, from the in- formation of many judicious practitioners who have frequently employed it, I can say, that it is a remedy which in numerous trials has been found to be of great service in this disease; and that, while the use of the am- biguous remedy of warm bathing is entirely laid aside, the use of cold bathing is over the whole of the Westindies commonly employ- ed. The administration of it is sometimes by bathing the person in the sea, or more fre- quently by throwing cold water from a bason or bucket upon the patient's body, and over the whole of it: When this is done, the body is carefully wiped dry, wrapped in blankets, and laid abed, and at the same time a large dose of an opiate is given. By these means a considerable remission of the symptoms is obtained; but this remission, at first, does not commonly remain long, but returning again in a few hours, the repetition both of the bath- ing and the opiate becomes necessary. By these repetitions, however, longer intervals of ease 31 OF PHYSIC. ease is obtained, and at length the disease is entirely cured; and this even happens some- times very quickly. I have only to add, that it does not appear to me, from any accounts I have yet had, that the cold bathing has been so frequently employed, or has been found so commonly successful in the cases of tetanus in consequence of wounds, as in those from the application of cold. MCCLXXXI. Before concluding this chapter, it is proper for me to take some notice of that peculiar case of the tetanus, or trismus, which attacks certain infants soon after their birth, and has been properly enough named the Trismus Nascentium. From the subjects it affects, it seems to be a peculiar disease: For these are infants not above two weeks, and commonly before they are nine days, old; insomuch that, in countries where the disease is fre- quent, if children pass the period now men- tioned, they are considered as secure against its attacks. The symptom of it chiefly taken notice of, is the trismus, or locked jaw, which is by the vulgar improperly named the Fall- ing of the Jaw. But this is not the only symptom, as, for the most part, it has all the same symptoms as the Opisthotonos and Te- tanus strictly so called, and which occur in the other varieties of tetanic complaints above described. Like the other varieties of teta- nus, 32 PRACTICE nus, this is most frequent in warm climates; but it is not, like those arising from the appli- cation of cold, entirely confined to such warm climates, as instances of it have occurred in most of the northern countries of Europe. In these latter it seems to be more frequent in certain districts than in others; but in what manner limited, I cannot determine. It seems to be more frequent in Switzerland than in France. I am informed of its frequently occurring in the Highlands of Scotland; but I have never met with any instance of it in the low country. The particular causes of it are not well known; and various conjectures have been offered; but none of them are sat- isfying. It is a disease that has been almost constantly fatal; and this, also, commonly in the course of a few days. The women are so much persuaded of its inevitable fatality, that they seldom or never call for the assistance of our art. This has occasioned our being little acquainted with the history of the disease, or with the effects of remedies in it. Analogy, however, would lead us to employ the same remedies that have proved useful in the other cases of tetanus; and the few experiments that are yet recorded, seem to approve of such a practice. CHAP. 33 OF PHYSIC. CHAP. II. Of EPILEPSY. MCCLXXXII. IN what sense I use the term Convulsion, I have explained above in MCCLVI. The convulsions that affect the human body are in several respects various; but I am to consider here only the chief and most frequent form in which they appear, and which is in the disease named Epilepsy. This may be defined, as consisting in convulsions of the greater part of the muscles of voluntary motion, attended with a loss of sense, and ending in a state of insensibility and seeming sleep. MCCLXXXIII. The general form or principal circum- stances of this disease, are much the same in all the different persons whom it affects. It comes by fits, which often attack persons seemingly in perfect health; and, after last- ing for some time, pass off, and leave the per- sons again in their usual state. These fits are sometimes 34 PRACTICE sometimes preceded by certain symptoms, which, to persons who have before experienc- ed such a fit, may give notice of its approach, as we shall hereafter explain; but even these preludes do not commonly occur long before the formal attack, which in most cases comes on suddenly without any such warning. The person attacked loses suddenly all sense and power of motion; so that, if standing, he falls immediately, or perhaps, with convul- sions, is thrown to the ground. In that sit- uation he is agitated with violent convulsions, variously moving his limbs and the trunk of his body. Commonly the limbs on one side of the body, are more violently or more con- siderably agitated than those upon the other. In all cases the muscles of the face and eyes are much affected, exhibiting various and vi- olent distortions of the countenance. The tongue is often affected, and thrust out of the mouth; while the muscles of the lower jaw are also affected; and, shutting the mouth with violence while the tongue is thrust out between the teeth, that is often grievously wounded. While these convulsions continue, there is commonly at the same time a frothy moisture issuing from the mouth. These convulsions have for some moments some remissions, but are suddenly again renewed with great vio- lence. Generally, after no long time, the convulsions cease altogether; and the person for some time remains without motion, but in a state 35 OF PHYSIC. a state of absolute insensibility, and under the appearance of a profound sleep. After some continuance of this seeming sleep, the person sometimes suddenly, but for the most part by degrees only, recovers his senses and power of motion; but without any memory of what had passed from his being first seized with the fit. During the convulsions, the pulse and respiration are hurried and irregular; but, when the convulsions cease, they return to their usual regularity and healthy state. This is the general form of the disease; and it varies only in different persons, or on dif- ferent occasions in the same person, by the phenomena mentioned being more or less vi- olent, or by their being of longer or shorter duration. MCCLXXXIV. With respect to the proximate cause of this disease, I might say, that it is an affection of the energy of the brain, which, ordinarily un- der the direction of the will, is here, without any concurrence of it, impelled by preternat- ural causes. But I could go no farther: For, as to what is the mechanical condition of the brain in the ordinary exertions of the will, I have no distinct knowledge; and therefore must be also ignorant of the preternatural date of the same energy of the brain under the irregular motions here produced. To form, therefore, the indications of a cure, from a knowledge 36 PRACTICE a knowledge of the proximate cause of this disease, I must not attempt; but, from a dili- gent attention to the remote causes which first induce and occasionally excite the disease, I think we may often obtain some useful direc- tions for its cure. It shall therefore be my business now, to point out and enumerate these remote causes as well as I can. MCCLXXXV. The remote causes of epilepsy may be con- sidered as occasional or predisponent. There are, indeed, certain remote causes which act independently of any predisposition; but, as we cannot always distinguish these from the others, I shall consider the whole under the usual titles of Occasional or Predisponent. MCCLXXXVI. The occasional causes may, I think, be properly referred to two general heads; the first being of those which seem to act by di- rectly stimulating and exciting the energy of the brain; and the second, of those which seem to act by weakening the same. With respect to both, for the brevity of expressing a fact, without meaning to explain the manner in which it is brought about, I shall use the terms of Excitement and Collapse. And though it be true, that with respect to some of the causes I am to mention, it may be a little 37 OF PHYSIC. little uncertain whether they act in the one way or the other, that does not render it im- proper for us to mark, with respect to others, the mode of their operating, wherever we can do it clearly, as the doing so may often be of use in directing our practice. MCCLXXXVII. First, then, of the occasional causes acting by excitement: They are either such as act immediately and directly upon the brain it- self; or those which are first applied to the other parts of the body, and are from thence communicated to the brain. MCCLXXXVIII. The causes of excitement immediately and directly applied to the brain, may be referred to the four heads of, 1. Mechanical Stimu- lants; 2. Chemical Stimulants; 3. Mental Stimulants; and, 4. The peculiar Stimulus of Over Distention. MCCLXXXIX. The mechanical stimulants may be, wound- ing instruments penetrating the cranium, and entering the substance of the brain; or splin- ters of a fractured cranium, operating in the same manner; or sharp pointed ossifications, either arising from the internal surface of the VOL. III. C cranium, 38 PRACTICE cranium, or formed in the membranes of the brain. MCCXC. The chemical stimulants (MCCLXXXVIII) may be fluids from various causes lodged in certain parts of the brain, and become acrid by stagnation or otherwise. MCCXCI. The mental irritations acting by excite- ment, are, all violent emotions of the active kind, such as joy and anger. The first of these is manifestly an exciting power, acting strongly, and immediately, on the energy or the brain. The second is manifestly, also, a power acting in the same manner. But it must be remarked, that it is not in this man- ner alone anger produces its effects: For it acts, also, strongly on the sanguiferous system, and may be a means of giving the stimulus of over distention; as, under a fit of anger, the blood is impelled into the vessels of the head with violence, and in a larger quantity. MCCXCII. Under the head of Mental Irritations, is to be mentioned, the sight of persons in a fit of epilepsy, which has often produced a fit of the like kind in the spectator. It may, indeed, be a question, 39 OF PHYSIC. a question, whether this effect be imputable to the horror produced by a sight of the seem- ingly painful agitations of the limbs, and of the distortions in the countenance of the epi- leptic person; or if it may be ascribed to the force of imitation merely? It is possible, that horror may sometimes produce the effect: But certainly much may be imputed to that propensity to imitation, at all times so power- ful and prevalent in human nature; and so often operating in other cases of convulsive disorders, which do not present any spectacle of horror. MCCXCIII. Under the same head of Mental Irritation, I think proper to mention as an instance of it, the Epilepsia Simulata, or the Feigned Epi- lepsy, so often taken notice of. Although this, at first, may be entirely feigned, I have no doubt but that the repetition renders it at length real. The history of Quietism and of Exorcisms leads me to this opinion; and which receives a confirmation from what we know of the power of imagination, in renew- ing epileptic and hysteric fits. MCCXCIV. I come now to the fourth head of the irri- tations applied immediately to the brain, and which I apprehend to be that of the Over Dis- C2 tention 40 PRACTICE tention of the bloodvessels in that organ. That such a cause operates in producing epi- lepsy, is probable from this, that the dissection of persons dead of epilepsy, has commonly discovered the marks of a previous congestion in the bloodvessels of the brain. This, per- haps, may be supposed the effect of the fit which proved fatal: But that the congestion was previous thereto, is probable from the epilepsy being so often joined, with headach, mania, palsy, and apoplexy; all of them dis- eases depending upon a congestion in the vessels of the brain. The general opinion receives also confirmation from this circum- stance, that, in the brain of persons dead of epilepsy, there have been often found tumours and effusions, which, though seemingly not sufficient to produce those diseases which de- pend on the compression of a considerable portion of the brain, may, however, have been sufficient to compress so many vessels as to render the others upon any occasion of a more than usual turgescence, or impulse of the blood into the vessels of the brain more liable to an over distention. MCCXCV. These considerations alone might afford foundation for a probable conjecture with respect to the effects of over distention. But the opinion does not rest upon conjecture alone. That it is also founded in fact, ap- pears 41 OF PHYSIC. pears from hence, that a plethoric date is fa- vourable to epilepsy; and that every occa- sional turgescence, or unusual impulse of the blood into the vessels of the brain, such as a fit of anger, the heat of the sun, or of a warm chamber, violent exercise, a surfeit, or a fit of intoxication, are frequently the immediately exciting causes of epileptic fits. MCCXCVI. I venture to remark further, that a piece of theory may be admitted as a confirmation of this doctrine. As I have formerly maintain- ed, that a certain fulness and tension of the vessels of the brain are necessary to the support of its ordinary and constant energy, in the distribution of the nervous power; so it must be sufficiently probable, that an over disten- tion of these bloodvessels may be a cause of violent excitement. MCCXCVII. We have now enumerated the several re- mote or occasional causes of epilepsy, acting by excitement, and acting immediately upon the brain itself. Of the causes acting by ex- citement, but acting upon other parts of the body, and from thence communicated to the brain, they are all of them impressions pro- ducing an exquisite or high degree either of pleasure or pain. C3 Impressions 42 PRACTICE Impressions which produce neither the one nor the other, have hardly any such effects; unless when such impressions are in a violent degree, and then their operation may be con- sidered as a mode of pain. It is, however, to be remarked, that all strong impressions which are sudden and surprising, or, in other words, unforeseen and unexpected, have frequently the effect of bringing on epileptic fits. MCCXCVIII. There are certain impressions made upon different parts of the body, which as they often operate without producing any sensa- tion, so it is uncertain to what head they be- long: But it is probable that the greater part of them act by excitement, and therefore fall to be mentioned here. The chief instances are, the teething of infants; worms; acidity or other acrimony in the alimentary canal; calculi in the kidneys; acrid matter in ab- scesses or ulcers; or acrimony diffused in the mass of blood, as in the case of some conta- gions. MCCXCIX. Physicians have found no difficulty in comprehending how direct stimulants, of a certain force, may excite the action of the brain, and occasion epilepsy; but they have hitherto taken little notice of certain causes which 43 OF PHYSIC. which manifestly weaken the energy of the brain, and act, as I speak, by collapse. These, however, have the effect of exciting the action of the brain in such a manner as to occasion epilepsy. I might, upon this sub- ject, speak of the vis medicatrix naturæ; and there is a foundation for the term: But, as I do not admit the Stahlian doctrine of an ad- ministering soul, I make use of the term only as expressing a fact, and would not employ it with the view of conveying an explanation of the manner in which the powers of collapse mechanically produce their effects. In the mean time, however, I maintain, that there are certain powers of collapse, which in effect prove stimulants, and produce epilepsy. MCCC. That there are such powers, which may be termed Indirect Stimulants, I conclude from hence, that several of the causes of epilepsy are such as frequently produce syncope, which we suppose always to depend upon causes weakening the energy of the brain (MCLXXVI). It may give some difficulty to explain, why the same causes sometimes occasion syncope, and sometimes occasion the reaction that appears in epilepsy; and I shall not attempt to explain it: But this, I think, does not prevent my supposing that the ope- ration of these causes is by collapse. That there are such causes producing epilepsy, will, C4 I think, 44 PRACTICE I think, appear very clearly from the partic- ular examples of them I am now to mention. MCCCI. The first to be mentioned, which I suppose to be of this kind, is hemorrhagy, whether spontaneous or artificial. That the same he- morrhagy which produces syncope, often at the same time produces epilepsy, is well known; and from many experiments and observations it appears, that hemorrhagies oc- curring to such a degree as to prove mortal, seldom do so without first producing epilepsy. MCCCII. Another cause acting, as I suppose, by col- lapse, and therefore sometimes producing syn- cope and sometimes epilepsy, is terror; that is, the fear of some great evil suddenly present- ed. As this produces at the same time a sud- den and considerable emotion, (MCLXXX), so it more frequently produces epilepsy than syncope. MCCCIII. A third cause acting by collapse, and pro- ducing epilepsy, is horror; or a strong aver- sion suddenly raised by a very disagreeable sensation, and frequently arising from a sym- pathy with the pain or danger of another per- son. 45 OF PHYSIC. son. As horror is often a cause of syncope, there can be no doubt of its manner of ope- rating in producing epilepsy; and it may perhaps be explained upon this general prin- ciple, that as desire excites action and gives activity, so aversion restrains from action, that is, weakens the energy of the brain; and, therefore, that the higher degrees of aversion may have the effects of producing syncope or epilepsy. MCCCIV. A fourth set of the causes of epilepsy, which I suppose also to act by collapse, are certain odours, which occasion either syncope or epilepsy; and, with respect to the former, I have given my reasons (MCLXXXII) for supposing odours in that case to act rather as disagreeable than as sedative. These reasons will, I think, also apply here; and perhaps the whole affair of odours might be consider- ed as instances of the effect of horror, and therefore belonging to the last head. MCCCV. A fifth head of the causes producing epi- lepsy by collapse, is the operation of many substances considered, and for the most part properly considered, as poisons. Many of these, before they prove mortal, occasion epi- lepsy. This effect, indeed, may in some cases be referred to the inflammatory operation VOL. 3. C5 which 46 PRACTICE which they sometimes discover in the stomach and other parts of the alimentary canal; but, as the greater part of the vegetable poisons show chiefly a narcotic, or strongly sedative power, it is probably by this power that they produce epilepsy, and therefore belong to this head of the causes acting by collapse. MCCCVI. Under the head of the remote causes pro- ducing epilepsy, we must now mention that peculiar one whose operation is accompanied with what is called the Aura Epileptica. This is a sensation of something moving in some part of the limbs or trunk of the body, and from thence creeping upwards to the head; and when it arrives there, the person is immediately deprived of sense, and falls in- to an epileptic fit. This motion is described by the person's feeling it sometimes as a cold vapour, sometimes as a fluid gliding, and sometimes as the sense of a small insect creep- ing along their body; and very often they can give no distinct idea of their sensation, otherwise than as in general of something moving along. This sensation might be sup- posed to arise from some affection of the ex- tremity or other part of a nerve acted upon by some irritating matter; and that the sen- sation, therefore, followed the course of such a nerve: But I have never found it following distinctly the course of any nerve; and it generally 47 OF PHYSIC. generally seems to pass along the teguments. It has been found in some instances to arise from something pressing upon or irritating a particular nerve, and that sometimes in con- sequence of contusion or wound: But in- stances of these are more rare; and the more common consequence of contusions and wounds is a tetanus. This latter effect wounds produce, without giving any sensa- tion of an aura or other kind of motion pro- ceeding from the wounded part to the head; while, on the other hand, the aura producing epilepsy often arises from a part which had never before been affected with wound or con- tusion, and in which part the nature of the irritation can seldom be discovered. It is natural to imagine that this aura epi- leptica is an evidence of some irritation or di- rect stimulus acting in the part, and from thence communicated to the brain, and should therefore have been mentioned among the causes acting by excitement; but the re- markable difference that occurs in seemingly like causes producing tetanus, gives some doubt on this subject. MCCCVII. Having now enumerated the occasional causes of epilepsy, I proceed to consider the predisponent. As so many of the above mentioned causes act upon certain persons, and not at all upon others, there must be sup- C6 posed 48 PRACTICE posed in those persons a predisposition to this disease: But in what this predisposition con- sists, is not to be easily ascertained. MCCCVIII. As many of the occasional causes are weak impressions, and are applied to most persons with little or no effect, I conclude, that the persons affected by those causes are more ea- sily moved than others; and therefore, that, in this case, a certain mobility gives the pre- disposition. It will, perhaps, make this mat- ter clearer, to show, in the first place, that there is a greater mobility of constitution in some persons than in others. MCCCIX. This mobility appears most clearly in the state of the mind. If a person is readily elat- ed by hope, and as readily depressed by fear, and passes easily and quickly from the one state to the other; if he is easily pleased, and prone to gaiety, and as easily provoked to anger, and rendered peevish; if liable, from slight impressions, to strong emotions, but te- nacious of none; this is the boyish tempera- ment, qui colligit ac ponit iram temere, et mu- tatur in horas; this is the varium et mutabile fœmina; and, both in the boy and woman, every one perceives and acknowledges a mo- bility of mind. But this is necessarily con- nected 49 OF PHYSIC. nected with an analogous state of the brain; that is, with a mobility, in respect of every impression, and therefore liable to a ready al- ternation of excitement and collapse, and of both to a considerable degree. MCCCX. There is, therefore, in certain persons, a mobility of constitution, generally derived from the state of original stamina, and more exquisite at a certain period of life than at others; but sometimes arising from, and par- ticularly modified by, occurrences in the course of life. MCCCXI. This mobility consists in a greater degree of either sensibility or irritability. These conditions, indeed, physicians consider as so necessarily connected, that the constitution with respect to them, may be considered as one and the same: But I am of opinion that they are different; and that mobility may sometimes depend upon an increase of the one, and sometimes on that of the other. If an action excited, is, by repetition, rendered more easily excited, and more vigorously per- formed, I consider this as an increase of irri- tability only. I go no farther on this subject here, as it was only necessary to take notice of the case just now mentioned, for the pur- pose 50 PRACTICE pose of explaining why epilepsy, and convul- sions of all kinds, by being repeated, are more easily excited, readily become habitual, and are therefore of more difficult cure. MCCCXII. However we may apply the distinction of sensibility and irritability, it appears that the mobility, which is the predisponent cause of epilepsy, depends more particularly upon de- bility, or upon a plethoric state of the body. MCCCXIII. What share debility, perhaps by inducing sensibility, has in this matter, appears clearly from hence, that children, women, and other persons of manifest debility, are the most fre- quent subjects of this disease. MCCCXIV. The effects of a plethoric state in disposing to this disease appears from hence, that ple- thoric persons are frequently the subjects of it: That it is commonly excited, as I have said above, by the causes of any unusual turges- cence of the blood; and that it has been fre- quently cured by diminishing the plethoric state of the body. That a plethoric state of the body should dispose to this disease, we may understand from 51 OF PHYSIC. from Several considerations. 1st, Because a plethoric state implies, for the most part, a laxity of the solids, and therefore some debil- ity in the moving fibres. 2dly, Because, in a plethoric state, the tone of the moving fi- bres depends more upon their tension, than upon their inherent power: And as their ten- sion depends upon the quantity and impetus of the fluids in the bloodvessels, which are very changeable, and by many causes fre- quently changed, so these frequent changes must give a mobility to the system. 3dly, Because a plethoric state is favourable to a congestion of blood in the vessels of the brain, it must render these more readily affected by every general turgescence of the blood in the system, and therefore more especially dispose to this disease. MCCCXV. There is another circumstance of the body disposing to epilepsy, which I cannot so well account for; and that is, the state of sleep: But whether I can account for it or not, it appears, in fact, that this state gives the dis- position I speak of; for, in many persons lia- ble to this disease, the fits happen only in the time of sleep, or immediately upon the per- son's coming out of it. In a case related by De Haen, it appeared clearly, that the dispo- sition to epilepsy depended entirely upon the state of the body in sleep. MCCCXVI. 52 PRACTICE MCCCXVI. Having thus considered the whole of the remote causes of epilepsy, I proceed to treat of its cure, as I have laid it is from the con- sideration of those remote causes only that we can obtain any directions for our practice in this disease. I begin with observing, that as the disease may be considered as sympathic or idiopathic, I must treat of these separately, and judge it proper to begin with the former. MCCCXVII. When this disease is truly sympathic, and depending upon a primary affection in some other part of the body, such as acidity or worms in the alimentary canal, teething, or other similar causes, it is obvious, that such primary affections must be removed for the cure of the epilepsy; but it is not our busi- ness here to say how these primary diseases are to be treated. MCCCXVIII. There is, however, a peculiar case of sym- pathic epilepsy; that is, the case accompa- nied with the aura epileptica, as described in MCCCVI, in which, though we can perceive by the aura epileptica arising from a particu- lar 53 OF PHYSIC. lar part, that there is some affection in that part; yet, as in many such cases we cannot perceive of what nature the affection is, I can only offer the following general directions. 1st, When the part can with safety be en- tirely destroyed, we should endeavour to do so try cutting it out, or by destroying it by the application of an actual or potential cautery. 2dly, When the part cannot be properly destroyed, that we should endeavour to cor- rect the morbid affection in it by blistering, or by establishing an issue upon the part. 3dly, When these measures cannot be exe- cuted, or do not succeed, if the disease seems to proceed from the extremity of a particular nerve which we can easily come at in its course, it will be proper to cut through that nerve, as before proposed on the subject of tetanus. 4thly, When it cannot be perceived that the aura arises from any precise place or point, so as to direct to the above mentioned operations; but, at the same time, we can perceive its progress along the limb; it fre- quently happens that the epilepsy can be pre- vented by a ligature applied upon the limb, above the part from which the aura arises: And this is always proper to be done, both because the preventing a fit breaks the habit of the disease, and because the frequent com- pression renders the nerves less fit to propa- gate the aura. MCCCXIX. 54 PRACTICE MCCCXIX. The cure of idiopathic epilepsy, as I have said above, is to be directed by our knowledge of the remote causes. There are therefore two general indications to be formed: The first is, to avoid the occasional causes; and the second is, to remove or correct the pre- disponent. This method, however, is not always pure- ly palliative; as in many cases the predispo- nent may be considered as the only proximate cause, so our second indication may be often: considered as properly curative. MCCCXX. From the enumeration given above, it will be manifest, that for the most part the occa- sional causes, so far as they are in our power, need only to be known, in order to be avoid- ed; and the means of doing this will be suf- ficiently obvious. I shall here, therefore, of- fer only a few remarks. MCCCXXI. One of the most frequent of the occasional causes are that of over distention (MCCCXIV), which, so far as it depends upon a plethoric state of the system, I shall say hereafter how it is to be avoided. But as, not only in the plethoric, 55 OF PHYSIC. plethoric, but in every moveable constitution, occasional turgescence is a frequent means of exciting epilepsy, the avoiding therefore of such turgescence is what ought to be most constantly the object of attention to per- sons liable to epilepsy. MCCCXXII. Another of the most frequent exciting caus- es of this disease are, all strong impressions suddenly made upon the senses; for as such impressions, in moveable constitutions, break in upon the usual force, velocity, and order of the motions of the nervous system, they thereby readily produce epilepsy. Such im- pressions therefore, and especially those which are suited to excite any emotion or passion of the mind, are to be most carefully guarded against by persons liable to epilepsy. MCCCXXIII. In many cases of epilepsy, where the pre- disponent cause cannot be corrected or re- moved, the recurrence of the disease can only be prevented, by the strictest attention to avoid the occasional; and as the disease is often confirmed by repetition and habit, so the avoiding the frequent recurrence of it is of the utmost importance towards its cure. These are the few remarks I have to offer with respect to the occasional causes; and must 56 PRACTICE must now observe, that, for the most part, the complete, or, as it is called, the Radical Cure, is only to be obtained by removing or cor- recting the predisponent cause. MCCCXXIV. I have said above, that the predisponent cause of epilepsy is a certain mobility of the sensorium; and that this depends upon a plethoric state of the system, or upon a cer- tain state of debility in it. MCCCXXV. How the plethoric state of the system is to be corrected, I have treated of fully above in DCCLXXXIII et seq. and I need not re- peat it here. It will be enough to say, that it is chiefly to be done by a proper manage- ment of exercise and diet; and, with respect to the latter, it is particularly to be observed here, that an abstemious course has been fre- quently found to be the most certain means of curing epilepsy. MCCCXXVI. Considering the nature of the matter pour- ed out by issues, these may be supposed to be a constant means of obviating the plethoric state of the system; and it is, perhaps, there- fore, that they have been so often found use- ful 57 OF PHYSIC. ful in epilepsy. Possibly, also, as an open issue may be a means of determining occasion- al turgescences to such places, and therefore of diverting them in some measure from their action upon the brain; so also, in this man- ner, issues may be useful in epilepsy. MCCCXXVII. It might be supposed that bloodletting would be the most effectual means of correct- ing the plethoric state of the system; and such it certainly proves when the plethoric state has become considerable, and imme- diately threatens morbid effects. It is there- fore, in such circumstances, proper and neces- sary: But as we have said above, that blood- letting is not the proper means of obviating a recurrence of the plethoric date, and, on the contrary, is often the means of favouring it; so it is not a remedy advisable in every cir- cumstance of epilepsy. There is, however, a case of epilepsy in which there is a periodical or occasional recurrence of the fulness and turgescence of the sanguiferous system, giving occasion to a recurrence of the disease. In such cases, when the means of preventing plethora have been neglected, or may have proved ineffectual, it is absolutely necessary for the practitioner to watch the returns of these turgescences, and to obviate their effects by the only certain means of doing it, that is, by a large bloodletting. MCCCXXVIII. 58 PRACTICE MCCCXXVIII. The second cause of mobility which we have assigned, is a state of debility. If this is owing, as it frequently is, to original con- formation, it is perhaps not possible to cure it; but when it has been brought on in the course of life, it possibly may admit of being mended; and, in either case, much may be done to obviate and prevent its effects. MCCCXXIX. The means of correcting debility, so far as it can be done, are, The person's being much in cool air; the frequent use of cold bath- ing; the use of exercise, adapted to the strength and habits of the person; and, per- haps, the use of astringent and tonic medi- cines. These remedies are suited to strengthen the inherent power of the solids or moving fibres: But as the strength of these depends also up- on their tension, so when debility has pro- ceeded from inanition, the strength may be restored, by restoring the fulness and tension of the vessels by a nourishing diet; and we have had instances of the propriety and suc- cess of such a practice. MCCCXXX. 59 OF PHYSIC. MCCCXXX. The means of obviating the effects of de- bility, and of the mobility depending upon it, are the use of tonic and antispasmodic rem- edies. The tonics are, Fear, or some degree of terror; astringents; certain vegetable and metallic tonics; and cold bathing. MCCCXXXI. That fear, or some degree of terror, may be of use in preventing epilepsy, we have a remarkable proof in Boerhaave's cure of the epilepsy, which happened in the Orphan- house at Haerlem. See Kauu Boerhaave's treatise, entitled Impetum Faciens, § 406. And we have met with several other instances of the same. As the operation of horror is in many res- pects analogous to that of terror, several seem- ingly superstitious remedies have been em- ployed for the cure of epilepsy; and, if they have ever been successful, I think it must be imputed to the horror they had inspired. MCCCXXXII. Of the astringent medicines used for the cure of epilepsy, the most celebrated is the viscus quercinus, which, when given in large quantities, 60 PRACTICE quantities, may possibly be useful; but I be- lieve it was more especially so in ancient times, when it was an object of superstition. In the few instances in which I have seen it employed, it did not prove of any effect. MCCCXXXIII. Among the vegetable tonics, the bitters are to be reckoned; and it is by this quality that I suppose the orange tree leaves to have been useful: But they are not always so. MCCCXXXIV. The vegetable tonic, which from its use in analogous cases are the most promising, is the Peruvian bark; this, upon occasion, has been useful, but has also often failed. It is espec- ially adapted to those epilepsies which recur at certain periods, and which are at the same time without the recurrence of any plethoric state, or turgescence of the blood; and in such periodical cases, if the bark is employed some time before the expected recurrence, it may be useful: But it must be given in large quantity, and as near to the time of the ex- pected return as possible. MCCCXXXV. 61 OF PHYSIC. MCCCXXXV. The metallic tonics seem to be more pow- erful than the vegetable, and a great variety of the former have been employed. Even arsenic has been employed in the cure of epilepsy; and its use in intermittent fevers give an analogy in its favour. Preparations of tin have been formerly rec- ommended in the cure of epilepsy, and in the cure of the analogous disease of hysteria; and several considerations render the virtues of tin, with respect to these diseases, probable: But I have had no experience of its use in such cafes. A much safer metallic tonic is to be found in the preparations of iron; and we have seen some of them employed in the cure of epilepsy, but have never found them to be effectual. This, however, I think, may be imputed to their not having been always em- ployed in the circumstances of the disease, and in the quantities of the medicine, that were proper and necessary. MCCCXXXVI. Of the metallic tonics, the most celebrated and the most frequently employed is copper, under various preparation. What prepara- tion of it may be the most effectual, I dare VOL. III. D not 62 PRACTICE not determine; but of late the cuprum am- moniacum has been frequently found suc- cessful. MCCCXXXVII. Lately the flowers of zinc have been rec- ommended by a great authority as useful in all convulsive disorders; but in cases of epi- lepsy, I have not hitherto found that medicine useful. MCCCXXXVIII. There have been of late some instances of the cure of epilepsy by the accidental use of mercury; and if the late accounts of the cure of tetanus by this remedy are confirmed, it will allow us to think that the same may be adapted also to the cure of certain cases of epilepsy. MCCCXXXIX. With respect to the employment of any of the above mentioned tonics in this disease, it must be observed, that in all cases where the disease depends upon a constant or occasional plethoric state of the system, these remedies are likely to be ineffectual; and if sufficient evacuations are not made at the same time; these medicines are likely to be very hurtful. MCCCXL. 63 OF PHYSIC. MCCCXL. The other set of medicines which re have mentioned as suited to obviate the effects of the too great mobility of the system, are the medicines named antispasmodics. Of these there is long list in the writers on the Ma- teria Medica, and by these authors recom- mended for the cure of epilepsy. The great- er part, however, of those taken from the veg- etable kingdom, are manifestly inert and in- significant. Even the root of the wild vale- rian hardly supports its credit. MCCCXLI. Certain substances taken from the animal kingdoms seem to be much more powerful: And of these the chief, and seemingly the most powerful, is musk; which, employed in its genuine state, and in due quantity, has often been an effectual remedy. It is probable also, that the oleum animale, as it has been named, when in its purest state, and exhibited at a proper time, may be an ef- fectual remedy. MCCCXLII. In many diseases, the most powerful anti- spasmodic is certainly opium; but the pro- priety of its use in epilepsy has been disputed D2 among 64 PRACTICE among physicians. When the disease de- pends upon a plethoric date in which bleed- ing may be necessary, the employment of opium is likely to be very hurtful; but, when there is no plethoric or inflammatory state present, and the disease seems to depend upon irritation or upon increased irritability, opium is likely to prove the most certain remedy. Whatever effects in this and other convulsive disorders have been attributed to the hyoscy- amus, must probably be attributed to its pos- sessing a narcotic power similar to that of opium. MCCCXLIII. With respect to the use of antispasmodics, it is to be observed, that they are always most useful, and perhaps only useful, when em- ployed at a time when epileptic fits are fre- quently recurring, or near to the times of the accession of fits which recur after considerable intervals. MCCCXLIV. On the subject of the cure of epilepsy, I have only to add, that as the disease in many cases are continued by the power of habit only, and that in all cases habit has a great share in increasing mobility, and therefore in contin- uing this disease; so the breaking in upon such habit, and changing the whole habits of the 65 OF PHYSIC. the system, is likely to be a powerful remedy in epilepsy. Accordingly, a considerable change of climate, diet, and other circum- stances in the manner of life, has often proved a cure of this disease. MCCCXLV. After treating of epilepsy, I might here treat of particular convulsions, which are to be distinguished from epilepsy by their being more partial: That is, affecting certain parts of the body only, and by their not being at- tended with a loss of sense, nor ending in such a comatose state as epilepsy always does. MCCCXLVI. Of such convulsive affections many differ- ent instances have been observed and record- ed by physicians. But many of these have been manifestly sympathic affections, to be cured only by curing the primary disease up- on which they depend, and therefore not to be treated of here: Or, though they are such as cannot be referred to another disease, as many of them however have not any specific character with which they occur in different persons, I must therefore leave them to be treated upon the general principles I have laid down with respect to epilepsy, or shall lay down with respect to the following convulsive D3 disorder; 66 PRACTICE disorder; which as having very constantly in different persons a peculiar character, I think necessary to treat of more particularly. CHAP. III. Of the CHOREA or DANCE of ST. VITUS. MCCCXLVII. THIS disease affects both sexes, and al- most only young persons. It generally hap- pens from the age of ten to that of fourteen years. It comes on always before the age of puberty, and rarely continues beyond that period. MCCCXLVIII. It is chiefly marked by convulsive motions, somewhat varied in different persons, but nearly of one kind in all; affecting the leg and arm on the same side, and generally on one side only. MCCCXLIX. These convulsive motions commonly first affect the leg and foot. Though the limb be at 67 OF PHYSIC. at rest, the foot is often agitated by convulsive motions, turning it alternately outwards and inwards. When walking is attempted, the affected leg is seldom listed as usual in walk- ing, but is dragged along as if the whole limb were paralytic; and when it is attempted to be listed, this motion is unsteadily performed, the limb becoming agitated by irregular con- vulsive motions. MCCCL. The arm of the same side is generally af- fected at the same time; and, even when no voluntary motion is attempted, the arm is fre- quently agitated with various convulsive mo- tions. But especially when voluntary mo- tions are attempted, these are not properly executed, but are variously hurried or inter- rupted by convulsive motions in a direction contrary to that intended. The most com- mon instance of this is in the person's at- tempting to carry a cup of liquor to his mouth, when it is only after repeated efforts, interrupted by frequent convulsive retractions and deviations, that the cup can be carried to the mouth. MCCCLI. It appears to me, that the will often yields to these convulsive motions, as to a propen- sity, and thereby they are often increased, D4 while 68 PRACTICE while the person affected seems pleased with increasing the surprise and amusement which his motions occasion in the bystanders. MCCCLII. In this disease the mind is often affected with some degree of fatuity; and often shows the same varied, desultory, and causeless emo- tions which occur in hysteria. MCCCLIII. These are the most common circumstances of this disease; but at times, and in different persons, it is varied by some difference in the convulsive motions, particularly by these af- fecting the head and trunk of the body. As in this disease there seem to be propensities to motion, so various fits of leaping and running occur in the persons affected; and there have been instances of this disease, consisting of such convulsive motions, appearing as an epi- demic in a certain corner of the country. In such instances, persons of different ages are affected, and may seem to make an exception to the general rule above laid down; but still the persons are, for the most part, the young of both sexes, and of the more manifestly moveable constitutions. MCCCLIV. 69 OF PHYSIC. MCCCLIV. The method of curing this disease has been variously proposed. Dr. Sydenham propos- ed to cure it by alternate bleeding and purg- ing. In some plethoric habits I have found some bleeding useful; but in many cases I have found repeated evacuations, especially by bleeding, very hurtful. In many cases, I have found the disease, in spite of remedies of all kinds, continue for many months; but I have also found it often readily yield to tonic remedies, such as the Peruvian bark, and chalybeates. The late Dr. De Haen found several per- sons labouring under this disease cured by the application of electricity. VOL. 3. D5 SECT. 70 PRACTICE SECT. II. OF THE SPASMODIC AFFECTIONS OF THE VITAL FUNCTIONS. CHAP. IV.* Of the PALPITATION of the HEART. MCCCLV. THE motion thus named is a contraction or systole of the heart, that is per- formed with more rapidity, and generally also with more force than usual; and when at the same time the heart strikes with more than usual violence against the inside of the ribs, producing often a considerable sound. MCCCLVI. This motion, or palpitation, is occasioned by a great variety of causes, which have been recited * Though I have thought it proper to divide this book into sections, I think it necessary, for the convenience of references, to number the chapters from the beginning. 71 OF PHYSIC. recited with great pains by Mr. Senac and others; whom, however, I cannot follow in all the particulars with sufficient discernment, and therefore shall here only attempt to refer all the several cases of this disease to a few general heads. MCCCLVII. The first is of those arising from the appli- cation of the usual stimulus to the heart's con- traction; that is, the influx of the venous blood into its cavities, being made with more velocity, and therefore, in the same time, in greater quantity than usual. It seems to be in this manner that violent exercise occasions palpitation. MCCCLVIII. A second head of the cases of palpitation, is of those arising from any resistance given to the free and entire evacuation of the ven- tricles of the heart. Thus a ligature made upon the aorta occasions palpitations of the most violent kind. Similar resistances, either in the aorta or pulmonary artery, may be readily imagined; and such have been often found in the dead bodies of persons who, during life, had been much affected with pal- pitations. To this head are to be referred all those cases of palpitation arising from causes pro- D6 ducing 72 PRACTICE ducing an accumulation of blood in the great vessels near to the heart. MCCCLIX. A third head of the cases of palpitation, is of those arising from a more violent and rapid influx of the nervous power into the muscular fibres of the heart. It is in this manner that I suppose various causes acting in the brain, and particularly certain emotions of the mind, occasion palpitation. MCCCLX. A fourth head of the cases of palpitation, is of those arising from causes producing a weakness in the action of the heart, by dimin- ishing the energy of the brain with respect to it. That such causes operate in producing palpi- tation, I presume from hence, that all the sev- eral causes mentioned above (MCLXXVII et seq.) as in this manner producing syncope, do often produce palpitation. It is on this ground that these two diseases are affections frequently occurring in the same person, as the same causes may occasion the one or the other, according to the force of the cause and mobility of the person acted upon. It seems to be a law of the human economy, that a degree of debility occurring in any function, often produces a more vigorous exertion of the 73 OF PHYSIC. the same, or at least an effort towards it, and that commonly in a convulsive manner. I apprehend it to be the convulsive action, frequently ending in some degree of a spasm, that gives occasion to the intermittent pulse so frequently accompanying palpitation. MCCCLXI. A fifth head of the cases of palpitation may perhaps be of those arising from a peculiar irritability or mobility of the heart. This, indeed, may be considered as a predisponent cause only, giving occasion to the action of the greater part of the causes recited above. But it is proper to observe, that this predispo- sition is often the chief part of the remote cause; insomuch that many of the causes pro- ducing palpitation would not have this effect but in persons peculiarly predisposed. This head, therefore, of the cases of palpitation, often requires to be distinguished from all the rest. MCCCLXII. After thus marking the several cases and causes of palpitation, I think it necessary, with a view to the cure of this disease, to observe, that the several causes of it may be again re- duced to two heads. The first is, of those consisting in, or depending upon, certain or- ganic affections of the heart itself, or of the great 74 PRACTICE great vessels immediately connected with it. The second is, of those consisting in, or de- pending upon, certain affections subsisting and acting in other parts of the body, and act- ing either by the force of the cause, or in con- sequence of the mobility of the heart. MCCCLXIII. With respect to the cases depending upon the first set of causes, I must repeat here what I said with respect to the like cases of syncope, that I do not know any means of curing them. They, indeed, admit of some pallia- tion, first, by avoiding every circumstance that may hurry the circulation of the blood; and, secondly, by every means of avoiding a plethoric state of the system, or any occasion- al turgescence of the blood. In many of these cases, bloodletting may give a tempo- rary relief: But in so far as debility and mo- bility are concerned, in such cases this reme- dy is likely to do harm. MCCCLXIV. With respect to the cases depending upon the other set of causes, they may be various, and require very different measures: But I can here say in general, that these cases may be considered as of two kinds; one depending upon primary affections in other parts of the body, and acting by the force of the particu- lar 75 OF PHYSIC. lar causes; and another depending upon a state of mobility in the heart itself. In the first of these, it is obvious, that the cure of the palpitation must be obtained by curing the primary affection; which is not to be treated of here. In the second, the cure must be obtained, partly by diligently avoiding the occasional causes, partly and chiefly by cor- recting the mobility of the system, and of the heart in particular; for doing which we have treated of the proper means elsewhere. CHAP. V. Of DYSPNOEA, or DIFFICULT BREATH- ING. MCCCLXV. THE exercise of respiration, and the or- gans of it, have so constant and considerable a connexion with almost the whole of the other functions and parts of the human body, that upon almost every occasion of disease, respiration must be affected. Accordingly some difficulty and disorder in this function, are in fact symptoms very generally accom- panying disease. MCCCLXVI. 76 PRACTICE MCCCLXVI. Upon this account, the symptom of diffi- cult breathing deserves a chief place and an ample consideration in the general system of Pathology; but what share of consideration it ought to have in a treatise of Practice, I find it difficult to determine. MCCCLXVII. On this subject, it is, in the first place nec- essary to distinguish between the symptomatic and idiopathic affections; that is, between those difficulties of breathing which are symp- toms only of a more general affection, or of a disease subsisting primarily in other parts than the organs of respiration, and that difficulty of breathing which depends upon a primary affection of the lungs themselves. The va- rious cases of symptomatic dyspnœa I have taken pains to enumerate in my Methodical, Nosology, and it will be obvious they are such as cannot be taken notice of here. MCCCLXVIII. In my Nosology I have also taken pains to point out and enumerate the proper, or at lead the greater part of the proper, idiopathic cases of dyspnœa; but from that enumeration it will, I think, readily appear, that few, and indeed 77 OF PHYSIC. indeed hardly any, of these cases will admit or require much of our notice in this place. MCCCLXIX. The Dyspnœa Sicca, species, 2d; the Dys- pnœa Aerea, sp. 3d, the Dyspnœa Terrea, sp. 4th, and Dyspnœa Thoracica, sp. 7th, are some of them with difficulty known, and are all of them diseases which in my opinion do not admit of cure. All, therefore, that can be said concerning them here is, that they may admit of some palliation; and this, I think, is to be obtained chiefly by avoiding a ple- thoric state of the lungs, and every circum- stance that may hurry respiration. MCCCLXX. Of the Dyspnœa Extrinseca, sp. 8th, I can say no more, but that these external causes marked in the Nosology, and perhaps some others that might have like effects, are to be carefully avoided; or, when they have been applied, and their effects have taken place, the disease is to be palliated by the means mentioned in the last paragraph. MCCCLXXI. The other species, though enumerated as idiopathic, can hardly be considered as such, or as requiring to be treated of here. The 78 PRACTICE The Dyspnœa Catarrhalis, sp. 1st, may be considered as a species of catarrh, and is pret- ty certainly to be cured by the same remedies as that species of catarrh which depends rath- er upon the increased afflux of mucus to the bronchiæ, than upon any inflammatory state in them. The Dyspnœa Aquosa, sp. 5th, is certainly to be considered as a species of dropsy, and is to be treated by the same remedies as the other species of that disease. The Dyspnœa Pinguedinosa, sp. 6th, is in like manner to be considered as a symptom or local effect of the Polysarcia, and is only to be cured by correcting the general fault of the system. MCCCLXXII. From this view of those idiopathic cases of dyspnœa, which are perhaps all I could prop- erly arrange under this title, it will readily appear that there is little room for treating of them here: But there is still one case of dif- ficult breathing, which has been properly distinguished from every other under the title of Asthma; and as it deserves our particular attention, I shall here separately consider it. CHAP. 79 OF PHYSIC. CHAP. VI. Of ASTHMA. MCCCLXXIII. THE term of Asthma has been commonly applied by the vulgar, and even by many writers on the Practice of Physic, to every case of difficult breathing, that is, to every species of Dyspnœa. The Methodical No- sologists, also, have distinguished Asthma from Dyspnœa chiefly, and almost solely, by the former being the same affection with the lat- er, but in a higher degree. Neither of these applications of the term seems to have been correct or proper. I am of opinion, that the term Asthma may be most properly applied, and should be confined, to a case of difficult breathing that has peculiar symptoms, and depends upon a peculiar proximate cause, which I hope to assign with sufficient certain- ty. It is this disease I am now to treat of, and it is nearly what Practical Writers have generally distinguished from the other cases of difficult breathing, by the title of Spas- modic Asthma, or of Asthma convulsivum; although, by not distinguishing it with suf- ficient 80 PRACTICE ficient accuracy from the other cases of Dys- pnœa, they have introduced a great deal of confusion into their treatises on this subject. MCCCLXXIV. The disease I am to treat of, or the Asth- ma to be strictly so called, is often a heredi- tary disease. It seldom appears very early in life, and hardly till the time of puberty, or after it. It affects both sexes, but most fre- quently the male. I have not observed it to be more frequent in one kind of tempera- ment than in another; and it does not seem to depend upon any general temperament of the whole body, but upon a particular consti- tution of the lungs alone. It frequently at- tacks persons of a full habit; but it hardly ever continues to be repeated for some length of time without occasioning an emaciation of the whole body. MCCCLXXV. The attacks of this disease are generally in the night time, or towards the approach of night; but there are also some instances of their coming on in the course of the day. At whatever time they come on, it is for the most part suddenly, with a sense of tightness and stricture across the breast, and a sense of straightness in the lungs impeding inspiration. The person thus attacked, if in a horizontal situation, 81 OF PHYSIC. situation, is immediately obliged to get into somewhat of an erect posture, and requires a free and cool air. The difficulty of breath- ing goes on for some time increasing; and both inspiration and expiration are perform- ed slowly, and with a wheezing noise. In violent fits, speaking is difficult and uneasy. There is often some propensity to coughing, but it can hardly be executed. MCCCLXXVI. These symptoms often continue for many hours together, and particularly from mid- night till the morning is far advanced. Then commonly a remission takes place by degrees; the breathing becomes less laborious and more full, so that the person can speak and cough with more ease; and, if the cough brings up some mucus, the remission becomes imme- diately more considerable, and the person falls into a much wished for sleep. MCCCLXXVII. During these fits the pulse often continues in its natural state; but in some persons the fits are attended with a frequency of pulse, and with some heat and thirst, as marks of some degree of fever. If urine be voided at the beginning of a fit, it is commonly in con- siderable quantity, and with little colour or odour; but, after the fit is over, the urine voided 82 PRACTICE voided is in the ordinary quantity, of a high colour, and sometimes deposits a sediment, In some persons, during the fit the face is a little flushed and turgid; but more common- ly it is somewhat pale and shrunk. MCCCLXXVIII. After some sleep in the mornings the pa- tient, for the rest of the day, continues to have more free and easy breathing, but it is seldom entirely such. He still feels some tightness across his breast, cannot breathe easily in a horizontal posture, and can hardly bear any motion of his body, without having his breathing rendered more difficult and uneasy. In the afternoon he has an unusual flatulency of his stomach, and an unusual drowsiness; and, very frequently, these symptoms precede the first attacks of the disease. But, whether these symptoms appear or not, the difficulty of breathing returns towards the evening; and then sometimes gradually increases, till it becomes as violent as in the night before: Of if, during the day, the difficulty of breathing has been moderate, and the person gets some sleep in the first part of the night, he is, how- ever, waked about midnight or at some time between midnight and two o'clock in the morning; and is then suddenly seized with a fit of difficult breathing, which runs the same course as the night before. MCCCLXXIX. 83 OF PHYSIC. MCCCLXXIX. In this manner fits return for several nights successively; but generally, after some nights passed in this way, the fits suffer more con- siderable remissions. This especially hap- pens when the remissions are attended with a more copious expectoration in the mornings, and that this continues from time to time throughout the day. In these circumstances, asthmatics, for a long time after, have not only more easy days, but enjoy also nights of entire sleep, without the recurrence of the disease. MCCCLXXX. When this disease, however, has once taken place in the manner above described, it is ready to return at times for the whole of life after. These returns, however, happen with different circumstances in different persons. MCCCLXXXI. In some persons the fits are readily ex- cited by external heat, whether of the weather or of a warm chamber, and par- ticularly by warm bathing. In such persons fits are more frequent in summer, and partic- ularly during the dog days, than at other colder seasons. The same persons are also readily 84 PRACTICE readily affected by changes of the weathers especially by sudden changes made from a colder to a warmer, or, what is commonly the same thing, from a heavier to a lighter atmos- phere. The same persons are also affected by every circumstance straitening the capaci- ty of the thorax, as by any ligature made, or even by a plaster laid, upon it; and a like ef- fect happens from any increased bulk of the stomach, either by a full meal, or by air col- lected in it. They are likewise much affect- ed by exercise, or whatever else can hurry the circulation of the blood. MCCCLXXXII. As asthmatic fits seem thus to depend upon some fulness of the vessels of the lungs, it is probable that an obstruction of perspiration, and the blood being less determined to the surface of the body, may favour an accumu- lation in the lungs, and thereby be a means of exciting asthma. This seems to be the case of those asthmatics who have fits most frequently in the winter season, and who have commonly more of a catarrhal affection ac- companying the asthma; which therefore oc- curs more frequently in winter, and more manifestly from the application of cold. MCCCLXXXIII. Beside these cases of asthma excited by heat or cold, there are others, in which the fits are especially 85 OF PHYSIC. especially excited by powers applied to the nervous system; as by passions of the mind, by particular odours, and by irritations of smoke and dust. That this disease is an affection of the ner- vous system, and depending upon a mobility of the moving fibres of the lungs, appears pretty clearly from its being frequently con- nected with other spasmodic affections de- pending upon mobility; such as hysteria, hy- pochondriasis, dyspepsia, and atonic gout. MCCCLXXXIV. From the whole of the history of asthma now delivered, I think it will readily appear, that the proximate cause of this disease is a preternatural, and in some measure a spas- modic, constriction of the muscular fibres of the bronchiæ; which not only prevents the dilatation of the bronchiæ necessary to a free and full inspiration, but gives also a rigidity which prevents a full and free expiration. This preternatural constriction, like many other convulsive and spasmodic affections, is readily excited by a turgescence of the blood, or other cause of any unusual fulness and dis- tention of the vessels of the lungs. MCCCLXXXV. This disease, as coming by fits, may be gen- erally distinguished from most other species VOL. III. E of 86 PRACTICE of dyspnœa, whose causes being more con- stantly applied, produce therefore a more constant difficulty of breathing. There may, however, be some fallacy in this matter, as some of these causes may be liable to have abatements and intensities, whereby the dys- pnœa produced by them may seem to come by fits; but I believe it is seldom that such fits put on the appearance of the genuine asthmatic fits described above. Perhaps, however, there is still another case that may give more difficulty; and that is, when sev- eral of the causes, which we have assigned as causes of several of the species of difficult breathing referred to the genus of Dyspnœa, may have the effect of exciting a genuine asthmatic fit. Whether this can happen to any but the peculiarly predisposed to asthma, I am uncertain; and therefore, whether, in any such cases, the asthma may be considered as symptomatic; or if, in all such cases, the asthma may not still be considered and treated as an idiopathic disease. MCCCLXXXVI. The asthma, though often threatening im- mediate death, seldom occasions it; and many persons have lived long under this disease. In many cases, however, it does prove fatal; sometimes very quickly, and perhaps always at length. In some young persons it has ended soon, by occasioning a phthisis pulmo- nalis. 87 OF PHYSIC. nalis. After a long continuance, if often ends in a hydrothorax; and commonly, by occa- sioning some aneurism of the heart or great vessels, it thereby proves fatal. MCCCLXXXVII. As it is seldom that an asthma has been en- tirely cured; I therefore cannot propose any method of cure which experience has approv- ed as generally successful. But the disease admits of alleviation in several respects from the use of remedies; and my business now shall be chiefly to offer some remarks upon the choice and use of the remedies which have been commonly employed in cases of asthma. MCCCLXXXVIII. As the danger of an asthmatic fit arises chiefly from the difficult transmission of the blood through the vessels of the lungs, threat- ening suffocation; so the most probable means of obviating this seems to be bloodletting; and therefore, in all violent fits, practitioners have had recourse to this remedy. In first at- tacks, and especially in young and plethoric persons, bloodletting may be very necessary, and is commonly allowable. But it is also evident, that, under the frequent recurrence of fits, bloodletting cannot be frequently re- peated without exhausting and weakening the E2 patient 88 PRACTICE patient too much. It is further to be ob- served, that bloodletting is not so necessary as might be imagined, as the passage of the blood through the lungs is not so much interrupted as has been commonly supposed. This I particularly conclude from hence, that, in- stead of the suffusion of face, which is the usual effect of such interruption, the face, in asthmatic fits, is often shrunk and pale. I conclude the same also from this, that, in asthmatic fits, bloodletting does not com- monly give so much relief as, upon the con- trary supposition, might be expected. MCCCLXXXIX. As I have alleged above, that a turgescence of the blood is frequently the exciting cause of asthmatic fits, so it might be supposed, that a plethoric state of the system might have a great share in producing a turgescence of the blood in the lungs; and especially, therefore, that bloodletting might be a proper remedy in asthma. I allow it to be so in the first at- tacks of the disease: But as the disease, by continuing, generally takes off the plethoric state of the system; so, after the disease has continued for some time, I allege that blood- letting becomes less and less necessary. MCCCXC. Upon the supposition of asthmatics being in a plethoric state, purging might be suppos- ed 89 OF PHYSIC. ed to prove a remedy in this disease: But, both because the supposition is not common- ly well founded, and because purging is sel- dom found to relieve the vessels of the thorax, this remedy has not appeared to be well suit- ed to asthmatics; and large purging has al- ways been found to do much harm. But as asthmatics are always hurt by the stagnation and accumulation of matters, in the aliment- ary canal, so costiveness must be avoided, and an open belly proves useful. In the time of fits, the employment of emollient and mode- rately laxative glysters has been found to give considerable relief. MCCCXCI. As a flatulency of the stomach, and other symptoms of indigestion, are frequent attend- ants of asthma, and very troublesome to asth- matics; so, both for removing these symp- toms, and for taking off all determination to the lungs, the frequent use of gentle vomits is proper in this disease. In certain cases, where a fit was expected to come on in the course of the night, a vomit given in the evening has frequently seemed to prevent it. MCCCXCII. Blistering between the shoulders, or upon the breast, has been frequently employed to relieve asthmatics; but in the pure spasmodic E3 asthma 90 PRACTICE asthma we treat of here, I have rarely found blisters useful, either in preventing or reliev- ing fits. MCCCXCIII. Issues are certainly useful in obviating pleth- ora; but as such indications seldom arise in cases of asthma, so issues have been seldom found useful in this disease. MCCCXCIV. As asthmatic fits are so frequently excited by a turgescence of the blood, so the obviating and allaying of this by acids and neutral salts, seems to have been at all times the object of practitioners. See FLOYER on the Asthma. MCCCXCV. Although a plethoric state of the system may seem to dispose to asthma, and the occa- sional turgescence of the blood may seem to be frequently the exciting cause of the fits; yet it is evident, that the disease must have arisen chiefly from a peculiar constitution in the moving fibres of the bronchiæ, disposing them upon various occasions to fall into a spasmodic constriction; and therefore, that the entire cure of the disease can only be ex- pected from the correcting of that predisposi- tion, or from correcting the preternatural mobility 91 OF PHYSIC. mobility or irritability of the lungs in that respect. MCCCXCVI. In cases wherein this predisposition de- pends upon original conformation, the cure must be difficult, and perhaps impossible; but it may perhaps be moderated by the use of antispasmodics. Upon this footing, various remedies of that kind have been commonly employed, and particularly the fetid gums; but we have not found them of any consid- erable efficacy, and have observed them to be sometimes hurtful by their heating too much. Some other antispasmodics which might be supposed powerful, such as musk, have not been properly tried. The vitriolic ether has been found to give relief, but its effects are not lasting. MCCCXCVII. As in other spasmodic affections, so in this, the most certain and powerful antispasmodic is opium. I have often found it effectual, and generally safe; and if there have arisen doubts with respect to its safety, I believe they have arisen from not distinguishing between certain plethoric and inflammatory cases of dyspnœa, improperly named Asthma, and the genuine spasmodic asthma we treat of here. E4 MCCCXCVIII. 92 PRACTICE MCCCXCVIII. As in many cases this disease depends upon a predisposition which cannot be corrected by our art, so in such cases the patient can only escape the disease by avoiding the occasional or exciting causes, which I have endeavoured to point out above. It is, however, difficult to give any general rules here, as different asthmatics have their different idiosyncrasies with respect to externals. Thus, one asth- matic finds himself easiest living in the midst of a great city, while another cannot breathe but in the free air of the country. In the latter case, however, most asthmatics bear the air of a low ground, if tolerably free and dry, better than that of the mountain. MCCCXCIX. In diet also, there is some difference to be made with respect to different asthmatics. None of them bear a large or full meal, or any food that is of slow and difficult solution in the stomach; but many of them bear an- imal food of the lighter kinds, and in mode- rate quantity. The use of vegetables which readily prove flatulent, are always very hurt- ful. In recent asthma, and especially in the young and plethoric, a spare, light, and cool diet is proper, and commonly necessary; but, after the disease has continued for years, asth- matics 93 OF PHYSIC. matics commonly bear, and even require, a tolerably full diet, though in all cases a very full diet is very hurtful. MCCCC. In drinking, water, or cool watery liquors, is the only safe and fit drink for asthmatics; and all liquors ready to ferment, and become flatulent, are hurtful to them. Few asthmat- ics can bear any kind of strong drink; and any excess in such is always very hurtful to them. As asthmatics are commonly hurt by taking warm or tepid drink; so, both upon that account and upon account of the liquors weakening the nerves of the stomach, neither tea nor coffee is proper in this disease. MCCCCI. Asthmatics commonly bear no bodily mo- tion easily but that of the most gentle kind. Riding, however, on horseback, or going in a carriage, and especially sailing, are very often useful to asthmatics. VOL. 3. E5 CHAP. 94 PRACTICE CHAP. VII. Of the CHINCOUGH, or HOOPINGCOUGH. MCCCCII. THIS disease is commonly epidemic, and manifestly contagious. It seems to proceed from a contagion of a specific nature, and of a singular quality. It does not, like most other contagions, necessarily produce a fever; nor does it, like most others, occasion any eruption, or produce otherwise any evident change in the state of the human fluids. It has, in common with the catarrhal contagion, and with that of the measles, a peculiar de- termination to the lungs; but with particular effects there, very different from those of the other two; as will appear from the history of this disease now to be delivered. MCCCCIII. This contagion, like several others, affects persons but once in the course of their lives; and therefore, necessarily, children are most commonly the subjects of this disease: But there are many instances of it occurring in persons 95 OF PHYSIC. persons considerably advanced in life; though it is probable, that the further that persons are advanced in life, they are the less liable to be affected with this contagion. MCCCCIV. The disease commonly comes on with the ordinary symptoms of a catarrh arising from cold; and often, for many days, keeps entire- ly to that appearance; and I have had in- stances of a disease which, though evidently arising from the chincough contagion, never put on any other form than that of a com- mon catarrh. This, however, seldom happens; for, gen- erally, in the second, and at farthest in the third week after the attack, the disease puts on its peculiar and characteristic symptom, a convulsive cough. This is a cough in which the exspiratory motions peculiar to coughing are made with more frequency, rapidity, and violence, than usual. As these circumstances, however, in different instances of coughing, are in very different degrees; so no exact limits can be put to determine when the cough can be strictly said to be convulsive; and it is therefore especially by another circumstance that the chincough is distinguished from every other form of cough. This circumstance is, when many exspiratory motions have been convulsively made, and thereby the air is in great quantity thrown out of the lungs, a full E6 inspiration 96 PRACTICE inspiration is necessarily and suddenly made; which, by the air rushing in through the glot- tis with unusual velocity, gives a peculiar sound. This sound is somewhat different in different cases, but is in general called a Hoop; and from it the whole of the disease is called the Hoopingcough. When this so- norous inspiration has happened, the convul- sive coughing is again renewed, and continues in the same manner as before, till a quantity of mucus is thrown up from the lungs, or the contents of the stomach are thrown up by vomiting. Either of these evacuations com- monly puts an end to the coughing, and the patient remains free from it for some time after. Sometimes it is only after several al- ternate fits of coughing and hooping that ex- pectoration or vomiting takes place; but it is commonly after the second coughing that these happen, and put an end to the fit. MCCCCV. When the disease, in this manner, has tak- en its proper form, it generally continues for a long time after, and generally from one month to three; but sometimes much longer, and that with very various circumstances. MCCCCVI. The fits of coughing return at various in- tervals, rarely observing any exact period. They 97 OF PHYSIC. They happen frequently in the course of the day, and more frequently still in the course of the night. The patient has commonly some warning of their coming on; and, to avoid that violent and painful concussion which the coughing gives to the whole body, he clings fast to any thing that is near to him, or demands to be held fast by any person that he can come at. When the fit is over, the patient sometimes breathes fast, and seems fatigued for a little after: But in many this appears very little; and children are commonly so entirely re- lieved, that they immediately return to their play, or what else they were occupied in before. MCCCCVII. If it happens that the fit of coughing ends in vomiting up the contents of the stomach, the patient is commonly immediately after seized with a strong craving and demand for food, and takes it in very greedily. MCCCCVIILI. At the first coming on of this disease, the expectoration is sometimes none at all, or of a thin mucus only; and while this continues to be the case, the fits of coughing are more violent, and continue longer: But commonly the expectoration soon becomes considerable, and 98 PRACTICE and a very thick mucus, often in great quan- tity, is thrown up; and as this is more readily brought up, the fits of coughing are of shorter duration. MCCCCIX. The violent fits of coughing frequently in- terrupt the free transmission of the blood through the lungs, and thereby the free re- turn of blood from the vessels of the head. This occasions that turgescence and suffusion of face which commonly attends the fits of coughing, and seems to occasion also those eruptions of blood from the nose, and even from the eyes and ears, which sometimes happen in this disease. MCCCCX. This disease often takes place in the man- ner we have now described, without any py- rexia attending it; but, though Sydenham had seldom observed it, we have found the disease very frequently accompanied with py- rexia, sometimes from the very beginning, but more frequently only after the disease had continued for some time. When it does ac- company the disease, we have not found it appearing under any regular intermittent form. It is constantly in some degree pres- ent; but with evident exacerbations towards evening, continuing till next morning. MCCCCXI. 99 OF PHYSIC. MCCCCXI. Another symptom very frequently attend- ing the chincough, is a difficulty of breath- ing; and that not only immediately before and after fits of coughing, but as constantly present, though in different degrees in differ- ent persons. I have hardly ever seen an in- stance of a fatal chincough, in which a con- siderable degree of pyrexia and dyspnœa had not been for some time constantly present. MCCCCXII. When by the power of the contagion this disease has once taken place, the fits of cough- ing are often repeated, without any evident exciting cause: But, in many cases, the con- tagion may be considered as giving a predis- position only; and the frequency of fits de- pends in some measure upon various exciting causes; such as, violent exercise; a full meal; the having taken in food of difficult solution; irritations of the lungs by dust, smoke, or dis- agreeable odours of a strong kind; and espec- ially any considerable emotion of the mind. MCCCCXIII. Such are the chief circumstances of this disease, and it is of various event; which, however, 100 PRACTICE however, may be commonly foreseen by at- tending to the following considerations. The younger that children are, they are in the greater danger from this disease; and of those to whom it proves fatal, there are many more under two years old than above it. The older that children are, they are the more secure against an unhappy event; and this I hold to be a very general rule, though I own there are many exceptions to it. Children born of phthisical and asthmatic parents are in the greatest danger from this disease. When the disease, beginning in the form of a catarrh, is attended with fever and difficult breathing, and with little expectoration, it often proves fatal, without taking on the form of the hoopingcough; but, in most of such cases, the coming on of the convulsive cough and hooping, bringing on at the same time a more free expectoration, generally removes the danger. When the disease is fully formed, if the fits are neither frequent nor violent, with mod- erate expectoration, and the patient, during the intervals of the fits, is easy, keeps his ap- petite, gets sleep, and is without fever or dif- ficult breathing, the disease is attended with no danger; and these circumstances becoming daily more favourable, the disease very soon spontaneously terminates. An expectoration, either very scanty or very copious, is attended with danger; espec- ially 101 OF PHYSIC. ially if the latter circumstance is attended with great difficulty of breathing. Those cases in which the fits terminate by a vomiting, and are immediately followed by a craving of food, are generally without danger. A moderate hemorrhagy from the nose often proves salutary; but very large hemor- rhagies are generally very hurtful. This disease coming upon persons under a date of much debility, has very generally an unhappy event. The danger of this disease sometimes arises from the violence of the fits of coughing, oc- casioning apoplexy, epilepsy, or immediate suffocation: But these accidents are very rare; and the danger of the disease seems generally to be in proportion to the fever and dyspnœa attending it. MCCCCXIV. The cure of this disease has been always considered as difficult, whether the purpose be to obviate its fatal tendency when it is vi- olent, or merely to shorten the course of it when it is mild. When the contagion is re- cent, and continues to act, we neither know how to correct, nor how to expel it; and therefore the disease necessarily continues for some time: But it is probable, that the con- tagion in this as in other instances ceases at length to act; and that then the disease con- tinues, 102 PRACTICE tinues, as in other convulsive affections, by the power of habit alone. MCCCCXV. From this view of the matter I maintain, that the practice must be different, and adapt- ed to two different indications, according to the period of the disease. At the beginning of the disease, and for some time after, the remedies to be employed must be such as may obviate the violent effects of the disease, and the fatal tendency of it; but, after the disease has continued for some time, and is without any violent symptoms, the only remedies which can be required are those which may interrupt its course, and put an entire stop to it sooner than it would have spontaneously ceased. MCCCCXVI. For answering the first indication. In ple- thoric subjects, or in others, when from the circumstances of the cough and fits it appears that the blood is difficultly transmitted through the lungs, bloodletting is a necessary remedy; and it may be even necessary to repeat it, es- pecially in the beginning of the disease: But, as spasmodic affections do not commonly ad- mit of much bleeding, so it is seldom proper in the chincough to repeat this remedy often. MCCCCXVII. 103 OF PHYSIC. MCCCCXVII. As costiveness frequently attends this dis- ease, so it is necessary to obviate or remove it by laxatives employed; and keeping an open belly is generally useful: But large evacuations in this way are commonly hurt- ful. MCCCCXVIII. To obviate or remove the inflammatory de- termination to the lungs that sometimes oc- curs in this disease, blistering is often useful, and even repeated blistering has been of ser- vice; but issues have not so much effect, and should by no means supersede the repeated blistering that may be indicated. When blisters are proper, they are more effectual when applied to the thorax, than when ap- plied to any distant parts. MCCCCXIX. Of all other remedies, emetics are the most useful in this disease; both in general by in- terrupting the return of spasmodic affections, and in particular by determining very power- fully to the surface of the body, and thereby taking off determinations to the lungs. For these purposes, I think, full vomiting is fre- quently to be employed; and, in the inter- vals 104 PRACTICE vals necessary to be left between the times of full vomiting, nauseating doses of the anti- monial emetics may be useful. I have never found the sulphur auratum, so much praised by Clossius, to be a convenient medicine, on account of the uncertainty of its dose; and the tartar emetic employed in the manner di- rected by the late Dr. Fothergill, has appear- ed to be more useful. MCCCCXX. These are the remedies to be employed in the first stage of the disease for obviating its fatal tendency, and putting it into a safe train. But in the second stage, when I suppose the contagion has ceased to act, and that the dis- ease continues merely by the power of habit, a different indication arises, and different remedies are to be employed. MCCCCXXI. This disease, which often continues for a long time, does not, in my opinion, continue during the whole of that time in consequence of the contagion's remaining in the body, and continuing to act in it. That the disease does often continue long after the contagion has ceased to act, and that too by the power of habit alone, appears to me probable from hence, that terror has frequently cured the disease; that any considerable change in the state 105 OF PHYSIC. state of the system, such as the coming on of the small pox, has also cured it; and, lastly, that it has been cured by antispasmodic and tonic medicines; whilst none of all these means of cure can be supposed either to cor- rect or to expel a morbific matter, though they are evidently suited to change the state and habits of the nervous system. MCCCCXXII. From this view we are directed to the in- dication that may be formed, and in a great measure to the remedies which may be em- ployed in what we suppose to be the second stage of the disease. It may perhaps be al- leged, that this indication of shortening the course of the disease is not very important or necessary, as it supposes that the violence or danger is over, and, in consequence, that the disease will soon spontaneously cease. The last supposition, however, is not well founded; as the disease, like many other con- vulsive and spasmodic affections, may con- tinue for a long time by the power of habit alone, and by the repetition of paroxysms may have hurtful effects; more especially as the violence of paroxysms, and therefore their hurtful effects, may be much aggravated by various external causes that may be accident- ally applied. Our indication, therefore, is proper; and we proceed to consider the sev- eral 106 PRACTICE eral remedies which may be employed to answer it. MCCCCXXIII. Terror may possibly be a powerful rem- edy, but it is difficult to measure the degree of it that shall be produced; and, as a slight degree of it may be ineffectual, and a high degree of it dangerous, I cannot propose to employ it. MCCCCXXIV. The other remedies which we suppose suit- ed to our second indication, and which in- deed have been frequently employed in this disease, are antispasmodics or tonics. Of the antispasmodics, castor has been par- ticularly recommended by Dr. Morris; but in many trials we have not found it effectual. With more probability musk has been em- ployed: But whether it be from our not hav- ing it of a genuine kind, or not employing it in sufficiently large doses, I cannot determine; but we have not found it commonly success- ful. Of antispasmodics, the most certainly powerful is opium: And when there is no considerable fever or difficulty of breathing present, opium has often proved useful in moderating the violence of the chincough; but I have not known it employed so as en- tirely to cure the disease. If 107 OF PHYSIC. If hemlock has proved a remedy in this disease, as we must believe from Dr. Butter's accounts, I agree with that author, that it is to be considered as an antispasmodic. Upon this supposition, it is a probable remedy; and from the accounts of Dr. Butter and some others, it seems to have been often useful: but, in our trials, it has often disappointed us, perhaps from the preparation of it not having been always proper. MCCCCXXV. Of the tonics, I consider the cupmoss, for- merly celebrated, as of this kind; as also the bark of the misletoe: But I have had no ex- perience of either, as I have always trusted to the Peruvian bark. I consider the use of this medicine as the most certain means of curing the disease in its second stage; and when there has been little fever present, and a sufficient quantity of the bark has been giv- en, it has seldom failed of soon putting an end to the disease. MCCCCXXVI. When convulsive disorders may be sup- posed to continue by the force of habit alone, it has been found that a considerable change in 108 PRACTICE in the whole of the circumstances and manner of life has proved a cure of such diseases; and analogy has applied this in the case of the chincough so far, that a change of air has been employed, and supposed to be useful. In several instances I have observed it to be so; but I have never found the effects of it durable, or sufficient to put an entire stop to the disease. SECT. 109 OF PHYSIC. SECT. III. OF THE SPASMODIC AFFECTIONS IN THE NATURAL FUNCTIONS. CHAP. VIII. Of the PYROSIS, or what is named in Scotland the WATER BRASH. MCCCCXXVII. THE painful sensations re- ferred to the stomach, and which are proba- bly occasioned by real affections of this organ, are of different kinds. Probably they proceed from affections of different natures, and should therefore be distinguished by different appel- lations; but I must own that the utmost precis- ion in this matter will be difficult. In my essay towards a methodical Nosology, I have, how- ever, attempted it. For those pains that are either acute and pungent, or accompanied with a sense of distention, or with a sense of constriction, if they are at the same time not attended with any sense of acrimony or heat, VOL. III. F I employ 110 PRACTICE I employ the appellation of Gastrodynia. To express those painful or uneasy sensations which seem to arise from a sense of acrimony irritating the part, or from such a sense of heat as the application of acrids, whether ex- ternally or internally applied, often gives, I employ the term of Cardialgia; and by this I particularly mean to denote those feelings which are expressed by the term Heartburn in the English language. I think the term Soda has been commonly employed by prac- tical writers to express an affection attended with feelings of the latter kind. MCCCCXXVIII. Beside the pains denoted by the terms Gas- trodynia, Periadynia, Cardialgia, and Soda, there is, I think, another painful sensation different from all of these, which is named by Mr. Sauvages Pyrosis Suecica; and his ac- count of it is taken from Linnæus, who names it Cardialgia Sputatoria. Under the title of Pyrosis Mr. Sauvages has formed a genus, of which the whole of the species, except the eighth, which he gives under the title of Py- rosis Suecica, are all of them species of the Gastrodynia or of the Cardialgia; and if there is a genus to be formed under the title of Py- rosis, it can in my opinion comprehend only the species I have mentioned. In this case, indeed, I own that the term is not very prop- er; but my aversion to introduce new names has 111 OF PHYSIC. has made me continue to employ the term of Mr. Sauvages. MCCCCXXIX. The Gastrodynia and Cardialgia I judge to be for the most part symptomatic affections; and therefore have given them no place in this work: But the Pyrosis, as an idiopathic disease, and never before treated of in any system, I propose to treat of here. MCCCCXXX. It is a disease frequent among people in lower life; but occurs also, though more rarely, in people of better condition. Though frequent in Scotland, it is by no means so frequent as Linnæus reports it to be in Lap- land. It appears most commonly in persons under middle age, but seldom in any persons before the age of puberty. When it has once taken place, it is ready to recur occa- sionally for a long time after; but it seldom appears in persons considerably advanced in life. It affects both sexes, but more frequent- ly the female. It sometimes attacks pregnant women, and some women only when they are in that condition. Of other women, it more frequently affects the unmarried; and of the married, most frequently the barren. I have had many instances of its occurring in women labouring under a fluor albus. F2 MCCCCXXXI. 112 PRACTICE MCCCCXXXI. The fits of this disease usually come on in the morning and forenoon, when the stomach is empty. The first symptom of it is a pain at the pit of the stomach, with a sense of con- striction, as if the stomach was drawn towards the back; the pain is increased by raising the body into an erect posture, and therefore the body is bended forward. This pain is often very severe; and, after continuing for some time, it brings on an eructation of a thin wa- tery fluid in considerable quantity. This fluid has sometimes an acid taste, but is very often absolutely insipid. The eructation is for some time frequently repeated; and does not immediately give relief to the pain which preceded it, but does so at length, and puts an end to the fit. MCCCCXXXII. The fits of this disease commonly come on without any evident exciting cause; and I have not found it steadily connected with any particular diet. It attacks persons using an- imal food, but I think more frequently those living on milk and farinacea. It seems often to be excited by cold applied to the lower ex- tremities; and is readily excited by any con- siderable emotion of mind. It is often with- out any symptoms of dyspepsia. MCCCCXXXIII. 113 OF PHYSIC. MCCCCXXXIII. The nature of this affection is not very ob- vious; but I think it may be explained in this manner: It seems to begin by a spasm of the muscular fibres of the stomach; which is afterwards, in a certain manner, communicat- ed to the blood vessels and exhalants, so as to increase the impetus of the fluids in these ves- sels, while a constriction takes place on their extremities. While therefore the increased impetus determines a greater quantity than usual of fluids into these vessels, the constric- tion upon their extremities allows only the pure watery parts to be poured out, analo- gous, as I judge, in every respect, to what happens in the diabetes hystericus. MCCCCXXXIV. The practice in this disease is as difficult as the theory. The paroxysm is only to be cer- tainly relieved by opium. Other antispas- modics, as vitriolic ether and volatile alkali, are sometimes of service, but not constantly so. Although opium and other antispas- modics relieve the fits, they have no effect in preventing their recurrence. For this pur- pose, the whole of the remedies of dyspepsia have been employed without success. Of the use of the nux vomica, mentioned as a rem- edy by Linnæus, I have had no experience. F3 CHAP. 114 PRACTICE CHAP. IX. Of the COLIC. MCCCCXXXV. THE principal symptom of this disease, is a pain felt in the lower belly. It is seldom fixed and pungent in one part, but is a pain- ful distention in some measure spreading over the whole of the belly; and particularly with a sense of twisting or wringing ground the navel. At the same time, with this pain, the navel and teguments of the belly are frequent- ly drawn inwards, and often the muscles of the belly is spasmodically contracted, and this in separate portions, giving the appear- ance of a bag full of round balls. MCCCCXXXVI. Such pains, in a certain degree, sometimes occur in cases of diarrhoea and cholera; but these are less violent and more transitory, and are named Gripings. It is only when more violent and permanent, and attended with costiveness, that they constitute colic. This is also commonly attended with vomiting, which 115 OF PHYSIC. which in many cases is frequently repeated, especially when any thing is taken down into the stomach; and in such vomitings, not only the contents of the stomach are thrown up, but also the contents of the duodenum, and therefore frequently a quantity of bile. MCCCCXXXVII. In some cases of colic, the peristaltic mo- tion is inverted through the whole length of the alimentary canal, in such a manner that the contents of the great guts, and therefore stercoraceous matter, is thrown up by vom- iting; and the same inversion appears still more clearly from this, that what is thrown into the rectum by glyster is again thrown out by the mouth. In these circumstances of in- version the disease has been named Ileus, or the Iliac Passion; and this has been suppos- ed to be a peculiar disease distinct from colic; but to me it appears that the two diseases are owing to the same proximate cause, and have the same symptoms, only in a different degree. MCCCCXXXVIII. The colic is often without any pyrexia at- tending it. Sometimes, however, an inflam- mation comes upon the part of the intestine especially affected; and this inflammation aggravates all the symptoms of the disease, being probably what brings on the most con- F4 siderable 116 PRACTICE siderable inversion of the peristaltic motion; and, as the stercoraceous vomiting is what especially distinguishes the ileus, this has been considered as always depending on an inflam- mation of the intestines. However, I can af- firm, that as there are inflammations of the intestines without stercoraceous vomiting, so I have seen instances of stercoraceous vomit- ing without inflammation; and there is there- fore no ground for distinguishing ileus from colic, but as a higher degree of the same af- fection. MCCCCXXXIX. The symptoms of the colic, and the dissec- tions of bodies dead of this disease, show very clearly that it depends upon a spasmodic con- striction of a part of the intestines; and that this therefore is to be considered as the prox- imate cause of the disease. In some of the dissections of persons dead of this disease, an intussusception has been remarked to have happened; but whether this be constantly the case in all the appearances of ileus, is not certainly determined. MCCCCXL. The colic has commonly been considered as being of different species, but I cannot follow the writers on this subject in the distinctions they have established. So far, however, as a difference 117 OF PHYSIC. difference of the remote cause constitutes a difference of species, a distinction may per- haps be admitted; and accordingly in my Nosology I have marked seven different spe- cies: But I am well persuaded, that in all these different species the proximate cause is the same, that is, a spasmodic constriction of a part of the intestines; and consequently, that in all these cases the indication of cure is the same, that is, to remove the conduc- tion mentioned. Even in the several species named Stercorea, Callosa, and Calculosa, in which the disease depends upon an obstruc- tion of intestine, I am persuaded that these obstructions do not produce the symptoms of colic, excepting in so far as they produce spas- modic constrictions of the intestines; and therefore, that the means of cure in these cases, so far as they admit of cure, must be obtained by the same means which the gen- eral indication above mentioned suggests. MCCCCXLI. The cure, then, of the colic universally, is to be obtained by removing the spasmodic constrictions of the intestines; and the rem- edies suited to this purpose may be referred to three general heads: 1. The taking off the spasm by various an- tispasmodic powers. VOL. 3. F5 2. The 118 PRACTICE 2. The exciting the action of the intestines by purgatives. 3. The employing mechanical dilatation. MCCCCXLII. Before entering upon a more particular ac- count of these remedies, it will be proper to observe, that in all cases of violent colic, it is adviseable to practise bloodletting; both as it may be useful in obviating the inflammation which is commonly to be apprehended, and even as it may be a means of relaxing the spasm of the intestine. This remedy may perhaps be improper in persons of a weak and lax habit, but in all persons of tolerable vigour it will be a safe remedy; and in all cases where there is the least suspicion of an inflammation actually coming on, it will be absolutely necessary. Nay, it will be even proper to repeat it perhaps several times, if, with a full and hard pulse, the appearance of the blood drawn, and the relief obtained by the first bleeding, shall authorise such repe- tition. MCCCCXLIII. The antispasmodic powers that may be employed, are, the application of heat in a dry or humid form, the application of blis- ters, the use of opium, and the use of mild oils. The 119 OF PHYSIC. The application of heat, in a dry form, has been employed by applying to the belly of the patient a living animal, or bladders filled with warm water, or bags of substances which long retain their heat; and all these have sometimes been applied with success; but none of them seem to me so powerful as the application of heat in a humid form. This may be employed either by the im- mersion of a great part of the body in warm water, or by fomenting the belly with cloths wrung out of hot water. The immersion has advantages from the application of it to a greater part of the body, and particularly to the lower extremities: But immersion cannot always be conveniently practised, and fomen- tation may have the advantage of being long- er continued; and it may have nearly all the benefit of immersion, if it be at the same time applied both to the belly and to the lower extremities. MCCCCXLIV. From considering that the teguments of the lower belly have such a connexion with the intestines, as at the same time to be affected with spasmodic contractions, we perceive that blisters applied to the belly may have the ef- fect of taking off the spasms both from the muscles of the belly and from the intestines; and accordingly, blistering has often been em- F6 ployed 120 PRACTICE ployed in the colic with advantage. Anal- ogous to this, rubefacients applied to the belly have been frequently found useful. MCCCCXLV. The use of opium in colic may seem to be an ambiguous remedy. Very certainly it may for some time relieve the pain, which is often so violent and urgent, that it is difficult to abstain from the use of such a remedy. At the same time, the use of opium retards or suspends the peristaltic motion so much, as to allow the intestines to fall into constrictions; and may therefore, while it relieves the pain, render the cause of the disease more obstinate. On this account, and further as opium pre- vents the operation of purgatives so often nec- essary in this disease, many practitioners are averse to the use of it, and some entirely re- ject the use of it as hurtful. There are, however, others who think they can employ opium in this disease with much advantage. In all cases where the colic comes on with- out any previous costiveness, and arises from cold, from passions of the mind, or other causes which operate especially on the ner- vous system, opium proves a safe and certain remedy; but in cases which have been pre- ceded by long costiveness, or where the colic, though not preceded by costiveness, has how- ever continued for some days without a stool, so that a stagnation of fæces in the colon is to be 121 OF PHYSIC. be suspected, the use of opium is of doubtful effect. In such cases, unless a stool has been first procured by medicine, opium cannot be employed but with some hazard of aggravat- ing the disease. However, even in those circumstances of costiveness, when, without inflammation, the violence of the spasm is to be suspected, when vomiting prevents the ex- hibition of purgatives, and when with all this the pain is extremely urgent, opium is to be employed, not only as an anodyne, but also as an antispasmodic, necessary to favour the operation of purgatives; and may be so em- ployed, when, either at the same time with the opiate, or not long after it, a purgative can be exhibited. Is the hyosciamus, as often showing, along with its narcotic, a purgative quality, better suited to this disease than opium? MCCCCXLVI. It is seemingly on good grounds that sev- eral practitioners have recommended the large use of mild oils in this disease, both as anti- spasmodics and as laxatives; and, where the palate and stomach could admit them, I have found them very useful. But as there are few Scottish stomachs that can admit a large use of oils, I have had few opportunities of employing them. MCCCCXLVII. 122 PRACTICE MCCCCXLVII. The second set of remedies adapted to the cure of colic, are purgatives; which, by ex- citing the action of the intestines, either above or below the obstructed place, may remove the constriction; and therefore these purga- tives may be given either by the mouth, or thrown by glyster into the anus. As the dis- ease is often seated in the great guts; as glys- ters, by having a more sudden operation, may give more immediate relief; and as purga- tives given by the mouth are ready to be re- jected by vomiting; so it is common, and in- deed proper, to attempt curing the colic in the first place by glysters. These may at first be of the mildest kind, consisting of a large bulk of water, with some quantity of a mild oil; and such are sometimes sufficiently effi- cacious: However, they are not always so; and it is commonly necessary to render them more powerfully stimulant by the addition of neutral salts, of which the most powerful is the common or marine salt. If these saline glysters, as sometimes happens, are rendered again too quickly, and on this account or oth- erwise are found ineffectual, it may be proper, instead of these salts, to add to the glysters an infusion of senna, or of some other purgative that can be extracted by water. The anti- monial wine may be sometimes employed in glysters with advantage. Hardly any glysters are 123 OF PHYSIC. are more effectual than those made of turpen- tine properly prepared. When all other in- jections are found ineffectual, recourse is to be had to the injection of tobacco smoke; and, when even this fails, recourse is to be had to the mechanical dilatation to be men- tioned hereafter. MCCCCXLVIII. As glysters often fail altogether in relieving this disease, and as even when they give some relief they are often imperfect in producing a complete cure; so it is generally proper, and often necessary, to attempt a more entire and certain cure by purgatives given by the mouth. The more powerful of these, or, as they are called, the Drastic Purgatives, may be some- times necessary; but their use is to be avoid- ed, both because they are apt to be rejected by vomiting, and because when they do not succeed in removing the obstruction they are ready to induce an inflammation. Upon this account it is usual, and indeed proper, at least in the first place, to employ the milder and less inflammatory purgatives. None have succeeded with me better than the crystals of tartar, because this medicine may be conve- niently given, in small but repeated doses, to a considerable quantity; and under this man- agement it is the purgative lead ready to be rejected by vomiting, and much less so than the other neutral salts. If a stronger purga- tive 124 PRACTICE tive be required, jalap, properly prepared, is less offensive to the palate, and sits better up- on the stomach, than most other powerful purgatives. On many occasions of colic, nothing is more effectually purgative than a large dose of calomel. Some practitioners have attempted to remove the obstruction of the intestines by antimonial emetics exhibited in small doses, repeated at proper intervals; and when these doses are not entirely rejected by vomiting, they often prove effectual pur- gatives. When every purgative has failed, the ac- tion of the intestines has been effectually ex- cited by throwing cold water on the lower extremities. MCCCCXLIX. The third means of overcoming the spasm of the intestines in this disease, is by employ- ing a mechanical dilatation; and it has been frequently supposed that quicksilver, given in large quantity, might operate in this manner. I have not, however, found it successful; and the theory of it is with me very doubtful. Some authors have mentioned the use of gold and silver pills, or balls, swallowed down; but I have no experience of such practices, and I cannot suppose them a probable means of relief. MCCCCL. 125 OF PHYSIC. MCCCCL. Another means of mechanical dilatation, and a more probable measure, is by injecting a large quantity of warm water by a proper syringe, which may throw it with some force, and in a continued stream, into the rectum. Both from the experiments reported by the late Mr. De Haen, and from those I myself have had occasion to make, I judge this rem- edy to be one of the most powerful and ef- fectual. MCCCCLI. I have now mentioned all the several means that may be employed for the cure of the colic, considered as a genus; but before I quit this subject, it may be expected that I should take notice of some of the species which may seem to require a particular con- sideration. In this view it may be expected that I should especially take notice of that species named the Colic of Poitou, and par- ticularly known in England by the name of the Devonshire Colic. MCCCCLII. This species of the disease is certainly a peculiar one, both in respect of its cause and its effects; but, as to the first, it has been lately 126 PRACTICE lately so much the subject of investigation, and is so well ascertained by the learned phy- sicians Sir George Barker and Dr. Hardy, that it is unnecessary for me to say any thing of it here. With respect to the cure of it, so far as it appears in the form of a colic, my want of ex- perience concerning it does not allow me to speak with any confidence on the subject; but, so far as I can learn from others, it ap- pears to me, that it is to be treated by all the several means that I have proposed above for the cure of colic in general. How far the peculiar effects of this disease are to be certainly foreseen and obviated, I have not properly learned; and I must leave the matter to be determined by those who have had sufficient experience in it. CHAP. X. Of the CHOLERA. MCCCCLIII. IN this disease, a vomiting and purging concurring together, or frequently alternating with one another, are the chief symptoms. The 127 OF PHYSIC. The matter rejected both upwards and down- wards appears manifestly to consist chiefly of bile. MCCCCLIV. From this last circumstance I conclude, that the disease depends upon an increased secretion of bile, and its copious effusion into the alimentary canal; and, as in this it irri- tates and excites the motions above mention- ed, I infer, that the bile thus effused in larger quantity is at the same time also of a more acrid quality. This appears likewise from the violent and very painful gripings that at- tend the disease, and which we can impute only to the violent spasmodic contractions of the intestines that take place here. These spasms are commonly communicated to the abdominal muscles, and very frequently to those of the extremities. MCCCCLV. In the manner now described, the disease frequently proceeds with great violence, till the strength of the patient is greatly, and often suddenly, weakened; while a coldness of the extremities, cold sweats, and faintings, coming on, an end is put to the patient's life, some- times in the course of one day. In other cases the disease is less violent, continues for a day or two, and then ceases by degrees; though 128 PRACTICE though such recoveries seldom happen with- out the assistance of remedies. MCCCCLVI. The attacks of this disease are seldom ac- companied with any symptoms of pyrexia; and though, during the course of it, both the pulse and respiration are hurried and irregu- lar, yet these symptoms are generally so en- tirely removed by the remedies that quiet the spasmodic affections peculiar to the disease, as to leave no ground for supposing that it had been accompanied by any proper py- rexia. MCCCCLVII. This is a disease attending a very warm state of the air; and, in very warm climates, it may perhaps appear at any time of the year: But even in such climates it is most frequent during their warmest seasons; and in temperate climates, it appears only in the warm seasons. Dr. Sydenham considered the appearances of this disease in England to be confined to the month of August; but he himself observed it to appear some- times towards the end of summer, when the season was unusually warm; and that, in proportion to the heat, the violence of the disease was greater. Others have observed that it appeared more early in summer, and always 129 OF PHYSIC. always sooner or later, according as the great heats sooner or later let in. MCCCCLVIII. From all these circumstances, it is, I think, very evident, that this disease is the effect of a warm atmosphere, producing some change in the state of the bile in the human body: And the change may consist, either in the matter of the bile being rendered more acrid, and thereby fitted to excite a more copious se- cretion; or, in the same matter, its being prepared to pass off in larger quantity than usual. MCCCCLIX. It has been remarked, that in warm cli- mates and seasons, after extremely hot and dry weather, a fall of rain cooling the atmos- phere seems especially to bring on this dis- ease; and it is very probable that an ob- structed perspiration may have also a share in this, though it is also certain that the disease does appear when no change in the temper- ature of the air, nor any application of cold, has been observed. MCCCCLX. It is possible, that, in some cases, the heat of the season may give only a predisposition, and 130 PRACTICE and that the disease may be excited by certain ingesta or other causes; but it is equally cer- tain, that the disease has occurred without any previous change or error, either in diet, or in the manner of life, that could be ob- served. MCCCCLXI. The Nosologists have constituted a Genus under the title of Cholera, said under this have arranged as species every affection in which a vomiting and purging of any kind happened to concur. In many of these spe- cies, however, the matter evacuated is not bilious; nor does the evacuation proceed from any cause in the date of the atmos- phere. Further, in many of these species also, the vomiting which occurs is not an es- sential, but merely an accidental symptom from the particular violence of the disease. The appellation of Cholera therefore should, in my opinion, be confined to the disease I have described above; which by its peculiar cause, and perhaps also by its symptoms, is very different from all the other species that have been associated with it. I believe that all the other species arranged under the title of Cholera by Sauvages or Sagar, may be properly enough referred to the genus of Di- arrhœa; which we are to treat of in the next chapter. The 131 OF PHYSIC. The distinction I have endeavoured to establish between the proper Cholera, and the other diseases that have sometimes got the same appellation, will, as I judge, super- sede the question, Whether the Cholera, in temperate climates, happens at any other season than that above assigned? MCCCCLXII. In the case of a genuine cholera, the cure of it has been long established by experience. In the beginning of the disease, the evacu- ation of the redundant bile is to be favoured by the plentiful exhibition of mild diluents, both given by the mouth, and injected by the anus; and all evacuant medicines, employed in either way, are not only superfluous, but commonly hurtful. MCCCCLXIII. When the redundant bile appears to be sufficiently washed out, and even before that, if the spasmodic affections of the alimentary canal become very violent, and are commu- nicated in a considerable degree to other parts of the body, or when a dangerous debility seems to be induced, the irritation is to be immediately obviated by opiates, in sufficient- ly large doses, but in small bulk, and given either by the mouth or by glyster. MCCCCLXIV. 132 PRACTICE MCCCCLXIV. Though the patient be in this manner re- lieved, it frequently happens, that when the operation of the opium is over, the disease shows a tendency to return; and, for at least some days after the first attack, the irritabili- ty of the intestines, and their disposition to fall into painful spasmodic contractions, seem to continue. In this situation, the repetition of the opiates, for perhaps several days, may come to be necessary; and as the debility commonly induced by the disease favours the disposition to spasmodic affections, it is often useful and necessary, together with the opiates, to employ the tonic powers of the Peruvian bark. CHAP. XI. Of DIARRHOEA or LOOSENESS. MCCCCLXV. THIS disease consists in evacuations by stool, more frequent and of more liquid mat- ter than usual. This leading and character- istic symptom is so diversified in its degree, in its causes, and in the variety of matter evac- uated, 133 OF PHYSIC. uated, that it is almost impossible to give any general history of the disease. MCCCCLXVI. It is to be distinguished from dysentery, by not being contagious; by being generally without fever; and by being with the evacu- ation of the natural excrements, which are, at least for some time, retained in dysentery. The two diseases have been commonly distin- guished by the gripings being more violent in the dysentery; and they are commonly less violent and less frequent in diarrhœa: But as they frequently do occur in this also, and sometimes to a considerable degree, so they do not afford any proper distinction. MCCCCLXVII. A diarrhœa is to be distinguished from cholera chiefly by the difference of their caus- es; which, in cholera, is of one peculiar kind; but in diarrhœa is prodigiously diversified, as we shall see presently. It has been common to distinguish cholera by the evacuation down- wards being of bilious matter, and by this be- ing always accompanied with a vomiting of the same kind; but it does not universally apply, as a diarrhœa is sometimes attended with vomiting, and even of bilious matter. VOL. III. G MCCCCLXVIII. 134 PRACTICE MCCCCLXVIII. The disease of diarrhœa, thus distinguish- ed, is very greatly diversified; but in all cases, the frequency of stools is to be imputed to a preternatural increase of the peristaltic mo- tion in the whole, or at least in a considerable portion, of the intestinal canal. This increas- ed action is in different degrees, is often con- vulsive and spasmodic, and at any rate is a motus abnormis: For which reason, in the Methodical Nosology, I have referred it to the order of Spasmi, and accordingly treat of it in this place. MCCCCLXIX. Upon the same ground, as I consider the disease named Lientery to be an increased peristaltic motion over the whole of the in- testinal canal, arising from a peculiar irrita- bility, I have considered it as merely a species of diarrhœa. The idea of a laxity of the in- testinal canal being the cause either of lientery, or other species of diarrhœa, appears to me to be without foundation, except in the single case of frequent liquid stools from a palsy of the sphincter ani. MCCCCLXX. The increased action of the peristaltic mo- tion, I consider as always the chief part of the proximate 135 OF PHYSIC. proximate cause of diarrhœa: But the dis- ease is further, and indeed chiefly, diversified by the different causes of this increased ac- tion; which we are now to inquire into. MCCCCLXXI. The several causes of the increased action of the intestines may be referred, I think, in the first place, to two general heads. The first is, of the diseases of certain parts of the body which, either from a consent of the intestines with these parts, or from the re- lation which the intestines have to the whole system, occasion an increased action in the intestines, without the transference of any stimulant matter from the primary diseased part to them. The second head of the causes of the in- creased action of the intestines is of the stim- uli of various kinds, which are applied direct- ly to the intestines themselves. MCCCCLXXII. That affections of other parts of the system may affect the intestines without the transfer- ence or application of any stimulant matter, we learn from hence, that the passions of the mind do in some persons excite diarrhœa. G2 MCCCCLXXIII. 136 PRACTICE MCCCCLXXIII. That diseases in other parts may in like manner affect the intestines, appears from the dentition of infants frequently exciting diar- rhœa. I believe that the gout often affords another instance of the same kind; and prob- ably there are others also, though not well ascertained. MCCCCLXXIV. The stimuli (MCCCCLXXI) which may be applied to the intestines are of very various kinds; and are either, 1. Matters introduced by the mouth. 2. Matters poured into the intestines by the several excretories opening into them. 3. Matters poured from certain preternat- ural openings made into them in certain dis- eases. MCCCCLXXV. Of those (MCCCCLXXIV, 1.) introduc- ed by the mouth, the first to be mentioned are the aliments commonly taken in. Too great a quantity of these taken in, often prevents their due digestion in the stomach; and by being thus sent in their crude, and probably acrid, state to the intestines, they frequently excite diarrhœa. The 137 OF PHYSIC. The same aliments, though in proper quan- tity, yet having too great a proportion, as fre- quently happens, of saline or saccharine mat- ter along with them, prove stimulant to the intestines, and excite diarrhœa. But our aliments prove especially the caus- es of diarrhœa, according as they, from their own nature, or from the weakness of the stom- ach, are disposed to undergo an undue de- gree of fermentation there, and thereby be- come stimulant to the intestines. Thus aces- cent aliments are ready to produce diarrhœa; but whether from their having any directly purgative quality, or only as mixed in an over proportion with the bile, is not well de- termined. MCCCCLXXVI. Not only the acescent, but also the putres- cent disposition of the aliments, seems to oc- casion a diarrhœa; and it appears that even the effluvia of putrid bodies, taken in any way in large quantity, have the same effect. Are oils or fats, taken in as a part of our aliments, ever the cause of diarrhœa? and if so, in what manner do they operate? MCCCCLXXVII. The other matters introduced by the mouth, which may be causes of diarrhœa, are those thrown in either as medicines, or poi- G3 sons 138 PRACTICE sons that have the faculty of stimulating the alimentary canal. Thus, in the list of the Materia Medica, we have a long catalogue of those named purgatives; and in the list of poisons, we have many possessed of the same quality. The former, given in a certain quantity, occasion a temporary diarrhœa; and given in very large doses, may occasion it in excess, and continue it longer than usual, producing that species of diarrhœa named a Hypercatharsis. MCCCCLXXVIII. The matters (MCCCCLXXIV, 2.) pour- ed into the cavity of the intestines from the excretories opening into them, and which may occasion diarrhœa, are either those from the pancreatic or biliary duct, or those from the excretories in the coats of the intestines them- selves. MCCCCLXXIX. What changes may happen in the pancre- atic juice, I do not exactly know; but I sup- pose that an acrid fluid may issue from the pancreas, even while dill entire in its struc- ture; but more especially, when it is in a sup- purated, schirrous, or cancerous state, that a very acrid matter may be poured out by the pancreatic duct, and occasion diarrhœa. MCCCCLXXX. 139 OF PHYSIC. MCCCCLXXX. We know well, that from the biliary duct the bile may be poured out in greater quan- tity than usual; and there is little doubt of its being also sometimes poured out of a more than ordinary acrid quality. It is very prob- able, that in both ways the bile is frequently a cause of diarrhœa. Though I have said above that diarrhœa may be commonly distinguished from chol- era, I must admit here, that as the causes pro- ducing that state of the bile which occasions cholera, may occur in all the different possible degrees of force, so as, on one occasion, to produce the most violent and distinctly mark- ed cholera; but, upon another, to produce only the gentlest diarrhœa; which, however, will be the same disease, only varying in de- gree: So I think it probable, that in warm climates, and in warm seasons, a diarrhœa bil- iosa of this kind may frequently occur, not to be always certainly distinguished from chol- era. However this may be, it is sufficiently probable, that, in some cases, the bile, with- out having been acted upon by the heat of the climate or season, may be redundant and acrid, and prove therefore a particular cause of diarrhœa. G4 MCCCCLXXXI. 140 PRACTICE MCCCCLXXXI. Beside bile from the several causes and in the conditions mentioned, the biliary duct may pour out pus, or other matter, from ab- scesses in the liver, which may be the cause of diarrhœa. Practical writers take notice of a diarrhœa wherein a thin and bloody liquid is discharg- ed; which they suppose to have proceeded from the liver, and have therefore given the disease the name of Hepatirrhœa: But we have not met with any instance of this kind; and therefore cannot properly say any thing concerning it. MCCCCLXXXII. A second set of excretories, from which matter is poured into the cavity of the intes- tines, are those from the coats of the intestines themselves; and are either the exhalants pro- ceeding directly from the extremities of ar- teries, or the excretories from the mucous fol- licles: And both these sources occur in pro- digious number over the internal surface of the whole intestinal canal. It is probable that it is chiefly the effusion from these sources which, in most instances, gives the matter of the liquid stools occurring in diar- rhœa. MCCCCLXXXIII. 141 OF PHYSIC. MCCCCLXXXIII. The matter from both sources may be pour- ed out in larger quantity than usual, merely by the increased action of the intestines, whether that be excited by the passions of the mind (MCCCCXXII), by diseases in other parts of the system (MCCCCLXXI, 1.), or by the various stimulants mentioned MCCCCLXXV, and following; or the quantity of matter poured out may be in- creased, not so much by the increased action of the intestines, as by an increased afflux of fluids from other parts of the system. Thus, cold applied to the surface of the body, and suppressing perspiration, may de- termine a greater quantity of fluids to the in- testines. Thus, in the ischuria renalis, the urine tak- en into the bloodvessels is sometimes deter- mined to pass off again by the intestines. In like manner, pus or serum may be ab- sorbed from the cavities in which they have been stagnant, and be again poured out into the intestines, as frequently happens, in par- ticular with respect to the water of dropsies. MCCCCLXXXIV. It is to be observed here, that a diarrhœa may be excited not only by a copious afflux of fluids from other parts of the system, but VOL. 3. G5 likewise 142 PRACTICE likewise by the mere determination of various acrid matters from the mass of blood into the cavity of the intestines. Thus it is supposed that the morbific matter of fevers is sometimes thrown out into the cavity of the intestines, and gives a critical diarrhœa: And whether I do or do not admit the doctrine of critical evacuations, I think it is probable that the morbific matter of the exanthemata is fre- quently thrown upon the intestines, and oc- casions diarrhœa. MCCCCLXXXV. It is to me further probable, that the pu- trescent matter diffused over the mass of blood in putrid diseases, is frequently poured out by the exhalants into the intestines, and proves there the cause, at least in part, of the diarrhœa so commonly attending these diseases. MCCCCLXXXVI. Upon this subject of the matters poured into the cavity of the intestines, I have chief- ly considered them as poured out in unusual quantity: But it is probable that, for the most part, they are also changed in their quality, and become of a more acrid and stimulant nature; upon which account especially it is, that they excite, or at least increase, a diar- rhœa. MCCCCLXXXVII. 143 OF PHYSIC. MCCCCLXXXVII. How far, and in what manner, the exha- lant fluid may be changed in its nature and quality, we do not certainly know: But with respect to the fluid from the mucous excre- tories, we know, that, when poured out in unusual quantity, it is commonly, at the same time, in a more liquid and acrid form; and may prove, therefore, considerably irritating. MCCCCLXXXVIII. Though the copious effusion of a more liquid and acrid matter from the mucous ex- cretories, be probably owing to the matter being poured out immediately as it is secreted from the blood into the mucous follicles, without being allowed to stagnate in the lat- er, so as to acquire that milder quality and thicker consistence we commonly find in the mucus in its natural state; and although we might suppose that the excretions of a thin and acrid fluid should always be the effect of every determination to the mucous follicles, and of every stimulant applied to them; yet it is certain, that the reverse is sometimes the case; and that, from the mucous follicles, there is frequently an increased excretion of a mucus, which appears in its proper form of a mild, viscid, and thickish matter. This commonly occurs in the case of dysentery; G6 and 144 PRACTICE and it has been observed to give a species of diarrhœa, which has been properly named the Diarrhœa Mucosa. MCCCCLXXXIX. A third source of matter poured into the cavity of the intestines, and occasioning diar- rhœa (MCCCCLXXIV, 3.), is from those preternatural openings produced by diseases in the intestines or neighbouring parts. Thus the bloodvessels on the internal surface of the intestines may be opened by erosion, rupture, or anastomosis, and pour into the cavity their blood, which, either by its quantity or by its acrimony, whether inherent, or acquired by stagnation, may sometimes give a diarrhœa evacuating bloody matter. This is what I think happens in that disease which has been called the Melæna or Morbus Niger. MCCCCXC. Another preternatural source of matter poured into the cavity of the intestines, is the rupture of abscesses seated either in the coats of the intestines themselves, or in any of the contiguous viscera, which, during an inflamed state, had formed an adhesion with some part of the intestines. The matter thus poured into their cavity may be various; purulent or sanious, or both together, mixed at the same time with more or less of blood; and in 145 OF PHYSIC. in each of these states may be a cause of diar- rhœa. MCCCCXCI. Amongst the stimuli that may be directly applied to the intestines, and which, by in- creasing their peristaltic motion, may occasion diarrhœa, I must not omit to mention worms, as having frequently that effect. MCCCCXCII. I must also mention here a state of the in- testines, wherein their peristaltic motion is preternaturally increased, and a diarrhœa produced; and that is, when they are affect- ed with an erythematic inflammation. With respect to the existence of such a state, and its occasioning diarrhœa, see what is said above in CCCXCVIII and following. Whether it is to be considered as a particular and dis- tinct case of diarrhœa, or is always the same with some of those produced by one or other of the causes above mentioned, I have not been able to determine. MCCCCXCIII. Lastly, by an accumulation of alimentary or of other matter poured into the cavity of the intestines from several of the sources above mentioned, a diarrhœa may be especially oc- casioned 146 PRACTICE casioned when the absorption of the lacteals, or of other absorbents, is prevented, either by an obstruction of their orifices, or by an ob- struction of the mesenteric glands, through which alone the absorbed fluids can be trans- mitted. In one instance of this kind, when the chyle prepared in the stomach and duodenum is not absorbed in the course of the intestines, but passes off in considerable quantity by the anus, the disease has been named Morbus Cœl- iacus, or simply and more properly Cœliaca; which accordingly I have considered as a spe- cies of diarrhœa. MCCCCXCIV. I have thus endeavoured to point out the various species of disease that may come un- der the general appellation of Diarrhœa; and from that enumeration it will appear, that many, and indeed the greater part of the cases of diarrhœa, are to be considered as sympa- thetic affections, and to be cured only by curing the primary disease upon which they depend; of which, however, I cannot prop- erly treat here. From our enumeration it will also appear, that many of the cases of di- arrhœa which may be considered as idiopath- ic, will not require my saying much of them here. In many instances, the disease is as- certained, and also the cause assigned, by the condition of the matter evacuated; so that what 147 OF PHYSIC. what is necessary to correct or remove it will be sufficiently obvious to practitioners of any knowledge. In short, I do not find that I can offer any general plan for the cure of di- arrhœa; and all that I can propose to do on this subject, is to give some general remarks on the practice that has been commonly fol- lowed in the cure of this disease. MCCCCXCV. The practice in this disease has chiefly pro- ceeded upon the supposition of an acrimony in the fluids, or of a laxity in the simple and moving fibres of the intestines; and the rem- edies employed have accordingly been, Cor- rectors of particular acrimony, general de- mulcents, evacuants by vomiting or purging, astringents, or opiates. Upon each of these kinds of remedy I shall now offer some re- marks. MCCCCXCVI. An acid acrimony is, upon several occa- sions, the cause of diarrhœa, particularly in children; and in such cases the absorbent earths have been very properly employed. The common, however, and promiscuous use of these, has been very injudicious; and where there is any putrescency, they must be hurtful. MCCCCXCVII. 148 PRACTICE MCCCCXCVII. The cases in which there is a putrid or pu- trescent acrimony prevailing, have been, I think, too seldom taken notice of; and, there- fore, the use of acids too seldom admitted. The acrimony to be suspected in bilious cases, is probably of the putrescent kind. MCCCCXCVIII. The general correctors of acrimony are the mild diluents and demulcents. The former have not been so much employed in diarrhœa as they ought; for, joined with demulcents, they very much increase the effects of the latter: And although the demulcents, both mucilaginous and oily, may by themselves be useful, yet without the assistance of diluents they can hardly be introduced in such quan- tity as to answer the purpose. MCCCCXCIX. As indigestion and crudities present in the stomach, are so often the cause of diarrhœa, vomiting must therefore be frequently very useful in this disease. In like manner, when the disease proceeds, as it often does, from obstructed perspiration, and increased afflux of fluids to the intestines, vomiting is perhaps the most effectual means of 149 OF PHYSIC. of restoring the determination of the fluids to the surface of the body. It is possible also, that vomiting may give some inversion of the peristaltic motion, which is determined too much downwards in diar- rhœa; so that upon the whole it is a remedy which may be very generally useful in this disease. MD. Purging has been supposed to be more uni- versally necessary, and has been more gen- erally practised. This, however, in my opin- ion, proceeds upon very mistaken notions with respect to the disease; and such a prac- tice seems to me for the most part superflu- ous, and in many cases very hurtful. It goes upon the supposition of an acrimony present in the intestines, that ought to be carried out by purging: But, if that acrimony has either been introduced by the mouth, or brought into the intestines from other parts of the body, purging can neither be a means of cor- recting nor of exhausting it; and must rather have the effect of increasing its afflux, and of aggravating its effects. From whatever source the acrimony which can excite a diarrhœa proceeds, it may be supposed sufficient to evacuate itself, so far as that can be done by purging; and as in cholera, so in the same kind of diarrhœa, it will be more proper to assist the evacuation by diluents and demul- cents, 150 PRACTICE cents, than to increase the irritation by pur- gatives. MDI. If, then, the use of purgatives in diarrhœa may be considered, even when an acrimony is present, as superfluous, there are many other cases in which it may be extremely hurtful. If the irritability of the intestines shall, from affections in other parts of the system, or other causes, have been already very much increas- ed, purgatives must necessarily aggravate the disease. In the case of lientery, nobody thinks of giving a purgative; and in many cases of diarrhœa approaching to that, they must be equally improper. I have already observed, that when diarrhœa proceeds from an afflux of fluids to the intestines, whether in too great quantity, or of an acrid quality, purgatives may be hurtful; and whoever, therefore considers the numerous and various sources from which acrid matter may be pour- ed into the cavity of the intestines, will readi- ly perceive, that, in many cases of diarrhœa, purgatives may be extremely pernicious. There is one case in particular to be taken notice of. When, from a general and acrid dissolution of the blood, the serous fluids run off too copiously into the cavity of the intes- tines, and excite that diarrhœa which attends the advanced state of hectic fever, and is prop- erly called a Colliquative Diarrhœa; I have, in 151 OF PHYSIC. in such cases, often seen purgatives given with the most baneful effects. There is still another case of diarrhœa in which purgatives are pernicious; and that is, when the disease depends, as we have alleged it sometimes may, upon an erythematic in- flammation of the intestines. I need hardly add, that if there be a case of diarrhœa depending upon a laxity of the solids, purgatives cannot there be of any ser- vice, and may do much harm. Upon the whole, it will, I think, appear, that the use of purgatives in diarrhœa are very much limited; and that the promiscuous use of them, which has been so common, is injudicious, and often pernicious. I believe the practice has been chiefly owing to the use of purgatives in dys- enteric cases, in which they are truly useful; because, contrary to the case of diarrhœa, there is in dysentery a considerable constric- tion of the intestines. MDII. Another set of remedies employed in diar- rhœa are astringents. There has been some hesitation about the employment of these in recent cases, upon the supposition that they might occasion the retention of an acrid mat- ter that should be thrown out. I cannot, however, well understand or assign the cases in which such caution is necessary; and I think that the power of astringents is seldom so 152 PRACTICE so great as to render their use very danger- ous. The only difficulty which has occurred to me, with respect to their use, has been to judge of the circumstances to which they are especially adapted. It appears to me to be only in those where the irritability of the in- testines depend upon a loss of tone: And this, I think, may occur either from the de- bility of the whole system, or from causes act- ing on the intestines alone. All violent or long continued spasmodic and convulsive af- fections of the intestinal canal necessarily in- duce a debility there; and such causes often take place, from violent irritation, in colic, dysentery, cholera, and diarrhœa. MDIII. The last of the remedies of diarrhœa that remain to be mentioned are opiates. The same objections have been made to the use of these, in recent cases of diarrhœa, as to that of astringents; but on no good grounds: For the effect of opiates, as astringent, is never very permanent; and an evacuation depend- ing upon irritation, though it may be for some time suspended by opiates, yet always returns very soon. It is only by taking off irritability that opiates are useful in diarrhœa; and therefore, when the disease depends upon an increase of irritability alone, or when, though proceeding from irritation, that irri- tation 153 OF PHYSIC. tation is corrected or exhausted, opiates are the most useful and certain remedy. And though opiates are not suited to correct or re- move an irritation applied, they are often of great benefit in suspending the effects of that irritation whenever these are violent: And, upon the whole, it will appear, that opiates may be very frequently, and with great pro- priety, employed in the cure of diarrhœa. CHAP. XII. Of the DIABETES. MDIV. THIS disease consists in the voiding of an unusually large quantity of urine. As hardly any secretion can be increased without an increased action of the vessels con- cerned in it, and as some instances of this dis- ease are attended with affections manifestly spasmodic, I have had no doubt of arranging the diabetes under the order of Spasmi. MDV. This disease is always accompanied with a great degree of thirds, and therefore with the taking 154 PRACTICE taking in of a great quantity of drink. This in some measure accounts for the very extra- ordinary quantities of urine voided: But still, independent of this, a peculiar disease certainly takes place; as the quantity of urine voided does almost always exceed the whole of the liquids, and sometimes the whole of both solids and liquids, taken in. MDVI. The urine voided in this disease is always very clear, and at first sight appears entirely without any colour; but viewed in a certain light, it generally appears to be slightly tinged with a yellowish green, and in this respect has been very properly compared to a solution of honey in a large proportion of water. Examined by the taste, it is very generally found to be more or less sweet; and many ex- periments that have now been made in dif- ferent instances of the disease show clearly that such urine contains, in considerable quantity, a saccharine matter which appears to be very exactly of the nature of common sugar. MDVII. Doctor Willis seems to me to have been the first who took notice of the sweetness of the urine in diabetes, and almost every phy- sician of England has since taken notice of the 155 OF PHYSIC. the same. It is to be doubted, indeed, if there is any case of idiopathic diabetes in which the urine is of a different kind. Though neither the ancients, nor, in the oth- er countries of Europe, the moderns, till the latter were directed to it by the English, have taken notice of the sweetness of the urine, it does not persuade me, that either in ancient or in modern times the urine in diabetes was of another kind. I myself, indeed, think I have met with one instance of diabetes in which the urine was perfectly in lipid; and it would seem that a like observation had oc- curred to Dr. Martin Lister. I am persuad- ed, however, that such instances are very rare; and that the other is by much the more com- mon, and perhaps the almost universal occur- rence. I judge, therefore, that the presence of such a saccharine matter may be considered as the principal circumstance in idiopathic diabetes; and it gives at least the only case of that disease that I can properly treat of here, for I am only certain that what I am further to mention relates to such a case. MDVIII. The antecedents of this disease, and conse- quently the remote causes of it, have not been well ascertained. It may be true that it fre- quently happens to men who, for a long time before, had been intemperate in drinking; that it happens to persons of a broken consti- tution, 156 PRACTICE tution, or who, as we often express it, are in a cachectic state; that it sometimes follows in- termittent fevers; and that it has often oc- curred from excess in the drinking of min- eral waters. But none of these causes apply very generally to the cases that occur: Such cases are not always, nor even frequently, fol- lowed by a diabetes; and there are many in- stances of diabetes which could not be refer- red to any of them. In most of the cases of this disease which I have met with, I could not refer it to any particular cause. MDIX. This disease commonly comes on slowly, and almost imperceptibly, without any pre- vious disorder. It often arises to a consider- able degree, and subsists long without being accompanied with evident disorder in any particular part of the system. The great thirst which always, and the voracious appe- tite which frequently, occurs in it, are often the only remarkable symptoms. Under the continuance of the disease, the body is often greatly emaciated; and a great weakness also prevails. The pulse is commonly frequent; and an obscure fever is for the most part pres- ent. When the disease proves fatal, it gen- erally ends with a fever, in many circum- stances, particularly those of emaciation and debility, resembling a hectic. MDX. 157 OF PHYSIC. MDX. The proximate cause of this disease is not certainly or clearly known. It seems to have been sometimes connected with calculous af- fections of the kidneys; and it is possible, that an irritation applied there may increase the secretion of urine. It perhaps often does so; but how it should produce the singular change that takes place in the state of the urine, is not to be easily explained. It cer- tainly often happens, that calculous matters are long present in the urinary passages, with- out having any such effect as that of produc- ing diabetes in any shape. Some have supposed that the disease oc- curs from a relaxed state of the secretory ves- sels of the kidneys; and indeed the dissections of persons who had died of this disease have shown the kidneys in a very flaccid state. This, however, is probably to be considered as rather the effect than the cause of the disease. That no topical affection of the kidneys has a share in producing this disease, and that a fault in the assimilation of the fluids is rather to be blamed, I conclude from hence, that even the solid food taken in, increases the quantity of the urine voided, at the same time with an increase of the saccharine matter above mentioned. VOL. III. H MDXI. 158 PRACTICE MDXI. The diabetes has been supposed to be ow- ing to a certain state of the bile; and it is true, that this disease has sometimes occurred in persons who were at the same time affected with diseases of the liver: But this concur- rence does not often take place; and the dia- betes frequently occurs separately from any affection of the liver. In twenty instances of diabetes which I have seen, there was not in any one of them any evident affection of the liver. The explanation that has been offered of the nature and operation of the bile, in pro- ducing diabetes, is very hypothetical, and no wise satisfying. MDXII. As I have already said, I think it probable, that in most cases the proximate cause of this disease is some fault in the assimilatory powers, or in those employed in converting aliment- ary matters into the proper animal fluids. This I formerly hinted to Dr. Dobson, and it has been prosecuted and published by him; but I must own, that it is a theory embarrass- ed with some difficulties which I cannot at present very well remove. MDXIII. 159 OF PHYSIC. MDXIII. The proximate cause of diabetes being so little known or ascertained, I cannot propose any rational method of cure in the disease. From the testimony of several authors, I be- lieve that the disease has been cured: But I believe also, that this has seldom happened; and when the disease has been cured, I doubt much if it was effected by the several reme- dies to which these cures have been ascribed. In all the instances of this disease which I my- self have seen, and in several others of which I have been informed, no cure of it has ever been made in Scotland, though many instances of it have occurred, and in most of them the remedies recommended by authors have been diligently employed. I cannot, therefore, with any advantage, enter into a detail of these remedies; and as the disease, together with its several circumstances, when they shall hereafter occur, is likely to become the sub- ject of diligent investigation, I avoid going farther at present, and judge it prudent to suspend my opinion till I shall have more ob- servations and experiments upon which I can form it more clearly. H2 CHAP. 160 PRACTICE CHAP. XIII. Of the HYSTERIA, or the HYSTERIC DIS- EASE. MDXIV. THE many and various symptoms which have been supposed to belong to a disease un- der this appellation, render it extremely dif- ficult to give a general character or definition of it. It is, however, proper in all cases to attempt some general idea; and therefore, by taking the most common form, and that con- currence of symptoms by which it is princi- pally distinguished, I have formed a charac- ter in my system of Methodical Nosology, and shall here endeavour to illustrate it by giving a more full history of the phenomena. MDXV. The disease attacks in paroxysms or fits. These commonly begin by some pain and ful- ness felt in the left side of the belly. From this a ball seems to move with a grumbling noise into the other parts of the belly; and, making as it were various convolutions there, seems to move into the stomach; and more distinctly 161 OF PHYSIC. distinctly still rises up to the top of the gullet, where it remains for some time, and by its pressure upon the larynx gives a sense of suf- focation. By the time that the disease has proceeded thus far, the patient is affected with a stupor and insensibility, while at the same time the body is agitated with various convulsions. The trunk of the body is wreathed to and fro, and the limbs are va- riously agitated; commonly the convulsive motion of one arm and hand, is that of beat- ing, with the closed fist, upon the breast very violently and repeatedly. This date contin- ues for some time, and has during that time some remissions and renewals of the convul- sive motions; but they at length cease, leav- ing the patient in a stupid and seemingly sleeping state. More or less suddenly, and frequently with repeated sighing and sobbing, together with a murmuring noise in the belly, the patient returns to the exercise of sense and motion, but generally without any recollec- tion of the several circumstances that had taken place during the fit. MDXVI. This is the form of what is called an hysteric paroxysm, and is the most common form; but its paroxysms are considerably varied in dif- ferent persons, and even in the same person at different times. It differs, by having more or fewer of the circumstances above mention- H3 ed; 162 PRACTICE ed; by these circumstances being more or less violent; and by the different duration of the whole fit. Before the fit, there is sometimes a sudden and unusually large flow of limpid urine. At the coming on of the fit, the stomach is some- times affected with vomiting, the lungs with considerable difficulty of breathing, and the heart with palpitations. During the fit, the whole of the belly, and particularly the navel, is drawn strongly inwards; the sphincter ani is sometimes so firmly constricted as not to admit a small glyster pipe, and there is at the same time an entire suppression of urine. Such fits are, from time to time, ready to re- cur; and during the intervals, the patients are liable to involuntary motions, to fits of laugh- ing and crying, with sudden transitions from the one to the other; while sometimes false imaginations, and some degree of delirium, also occur. MDXVII. These affections have been supposed pecu- liar to the female sex; and indeed they most commonly appear in females: But they some- times, though rarely, attack also the male sex; never, however, that I have observed, in the same exquisite degree. In the female sex, the disease occurs espec- ially from the age of puberty to that of thirty five years; and though it does sometimes, yet very 163 OF PHYSIC. very seldom appears before the former or after the latter of these periods. At all ages, the time at which it most read- ily occurs is that of the menstrual period. The disease more especially affects the fe- males of the most exquisitely sanguine and plethoric habits, and frequently affects those of the most robust and masculine constitu- tions. It affects the barren more than the breed- ing women, and therefore frequently young widows. It occurs especially in those females who are liable to the Nymphomania; and the Nosologists have properly enough marked one of the varieties of this disease by the title of Hysteria Libidinosa. In the persons liable to the fits of this dis- ease, it is readily excited by the passions of the mind, and by every considerable emotion, especially those brought on by surprise. The persons liable to this disease acquire often such a degree of sensibility, as to be strongly affected by every impression that comes upon them by surprise. MDXVIII. In this history, there appears to be a con- currence of symptoms and circumstances prop- erly marking a very particular disease, which I think may be distinguished from all others. It seems to me to have been improperly con- H4 sidered 164 PRACTICE sidered by physicians as the same with some other diseases, and particularly with hypo- chondriasis. The two diseases may have some symptoms in common, but for the most part are considerably different. Spasmodic affections occur in both diseas- es; but neither so frequently, nor to so great a degree, in hypochondriasis as in hysteria. Persons liable to hysteria are sometimes af- fected at the same time with dyspepsia. They are often, however, entirely free from it; but I believe this never happens to persons af- fected with hypochondriasis. These different circumstances mark some difference in the two diseases; but they are still more certainly distinguished by the tem- perament they attack, and by the time of life at which they appear to be most exquisitely formed. It has been generally supposed, that the two diseases differ only in respect of their ap- pearing in different sexes. But this is not well founded: For although the hysteria ap- pears most commonly in females, the male sex is not absolutely free from it, as I have observed above; and although the hypochon- driasis may be most frequent in men, the in- stances of it in the female sex are very common. MDXIX. From all these considerations, it must, I think, appear, that the hysteria may be very well, 165 OF PHYSIC. well, and properly, distinguished from hypo- chondriasis. Further, it seems to me to have been with great impropriety, that almost every degree of the irregular motions of the nervous system has been referred to the one or other of these two diseases. Both are marked by a pecu- liarity of temperament, as well as by certain symptoms commonly accompanying that; but some of these, and many others usually mark- ed by the name of nervous symptoms, may, from various causes, arise in temperaments different from that which is peculiar to either hysteria or hypochondriasis, and without be- ing joined with the peculiar symptoms of ei- ther the one or the other disease: So that the appellations of Hysteric and Hypochondriac are very inaccurately applied to them. Un- der what view these symptoms are otherwise to be considered, I am not ready to deter- mine; but must remark, that the appellation of Nervous Diseases is too vague and unde- fined to be of any useful application. MDXX. Having thus endeavoured to distinguish hysteria from every other disease, I shall now attempt its peculiar pathology. With respect to this, I think it will, in the first place, be obvious, that its paroxysms begin by a con- vulsive and spasmodic affection of the alimen- tary canal, which is afterwards communicated VOL. 3. H5 to 166 PRACTICE to the brain, and to a great part of the nervous system. Although the disease appears to be- gin in the alimentary canal, yet the connexion which the paroxysms so often have with the menstrual flux, and with the diseases that de- pend on the state of the genitals, shows, that the physicians have at all times judged rightly in considering this disease as an affection of the uterus and other parts of the genital system. MDXXI. With regard to this, however, I can go no farther. In what manner the uterus, and in particular the ovaria, are affected in this dis- ease; how the affection of these is communi- cated, with particular circumstances, to the alimentary canal; or how the affection of this, rising upwards, affects the brain, so as to oc- casion the particular convulsions which occur in this disease, I cannot pretend to explain. But although I cannot trace this disease to its first causes, or explain the whole of the phenomena, I hope, that with respect to the general nature of the disease, I may form some general conclusions, which may serve to direct our conduct in the cure of it. MDXXII. Thus, from a consideration of the predispo- nent and occasional causes, it will, I think, ap- pear, 167 OF PHYSIC. pear, that the chief part of the proximate cause is a mobility of the system, depending generally upon its plethoric state. MDXXIII. Whether this disease ever arises from a mo- bility of the system, independent of any ple- thoric state of it, I cannot positively deter- mine; but in many cases that have subsisted for some time, it is evident that a sensibility, and consequently a mobility, are acquired, which often appear when neither a general plethora can be supposed to subsist, nor an occasional turgescence to have happened. However, as we have shown above, that a dis- tention of the vessels of the brain seems to oc- casion epilepsy, and that a turgescence of the blood in the vessels of the lungs seems to pro- duce asthma; so analogy leads me to suppose, that a turgescence of blood in the uterus, or in other parts of the genital system, may occasions the spasmodic and convulsive mo- tions which appear in hysteria. It will, at the same time, be evident, that this affection of the genitals must especially occur in ple- thoric habits; and every circumstance men- tioned in the history of the disease serves to confirm this opinion with respect to its prox- imate cause. H6 MDXXIV. 168 PRACTICE MDXXIV. From this view of the subject, the analogy of hysteria and epilepsy will readily appear; and why, therefore, I am to say that the indi- cations of cure are the same in both. As the indications, so the several means of answering them, are so much the same in both diseases, that the same observations and di- rections, with regard to the choice and em- ployment of these remedies, that have been delivered above on the subject of epilepsy, will apply pretty exactly to hysteria; and therefore need not to be repeated here. CHAP. IX. Of CANINE MADNESS and HYDROPHOBIA. MDXXV. THIS disease has been so exactly and fully described in books that are in every body's hands, that it is on no account necessary for me to give any history of it here; and with respect to the pathology of it, I find that I can say nothing satisfying to myself, or that I can expect to prove so to others. I find also, with 169 OF PHYSIC. with respect to the cure of this disease, that there is no subject in which the fallacy of ex- perience appears more strongly than in this. From the most ancient to the present times, many remedies for preventing and curing this disease have been recommended under the sanction of pretended experience, and have perhaps also kept their credit for some time: But succeeding times have generally, upon the same ground of experience, destroyed that credit entirely; and most of the remedies for- merly employed are now fallen into absolute neglect. In the present age, some new rem- edies have been proposed, and have expe- rience alleged to vouch for their efficacy; but many doubts still remain with respect to this: and though I cannot determine in this matter from my own experience, I think it incum- bent on me to give the best judgment I can form with respect to the choice of the reme- dies at present recommended. MDXXVI. I am, in the first place, firmly persuaded, that the most certain means of preventing the consequences of the bite, is to cut out, or oth- erwise destroy, the part in which the bite has been made. In this every body agrees; but with this difference, that some are of opinion that it can only be effectual when it is done very soon after the wound has been made, and they therefore neglect it when this opportu- nity 170 PRACTICE, &c. nity is missed. There have been, however, no experiments made proper to determine this matter: And there are many considera- tions which lead me to think, that the poison is not immediately communicated to the sys- tem; and therefore, that this measure of de- stroying the part may be practised with ad- vantage, even many days after the bite has been given. MDXXVII. Whilst the state of our experience, with respect to several remedies now in use, is un- certain, I cannot venture to assert that any of these is absolutely ineffectual; but I can give it as my opinion, that the efficacy of mercury, given very largely, and persisted in for a long time, both as a means of prevent- ing the disease, and of curing it when it has actually come on, is better supported by ex- perience than that of any other remedy now proposed, or commonly employed. BOOK 171 BOOK IV. OF VESANÆ, OR OF THE DISOR- DERS OF THE INTELLECTUAL FUNCTIONS. CHAP I. OF VESANIÆ IN GENERAL. MDXXVIII. THE Nosologists, Sauvages and Sagar, in a class of diseases under the title of VESANIÆ, have comprehended the two orders, of Hallucinationes or False Per- ceptions, and of Morositates or Erroneous Appetites and Passions; and in like manner, Linnæus in his class of MENTALES, corres- ponding to the Vesaniæ of Sauvages, has com- prehended the two orders of Imaginarii and Pathetici, 172 PRACTICE Pathetici, nearly the same with the Halluci- nations and Morositates of that author. This, however, from several considerations, appears to me improper; and I have there- fore formed a class of Vesaniæ nearly the same with the Paranoiæ of Vogel, excluding from it the Hallucinationes and Morositates, which I have referred to the Morbi Locales. Mr. Vogel has done the like, in separating from the Paranoiæ the false perceptions and erroneous appetites; and has thrown these into another class, to which he has given the title of Hyperæstheses. MDXXIX. It is indeed true, that certain hallucinationes and morositates are frequently combined with what I propose to consider as strictly a vesa- nia or an erroneous judgment; and some- times the hallucinationes seem to lay the foun- dation of, and to form almost entirely, the vesania. But as most part of the hallucina- tiones enumerated by the Nosologists are af- fections purely topical, and induce no other error of judgment beside that which relates to the single object of the sense or particular or- gan affected; so these are certainly to be sep- arated from the diseases which consist in a more general affection of the judgment. Even when the hallucinationes constantly ac- company or seem to induce the vesania, yet being such as arise from internal causes, and may 173 OF PHYSIC. may be presumed to arise from the same cause as the more general affection of the judgment, they are therefore to be considered as symp- toms of this only. In like manner I judge with respect to the morositates, or erroneous passions, that ac- company vesania; which, as consequences of a false judgment, must be considered as arising from the same causes, and as symptoms only, of the more general affection. There is, indeed, one case of a morositas which seems to induce a vesania, or more gen- eral affection of the judgment; and this may lead us to consider the vesania, in this case, as a symptom of an erroneous appetite, but will not afford any good reason for comprehend- ing the morositates in general under the ve- saniæ, considered as primary diseases. The limitation, therefore, of the class of Vesaniæ to the lesions of our judging fac- ulty, seems from every consideration to be proper. The particular diseases to be comprehend- ed under this class, may be distinguished ac- cording as they affect persons in the time of waking or sleeping. Those which affect men awake, may again be considered, as they con- sist in an erroneous judgment, to which I shall give the appellation of Delirium; or as they consist in a weakness or imperfection of judgment, which I shall name Fatuity. I be- gin with the consideration of Delirium. MDXXX. 174 PRACTICE MDXXX. As men differ greatly in the soundness and force of their judgment, so it may be proper here to ascertain more precisely what error or imperfection of our judging faculty is to be considered as morbid, and to admit of the ap- pellations of Delirium and Fatuity. In do- ing this, I shall first consider the morbid errors of judgment under the general appellation of Delirium, which has been commonly employ- ed to denote every mode of such error. MDXXXI. As our judgment is chiefly exercised in discerning and judging of the several relations of things, I apprehend that delirium may be defined to be,——In a person awake, a false or mistaken judgment of those relations of things, which, as occurring most frequently in life, are those about which the generality of men form the same judgment; and particularly when the judgment is very different from what the person himself had before usually formed. MDXXXII. With this mistaken judgment of relations there is frequently joined some false percep- tion of external objects, without any evident fault 175 OF PHYSIC. fault in the organs of sense, and which seems therefore to depend upon an internal cause; that is, upon the imagination arising from a condition in the brain presenting objects which are not actually present. Such false perceptions must necessarily occasion a de- lirium, or an erroneous judgment, which is to be considered as the disease. MDXXXIII. Another circumstance, commonly attend- ing delirium, is a very unusual association of ideas. As, with respect to most of the affairs of common life, the ideas laid up in the mem- ory are, in most men, associated in the same manner; so a very unusual association, in any individual, must prevent his forming the or- dinary judgment of those relations which are the most common foundation of association in the memory: And therefore this unusual and commonly hurried association of ideas, usual- ly is, and may be considered as, a part of de- lirium. In particular it may be considered as a certain mark of a general morbid affec- tion of the intellectual organs, it being an in- terruption or perversion of the ordinary ope- rations of memory, the common and neces- sary foundation of the exercise of judgment. MDXXXIV. A third circumstance attending delirium, is an emotion or passion, sometimes of the angry, 176 PRACTICE angry, sometimes of the timid kind; and from whatever cause in the perception or judgment, it is not proportioned to such cause, either in the manner formerly customary to the person himself, or in the manner usual with the generality of other men. MDXXXV. Delirium, then, may be more shortly defin- ed,——In a person awake, a false judgment arising from perceptions of imagination, or from false recollection, and commonly pro- ducing disproportionate emotions. Such delirium is of two kinds; as it is com- bined with pyrexia and comatose affections; or, as it is entirely without any such combi- nation. It is the latter case that we name In- sanity; and it is this kind of delirium only that I am to treat of here. MDXXXVI. Insanity may perhaps be properly consid- ered as a genus comprehending many differ- ent species, each of which may deserve our attention; but before proceeding to the con- sideration of particular species, I think it proper to attempt an investigation of the cause of insanity in general. MDXXXVII. 177 OF PHYSIC. MDXXXVII. In doing this, I shall take it for granted, as demonstrated elsewhere, that although this disease seems to be chiefly, and sometimes solely, an affection of the mind; yet the con- nexion between the mind and body in this case is such, that these affections of the mind must be considered as depending upon a certain state of our corporeal part. See Halleri Prim. Lin. Physiolog. § DLXX. See Boerhaavii Inst. Med. §DLXXXI. DCXCVI. MDXXXVIII. Admitting this proposition, I must in the next place assume another, which I likewise suppose to be demonstrated elsewhere. This is, that the part of our body more immediate- ly connected with the mind, and therefore more especially concerned in every affection of the intellectual functions, is the common origin of the nerves; which I shall, in what follows, speak of under the appellation of the Brain. MDXXXIX. Here, however, in assuming this last prop- osition, a very great difficulty immediately presents 178 PRACTICE presents itself. Although we cannot doubt that the operations of our intellect always de- pend upon certain motions taking place in the brain (see Gaub. Path. Med. § 523); yet these motions have never been the objects of our senses, nor have we been able to perceive that any particular part of the brain has more concern in the operations of our intellect than any other. Neither have we attained any knowledge of what share the several parts of the brain have in that operation; and therefore, in this situation of our science, it must be a very difficult matter to discover those dates of the brain that may give occa- sion to the various date of our intellectual functions. MDXL. It may be observed, that the different state of the motion of the blood in the vessels of the brain has some share in affecting the opera- tions of the intellect; and physicians, in seek- ing for the causes of the different dates of our intellectual functions, have hardly looked fur- ther than into the date of the motion of the blood, or into the condition of the blood it- self: Butt it is evident that the operations of the intellectual functions ordinarily go on, and are often considerably varied, without our being able to perceive any difference ei- ther in the motions or in the condition of the blood. MDXLI. 179 OF PHYSIC. MDXLI. Upon the other hand, it is very probable that the state of the intellectual functions de- pends chiefly upon the date and condition of what is termed the Nervous Power, or, as we suppose, of a subtitle very moveable fluid, in- cluded or inherent, in a manner we do not clearly understand, in every part of the me- dullary substance of the brain and nerves, and which in a living and healthy man is capable of being moved from every one part to every other of the nervous system. MDXLII. With respect to this power, we have pretty clear proof that it frequently has a motion from the sentient extremities of the nerves to- wards the brain, and thereby produces sensa- tion; and we have the same proof, that in consequence of volition the nervous power has a motion from the brain into the muscles or organs of motion. Accordingly, as sensa- tion excites our intellectual operations, and volition is the effect of these, and as the con- nexion between sensation and volition is al- ways by the intervention of the brain and of intellectual operations; so we can hardly doubt, that these latter depend upon certain motions, and the various modification of these motions, in the brain. MDXLIII. 180 PRACTICE MDXLIII. To ascertain the different states of these motions may be very difficult; and physi- cians have commonly considered it to be so very mysterious, that they have generally des- paired of attaining any knowledge with re- gard to it: But I consider such absolute des- pair, and the negligence it inspires, to be al- ways very blameable; and I shall now ven- ture to go some length in the inquiry, hoping that some steps made with tolerable firmness may enable us to go still further. MDXLIV. To this purpose, I think it evident, that the nervous power, in the whole as well as in the several parts of the nervous system, and par- ticularly in the brain, is at different times in different degrees of mobility and force. To these different states, I beg leave to apply the terms of Excitement and Collapse. To that state in which the mobility and force are suf- ficient for the exercise of the functions, or when these states are any way preternaturally increased, I give the name of Excitement; and to that state in which the mobility and force is not sufficient for the ordinary exer- cise of the functions, or when they are dimin- ished from the state in which they had been before, I give the name of Collapse. I beg, however, 181 OF PHYSIC. however, it may be observed, that by these terms I mean to express matters of fact only; and without intending, by these terms, to ex- plain the circumstance or condition, mechan- ical or physical, of the nervous power or fluid in these different states. MDXLV. That these different states of excitement and collapse take place on different occasions, must, I think, be manifest from numberless phenomena of the animal economy: But it is especially to our present purpose to observe, that the different states of excitement and col- lapse, are in no instance more remarkable, than in the different states of waking and sleeping. In the latter, when quite com- plete, the motion and mobility of the nervous power, with respect to the whole of what are called the Animal Functions, entirely cease, or, as I would express it, are in a state of col- lapse; and are very different from the state of waking, which in healthy persons I would call a state of general and entire excitement. MDXLVI. This difference in the states of the nervous power in sleeping and waking being admitted, I must in the next place observe, that when these states are changed from the one into the other, as commonly happens every day, the VOL. III. I change 182 PRACTICE change is hardly ever made instantaneously, but almost always by degrees, and in some length of time only: And this may be ob- served with respect to both sense and motion. Thus when a person is falling asleep, the sen- sibility is gradually diminished: So that, al- though some degree of sleep has come on, slight impressions will excite sensation, and bring back excitement; which the same, or even stronger impressions, will be insufficient to produce when the state of sleep has con- tinued longer, and is, as we may say, more complete. In like manner, the power of vol- untary motion is gradually diminished. In some members it fails sooner than in others; and it is some time before it becomes general and considerable over the whole. The same gradual progress may be remark- ed in a person's coming out of sleep: The ears in this case are often awake before the eyes are opened or see clearly, and the senses are often awake before the power of voluntary motion is recovered; and it is curious to ob- serve, that, in some cases, sensations may be excited without producing the ordinary asso- ciation of ideas. See Mem. de Berlin, 1752. MDXLVII. From all this, I think it will clearly ap- pear, that not only the different states of ex- citement and collapse can take place in differ- ent degrees, but that they can take place in different 183 OF PHYSIC. different parts of the brain, or at least, with respect to the different functions, in different degrees. As I presume that almost every person has perceived the gradual approach of sleeping and waking, I likewise suppose every person has observed, that, in such intermediate state of unequal excitement, there almost always occurs more or less of delirium, or dreaming, if any body chooses to call it so. There are in this state false perceptions, false associations, false judgments, and disproportionate emo- tions; in short, all the circumstances by which I have above defined delirium. This clearly shows that delirium may de- pend, and I shall hereafter endeavour to prove that it commonly does depend, upon some inequality in the excitement of the brain; and that both these assertions are founded on this, that, in order to the proper exercise of our intellectual functions, the excitement must be complete, and equal in every part of the brain. For though we cannot say that the vestiges of ideas are laid up in different parts of the brain, or that they are in some measure diffused over the whole, it will follow upon either supposition, that as our reason- ing or intellectual operations always require the orderly and exact recollection or memory of associated ideas; so, if any part of the brain is not excited, or not excitable, that rec- ollection cannot properly take place, while at the same time other parts of the brain, more I2 excited 184 PRACTICE excited and excitable, may give false percep- tions, associations, and judgments. MDXLVIII. It will serve to illustrate this, that the col- lapse in sleep is more or less complete; or that the sleep, as we commonly speak, is more or less profound: And therefore, that in many cases, though sleep takes place to a con- siderable degree, yet certain impressions do still take effect, and excite motions, or, if you will, sensations in the brain; but which sen- sations, upon account of the collapsed state of so great a part of the brain, are generally of the delirious kind, or dreams, consisting of false perceptions, associations, and judgments, that would have been corrected if the brain had been entirely excited. Every one, I believe, has observed, that the most imperfect sleeps are those chiefly attend- ed with dreaming; that dreams, therefore, most commonly occur towards morning, when the complete state of sleep is passing away; and further, that dreams are most commonly excited by strong and uneasy impressions made upon the body. I apprehend it may also be an illustration of the same thing, that, even in waking hours, we have an instance of an unequal state of ex- citement in the brain producing delirium. Such, I think, occurs in the case of fever. In this, it is manifest, that the energy of the brain, 185 OF PHYSIC. brain, or its excitement, is considerably di- minished with respect to the animal functions: And it is accordingly upon this ground that I have explained above, in XLV, the delir- ium which so commonly attends fever. To what I have there said I shall here only add, that it may serve to confirm my doctrine, that the delirium in fever comes on at a certain period of the disease only, and that we can commonly discern its approach by a more than usual degree of it appearing in the time of the patient's falling into or coming out of sleep. It appears, therefore, that delirium, when it first comes on in fever, depends upon an inequality of excitement; and it can hard- ly be doubted, that the delirium which comes at length to prevail in the entirely weakened state of fevers, depends upon the same cause prevailing in a more considerable degree. MDXLIX. From what has been now delivered, I hope it will be sufficiently evident, that delirium may be, and frequently is, occasioned by an inequality in the excitement of the brain. How the different portions of the brain may at the same time be excited or collapsed in different degrees, or how the energy of the brain may be in different degrees of force, with respect to the several animal, vital, and natural functions, I cannot pretend to ex- plain; but it is sufficiently evident in fact, I3 that 186 PRACTICE that the brain may be at one and the same time in different conditions with respect to these functions. Thus in inflammatory dis- eases, when by a stimulus applied to the brain the force of the vital functions is preternat- urally increased, that of the animal is either little changed, or considerably diminished. On the contrary, in many cases of mania, the force of the animal functions depending al- ways on the brain, is prodigiously increased, while the state of the vital function in the heart is very little or not at all changed. I must therefore say again, that how difficult soever it may be to explain the mechanical or physical condition of the brain in such cases, the facts are sufficient to show that there is such an inequality as may disturb our intel- lectual operations. MDL. I have thus endeavoured to explain the general cause of Delirium; which is of two kinds, according as it is with, or without, py- rexia. Of the first I take no further notice here, having explained it as well as I could above in XLV. I proceed now to consider that delirium which properly belongs to the class of Vesa- niæ, and which I shall treat of under the gen- eral title of Insanity. MDLI. 187 OF PHYSIC. MDLI. In entering upon this subject, it imme- diately occurs, that in many instances of insanity, we find, upon dissection after death, that peculiar circumstances had tak- en place in the general condition of the brain. In many cases, it has been found of a drier, harder, and firmer consistence, than what it is usually of in persons who had not been affected with that disease. In other cases, it has been found in a more humid, soft, and flaccid state; and in the observa- tions of the late Mr. Meckel, * it has been found considerably changed in its density or specific gravity. Whether these different states have been observed to be uniformly the same over the whole of the brain, I cannot certainly learn; and I suspect the dissectors have not always accurately inquired into this circumstance: But in several instances, it ap- pears that these states had been different in different parts of the brain; and instances of this inequality will afford a confirmation of our general doctrine. The accurate Morgagni has observed, that in maniacal persons the medullary portion of the * Memoir, de Berlin pour l'année 1764. It appeared in many instances of insane persons, that the medullary substance of the cerebrum was drier, and of a less specif- ic gravity, than in persons who had been always of a sound judgment. I4 188 PRACTICE the brain is unusually dry, hard, and firm: And this he had so frequently observed, that he was disposed to consider it as generally the case. But in most of the particular instances which he has given, it appears, that, for the most part, while the cerebrum was of an un- usually hard and firm consistence, the cere- bellum was of its usual softness, and in many of the cases it was unusually soft and flaccid. In some other cases, Morgagni observes, that while a part of the cerebrum was harder and firmer than ordinary, other parts of it were preternaturally soft. MDLII. These observations tend to confirm our general doctrine: And there are others which I think will apply to the same purpose. Upon the dissection of the bodies of per- sons who had laboured under insanity, various organic affections have been discovered in particular parts of the brain; and it is suf- ficiently probable, that such organic affections might have produced a different degree of excitement in the free and affected parts, and must have interrupted in some measure the free communication between the several parts of the brain, and in either way have occasion- ed insanity. There have occurred so many instances of this kind, that I believe physicians are gen- erally disposed to suspect organic lesions of 189 OF PHYSIC. of the brain to exist in almost every case of insanity. MDLIII. This, however, is probably a mistake: For we know that there have been many instances of insanity from which the persons have en- tirely recovered; and it is difficult to sup- pose that any organic lesions of the brain had in such case taken place. Such transitory cases, indeed, render it probable, that a state of excitement, changeable by various caus- es, had been the cause of such instances of insanity. MDLIV. It is indeed further asserted, that in many instances of insane persons, their brain had been examined after death, without showing that any organic lesions had before subsisted in the brain, or finding that any morbid state of the brain then appeared. This, no doubt, may serve to show, that organic lesions had not been the cause of the disease; but it does not assure us that no morbid change had tak- en place in the brain: For it is probable, that the dissectors were not always aware of its be- ing the general condition of hardness and den- sity, as different in different parts of the brain, that was to be attended to, in order to discov- er the cause of the preceding disease; and VOL. 3. I5 therefore 190 PRACTICE therefore many of them had not with this view examined the state of the brain, as Mor- gagni seems carefully to have done. MDLV. Having thus endeavoured to investigate the cause of insanity in general, it were to be wished that I could apply the doctrine to the distinguishing the several species of it, accord- ing as they depend upon the different state and circumstances of the brain, and thereby to the establishing of a scientific and accurate- ly adapted method of cure. These purposes, however, appear to me to be extremely diffi- cult to be attained; and I cannot hope to execute them here. All I can do is to make some attempts, and offer some reflections, which further observation, and greater sagaci- ty, may hereafter render more useful. MDLVI. The ingenious Dr. Arnold has been com- mendably employed in distinguishing the dif- ferent species of insanity as they appear with respect to the mind; and his labours may hereafter prove useful, when we shall come to know something more of the different states of the brain corresponding to these different states of the mind; but at present I can make little application of his numerous distinctions. It appears to me that he has chiefly pointed out 191 OF PHYSIC. out and enumerated distinctions, that are merely varieties, which can lead to little or no variety of practice: And I am especially led to form the latter conclusion, because these varieties appear to me to be often combined together, and to be often changed into one another, in the same person; in whom we must therefore suppose a general cause of the disease, which, so far as it can be known, must establish the pathology, and especially direct the practice. MDLVII. In my limited views of the different states of insanity, I must go on to consider them un- der the two heads of Mania and Melancholia: And though I am sensible that these two gen- eral do not comprehend the whole of the spe- cies of insanity, I am not clear in assigning the other species which may not be compre- hended under those titles. I shall, however, endeavour, on proper occasions as I go along, to point them out as well as I can. I6 CHAP. 192 PRACTICE CHAP. II. OF MANIA, OR MADNESS. MDLVIII. THE circumstances which I have mentioned above in MDXXXV, as constituting delirium in general, do more especially belong to that kind of it which I shall treat of here under the title of MANIA. There is sometimes a false perception or imagination of things present that are not; but this is not a constant, nor even a frequent, attendant of the disease. The false judgment, is of relations long before laid up in the mem- ory. It very often turns upon one single subject: But more commonly the mind ram- bles from one subject to another, with an equally false judgment concerning the most part of them; and as at the same time there is commonly a false association, this increases the confusion of ideas, and therefore the false judgments. What for the most part more especially distinguishes the disease, is a hurry of mind, in pursuing any thing like a train of thought, and in running from one train of thought 193 OF PHYSIC. thought to another. Maniacal persons are in general very irascible; but what more par- ticularly produces their angry emotions is, that their false judgments lead to some action which is always pushed with impetuosity and violence; when this is interrupted or restrain- ed, they break out into violent anger and fu- rious violence against every person near them, and upon every thing that stands in the way of their impetuous will. The false judgment often turns upon a mistaken opinion of some injury supposed to have been formerly re- ceived, or now supposed to be intended: And it is remarkable, that such an opinion is often with respect to their former dearest friends and relations; and therefore their resentment and anger are particularly directed towards these. And although this should not be the case, they commonly soon lose that respect and regard which they formerly had for their friends and relations. With all these cir- cumstances, it will be readily perceived, that the disease must be attended very constantly with that incoherent and absurd speech we call raving. Further, with the circumstances mentioned, there is commonly joined an un- usual force in all the voluntary motions; and an insensibility or resistance of the force of all impressions, and particularly a resistance of the powers of sleep, of cold, and even of hun- ger; though indeed in many instances a vo- racious appetite takes place. MDLIX. 194 PRACTICE MDLIX. It appears to me, that the whole of these circumstances and symptoms point out a con- siderable and unusual excess in the excite- ment of the brain, especially with respect to the animal functions; and it appears at the same time to be manifestly in some measure unequal, as it very often takes place with res- pect to these functions alone, while at the same time the vital and natural are common- ly very little changed from their ordinary healthy state. MDLX. How this excess of excitement is produced, it may be difficult to explain. In the va- rious instances of what Sauvages has named the Mania Metastatica, and in all the instances I have mentioned in my Nosology under the title of the Mania Corporea, it may be sup- posed that a morbid organic affection is pro- duced in some part of the brain; and how that may produce an increased or unequal excitement in certain parts of it, I have en- deavoured to explain above in MDLII. But I must at the same time acknowledge, that such remote causes of mania have very rarely occurred; and that therefore some other caus- es of the disease must be sought for. The 195 OF PHYSIC. The effects of violent emotions or passions of the mind have more frequently occurred as the remote causes of mania; and it is suf- ficiently probable, that such violent emotions, as they do often immediately produce a tem- porary increase of excitement, so they may, upon some occasions of their permanent in- herence or frequent repetition, produce a more considerable and more permanent ex- citement, that is, a mania. With respect to those causes of mania which arise in consequence of a melancholia which had previously long subsisted; whether we consider that melancholia as a partial in- sanity, or as a long persisting attachment to one train of thinking, it will be readily per- ceived, that in either case such an increase of excitement may take place in so considerable a degree, and in so large a portion of the brain, as may give occasion to a complete mania. MDLXI. These considerations with regard to the re- mote causes appear to me to confirm suffi- ciently our general doctrine of increased and unequal excitement in the mania which I have described above; but I must own, that I have not exhausted the subject, and that there are cases of mania of which I cannot as- sign the remote causes: But although I can- not in all cases explain in what manner the mania 196 PRACTICE mania is produced, I presume, from the ex- planation given, and especially from the symptoms enumerated above, to conclude, that the disease described above depends up- on an increased excitement of the brain; an opinion in which I am the more confirmed, as I think it will point out the proper method of cure. At least I think it will most clearly explain the operation of those remedies, which, so far as I can learn from my own experience and that of others, have proved the most suc- cessful in this disease; and, to illustrate this, I now enter upon the consideration of these remedies, and to make some remarks upon the proper manner of employing them. MDLXII. Restraining the anger and violence of mad- men are always necessary for preventing their hurting themselves or others: But this re- straint is also to be considered as a remedy. Angry passions are always rendered more vi- olent by the indulgence of the impetuous motions they produce; and even in madmen the feeling of restraint will sometimes prevent the efforts which their passion would otherwise occasion. Restraint, therefore, is useful, and ought to be complete; but it should be exe- cuted in the easiest manner possible for the pa- tient, and the strait waistcoat answers every purpose better than any other that has yet been thought of. The restraining madmen by 197 OF PHYSIC. by the force of other men, as occasioning a constant struggle and violent agitation, is often hurtful. Although, on many occasions, it may not be safe to allow maniacs to be up- on their legs or to walk about, it is never de- sirable to confine them to a horizontal situa- tion; and whenever it can be admitted, they should be more or less in an erect posture. Although there may be no symptoms of any preternatural fulness or increased impetus of blood in the vessels of the brain, a horizontal posture always increases the fulness and ten- sion of these vessels, and may thereby increase the excitement of the brain. MDLXIII. The restraint mentioned requires confine- ment within doors, and it should be in a place which presents as few objects of sight and hearing as possible; and particularly, it should be removed from the objects that the patient was formerly acquainted with, as these would more readily call up ideas and their various associations. It is for this reason that the confinement of madmen should hardly ever be in their usual habitation; or if they are, that their apartment should be stripped of all its former furniture. It is also for the most part proper, that maniacs should be without the company of any of their former acquaint- ance; the appearance of whom commonly excites emotions that increase the disease. Strangers 198 PRACTICE Strangers may at first be offensive; but in a little time they come to be objects either of indifference or of fear, and they should not be frequently changed. MDLXIV. Fear being a passion that diminishes excite- ment, may therefore be opposed to the excess of it; and particularly to the angry and iras- cible excitement of maniacs. These being more susceptible of fear than might be ex- pected, it appears to me to have been com- monly useful. In most cases it has appeared to be necessary to employ a very constant im- pression of fear; and therefore to inspire them with the awe and dread of some particular persons, especially of those who are to be con- stantly near them. This awe and dread are therefore, by one means or other, to be ac- quired; in the first place, by their being the authors of all the restraints that may be occa- sionally proper; but sometimes it may be necessary to acquire it even by stripes and blows. The former, although having the ap- pearance of more severity, are much safer than strokes or blows about the head. Nei- ther of them, however, should be employed further than seems very necessary, and should be trusted only to those whose discretion can be depended upon. There is one case in which they are superfluous; that is, when the maniacal rage is either not susceptible of fear, or 199 OF PHYSIC. or incapable of remembering the objects of it; for in such instances, stripes and blows would be wanton barbarity. In many cases of a moderate disease, it is of advantage that the persons who are the authors of restraint and punishment should be upon other occa- sions the bestowers of every indulgence and gratification that is admissible; never, however, neglecting to employ their awe when their indulgence shall have led to any abuse. MDLXV. Although in mania, no particular irritation nor fulness of the system seem to be present, it is plain, that the avoiding all irritation and means of fulness is proper; and therefore, that a diet neither stimulating nor nourishing is commonly to be employed. As it may even be useful to diminish the fulness of the system, so both a low and a spare diet is likely in most cases to be of service. MDLXVI. Upon the same principle, although no un- usual fulness of the body be present, it may be of advantage to diminish even its ordinary fulness by different evacuations. Bloodletting, in particular, might be sup- posed useful; and in all recent cases of ma- nia it has been commonly practised, and I think with advantage; but when the disease has 200 PRACTICE has subsisted for some time, I have seldom found bloodletting of service. In those in- stances in which there is any frequency or fulness of pulse, or any marks of an increased impetus of the blood in the vessels of the head, bloodletting is a proper and even a nec- essary remedy. Some practitioners, in such cases, have preferred a particular manner of bloodletting, recommending arteriotomy, scar- ifying the hind head, or opening the jugular vein; and where any fulness or inflammatory disposition in the vessels of the brain, is to be suspected, the opening of the vessels nearest to them is likely to be of the greatest service. The opening, however, of either the temporal artery or the jugular vein in maniacal persons is very often inconvenient; and it may gen- erally be sufficient to open a vein in the arm, while the body is kept in somewhat of an erect posture, and such a quantity of blood drawn as nearly brings on a deliquium animi, which is always a pretty certain mark of some diminution of the fulness and tension of the vessels of the brain. MDLXVII. For the same purpose of taking off the ful- ness and tension of these vessels of the brain, purging may be employed; and I can in no other view understand the celebrated use of hellebore among the ancients. I cannot, however, suppose any specific power in hel- lebore; 201 OF PHYSIC. lebore; and can by no means find that, at least the black hellebore, is so efficacious with us as it is said to have been at Anticyra. As costiveness, however, is commonly a very con- stant and hurtful attendant of mania, purga- tives come to be sometimes very necessary; and I have known some benefit obtained from the frequent use of pretty drastic purgatives. In this, however, I have been frequently dis- appointed; and I have found more advantage from the frequent use of cooling purgatives, particularly the soluble tartar, than from more drastic medicines. MDLXVIII. Vomiting has also been frequently employ- ed in mania; and by determining powerfully to the surface of the body, it may possibly di- minish the fulness and tension of the vessels, and thereby the excitement of the brain; but I have never carried the use of this remedy so far as might enable me to judge properly of its effects. Whether it may do harm by im- pelling the blood too forcibly into the vessels of the brain, or whether by its general agita- tion of the whole system it may remove that inequality of excitement which prevails in mania, I have not had experience enough to determine. MDLXIX. 202 PRACTICE MDLXIX. Frequent shaving of the head has been found of service in mania, and by promoting perspiration it probably takes off from the excitement of the internal parts. This, how- ever, it is likely, may be more effectually done by blistering, which more certainly takes off the excitement of subjacent parts. In recent cases it has been found useful by inducing sleep; and when it has that effect, the repe- tition of it may be proper: But in maniacal cases that have lasted for some time, blistering has not appeared to me to be of any service; and in such cases also I have not found per- petual blisters, or any other form of issue, prove useful. MDLXX. As heat is the principal means of first ex- citing the nervous system, and establishing the nervous power and vital principle in animals; so, in cases of preternatural excitement, the application of cold might be supposed a prop- er remedy: But there are many instances of maniacs who have been exposed for a great length of time to a considerable degree of cold without having their symptoms anywise relieved. This may render in general the application of cold a doubtful remedy; but it is at the same time certain, that maniacs have 203 OF PHYSIC. have often been relieved, and sometimes en- tirely cured, by the use of cold bathing, es- pecially when administered in a certain man- ner. This seems to consist, in throwing the madman into the cold water by surprise; by detaining him in it for some length of time; and pouring water frequently upon the head, while the whole of the body except the head is immersed in the water; and thus managing the whole process, so as that, with the assist- ance of some fear, a refrigerant effect may be produced. This, I can affirm, has been often useful; and that the external application of cold may be of service, we know further, from the benefit which has been received in some maniacal cases from the application of ice and snow to the naked head, and from the appli- cation of the noted Clay Cap. Warm bathing also has been recommended by some practical writers; and in some rigid melancholic habits it may possibly be useful, or as employed in the manner prescribed by some, of immersing the lower parts of the body in warm water, while cold water is pour- ed upon the head and upper parts. Of this practice, however, I have had no experience; and in the common manner of employing warm bathing I have found it rather hurtful to maniacs. MDLXXI. According to my supposition that the dis- ease depends, upon an increased excitement of the 204 PRACTICE the brain, especially with respect to the ani- mal functions, opium, so commonly powerful in inducing sleep, or a considerable collapse as to these functions, should be a powerful remedy of mania. That it has truly proved such, I believe from the testimony of Bernard Huet, whose practice is narrated at the end of Wepseri Historia Apoplecticorum. I leave to my readers to study this in the work I have referred to, where every part of the practice is fully, and, as it appears to me, very judiciously delivered. I have never indeed carried the trial so far as seems to be requisite to an entire cure: But I have frequently em- ployed in some maniacal cases, large doses of opium; and when they had the effect of in- ducing sleep, it was manifestly with advan- tage. At the same time, in some cases, from doubts, whether the disease might not depend upon some organic lesions of the brain, when the opium would be superfluous; and in oth- er cases, from doubts, whether there might not be some inflammatory affection joined with the mania, when the opium would be hurtful, I have never pushed this remedy to the extent that might be necessary to make an entire cure. MDLXXII. Camphire has been recommended as a rem- edy of mania, and there are instances alleged of its having performed an entire cure. As it 205 OF PHYSIC. it appears from the experiments of Beccaria that this substance is possessed of a sedative and narcotic virtue, these cures are not alto- gether improbable: But in several trials, and even in large doses, I have found no benefit from it; and excepting those in the Philo- sophical Transactions, N° 400, I have hard- ly met with any other testimonies in its fa- vour. MDLXXIII. I have been informed that some maniacs have been cured by being compelled to con- stant and even hard labour; and as a forced attention to the conduct of any bodily exer- cise, is a very certain means of diverting the mind from pursuing any train of thought, it is highly probable that such exercise may be useful in many cases of mania. I must conclude this subject with observ- ing, that even in several cases of complete ma- nia, I have known a cure take place in the course of a journey carried on for some length of time. MDLXXIV. These are the remedies which have been chiefly employed in the mania that has been above described, and I believe they have been employed promiscuously without supposing that the mania was to be distinguished into VOL. III. K different 206 PRACTICE different species. Indeed I am not ready to say how far it is to be so distinguished, but I shall offer one observation which may possibly merit attention. It appears to me, that there are two differ- ent cases of mania that are especially different according to the original temperament of the persons whom the disease affects. It perhaps occurs most frequently in persons of a melan- cholic or atrabilarian temperament; but it certainly does also often occur in persons of that very opposite temperament which phy- sicians have named the Sanguine. Accord- ing as the disease happens to occur in persons of the one or other of these temperaments, I apprehend it may be considered as of a differ- ent nature; and I believe, that accurate ob- servation, employed upon a sufficient number of cases, would discern some pretty constant difference, either of the symptoms, or at least of the state of symptoms, in the two cases. I imagine that false imaginations, particular aversions and resentments, are more fixed and steady in the melancholic than in the san- guine; and that somewhat inflammatory is more commonly joined with mania in the sanguine than in the melancholic. If such difference, however, does truly take place, it will be obvious, that it may be proper to make some difference also in the practice. I am of opinion, that in the mania of sanguine persons, bloodletting and other antiphlogistic measures are more proper, and have been more 207 OF PHYSIC. more useful, than in the melancholic. I likewise apprehend that cold bathing is more useful in the sanguine than in the melanchol- ic: But I have not had experience enough to ascertain these points with sufficient confi- dence. I have only to add this other observation, that maniacs of the sanguine temperament re- cover more frequently and more entirely than those of the melancholic. K2 CHAP. 208 PRACTICE CHAP. III. OF MELANCHOLY, AND OTHER FORMS OF INSANITY. MDLXXV. MELANCHOLY has been commonly considered as a partial insanity; and as such it is defined in my Nosology; But I now entertain doubts if this be alto- gether proper. By a partial insanity, I un- derstand a false and mistaken judgment up- on one particular subject, and what relates to it; whilst, on every other subject, the person affected judges as the generality of other men do. Such cases have certainly occurred; but, I believe, few in which the partial insan- ity is strictly limited. In many cases of gen- eral insanity, there is one subject of anger or fear, upon which the false judgment more par- ticularly turns, or which is at least more fre- quently than any other the prevailing object of delirium: And though, from the incon- sistency which this principal object of delirium must produce, there is therefore also a great deal of insanity with regard to most other ob- jects; yet this last is in very different degrees, both in different persons, and in the same per- son 209 OF PHYSIC. son at different times. Thus persons con- sidered as generally insane, will, however, at times, and in some cases, pretty constantly judge properly enough of present circum- stances and incidental occurrences; though, when these objects engaging attention are not presented, the operations of imagination may readily bring back a general confusion, or re- call the particular object of the delirium. From these considerations, I am inclined to conclude, that the limits between general and partial insanity cannot always be so exactly assigned, as to determine when the partial af- fection is to be considered as giving a peculiar species of disease, different from a more gen- eral insanity. MDLXXVI. When insanity, neither strictly partial, nor entirely nor constantly general, occurs in per- sons of a sanguine temperament, and is at- tended with agreeable, rather than with angry or gloomy emotions, I think such a disease must be considered as different from the Ma- nia described above; and also, though par- tial, must be held as different from the proper Melancholia to be mentioned hereafter. MDLXXVII. Such a disease, as different from those de- scribed MDLIV, requires, in my opinion, a K3 different 210 PRACTICE different administration of remedies; and it will be proper for me to take particular no- tice of this here. Although it may be necessary to restrain such insane persons as we have mentioned MDLXXVI, from pursuing the objects of their false imagination or judgment, it will hardly be requisite to employ the same force of restraint that is necessary in the impetuous and angry mania. It will be generally suf- ficient to acquire some awe over them, that may be employed, and sometimes even be necessary, to check the rambling of their imag- ination, and incoherency of judgment. MDLXXVIII. The restraint just now mentioned as neces- sary will generally require the patient's being confined to one place, for the sake of exclud- ing the objects, and more particularly the persons, that might excite ideas connected with the chief objects of their delirium. At the same time, however, if it can be perceiv- ed there are objects or persons that can call off their attention from the pursuit of their own disordered imagination, and can fix it a little upon some others, these last may be fre- quently presented to them: And for this rea- son, a journey, both by its having the effect of interrupting all train of thought, and by pre- senting objects engaging attention, may often be useful. In such cases also, when the in- sanity, 211 OF PHYSIC. sanity, though more especially fixed upon one mistaken subject, is not confined to this alone, but is further apt to ramble over other sub- jects with incoherent ideas, I apprehend the confining or forcing such persons to some constant uniform, labour, may prove an use- ful remedy. MDLXXIX. When such cases as in MDLXVI occur in sanguine temperaments, and may therefore approach more nearly to Phrenitic Delirium; so, in proportion as the symptoms of this ten- dency is more evident and considerable, bloodletting and purging will be the more proper and necessary. MDLXXX. To this species of insanity, when occurring in sanguine temperaments, whether it be more or less partial, I apprehend that cold bathing is particularly adapted; while, in the partial insanity of melancholic persons, as I shall show hereafter, it is hardly admissible. MDLXXXI. Having thus treated of a species of insan- ity, different, in my apprehension, from both the Mania and Melancholia, I proceed to K4 consider 212 PRACTICE consider what seems more properly to belong to this last. MDLXXXII. The disease which I name Melancholia is very often a partial insanity only. But as in many instances, though the false imagination or judgment seems to be with respect to one subject only; yet it seldom happens that this does not produce much inconsistency in the other intellectual operations: And as, between a very general and a very partial insanity, there are all the possible intermediate de- grees; so it will be often difficult, or perhaps improper, to distinguish Melancholia by the character of Partial Insanity alone. If I mistake not, it must be chiefly distinguished by its occurring in persons of a melancholic temperament, and by its being always attend- ed with some seemingly groundless, but very anxious, fear. MDLXXXIII. To explain the cause of this, I must ob- serve, that persons of a melancholic tempera- ment are for the most part of a serious thought- ful disposition, and disposed to fear and cau- tion, rather than to hope and temerity. Per- sons of this cast are less moveable than others by any impressions; and are therefore capa- ble of a closer or more continued attention to one 213 OF PHYSIC. one particular object, or train of thinking. They are even ready to be engaged in a con- stant application to one subject; and are re- markably tenacious of whatever emotions they happen to be affected with. MDLXXXIV. These circumstances of the melancholic: character, seem clearly to show, that persons strongly affected with it may be readily seiz- ed with an anxious fear; and that this, when much indulged, as is natural to such persons, may easily grow into a partial insanity. MDLXXXV. Fear and dejection of mind, or a timid and desponding disposition, may arise in certain states, or upon certain occasions, of mere de- bility: And it is upon this footing, that I sup- pose it sometimes to attend dyspepsia. But in these cases, I believe the despondent dis- position hardly ever arises to a considerable degree, or proves so obstinately fixed as when it occurs in persons of a melancholic tem- perament. In these last, although the fear proceeds from the same dyspeptic feelings as in the other case, yet it will be obvious, that the emotion may rise to a more considerable de- gree; that it may be more anxious, more fix- ed, and more attentive; and therefore may exhibit all the various circumstances which I VOL. 3. K5 have 214 PRACTICE have mentioned in MCCXXII to take place in the disease named HYPOCHONDRIASIS. MDLXXXVI. In considering this subject formerly in dis- tinguishing Dyspepsia from Hypochondriasis, although the symptoms affecting the body be very much the same in both, and even those af- fecting the mind be somewhat similar, I found no difficulty in distinguishing the latter disease, merely from its occurring in persons of a mel- ancholic temperament. But I must now ac- knowledge, that I am at a loss to determine how in all cases hypochondriasis and melan- cholia may be distinguished from one another, whilst the same temperament is common to both. MDLXXXVII. I apprehend, however, that the distinction may be generally ascertained in the following manner. The hypochondriasis I would consider as being always attended with dyspeptic symp- toms: And though there may be, at the same time, an anxious melancholic fear arising from the feeling of these symptoms; yet while this fear is only a mistaken judgment with respect to the state of the person's own health, and to the danger to be from thence apprehended, I would still consider the disease as a hypochon- driasis, 215 OF PHYSIC. driasis, and as distinct from the proper melan- cholia. But when an anxious fear and des- pondency arises from a mistaken judgment with respect to other circumstances than those of health, and more especially when the per- son is at the same time without any dyspep- tic symptoms, every one will readily allow this to be a disease widely different from both dyspepsia and hypochondriasis; and it is, what I would strictly name Melancholia. MDLXXXVIII. In this there seems little difficulty: But as an exquisitely melancholic temperament may induce a torpor and slowness in the action of the stomach, so it generally produces some dyspeptic symptoms; and from thence there may be some difficulty in distinguishing such a case from hypochondriasis. But I would maintain, however, that when the characters of the temperament are strongly marked; and more particularly when the false imagination turns upon other subjects than that of health, or when, though relative, to the person's own body, it is of a groundless and absurd kind; then, notwithstanding the appearance of some dyspeptic symptoms, the case is still to be considered as that of a melancholia, rather than a hypochondriasis. K6 MDLXXXIX. 216 PRACTICE MDLXXXIX. The disease of melancholia, therefore, man- ifestly depends upon the general temperament of the body: And although, in many persons, this temperament is not attended with any morbid affection either of mind or body; yet when it becomes exquisitely formed, and is in a high degree, it may become a disease af- fecting both, and particularly the mind. It will therefore be proper to consider in what this melancholic temperament especially con- sists; and to this purpose, it may be observ- ed, that in it there is a degree of torpor in the motion of the nervous power, both with res- pect to sensation and volition; that there is a general rigidity of the simple solids; and that the balance of the sanguiferous system is up- on the side of the veins. But all these cir- cumstances are the directly opposite of those of the sanguine temperament; and must therefore also produce an opposite state of mind. MDXC. It is this state of the mind, and the state of the brain corresponding to it, that is the chief object of our present consideration. But what that state of the brain is, will be suppos- ed to be difficult to explain; and it may per- haps seem rash in me to attempt it. I will, 217 OF PHYSIC. I will, however, venture to say, that it is probable the melancholic temperament of mind depends upon a drier and firmer tex- ture in the medullary substance of the brain; and that this perhaps proceeds from a certain want of fluid in that substance, which appears from its being of a lesser specific gravity than usual. That this state of the brain in melan- cholia does actually exist, I conclude, first, from the general rigidity of the whole habit; and, secondly, from dissections, showing such a state of the brain to have taken place in ma- nia, which is often no other than a higher de- gree of melancholia. It does not appear to me anywise difficult to suppose, that the same state of the brain may in a moderate degree give melancholia; and in a higher, that ma- nia which melancholia so often passes into; especially if I shall be allowed further to sup- pose, that either a greater degree of firmness in the substance of the brain may render it susceptible of a higher degree of excitement, or that one portion of the brain may be liable to acquire a greater firmness than others, and consequently give occasion to that inequality of excitement upon which mania so much de- pends. MDXCI. I have thus endeavoured to deliver what appears to me most probable with respect to the proximate cause of melancholia; and al- though 218 PRACTICE though the matter should in some respects re- main doubtful, I am well persuaded that these observations may often be employed to direct our practice in this disease, as I shall now en- deavour to show. MDXCII. In most of the instances of melancholia, the mind is to be managed very much in the same manner as I have advised above with regard to hypochondriasis; but as in the case of proper melancholia, there is commonly a false imagination or judgment appearing as a par- tial insanity, it may be further necessary in such cases to employ some artifices for cor- recting such imagination or judgment. MDXCIII. The various remedies for relieving the dys- peptic symptoms which always attend hypo- chondriasis, will seldom be either requisite or proper in melancholia. There is only one of the dyspeptic symp- toms, which, though there should be no oth- er, is very constantly present in melancholia, and that is costiveness. This it is always proper and even necessary to remove; and I believe it is upon this account that the use of purgatives have been found so often useful in melancholia. Whether there be any purga- tives peculiarly proper in this case, I dare not positively determine; but with respect to the choice. 219 OF PHYSIC. choice of purgatives in melancholia, I am of the same opinion that I delivered above on this same subject with respect to mania. MDXCIV. With respect to other remedies, I judge that bloodletting will more seldom be proper in melancholia than in mania; but how far it may be in any case proper, must be deter- mined by the same considerations as in the case of mania. MDXCV. The cold bathing that I judged to be so very useful in several cases of insanity, is, I believe, in melancholia, hardly ever fit to be admitted; at least while this is purely a par- tial affection, and without any marks of vio- lent excitement. On the contrary, upon ac- count of the general rigidity prevailing in mel- ancholia, it is probable that warm bathing may be often useful. MDXCVI. With respect to opiates which I have sup- posed might often be useful in cases of mania, I believe they can seldom be properly em- ployed in the partial insanities of the melan- cholic, except in certain instances of violent excitement, when the melancholia approach- es nearly to the state of mania. MDXCVII. 220 PRACTICE, &c. MDXCVII. In such cases of melancholia approaching to a state of mania, a low diet may sometimes be necessary; but as the employing a low diet almost unavoidably leads to the use of vege- table food, and as this in every torpid state of the stomach is ready to produce some dyspep- tic symptoms, such vegetable food ought, in moderate cases of melancholia, to be used with some caution. Though exercise, as a tonic power, is not proper either in hypochondriasis or melan- cholia; yet, with respect to its effects upon the mind, it may be extremely useful in both, and in melancholia is to be employed in the same manner that I have advised above in the case of hypochondriasis. MDXCVIII. Having now delivered my doctrine with respect to the chief forms of insanity, I should in the next place proceed to consider the other genera of Amentia and Oneirodynia, which in the Nosology I have arranged un- der the order of Vesaniæ: But as I cannot pretend to throw much light upon these subjects, and as they are seldom the objects of practice, I think it allowable for me to pass them over at present; and the particular cir- cumstances of this work in some measure re- quires that I should do so. PART PART III. Of Cachexies. MDXCIX. UNDER this title I propose to establish a class of diseases, which consist in a depraved state of the whole, or of a con- siderable part, of the habit of the body, without any prima- ry pyrexia or neurosis combined with that state. MDC. The term Cachexy has been employed by Linnæus and Vogel, as it had been formerly by other authors, for the name of a particular disease: But the disease to which these au- thors 222 PRACTICE, &c. thors have affixed it, comes more properly under another appellation; and the term of Cachexy is more properly employed by Sau- vages and Sagar for the name of a class. In this I have followed the last mentioned no- sologists, though I find it difficult to give such a character of the class as will clearly apply to all the species I have comprehended under it. This difficulty would be still great- er, if, in the class I have established under the title of Cachexies, I was to comprehend all the diseases that those other nosologists have done; but I am willing to be thought deficient rather than very incorrect. Those difficulties, however, which still remain in methodical nosology, must not affect us much in a treatise of practice. If I can here prop- erly distinguish and describe the several spe- cies that truly and most commonly exist, I shall be the less concerned about the accuracy of my general classification: Though at the same time this, I think, is always to be at- tempted; and I shall pursue it as well as I can. BOOK 223 BOOK I. OF EMACIATIONS. MDCI. EMACIATION, or a con- siderable diminution of the bulk or plump- ness of the whole body, is for the most part only a symptom of disease, and very seldom to be considered as a primary and idiopathic affection. Upon this account, according to my general plan, such a symptom might per- haps have been omitted in the Methodical Nosology: But both the uncertainty of con- cluding it to be always symptomatic, and the consistency of system, made me introduce in- to the Nosology, as others had done, an order under the title of Marcores; and this renders it requisite now to take some notice of such diseases. MDCII. 224 PRACTICE MDCII. Upon this occasion, therefore, I hope it may be useful to investigate the several causes of emaciation in all the different cases of dis- ease in which it appears. And this I attempt, as the surest means of determining how far it is a primary, or a symptomatic affection only; and even in the latter view, the investigation may be attended with some advantage. MDCIII. The causes of emaciation may, I appre- hend, be referred to two general heads; that is, either to a general deficiency of fluid in the vessels of the body, or to the particular deficiency of the oil in the cellular texture of it. These causes are frequently combined together; but it will be proper, in the first place, to consider them separately. MDCIV. As a great part of the body of animals is made up of vessels filled with fluids, the bulk of the whole must depend very much on the size of these vessels, and the quantity of fluids present in them: And it will therefore be sufficiently obvious, that a deficiency of the fluids in these vessels must, according to its degree, occasion a proportionate diminution of 225 OF PHYSIC. of the bulk of the whole body. This, how- ever, will appear still more clearly, from con- sidering that in the living and sound body the vessels every where seem to be preternaturally distended by the quantity of fluids present in them; but being at the same time elastic, and constantly endeavouring to contract themselves, they must, on the withdrawing of the distending force, or, in other words, upon a diminution of the quantity of fluids, be in proportion contracted and diminished in their size: And it may be further observed, that as each part of the vascular system communi- cates with every other part of it; so every de- gree of diminution of the quantity of fluid, in any one part, must in proportion diminish the bulk of the vascular system, and conse- quently of the whole body. MDCV. The diminution and deficiency of the fluids may be occasioned by different causes: Such as, first, by a due quantity of aliments not be- ing taken in; or by the aliment taken in, not being of a sufficiently nutritious quality. Of the want of a due quantity of aliment not be- ing taken into the body, there is an instance in the Atrophia lactantium Sauvagesii, species 3; and many other examples have occurred of emaciation from want of food, occasioned by poverty, and other accidental causes. With 226 PRACTICE With respect to the quality of food, I ap- prehend it arises from the want of nutritious matter in the food employed, that persons liv- ing very entirely on vegetables are seldom of a plump and succulent habit. MDCVI. A second cause of the deficiency of fluids may be, the aliments taken in not being con- veyed to the bloodvessels. This may occur from a person's being affected with a frequent vomiting; which, rejecting the food soon after it had been taken in, must prevent the neces- sary supply of fluids to the bloodvessels. Another cause, frequently interrupting the conveyance of the alimentary matter into the bloodvessels, is an obstruction of the conglo- bate or lymphatic glands of the mesentery, through which the chyle must necessarily pass to the thoracic duct. Many instances of ema- ciation, seemingly depending upon this cause, have been observed by physicians, in persons of all ages, but especially in the young. It has also been remarked, that such cases have most frequently occurred in scrophulous per- sons, in whom the mesenteric glands are com- monly affected with tumour or obstruction, and in whom, generally at the same time, scrophula appears externally. Hence the Tabes scrophulosa Synop. Nosolog. vol. ii. p. 266: And under these I have put as synon- imes Tabes glandularis, sp. 10; Tabes mesen- terica, 227 OF PHYSIC. terica, sp. 9; Scrophula mesenterica, sp. 4; Atrophia infantilis, sp. 13; Atrophia rachit- ica, sp. 8; Tabes rachialgica, sp. 16. At the same time, I have frequently found the case occurring in persons who did not show any external appearance of scrophula, but in whom the mesenteric obstruction was after- wards discovered by dissection. Such also I suppose to have been the case in the disease frequently mentioned by authors under the title of the Atrophia infantum. This has re- ceived its name from the time of life at which it generally appears; but I have met with in- stances of it at fourteen years of age ascer- tained by dissection. In several such cases which I have seen, the patients were without any scrophulous appearances at the time, or at any period of their lives before. In the case of phthisical persons, I shall hereafter mention another cause of their ema- ciation; but it is probable that an obstruction of the mesenteric glands, which so frequently happens in such persons, concurs very power- fully in producing the emaciation that takes place. Although a scrophulous taint may be the most frequent cause of mesenteric obstruc- tions, it is sufficiently probable that other kinds of acrimony may produce the same, and the emaciation that follows. It may perhaps be supposed, that the in- terruption of the chyle's passing into the bloodvessels may be sometimes owing to a fault 228 PRACTICE fault of the absorbents on the internal surface of the intestines. This, however, cannot be readily ascertained: But the interruption of the chyle's passing into the bloodvessels may certainly be owing to a rupture of the tho- racic duct; which, when it does not prove soon fatal, by occasioning a hydrothorax, must in a short time produce a general ema- ciation. MDCVII. A third cause of the deficiency of the fluids may be a fault in the organs of digestion, as not duly converting the aliment into a chyle fit to form in the bloodvessels a proper nu- tritious matter. It is not, however, easy to ascertain the cases of emaciation which are to be attributed to this cause; but I apprehend that the emaciation which attends long sub- sisting cases of dyspepsia, or of hypochondri- asis, is to be explained chiefly in this way. It is this which I have placed in the Nosol- ogy under the title of the Atrophia debilium; and of which the Atrophia nervosa, Sauv. sp. 1, is a proper instance, and therefore put there as a synonime. But the other titles of Atro- phia lateralis, Sauv. sp. 15, and Atrophia sen- ilis, Sauv. sp. 11, are not so properly put there, as they must be explained in a differ- ent manner. MDCVIII. 229 OF PHYSIC. MDCVIII. A fourth cause of a deficiency of the fluids in the body, may be excessive evacuations made from it by different outlets; and Sau- vages has properly enumerated the following species, which we have put as synonimes un- der the title of Atrophia inanitorum; as, Tabes nutricum, sp. 4, Atrophia nutricum, sp. 5, Atrophia à leucorrhœa, sp. 4, Atrophia ab alvi fluxu, sp. 6, Atrophia à ptyalismo, sp. 7, and lastly, the Tabes à sanguifluxu; which, it is to be observed, may arise not only from spontaneous hemorrhagies or accidental wounds, but also from bloodletting in too large a quantity, and too frequently re- peated. Upon this subject it seems proper to ob- serve, that a meagre habit of body frequently depends upon a full perspiration being con- stantly kept up, though at the same time a large quantity of nutritious aliment is regu- larly taken in. MDCIX. Besides this deficiency of fluids from evac- uations by which they are carried entirely out of the body, there may be a deficiency of fluid and emaciation in a considerable part of the body, by the fluids being drawn into one part, or collected into one cavity; and of this we VOL. III. L have 230 PRACTICE have an instance in the Tabes à hydrope, Sauv. sp. 5. MDCX. In the Methodical Nosology, among the other synonimes of the Atrophia inanitorum I have set down the Tabes dorsalis; but wheth- er properly or not, I at present very much doubt. In the evacuation considered as the cause of this tabes, as the quantity evacuat- ed is never so great as to account for a gen- eral deficiency of fluids in the body, we must seek for another explanation of it. And whether the effects of the evacuation may be accounted for, either from the quality of the fluid evacuated, or from the singularly ener- vating pleasure attending the evacuation, or from the evacuation's taking off the tension of parts, the tension of which has a singular power in supporting the tension and vigour of the whole body, I cannot positively deter- mine; but I apprehend that upon one or other of these suppositions the emaciation at- tending the tabes dorsalis must be accounted for; and therefore that it is to be considered as an instance of the Atrophia debilium, rather than of the Atrophia inanitorum. MDCXI. A fifth cause of a deficiency of fluids and of emaciations in the whole or in a particular part 231 OF PHYSIC. part of the body, may be the concretion of the small vessels, either not admitting of fluids, or of the same proportion as before; and this seems to me to be the case in the Atrophia senilis, Sauv. sp. 2. Or it may be a palsy of the larger trunks of the arteries rendering them unfit to propel the blood into the small- er vessels; as is frequently the case of para- lytic limbs, in which the arteries are affected as well as the muscles. The Atrophia late- ralis, Sauv. sp. 15, seems to be of this nature. MDCXII. A second general head of the causes of emaciation I have mentioned in MDCII to be a deficiency of oil. The extent and quan- tity of the cellular texture in every part of the body, and therefore how considerable a part it makes in the bulk of the whole is now well known. But this substance, in different circumstances, is more or less filled with an oily matter; and therefore the bulk of it, and in a great measure that of the whole body, must be greater or less according as this substance is more or less filled in that manner. The deficiency of fluids, for a reason to be imme- diately explained, is generally accompanied with a deficiency of oil: But physicians have commonly attended more to the latter cause of emaciation than to the other, that being usually the most evident; and I shall now en- deavour to assign the several causes of the L2 deficiency 232 PRACTICE deficiency of oil as it occurs upon different occasions. MDCXIII. The business of secretion in the human body is in general little understood, and in no instance less so than in that of the secretion of oil from blood which does not appear pre- viously to have contained it. It is possible, therefore, that our theory of the deficiency of oil may be in several respects imperfect; but there are certain facts that may in the mean time apply to the present purpose. MDCXIV. First, it is probable, that a deficiency of oil may be owing to a state of the blood in ani- mal bodies less fitted to afford a secretion of oil, and consequently to supply the waste of it that is constantly made. This state of the blood must especially depend upon the state of the aliments taken in, as containing less of oil or oily matter. From many observations made, both with respect to the human body and to that of other animals, it appears pretty clearly, that the aliments taken in by men and domestic animals, according as they contain more of oil, are in general more nutritious, and in particular are better fitted to fill the cellular texture of their bodies with oil. I might illustrate this, by a minute and partic- ular 233 OF PHYSIC. ular consideration of the difference of ali- mentary matters employed; but it will be enough to give two instances. The one is, that the herbaceous part of vegetables, does not fatten animals, so much as the seeds of vegetables, which manifestly contain in any given weight a greater proportion of oil; and a second instance is, that in general vegetable aliments do not fatten men so much as animal food, which generally contains a larger pro- portion of oil. It will be obvious, that upon the same principles a want of food, or a less nutritious food, may not only occasion a general defi- ciency of fluids (MDCIV), but must also af- ford less oil, to be poured into the cellular texture. In such cases, therefore, the ema- ciation produced, is to be attributed to both these general causes. MDCXV. A second case of the deficiency of oil may be explained in this manner. It is pretty manifest, that the oil of the blood is secreted and deposited in the cellular texture in great- er or lesser quantity, according as the circula- tion of the blood is faster or slower; and therefore that exercise, which hastens the cir- culation of the blood, is a frequent cause of emaciation. Exercise produces this effect in two ways, 1st, By increasing the perspira- tion, and thereby carrying off a greater quan- L3 tity 234 PRACTICE tity of the nutritious matter, it leaves less of it to be deposited in the cellular texture; thereby not only preventing an accumulation of fluids, but, as I have said above, causing a general deficiency of these, which must also cause a deficiency of oil in the cellular tex- ture. 2dly, It is well known, that the oil de- posited in the cellular texture is upon many occasions, and for various purposes of the economy, again absorbed, and mixed or dif- fused in the mass of blood, to be from thence perhaps carried entirely out of the body by the several excretions. Now, among other purposes of the accumulation and reabsorp- tion of oil, this seems to be one, that the oil is requisite to the proper action of the moving fibres in every part of the body; and there- fore that nature has provided for an absorp- tion of oil to be made according as the action of the moving fibres may demand it. It will thus be obvious, that the exercise of the mus- cular and moving fibres every where, must occasion an absorption of oil; and conse- quently that such exercise not only prevents the secretion of oil, as has been already said, but may also cause a deficiency of it, by oc- casioning an absorption of what had been deposited; and in this way, perhaps especial- ly, does it produce emaciation. MDCXVI. A third case of the deficiency of oil may occur from the following cause. It is prob- able, 235 OF PHYSIC. able, that one purpose of the accumulation of oil in the cellular texture of animals is, that it may, upon occasion, be again absorbed from thence, and carried into the mass of blood, for the purpose of enveloping and cor- recting any unusual acrimony arising and ex- isting in the date of the fluids. Thus, in most instances in which we can discern an acrid state of the fluids, as in scurvy, cancer, syphilis, poisons, and several other diseases, we find at the same time a deficiency of oil and an emaciation take place; which, in my apprehension, must be attributed to the ab- sorption of oil, which the presence of acrimo- ny in the body excites. It is not unlikely that certain poisons intro- duced into the body, may subsist there; and, giving occasion to an absorption of oil, may lay a foundation for the Tabes à veneno, Sauv. sp. 17. MDCXVII. A fourth case of emaciation, and which I would attribute to a sudden and considerable absorption of oil from the cellular texture, is that of fever, which so generally produces emaciation. This may perhaps be in part attributed to the increased perspiration, and therefore to the general deficiency of fluids that may be supposed to take place: But whatever share that may have in producing the effect, we can, from the evident shrinking L4 and 236 PRACTICE and diminution of the cellular substance, wherever it falls under our observation, cer- tainly conclude, that there has been a very considerable absorption of the oil which had been before deposited in that substance. This explanation is rendered the more probable from this, that I suppose the absorption mentioned is necessarily made for the purpose of enveloping or correcting an acrimony, which manifestly does in many, and may be suspected to arise in all, cases of fever. The most remarkable instance of emaciation oc- curring in fevers, is that which appears in the case of hectic fevers. Here the emaciation may be attributed to the profuse sweatings that commonly attend the disease: But there is much reason to believe, that an acrimony also is present in the blood; which, even in the beginning of the disease, prevents the se- cretion and accumulation of oil; and in the more advanced states of it, must occasion a more considerable absorption of it; which, from the shrinking of the cellular substance, seems to go farther than in almost any other instance. Upon the subject of emaciations from a de- ficiency of fluids, it may be observed, that every increased evacuation excites an absorp- tion from other parts, and particularly from the cellular texture; and it is therefore prob- able, that a deficiency of fluids, from increas- ed evacuations, produces an emaciation, not only by the waste of the fluids in the vascu- lar 237 OF PHYSIC. lar system, but also by occasioning a consider- able absorption from the cellular texture. MDCXVIII. I have thus endeavoured to explain the several cases and causes of emaciation; but I could not prosecute the consideration of these here in the order they are set down in the Methodical Nosology. In that work I was engaged chiefly in arranging the Species of Sauvages; but it is my opinion now, that the arrangement there given is erroneous, in both combining and separating species improper- ly: And it seems to me more proper here to take notice of diseases, and put them together, according to the affinity of their nature, rath- er than by that of their external appearances. I doubt, if even the distinction of the Tabes and Atrophia, attempted in the Nosology, will properly apply; as I think there are certain diseases of the same nature, which sometimes appear with, and sometimes with- out, fever. MDCXIX. After having considered the various cases of emaciations, I should perhaps treat of their cure: But it will readily appear, that the greater part of the cases above mentioned are VOL. 3. L5 purely 238 PRACTICE, &c. purely symptomatic, and consequently that the cure of them must be that of the primary diseases upon which they depend. Of those cases that can anywise be considered as idio- pathic, it will appear that they are to be cur- ed, entirely by removing the remote causes; the means of accomplishing which must be sufficiently obvious. BOOK 239 BOOK II. OF INTUMESCENTIÆ, OR GENER- AL SWELLINGS. MDCXX. THE swellings to be treated of in this place, are those which extend over the whole or a great part of the body; or such at least, as, though of small extent, are however of the same nature with those that are more generally extended. The swellings comprehended under this ar- tificial order, are hardly to be distinguished from one another otherwise than by the mat- ter they contain or consist of: And in this view I have divided the order into four sec- tions, as the swelling happens to contain, 1st, L6 Oil; 240 PRACTICE Oil; 2d, Air; 3d, A watery fluid; or, 4th, As the increased bulk depends upon the en- largement of the whole substance of certain parts, and particularly of one or more of the abdominal viscera. CHAP. 241 OF PHYSIC. CHAP. I. OF ADIPOSE SWELLINGS. MDCXXI. THE only disease to be men- tioned in this chapter, I have, with other No- sologists, named Polysarcia; and in English it may be named Corpulency, or, more strict- ly, Obesity; as it is placed here upon the common supposition of its depending chiefly upon the increase of oil in the cellular texture of the body. This corpulency, or obesity, is in very different degrees in different persons, and is often considerable without being con- sidered as a disease. There is, however, a certain degree of it, which will be generally allowed to be a disease; as, for example, when it renders persons, from a difficult res- piration, uneasy in themselves, and, from the inability of exercise, unfit for discharging the duties of life to others: And for that reason I have given such a disease a place here. Many physicians have considered it as an object of practice, and as giving, even in no very high degree, a disposition to many diseases; I am of opinion that it should be an object of prac- tice 242 PRACTICE tice more frequently than it has been, and therefore that it merits our consideration here. MDCXXII. It may perhaps be alleged, that I have not been sufficiently correct, in putting the disease of corpulency as an intumescentia pinguedi- nosa, and therefore implying its being an in- crease of the bulk of the body from an accu- mulation of oil in the cellular texture only. I am aware of this objection: And as I have already said, that emaciation (MDCII) de- pends either upon a general deficiency of flu- ids in the vascular system, or upon a deficien- cy of oil in the cellular texture; so I should perhaps have observed farther, that the cor- pulency, or general fulness of the body, may depend upon the fulness of the vascular sys- tem as well as upon that of the cellular tex- ture. This is true; and for the same reasons I ought, perhaps, after Linnæus and Sagar, to have set down plethora as a particular dis- ease, and as an instance of morbid intumes- cence. I have, however, avoided this, as Sau- vages and Vogel have done; because I ap- prehend that plethora is to be considered as a state of temperament only, which may indeed dispose to disease; but not as a disease in it- self, unless, in the language of the Stahlians, it be a plethora commota, when it produces a disease accompanied with particular symp- toms, 243 OF PHYSIC. toms, which give occasion to its being distin- guished by a different appellation. Further, it appears to me, that the symptoms which Linnæus, and more particularly those which Sagar employs in the character of plethora, never do occur but when the intumescentia pinguedinosa has a great share in producing them. It is, however, very necessary to ob- serve here, that plethora and obesity are gen- erally combined together; and that in some cases of corpulency it may be difficult to de- termine which of the causes has the greatest share in producing it. It is indeed very pos- sible that a plethora may occur without great obesity; but I apprehend that obesity never happens to a considerable degree without pro- ducing a plethora ad spatium in a great part of the system of the aorta, and therefore a plethora ad molem in the lungs, and in the vessels of the brain. MDCXXIII. In attempting the cure of polysarcia, I am of opinion, that the conjunction of plethora and obesity, in the manner just now men- tioned, should be constantly attended to; and when the morbid effects of the plethoric hab- it is threatened, either in the head or lungs, that bloodletting is to be practised: But at the same time it is to be observed, that per- sons of much obesity do not bear bloodletting well; and when the circumstances I have mentioned 244 PRACTICE mentioned do not immediately require it, the practice upon account of obesity alone, is hardly ever to be employed. The same re- mark is to be made with respect to any other evacuations that may be proposed for the cure of corpulency: For without the other means I am to mention, they can give but a very imperfect relief; and, in so far as they either empty or weaken the system, they may favour the return of plethora, and the increase of obesity. MDCXXIV. Polysarcia, or corpulency, whether it de- pend upon plethora or obesity, whenever it either can be considered as a disease, or threatens to induce one, is to be cured, or the effects of it are to be obviated, by diet and exercise. The diet must be sparing; or rather, what is more admissible, it must be such as affords little nutritious matter. It must therefore be chiefly, or almost only, of vegetable matter, and at the very utmost of milk. Such a diet should be employed, and generally ought to precede exercise; for obe- sity does not easily admit of bodily exercise; which is, however, the only mode that can be very effectual. Such, indeed, in many cases, may seem difficult to be admitted; but I am of opinion, that even the most corpulent may be brought to bear it, by at first attempting it very moderately, and increasing it by degrees very 245 OF PHYSIC. very slowly, but at the same time persisting in such attempts with great constancy. MDCXXV. As these, though the only effectual meas- ures, are often difficult to be admitted or car- ried into execution, some other means have been thought of and employed for reducing corpulency. These, if I mistake not, have all been certain methods of inducing a saline state in the mass of blood; for such I suppose to be the effects of vinegar and of soap, which have been proposed. The latter, I believe, hardly passes into the bloodvessels, without being resolved and formed into a neutral salt, with the acid which it meets with in the stom- ach. How well acrid and saline substances are fitted to diminish obesity, may appear from what has been said above in MDCXV. What effects vinegar, soap, or other sub- stances employed, have had in reducing cor- pulency, there have not proper opportunities of observing occurred to me: But I am well persuaded, that the inducing a saline and acrid state of the blood, may have worse conse- quences than the corpulency it was intended to correct; and that no person should hazard these, while he may have recourse to the more safe and certain means of abstinence and ex- ercise. CHAP. 246 PRACTICE CHAP. II. OF FLATULENT SWELLINGS. MDCXXVI. THE cellular texture of the human body very readily admits of air, and allows the same to pass from any one to every other part of it. Hence Emphysemata have often appeared from air collected in the cel- lular texture under the skin, and in several other parts of the body. The flatulent swell- ings under the skin, have indeed most com- monly appeared in consequence of air imme- diately introduced from without: But in some instances of flatulent swellings, espec- ially those of the internal parts not commu- nicating with the alimentary canal, such an introduction cannot be perceived or suppos- ed; and therefore, in these cases, some other cause of the production and collection of air must be looked for, though it is often not to be clearly ascertained. In every solid as well as every fluid sub- stance which makes a part of the human body, there is a considerable quantity of air in a fixed state, which may be again restored to its 247 OF PHYSIC. its elastic state, and separated from those sub- stances, by the power of heat, putrefaction, and perhaps other causes: But which of these may have produced the several instances of pneumatosis and flatulent swellings that have been recorded by authors, I cannot pretend to ascertain. Indeed, upon account of these difficulties, I cannot proceed with any clear- ness on the general subject of pneumatosis; and, therefore, with regard to flatulent swell- ings, I find it necessary to confine myself to the consideration of those of the abdominal region alone; which I shall now treat of un- der the general name of Tympanites. MDCXXVII. The tympanites is a swelling of the abdo- men; in which the teguments appear to be much stretched by some distending power within, and equally stretched in every posture of the body. The swelling does not readily yield to any pressure; and in so far as it does, very quickly recovers its former state upon the pressure being removed. Being struck, it gives a sound like a drum, or other stretched animal membranes. No fluctuation within is to be perceived: And the whole feels less weighty than might be expected from its bulk. The uneasiness of the distention is commonly relieved by the discharge of air from the ali- mentary canal, either upwards or down- wards. MDCXXVIII. 248 PRACTICE MDCXXVIII. These are the characters by which the tym- panites may be distinguished from the ascites or physconia; and many experiments show, that the tympanites always depends upon a preternatural collection of air, somewhere within the teguments of the abdomen: But the seat of the air is in different cases some- what different; and this produces the differ- ent species of the disease. One species is, when the air collected is entirely confined within the cavity of the ali- mentary canal, and chiefly in that of the in- testines. This species, therefore, is named the Tympanites intestinalis, Sauv. sp. 1. It is, of all others, the most common; and to it especially belong the characters given above. A second species is, when the air collected is not entirely confined to the cavity of the intestines, but is also present between their coats; and such is that which is named by Sauvages Tympanites enterophysodes, Sauv. sp. 3. This has certainly been a rare occurrence; and has probably occurred only in conse- quence of the tympanites intestinalis, by the air escaping from the cavity of the intestines into the interstices of the coats. It is, how- ever, possible that an erosion of the internal coat of the intestines may give occasion to the air, so constantly present in their cavity, to escape into the interstices of their coats, though 249 OF PHYSIC. though in the whole of their cavity there has been no previous accumulation. A third species is, when the air is collected in the sac of the peritonæum, or what is com- monly called the cavity of the abdomen, that is, the space between the peritonæum and vis- cera; and then the disease is named Tympa- nites abdominalis, Sauv. sp. 2. The existence of such a tympanites, without any tympanites intestinalis, has been disputed; and it certain- ly has been a rare occurrence: But from sev- eral dissections, it is unquestionable that such a disease has sometimes truly occurred. A fourth species of tympanites is, when the tympanites intestinalis and abdominalis are joined together, or take place at the same time. With respect to this, it is probable that the tympanites intestinalis is the primary disease; and the other, only a consequence of the air escaping, by an erosion or rupture of the coats of the intestines, from the cavity of these into that of the abdomen. It is in- deed possible, that in consequence of erosion or rupture, the air which is so constantly pres- ent in the intestinal canal, may escape from thence in such quantity into the cavity of the abdomen, as to give a tympanites abdominalis, whilst there was no previous considerable ac- cumulation of air in the intestinal cavity it- self; but I have not facts to ascertain this mat- ter properly. A fifth species has also been enumerated. It is when a tympanites abdominalis happens to 250 PRACTICE to be joined with the hydrops ascites; and such a disease therefore is named by Sauvages Tympanites asciticus, Sauv. sp. 4. In most cases of tympanites, indeed, some quantity of serum has, upon dissection, been found in the sac of the peritonæum; but that is not enough to constitute the species now mentioned; and when the collection of serum is more consid- erable, it is commonly where, both from the causes which have preceded, and likewise from the symptoms which attend, the ascites may be considered as the primary disease; and therefore that this combination does not exhibit a proper species of the tympanites. MDCXXIX. As this last is not a proper species, and as some of the others are not only extremely rare, but even, when occurring, are neither primary, nor to be easily distinguished, nor, as considered in themselves, admitting of any cure, I shall here take no further notice of them; confining myself, in what follows, to the consideration of the most frequent case, and almost the only object of practice, the tympanites intestinalis. MDCXX. With respect to this, I cannot perceive that it arises in any peculiar temperament, or de- pends upon any predisposition, which can be discerned. 251 OF PHYSIC. discerned. It occurs in either sex, at every age, and frequently in young persons. MDCXXXI. Various remote causes of it have been as- signed: But many of these have not common- ly the effect of producing this disease; and although some of them have been truly ante- cedents of it, I can in few instances discover the manner in which they produce the dis- ease, and therefore cannot certainly ascertain them to have been causes of it. MDCXXXII. The phenomena of this disease in its several stages are the following. The tumour of the belly sometimes grows very quickly to a considerable degree, and seldom in the slow manner the ascites com- monly comes on. In some cases, however, the tympanites comes on gradually, and is introduced by an unusual flatulency of the stomach and intestines, with frequent borbo- rygmi, and an uncommonly frequent expul- sion of air upwards and downwards. This state is also frequently attended with colic pains, especially felt about the navel, and up- on the sides towards the back; but generally as the disease advances, these pains become less considerable. As the disease advances, there 252 PRACTICE there is a pretty constant desire to discharge air, but it is accomplished with difficulty; and when obtained, although it gives some relief from the sense; of distention, this relief is com- monly transient and of short duration. While the disease is coming on, some inequality of tumour and tension may be perceived in dif- ferent parts of the belly; but the distention soon becomes equal over the whole, and ex- hibits the phenomena mentioned in the char- acter. Upon the first coming on of the dis- ease, as well as during its progress, the belly is bound, and the fæces discharged are com- monly hard and dry. The urine, at the be- ginning, is usually very little changed in quantity or quality from its natural state: But as the disease continues, it is commonly chang- ed in both respects; and at length sometimes a stranguary, and even an ischuria, comes on. The disease has seldom advanced far, before the appetite is much impaired, and digestion ill performed; and the whole body, except the belly, becomes considerably emaciated. Together with these symptoms, a thirst and uneasy sense of heat at length come on, and a considerable frequency of pulse occurs, which continues throughout the course of the dis- ease. When the tumour of the belly arises to a considerable bulk, the breathing becomes very difficult, with a frequent dry cough. With all these symptoms the strength of the patient declines; and the febrile symptoms daily increasing, death at length ensues, some- times 253 OF PHYSIC. times probably in consequence of a gangrene coming upon the intestines. MDCXXXIII. The tympanites is commonly of some du- ration, and to be reckoned a chronic disease. It is very seldom quickly fatal, except where such an affection suddenly arises in fevers. To this Sauvages has properly given a differ- ent appellation, that of Meteorismus; and I judge it may always be considered as a symp- tomatic affection, entirely distinct from the tympanites we are now considering. MDCXXXIV. The tympanites is generally a fatal disease, seldom admitting of cure; but what may be attempted in this way, I shall try to point out, after I shall have endeavoured to explain the proximate cause, which alone can lay the foundation of what may be rationally attempt- ed towards its cure. MDCXXXV. To ascertain the proximate cause of tym- panites, is somewhat difficult. It has been supposed in many cases, to be merely an un- common quantity of air present in the ali- mentary canal, owing to the extrication and detachment of a greater quantity of air than VOL. III. M usual 254 PRACTICE usual from the alimentary matters taken in. Our vegetable aliments, I believe, always un- dergo some degree of fermentation; and in consequence, a quantity of air is extricated and detached from them in the stomach and intestines: But it appears, that the mixture of the animal fluids which our aliments meet with in the alimentary canal, prevents the same quantity of air from being detached from them that would have been in their fermen- tation without such mixture; and it is prob- able that the same mixture contributes also to the reabsorption of the air that had been be- fore in some measure detached. The extri- cation, therefore, of an unusual quantity of air from the aliments, may, in certain circum- stances, be such, perhaps, as to produce a tympanites; so that this disease may depend upon a fault of the digestive fluids, whereby they are unfit to prevent the too copious ex- trication of air, and unfit also to occasion that reabsorption of air which in sound persons commonly happens. An unusual quantity of air in the alimentary canal, whether owing to the nature of the aliments taken in, or to the fault of the digestive fluid, does certainly sometimes take place; and may possibly have, and in some measure certainly has, a share in producing certain flatulent disorders of the al- imentary canal; but cannot be supposed to produce the tympanites, which often occurs when no previous disorder had appeared in the system. Even in those cases of tympa- nites 255 OF PHYSIC. nites which are attended at their beginning with flatulent disorders in the whole of the alimentary canal, as we know that a firm tone of the intestines both moderates the extrica- tion of air, and contributes to its reabsorption or ready expulsion, so the flatulent symptoms which happen to appear at the coming on of a tympanites, are, in my opinion, to be refer- red to a loss of tone in the muscular fibres of the intestines, rather than to any fault in the digestive fluids. MDCXXXVI. These, and other considerations, lead me to conclude, that the chief part of the proxi- mate cause of tympanites, is a loss of tone in the muscular fibres of the intestines. But further, as air of any kind accumulated in the cavity of the intestines should, even by its own elasticity, find its way either upwards or downwards, and should also, by the assistance of inspiration, be entirely thrown out of the body; so, when neither the reabsorption nor the expulsion takes place, and the air is accu- mulated so as to produce tympanites, it is probable that the passage of the air along the course of the intestines is in some places of these interrupted. This interruption, how- ever, can hardly be supposed to proceed from any other cause than spasmodic constrictions in certain parts of the canal; and I conclude, therefore, that such constrictions concur as M2 part 256 PRACTICE part in the proximate cause of tympanites. Whether these spasmodic constrictions are to be attributed to the remote cause of the dis- ease, or may be considered as the consequence of some degree of atony first arising, I cannot with certainty, and do not find it necessary to determine. MDCXXXVII. Having thus endeavoured to ascertain the proximate cause of tympanites, I proceed to treat of its cure; which indeed has seldom succeeded, and almost never but in a recent disease. I must, however, endeavour to say what may be reasonably attempted; what has commonly been attempted; and what at- tempts have sometimes succeeded in the cure of this disease. MDCXXXVIII. It must be a first indication to evacuate the air accumulated in the intestines: And for this purpose it is necessary that those constric- tions, which had especially occasioned its ac- cumulation, and continue to interrupt its pas- sage along the course of the intestines, should be removed. As these, however, can hardly be removed but by exciting the peristaltic motion in the adjoining portions of the intes- tines, purgatives have been commonly em- ployed; but it is at the same time agreed, that 257 OF PHYSIC. that the more gentle laxatives only ought to be employed, as the more drastic, in the over stretched and tense state of the intestines, are in danger of bringing on inflammation. It is for this reason also, that glysters have been frequently employed; and they are the more necessary, as the fæces collected are gen- erally found to be in a hard and dry state. Not only upon account of this state of the fæces, but, farther, when glysters produce a considerable evacuation of air, and thus show that they have some effect in relaxing the spasms of the intestines, they ought to be re- peated very frequently. MDCXXXIX. In order to take off the constrictions of the intestines, and with some view also to the car- minative effects of the medicines, various an- tispasmodics have been proposed, and com- monly employed; but their effects are sel- dom considerable, and it is alleged that their heating and inflammatory powers have some- times been hurtful. It is, however, always proper to join some of the milder kinds with both the purgatives and glysters that are em- ployed; and it has been very properly advis- ed to give always the chief of antispasmodics, that is, an opiate, after the operation of pur- gatives are finished. M3 MDCXL. 258 PRACTICE MDCXL. In consideration of the overstretched, tense, and dry state of the intestines, and especially of the spasmodic constrictions that prevail, fo- mentations and warm bathing have been pro- posed as a remedy; and are said to have been employed with advantage: But it has been remarked, that very warm baths have not been found so useful as tepid baths long con- tinued. MDCXLI. Upon the supposition that this disease de- pends especially upon an atony of the ali- mentary canal, tonic remedies seem to be properly indicated. Accordingly chalybe- ates, and various bitters, have been employ- ed; and, if any tonic, the Peruvian bark might probably be useful. MDCXLII. But as no tonic remedy is more powerful than cold applied to the surface of the body, and cold drink thrown into the stomach; so such a remedy has been thought of in this dis- ease. Cold drink has been constantly pre- scribed, and cold bathing has been employed with advantage; and there have been several instances of the disease being suddenly and entirely 259 OF PHYSIC. entirely cured by the repeated application of snow to the lower belly. MDCXLIII. It is hardly necessary to remark, that, in the diet of tympanitic persons, all sorts of food ready to become flatulent in the stomach are to be avoided; and it is probable, that the fossil acids and neutral salts, as antizymics, may be useful. MDCXLIV. In obstinate and desperate cases of tym- panites, the operation of the paracentesis has been proposed: But it is a very doubtful remedy, and there is hardly any testimony of its having been practised with success. It must be obvious, that this operation is a rem- edy suited especially, and almost only, to the tympanites abdominalis; the existence of which, separately from the intestinalis, is very doubt- ful, at least not easily ascertained. Even if its existence could be ascertained, yet it is not very likely to be cured by this remedy: And how far the operation might be safe in the tympanites intestinalis, is not yet determined by any proper experience. M4 CHAP. 260 PRACTICE CHAP. III. OF WATERY SWELLINGS, OR DROP- SIES. MDCXLV. A PRETERNATURAL col- lection of serous or watery fluids, is often formed in different parts of the human body; and although the disease thence arising be distinguished according to the different parts which it occupies, yet the whole of such col- lections come under the general appellation of Dropsies. At the same time, although the particular instances of such collection are to be distinguished from each other according to the parts they occupy, as well as by other cir- cumstances attending them; yet all of them seem to depend upon some general causes, very much in common to the whole. Before proceeding, therefore, to consider the several species, it may be proper to endeavour to as- sign the general causes of dropsy. MDCXLVI. In persons in health, a serous or watery fluid seems to be constantly poured out, or exhaled 261 OF PHYSIC. exhaled in vapour, into every cavity and in- terstice of the human body capable of receiv- ing it; and the same fluid, without remaining long or being accumulated in these spaces, seems constantly to be soon again absorbed from thence by vessels adapted to the pur- pose. From this view of the animal econo- my, it will be obvious, that if the quantity poured out into any space, happens to be greater than the absorbents can at the same time take up, an unusual accumulation of se- rous fluid will be made in such parts; or though the quantity poured out be not more than usual, yet if the absorption be anywise interrupted or diminished, from this cause al- so an unusual collection of fluids may be oc- casioned. Thus, in general, dropsy may be imputed to an increased effusion, or to a diminished absorption; and I therefore proceed to in- quire into the several causes of these. MDCXLVII. An increased effusion may happen, either from a preternatural increase of the ordinary exhalation, or from the rupture of vessels car- rying, or of sacs containing, serous or watery fluids. MDCXLVIII. The ordinary exhalation may be increased by various causes, and particularly by an in- VOL. 3. M5 terruption 262 PRACTICE terruption given to the free return of the ve- nous blood from the extreme vessels of the body to the right ventricle of the heart. This interruption seems to operate by resisting the free passage of the blood from the arteries into the veins, thereby increasing the force of the arterial fluids in the exhalants, and conse- quently the quantity of fluid which they pour out. MDCXLIX. The interruption of the free return of the venous blood from the extreme vessels, may be owing to certain circumstances affecting the course of the venous blood; very fre- quently, to certain conditions in the right ventricle of the heart itself, preventing it from receiving the usual quantity of blood from the vena cava; or to obstructions in the vessels of the lungs preventing the entire evacuation of the right ventricle, and thereby hindering its receiving the usual quantity of blood from the cava. Thus, a polypus in the right ven- tricle of the heart, and the ossification of its valves, as well as all considerable and perma- nent obstructions of the lungs, have been found to be causes of dropsy. MDCL. It may serve as an illustration of the ope- ration of these general causes, to remark, that the 263 OF PHYSIC. the return of the venous blood is in some measure resisted when the posture of the body is such as gives occasion to the gravity of the blood to oppose the motion of it in the veins, which takes effect when the force of the cir- culation is weak; and from whence it is that an upright posture of the body produces or increases serous swellings in the lower extrem- ities. MDCLI. Not only those causes interrupting the mo- tion of the venous blood more generally, but, farther, the interruption of it in particular veins, may likewise have the effect of increas- ing exhalation, and producing dropsy. The most remarkable instance of this is, when con- siderable obstructions of the liver prevent the blood from flowing freely into it from the vena portarum and its numerous branches; and hence these obstructions are a frequent cause of dropsy. MDCLII. Scirrhosities of the spleen and other viscera, as well as the scirrhosity of the liver, have been considered as causes of dropsy; but the manner in which they can produce the dis- ease, I do not perceive, except it may be where they happen to be near some consid- erable vein, by the compression of which they may occasion some degree of ascites; or, by M6 compressing 264 PRACTICE compressing the vena cava, may produce an anasarca of the lower extremities. It is in- deed true, that scirrhosities of the spleen and other viscera, have been frequently discover- ed in the bodies of hydropic persons: But I believe they have been seldom found unless when scirrhosities of the liver were also pres- ent; and I am inclined to think, that the former have been the effects of the latter, rather than the cause of the dropsy; or that, if scirrhosities of the other viscera have ap- peared in hydropic bodies when that of the liver was not present, they must have been the effects of some of those causes of dropsy to be hereafter mentioned; and consequently to be the accidental attendants, rather than the causes, of such dropsies. MDCLIII. Even in smaller portions of the venous system, the interruption of the motion of the blood in particular veins has had the same ef- fect. Thus, a polypus formed in the cavity of a vein, or tumours formed in its coats, pre- venting the free passage of the blood through it, have had the effect of producing dropsy in parts towards the extremity of such veins. MDCLIV. But the cause most frequently interrupting the motion of the blood through the veins is, the compression of tumours existing near to them; 265 OF PHYSIC. them; such as aneurisms in the arteries, ab- scesses, and scirrhous or steatomatous tumours in the adjoining parts. To this head, may be referred, the com- pression of the descending cava by the bulk of the uterus in pregnant women, and the compression of the same by the bulk of water in the ascites; both of which compressions fre- quently produce serous swellings in the lower extremities. MDCLV. It may be supposed, that a general preter- natural plethora of the venous system may have the effect of increasing exhalation; and that this plethora may happen from the sup- pression of fluxes, or evacuations of blood, which had for some time taken place in the body, such as the menstrual and hemorrhoidal fluxes. A dropsy, however, from such a cause, has been at least a rare occurrence; and when it seems to have happened, I should suppose it owing to the same causes as the suppression itself, rather than to the plethora produced by it. MDCLVI. One of the most frequent causes of an in- creased exhalation, I apprehend to be the laxity of the exhalant vessels. That such a cause may operate, appears probable from this, that paralytic limbs, in which such a lax- ity 266 PRACTICE ity is to be suspected, are frequently affected with serous, or, as they are called, œdematous swellings. But a much more remarkable and frequent example of its operation occurs in the case of a general debility of the system, which is so often attended with dropsy. That a general debility does induce dropsy, appears suffi- ciently from its being so commonly the conse- quence of powerfully debilitating causes; such as fevers, either of the continued or in- termittent kind, which have lasted long; long continued and somewhat excessive evacuations of any kinds; and, in short, almost all diseases that have been of long continuance, and have at the same time induced the other symptoms of a general debility. Among other causes inducing a general de- bility of the system, and thereby dropsy, there is one to be mentioned as frequently occur- ring, and that is, intemperance in the use of intoxicating liquors; from whence it is that drunkards of all kinds, and especially dram drinkers, are so affected with this disease. MDCLVII. That a general debility may produce a lax- ity of the exhalants, will be readily allowed; and that by this especially it occasions drop- sy, I judge from thence, that while most of the causes already mentioned are suited to produce dropsies of particular parts only, the state 267 OF PHYSIC. state of general debility gives rise to an in- creased exhalation into every cavity and in- terstice of the body, and therefore brings on a general disease. Thus, we have seen effu- sions of a serous fluid made, at the same time, into the cavity of the cranium, into that of the thorax and of the abdomen, and likewise into the cellular texture almost over the whole of the body. In such cases, the operation of a general cause discovered itself, by these sev- eral dropsies increasing in one part as they diminished in another, and this alternately in the different parts. This combination, there- fore, of the different species of dropsy, or rather, as it may be termed, this universal dropsy, must, I think, be referred to a general cause; and in most instances, hardly any oth- er can be thought of, but a general laxity of the exhalants. It is this, therefore, that I call the hydropic diathesis; which frequently ope- rates by itself; and frequently, in some meas- ure, concurring with other causes, is especial- ly that which gives them their full effect. This state of the system, in its first appear- ance, seems to be what has been considered as a particular disease under the name of Cachexy; but in every instance of it that has occurred to me, I have always considered, and have al- ways found, it to be the beginning of general dropsy. MDCLVIII. The several causes of dropsy already men- tioned may produce the disease, although there 268 PRACTICE there be no preternatural abundance of serous or watery fluid in the bloodvessels; but it is now to be remarked, that a preternatural abundance of that kind may often give occa- sion to the disease, and more especially when such abundance concurs with the causes above enumerated. One cause of such preternatural abundance may be an unusual quantity of water taken into the body. Thus an unusual quantity of water taken in by drinking, has sometimes oc- casioned a dropsy. Large quantities of water, it is true, are upon many occasions taken in; and being as readily thrown out again by stool, urine, or perspiration, have not pro- duced any disease. But it is also certain, that, upon some occasions, an unusual quan- tity of watery liquors taken in has run off by the several internal exhalants, and produced a dropsy. This seems to have happened, ei- ther from the excretories not being fitted to throw out the fluid so fast as it had been taken in, or from the excretories having been ob- structed by accidentally concurring causes. Accordingly it is said, that the sudden taking in of a large quantity of very cold water, has produced dropsy, probably from the cold producing a constriction of the excretories. The proportion of watery fluid in the blood may be increased, not only by the taking in a large quantity of water by drinking, as now mentioned, but it is possible that it may be in- creased also by water taken in from the at- mosphere 269 OF PHYSIC. mosphere by the skin in an absorbing or im- bibing state. It is well known that the skin may be, at least, occasionally in such a state; and it is probable, that in many cases of be- ginning dropsy, when the circulation of the blood on the surface of the body is very lan- guid, that the skin may be changed from a perspiring, to an imbibing, state; and thus, at least, the disease may be very much in- creased. MDCLIX. A second cause of a preternatural abund- ance of watery fluids in the bloodvessels, may be, an interruption of the ordinary watery ex- cretions; and accordingly it is alleged, that persons much exposed to a cold and moist air are liable to dropsy. It is also said, that an interruption, or considerable diminution, of the urinary secretion, has produced the dis- ease: And it is certain, that, in the case of an ischuria renalis, the serosity retained in the bloodvessels has been poured out into some internal cavities, and has occasioned dropsy. MDCLX. A third cause, of an over proportion of se- rous fluid in the blood ready to run off by the exhalants, has been very large evacuations of blood, either spontaneous or artificial. These evacuations, by abstracting a large proportion of 270 PRACTICE of red globules and gluten, which are the principal means of retaining serum in the red vessels, allow the serum to run off more read- ily by the exhalants: And hence dropsies have been frequently the consequence of such evacuations. It is possible also, that large and long con- tinued issues, by abstracting a large propor- tion of gluten, may have the same effect. An over proportion of the serous parts of the blood, may not only be owing to the spo- liation just now mentioned, but may, I appre- hend, be likewise owing to a fault in the di- gesting and assimilating powers in the stomach and other organs; whereby they do not pre- pare and convert the aliments taken in, in such a manner as to produce from them the due proportion of red globules and gluten; but, still continuing to supply the watery parts, occasion these to be in an over propor- tion, and consequently ready to run off in too large quantity by the exhalants. It is in this manner that we explain the dropsy, so often attending chlorosis: Which appears al- ways at first by a pale colour of the whole body, showing a manifest deficiency of red blood; which in that disease can only be at- tributed to an imperfect digestion and assim- ilation. Whether a like imperfection takes place in what has been called a Cachexy, I dare not determine. This disease indeed has been commonly and very evidently owing to the general 271 OF PHYSIC. general causes of debility above mentioned: And it being provable that the general debil- ity may affect the organs of digestion and as- similation; so the imperfect state of these functions, occasioning a deficiency of red globules and gluten, may often concur with the laxity of the exhalants in producing dropsy. MDCLXI. These are the several causes of increased exhalation, which I have mentioned as the chief cause of the effusion producing dropsy; but I have likewise observed in MDCXLVII, that with the same effect, an effusion may also be made by the rupture of vessels carrying watery fluids. In this way, a rupture of the thoracic duct, has given occasion to an effusion of chyle and lymph into the cavity of the thorax; and a rupture of the lacteals has occasioned a like effusion into the cavity of the abdomen; and in either case, a dropsy has been produced. It is sufficiently probable, that a rupture of lymphatics, in consequence of strains, or the violent compression of neighbouring mus- cles, has occasioned an effusion; which, be- ing diffused in the cellular texture, has pro- duced dropsy. It belongs to this head of causes, to remark, that there are many instances of a rupture or erosion of the kidneys, ureters, and bladder of 272 PRACTICE of urine; whereby the urine has been pour- ed into the cavity of the abdomen, and pro- duced an ascites. MDCLXII. Upon this subject, of the rupture of vessels carrying, or of vesicles containing, watery flu- ids, I must observe, that the dissection of dead bodies have often shown vesicles formed upon the surface of many of the internal parts; and it has been supposed, that the rupture of such vesicles, commonly named Hydatides, together with their continuing to pour out a watery fluid, has been frequently the cause of dropsy. I cannot deny the possibility of such a cause, but suspect the matter must be explained in a different manner. There have been frequently found, in al- most every different part of animal bodies, collections of spherical vesicles, containing a watery fluid; and in many cases of supposed dropsy, particularly in those called the pre- ternatural encysted dropsies, the swelling has been entirely owing to a collection of such hydatides. Many conjectures have been formed with regard to the nature and pro- duction of these vesicles; but the matter at last seems to be ascertained. It seems to be certain, that each of these vesicles has within it, or annexed to it, a living animal of the worm kind; which seems to have the power of forming a vesicle for the purpose of its own economy, 273 OF PHYSIC. economy, and of filling it with a watery fluid drawn from the neighbouring parts: And this animal has therefore been properly named by late naturalists, the Tœnia hydatigena. The origin and economy of this animal, or an account of the several parts of the human body which it occupies, I cannot prosecute further here; but it was proper for me, in de- livering the causes of dropsy, to say thus much of hydatides: And I must conclude with ob- serving, I am well persuaded, that most of the instances of preternatural encysted dropsies which have appeared in many different parts of the human body, have been truly collec- tions of such hydatides; but how the swell- ings occasioned by these are to be distinguish- ed from other species of dropsy, or how they are to be treated in practice, I cannot at pres- ent determine. MDCLXIII. After having mentioned these, I return to consider the other general cause of dropsy, which I have said in MDCXLVI may be, an interruption or diminution of the absorp- tion that should take up the exhaled fluids from the several cavities and interstices of the body; the causes of which interruption, how- ever, are not easily ascertained. MDCLXIV. 274 PRACTICE MDCLXIV. It seems probable, that absorption may be diminished, and even cease altogether, from a loss of tone in the absorbent extremities of the lymphatics. I cannot indeed doubt that a certain degree of tone or active power is necessary in these absorbent extremities; and it appears probable, that the same general de- bility which produces that laxity of the ex- halant vessels, wherein I have supposed the hydropic diathesis to consist, will at the same time occasion a loss of tone in the absorbents; and therefore that a laxity of the exhalants will generally be accompanied with a loss of tone in the absorbents; and that this will have a share in the production of dropsy. Indeed it is probable that the diminution of absorption has a considerable share in the matter; as dropsies are often cured by med- icines which seem to operate by exciting the action of the absorbents. MDCLXV. It has been supposed, that the absorption performed by the extremities of lymphatics may be interrupted by an obstruction of these vessels, or at least of the conglobate glands through which these vessels pass. This, how- ever, is very doubtful. As the lymphatics have branches frequently communicating with 275 OF PHYSIC. with one another, it is not probable that the obstruction of any one, or even several of these, can have any considerable effect in in- terrupting the absorption of their extremities. And for the same reason, it is as little prob- able that the obstruction of conglobate glands can have such an effect: At least it is only an obstruction of the glands of the mesentery, through which so considerable a portion of the lymph passes, that can possibly have the effect of interrupting absorption. But even this we should not readily suppose, there be- ing reason to believe that these glands, even in a considerably tumefied date, are not en- tirely obstructed: And accordingly I have known several instances of the most part of the mesenteric glands being considerably tu- mefied, without either interrupting the trans- mission of fluids to the bloodvessels, or occa- sioning any dropsy. An hydropic swelling, indeed, seems often to affect the arm from a tumour of the axil- lary gland: But it seems to me doubtful, whether the tumour of the arm may not be owing to some compression of the axillary vein, rather than to an obstruction of the lymphatics. MDCLXVI. A particular interruption of absorption may be supposed to take place in the brain. As no lymphatic vessels have yet very certainly been 276 PRACTICE been discovered in that organ, it may be thought that the absorption, which certainly takes place there, is performed by the extrem- ities of veins, or by vessels that carry the fluid directly into the veins; so that any impedi- ment to the free motion of the blood in the veins of the brain, may interrupt the absorp- tion there, and occasion that accumulation of serous fluid which so frequently occurs from a congestion of blood in these veins. But I give all this as a matter of conjecture only. MDCLXVII. Having thus explained the general causes of dropsy, I should proceed, in the next place, to mention the several parts of the body in which serous collections take place, and so to mark the different species of dropsy: But I do not think it necessary for me to enter into any minute detail upon this subject. In many cases, these collections are not to be ascertain- ed by any external symptoms, and therefore cannot be the objects of practice; and many of them, though in some measure discernible, do not seem to be curable by our art. I the more especially avoid mentioning very par- ticularly the several species, because that has already been sufficiently done by Dr. D. Monro, and other writers, in every body's hands. I must confine myself here to the consideration of those species which are the most frequently occurring and the most com- mon 277 OF PHYSIC. mon objects of our practice; which are, the Anasarca, Hydrothorax, and Ascites; and each of these I shall treat in so many separate sections. SECT. I. Of ANASARCA. MDCLXVIII. THE Anasarca is a swelling upon the sur- face of the body, at first commonly appearing in particular parts only, but at length fre- quently appearing over the whole. So far as it extends, it is an uniform swelling over the whole member, at first always soft, and read- ily receiving the pressure of the finger, which forms a hollow that remains for some little time after the pressure is removed, but at length rises again to its former fulness. This swelling generally appears, first, upon the lower extremities; and there too only in the evening, disappearing again in the morning. It is usually more considerable as the person has been more in an erect posture during the day; but there are many instances of the ex- ercise of walking preventing altogether its oth- erwise usual coming on. Although this swelling appears at first only upon the feet VOL. III. N and 278 PRACTICE and about the ankles; yet if the causes pro- ducing it continue to act, it gradually extends upwards, occupying the legs, thighs, and trunk of the body, and sometimes even the head. Commonly the swelling of the lower extremities diminishes during the night; and in the morning, the swelling of the face is most considerable, which again generally dis- appears almost entirely in the course of the day. MDCLXIX. The terms of Anasarca and Leucophlegmatia have been commonly considered as synony- mous; but some authors have proposed to consider them as denoting distinct diseases. The authors who are of this last opinion em- ploy the name of Anasarca for that disease which begins in the lower extremities, and is from thence gradually extended upwards in the manner I have just now described; while they term Leucophlegmatia, that in which the same kind of swelling appears even at first very generally over the whole body. They seem to think also, that the two diseases pro- ceed from different causes; and that, while the anasarca may arise from the several causes in MDCXLVIII——MDCLIX, the leuco- phlegmatia proceeds especially from a defi- ciency of red blood, as we have mentioned in MDCLX et seq. I cannot, however, find any proper foundation for this distinction. For 279 OF PHYSIC. For although in dropsies proceeding from the causes mentioned in MDCLX et seq. the dis- ease appears in some cases more immediately affecting the whole body; yet that does not establish a difference from the common case of anasarca: For the disease, in all its circum- stances, comes at length to be entirely the same; and in cases occasioned by a deficiency of red blood, I have frequently observed it to come on exactly in the manner of an anasar- ca, as above described. MDCLXX. An anasarca is evidently a preternatural collection of serous fluid in the cellular tex- ture immediately under the skin. Some- times pervading the skin itself, it oozes out through the pores of the cuticle; and some- times, too gross to pass by these, it raises the cuticle in blisters. Sometimes the skin, not allowing the water to pervade it, is compress- ed and hardened, and at the same time so much distended, as to give anasarcous tu- mours an unusual firmness. It is in these last circumstances also that an erythematic inflammation is ready to come upon anasar- cous swellings. MDCLXXI. An anasarca may immediately arise from any of the several causes of dropsy which N2 act 280 PRACTICE act more generally upon the system: And even when other species of dropsy, from par- ticular circumstances, appear first; yet when- ever these proceed from any causes more gen- erally affecting the system, an anasarca soon- er or later comes always to be joined with them. MDCLXXII. The manner in which this disease common- ly first appears, will be readily explained by what I have said in MDCL respecting the effects of the posture of the body. Its grad- ual progress, and its affecting, after some time, not only the cellular texture under the skin, but probably also much of the same texture in the internal parts, will be understood part- ly from the communication that is readily made between the several parts of the cellular texture; but especially from the same general causes of the disease producing their effects in every part of the body. It appears to me, that the water of anasarcous swellings is more readily communicated to the cavity of the thorax, and to the lungs, than to the cavity of the abdomen, or to the viscera contained in it. MDCLXXIII. An anasarca is almost always attended with a scarcity of urine; and the urine voided, is, from 281 OF PHYSIC. from its scarcity, always of a high colour; and from the same cause, after cooling, readily lets fall a copious reddish sediment. This scar- city of urine may sometimes be owing to an obstruction of the kidneys; but probably is generally occasioned by the watery parts of the blood running off into the cellular tex- ture, and being thereby prevented from pass- ing in the usual quantity to the kidneys. The disease is also generally attended with an unusual degree of thirst; a circumstance I would attribute to a like abstraction of fluid from the tongue and fauces, which are ex- tremely sensible to every diminution of the fluids in these parts. MDCLXXIV. The cure of anasarca is to be attempted upon three general indications. 1. The removing the remote causes of the disease. 2. The evacuation of the serous fluid al- ready collected in the cellular texture. 3. The restoring the tone of the system, the loss of which may be considered in many cases as the proximate cause of the disease. MDCLXXV. The remote causes are very often such as had not only been applied, but had also been removed, long before the disease came on. N3 Although, 282 PRACTICE Although, therefore, their effects remain, the causes themselves cannot be the objects of practice; but if the causes still continue to be applied, such as intemperance, indolence, and some others, they must be removed. For the most part, the remote causes are certain diseases previous to the dropsy, which are to be cured by the remedies particularly adapt- ed to them, and cannot be treated of here. The curing of these, indeed, may be often difficult; but it was proper to lay down the present indication, in order to show, that when these remote causes cannot be remov- ed, the cure of the dropsy must be difficult, or perhaps impossible. In many cases, there- fore, the following indications will be too little purpose; and particularly, that often the ex- ecution of the second will not only give the patient a great deal of fruitless trouble, but commonly also hurry on his fate. MDCLXXVI. The second indication for evacuating the collected serum, may be sometimes executed with advantage, and often, at least, with tem- porary relief. It may be performed in two ways. First, by drawing off the water di- rectly from the dropsical part, by openings made into it for that purpose: Or, secondly, by exciting certain serous excretions; in con- sequence of which, an absorption may be ex- cited in the dropsical parts, and thereby the serum 283 OF PHYSIC. serum absorbed and carried into the blood- vessels, may afterwards be directed to run out, or may spontaneously pass out, by one or oth- er of the common excretions. MDCLXXVII. In an anasarca, the openings into the drop- sical part are commonly to be made in some part of the lower extremities; and will be most properly made by many small punctures reaching the cellular texture. Formerly, considerable incisions were employed for this purpose: But as any wound made in drop- sical parts, which, in order to their healing, mud necessarily inflame and suppurate, are liable to become gangrenous; so it is found to be much safer to make the openings by small punctures only, which may heal up by the first intention. At the same time, even with respect to these punctures, it is proper to observe, that they should be made at some distance from one another, and that care should be taken to avoid making them in the most depending parts. MDCLXXVIII. The water of anasarcous limbs may be sometimes drawn off by pea issues, made by caustic a little below the knees: For as the great swelling of the lower extremities is chief- ly occasioned by the serous fluid exhaled into N4 the 284 PRACTICE the upper parts constantly falling down to the lower; so the issues now mentioned, by evacuating the water from these upper parts, may very much relieve the whole of the dis- ease. Unless, however, the issues be put in before the disease is far advanced, and before the parts have very much lost their tone, the places of the issues are ready to become af- fected with gangrene. Some practical writers have advised the employment of setons for the same purpose that I have proposed issues; but I apprehend, that setons will be more liable than issues to the accident just now mentioned. MDCLXXIX. For the purpose of drawing out serum from anasarcous limbs, blisters have been applied to them, and sometimes with great success; but the blistered parts are ready to have a gangrene come upon them. Blistering is therefore to be employed with great caution; and perhaps only in the circumstances that I have mentioned above to be fit for the em- ployment of issues. MDCLXXX. Colewort leaves applied to the skin, readily occasion a watery exudation from its surface; and applied to the feet and legs affected with anasarca, 285 OF PHYSIC. anasarca, have sometimes drawn off the water very copiously, and with great advantage. Analogous, as I judge, to this, oiled silk hose put upon the feet and legs, so as to shut out all communication with the external air, have been found sometimes to draw a quanti- ty of water from the pores of the skin, and are said in this way to have relieved anasarcous swellings: But in several trials made, I have never found either the application of these hose, or that of the colewort leaves, of much service. MDCLXXXI. The 2d means proposed in MDCLXXVI for drawing off the water from dropsical places, may be the employment of emetics, purgatives, diuretics, or sudorifics. MDCLXXXII. As spontaneous vomiting has sometimes excited an absorption in hydropic parts, and thereby drawn off the waters lodged in them, it is reasonable to suppose that vomiting ex- cited by art may have the same effect; and accordingly it has been often practised with advantage. The practice, however, requires that the strong antimonial emetics be em- ployed, and that they be repeated frequently after short intervals. VOL. 3. N5 MDCLXXXIII. 286 PRACTICE MDCLXXXIII. Patients submit more readily to the use of purgatives, than to that of emetics; and in- deed they commonly bear the former more easily than the latter. At the same time, there are no means we can employ to pro- cure a copious evacuation of serous fluids with greater certainty than the operation of purgatives; and it is upon these accounts that purging is the evacuation which has been most frequently, and perhaps with most suc- cess, employed in dropsy. It has been gen- erally found necessary to employ purgatives of the more drastic kind; which are common- ly known, and need not be enumerated here. I believe indeed, that the more drastic pur- gatives are the most effectual for exciting absorption, as their stimulus is most readily communicated to the other parts of the sys- tem; but of late an opinion has prevailed, that some milder purgatives may be employ- ed with advantage. This opinion has pre- vailed particularly with regard to the crystals vulgarly called the Cream of Tartar, which in large doses, frequently repeated, have some- times answered the purpose of exciting large evacuations both by stool and urine, and has thereby cured dropsies. This medicine, however, has frequently failed, both in its operation and effects, when the drastic pur- gatives have been more successful. Practitioners 287 OF PHYSIC. Practitioners have long ago observed, that, in the employment of purgatives, it is requi- site they be repeated after as short intervals as the patient can bear; probably for this reason, that when the purging is not carried to the degree of soon exciting an absorption, the evacuation weakens the system, and there- by increases the afflux of fluids to the hy- dropic parts. MDCLXXXIV. The kidneys afford a natural outlet for a great part of the watery fluids contained in the bloodvessels; and the increasing the ex- cretion by the kidneys to a considerable de- gree, is a means as likely as any other of ex- citing an absorption in dropsical parts. It is upon this account that diuretic medicines have been always properly employed in the cure of dropsy. The various diuretics, that may be employed, are enumerated in every treatise of the Materia Medica and of the Practice of Physic, and therefore need not be repeated here. It happens, however, unluckily, that none of them are of very certain operation; neither is it well known why they sometimes succeed, and why they so often fail; nor why one medicine should prove of service when another does not. It has been generally the fault of writers upon the Practice of Physic, that they give us instances of cases in which certain medicines have proved very effica- N6 cious, 288 PRACTICE cious, but neglect to tell us in how many oth- er instances the same have failed. MDCLXXXV. It deserves to be particularly observed here, that there is hardly any diuretic more certain- ly powerful than a large quantity of common water taken in by drinking. I have indeed observed above in MDCLVIII, that a large quantity of water, or of watery liquors, taken in by drinking, has sometimes proved a cause of dropsy; and practitioners have been for- merly so much afraid that watery liquors tak- en in by drinking might run off into dropsical places and increase the disease, that they have generally enjoined the abstaining as much as possible, from such liquors. Nay, it has been further asserted, that by avoiding this supply of exhalation, and by a total abstinence from drink, dropsies have been entirely cured. What conclusion is to be drawn from these facts are, however, very doubtful. A dropsy arising from a large quantity of liquids taken in to the body has been a very rare occurrence; and there are, on the other hand, innumerable instances of very large quantities of water hav- ing been taken in and running off again very quickly by stool and urine, without produc- ing any degree of dropsy. With respect to the total abstinence from drink, it is a practice of the most difficult execution; and therefore has been so seldom practised, that we cannot possibly 289 OF PHYYSIC. possibly know how far it might prove effectu— al. The practice of giving drink very spar- ingly has indeed been often employed: But in a hundred instances, I have seen it car- ried to a great length without any manifest advantage: while, on the contrary, the prac- tice of giving drink very largely has been found not only safe, but very often effectual in curing the disease. The ingenious and learned Dr. Millman has, in my opinion, been commendably employed in restoring the prac- tice of giving large quantities of watery liquors for the cure of dropsy. Not only from the instances he mentions from his own practice, and from that of several eminent physicians in other parts of Europe, but also from many instances in the records of physic, of the good effects of drinking large quantities of mineral waters in the cure of dropsy, I can have no doubt of the practice recommended by Dr. Millman being very often extremely proper. I apprehend it to be especially adapted to those cases in which the cure is chiefly at- tempted by diuretics. It is very probable, that these medicines can hardly be carried in any quantity to the kidneys without being ac- companied with a large portion of water; and the late frequent employment of the crystals of tartar has often shown, that the diuretic effects of that medicine are almost only re- markable when accompanied with a large quantity of water; and that without this, the diuretic effects of the medicine seldom ap- pear. 290 PRACTICE pear. I shall conclude this subject with ob- serving, that as there are so many cases of dropsy absolutely incurable, the practice now under consideration may often fail, yet in most cases it may be safely tried; and if it appear that the water taken in passes readily by the urinary secretion, and especially that it increases the urine beyond the quantity of drink taken in, the practice may probably be continued with great advantage: But, on the contrary, if the urine be not increased, or be not even in proportion to the drink taken in, it may be concluded, that the water thrown in runs off by the exhalants, and will augment the disease. MDCLXXXVI. Another set of remedies which may be em- ployed for exciting a serous excretion, and thereby curing dropsy, is that of sudorifics. Such remedies, indeed, have been sometimes employed: But however useful they may have been thought, there are few accounts of their having effected a cure; and although I have had some examples of their success, in most instances of their trial they have been ineffectual. Upon this subject it is proper to take notice of the several means that have been proposed and employed for dissipating the humidity of the body; and particularly that of heat ex- ternally applied to the surface of it. Of such applications 291 OF PHYSIC. applications I have had no experience; and their propriety and utility must rest upon the credit of the authors who relate them. I shall offer only this conjecture upon the sub- ject: That if such measures have been truly useful, as it has seldom been by the drawing out of any sensible humidity, it has probably been by their restoring the perspiration, which is so often greatly diminished in this disease; or, perhaps, by changing the state of the skin, from the imbibing condition which is alleged to take place, into that of perspiring. MDCLXXXVII. When, by the several means now men- tioned, we shall have succeeded in evacuating the water of dropsies, there will then especial- ly be occasion for our third indication; which is, to restore the tone of the system, the loss of which is so often the cause of the disease. This indication, indeed, may properly have place from the very first appearance of the disease; and certain measures adapted to this purpose may, upon such first appearance, be employed with advantage. In many cases of a moderate disease, I am persuaded that they may obviate any future increase of it. MDCLXXXVIII. Thus, upon what is commonly the first symptom of anasarca, that is, upon the ap- pearance 292 PRACTICE pearance of what are called Oedematous Swellings of the feet and legs, the three rem- edies of bandaging, friction, and exercise, have often been used with advantage. MDCLXXXIX. That some degree of external compression, is suited to support the tone of the vessels, and particularly to prevent the effects of the weight of the blood in dilating those of the lower extremities, must be sufficiently evident; and the giving that compression by a bandage properly applied, has been often useful. In applying such a bandage, care is to be taken that the compression may never be greater on the upper than on the lower part of the limb; and this, I think, can hardly ever be so cer- tainly avoided, as by employing a properly constructed laced stocking. MDCXC. Friction is another means by which the ac- tion of the bloodvessels may be promoted, and thereby the stagnation of fluids in their ex- tremities prevented. Accordingly, the use of the flesh brush has often contributed to dis- cuss œdematous swellings. It appears to me, that friction, for the purposes now mention- ed, is more properly employed in the morn- ing, when the swelling is very much gone off, than in the evening, when any considerable degree 293 OF PHYSIC. degree of it has already come on. I appre- hend also, that friction being made from be- low upwards only, is more useful than when made alternately upwards and downwards. It has been common, instead of employing the flesh brush, to make the friction by warm and dry flannels; and this may in some cases be the most convenient: But I cannot per- ceive that the impregnation of these flannels with certain dry fumes is of any benefit. MDCXCI. With respect to exercise, I must observe, that although persons being much in an erect posture during the day, may seem to increase the swelling which comes on at night; yet as the action of the muscles has a great share in promoting the motion of the venous blood, so I am certain, that as much exercise in walk- ing as the patient can easily bear, will often prevent that œdematous swelling which much standing, and even sitting, would have brought on. MDCXCII. These measures, however, although they may be useful at the coming on of a dropsy, whose causes are not very powerful, will be often insufficient in a more violent disease; and such therefore will require more powerful remedies. These are, exercise and tonic medicines; 294 PRACTICE medicines; which may be employed both during the course of the disease, and especial- ly after the water has been evacuated. MDCXCIII. Exercise is suited to assist in every function of the animal economy, particularly to pro- mote perspiration, and thereby prevent the accumulation of watery fluids in the body. I apprehend also, that it may be the most ef- fectual means for preventing the skin from being in an imbibing state; and, as has been hinted above on the subject of Emaciation (MDCVII), I am persuaded, that a full and large perspiration will always be a means of exciting absorption in every part of the sys- tem. Exercise, therefore, promises to be highly useful in dropsy; and any mode of it may be employed that the patient can most conveniently admit of. It should, however; always be as much as he can easily bear; and in anasarca, the share which the exercise of muscles have in promoting the motion of the venous blood, induces me to think that bodi- ly exercise, to whatever degree the patient can bear it, will always be the most useful. From some experience also, I am persuaded, that by exercise alone, employed early in the disease, many dropsies may be cured. MDCXCIV. 295 OF PHYSIC. MDCXCIV. Besides exercise, various tonic remedies are properly employed to restore the tone of the system. The chief of these are, chalybeates, the Peruvian bark, and various bitters. These are not only suited to restore the tone of the system in general, but are particularly useful in strengthening the organs of diges- tion, which in dropsies are frequently very much weakened: And for the same purpose also aromatics may be frequently joined with the tonics. MDCXCV. Cold bathing is upon many occasions the most powerful tonic we can employ; but at the beginning of dropsy, when the debility of the system is considerable, it can hardly be attempted with safety. After, however, the water of dropsies has been very fully evacu- ated, and the indication is to strengthen the system for preventing a relapse, cold bathing may perhaps have a place. It is, at the same time, to be admitted with caution; and can scarcely be employed till the system has oth- erwise recovered a good deal of vigour. When that indeed has happened, cold bath- ing may be very useful in confirming and completing it. MDCXCVI. 296 PRACTICE MDCXCVI. In persons recovering from dropsy, while the several means now mentioned for strength- ening the system is employed, it will be proper at the same time to keep constantly in view the support of the watery excretions; and consequently the keeping up the perspi- ration by a great deal of exercise, and contin- uing the full flow of the urinary excretions by the frequent use of diuretics. SECT. II. Of the HYDROTHORAX, or DROPSY of the BREAST. MDCXCVII. THE preternatural collection of serous fluid in the thorax, to which we give the ap- pellation of Hydrothorax, occurs more fre- quently than has been imagined. Its pres- ence, however, is not always to be very cer- tainly known; and it often takes place to a considerable degree before it be discovered. MDCXCVIII. 297 OF PHYSIC. MDCXCVIII. These collections of watery fluids in the thorax, are found in different situations. Very often the water is found at the same time in both sacs of the pleura, but frequent- ly in one of them only. Sometimes it is found in the pericardium alone; but for the most part it only appears there when at the same time a collection is present in one or both cavities of the thorax. In some instances, the collection is found to be only in that cel- lular texture of the lungs which surrounds the bronchiæ, without there being at the same time any effusion into the cavity of the thorax. Pretty frequently the water collected con- sists chiefly of a great number of hydatides in different situations; sometimes seemingly floating in the cavity, but frequently con- nected with and attached to particular parts of the internal surface of the pleura. MDCXCIX. From the collection of water being thus in various situations and circumstances, symp- toms arise which are different in different cases; and from thence it becomes often dif- ficult to ascertain the presence and nature of the affection. I shall, however, endeavour here to point out the most common symp- toms, 298 PRACTICE toms, and especially those of that principal and most frequent form of the disease, when the serous fluid is present in both sacs of the pleura, or, as we usually speak, in both cav- ities of the thorax. MDCC. The disease frequently comes on with a sense of anxiety about the lower part of the sternum. This, before it has subsisted long, comes to be joined with some difficulty of breathing; which at first appears only upon the person's moving a little faster than usual, upon his walking up an acclivity, or upon his ascending a staircase: But after some time, this difficulty of breathing becomes more con- stant and considerable, especially during the night, when the body is in a horizontal situa- tion. Commonly, at the same time, lying upon one side is more easy than upon the other, or perhaps lying upon the back more easy than upon either side. These circum- stances are usually attended with a frequent cough, that is at first dry; but which, after some time, is accompanied with an expecto- ration of thin mucus. With all these symptoms, the hydrothorax is not certainly discovered, as the same symp- toms often attend other diseases of the breast. When, however, along with these symptoms, there is at the same time an œdematous swell- ing of the feet and legs, a leucophlegmatic paleness 299 OF PHYSIC. paleness of the face, and a scarcity of urine, the existence of a hydrothorax can be no longer doubtful. Some writers have told us, that sometimes in this disease, before the swell- ing of the feet comes on, a watery swelling of the scrotum appears; but I have never met with any instance of this. MDCCI. Whilst the presence of the disease is some- what uncertain, there is a symptom which sometimes takes place, and has been thought to be a certain characteristic of it; and that is, when, soon after the patient has fallen asleep, he is suddenly awaked with a sense of anxiety and difficult breathing, and with a violent palpitation of the heart. These feel- ings immediately require an erect posture; and very often the difficulty of breathing con- tinues to require and to prevent sleep for a great part of the night. This symptom I have frequently found attending the disease; but I have also met with several instances in which this symptom did not appear. I must remark further, that I have not found this symptom attending the empyema, or any oth- er disease of the thorax; and therefore, when it attends a difficulty of breathing, accompa- nied with any the smallest symptom of drop- sy, I have had no doubt in concluding the presence of water in the chest, and have al- ways 300 PRACTICE ways had my judgment confirmed by the symptoms which afterwards appeared. MDCCII. The hydrothorax, often occurs with very few, or almost none, of the symptoms above mentioned; and is not, therefore, very cer- tainly discovered till some others appear. The most decisive symptom is a fluctuation of water in the chest, perceived by the patient himself, or by the physician, upon certain motions of the body. How far the method proposed by Auenbrugger will apply to as- certain the presence of water and the quantity of it in the chest, I have not had occasion or opportunity to observe. It has been said, that in this disease some tumour appears upon the sides or upon the back; but I have not met with any instance of this. In one instance of the disease, I found one side of the thorax considerably en- larged, the ribs standing out farther on that side than upon the other. A numbness and a degree of palsy in one or both arms, has been frequently observed to attend a hydrothorax. Soon after this disease has made some prog- ress, the pulse commonly becomes irregular, and frequently intermitting: But this hap- pens in so many other diseases of the breast, that unless when it is attended with some other 301 OF PHYSIC. other of the above mentioned symptoms it cannot be considered as denoting the hydro- thorax. MDCCIII. This disease, as other dropsies, is commonly attended with third, and a scarcity of urine, to be explained in the same manner as in the case of anasarca (MDCLXXIII). The hy- drothorax, however, is sometimes without thirst, or any other febrile symptom; al- though I believe this happens in the case of partial affections only, or when a more gen- eral affection is yet but in a slight degree. In both cases, however, and more especially when the disease is considerably advanced, some degree of fever is generally present: And I apprehend it to be in such case, that the persons affected are more than usually sensible to cold, and complain of the coldness of the air when that is not perceived by oth- er persons. MDCCIV. The hydrothorax sometimes appears alone, without any other species of dropsy being present at the same time: And in this case the disease, for the most part, is a partial af- fection, as being either of one side of the thorax only, or being a collection of hydatides in one part of the chest. The hydrothorax, VOL. III. O however, 302 PRACTICE however, very often a part of more univer- sal dropsy, and when at the same time there is water in all the three principal cavities and in the cellular texture of a great part of the body. I have met with several instances, in which such universal dropsy began first by an effusion into the thorax. The hydrothorax, however, more frequently comes on from an anasarca gradually increasing; and, as I have said above, the general diathesis seems often to affect the thorax sooner than it does either the head or the abdomen. MDCCV. This disease seldom admits of a cure, or even of alleviation, from remedies. It com- monly proceeds to give more and more diffi- culty of breathing, till the action of the lungs be entirely interrupted by the quantity of water effused; and the fatal event frequently happens more suddenly than was expected. In many of the instances of a fatal hydrotho- rax, I have remarked a spitting of blood to come on several days before the patient died. MDCCVI. The cause of hydrothorax is often mani- festly one or other of the general causes of dropsy pointed out above: But what it is that determines these general causes to act more especially in the thorax, and particular- ly 303 OF PHYSIC. ly what it is that produces the partial collec- tions that occur there, I do not find to be ea- sily ascertained. MDCCVII. From what has been said above, it will be evident, that the cure of hydrothorax must be very much the same with that of anasarca; and when the former is joined with the latter as an effect of the same general diathesis, there can be no doubt of the method of cure being the same in both. Even when the hydrotho- rax is alone, and the disease partial, from par- ticular causes acting in the thorax only, there can hardly be any other measures employed, than the general ones proposed above. There is only one particular measure adapted to the hydrothorax; and that is, the drawing off the accumulated waters by a paracentesis of the thorax. MDCCVIII. To what cases this operation may be most properly adapted, I find it difficult to deter- mine. That it may be executed with safety, there is no doubt; and that it has been some- times practised with success, seems to be very well vouched. When the disease depends upon a general hydropic diathesis, it cannot alone prove a cure, but may give a temporary relief; and when other remedies seem to be O2 employed 304 PRACTICE employed with advantage, the drawing off the wafer may very much favour a complete cure. I have not, however, been so fortu- nate as to see it practised with any success; and even where it was most promising, that is, in cases of partial affection, my expectations have been disappointed from it. SECT. III. Of ASCITES, or DROPSY of the LOWER BELLY. MDCCIX. THE name of Ascites is given to every col- lection of waters causing a general swelling and distention of the lower belly; and such collections are more frequent than those which happen in the thorax. MDCCX. The collections in the lower belly, like those of the thorax, are found in different situa- tions. Most commonly they are in the sac of the peritonæum, or general cavity of the ab- domen: But they often begin by sacs formed upon, and connected with, one or other of the viscera; and perhaps the most frequent instances 305 OF PHYSIC. instances of this kind occur in the ovaria of females. Sometimes the water of ascites is found entirely without the peritonæum, and between this and the abdominal muscles. MDCCXI. These collections connected with particular viscera, and those formed without the perito- næum, form that disease which authors have termed the encysted dropsy, or hydrops saccatus. Their precise seat, and even their existence, is very often difficult to be ascertained. They are generally formed by collections of hy- datides. MDCCXII. In the most ordinary case, that of abdom- inal dropsy, the swelling at first is in some measure over the whole belly, but generally appears most considerable in the epigastrium. As the disease, however, advances, the swell- ing becomes more uniform over the whole. The distention, and sense of weight, though considerable, vary a little according as the posture of the body is changed; the weight being felt the most upon the side on which the patient lies, while at the same time on the opposite side the distention becomes some- what less. In almost all the instances of as- cites, the fluctuation of the water within, may be perceived by the practitioner's feeling, and O3 sometimes 306 PRACTICE sometimes by his hearing. This perception of fluctuation does not certainly distinguish the different states of dropsy; but serves very well to distinguish dropsy from tympanites, from cases of physconia, and from the state of pregnancy in women. MDCCXIII. An ascites frequently occurs when no other species of dropsy does at the same time ap- pear; but sometimes the ascites is a part only of universal dropsy. In this case, it usually comes on in consequence of an anasarca, grad- ually increasing; but its being joined with anasarca, does not always denote any general diathesis, as for the most part an ascites soon- er or later occasions œdematous swellings of the lower extremities. When the collection of water in the abdomen, from whatever cause, becomes considerable, it is always at- tended with a difficulty of breathing: But this symptom occurs often when, at the same time, there is no water in the thorax. The ascites is sometimes unaccompanied with any fever; but frequently there is more or less of fever present with it. The disease is never considerable, without being attended with thirst and a scarcity of urine. MDCCXIV. In the diagnosis of ascites, the greatest dif- ficulty that occurs, is in discerning when the water 307 OF PHYSIC. water is in the cavity of the abdomen, or when it is in the different states of encysted dropsy above mentioned. There is, perhaps, no cer- tain means of ascertaining this in all cases; but in many we may attempt to form some judgment with regard to it. When the antecedent circumstances give suspicion of a general hydropic diathesis; when at the same time some degree of dropsy appears in other parts of the body; and when, from its first appearance, the swelling has been equally over the whole belly, we may gen- erally presume that the water is in the cavity of the abdomen. But when an ascites has not been preceded by any remarkably cachec- tic state of the system, and when at its begin- ning the tumour and tension had appeared in one part of the belly more than another, there is reason to suspect an encysted dropsy. Even when the tension and tumour of the belly have become general and uniform over the whole; yet if the system of the body in gen- eral appear to be little affected; if the pa- tient's strength be little impaired; if the ap- petite continue pretty entire, and the natural sleep be little interrupted; if the menses in females continue to flow as usual; if there be yet no anasarca; or, though it may have al- ready taken place, if it be still confined to the lower extremities, and there be no leucophleg- matic paleness or sallow colour in the counte- nance; if there be no fever, nor so much thirst, or scarcity of urine, as occur in a O4 more 308 PRACTICE more general affection; then, according as more of these different circumstances take place, there will be the stronger ground for supposing the ascites to be of the encysted kind. The chief exception to be made from this as a general rule, will, in my opinion, be when the ascites may, with much probability, be presumed to have come on in consequence of a scirrhous liver; which, I apprehend, may occasion a collection of water in the cavity of the abdomen, while the general system of the body may not be otherwise much affected. MDCCXV. With respect to the cure of ascites when of the encysted kind, it does not, so far as I know, admit of any. When the collection of water is in the abdominal cavity alone, without any other species of dropsy present at the same time, I apprehend the ascites will always be of difficult cure; for it may be presumed to depend upon a scirrhosity of the liver, or oth- er considerable affection of the abdominal vis- cera, which I conceive to be of very difficult cure, and therefore the ascites depending up- on them. At the same time, such cases may often admit of a temporary relief by the par- acentesis. MDCCXVI. 309 OF PHYSIC. MDCCXVI. When the ascites is a part of universal drop- sy, it may, as far as other cases of that kind can, admit of a cure; and it will be obvious, that such a cure must be obtained by the same means as above proposed for the cure of gen- eral anasarca. It frequently happens, that the ascites is at- tended with a diarrhœa; and, in that case, does not admit of the use of purgatives so freely as cases of anasarca commonly do. It is therefore often to be treated by diuretics almost alone. The diuretics that may be employed, are chiefly those above mentioned; but in ascites, a peculiar one has been found out. It is a long continued gentle friction of the skin over the whole of the abdomen, by the fingers dipped in oil. This has sometimes been use- ful in exciting an increased flow of urine; but in most of the trials of it which I have known made, it has failed in producing that effect. MDCCXVII. The ascites admits of a particular means for immediately drawing off the collected waters; and that is the well known operation of the paracentesis of the abdomen. In what circumstances of ascites this operation can most properly be proposed, it is difficult to VOL. 3. O5 determine; 310 PRACTICE determine; but, so far as I can judge, it must be regulated by very much the same consid- erations as those above mentioned with regard to the paracentesis of the thorax. The manner of performing the paracentesis of the abdomen, and the precautions to be taken with respect to it, are now so commonly known, and delivered in so many books, that it is altogether unnecessary for me to offer any directions upon that subject here; especially after the full and judicious information and directions given by Mr. Bell, in the second volume of his System of Surgery. CHAP. 311 OF PHYSIC. CHAP. IV. OF GENERAL SWELLINGS, ARISING FROM AN INCREASED BULK OF THE WHOLE SUBSTANCE OF PARTICULAR PARTS. MDCCXVIII. UPON the subjects of this chapter, several nosological difficulties occur, and particularly with respect to admitting the Physconia into the order of General Swellings. At present, however, it is not necessary for me to discuss this point, as I am here to omit entirely the consideration of Physconia; both because it can seldom admit of any successful practice, and because I cannot deliver any thing useful either with regard to the patholo- gy or practice in such a disease. MDCCXIX. The only other genus of disease compre- hended under the title of the present chapter, is the Rachitis; and this being both a proper example of the class of Cachexy, and of the O6 order 312 PRACTICE order of Intumescentia: or General Swellings, I shall offer some observations with regard to it. Of RACHITIS, or RICKETS. MDCCXX. THIS disease has been supposed to have appeared only in modern times, and not above two hundred years ago. This opinion, not- withstanding it has been maintained by per- sons of the most respectable authority, ap- pears to me, from many considerations, im- probable; but it is a point of too little conse- quence to detain my readers here. The only application of it which deserves any notice is, that it has led to a notion of the disease having arisen from the lues venerea, which had cer- tainly made its first appearance in Europe not very long before the date commonly as- signed for the appearance of rachitis: But I shall hereafter show, that the supposed con- nexion between the Siphylis and Rachitis is without foundation. MDCCXXI. In delivering the history of the Rickets, I must, in the first place, observe, that with res- pect to the antecedents of the disease, every thing to be found in authors upon this sub- ject, appears to me to rest upon a very un- certain 313 OF PHYSIC. certain foundation. In particular, with res- pect to the state of the parents whose offspring become affected with this disease, I have met with many instances of it, in children from seemingly healthy parents; and have met likewise with many instances of children who never became affected with it, although born of parents who, according to the common ac- counts, should have produced a rickety off- spring: So that, even making allowance for the uncertainty of fathers, I do not find the general opinion of authors upon this subject to be properly supported. MDCCXXII. The disease, however, may be justly, con- sidered as proceeding from parents; for it often appears in a great number of the same family: And my observation leads me to judge, that it originates more frequently from mothers than from fathers. So far as I can refer the disease of the children to the state of the parents, it has appeared to me most com- monly to arise from some weakness, and pretty frequently from a scrophulous habit, in the mother. To conclude the subject, I must re- mark, that in many cases I have not been able to discern the condition of the parents, to which I could refer it. When nurses, other than the mothers, have been employed to suckle children, it has been supposed that such nurses have frequently given 314 PRACTICE given occasion to the disease: And when nurses have both produced and have suckled children who became rickety, there may be ground to suspect their having occasioned the disease in the children of other persons: But I have had few opportunities of ascertaining this matter. It has in some measure appear- ed to me, that those nurses are most likely to produce this disease, who give infants a large quantity of very watery milk, and who con- tinue to suckle them longer than the usual time. Upon the whole, however, I am of opinion, that hired nurses seldom occasion this disease, unless when a predisposition to it has proceeded from the parents. MDCCXXIII. With regard to the other antecedents, which have been usually enumerated by authors as the remote causes of this disease, I judge the accounts given to be extremely fallacious; and I am very much persuaded, that the cir- cumstances in the rearing of children, have less effect in producing rickets than has been imagined. It is indeed not unlikely, that some of these circumstances mentioned as re- mote causes may favour, while other circum- stances may resist, the coming one of the dis- ease; but at the same time, I doubt if any of the former would produce it where there was no predisposition in the child's original con- stitution. This opinion of the remote causes, I have 315 OF PHYSIC. I have formed from observing, that the dis- ease comes on when none of these had been applied; and more frequently that many of them had been applied without occasioning the disease. Thus the learned ZEVIANI al- leges, that the disease is produced by an acid from the milk with which a child is fed for the first nine months of its life: But almost all children are fed with the same food, and in which also an acid is always produced; while, at the same time, not one in a thousand of the infants so fed becomes affected with the rick- ets. If, therefore, in the infants who become affected with this disease, a peculiarly noxious acid is produced, we must seek for some pe- culiar cause of its production, either in the quality of the milk, or in the constitution of the child; neither of which, however, Mr. Zeviani has explained. I cannot indeed be- lieve that the ordinary acid of milk has any share in producing this disease, because I have known many instances of the acid being produced and occasioning various disorders, without, however, its ever producing rickets. Another of the remote causes commonly assigned, is the child's being fed with unfer- mented farinaceous food. But over the whole world children are fed with such farinacea, while the disease of rickets is a rare occur- rence: And I have known many instances where children have been fed with a greater than usual proportion of fermented farinacea, and also a greater proportion of animal food, without 316 PRACTICE without these preventing the disease. In my apprehension, the like observations might be made with respect to most of the circum- stances that have been mentioned as the re- mote causes of rickets. MDCCXXIV. Having thus offered my opinion concern- ing the supposed antecedents of this disease, I proceed now to mention the phenomena oc- curring after it has actually come on. The disease seldom appears before the ninth month, and seldom begins after the second year, of a child's age. In the interval between these periods, the appearance of the disease is sometimes sooner, sometimes later; and commonly at first the disease comes on slowly. The first appearances are a flaccidity of the flesh, the body at the same time becom- ing leaner, though food be taken in pretty largely. The head appears large with respect to the body; with the fontanelle, and per- haps the futures, more open than usual in children of the same age. The head contin- ues to grow larger; in particular, the fore- head becoming unusually prominent; and at the same time the neck continues slender, or seems to be more so, in proportion to the head. The dentition is slow, or much later than usual; and those teeth which come out, readily become black, and frequently again fall out. The ribs lose their convexity, and become 317 OF PHYSIC. become flattened on the sides; while the ster- num is pushed outward, and forms a sort of ridge. At the same time, or perhaps sooner, the epiphyses at the several joints of the limbs become swelled; while the limbs be- tween the joints appear, or perhaps actually become, more slender. The bones seem to be every where flexible, becoming variously distorted; and particularly the spine of the back becoming incurvated in different parts of its length. If the child, at the time the disease comes on, had acquired the power of walking, it becomes daily more feeble in its motions, and more averse to the exertion of them, losing at length the power of walk- ing altogether. Whilst these symptoms go on increasing, the abdomen is always full, and preternaturally tumid. The appetite is often good, but the stools are generally frequent and loose. Sometimes the faculties of the minds are impaired, and stupidity or fatuity prevails; but commonly a premature sensi- bility appears, and they acquire the faculty of speech sooner than usual. At the first coming on of the disease, there is generally no fever attending it; but it seldom continues long, till a frequent pulse, and other febrile symptoms, come to be constantly present. With these symptoms the disease proceeds, and continues in some instances for some years; but very often, in the course of that time, the disease ceases to advance, and the health is entirely established, except that the distorted limbs 318 PRACTICE limbs produced during the disease continue for the rest of life. In other cases, however, the disease proceeds increasing till it has af- fected almost every function of the animal economy, and at length terminates in death. The variety of symptoms which in such cases appear, it does not seem necessary to enume- rate, as they are not essential to the constitu- tion of the disease, but are merely conse- quences of the more violent conditions of it. In the bodies of those who have died, various morbid affections have been discovered in the internal parts. Most of the viscera of the abdomen have been found to be preternatur- ally enlarged. The lungs have also been found in a morbid state, seemingly from some inflammation that had come on towards the end of the disease. The brain has been com- monly found in a flaccid state, with effusions of a serous fluid into its cavities. Very uni- versally the bones have been found very soft, and so much softened as to be readily cut by a knife. The fluids have been always found in a dissolved state, and the muscular parts very soft and tender; and the whole of the dead body without any degree of that rigidity which is so common in almost all others. MDCCXXV. From these circumstances of the disease, it seems to consist in a deficiency of that matter which should form the solid parts of the body. This 319 OF PHYSIC. This especially appears in the faulty state of ossification, seemingly depending upon the de- ficiency of that matter which should be depos- ited in the membranes which are destined to become bony, and should give them their due firmness and bony hardness. It appears that this matter is not supplied in due quantity; but that in place of it, a matter fitted to in- crease their bulk, particularly in the epiphy- ses, is applied too largely. What this defi- ciency of matter depends upon, is difficult to be ascertained. It may be a fault in the or- gans of digestion and assimilation, which pre- vents the fluids in general from being prop- erly prepared; or it may be a fault in the or- gans of nutrition, which prevents the secretion of a proper matter to be applied. With res- pect to the latter, in what it may consist, I am entirely ignorant, and cannot even discern that such a condition exists: But the former cause, both in its nature and existence, is more readily perceived; and it is probable that it has a considerable influence in the matter; as in rachitic persons a thinner state of the blood, both during life and after death, so commonly appears. It is this state of the fluids, or a deficiency of bony matter in them, that I consider as the proximate cause of the disease; and which again may in some meas- ure depend upon a general laxity and de- bility of the moving fibres of the organs that perform the functions of digestion and assim- ilation. MDCCXXVI. 320 PRACTICE MDCCXXVI. There is, however, something still wanting to explain, why these circumstances discover themselves at a particular time of life, and hardly ever either before or after a certain period; and as to this I would offer the fol- lowing conjectures. Nature having intended that human life should proceed in a certain manner, and that certain functions should be exercised at a certain period of life only; so it has generally provided, that at that period, and not sooner, the body should be fitted for the exercise of the functions suited to it. To apply this to our present subject, nature seems to have intended that children should walk only at twelve months old; and accord- ingly has provided, that against that age, and no sooner, a matter should be prepared fit to give that firmness to the bones which is neces- sary to prevent their bending too easily under the weight of the body. Nature, however, is not always steady and exact in executing her own purposes; and if therefore the prep- aration of bony matter shall not have been made against the time there is particular oc- casion for it, the disease of rickets, that is, of soft and flexible bones, must come on; and will discover itself about the particular period we have mentioned. Further, it will be equally probable, that if at the period men- tioned the bones shall have acquired their due 321 OF PHYSIC. due firmness, and that nature goes on in pre- paring and supplying the proper bony matter, it may be presumed, that against the time a child is two years old, such a quantity of bony matter will be applied, as to prevent the bones from becoming again soft and flexible during the rest of life; unless it happens, as indeed it sometimes does, that certain causes occur to wash out again the bony matter from the membranes in which it had been deposited. The account I have now given of the period at which the rickets occur, seems to confirm the opinion of its proximate cause being a deficiency of bony matter in the fluids of the body. MDCCXXVII. It has been frequently supposed, that a siphylitic taint has a share in producing rick- ets; but such a supposition is altogether im- probable. If our opinion of the rickets hav- ing existed in Europe before the siphylis was brought into it, be well founded, it will then be certain that the disease may be occasioned without any siphylitic acrimony having a share in its production. But further, when a siphylitic acrimony is transmitted from the parent to the offspring, the symptoms do not appear at a particular time of life only, and commonly more early than the period of rick- ets; the symptoms also are very different from those of rickets, and unaccompanied with 322 PRACTICE with any appearance of the latter; and, lastly, the symptoms of siphylis are cured by means which, in the case of rickets, have either no effect, or a bad one. It may indeed possibly happen, that siphylis and rickets may appear in the same person; but it is to be considered as an accidental complication: And the very few instances of it that have occurred, are by no means sufficient to establish any necessary connexion between the two diseases. MDCCXXVIII. With respect to the deficiency of bony matter, which I consider as the proximate cause of rickets, some further conjectures might be offered concerning its remote caus- es: But none of them appear to me very sat- isfying; and whatever they might be, it ap- pears to me they must again be resolved into the supposition of a general laxity and debil- ity of the system. MDCCXXIX. It is upon this supposition almost alone that the cure of rickets has entirely proceeded. The remedies have been such especially as were suited to improve the tone of the system in general, or of the stomach in particular: And we know that the latter are not only suited to improve the tone of the stomach it- self, 323 OF PHYSIC. self, but by that means to improve also the tone of the whole system. MDCCXXX. Of tonic remedies, one of the most prom- ising seems to have been cold bathing; and I have found it the most powerful in preventing the disease. For a long time past, it has been the practice in this country, with people of all ranks, to wash their children from the time of their birth with cold water; and from the time that children are a month old, it has been the practice with people of better rank to have them dipped entirely in cold water every morning: And wherever this practice has been pursued, I have not met with any instance of rickets. Amongst our common people, although they wash their children with cold water only, yet they do not so com- monly practice immersion: And when a- mongst these I meet with instances of rickets, I prescribe cold bathing; which accordingly has often checked the progress of the disease, and sometimes seems to have cured it en- tirely. MDCCXXXI. The remedy of Ens Veneris, recommended by Mr. Boyle, and since his time very uni- versally employed, is to be considered as en- tirely a tonic remedy. That or some other preparation 324 PRACTICE preparation of iron I have almost constantly employed, though not indeed always with success. I have been persuaded, that the ens veneris of Mr. Boyle, notwithstanding his giving it this appellation, was truly a prepa- ration of iron, and no other than what we now name the Flores Martiales: But it appears, that both Benevoli and Buchner have em- ployed a preparation of copper; and I am ready to believe it to be a more powerful to- nic than the preparations of iron. MDCCXXXII. Upon the supposition of tonic remedies being proper in this disease, I have endeav- oured to employ the Peruvian bark: But from the difficulty of administering it to in- fants in any useful quantity, I have not been able to discover its efficacy; but I am very ready to believe the testimony of De Haen upon this subject. MDCCXXXIII. Exercise, which is one of the most power- ful tonics, has been properly recommended for the cure of rickets; and as the exercise of gestation only can be employed, it should al- ways be, with the child laid in a horizontal situation; as the carrying them, or moving them in any degree of an erect posture, is very apt to occasion some distortion. It is extremely 325 OF PHYSIC. extremely probable, that, in this disease, fric- tion with dry flannels may be found an useful remedy. MDCCXXXIV. It is also sufficiently probable, that the a- voiding of moisture is not only adviseable, but may likewise be of service in the cure of this disease. There is no doubt that a certain diet may contribute to the same end; but what may be the most eligible, I dare not determine. I have no doubt that leavened bread may be more proper than unfermented farinacea; but I cannot find any reason to believe that strong beer can ever be a proper remedy. Practitioners have been divided in opinion concerning the use of milk in this disease. Zeviani, perhaps from theory, condemns the use of it; but Benevoli employed it without its impeding the cure of the disease. This last I have often remarked in the course of my own practice. As it is difficult to feed children entirely without milk; so I have commonly admitted it as a part of the diet of rickety children; and in many instances I can affirm, that it did not prevent the cure of the disease. In cases, however, of any appear- ance of rickets, and particularly of a slow dentition, I have dissuaded the continuance of a child upon the breast; because the milk of women is a more watery nourishment than VOL. III. P that 326 PRACTICE that of cows: And I have especially dissuad- ed the continuing a child upon the breast, when I thought the nurse gave rather too much of such a watery nourishment; for, as has been above mentioned, I have had fre- quent occasion to suspect, that the milk of such nurses have a tendency to favour the com- ing on of rickets. MDCCXXXV. Besides the remedies and regimen now mentioned, practitioners have commonly em- ployed in this disease, both emetics and pur- gatives. When the appetite and digestion are considerably impaired, vomiting, if nei- ther violent, nor frequently repeated, seems to be of service; and by a moderate agita- tion of the abdominal viscera, may in some measure obviate the stagnation and conse- quent swelling that usually occur in them. As the tumid state of the abdomen, so con- stantly to be met with in this disease, seems to depend very much upon a tympanitic af- fection of the intestines; so, both by obviat- ing this, and by deriving from the abdominal viscera, frequent gentle purgatives may be of service. Zeviani, perhaps properly, recom- mends in particular rhubarb; which, besides its purgative quality, has those also of bitter and astringent. MDCCXXXVI. 327 OF PHYSIC. MDCCXXXVI. I have now mentioned most of the reme- dies commonly employed by the practitioners of former times; but I must not omit men- tioning some others that have been lately sug- gested. The late Mr. De Haen recommends the testacea; and assures us of their having been employed with success: But in the few trials which I have had occasion to make; their good effects did not appear. The late Baron Van Swieten gives us one instance of rickets cured by the use of hem- lock; but I do not know that the practice has been repeated. P2 BOOK 328 BOOK III. OF THE IMPETIGINIS; OR DEPRAV- ED HABIT, WITH AFFECTIONS OF THE SKIN. MDCCXXXVII. I FIND it difficult to give any sufficiently correct and proper character of this order. The diseases comprehended under it, depend, for the most part, upon a depraved state of the whole of the fluids, producing tumours, eruptions, or other pre- ternatural affections of the skin. Although it be extremely difficult to find a general character of the order that will apply to each of the genera and species, I shall here treat of the principal genera which have been commonly comprehended under this order, and which I have enumerated in my No- sology. CHAP. 329 OF PHYSIC. CHAP. I. OF SCROPHULA, OR THE KING'S. EVIL. MDCCXXXVIII. THE character of this disease I have attempted in my Nosology: But it will be more properly taken from the whole of its history, now to be delivered. MDCCXXXIX. It is commonly, and very generally, a he- reditary disease; and although it sometimes may, yet it rarely appears, but in children whose parents had at some period of their lives been affected with it. Whether it may not fail to appear in the children of scrophu- lous parents, and discover itself afterwards in their offspring in the succeeding generation, I cannot certainly determine; but believe that this has frequently happened. It ap- pears to me to be derived more commonly from fathers than from mothers; but whether this happens from there being more scrophu- P3 lous 330 PRACTICE lous men than scrophulous women married, I am not certain. With respect to the influence of parents in producing this disease, it deserves to be re- marked, that in a family of many children, when one of the parents has been affected with scrophula, and the other not; as it is usual for some of the children to be in consti- tution pretty exactly like the one parent, and others of them like the other; it commonly happens that those children who most resem- ble the scrophulous parent become affected with scrophula, while those resembling the other parent entirely escape. MDCCXL. The scrophula generally appears at a par- ticular period of life. It seldom appears in the first, or even in the second year of a child's life; and most commonly it occurs from the second, or, as some allege, and per- haps more properly, from the third, to the seventh year. Frequently, however, it dis- covers itself at a later period; and there are instances of its first appearance, at every pe- riod till the age of puberty; after which, however, the first appearance of it is vexy rare. MDCCXLI. When it does not occur very early, we can generally distinguish the habit of body pecu- liarly 331 OF PHYSIC. liarly disposed to it. It most commonly af- fects children of soft and flaccid habits, of fair hair and blue eyes; or at least affects those much more frequently than those of an op- posite complexion. It affects especially chil- dren of smooth skins and rosy cheeks; and such children have frequently a tumid upper lip, with a chop in the middle of it; and this tumour is often considerable, and extended to the columna nasi and lower part of the nos- trils. The disease is sometimes joined with, or follows rickets; and although it frequently appears in children who have not had rickets in any great degree, yet it often attacks those who by a protuberant forehead, by tumid joints, and a tumid abdomen, show that they had some rachitic disposition. In parents who, without having had the disease them- selves, seem to produce scrophulous children, we can commonly perceive much of the same habit and constitution that has been just now described. Some authors have supposed that the small pox has a tendency to produce this disease; and Mr. De Haen asserts its following the in- oculated, more frequently than the natural, small pox. This last position, however, we can confidently affirm to be a mistake; al- though it must be allowed, that in fact the scrophula does often come on immediately after the small pox. It is, however, difficult to find any connexion between the two dis- eases. According to my observation, the ac- P4 cident 332 PRACTICE cident only happens in children who have pretty manifestly the scrophulous disposition; and I have had several instances of the nat- ural small pox coming upon children affected at the same time with scrophula, not only without this disease being any ways aggravat- ed by the small pox, but even of its being for some time after much relieved. MDCCXLII. The scrophula generally shows itself first at a particular season of the year; and at some time between the winter and summer solstice; but commonly long before the latter period. It is to be observed further, that the course of the disease is usually connected with the course of the seasons. Whilst the tumours and ul- cerations peculiar to this disease, appear first in the spring, the ulcers are frequently healed up in the course of the succeeding summer, and do not break out again till the ensuing spring, to follow again with the season the same course as before. MDCCXLIII. Frequently the first appearance of the dis- ease is the tumid and chopped lip above men- tioned. Upon other occasions the first ap- pearance is that of small spherical or oval tu- mours, moveable under the skin. They are soft, but with some elasticity. They are without 333 OF PHYSIC. without pain; and without any change in the colour of the skin. In this state they often continue for a long time; even for a year or two, and sometimes longer. Most commonly they first appear upon the sides of the neck below the ears; but sometimes also under the chin. In either case, they are supposed to affect in these places the conglobate or lym- phatic glands only; and not at all the salivary glands, till the disease is very greatly advanced. The disease frequently affects, and even at first appears in, other parts of the body. In particular, it affects the joints of the elbows and ankles, or those of the fingers and toes. The appearances about the joints are not commonly, as elsewhere, small moveable swellings; but a tumour almost uniformly surrounding the joint, and interrupting its motion. MDCCXLIV. These tumours, as I have said, remain for some time little changed; and, from the time they first appeared in the spring, they often continue in this way till the return of the same season in the next, or perhaps the second year after. About that time, however, or perhaps in the course of the season in which they first appear, the tumour becomes larger and more fixed; the skin upon it acquires a purple, seldom a clear redness: But growing redder by degrees, the tumour becomes softer, and VOL 3. P5 allows 334 PRACTICE allows the fluctuation of a liquid within to be perceived. All this process, however, takes place with very little pain attending it. At length some part of the skin becomes paler; and by one or more small apertures a liquid is poured out. MDCCXLV. The matter poured out has at first the ap- pearance of pus, but it is usually of a thinner kind than that from phlegmonic abscesses; and the matter as it continues to be discharg- ed, becomes daily less purulent, and appears more and more a viscid serum, intermixed with small pieces of a white substance resem- bling the curd of milk. By degrees the tu- mour almost entirely subsides, while the ulcer opens more, and spreads broader; unequally, however, in different directions, and therefore is without any regular circumscription. The edges of the ulcer are commonly flat and smooth, both on their outside and their inner edge, which seldom puts on a callous appear- ance. The ulcers, however, do not generally spread much, or become deeper; but at the same time their edges do not advance, or put on any appearance of forming a cicatrix. MDCCXLVI. In this condition the ulcers often continue for a long time; while new tumours, with ul- cers 335 OF PHYSIC. cers succeeding them in the manner above described, make their appearance in different parts of the body. Of the first ulcers, how- ever, some heal up, while other tumours and ulcers appear in their vicinity, or in other parts of the body: And in this manner the disease proceeds, some of the ulcers healing up, at least to a certain degree, in the course of summer, and breaking out again in the suc- ceeding spring: Or it continues, by new tu- mours and ulcers succeeding them, in the spring season, making their appearance suc- cessively for several years. MDCCXLVII. In this way the disease goes on for several years; but very commonly in four or five years it is spontaneously cured, the former ulcers being healed up, and no new tumours appearing: And thus at length the disease ceases entirely, leaving only some indelible eschars, pale and smooth, but in some parts shrivelled; or, where it had occupied the joints, leaving the motion of these impaired, or entirely destroyed. MDCCXLVIII. Such is the most favourable course of this disease; and with us, it is more frequently such, than otherwise: But it is often a more violent, and sometimes, a fatal malady. In P6 these 336 PRACTICE these cases, more parts of the body are at the same time affected; the ulcers also seeming to be imbued with a peculiarly sharp acrimo- ny, and therefore becoming more deep, erod- ing, spreading, as well as seldomer healing up. In such cases, the eyes are often particularly affected. The edges of the eyelids are affect- ed with tumour and superficial ulcerations; and these commonly excite obstinate inflam- mation in the adnata, which frequently pro- duces an opacity of the cornea. When the scrophula especially affects the joints, it sometimes produces there considera- ble tumours; in the abscesses following which, the ligaments and cartilages are eroded, and the adjoining bones are affected with a caries of a peculiar kind. In these cases, also, of more violent scrophula, while every year pro- duces a number of new tumours and ulcers, their acrimony seems at length to taint the whole fluids of the body, occasioning various disorders; and particularly a hectic fever, with all its symptoms, which at length proves fatal, with sometimes the symptoms of a phthisis pulmonalis. MDCCXLIX. The bodies of persons who have died of this disease show many of the viscera in a very morbid state; and particularly most of the glands of the mesentery very much tumefied, and frequently in an ulcerated state. Com- monly 337 OF PHYSIC. monly also a great number of tubercles or cysts, containing matter of various kinds, ap- pear in the lungs. MDCCL. Such is the history of the disease; and from thence it may appear, that the nature of it is not easily to be ascertained. It seems to be a peculiar affection of the lymphatic system; and this in some measure accounts for its con- nexion with a particular period of life. Prob- ably, however, there is a peculiar acrimony of the fluids that is the proximate cause of the disease; although of what nature this is, has not yet been discovered. It may perhaps be generally diffused in the system, and exhaled into the several cavities and cellular texture of the body; and therefore, being taken up by the absorbents, may discover itself especially in the lymphatic system. This, however, will hard- ly account for its being more confined to that system, than happens in the case of many oth- er acrimonies which may be supposed to be as generally diffused. In short, its appearance in particular constitutions, and at a particular period of life, and even its being a hereditary disease, which so frequently depends upon the transmission of a peculiar constitution, are all of them circumstances which lead me to con- clude, upon the whole, that this disease de- pends upon a peculiar constitution of the lym- phatic system. MDCCLI. 338 PRACTICE MDCCLI. It seems proper to observe here, that the scrophula does not appear to be a contagious disease; at least I have known many instances of sound children having had frequent and close intercourse with scrophulous children without being infected with the disease. This certainly shows, that in this disease the pecu- liar acrimony of it is not exhaled from the surface of the body, but that it depends especially upon a peculiar constitution of the system. MDCCLII. Several authors have supposed the scroph- ula to have been derived from the venereal disease; but upon no just grounds that I can perceive. In very many instances; there can hardly be any suspicion of the parents pro- ducing this disease having been imbued with siphylis, or with any siphylitic taint; and I have known several examples of parents con- veying siphylis to their offspring, in whom, however, no scrophulous symptoms at any time afterwards appeared. Further, the symptoms of the two diseases are very differ- ent; and the difference of their natures ap- pears particularly from hence, that while mer- cury commonly and readily cures the siphy- lis, 339 OF PHYSIC. lis, it does no service in scrophula, and very often rather aggravates the disease. MDCCLIII. For the cure of scrophula, we have not yet learned any practice that is certainly or even generally successful. The remedy which seems to be the most successful, and which our practitioners espec- ially trust to and employ, is the use of mineral waters; and indeed the washing out, by means of these, the lymphatic system, would seem to be a measure promising success: But in very many instances of the use of these waters, I have not been well satisfied that they had shortened the duration of the disease more than had often happened when no such rem- edy had been employed. MDCCLIV. With regard to the choice of the mineral waters most fit for the purpose, I cannot with any confidence gives an opinion. Almost all kinds of mineral waters, whether chalybeate, sulphureous, or saline, have been employed for the cure of scrophula, and seemingly with equal success and reputation: A circumstance which leads me to think, that, if they are ever successful, it is the elementary water that is the chief part of the remedy. Of 340 PRACTICE Of late, sea water has been especially rec- ommended and employed; but after nume- rous trials, I cannot yet discover its superior efficacy. MDCCLV. The other remedies proposed by practical writers are very numerous; but, upon that very account, I apprehend they are little to be trusted; and as I cannot perceive any just reason for expecting success from them, I have very seldom employed them. Of late, the Peruvian bark has been much recommended: And as in scrophulous per- sons there are generally some marks of laxity and flaccidity, this tonic may possibly be of service; but in a great variety of trials, I have never seen it produce any immediate cure of the disease. In several instances, the leaves of coltsfoots have appeared to me to be successful. I have used it frequently in a strong decoction, and even then with advantage; but have found more benefit from the expressed juice, when the plant could be had in somewhat of a suc- culent state, soon after its first appearance in the spring. MDCCLVI. I have also frequently employed the hem- lock, and have sometimes found it useful in discussing 341 OF PHYSIC. discussing obstinate swellings: But in this, it has also often disappointed me; and I have not at any time observed that it disposed scrophulous ulcers to heal. I cannot conclude the subject of internal medicines without remarking, that I have never found, either mercury or antimony, in any shape, of use in this disease; and when any degree of a feverish state had come on, the use of mercury proved manifestly hurtful. MDCCLVII. In the progress of scrophula, several exter- nal medicines are requisite. Several applica- tions have been used for discussing the tu- mours upon their first coming on; but hith- erto my own practice, in these respects, has been attended with very little success. The solution of saccharum saturni has seemed to be useful; but it has more frequently failed: And I have had no better success with the spiritus Mindereri. Fomentations of every kind have been frequently found to do harm; and poultices seem only to hurry on a sup- puration. I am doubtful if this last be ever practised with advantage; for scrophulous tumours sometimes spontaneously disappear, but never after any degree of inflammation has come upon them; and therefore poul- tices, which commonly induce inflammation, prevent that discussion of tumours, which might otherwise have happened. Even 342 PRACTICE Even when scrophulous tumours have ad- vanced towards suppuration, I am unwilling to hasten the spontaneous opening, or to make it by the lancet; because I apprehend the scrophulous matter is liable to be rendered more acrid by communication with the air, and to become more eroding and spreading than when in its inclosed state. MDCCLVIII. The management of scrophulous ulcers has, so far as I know, been as little successful as that of the tumours. Escharotic prepara- tions, of either mercury or copper, have been sometimes useful in bringing on a proper sup- puration, and thereby disposing the ulcer to heal; but they have seldom succeeded, and more commonly they have caused the ulcer to spread more. The escharotic from which I have received most benefit is burnt alum; and a portion of that mixed with a mild oint- ment, has been as useful an application as any I have tried. The application, however, that I have found most serviceable, and very uni- versally admissible, is that of linen cloths wetted with cold water, and frequently chang- ed when they are becoming dry, it being in- convenient to let them be glued to the fore. They are therefore to be changed frequently during the day; and a cloth spread with a mild ointment or plaster may be applied for the night. In this practice I have sometimes employed 343 OF PHYSIC. employed sea water: But generally it proved too irritating; and neither that nor any min- eral water has appeared to be of more service than common water. MDCCLIX. To conclude what I have to offer upon the cure of scrophula, I must observe, that cold bathing seems to have been of more benefit than any other remedy that I have had occa- sion to see employed. CHAP. 344 PRACTICE CHAP. II. OF SIPHYLIS, OR THE VENEREAL DISEASE. MDCCLX. AFTER practitioners have had so much experience in treating this dis- ease, and after so many books have been pub- lished upon the subject, it does not seem nec- essary, or even proper, for me to attempt any full treatise concerning it; and I shall there- fore confine myself to such general remarks, as may serve to illustrate some parts of the pathology or of the practice. MDCCLXI. It is sufficiently probable, that, anciently, in certain parts of Asia, where the leprosy, prevailed, and in Europe after that disease had been introduced into it, a disease of the genitals, resembling that which now common- ly arises from siphylis, had frequently appear- ed: But it is equally probable, that a new disease, and what we at present term Siphylis, was first brought into Europe about the end of 345 OF PHYSIC. of the fifteenth century; and that the distem- per now so frequently occurring, has been very entirely derived from that which was imported from America at the period men- tioned. MDCCLXII. This disease, at least in its principal circum- stances, never arises in any person but from some communication with a person already affected with it. It is most commonly con- tracted in consequence of coition with an in- fected person; but in what manner the in- fection is communicated, is not clearly ex- plained. I am persuaded, that in coition, it is communicated without there being any open ulcer either in the person communicat- ing or in the person receiving the infection; but in all other cases, I believe it is never communicated in any other way than by a contact of ulcer, either in the person com- municating, or in the person receiving the infection. MDCCLXIII. As it thus arises from the contact of partic- ular parts, so it always appears first in the neighbourhood of the parts to which the in- fecting matter had been immediately applied; and therefore, as most commonly contracted by 346 PRACTICE by coition, it generally appears first in the genitals. MDCCLXIV. After its first appearance in particular parts, more especially when these are the genitals of either sex, its effects for some time seem to be confined to these parts; and in- deed, in many cases, never extends further. In other cases, however, the infecting mat- ter passes from the parts first affected, and from the genitals therefore, into the bloodves- sels; and being there diffused, produces dis- orders in many other parts of the body. From this view of the circumstances, phy- sicians have very properly distinguished the different states of the disease, according as they are local or are more universal. To the former, they have adapted appellations suited to the manner in which the disease appears; and to the other the general affection, they have almost totally confined the appellations of Siphylis, Lues Venerea, or Pox. In the re- marks I am now to offer, I shall begin with considering the local affection. MDCCLXV. This local affection appears chiefly in the form of gonorrhœa or chancre. The phenomena of gonorrhœa either upon its first coming on or in its after progress, or the 347 OF PHYSIC. the symptoms of ardor urinæ, chordee, or others attending it, it is not necessary for me to describe. I shall only here observe, that the chief circumstance to be taken notice of, is the inflamed state of the urethra, which I take to be inseparable from the disease. MDCCLXVI. In these well known circumstances, the gonorrhœa continues for a time longer or shorter, according to the constitution of the patient; it usually remaining longest in the most vigorous and robust, or according to the patient's regimen, and the care taken to re- lieve or cure the disease. In many cases, if by a proper regimen the irritation of the in- flamed state is carefully avoided, the gonor- rhœa spontaneously ceases, the symptoms of inflammation gradually abating, the matter discharged becoming of a thicker and more vifcid consistence, as well as of a whiter col- our; till at length, the flow of it ceases alto- gether; and whether it be thus cured spon- taneously, or by art, the disease often exists without communicating any infection to the other parts of the body. MDCCLXVII. In other cases, however, the disease having been neglected, or by an improper regimen aggravated, it continues with all its symptoms for 348 PRACTICE for a long time; and produces various other disorders in the genital parts, which, as com- monly taken notice of by authors, need not be described here. I shall only observe, that the inflammation of the urethra, which at first seems to be seated chiefly, or only, in its an- terior parts, is in such neglected and aggravat- ed cases spread upwards along the urethra, even to the neck of the bladder. In these circumstances, a more considerable inflam- mation is occasioned in certain parts of the urethra; and consequently, suppuration and ulcer are produced, by which the venereal poison is sometimes communicated to the sys- tem, and gives rise to a general siphylis. MDCCLXVIII. It was some time ago a pretty general sup- position, that the gonorrhœa depended al- ways upon ulcers of the urethra, producing a discharge of purulent matter; and such ul- cers do indeed sometimes occur in the manner that has been just now mentioned. We are now assured, however, from many dissections of persons who had died when labouring un- der a gonorrhœa, that the disease may exist, and from many considerations it is probable that it commonly does exist, without any ulceration of the urethra; so that the dis- charge which appears, is entirely that of a vitiated mucus from the mucous follicles of the urethra. MDCCLXIX. 349 OF PHYSIC. MDCCLXIX. Although most of the symptoms of gonor- rhœa should be removed, yet it often happens that a mucous fluid continues to be discharg- ed from the urethra for a long time after, and sometimes for a great part of a person's life. This discharge is what is commonly called a Gleet. With respect to this, it is proper to observe, that in some cases, when it is certain that the matter discharged contains no venereal poison, the matter may, and often does put on that pyriform appearance, and that yellow and greenish colour, which appears in the discharge at the beginning and during the course of a virulent gonorrhœa. These appearances in the matter of a gleet which before had been of a less coloured kind, have frequently given occasion to suppose that a fresh infection had been received: But I am certain that such appearances may be brought on by, perhaps various other causes; and particularly, by in- temperance in venery and drinking concur- ring together. I believe, indeed, that this seldom happens to any but those who had be- fore frequently laboured under a virulent gonorrhœa, and have more or less of gleet remaining with them: But I must also ob- serve, that in persons who at no period of their life had ever laboured under a virulent gon- orrhœa, or any other symptom of siphylitic VOL. III. Q affection, 350 PRACTICE affection, I have met with instances of dis- charges from the urethra resembling those of a virulent gonorrhœa. The purpose of these observations is, to suggest to practitioners what I have not found them always aware of, that in persons labour- ing under a gleet, such a return of the appear- ances of a virulent gonorrhœa may happen without any new infection having been re- ceived, and consequently not requiring the treatment which a new infection might per- haps demand. When in the cure of gonor- rhœa it was the practice to employ purgatives very frequently, and sometimes those of the drastic kind, I have known the gleet, or spu- rious gonorrhœa, by such a practice much in- creased, and long continued, and the patient's constitution very much hurt. Nay, in order more certainly further to prevent mistakes, it is to be observed, that the spurious gonorrhœa is sometimes attended with heat of urine, and some degree of inflammation; but these symptoms are seldom considerable, and, mere- ly by the assistance of a cool regimen, com- monly disappear in a few days. MDCCLXX. With respect to the cure of a virulent gon- orrhœa, I have only to remark, that if it be true, as I have mentioned above, that the disease will often, under a proper regimen, be spontaneously cured; and that the whole of the 351 OF PHYSIC. the virulent matter may be thus entirely dis- charged without the assistance of art; it would seem that there is nothing required of prac- titioners, but to moderate and remove that inflammation which continues the disease, and occasions all the troublesome symptoms that ever attend it. The sole business therefore of our art in the cure of gonorrhœa, is to take off the inflammation accompanying it: And this I think may commonly be done, by avoiding exercise, by using a low and cool diet, by abstaining entirely from fermented and spirituous liquors, and by taking plenti- fully of mild diluent drinks. MDCCLXXI. The heat of urine, which is so troublesome in this disease; as it arises from the increased sensibility of the urethra in its inflamed state; so, on the other hand, the irritation of the urine has the effect of increasing the inflam- mation, and is therefore to be removed as soon as possible. This can be done most effectu- ally by taking in a large quantity of mild watery liquors. Demulcents may be em- ployed; but unless they be accompanied with a large quantity of water, they will have little effect. Nitre has been commonly employed as a supposed refrigerant: But, from much observation, I am convinced, that in a small quantity it is useless, and in a large quan- tity certainly hurtful; and, for this rea- Q2 son, 352 PRACTICE son, that every saline matter passing with the urine generally gives some irritation to the urethra. To prevent the irritation of the urethra arising from its increased sensibility, the injection of mucilage or of mild oil into it has been practised; but I have seldom found this of much service. MDCCLXXII. In gonorrhœa, as costiveness may be hurt- ful, both by an irritation of the system in gen- eral, and of the urethra in particular, as this is occasioned always by the voiding of hard- ened fæces; so costiveness is to be carefully avoided or removed; and the frequent use of large glysters of water and oil, I have found of remarkable benefit in this disease. If glysters, however, do not entirely obviate cos- tiveness, it will be necessary to give laxatives by the mouth: Which, however, should be of the mildest kind, and should do no more than keep the belly regular and a little loose, without much purging. The practice of frequent purging, which was formerly so much in use, and is not yet entirely laid aside, has always appeared to me to be generally superfluous, and often very hurtful. Even what are supposed to be cool- ing purgatives, such as Glauber's salt, soluble tartar, and crystals of tartar, in so far as any part of them pass by urine, they, in the same manner as we have said of nitre, may be hurt- ful; 353 OF PHYSIC. ful; and so far as they produce very liquid stools, the matter of which is generally acrid, they irritate the rectum, and consequently the urethra. This last effect, however, the acrid, and in any degree drastic purgatives, more certainly produce. MDCCLXXIII. In cases of a gonorrhœa attended with vi- olent inflammation, bloodletting may be of service; and in the case of persons of a robust and vigorous habit, in whom the disease is commonly the most violent, bloodletting may be very properly employed. As general bleedings, however, when there is no phlo- gistic diathesis in the system, have little effect in removing topical inflammation; so in gon- orrhœa, when the inflammation is considera- ble, topical bleeding applied to the urethra by leeches, is generally more effectual in re- lieving the inflammation. MDCCLXXIV. When there is any phymosis attending a gonorrhœa, emollient fomentations applied to the whole penis are often of service. In such cases it is necessary, and in all others useful, to keep the penis laid up to the belly, when the patient either walks about or is sitting. Q3 MDCCLXXV. 354 PRACTICE MDCCLXXV. Upon occasion of frequent pirapism and chordee, it has been found useful to apply to the whole of the penis a poultice of crumb of bread moistened with a strong solution of sugar of lead. I have, however, been often disappointed in this practice, perhaps by the poultice keeping the penis too warm, and thereby exciting the very symptoms I wished to prevent. Whether lotions of the external urethra with a solution of the sugar of lead, might be useful in this case, I have not prop- erly tried. MDCCLXXVI. With respect to the use of injections, so frequently employed in gonorrhœa, I am persuaded, that the early use of astringent in- jections are pernicious; not by occasioning a siphylis, as has been commonly imagined; but by increasing and giving occasion to all the consequences of the inflammation, partic- ularly to the very troublesome symptoms of swelled testicles. When, however, the disease has continued for some time, and the inflam- matory symptoms have very much abated, I am of opinion, that by injections of moderate astringency, or at least of this gradually in- creased, an end may be sooner put to the dis- ease than would otherwise have happened; and 355 OF PHYSIC. and that a gleet, so readily occurring, may be generally prevented. MDCCLXXVII. Besides the use of astringent injections, it has been common enough to employ those of a mercurial kind. With respect to these, al- though I am convinced that the infection producing gonorrhœa and that producing chancres and siphylis, are one and the same; yet I apprehend, that in gonorrhœa mercury cannot be of use by correcting the virulence of the infection; and therefore that it is not universally necessary in this disease. I am persuaded, however, that mercury applied to the internal surface of the urethra, may be of use in promoting the more full and free dis- charge of virulent matter from the mucous glands of it. Upon this supposition, I have frequently employed mercurial injections; and, as I judge, with advantage; those injec- tions often bringing on such a state of the consistence and colour of the matter discharg- ed, as we know usually to precede its spon- taneous, ceasing. I avoid these injections, however, in recent cases, or while much in- flammation is still present; but when that in- flammation has somewhat abated, and the discharge notwithstanding still continues in a virulent form, I employ mercurial injections freely. I employ those only that contain mercury entirely in a liquid form, and avoid Q4 those 356 PRACTICE those which may deposite an acrid powder in the urethra. That which I have found most useful is a solution of the corrosive sublimate in water; so much diluted as not to occasion any violent smarting, but not so much diluted as to give no smarting at all. It is scarce necessary to add, that when there is reason to suspect there are ulcerations already formed in the urethra, mercurial injections are not only proper, but the only effectual remedy that can be employed. MDCCLXXVIII. With regard to the cure of gonorrhœa, I have only one other remark to offer. As most of the symptoms arise from the irritation of a stimulus applied, the effects of this irri- tation may be often lessened by diminishing the irritability of the system; and it is well known, that the most certain means of accom- plishing this is by employing opium. For that reason, I consider the practice both of applying opium directly to the urethra, and of exhibiting it by the mouth, to be extremely useful in most cases of gonorrhœa. MDCCLXXIX. After thus offering some remarks with res- pect to gonorrhœa in general, I might pro- ceed to consider particularly the various symp- toms which so frequently attend it; but it does 357 OF PHYSIC. does not seem necessary for me to attempt this after the late publications of Dr. Foart Simmons, and of Dr. Schwediaur, who have treated the subject so fully, and with so much discernment and skill. MDCCLXXX. The other form of the local affection of siphylis, is that of chancre. The ordinary appearance of this I need not describe, it hav- ing been already so often done. Of the few remarks I have to offer, the first is, that I be- lieve chancres never appear in any degree without immediately communicating to the blood more or less of the venereal poison: For I have constantly, whenever chancres had appeared, found, that unless mercury was immediately given internally, some symptoms of a general siphylis did certainly come on afterwards; and though the internal use of mercury should prevent any such appearance, it is still to be presumed that the poison had been communicated, because mercury could act upon it in no other manner than as dif- fused in the fluids. MDCCLXXXI. It has been a question among practitioners, upon the subject of chancres, whether they VOL. 3. Q5 may 358 PRACTICE may be immediately healed up by applications made to the chancres, or if they should be left open for some time without any such appli- cation? It has been supposed, that the sud- den healing up of chancres might immediate- ly force into the blood a poison which might have been excluded by being discharged from the chancre. This, however, is a supposition that is very doubtful; and, upon the other hand, I am certain, that the longer a chancre is kept open, the more poison it perhaps gen- erates, and certainly supplies it more copiously to the blood. And although the above men- tioned supposition were true, it will be of little consequence, if the internal use of mercury, which I judge necessary in every case of chan- cre, be immediately employed. I have often seen very troublesome consequences follow from allowing chancres to remain unhealed; and the symptoms of general siphylis have always seemed to me to be more considerable and violent in proportion as chancres had been suffered to remain longer unhealed. They should always, therefore, be healed as soon as possible; and that, by the only very effectual means, the application of mercurials to the chancre itself. Those that are recent, and have not yet formed any considerable ul- cer, may often be healed by the common mer- curial ointment; but the most powerful means of healing them has appeared to me, to be the application of red precipitate in dry a powder. MDCCLXXXII. 359 OF PHYSIC. MDCCLXXXII. When, in consequence of chancres, or of the other circumstances above mentioned, by which it may happen the venereal poison has been communicated to the blood, it produces many different symptoms in different parts of the body, not necessary to be enumerated and described here, that having been already done by many authors with great accuracy. MDCCLXXXIII. Whenever any of those symptoms do in any degree appear, or as soon as it is known that the circumstances which give occasion to the communication of the venereal poison has taken place, I hold the internal use of mercu- ry to be immediately necessary; and I am well persuaded, that mercury employed with- out delay, and in sufficient quantity, will pret- ty certainly prevent the symptoms which would otherwise have soon appeared, or will remove those that may have already discover- ed themselves. In both cases, it will secure the person from any future consequences of siphylis from that infection. MDCCLXXXIV. This advice for the early and full use of mercury, I take to be the most important that Q6 can 360 PRACTICE can be given with respect to the venereal dis- ease: And although I must admit that the virulence of the poison may be greater in one case than in another, and even that one con- stitution may be more favourable than anoth- er to the violence of the disease; yet I am thoroughly convinced, that most of the in- stances which have occurred of the violence and obstinacy of siphylis have been owing very entirely to the neglect of the early ap- plication of mercury. MDCCLXXXV. Whatever other remedies of siphylis may be known, or may hereafter be found out, I cannot pretend to determine; but I am well persuaded, that in most cases mercury prop- erly employed will prove a very certain and effectual remedy. With respect to others that have been proposed, I shall offer this re- mark only, that I have found the decoction of the mezereon contribute to the healing of ulcers which seemed to have resisted the pow- er of mercury. MDCCLXXXVI. With regard to the many and various prep- arations of mercury, I do not think it neces- sary to give any enumeration of them here, as they are commonly very well known, and have been lately well enumerated by Dr. Schwediaur. 361 OF PHYSIC. Schwediaur. The choice of them seems to be for the most part a matter of indifference; as I believe cures have been, and still may be, effected by many different preparations, if properly administered. The proper admin- istration seems to consist, first, In the choosing those preparations which are the least ready to run off by stool; and therefore the appli- cations externally by unction, are in many cases the most convenient. 2dly, In employ- ing the unction, or in giving a preparation of mercury internally, in such quantity as may show its sensible effects in the mouth. And, 3dly, without carrying these effects to a great- er length, In the continuing the employment of mercury for several weeks, or till the symp- toms of the disease shall have for some time entirely disappeared. I say nothing of the regimen proper and necessary for patients dur- ing the employment of mercury, because I presume it to be very well known. MDCCLXXXVII. Amongst the other preparations of mercu- ry, I believe the corrosive sublimate has often been employed with advantage: But I believe also, that it requires being continued for a longer time than is necessary in the employ- ment of other preparations in the manner above proposed; and I suspect it has often failed in making a cure, because employed while 362 PRACTICE while persons were at the same time exposed to the free air. MDCCLXXXVIII. Upon these points, and others relative to the administration of mercury, and the cure of this disease, I might offer some particular remarks: But I believe they are generally understood; and it is enough for me to say here, that if practitioners will attend, and pa- tients will submit, to the general rules given above, they will seldom fail of obtaining a certain and speedy cure of the disease. CHAP. 363 OF PHYSIC. CHAP. III. OF SCURVY. MDCCLXXXIX. THIS disease appears so fre- quently, and the effects of it are so often fatal, in fleets and armies, that it has very properly engaged the particular attention of physicians. It is indeed surprising that it had not sooner attracted the especial notice both of statesmen and physicians, so as to have produced those measures and regulations that might prevent the havock which it so often occasions. Within these last fifty years, however, it has been so much attended to and studied, that we might suppose every circumstance relating to it so fully and exactly ascertained, as to render all further labour upon the subject superfluous. This perhaps may be true; but it appears to me, that there are still several circumstances regarding the disease not agreed upon among physicians, as well as different opinions form- ed, some of which may have a bad effect upon the practice: And this seems to me to be so much the case, that I hope I shall be ex- cused in endeavouring here to state the facts as 364 PRACTICE as they appear to me from the best authorities, and to offer remarks upon opinions which may influence the practice in the prevention and cure of this disease. MDCCXC. With respect to the phenomena of the dis- ease, they have now been so fully observed, and so accurately described, that there is no longer any doubt in discerning the disease when it is present, or in distinguishing it from almost every other ailment. In particular, it seems now to be fully determined, that there is one disease only, intitled to the appellation of Scurvy; that it is the same upon the land as upon the sea; that it is the same in all climates and seasons, as depending on every where upon nearly the same causes; and that it is not at all diversified, either in its phenomena or its causes, as had been imagined some time ago. MDCCXCI. The phenomena of scurvy, therefore, are not to be described here, as it has been so fully and accurately done elsewhere; and I shall only endeavour to ascertain those facts with respect to the prevention and cure of the dis- ease which seems not yet to be exactly agreed upon. And, first, with respect to the ante- cedents 365 OF PHYSIC. cedents that may be considered as the remote causes of the disease. MDCCXCII. The most remarkable circumstance amongst the antecedents of this disease is, that it has most commonly happened to men living very much on salted meats; and whether it ever arise in any other circumstances, is extremely doubtful. These meats are often in a putres- cent state; and to the circumstance of the long continued use of animal food in a pu- trescent and somewhat indigestible state, the disease has been especially attributed. Wheth- er the circumstance of the meat's being salt- ed, has any effect in producing the disease, otherwise than by being rendered more indi- gestible, is a question that remains still in dis- pute. MDCCXCIII. It seems to me, that the salt concurs in pro- ducing the effect; for there is hardly any in- stance of the disease appearing unless where salted meats had been employed, and scarcely an example where the long continued use of these did not produce it: Besides all which, there are some instances where, by avoiding salted meats, or by diminishing the propor- tion of them in diet, while other circumstances remained much the same, the disease was pre- vented 366 PRACTICE vented from appearing. Further, if it may be admitted as an argument upon this subject, I shall hereafter endeavour to show, that the large use of salt has a tendency to aggravate and increase the proximate cause of scurvy. MDCCXCIV. It must however be allowed, that the prin- cipal circumstance in causing scurvy, is the living very much and very long upon animal food, especially when in a putrescent state; and the clear proof of this is, that a quantity of fresh vegetable food will always certainly prevent the disease. MDCCXCV. While it has been held, that, in those cir- cumstances in which scurvy is produced, the animal food employed was especially hurtful by its being of difficult digestion, this opinion has been attempted to be confirmed, by ob- serving, that the rest of the food employed in the same circumstances were also of difficult digestion. This is supposed to be especially the case of unfermented farinacea which so commonly makes a part of the sea diet. But I apprehend this opinion to be very ill found- ed; for the unfermented farinacea, which are in a great proportion the food of infants, of women, and of the greater part of mankind, can hardly be supposed to be food of difficult digestion: 367 OF PHYSIC. digestion: And with respect to the production of scurvy, there are facts which show, that unfermented farinacea, employed in large proportion, have had a considerable effect in preventing the disease. MDCCXCVI. It has been imagined, that a certain im- pregnation of the air upon the sea had an ef- fect in producing scurvy. But it is altogeth- er improbable: For the only impregnations which could be suspected, are those of inflam- mable or mephitic air; and it is now well known, that these impregnations are much less in the air upon the sea than in that upon the land; besides, there are otherwise many proofs of the salubrity of the sea air. If, therefore, sea air has any effect in producing scurvy, it must be by its sensible qualities of cold or moisture. MDCCXCVII. That cold has an effect in favouring the production of scurvy, is manifest from hence, that the disease is more frequent and more considerable in cold than in warm climates and seasons; and that even warm clothing has a considerable effect in preventing it. MDCCXCVIII. 368 PRACTICE MDCCXCVIII. Moisture may in general have an effect in favouring the production of scurvy, where that of the atmosphere in which men are placed is very considerable: But the ordinary moisture of the sea air is far from being such. Probably it is never considerable, except in the case of unusual rains; and even then, it is perhaps by the application of moisture to the bodies of men in damp clothing only that it has any share in the production of scurvy. At the same time, I believe there is no instance of either cold or moisture produc- ing scurvy, without the concurrence of the faulty sea diet. MDCCXCIX. Under those circumstances which produce scurvy, it commonly seems to occur most readily in the persons who are the least exer- cised; and it is therefore probable, that con- finement and want of exercise may have a great share in producing the disease. MDCCC. It appears that weakness, in whatever man- ner occasioned, is favourable to the produc- tion of scurvy. It is therefore probable, that unusual labour and fatigue may often have some 369 OF PHYSIC. some share in bringing it on: And upon the same account, it is probable, that sadness and despondency may induce a weakness of the circulation; and thereby, as has been remarked, favourable to the production of scurvy. MDCCCI. It has also been observed, that persons neg- ligent in keeping their skin clean by washing and change of clothing, are more liable than others to be affected with scurvy. MDCCCII. Several of these causes, now mentioned, concurring together, seem to produce scurvy; but there is no proper evidence that any one of them alone will produce it, or that all the others uniting together will do it, without the particular concurrence of the sea diet. A- longst with this, however, several of the other circumstances mentioned, have a great effect in producing it sooner, and in a more consid- erable degree, than would otherwise have hap- pened from the diet alone. MDCCCIII. From this view of the remote causes, it will readily appear, that the prevention of the dis- ease may in some measure depend upon the avoiding 370 PRACTICE avoiding of those circumstances which we have enumerated as contributing to bring on the disease sooner than it would otherwise come on. At the same time, the only effectu- al means will be, by avoiding the diet of salt- ed meats; at least by lessening the proportion of these, and using meat preserved otherwise than by salt; by using in diet any kind of es- culent vegetable matter that can be obtained; and especially by using vegetable matters the most disposed to acescency, such as malt; and by drinking a large quantity of pure water. MDCCCIV. The cure of scurvy seems now to be very, well ascertained; and when the necessary means can be obtained, the disease is com- monly removed very quickly. The chief means is a food of fresh and succulent vegeta- bles, and those almost of any kind that are at all esculents. Those most immediately ef- fectual are the acid fruits, and, as being of the same nature, all sort of fermented liquor. MDCCCV. The plants named alkalescent, such as those of the garlic tribe and of the tetradynamiæ, are also particularly useful in the cure of this disease; for, notwithstanding their appellation, they in the first part of their fermentation un- dergo 371 OF PHYSIC. dergo an acescency, and seem to contain a great deal of acescent matter. At the same time, they have generally in their composition an acrid matter that readily passes by urine, probably by perspiration; and by promoting both excretions, are useful in the disease. It is probable, that some plants of the coniferous tribe, such as the spruce fir, and others possess- ed of a diuretic power, may likewise be of some use. MDCCCVI. It is sufficiently probable, that milk of every kind, and particularly its productions whey and butter milk, may prove a cure of this disease. MDCCCVII. It has been common in this disease to em- ploy the fossil acids; but there is reason to doubt if they be of any service, and it is cer- tain they are not effectual remedies. They can hardly be thrown in in such quantity as to be useful antiseptics; and as they do not seem to enter into the composition of the an- imal fluids, and probably pass off unchanged by the excretions, so they can do little in changing the state of the fluids. MDCCCVIII. 372 PRACTICE MDCCCVIII. The great debility which constantly attends scurvy, has naturally led physicians to employ tonic and strengthening medicines, particular- ly the Peruvian bark; but the efficacy of it seems to me very doubtful. It is surprising how soon the use of a vegetable diet restores the strength of scorbutic persons; which seems to show that the preceding debility had depended upon the state of the fluids; and consequently, till the sound state of these can be restored, no tonic remedy can have much effect: But as the Peruvian bark has little power in changing the state of the fluids, so it can have little effect in scurvy. MDCCCIX. I shall conclude my observations upon the medicines employed in scurvy, with remark- ing, that the use of mercury is always mani- festly hurtful. MDCCCX. After having observed that both the pre- vention and cure of this disease are now very well known, it may seem unnecessary to enter into much discussion concerning its proximate cause: But as such discussions can hardly be avoided, and as false opinions may in some measure 373 OF PHYSIC. measure corrupt the practice, I shall venture to suggest here what appears to me most prob- able upon the subject. MDCCCXI. Notwithstanding what has been asserted by some eminent persons, I trust to the concur- ring testimony of the most part of the authors upon the subject, that in scurvy the fluids suffer a considerable change. From these authors we learn, that in the blood drawn from the veins of persons la- bouring under the scurvy, the crassamentum is different both in colour and consistence from what it is in healthy persons; and that at the same time the serum is commonly changed both in colour and taste. The ex- cretions also, in scorbutic persons, show a change in the state of the fluids. The breath is fetid; the urine is always high coloured, and more acrid than usual; and if that acrid exsudation from the feet, which Dr. Hulme takes notice of, happens especially in scorbutic persons, it will be a remarkable proof to the same purpose. But however this may be, there is evidence enough that in scurvy the natural state of the fluids is considerably changed. Further, I apprehend it may be confidently presumed from this, that the dis- ease is brought on by a particular nourishment introduced into the body, and is as certainly cured by the taking in of a different diet. In VOL. III. R the 374 PRACTICE the latter case, the diet used has no other evi- dent operation, than that of giving a particu- lar state and condition to the fluids. MDCCCXII. Presuming, therefore, that the disease de- pends upon a particular condition of the fluids of the body, the next subject of inquiry is, What that condition may be? With this view, I must observe, that the an- imal economy has a singular power of chang- ing acescent aliments, in such a manner, as to render them much more disposed to putre- faction; and although, in a living state, they hardly ever proceed to an actually putrid state; yet in man, whose aliment is of a mixed kind, it is pretty certain, that if he were to live entirely upon animal food, without a fre- quent supply of vegetable aliment, his fluids would advance further towards putrefaction than is consistent with health. This advance towards putrefaction seems to consist in the production and evolution of a saline matter which did not appear in the vegetable ali- ment, and could not be produced or evolved in it, but by carrying on its fermentation to a putrefactive state. That this saline state is constantly in some measure produced and evolved by the animal process, appears from this, that certain excretions of saline matter are constantly made from the human body, and 375 OF PHYSIC. and are therefore presumed necessary to its health. From all this, it may be readily understood, how the continual use of animal food, espec- ially when already in a putrescent state, with- out a mixture of vegetable, may have the ef- fect of carrying the animal process too far, and particularly of producing and evolving a larger proportion of saline matter. That such a preternatural quantity of saline matter does exist in the blood of scorbutic persons, appears from the state of the fluids above mentioned. It will be a confirmation of all this to observe, that every interruption of perspiration, that is, the retention of saline matter, contributes to the production of scurvy; and this inter- ruption is especially owing to the application of cold, or to whatever else weakens the force of the circulation, such as the neglect or want of exercise, fatigue, and despondency of the mind. It deserves indeed to be remarked here, that one of the first effects of the scurvy once induced, is very soon to occasion a great debility of the system, which occasions of course a more rapid progress of the disease. How the state of the fluids may induce such a debility is not well understood; but that it does depend upon such a state of the fluids, is rendered sufficiently presumable from what has been said above with regard to both the causes and the cure of scurvy. R2 MDCCCXIII. 376 PRACTICE MDCCCXIII. It is possible, that this debility may have a great share in producing several of the phe- nomena of scurvy; but a preternaturally sa- line, and consequently dissolved state of the blood, will account for them with more prob- ability; and I do not think it necessary to persons who are at all accustomed to reason upon the animal economy, to explain this matter more fully. I have only to add, that if my opinion in supposing the proximate cause of scurvy to be a preternaturally saline state of the blood, be at all founded, it will be sufficiently obvious, that the throwing into the body along with the aliment an unusual quantity of salt, may have a great share in pro- ducing the disease. Even supposing such salt to suffer no change in the animal body, the effect of it may be considerable; and this will be rendered still more probable, if it may be presumed, that all neutral salts, consisting of a fixed alkali, are changed in the animal body into an ammoniacal salt; which I apprehend to be that especially prevailing in scurvy. If I be at all right in concluding, that meats, from being salted, contribute to the produc- tion of scurvy, it will readily appear, how dan- gerous it may be to admit the conclusion from another theory, that they are perfectly innocent. MDCCCXIV. 377 OF PHYSIC. MDCCCXIV. Having thus endeavoured to explain what relates to the cure of scurvy in general, I judge it proper to leave to other authors, what relates to the management of those symptoms which require a particular treat- ment. R3 CHAP. 378 PRACTICE CHAP. IV. OF JAUNDICE. MDCCCXV. I HAVE here passed over sev- eral of the titles in my nosology, because they are diseases not of this Island. In these, therefore, I have no experience; and with- out that, the compiling from other writers is always extremely fallacious. For these rea- sons I omit them; and shall now only offer some remarks upon the subject of jaundice, the last in order that I can possibly introduce in my course of Lectures. MDCCCXVI. The jaundice consists in a yellow colour of the skin over the whole body, and particular- ly of the adnata of the eyes. This yellow colour may occur from different causes: But in the jaundice, hereafter to be more exactly characterised, I judge it to depend upon a quantity of bile present in the mass of blood; and which, thrown out upon the surface, gives its own proper colour to the skin and eyes. MDCCCXVII. 379 OF PHYSIC. MDCCCXVII. That the disease depends upon this, we know particularly and certainly from the causes by which it is produced. In order to explain thee, I must observe, that bile does not exist in its proper form in the mass of blood, and cannot appear in this form till it has passed the secretory organ of the liver. The bile therefore cannot appear in the mass of blood, or upon the surface of the body, that is, produce jaundice from any interrup- tion of its secretion; and accordingly, if jaun- dice does appear, it must be in consequence of the bile, after it had been secerned, being again taken into the bloodvessels. This may happen in two ways; either by an interruption of its excretion, that is, of its passage into the duodenum, which by accu- mulating it in the biliary vessels, may give oc- casion to its passing again into the bloodves- sels; or it may pass into these, by its being absorbed from the alimentary canal when it happens to be accumulated there in an un- usual quantity. How far the latter cause can take place, or in what circumstances it does occur, I cannot clearly ascertain, and I ap- prehend that jaundice is seldom produced in that manner. MDCCCXVIII. The former cause of stopped excretion may be understood more clearly; and we R4 have 380 PRACTICE have very certain proof of its being the ordi- nary, and indeed almost the universal cause of this disease. Upon this subject it will be obvious, that the interrupted excretion of the bile must depend upon an obstruction of the ductus communis choledochus; the most com- mon cause of which is a biliary concretion formed in the gall bladder, and from thence fallen down into the ductus communis, it be- ing at the same time of such a size as not to pass readily through that duct into the duo- denum. This duct may likewise be obstruct- ed by a spasmodic constriction affecting it: And such spasm may happen, either in the duct itself, which we supposed to be contractile; or in the duodenum pressing the sides of the duct close together; or, lastly, the duct may be obstructed by a tumour compressing it, and that arising either in the coats of the duct it- self, or in any of the neighbouring parts that are, or may come to be, contiguous to it. MDCCCXIX. When such obstruction happens, the se- creted bile must be accumulated in the biliary ducts; and from thence it may either be ab- sorbed and carried by the lymphatics into the bloodvessels, or it may regurgitate in the ducts themselves, and pass from them directly into the ascending cava. In either way, it comes to be diffused in the mass of blood; and from thence 381 OF PHYSIC. thence may pass by every exhalant vessel, and produce the disease in question. MDCCCXX. I have thus shortly explained the ordinary production of jaundice: But it must be ob- served further, that it is at all times accompa- nied with certain other symptoms, such as a whiteness of the fæces alvinæ, which we read- ily account for from the absence of bile in the intestines; and generally, also, with a certain consistence of the fæces, the cause of which it is not so easy to explain. The disease is al- ways accompanied also with urine of a yellow colour, or at least with urine that tinges a linen cloth with a yellow colour. These are constantly attending symptoms; and though not always, yet there is commonly a pain felt in the epigastrium, corresponding, as we sup- pose, to the seat of the ductus communis. This pain is often accompanied with vomit- ing; and even when the pain is not consid- erable, a vomiting sometimes occurs. In some cases, when the pain is considerable, the pulse becomes frequent, full, and hard, and some other symptoms of pyrexia appear. MDCCCXXI. When the jaundice is occasioned by tu- mours of the neighbouring parts compressing the biliary duct, I believe the disease can very VOL. 3. R5 seldom 382 PRACTICE seldom be cured. That such is the cause of jaundice, may with some probability be sup- posed, when it has come on in consequence of other diseases which had subsided long before, and more especially such as had been attend- ed with symptoms of obstructed viscera. Even when the jaundice has subsided long without any intermission, and without any pain in the epigastrium, an external compression is to be suspected. MDCCCXXII. In such circumstances, I consider the dis- ease as incurable; and it is almost only when the disease is occasioned by biliary concretions obstructing the biliary duct, that we may com- monly expect relief, and that our art may contribute to the obtaining it. Such cases may be generally known, by the disease fre- quently disappearing and returning again; by our finding, after the former accident, biliary concretions amongst the fæces; and by the disease being frequently accompanied with pain of the epigastrium, and with vomitings arising from such pain. MDCCCXXIII. In these cases, we know of no certain and immediate means of expediting the passage of the biliary concretions. This is generally a work of time, depending upon the gradual dilatation 383 OF PHYSIC. dilatation of the biliary duct; and it is sur- prising to observe, from the size of the stones which sometimes pass through, what dilata- tion the duct will admit of. It proceeds, however, faster or slower upon different occa- sions; and therefore the jaundice, after a va- rious duration, often ceases suddenly and spontaneously. It is this which has given rise to the belief, that the jaundice has been cured by such a number and such a variety of dif- ferent remedies. Many of these, however, are perfectly inert, and many others of them such as cannot be supposed to have any effect in ex- pending the passage of a biliary concretion. I shall here, therefore, take no notice of the nu- merous remedies of jaundice mentioned by the writers on the Materia Medica, or even of those to be found in practical authors; but shall confine myself to the mention of those that may with probability be supposed to fa- vour the passage of the concretion, or remove the obstacles to it which may occur. MDCCCXXIV. In the treatment of this disease, it is, in the first place to be attended to, that as the dis- tention of the biliary duct, by a hard mass that does not easily pass through it, may ex- cite inflammation there; so, in persons of tol- erable vigour, bloodletting may be an useful precaution; and when much pain, together with any degree of pyrexia occurs, it becomes R6 an 384 PRACTICE an absolutely necessary remedy. In some in- stances of jaundice accompanied with these symptoms, I have found the blood drawn covered with an inflammatory crust as thick as in cases of pneumonia. MDCCCXXV. There is no means of pushing forward a biliary concretion that is more probable than the action of vomiting; which, by compres- sing the whole abdominal viscera, and partic- ularly the full and distended gall bladder and biliary vessels, may contribute, sometimes gently enough, to the dilatation of the biliary duct. Accordingly vomiting has often been found useful for this purpose: But at the same time it is possible, that the force exerted in the act of vomiting may be too violent, and therefore gentle vomits ought only to be employed. And either when, by the long continuance of the jaundice, it may be sus- pected that the size of the concretion then passing is large; or more especially when pain attending the disease gives apprehension of inflammation, it may be prudent to avoid vomiting altogether. MDCCCXXVI. It has been usual in the jaundice to em- ploy purgatives; and it is possible that the action of the intestines may excite the action of 385 OF PHYSIC. of the biliary ducts, and thus favour the ex- pulsion of the biliary concretion: But this, I think, cannot be of much effect, and the at- tempting it by the frequent use of purgatives, may otherwise hurt the patient. For this reason I apprehend, that purgatives can never be proper, excepting when there is a flow and bound belly. MDCCCXXVII. As the relaxation of the skin contributes to relax the whole system, and particularly to relieve the constriction of subjacent parts; so, when the jaundice is attended with pain, fomentations of the epigastrium may be of service. MDCCCXXVIII. As the solids of the living body are very flexible and yielding; so it is probable, that biliary concretions would in many cases find the biliary duct readily admits of such dilata- tion as to render their passage through it easy, were it not that the distention occasions a preternatural spasmodic contraction of the parts below. Upon this account, opium is often of great benefit in jaundice; and the benefit resulting from its use, proves sufficient- ly the truth of the theory upon which the using of it has been founded. MDCCCXXIX. 386 PRACTICE, &c. MDCCCXXIX. It were much to be wished, that a solvent of biliary concretions, which might be ap- plied to them in the gall bladder or biliary ducts, was discovered: But none such, so far as I know, has yet been found; and the em- ployment of soap in this disease, I consider as a frivolous attempt. Dr. White of York has found a solvent of biliary concretions when these are out of the body; but there is not the least probability that it could reach them while lodged within. INDEX INDEX TO THE THREE VOLUMES. N. B. The Ciphers refer to the number of the Paragraphs. A. ABSCESS, 250 ABSCESSES AND ULCERS, the causes of their different states, 254 ACIDS employed in fever, 134 refrigerant in fever, 134 ACTION of the heart and arteries, how increased for preventing the recurrence of the paroxysms of inter- mitting fever, 230 ADYNAMIÆ, 1171 AMENORRHOEA, 995 from retention, 996 when occurring, 998 symptoms of, 999 causes of, 1000-2 cure of, 1002-6 from suppression, 996 when occurring, 1008 symptoms of, 1010 causes of, 1008-9 cure of 1011-12 AMENTIA, 1598 ANASARCA, 1668 the character of, 1668 phenomena of, 1668-73 cure of, 1674-96 distinguished from Leucophlegmatia, 1669 ST. 388 INDEX. St. Anthony's Fire. See Erythema. ANTIMONIAL EMETICS, employed in fevers, 181 their different kinds, 181 the administration of them in fevers, 183—186 ANTIPHLOGISTIC REGIMEN, 129 how conducted, 130 when employed in inter- mittent fever, 234 ANTISPASMODICS, employed in fevers, 152—187 APHTHA, 733 APOPLEXY, 1094 distinguished from palsy, 1094 distinguished from syncope, 1094 predisponent causes of, 1095 exciting causes of, 1098—1115-16 proximate cause of, 1100—21 SEROSA, proximate cause of, 1114 prognostic, 1122—23 frequently ending in hemi- plegia, 1122 prevention of, 1124 whether sanguine or serous, stimulants hurtful in it, 1136—37 from powers that destroy the mobility of the nervous power, 1138 cure of, 1131—39 APYREXIA, 24 ASCITES, 1709 character of, 1709 its various seat, 1710—11 the phenomena of, 1712—13 its particular seat difficultly ascertained, 1714. the cure of, l7l5-17 ASTHMA, 1373 phenomena of, 1375 exciting causes of, 1381 proximate cause of, 1384 distinguished from other kinds of dyspnœa, 1385 sometimes occasions phthisis pulmonalis, 1386 frequently ends in hydrothorax, 1386 seldom entirely cured, 1387 ASTRINGENTS employed in intermittent fevers, 231 joined with aromatics, employed in in- termittent fevers, 231 joined with bitters, employed in inter- mittent fevers, 231 ATRABILIS, 1029 ATROPHIA ab alvi fluxu, 1607 debilium, 1606 inanitorum, 1607 ATROPHIA, 389 INDEX. ATROPHIA, infantilis, 1605 lactantium, 1605 lateralis, 1606-11 a leucorrhœa, 1607 nervosa, 1606 nutricum, 1607 a ptyalisma, 1607 rachitica, 1605 senilis, 1606-11 AURA EPILEPTICA, 1306 B. BITTERS employed in intermittent fevers, 231 joined with astringents, employed in inter- mittents, 231 BLISTERING, its effects, 189—197 its mode of operation in the cure of fevers, 190—194 when to be employed in fevers, 195 where to be applied in fevers, 196 BLOODLETTING, the employment of it in fevers, 138-143 the circumstances directing its use in fevers, 142 the administration of it in fevers, 143 when employed in intermittent fevers, 234 C. CACHEXIES, character of the class, CACHEXY, the term, how applied by authors, CALCULUS RENALIS, CALX NITRATA ANTIMONII, its use in fevers, CANINE MADNESS, the cure of, CARDIALGIA, CARDITIS, of the chronic kind CARUS, CATAPHORA, CATARRH, predisposition to, symptoms of, remote causes of, proximate cause of, cure of, produces phthisis, passes into pneumonia, produces a peripneumonia notha, CATARRH, 390 INDEX. CATARRH, CONTAGIOUS, 1062 CATARRHUS SUFFOCATIVUS, 376 CHANCRE, method of treating, 1781 CHICKEN POX, 631 how distinguished from small pox, 632 CHINCOUGH, 1402 contagious, 1402 frequently accompanied with fever, 1410 phenomena, 1404 prognostic in, 1413 cure of, 1414 CHLOROSIS, 998 CHOLERA, 1453 symptoms of, 1453-56 remote causes of, 1458—60 proximate cause of, 1454 cure of, 1462—64 CHOREA, 1347 phenomena, 1347-53 cure of, 1354 CHRONIC weakness, 1191 COELIACA, 1493 COLD, its operations, 88 absolute, 88 relative, 89 its general effects on the human body, 90-91 its morbid effects, 92 moderates the violence of reaction in fever, 133 its tonic power, how to be employed in fevers, 205 COLD drink, an useful tonic in fevers, 206 the limitation of its use in fevers, 207 air applied in fevers, 208 water applied to the surface of the body in fevers, 205—209 COLIC, 1435 symptoms of, 1435-38 proximate cause of, 1439 cure of, 4441 Devonshire. See Colic of Poitou. of Poitou, 1451 cure of, 1452 COMA, 1094 COMATA, 1093 CONTAGIONS, 78 their supposed variety, 79 CONVULSIONS, 1253 CORPULENCY, 1621 CYNANCHE, 300 MALIGNA, 311 PAROTIDEA, 332 PHARYNGEA, 331 CYNANCHE, 391 INDEX CYNANCHE, TONSILLARIS, 301 TRACHEALIS, 318 as affecting infants, 322—329 the cure of it, 330 CYSTITIS, 431 D. DAYS, critical, in fevers, 107—124 noncritical, 113 DEATH, the causes of in general, 100 the direct causes of, 100 the indirect causes of, 100 the causes of in fever, 101 DEBILITY in fevers, the symptoms of, 104 how obviated, 202 DELIRIUM in general, explained, 1529—50 in fever of two kinds, 45 or INSANITY without fever, 1550—57 DIABETES, 1504 symptoms of, 1504—9 remote causes of, 1508 proximate cause of, 1510—12 cure of, 1513 DIÆTA AQUEA, 157 DIARRHOEA, 1465 distinguished from dysentery, 1466 distinguished from cholera, 1467 proximate cause of, 1468 remote causes of, 1471—93 cure of, 1494—1503 BILIOSA, 1480 COLLIQUATIVE, 1501 MUCOSA, 1488 DIATHESIS PHLOGISTICA, 62—247 how removed, 266 DILUENTS, their use in fevers, 154—158 DISEASES, the distinguishing of them, how attained, 2 the prevention of them, on what founded, 3 the cure of them, on what founded, 4 DROPSIES, 1645 in general, the cause of them, 1646 of the breast. See Hydrothorax. of the lower belly. See Ascites. DYSENTERY, 1067 contagious, 1075 remote causes of, 1072 proximate cause of, 1077 cure of, 1080 use of mild cathartics to be frequently repeated in it, 1080 DYSENTERY, 392 INDEX DYSENTERY, rhubarb improper in it, 1080 DYSENTERIA ALBA, 1070 DYSMENORRHOEA, 1014 DYSPEPSIS, 1190 remote causes of, 1198 proximate cause of, 1193 cure of, 1201 flatulence in it, cure of, 1221 heartburn in it, cure of, 1221 pains of stomach in it, cure of, 1221 vomiting in it, cure of, 1221 DYSPNOEA, 1365 E. EFFLUVIA, human, 85 from marshes, 85 EMACIATIONS, 1600 causes of, 1602—18 cure of, 1619 EMANSIO MENSIUM, 998 EMETICS, suited to the cure of fevers, 174 their effects, 176—180 a mean of removing spasm, 170 the administration of in fevers, 175 their use in intermittent fevers, 230—233 EMPROSTHOTONOS, 1267 ENTERITIS, 404 phlegmonic or erythematic, 404 causes of, 407 cure of, 409 EPILEPSY, 1282 phenomena of, 1283 proximate cause of, 1284 remote causes of, 1285 predisponent causes of, 1310 sympathic, 1316 cure of, 1317 idiopathic, 1316 cure of, 1319 EPISTAXIS, 806 the causes of it, 808 the various circumstances of, 807—818 the management and cure of, 819—829 ERYSIPELAS, 274 of the face, 708 symptoms of, 705—708 prognosis of, 706 proximate cause of, 697 cure of, 708—711 phlegmonodes in different parts of the body, 712 ERYSIPELAS, 393 INDEX. ERYSIPELAS, attending putrid fever, 713 ERYTHEMA, 274 EXANTHEMATA, 585 EXERCISE, useful in intermittent fevers, 231 F. FAINTING. See Syncope. 1171 FATUITY, 1529 FEAR, a remote cause of fever, 97 FEVER, 8 strictly so called, the character of, 8—32 phenomena of, 8 remote causes of, are of a sedative nature, 36 proximate cause of, 33 atony of the extreme vessels, a principal cir- cumstance in the proximate cause of it, 43—44 spasm, a principal part in the proximate cause of it, 40 general doctrine of, 46 the causes of death in it, 101 the prognosis of, 99 indications of cure in, 126 differences of, 53 continent, 28 continued, 27 inflammatory, 67 miliary. See Miliary Fever. nervous, 67 bilious, 71 scarlet. See Scarlet Fever. putrid, 72 named synocha, 67 synochus, 69 typhus, 67 hectic, 74 intermittent, the paroxysms of, described, 10 the cold stage of, 11 the hot stage of, 11 the sweating stage of, 11 of a tertian period, 25 of a quartan period, 25 of a quotidian period, 25 caused by marsh effluvia, 84 bile not the cause of it, 51 cure of, 228 its paroxysms, how prevented, 229 attended with phlogistic diathesis, 234 attended with congestion in the abdominal viscera, 234 remittent, 26 FLUXES, 394 INDEX. FLUXES, without fever. See Profluvia. FLUOR ALBUS. See Leucorrhœa. FOMENTATION of the lower extremities, its use in fevers, 199 FOMITES of contagion, 82 FUNCTIONS intellectual, disorders of, 1528—29 G. GANGRENE of inflamed parts, the cause of, 255—256 marks of the tendency to, 257 marks of its having come on, 257 GASTRITIS, 384 phlegmonic or erythematic, 385 phlegmonic, the seat of, 385 the symptoms of, 386 the causes of, 387 the cure of, 393—397 erythematic, how discovered, 400 the seat of, 385 the cure of, 401 GASTRODYNIA, 1427 GLEET, 1769 GONORRHOEA, 1765 phenomena of, 1767—69 cure of, 1770—78 GOUT, the character of, 492 a hereditary disease, 500 distinguished from rheumatism, 526 predisponent causes of, 493—500 occasional causes of, 502—505 proximate cause of, 527 — 533 not a morbific matter, 529 Regular, described, 506—518 pathology of, 533 cure of, 537—573 no effectual or safe remedy yet found for the cure of it, 539 medicines employed for it, 556 whether it can be radically cured, 540 treatment in the intervals of parox- ysms, 542 treatment in the time of paroxysms, 560 regimen during the paroxysms, 561 external applications, how far safe, 568—569 bloodletting in the intervals of paroxysms, 553 -in the time of parox- ysms, 563 costiveness hurtful, 559 GOUT, 395 INDEX. GOUT, Regular, laxatives to be employed, 559 effects of alkalines, 558 effects of Portland powder, 557 Irregular, 518 Atonic, 574—79 pathology of, 534 cure of, 580-82 Retrocedent, 522 pathology of, 535 cure of, 580— 582 Misplaced, 523 pathology of, 536 cure of, 583—584 Translated, two particular cases of, 525 H. HÆMATEMESIS, 1017 arterial and venous, 1027 from obstructed menstruation, 1020 from suppression of the hemorrhoidal flux, 1025 from compression of the vasa brevia, by the spleen, 1027 from obstruction of the liver, 1028 HÆMATURIA, 1033 idiopathic, improbable, 1033—34 calculosa, 1037 cure of, 1038 violenta, 1039 from suppression of accustomed dis- charges, 1041 putrida, 1043 spuria et lateritia, 1044 HÆMIPLEGIA, 1140 causes of, 1141 frequently occasioned by apoplexy, 1142 frequently alternates with apoplexy, 1144 cure of, 1152 stimulants, of ambivious use in, 1160 stimulants, external, in, 1161 HÆMOPTYSIS, the symptoms of, 838—840 the causes of, 760—63—830—836 how distinguished from other spittings of blood, 841—45 cure of, 846-52 HÆMORRHAGIA UTERI, 966 HEMORRHAGY, active or passive, 735 character of, 736 HEMORRHAGY, 396 INDEX. HEMORRHAGY, arterial, 744 venous, 768 the causes of the different species appearing at different periods of life, 750—773 the general phenomena of, 738—743 the remote causes of, 774 cure of, 776 - whether to be attempted by art, 776—81 prevention of the first attacks, or of the recurrence of, 782—789 treatment of when present, 789—805 symptomatic, 1015 HÆMORRHOIDES VESICÆ, 1042 HÆMORRHOIS, external and internal, 925 phenomena of, 925—931 nature of the tumours, 932 causes of, 933—943 acquire a connexion with the sys- tem, 943—944 particularly with the stomach, 946 cure of, 947—965 HEPATIRRHOEA, 1481 HEPATITIS, 412 acute and chronic, 412 acute, the symptoms of, 413—415 combined with pneumonic inflam- mation, 416 remote causes of it, 416 seat of, 418 various exit of pus produced in, 421 cure of, 422 chronic, the seat of, 418 how discovered, 423 HOOPINGCOUGH. See Chin cough. 1402 HORROR, impression of, employed in intermittent fevers, 231 HUMAN effluvia, the cause of fever, 81 body, its temperature, 88 body has a power of generating heat, 88 HYDROPHOBIA, 1525 HYDROTHORAX, 1697 where seated, 1692 symptoms of, 1701—09 often combined with universal dropsy, 1704 proximate cause of, 1706 cure of, 1707—08 paracentesis in it, when proper, 1708 HYPERCATHARSIS, INDEX. 397 HYPERCATHARSIS, 1477 HYPOCHONDRIASIS, 1222 phenomena of, 1222 distinguished from dyspepsia, 1226 proximate cause of, 1230 cure of, 1232 treatment of the mind in, 1244 HYSTERIA, 1514 symptoms of, 1515—16 paroxysm or fit described, 1515—16 rarely appears in males, 1517 how distinguished from hypochondri- asis, 1518—19 proximate cause of, 1522 analogy between and epilepsy, 1523 cure of, 1524 libidinosa, 1517 HYSTETIC disease. See Hysteria. I. JAMES'S powder, its use in fever, 163 JAUNDICE, 1815-16 causes of, 1816—21 cure of, 1823—29 ICTERUS. See Jaundice. ILIAC passion. See Ileus. ILEUS, 1437 IMPETIGINIS, 1737 character of the order, 1737 INDIGESTION. See Dyspepsia. INFLAMMATION, the phenomena of, 235 internal, the marks of, 236 the state of the blood in, 237 the proximate cause of, 239 not depending upon a lentor of the blood, 241 spasm the proximate cause of, 243—248 terminated by resolution, 249 by suppuration, 250 by gangrene, 255 by scirrhus, 258 by effusion, 259 by blisters, 260 by exsudation, 261 the remote causes of, 262 the cure of in general, 264 by resolution, 264 VOL. III. S INFLAMMATION, 398 INDEX. INFLAMMATION, the cure of, when tending to sup- puration, 268—70 when tending to gan- grene, 271 its general divisions, 273 more strictly cutaneous, 274 of the bladder. See Cystitis. of the brain. See Phrenitis. of the heart. See Carditis. of the intestines. See Enteritis. of the kidneys. See Nephritis. of the liver. See Hepatitis. of the lungs. See Pneumonia. of the pericardium. See Pericarditis. of the peritonæum. See Peritonitis. of the spleen. See Splenitis. of the stomach. See Gastritis. of the uterus, 432 INSANITY, 1535 causes of, 1550-57 of different species, 1557 partial and general, difference of, 1575 INTEMPERANCE IN DRINKING, a remote cause of fever, 97 IINTERMISSION OF FEVER, 24 INTERVAL OF FEVER, 24 INTUMESCENTIÆ, 1610 character of the order, 1620 K. KING'S EVIL. See Scrophula. L. LEUCOPHLEGMATIA, 1669 LEUCORRHOEA, 985 character of, 986 appearance of the matter discharg- ed in, 987—992 the causes of, 988 the effects of, 990 the cure of, 993 LETHARGUS, 1094 LIENTERY, 1469 LOOSENESS. See Diarrhœa. M. MADNESS. See Mania. CANINE. See Canine. MANIA, 399 INDEX. MANIA, 1558 the symptoms of, 1558 the remote causes of, 1559—61 the treatment of, 1562—74 occurring in sanguine temperaments, 1576 in sanguine temperaments, cure of, 1577 MARCORES, 1600 MARSH EFFLUVIA, a cause of fever, 84 MEASLES, 633 the symptoms of, 637—642 the nature of, 644 the cure of, 645—650 of a putrid kind, 643 MEDICINE, the institutions of, 4 MELÆNA, 1017 MELANCHOLIA, 1575 how distinguished from hypochon- driasis, 1587—88 the character of, 1582—89 the proximate cause of, 1590 the treatment of, 1592—97 MELANCHOLIC TEMPERAMENT, 1230 MELANCHOLY. See Melancholia. MENORRHAGIA, 966 active or passive, 966 when a disease, 968—75 effects of, 972 proximate cause of, 977 remote causes of, 978 cure of, 980 MENSES, immoderate flow of them. See Menorrhagia. METALLIC TONICS, employed in intermittent fevers, 231 SALTS, refrigerant, 136 METEORISMUS, 1633 MIASMATA, 78 MILIARY FEVER, the general history of, 714—715 of two kinds, red and white, 716 white, the symptoms of, 717—719 the cure of, 720 MORBUS COELIACUS, 1493 MUCOSUS, 1070 NIGER, 1O29 N. NEPHRITIS, 426 the symptoms of, 426 the remote causes of, 427 the cure of, 430 NERVOUS 400 INDEX. NERVOUS DISEASES. See Neuroses. NEUROSES, 1090 NEUTRAL SALTS, diaphoretic in fevers, 159—161 refrigerant in fevers, 135 NOSOLOGY, Methodical, 2 O. OBESITY, when a disease, 1621 ONEIRODYNIA, 1598 OPHTHALMIA, 278 membranarum, 278 its different de- grees, 279—280 its remote causes, 280 the cure of, 288—290 tarsi, 278 the cure of, 288—290 OPIATES, employed in the hot stage of intermittent fevers, 233 in the interval of intermittent fevers, 231 OPISTHOTONOS. See Tetanus. P. PALPITATION of the heart, 1355 the phenomena of, 1355 the causes of, 1356 the cure of, 1363 PALSY, 1140 distinguished from apoplexy, 1094 causes of, 1141 PARACENTESIS in ascites, when to be attempted, 1717 in hydrothorax, when proper, 1708 PARAPHRENITIS, 343 PAROXYSM of intermittent fevers, the recurrence, how to be prevented, 229 PEMPHIGUS, 732 PERICARDITIS, 383 PERIPNEUMONIA NOTHA, 376 symptoms of, 379 pathology of, 380 the cure of, 381—382 some of the symptoms ex- plained, 350 PERIPNEUMONY, 342 PERITONITIS, 384 PERUVIAN BARK, not a specific, 213 its tonic power, 214 when proper in fever, 215 how most effectually employed, 216 PERUVIAN 401 INDEX. PERUVIAN BARK, the administration of, in inter- mittent fevers, 232 the tonic chiefly employed in inter- mittent fevers, 232 PETECHIA, 734 PHLEGMASIÆ, 235 PHLEGMON, 274 PHRENITIS, 291 the character of, 293 the remote causes of, 294 the cure of, 295-299 PHRENSY. See Phrenitis. PHYSIC, the practice of, how taught, 1 the theory of, how to be employed, 4 PHYSCONIA, 1718 PHTHISIS PULMONALIS, the general character of, 853 always with an ulceration of the lungs, 855 the pus coughed up in, how distinguished from mucus, 856 accompanied with hectic fever, 857 the various causes of it, 863 from hæmoptysis, 864-865 from pneumonia, 866-869 from catarrh, 870-873 from asthma, 875 from tubercles, 876-882 from calcareous matter in the lungs, 884 if contagious, 886 from tubercles, symptoms of, 889 its different duration, 896 the prognosis in, 897 the cure of, 899-924 the treatment of when arising from tuber- cles, 906-921 the palliation of symp- toms, 922-924 PLAGUE, the general character of, 665 phenomena of, 665 principal symptoms of, 667 proximate cause of, 668 prevention of, 670-685 cure of, 686-695 PLEURISY, 341 PLEUROSTHOTONOS. See Tetanus. PNEUMONIA, VOL. 3. S2 402 INDEX. PNEUMONIA, or PNEUMONIC INFLAMMATION, 334 general symptoms of, 335-339 seat of, 340—344 prognosis of, 352—360 cure of, 361 the management of bloodletting in the cure of, 362—367 the use of purgatives in, 370 the use of emetics in, 371 the use of blisters in, 372 the means of promoting expectoration in, 373 the use of sweating in, 374 the use of opiates in, 375 POLYSARCIA, when a disease, 1621 cure of, 1623-25 PROFLUVIA, 1045 character of the class, 1045 PULSE, the state of the, during the paroxysm of an intermittent fever, 12 PURGING, its use in continued fevers, 144 intermittent fevers, 234 PUS, how produced, 250 PUTRESCENCY of the fluids in fever, the symp- toms of, l05 the tendency to in fever, how to be corrected, 222-226 PYLORUS, SCIRRHOUS. See Dyspepsia. PYREXIÆ, 6 character of the class, 6 orders of the class, 7 PYROSIS, 1427 symptoms of, 1431 proximate cause of, 1433 remote causes of, 1432 cure of, 1434 Suecica of Sauvages, 1428 Q. QUINSY. See Cynanche. R. RACHITIS, 1719 its origin, 1720 remote causes of, 1721-23 phenomena of, 1724 proximate cause of, 1725-28 cure of, 1729—36 REACTION 403 INDEX. REACTION of the system, 59 violent in fever, symptoms of, 103 violence of, how moderated, 127 REFRIGERANTS, the use of them in fever, 134 REMEDIES, table of those employed in continued fevers, 22 REMISSION of fever, 26 RESOLUTION of inflammation, how produced, 249 RESPIRATION, the changes of, during the paroxysm of an intermittent, 13 REVOLUTION, diurnal, in the human body, 55 RHEUMATISM, acute or chronic, 433 Acute, the remote causes of, 436 the proximate cause of, 455—460 the symptoms of, 439—447 cure of, 461—470 Chronic, symptoms of, 450 how distinguished from the acute, 451 proximate cause of, 472 cure of, 473—476 how distinguished from gout, 526. RICKETS. See Rachitis. ROSE. See Erythema. RUBEFACIENTS, the effects of them. S. SCARLET FEVER, 651 the symptoms of, 656 different from cynanche ma- ligna, 651-655 the cure of, 657—664 SCROPHULA, 1738 the phenomena of, 1738-1749 the proximate cause of, 1750 not contagious, 1751 not arising from the lues venerea, 1752 the cure of, 1753-59 Mesenterica, 1606 SCURVY, 1789 remote causes of, 1792—1802 cure of, 1804-09 proximate cause of, 1811—14 SINAPISMS, the effects of them, 197 SKIN, affections of. See Impetiginis. SMALL POX, general character of, 587 symptoms of the distinct kind, 589 of the confluent kind, 590—593 general differences between distinct and confluent, 594 SMALL 404 INDEX. SMALL POX, causes of these differences, 595—600 prognosis in, 593 cure of, 601—630 inoculation of, 602 the several practices of which it consists, 603 the importance of the several practices be- longing to, 604—615 management of small pox received by infection, 616—630 SODA, 1427 SPSASM, internal, means of removing in fevers, 152—187 the proximate cause of inflamma- tion, 243—248 SPASMODIC affections without fever, 1251 of the animal functions, 1254 of the vital functions, 1355 of the natural functions, 1427 SPHACELUS, 255 SPLENITIS, 425 STIMULANTS, when to be employed in fevers, 217 their use in intermittent fevers, 230 STOMACH, its consent with the vessels on the surface of the body, 44 SUDORIFICS, arguments for their use in fevers, 163-167 against their use in fevers, 164 SUPPURATION of inflamed parts, the causes of, 251 the marks of a tendency to, 251 formed, the marks of, 251 SURFACE of the body, its consent with the stomach, 44 SWELLINGS, general. See Intumescentiæ. adipose, 1621 flatulent, 1626 watery. See Dropsies. SWEATING, when hurtful in continued fevers, 165 rules for the conduct of in continued fevers, 168 use of in intermittent fevers, 230 SYNCOPE, 1171 phenomena of, 1171 remote causes of, 1174—1178 predisposition to, 1184 cure of, 1189 distinguished from apoplexy, 1094 SYNOCHA. See Fever. SYNOCHUS. See Fever. SYPHILIS, 1760 originally from America, 1761 how propagated, 1762 and gonorrhœa, how distinguished, 1764 SYPHILIS, 405 INDEX. SYPHILIS, cure of, 1783—88 T. TABES à hydrope, 1609 à sanguifluxu, 1608 dorsalis, 1610 glandularis, 1606 mesenterica, 1606 nutricum, 1608 rachialgia, 1606 scrophulosa, 1606 TARTAR EMETIC, its use in fevers, 185 TETANUS, 1257 remote causes of, 1268 cure of, 1270 pissileum Barbadense, or Barbadoes tar, in, 1280 LATERALIS, 1268 TONIC medicines employed in continued fevers, 211 intermittent fevers, 231 TOOTHACH, how far different from rheumatism, 477—480 symptoms of, 478 predisposition to, 481 remote causes of, 481—482 proximate cause of, 483 cure of, 485—491 TRIMUS. See Tetanus. NASCENTIUM, 1281 TUSSUS. See Catarrh. TYPPANITES, the character of, 1627 the different species of, 1628—30 intestinalis, 1628 enterophysodes, 1628 abdominalis, 1628 asciticus, 1628 phenomena of, l632 proximate cause of, 1635—36 cure of, 1637—44 TYPHUS. See Fever. the species of, 70 V. VAPOURS, or low spirits. See Hypochondriasis. VENEREAL DISEASE. See Syphilis. VENERY, excess in, a remote cause of fever, 97 VESANIÆ, in general, 1528 VlS MEDICATRIX NATURÆ, 38 ST. VITUS'S DANCE. See Chorea, VOMITING 406 INDEX. VOMITING OF BLOOD. See Hæmatemesis. effects of in continued fevers, 172, 173 the use of in intermitting fevers, 230—34 URINE, bloody. See Hamaturia. URTICARIA, the history and treatment of, 730 W. WATER BRASH. See Pyrosis. WHITES. See Leucorrhoea. WARM BATHING, the effects of in fever, 198 the administration of in fevers, 199 the marks of the good effects, 200 WINE, the most proper stimulant in fevers, 218 its convenient use in fevers, 219 when hurtful or useful in fevers, 220 FINIS. PTINT AT WORCESTER, BY ISAIAH THOMAS, MDCCXC.